Validation of a simple tool to assess risk of waterpipe tobacco smoking among sixth and seventh graders in Lebanon.

BACKGROUND: Waterpipe tobacco smoking (WTS) is highly prevalent in the Eastern Mediterranean region. While studies have identified socio-demographic factors differentiating smokers from non-smokers, validated tools predicting WTS are lacking. METHODS: Over 1000 (n = 1164) sixth and seventh grade students in Lebanon were randomly assigned to a prediction model group and validation model group. In the prediction model group, backward stepwise logistic regression enabled the identification of socio-demographic and psychosocial factors associated with ever and current WTS. This formed risk scores which were tested on the validation model group. RESULTS: The risk score for current WTS was out of four and included reduced religiosity, cigarette use and the perception that WTS was associated with a good time. The risk score for ever WTS was out of seven and included an additional two variables: increased age and the belief that WTS did not cause oral cancer. In the validation model group, the model displayed moderate discrimination [area under the curve: 0.77 (current), 0.68 (ever)], excellent goodness-of-fit (P > 0.05 for both) and optimal sensitivity and specificity of 80.1 and 58.4% (current), and 39.5 and 94.4%, (ever), respectively. CONCLUSIONS: WTS use can be predicted using simple validated tools. These can direct health promotion and legislative interventions.

Serenity in political uncertainty.

College students are often faced with academic and personal stressors that threaten their well-being. Added to that may be political and environmental stressors such as acts of violence on the streets, interruptions in schooling, car bombings, targeted religious intimidations, financial hardship, and uncertainty of obtaining a job after graduation. Research on how college students adapt to the latter stressors is limited. The aims of this study were (1) to investigate the associations between stress, uncertainty, resilience, social support, withdrawal coping, and well-being for Lebanese youth during their first year of college and (2) to determine whether these variables predicted well-being. A sample of 293 first-year students enrolled in a private university in Lebanon completed a self-reported questionnaire in the classroom setting. The mean age of sample participants was 18.1 years, with nearly an equal percentage of males and females (53.2% vs 46.8%), who lived with their family (92.5%), and whose family reported high income levels (68.4%). Multiple regression analyses revealed that best determinants of well-being are resilience, uncertainty, social support, and gender that accounted for 54.1% of the variance. Despite living in an environment of frequent violence and political uncertainty, Lebanese youth in this study have a strong sense of well-being and are able to go on with their lives. This research adds to our understanding on how adolescents can adapt to stressors of frequent violence and political uncertainty. Further research is recommended to understand the mechanisms through which young people cope with political uncertainty and violence.

Effectiveness of pictorial health warnings on cigarette packs among Lebanese school and university students.

BACKGROUND: Pictorial health warnings are more effective than text warnings in enhancing motivation to quit and not to start smoking among youth. In Lebanon, packs still have only a very small text warning. The aim of this study was to evaluate the perceived effectiveness of pictorial health warnings on cigarette packs among Lebanese youth. METHODS: This was a cross-sectional study including school students (n=1412) aged 13-18 years recruited from 28 schools and university students (n=1217) aged 18-25 years recruited from 7 universities. A variety of warnings were adapted from other countries. In all, 4 warnings were tested among school students and 18 among university students. RESULTS: All pictorial warnings were considered more effective than the current text warning on message-related and impact-related variables, including intentions to quit or not to start smoking among school and university students. Selected examples related to the top-ranked pictorial warnings are: among male non-smoking school students, 81% agreed that the 'lung' warning had more impact on their intentions not to start smoking as compared to 57% for the current text warning (p<0.001) with a significant difference compared to the current text warning; among female non-smoking university students, 75% agreed that the 'economic impact' pictorial had more impact on their intentions not to start smoking with significant difference as compared to 43% for the current text warning (p value=0.001); finally, the 'heart attack' pictorial resulted in 52% of male university students smokers stating they intended to quit as opposed to 20% for the current text warning (p value=0.019). CONCLUSIONS: The results of the present study add to the general international literature on the impact of pictorial warnings on youth and young adults. This study is also the first to test a non-health pictorial warning about the negative economic consequences of smoking, and to find that such a warning was effective among specific sociodemographic groups.

Challenges to obtaining parental permission for child participation in a school-based waterpipe tobacco smoking prevention intervention in Qatar.

BACKGROUND: Involving children in research studies requires obtaining parental permission. A school-based intervention to delay/prevent waterpipe use for 7th and 8th graders in Qatar was developed, and parental permission requested. Fifty three percent (2308/4314) of the parents returned permission forms; of those 19.5% of the total (840/4314) granted permission. This paper describes the challenges to obtaining parental permission. No research to date has described such challenges in the Arab world. METHODS: A random sample of 40 schools in Doha, Qatar was selected for inclusion in the original intervention. Permission forms were distributed to parents for approval of their child's participation. The permission forms requested that parents indicate their reasons for non-permission if they declined. These were categorized into themes. In order to understand reasons for non-permission, interviews with parents were conducted. Phone numbers of parents were requested from the school administration; 12 of the 40 schools (30%) agreed to provide the contact information. A random sample of 28 parents from 12 schools was interviewed to reach data saturation. Thematic analysis was used to analyze their responses. RESULTS: Reasons for non-permission documented in both the forms and interviews included: poor timing; lack of interest; the child not wanting to participate; and the child living in a smoke-free environment. Interviews provided information on important topics to include in the consent forms, parents' decision-making processes regarding their child's participation, and considerations for communicating with parents. Many parents also indicated that this was the first time they had been asked to give an informed consent for their child's participation in a study. CONCLUSIONS: Results indicate that more attention needs to be given to the informed parental consent process. Researchers should consider enhancing both the methods of communicating information as well the specific information provided. Before embarking on recruitment of children for studies, formative research on the parental consent process is suggested.

Process evaluation of a community-based mental health promotion intervention for refugee children.

Public health interventions are complex in nature and composed of multiple components. Evaluation of process and impact is necessary to build evidence of effectiveness. Process evaluation involves monitoring extent of implementation and comparison against the program plan. This article describes the process evaluation of the 'Qaderoon' (We are Capable) intervention; a community-based mental health promotion intervention for children living in a Palestinian refugee camp of Beirut, Lebanon. The manuscript describes the context of Palestinian refugees in Lebanon, the intervention, the process evaluation plan and results. The process evaluation was guided by the literature and by a Community Youth Committee. Findings indicated that attendance was 54 and 38% for summer and fall sessions, respectively. Session objectives and activities were commonly achieved. Over 78.4% of activities were reported to be implemented fully as planned. Over 90% of the children indicated high satisfaction with the sessions. Contextual facilitators and challenges to implementing the intervention are discussed. The most challenging were maintaining attendance and the actual implementation of the process evaluation plan. Findings from process evaluation will strengthen interpretation of impact evaluation results.

'I felt that I was benefiting someone': youth as agents of change in a refugee community project.

Youth can be 'powerful catalysts' in their own and their community's development. The paper describes the experience of youth based on their participation as decision makers in and implementers of a community-based research project in a Palestinian refugee camp of Beirut, Lebanon. In-depth interviews were conducted with 18 youth and 10 of their family members or friends. The participants were asked to describe the reasons they joined the project, why they stayed on, what they liked most/least about the project, how the project influenced their lives and what they would change about the project. Thematic analysis identified recurrent themes. Youth joined the program because of its benefit to children and their community. They stayed with the program because of the solidarity they found with the team and because of their relationship with the children. They perceived that they had an important role to play in the project's success. Youth acknowledged all the skills they gained from the project. Focus groups with others corroborated their statements. This project confirmed that youth can be powerful change agents in their own development and that of their communities. An Enabling Attributes Model is proposed for projects that aim to actively engage youth as community catalysts.

Jarrib Baleha--a pilot nutrition intervention to increase water intake and decrease soft drink consumption among school children in Beirut.

UNLABELLED: The Global School-based Student Health Survey (2005) indicated that in Lebanon, 33% of students in grades 7-9 drink carbonated soft drinks two or more times per day. Observational evidence suggests that students do not drink enough water. OBJECTIVE: A pilot project called Jarrib Baleha ['try without it'] was implemented with 110 students in grades 3 and 4 in two schools in Lebanon to promote drinking water instead of soft drinks. Specific objectives included increasing knowledge about the benefits of water and the harms of soft drinks, increasing confidence in choosing water over soft drinks, and increasing actual water drinking behavior while decreasing soft drink consumption. METHODS: Four 50-minute theory-informed, interactive and participatory sessions were implemented --by a graduate student in partial fulfillment of requirements for a MPH degree--over a period of two weeks. The intervention sessions--based on the Health Belief Model--took place during a class period. Process evaluation measured satisfaction of the students with the sessions. Impact evaluation measured changes in knowledge, attitudes including self-efficacy, and behavior, using a self-administered questionnaire completed prior to and after the intervention. Bivariate analysis using crosstabs was carried out to compare pretest and posttest scores on knowledge, attitudes, and behavior. RESULTS: Comparison of the knowledge index between pretest and posttest indicated that, overall, knowledge increased from 6.0769 to 9.1500 (p = 0.000). Compared to pretest, students at posttest also felt more confident to drink less soft drinks and more water (p < 0.05), to drink water when thirsty (p < 0.05), and to choose water over soft drinks when going to a restaurant (p < 0.05). The percentage of students drinking 6 or more cups of water increased from 27.7% to 59.1% (p = 0.000); and those drinking less than one can of soft drink/day increased from 25.5% to 57.6% (p = 0.000). DISCUSSION: These results are encouraging and suggest the Jarrib Baleha intervention could be implemented on a wider scale with students from both public and private schools. A more robust evaluation design is recommended. A comprehensive approach to school-based nutrition is also suggested.

The rise in narghile (shisha, hookah) waterpipe tobacco smoking: a qualitative study of perceptions of smokers and non smokers.

BACKGROUND: The prevalence of waterpipe tobacco smoking (WTS) in the Middle East region and worldwide is increasing. There is evidence to indicate both short term and long term health effects of WTS, resulting in the issuance of an advisory note by the World Health Organization. METHODS: This research aimed at gaining an in-depth understanding of the factors contributing to the rise in WTS in Lebanon. Qualitative focus groups (25) and in-depth interviews (9) were conducted with adults in Lebanon in 2007. Participants were recruited to represent diversity in smoking status, gender, age groups and urban/rural residence. The interviews and focus groups were thematically analyzed, and recurrent themes noted and summarized. RESULTS: The main themes identified were availability, affordability, innovation, influence of media, lack of a policy framework, and the sensory characteristics evoked from WTS. Men and women, smokers and non-smokers, and younger and older participants differed in their emphases on the above themes. These themes, though specific to waterpipe, are similar to themes manipulated by the cigarette industry, and eventually controlled through tobacco control policies. CONCLUSIONS: Understanding reasons behind the rise in waterpipe tobacco use is important if appropriate prevention, cessation, and policy interventions are to be formulated. Strict adherence to the FCTC is warranted, with careful and vigilant attention that all tobacco products are covered by laws in both high as well as middle to lower income countries.

Violence and social capital among young men in Beirut.

BACKGROUND: Research on the links between violence and social capital has produced mixed results and is mainly limited to Western countries. AIMS: To assess the relationship of social capital to physical fights among unmarried boys aged 13-19 years living in three disadvantaged neighbourhoods in the outskirts of Beirut, controlling for variables associated with youth violence. Lebanon has a history of civil and cross-border war, which may influence the production of violence at the individual level. METHODS: 674 boys were interviewed. The dependent variable was being involved in a physical fight in the last 3 months. The independent variable was social capital, classified into six categories: civic engagement and community development; locational capital; trust; reciprocity; hypothetical social support; and social network. RESULTS: One fifth (20%) had been in a fight in the last 3 months. Youth who were members of a group, who had been victimised, who could ask for help from a family member/friend/neighbour when they had a problem, and who liked living in their neighbourhood were more likely to be involved in a fight. CONCLUSION: This research supports the literature that indicates that physical fights are positively related to both individual and social capital variables. Social capital had a detrimental effect on physical fights. This may be related to bonding in a gang-like way. While high levels of social capital are good for other health outcomes and thus should not be reduced, interventions that channel youth energy in positive ways are needed.

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.

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.

Prevalence and determinants of suicide ideation among Lebanese adolescents: results of the GSHS Lebanon 2005.

The current study examined prevalence and risk factors for suicide ideation in 5038 Lebanese adolescents using Global School Health Survey data. Around 16% of Lebanese adolescents thought of suicide. Multivariate logistic regression models showed that risk factors for suicide ideation included poor mental health (felt lonely, felt worried, felt sad or hopeless), substance use (got drunk, used drugs), victimization (was bullied, was sexually harassed), and lack of parental understanding. Recommendations for future research and interventions are discussed.

Building research evidence for policy advocacy: a qualitative evaluation of existing smoke-free policies in Lebanon.

UNLABELLED: Secondhand smoke is harmful to smokers and nonsmokers, and smoke-free legislation worldwide improves health status. Lebanon has one of the weakest tobacco control regulatory environments in the Eastern Mediterranean region. However, several Lebanese workplaces and hospitality venues have chosen to implement such policies on their own. The objective of this study was to document their experiences. Qualitative interviews and focus group discussions were conducted with management, employees, and clients. Thematic analysis was used to identify recurrent themes. RESULTS: describe the types of bans implemented; the reasons for adopting a policy; and the barriers and facilitators to implementation, enforcement, and compliance. A main facilitator was management support, whereas a main barrier was prosmoking norms. This analysis provides insight and lessons learned that can aid in scaling up tobacco control efforts in Lebanon and the Eastern Mediterranean region.

The influence of parent-child relationship on safety belt use among school children in Beirut.

Parent-child relationships have been linked to the health and social well-being of adolescents. This relationship may be especially influential in areas of the world where family bonds remain the strongest for children. The association of parent-child relations and safety belt use has not been extensively documented. The objective of this research was to investigate the influence of parent-child relationship on adolescent safety belt use, controlling for other variables. To our knowledge, this is the first study to examine determinants of safety belt use among school students in Lebanon. A two-stage sampling design resulted in the inclusion of 3/3 public and 10/23 private schools. Over 2400 students in grades 6-12 completed a cross-sectional self administered survey. Current safety belt use included student report to wearing seat belts in the front seat only or the front and back seat. Parent-child relationship was measured through student reports of 'getting along with parents'. Other variables included socio-demographic status, health, lifestyle and social characteristics. Logistic regression was performed for variables significant at the bivariate level resulting in three models. Getting along with parents was a significant predictor of safety belt use in the bivariate and all multiple regression models. In the most comprehensive multiple regression model, having a good relationship with parents doubled the likelihood of using a safety belt (95% CI: 1.1-3.1). The study provides enhanced evidence of the importance of the parent-adolescent relationship. Interventions with parents are recommended to enhance their awareness of their influence on their children.

Social capital, women's autonomy and smoking among married women in low-income urban neighborhoods of Beirut, Lebanon.

PURPOSE: We sought to examine the associations between social capital, women's empowerment, and smoking behavior among married women in three low-income neighborhoods in Beirut, Lebanon. METHODS: Data from currently married women aged 15 to 59 years in the 2003 Urban Health Study were used. The dependent variable was cigarette smoking. The main independent variables were five social capital items and three women's empowerment indices. Other socioeconomic variables as well as mental distress, happiness, and community of residence were included as covariates. Bivariate associations were conducted on all variables using chi-square tests. Adjusted odds ratios from binary logistic regression models were then modeled on smoking behavior separately for younger and older women. RESULTS: More than one third (35.9%) of married women reported smoking cigarettes. At the bivariate level, a variety of socioeconomic and demographic variables predicted smoking. With respect to social capital, women who lacked trust and were dissatisfied with the number friends or relatives living nearby were more likely to smoke. As for women's autonomy, high decision making and high mobility were associated with smoking. When analyzed multivariately, social capital items were statistically significant for younger women but not for older women. And the mobility variables were significant for older women but not younger women. CONCLUSION: Our results support the conclusion that determinants of women's tobacco use are multilayered, and include social capital and women's autonomy. Our results also suggest that younger and older married women may be influenced by differential determinants. Reasons for these differences are explored. Interventions may need to be tailored to each age group separately.

Neighbourhood influences on narghile smoking among youth in Beirut.

BACKGROUND: Increasingly neighbourhoods are identified as influencing health. Neighbourhood characteristics have been linked to cigarette use. In Lebanon, the water pipe (narghile) use is most frequent among youth. The current study is aimed at identifying differential neighbourhood influences on smoking narghile among youth. METHODS: A quantitative interview was completed with 1294 adolescents, 13-20 years, in three urban disadvantaged neighbourhoods of Beirut. Individual and social factors, suggested by the literature, were associated with smoking narghile. The neighbourhood variation in the influence of these factors was then explored. Bivariate and stratified logistic regression analysis were conducted, neighbourhood being the stratification variable. RESULTS: About 60% of respondents had ever tried a narghile, about one-fifth continued to smoke. Several individual-level and social variables predicted narghile smoking bivariately. The influences on narghile smoking varied by neighbourhood. Neighbourhood differences persisted at the multivariate level. Consistently across neighbourhoods, the influence of friends was the predominant predictor of narghile smoking. In one neighbourhood, maternal smoking was a risk factor for narghile smoking of youth, in another paternal smoking. Being female seems to be protective in two of the three neighbourhoods. Other factors also differentially influence narghile use by neighbourhood. CONCLUSIONS: The mechanisms of influence of neighbourhoods on health are not clearly understood, but a transactional paradigm seems most fitting with the results found in this research. Interventions to prevent the narghile smoking should address multiple levels of influence; and must be tailored to the particular aspects of neighbourhoods which are influential in the uptake of this behaviour.

Gender differences in determinants of weight-control behaviours among adolescents in Beirut.

OBJECTIVE: To investigate the association between self-esteem, physical activity, engaging in risky behaviours, social and cultural capital, attitudes towards thinness, parental and personal characteristics with weight-control behaviours among adolescents in Beirut, Lebanon. DESIGN: A community-based cross-sectional study. A stratified cluster sampling design was used and information gathered by means of a questionnaire. Associations were investigated using multinomial logistic regression, accounting for the survey design. Odds ratios were calculated for trying to lose weight, or trying to gain weight, compared with no weight-control behaviour. SETTING: The study was conducted in three underprivileged urban areas of Beirut in 2003. SUBJECTS: The sample size was 1294 adolescents aged 13-19 years. RESULTS: Determinants of weight-control behaviour among girls included their attitudes towards thinness (OR(loss) = 4.29, OR(gain) = 0.38), dissatisfaction with weight (OR(loss) = 10.9, OR(gain) = 9.63), engaging in physical activity (OR(loss) = 2.22), smoking (OR(loss) approximately 3) and the mother working (OR(loss) = 2.77). Determinants of weight-control behaviour in boys included their attitudes towards thinness (OR(loss) = 14.7, OR(gain) = 0.35), dissatisfaction with weight (OR(loss) = 15.6, OR(gain) = 17.7), being involved in a cultural activity (OR(gain) = 2.51), engaging in a fight (OR(loss) = 5.25, OR(gain) = 1.64) and engaging in physical activity (OR(loss) = 2.56, OR(gain) = 2.17). CONCLUSIONS: Attitudes towards thinness, weight dissatisfaction and physical activity are common determinants for weight-control among boys and girls, although to varying degrees of influence. Self-esteem, social capital, cultural capital and parental characteristics were not significant predictors when accounting for the other variables.

'It won't happen to me': the knowledge-attitude nexus in adolescent smoking.

BACKGROUND: Behavioral models state that adolescents need not only to know about the dangers of smoking, but also to perceive themselves as susceptible to those dangers prior to modifying their smoking behavior. However, this hypothesis has not been tested in developing world settings where the context of tobacco use may differ. METHODS: Survey data were collected from a sample of 1294 adolescents 13-20 years of age--from three under-privileged suburbs of Beirut, Lebanon. Scores were calculated to measure the knowledge of and the perceived susceptibility by a series of statements related to the consequences of tobacco use. Bivariate and multivariate methods were used to assess the association of knowledge and perceived susceptibility with smoking, controlling for socio-demographic variables. RESULTS: A logistic regression model showed that the odds of ever smoking among adolescents who had less knowledge of smoking were 1.9 times those of adolescents with more knowledge. Similar odds were demonstrated for adolescents who did not perceive themselves susceptible to smoking hazards compared with those who did. CONCLUSIONS: These results suggest that awareness campaigns should focus on raising the perceived susceptibility of adolescents by including items that are more within the realm of an adolescent's frame of mind such as smelly clothes and discolored teeth.