THE COPING STRATEGIES OF SUDANESE REFUGEE WOMEN IN KAKUMA REFUGEE CAMP, KENYA By Jessica Lyn Gladden A DISSERTAION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Social Work 2012 ABSTRACT THE COPING STRATEGIES OF SUDANESE REFUGEE WOMEN IN KAKUMA REFUGEE CAMP, KENYA By Jessica Lyn Gladden The coping strategies of refugees is an area that is rarely explored, particularly with refugees who are currently living in refugee camps and with women refugees. This study builds knowledge in this area by examining the literature on coping strategies in refugees, with a focus on the currently literature regarding East African refugees. A qualitative study interviewing thirty adult refugee women living in Kakuma Refugee Camp, Kenya in May 2011 examined the reported experience of refugee women and their coping strategies. The three central areas of discussion for the study were informal social support, the role of the women’s beliefs, and formal supports in the camp and how these items contributed to coping strategies. Several strategies similar to those in the literature were reported by the women, especially the use of religious or spiritual beliefs and in some cases assistance from friends and family. Much of what the women reported was related to coping with physical needs such as lack of food, instead of emotional needs, as was the intension of the study. Formal support that assisted in filling these physical needs was a major point of discussion for the women interviewed. In addition to the themes around coping strategies, the qualitative analysis of the words of the refugee women from this study brought out a theme of dependency. Due to the structure of the refugee camps, the long term waiting for a solution, and the disruption of cultural and social structures, refugees often end up becoming dependent on the physical assistance from the United Nations High Commissioner for Refugees and other aid groups. The difficulties that arise from dependency and recommendations regarding this issue conclude the study. Social work practice, policy and research recommendations are given around both the areas of coping and dependency issues. Copyright by JESSICA LYN GLADDEN 2012 Dedication This dissertation is dedicated to two very special people, without whom this would not have been possible- my partner Matt and my mother. My mom always believes in me and makes me believe that anything is possible. She encourages me to be my best, and makes me want to be a better person through her example. Matt has been an amazingly supportive and patient partner. Thank you for never giving up on me. I can’t imagine doing this without you and your support. v ACKNOWLEDGEMENTS A special thank you must go out to numerous people for helping me through the process of the doctoral program and dissertation. First of all, thanks to Dr. Cho, my committee chair, for always being supportive and a good critic. Thank you to Dr. Riebschelger as well as the committee members from outside of the Social Work program, Dr. Glew and Dr. Nawyn, for their ongoing support. The funding utilized for this research was obtained from MSU’s School of Social Work, including the Doctoral Fellowship for Research, and MSU’s College of Social Science Dean’s Office Research Enrichment Fellowship. A special thanks goes to each of these departments for their financial support of this research. The outside partner agency, the Africa Mental Health Foundation, provided assistance in coordinating research activities within Kenya. Additional thanks is given to Dr. Ndetei and this agency for their support, without which this research would not have been possible. vi TABLE OF CONTENTS List of Tables x Chapter One: Introduction Introduction and Overview Statement of Problem Purpose of Study Research Questions Research Approach Contributions to field Format of Dissertation References 1 1 2 3 3 4 4 6 8 Chapter Two: Coping Skills of East African Refugees- A Literature Review Abstract Introduction Literature Review Methods Background Literature Trauma and Mental Health Definitions Theories of Coping Findings in Literature Coping in Refugee Studies Internal Resources- Personality Variables Internal Resources- Outlook and Personal Beliefs Internal Resources- Hope for Future through Education Internal Resources- Health and Energy External Resources- Social Support and the Environment Refugee Activities Conclusion Appendix – Coping in East African Literature Chart References 10 10 11 13 14 14 17 19 21 21 22 23 25 26 27 29 30 34 37 Chapter Three: Coping Strategies in Sudanese Refugee Women in Kakuma Refugee Camp, Kenya 44 Abstract 44 Introduction 45 Literature Review 47 Purpose 50 Method 51 Design 51 vii Selection of Participants Data Collection Data Analysis Results Participant Characteristics Coping Strategies- Family, friends and neighbors Coping Strategies- Religious and Spiritual beliefs Coping Strategies- Hope in Education Coping Strategies- Formal Supports Discussion Limitations Conclusions and Recommendations References 52 53 55 58 58 59 62 64 66 69 75 79 85 Chapter Four: System of Dependency in the Sudanese Refugee Women of Kakuma Refugee Camp, Kenya 90 Abstract 90 Introduction 91 Literature Review 92 Purpose 94 Method 94 Design 94 Selection of Participants 95 Data Collection 97 Data Analysis 99 Results 102 Participant Characteristics 102 Dependency through Physical Assistance 103 Dependency in Relationships 106 Time Factors and Hope 107 Discussion 112 Limitations 114 Conclusions and Recommendations 119 References 123 Chapter Five: Summary and Implications Summary Chapter Two Summary Chapter Three Summary Chapter Four Summary Implications for Social Work Practice and Social Policy Implications for Future Research References viii 127 127 128 130 132 133 138 140 Appendices Appendix A: Consent Script Appendix B: Consent Form Appendix C: Interview Protocol for Kakuma Study ix 145 145 148 149 LIST OF TABLES Table 2.1 East African Refugees and Coping in Literature x 34 CHAPTER ONE: Introduction Introduction and Overview There are currently around 14 million refugees in the world and roughly three million in Africa alone (U.S. Committee for Refugees and Immigrants, 2009, p. 32-33). It is well documented that refugees have been exposed to a high number of traumatic events and that “refugees who have fled from war regions often report a number of extremely stressful experiences such as physical and psychological torture, shelling, sexual violence, and other atrocities” (Neuner, Schauer, Klaschik, & Karunakara, 2004, p. 579). Due to the high number of people affected and the seriousness of the problem, social work has a responsibility to respond. The vulnerability of all refugees makes an appropriate reaction a necessity due to social work’s specific commitment to the value of social justice “particularly with and on behalf of vulnerable and oppressed individuals and groups of people” (NASW Code of Ethics, 1996, p.5). It is hoped that this professional responsibility will be fulfilled through dissertation research that is focused on this vulnerable population, assisting them in learning how to cope with and recover from their past experiences. This dissertation research focuses on the coping strategies of one group of refugees under-represented in the research: Sudanese women currently living in East Africa. Literature for both women and refugees who have yet to be resettled into a third (usually Western) country is quite limited; this shortcoming will be discussed in Chapter 2. This research explores the experiences of women in the refugee camp where they reside, Kakuma Refugee Camp in Northern Kenya, and partnered with the staff members at Africa Mental Health Foundation (AMHF). Thirty (30) women were interviewed regarding their coping strategies and resources. These interviews were then analyzed for common themes using Grounded Theory (Strauss and 1 Corbin, 1990), as will be explained in more detail in the methods sections. The study will attempt to identify at least some similar ways of coping across many of the women, and will compare this to the coping strategies of refugees in other studies in the literature. Other research themes will be explored to further the understanding of refugee women and their lives in the refugee camps in Africa. This information can then be utilized to contribute to building knowledge and to inform policy and future interventions. Statement of the problem There are very high numbers of refugees, particularly women, who continue to reside in refugee camps near their home countries under difficult circumstances. Many of these refugee women have experienced high levels of trauma; many are also currently responsible for providing for their families in the camp settings. Little is known about resources available to assist refugee women, especially those still residing in camps (Pavlish, 2005). In addition, little is known about how they cope with past trauma and current living situations, either physically, with daily needs, or emotionally, with their needs for psychological support. This lack of knowledge makes it difficult to provide for the needs of this population. For example, if literature documenting a need for support groups or desire for spiritual guidance was extant, systems providing these could be established. Policies could be developed for supporting women; social workers and other workers in the refugee system would be able to have a greater understanding and means of meeting needs. A better understanding of what is or is not assisting these women in coping will allow for the formation of better programs to meet the needs of refugee women as they attempt to cope with their past trauma and current situation while supporting their families. 2 Purpose of the study The purpose of the study undertaken by this author is to explore refugee women’s coping strategies and available resources. This includes explaining how they cope with their day to day lives, past trauma, and possibly recent trauma. It also includes uncovering the nature of the women’s experience with coping strategies that allow them to manage their situations. The roles of spiritual beliefs, the ability to make meaning out of situation and the possible use of formal supports such as clinics will also be explored as a possible portion of how they cope with their situations. Research questions The research focus is the coping strategies of the Sudanese women refugees currently living in Kenya. This population was chosen due to the lack of literature regarding refugees living in East African and women in particular, and at the suggestion of the staff at the partner agency in Kenya. The three central questions of the research will be: 1. How do Sudanese refugee women living in Kakuma describe their informal support systems for coping? 2. How are the beliefs of Sudanese refugee women living in Kakuma reported to influence their coping? 3. How do the Sudanese refugee women living in Kenya report that formal supports or resources in the camp such as clinics or counseling centers, or lack of these supports, influences their coping? These three questions are the basis for the instrument written by this author and used for the research study. 3 Research Approach The research for this dissertation took place in Kakuma Refugee Camp of northern Kenya in May 2011. As the majority of refugees in East African continue to reside in refugee camps, it was decided that this location would provide an appropriate basis to describe the real life experience of many refugee women through the words of the Sudanese women. It is important to understand their lived experiences to have build knowledge about their lives in the refugee camp settings. The highest concentration of women with the most common experiences was expected to be found in this type of location. The staff at the partner agency in Kenya, AMHF, suggested this location as the best for the study, as this particular camp is currently in a stable situation and safe for the researcher. The study consists of a set of semi- structured qualitative interviews, as this is a study to understand the essence and experiences of the women and their situation. See Appendix A, B, C and D for the Consent Forms and Questionnaire for the study. Contributions to the field The research for this dissertation is expected to contribute to the field by beginning to build knowledge in the literature. The literature on refugees and their mental health is limited, and the literature specifically relating to Africa is particularly scarce. The majority of research completed on the mental health or coping of refugees and on interventions for these difficulties takes place in third countries of resettlement, usually in the United States, Canada, Australia, the United Kingdom, and other areas of Europe (Paadekooper et al., 1999). Very little research has been completed in host countries in Africa, even though the overwhelming majority of refugees continue to reside in a host country- usually close to their country of origin. A focus on the refugee hosting countries is especially needed, but lacking, as the majority of refugees are never 4 resettled into a third country - of the 14 million refugees at the end of 2008, only 86,460 were resettled into a third country (U.S. Committee for Refugees and Immigrants, 2009, p. 29-33). A significant gap exists for the 99.5% of refugees who are still living in Africa, Asia, and other refugee hosting areas. As Nyamai and Njenga (2000) state, “the literature on the consequences of trauma in Africa is conspicuous by its paucity” (p. 228). The American Red Cross Symposium Report in 1999 also agree that “there is a general lack of published literature” on this topic, although there is some unpublished literature and private evaluations of programs through NGOs (p. 10). Some of the research that has been completed on refugees living in Africa is in the form of theses and dissertations written by students and not available to the general population, as they have not been published (D. Bukusi, Personal communication, July 3, 2009, Kenyatta National Hospital, Nairobi, Kenya). This new knowledge in the body of literature is also expected to contribute to the research available regarding the experiences of refugee women. Several sources state that there have been relatively few studies focusing specifically on refugee women, even though women are a large percentage of the refugee population, and encourage future research to move in this direction (Friedman, 1992, Pavlish, 2005). The need for research focusing on women in particular is quite important and should not be underestimated. This research will also contribute to the areas of policy and practice. The lack of knowledge regarding the trauma and daily life situations of these women and coping resources of this population may also contribute to an overall lack of appropriate interventions and policy to guide these interventions. With better knowledge, policies can be developed to better assist refugee women both in the refugee camps in East Africa and in other locations. For example, these policies could include funding and support for an increased number of clinics, if it is found 5 that formal supports are important; support for local elders and spiritual leaders to work with refugee women, if it is found that these are important sources of support; or even procedures dictating how often to re-assess these needs. In turn, social work practice may be informed and supported to provide more culturally relevant treatment. For example, with research supporting the need for close family connections for support, social workers could advocate for reunification of separated families and assist refugees in strengthening family ties for available family members. Format of the dissertation The proposed format of the dissertation is that of a multiple manuscript dissertation. In a multiple manuscript dissertation format, the student completes three manuscripts of a length and quality submissible for publication. Each of the manuscripts must be able to stand on its own. The student is to be the first author on all three articles, however, co-authored articles may be accepted if the student is the first author and took the lead role of the paper. This author wrote three manuscripts, all either submitted or to be submitted for publication. The first manuscript is a literature review paper of the overall topic area, and the second and third manuscripts are based on the results of the research project. An outline of this dissertation as required by the department is as follows: Chapter 1: Chapter 2: Chapter 3: Introduction of the overall topic of the dissertation and a very brief discussion of the chapters that follow and how they relate to the topic. Paper #1 – Literature review paper. Title: The Coping Skills of Refugees Living in East Africa. Paper #2 – A research project/ study including: a) Introduction, b) Literature 6 Chapter 4: Chapter 5: review, c) Method, d) Results, and e) Discussion. Title: The Coping Strategies of Sudanese Refugee Women in Kakuma Refugee Camp, Kenya. Paper #3 – A research project/ study as reported above in Paper #2. Title: System of Structural Dependency in the Sudanese Refugee Women of Kakuma Refugee Camp, Kenya. Conclusions/ summaries for the dissertation across all three papers. This dissertation followed the above outline for chapters and manuscripts for submission to peerreviewed journals. The journals to which these articles will be submitted for publication are related to the field of refugee studies. The top three journals in which this author hopes the articles may be published include the Journal of Refugee Studies, Refugee Survey Quarterly and African Affairs. These journals are all published by Oxford Journals. Both the Journal of Refugee Studies and African Affairs suggest a length of approximately 8,000 words for articles submitted, which was used as a guideline for Chapters Two through Four, the three submissible articles. 7 REFERENCES 8 References Al Gasseer, N., Dresden, E., Keeney, G., & Warren, N. (2004). Status of women and infants in complex humanitarian emergencies. Journal of Midwifery & Women’s Health, 49 (4), 7-13. doi: 10.1016j.jmwh.2004.05.001 American Red Cross. (1999). Symposium report: Psychosocial effects of complex emergencies. Washington, D.C.: American Red Cross. Friedman, A. (1992). Rape and domestic violence: The experience of refugee women. Women & Therapy, 13 (1/2), 65 – 78. doi: 10.1300/J015V13N01_07 Harris, R. (1996). Traumatized women: Dealing with violence against women: The contribution of Non- Governmental Organizations. In Y. Danieli, N. Rodley, & L. Weisaeth (Eds.), International responses to traumatic stress (pp. 367-382). Amityville, New York: Baywood Publishing Company, Inc. Karunakara, U., Neuner, F., Schauer, M., Singh, K., Hill, K., Elbert, T., & Burnha, G. (2004). Traumatic events and symptoms of post- traumatic stress disorder amongst Sudanese nationals, refugee and Ugandans in the West Nile. African Health Sciences, 4 (2), 83- 93. National Association of Social Workers. (1996). Code of Ethics. Washington, D.C.: NASW. Neuner, F., Schauer, M., Klaschik, C., & Karunakara, U. (2004). A comparison of Narrative Exposure Therapy, supportive counseling, and psychoeducation for treating Posttraumatic Stress Disorder in an African refugee settlement. Journal of Counseling and Clinical Psychology, 4, 579 – 587. doi: 10.1037/0022-06X.72.4.579 Nyamai, C., & Njenga, F. (2000). Post-traumatic stress disorder: Case report. East African Medical Journal, 77, 228-230. Pavlish, C. (2005). Action responses of Congolese refugee women. Journal of Nursing Scholarship, 37 (1), 10-17. doi: 10.1111/j.1547-5069.2005.00010.x Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. London: Sage Publications. United States Committee for Refugees and Immigrants. (2009). World Refugee Survey 2009. Washington, D.C.: U.S. Committee for Refugees and Immigrants. 9 CHAPTER TWO Coping Skills of East Africa Refugees: A Literature Review Abstract This paper is a summary of the literature currently available in peer- reviewed journals, edited books, and theses regarding the various coping skills that are utilized by refugees from East Africa who are currently living in countries around the world. The most common coping skills included faith/ religion, social support, and cognitive reframing by finding meaning in the situation. Hope for the future, especially through education, was a common theme among younger refugees, in particular those who were resettled in a Western country. Additional research into the experiences of refugee women, refugees who have not been resettled into Western countries, specific refugee groups and studies utilizing qualitative methodologies are suggested. 10 Introduction War, civil unrest, torture, violence and discrimination take place on every continent in the world and results in many millions of people displaced from their homes each year. The number fluctuates, however there might be approximately 50 million displaced people each year (Petevi, 1996). In 2009 about 14 million of these displaced people were refugees, or displaced people who have crossed the borders into another country (U.S. Committee for Refugees and Immigrants, 2009). The most commonly used definition of a refugee is from the United Nations (UN) Geneva Convention Relating to the Status of Refugees, which stated in 1951 that a refugees is: owing to a well- founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable to, or, owing to such fear, is unwilling to avail himself of the protection of that country. (Article 1A [2]). This is the definition that will be utilized by this paper, as it is the most common is accepted world wide. However, there are other definitions of what constitutes refugee status, as each individual nation sets forth the guidelines for who may be declared a refugee and given protection by that nation. For example, some entities such as the Organization of African Unity (OAU, an organization formed to promote cooperation between African countries) have formed their own definitions of refugees, broadening the category to include individuals who may not be covered in the Geneva Convention. The OAU includes the following in their Convention Governing the Specific Aspects of Refugee Problems in Africa (1969, p. 2): The term “refugee” shall also apply to every person who, owing to external aggression, occupation, foreign domination or events seriously disturbing public order in either part or the whole of his country of origin or nationality, is compelled to leave his place of habitual residence in order to seek refuge in another place outside his country of origin or nationality. 11 It is also noted that an internally displaced person (IDP) may have all of the same experiences as a refugee, however has not crossed the border into another country: some researchers are beginning to categorize people as being impacted by “complex humanitarian emergencies” to account for the various sets of people similarly affected (Al Gasseer, Dresden, Keeney, & Warren, 2004, p. 7). However, once a person has crossed the border into a nearby host country, they are then considered a refugee, and some refugees are selected by specific (usually Western) countries for permanent resettlement. The numbers of refugees are reported yearly by the United Nations High Commissioner of Refugees as well as the United States Committee for Refugees and Immigrants. The majority of the literature focuses on the experiences of refugees, possibly due to the difficulty in reaching internally displaced people in turbulent areas of the world for study. This literature review will discuss common difficulties in the area of trauma and mental health for refugees worldwide. Common diagnoses found in the literature will also be explored. Then, the coping skills that refugees utilize to assist with the issues brought on by trauma and mental health issues, as well as current living situations will be discussed. A more narrow focus on the coping skills for East African refugees will be given at the end of the paper, as the literature for this group is limited and needs to be expanded. This review will show what coping strategies have been explored and noted as being used by this particular group and the findings of the studies that focus on this topic, as well as which areas need to be explored in further research. There is some literature to support that there may be commonly utilized coping strategies across various refugee groups, such as the importance of spirituality or religion in both Sudanese men in Canada and in Bosnian refugee women in the United States (Sossou, Craig, Ogren & Schnak, 2008; Stoll & Johnson, 12 2007) and the importance of social support and family in both Bosnian refugees and Eritrean youth (Farewell, 2004; Plante, Simicic, Andersen & Manuel, 2002). However, a more narrow focus can assist in adding to the knowledge regarding specific areas of the world. By focusing on this rarely explored population of East Africans, additional conclusions will be drawn as to what the most commonly used coping strategies are in both refugee host and resettlement countries. This may assist social workers and other mental health workers to be able to utilize these commonalities and assist other refugees in the future. As Folkman and Moskiwitz (2004) state, “coping is unlike…other concepts in that it lends itself to cognitive-behavioral intervention” (p. 746). Adding to knowledge of coping skills in this population allows mental health workers to apply this knowledge and improves the culturally appropriate treatment of this population. Teachers and workers in schools with refugee students may be able to use this information to assist their students with difficulties. In addition, policymakers, community service workers and others involved in work with the refugee population may be able to utilize this information to provide for better care in their specific area or advocate for changes when needed. Literature Review Methods In searching for refugee related literature regarding coping skills, this author searched the following Databases: Proquest, Social Work Abstracts, Social Services Abstracts, Sociological Abstracts, PsychInfo including PsychARTICLES, JSTOR and PILOTS (a specialized database regarding PTSD maintained by the United States Department of Veteran Affairs). Keywords searched included: Sudanese, Sudan, Kenya, Tanzania, Uganda, Rwanda, Burundi, Somalia, Djibouti, Ethiopia, Eritrea, Africa, refugee, trauma, coping, adaptation, resilience, social support, post traumatic stress disorder (PTSD) and stress. In addition, the works cited for each source 13 found was reviewed and relevant sources were located. This search took place from May to August 2010, with some updates in October 2010 and December 2010. A great deal of literature is available regarding coping and the theories pertaining to coping. However, the literature specific to East African refugees, and especially for women and refugees in host countries, was limited. A chart showing the literature relating to the coping skills of East African refugees (see Appendix) is provided to assist this discussion. In order to be included in this chart, the article or book chapter was required to not be focused solely on an intervention (must have information on coping included), to be new research or information and to directly include research on how refugees from one of the above mentioned countries coped with their past and current situations. Literature reviews that did not include new research were examined to find additional sources and information for this article but not included in the chart. Several articles, including the literature reviews, provided helpful information relating to the resilience and conditions of this population group without a specific focus on coping; these articles are not included in the chart but are included in the discussion as relevant. Background Literature Trauma and mental health While each individual’s situation is different, it is well known that many refugees have experienced various forms of violence, including death of family members, physical violence, sexual assaults, shelling and other forms of torture (Neuner, Schauer, Klaschik, & Karunakara, 2004). Increasingly, civilians have been the targets of conflicts within a nation. Mass killings and forced resettlement have also increased as tactics of war (Al Gasseer, Dresden, Keeney & Warren, 2004). Refugees are often forced to flee from their homes due to violence or the fear of 14 violence. Some of the issues refugees have faced include “prolonged physical insecurity, extraordinary life- threatening situations, multiple losses, torture, family disruptions, during the uprooting process, years of living in a camp, feeling that their suffering will never end and that they have lost control of their lives” (Petevi, 1996, p. 177.) Due to their history of surviving these types of events and situations, some refugees may have lasting mental health issues. Refugees live with a wide variety of mental disorders. Just as with any population, an individual may suffer from almost any disorder within the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000). As van der Veer (1992) states “refugees can suffer from any psychiatric disorder that is found among human beings” (p. 30). Additionally, while refugees are at risk for a variety of disorders, by no means do all refugees have mental health problems. PotockyTripodi (2002) reminds her readers that “it is critical to remember that in reality most immigrants and refugees do not develop significant mental health problems” (p. 272). Ochberg (1987), a leading physician in the field of trauma work, also states that being “a survivor of human cruelty is not the equivalent of being mentally ill” (p. 4). However, the refugee population has high numbers of prevalence for certain disorders due to their situation and the traumatic events that many refugees have experienced. The measurement of the specific prevalence is difficult to accurately obtain. At this time, there is no “systematic and reliable means of evaluating the incidence and prevalence of disease in the U.S. refugee population” (Weinstein, Sarnoff, Gladstone, & Lipson, 2000, p. 307), much less the worldwide refugee population. This includes both physical and mental disorders. The authors of the study cited earlier discuss difficulties with “inadequate surveillance mechanisms, lack of demographic data, and an inability to distinguish refugees from the foreign- born or from larger groupings defined by ethnicity” (2000, 15 p. 307). This places limits on how precisely researchers can determine the prevalence of diagnosis in the overall refugee population. In spite of a lack of overall numbers, there are several mental health diagnoses that are commonly agreed upon by experts in the field as having a high incidence of occurrence in the population by the available research and literature. Post Traumatic Stress Disorder (PTSD) is perhaps the most common mental health diagnosis for refugees due to the high incidence of violence in their lives (Lie, Lavik, & Laake, 2001; Moreno, Piwowarczyk, LaMorte, & Grodin, 2006; Piwowarczyk, 2007; Potocky- Tripodi, 2002; van der Veer, 1992). Potocky- Tripodi (2002) states that “the multiple pre-migration, departure, and transit trauma experienced by refugees in particular place them at risk of developing symptoms of post-traumatic stress disorder” (p. 271). Research on the prevalence of PTSD in refugees varies widely, ranging from 4% to 86% across an assortment of studies (Keller, Lhewa, Rosenfeld, Sachs, Aladjem, & Cohen et al., 2006). A meta- analysis of refugee mental health literature in 2009 found that studies vary from 0% to 99%; however the “unadjusted weighted prevalence rate” across all surveys was 30.6% (Steel, Chey, Silove, Marnane, Bryant & van Ommeren, 2009, p. 537). Frazel, Wheeler and Danesh (2005) completed a systematic review of 20 studies on refugees living in Western countries, and found that the studies with larger samples noted a smaller percentage of the population diagnosed with either PTSD or depression. Both of these studies discuss the variation in prevalence rate due to methodological issues within the studies’ designs. Depression and anxiety are also widely discussed as common difficulties for the refugee population (Allden, 1998; Jaranson, Butcher, Halcon, Johnson, Robertson, & Savik et al., 2004; Keller et al., 2006; Lie et al., 2001; Piwowarczyk, 2007). Other diagnoses with high prevalence include somatization (Jaranson et al., 2004), adjustment disorders (Orley, 1994) and substance abuse (Potocky16 Tripodi, 2002). The rates of these mental health challenges suggest that this population is in need of assistance in coping with their conditions and circumstances, as they are at times unable to successfully cope without professional assistance. By learning more about what has helped some refugees to cope successfully, it is possible to build on these strengths to further assist those with continuing difficulties. Definitions While some refugees may have a mental health disorder or display symptoms of disorders due to their past experiences, all refugees must find some way to deal with the events that have caused them to lose, at minimum, their homes and countries. Refugees may utilize a variety of coping skills to deal with the loss of home, country and security. A review of the literature available regarding the coping skills of refugees is helpful to any social worker or practitioner who is interested in working with this population. However, before a discussion on this topic takes place, several definitions need to be discussed. One definition of coping is “constantly changing cognitive and behavioral efforts to manage specific external and/ or internal demands that are appraised as taxing or exceeding the resources of the person” (Lazarus & Folkman, 1984, p. 141). This became the most widely accepted and used definition during the 1980’s (Folkman & Moskowitz, 2004). A newer definition, which is a simplified statement by one of the founding authors in the field, states that the definition of coping is “the thoughts and behaviors used to manage the internal and external demands of situations that are appraised as stressful” (Folkman & Moskowitz, 2004, p. 745). This second definition will be utilized by this author as it is fairly recent, is from one of the primary researchers in the field and fits the scope of the research of this author. 17 Informal support systems or social networks are commonly discussed in the area of coping. Mitchell (1969, as cited in Folkman and Lazarus 1984), provide a definition of the social network as “the specific linkages among a defined set of persons” (p. 247). In other words, the network or system is those known to the person, such as friends, family members and neighbors. Support systems such as family and friends are often seen in the refugee research as an important resource for coping. The availability and quality of this social network may impact the person’s ability to cope, which is one area that will be investigated in this study (Farwell, 2004; Plante, Simicic, Andersen and Manuel, 2002; Schweitzer et al. 2006). The belief system, religion, or spirituality of the refugee may also impact coping skills. In the literature reviewed, the belief system the person holds may include religious, spiritual, political and other viewpoints about the world around the person that influences them. According to Matheson, Jorden, and Anisman (2008), “holding a strong belief system, which might include religions, social, or political beliefs, may serve as a powerful shared strategy that allows individuals to confront or derive meaning from their traumas” (p. 304). These beliefs are not limited to religion or any other specific topic, but may include a variety of items, including how the meaning of the person’s situation is thought of or what the person’s hope for the future may be. Changing these beliefs from possible negatives to positives may assist the refugee or other trauma survivor in reframing their thoughts or making meaning out of their situations to assist with improved coping (Farwell, 2004; Kamya, 2009; Kwawaja, White, Schweitzer & Greenslade, 2008). Formal support is one additional area outside of the persons’ daily life. It has been found to be important in general coping literature as well as discussed in literature around refugees. Formal supports may include medical clinics, mental health clinics, social workers, or other 18 agencies and workers that provide a service in exchange for payment. Services received through this form of support (such as medication) are also included in the area. Formal support services are not often discussed directly in the literature; however there are some instances where these supports are discussed as being helpful by the refugees (Robertson et al., 2006). As this is an area that social work and other forms of direct service may directly impact (by providing these formal supports, including in schools, camps and refugee centers), this researcher included this category in the study to determine if refugees are being assisted in this manner. Theories of Coping There is some literature regarding coping available as early as the 1920’s. Frankl’s Man’s search for meaning, written based on his experiences in the Nazi concentration camps, is one of the earliest works on the subject and was first published in 1946. Freud also discussed information relating to coping, specifically starting with his use of the word “defense” in 1926 as a term describing the “ego’s struggle against unpleasant ideas and feelings” (Parker & Endler, 1996, p. 4). However, the 1970’s and 1980’s saw the field of coping emerging as a distinct and specific area of study (Folkman & Moskowitz, 2004). Lazarus and Folkman (1984), two of the leading researchers and authors in the field, discuss the fragmented nature of the field in 1984, stating that “despite the rich history and current popularity associated with coping, however, there is little coherence in theory, research, and understanding. Even the most cursory inspection of readings… reveals confusion as to what is meant by coping and how it functions in the process of adaptation” (p. 117). This fragmentation continues to be an issue today. One can see some of this difficulty in the multiple formats utilized for categorizing coping. 19 Coping is often broken down into categories of function and strategies. The two main functions of coping, coming from the founding authors Lazarus and Folkman (1984), include: 1. to manage or change the problem causing stress (problem- focused coping), or 2. to deal with the emotional response to the problem (emotion- focused coping). These two categories were formed out of the available research at the time, and current research often continues to allow these two categories to be utilized. Other sources describe the functions of coping in different manners, such as problem- focused, emotion- focused, and meaning- focused, with a sometimes added category of social coping (Folkman & Moskowitz, 2004). Coping can be examined as having specific functions, but are also often formed into main sets of strategies. These strategies focus on specific thoughts or actions that assist in allowing the functions of either managing/ changing the problem or dealing with the emotional response. These are categorized in several different manners, which are sometimes related to the functions discussed above. Some authors, such as Araya, Chotai, Komproe and de Jong (2007) discuss these strategies as task- oriented, avoidance- oriented, or emotion- oriented strategies. Mikulincer and Florian (1996) discuss the problems with categorizing the strategies of coping. In their attempts, they developed four categories: problem- focused, reappraisal, reorganization and avoidance. However, they note that different items could cross categories; for example, talking to friends could be problem- focused or avoidance, depending on the motivation, and additional categories could possibly be formed. Halcón, Robertson, Monsen & Claypatch (2007) examines these same strategies, but think of them as both internal and external resources, which may also be a useful manner of categorization. These authors suggest categories of internal coping strategies or resources such as personality variables, outlook or personal beliefs about the world (including faith or religious beliefs), education, and health/ energy. External coping 20 resources were social support and the environment. Thinking of strategies as internal and external may assist in knowing how to approach the challenges of each particular client. For example, being aware of internal supports the refugee may be utilizing such as religious beliefs, political beliefs, or even the need to change specific thoughts or behaviors (reframing) may assist direct care workers in forming strategies to assist the refugee. Knowledge of possible external supports, including various forms of social support or formal support sources may give the worker (social worker, teacher, of policymaker) ideas of resources to refer the refugee in need of additional care. This method of distinction between different types of coping strategies will be helpful to clinicians in finding a variety of specific strategies that can be built upon in future interventions. Findings in Literature Coping in Refugee Studies There is limited set of literature available regarding coping skills and behaviors specific to the East African refugee population. Using the literature found in the search described above, this author compiled a table of the book chapters and articles found on the topic (See Appendix). Nineteen relevant articles and book chapters were located. Of these nineteen, fourteen regarded populations resettled in Western countries. Twelve of the sources were regarding the Sudanese population, which is not surprising, given the high amount of attention the younger male Sudanese population (often referred to as “The Lost Boys” in Bates, Johnson, & Lee et al., 2995; Luster & Qin et al., 2009) has been given. Only three articles focused on the experiences of women: one regards Somali and Oromo women, one is about Congolese women and a third is a study of Sudanese men and women with a focus in the article on women. One unpublished thesis 21 from Kenya regarding Sudanese women and children that included a minimal discussion on their coping and lack of hope for the future was found but not included in the chart due to the lack of focus on this particular theme. Several themes in coping arise in the literature reviewed, which are often parallel to the primary themes seen in the general literature on coping. In the refugee related literature themes of meaning making, beliefs and religion, social networks and support and use of formal supports are discussed. Types of coping strategies, such as emotion- focused coping, are occasionally discussed as well. As discussed above, Halcón, Robertson, Monsen, et al. (2007) suggest categories of internal and external coping strategies. This framework will be followed to give structure to the discussion, and will add specific activities partaken by the refugees, such as sleeping and talking with friends, at the end. Internal Resources - Personality Variables Some of the literature on refugees’ coping discusses what personality variables or traits assist refugees in coping with their past and present situations. Coping traits, according to Lazarus and Folkman (1984), are the “properties of persons that dispose them to react in certain ways” (p. 139). These traits are not always categories specifically as coping strategies, as these are often more process- oriented than trait- oriented (Lazarus & Folkman, 1984). The personality traits or abilities that assist refugees in coping vary greatly from different researchers. Farwell (2001) discusses the Eritrean youth, who stated their abilities to be patient and have self control were essential for them during their time in exile in Sudan. Another study noted that the refugees believed their strength and endurance allowed them to survive (Farwell, 2004). Similarly, in Bolea, Grant, Burgess and Plasa (2003), having a strong work ethic was seen as a 22 strength that assisted the refugee children in coping. Although there is a wide variety of personality traits discussed by the authors and little overlap between them, this area may benefit from further research to better determine which traits appear to assist refugees in coping most effectively. Additional knowledge in this area would assist refugee workers in identifying negative and positive traits which could then be addressed in treatment: traits which lead to positive coping could be built upon, and traits which lead to negative coping could be given additional attention to limit the less desired affects. Internal Resources - Outlook and Personal Beliefs Making meaning of traumatic events has been a theme in coping literature. One of the first large works was Frankl’s Man’s search for meaning in 1946, discussing his experiences in the Holocaust. According to Frankl, some of the people who were interned in the Nazi camps would find some meaning to their life or to their suffering – for example, one person might consider his or her suffering as a tradeoff for the life of a family member. Refugees also attempt to cope with the events that have taken place in their lives by making meaning out of these events (Farewell, 2004; Goodman, 2004; Jeppsson & Hjern, 2005; Luster, Qin, Bates, Johnson & Rana, 2009; Tankink & Richters, 2007; Tipping, Bretherton & Kaplan, 2007). Some refugees made meaning out of the situation by placing a high value on their country and the fight for freedom, such as is discussed by the Eritrean refugee youth by Farwell (2001). Farwell (2004) notes in another study that the young refugees often ask “existential questions regarding good, evil, and the nature of humanity” (p. 39). Similar to what is seen in Frankl, the difficult circumstances of these groups at times cause questions such as what was asked by one Eritrean refugee: “What are we?” (Farwell, 2004, p. 39). 23 One’s beliefs often have a large effect on the ability to cope. Not all beliefs are positive coping resources, and some may actually hinder a person’s ability to cope (Lazarus & Folkman, 1984). For example, if one believes that their situation will never improve, the person may give up and could withdraw from others, not attend to basic needs, or even commit suicide. Having strong positive beliefs, such as believing a situation is manageable or belief in a caring God, can bring a person hope that allows them to better cope with a situation (Lazarus & Folkman, 1984). Religious beliefs often form the backbones of refugees’ beliefs about their situations, their futures and their ability to make meaning out of the events that have taken place in their lives. Several studies have found that turning to religious faith was one of the major coping strategies of East African refugees (Bolea et al., 2003; Goodman, 2004; Grant- Knight, Geltman & Ellis, 2009; Halcón et al., 2004, Jeppsson & Hjern, 2005; Matheson et al., 2008; Pavlish, 2005; Stoll & Johnson, 2007; Tankink & Richters, 2007). There is a frequent overlap between meaning making and faith/ belief in God, as some literature shows refugees utilizing faith to make meaning out of their situation, especially the question of why they are still alive when others are not. Luster et al. (2009) discuss the Sudanese refugees in their study using religious beliefs to find meaning in their losses, as well as to know how to conduct their lives. In Goodman’s (2004) study of Sudanese youth and how they have coped with their past trauma and current situations, many of the participants utilized their belief in God to answer questions of why they are still alive. One refugee simply states “God did not want me to die. Otherwise I would have died like the others” (p. 1187). Continued research on the impact of religious and political beliefs on the overall coping of refugees may help workers to assist their clients in building more positive coping strategies. In particular, looking at how to help shift negative beliefs into more positive ways of 24 thinking (reframing) could be of great assistance to workers whose clients may be struggling with mental health issues. Internal Resources – Hope for Future through Education Many refugees, especially the younger generations, place a high value on education. This ties in strongly to the younger generations of refugees’ future orientation, and places a strong emphasis on a hope for a better future (Farwell, 2004). Having hope for the future, including through education, is a part of the cognitive reframing that takes place for some refugees. In these cases, the refugees are able to reframe their current situations in a manner that allows for some good to come out of their situation. This hope and stress on education is particularly strong in young refugees who have been resettled in a Western country. One group of Sudanese refugees discussed their time in the Kakuma Refugee Camp in Kenya, stating “We had eight years in Kenya… you can’t go to school, you can’t even hope for your future. There was no hope for the future. So we just lived there as… we didn’t even count ourselves” (Goodman, 2004, p. 1188). However, after these refugees were resettled, one of them stated “Now we feel like people, that we have hope for our future” (Goodman, 2004, p. 1189). Goodman (2004) states that the young refugees’ hope for their future was in education, as “knowledge was seen as the one thing that could not be taken from them” (p. 1190). As one of these refugees stated, “My hope is that since I will study I will have a good future… If I get my education I will be somebody” (2004, p. 1191). A study by Bates et al. (2005) also shows the strong emphasis placed on education in order to form hope for the future, as 98% of the sample population was in school after between twelve to 18 months of initial resettlement, and 91% expected to get at least a 4year college degree. Although this study noted that school in a resettlement country is often a 25 challenge, refugees were able to find social support from peers at school in some cases. Luster et al. (2009) and Tipping et al. (2007) both discuss how getting an education was a way for the sample population of that study, Sudanese youth resettled in the United States and Australia respectively, to not only help themselves but also their families, and possibly their country in the future as well. Bolea et al. (2003) also show that some of the refugee children in their sample were very committed to education, some with the desire to return to Sudan as educated people. One study completed with Sudanese refugee women in Kenya showed that the women did not have a hope for the future, and experienced negative coping due to a lack of hope and their disbelief that there was peace in Sudan (Sindan, 2006). This area of research could be further explored in order to determine how to best build hope for the future in different refugee populations based on what is important to that particular group (whether it is education, family reunification, returning to the country of origin, or some other area). Internal Resources - Health and Energy It is difficult to cope with any difficult situation without having good health and energy. Lazarus and Folkman (1984) consider health and energy to be “among the most pervasive resources in that they are relevant to coping in many, if not all, stressful encounters” (p. 159). Without good health and energy, it becomes much more difficult to cope with difficult situations. At times, it becomes physically impossible to cope with difficult situations, such as the conditions of the Sudanese children walking across the country in search of safety, and some “died along the way. Children too tired, sick, or hungry to continue walking sat down, never to get up again” (Goodman, 2004, p. 1186). This example shows how the lack of health and energy can cause failure of coping, and loss of life in extreme circumstances. A very few studies noted a 26 connection between refugees seeking assistance from the medical community for issues that are related to their mental health and coping with their situation. Geltman et al. (2005) notes that there was a high rate of refugees seeking medical assistance for issues often related to somatization, such as headaches and chest pains. Robertson et al. (2006) notes that many of the Somali and Oromo refugee women in their study had found it necessary to consult a medical professional in previous months. While health and energy is not often measured in studies regarding coping skills, this area deserves some attention in the research and practice, as without good health and energy it is unlikely that the refugee will be able to cope with their individual circumstances. External Resources – Social Support and the Environment As Lazarus and Folkman (1984) state, “the social environment is not just a major source of stress; it also provides vital resources which the individual can and must draw upon in order to survive” (p. 243). Social support from other people is essential to human survival in all situations, and can be particularly important in assisting people to cope during difficult situations. Social support from social networks, especially in the form of family and friends, is one of the most often discussed coping strategies in the literature (Bates, Baird, Johnson, Lee, Luster & Rehagen, 2005; Farwell, 2001; Jeppsson & Hjern, 2005; Jorden, Matheson, & Anisman, 2009; Khawaja, White, Schweitzer & Greenslade, 2008; Schweitzer, Greenslade & Kagee, 2007; Schweitzer, Melville, Steel & Lacherez, 2006; Stoll & Johnson, 2007; Tankink & Richters, 2007; Tipping et al., 2007). For some, this social support from family, teachers and elders assist the person in being able to make sense of the situation (Farwell, 2004). For others, the social support given by peers helped the person to feel they were not alone, and they 27 encouraged each other as discussed by one Sudanese youth, who said, “We had to encourage each other, advise each other not to give up, to still struggle for the future life” (Goodman, 2004, p. 1183). Luster et al. (2009) also stresses the importance of peers in coping, stating that many of the Sudanese youth in their study had said that the support that had helped them the most was their friends. For many, the need to stay alive or continue struggling was based on the need to provide for their families (Farwell, 2001; Pavlish, 2005). The African beliefs around continuing the family also plays a role. As one refugee states, “If God wishes I will be alive. My family will not be lost totally. I will be my family” (Goodman, 2004, p. 1188). Although not commonly reported, some studies have shown refugees relying on the formal supports available through the medical realm. Robertson et al. (2006) noted in their study on resettled Somali and Oromo refugee women that most of the women reported seeing a doctor or nurse in the past few months and nearly half of this study population took medicine to calm down. In this sample population, about one tenth of the refugee women spoke with a professional about a mental health problem. Geltman et al. (2005) noted that there was a high rate of the Sudanese minors in their study population seeking medical care for health issues that are often associated with somatic issues, such as headaches, stomachaches, bad dreams, and lack of energy. Additional studies examining the utilization of medical and counseling services would be of great assistance in developing a more appropriate response from the clinical arena. It could be extremely beneficial to explore the reasons why medical and counseling services are sometimes utilized but not others (as has begun to be explored in some studies; Gong-Guy, Cravens, & Patterson, 1991; Robertson et al., 2006) in order to address the barriers to services. 28 Refugee Activities In some of the literature reviewed, refugees discuss specific activities that they engaged in when negative feelings arose. Lazarus and Folkman (1984) would define these as emotionfocused coping strategies, as they “do not change the meaning of the event directly” and may take place when the person has decided there is nothing that can be done about the situation directly (p. 150 – 151). Araya et al. would call these emotion oriented activities (2007). Halcón et al. (2004) discusses praying, sleeping, reading, and talking to friends as common ways of dealing with sadness in a study of Somali and Oromo refugee youth. A similar study of Somali and Oromo refugee women notes similar strategies: sleeping, talking with friends, and praying were the most common activities (Robertson et al., 2006). Goodman (2004) notes similar activities, mostly focused on avoiding thinking about the past, such as reading a book or playing a game. Paardekooper, de Jong and Hermanns (1999) discuss Sudanese children in Uganda using strategies such as keeping quiet, spending time with others, trying to see the good side of things, wishful thinking and blaming oneself (a negative coping strategy) along with the often discussed use of prayer. Matheson et al. (2008) note that individuals with higher numbers of traumatic events were more likely to engage in more avoidant- coping strategies. While Luster et al. (2009) noted some avoidant- coping strategies in their sample of Sudanese youth, such as sleeping and distraction through school work, reading the Bible, or playing with other children, this study noted the same population also engaging in problem- focused techniques, such as attempting to find their families through the channels available to them and finding meaning through a variety of mechanisms. These different activities could be placed in a variety of categories (internal or external, problem focused, emotion focused or avoidant) depending on the reasoning and purpose behind them, and may be either positive or negative coping strategies. 29 Additionally, this is an area in which there is an overlap between specific activities that refugees (or others) may participate in and previous categories that are seen in this area of research. For example, social support in general is a major category that many rely on for their method of coping. One example of how social support turns into a specific activity that one may engage in is talking with friends. This example can then fall into multiple categories- the larger category of an external resource in social support, and an activity that some participate in to utilize this activity. Depending on the source, this coping skill could fall into either category. Thus the categories are not static and solid, but can at times be fluid. Research into how to utilize these types of activities could give workers improved methods of assisting their refugee clients, as specific activities are often easier to examine than larger categories and may seem more concrete to the refugees themselves. Conclusion The field of coping literature is growing, but there continues to be a need for further study. In the literature relating to East African refugees’ coping strategies, there are several themes that are commonly found. The most common coping strategies discussed are faith/ religion, social support and reframing or finding meaning in the situation. Other common discussions were around personality traits; education and hope for the future; the role of health and energy; and specific activities refugees engage in to cope with negative feelings, such as reading or sleeping. There are several noticeable gaps in the coping literature around East African refugees. There are few studies that focus on the experience of women. Only three of the 19 articles utilized in the chart (Table 1) had a focus on women. Refugee women tend to have different 30 experiences from refugee men, as they are more likely to have experienced sexual violence in both the situations that drove them from their homes as well as often continuing during their time in the refugee camps. Several studies have noted the high rate of sexual violence that occurs when women gather firewood for cooking outside of the camp’s borders (Kim, Torbay & Lawry, 2007; Karunakara et al., 2004). Many refugee women are also the caregivers for their immediate and extended family, often without support from their husbands who may have been killed or gone missing. Al Gasseer et al. (2004) discuss that civilian women may experience the highest burdens during a war or disaster. Health factors, especially reproductive health, and genderbased violence are two areas in particular that cause women to have a higher burden than men. Even the family members of women, such as husbands and fathers, may consider it permissible to beat their daughters and wives to the point of breaking their bones (Harris, 1996). These factors give women a unique experience, and the coping skills for this group specifically should be examined. Many of the studies (14 of 19) found to have specifically examined coping in East African refugees are completed in countries of resettlement. However, it has been noted that the experience of refugees in resettlement countries is very different from the experience of refugees in host countries. Literature often discusses the specific struggles that resettled refugees face, such as family pressures, loss of status and discrimination in the resettlement countries (Jorden et al., 2009) or the need to send money back to family in Africa (Stoll & Johnson, 2007). As the overwhelming majority of refugees continues to reside in host countries and is unlikely to be resettled, it is extremely important to undertake research on the unique challenges and coping experiences of this majority population. The set of challenges for the population in host countries is very different from that of refugees in resettlement countries, so it follows that there may be a 31 difference in coping strategies as well. Research of refugees in host countries is highly recommended. There is also a continued need for research utilizing qualitative methods. As Schweitzer et al. (2007) point out, studies that use quantitative methods “rely on a priori assumptions about the range of variables to be assessed”, which may “be problematic in under- researched areas where little is known about the phenomenon being examined” (p. 284). These authors suggest that qualitative studies around refugee coping strategies would be helpful in allowing researchers and practitioners to understand the phenomenon of coping in this population. Although many of the articles and chapters found in this study included qualitative methods, additional qualitative studies to further understand the experience of coping in refugees would be beneficial. Further research into specific people groups as well as across people groups will assist researchers and field workers in better understanding what each population of refugees needs to cope with their past and present situations. Examining coping strategies over large groups of refugees may allow researchers and practitioners to have general ideas about what may assist their clientele in coping with these specific situations. However, this does not take into account the specific histories and cultures of the people groups they may be working with. Knowing the specific cultural characteristics of a group may assist in providing better support to clients. For example, having a specific understanding of the extended familial system of the Sudanese Dinka that consists of both blood kin (called mar) and also members of the tribe or region through buth bonds (Stoll & Johnson, 2007) might allow the practitioner to build on this strength by assisting the Dinka client to locate other refugees from this group to consider as ‘family’ and build a stronger support system. Similarly, discovering the coping strategies that one group utilizes with success could allow the practitioner to explore the use of these strategies in the particular client 32 and help build on them to assist the person in treatment. A great deal of research on the different people groups that have been impacted by war and political unrest needs to be continued in order to better know how to work with each of these groups. 33 Table 2.1: Coping in East African Refugees literature chart Author Bates, Baird, Johnson, Lee, Luster & Rehagen (2005) Bolea, Grant, Burgess & Plasa (2003) Farwell (2001) Farwell (2004) East African Refugees in Resettlement Coping in Literature Method Population Main Findings Mixed: Sudanese Focus on challenges and successes of youth in Quantitative, youth in the resettlement process. Discussion on (n=43), U.S., primarily resilience factors/ coping skills include Qualitative, male strengths in education, social support (people (n=33) to talk to and help solve problems) and membership and attendance in church. Qualitative, Sudanese Focus on trauma. Youth turned to religious (n=8) youth and faith as source of strength, also discussed foster family in work ethics, education, hope for better lives U.S. and returning to country as educated men. Qualitative Eritrean youth Coping responses and themes of youth (n=33) returning to include: inner strength, separation and loss, Eritrea from community solidarity, concerns about Sudan subsistence, importance of education, desire for peaceful future, making meaning or finding greater good. Relationships and family were important for psychological support. Mixed: Eritrean youth Making meaning main theme, belief in own Quantitative, refugees and strength and endurance, hope for the future. (n=97), non-refugees, Social support assisted youth in making sense Qualitative in Eritrea of situation. Discussion on negative skills (n=60) and PTSD symptoms. Goodman (2004) Qualitative, (n=14) GrantKnight, Geltman and Ellis (2009) Halcón et al. (2004) Quantitative, (n=476) Quantitative (n=338) Sudanese male (Dinka) youth in U.S. Identified coping strategies. 1) Collectivity and the communal self, 2) suppression and distraction, 3) making meaning, 4) emerging from hopelessness to hope (especially of future and in education). Sudanese Religious faith major coping skill, also used unaccompanied active strategies of coping such as seeking minors in U.S. help or doing something active Somali and Oromo youth in U.S. Trauma history strongly associated with physical, psychological and social problems. Most frequent strategies to combat sadness were praying (55.3%) sleeping (39.9%) reading (32.3%) and talking to friends (27.8%). 34 Table 2.1 (cont’d) Jeppsson & Hjern (2005) In Ingleby, Ed. Mixed: (selfdeveloped questionnaire based on 20 interviews) (n=147) Mixed: (n=169) Qualitative, (n=23) Sudanese minors (Dinka) in Kakuma Khawaja, White, Schweitzer & Greenslade, (2008) Luster, Qin, Bates, Johnson, & Rana (2009) Qualitative (n=23) Sudanese refugees in Australia Qualitative, (n=10) Sudanese male youth in U.S. Matheson, Jorden & Anisman (2008) Paardekooper, de Jong & Hermanns (1999) Quantitative and medical. (n=90) Somali Refugees in Canada Quantitative, (n=316) Sudanese refugee children in Uganda Pavlish (2005) Qualitative, (n=14) Congolese women in Rwanda Robertson et al. (2006) Quantitative, (n=458) Somali and Oromo women in the U.S. Jorden, Matheson & Anisman (2009) Somali refugees in Canada 35 Percent of children with various trauma symptoms given. Strategies they used to recover such as seeking social support or religious practices are given with percents as well as discussion on skills of meaning making and hope for the future. Four interview themes were: 1) sense of loss, 2) Difficulty deriving meaning from experiences, 3) Sense of connection to community and family, and 4) psychological distress. Social support and religion as coping (“drew strength from”) Coping strategies included religion, social support, reframing, inner resources and hope for the future Emotion- focused coping strategies such as avoidance and distraction used; problemfocused strategies such as finding meaning in religion or in acceptance of situation, support from people in camp, connection with missing parents also used. Relationships, social support and culture important. Dominant coping strategy was to turn to religious faith. Type of trauma influenced coping strategies used. Social support main coping strategy. Specific active strategies included keeping quiet, blaming self (negative coping), spending time with others and looking for the good in things. Social support – especially caring for family members - and religious faith were major themes in coping. Many reported lack of hope. Coping strategies included sleep (29%), talking with friends (46%) and prayer (71%). About 50% use medication to calm down, about 10% went to doctor or counselor for mental health problems. Table 2.1 (cont’d) Schweitzer, Greenslade & Kagee (2007) Qualitative, (n=13) Sudanese refugees in Australia Stoll & Johnson (2007) Tankink & Richters (2007) Quantitative, (n=164) Sudanese men in Canada Qualitative, (n=15) individuals and 7 focus groups Qualitative, (n=30) Sudanese in Netherlands, article focus on women Tripping, Bretherton & Kaplan (2007) Sudanese young adults in Australia 36 Examines coping during three time periods (pre- during, and post- migration). Social support, religion/ belief in God and personal qualities important. Religion, social support and reduced financial role strain important in predicting social adjustment/ coping. 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(1996). Forced displacement: Refugee trauma, protection and assistance: The contribution of the United Nations High Commissioner for Refugees. In Y. Danieli, N. Rodley, & L. Weisaeth (Eds.), International responses to traumatic stress (pp. 161-192). Amityville, New York: Baywood Publishing Company, Inc. Piwowarczyk, L. (2007). Asylum seekers seeking mental health services in the United States: Clinical and legal implications. The Journal of Nervous and Mental Disease, 195, 715-722. doi: 10.1097/NMD.0b013e318142ca0b 41 Plante, T., Simicic, A., Andersen, E., & Manuel, G. (2002). Stress and coping among displaced Bosnian refugees: An exploratory study. International Journal of Stress Management, 9 (1), 31 – 41. doi: 1072-5245-02-0100-0031-0 Potocky- Tripodi, M. (2002). Best practices for social work with refugees and immigrants. New York: Columbia University Press. Robertson, C., Halcón, L., Savik, K., Johnson, D., Spring, M., Butcher, J., et al. (2006). Somali and Oromo refugee women: Trauma and associated factors. Journal of Advanced Nursing, 56(6), 577 - 587. doi: 10.1111/j.1365-2648.2006.04057.x Schweitzer, R., Greenslade, J., and Kagee, A. (2007). Coping and resilience in refugees from the Sudan: A narrative account. Australian and New Zealand Journal of Psychiatry, 41, 282 – 288. doi: 10.1080/00048670601172780 Schweitzer, R., Melville, F., Steel, Z., & Lacherez, P. (2006). Trauma, post- migration living difficulties, and social support as predictors of psychological adjustment in resettled Sudanese refugees. Australian and New Zealand Journal of Psychiatry, 40, 179 – 187. doi: 10.111/j.1440-1614.2006.01766.x Simich, L. Beiser, M., Stewart, M., & Mwakarimba, E. (2005). Providing social support for immigrants and refugees in Canada: Challenges and directions. Journal of Immigrant Health, 7 (4), 259 – 268. doi: 10.1007/s10903-005-5123-1. Sindan, B. (2006). The refugee trauma and its effects on future hopes: A study of Sudanese refugee women and children at Kakuma Camp, Kenya. Master’s Thesis for Master of Arts in Rural Sociology and Community Development. University of Nairobi, Kenya. Sossou, M., Craig, C., Ogren, H., & Schnak, M. (2008). A qualitative study of resilience factors of Bosnian refugee women resettled in the Southern United States. Journal of Ethnic and Cultural Diversity in Social Work, 17 (4), 365 - 385. doi: 10.1080/15313200802467908 Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta- analysis. JAMA, 302 (5): 537-549. doi: 10.1001/jama.2009.1132 Stoll, K. & Johnson, P. (2007). Determinants of the psychosocial adjustment of Southern Sudanese men. Journal of Refugee Studies, 20 (4), 621 – 640. doi: 10.1093/jrs/fem037 Tankink, M., & Richters, A. (2007). Silence as a coping strategy: The case of refugee women in the Netherlands from South- Sudan who experienced sexual violence in the context of war. In B. Drozdek and J.P. Wilson (Eds.), Voices of trauma: Treating survivors across 42 cultures. (pp. 191- 210). New York, New York: Springer Science and Business Media. Tipping, S., Bretherton, D., & Kaplan, I. (2007). Meaning in life and social connectedness: The experience of Sudanese young people (re)settling in Australia. In D. Lusher and N. Haslam (Eds.), Yearning to breathe free: Seeking asylum in Australia. (pp. 157 – 168). Sydney, Australia: The Federation Press. UNHCR. (1951). Text of the 1951 Convention Relating to the Status of Refugees. Retrieved, August 18, 2010, from http://www.unhcr.org/protect/PROTECTION/3b66c2aa10.pdf. U.S. Committee for Refugees and Immigrants. (2009). World refugee survey 2009. Arlington, VA: U.S. Committee for Refugees and Immigrants. van der Veer, G. (1992). Counselling and therapy with refugees: Psychological problems of victims of war, torture, and repression. New York, NY: John Wiley & Sons. Weinstein, H., Sarnoff, R., Gladstone, E., & Lipson, J. (2000). Physical and psychological health issues of resettled refugees in the United States. Journal of Refugee Studies, 13, 303-327. 43 CHAPTER THREE Coping Strategies of Sudanese Refugee Women in Kakuma Refugee Camp, Kenya. Abstract Thirty Sudanese women currently living in Kakuma Refugee Camp, Kenya were interviewed regarding their coping strategies in May 2011. The three central areas of discussion for the study were informal social support, the role of the women’s beliefs, and formal supports in the camp and how these items contributed to coping strategies. It was found that women were limited in their emotional coping strategies by their many physical needs. Much of the focus of their discussion was around their attempts to meet these physical needs. Formal supports, in particular the United Nations High Commissioner for Refugees, was the primary support available and utilized by the women in the study. Beliefs in God and education were the primary means of emotional support, with little assistance from friends and family. 44 Introduction Refugee women and children account for the majority of refugees in Africa (U.S. Committee for Refugees and Immigrants, 2009; Pavlish, 2005). Unfortunately, the majority of research completed on the mental health or coping strategies of refugees takes place in after resettlement, usually in the United States, Canada, Australia, the United Kingdom, and other areas of Europe (Karunakara et al, 2004). Very little research has been completed in host countries in Africa, even though the overwhelming majority of refugees continue to reside in these host countries- usually close to their country of origin (U.S. Committee for Refugees and Immigrants, 2009). The experiences of women in host countries is often very different from those in resettlement countries, which must be reflected in research. While a refugee woman who has been resettled may have new stressors including adjustment to a new culture and language, women in camps have long term and often unchanging stressors of not having enough to provide for their families and ongoing violence (Pavlish, 2005; Stoll and Johnson, 2007). A focus on the experiences and coping strategies of women in refugee camps is lacking and may be quite different from other settings. Refugee women face a variety of challenges which are often quite different than those of refugee men- even while in the refugee camp or host country. Several sources state that there have been relatively few studies focusing specifically on refugee women, even though women are a large percentage of the refugee population, and encourage future research to move in this direction (Friedman, 1992; McFarland, 2008; Pavlish, 2005). For example, one study showed that after the Rwandan genocide, 70% of the remaining population was women, and more than half of these were widowed. Refugee women face high rates of sexual and gender-based violence. They also suffer the added burden of caring for children, which often places them in 45 the unfamiliar and stressful role of head of the household (Al Gasseer, Dresden, Keeney, & Warren, 2004). Women are often subjected to various traumas specifically due to their roles as women – they may lose children or others for which they are the primary caregivers (Harris, 1996) or they may become a victim of violence due to their duties as a caregiver, as have the high number of refugee women who suffered from sexual violence while searching for firewood outside the refugee camps in order to cook for the family (Karunakara et al, 2004). Many refugee women have experienced high levels of trauma; many are also currently responsible for providing for their families in the camp settings where there are few resources available to them. Little is known about what resources are available to assist refugee women, especially those still residing in these camps (Pavlish, 2005). In addition, little is known about how they cope with past trauma and current living situations, either physically, with daily needs, or emotionally, with their needs for psychological support. This article will explore some of what is known about refugee’s coping strategies in the literature review section, although much of this is not specific to women in refugee camps. However, this lack of knowledge makes it difficult to provide for the specific needs of this population. Exploring the experiences and coping strategies of one group of refugee women can shed light on the types of situations and strategies that might be found with other groups of refugee women residing close to their home countries. Although there will be differences within each group that are specific to their culture, political situation and setting, there are also likely to be more similarities within this group than compared to groups of refugee women living in resettled Western countries. 46 Literature Review In order to provide background for the study and formulate the instrument, a comprehensive literature review on coping strategies in East African refugees, both near their home countries and those who had been resettled to other locations, was completed. The complete results of the review can be found elsewhere (Gladden, 2012; as seen in Chapter Two of this dissertation), but will be briefly summarized here. One of the commonly utilized definitions of coping formed by two of the leaders in the field of coping literature state that coping is “the thoughts and behaviors used to manage the internal and external demands of situations that are appraised as stressful” (Folkman & Moskowitz, 2004, p. 745). There were multiple forms of coping strategies in the literature regarding the general population as well as refugees (Bates et al., 2005; Farwell, 2001; Khawaja et al., 2008; Pavlish, 2005, Schweitzer et al., 2007). Support systems of networks, the belief system or spirituality, meaning making, hope for the future, health and energy, personality traits and formal support by outside resources are the most often discussed and being helpful for refugees in the literature found. While not all of these were noted in the present study, the major areas of support systems, belief systems and a high value in education giving younger refugees a hope for the future were strongly represented by the women and will be discussed in greater depth. Support systems such as family and friends are often seen in the refugee research as an important resource for coping, and was one of the most common resources utilized by refugee populations (Bates, Baird, Johnson, Lee, Luster & Rehagen, 2005; Farwell, 2004; Khawaja, White, Schweitzer & Greenslade, 2008; Plante, Simicic, Andersen and Manuel, 2002; Schweitzer et al. 2006; Tipping, Bretherton & Kaplan, 2007). The availability and quality of this social network may impact the person’s ability to cope with their current situation and possible 47 past traumatic events. Social support may come from family and friends, neighbors, or others in the community. This support may assist the person in making meaning out of their situation (Farwell, 2004) or help them feel that they are not alone (Goodman, 2004), in addition to possibly providing more tangible forms of physical support such as food or shelter. The belief system, religion, or spirituality of the refugee may also impact coping skills. The literature reviewed to provide a context for the questionnaire indicated that the belief system the person holds may include religious, spiritual, political and other viewpoints about the environment that influences them. According to Matheson, Jorden, and Anisman (2008), “holding a strong belief system, which might include religions, social, or political beliefs, may serve as a powerful shared strategy that allows individuals to confront or derive meaning from their traumas” (p. 304). These beliefs are not limited to religion or any other specific topic, but may include a variety of items, including how the meaning of the person’s situation is thought of or what the person’s hope for the future may be. Many sources specifically discuss refugees turning to their beliefs in God or support from religious institutions as a major source of coping (Bolea, Grant, Burgess & Plasa, 2003; Grant- Knight, Geltman and Ellis, 2009; Jeppsson & Hjern, 200; Khawaja, White, Schweitzer & Greenslade, 2008; Pavlish, 2005; Roberson et al., 2006; Schweitzer, Greenslage & Kagee, 2007; Stoll & Johnson, 2007; Tankink & Richters, 2007; and Tipping, Bretherton & Kaplan, 2007). Many refugees place a high value on education. This ties in strongly to some refugees’ future orientation, placing a strong emphasis on a hope for a better future (Farwell, 2004). This hope and stress on education is particularly strong for younger refugees (and for some older refugees, in the hope for their children). Goodman (2004) states that the young refugees’ hope for their future was in education. As one of these refugees stated, “My hope is that since I will 48 study I will have a good future… If I get my education I will be somebody” (Goodman, 2004, p. 1191).. Luster et al. (2009) and Tipping et al. (2007) both discuss how getting an education was a way for the sample population of that study to not only help themselves but also their families, and possibly their country in the future as well. Formal supports are not often mentioned in the literature regarding refugee coping skills, but it is an important category to explore as is it one that social workers may provide. There are several mentions of social support being utilized by refugees. Robertson et al. discusses that many of the refugee women in their study had visited a physician or nurse for a medical problem in the past several months, and that about half of the women also took medication to help them ‘calm down’. This support provided for the women in ways that their network of family and friends were unable to provide. Bates et al. (2005) discusses the use of an increase in need for a variety of formal supports for newly arriving refugee children, including improved educational services and cultural training for those who work with refugees. Within one study in a refugee camp, about one percent of the sample had received mental health treatment- however the study notes that far more could have been provided treatment if additional resources had been available (Jeppsson and Hjern, 2005). Sossou also notes that most humanitarian activities for refugees focuses on physical needs, but that a variety of psychosocial and mental health interventions would be helpful for women (and other refugees) in coping with their trauma, and advocates for services such as group work and community development programs to assist with the challenges these women are facing (2006). These examples show various manners of formal support that have been utilized by refugees, and that these supports can be important for refugees. 49 Purpose Refugee women have many specific needs. Increased research focusing on these needs is important to understand the depth of the challenges this group faces. Due to these problems, the purpose of this study was to explore the coping strategies and available resources of a group of refugee women who continued to reside in a refugee camp. This included examining how they manage the physical realities of their day to day lives while coping with their past (and possibly recent) traumatic events, and uncovering the nature of the women’s experience with coping strategies that allow them to manage their situations. The roles of spiritual beliefs, the ability to make meaning out of situation and formal supports (such as clinics) were also explored as possible methods of coping with their situations, as these were several of the common strategies found in the literature available. Not all possibly coping strategies from the literature was utilized for the study guidelines, however the most commonly found were all included. The three central questions of this research were: 1. How do Sudanese refugee women living in hosting countries describe their support systems for coping? 2. How do the beliefs of Sudanese refugee women living in hosting countries appear to influence coping? 3. How does formal support in the camp, such as clinics or counseling centers (or lack of these supports), appear to influence the coping of Sudanese refugee women living in hosting countries? These three questions were the basis for the instrument written by this author and used for the research study. This study is unique in that the focus is on a group of refugee women currently living in a refugee camp and how they relate to their situation through their coping. These specific central questions have not been directly explored in the refugee camps in relation to refugee women previous to this study. 50 Method Design A qualitative structured interview questionnaire based on a review of coping literature with nineteen open ended questions and a collection of demographics was designed by the author for use in this study to examine coping strategies (See Appendix C). This guide included questions based on the major themes of coping seen in the literature, such as “how have friends supported you or assisted you since you came to Kakuma?” and “Do you have any religious beliefs regarding your current living situation? If yes, what are they?” The possibility of including an assessment of the levels of trauma in the women interviewed was considered, however due to the short length of time the researcher was to be in Kakuma Refugee Camp and the increased possibility of trauma related symptoms by bringing up incidents of trauma in the interview, it was decided to omit this area of concern. While it may have been helpful to better understand the levels of trauma the women have experienced to better explore the appropriateness of the coping strategies, other studies have reviewed trauma in the Sudanese and other East African refugee populations (Araya et al, 2007; Farwell, 2004, Karunakara et al., 2004; Paardekooper et al., 1999; Robertson et al, 2006). The coping strategies questionnaire written by this author was pilot tested with five Sudanese refugee women living in the United States before it was utilized with the women in Kenya, as suggested by Kreuger and Casey (2009) to increase validity. The five women who participated in the pilot study were all of Dinka origin, belonged to a local Christian church, were between 18 and 50 years old, and had between one and four children. Only one of the women spoke English well, and she translated for the other women. The women had been in the United States for a variety of years, but all less than eight. Several of the women had previously lived in 51 the same refugee camp in which the study took place. Each woman was asked each of the questions in the interview. At the end of the interview, the women were asked how well they understood the questions and what changes would help make the instrument better. No changes were made to the instrument based on the pilot study participants’ approval of the format. In addition to the interviews with refugee women in Kakuma, informal interviews with camp authorities, workers and interpreters took place and field notes were taken to provide triangulation and context for the interviews. Selection of the Participants The participants of this study was narrowed to Sudanese refugee women in Kakuma Refugee Camp, Kenya, due to the language skills (Swahili) and local connections of the researcher and the staff at the Africa Mental Health Foundation, as well as the large size of Sudanese refugee population. Sudan is one of the largest refugee producing countries in Africa (U.S. Committee for Refugees and Immigrants, 2009) and consists of almost one third of the 80,000 people in Kakuma Refugee Camp in Kenya (Jeffery Savage, Senior Protection Officer, UNHCR, personal communication, May 8, 2011). A random sample was not determined for this study, as a complete list of Sudanese refugee women living in the camp was not possible to obtain. There were three methods of selection for this study: interpreters located women who were likely willing to participate; one woman was located who was a relative to one of the United States pilot study participants; the rest of the participants were located by referrals from the women who had already participated in the study in a snowball sample. The sample population for this study consisted of Sudanese refugee women 18 years old and over who were currently living within the Kakuma Refugee Camp in Kenya. While no 52 attempt was made to select or de-select members of various ethnic groups within this community, all participants were from the Dinka language and people group, perhaps due to their large numbers and the interpreters’ affiliations and the partial snowball sampling. The Dinka people are the largest people group from South Sudan, with two million people and over five hundred sub-groups (Deng, 1972). The Dinka population makes up about half of the Sudanese in Kakuma Refugee Camp (Sindan, 2006). As this is one of the largest people groups from southern Sudan that have been impacted by the war and forced to relocate, this sample was reasonable for the study. Part way through the study a decision was made to attempt to interview a number of women from the 18-19 year old age range, as this group of women appeared to have a different story and possibly different coping strategies than the older groups of women, particularly in the areas of education and hope for the future, as will be discussed later in the paper. Data Collection The author obtained consent from Michigan State University’s Human Review Board as well as the Kenyan government and Kakuma camp administrators before the study was initiated. The Africa Mental Health Foundation (AMHF) based in Nairobi, Kenya partnered with the author of this study and assisted with permissions in Kenya. Upon arrival in Kenya, the researcher met with contacts from the AMHF, one of whom then traveled with the researcher to Kakuma Refugee Camp and met with the camp authorities. After obtaining verbal permission and a stamp on the previously obtained letter of authorization to work in the camp, the researcher and staff member from the AMHF then sought out the leaders of one section of the Sudanese camp community and explained the study, requested their permission to work with members of 53 the community, and enlisted their assistance in finding the interpreters for the study. The staff member from AMHF did not participate in the interviews as he was a male and it was preferred to allow the women to speak with only other women present. The study interviews took place in May 2011 within several different Sudanese communities of Kakuma Refugee Camp. Participants were allowed to choose the site of the interview. All thirty of the interviewees chose to be interviewed either in their own homes or in an outside location near their homes. Interviews were conducted in English with a Dinka speaking translator, except one which took place in English at the interviewees request. Interviews were conducted in English with a Dinka translator. The interpreters spoke English, Dinka, and Swahili. The instrument questions were translated directly into Dinka by the interpreters after being asked in English by the researcher, with Swahili being utilized when the interpreters had questions about the English wording of questions. Each interview began with a description of the study, its purpose and risks, to allow for informed consent. Due to language and time restrictions, there was no inclusion of small talk at the onset of the interview, although it did occasionally take place at the end of the interview. A signature and thumbprint were obtained from each participant as required by the Kenyan government. The interviews lasted from 15 minutes to 45 minutes. Each interview consisted of asking each question from the interview protocol in the order of the protocol. At times, probes were used to give examples if the participants did not appear to understand the question. For example, the question “what kinds of assistance did they give you?” might be followed with probes or possible examples such as providing food, letting you stay at their house, or being someone to talk to or get advice from. There were time differences in the interviews themselves depending on how thoroughly each interviewee discussed the answers to the questions asked. Check back procedures similar to 54 those described for interviews with focus groups by Kreuger and Casey (2009) were utilized in each interview. This source suggests that “when presenting the brief summary, the researchers should watch the participants for signs of agreement, hesitation, or confusion. When the 2- to 3minute summary is completed, the moderator invites comments, amendments, or corrections” (p. 105). Similar to this procedure, a summary of the comments from each participant was read to her at the conclusion of the interview, and was requested to comment on the accuracy. Each participant was watched for body language or verbal cues that they may feel that there were inaccuracies in the summary which was included in the field notes, in additional to asking for verbal verification of the information. At the end of the interview, the participants were given an opportunity to ask questions and compensation for their time with a token package of goods that consisted of soap, matches and sanitary pads. Data Analysis Each interview with the research participants was audio recorded. The English translation section interviews were transcribed verbatim and in full by an outside source and then checked in full for accuracy by the author. It was noted that throughout the audio recordings it was sometimes difficult to understand the words of the Dinka- English interpreters due to levels of noise and the accents of the interpreters, although approximately 95 to 98% of the time their words were clear enough to record in the written transcription. Due to the poor quality of the recordings of the original Sudanese women’s words in Dinka, the interpreters being closer to the recording microphone, a secondary transcription by a Dinka speaker of the participants’ words was not possible. All thirty interviews had enough of the data present to analyze. 55 Field notes were written during the interview process for each of the interviews. These field notes included the location of the interview, descriptions of others present, the appearance of possible emotional responses to specific questions, the length of time of the interviews and any other information that appeared to be important to the researcher. These field notes were reviewed during the data analysis for possible triangulation with recorded data from interviews. Data analysis occurred by utilizing NVivo with a research assistant also analyzing a random 20% of the full interviews to check for coding discrepancies. A doctoral level specialist in social science qualitative research was also brought in as a consultant at several levels of the coding process to ensure accurate technique. The research consultant assisting in utilizing NVivo, setting up the files correctly, reviewing the coding process once complete, and setting up the multiple levels of coding within NVivo. The Grounded Theory techniques of Glaser and Strauss (1967) were utilized as much as possible, as a “general method of comparative analysis” (p. 1). In this method, “categories are discovered by an examination of the data” (p. 3), and that theories and hypotheses come out of the data through the process and course of the research. It is also important to discover theory through this method by “generating conceptual categories or their properties from evidence; then the evidence from which the category is emerged is used to illustrate the concept” (p. 23). Previous theory was reviewed from the literature and utilized to in formulating the interview questions in the interview protocol. Whereas in pure grounded theory there would be no previous use of theory or a semi- structured set of questions exploring specific areas of concern, when analyzing the data all previous theory was attempted to be set aside, so that only ideas directly generated by the data would remain in order to stay as close to Grounded Theory as possible. One method utilized to assist in this was the use of a second data analyst who was not familiar with the literature around coping strategies. The second date analyst coding full 56 interviews and the codes were compared line by line with the first researcher until there was agreement in coding. This check attempted to ensure that the first researcher who was familiar with the background theory was not adding this theory to the words of the women interviewed unless it was present and seen by both researchers. According to the research consultant, specific percentages of coding agreement or inter-rater coding between the two researchers was not necessary as long as the information and coding was discussed until the appropriate code was agreed upon by both. Both open coding and axial coding was utilized as described by Strauss and Corbin (1990). During the first coding process, the open coding, “data are broken down into discrete parts...by breaking down and conceptualizing we mean taking apart a n observation, a sentence, a paragraph, and giving each discrete incident, idea, or event, a name, something that stands for or represents a phenomenon” (p. 62-63). In this section of coding, the words of the interviewees are used as much as possible, as Strauss and Corbin state it is important to have “phrases used by informants themselves” (1990, p. 69). For example, a woman might state that “I cannot find enough food to feed my children”, and the code might be “not enough food.” Strauss and Corbin (1990) state that one may code line-by-line, by sentence or paragraph, or in an entire document. In this analysis, each sentence was coding separately, although some sentences may receive more than one code. The second half of the coding process is axial coding, in which the researcher “puts those data back together again in new ways by making connections between a category and it’s subcategories….our focus is on specifying a category in terms of the conditions that give rise to it” (Strauss and Corbin, 1990, p. 97). In the actual process of forming these axial codes, the researcher “alternates between the two modes” (p. 98) of open and axial coding. The hope is that working with these categories will allow the researcher to find a type of relationship between the 57 words of the interviewees and a larger phenomenon. In the analysis for this project, multiple attempts were made to organize the open codes into categories of axial codes before the major themes were discovered. As in selective coding, this system was utilized to “integrate [the] categories to form a grounded theory”, (Strauss and Corbin, 1990, p. 116) or the two core categories or major themes found that are discussed within Chapters Three and Four. The line by line content was placed into axial codes to form these larger themes. Negative case analysis with a review for contradictory evidence was also used to discover if there were any cases in which one interviewee’s experience showed that not all women shared the general categories of these phenomenon. The field notes, informal interviews with three local camp authorities with field notes, and previous theory from the literature were later reviewed to provide triangulation for this analysis as they were reviewed for similarities and possible contradictory evidence. Results A brief description of the participants’ characteristics will begin this section to give some outline of the women who were involved in this study. Following this, a description of the main results found in the three main sections of the study will be highlighted with quotes from members of the study (all names have been changed). A set of recommendations based on what was learned in the camp will assist in the conclusion of the article. Participant Characteristics Thirty adult Sudanese refugee women who were living in Kakuma Refugee Camp at the time of the study were interviewed for the study. The participant’s ages ranged from 18 to approximately 50 (not all women were aware of their ages) and all were from Dinka people 58 group or stated they were not a part of any ethnic group (via interpreters) but spoke the Dinka language. As one of the primary languages spoken by Sudanese refugees in Kakuma is Dinka, Dinka- speaking interpreters were used for the study. Both English and Swahili languages were common to the researcher and the translators, although the interviewees rarely spoke Swahili. Thus the words of the interviewees in their original language were not understandable to the researcher. The translators were instructed to repeat the exact words of the interviewees. Twenty six of the interviewees described themselves as unemployed, while the remaining four were self- employed, primarily in carrying water from the well to the homes of other women. Fifteen of the women had some primary level education, one woman had begun secondary education and the rest of the women had no formal education. The majority of the women with several years’ education were from the 18-19 year old age range. The majority of this youngest age group (n=10) had never been married and did not have children, although one person had one child and was never married. The older age groups (age 20 and above, n=20) reported being either widowed, divorced or separated, with only two participants stating she was currently married, and one of those was to the brother of her deceased first husband- a not uncommon practice in East Africa. None of the husbands currently lived with them in Kakuma. The number of children the women had varied from zero to eight. Many of the women reported having children who had previously died or had lost other relatives. Coping Strategies- Family, friends and neighbors Informal social support systems such as family and friends are very important coping strategies for many refugees. One of the major sections of the questionnaire involved questions regarding who assisted or supported the women with both physical and emotional forms of 59 support. Unfortunately, overall a lack of support in this area seemed to be prevalent based on the participants’ reports. Some of the women were able to identify family or neighbors who were able to assist them at times. Some neighbors were reported to be more helpful than others. Mary, a woman with an injured leg, said that she is able to eat with the neighbors and that “people ask if I am okay”. She also said that “sometimes I don’t have food in the house, neighbor give that. Don’t have water. Share it. Help each other.” At times the neighbors shared physical good such as food and water, and occasionally shelter. However, the women said it was not enough help. Mayek summarized their feelings saying, “There are neighbors, but they don’t have help. There is no help”. Although occasionally there were ways that neighbors could help each other, overall the women reported that they did not feel like these gestures were notable or had any long term assistance. Unfortunately most of the time the women interviewed for this study reported a lack of support available from others. They reported that neither neighbors, friends or family member were able to provide the types of support they needed and were looking for. Mariah stated, “I am alone…just the mother and the mother is old, yes she grow old. And I am separate from the husband.” Of the 21 women who were currently or had been married, none of them lived with their husbands in the camp. Not having a husband with them appeared to be a difficulty for many of the women. As Lulu stated, “here if you don’t have a husband, no one, life is a struggle- so you can get a thing- house like that with the tin [roof]. Unless you have someone who is protecting you.” Martha agreed, saying “it depends on the husband. If he is strong, you stay safe.” Some of the women who were separated from their husbands spoke of the husbands as also causing problems for them. For example, Yar spoke of her husband from whom she was 60 separated as someone who had “provide[d] children but not money [for the children]. Just children.” Martha agreed, “the husband does not give support with the children.” Some women also discussed the difficulties of having a “new” husband. Within their culture, if their husband has died, they become the “wife” to the husband’s brother. Martha spoke about this second husband saying, “he just come and then [make me] pregnant and then go, he come again in the night.” The situations with the husbands and second husbands were not a reported form of support for these women, but appeared to be an additional burden. Although a few of the women had spoken of a good husband as someone who would be able to provide safety and goods for them, none of the women currently had this form of support. For the younger women, not having parents was reported as a difficulty. Ana said “The family died. I live orphan. The mother died. I have nobody in Sudan. So I come here.” Almost all of the thirty women reported that some of their family members had died, and a few of them specifically said they were orphans. Most of them reported they were also in the camps without having other relatives there with them, other than their own dependents. Yar said “I struggle alone. No friends. No neighbors. Nobody else.” Not having any family other than their own children appeared to be difficult for many women; many did not speak of having social support, but instead spoke of being or struggling alone. As Elizabeth said, “everyone has their own problems.” The women all appeared to feel so overwhelmed with their problems that they were unable to provide any support for others, not even the other women around them with similar problems. According to their own words, at times many appear to feel helpless. As Mariel said, “I am helpless. There is no one who can help.” Hannah agreed, saying “I usually sit alone with myself and no one can help me.” Yar summarized what the rest of the women expressed, saying “everybody keep her own life. You get water, you selling water, cook for yourself, you sleep 61 alone. Everybody looking for her life…struggle, her life.” The women expressed words that seemed to imply feelings of isolation even in the midst of a crowded camp. Coping Strategies- Religious and spiritual beliefs The overwhelming majority of the thirty women discussed turning to beliefs in God to cope with their situations, similarly to what has been found in studies on other refugee populations (Grant-Knight, Geltman and Ellis, 2009; Khawaja et al., 2008; Matheson, Jorden and Anisman, 2008). While friends and family members often were reportedly not able to provide physical or emotional support, many of these women said that they were able to find at least some emotional support from their religious beliefs. The women said they often relied on believing that God knew their situation and could help them by eventually changing it. Mary stated that, “He will help us too, because God is the one who created us.” Karen made a very similar statement, saying “God is the one who create and is the one who can help us.” Susan said, “I’m under God’s hand.” Elizabeth also said, “We believe in God for those difficulties to take them away.” She continued and spoke of God knowing their situations, saying “Only God will know what has been done to you…everything has been arranged by God. So God is the one who knows what has happened at the time.” Other women spoke of their belief in God assisting directly with negative emotions, such as when Elizabeth stated, “I pray to God and I say to myself, to leave that sadness.” Mary said, “I used to pray to God to wipe those bad things away from me.” Jennifer said, “The emotion is inside. I pray to God to change that emotion.” She continued by saying, “If I have those emotions I used to pray to God.” These women were expressing their lack of other sources to turn to with negative or difficult emotions. God and the church seems to be the only place they felt they could turn to. 62 The belief that God knows and could change their future seemed to bring them hope. Susan also said, “While I live here I hope with God…I think that one day, one time, God will change my everything. That is my hope.” Elizabeth also expressed this hope, saying she had “hope in God that everything will go that better thing will come.” Hazel said, “It is only God if I used to pray the one who can help my life.” Similarly, Delilah said, “If you believe in God it will change.” The older women in the 20 years and above age groups especially did not seem have other things to turn to in the hopes that their situations would change- they reported that their beliefs in God were the main form of what they thought could change their lives. Two of the thirty women expressed their fears and doubts that God would help themoften just after expressing a hope that he would. Lulu said first that she “will be strong in sight of God”, but followed this statement with the “problem he can let me down.” Janet also said she didn’t know “whether God can help.” The idea that God was able to do anything to change their situation was not universal and there were times the women feared no one, including God, would be able to bring about any change in their lives. While the majority they hoped that their lives might someday be better, at times some of the women expressed doubt that God would help bring that change to their lives. Many women also spoke of God as the one who gave them strength. Debora said “if God has not killed me, make me strong.” Yar stated that God is the “One making me strong, who can make me believe everything and with me I’m strong.” Susan made several statements, saying that “I stay with one God who was created me. I will be strong in life.” Jennifer discussed her belief in God and that he “give me the strongness and even He also protects me from the hurtness, hardships I have had.” These women seemed to feel that God could give them strength to cope with their situations, even if there were no changes. 63 When talking about their belief in God and about who has helped them or given them advice, several women discussed receiving support from within the church. Many of the women seemed to feel that there were few others in the community to whom they were able to turn for advice. For example, Mariel did not relay that she felt she had anyone to talk to. She said that when she feels sad, “there is no one…to advise me. So, if I feel that emotion…used to read the Bible.” Other women reported that they found support not just through the Bible but through the people in the church. Mayek said “in the church they can advise each other,” showing that in some situations there were other people they could turn to for emotional support. Sarah spoke of going to the elders, saying that they “used to talk and give advice and God is there and can help you in your situation.” Karen also spoke of how she “used to go to church and could get advice from the church.” Although the church did not seem to offer much support, especially not the physical support the women often seemed to desire, it was sometimes able to provide a small amount of emotional support through its members and leaders through the reported visits and talks with elders. Coping Strategies- Hope in Education Similar to the studies found with other refugee populations, there was a segment of the population involved in this research study who also found some hope for their future through education. The 18-19 year old age category (n=10) was made up primarily of unmarried young women who were either still in school or verbalized that they desperately wanted to return to school. The women in school expressed a hope that through school their lives could be different. Magdalena said “Only God will know what happen in life, so I used to pray my God to give me knowledge, then that knowledge can solve everything.” Hannah said that “if I finish my 64 education maybe at that time it can change life…if I get a job I can.” Salima agreed, “If I get an education it can change my life.” Norah also appeared to shared this hope, saying, “If I get knowledge I can help somebody and I can help myself.” Magdalena said, “If I get education and then get employed. I will get money and then life will be changed.” Bethany agreed that with this education she would be able to help others, saying “If you get knowledge…if you get job, then you should give your knowledge to other people, and you can help those people, and it can help me with the money I will get.” Many of these young women seemed to believe that education would lead to future employment, and that the money from the job would change the situations that both they and their families face. The women in this group who were not attending school expressed a strong desire to return, such as Alek who said, “I want to go back to school…if I finish school I will get good life. We can’t survive anymore [like this].” The older age categories of women did not appear to have a hope that going to school could change their lives; many of them had never attended school before. One woman with seven children stated, “Even now I feel like go to school”. Although she was not able to attend school, she appeared to have some hope that perhaps her children might be able to, but worried about that possibility. She said about her children “if they go to school they will get a better life, but now they don’t go to school maybe they will be poor or end up survive like me…if the children cannot go to school, how can my life change?” Another woman agreed, saying “the only important thing is children need school fees.” The women expressed a need for many things, but what was asked for the most often (other than the need for physical items such as food) was assistance providing for an education for themselves or their children. 65 Coping Strategies- Formal supports Formal support is one additional area outside of the persons’ daily life that has been found to be important at times in general coping literature as well as discussed in literature around refugees (Robertson et al., 2006). Formal supports may include medical clinics, mental health clinics, social workers, or other agencies and workers that provide a service in exchange for payment. Formal support services are not often discussed directly in the literature; however, there are some instances where these supports are discussed as being helpful by the refugees (Robertson et al., 2006). As this is an area that social work and other forms of direct service may directly impact (by providing these formal supports, including in schools, camps and refugee centers), this researcher included this category in the study to determine if refugees are being assisted in this manner. The primary form of support discussed by 29 research participants and utilized by all 30 was the United Nations High Commissioner for Refugees (UNHCR). This formal support was reported as being used almost entirely for physical needs. When discussing how the UNHCR has helped them, almost all of the women listed physical items such as various forms of food, supplies for building a house, blankets, mats and cooking pans. Some women appeared grateful. Mary stated, “in Kakuma and my life is good. I will stay with the UN here.” Similarly, Janet said, “if I was still in Sudan, maybe I was dead with the children and husband. Now UNHCR is here and helping me a lot.” Some women discussed the UNHCR as their main source of support, such as Teresa, who stated, “I am under UNHCR- I am orphan, there is no father and no mother.” Others, such as Julie, noted feeling that the UNHCR was helpful for physical protection and security, saying, “Since UN is here, it is not as bad. I am safe.” 66 The overwhelming majority of the women stated that the UNHCR was very involved in providing for food and shelter for them. Although not all of the women had been provided shelter, they were each vocal about the assistance they did or did not get in this area. Thirteen of the women specifically shared that they did receive food and shelter directly from the UNHCR, as Mariel stated that the “UN people gave us food, the house, even those plate for eating.” Mary shared that the “UN distributed a house, blanket”, and Jennifer said “the UN people give me, help me with the house and the food.” Other women stated they did not receive shelter, and appeared unhappy with this gap. One woman, Ana, stated that she “built house alone. Only food, the UN help.” Another stated she had “nobody to support me, nobody for my help. When the rain falls there is no house for the children to stay.” While some of these women for whom the UNHCR did not help with a house reported that they were able to stay with neighbors or relatives, others were without shelter and slept outside. It is not known why some women received assistance for shelter and others did not. The primary complaint from the women, and a major theme throughout all the discussions, was that there was not enough help. There was especially high number of complaints regarding the amount of food that was given to the women by the UNHCR (note: not all services ascribed by the women as being provided by the UNHCR were provided by this program- other programs such as the United Nations World Food Programme were also involved but not recognized as independent programs). Janet stated, “You get food, but nothing else. Not enough for that month.” Naam said, “They can distribute by 15 days, but that sometimes food is not enough. It is too small.” Salima agreed in saying, “it is not enough for us. Some days are going without food.” Magdalena also stated, “The food is not enough for the days.” This lack of food was a major concern for the women. Women who had more children reported being given 67 a larger ration of food; however, none of them reported having enough food. This overriding concern is possibly a factor that kept the women from focusing on other forms of support in their discussions. Although a few of them did make the previous comments noted about how it was helpful being under the UNHCR, they were primarily referring to the physical items that were provided for them by this program. No forms of emotional or other support were discussed by the women in relation to the UNHCR. The women were also asked questions regarding other forms of formal support, specifically about hospitals and counseling centers, both of which are present in the camp. About a third of the women shared that they had utilized the hospital for medical issues, especially relating to the birth of a baby. Three or four women with small children who were ill had taken their children to the feeding center at the hospital. Some did feel that the hospital was able to assist, such as Rebecca, who said that “if I feel sick I can go to the hospital for help”. However, similar to other areas of physical need, they often stated that what they received at the hospital was not enough. Sarah stated, “If you go there, there is not enough medicine to take the disease away from your body of your life… maybe they go and give her the pills. It is a reliever. Does not take it away.” Dina simply stated “they don’t help”. Although only about a third of the women utilized the hospital for some form of assistance, there appeared to be a high level of dissatisfaction with the medicine and treatment received from the hospital from those who had utilized the services. The area of formal support available within the camp to assist with emotional support is the counseling centers. There are several counseling centers in the camp; few of the women had utilized this form of support. Of the women interviewed in this study, only three said that she had gone to the counseling center for advice and support. Ana said it was not helpful, and that the 68 translators were not very good so she didn’t know what they did. Another woman, Mary, went one time, and that they did help by “advis[ing] me how to manage the family.” The third woman, Sarah, appeared to have the most in depth relationship with the counseling center. She stated that she went to the center because she was very worried about a child that had been kidnapped from her. She said that the center did help and that they “used to talk and give advice and God is there and can help you in your situation.” She said that although the counseling was helpful, she stated she does not go now because her problem had been solved- the kidnapped child had been returned to her care. The three women discussed varying levels of satisfaction and support from the counseling centers they attending. Other women appeared to have varying levels of knowledge that this program was available. Elizabeth stated, “I have not had time for counseling… [even] I have been able to attend to counseling; I did not even think there was a place for counseling. You cannot even think it.” Even for women who were aware of the service, the thought of utilizing it did not seem to always be present. Mariah said, “I have heard about the counseling, but I have not gone one day. I used to stay inside my house, but there is nobody to advise me”. With only three of the thirty women using counseling services in the camp, and only one of those appearing to believe it was a helpful form of support, this does not appear to be a major form of emotional support for the women. Discussion The analysis of the interviews with these research participants revealed three major sets of coping strategies: occasionally depending on other women or family members for both physical and emotional support; a belief in God or hope in education for change in their future lives; and depending on camp structures such as the UNHCR for physical needs. Unfortunately, 69 several of these areas were focused primarily on dealing with physical needs such as food, shelter and medical care. Similar to what is seen in Maslow’s work, where the “physiological needs, when unsatisfied, dominate the organism, pressing all capacities into their service” (1954, p. 107), the refugee women’s focus seemed to be on the physical needs such as food, water, and shelter. While the main goal of this study was to determine emotional supports, the overwhelming focus of the participants on physical needs shows that this is an area of great need. While social workers and other may desire to assist with problems relating to mental health, additional assistance relating to physical needs may need to be addressed prior to other forms of assistance. Another result from this study was how little the women appeared to feel they received sufficient support from the other women in the camp, or from family, friends and neighbors. Numerous statements were made by the women about feeling alone and that everyone had their own struggles, so it was not helpful to share them with others, is quite discouraging. Simich, Beiser, Setward and Mwakarimba (2005) discuss the many functions of social support, which included “reducing stress, maintaining health, and achieving eventual self- sufficiency and well being…social support helps individuals cope with stress during crisis situations and reinforces the self- confidence needed to manage ongoing challenges critical to the adaptation process” (p. 260). These appeared to be areas that the women very much needed assistance in, and yet without the social support which is so crucial to this, the level of positive coping one would hope to find was not taking place- although they were able to cope on some levels, there did not appear to be many positive emotional coping strategies being reported by the women. The women presented as having difficulties in each of the areas described above: they reported not 70 having many (if any) people to support them, only four of the thirty reported their health as good, and they were generally not able to have the physical needs such as food met. An additional area of this study found a major difference between the older (20 and above, n=20) and younger (18 and 19 year olds, n=10) participants’ views, particularly around education and a hope for the future. Education plays an important role in coping in East African refugees resettled in the West (Bates et al., 2005; Bolea et al., 2003; Goodman, 2004; Tripping et al, 2007). However, no literature was found supporting the strong desire for education in the women within the refugee camp, which was found to be present in all of the younger women interviewed. This was also the major difference found in the different segments of the population interviewed in this study. The women who were 20 years old and above generally had children and had been married. When they spoke of coping strategies in the area of hope for a change in the future, most of them referred to a hope that God would change their situation, or of a dependence on outside formal sources. About 10% of these women brought up the possibility of education for their children, but did not appear to believe that education for themselves was possible. However, the youngest category interviewed for this study, the 18 and 19 year old women, were generally were not yet married and most had no children, or only had one child. Although only one of the ten women in this age category had even begun secondary school, the desire to continue their education and the hope that this would change their lives seemed to be strong. They stated that with knowledge (from schooling) they hoped to be able to find employment, and a few of the young women even spoke of helping others by obtaining this. This was the only mention within the interviews of being able to help other refugees- in all other cases, the focus of help was entirely on needing it, not giving it. The ability of these young women to look beyond their own situation to the needs of others through their hope of education 71 should not be overlooked, and shows how important education may be for refugee women in the camps. There are some major differences in the coping strategies notes by the women in this study and the strategies noted in the literature of East African refugee coping strategies. The majority of the literature on this population is concentrated on refugees who have been resettled into a third, primarily Western, country (Bates et al., 2005; Bolea et al., 2003; Goodman, 2004; Grant- Knight et al., 2009; Halcón et al, 2004; Jorden et al., 2009; Khawaja et al., 2008; Luster et al., 2009; Matheson et al., 2008; Robertson et al., 2006; Schweitzer et al., 2007; Stoll and Johnson, 2007; Tankink & Richters, 2007; and Tipping et al., 2007). In this literature (including East African refugees still in Africa), the main coping strategies noted included several areas that were seen in these women, particularly the large role of social support from family and others in the community, the role of faith or religion and education in giving the women hope, and formal supports through the camp structure (Bates et al., 2005; Bolea et al., 2003; Grant- Knight et al., 2009; Jeppsson & Hjern, 2005; Jorden et al., 2009; Khawaja et al., 2008; Luster et al., 2009; Matheson et al., 2008; Paardekooper et al., 1999; Pavlish, 2005; Roberston et al., 2006; Schweitzer et al., 2007; Stoll and Johnson, 2007; Tipping et al., 2007). However, there were also areas in the literature that were not noted in the refugee women in this study. There are no references from the women interviewed on the areas of personality traits such as the ability to be patient and have self control (Farwell, 2001) or strength and endurance (Bolea et al., 2003). The women also did not discuss any attempts to make meaning out of the events (cognitive reframing such as is seen in Farewell, 2004; Goodman, 2004; Jeppsson & Hjern, 2005; Luster, Qin, Bates, Johnson & Rana, 2009; Tankink & Richters, 2007; Tipping, Bretherton & Kaplan, 2007). Although the women at times discussed emotion focused coping strategies that do not change the 72 meaning of the event (Lazarus & Folkman, 1984) such as activities they participated in to assist in coping like praying or talking to relative, this was rare and only occurred indirectly, not as a main discussion point. These gaps or differences in the literature and the results from this study could be explained in several ways. It is possible that the women in this study, as they are a different population from most of the literature due to the fact that they continue to reside in a camp close to their home country, may actually have different coping strategies. For example, in a resettlement country, a refugee might be able to depend on the government assistance system to ensure that even the low- income have food. However, in a refugee camp where not enough food is provided, might rely more on the belief that one day God will improve their lives and they will have food to cope with the struggles of the day. However, this is difficult to conclude from one study with such a small sample. In order to explore this possibility, further research would be needed. It is more likely that the research instrument and language challenges in the study limited the ability of the researcher to capture these areas of discussion on way to cope from the women in this specific study. Meaning making (or cognitive reframing) is an area that may be present in the women in this study. However, due to language challenges, this higher level area of discussion was difficult to capture. Although one of the instrument’s questions attempted to specifically explore this information (specifically question #16: have these beliefs changed over time in a way that helps you in your current life situation?), either the question itself or the translation of it appeared to be difficult for the women, who were unable to directly discuss it in the interviews. A study that attempts to more specifically address this particular area of coping could assist in learning more in this area. Additionally, this study focused on what was reported by the women- there was no observation of actual methods of coping. An in73 depth observational study may uncover different strategies than the reported coping strategies. This may also be contributed to the researcher’s short time in the camp setting and lack of opportunity to spend time gaining the women’s trust. The women may have seen the researcher as a person to whom the “correct” answer should be given, or as a part of the UNHCR system. In this case, they may have reported little assistance in particular areas hoping that this would bring additional services to their homes. This study is able to provide several important insights into the lives of refugee women in the camps and their ability to cope with their past and current situations. The first is that while the women have undoubtedly suffered past traumas, their current life situations seem to be of a greater day to day difficulty. Focusing on the daily needs of food and shelter often appeared to be their primary concern, based on their report. Some of the women shared in brief about events that had happened to them in the past such as being bombed or chased out of town by the “Arabs”. However the women spoke much more often and in greater depth about items such as the lack of food that is given to them in the camp. They spoke often of food and shelter lacking or being inadequate. The discussions were focused more regularly on the physical needs such as these than on emotions needs as well, which was not expected as it was not the focus of the study questions, but was a more prevalent need in their lives. It is questionable whether these or other refugees would be able to focus on coping with their emotional difficulties when physical challenges were so strongly present. According to Maslow’s (1954) research, these lower needs dominate the focus of the individual until they are satisfied and allow the focus of the individual to move to higher level concerns. While social workers and others might wish to assist refugees with emotional issues, they should be aware of these physical needs and the barrier that they could cause in attempts to provide any form of treatment or assistance in the camp. A woman 74 might not be interested in speaking with a counselor if they have the possibility of carrying water for someone to earn enough money for some food for their children. They might also be too exhausted and hungry from the lack of food and/ or shelter to be willing to speak with a counselor and explore these other areas of need. The resources that counselors might suggest to women to strengthen might also be lacking in the women in the refugee camps. One strengthbased recommendation that counselors might offer women they are working with is to increase their social support from family members or friends. However, the women in this study spoke often of “being alone” and that others were unable to help them, as other women are also in the same situation as they are and also do not have resources to provide. Going to a neighbor for food is unlikely to be a possibility when the neighbor is also not provided with enough food for their family, although they are not in competition for food, as each family is given an allotment from UNHCR depending on the number of people in the family. Interventions that focus on a community level, or on interventions that may improve the physical needs of groups of women, may be an appopriate form of activity. These difficulties would change some of the methods that social workers or counselors would offer to the women when working with them in the camps. Limitations While this study is rare in that it centered on the actual narrative words and experiences of Sudanese refugee women still residing in Kakuma Refugee Camp in Kenya, it should be noted that there are a variety of limitations to the study which may have interfered in the study results. Although these limitations were addressed as much as possible by the author, they still present challenges in the data. 75 A primary limitation is the non- random sample utilized by the research. Although a random sample would have been preferred, the camp authorities did not allow access to a complete list of Sudanese refugees in the camp that could be utilized for randomization. The researcher attempted to work within several different sections of the camp to obtain information that was not related to one neighborhood or area. Three different methods were utilized for obtaining the sample: requesting that the Sudanese leaders in the community direct the researcher towards women who might be willing to be interviewed, locating one women related to a women from the pilot study in Grand Rapids, MI, and snowball sampling from those women. An additional main difficulty revolves around language. The author is an English speaker with some Swahili skills. However, the primary language of the participants was Dinka. Finding a Dinka interpreter with an appropriate level of English skills was a difficulty, although several were located through the UN and through the Sudanese communities. While the survey instrument was translated from English to Dinka, at times Swahili was utilized to help explain the research questions to the interpreters when there was possible misunderstanding. However, due to the level of the interpreters’ English skills, it is highly likely that there were misunderstandings between the participants and the researcher. While some questions appeared to translate fairly easily, such as “Who has supported you or assisted you since you came to Kakuma?”, others seemed more difficult for the interpreters and participants to understand, such as “What has influenced your life so far?” and “Have these beliefs changed over time in a way that helps you in your current life situation?” These difficulties in language undoubtedly had an impact on the results of these higher level or more abstract questions. The use of the pilot study to attempt to find language or cultural challenges and the use of both English and Swahili with 76 the interpreters attempted to eliminate as much of this difficulty as possible, however language differences are difficult to overcome. The use and design of an original questionnaire for the study may also have its own limitations. While the instrument was based in current research, it was not used in any study previous to this one so it could not be validated as gathering the information it intended to. The instrument was pilot tested with five Sudanese refugee women from the Dinka sub-group in the United States before it was finalized. The women had some level of English, however an interpreter from within the group was utilized. The study was explained to the women and the questions from the instrument asked just as they would be to the same group in Kenya. The women did not have any changes to suggest to the instrument after going through this process, so the instrument was then finalized. While it is hoped this may have removed some of the possible errors or misunderstandings, it is possible that they remained. Upon later reflection of the instrument, the structure of it may also have caused difficulties, as it begins with questions that could be emotionally difficult and did not being with safer warm up questions. The number of questions in the instrument might also be higher than would be preferred. The position as researcher may have caused additional limitations to this study. This researcher was only able to stay in the refugee camp for a limited time, which did not allow for the building of rapport previous to interviews. Due to this, it is possible that the participants may not have felt comfortable sharing their thoughts in some areas with the researcher. This also did not allow for the researcher to observe participants’ actions, but relied solely on their own report of activities and needs. Additionally, the participants may have viewed the researcher as someone who could provide food or other concrete forms of assistance, although this was explained not to be the case at the beginning of each session. However, the possible belief of the 77 participants that the researcher could either directly provide assistance or could inform those who could give assistance of their requests is a real possibility and challenge. A last area which may limit the results of the study is simply culture. The researcher and participants come from very different cultures with different ways of looking at the world. For example, several of the women reported their personal experience with a reportedly common practice of being married off to the brother of their husband if their husband had died. Questions and answers may have varying cultural meanings that the other side was unaware of. While there are no known differences in this area that would have an impact on the study, it must be brought up as a possibility. Although this study had multiple limitations, it is believed that there are also a good number of strengths in the study. Creswell (2003) states that pilot testing is “important to establish the content validity of an instrument and to improve questions, format, and the scales. Indicate the number of people who will test the instrument and the plans to incorporate their comments into final instrument revisions” (p. 158). This study included from the beginning a plan to interview Sudanese refugees who were currently living in the United States to test the instrument. Five women were interviewed, which is over 15% of the final number of interviewees. While it was expected to make changes in the instrument based on the feedback of the women, they did not have any changes to suggest. Their feedback appeared to indicate the instrument was able to be utilized as it was written. In order to address language difficulties, four years of Swahili, the major language of East Africa, was studied by the author. This language study became useful with the translators in order to better assist in their understanding of the English questions in order to translate into Dinka, the language of the women interviewed. One younger woman was able to complete the 78 interview in English, and also appeared to understand the questions as well as when they were interpreted into Dinka. The interpreters utilized were located through the leaders in the Sudanese community and later through the United Nations itself, which indicates they were likely the most reliable interpreters available. This study is also positive in that it relied on going into the refugee camp and recording the words of the refugee women themselves, although through the translators. As noted in the literature section, few studies have focused specifically on the words of refugee women, or women currently living in the camp setting. These strengths were the primary motivation for completing the research in this manner, in order to contribute to the small body of knowledge regarding refugee women living in refugee camps near their home countries. Conclusion and Recommendations The findings from this study show that while Sudanese refugee women in the Kakuma Refugee Camp of Kenya do have some coping strategies, they appear to be in fact quite limited. Many of the women appear to be so concerned with physical survival that emotional coping is not a major point of discussion, which is understandable due to the severe and long term conditions of their lives. A focus on the physical needs of the women in the camp needs to be a priority, in addition to the methods of addressing emotional needs. Due to the large numbers of women in the refugee camps in East Africa as well as in other parts of the world, a focus on group or community based interventions may be a preferred method of reaching as many women as possible. The primary coping strategies used by the Sudanese refugee women in this study in Kakuma were similar to strategies used by other refugees, as seen in other studies. The strategies 79 they employed were centered upon religious and other beliefs about the future and dependence upon other formal and informal supports, primarily for physical needs. Some forms of coping strategies, such as cognitive reframing, were not seen in this study- possibly a result of language barriers or even design flaws in the study instrument, such as a disconnect in cultural ideas that was not captured and fixed in the pilot study. While these strategies may have been present, they were not found in the words of the women and thus not one of the findings of the study. Due to these conditions and findings, it is recommended by this researcher that several changes could improve the lives of these women in the area of practice. A primary recommendation would be the increase of physical support of items such as food, shelter and firewood, so that the women would not require so much energy to be put into these areas; many women spoke of the need for an increase in food – both amount and variety. In addition, many women appeared to be either without their own form of shelter or had very poor conditions within their shelters, for example, many roofs had rusted through and now allowed the rain to come in. Based on Maslow’s theories, these types of physical needs should be addressed first. After these needs are met, the attention could then be focused on forming more opportunities to increase emotional coping strategies. Several ways this might be done include an increase in numbers of counseling centers and counselors, additional outreach from the counseling centers into the community to reach a higher number of women, an increase of women’s groups or activities- especially if these activities can also provide the possibility of financial assistance such as in a craft program or microfinance business program- or increased support from the church, as many of the women already relied on faith as an important coping strategy. Some authors have suggested group based activities or community interventions, which would likely work well in this setting (Sossou, 2006). Trauma education or other topics included 80 in psychoeducational settings to groups of people could better allow entire communities to have increased understanding of mental health challenges, and how to assist friends, family, or neighbors who show these types of symptoms. Feminist practice, which would encourage women to take part in organizing their own forms of mental health systems, are also recommended to assist women in feeling they have gained a measure of control over their lives (Sossou, 2006). In a study completed with refugees in the United States, transferring advocacy skills to refugees for work within their own community decreased the distress in the participants (Goodkind, 2005). Thus allowing refugees to be involved in the formation of treatment programs for their own community may be helpful in their long term coping. Empowerment techniques are also suggested by Herbst (1992) to assist them in regaining a sense of power. Herbst suggests empowering refugees through the use of oral histories, which enhances the participant’s self esteem and can help them see their past trauma as only one part of their life experiences, implying that they are strong and survivors (1992). This could be done by encouraging women to meet in groups, possibly at a church or community center, and having their share their stories over a series of sessions. Aron (1992) suggests a similar form of activity, a “testimony”, which also allows the person to view their history of trauma in the context of a social and political therapy. These types of activity is positive in that is reaches groups of people at a time, and encourages empowerment, which may allow refugee women to then reach out to others in their community. Employment opportunities for women could be an important practice area to explore. None of these women currently had a husband to assist in providing for the physical needs of the family. Four of the women were involved in casual employment, collecting water for Somali refugees. Other employment opportunities, such as micro-finance that might enable the women 81 to run a small business, could greatly improve their lives. They may be able to better meet the physical needs of the family through this work. Their safely might be increased as the activities could possibly contribute to limiting risky activities such as gathering firewood even with the possibility of sexual assault during collection. Increased security through finding alternatives to risky but often necessary activities could greatly improve the women’s lives. The women might also find hope, social connections, or other methods of positive coping from within the working environment. An additional area of practice that was actually requested by a number of the research participants is to increase the opportunities for education; many of the younger participants expressed a hope that education could lead to an improved life. Several of the older participants requested assistance in finding educational opportunities for their children, perhaps with the hope that this would enable the children to improve their future. Whether or not there are actual changes in their lives, having the hope for a better future could considerably increase the women’s coping ability. Assistance in providing for school fees would make a big difference in these women’s lives, as they might have the hope that their children’s lives would be different or that the children would have additional resources upon completion of school to help the rest of the family. Finding stakeholders from wealthier countries that could either assist in sponsoring children in the camp or even partnering with a school to provide increased educational opportunities would be ideal. For example, a classroom or school system from the United States could become involved in a classroom or with a student from the camp through a system of sponsorship. Employment opportunities for the children upon completion of school might also help in this area. 82 In order for these areas of practice to be implemented, policy changes relating to the refugee camps and the current systems of support would have to be made. The largest area of policy change would be funding. In order to implement these additional items, funding would need to be available to pay for increase food and other physical supports, education and employment opportunities. Ideally, these funds would be made available to the UNHCR as the main body that works within the camps. Funding would likely come from countries around the world, such as the already donating nations of Luxembourg, Norway, Sweden, Denmark, Ireland, Canada, the United States, and Australia (U.S. Committee for Refugees and Immigrants, 2009). An increase in the funds from these countries could give the UNHCR ability to implement these further items. Some smaller organizations do work within the camps, such as the Red Cross. Funds could also be made available to these organizations for specific parts of the work needed, such as increased education or employment opportunities. A redistribution of currently managed funds would also be a possibility. For example, if some funds were utilized to assist farmers in growing crops in the areas surrounding the camps (which would also require some policy changes by the host countries), then less money could be spent on food assistance. Some microfinance programs could focus on providing opportunities for women in the camps, especially if they were able to partner with a program already in the camp to assess needs and possible areas for the women to invest. These programs could focus on alternate fuel and cooking sources, gardening or food growing, craft projects, or obtaining or making hard to find but necessary items such as soap for washing clothing. Additional research into the area of coping strategies is also needed. This study is near the beginning of the process of examining coping strategies in a population within a refugee camp; however it is a small study and should be duplicated in multiple settings, and with larger 83 samples if possible. Examining the strategies of women is especially important due to their high numbers in the camps and the challenges they face. A greater understanding of the positive coping strategies that are helpful for this population would better enable workers in the field to attempt to provide additional assistance in the areas of strengths of the women. A selection of research recommendations would include additional qualitative research to explore the words and lives of refugee women in several settings. Additional studies should be done with the Sudanese population in Kakuma Refugee Camp and other refugee camps, especially as this is a large and long- standing refugee population. Larger sample sizes should be included. Ideally, researchers who are able to spend longer periods of time within the refugee camp and with the women in their daily lives would be included. Studies with refugee women in other parts of Africa and around the world should also be completed, with a focus on both their daily lives and needs and their methods of coping. Ideally, some of these studies would take place using the same instruments and comparing the experiences of women from different people groups and different parts of the world. Building the body of knowledge regarding women and their coping within the refugee camp system will allow researchers and practitioners to better support the women and their needs. 84 REFERENCES 85 References Al Gasseer, N., Dresden, E., Keeney, G., & Warren, N. (2004). Status of women and infants in complex humanitarian emergencies. Journal of Midwifery & Women’s Health, 49 (suppl 1), 7 - 13. doi: 10.1016j.jmwh.2004.05.001 Aron, A. (1992). 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World refugee survey 2009. Arlington, VA: U.S. Committee for Refugees and Immigrants. 89 CHAPTER FOUR System of Structural Dependency in the Sudanese Refugee Women of Kakuma Refugee Camp, Kenya. Abstract Thirty Sudanese women currently living in Kakuma Refugee Camp, Kenya were interviewed regarding their coping strategies in May 2011. One of the themes that emerged from the of the qualitative data analysis was the issue of structural dependency. Due to the structure of the refugee camps, the long term waiting for a solution, and the disruption of cultural and social structures, refugees often end up becoming dependent on the physical assistance from the United Nations High Commissioner for Refugees and other aid groups for their survival in both the short and long term camp setting. It is recommended that shortening the time in camps, allowing additional methods of independence actions, and the empowerment of refugees within the camp system might help alleviate these difficulties. 90 Introduction Many refugee groups spend long periods of time- often ten, twenty, or more years- in refugee camps, a situation often known as warehousing. These refugees are unable to return to their home country due to ongoing safety concerns or political situations, and a permanent solution (such as resettlement, repatriation or local integration) has not been found for them. Palestinians have the longest warehousing situation, continuing for over 60 years at this time (U.S. Committee for Refugees and Immigrants, 2009). There are also Sudanese populations who have been warehoused in Uganda, Kenya, Ethiopia, Egypt and other counties for 25 years or more. Sudan has been a source of refugee flows since the mid 1950s, when many fled to escape the civil war between the Government of Sudan and southern rebel forces (Karunakara et al., 2004). A particularly large refugee flow was formed in 1986, when tens of thousands of young boys (as well as adults and young girls) were forced to flee from southern Sudan into Ethiopia, and were expelled into Kenya in 1991 (Jeppsson and Hjern, 2005), and have lived there, especially in Kakuma Refugee Camp which was established specifically due to this large group of refugees, ever since- currently for about 25 years. Long term life in refugee camps has its own consequences, as adults adjust to the system of survival available in camps, and as entire youth populations grow up in camps. In Kakuma as in other refugee camps, the host country does not allow refugees to integrate into the local society but requires them to stay within the confines of the camp and under UNHRC maintenance (Jansen, 2008). As seen in the previous chapters, women in particular have special circumstances that may differ from other refugee populations and need to be further explored in research in the camps and refugee hosting countries, especially in these long term settings. 91 Literature Review Structural Dependency Refugee camps form a unique society. Specifically, the idea that refugee camps are only temporary creates an unusual system. As Agier (2008) labels it, what is created is a permanent precariousness as an emergency situation gives way to a long term situation. The camp becomes a situation where “models of uncertainty” exist, as “spaces and populations are administered in the mode of emergency and exception…a camp is an emergency intervention that has been on ‘stand-by’ for months or years: five to ten years, or even more” (p. 72). When people flee to these camps, the idea and hope is often that it will be for a short time, and then they will be able to return home. While in the camp, certain items are provided by the UNHCR and other relief programs that will assist in keeping the person alive and safe; food, shelter, a police force. What is not generally provided is a manner for which the person to support legally themselves. While a person resides in a refugee camp, they usually have few rights or opportunities. Many host country governments follow a policy similar to the one explored by Kibreab (1993) where there is a “reluctance to allow refugees to settle in projects that would hae allowed selfsufficiency….[as a] continuation of its policy of institutionalizing the camps” (p. 324). Host countries have a variety of reasons to desire to contain refugees in this system, including the examples given by Kibreab of keeping pressure on the international community to bring aid into the country (1993). In general, refugees have “no right to move freely or work in the countries” where they reside in the refugee camps (Agier, 2008, p. 81). With these restrictions, refugees are forced to legally be able to utilize only what is given to them by aide programs or other refugees, or on rare occasions sent to them from family members outside the camp system. The society 92 created by this long term temporary situation has several major parts that form dependency in its inhabitants. Refugee camps undoubtedly change the traditional forms of relationships that are found in the refugees’ home communities, and these shifts also contribute to the dependency that is formed within the camp system. It is noted that “participation and membership in family groups, social networks, or other social structures also significantly benefit people’s well being” (McMichael and Manderson, 2004, p. 89). Not having the social network that the women previously may have had in their home countries can be a challenge in many areas of life, from finding ways to provide for basic needs to having a support system for emotional needs. The refugee women’s well being can be perilous without this support. Farwell notes in her study of Eritrean youth in Sudan that “family also constituted a structure within which the participants derived emotional and psychological sustenance” (2001, p. 55). The more connections a refugee can have with family members or even friends from their home culture, the more likely positive adjustment within the camp or resettlement structures is. Unfortunately, having a lack in these relationships can have negative impacts on the refugee individuals. As Jorden et al. discusses with Somali refugees, there is a “sense of interdependence wherein they recognized that their survival depended on their ability to rely on one another” and for many, the “most devastating aspect of their experience was their continued separation from family” (2009, p. 869). Much of the research on coping strategies showed the importance of relationships in coping (Bates et al, 2005; Farwell, 2001; Jeppsson & Hjern, 2005; Jorden, Matheson & Anisman, 2009; Khawaja et al, 2008; Paardekooper, de Jong & Hermanns, 1999). Refugee women have many specific needs that may differ from refugee men or children. There has been a lack of research in the past focusing solely on this population (Pavlish, 2005) 93 and on the long term impact of living in a refugee camp, and this research has been one attempt to build knowledge and contribute to the little that is known about the group. For example, refugee women often face violence in the camp setting due to the daily tasks of caring for their families, such as carrying firewood to cook food (Harris, 1996). Facing this type of struggle for decades may cause refugee women to have different coping strategies or dependency issues. Due to these problems, refugee women may have a different narrative than refugee men or refugee women while in the refugee camp setting. Purpose The original purpose of this study was to explore the coping strategies and available resources of the Sudanese refugee women who continued to reside in a refugee camp in Kenya. The primary questions for the study focused on coping strategies and were the basis for the instrument written by this author and used for the research study. Results focusing on coping are reported in a previous chapter. However, additional results outside of the original purpose were revealed during data analysis, and are reported in this article. In particular, a theme around dependency of refugee women on the camp system became prominent and was then explored through further analysis of the women’s words in the interviews and then triangulated by reviewing additional literature related to this theme. Method Design A qualitative structured interview questionnaire based on a review of coping literature with nineteen open ended questions and a collection of demographics was designed by the author 94 for use in this study to examine coping strategies (See Appendix C). This guide included questions based on the major themes of coping seen in the literature, such as “how have friends supported you or assisted you since you came to Kakuma?” and “Do you have any religious beliefs regarding your current living situation? If yes, what are they?” This specific population was chosen due to the connections (to the African Mental Health Foundation) and language skills (Swahili) of the researcher, with guidance from the partner agency in Kenya, and due to the large size of this population within one of the larger refugee camps in Africa. The coping strategies questionnaire was pilot tested with five Sudanese refugee women living in the United States before it was utilized with the women in Kenya, as suggested by Kreuger and Casey (2009) to increase validity. The five women who participated in the pilot study were all of Dinka origin, belonged to a local Christian church, were between 18 and 50 years old, and had between one and four children. Only one of the women spoke English well. They had been in the United States for a variety of years, but all less than eight years. Several of the women had previously lived in the same refugee camp in which the study took place. No changes were made to the instrument based on the pilot study participants’ approval of the format. In addition to the interviews with refugee women in Kakuma, informal interviews with three camp authorities, workers and interpreters took place and were recording in field notes to provide triangulation and context for the interviews. Selection of the Participants The participants of this study was narrowed to Sudanese refugee women in Kakuma Refugee Camp, Kenya, due to the language skills (Swahili) and local connections of the researcher to the Africa Mental Health Foundation, as well as the large size of Sudanese refugee 95 population. Kakuma Refugee Camp, where this study was completed, was established near the border of Kenya and Sudan in 1992 to accommodate these newer refugee flows, particularly from Southern Sudanese people groups. At the time of this study, the camp hosted approximately 80,000 people, about of third of who were from Sudan (Jeffery Savage, UNHCR Senior Protection Officer, Personal communication, May 8, 2011). A random sample was not determined for this study, as a complete list of Sudanese refugee women living in the camp was not possible to obtain. There were three methods of selection for this study: interpreters located women who were likely willing to participate; one woman was located who was a relative to one of the United States pilot study participants; the rest of the participants were located by referrals from the women who had already participated in the study in a snowball sample. The sample population for this study consisted of Sudanese refugee women 18 years old and over who were currently living within the Kakuma Refugee Camp in Kenya. While no attempt was made to select or de-select members of various ethnic groups within this community, all participants were from the Dinka language and people group, perhaps due to their large numbers and the interpreters’ affiliations. The Dinka people are the largest people group from South Sudan, with two million people and over five hundred sub-groups (Deng, 1972). The Dinka population makes up about half of the Sudanese in Kakuma Refugee Camp (Sindan, 2006). As this is one of the largest people groups from southern Sudan that have been impacted by the war and forced to relocate, this sample was reasonable for the study Part way through the study a decision was made to attempt to interview a number of women from the 18-19 year old age range, as this group of women appeared to have a different story and possibly different coping strategies than the older groups of women, particularly in the areas of education and hope for the future. 96 Data Collection The author obtained consent from Michigan State University’s Human Review Board as well as the Kenyan government and Kakuma camp administrators before the study was initiated. The Africa Mental Health Foundation partnered with the author of this study and assisted with permissions in Kenya. Upon arrival in Kenya, the researcher met with contacts from the African Mental Health Foundation (AMHF), one of whom then traveled with the researcher to Kakuma Refugee Camp and met with the camp authorities. After obtaining verbal permission and a stamp on the previously obtained letter of authorization to work in the camp, the researcher and staff member from the AMHF then sought out the leaders of one section of the Sudanese camp community and explained the study, requested their permission to work with members of the community, and enlisted their assistance in finding the interpreters. The staff member from AMHF did not participate in the interviews as he was a male and it was preferred to allow the women to speak with only other women present. The study interviews took place in May 2011 within several different Sudanese communities of Kakuma Refugee Camp. Participants were allowed to choose the site of the interview. The majority of the interviewees choose to be interviewed either in their own homes or in an outside location near their homes. Interviews were conducted in English with a Dinka translator. The interpreters spoke English, Dinka, and Swahili. The instrument questions were translated directly into Dinka by the interpreters after being asked in English by the researcher, with Swahili being utilized when the interpreters had questions about the English wording of questions. Each interview began with a description of the study and its purpose and risks to allow for informed consent, and obtained a signature and thumbprint from each participant as 97 required by the Kenyan government. Due to language and time restrictions, there was no inclusion of small talk at the onset of the interview, although it did occasionally take place at the end of the interview. The interviews lasted from 15 minutes to 45 minutes. Each interview consisted of asking each question from the interview protocol in the order of the protocol. At times, probes were used to give examples if the participants did not appear to understand the question. For example, the question “what kinds of assistance did they give you?” might be followed with probes or possible examples such as providing food, letting you stay at their house, or being someone to talk to or get advice from. There were time differences in the interviews themselves depending on how thoroughly each interviewee discussed the answers to the questions asked. Check back procedures similar to those described for interviews with focus groups by Kreuger and Casey (2009) were utilized in each interview. This source suggests that “when presenting the brief summary, the researchers should watch the participants for signs of agreement, hesitation, or confusion. When the 2- to 3- minute summary is completed, the moderator invites comments, amendments, or corrections” (p. 105). Similar to this procedure, a summary of the comments from each participant was read to her at the conclusion of the interview, and was requested to comment on the accuracy. Each participant was watched for body language or verbal cues that they may feel that there were inaccuracies in the summary which was included in the field notes, in additional to asking for verbal verification of the information. At the end of the interview, the participants were given an opportunity to ask questions and compensation for their time in a token package of goods that consisted of soap, matches and sanitary pads. 98 Data Analysis Each interview with the research participants was audio recorded. The interviews were transcribed verbatim by an outside source and then were all checked for accuracy by the author. It was noted that throughout the audio recordings it was sometimes difficult to understand the words of the English interpreters due to levels of noise and the accents of the interpreters, although approximately 95 to 98% of the time their words were clear enough to record in the written transcription. Due to the poor quality of the recordings of the original Sudanese women’s words in Dinka (the placement of the interpreters was closer to the recording microphone); a secondary transcription by a Dinka speaker of the participants’ words was not possible. All thirty interviews had enough of the data present to analyze. Field notes were written during the interview process for each of the interviews. These field notes included the location of the interview, descriptions of others present, the appearance of possible emotional responses to specific questions, the length of time of the interviews and any other information that appeared to be important to the researcher. These field notes were reviewed during the data analysis for possible triangulation with recorded data from interviews. Data analysis occurred by utilizing NVivo with a research assistant also analyzing a random 20% of the full interviews to check for coding discrepancies. A doctoral level specialist in social science qualitative research was also brought in as a consultant at several levels of the coding process to insure accurate technique. The research consultant assisting in utilizing NVivo, setting up the files correctly, reviewing the coding process once complete, and setting up the multiple levels of coding within NVivo. The Grounded Theory techniques of Glaser and Strauss (1967) were utilized as much as possible, as a “general method of comparative analysis” (p. 1). In this method, “categories are discovered by an examination of the data” (p. 3), and that 99 theories and hypotheses come out of the data through the process and course of the research. It is also important to discover theory through this method by “generating conceptual categories or their properties from evidence; then the evidence from which the category is emerged is used to illustrate the concept” (p. 23). Previous theory was reviewed from the literature and utilized to in formulating the interview questions in the interview protocol. Whereas in pure grounded theory there would be no previous use of theory or a semi- structured set of questions exploring specific areas of concern, when analyzing the data all previous theory was attempted to be set aside, so that only ideas directly generated by the data would remain in order to stay as close to Grounded Theory as possible. One method utilized to assist in this was the use of a second data analyst who was not familiar with the literature around coping strategies. The second date analyst coding full interviews and the codes were compared line by line with the first researcher until there was agreement in coding. This check attempted to ensure that the first researcher who was familiar with the background theory was not adding this theory to the words of the women interviewed unless it was present and seen by both researchers. According to the research consultant, specific percentages of coding agreement or inter-rater coding between the two researchers was not necessary as long as the information and coding was discussed until the appropriate code was agreed upon by both. Both open coding and axial coding was utilized as described by Strauss and Corbin (1990). During the first coding process, the open coding, “data are broken down into discrete parts...by breaking down and conceptualizing we mean taking apart a n observation, a sentence, a paragraph, and giving each discrete incident, idea, or event, a name, something that stands for or represents a phenomenon” (p. 62-63). In this section of coding, the words of the interviewees are used as much as possible, as Strauss and Corbin state it is important to have “phrases used by informants themselves” (1990, p. 69). For example, a woman might state that 100 “I cannot find enough food to feed my children”, and the code might be “not enough food.” Strauss and Corbin (1990) state that one may code line-by-line, by sentence or paragraph, or in an entire document. In this analysis, each sentence was coding separately, although some sentences may receive more than one code. The second half of the coding process is axial coding, in which the researcher “puts those data back together again in new ways by making connections between a category and it’s subcategories….our focus is on specifying a category in terms of the conditions that give rise to it” (Strauss and Corbin, 1990, p. 97). In the actual process of forming these axial codes, the researcher “alternates between the two modes” (p. 98) of open and axial coding. The hope is that working with these categories will allow the researcher to find a type of relationship between the words of the interviewees and a larger phenomenon. In the analysis for this project, multiple attempts were made to organize the open codes into categories of axial codes before the major themes were discovered. As in selective coding, this system was utilized to “integrate [the] categories to form a grounded theory”, (Strauss and Corbin, 1990, p. 116) or the two core categories or major themes found that are discussed within Chapters Three and Four. The line by line content was placed into axial codes to form these larger themes. Negative case analysis with a review for contradictory evidence was also used to discover if there were any cases in which one interviewee’s experience showed that not all women shared the general categories of these phenomenon. The field notes, informal interviews, and previous theory from the literature later provided triangulation for this analysis as they were reviewed for similarities and possible contradictory evidence. 101 Results A brief description of the participants’ characteristics will begin this section to give some outline of the women who were involved in this study (all names have been changed). The primary goal of this larger study was to examine the coping strategies of the women. However, as often takes place in qualitative research, a different theme emerged upon deeper analysis of the data. In this case, many of the women spoke of issues related to dependency on the camp structure, which became an important part of their story. A discussion of the results of this substudy will be discussed along with a set of recommendations based on what was learned in the camp will assist in the conclusion of the article. Participant Characteristics Thirty adult Sudanese refugee women who were living in Kakuma Refugee Camp at the time of the study were interviewed for the study. The participant’s ages ranged from 18 to approximately 50 (not all women were aware of their ages) and all were from Dinka people group or stated they were not a part of any ethnic group (via interpreters) but spoke the Dinka language. As the primary language spoken by this group was Dinka, Dinka speaking interpreters were used for the study. The questions for the interviews were translated from English into Dinka by the interpreters, with Swahili occasionally being utilized for clarification. Both English and Swahili languages were common to the researcher and the translators, although the interviewees rarely spoke Swahili. Thus the words of the interviewees in their original language (Dinka) were not understandable to the researcher. The translators were instructed to repeat the exact words of the interviewees. Twenty six of the interviewees described themselves as unemployed, while the remaining four stated they were self- employed, primarily in carrying 102 water from the well to the homes of other women, mostly from the Somali community. Fifteen of the women had some primary level education, one woman had begun secondary education and the rest of the women had no formal education. The majority of the women with several years of education were from the 18-19 year old age range. The majority of this youngest age group (n=10) had never been married and did not have children. The older age groups (n=20, age 20 and above) all reported being either widowed, divorced or separated, with only two participants stating she was currently married, and one of those was to the brother of her deceased first husband- a not uncommon practice in East Africa. The number of children the women had varied from zero to eight. Many of the women reported having children who had previously died or had lost other relatives. Dependency through Physical Assistance One of the major characteristics of refugee camps is the physical aide given to the residents. All of the refugee women in this study discussed the physical assistance they were given by United Nations High Commissioner for Refugees (note: the women often attributed all aide by agencies as coming from the United Nations, even if the assistance was actually from a related program such as the World Food Programme). There was a large dichotomy in the discussion by the women: while the UN was spoken of as the place that provided them with what they needed to survive, they also used language that indicated that they were not given all they felt they needed. Some of the women spoke of the UN in very close terms, saying “nobody else support me, but then they give me house. Apart from UN, they did not help”. Susan shared that the UN was the only person/ program helping her, “so I will be stay with UNHCR here.” She continued to say that “if I was still in Sudan, maybe [I would be] dead with the children and the 103 husband…UNHCR is here and helping me a lot.” Jennifer said that “the life… here with UNHCR it is good.” Julie also shared that “since UN is here it is not as bad… is safe.” Especially in the absence of family, the UN was often very important. Hannah said, “I am an orphan…want to stay with UNHCR.” Magdalena had a similar statement, that she was “under UNHCR… is orphan, there is no father and mother.” Mayek also shared that she felt “only UN is the father to [me] and the mother and the child.” It seemed to be common for the women to share the types of assistance UNHCR provided them. In general, the women spoke of help with food, shelter, and cooking utensils such as cooking pots. Mariel shared that “UN people gave them food, the house, even those plate for eating.” Hannah stated that “they have been distributed by UN, those plate of cooking, those of eating, blanket, and the food.” These were common descriptions of the types of assistance offered. This focus on items that meet basic physical needs may be due to the theory presented by Maslow (1954), in which lower needs such as food and shelter must be cared for before a person is able to move on to higher level needs, even those of safety or intimacy. However, the frustration with lacking items that they felt they needed often came out in the interviews as well. Yar stated, “they just give food. Maybe when it is coming fast…just give food and house, struggle alone. It is not proper. Latrines. Nothing for the toilet...for the house…” Another woman, Janet, shared “You get food, but nothing else. Not enough for that month. They just give maybe only for three day, four days. Four days”. Jennifer said that the “UN they used to for the food, house, blanket, clothes, plate, but they don’t distribute other things.” Mariel stated that it was “Not enough. It is not enough. Some days, maybe 5 days or 4 days they are stay without food”. The women presented as discouraged by the level of assistance provided. It was often enough to survive on, but barely. This theme may be partially 104 contributed to the researcher being seen as a part of the system that would be able to give them additional supplies, as will be discussed in a later section. Some women shared “there is no other help except UN”- even though they were frustrated, they had nowhere else to turn for assistance. While living in a refugee camp it can be very difficult to obtain even the simple items spoke of above, such as food, blankets, and cooking utensils though the allowed system. In the refugee camps the women appear to often have limited familial and community support, and often do not have the opportunity to grow their own food in the manner they were accustomed to in their home country. The opportunities for allowable employment seem to be severely limited for most Sudanese women in the camp. First of all, while in the camp, the women (as well as men) are not supposed to have legal employment, although there is a system within many camps of non- governmental organizations (NGOs) unofficially hiring refugees for certain positions (Agier, 2008). Secondly, most of these “unofficial” positions are for refugees with specific skills that are needed, such as teaching and language skills for interpretation (Agier, 2008, UNHCR interpreters, Personal communication, May 7, 2011). None of the women in this study had these types of qualifications. While four of the women in this study admitted to some self employment opportunities in carrying water to the homes of Somali women, this was not enough to provide for them or their families except in a very limited fashion. Lastly, while there are occasionally programs in refugee camps that assist women in creating opportunities through crafts, sewing or other services, none of these women from the study (and likely only a very small percent of the entire population due to their limited availability) were ever able to participate in these programs. Due to these factors, it seems that these women are almost entirely dependent on what the UN and other Non- Governmental 105 Organizations (NGOs) are able to give them- such as the food, blankets, and housing as discussed above. Dependency in Relationships As stated previously, several of the women earlier spoke of thinking of the UNHCR in very close relational terms, such as being the father and mother to one who is orphaned. Unfortunately, most of these women reported that they did not currently have family members to depend on. In a more traditional society, the Dinka (and other Sudanese) women are part of an extensive system involving extended families and networks. While many of the women either arrived with a family member or had some family in the camp, the deeper network appeared to have been broken and the system that was utilized at home was no longer functioning in the manner that is was previously. The family members that were mentioned by these women were often not discussed as a source of assistance for them, such as in one case where a woman came to the camp with her cousin who then left for Nairobi. She stated that her fear was that if the cousin returned to the camp, they would force her to leave the house she was currently living in, which ‘belonged’ to the cousin. One woman was here with her mother, but stated she was “alone, there is no, just my mother only and my mother is old, yes she grow old. And I am separate from the husband. They are divorce.” Another woman spoke of her mother as one who made life difficult and did not allow her to stay in the same house. She said, “You know, the first time I come and sleep, after that the mother chase me, after that helped by relative, another house relative, cousin.” Thus, the family that is in the camp presented as a difficulty, such as when the parent is not able to care for themselves, and they become a burden for the women instead of a support. Many of the refugee women had previously been married, but were now 106 separated or widowed and had multiple young children. In addition to the challenge of being a single mother needing to provide for her children in a location with little support, some women discussed having added social challenges due to their husband’s fate. Multiple women shared that their husbands had left them. One woman spoke of her husband only returning to force her to have sex with him, and then leaving again once she was pregnant. Another spoke of being forced by her uncle to marry another man for the dowry that is given to the family. In these cases the husbands did not appear to be providing for their families in the traditional Sudanese manner. Lacking the family support system that they may have previously utilized, these refugee women instead reported relying on the UNHCR and camp systems to take on many of their needs at a much higher level than they may have with additional supports. In addition, the relationships with family members both within the camp system and may have been altered, as the women stated multiple times that they were no longer able to trust that family or others who would have likely helped them in their home situations will still be a source of assistance. Time Factors and Hope An additional set of factors plays into the levels of hopelessness that the women often spoke of, and may at times be formed in the refugee camps. It is one situation to be forced to leave one’s home and accept donations to re-establish oneself in a new place (Agier, 2008). Unfortunately most refugees are in a much more complicated and long term situation, and are not able to establish themselves permanently at the location they have fled to for safety. Many refugees live in camps for five to ten years or longer. A number of the women interviewed for this project have been in Kakuma or other refugees camps and ended in Kakuma since the early 1990s, occasionally since the early 1980’s. The living situations in the camps themselves are 107 often difficult and unpleasant: one author described the refugee camps in Africa as “overcrowded, living conditions were very primitive, and infectious diseases were a continuous threat” (de Jong et. al, 2000). Once a refugee has established themselves in the relative safety (if not pleasant) setting of a camp, they then must wait for a long term solution, such as being able to eventually return to their home country or being resettled into a third country. However, in many ways life is on hold, as they are not able to participate in the daily activities that would have previously provided for their families. As discussed earlier, many refugees live for decades in refugee camps before some form of long term solution is found for them. Agier (2008) considers this time to be similar to being in a ‘waiting room’. Goodman (2004) completed a study with Sudanese men who were resettled into the United States. While these young men were in the refugee camps, they reported having a lack of hope related to the many years in the ‘waiting room’ of the refugee camp. As one young man in the study stated, We had eight years in Kenya, and it was really boring. Because you can’t work, you can’t go to school, you can’t even hope for your future. There was no hope for the future. So we just lived there as…we didn’t even count ourselves (2004, p. 1188). The women in this study reported feeling that they had no options of where they were able to go. All thirty of the women stated they were not able to return to Sudan due to conflicts that their families were in that resulted in people still wanting to harm them if they returned, or not having any family members left in the country. For example, Ana stated “The family died. I live orphan…mother died. I have nobody in Sudan. So I come here.” Lulu said that when she was in Sudan, “the war came to Sudan…everybody separate, it is only me, that is why I ran.” Unfortunately, even though the new country of South Sudan was being formed at the times of these interviews, this did not seem to change the personal situations the women were in order to 108 allow them to return home. At the time there was no known discussion around local integration of the Sudanese population into Kenya reported by camp authorities or the literature, with some sources reporting specifically that refugees from Kakuma and other Kenyan camps specifically stating that Kenya does not allow refugees to integrate (Jansen, 2008). A few refugees were being accepted for resettlement, but as always, this is a very small percent of the refugees who seek it. At the time of this study the U.S. allotment in 2011 for refugees coming out of Kakuma Refugee Camp was 1,500 out of the 80,000 who were there (Jeffery Savage, Senior Protection Officer, UNHCR, Personal communication, May 8, 2011). The women in the study seemed to generally believe that resettlement was their best option. Martha stated “the only important thing in good life…will be outside, is America, outside of the camp. That is the good life”. Yar stated “Even though people say, the UN say to let me go to Sudan I will stay here, it is fit to kill someone. If they don’t allow me to go abroad, I will die in the camp”. The long periods of time that these women have been in the camps and the small numbers of people currently being resettled from these camps make it unlikely that they will be able to leave the camp by resettlement any time in the near future. The women seemed to recognize that and did not sound as though they believed they would be allowed to resettle in the near future. In addition to the long term wait for a solution, refugees face what Agier describes as the “problem of inactivity” where “moral suffering, or even the psychological disturbance bound up with lack of occupational activity, play an important role in individual daily life” (2008, p. 137). As was seen with the women in this study as well as in Goodman’s research, there was often little to focus their hopes on. In particular, there are few legal options for employments, although a few women admitted to working in what would likely be considered illegal options, in this case by carrying water. Many of the women were previously involved in farming or cattle keeping, 109 which is not an option in the camp. Some of the younger women continued to attend school, however once they reached secondary school there is rarely the funds to support their education. They are not allowed the freedom of movement to leave the camp. When Mary was asked what she thinks might happen to her or her children in the future, she said simply “nothing. Just staying like this.” Agier notes that in one group who spent nine years in a camp, the people seemed to be “physically and mentally imprisoned- ‘homeless and hopeless’- as they say- and talk of suicide” (2008, p. 137). Similar to this group, the women in the study seemed to have little hope. The lack of hope for changes in the future seemed to be one of the serious, long term problems. The women seemed to think there was little change that their lives could be different. Martha said of her future “It is going to be like this.” Yar said, “there is nothing else you can do. Only to die here in Kakuma. Or killed by someone.” Ten percent of the women interviewed for this study spoke of a desire to end their lives. For example, Lulu stated at one point that “I want to kill myself, maybe my children no go to school because I am poor…its shame, if you can’t have food for the kids.” According to the interpreters for this project, this is fairly common. The interpreter explained, “the only solution is that you can kill yourself, so that you can pass problem”. According to the interpreters, what seemed to keep these women from following through on this desire was concern for their children. The system set up within the camp structure seems to encourage this lack of formal and legal employment and activity options, and allows the refugees to be dependent on the structures of the camp for their needs, or “institutionalized”, as some literature refers to it (Kibreab, 1993). However, literature also points out that this is often referring only to the legal requirements, and that many refugees supplement their needs with creative and sometimes illegal means, such as trading on the black market, or as several of the women admitted to, causal work as laborers for 110 other refugees. Kibreab points out that many factors are involved in this institutionalization, including an assumption by governments and camp authorities that the refugees are helpless. Many of the women reported a desire to work or to return to school, which indicates that it may in fact be the system that is attempting to place the refugees in the category of helpless and keeps them in a setting where they are dependent on others as much as possible. The women who desired to work or become more educated are possibly also involved in other activities that they did not discuss with the researcher that benefited their family beyond the system that was visible. One small portion of the study that was an exception to the hopelessness and inactivity of the system required by refugee camp life was in the youngest segment of the sample. Women in the 18-19 year old age range (n=10) seemed to find some hope in education, whether they were currently attending school or not. Even if they were not attending school presently, these young women discussed having a hope that if they completed their education, their lives could be different, and they might even be able to help others, such as family or friends, out of their difficult situations. Many of these women were at an age where returning to school was still a possibility, and thus the reported higher levels of belief that it was still possibly for them to do so. These younger women reported hopes that education would directly impact their lives for the better. As Magdalena said, “If I get education and then get employed. I will get money and then life will be changed.” Bethany agreed that with this education she would be able to help others, saying “If you get knowledge…if you get job, then you should give your knowledge to other people, and you can help those people, and it can help me with the money I will get.” This hope and form of activity appeared to help them have a better focus, and if education was provided, could form a way out of the dependency that is often the case in the camps. 111 Unfortunately, the majority of the women in this age group as well as others, while they did hope to return to school, reported not have the funds to be able to pay for school. Only one of the thirty was able to begin Secondary School at all. Their likelihood of finding employment or methods to support themselves based on their education seems to be unlikely. This may have negative impacts on their lives no matter what form of long term solution is found for them, as they may, as will the other women, have difficulty making the shift away from dependency. Discussion The system of structural dependency that is created in the camps often has long term implications for the refugees (Agier, 2008). This may include It is hoped that eventually people will be able to leave the refugee camps for some other long term solution, whatever that may be. However, as seen in the example of Kakuma Refugee Camp, many refugees live within the camp (or between multiple camps) for very long periods of time. Many of the women in this study arrived within the first few years after the camp opened in 1992, and some reported having been in other camps before this time. Some of the younger women reported either being born in the camp or coming to the camp as an infant, and may have little experience in living outside of the refugee camps. Some authors discuss this as the “victim” or learned helplessness mindset. Agier discusses how “refugees are adopted by national or international NGOs and UN agencies in the name of human rights, and these take responsibility for them as pure victims…being desocialized and in a state of purely biological life…individuals are treated and managed as nameless victims devoid of identity” (2008, pp. 155, 213-214). According to this mindset, the people the agencies are assisting are only victims who need to be given help, not whole people 112 who would like to have a full life and support themselves. However, there is an increasing body of literature that suggests that it is not the people who are helpless or dependent, but rather the system created within the camps that force people to become primarily dependent on the aide system for their basic needs. One (of possibly many) reason behind this system is the need to establish control over a large group of people who could easily overwhelm nearby poor and often struggling countries, which may not have the resources to support such an influx of people. Even the physical conditions of the land to which the refugees migrate may be a part of the difficulty, as the camps are often in dry areas unable to support farms or animal husbandry (Kibreab, 1993). An interesting quote from Agier notes, “every policy of assistance is simultaneously an instrument of control over its beneficiaries” (2008, p. 12). Refugees are often dependent on long term aide from these agencies not necessarily because they are helpless to do otherwise, but rather “the explanation is to be sought in the government’s policy, misconception of the relief agencies about the refugees’ traditions, coping mechanisms, capabilities, etc. and in the severe constraints imposed by the climatic and physical conditions of the country” (Kibreab, 1993, p. 332). There are some programs attempt to work within the camp system to increase the refugees ability to support themselves within a legally allowable framework, such as is discussed in an article by Hermanson, where a program is described that attempts to “alleviate the victim mindset and resulting dependency” by providing programs such as basket weaving that are designed to increase self sufficiency and reduce vulnerability (2007, p. 154). Many of these programs look towards craft making as a skill that would be appropriate for the culture and give the women activities they can focus their energy on and perhaps make some extra money to support themselves with. Some refugees also turn to small business enterprises (Kibreab, 1993), 113 and programs may be able to encourage and provide start up funds for them to be able to do so. Unfortunately, programs such as these tend to reach only a small portion of the population (Hermanson, 2007). The changes in relationships also carry long term settings in the refugee camps. If a refugee is able to return to their home country, there may be difficulties in re-establishing trust around people who may have been a part of the reason they were forced to leave, or who did not help them in their previous difficult times in the camp. As one subject in the study by Simich, Beiser, Stewart and Mwakarimba stated, “social support makes you feel emotionally well and I believe that influences your physical health…And it goes the other way around, too. The lack of social support or a threat from your surroundings can hugely impact your health” (2005, p. 263). In the refugee camps, even though there was often not much as much social support from other refugees as desired (as reported by the women in this study), at least there are people from their home country who spoke their own language. It is noted that war in general “erodes reciprocity, trust, and social cohesion, and social capital is not readily reformed” (McMichael and Manderson, 2004, p. 89). After having these experiences where even the people who should have been supports, such as husbands, break that trust, it is even more difficult to be able regain the ability to trust people within the camp that may be from different people groups, with unfamiliar languages and customs. Limitations While this study is rare in that it centered on the actual narrative words and experiences of Sudanese refugee women still residing in Kakuma Refugee Camp in Kenya, it should be noted that there are a variety of limitations to the study which may have interfered in the study results. 114 Although these limitations were addressed as much as possible by the author, they still present challenges in the data. A primary limitation is the non- random sample utilized by the research. Although a random sample would have been preferred, the camp authorities did not allow access to a complete list of Sudanese refugees in the camp that could be utilized for randomization. The researcher attempted to work within several different sections of the camp to obtain information that was not related to one neighborhood or area. Three different methods were utilized for obtaining the sample: requesting that the Sudanese leaders in the community direct the researcher towards women who might be willing to be interviewed, locating one women related to a women from the pilot study in Grand Rapids, MI, and snowball sampling from those women. An additional main difficulty revolves around language. The author is an English speaker with some Swahili skills. However, the primary language of the participants was Dinka. Finding a Dinka interpreter with an appropriate level of English skills was a difficulty, although each of the interpreters utilized did seem to have a high level of fluency in English, as well as Dinka and Swahili. At times Swahili was utilized to help clarify the research questions to the interpreters or to give examples. Due to the level of the interpreters’ English skills, it is highly likely that there were misunderstandings between the participants and the researcher. While some questions appeared to translate from English to Dinka fairly easily, such as “Who has supported you or assisted you since you came to Kakuma?”, others seemed more difficult for the interpreters and participants to understand, such as “What has influenced your life so far?” and “Have these beliefs changed over time in a way that helps you in your current life situation?” These difficulties in language undoubtedly had an impact on the results of these higher level or more 115 abstract questions. The use of the pilot study to attempt to find language or cultural challenges and the use of both English and Swahili with the interpreters attempted to eliminate as much of this difficulty as possible, however language differences are difficult to overcome. The use and design of an original questionnaire for the study may also have its own limitations. While the instrument was based in current research, it was not used in any study previous to this one so it could not be validated as gathering the information it intended to. The instrument was pilot tested with five Sudanese refugee women from the Dinka sub-group in the United States before it was finalized. The women had some level of English, however an interpreter from within the group was utilized. The study was explained to the women and the questions from the instrument asked just as they would be to the same group in Kenya. The women did not have any changes to suggest to the instrument after going through this process, so the instrument was then finalized. While it is hoped this may have removed some of the possible errors or misunderstandings, it is possible that they remained. Upon later reflection of the instrument, the structure of it may also have caused difficulties, as it begins with questions that could be emotionally difficult and did not being with safer warm up questions. The number of questions in the instrument might also be higher than would be preferred. The position as researcher may have caused additional limitations to this study. This researcher was only able to stay in the refugee camp for a limited time, which did not allow for the building of rapport previous to interviews. Due to this, it is possible that the participants may not have felt comfortable sharing their thoughts in some areas with the researcher. Additionally, the participants may have viewed the researcher as someone who could provide food or other concrete forms of assistance, although this was explained not to be the case at the beginning of each session. Another possibility is that the participants viewed the researcher as part of the 116 United Nations system, and thus reported in a manner they may have believed would either lead to additional assistance or would keep them out of trouble (for example, some women may not have reported work activities as they are not legally supposed to be employed). The possible belief of the participants that the researcher could either directly provide assistance or could inform those who could give assistance of their requests is a real possibility and challenge. Many refugees within the camps have little connection with Caucasian people or foreigners except in the role of a person from the United Nations or other aid agencies. This lack of exposure may again cause the refugees being interviewed to either feel they should report or not discuss certain items. The view of the data relies on the self report of the participants and their perceptions, in addition to what they felt comfortable reporting. Additional studies would benefit from exploring specific behaviors of the women in relation to the varying areas of coping strategies, as well as other areas reported by the women (again, work could be a concrete example). The ability to observe the behaviors of the women being interviewed might show very different results from what is reported by the women in a one- time interview setting. A last area which may limit the results of the study is simply culture. The researcher and participants come from very different cultures with different ways of looking at the world. For example, several of the women discussed the tradition of being expected to marry the brother of their husband if their husband died. This type of relationship is outside of the experience of the researcher, but very real in the lives of the women. Similar experiences likely shape the women’s lives in ways that could not be anticipated. Questions and answers may have varying cultural meanings that the other side was unaware of. Even the definition of work may vary between cultures, as work may relate to trading goods for services, trading items on a black 117 market, or physical labor with other forms of compensation. While there are no known differences in this area that would have an impact on the study, it must be brought up as a possibility. Although this study had multiple limitations, it is believed that there are also a good number of strengths in the study. Creswell (2003) states that pilot testing is “important to establish the content validity of an instrument and to improve questions, format, and the scales. Indicate the number of people who will test the instrument and the plans to incorporate their comments into final instrument revisions” (p. 158). This study included from the beginning a plan to interview Sudanese refugees who were currently living in the United States to test the instrument. Five women were interviewed, which is over 15% of the final number of interviewees. While it was expected to make changes in the instrument based on the feedback of the women, they did not have any changes to suggest. Their feedback appeared to indicate the instrument was able to be utilized as it was written. In order to address language difficulties, four years of Swahili, the major language of East Africa, was studied by the author. This language study became useful with the translators in order to clarify some of the English questions that were being translated into Dinka, the language of the women interviewed. One younger woman was able to complete the interview in English, and also appeared to understand the questions as well as when they were interpreted into Dinka. The interpreters utilized were located through the leaders in the Sudanese community and later through the United Nations itself, which indicates they were likely the most reliable interpreters available. This study is also positive in that it relied on going into the refugee camp and recording the words of the refugee women themselves, although through the translators. As noted in the 118 literature section, few studies have focused specifically on the words of refugee women, or women currently living in the camp setting. These strengths were the primary motivation for completing the research in this manner, in order to contribute to the small body of knowledge regarding refugee women living in refugee camps near their home countries. Conclusion and Recommendations The findings from this study show that Sudanese refugee women in the Kakuma Refugee Camp of Kenya often appear to be engrossed in a system that creates and encourages long term dependency. Due to these conditions and findings, it is recommended by this researcher that several changes could improve the lives of these women. A primary practice recommendation would be an increase in programs to target women specifically and create skills that would enable them to support their families. Programs such as the basket weaving program discussed by Hermanson (2007) create culturally appropriate manners for the women to increase their self sufficiency within the camp system, in a manner allowed by the camp structure. Any form of job skills that might also assist women when they are able to return to their home country, be integrated, or be resettled would also be beneficial, such as child care classes, English training, or sewing would be appropriate programs. Many of the women also spoke of a desire for continued education. Attending school may give the women a hope for their future (and specifically for employment in the future), and give them the skills needed to possibly obtain some form of employment. Even though school attendance had not resulted in employment for any of the women in the study, just the hope for a possibly job in the future appeared to be very important to especially the younger women. Other allowable employment opportunities, such as micro-finance that might enable the women to run a small business, could greatly improve their 119 lives. They may be able to better meet the physical needs of the family through this work. Their safely might be increased as the activities could possibly contribute to limiting risky activities such as gathering firewood even with the possibility of sexual assault during collection. Increased security through finding alternatives to risky but often necessary activities could greatly improve the women’s lives. The women might also find hope, social connections, or other methods of positive coping from within the working environment. Any form of program that is able to combat the inactivity and hopelessness would possibly be of great benefit to the women. A much more difficult and long term challenge is the length of time that many refugees are forced to stay in refugee camps. Policy changes and political solutions may take decades, as could the decision for a country to accept a refugee for resettlement. This long period of waiting in a refugee camp has quite negative effects on the refugees, including over time the dependency on support from UN and NGOs, and a difficulty adjusting to a system where they are able to support themselves if and when a long term solution is found. If political pressure could be increased to find long term solutions more quickly, a great many refugees would benefit. International groups such as Amnesty International or independent nations that provide funding to programs such as UNHCR could put pressure on the refugee producing countries to find political solutions that could allow numbers of refugees to return home. Changes in policy relating to the host country could also be included in the international pressure. For example, if refugees within Kenya were allowed to have employment in the country, then perhaps more of the men and women would be able to have positions inside or outside of the camps, which would then allow them to support themselves and their families. Increased financial support to refugee hosting countries from the international community or UNHCR might be needed to encourage 120 these generally impoverished countries to allow non- nationals to take possible employment away from citizens. One of the struggles in providing for refugees, especially those who are integrating into a local society, is to have the refugee and local nationals accessing relatively similar levels of goods and resources. The international communities would need to support both the local populations and refugees to be able to meet a basic level of self- sufficiency through cultivation of new farms, wells, or procuring animals for animal husbandry. While this would reflect a fairly major policy change in that few refugees are allowed to integrate into host communities, it would likely be beneficial to both the refugee and host country populations, as each would receive needed resources and skills training to increase their overall welfare. Additional research also needs to take place regarding refugee women’s relationship to the system of dependency that is created in the refugee camp. As stated before, there is little research on refugee women in refugee camps or other host country settings, or on refugee women separate from men, even though most refugees in Africa are women or children (Pavlish, 2005). This study increased the knowledge in this area by examining the experiences of Sudanese women in Kakuma Refugee Camp, however this was a small study and should be repeated with this and other groups in other camp settings. Future research that examines other populations would show if there are similar difficulties with multiple populations. A selection of research recommendations would include additional qualitative research to explore the words and lives of refugee women in several settings. Additional studies should be done with the Sudanese population in Kakuma Refugee Camp and other refugee camps, especially as this is a large and long- standing refugee population. Larger sample sizes should be included. Ideally, researchers who are able to spend longer periods of time within the refugee camp and with the women in their daily lives would be included. Studies with refugee women in other parts of 121 Africa and around the world should also be completed, with a focus on both their daily lives and needs and their methods of coping. Some of these studies could take place using the same instruments and comparing the experiences of women from different people groups and different parts of the world. Issues of dependency could be explored through these multiple avenues to determine how systematic the problem is, or it if is limited to this particular segment of the population. There was only one in depth study found by this author that specifically addressed the long term reactions and consequences of refugee camp life (Agier, 2008). This is an important area to examine, as some refugee populations are ‘warehoused’ into refugee camps for 20 years or more (U.S. Committee for Refugees and Immigrants, 2009). For resettlement countries, this issue particularly impacts the refugees that are brought into their new resettlement country. As noted by Potocky (1996), the services that are often given to refugees upon their arrival are often not enough to allow the refugee to become self- sufficient in the time allowed. Research studies that examine what is and what is not working in the resettlement process in relation to refugees become self sufficient would be of great value to all resettlement countries, and enable them to better provide what is needed for this transition. Similarly, research into what is working and what might be needed to provide for refugees who return to their home countries or integrate into their host countries would be beneficial. This research could be supported by the UNHRC as well as universities and refugee related programs from around the world. 122 REFERENCES 123 References Agier, M. (2008). Managing the undesirables: Refugee camps and humanitarian government. Cambridge, UK: Polity Press (English version, 2011). Al Gasseer, N., Dresden, E., Keeney, G., & Warren, N. (2004). Status of women and infants in complex humanitarian emergencies. Journal of Midwifery & Women’s Health, 49 (suppl 1), 7 - 13. doi: 10.1016j.jmwh.2004.05.001 Bates, L., Baird, D., Johnson, D., Lee, R., Luster, T., & Rehagen, C. (2005). Sudanese refugee youth in foster care: The “Lost Boys” in America. Child Welfare, 84 (5), 631 – 648. Retrieved May 10, 2010, from the PsychINFO database. Creswell, J. (2003). Research Design: Qualitative, quantitative, and mixed methods approaches. 2nd Edition. Sage Publications, Inc.: London, England. de Jong, J.P., Scholte, W.F., Koeter, M.W.J., Hart, A.A.M. (2000). 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Providing social support for immigrants and refugees in Canada: Challenges and directions. Journal of Immigrant Health, 7 (4), 259 – 268. doi: 10.1007/s10903-005-5123-1 Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Sage Publications: London. U.S. Committee for Refugees and Immigrants. (2009). World refugee survey 2009. Arlington, VA: U.S. Committee for Refugees and Immigrants. 126 CHAPTER FIVE: Summary and Implications Summary Throughout this dissertation, the focus of the research and discussion has been coping strategies in East African refugees. Coping skills or strategies is important to examine in refugee populations, as it is an area that can be utilized to form cognitive behavioral or other forms of interventions when working with clients from this group (Folkman and Moskiwitz, 2004). The definition of coping from two of the main authors in the field of coping that was used as a basis for the research is “the thoughts and behaviors used to manage the internal and external demands of situations that are appraised as stressful” (Folkman & Moskowitz, 2004, p. 745). This definition captures both internal resources such as hope and outside resources such as the influence of other people in a support network. This examination began with a look at current literature on coping in general, and also in East African refugees in the second chapter. The literature found in this area showed several primary areas of coping that were being used by this population. The major gaps noted included the lack of a focus specifically on refugee women (Pavlish, 2005) and the lack of research that takes place in refugee hosting countries, instead of in resettlement countries (Gladden, 2012). In the third chapter, an examination of the coping strategies of a group of 30 Sudanese refugee women in one refugee camp in Kenya. This research, performed by the author, showed a variety of coping strategies, some of which were similar to those found in the previous literature review. However, there were some differences found, primarily in what was lacking in coping strategies in the Sudanese women. Finally, a closer look at the words and experiences of these same 30 women formed another story, one that spoke of life in a refugee camp and the dependency on the 127 camp system that was formed. The fourth chapter discusses these findings. In this chapter, a discussion on the implications of this research and findings will conclude the dissertation. Chapter Two Summary The current literature on East African refugee’s coping strategies showed that there are several areas that may be particularly important in assisting this population with coping. One of the most common resources utilized for coping is faith and/ or religion. Believing that there is a caring God that knows of their situation and may one day help change it assists many refugees (and non- refugees) in believing their situation is manageable (Lazarus & Folkman, 1984). Indeed, turning to religious faith was one of the most common coping strategies found in the literature (Bolea et al., 2003; Goodman, 2004; Grant- Knight, Geltman & Ellis, 2009; Halcón et al., 2004, Jeppsson & Hjern, 2005; Matheson et al., 2008; Pavlish, 2005; Stoll & Johnson, 2007; Tankink & Richters, 2007). Some refugees found that cognitive reframing, or finding meaning in the situation or event, was helpful in their coping. There is a frequent overlap between meaning making and faith/ belief in God, as some literature shows refugees utilizing faith to make meaning out of their situation, especially the question of why they are still alive when others are not (Goodman, 2004; Luster et al., 2009). Social support is another important coping skill found in the literature. These social supports are often found in the form of family and friends, and is one of the most often discussed coping strategies discussed in the literature (Bates, Baird, Johnson, Lee, Luster & Rehagen, 2005; Farwell, 2001; Jeppsson & Hjern, 2005; Jorden, Matheson, & Anisman, 2009; Khawaja, White, Schweitzer & Greenslade, 2008; Schweitzer, Greenslade & Kagee, 2007; Schweitzer, Melville, Steel & Lacherez, 2006; Stoll & Johnson, 2007; Tankink & Richters, 2007; Tipping et 128 al., 2007). For some, this social support from family, teachers and elders assist the person in being able to make sense of the situation (Farwell, 2004). For others, the social support given by peers helped the person to feel they were not alone (Goodman, 2004). At times, the idea of being a social support for others, or being able to provide for their families, was one of the ways that people were able to cope with their situation (Farwell, 2001; Pavlish, 2005). Additionally, and especially for the younger populations, hope for the future and through education was highly important (Bates et al., 2005). This ability to hope that the future will be better was found more in the younger populations. Many of these younger refugees had hopes that by obtaining education, there would be the ability to change their situations, and that some good might come out of their situation. Some hoped that they would be able to use this education to not only change their own lives, but possibly their families or even their home countries futures as well (Luster et al., 2009; Tipping et al, 2007). The literature in this chapter did note several gaps in research in this area. A table of articles with research focusing on coping in East African refugees was compiled (see Appendix for Chapter Two). In this table, several of these areas can be seen. It is noted that there is little research on refugee women. The majority of the research that takes place is on refugee men or just refugees in general. As was noted, of the nineteen articles in the table, three focused at least partially on refugee women’s experience. Additionally, there is little research taking place with refugees in non- Western, non resettlement countries, even though most refugees live in camps or other locations in countries close to their country of origin. Only five of the articles in the table were regarding refugees who were currently in non- Western countries near their country of origin. Of these articles, only one focused specifically on coping strategies of women living near their home countries, regarding Congolese women in Rwanda (Pavlish, 2005). Similar to the 129 research completed by Pavlish, the research for this dissertation showed the women in the study discussing social support and religious faith as several important coping strategies, but also noted a lack of hope. The two coping strategies of social support and faith or religion consistently came out of the literature review as two of the most commonly used coping skills. Chapter Three Summary The third chapter shows and discusses the results of the independent research completed for this dissertation, for which 30 Sudanese refugee women living in Kakuma Refugee Camp, Kenya were interviewed regarding their coping strategies in May 2011. In this research, many of the areas of coping that were discussed in the literature review were also reported by the women in the camp. The women’s beliefs around the role of faith/ religion and social support were two of the primary strategies that were found in both the literature review and this research. Faith and the women’s beliefs around God and their religion were reported as the most common area of discussion for coping with emotional struggles. The majority of the women spoke of believing that God knew about their situation, and that he would help them. They often spoke of the hope that God would change their situations, so that one day their lives might be different. All ten of the younger women reported combining this hope for the future by God’s assistance with a hope that education could change their lives. While few of them were currently in school, they all reported hoping to be able to return. With education they reported that they felt they might be able to find a job, which would allow them to change their lives and also to help others, such as family members. Social support also played a role in the women’s coping. One of the areas of discussion in the instrument involved questions around who supported the women, both emotionally and 130 physically. Many of the women were able to identify a neighbor or family member who was able to help them. Some women spoke of people asking if they were okay, occasionally giving them someone to talk to, or providing small amounts of food, water or shelter. Unfortunately, this is an area where many of the women felt that they did not have enough of a support system. The women often stated that they felt alone. Most of the women were widowed or separated, and some spoke of life being a struggle without a husband to provide and protect them. In some cases, husbands caused additional difficulty but not support, such as a few that would appear long enough to make the women pregnant again, and then leave without supporting the child. Younger women spoke of not having parents, and the struggles of being an orphan. Overall, the women seemed to feel that everyone else had too much trouble trying to support themselves and their children and were not able to do much for others. This left many of them stating that they feel helpless and alone. Formal supports, which are briefly discussed in the literature but were not a main focus, was found to be very important for the refugee women interviewed, although not in the ways that might be expected. The main discussion regarding coping has been around emotional coping strategies, or coping with emotional struggles due to the refugee’s situations (past and present). However, this was not the main discussion that the women in Kakuma Refugee Camp discussed. For them, finding ways to cope with physical difficulties were much more of a priority. When the women discussed their support system, they often discussed others not being able to give them food or shelter. The women therefore turned to the systems that were able to provide at least some of these needs. The formal supports, particularly in the form of the UNHCR and the World Food Programme provided for a higher level of their physical needs. Every one of the women spoke of how these programs had helped her, but also that their physical needs were still 131 unmet. While the study intended to explore the use of formal supports for emotional needs, such as through counseling centers, these physical needs and the resources provided by these programs were much more important to the women. Only a few of the women had utilized formal supports in the form of counseling services. According to the women’s reports, it appears that the physical needs may play a much more important role in the women’s lives than seeking out manners of coping with the emotional difficulties. Chapter Four Summary Ongoing qualitative data analysis of the narratives of the women’s words revealed another story behind the initial examination of coping strategies. The women may depend on the camp system for their physical needs, and had no other manner of providing for themselves and their families. This structural dependency can become a long term issue, as many of the women in the study (and other refugees as well) live in the camps for long periods of time, sometimes decades. All of the refugee women in this study reported relying on the physical support and assistance of international programs for food and shelter. Many women stated that these programs were the only places that were helping (although it is possible that this would not be reflected in their actions, this study was only able to capture what the women reported). The women often said that their families, husbands or parents were not present or could not provide for their needs. The traditional forms of relationships that are found in the refugees’ home communities seems to have shifted, and these shifts also contribute to the dependency that is formed within the camp system. The refugee women in this study at times referred to the UNHCR is terms of relative, saying that it was their father, mother, or other relative- primarily 132 showing the level of support that is given to them by this system. While the women often shared their dissatisfaction with the levels of support with which they were provided, they reported no other methods of support. An additional set of factors plays into the structural dependency that may be formed in the refugee camps. Unfortunately most refugees are in a long term camp situations, and are not able to legally establish themselves permanently at the location they have fled to for safety. In many ways life is on hold, as they report not able to participate in the daily activities that would have previously provided for their families, such as farming or animal husbandry. In order to better meet the long term needs of refugees, alternative methods that would allow refugees to support themselves in the camps need to be explored. Implications for Social Work Practice and Social Policy Social work has a unique commitment to vulnerable populations, and refugee populations certainly fall into this category. The vulnerability of refugees makes an appropriate response a necessity due to social work’s specific commitment to the value of social justice “particularly with and on behalf of vulnerable and oppressed individuals and groups of people” (NASW Code of Ethics, 1996, p.5). Finding methods of securing food, shelter and safety are particularly important to begin assisting this population. This research gives insight into multiple areas of refugee work. Primarily, the coping strategies that were discussed in both the literature and in dissertation research are important for the social worker to be aware of. When working with a refugee client, knowledge of the types of coping skills that have worked for other refugees may enable a more insightful exploration of possible forms of coping that the refugee client may utilize, and could be strengthened to 133 encourage improvement in treatment. For example, understanding the important role faith and religion plays in many refugee’s coping could allow for the social worker to explore the role of spirituality in the person and use this as a strength to build increased positive coping strategies. Having an understanding of the role that social support plays in coping and the importance of relationships in the refugee’s home culture may allow the social worker to better understand the need for finding similar or substitute forms of social support, if the refugee is separated from their family and friends in their resettled location. Also, an awareness of the focus on physical needs may allow to worker to first explore this area of need before moving into coping on emotional levels. The research from this dissertation may also have important implications in resettlement and social work practice with resettled refugees, as well as with refugees who have long term settings within the camps. Potocky (1996) discusses the refugee resettlement process in the United States, stating “the manifest goals of the refugee resettlement policy are (1) to provide for effective and coordinated resettlement efforts and (2) to increase self sufficiency and decrease welfare dependence of refugees” (p. 167). Social workers can advocate for changes within our current refugee resettlement program to attempt to meet some of these long term challenges. An increase in the length of time that resettled refugees have access to a case worker, for example, may be helpful for a refugee family as they adjust to the new society. Even for refugees who are not resettled but who spend long periods of time within the camp setting, changes that would allow for refugees to support themselves legally and for the long term should be sought. It is hoped that research such as this will encourage the social work field to also respond to the international refugee situation. Social workers and social work students should be made more aware of the situations in refugee camps. Long term residence in the refugee camps may 134 form a number of difficulties for refugees. The system of structural dependency that may be created in this setting will impact the refugee even as they continue to live in these camp settings for long periods of time. As the refugees in camps rarely seem to have the opportunity to advocate for themselves, it is the responsibility of social workers to advocate for them. However, it would be even better to give the refugees the tools to empower themselves through various methods such as testimonies and oral histories. Community based interventions, such as large group psychoeducation of mental health challenges would also benefit the population, as refugees would then be aware of issues and methods of assistance for those around them. One suggestion might include psychoeducation through radio shows, and possibly the distribution of battery or solar powered radios. Social workers should be aware of the international refugee problems, learn about the policies that are related to these issues, and advocate for changes when problems are discovered. If political pressure could be increased to encourage finding long term solutions more quickly, a great many refugees would benefit. Refugees may be able to return to their home country instead of living in the refugee camp. Social workers should be involved in advocacy projects including letter writing campaigns, meeting with legislators that are involved in formulating foreign policy, and utilizing media to educate the general population about the challenges that refugees face around the world. Media campaigns that show the stories of particular refugees living in camps would serve to both empower refugees in the camps who would be involved in making the reports and to allow the general public to have a better understanding of refugee life. In cases where major changes are unlikely (such as an end to long term residence in camps in the near future), social workers could encourage programs and services that can limit or work to change these problems. For example, the basket weaving program discussed by 135 Hermanson (2007) could create culturally appropriate ways for the women to increase their self sufficiency within the camp system. Another method of creating allowable employment through microfinance options could also assist finding a way for a family to support themselves. Social workers should be involved in encouraging individuals and businesses within their own countries to sponsor program such as these within the refugee camps. Again, political pressure from refugee related programs such as the UNHCR or refugee funding countries could advocate that the host countries modify their laws regarding employment in the host country. This may also require increased financial support from these bodies to encourage the possibility of employment for refugees. Specific laws could perhaps limit the range of distance from the camp that refugees would be allowed to legally work to keep them within a particular area, but would encourage self- sufficiency and self- empowerment through allowing them to enter into businesses or farming in surrounding areas. Social work education is also a portion of social work practice that can learn from the research that has been presented. As discussed above, knowledge of the international political situations that impact refugees as well as the personal implications for refugees should be known and applied to macro and micro social work practice. In order to better apply this knowledge to practice, it should be included in social work education. As the world grows increasingly smaller and students and practitioners are exposed to more and more diversity, it becomes highly important to include information on other population in the classroom. The classroom is the time in a social workers education when they are exposed to the widest variety of ideas and theories. Giving social work students the basis of understanding of the issues that impact our current residents who were born outside this country will help them in serving not only refugee clients but other immigrant populations as well. Social work students should also learn how to advocate 136 for clients in a macro setting. This will allow them to have multiple avenues of impact regarding these populations. The research reported here may also have an impact on areas of social policy. Refugee camps and situations are closely related to policy- it is the international and national policies that have allowed refugee producing situations to continue and that has allowed refugee camps to be formed and continue for long periods of time. While these policies may be difficult to change, social worker and others could also explore policy related to funding determines the types and amounts of assistance that refugees in camps receive, and encourage areas in which additional funds could be useful. This research shows the importance of increasing services within the refugee camps. These services may include educational opportunities, employment, microfinance, the availability of activities that would allow women to raise money to assist their families, or even increased funds for counseling centers to assist women who are having difficulty with emotional coping. Social workers and others can advocate for policy changes that will shorten the length of time the women and others are in refugee camps, to limit the structural dependency that is formed over time. Specifically, if the limitations that do not allow refugees freedom of movement and the ability to hold many employment positions were changed, then refugees would be able to better empower themselves and their financial situations. Perhaps laws allowing movement and employment within a certain distance from the camps would give more people the opportunities to develop small businesses or farms to support themselves. This advocacy may take place on a national level, such as asking the United States to request that the government of Sudan make changes to support national security, or on a smaller level. For example, a smaller organization that has access to the camps, such as the Red Cross, could be encouraged to increase their services to include a microfinance component, or partner with a 137 program that is involved in this activity. Social workers should be involved in a range of activities to advocate for change at these many levels. Meetings with legislators, letter writing campaigns, and the use of media are several strategies that might allow for change in these systems. Implications for Future Research There are still many areas of research that need to be explored in relation to the coping strategies of refugees. Throughout this dissertation, several of these have been discussed. Refugee women, people still residing near their home country, and specific coping strategies within different ethnic groups are all areas that need continued or additional research in order to form a more complete picture of the needs and strengths of refugee populations in relation to their coping strategies. As was shared previously, there is a fair amount of research on refugees in general at this time. However, women do have different situations and also have different reactions and struggles in their lives. Female refugees face high rates of sexual and gender-based violence. They also suffer the added burden of caring for children (Al Gasseer, Dresden, Keeney, & Warren, 2004). Women are often subjected to various traumas specifically due to their roles as women – they may lose children or others for which they are the primary caregivers (Harris, 1996) or they may become a victim of violence due to their duties as a caregiver. For all these reasons, women have different stressors and thus may have different forms of coping than refugee men. Due to these factors, this researcher, along with other previous studies encourages continued work and research specifically with refugee women (Friedman, 1992, Pavlish, 2005). 138 Another specific area that is in need of continued research is refugees who have not been resettled but continue to reside near their home country. The sheer number of this population makes this a requirement. Less than 1% of refugees are resettled into a Western country, yet this is where the majority of the research takes place (U.S. Committee for Refugees and Immigrants, 2009). There needs to be a growth in the research near the home countries of refugees, where most of them reside. This will enable researchers and workers to better understand the situations and coping abilities of a larger group of refugees than those in resettlement countries, and could enable aide workers in those countries to have improved methods of working with this population. Each specific refugee group may have differences in their coping strategies, just as each individual person may. Learning some specifics about how the refugee group one is working with tends to cope may allow for more culturally appropriate treatment. In order to be able to learn this, more research needs to take place with individual groups to learn their strategies, and then be able to compare it to the whole. Studies including larger samples sizes should take place. Additional qualitative studies examining the lives of refugee women should examine different ethnic groups in different parts of the world. Researchers who are able to spend longer periods of time with the refugee women in the camp environment would also contribute to building this knowledge. With this in depth exploration of different refugee coping strategies and the lives of refugee women, each refugee group may be able to be encouraged to further strengthen their own coping strategies in order to better function within their current situations and needs. 139 REFERENCES 140 References Agier, M. (2008). Managing the undesirables: Refugee camps and humanitarian government. Cambridge, UK: Polity Press (English version, 2011). Al Gasseer, N., Dresden, E., Keeney, G., & Warren, N. (2004). Status of women and infants in complex humanitarian emergencies. Journal of Midwifery & Women’s Health, 49 (4), 7-13. doi: 10.1016j.jmwh.2004.05.001 Bates, L., Baird, D., Johnson, D., Lee, R., Luster, T., & Rehagen, C. (2005). Sudanese refugee youth in foster care: The “Lost Boys” in America. Child Welfare, 84 (5), 631 – 648. 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Arlington, VA: U.S. Committee for Refugees and Immigrants. 143 Appendices 144 Appendix A: Consent Script The Coping Strategies of Sudanese Refugee Women in Kakuma Refugee Camp, Kenya Consent Explanation A research project supervised by: Dr. Hyunkag Cho School of Social Work, Michigan State University And conducted by: Ms. Jessica Gladden, LMSW School of Social Work, Michigan State University Partnering with: Dr. David Ndetei University of Nairobi, Africa Mental Health Foundation The following script will be read to the interview participants in order to obtain their informed and voluntary consent. PURPOSE OF THE STUDY This research study is designed to better understand how refugee women cope with the difficulties in their lives, including past trauma and current living situations, and to determine what coping strategies or religious beliefs have been helpful with these situations. The research study is being supervised by Dr. Hyunkag Cho and conducted by Ms. Jessica Gladden, both of the School of Social Work at Michigan State University. PROCEDURES Participation in this study involved doing an interview, in which you will be asked questions about different coping skills and how they relate to your life. You will be asked about what assistance friends, family member, religion, and formal organizations such as clinics have provided. After completing the interview, you will receive a reimbursement for your time and costs of an amount of no more than $10.00 U.S. Dollars. All interviews will be tape recorded and transcribed. You cannot participate in the study without having your interview tape recorded. Only the investigators and research assistant(s) will know what you have said. Interviews will last between one and two hours. PARTICIPATION AND WITHDRAWAL Participation is voluntary – you do not need to participate in this study unless you wish to, and any refusal will not cause threat to your security or benefits in the camp. The researchers for this study are not employed by the Kenyan government or this refugee camp. You may choose not to participate, or you may choose to withdraw from the study at a later date, even if you agree to participate now. You may also agree to participate but refuse to answer particular questions. If you choose to withdraw at a later date or choose not to answer particular questions, you will still 145 receive reimbursement. In addition, withdrawal from the study or refusal to participate in the study will in no way affect any of the benefits you receive from the refugee camp or cause any threat to your security or the security of your family. CONFIDENTIALITY Any information that is obtained in connection with this study and that can be identified with you will remain private and confidential. Your name will not be recorded on the tape recorder and will not be associated with the information you provide. Any identifying information will remain confidential and your privacy will be protected to the maximum extent allowable by law. We will keep recordings and transcriptions in a locked drawer in the United States. When the results of the research are published or discussed at conferences, no information will be included that reveal your identity. Transcriptions and audio recordings of the interviews will be destroyed after the study is complete, approximately August 2013. POTENIAL RISKS You may find that the interview requires you to talk about experiences that are distressing to you or too personal (such as religious beliefs), takes up too much of your time, or that you may believe that something you say might be used against you. Remember, you can stop the interview at any time or refuse to answer any question you are not comfortable with. The research will ensure that no one else knows what you have said in your interview. You will still receive your thank you gift even if you choose to stop the interview or skip questions. POTENIAL BENEFITS This research could help us to better understand how refugee women cope with their past and current situations. Your participation will potentially provide valuable information. You may also gain satisfaction in description your experiences and giving your opinion in a manner that may help others in the future. The information you provide in this research could be useful to other refugees and agencies that assist refugees. REIMBURSEMENT You will receive reimbursement for your time and expenses of an amount of no more than $10.00 U.S. Dollars for participating in this research study. You may keep this reimbursement even if you decide not to answer some questions, choose to stop the interview before it is completed, or if you decide to withdraw at a later date. QUESTIONS Do you have any questions about this information or the study for the researchers? Please ask them now. CONTACT INFORMATION If you have any questions about the study or your participation in the study, you may ask the researcher at the time of the study, or contact Ms. Gladden by phone at (616) 206-4477, by email at gladdenj@msu.edu, or by sending mail to the School of Social Work, Michigan State University, 60 Baker Hall, East Lansing, MI 48824, U.S.A. You may also contact Kenya 146 Medical Research Institute (KEMRI/ NERC) at Tel: 2722541, 072205901, or 0733400002 within Kenya. If you have questions or concerns about your rights as a research participant, or would like to register a complaint about this study, you may contact, anonymously if you wish, the Michigan State University’s Human Research Protection Program at (517) 355-2180, fax (517) 432-4503, or email irb@msu.edu or regular mail at 202 Olds Hall, MSU, East Lansing, MI 48824, U.S.A. You indicate your voluntary agreement to participate in this study signing and providing your thumbprint on the following document. 147 Appendix B: Consent Form The Coping Strategies of Sudanese Refugee Women in Kakuma Refugee Camp, Kenya Consent Form A research project supervised by: Dr. Hyunkag Cho School of Social Work, Michigan State University And conducted by: Ms. Jessica Gladden, LMSW School of Social Work, Michigan State University Partnering with: Dr. David Ndetei University of Nairobi, Africa Mental Health Foundation By providing my signature and thumbprint below, I am agreeing to participate in this study. I understand that I am in no way obligated to participate, and may withdraw at any time with no threat to my safety and security. I understand that even if I do withdraw, I will still receive compensation for my time and expenses in this study. I understand that my name will not be associated with anything I say during this study, but will be kept confidential. Signature: ___________________________________________________ Thumbprint: 148 Appendix C: Interview Protocol for Kakuma Study Dr. Hyunkag Cho, Dr. David Ndetei and Jessica Gladden Interview Protocol for Kakuma Study This interview is designed to learn about your coping strategies, or the people, beliefs, and organizations that assist you emotionally, mentally and physically. I will ask you a set of questions to try to learn about these strategies. Before we begin the questions, could you please tell me a little bit about yourself, including briefly how you came to live in Kakuma and how long you have been here? Thank you. First, I want to ask some questions about your family and friends. 1. Who has supported you or assisted you since you came to Kakuma? (Probes: Family? Friends? Neighbors? Others?) 2. What kinds of assistance did they give you? What did they do? (Probes: some examples may be by providing food, money, someone to talk to, advice, or childcare) 3. Which of these sets of people (family, friends, neighbors, or others) has helped you the most? 4. What forms of assistance was most helpful? (Probes: some examples may be by providing food, money, someone to talk to, advice, or childcare) 5. Do you remember any other people who helped you or supported you, other than those you have already mentioned? 6. Do you feel that these people have given you the physical support you need? 7. Do you feel that these people have given you the emotional support you need? Next, I want to talk a little bit about your personal and religious beliefs. 8. What is the most important thing to you? 9. What has influenced your life the most so far? 10. Your life story sounds very hard sometimes. How do you overcome those difficulties? 149 11. Do you have any religious beliefs regarding your current living situation? (Some examples could be it is a test from God or it is a blessing from God.) 12. If yes, what are they? 13. What do you believe may happen to you and your children in the future? 14. Do these religious beliefs or your beliefs about the future make you feel more strong or less strong? 15. How else do these beliefs make you feel? 16. Have these beliefs changed over time in a way that helps you in your current life situation? I would like to ask you about the formal supports that you may have utilized in the camp, such as clinics or counseling centers. 17. Are there any supports such as clinics or counseling centers that you have utilized? 18. If yes, which services did you utilize? 19. If yes, how helpful did you find these services to be for you? We are almost finished with the interview. I would like to ask you just a few questions about yourself. Demographic Characteristics What is your age? _____ 18-19 _____50-59 _____20-29 _____60-69 _____30-39 _____70 and over _____40-49 What is your current marital status? _____ Never Married _____Married _____ Separated/ Divorced How many years of school have you had? _____ years Primary (Elementary) _____years Junior Secondary (Middle) _____ Widowed _____ years Senior Secondary (High School) _____ years other (college or vocational) Employment Status ______ Employed _____ Self- Employed Number of Children: _____ 150 _____Unemployed How do you rate your overall health? ____ Poor ____ Fair ____ Good ____ Very Good ____ Excellent Do you identify with a particular ethnic group, tribe, or clan? _____________ If yes, what is your ethnic/ tribal/ clan identification?___________________ That completes our interview questions. Is there anything else you would like to share with me at this time? Thank you for your time and willingness to share your story. 151