Natural disasters affect 200 million people every year, and since 2008 an average of 26.4 million people have been displaced due to natural disasters per year (UNFPA, 2015).
In April and May 2015, two earthquakes struck Nepal. 8,856 people died and almost three times more were injured. Damage to infrastructure was extensive - 887,356 houses and 963 health facilities were affected. In May 2015, the United Nations Office for the Co-ordination of Humanitarian Affairs estimated that 2.8 million people had been displaced by the earthquake. In April 2016, 2.6 million of these remained displaced.
Research suggests that disasters are experienced as a gendered event - their impact is both more extensive and different for women than men. In 2002, the World Health Organization (WHO) published a briefing note highlighting both the general lack of research into the gendered impact
of disasters and displacement on health. In 2013, the United Kingdom’s Department for International Development repeated the WHO’s call for further research into these specific concerns and the Internal Displacement Monitoring Centre echoed the need for research enabling a better understanding of displaced women’s experience. However, research into these issues remains sparse.
EXAMINING POST-EARTHQUAKE HEALTHCARE IN NEPAL
We explored the impact of the earthquake in Nepal on internally displaced women’s health in Dhading district which was one of the worst affected. In Dhading district, there are estimated to be 2852 internally displaced people living in nine camps. We looked at:
- Participant’s constructions of ‘health’;
How the earthquake and displacement impacted their health and ability to access healthcare; and
- Potential solutions identified by women to meet their health concerns and remove barriers to healthcare.
Our work was informed by critical theory and feminist paradigms and methodological approaches attempted to redress the traditionally male-orientated production of knowledge. This included acknowledging the gendered nature of knowledge, contemplating researcher positionality, and articulating the impact of bias on knowledge.
Between May-July 2016 a research team of four women collected the data. The team was comprised of a Nepalese gender-based violence lawyer, an English MA student, a Nepalese conflict, peace and development master’s student, and two internally displaced Nepalese women who were of the same indigenous group as the participants and were working as camp volunteers for a local NGO. We conducted ten semi-structured interviews, three key informant interviews and six focus group discussions (FGDs), involving 58 participants. The participants were women over 18 living in the internally displaced person’s camps. All participants identified as ‘Tamang’ a marginalised indigenous ethnic group. Participants were a mixture of religions and aged between 18-62. All of them had been residing at a camp in Dhading district from within one month after the earthquake.
We allowed participants to de ne their own notions of health and discuss the impact of the earthquake on their own terms; the topic guide was constructed from participants construct of what health was and iteratively adjusted according to participant feedback, allowing participants to guide the data that was produced. The research was preceded by a discussion with camp volunteers and female NGO staff about how best to convey to participants that we wanted them to have equal roles in the research and how to increase participation during data collection. We gave consideration to how to make data collection a ‘safe space’.
There was a participatory element to all parts of the data collection, aside from the key informant interviews, through participatory ranking exercises. These were used to generate data about priority needs and increase participant involvement. Based on issues and barriers to access identified by participants and previous participants a set of pictorial cards were presented to the participant or focus group and they were asked to rank them in order of priority; to the extent possible they were left to complete this activity independently and in the FGDs were encouraged to come to a consensus decision.
LIMITATIONS OF THE STUDY
The research process facilitated participants in proposing solutions to issues but could not facilitate taking action for ethical and logistical reasons. Participants were not involved in the research process prior to data collection. We planned to include participants as equals in the collection and analysis of data. However, for practical and ethical reasons it was challenging to get FGD participants to meet more than once.
Trustworthiness was increased through a rigorous approach to data collection and analysis, a reflexive approach to the process and the use of a wide range of methodologies. However, challenges to trustworthiness included: difficulties in translating between Tamang, Nepali and English, difficulties in direct translation of some phrases pertaining to psychological symptoms, the positionalities of the research team and the emergence of dominant FGD members during participatory ranking exercises.
The results may be broadly transferable to other women living in the IDP camps included in the study. Limitations included that:
Disabled and older women were under-represented in the sample
Women under 18 were excluded due to ethical concerns
The dominance of Tamang participants in the sample reflected distinctive sociocultural influences on the construction of meanings around health and access to health care
The relative proximity of all sample camps to the district headquarters (a large town) meant that the health issues and barriers raised may be different in camps with less access to urban amenities
WHAT DID WE FIND?
Alongside specific health issues, participants often identified the ‘social determinants of health’ when asked about the health issues women face in internally displaced people’s camps. Participants spoke of structural mechanisms, such as culture, societal values, and their socioeconomic position, and intermediary factors, such as their material circumstances.
These were not identified as health problems after their displacement, perhaps due to the removal of these two driving factors. After the earthquake, menstrual hygiene represented a widespread concern amongst participants, although only one participant related this to specific health issues such as rashes and wounds. Participants identified not being able to dry menstrual cloths in view of men as a challenge. Displacement exacerbated this, by reducing private space and access to water.
Participants reported vaginal discharge, vaginal itching, pain on intercourse, and lower abdominal pain as concerns. Denial of family planning access by family members was a barrier to healthcare. Inaccurate, or poor health education, relating to contraception further reduced participant’s control over their health.
Gender based violence (GBV) is a health issue in its own right, and a determinant of other health problems. Intimate partner violence was identified
as a health problem for women both pre- and post- displacement. Post-displacement feelings of insecurity and fear were widespread due to aspects of camp life such as long distances to toilets and insecure shelters. Fears (as well as accounts of violence that had occurred) centred around sexual assault by strangers. Another key dimension of GBV was sociocultural pressure on women to remain silent about violence and the lack of legal structures to allow reporting of violence. Furthermore, victim-blaming by communities was identified as fuelling the silencing of women in their community both before and after the earthquake.
DIFFICULTIES FULFILLING BASIC NEEDS
Often lack of fulfilment of basic needs was the first things mentioned during the FGDs and interviews. These were primarily caused by displacement;
and poor governance has played a role in this displacement becoming protracted. In the ranking exercise participants said that the three main health issues facing women are shelter, water and food.
EMOTIONAL AND MENTAL HEALTH
Whilst no internally displaced women identified mental health as a health issue for women before the earthquake, key informants felt the mental health of women had been directly affected by the earthquake and one felt there were ‘high levels’ of mental illness in in rural Dhading prior to the disaster. Commonly, when participants were asked about the main health concerns for women in their communities, discussion turned to the worries women have. When participant’s identified symptoms related to emotional and mental health, they were often expressed in the context of concern about the current instability and lack of security for their future.
Women expressed two main areas they worried or were fearful about: their children’s future and an earthquake re-occurring. Beyond their fears and worries, some participants described various symptoms of mental ill-health such as: anxiety, tearfulness, suicidal ideation, sleeplessness, and lack of energy.
SEXUAL AND REPRODUCTIVE HEALTH
The main sexual and reproductive problems described by participants, prior to the earthquake, were problems in pregnancy, including miscarriage, and uterine prolapse. Participants emphasized the role of heavy workloads and poor geographic access to health clinics as causing these problems.
Post-earthquake health interventions in Nepal need to address the underlying social determinants of health, rather than just health conditions. Women’ lack of autonomy and access to resources due to patriarchal oppression underlies many issues women face in relation to their health, which have been exacerbated by the earthquake and their displacement. This needs to be a focus of health interventions as without transformation in harmful norms many of the challenges found in this study will not be addressed. As many internally displaced people show no signs of imminently leaving the camps, the instability of their current situation needs to be immediately addressed, which would involve creating more permanent shelters, improving access to water and providing gender segregated wash areas and toilets.
Government and donors should prioritise psychological assessments and counselling to female internally displaced people which is gender-sensitive
Good health is reliant on the provision of financial support so that women can access healthcare services (including mental health and gender-based violence) and health education and information
Camp design should prioritise female-only spaces to facilitate better management of menstrual hygiene
Participatory interventions should be instituted within the camps in order to educate communities about sexual and reproductive health and rights and tackle the patriarchal norms which are a hazard to women’s health and well being
Income generating activities, employment and educational and vocational training should be introduced in order to increase livelihood opportunities and support their access to health services
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We would like to thank Anjila Bhatta, Tola Pathak, FOCUS Nepal camp volunteers, Rachel Tolhurst, the Staff of Green Tara Nepal & FOCUS Nepal, Padam Simkhada and Sara Parker. This brief was written by Kitty Worthing and edited by Kate Hawkins.