This research study describes, from the perspective of women themselves, the health of Salvadoran refugee women, their understanding of the causes of health and illness, and the strategies they use to maintain health and cope with health problems.

Winnipeg received approximately 2,000 refugees from El Salvador over the ten year period from 1982-92. These new arrivals fled extreme violence and many had been exposed to war- related trauma. Participants had been in Canada from 7-17 years at the time of the study. As the Peace Accord brought an end to the civil conflict in 1992, community members do have the option of returning to their country of origin. This set of circumstances provided a unique opportunity to investigate medium to longer term effects of trauma and migration on a population.

Method

This qualitative study was designed in collaboration with women from the Salvadoran community in Winnipeg. In-depth interviews, community focus groups and participant observation techniques were used. Twelve women participated in the interviews. In addition, there were a total of 18 other participants in two focus groups. Interviews were generally scheduled over two or more visits, providing the opportunity for clarification and elaboration of issues raised. A feedback phase followed the completion of the report. Individual participants were provided with the opportunity to review narrative excerpts from their stories, and to respond to the themes and conclusions emerging from the study.

Findings

Several key themes emerged through this research, and are interwoven throughout the report:

Identification of Self in Terms of Family
Women from all social classes identified themselves as members of families and saw themselves as having a central role in the life and health of their families. Because the role of the mother was of central importance, women who experienced neglect or rejection from their mothers demonstrated great distress. Family difficulties appeared to be of greater importance to the women's sense of well-being than the factors related to external violence and deprivation.

Importance of Social Class and Support
Social class emerged as a key factor in explaining different experiences during the pre-war period, during the war, and in adapting to Canada. Experiences and expectations of life in Canada, and of health and health care are linked to class. In Canada, for the first time, those of different social classes are using the same health, social and educational services, and often forced to participate in the work force at the same level. This mixing of socioeconomic classes in Canada is perceived as contributing to community tension, and while earlier in the adaptation process political divisions were of greatest concern, at this point, class differences are identified as the most divisive.

Violence
The participants described a culture of pervasive violence, which existed before the "war" erupted. The types and level of violence to which individual women were exposed, however, was moderated by social class. Structural violence, originating with colonialization, denied rights and basic resources to a large segment of the population. Violence within the family, and within the community was also common. War - related violence and exposure to violence during migration had the greatest impact on the poor, particularly those living in rural areas. However, in Canada, women reported taking an active role in addressing violence within the family, by adopting different techniques of child discipline, and using societal resources to protect themselves and others from abuse and violence.

Faith and the Church
Another theme which crossed the lines of social class was that of religious faith. In general women saw God, and ones faith in Him, as central to their lives and the source of health and protection. Informants also described prayer as a key coping technique. God was understood to transcend ordinary cause - effect relationships and so is key to explaining survival and health.

The Assault on Community
The theme of assault on community begins in El Salvador, and the effects continue through to the present day. Study participants described a community that continues to be marked by intense and sometimes dehabilitating distrust. This mistrust, like the violence, appeared rooted in the national history of state terrorism, and linked to the characteristics of the Salvadoran conflict: a deliberate strategy of warfare which led to fear, anxiety and the destruction of normal social relations. For a society which is based on extended family an social networks, this had a devastating effect. A number of women reported events of betrayal or suspected betrayal, by those close to them, including family members. This mistrust and betrayal continues in the community today, and was a dominant theme in the interviews.

Resilience
Another theme which was expressed by informants was that of resilience, at both the community and individual level. Closely linked to this was the characteristic of pragmatism: women showed little commitment to past practice or tradition, unless it was perceived as useful. Utilization of services, participation in the work force, health care practices, or child rearing approaches, can be best explained by the women's concrete experience of what is effective for them, rather than adherence to any particular belief system. Women describe themselves, and are described by others as strong, adaptable, assertive and practical.

Conclusions

Perceptions of Health Status
Generally, women described themselves as healthy . Most differentiated between physical and emotional health, and tended to rate their emotional health somewhat lower than their physical health. They describe clear links between psychological health and somatic symptoms.

Many women described their lives as having been full of challenge, loss and suffering. However, they did not see themselves as victims, and resented pity. In most cases they have found ways to survive and to adapt, while protecting and supporting those close to them.

Explanations for Health and Illness
Study participants described an understanding of the determinants of health and illness that was multi-causal and multidimensional, and which emphasized the social roots of health and illness. Their perspective suggests major limitations to the Determinants of Health model emphasized in North America.

Psychological concerns and family problems were understood as a major cause of illness. Both stress and depression were major factors in women's lives, and many women believed that these factors were key to understanding health complaints. A number of women reported some symptoms consistent with post traumatic stress, however the women usually normalized these reactions. There was a tendency to focus on the migration and adaptation experience as the major focus of psychological causes for distress. This appears consistent with the emphasis on "present" orientation, the tendency to attribute current health problems to current events. The focus on adaptation difficulties captured one major trauma experienced by all arrivals, and unlike trauma experienced in the home country could even be shared safely with others in the community. Continuing community polarization and mistrust were described as having a greater effect on current health than past trauma.

Most women were open to a number of different possible explanations for illness and health, but generally did not look to family history or genetic susceptibility as an important causes of illness. Although illness due to infective agents was also recognized, this was not seen as a major factor at present. Social factors, consistent with the determinants of health, were recognized as of major impact. God, and ones faith Him, was the key factor in explaining health, or survival, and could override other health determinants.

Coping Techniques
Women used a range of coping techniques to maintain health and treat illness (physiological, or psychological).

There was no organized alternate system of health belief or system of medical practice, although there were various family or community based traditional treatments that some women continued to use. The use of these home remedies was eclectic in nature and variation in patterns of use appeared to be only loosely connected to social class. Effectiveness of treatment in the past predicted current usage. Use of home/herbal remedies and modern medicine were not seen as mutually exclusive and many families used both.

Focusing on the needs of the family, praying, talking , crying and working were reported as useful coping techniques. These were viewed by the participants as gender specific strategies, and there was some suggestion that male coping strategies may be very different.

Family and Community Health
A number of issues were perceived as influencing family health. Most women express concern about their children, and there was a general concern about the youth in the community, particularly around issues of intergenerational communication, substance use, adolescent pregnancy and involvement in the justice system. Domestic violence continued to be of concern, and there was also concern expressed by some women regarding sexual abuse. Unlike domestic violence, child sexual abuse does not appear to be recognized, or discussed within the community.

A high level of concern was expressed by most informants regarding tension and distrust within the Salvadoran community. This remains the source of much anxiety to individuals.

Experiences with and Expectations of Health and Social Services
Experiences with health care provision in country of origin, and satisfaction with Canadian health services were strongly linked to social class. In general, the poorer women were highly appreciative of health care services in Canada, while those from more privileged backgrounds were less impressed. However, there appeared to be no significant differences in use of the Canadian health care system related to class.

Participants used the health service system confidently for physiological complaints, however, they shared little of their past lives and were frustrated in finding solutions for problems they felt were emotionally based. Generally there was no sharing with health professionals of past history, even when this may have been relevant to treatment.

Settlement services, as well as English as a Second Language services, were perceived less positively, and a number of women described negative experiences with them. More positively described were the culture or language specific services offered through community organizations. Participants also reported confident use of the police for issues related to domestic violence. There remains limited awareness of the range of services available through other not for profit community organizations, including counselling services. In general, women stated they would prefer to use "Canadian" rather than "Spanish" professionals for psychological or sensitive family concerns, and distrust regarding breakdown of confidentiality remained.

Long Term Adaptation and Integration
Even though all of the women have been living in Canada for a number of years, with the exception of workforce participation, there was limited participation in the larger society. Many of the women, for example, reported no "Canadian friends". Many women expressed feelings of on-going depression and grieving related to loss of family and of country. A number of women were still limited in their social participation by limited fluency in English. Many still struggled with lack of access to services and limited opportunities for employment.
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Summary/Recommendations

The key challenges facing the community were described by informants as rooted in social causes: the violence and resulting destruction of community during the civil conflict. The results of this continue to be seen in Winnipeg, in ongoing suspicion and distrust of other community members. The solutions then must also be rooted in the community.

While there is some indication that resources to help individuals cope could be better utilized, the focus for addressing the community problems must be based in the community, and realities of the past. There is evidence that dramatic changes to old patterns (e.g. in child discipline and domestic violence) can be made in a new environment, wherever women can find opportunities. The issue of negative gossip, mistrust and betrayal, are issues private to the community and the solutions must come from within. Until this occurs, there is a risk that unresolved community dynamics may delay or complicate the process of long term adaptation and integration. At present, community problems, along with limited integration into the larger Canadian society, continue to create stress and are expressed in terms of individual health concerns.

Study findings challenge the emphasis on individual diagnoses of psychological disorder, suggesting that efforts should be addressed to the social and behavioral effects of mistrust and violence.