WHAT IS HEALTH

1

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

2

“/…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)

3

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.

4

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.

5

CONTENTS

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

6

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

7

INTRODUCTION

The aim of this study isto 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 inthe

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 isgenerally 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 fora 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.

8

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).

Georgia has used a lot of its economic resources in the various conflicts, and corruption is a crucial problem in the country. More than 85% of the population in Georgia is considered poor. (Burke, 2004)

The conflict is multifaceted and who to be held responsible is depending on which source turned to. As in all war losses have been suffered on both sides (The Council of European Union, 2009).

Theoretical Framework

Michael Marmots theory on Social determinants of health (2004, 2006, 2006b) will be used as a theoretical framework in this study. Marmot (2006b) emphasize that the social status a person possess will affect their health. Marmot (a a) stresses the social status as being influenced by factors as educational level, economic situation, housing conditions and so forth. The status is to be referred to the society lived in, and it might change if displaced to another society. Marmot (2006) means that social hierarchy in a society is an absolute but the

9

health gradient linked to this hierarchy might change during time. Marmot emphasize that the further down in this hierarchy, the poorer health and shorter life expectancy (a a).

Marmot (2006b) purpose the reason for the relationship between social status and health to be related to the degree of control over life and the participation in the society. Further Marmot (2006) emphasizes autonomy, empowerment and freedom as essential human needs, and having control over life and the ability of leading a life valued as being determent for health (a a). People higher up in the social hierarchy often have more control over their life, as well as the possibility of a higher degree of participation in the society (a a). Accordingly, rendering Marmot, this person will be healthier, and live longer than a person with lower social status (a a).

What is Health?

Health, construed as a concept by an individual, can be seen as depending on context. Conditions that might effect, or should be emphasized, according to Radley (1994), are culture, period of time and social situation (a a). Apart from this, efforts are made to find a universal definition of health, often in relation to human rights. The World Health

Organization (WHO) defines health as following;

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948)

As quoted above, this definition cannot capture aspects that are important to an individual (Radley, 1994), as it aims to be applicable on every circumstance. This definition may though be accepted as a maxim where in one may specify the individuals particular conditions given the context of living. Some go even further in their critic and render this definition of health as totally useless and completely out of touch with recurrent understanding of disease at molecular, individual and societal levels (E. The Lancet, 2009).

The health concept, and what it comprises, is also discussed within both international and national institutions and authorities around the world. Having a mutual definition might be important in order for both national and international institutions and authorities to have guidelines to follow in their health-promoting work around the world (Nordenfeldt, 1986). To promote the health of these female IDP’s we wish to add a few of these women’s perspectives on the concept of health to the discussion.

Nordenfeldt (1991) endorse that health refers to a holistic point of view as well as a strictly medical one. The holistic view offers a broad picture which allows the encapsulation of several aspects on health (a a). In this study the initial position will be a holistic view on health, in order to be open-minded towards all aspects that might come forward during the interviews.

The ethical code for nurses (ICN, 2005) emphasize that nurses are obligated to promote, as well as improve health among the people (a a). To follow this standard all patient’s specific needs, and beliefs about health, has to be recognized. Not generalize, but to see the person behind the diagnosis is essential in this work (Travelbee, 2002). Seeing the individual and trying to recognize every patient’s own perception on what the concept health comprises will help the nurse in doing a better job. To do this, the nurse has to communicate with the patient, communication is a central part for a nurse during work (a a).

10

Apart from the individual aspect of health, it might also be of great importance for the nurse to have in mind different cultural aspects of the concept. This might differ in various parts of the world, and can comprise aspects as spiritual balance as well as physical well-being (Spector, 2009).

Living as a Female IDP

Civilians are an important target in wars all over the world. Large parts of the civilians

affected by wars are women, who often suffer from gender based violence. Their bodies often become battle fields used by forces to take control over the situations and harm the enemy. In the trace of a conflict women’s rights are usually not prioritized, or not even recognized. (Rehn&Sirleaf 2002)

In the end of 2008 observers from UNIFEM reported discrimination against groups of women in Georgia, as well as gender based violence (UNIFEM, 2009). In the Abkhazian conflict, systematic raping was used from both sides as a tool of ethnic cleansing (Buck, Morton et. Al, 2000).The observers considered the situation for women affected by the conflict as bad

(UNIFEM, 2009). Violence against women is common in the Caucasian area, but it´s not a topic the government prioritizes (Kvinna till Kvinna,727).

In a civil war the institutions that constitute the civil society fail to function properly, and this includes the health care.70% of all IDP’s in Georgia have limited access to, or completely lack access to healthcare (ICRC, 2009). The official healthcare is supposedly free for all IDP´s in Georgia, but reports shows that this is not the actual case. Because of the hard economic situation for most of the IDP´s they usually cannot afford healthcare nor medicine (Buck, Morton et. Al, 2000). In the refugee settlements there are special health hazards due to failing hygiene facilities, lack of clean water and the crowdedness which leads to rapid spread of infectious diseases.This tends to affect women foremost due to the fact that they often have the main responsibility for the care of the family. (Rehn&Sirleaf 2002)

The long term needs for refugees of all kind are usually of a psychological nature. Living as an IDP has a profound impact on mental health. The clash of the former life and the present situation in addition to traumas has to be processed in order to regain a sound mental health (Rehn&Sirleaf 2002). Studies from different areas in Georgia showed that around 86% of all displaced adults suffered from post-traumatic stress syndrome in 1995 (Buck, Morton et. Al, 2000).Stress and lack of mental health do likely also affect organs in the body in a way that leads to physical health problems, like heart diseases and diabetes (Hedner, 2007). A report from the International Committee of the Red Cross (ICRC) in 2009 shows that 70% of the IDP’s in Georgia lost contact with close relatives during the escape, a circumstance that might have a significant effect on their health (ICRC, 2009).

In the end of June 2009 many of the IDP`s in Georgia were still living in temporary

settlements, where the houses are often of bad quality. Furthermore limited access to water, among other things, leads to bad harvest and in the end lack of food and income among the IDP´s (Edgren-Schori, 2009). Most of the IDP’s in Zugdidi arrived in 1992-1993 and accordingly they’ve stayed in these temporary centers for around 18 years (Gaenati, 2008). Since April 2008 all IDP´s in Georgia are given 28 GEL (about120 SEK) per month from the Government, as well as housing in the Community centers, including electricity. The

Community centers comprise of old schools, hospitals and so forth. The numbers of people living in one center differs, as well as the quality of the Community centers. Many of the

11

IDP’s in the centers lack basic living items as well as sanitary facilities. Furthermore the unemployment among the IDP’s is very high. (Gaenati, 2008)

Many of the IDP’s lack economical resources to give their children a proper education. Primary school is free in Georgia, though money is required for books and other items necessary for school (Gaenati, 2008). The lack of money, as well as the location of some of the centers, leads to lack in access to healthcare and medication. All IDP’s gets an insurance card from the government in order to use for healthcare, but reports shows that the healthcare available with this card is insufficient (Edgren-Schori, 2009).

Coping with the Situation

The mental health among the IDP´s in Georgia is bad. It seems, however, as the women generally have developed task oriented coping strategies, and are working hard for the daily bread. The men have a generally more passive attitude than the women, and are handling the situation by brooding about their former life in Abkhazia. As a result the women become the main provider for the family. (Edgren-Schori, 2009)

Losing control over life affects people in different ways, with diverse strategies to take the control back. These kinds of strategies are often defined as coping strategies, and might be of different approach depending on the person. The coping strategies can be either dysfunctional or adaptive (Usta, Farver, Zein 2008). The women in Georgia seem to have an adaptive way of coping with the situation, adapting to the new situation by working hard and trying to be the provider of the family and one self, in order not to be dependent on someone else (Edgren-Schori, 2009). This is a way of empowering oneself, taking control over life back and in this way have the autonomy and freedom, all crucial for health (Marmot, 2006b).

Meeting Refugees

Nurses have the responsibility to help the patients with needs they cannot fulfill themselves (Kirkevold, 2007), as well as to provide support in giving the patient the tools towards being independent after periods of illness. Nurses need to communicate with the patients, observe and interpret their behavior and at the same time being humble to the fact that we cannot fully understand another person’s needs (Travelbee, 2002).

In war affected areas resources are limited, and priorities are vital. To fully meet the female IDP’s most urgent and essential long term needs the nurses have to identify these priorities. The nurses ought to provide knowledge in order to give the women the prerequisites to make informed choices, and to fully recognize the grasp of health (Fagermoen 2006). To do this communication is central (Travelbee, 2002).

In addition to the basic needs concerning food, shelter and so forth, there is also an urge for psychological support as well as to regain respect and dignity amongst IDP’s in Georgia (ICRC, 2009). This is something nurses working among the IDP’s should have in mind. Nurses ought to meet all humans with respect and dignity (ICN, 2005), and the IDP’s are in such situation where this might be essential in improving their health. Lack of respect and dignity, as well as the low income, low level of education and bad housing condition are all factors influencing the social status of the IDP’s in a negative way (Marmot, 2006b). With a low social status in the society, it is likely that their health is affected in a negative way (Marmot, 2006).

12

AIM

The aim of this study is to examine the health concept of Georgian female IDP´s. The research questions were:

 To define which main factors that constitutes health for women in IDP settlements in Georgia.

 To define physical and mental factors that affect these women´s health in a positive way.

 To define physical and mental factors that affect these women´s health in a negative way.

Definitions

The health concept in this study will mainly refer to a holistic way of understanding health, as it allows the encapsulation of all aspects of health (Nordenfeldt 1991).

In this study IDP’s refers to “persons or groups of persons who have been forced or obliged

to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalised violence, violations of human rights or natural or human-made disasters, and who have not crossed an

internationally recognised State border." (IDMC)

Method

The aim of the study is to examine female IDP´s concepts of health. A qualitative design implying a flexible research design to gain an in-depth understanding for the subject under inquiry was used. Using an inductive process furthermore allowed weaving together pieces of narrative information collected into a coherent and cohesive pattern. (Polit & Beck, 2006, Lundman & Hällgren Graneheim, 2008)

Human’s ability to communicate verbal self-reports are an important tool in nursing research and of data collection. Semi-structured interviews were performed. A topic guide was used to make sure all areas of inquire were covered and that all questions that had to be addressed in the interviews were asked. The number of participants was determined by data saturation. The aim was not to reach generalizability but to gain an in-depth, and a holistic understanding of the concept of health, as intended by inductive, qualitative design. (Polit & Beck, 2006) The findings were discussed against Marmots thesis concerning parameters determine health. This was decided after the categorization was made and the similarities to Marmots thesis about health parameters became obvious.

The Participants

The sample size was partially affected by data saturation (Polit & Beck, 2006). Time schedule as well managing the amount of data also played a part (Lundman & Hällgren Graneheim, 2008). Saturation can usually be achieved with a fairly small number of participants if the

13

information is of sufficient depth and collected in a manner of persistent observation (Polit & Beck, 2006).

Inclusion criteria were being a woman in the age of 16-64 years old, which had spent at least 6 months in one of the Community centers. Using a heterogeneous group was useful in documenting the scope of their concepts of health and in identifying important patterns that cut across variation (Polit & Beck, 2006).

The participants consisted of a volunteer sample, commonly used when researchers need participants to come forward (Polit & Beck, 2006). A social worker at the NGO Gaenati acted as gatekeeper. According to this NGO these IDP women are reluctant to speak to strangers. Gaenati has worked for a long time to gain their trust. Gaining entrée to marginalized groups usually involves negotiations with gatekeepers who have the authority to permit entry into the respondents’ world (Polit & Beck, 2006). To establish contact and perform our interviews we needed to use Gaenati as our gatekeeper, in order to ensure cooperation and access to

respondents.

After have been shown around in different Community centers, and introduced to several IDP’s, whom some we ended up interviewing, the inclusion criteria were discussed with our gatekeeper. The gatekeeper then asked seven suitable women if they were willing to

participate in the study, all the asked women agreed.

Data Collection

Interviews are an important tool in nursing research and of data collection (Polit & Beck, 2006). With an inductive qualitative approach, semi-structured interviews were performed to gain an in-depth understanding of the subject health as well as toencourage the participants to talk freely.

A topic guide, which contained eight broad questions concerning areas that had to be covered in the semi structured interview, was used (Appendix 1, Lantz, 1993, Polit & Beck, 2006). It concerned the participants’ concepts of health, what is good versus bad health, what is having or not having health, further what made the participant feel good versus bad, and finally a situation wished for concerning health. The topic guide was used to make certain that all areas were covered and that we hadfulfilled our aim. The opening question was as follow; “What do you think about when I say the word health”.

Before the interviewing started a few Collective centers were visited to become acquainted with the circumstances under which the IDP’s live, as well as their life world. The life world is a person’s frame of reference, or in other words, the reality in which a person’s life is created and regenerated (Burnard, 1991). A social worker at Gaenati whom acted as gatekeeper and interpreter were able to help us during the week 14 and 15, hence were the interviews performed during this period. Furthermore we wanted to perform the interviews as soon as possible to be able to start the analyzing process, and in case of discovering lacking data saturation, having the time to perform more interviews before returning back to Sweden. At first a successful pilot interview with a woman in one of the Community Centers was performed, it was thereby included in the result and confirmed the accuracy of our topic guide. After the pilot interview another six interviews were performed. In total seven

interviews were performed. This was a suitable amount of informationto handle and enough to accomplish data saturation (Polit & Beck, 2006, Lundman & Hällgren Graneheim, 2008).

14

The interviews were held in the IDP’s own room at the Community center where they live. According to our gatekeeper this was the best option due to some women not being able to leave their homes due to different reasons, as well as the home environment being the most comfortable place to be interviewed for the IDP’s.

The interviews were held in private. During two of the interviews the women’s children were present, and again due to it being the least stress full situation for the respondent.

The interviews were opened with introducing questions of demographic type, they were however not included in the result due to lack of relevance. Amongst these were questions about the respondent’s age, time in the Community centers, origin, if they left Abkhazia alone, occupation, current activity, and so forth. The semi structured interview, conducted by the topic guide, followed the introducing questions.

The interviews were recorded with two Dictaphones, in case one of them would malfunction. The recordings were stored in a locked cupboard. When transcribed, both the transcripts and copies of the recordings were stored on two different computers with safety access.

The interviews were performed with both of us present, in way to enhance credibility. Investigator triangulation, using more than one person to collect and analyze a set of data, were performed with the aim of decreasing intrinsic bias, and also help capture a more complete and contextualized portrait of the health concept (Polit & Beck, 2006). The task as interviewer was alternated with the responsibility to take notes in accordance with Burnard (1991), and to generate follow up questions as well keeping track on the topic guide being covered. The interviews lasted in between 19 to 36 minutes, with an average of 25 minutes. An interpreter was used, and rigorous reflexivity was performed. Using an interpreter can provide access to presumptive participants of different identity, that where before restricted (Temple & Edwards, 2002). Yet the research becomes subject to “triple subjectivity”, the interactions between the participants, the researcher and the interpreter. The interpreter should preferably share the same culture, religion, and, most important, same sex as the interviewee or participants. This enhances the truthfulness and the accuracy of the data. A professional interpreter is to prefer (a a). To gain access to the IDP women a social worker from the organization Gaenati was used as interpreter, who however shared the same sex, religion and culture. The interpretation was performed in third person due little experience to interpret by the gatekeeper, hence are the quotes also in third person.

Data Analysis

Our approach of analyzing the interviews will be influenced by Philip Burnards’ Content Analysis. Content analysis is a method of analysis that can be used on both qualitative and quantitative data; it’s used in different disciplines and amongst them nursing research. Aimed at describing variations by identifying similarities and differences in the data (Lundman & Hällgren Graneheim, 2008). It is a process of organizing and integrating narrative and qualitative data by using themes and concepts as a way of coding the material. These themes are then linked together in different categories and can then be further investigated (Polit & Beck, 2006, Lundman & Hällgren Graneheim, 2008). As preconditioned when inspired by Philip Burnard (1991), open-ended interviews had been carried out; they were recorded in full, and then transcribed word by word (Philip Burnard, 1991).

15

Content analysis according to Philip Burnards 14 stages (1991).

1. After each interview, notes are taken about the topics talked about in that interview. During the research project memos are written about ways of categorizing the data. These memos may record anything that attracts the researcher’s attention during the initial phases of the analysis.

2. Transcripts from the interviews are read through and notes are made, throughout the reading, and general themes are identified. This to become immersed in the data and to

become more aware of the “life world” of the respondent, which is the other person’s frame of reference

3. The transcripts are again being read through and “headings” or “categories” are being made. These categories should describe all aspects of the content. At the same time all dross, or issues that are unrelated to the topic in hand, are excluded. The “category system” or “headings” should account for almost all of the interview data. This stage is called “open coding”.

4. The numbers of categories are being reduced by collapsing some of the ones that are similar into broader categories, under so called higher-order headings.

5. The new list of categories and sub-headings is worked through and very similar headings are removed and a final list is produced.

6. Two independent researchers work through the transcripts in order to make their own categories. These are then compared with the researchers in an attempt to guard against researcher bias.

7. Transcripts are re-read alongside with the list of categories and sub-headings to make sure that the categories cover all aspects of the interviews. Necessary adjustments are made if needed.

8. The transcripts are coded by working each one through, with the list of categories and headings, and each piece of the transcripts are being marked after which category or sub-heading it is being allocated to.

9. Each coded section of the interviews is cut out of the transcript and all items of each code are collected together. Copies of the original coded transcripts’ are used to make sure that the context of the coded sections is maintained.

10. The cut out sections are pasted onto sheets, headed up with the appropriate headings and sub-headings.

11. To maintain the validity during the categorizing process selected respondents check category system by reading them trough and if they have any objections necessary adjustments are made.

12. Before the writing up stage all the sections are filed together for direct reference, and if anything appears unclear references will be made directly back to the transcripts or the recordings.

16

13. When all the sections are together the writing up process begins. The researcher selects the various examples of data that have been filed under that section and offers a commentary that links the examples together. If needed the researcher refer back to the tape recordings or the “complete” transcripts of the interviews as a way of staying close to the original meanings and context.

14. The result is linked with literature (a a).

As noted above the analysis was inspired by Philip Burnard. All the stages were performed in full and in numeric order, except for stage number six and eleven. Those stages were excluded early in the planning of the study. Instead of having two objective researchers making their own separate categories, separate categorizing of the transcripts was performed and stage number six was excluded. Due the varying educational backgrounds and lack of time to integrate the informants on the analyze process was stage number eleven excluded. After approval all the interviews were recorded. Memos concerning specific topics that arouse, demographic information and noteworthy behavior of the informant were written during the interviews.

The recordings were transcribed the same day as recorded, to improve the accuracy of the transcripts. The transcripts were exchanged and possible mistakes in the transcripts were corrected, this strengthens the credibility by the performance of investigator triangulation (Polit & Beck, 2006).

The material was read through several times mean while categories were produced. The categories were influenced by Marmot (2006b). Two lists of categories and sub-headings were created separately. The lists were then compared and revised into a complete set of categories and sub-headings, also to strengthen the credibility.

The transcripts were coded by using different colors for each category and sub-heading. The different categories were copied and pasted onto new word documents, one for each category and its sub-headings. The documents were read through and some rearrangements were made. The writing up process was then initiated and quotations were picked out to strengthen the result. Quotations enhance the credibility and authenticity of the data by offering a way of examining the interpretation of it (Burnard, 1991, Lundman & Hällgren Graneheim, 2008).

Credibility

When discussing trustworthiness Burnard (1991) talks about validity which in qualitative research often is referred to as credibility; the confidence in the truth of the data (Polit & Beck, 2006, Lundman & Hällgren Graneheim, 2008). Burnards 14 stages are partially designed to endorse the credibility, or the validity as Burnard puts it (1996).

A thoroughly described analyze of the data is essential for the credibility (Lundman &

Hällgren Graneheim, 2008). We have been inspired by Burnards 14 stages, and our process of analyzing the data has been systematically described.

The transcripts have been thoroughly processed, and possible mistakes have been corrected, after the individual transcription the recordings and transcripts were exchanged as a way of

17

enhancing credibility.When categorizing two separate lists of categories and sub-headings were made individually, these were afterwards discussed and revised into a final list of categories and sub- headings. Investigator triangulation is a way of enhancing credibility. (Polit & Beck, 2006, Lundman & Hällgren Graneheim, 2008)

Furthermore quotes are used to give the reader the opportunity to examine the accuracy of the interpretations of the interviews, to alter credibility (Lundman & Hällgren Graneheim, 2008). Using a topic guide further enhances credibility by offering the reader a list of broad question that were asked (Polit & Beck, 2006).

To check the accuracy of the topic guide a pilot interview were performed. The pilot interview was successful and no modifications had to be made. A pilot interview should be made to test the adequacy of the questions (Polit & Beck, 2006).

Preconception

As researchers we have preconceptions concerning the concept health, ideas of health are formed by one’s personal experiences as well as the society you’ve grown up in (Leininger, 1995). There´s always a risk that we construe what the participants’ say and do in a way that doesn´t agree with their experiences. Though, preconceptions are the tool, the knowledge and norms that everyone carries with them to understand and interpret the world around them (Lundman & Hällgren Graneheim, 2008).

Bracketing, commonly used in Phenomenology, is according to Polit and Beck the process of identifying and dismantling the preconceived beliefs and opinions about a phenomenon (2006). The researchers should strive towards confronting the data in pure form. This, however, is not considered possible to achieve totally (a a). Some even means that it is impossible to interpret without having any preconceptions; we use them when understanding the world around us (Lundman & Hällgren Graneheim, 2008). Research is always subjective hence to have been produced by a researcher, a person (a a).

Being two nurse students, feminists and firm believers of Human Rights, a particular interest in Women rights and the possibility to live a healthy fulfilling life is shared. Several travels around the world, acquaintances with different cultures and destinies, as well as participation in Human Rights organizations, have affected the interpretations of the world around us, as well as the interpretation of data in this study.

The right to participate in society and living your life as wished; is health as well as a

precondition for health, and ought to be everyone’s right no matter sex, religion or nationality. This made us wanting to become nurses as a way of working with health, and women’s health in particular, with the aim of strengthening health and in the long turn the ability to participate and be an equal participant in society.

ETHICAL CONSIDERATIONS

Health can be a sensitive topic which was accounted for when meeting the women. One’s health is personal and might be sensitive to discuss with strangers or people from a different culture and background, and on top of that with an interpreter present as well. Furthermore

18

our roles as future nurses might enact hope in the women that we might in some way change their health situation. Coming as foreigners might in itself enact hope, when a majority of the foreigners in the area are working for various aid-organizations. Hence it was of great

importance to be clear concerning the reason for the visits in the Collective centers, as well as the aim of the study.

This study has been accepted by the ethical committee at the institution of Health and Society at Malmö University (recordal HS60-10/156:8).

“Kvinna till Kvinna’s” coordinator in southern Caucasus read and approved the project plan in October 2009, as well did the manager at Gaenati in February 2010. Thus their work with the IDP’s, they might have some knowledge about the situation and the ethical considerations that might ascend during the study. Hence their opinions were of great importance before starting the study.

Before the interviews the informants were informed both verbally and in written about the aim of the study, about the fact that their participation were voluntarily and that they thereby had the freedom to interrupt the interview at any time. Furthermore the informants got information on the confidentiality of their participation, and that the recordings and memos from the interviews would only be known by us and the interpreter. Before the interviews started the informants signed an informed consent paper. All the information, verbal as well as written, was translated into their native language.

All recordings and written materials from the interviews were stored in a locked cupboard. As soon as the study is approved upon the tape recordings and the written memos will be erased.

RESULT

Here follows the outcome of the interviews. It will be presented under different categories, and with verbatim sections, as to give the reader a deeper understanding of the material, as well to strengthen the credibility. Throughout the interviews there was a clear outline, all the women brought up similar topics concerning what the health concept encapsulates for them. Out of these topics we generated the categories used under result. The material consists mainly of two categories, with subsequent three subheadings.

The first category is Experience of control with the subheadings:

 Social situation

 Family

 Lack of money

The second category is Experience of identity with the subheadings:

 Origin

 Ability to cope

 Self-worth

Experience of Control

The subheading Experience of Control refers to the ability to define and determine your own life. It involves practical things, like education, having a job, being able to provide for one

19

self, housing condition, and so forth. Also included is the image one wishes to portray of one’s self, both before one self and before others.

One apparent factor often mentioned by the women was the lack of and need for control over their life. Many of them talked about worries about their families, friends, and the future of their children. Furthermore they talked about lack of money and worries of future expenses, like medical bills, which they feared they might not have enough money for. They also expressed feelings that physical illness affected them in a way where they did not have the control over their body, which for them is crucial for having health. Additionally the social situation was of great importance to them. The women meant that living in a country without peace means not having control over your everyday and your living environment. They meant that this is a contradiction to having good health.

Social Situation

The social situation refers to the situation in the country concerning to the economic and political situation in general. The warthorn families apart, affecting their social situation. Furthermore the heading refers to their living condition, with poor housing, lack of jobs, coming with being a marginalized group in the society. Also included are the physical illnesses related to the social situation, described above. These are all circumstances beyond the individual’s control.

Several of the women mentioned the situation in the country with the conflict amongst Abkhazians and Georgians as affecting their health in a fundamental way. Many of them expressed fear of the conflict fully blooming up again. Several have family members or friends whom live back in Abkhazia, and they worry about their security and their everyday situation.

“Because after the war nobody has the good health. When they came here they have big

depress, and psychological problems also. /…/And everything is the war, coming from the war, these problems, psychological and depression and everything./…/ She think that if the social life became better everything will be good, for her and everyone.” (Respondent 4)

The women expressed being nervous due to the political situation in the country, believing that it affects their physical and psychological health in a negative manner. Most of them mentioned having illnesses like high blood pressure and depressions, according to themselves stress and war related problems.

“/…/Heart problems she has four years, but headaches she has/…/when she arrived from Abkhazia here/…/” (Respondent 3)

All of the women amplify their living conditions in the Community centers. They believe these have a negative impact on their health. They mention worrying about the winters and not having enough wood to keep warm.

“/…/that you will never have the health problems if you have job, money, food water and social life.” (Respondent 3)

Family

20

Most of the women mention their families’ health and general situation as being one of the most important causes for their own health.

“/…/ she wants the daughter’s health first of all. If she feels good she [the mother] will feel good” (Respondent 7)

Another important issue for the mothers is their children’s future. They express that these worries have a big impact on their health. They believe that the poor living conditions in the centers are a bad environment for the children to grow up in. According to the women these living condition are a cause to many illnesses which they fear not being able to manage the costs for. They also mention worrying about their children lacking jobs, and not being able to afford a proper education.

“/…/ she has some heart problem, because she’s getting nervous about her kid/…/” (Respondent 7)

Several of the women also mention that the family and friends being their support is a crucial component in their health. The family functions as source of power and strength in difficult situations. The women mean that friends and neighbors in the Community centers also act as an extended or for some the only family to share the good and bad with.

“When she was bad her kids were standing with her and they were helping her in every way. /…/ her children were standing by her side during this period. Helping and giving power.” (Respondent 6)

One woman express the importance of having someone to talk to, when she’s just sitting at home by her selves she feels like she brood too much. To be able to share your problems, and giving as well as getting advices, she feels, is improving her health.

“/…/ she feel better when she’s talking about her problems with somebody/…/ sometime her friend also have the problem, and when she’s [the friend] talking about problems with X, and X helps in some way, giving advices or doing something she’s [the respondent] feels better inside/…/” (Respondent1)

Some of the women pointed out the distance to the family members and friends, which still remain in Abkhazia, as a negative factor for their health. The ongoing conflict and insecure situation in Abkhazia makes it hard, and in some cases impossible, to visit them. One woman mentioned that young women are especially vulnerable, which was the reason for her to maintain in the Community center when her family returned back to Abkhazia.

“/…/It’s very dangerous she said, to live in Abkhazia when you are a young woman and if not married. /…/ “ (Respodent 5)

Lack of Money

Lack of money refers to circumstances deriving directly from the lack of money.

Overall the women talked about the lack of money as negatively affecting their health. Most of the women expressed the wish to return and visit the family and friends whom still live in Abkhazia, but they can’t afford to. Another worry was the fears of future expenses for healthcare and possible medical treatment.

21

“At first she felt the pain from leg, it was very painful to walk. She never visited a doctor because she didn’t have any money, she took painkillers that she got by herself. She was walking with a stick, and it was the worst period of her life.” (Respondent 6)

Several of the women mentioned having pain caused of different reasons. They all considered having pain as a hindrance of having health, since they can’t afford paying for treatment.

“/…/ She has no money to visit the doctor and discover everything about this Polynefrit. She has this insurance card, but this is nothing to visit the doctor and explain what the problem she has is and what she need. /…/ She needs 17,4 GEL to buy this medicine. She only bought the tea, because she has no money for the other medicine. /…/”” (Respondent 4)

Above this many of the women and their family members have current medical issues which they cannot afford to pay visits to the doctor or treatment for. Furthermore they mention problems with putting food on table, and affording firewood during the winter. One woman mentioned the winter as her worst period, because she could not afford paying for firewood to heat up the room and keep her and her children warm.

“The worst period for X every year is winter/…/ sometimes she has no wood for fire and keeping the place warm and she’s feeling very bad this time. /…/” (Respondent 1)

The women talked about lacking jobs and the worrying about their children lacking jobs, the main reason for these worries are the shortage of income to cope with daily expenses.

“The main problem for X is not having the job, nor her sons. /…/” (Respondent 3)

A few of the women also mentioned that the physical pain from time to time has been a hindrance in performing their job which generate an income. This is, as mentioned above, crucial for their health.

“/…/got this osteoporosis, back pain, stomach pain /…/ when she was feeling bad, and it was difficult to teach the kids, and she sometimes stopped teaching at the school/…/” (Respondent 2)

Experience of Identity

Health was frequently associated with aspects concerning their identity. Many women expressed a need and desire to show their children where they origin from, their Abkhazian heritage. As well as where they used to live, old friends, neighbors and in general their former life in Abkhazia. Frequently the women expressed how the solution to their many problems would be the return to Abkhazia. Furthermore they were commonly discussing their ability to complete different plans and tasks. This ability could be connected to having a physical or physiological illness, giving them an image they could not identify themselves with. In relation to this the women often expressed not having the mental strength they wish for. Likewise was the wish to feel needed, and to contribute to their family and society important for their health.

“/…/ she will so happy, and she has no word for how to say this, she wants to go back home, and have her work back, her friends. And first she wants to show her son her house, and relatives, and friends, and everything in Abkhazia.” (Respondent 2)

22

Origin

Origin refers to their Abkhazian inherency and a need to feel a sense of belonging, according to the women an important part of the concept health.

As mentioned a common topic was the positive impact that the return to Abkhazia would have on their health. Several women expressed how they never used to have any problems, and that most of their current problems are related to having left Abkhazia.

“/…/ She will feel good if she went back to Abkhazia, and lived with her family in her own house./…/” (Respondent 6)

Several times expressed by the women was also the desire to provide their children with a sense of history of, and sense of belonging to Abkhazia. Most of the women align their former life in Abkhazia with a healthy life.

“/…/When she was living in Abkhazia she had no pain and no problems/…/” (Respondent 6) Ability to Cope

The ability to cope refers to the actual ability as well as one’s believed ability of what one can reasonably achieve in the society lived in.

Two different aspects of the ability to cope came up during the interviews; the first was connected to physical condition. Some of the women described that physical disability

prevent them from achieving what they consider to be health for them. The women mentioned these physical illnesses as an obstacle in their daily life and for future dreams and plans. They meant that to be able to do what you wish for is an important aspect of health.

“/…/She had Myoma /…/ she had no pain but she was worried because she’s not married, and she wants to be a future mother, so she was worried about it.” (Respondent 5)

“/…/ Today she is very powerful, because she can walk without a stick./…/” (Respondent 6)

The other facet of the ability to cope is more related to the emotional state of the women. Some of the women expressed thoughts about the importance of the compatibility between their state of mind and their physics for having health. A few also talked about how being able to find the strength inside of them was crucial in achieving health.

“When your inside /…/and your own character is working together /…/body and soul together /…/ It’s everything for X, when she feels that they are both working together good she is one a high level, it’s everything for her.” (Respondent 2)

A few of the women mention that their psychological condition prevents them from achieving the kind of life they would wish for. One of the women talks about a former depression, and how she wasn’t able to enjoy her social life.

Furthermore the women talked about the importance of being able to support and help their family and friends. Again the inner strength was one of the things they mentioned concerning the ability to be there as a mother, and friend. This was of great importance for them when discussing the health concept, and for many of them a source of pride, and the feeling of being important hence to being needed.

23

“/…/ but now she is feeling so good /…/ She feels like she has more power inside. In the future she will help her kids, she feels like she’s back.” (Respondent 6)

Self-worth

Self-worth refers to the feeling of being wanted and needed, and having a worth in one’s own. Many women talked about the need of feeling and acknowledging theirs owns’ worth. They mentioned that only sitting at home, waiting for their children or friend to return makes them feel miserable. While having a job to go to everyday on the other hand made the women feel good.

“/…/when she’s working she never feels bad, never. Not having the health she explain like, first thing for X is job. /…/ When she’s working she feels good/…/” (Respondent 3)

The lack of activation is very stressful, according to the women. Several of the women mention that the feeling of contributing to the society and being able to support themselves is important for them being able to appreciate themselves. Feeling like you matter is important for their health, according to the women. Several of the women also talks about how having a job make them feel good about themselves, simply because of the stimulation the job provides them with.

“/…/First of all she said that they have no job. And they are sitting at home all days, every day. They are not going out to do something. And it feels bad for her health. They have no contact with any persons outside. Only sitting at home and waiting for the kids from the school.” (Respondent 7)

DISCUSSION

Following is a discussion concerning the methodological procedure, and how this may have affected the result. Furthermore a discussion will be held regarding the result, with basis mainly in Michel Marmots theory concerning social determinants on health (Marmot, 2006b, 2004b, 2006).

Method Discussion

A qualitative approach was preferred because of its suitability for examining a persons’ experience and when aspiring for a holistic understanding of a subject (Polit & Beck, 2006, Kvale & Brinkmann, 2009). The aim of this study was to examine Georgian female IDP’s on their concept of health. Semi-structured interviews were performed since they allowed follow up questions which in a better way provide entry to life world of the participant (Kvale & Brinkmann, 2009). Qualitative research does usually not aim at generalizability but focus on the experience of the study participants. Transferability is in qualitative research what

generalizability is to quantitative research (a a). However this study is transferable in another discus is difficult to answer. Never the less are the findings in many ways similar to Marmots (2006b) thesis about health and a person’s control over her life. This supports transferability of our study.

In the initial point of this study a lot of efforts were taken to find research made in the same area, in order to get a first impression of the subject. Studies made on the health concept

24

among refugees, and IDP’s in specific, were not found. In fact, no studies were found at all concerning peoples individual comprehension of the health concept, and what it comprises. The lack of these kinds of studies is unintelligible in an era where the healthcare suggests focus on each patient, aiming for the best care for every specific individual (SFS 1982:763). This is the obvious importance of asking the people, rather than professor’s and doctors, what the health concept comprises of.

The Participants

A smaller but heterogeneous group of participants were used allowing range of the various concepts of health and identifying important patterns that cut across variation (Polit & Beck, 2006). The inclusion criteria were based on the women being old enough to have thoughts about the concept of health as well as having had some experience related to the subject. Furthermore they referred to having lived in a Community center long enough time to be able to identify oneself as an IDP.

Even though being a heterogeneous group there were no notable difference in the answers, and data saturation was established relatively quickly. The sample size was based on time schedule and amount of data to handle, but settled by the reaching of data saturation which was done with the planned seven participants (Polit & Beck, 2006, Lundman & Hällgren Graneheim, 2008).

The choice of only including women in the study was based on an interest in women’s health due to subordinate position in conflict societies (Rehn&Sirleaf 2002).

IDP’s are an even more marginalized group in society, additionally we see more and more refugees in Swedish healthcare, this was a strong reason for wanting to look further into a few IDP women’s view of health. Further men are the norm in health research and therefore we wanted to talk to women specifically about their concept of health.

To gain entrée to this marginalized group of IDP women a gatekeeper had to be used, not uncommonly when having to negotiate achieving entry into the world of the respondent (Polit & Beck, 2006). While considered no dilemma appeared in using a gatekeeper working for the local NGO Gaenati. This organization has worked for several years in the Community

centers, and thereby gained the trust of the IDP’s. The gatekeeper is founded by the Swedish organization “Kvinna till Kvinna” and thereby in some aspects independent of the local NGO. The use of a gatekeeper was our only entrée to these IDP women due the limited time

schedule, language and trust barrier. Data Collection

A first pilot interview was performed, to verify the accuracy of the topic guide. It was successful and therefore included in the result (Polit & Beck, 2006).

To make the interview situation as comfortable as possible for the participants the interviews began with demographic questions, but these were not included in the result due to lack of relevance. Since the participants were inexperienced interviewees it was emphasized that their understanding was the subject of interest, also that there were no right or wrong answers. Several of the women expressed their gratitude of someone visiting and listening to them. This facilitated the data collection. (Dahlberg, 1997)

25

The interviews were recorded to enable word by word obtainment. This could have made the women feel uncomfortable. Information was yet given in connection to the interviews about the aim of the study and the confidentiality, furthermore who would have access to the recordings. All of the asked women choose to participate, and none seemed hesitant even though it would be recorded. The recordings were of good quality and only on a few occasions were there any troubles to understand and transcribe the recordings. This did not affect the result being only minor blurriness. They were transcribed the same day to contain the context fresh at mind, and to improve the accuracy of the transcripts and to thereby alter credibility (Burnard, 1991, Polit & Beck, 2006).

Before the interview was completed the participant was asked if she wanted to add anything. Notions were also taken on how the participant experienced the situation. The both of us and an interpreter present during the interviews might have made the women feel uneasy being the minority. Our interpreter ditto gatekeeper yet informed us that it was not a problem.

Furthermore the both of ours’ presences enhance Conformability since the interpretation was not one handed (Polit & Beck, 2006). Also notes could be taken accordingly to Burnard (1991), and feedback on the interview technique as well as follow up questions could be given by the part not performing the interviews. This alters the credibility of the data (Polit & Beck, 2006). Due the fact that two interviews were performed a day, the interviewing and memo writing was alternated. This was to avoid mixing up the different information obtained. The interviews taking place in the participants’ home, as well as the interpreter being someone trusted might have evened out us being of greater number and made the situation more comfortable.

An interpreter had to be used due to language barriers. This takes the researcher further away from the original source of information, as well as bringing a third element into the study, leading to an interaction between the participants, the researcher and the interpreter (Temple & Edwards, 2002). To minimize destructive additional interpretation of data thorough

reflexivity in the research ought to be performed, to alter credibility. This is facilitated by the interpreter preferably sharing the same culture, religion, and sex as the participants, to

enhance the truthfulness and the accuracy of the data (a a). The interpreter used was a woman, whom shares the same culture and religion as the participants, and her work at Gaenati has given her an understanding and knowledge about the IDP’s situation. This might level her bringing extra preconditions into the study. Her specific knowledge and the IDP’s confidence in her make her more suitable than an unfamiliar professional interpreter. Without our

interpreter ditto gatekeeper we would not have been granted access to these IDP women. Even though also widening the gap between the researcher and the researched using an interpreter can grant access to field of inquiry that otherwise can’t be reached (Temple & Edwards, 2002).

The women were encouraged to speak freely on the topic health. Data Analysis

Content analysis is a method commonly used in different disciplines and amongst them nursing research (Lundman & Hällgren Graneheim, 2008). Compared to several other methods content analysis are not connected to a specific theory, which make it fairly easy to use. Using a method that requires learning a theory thoroughly would oblige a different time schedule than ours, if aiming to do it properly.

26

The analysis was inspired by Philip Burnards 14 stages of Content analysis (1991). Stage six and eleven was however excluded. It was not possible to invite external researchers. In an attempt to compensate for this, two individual lists of categories and sub-headings were performed, these were then compared and revised into a complete set of categories and sub-headings, to strengthen credibility (Polit & Beck, 2006). The two original lists contained no contradictive categories, and were revised into a final list after discussion. The differences were in choice of word rather than in difference of contents. Allowing selected participants to check the category system was not either possible due the participants lacking knowledge concerning the chosen method as well as the English language. This might affect credibility negatively.

Individually the transcripts were read through while simultaneously listening to the recordings several times. When blurriness occurred the interpretation was discussed together, to obtain congruence of the accuracy of the data and thereby alter the Confirmability or neutrality of the data (Polit & Beck, 2006). Blurriness only occurred a few times and none of that particular information was included or of relevance for the result.

Preconception

Researchers have preconceptions concerning the concept of health; ideas of health are formed by one’s personal experiences as well as the society you’ve grown up in (Leininger, 1995). The cultural and social differences between us and the participants might affect the

interpretation of the answers, as well as the answers given by the participants. However preconceptions are not utterly bad, some even means that it is impossible to interpret without having any preconceptions; we use them when understanding the world around us (Lundman & Hällgren Graneheim, 2008). Studying to become nurses have reevaluated the understanding of health as something essential and multifaceted, hopefully allowing for a more open attitude and a greater understanding for others concept of health. Further by not having a planned theory no specific information was sought for, which might decrease the risk of bias. Many of the women expressed appreciation for us showing an interest in their opinions concerning their concept of health. We did not experience them giving us answers modified after their belief about what two western nursing students could be expected to want to hear. Their experience was emphasized.

Result Discussion

The result of this study concerns IDP women’s concept on health, which is of great relevance and importance for nurses all over the world. Refugees are found in all parts of the world, and the result of this study might give healthcare personnel working with them a notion on where to put effort when dividing scares resources. The ethical code for nurses (ICN, 2005) confine that a nurse is obligated to promote, as well as improve, patients’ health (a a). In accordance with this, the result of this study will give nurses some aspects on what health can refer to. All of the women expressed health as being a most essential part of life. The women talked, in different ways, about the control over life. The feeling of having control over life is,

according to the women, a crucial factor for health. This is also what Marmot (2006b) emphasizes in his theory concerning how social determinants affect health. His studies show that control is one of the main factors for health, which is also in accordance with the result of this present study.

27

Furthermore was identity a subject often brought up by the women. They meant that the possibility to fully express their identity has a significant impact on health. Dignity is an important part of a person’s identity, and Marmot (2004) emphasizes dignity to be an important factor for health. As implied by the name, these IDP’s have had to leave the lives they knew and start something new. Due reasons within and beyond their control several of these people now live in poverty, with poor housing, lacking income and as marginalized in the public society. These conditions affect the social status of a person negatively, thereby also their health in negative manner (a a). These women might feel depraved of their dignity and identity due the changed social status derived by their new position in society as IDP’s. Experience of Control

Control a crucial factor for health according to the participants. The women express that the ability to have control over their social situation, their family’s situation and future as well as their economic situation is of great importance for their health. According to Marmot (2006b) health follows a social gradient, where higher status is followed by stronger health. Or in reverse, there is a significant positive association between lower social status and higher mortality, with the feeling of having or not having control over life as an aspect giving this positive association (Marmot, 2006). The participants have had to leave their home, job, school, friends and family, and the region they considered to be theirs. They are now living as IDP’s in Community centers, depending on the government for housing, electricity and money for daily costs of food and so forth. They have declined on the social gradient and therefore also altered the risks of losing their health (a a). Having control, as in having a ready supply of food and water, adequate shelter, and sanitary facilities makes leading a life one values more of a possibility and should alter the possibility of a healthy life (Marmot, 2006). Control can thereby be seen as following a health gradient.

A majority of the women discussed the situation in the country in general, and the political situation in specific, as affecting their health significantly. According to Marmot (2006b) is the degree of control and participation in society determinants for a person’s health. Living in a country where conflict is ever present is an obstacle for having health by complicating the participation in society, and the everyday life. Further are the possibilities of controlling one’s life significantly decreased when living in a country with conflict, due to the fact that the conflict is beyond the individual’s control. Decisions affecting civilians’ life significantly are taken above their head, on a high political level; giving a situation where the individual have little or no control over facts affecting the everyday life (Rehn&Sirleaf 2002).

The fear of the conflict fully blooming up again was one main issue brought up by the women. To be in a stressful situation, as fear imply, will affect not only the psychological condition but also the physical condition (Hedner, 2007). Historic and the present conflict in the country has led to reduced investments in infrastructure, such as public transportation, stores, municipal services, sport activities and other commodities. This type of social

infrastructure enable participation in society, without it the participation is reduced and with that the health (Marmot, 2006b). Societies characterized by high social coherence have better health than societies with low coherence (a a). The participants emphasized the conflicts impact on society and their health, often referring to depression and other psychological issues as important health-problems. The participants explained that the stressful situation is causing heart-problems, high blood pressure and so forth. The health concept for these women comprises of both physical and psychological conditions, and is influenced by the political situation in the country.