WHAT IS HEALTH A qualitative study on the concept of health of Internal Displaced women in Georgia Anneli Hagen Andersson Zandra Persson Examensarbete i omvårdnad Malmö Högskola Nivå 61-90 Hälsa och Samhälle Sjuksköterskeprogrammet 205 06 Malmö Juni 2010 1 “/…when you eat quality food, and you have no problems, that you are living in freedom and you have no problem, you have job, you have everything you need for your health, and what the person need in her life.” (Respondent 2) 2 Vad är hälsa En kvalitativ studie om begreppet hälsa bland kvinnliga interna flyktingar i Georgien Anneli Hagen Andersson Zandra Persson Hagen, A & Persson, Z. Vad är hälsa för kvinnliga internflyktingar i Georgien. En kvalitativ studie om begreppet hälsa bland kvinnliga internflyktingar i Georgien. Examensarbete, 15 högskolepoäng. Omvårdnad, Malmö högskola: Hälsa och Samhälle, Utbildningsområde omvårdnad, 2010. Syftet med denna studie var att undersöka begreppet hälsa bland kvinnliga georgiska internflyktingar (Internal Displaced People, IDP). Detta är en empirisk studie med en kvalitativ metod som bygger på semi-strukturerade intervjuer. Sammanlagt sju IDP kvinnor i staden Zugdidi i Georgien deltog. Dataanalysen var inspirerad av Burnard's (1991) innehållsanalys, och resulterade i två kategorier: 1) Upplevelsen av kontroll med underrubrikerna Social situation, Familj och Avsaknad av pengar och 2) Upplevelsen av identitet med underrubrikerna Ursprung, Anpassningsförmåga och Självkänsla. Dessa är alla avgörande faktorer för att deltagarna skall kunna leva ett liv med värdighet och kontroll; båda viktiga faktorer för hälsan. Marmots teori om sociala bestämningsfaktorer för hälsa har influerat dataanalys och kategorisering. Ytterligare studier i detta ämne skulle vara av värde för att vägleda sjukvården i hur man bättre kan arbeta förebyggande samt möta behoven hos kvinnliga internflyktingar samt internationella flyktingar. Nyckelord: Begreppet hälsa, Kontroll, Georgien, Identitet, Internflyktingar, Marmot, Kvalitativ studie, Kvinnor. 3 WHAT IS HEALTH A qualitative study on the concept of health of Internal Displaced women in Georgia Anneli Hagen Andersson Zandra Persson Hagen, A & Persson, Z. What is health for female IDP’s in Georgia. A qualitative study on the concept of health of female IDP’s in Georgia. Degree project, 15 Credit Points. Nursing, Malmö University: Health and Society, Department of Nursing, 2010. The aim of this study was to examine the health concept of Georgian female IDP´s. This is an empirical study with a qualitative approach based on semi-structured interviews. In total seven IDP women in the city of Zugdidi in Georgia participated. The data analysis was inspired by Burnard’s (1991) content analysis, and resulted in two categories: 1) The experience of Control with the sub-headings Social Situation, Family and Lack of money and 2) The experience of Identity with the sub-headings Origin, Ability to cope and Self-worth. These are all crucial factors for the participants to lead a life with dignity and in control, which are important for having health. Marmot’s theory on social determinants of health has influenced the data analysis and categorization. Further studies on this subject would be of value to guide the healthcare system in how to better prevent and meet the needs of female IDP’s and refuges. Keywords: Concept of health, Control, Georgia, Identity, Internal Displaced People, Marmot, Qualitative study, Women. 4 CONTENTS INTRODUCTION 7 BACKGROUND 8 Historical Overview 8 Theoretical Framework 8 What is Health? 9 Living as a Female IDP 10 Coping with the Situation 11 Meeting Refugees 11 AIM 12 Definitions 12 METHOD 12 The Participants 12 Data Collection 13 Data Analysis 14 Credibility 16 Preconception 17 ETHICAL CONSIDERATIONS 17 RESULT 18 Experience of Control 18 Social Situation 19 Family 19 Lack of Money 20 Experience of Identity 21 Origin 22 Ability to Cope 22 Self-worth 23 DISCUSSION 23 Method Discussion 23 The Participants 24 Data Collection 24 Data Analysis 25 Preconception 26 Result Discussion 26 Experience of Control 27 5 Experience of Identity 29 CONCLUSION 32 Model Presenting the Concept of Health 33 Further Research and Value of the Study 33 REFERENCES 34 APPENDIX 37 Appendix I 38 Appendix II 39 Appendix III 40 6 INTRODUCTION The aim of this study is to examine the health concept of female Internal Displaced People’s (IDP'’) in the Georgian city of Zugdidi. IDP’s refers to persons who have been dislocated from their homes as a result of an armed conflict, and whom have not crossed an international border (IDMC). This study was done with the ambition to give social workers and health personnel working among these women a better notion of where to put their effort. The study was performed by interviewing seven IDP women concerning their concept of health. The study was carried out in the refugee settlements in the area in and around Zugdidi, with the support from the Non Governmental Organization (NGO) Gaenati. Gaenati have projects in the Community center, where the IDP´s live. Gaenati have different projects in the Community centers, trying to provide the IDP’s with tools to help them cope with their situation (Kvinna till Kvinna,730). The contact with Gaenati was established through the Swedish organization “Kvinna till Kvinna”, a foundation with the objective to support women in war-affected areas (Kvinna till Kvinna, 388). According to the ethical code for nurses (ICN, 2005) a nurse is obligated to promote, as well as improve, patients’ health (a a). In order to follow this guideline it’s central to recognize all patients’ specific needs, and approach to health. In Sweden today nurses meet many patients with different social background and cultural inherence. To give the patients the healthcare required we find it important for nurses to have information on different views of health, as well as the knowledge about various lived experiences of health. Further the nurse ought to endorse a society where human rights are respected and efforts are taken to improve the health and social situation of marginalized groups (ICN, 2005). Refugees is generally a marginalized group, and according to UNHCR (Solheim, 2005) IDP’s is one of the largest vulnerable populations in the world, with a crucial impact on their health (a a). In Zugdidi there is 16453 IDP’s living in different refugee settlements, so called Collective centers (Ministry of Refugees and Accommodation, 2009). These centers are of different quality and located in various parts of the area in and around Zugdidi. Access to food markets depends on the centers location. Many of the centers in the suburbs of Zugdidi are far from the places to buy food and other necessities for a healthy life. These IDP’s have to take the bus into Zugdidi. The bus to get to market and back is 1 Georgian Lari (GEL). The IDP’s get 28 GEL per month from the government (Gaenati, 2008). All IDP’s in Georgia get an insurance card in order to use for the healthcare. From what we’ve experienced when discussing with IDP’s, the healthcare provided this card is very poor. In order to get better healthcare they would have to pay, as well as to get the medicine prescribed by the doctor. The situation for the IDP’s in Zugdidi appear in many ways poor, and so far it seems like very little is written concerning the issue of female IDP’s concept of health in the area. BACKGROUND 7 The whole Caucasus is a region burdened with ethnic and religious conflicts, both historically and in present time (Burke, 2004). In Georgia today, there are many ethnic Georgians who fled from the regions South Ossetia and Abkhazia, and whom now live as IDP’s in refugee settlements in different parts of the country. In Zugdidi in specific there are in total 46388 refugees, 16453 of these living in so called Collective centers (Ministry of Refugees and Accommodation, 2009). Living as an IDP has a crucial impact on health, both physical and psychological, and women are especially vulnerable (Rehn&Sirleaf 2002). Historical Overview Georgia is located in the southern part of the Caucasus region. Since the fall of the Soviet Union in the early 1990´s violence and conflicts has been an ever present element in the region (Babtjenko, 2009). At the time of the breakdown of the Soviet Union the three republics Abkhazia, South Ossetia and Adzhazia declared themselves independent, and no longer a part of the Soviet-republic Georgia. The president of Georgia tried to annex his protectorate in late 1991, which led to war with Abkhazia and South Ossetia (Babtjenko, 2009). In September 1992 a ceasefire was agreed upon, and in 1994 the parts came to a US-sponsored peace agreement (Burke, 2004). The main concern in the conflict is of land, resulting in a situation with different ethnic groups harassing each other. This has led to a violent situation for the people, even in between the wars (a a). Since the peace agreement in 1994 the situation in the area is tense, and in the beginning of August 2008 a new war broke out (Babtjenko, 2009). Georgian forces went into South Ossetia on the 8th of August 2008 and Russian forces struck back to protect the Russian citizens in South Ossetia. The war lasted for about five days, and Russian soldiers also extended to Abkhazia during this time. The number of Russian soldiers remained in Abkhazia and was extended to a higher number than agreed upon during the ceasefire, thus Russia has now the military control over Abkhazia (Kvinna till Kvinna, 728). Before the war 2008 there were over 200.000 internal displaced persons (IDP’s) in Georgia, and during August 2008 this number largely increased (Mathisen, 2008). From the conflict with Abkhazia in the beginning of the 90’s, there still remains 46388 IDP’s in the Zugdidi region (Ministry of Refugees and Accommodation, 2009).