Three of the southernmost Thai provinces have experienced political unrest in the past 8 years. During that time, the number of trauma victims has continued to increase steadily. Data from 2004 to 2012, from the Research Institute for Southern Conflict and Cultural Diversity, Prince of Songkla University, document 11 542 unrest events, 5086 deaths, and 8485 injuries. Up to 60.59% of these victims were Buddhists, and 38.36% of them lost their families.1

Previous studies indicate that trauma survivors living in an unrest situation may experience lifelong suffering from both physical and psychosocial difficulties. The physical impact ranged from minor disorders to major handicaps.2 These physical problems could make it difficult or impossible to find employment, and eventually lead to a reliance on social welfare.3

Most trauma patients also developed psychological problems. Six months after the 9-11 event in the United States, 56% of the victims still had stress disorder.4 After the war in Kosovo, 1358 people (17.1%) developed posttraumatic stress disorder.5 Many teachers experiencing the unrest situation in the 3 southernmost Thai provinces cannot control their emotions and feelings, reacting to that situation in a way that would be different from a reaction to a natural disaster.6

These physical and psychological problems need long-term rehabilitation and holistic self-care. Normally, trauma patients usually receive follow-up home health care after discharge. However, nursing and health care delivery systems can be interrupted by the unsafe travel conditions created by an unsafe situation of political unrest.7,8 Health care officials in one of the 3 southernmost Thai provinces, in an attempt to perform home health care, experienced many limitations, such as being unable to visit homes in unsafe areas. In some cases, patients were unable to go to the health care facility because of a lack of security.8 As a result, some patients had to attend to their own health needs and rehabilitation, while having little knowledge of how to do so.

In searching the literature for care of trauma patients in situations of political unrest in the 3 southernmost Thai provinces, 15 studies were found from 2004 to 2011. Thirteen of these were published; 2 were unpublished. The review indicated that care was mostly considered from the health care providers' perspectives, with less attention being paid to the patients' views. In addition, a system for monitoring and evaluating the outcome of care seemed to be lacking or inadequate.9 Research on the perspectives of people suffering illness can lead to a better understanding of the challenges they face for rehabilitation. Under the Thai Buddhist belief and religious doctrine, such understanding could help people cope with bearing the burden of care, and learn how to apply and integrate these into holistic health care. Therefore, this qualitative research was conducted to describe experiences of holistic care applied to rehabilitation, as viewed by Thai Buddhist trauma patients living in areas of political unrest.

OBJECTIVES

This qualitative research aimed to describe the meaning and practice of holistic health for rehabilitation among Thai Buddhist trauma patients living in areas of political unrest.

METHODS

Design

This was a qualitative study based on and guided by Gadamerian hermeneutic phenomenology. The 11 participants were Thai Buddhists injured from terrorist attacks related to political unrest in the 3 southernmost Thai provinces. Each subject was older than 18 years and each had received continuing care from the rehabilitation units of hospitals or the Deep South Coordination Center, Princess of Naradhiwas University, for at least 3 months after discharge. The researcher contacted the participants with the aid of nurses at the hospitals or staff at the Deep South Coordination Center, Princess of Naradhiwas University. All 11 participants contacted were willing to participate. After receiving their permission, the researcher telephoned each person to arrange an interview.

Ethical Considerations

The study was approved by the Research Ethics Committee, Faculty of Nursing, Prince of Songkla University. Approval was also obtained from representatives of the hospital and the Deep South Coordination Center, where data were initially collected to reach the potential informants who fit the above criteria. Participants were introduced by the staff and a few were recruited through a snowball technique. The objectives and methods of the study were explained to them, and verbal consent was obtained before starting the interviews. Participants were given a guarantee of confidentiality and anonymity in the report findings. The researcher was sensitive to the needs and comfort of all participants during the interview and offered an opportunity for their reflection after the interview.

Data Collection

The researcher developed an approach to data collection by reviewing the literature on holistic self-care for Buddhist trauma patients in an unrest situation. The researcher developed a data recording form, a history of injury and treatment recording form, and unstructured questions for an in-depth interview. The questions developed were intended to explore the experiences of holistic self-care for rehabilitation among Thai Buddhist trauma patients from an unrest situation in the 3 southernmost Thai provinces. Example questions included: "Please tell me about your holistic self-care" and "How did you take care of your health and rehabilitation after you were discharged and went home?" When participants described difficulties in self-care for rehabilitation, follow-up questions included: "How did you deal with the situation, or apply your religious doctrines or beliefs for healing and maintaining self-care for rehabilitation, particularly while living in areas of political/social unrest?" Subsequent interviews were conducted until no new data regarding holistic self-care for rehabilitation were generated.

Data were collected at participants' homes from November 2011 to April 2012. To obtain rich and complete data, each participant was interviewed at least twice, with each interview lasting 45 to 60 minutes per visit. All interviews were recorded and transcribed verbatim. The researcher used the techniques of reflection, repeating the question, giving an example, and asking unstructured questions, until the data were saturated.

Data Analysis

The researchers analyzed every day's data. Every sentence and word, whether dictated or transcribed from a recording, was interpreted, grouped, and rechecked to ensure the correct understanding. This analysis was based on the principles of Van Manen (1990).

FINDINGS

The participants comprised 5 men and 6 women, from age 28 to 59 years. Most were married, with 10 participants having at least one child. Income ranged from 4001 to 5000 baht per month. Education level for most was that of primary school. Seven suffered from gunshot wounds, and 4 had been injured by a bomb. Injuries were associated with spinal cord (4 cases), lower limb loss (3 cases), facial (1 case), and 3 others had minor injuries. Length of participants' hospitalization ranged from 1 to 6 months, with the average being 2.36 months. Most participants had been discharged more than 1 year before the study (the range being 1-8 years). Five participants found it necessary to change careers after discharge; the rest returned to their former jobs.

MEANINGS OF HOLISTIC SELF-CARE FOR REHABILITATION

Two themes emerged from the participants' narratives that explicated the meanings of holistic self-care for rehabilitation: (1) learning to have a new life and (2) learning to bear the increased demands of care as a chronic disease. Quotes elucidated each theme.

Learning to Have a New Life

Participants perceived their rehabilitation as important for health and recovery. They learned how to take care of themselves in ways new to them. To reduce their dependence, most participants perceived the need to attempt to live as normally as possible, as supported by this statement:

I had to learn to live again because there were some things I had never done before. Even though it was hard to do, I must do it at present for living, such as: In the past I could urinate whenever I wanted to, but now I have to learn how to do urinary catheter by myself. I have to do it by myself for living as usual as possible. (P 4)

Learning to Bear the Increased Demands of Care as a Chronic Disease

After discharge, some participants perceived themselves to be chronically ill with the demands made by increased self-care. They also soon recognized an increased ability to take care of themselves, and to bear the increased demands that resulted from their injuries. Both physical and psychosocial care was required, just as it would be with care needed for chronic diseases such as diabetes. Chronic pain was the symptom causing the most suffering and requiring the most demanding care, as supported by this statement:

In the past I was healthy but today I feel pain every day. It looks like I am carrying something, just like a chronic disease within my body. Even though the wounds were healed but I still feel pain. Sometimes I feel pain very much so that I cannot sleep. (P 3)

METHODS OF HOLISTIC SELF-CARE FOR REHABILITATION

As Thai Buddhists, all participants sought ways to improve their health and relieve suffering after discharge. Three main methods of holistic self-care practiced for rehabilitation were described.

1. Continuous improvement of physical rehabilitation. Most participants reported living a new life as a result of continuously performing physical rehabilitation activities. This helped them face the difficulties resulting from injury or chronic difficulties. One such difficulty was being unable to return to a previous job.

Common methods of physical rehabilitation are described as follows:

1.1. Increasing muscle strength. Some patients invented their own methods to exercise their muscles, often involving homemade devices or traditional massage, as 2 participants stated:

I developed paraplegia. I cannot feel or move my legs. My legs will become atrophied, so I have to exercise them every day. I made it at home, apply it. I exercise my legs in the morning on my bed. I use a rope to help me stand up, then I have a bar to help me exercise my body. I do it every day. (P 5)

I believe that traditional massage can help. I think it should be better after massage. I feel better. My leg is stronger and now I do not need it. (P 1)

1.2. Integrating modalities with pain relief. The continued illness in the lives of people with severe symptoms such as pain triggered them to use several management modalities. The study participants used both traditional and modern medicine to relieve pain, as reported:

I use warm water. I use a bag with warm water inside and put it on my leg. It works and then I can sleep. I learned this method from a traditional healer. (P 1)

I use oil. I got it from the hospital. It works but just temporarily. I also take tablets to relieve my pain. (P 10)

1.3. Preventing and managing pressure sores. The pressure sore was the most common complication in patients with spinal cord injury. Before being discharged, participants learned from health personnel various methods to prevent pressure sores, such as changing position when lying in bed, sitting on car tires, dressing wounds, and ventilating and drying wounds with an electric fan. They stated as follows:

To prevent bedsore, the doctor told me that I can use a car tire. I used it and it works. I try not to sleep in supine position and always change my position. (P 4)

I take care of the wound at the buttocks.... I make it clean and dry by electric fan. I do it by myself every day. (P 5)

2. Healing the mind. Injuries resulting in loss of physical functioning and chronic conditions after discharge may also result in many psychological problems. Although participants received most support from others, they comforted themselves with religious and spiritual beliefs to heal the mind and improve the body and self in their new life. Three means of self-support were given as follows:

2.1. Thinking positively. Participants mentioned the Buddhist ways of thinking to cope with situations experienced after trauma. Thinking positively was used by participants to help get them through stressful or bad situations. The disabled participants stated as follows:

I think it is OK for me that I was injured not too much. I still can use my hands, I still can walk. I think I am luckier than those who lost their limbs. (P 6)

Sometimes, I think I cannot stand with pain and rehab, but I think I am luckier than others. The other persons cannot take care of themselves but I can. I still can do many things by myself (P 1)

2.2. Fighting for life. Rehabilitation requires much effort over a long period. Participants strengthened their minds by viewing the rehabilitation process as a fight for survival. Support from family could also help participants to face their chronic conditions. They focused on changing their mindsets from one of flight, to fighting for their lives, as they learned to care for themselves and live in society as other people. As 2 participants reflected:

I only think that I had to be alive, to survive, and to live with other people. Although I am handicapped, it must not be an obstacle to my living. (P 4)

I always strengthen my mind. I can walk. Why not fight. So, I must go ahead. I must take care of myself as best as I can. (P 11)

2.3. Practicing religion. In facing lifestyle limitations resulting from chronic conditions and trauma, most participants comforted themselves by practicing religion. Participants gained comfort, cultivated their minds, and relieved their sufferings from the belief in Karma and other Buddhist beliefs. They stated as follows:

I think it may be my sin in the past that made me experience the bad thing at present. So I am not angry with the persons who injured me. (P 4)

When I feel sad and hopeless, I read a book about Buddhism. Then I feel better. It taught me that everything is uncertain. There is nothing that belongs to me forever, so I feel that I can live further. (P 11)

3. Finding harmony in life through caution and a willingness to adjust one's lifestyle.

During rehabilitation, participants had to adjust their lives by looking for jobs, and by changing their lifestyles for living in a situation of social unrest. They took more security precautions, while living at home and while working outside the home. They stated as follows:

I had to repair my shop, made a bunker in front of the shop. If the bomb happens again, it may be able to protect my life and shop. (P 2)

When I go outside, I have to be careful. When I park my car, I have to look if there is any suspected car or motorcycle. If there is, I will leave that area and go far from them. I choose to walk. (P 3)

I will not go to high-risk areas (where people are known) or somewhere that is very crowded. For safety, I will rarely go out but I will buy a lot of food to keep in the house for a long time. (P 11)

DISCUSSION

There were meanings of holistic self-care for rehabilitation described in this study. Although holistic self-care is often related to physical, psychological, and spiritual care, it was also found to have applications to the rehabilitation of Thai Buddhist patients in their struggle to cope with constraints and difficulties resulting from trauma. Part of "learning to have a new life" for participants, who suffered a loss of mobility or had other disabilities, was a new need to learn how to take care of themselves. They initially learned techniques from others, such as nurses, doctors, and physical therapists. Later, they learned by themselves how to cope with a new life in their environment. They became more active in their own rehabilitation and thus became more independent. These findings are consistent with a previous study of Thai paraplegics, who reflected that, even though they were physically handicapped, their hearts and brains still functioned normally, and thus they could learn to have a normal life.10

According to Buddhist beliefs, having endurance with consciousness is a means of coping with difficulties. The study participants could accept their conditions, and then continue to bear the illnesses. "Bearing with the increased care demands as a chronic disease" was how they described a recognition of remaining physical or psychological problems after being discharged. It is well known that chronic disease can have recurrent symptoms and permanent organ dysfunction.11 It is the same with patients who have suffered trauma. Once they accepted their problems, participants would start learning to take care of themselves. When they recognized their ability to do that, their self-care behaviors improved.12 Upon discharge and returning home, some physical and psychological problems required continued self-rehabilitation. For physical rehabilitation, they improvised by using everyday objects, strengthening their muscles and preventing pressure sores. They also used traditional medicine to relieve pain. This integrated approach to health care was consistent with the health system theory of Kleinman.13

For psychological problems, trauma patients used positive thinking, which was consistent with the copy theory of Lazarus and Folkman.14 They also applied the Buddhist belief that everything is uncertain and that nothing belongs to us.15 With this type of belief, they could accept what had happened to them, and learn to live again.16 Religious activities such as praying, going to temple, and making merit were usually performed to heal the mind and body, and develop peace of mind when living in the midst of political unrest. These practices could make people calm in an unrest situation.17 This finding is similar to the previous study of the 9-11 terrorist attack, in which religious activity was found to reduce stress and posttraumatic stress disorder.18 Religious beliefs and activities are recognized as a means of psychological rehabilitation.19

In addition to physical and psychological rehabilitation, postdischarge self-care practice also addressed adapting lifestyles to live in an environment of unrest. Participants described many ways of accomplishing this, including avoiding crowded places and avoiding travel to remote places. Support also came from the family and social sources. Mental health support may also have an indirect positive impact on the patient's self-care for rehabilitation.

This study showed that the trauma patients living in a situation of political unrest could apply holistic rehabilitative self-care by themselves, incorporating their religious beliefs and activities, and receive assistance from society. Information from this study can be used by nurses and health care staff to guide their continuing care for trauma patients suffering from a situation of social unrest. For example, it could be useful to establish support groups, or promote holistic self-care with religious healing practices.

LIMITATIONS AND RECOMMENDATIONS

The study was conducted with only a small sample of Buddhist trauma patients who suffered from terrorism in southern Thailand. It did not include patients living in areas that were unsafe for the researcher to enter. This may somewhat limit the extent to which the findings may be generalized. Nevertheless, the study indicates that the insight gained into how holistic self-care is perceived and practiced by trauma patients could benefit the planning and implementation of interventions to achieve an acceptable quality of life, and may provide a model for similar study among other groups of trauma patients, albeit in context-specific ways. Therefore, future studies need to address the self-care experiences among other trauma populations, for instance those living in other cultural backgrounds such as Muslims, who comprise the majority of the population in southern Thailand, to identify the similarities and differences.

CONCLUSIONS

This study provides a description and understanding of the holistic health care experience of those who survive trauma as a result of terrorist situations during times of political/social unrest. Nurses could use the results to improve the planning of discharge, the development of an intervention, and the promotion of quality of life for such patients.

Acknowledgment

This study was supported by the Higher Education Research Promotion and the National Research University Project of Thailand, Office of the Higher Education Commission.

REFERENCES