Mental health challenges facing adolescents in Gaza and Jordan
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A presentation by Dr Bassam Abu Hamad to the 19th WPA 2019 World Congress of Psychiatry, Lisbon, Portugal, August 2019
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Mental health challenges facing adolescents in Gaza and Jordan
- 1. Mental and psychosocial wellbeing of adolescents in Gaza and Jordan: Emerging Findings from the GAGE research Programme Dr Bassam Abu Hamad, GAGE Associate Director-MENA, August 2019 © Adolescent girls in Zatari camp © C Herwig / UNICEF 2017
- 2. Please note that the photographs of adolescents DO NOT capture GAGE research participants and consent was gained from their guardians for the photographs to be used for GAGE communications purposes. Overview: GAGE research 12 year old Syrian girl in Mafraq @ Natalie Bertrams / GAGE 2019
- 3. Faculty Disclosure Company Name Honora ria/ Expens es Consultin g/ Advisory Board Funde d Resea rch Royalt ies/ Patent Stock Option s Owner ship/ Equity Positio n Employ ee Other (please specify) x x x X No, nothing to disclose Yes, please specify:
- 4. By finding out ‘what works,’ for whom, where and why, we can better support adolescent girls to maximise their capabilities now and in the future Gender and Adolescence: Global Evidence (GAGE): A longitudinal research programme (2015-2024)
- 5. GAGE’s 3 Cs conceptual framework
- 6. Quantitative survey with: • Adolescent girls and boys + their caregivers • 2 age cohorts: 10-12 yrs + 15-17 yrs in rural and urban locales, in programme intervention and non-intervention sites • Sub-sample of adolescents with disabilities Qualitative research with: • 1000 adolescents, their siblings, caregivers, community leaders • Nested sample of adolescents with disabilities • Key informant interviews and historical process tracing with officials, service providers and donors Annual qualitative and participatory research with: • 300 girls, their caregivers and peer networks to better pinpoint shifts in adolescent capabilities over time • Social network analysis to understand evolving influence of peer groups
- 7. Exploring adolescent psychosocial- related experiences and responses in conflict affected setting (Gaza and Jordan) Stemming from our conceptual framework, we aim at: Recognizing the availability of age and gender-appropriate PSS and mental health services and the extent to which adolescents' needs are supported by these services in Gaza and Jordan Study objectives
- 8. Methodology: Mixed methods quantitative, qualitative and participatory research approach In Jordan, Quantitative survey, with large number of younger and older adolescent girls and boys (4000), and their caregivers in rural and urban locales, with sub-sample of adolescents with disabilities in addition to qualitative and participatory methods in both Gaza and Jordan: Community mapping and timeline, including changing norms and perceptions of adolescents Key informant interviews with district and community level officials, service providers, adolescent empowerment programme graduates In-depth interviews with adolescents and parents on their experiences and perspectives relating to the second decade of life Focus Group Discussions with adolescents using participatory community mapping, vignettes to explore social norms and body mapping Inter-generational trios to explore generational shifts regarding adolescent experiences and age and gender-related social norms Interactive participatory research tools including photography, daily schedules, social support quadrant, Madam President and child-friendly tablet based survey
- 9. Methodology: Mixed methods participatory approach • In Gaza, literature review, secondary analysis of available databases, 70 KII, 10 FGDs groups with 97 adolescents, 35 in-depth interviews with adolescents, 107 QuickTapSurvey™ respondents. We also drew on findings from our 2016 participatory action research project in Khanyounis, Gaza, involving 35 adolescents (for 8 weeks) • In Jordan, quantitative survey, with large number of adolescent (4000), and their caregivers, in addition to qualitative methods which involved 220 interviews with adolescents, 158 KII with Makani staff, 30 FGDs with caregivers; • In both sites, we used a range of qualitative participatory tools e.g vignettes, object-based interviews, social network mapping, bodily mapping, peer-to-peer interviewing and participatory photography and videography (see the participatory research guide for GAGE)
- 10. 15-years-old boy © C Herwig / UNICEF 2019 Research findings
- 11. 1 • Key stressors affecting adolescents in Gaza, originating from political turbulence, conflict and chronic exposure to repetitive traumas 2 • Economic hardship (acute and chronic) e.g. inability of HHs to sustain basic livelihoods including food, communication means and access to recreational activities 3 • Increasingly conservative social norms, with restrictions on movement, and in the case of girls being preoccupied with ‘family honour’, early marriage, lack of understanding about puberty 4 • Lack of voice, power and agency, intergenerational conflict 5 • Wide spread violence (all forms including sexual violence) Key stressors affecting adolescents in Gaza
- 12. 1 • Exposure to trauma, loss of beloved family member/persons and witnessing traumatic events (Syrians), lack of safety, fear of trafficking/kidnaping 2 • Poverty e.g inability of HHs to sustain basic livelihoods including food, communication means and access to recreational activities 3 • Conservative social norms, being preoccupied with ‘family honour’ 4 • Displacement, discrimination by host communities (mostly against Syrians) 5 • Violence, sexual harassment, bullying, which lead to school drop out among older girls; Overall, 42% of young people in our sample reported that they had experienced peer violence in the last year, more than 70% experienced parental violence. Key stressors affecting adolescents in Jordan differ by nationality
- 13. Many adolescents in Gaza developed mental health symptoms suggesting PTSD, feeling unsafe, fear of upcoming wars, loss of hope, frustration, increasing suicidal behaviours which increased from 20 to 50 cases monthly. 26% of adolescents regarded psychosocial problems as the most important health issue they faced. Different forms of anxiety and depression are common in girls, many of whom are socially isolated after puberty due to concerns about sexual harassment and family honour. Increasingly, psychosomatic complaints such as bed-wetting and speech issues are common. Significant increase in substance abuse especially among boys Psychosocial and mental health issues affecting adolescents- Gaza
- 14. In Jordan, 32% of GAGE adolescents reported symptoms of psychological distress. Compared to older boys, older girls are 11% more likely to exhibit emotional distress, linked to their greater social isolation, their anxiety about being forced to marry as children, their experiences with child marriage, and their more limited access to psychosocial support. Adolescents living in ITS, are especially likely to exhibit distress (40% versus 33% in host communities and 29% in camps). Significant increase in substance abuse especially among boys. Increasingly, psychosomatic complaints such as bedwetting and speech issues are common— and are a symptom of the rampant bullying that boys experience. The overall mean of social cohesion score was medium level 2.5/4 (higher is positive), yet 81% of adolescents believe that peer pressure is a concern for boys and 75% believe that it is a concern for girls. Adolescent girls more likely than their male peers to feel sad, fearful and depressed, especially likely to experience physical and social isolation and more likely than boys to have eating disorders and engage in suicide ideation. Psychosocial and mental health issues affecting adolescents in Jordan
- 15. How do adolescents cope? • Generally, strong reliance on emotion- focused coping strategies, rather than on problem solving strategies especially in Gaza, including joining religious activities • Adolescents isolate themselves – they prefer not to reach out for help, rather internalizing stress-more in Gaza. • There was also a tendency among girls more than boys to use positive coping approaches like investing in education (more in Gaza) and using social media outlets, watching TV. • Seeking the available PSS services such as joining Makani centers (Jordan), which provide a comprehensive package of services that includes psychosocial support, life skills training, informal education, and is linked to a cash transfer. • Controversial family support (better in Jordan) with mothers being a source of support but also stress/risk. • In Jordan, 94% of GAGE adolescents have someone in their lives (usually parents) who supports them. In Gaza families are less supportive.
- 16. Emerging findings – most marginalized… Syrians, refugees Ex-Gazans Divorced young adolescents Poor adolescents with limited education Orphans Adolescents with disabilities Adolescents who lost homes/ resources as a result of conflict Living in ITS then host communities Boys who dropped out and are already working Girls, especially older girls 15> (in particular the pretty ones) Early married adolescents - and particularly young adolescent mothers Girls living in conservative areas and in marginalized or border areas Girls who dropped out of school and are home bound
- 17. Service provision in Gaza Despite the availability of many PSS support services in Gaza, adolescent access is limited, many participants reported that they were unaware of how to access such services or not allowed to do so. Families almost try everything before seeking PSS services! Generally, PSS services are short-term, fragmented, donor-driven, and focusing on younger children. PSS programmes are reactive in nature, not proactively targeting adolescents. Services are neither gender nor age sensitive. Access to specialized mental health is problematic both in coverage and the quality. Skilled service providers seldom exist. Conservative norms, family honour, social stigma and the attitudes of service providers limit or seriously delay service uptake. UNRWA and the MoE run a large-scale school counselling programme, but counsellors usually focus on adolescents with poor academic performance, not on adolescents’ PSS related needs.
- 18. Service provision in Jordan Makani centres provides a comprehensive package of services to vulnerable adolescents, coupling non-formal education with a package of services that includes psychosocial support and life skills training, and is now linked to UNICEF’s labelled cash transfer – Hajati. • In host communities, the main psychosocial services that adolescents are using are in schools, but school counsellors focus more on vocational training not on PSS issues. • A few parents reported making use of psychosocial services from medical professionals and NGOs. • Informal, and specialized psychosocial services are chronically under-funded and sustained support appears to be the exception rather than the rule. • Service uptake varies by nationality, income and cultural norms; many don’t know where to go. • Specialized mental health services are almost entirely limited to hospitals in urban areas.
- 19. Positive experiences –Jordan Makani contributes to improved mental wellbeing among older adolescent boys through life skills, child protection activities and opportunities to interact with peers and trusted mentors. Our survey found that older boys who attend Makani are 16% less likely to suffer from emotional distress than their peers who do not participate. They are also 35% more likely to play a sport (51% versus 38%), score 21% higher on the index of issues they can discuss with their fathers, and score 10% higher on the index of issues they can discuss with their mothers.
- 20. Positive experiences -Gaza • Integration of Mental health services into the regular PHC services at MOH and UNRWA centres (stepped care model) is an interesting model to reduce stigma and promote proactive targeting (Gaza) • Provision of tailored integrated comprehensive services (individual empowerment model) including PSS, social protection, legal support, economic empowerment, health, empowerment, TEVT is more effective than vertical programmes (like AISHA in Gaza) Adolescent girls in Zatari camp © C Herwig / UNICEF 2019
- 21. Priority actions 1 • Strategies and policies should address the key determinants of psychosocial and mental wellbeing. Intersectoral interventions to address the multiple vulnerabilities adolescents face are essential. 2 • Expand opportunities for adolescents-especially girls-to interact with peers and participate in empowerment and reactional activities such as Makani 3 • Strengthening the links between PSS services and social protection programmes especially the large scale cash assistance programmes implemented in Gaza and Jordan 4 • Support service providers to provide more age- and gender-sensitive services, filling gaps is the quality of services provided, enhance coordination, provision of training to service providers 5 • Develop and expand a cadre of social workers trained to support young people’s mental health needs, and simultaneously provide training to healthcare workers and teachers on how to identify and refer young people in need of support and counselling
- 22. Priority actions 1 • Invest in hotlines for young people with psychosocial illbeing/ mental ill-health, given increasing access to mobile phones for adolescents and drawing on international good practice 2 • Invest in courses on psychosocial first aid to support refugees who have gone through considerable upheaval and/or trauma so as to enhance their coping and resilience skills 3 • Address gaps in adolescents' access and utilization of specialized services through community outreach services, referrals and awareness-raising and proactive training/early detection esp. in schools/NGOs, invest in recruiting specialized service providers 4 • Support positive parenting practices, adolescents’ friendly spaces, gender equity, combating violence
- 24. Contact Us Dr Nicola Jones, GAGE Director n.jones@odi.org.uk Dr Bassam Abu Hamad, ghsrcb@gmail.com www.gage.odi.org @GAGE_programme GenderandAdolescence About GAGE: Gender and Adolescence: Global Evidence (GAGE) is a nine-year (2015-2024) mixed- methods longitudinal research programme focused on what works to support adolescent girls’ and boys’ capabilities in the second decade of life and beyond. We are following the lives of 18,000 adolescents in six focal countries in Africa, Asia and the Middle East.
Editor's Notes
- GAGE is a new nine-year (2015-2024) longitudinal research programme that aims to understand what programmes are most effective in transforming adolescent girls’ lives at specific junctures during the second decade of life, based on an in-depth multi-disciplinary understanding of adolescents’ gendered perspectives and experiences in diverse developing country contexts. The purpose of the GAGE evidence base is threefold: i) To promote state-of-the-art knowledge about what works for adolescent girls, using not only a longitudinal lens but also layering objective measures of policy and programmatic change strategies with girls’ perspectives to understand what works, where and why. ii) To improve the research tools and methodologies available to the global community to formulate the tailored and interdisciplinary knowledge generation approach necessary to capture gendered adolescent realities. iii) To fast-track social change for adolescent girls by informing policy, programming design, monitoring and evaluation (M&E) and advocacy with cutting edge primary and secondary evidence and analysis. We are working in seven countries spread across SSA, Sth Asia and MENA where we have a specific focus on refugee and host community relations
- All GAGE’s work is underpinned by what we are calling a 3Cs conceptual framework with three Cs standing for capabilities, contexts (both local and global) and change strategies (from behavioural change communications interventions through to cash transfers). We draw on Amartya Sen and Martha Nussbaum’s capability approach which emphasises the importance of individuals having the ability to achieve a life that they find meaningful and so we are interested in understanding the effects of multi-sectoral interventions on six key capability areas that appear to be critical to adolescent girls wellbeing and the ways these capability areas overlap/ intersect. While adolescence heralds significant changes for girls and boys, and notwithstanding significant progress for girls esp in terms of education over the course of the MDGs, in many contexts they still face a range of gender-specific vulnerabilities. Of particular importance for sustainable change in girls life chances are also what our colleague Naila Kabeer calls ‘inter’ capabilities, not only individual capabilities such as knowledge, analytical skills, and lifeskills which shape their capacity for exercising agency (knowledge, but also the collective capabilities embodied in social relationships which allow them to claim rights, tackle injustice, and ultimately bring about structural change.
- Stemming from our conceptual framework, GAGE will seek to address two core sets of questions. The first is framed around adolescent perspectives and experiences and based on the capabilities. On adolescent perspectives + experiences: What is the patterning of girls’ and boys’ experiences, attitudes and identities across adolescence - including those of the most marginalised? What role do national and community contexts play in shaping their gendered experiences? The second set, around the relative efficacy of different types of change strategies in diverse contexts. On programme effectiveness: Capability Outcomes – what effect do programs have on adolescent outcomes? Bundling components – what is the relative efficacy of specific program components? Timing – when is it critical to intervene? Duration – with what intensity, for how long? Legacy – what are the sustained cumulative benefits over time and into early adulthood? To contribute to the global evidence base, we are employing an ambitious mixed methods impact evaluation design following 18000 early and older adolescent girls and boys over the next 8 years, and undertaking qualitative and participatory work with a sub-sample but still substantial number of adolescents to explore their experiences and perceptions over time as they pass through critical adolescent transitions and eventually into early adulthood.
- Overview of findings of our GAGE Gaza research….
- In Gaza, 64% of girls, 33% of boys are not invited to go out with friends, Only 14% of boys and 0.8% reported being a member of a sport club I don't think there will be future for us. I am desperate about the whole life. I want to commit suicide-it’s better than this life’ (Girl, 16y early married Gaza). “Since the last conflict in Gaza, I scream when I hear bombing. I even feel frightened to go to the toilet by myself” (Young girls, Jabalia Gaza). We should go with our families or after taking a permission from my family to go with my friends. However, males do not need the permission we need. Our families ask about the details of our friends; their address, phone number and families…etc. (Gaza, 16 years girl-Jabalia) “My mother asked me to stop complain about my husband and to be patient because I have to worry about my younger’s sisters’ future and marriage chances”. (Gaza, early married girls 15 years old)
- Sexual harassment is endemic Younger girls are 33% less likely—and older girls 61% less likely—to play a sport compared to their male peers. In Jordan, of all GAGE adolescents, 76% leave home daily and 14% leave their community weekly. Depression… comes from very severe poverty… it has a high effect on adolescents as all their needs aren’t complete, and we know of suicide attempts… families may try to hide it but it’s happening’. (Social worker in Jordan, Gaza Camp) ‘If he (the father) likes the person, he will agree to marry her….Even if she doesn’t agree, he will not listen to her opinion.’ (Mother, Jordan, Gaza camp) I’m Syrian and no one wants to be a friend with a Syrian, and they revile at each other and I don’t love being reviled (Syrian refugee in Jordan) “I would like to go back to school, I would really like to go back to school but I don't have enough to eat, I don't have enough money to go to school and to eat.” (older boy, Amman) When the boy earns some money, he goes to buy cigarettes and it may change to Marijuana and drugs…” (key informant, Jerash)
- The mother of an 11-year-old boy who is deaf explained that her son endures so much taunting when he leaves home that the family is looking to move: ‘They were calling him deaf, speechless, and unable to walk. You know how are our community and their perception about the disabled... So, I wanted to move to another house’.
- Boys reported more a desire of immigration, smoking, substance abuse, hanging out with friends, school drop out, turning violent, joining child labour, and internet use.
- Purple girls, pink boys and red both.
- Sometimes they school counselors perceive us wrong and always blame us. They usually tell what we told them to the teachers” - School counselors tell the mgmt. about everything. Gaza Older adolescent girl, Jabalia There are lots of services that I am hoping would be available at NGOs Centers but are not available for us. Summer camps for example are only available for ones from the fifth to the eighth grade (10-15), but not ones in our age (16-19)” – Gaza, Older adolescent girl
- I Would rather handle the problem on my own [than report]… … after that everyone is going to be gossiping about that…’ (Focus group, Zaatari Camp) ‘Until now he keeps reminding her [the life skills facilitator] that he didn’t know until that point that he had a value in this society.’ (Makani facilitator, Amman)
- Develop and deliver parent support groups and education classes for parents of adolescents (as opposed to younger children), to foster better parent–child communication, promote space for adolescent decision-making, and shift gender norms that leave girls socially isolated and at risk of child marriage. 2) Over time, work to ensure that public schools are mixed in terms of student nationality, so as to enhance young people’s appreciation of diversity, foster social cohesion, and strengthen their sense of shared belonging . This will in turn have positive spillover effects on the attendees of extra-curricula programmes like Makani given that class composition depends to a significant extent on the hours during which students are in school. 2) Expand opportunities for adolescents – especially girls – to spend time with peers in safe spaces by developing more age-tailored programming for older adolescents, including Social Innovation Labs, which combine problem-solving and teamwork with community volunteering and access to positive role models. 3) Continue expanding the Ministry of Education’s Nashatati Programme into more schools in order to reach more adolescents with opportunities to develop confidence, express their thoughts and feelings, and collaborate with one another to solve problems. 4) Expand coverage of courses on psychosocial first aid and hotlines for young people with mental ill-health, especially given the high levels of trauma that many refugee adolescents have encountered.
- Develop and deliver parent support groups and education classes for parents of adolescents (as opposed to younger children), to foster better parent–child communication, promote space for adolescent decision-making, and shift gender norms that leave girls socially isolated and at risk of child marriage. 2) Over time, work to ensure that public schools are mixed in terms of student nationality, so as to enhance young people’s appreciation of diversity, foster social cohesion, and strengthen their sense of shared belonging . This will in turn have positive spillover effects on the attendees of extra-curricula programmes like Makani given that class composition depends to a significant extent on the hours during which students are in school. 2) Expand opportunities for adolescents – especially girls – to spend time with peers in safe spaces by developing more age-tailored programming for older adolescents, including Social Innovation Labs, which combine problem-solving and teamwork with community volunteering and access to positive role models. 3) Continue expanding the Ministry of Education’s Nashatati Programme into more schools in order to reach more adolescents with opportunities to develop confidence, express their thoughts and feelings, and collaborate with one another to solve problems. 4) Expand coverage of courses on psychosocial first aid and hotlines for young people with mental ill-health, especially given the high levels of trauma that many refugee adolescents have encountered.