Jihad Makhoul

Eliciting policymakers' and stakeholders' opinions to help shape health system research priorities in the Middle East and North Africa region

Evidence-informed decisions can strengthen health systems. Literature suggests that engaging policymakers and other stakeholders in research priority-setting exercises increases the likelihood of the utilization of research evidence by policymakers. To our knowledge, there has been no previous priority-setting exercise in health policy and systems research in countries of the Middle East and North Africa (MENA) region. This paper presents the results of a recent research priority-setting exercise that identified regional policy concerns and research priorities related to health financing, human resources and the non-state sector, based on stakeholders in nine low and middle income countries (LMICs) of the MENA region. The countries included in this study were Algeria, Egypt, Jordan, Lebanon, Morocco, Palestine, Syria, Tunisia and Yemen. This multi-phased study used a combination of qualitative and quantitative research techniques. The overall approach was guided by the listening priority-setting approach, adapted slightly to accommodate the context of the nine countries. The study was conducted in four key phases: preparatory work, country-specific work, data analysis and synthesis, and validation and ranking. The study identified the top five policy-relevant health systems research priorities for each of the three thematic areas for the next 3-5 years. Study findings can help inform and direct future plans to generate, disseminate and use research evidence for LMICs in the MENA region. Our study process and results could help reduce the great chasm between the policy and research worlds in the MENA region. It is hoped that funding agencies and countries will support and align financial and human resources towards addressing the research priorities that have been identified.

Parental attitudes towards and perceptions of their children's participation in clinical research: a developing-country perspective

Background Paediatric clinical research faces unique challenges that compromise optimal recruitment of children into clinical trials. A main barrier to enrolment of children is parental misconceptions about the research process. In developing countries, there is a knowledge gap regarding parental perceptions of and attitudes towards their childrens participation in clinical trials. Objective To explore such perceptions and attitudes in Lebanese parents. Study design 33 in-depth interviews were conducted with parents with and without previous research experience. Interviews were tape-recorded, transcribed in colloquial Arabic, and later subjected to thematic analysis. Results Benefit/risk ratio assessment was a major determinant of parental consent. Fear of adverse events or painful procedures in research was a recurring theme in most interviews. Whereas perception of direct benefit to the child, trust in the physician or institution, financial gains or having a positive previous experience in research facilitated consent, a complex informed consent form and misunderstanding of the term ‘randomisation’ hindered parental approval of participation. Conclusion Lebanese parents have perceptions of and attitudes towards childrens participation in clinical trials that are similar to those reported from the industrialised world. Improving communication with parents and building trust between researchers and parents is important for successful recruitment. Investigators planning to conduct paediatric trials in developing countries need to simplify consent forms and devise new ways to explain randomisation.

Developing a logic model for youth mental health: participatory research with a refugee community in Beirut.

Although logic models are now touted as an important component of health promotion planning, implementation and evaluation, there are few published manuscripts that describe the process of logic model development, and fewer which do so with community involvement, despite the increasing emphasis on participatory research. This paper describes a process leading to the development of a logic model for a youth mental health promotion intervention using a participatory approach in a Palestinian refugee camp in Beirut, Lebanon. First, a needs assessment, including quantitative and qualitative data collection was carried out with children, parents and teachers. The second phase was identification of a priority health issue and analysis of determinants. The final phase in the construction of the logic model involved development of an intervention. The process was iterative and resulted in a more grounded depiction of the pathways of influence informed by evidence. Constructing a logic model with community input ensured that the intervention was more relevant to community needs, feasible for implementation and more likely to be sustainable.

An ethnographic study of the consequences of social and structural forces on children: the case of two low-income Beirut suburbs

This ethnographic study of two low-income suburban communities in Beirut highlights the negative impacts that wider social circumstances can have on the young. The two communities of interest are a Palestinian refugee camp and another community in the suburbs of Beirut where displaced families and daily labourers reside. Using observations and in-depth interviews with residents and key informants in these communities over a period of four months, a research team obtained an inside view of the residents’ experiences. State political and economic policies place restrictions on work and mobility for the Palestinians in Lebanon and allow the religious sects to regulate civil life for the Lebanese. This paper discusses how, as a result of these and other difficult conditions, children and youth face consequences that can include illegal status, dropping out of school, abuse, child labour and substance abuse. Policies to alleviate these outcomes need to address the root causes situated within these structural forces.

Obtaining informed consent: observations from community research with refugee and impoverished youth

This paper presents challenges facing researchers in applying basic ethical principles while conducting research with youth in a developing country context. A discussion of the cultural and social challenges to adherence to the elements of informed consent: disclosure, comprehension, capacity, voluntariness and consent is presented. The authors argue that the current institutional review board requirements that guide research reflect values and stem from western contexts that may not be fully applicable to non-western contexts. More dialogue is needed among researchers in developing world contexts on challenges of and possible revisions to requirements that maintain respect for persons, beneficence, autonomy and justice, particularly when working with youth.

Development and Validation of the Arab Youth Mental Health Scale

A variety of measures of mental health have been used with youth. The reason for choosing one scale over another in any given situation is rarely stated, and cross-cultural validation is scarce. Psychometric testing is crucial before utilizing any measure of mental health with a certain population, due to possible cultural variations in interpreting meaning. The research reported herein describes the development and psychometric testing of the Arab Youth Mental Health Scale. The process included 5 phases: (1) reviewing existing scales leading to the identification of 14 non-clinical and relatively short mental health scales used previously with youth; (2) rating the scales by the researchers and community members leading to the identification of 3 scales with apt structure, and that were judged to be suitable, applicable, and appropriate; (3) soliciting youth input to assess comprehension of each item in the selected 3 scales and to discover context specific mental health related feelings, thoughts, and expressions; (4) seeking expert opinion to classify items remaining after phase 3 that measured common mental disorders, and to limit repetitiveness; and (5) testing for psychometric properties of the 28 items that remained after the previous 4 phases. The contribution of each phase to the process is described separately. Results of the exploratory principal component analysis resulted in one factor which explained 28% of the variance and for which 21 items loaded above an eigenvalue of 0.5. No other factor added significantly to the explanation of variance, nor had items that added theoretical or conceptual constructs. The process of soliciting feedback from youth groups, the community and professionals; and of field testing was challenging; but resulted in a contextually sensitive, culturally appropriate and reliable scale to measure mental health of youth. We recommend that researchers measuring mental health of youth critically analyze the relevance of existing scales to their context; consider using the AYMH scale if appropriate to their target population; and when needed, use a similar methodology to construct a relevant, culturally and contextually sensitive measure.

Validation of the Arab Youth Mental Health scale as a screening tool for depression/anxiety in Lebanese children

BackgroundEarly detection of common mental disorders, such as depression and anxiety, among children and adolescents requires the use of validated, culturally sensitive, and developmentally appropriate screening instruments. The Arab region has a high proportion of youth, yet Arabic-language screening instruments for mental disorders among this age group are virtually absent.MethodsWe carried out construct and clinical validation on the recently-developed Arab Youth Mental Health (AYMH) scale as a screening tool for depression/anxiety. The scale was administered with 10-14 year old children attending a social service center in Beirut, Lebanon (N = 153). The clinical assessment was conducted by a child and adolescent clinical psychiatrist employing the DSM IV criteria. We tested the scales sensitivity, specificity, and internal consistency.ResultsScale scores were generally significantly associated with how participants responded to standard questions on health, mental health, and happiness, indicating good construct validity. The results revealed that the scale exhibited good internal consistency (Cronbachs alpha = 0.86) and specificity (79%). However, it exhibited moderate sensitivity for girls (71%) and poor sensitivity for boys (50%).ConclusionsThe AYMH scale is useful as a screening tool for general mental health states and a valid screening instrument for common mental disorders among girls. It is not a valid instrument for detecting depression and anxiety among boys in an Arab culture.

Obstacles to health in the Arab world

EDITOR—Health indicators in the Arab world show stark differences between individual countries. But aggregate figures provide only a narrow perspective. They do not show variation according to socioeconomic group, sex, education, or political affiliation. The scarcity of databases available to collect such detailed data reflects the fact that inadequate political support exists for rigorous intersectoral research of relevance for health in the region. National development agendas and public policies are focused on economic development. Funding for health tends largely to be directed at providing curative medical services designed …

VIOLENCE: The silent determinant of child labor

This qualitative research study explores determinants of child labor in two low‐income urban communities in Beirut and reveals that violence against children, both at home and at school, is a recurring theme. Our analysis of interviews with and observations of working children and their parents in their homes and at the childrens work places shows that violence is an important determinant of child labor. Findings reveal that, contrary to the importance usually placed on family and school for childrens well‐being, certain home and school environments may indeed be unfavorable for learning and development and thereby play a role in a childs decision to leave school and start work at a young age.This qualitative research study explores determinants of child labor in two low‐income urban communities in Beirut and reveals that violence against children, both at home and at school, is a recurring theme. Our analysis of interviews with and observations of working children and their parents in their homes and at the childrens work places shows that violence is an important determinant of child labor. Findings reveal that, contrary to the importance usually placed on family and school for childrens well‐being, certain home and school environments may indeed be unfavorable for learning and development and thereby play a role in a childs decision to leave school and start work at a young age.

War as a positive medical educational experience

Context  There is little empirical evidence in the literature regarding the nature of the experiences of medical students during war. In this study we set out to assess and analyse the experiences of medical students and residents in Beirut, Lebanon during the 2006 Lebanon–Israel war.