Burj El Barajneh is a Palestinian refugee camp (BBC) in Beirut, Lebanon, and the 6th largest of the 12 official campus established after 1948. According the data collected in 2008-2009, it is home to approximately 14,000-18,000 inhabitants over an area of 1.6 km squared, a number that has continued to increase significantly over time. The dire social and environmental conditions faced by Palestinian refugees in Lebanon are recurrently stated to be the most severe in the region, especially due to limitations in economic resources, employment opportunities and basic health services.
Describe the intended uses of your framework or model of change
The logic model was developed to help with planning a mental health intervention for youth ages 10-14 in the Burj El Barajneh Palestinian refugee camp.
The initiative the logic model was being created for—Qaderoon (Arabic for ‘we are capable’)—aimed to develop a year-long social skills building intervention in order to promote positive mental health of the refugee children and increase attachment to school. In order to reach these goals, practitioners had to develop an evidence-informed intervention that included activities for children, parents and teachers and focused on skills such as improving communication skills, problem-solving skills, and relationships.
Phases of development of the logic model
Phase 1: Exploratory phase
A needs assessment survey was conducted during the spring of 2003 with never-married youth ages 13-19. The household sample was chosen using a probability proportional to size sampling design. The data from the adolescents was gathered through interviews conducted face-to-face with the participants identified from a household roster, with consent given by both the parents/guardians and the adolescents themselves. The data collectors were recruited from the community and trained intensively by CRPH staff and study investigators. Response rate for the survey was 96.4% in BBC. The process of logic model development began with the dissemination of results of a needs assessment survey.
Selected results (seen in Table 1) indicated that the youth surveyed were relatively disadvantaged, residing in households of mean annual income of 4,854,000 Lebanese Liras (approximately US$3236), with only 54% of the sample currently enrolled in school and 27% working. Stressful life events were evident for many of them, with 60% having a family member hospitalized, or having parents who needed to repay a loan (48%). The results were disseminated and discussed at length in June 2005 in a meeting with organizations and individuals that work and live in the camp. The result were verified, indicating that the community practitioners’ ‘felt need’ matched scientifically assessed need, and that there was interest in an intervention with the camp youth. At this first planning meeting, a Community Youth Committee (CYC) was formed and all those in attendance were invited to join.
One of CYC’s primary decisions was to explore the survey results in greater depth. To do so, focus group discussions were conducted with youth aged 13–19 years of both genders to get their feedback on the results, to explore other issues that were not included in the survey, and to begin to prioritize youth issues (Makhoul and Nakkash 2009). After hearing the results and providing their perspective on the data, the youth then prepared short plays that demonstrated their prioritized issue, and presented them to an audience of the CYC and adults from the community. These skits highlighted the importance of parents and teachers in the lives of youth.
The exploratory phase also included conducting focus groups with mothers and teachers of 13-19 year olds with the objective of getting their perspective on youth health and social issues. Parents emphasized that youth have no guarantees: they live in difficult socio-economic circumstances, are not well engaged by the school system, and have no work opportunities. Their daily life pressures inside and outside the house affect their mental health. Teachers discussed their difficult situation: they are underpaid, have to work double shifts, and they themselves come from the stressful environment that the children come from. They stated that the relationship between teachers and students is not ideal. Although the teachers are exposed to many training workshops, these are often irrelevant and inapplicable to their context and unique classroom circumstances.
Phase 2: Problem identification phase
The second phase of logic model development involved prioritizing issues and exploring determinants. The results of the data analysis from the first phase were categorized into main health/social themes and determinants, and five main health or social issues seemed to pervade: violence, mental health, school drop-out, tobacco use, and drug use. Each of these issues was ranked according to a set of criteria: size, seriousness, effectiveness of solution, acceptability to the community, feasibility and legality. Next, each of these criteria was rated from 1–3, given equal weight and a total was obtained. The decision on ranking of each criterion for each issue was made by the group keeping in mind evidence as well as community context. School drop-out and mental health received the highest overall ranking and were thus selected as primary outcomes for intervention.
The academic team began to think about interventions with three frameworks in mind: the Ecological Model of Health Promotion, Positive Youth Development, and Social Cognitive Theory. The specific choice of frameworks for this case was based on community and context. The Ecological Model of Health Promotion served as the primary model of reference (McLeroy et al. 1988), and a Positive Youth Development approach (Nansook 2004) was chosen as the conceptual framework for youth. The latter was chosen based on its aim to “promote development to foster positive youth outcomes’ (Catalano et al. 2002). This focus on positive aspects was important, especially because the BBC environment is rampant with negative situations and high risks.
With respect to the outcome of mental health, the focus was decided to be on positive mental health, which, much like the concept of resilience (Fergus and Zimmerman 2005), is defined as ‘a person’s ability to cope with adversity, and avoid breakdown or diverse health problems when confronted with adverse experiences’ (Korkeila 2000). This pertains to the BBC youth, who have exhibited hope despite their restrictions. An emphasis on ‘immunizing’ the youth and preparing them for adversity was chosen. The detailed consent procedures applied for participation in this intervention facilitated community understanding.
In regards to theoretical frameworks, Social Cognitive Theory was chosen (Baranowski et al. 2002) as it emphasizes the interaction between personal factors, environmental conditions and human behavior. The interrelated aspects apply to the camp, where it is impossible to escape the influence of environmental conditions on health and behavior.
Once the outcomes and conceptual frameworks were selected, the literature on determinants of mental health and school drop-out were reviewed. Using a wide search strategy, determinants were explored and examined at a variety of levels (McLeroy et al. 1988). These were linked to each of the main outcomes of ecologic influence from individual, to interpersonal (peers, families), to organization (schools) and to those relevant to the larger environment (context of Lebanon and the camp). For example, problem solving skills were identified as a determinant of mental health at the individual level, healthy parent– child relations at the interpersonal level, neighborhood safety at the community level, and access to education at the policy level. A decision was made to focus only on the proximal determinants (individual, interpersonal and organizational). Despite the recognized importance of distal structural factors in both these outcomes, the CYC acknowledged the impossibility of changing political, sectarian and legal factors linked to being a Palestinian refugee in Lebanon. Within the range of proximal determinants, those perceived by the CYC to be most amenable to intervention were selected as targets of change.
Phase 3: Intervention development phase
The last phase of logic model development included defining interventions. Four evidence-based reviews of mental health interventions for youth were examined (Durlak and Wells 1997; Greenberg et al. 2000; Greenberg et al. 2001; Browne et al. 2003), and subsequently, the CYC chose specific interventions based on the following criteria:
- The outcome measure was linked to mental health/positive youth development
- The target age group was appropriate—the aim was a preventative intervention, and the ideal age group was 10-14, as the high drop-out age in regards to Palestinian refugee children occurs at age 14
- The intervention was intended for a universal audience
- The length of the program
- The program involved parents and/or teachers
- The setting of the program was not in a clinical setting, but rather in school or the community
- The main activities of the program fit the identified determinants
- The program was perceived to be adaptable to the context of the camp.
Three evidence-based interventions were selected after extensive discussion and revision as most appropriate to the context: Stress Inoculation Training, Improving Social Awareness and Social Problem Solving, and Positive Youth Development Programme (Maag and Kotlash 1994; Bruene-Butler et al. 1997; Kegler et al. 2005). The manuals of these interventions were requested and received from the organizations. As these interventions collectively included activities addressing the identified determinants, the sessions in each were added to estimate the scope of our intervention. Context specific sessions were also added. In keeping with the ecological model, activities with parents and teachers were included.
Once all current components and elements are identified and incorporated into the framework or logic model, put it to use.
The logic model was utilized in the Qaderoon intervention, with the process evaluation indicating that intervention implementation was successful. Children had very high satisfaction with the sessions, with results indicating that in the summer session, in all sessions and groups combined, 90.4% of children chose a happy face to express their rating of the session.
For more information about development of the intervention, see Toolkit 7: Developing an Intervention, Example 1.
Afifi RA, Makhoul J, El Hajj T, Nakkash RT. Developing a logic model for youth mental health: participatory research with a refugee community in Beirut. Health Policy Plan. 2011;26(6):508–517.
Contributed by Leah Soweid, American University of Beirut, Intern with the Community Tool Box.