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. Author manuscript; available in PMC: 2020 Nov 16.
Published in final edited form as: Health Care Women Int. 2019 Feb 6;40(7-9):744–760. doi: 10.1080/07399332.2019.1568439

“Sleeping in a boundary”: Constructing the meaning of health in a refugee camp

Sarah J Hoffman 1, Jaci Stich 1, Sidhra Musani 1, Cheryl L Robertson 1
PMCID: PMC7669325  NIHMSID: NIHMS1635696  PMID: 30724125

Abstract

Sociopolitical discourses surrounding refugee migration and resettlement are characterized by divisiveness, assumptions, and fear. When these discussions are grounded in the narratives of women refugees a deeper understanding of issues impacting health, family, and resilience emerges. We examine how 26 Karen women living in camps along the Thai-Burma border construct meaning around health, in relation to livelihoods. Through directed content analysis, themes emerged: precursors to achieving health, health and livelihoods, and position and agency. Women identified barriers and facilitators to health, identified a dynamic relationship between health and livelihoods, and described their position and agency in the systems they navigate.

Existence in a refugee camp is experienced through defined geographical borders and imposed sociopolitical structures (Fuertes, 2010). A restricted formal camp economy reinforces these restrictions through limited work and livelihood opportunities resulting in a near dependence on humanitarian aid among refugees living in camps (Tanaka, 2013; Burma Link, 2016; Cardozo et al., 2004). Across the trajectory of migration, this is problematic because limited livelihood opportunities may influence the mental and physical health of refugees to a greater extent than understood previously. In the midst of a divisive global discourse on the economic impact of refugee migration, a sample of Karen women living in two refugee camps along the Thai-Burma border shared their migration and family narratives. In this analysis we explore the ways in which women described the relationship between health and livelihoods.

Nine well-established and geopolitically secure refugee camps are situated along the Thai-Burma border. The camps currently host more than 100,000 refugees from Burma, a majority of which are members of the Karen ethnic group. The protracted conflict in Burma has resulted in the global resettlement of tens of thousands Karen refugees. Presently, as tripartite negotiations progress, a small number of voluntary refugee returns to Burma are being observed. There is hope that a durable and final solution to the circumstances of displacement is attainable. However, the fact remains that for those who remain in waiting in the camps, and in numerous other temporary settlements hosting refugees around the world, the future is uncertain.

Constructing meaning in the context of individual, familial, and community health is multifactorial and multigenerational. Globally, the number of displaced persons is higher than at any point in recorded history. The statistic includes over twenty-one million refugees living in camps in 128 different countries (UNHCR, 2016). An estimated one third of the world’s refugee population lives in the Asia-Pacific region. Individuals and families flee their communities of origin because of war, political or social conflict and instability, or fear of persecution. Refugee camps are structured to meet the basic and temporary needs of thousands of displaced people (UNHCR, 2012).

We examine the ways in which Karen refugee women living in camps along the Thai-Burma border individually and collectively formulate the meaning of health. We frame our analysis by asking what factors, with a particular focus on engagement in livelihood opportunities, are most relevant as Karen refugee women assign meaning to their health experiences?

Background

An estimated ten percent of refugees living in camps are employed within a formal employment sector. Available positions generally involve humanitarian services, trade, agriculture, or communications (Porter et al., 2008). It is more likely that skilled, educated, or English-proficient refugees will qualify for these positions. Work opportunities in the formal sector are often lower paying (Jacobsen, 2006), and may provide limited contributions to the economic stability or profitability of an individual or family (Werker, 2007). The lack of livelihood opportunities fosters an obligatory dependence on humanitarian aid (Couldrey, Herson, & Brees, 2008; Lee, 2014).

Education, language, and skills training comprise an important aspect of livelihood strategies in refugee camps. These initiatives stimulate intellectual growth and the development of skills such as reading, language acquisition, and skill building. The educational setting often increases social interaction and cultural integration, which may indirectly support participation in the labor market and camp-based economies (Tanle, 2013). Across global contexts, refugees assert that education will play a crucial role in minimizing the likelihood of poverty when they resettle outside of the refugee camp (Valatheeswaran & Rajan, 2011). However, due to the altered and complex environments that refugees face, accessing educational advancement is a challenge (Koyama, 2013). Adult educational facilities and learning materials are limited within refugee camps (Tanle, 2013). In contrast to primary education for children that is more widely available within the camp, the majority of adult refugees will not have access to educational resources (Dryden-Peterson, 2010).

Regulatory Context of the Camp

Social and political regulations impact nearly every aspect of a refugee’s life, from resource allocation, to movement, to the structure of familial systems (Author & Author, 2016; Jolliffe, 2016). It is illegal or in violation of refugee camp policy to seek formal employment outside of the refugee camps along the Thai-Burma border without a Thai residence permit (Brees, 2008; Agier, 2002). However, an extensive network of informal livelihood and trade opportunities circulates in and around the camps along the Thai-Burma border (Author et al., 2017; Mcleary & Wieling, 2016).

Additional contextual factors influence access to and the distribution of goods, services, and the opportunity to pursue livelihoods. For example, local host country citizens who have been subjected to poor economic conditions within their communities may pose as refugees, or register as refugees, in order to profit from humanitarian aid (Jansen, 2016). Humanitarian agencies aim to produce a system of support for refugees that facilitates access to fundamental human rights, including access to food, medicine, shelter, and education (Werker, 2007). However, circumstances exist where aid is insufficient. For example, due to a set of complex sociopolitical factors that influenced the availability of humanitarian aid in a large temporary settlement in Ghana, Porter et al. (2008) estimated that a majority of refugees living in Buduburam camp struggled to achieve self-reliance, in the midst of a drastic shortage of material humanitarian aid.

Connecting Refugee Health and Livelihoods

Within refugee migration, similar to the fluidity of identity (Author et al., 2017), the meaning of health is dynamic because of rapidly shifting circumstances of displacement. Stress and trauma experienced along this trajectory impact the experience of health in a number of ways (Hugher & Kleine, 2004). For example, separation from family members is associated with mental health consequences such as depression and anxiety (Choummanivong, Poole & Cooper, 2014). Negative healthcare encounters within a refugee camp or through migration and resettlement impact willingness to adopt wellness behaviors (Mabaya & Ray, 2014). Perceiving that access to healthcare is restricted or unavailable may influence attitudes about seeking healthcare (Fung & Wong, 2007; Khawaja et al., 2008).

Engagement in livelihoods is a factor that stabilizes the ways in which an individual conceptualizes health (Blaxter 1983; Hugher & Kleine, 2004). Reed et al. (2012) identified that farmers equated health to the ability to work, because they relied on manual labor to produce an income. A sample of Chinese immigrants working in restaurants in the United States reported that working was the top priority in their life. Participants reported that as long as they were able to work, they perceived themselves to be healthy (Gao, Dutta, & Okoror, 2016). In interviews, Afghan refugee women were asked about their views of healthcare. Women disclosed that being healthy meant they were able to provide for their family. Participants in the sample stated that they would rather die than suffer from an illness that would disable them from working (Feldman et al., 2007). Chambers & Conway (1992) concluded that livelihoods enabled refugees to feel secure, recover from stress or trauma, and provide for their families. Establishing a livelihood may increase resilience to the shock of immersion into a new social environment (Valatheeswaran & Rajan, 2011). Livelihood strategies increase the likelihood that individuals who are forcibly displaced can establish new skillsets and position themselves to pursue employment upon reaching a stable endpoint to migration (Crisp et al., 2009; Jacobsen, 2004).

Limited livelihood opportunities may result in poorer health-related quality of life (Alduraidi & Waters, 2017). Past traumas associated with conflict and displacement influence the mental and physical health status of refugees. The restricted circumstances of life in the camps, including the loss of livelihood, compound these health experiences (Seguin et. al, 2016; Fuertes, 2010;). Limited livelihood opportunities can exacerbate gendered disparities. Women may be forced to engage in harmful survival strategies, such as commercial sex work, to support themselves and their families (Porter et al., 2008). Limited opportunity restricts autonomy and the capacity of individuals and families to plan for their future (Werker, 2007).

Prior research reinforces the importance of describing the connections between the circumstances within which refugees negotiate livelihoods and how they construct health within those systems. Understanding how Karen refugee women define health can inform tailored interventions to support health within refugee camps and along the trajectory of migration.

Theoretical Framework

Sense of Coherence (SOC) is a model applied across cultures to understand internal and external factors that influence trajectories of health and illness (Antonovsky & Sourani, 1988; Antonovsky, 1979). Three constructs interact and collectively formulate the SOC model, thus configuring the ways in which individuals interpret their own life and position in the world. Comprehensibility is defined as how one’s environment makes logical sense. Manageability is the extent to which one is able to cope with their given environment. Meaningfulness is how one feels that their environment is worthy of their engagement.

SOC serves as a lens through which to interpret ways that people comprehend, function within, and relate to their environment. SOC has been used in prior studies with refugees to explore psychological adjustment (Ying & Akustu, 1997); factors associated with resilience while living in the camp (Almedom et al, 2007); and intergenerational dynamics in resettlement (Atwell, Gifford, & McDonald-Wilmsen, 2009). This framework can be utilized in multiple ways, as it broadly determines one’s movement toward health by examining individual relationships with the external environment. We relate the SOC model to Karen refugee women’s interpretation of and engagement in livelihoods, which facilitated consistency, balance, and autonomy in the refugee camp setting.

Methods

This analysis is situated within a series of ethnographic case studies examining resilience, identity, and the recontextualization of mothering in samples of Karen refugee women living in two camps along the Thai-Burma border, and post resettlement in the United States (Author et al., 2017).

Study Setting and Sample

Data examined were collected through participant observation and individual, in-depth interviews. Key informants were a sample of twenty-six Karen refugee women living in the Nu Po and Umpiem refugee camps. Women were approached to participate in the study if they: 1) identified as ethnic Karen, 2) spoke Sgaw or Pwo Karen, and 3) resided in either the Nu Po or Umpiem refugee camps. We planned to exclude participants if they self-reported physical or mental health distress at the time of the interview. No participants reported or demonstrated distress during the interviews. Additionally, we include perspectives shared by the Vice Chairperson of the Karen Women’s Organization, a Karen-led human rights organization, working on behalf of Karen refugee women.

The American Refugee Committee facilitated access to the camps and provided skilled interpreters to facilitate the collection of data. All interviews were conducted in the Karen language. Through purposive sampling the interpreter and members of the study team approached women and families from diverse geographical sections within the refugee camps. Women who consented to participate in the interviews lived in the camps for an average of twelve years (range one to twenty years). The age of participants ranged from eighteen to seventy-five years old. Women who were interviewed predominately reported that they were married with children. The average number of children in the household among all participants was three. Within the sample, three of the participants were single, one was divorced, and four were widowed.

Analysis

Our approach to analysis integrated strategies of directed content analysis. Content analysis is the process by which written, verbal, or visual communication messages are analyzed with the goal of being able to draw valid, replicable inferences from that data (Elo & Kyngas, 2007). Through open coding and subsequent directed content analysis we narrowed the scope of the analysis to focus on meaning of health specifically in relation to livelihoods (Hsieh & Shannon, 2005).

Interviews were recorded and subsequently professionally transcribed. The three-member study team independently coded the interview transcripts. During weekly study meetings the team reached consensus in our approach to the data through a comparison of code names, descriptions, and examples. We integrated content from field and analytic memos during these meetings. The process of coding allowed us to label units, or statements within the interview transcript. We then grouped these codes into broader categories (Graneheim & Lundman, 2003). Paragraph or phrase-style coding was utilized to holistically interpret experiences shared by the respondents. Our approach to the transcripts was initially inductive, as previous studies had not assessed meaning of health in this population (Elo & Kyngas, 2007).

Ethical Considerations

The University of Minnesota Institutional Review Board (IRB) approved the research proposal. We concurrently submitted the research proposal for review to the Karen Refugee Committee, the discerning body that oversees research conducted in the camps along the Thai-Burma border. We obtained a waiver of signed informed consent. Consent was read orally to participants, and hard copies of the translated consent form were distributed.

Findings

Key findings from the analysis yielded three themes: precursors to health; health and livelihoods; and position and agency. Precursors integrate a notion derived from the Sense of Coherence model that acknowledges that various environmental factors and experiences inform individual and collective movement towards health. In health and livelihoods, we amplify the voices and statements of women participants and look concretely at the ways in which members of the sample defined and conceptualized health. Finally, we consider how women exert agency as they shift their positions to maximize health as they have constructed it in the context of the camp.

Precursors to Health

Karen refugee women participants described that the presence or absence and perceived accessibility of a set of factors influenced the ways in which women assigned meaning to their individual and family experiences of health. While challenges experienced by refugees pre- and post- migration are well documented in the literature, we begin our analysis by reporting how women in our sample described the challenges they personally experienced. We found that within the narratives of women in this sample, the contextual understanding around what informed perceptions of health was central to the ways they framed and interpreted their experiences.

Resources.

Within the camps physical necessities such as food and water were rationed to camp residents. International humanitarian aid organizations provided access to medicine and basic healthcare. Women discussed that the need for tangible goods such as water and food was met inconsistently for some residents of the camps. The rations are not enough reflected a pattern of experiences shared across the sample. There were five hundred people not receiving rations, but only thirty-five people are now receiving rations of the five hundred, so more than four hundred are not receiving rations. Women also described barriers to water access. Water is only available for one hour daily, and everyone is sharing. We have a small container to keep water in.

Women offered varying perspectives on security. Members of the sample indicated that security was a resource provided through camp structures. The official military presence offered protection from the potential of persecution on the outside. Others expressed a sense of physical insecurity sustained through displacement. This resulted from an ongoing perceived potential for violence. A participant described her concern for the lack of security saying, Most of the security, their income is not good, so they cannot guard you all the time…They just stay in their houses. Individuals serving in official capacities who were interviewed such as camp and section leaders and representatives of humanitarian aid organizations reported that domestic violence was a growing concern. This was referenced particularly in the context of alcohol use.

Livelihood.

The absence of camp-based and readily available income-generating activities positioned refugees as passive recipients of aid. The jobs are not available for everyone, and the people cannot really make [an income]. Women navigated this liminal space by creating opportunities for barter and income generation, but in doing so were forced to make choices about priorities. For example, a woman in the sample shared her experiences of pursuing labor outside of the camp, If I go outside, we are being arrested and harassed, so it’s not easy to go out anymore to make a little income.

Education was explained as a strong value among women in the sample, If you are educated, you can know how to take care of yourself. Women discussed advancing their own education through skills training or formal education in a traditional school setting. Women in the sample also talked about wanting to provide an opportunity for education to their children, I am not an educated person, I want my children to be an educated person. It’s the best way for my children. Participants discussed their perceptions of education as a means to a better life, and that once educated, children would reciprocate care towards the parents and family, If children become an educated person, they can look after their mother. Another participant stated, education is for their future. If they are not educated, they cannot do anything and they have to grow and they have to know how to cope with difficult problems. Though formal education for children was available in the refugee camps, some women in the sample were unable to send their children to school because they lacked funds for uniforms or school fees. A participant indicated she elected not to send her child to school because, The schools here are underdeveloped. Karen women talked about the relationship between health and engagement in livelihood opportunities, such as school, saying, If you are a healthy person, you can go to school. Women connected the ability to access education in the present with how they envisioned a future for their youth, [they will be] able to take care of themselves and they will have jobs and they will really take care of the future and they will take care of their children.

Health and Livelihood

When asked to define health, the most prevalent and concrete responses that women in the sample gave highlighted a dynamic understanding of the relationship between health and the ability to work. If we are sick we cannot do anything. If we are working in a group, if you aren’t always sick it helps the group a lot because it means you can work with them for a long time. Women used health to define ability, in this case the ability to work, If we have good health, we can work and we can talk and then we can do everything. Work offered a reprieve from the monotony of life in the camp in meaningful ways. Among the sample, consciousness of the rising prevalence and visibility of alcohol use was deeply present. As we discussed this, one participant stated, Sometimes I call the women who drink. ‘Come and join with us; we can work together.’ If she is working she will forget about alcohol. Work also facilitated the independence that accompanied additional income, We have to work to make some income, so we have to be healthy to do that. Women in the sample discussed a lack of control over aspects of their lives in the camp. The ability to provide for her family was an important and accessible source of influence.

Another facet of the relationship between health and ability originated from the physical nature of work available outside of the camp. I have to work to make some income, so I have to be healthy to do that. Opportunities to generate income included hauling loads or manual farm labor. When working outside of the camp, individuals generally had to walk long distances, sometimes with travel spanning days, in order to secure a paying livelihood opportunity. Women consistently related the physicality of available work to health, [If] I am unwell; I can’t carry heavy loads.

Position and Agency

Karen refugee women described positioning themselves within the surrounding systems of migration and familial structures, and the potential existed for them in those spaces in relation to pursuing health and livelihoods. Women in the sample reflected on the roles and responsibilities they had, collective value structures that they honored, and how they envisioned the life of their family. Remaining in waiting in the refugee camp fostered uncertainty in terms of what the future could hold. Values and vision for the future drove behaviors and actions.

Roles.

Women aligned prominent responsibilities with inherited Karen cultural values. A participant described the importance of her maternal role, I have the responsibility of taking care of my children, and supporting them, providing them something to benefit, like food. Women described their contribution to their families through caring for children, through the management of the household, and through the pursuit of income generating activities. Across the sample, women emphasized a responsibility to ensure that their children were educated. Education is important because if my children are educated, then they can support me. In conversations with women about the relationship between health and livelihood, some participants explicitly defined their work as raising children, If I am healthy, I can take care of my children. Women sustained the role of mothering as an essential livelihood.

Values.

Women valued security. Decisions surrounding displacement and migration to the refugee camps were made as a result of the oppression and persecution they endured. The security provided by the camp allowed them to feel safe, I feel like I am sleeping in a boundary… that’s protecting me. Individual health, in connection with the ability to work, was another opportunity to produce security in their positions, I just want to have good health, and I want to see that all of my family is healthy.

Good life.

Ideas about the future centered on providing a good life for family. Women described varying notions of a good life. In terms of the family’s trajectory of migration, ideas encompassed third country resettlement, remaining in the camp, or return to Burma. Education was a central means through which women perceived obtaining a good life, If they are educated, I won’t worry about them anymore and [they will be] able to take care of themselves and they will have jobs and they will really take care of the future and they will take care of their children. The importance of positioning youth in ways that empowered them to address the needs of future generations, as well as the older generation who brought them to the camps, is reflected in this statement.

Precursors to health described by participants influenced the migration experience. Health and livelihoods, and the position that women take up along the trajectory of migration contributed to the ways in which women comprehend, manage, and make meaning from their health experiences. In particular in this analysis, we focused on how women describe the relevance of these ideas to the relationship between health and livelihoods.

Discussion

The sociopolitical discourses surrounding global immigration and refugee resettlement are currently characterized by stark divisiveness, misinformation, assumptions, and fear. Our intent is to contribute to and influence these discourses in a way that integrates scientific evidence, appreciative inquiry, and a holistic approach to health. Specifically, we assert that refugee women’s narratives should exist at the center of the economic debate on migration, and guide policy responses to war, displacement, and migration. In this study we sought to interpret how a sample of Karen refugee women living in two refugee camps along the Thai-Burma border constructed the meaning of health in relation to livelihoods. We documented the ways in which women assigned meaning to health experiences, in particular in the context of livelihoods, described by Karen women participants as income-generating work and education.

As women figured their experiences of health within refugee camp structures and norms, the Sense of Coherence model framed the ways in which women in the sample interpreted their positions in the world (Antonovsky, 1979).

As participants explained their relationships with their contexts and what they valued in those circumstances, they also facilitated our understanding of how women in the sample perceived health and constructed meaning around that perception (Antonovsky & Sourani, 1988). This relationship extends beyond the theoretical. Repeatedly, women connected in concrete ways the relationship between health and work – one was not possible without the other.

As women in the sample described this connection, they were simultaneously describing tools they engaged to navigate forced migration, promote the resilience of interpersonal connections, and cope individually and collectively with the challenges inherent to cultural transformation (Author et al., 2017). In this context, the response strategies that women in the sample described were influential in defining their position relevant to livelihoods. In our prior work we defined response strategies as, “a tool engaged by an individual or community to navigate forced migration and promote the resilience of interpersonal connections, and cope individually and collectively with the challenges inherent to cultural transformation (Author, 2016; Vincent & Sorensen, 2001).” Central to the findings reported in this manuscript are the ways that women refugees engaged response strategies relevant to individual and collective meanings of health.

Karen refugee women in our sample were intentional in describing their position within the camp. The roles and responsibilities that surrounded these positions guided actions. Education as a livelihood strategy was deeply valued by women in this sample. Ways that women described access to educational resources, with a focus on integrating and positioning youth within that experience, helped to explain the connectedness of youth and maternal caregiver through the migration trajectory. Providing children with the opportunity to attend school helped to achieve the predictability and the security afforded through livelihoods. For women themselves, a lack of training resources could later exclude refugee women from job opportunities in countries of resettlement. Post-resettlement in the United States, refugees are generally placed in low-paying, entry level jobs such as janitorial work or food processing facilities. A tailored focus on the ways refugee groups positively impact economies post-resettlement or return, through entrepreneurial endeavors, high motivation and drive, and collective partnerships offers an innovative lens to systems of adult education and training in the camps (Capps et. al, 2015; Long, 2015).

Globally, the Office of the United Nations Commissioner for Refugees (UNHCR) is increasingly underfunded. Refugees must be more creative in efforts to support themselves and their families with fewer resources. A Karen news outlet recently reported a gradual decrease in funding for food aid in the Southeast Asia region by international donors (Refugees from Burma, 2017). In 2015, the Karen Women’s Organization and the Karen Education Department reported that the humanitarian aid funds had been reduced by half. Camp-based healthcare resources have also been substantially reduced (Burma Link, 2015; Shar, 2017). Programs that support access to basic needs for internally displaced persons in Burma have closed (Keep Supporting, 2017). Karen refugees living in the refugee camps have reported that it is becoming increasingly difficult to thrive (Burma Link, 2015). There has been no corresponding easing of restrictions that address work outside of the camps.

Limitations.

Situated within the broader context of policy shifts and political reform in Burma, it appeared to the research team that women in the sample were at times guarded in their responses. Thus, our analyses relied on partial accounts of experiences. These circumstances also make the silences in the data important. We are limited as non-Karen speaking researchers and acknowledge that the use of an interpreter is a limitation. Ultimately, the responses and exchanges analyzed are the words of the interpreter. It is likely that linguistic nuances and meaning were lost in translation. Finally, though our findings may be transferrable to other groups of refugees, the same conclusions cannot be assumed, as other cultures likely have different values and beliefs surrounding health.

Conclusion

Identity is not fixed. Fluidity of identity exists for every individual. However, for those who are displaced from their communities of origin and remain in transit, the refiguring of identity is heightened. Similarly, the ways in which an individual conceptualizes health becomes more fluid when an individual must ask the question “who am I?” every day because of constant and shifting contexts. For women in our sample, livelihoods, the means by which a person survives through work, education, or skills training, represented a strategy for women in the sample to find stability within the fluidity. We make this assertion in consideration of the narratives shared by the twenty-six women reported in this analysis, as well as findings reported from the broader ethnographic case study that encompassed this work (Hoffman et al., 2017; Hoffman et al., 2017).

Current literature considers health and livelihoods as important but discrete foci within refugee camp structures. Our findings provide new insights as we suggest an important relationship between these concepts, particularly in terms of pursuing optimal individual and family health in the refugee camp context. Future research must consider intentionally the ways in which the notions of health and livelihoods connect and overlap in the refugee camp setting, and develop interventions to support health that integrate these factors within the existing systems and structures of migration and displacement. Even more broadly, methodologies that establish convergence and transferability in the conceptualizations of health among migrant and refugee groups are essential. Culturally derived approaches to understanding the ways in which those who are displaced and migrating assign meaning to health enable health providers to center the narratives of women in responses as we participate in and influence the discourses of migration.

Figure 1.

Figure 1.

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Movement towards health reflected through a theoretical lens of Sense of Coherence (Antonovsky, 1987)

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