Social and cultural conditions affecting the mental health of Syrian, Lebanese and Palestinian adolescents living in and around Bar Elias, Lebanon

Highlights

• •Place-based approaches to mental health research can foster understandings of shared or communal factors of mental health.
• •Forced migrant adolescents and long-term resident adolescents experience similar challenges to having good mental health.
• •Limited mobility through public spaces, overcrowded housing and interpersonal violence is a risk factor for adolescent forced migrant and long-term residents’ mental health.
• •Phones with internet capabilities are associated with emotional support, particularly for adolescents who have been recently displaced.
• •Gender and being differently-abled are important intersectional identities which cut across refugee/citizen identity, and play an important role in how adolescents are affected by shared conditions.

Abstract

An estimated 1.5 million displaced Syrians live in Lebanon, sharing neighbourhoods and communal spaces with longer-term Lebanese and Palestinian residents. The Syrian Civil War has lasted over one decade. Protracted mass displacement means that many young people are growing up in neighbourhoods, towns and cities which include comparable numbers of recently displaced and longer-term residents.

In this study, we explore adolescent mental health and the intersections between Syrians, Lebanese and Palestinians in the town of Bar Elias, where comparable numbers of displaced people and citizens live. We conducted semi-structured interviews with 30 adolescents in April 2019. We found that Palestinian, Syrian and Lebanese adolescents in Bar Elias identified the same shared conditions as affecting their mental health, although with different impacts on each individual. Sometimes, this difference accords with nationality, but it is also determined by gender and different physical and cognitive abilities. We conclude that recently displaced and host community adolescents can be seen to be affected by shared conditions, and that intersectional identities affect how adolescent mental health is affected by these conditions. We argue that investments in shared infrastructures can support the improvement of mental health for all adolescents.

1. Introduction

1.1. Syrian conflict in the Lebanese context

Since it began in 2011, the Syrian conflict has exposed the population to years of violence, human rights violations, intrusion by geopolitical power players, infrastructural collapse, and economic hardship. It has resulted in over 5.6 million people fleeing to Turkey, Lebanon, Jordan, Egypt and Iraq (UNHCR, 2021). Approximately 1.5 million people from Syria are currently displaced in Lebanon, including 879,598 Syrians who are registered with UNHCR, making Lebanon the country with the highest number of refugees per capita in the world (UN and Government of Lebanon, 2021).

In response to displacement from Syria, the Government of Lebanon has pursued a policy of non-encampment, meaning that displaced people are encouraged to self-settle in Lebanon rather than being situated in formal refugee camps (Turner, 2015). Although the UNHCR has registered some displaced people as ‘refugees’, the Government of Lebanon has not formally recognised displaced people from Syria as refugees (Nassar and Stel, 2019), considering Lebanon a country of transit and not asylum (Janmyr, 2016). Thus, 67% live in residential shelters, 12% in non-residential buildings repurposed as homes, and 21% in informal tented settlements (UN and Government of Lebanon, 2021). Displaced people from Syria share buildings, neighbourhoods, towns and cities with other residents, including people who have been displaced from elsewhere (Fiddian-Qasmiyeh, 2016), (Fawaz, 2016).

Mass protracted displacement has put a severe strain on job availability, public services and affordable goods, and has therefore impacted host communities (World Bank, 2013). Displaced people are often settled in areas where there were high pre-existing poverty rates (UN and Government of Lebanon, 2021). The Beqaa Valley, for example, has the highest number of registered displaced Syrians (UNHCR, 2021) and one of the highest numbers of households in the National Poverty Targeting Programme (UN and Government of Lebanon, 2021).

1.2. Adolescent mental health in Lebanon

Over half of the displaced Syrians are children and adolescents (UN and Government of Lebanon, 2021).1 An estimated 1.4 million people in Lebanon under 18 (including Lebanese, Syrian and other migrants and displaced people) are ‘currently growing up at risk, deprived, and with acute needs for basic services and protection’ (UN and Government of Lebanon, 2017). A ‘lost generation’ is seen to be emerging within Lebanon: young people who are growing up without basic goods and services, or hope for positive change in the form of either employment in, or migration from, Lebanon (including returning to Syria) (No Lost Generation Initiative, 2016).

A systematic review of mental illness in child and adolescent refugees and asylum seekers in low-and middle-income countries identified the main mental health disorders suffered by this group as being post-traumatic stress disorder (PTSD), anxiety and depression (Reed et al., 2012). Compared with non-refugee populations, refugee children and adolescent populations have significantly higher rates of these disorders (Reed et al., 2012). Studies have shown that, within refugee populations, girls’ and boys’ mental health outcomes are different. This is linked to differing responses to pre-migration trauma, but also to different post-migration stressors (Reed et al., 2012). Research on Lebanese adolescents indicates that mental illness is a significant issue for this group as well (Chahine et al., 2020), (Maalouf et al., 2016).

1.3. Bar Elias

This study was conducted in Bar Elias: the second-largest town in the Beqaa Valley in Lebanon. Bar Elias is located fifteen kilometres from the Syrian border on the Beirut-Damascus Highway: this notable infrastructure made it an important commercial hub for the Beqaa region and a place of short-term transit, before the Syrian conflict. Bar Elias was chosen as a study site due to its demographic mix of recently displaced Syrians, Palestinian and Lebanese host residents. Bar Elias has a high number of Syrian refugees and has undergone a dramatic change in the local economy since more people have moved in (Dabaj et al., 2021). It currently hosts the highest number of registered Syrian refugees in the Beqaa, with 30,550 registered in 2019 (UNHCR, 2020). There are currently an estimated 60–70,000 Lebanese people living in Bar Elias, 45,000 displaced Syrians (Al Ayoubi, 2018), and around 7000 long-term displaced Palestinian refugees.2 The study was conducted in 2019, before the economic crisis began in August 2019, or the Lebanese Revolution in September 2019, and before COVID-19 lockdowns began in March 2020. These events have placed further financial and emotional stress on residents (UN and Government of Lebanon, 2021). There are approximately 100 Informal Tented Settlements (ITSs) in and around Bar Elias (Inter-Agency Mapping Platform, MEDAIR, PU-AMI, CISP, Solidarites International, and REACH, 2016). These are temporary structures made of wood and tarpaulin, mostly set up in fields on the outskirts of Bar Elias, on roadsides and in empty building plots (Dabaj et al., 2021). Most displaced people in the Beqaa Valley live in ITSs (Habib et al., 2019), which are managed by a shaweesh: normally a displaced person who acts as a central contact point between residents and authorities. Other displaced people are settled in existing housing, repurposed buildings or in new homes that have been rented out.3 Hence, neighbourhoods in Bar Elias have changed as a result of protracted displacement: they have become more densely populated as more people move in, as well as more urbanized as more buildings are built or subdivided. (Dabaj et al., 2021).

2. Study aims and methods

2.1. Aim and objectives

The aim of this research was to identify the cultural and social conditions which affect the mental health of adolescents living in and around Bar Elias. Our objectives were to:

• 1Understand the risk and protective factors for adolescent mental health using a place-based approach;
• 2Explore common challenges to, and opportunities for, good mental health in Bar Elias, amongst forced migrant and host-community adolescents;
• 3Identify intersectionalities which might be relevant to adolescent mental health; such as gender, different physical and cognitive abilities, family income and living conditions.

2.2. Definitions

2.2.1. Adolescence

In this study, adolescence was conceptualised as a life stage between childhood and adulthood, between 10 and 24 years (Sawyer et al., 2012). Hormonal and neurological changes can differ across contexts; where nutritional status, critical life events and even urbanisation play a role in biological development (Odongkara Mpora et al., 2014). Adolescence, youth, and being ‘young’ are culturally-defined concepts determined by commonly-held expectations for adolescent boys and girls, which can be affected by political and environmental conditions. In Lebanon, ‘adolescence’ is compounded by ‘religious divisions, unique political discord and complicated cultural situations’ (Kaddoura and Sarouphim, 2019). Young people themselves are not passive recipients of identity markers, but are capable of critically assessing these factors and their relevance to themselves and contemporary national and global culture (Deeb and Harb, 2013), (Larkin, 2012).

In this study, we focus on a life phase which is associated with important social role transitions: the Brevet examination (the foundational educational certificate received in Lebanon), finishing or leaving school, beginning work, and – particularly for girls – preparing for marriage. This life phase generally happens in mid-adolescence, at around 14–18 years old.

Adolescence is a critical stage for mental development. Around 70% neuroses and psychoses start in adolescence. Adolescent mental health is affected by the environments young people live in (Viner et al., 2012). In this study, we used the WHO definition of mental health as a ‘state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community’ (WHO, 2013), and not merely as the presence or absence of clinical disorders. This research aimed to explore the nexus between this transitional period, being situated in a context affected by mass protracted displacement (whether or not the individual(s) had been physically displaced themselves); and mental health.

2.2.2. Mental health

Given that both adolescence and mental health are culturally-specific concepts, the study prioritised young people's understandings of their own mental health, as well as complemented these understandings with an adapted Strengths and Difficulties Questionnaire. This paper reflects on how young people expressed mental health outcomes, such as ‘hope for the future’ or sadness. In doing so, it follows studies such as Betancourt, Speelman, Onyango, & Bolton (Betancourt et al., 2009), which use the terms that adolescents themselves use when describing their mental health.

2.3. Methods

Fieldwork was conducted in Bar Elias; where scoping fieldwork had previously been carried out in September 2018. An interdisciplinary team from public and mental health, urban planning and architecture from Lebanon and the UK conducted fieldwork in Bar Elias in March-April 2019.

To best understand adolescent mental health in Bar Elias, it was important to select participants within the same age range who will have overlapping experiences with prolonged displacement in this context. Potential participants were identified on the basis of their age, nationality, gender and living in or close to Bar Elias. The team conducted 30 semi-structured interviews with 15–18 year olds living in and around Bar Elias (16 boys and 14 girls), from Syrian, Palestinian and Lebanese communities, including nine differently-abled participants. We worked with Lebanese Union for People with Physical Disabilities (LUPD) to ensure that our understanding of protracted displacement conditions and mental health did not develop without differently-abled adolescents (Pisani et al., 2016). Potential participants were identified by NGOs working with young people in Bar Elias, with whom project partners have existing relationships through previous projects.4 Our connection with Palestinians was through a local Palestinian man, who was trained as a researcher by our project partner, CatalyticAction. The local Palestinian belongs to the middle-class, and we therefore believe the Palestinian participants were more financially secure than most of the other participants.

We approached participants’ parents/guardians with information about the research project to seek informed consent. We recognise that this may have excluded some of those most vulnerable within these communities, who were not able to access these community or NGO services. Participants were reimbursed their travel expenses for taking part in the study. Interviews were audio-recorded and translated and transcribed by members of the research team.

We used Sawyer et al.’s conceptual model for adolescent mental health (2012) to inform our interview guides. We chose this model because it identifies multiple scales with which political, social and economic factors of health can be identified, and indicates how these interact with one another across the life course. We adapted Sawyer et al's model to focus solely on mental health factors and outcomes. Through semi-structured interviews, we aimed to identify: a) social determinants of health; b) risk and protective factors; c) health-related behaviours and states; and d) adolescent mental health outcomes. We used this model in our analysis as a framework for axial coding (see Section 2.5).

2.4. Ethics

Ethical approval was granted from both the American University of Beirut ethics board and UCL Research Ethics Committee [approval number 2744/006]. Adolescents identified with any mental illness or who the data collection staff were concerned about were referred to the NGO International Medical Corps which provides psychosocial support to vulnerable young people in Bar Elias. The researchers were trained to ask questions sensitively and a referral pathway was in place. We also discussed tools for recognising and dealing with researcher trauma during fieldwork.

2.5. Analysis

Interview data was initially analysed using a thematic analysis approach, to identify intervening conditions that imply relationships between place, mental health and wellbeing. Three researchers took turns coding the data (HS, MO, SC). The first researcher (HS) conducted attribute coding for each of the participants, including age, gender, home town and nationality. Each researcher coded the data inductively, and axial coding was conducted as a team at each handover and at the end of the third round of inductive coding, to organise codes into overarching themes and subthemes. Two of the researchers (HS, MO) had been involved in data collection, and one researcher was an external researcher with expertise in adolescent mental health in a different geographic context (SC). Themes which emerged included mental health factors and emotions. Thematic saturation was achieved when all three researchers agreed that each code effectively described an emotion or a distinct mental health factor and each factor could be linked with a dimension of adolescent health outlined in Sawyer et al's model in each round of axial coding. Deviant cases were included in analysis and write up.

Some participants had diverse physical and/or cognitive disabilities, within a range of severity, which meant that it did not make sense to treat participants with disabilities as a distinct or homogenous group. Therefore, we include their narratives in this paper without distinguishing them as differently abled, unless their disability is relevant to the finding.

3. Results

The following section outlines the main themes and sub-themes generated from the interviews. These are organised into the dimensions of adolescent health in Sawyer et al.’s model. The first dimension is social determinants of health: structural and proximal/immediate determinants, including ‘policies and environments that support access to education, provide relevant resources for [mental] health and create opportunities to enhance young people's autonomy, decision-making capacities, employment and human rights’ (Sawyer et al., 2012). Second, risk and protective factors: determinants which operated ‘within the individual and their family, peers, school, and community’ (Sawyer et al., 2012). Third, behaviours and states: ‘health-related behaviours’ such as substance misuse and antisocial activities (Sawyer et al., 2012). Finally, mental health and wellbeing: mental health outcomes, including clinical disorders such as depression and psychosocial outcomes such as hope for the future.

3.1. Social determinants of health

3.1.1. Place

This overarching theme is defined as a geographical territory which includes buildings, neighbourhoods, and countries. The most common sub-themes were ‘Bar Elias’, ‘home’ and ‘school’. Places were typically associated with cultural norms and social and economic characteristics (e.g. unequal, conservative, liberal), which means there is a lot of overlap with ‘Social, economic and political conditions’ (3.1). In this theme, we also include adolescents’ comparative statements, which compare places to one another. Many adolescents had experience living in other towns or cities, in Lebanon or in Syria. Those with friends or family abroad also made comparisons with other places even if they had not visited those places personally. Young people used this comparative lens to determine whether they were happier or worse off in Bar Elias.

Bar Elias was seen as a ‘conservative’ place which has views about appropriate behaviour. Young men and women mentioned this, but young women suggested that it affected their lives day-to-day more evidently than young men.

Dina:5 People are very frightening, [neighbours] look at you with an attitude, they gossip. For example, if you were out to do sports, especially on your own, [neighbours] start saying her parents didn't raise her well. Here the attitude is not like other countries.

Palestinian girl, age 17

This view of Bar Elias as a place where people ‘gossip’ and have an ‘attitude’ leads to a perception of public spaces in Bar Elias as being unsafe. This view was mentioned most often by girls of all nationalities and Syrian boys.

Home can be a place of security, but also a place of stress, particularly when the home is sub-standard and overcrowded. Affordable and decent brick-and-mortar housing was severely limited for all residents. 16 adolescents described some form of housing insecurity, including being forced to move house, living in overcrowded and in substandard conditions. Syrians and Lebanese adolescents reported having to move within Lebanon due to changed family financial circumstances, to escape pressure for more rent from landlords, or, in the case of Syrians, to avoid shaweesh asking for more rent or work in exchange for rent.

Hussein: Life changed, expenses changed, miseries followed. What more can I tell you? Our house – a bedroom and a living room – is being rented for $300 and is full of cockroaches, and we have expenses for the electricity generator. We have to pay 10,000 lira or else we get kicked out of the house.

Syrian boy, (no age given)

School was another key place for young people, including those who did not attend school. Adolescents in Bar Elias face major restrictions on continuing their education. 17 out of 30 interviewees had dropped out of school. Whilst some were forced to leave school due to financial costs and pressure to work (including helping with domestically), some dropped out because the public schools’ environment was unwelcoming and hostile, particularly for displaced Syrian students and for differently abled adolescents (see also 3.3).

Jahid: I did go to school [in Bar Elias], I studied here about five months, they placed me in the sixth grade although I should have been placed in Grade 7. I didn't like [the school], it was full with hitting and things like that. I turned my back and walked away.

Syrian boy, age 17

Young people who had left school before completing their secondary education and who did not then attend a technical college, felt regret (see 3.4). They linked a lack of work opportunities, and opportunities to leave Bar Elias, with leaving school. But it was not only their futures which had been affected: they also connected dropping out with their current boredom at home, loneliness and isolation from peers.

From those adolescents who were attending school regularly, most were satisfied with the state of their education. Those who did complain only mentioned the mis-behaviour of other students, and not the quality of the education. Palestinians were the most content with their schooling, and were likely to be in a school run by UNRWA.

3.1.2. Social, economic and political conditions

This overarching theme is defined as the broad national conditions (e.g. threat of military service in Syria, inequalities between residents), local conditions (e.g. social conservativism) or personal conditions (household debt, poverty, personal mobility around the local area) in which adolescents live. This theme overlaps with ‘Place’, because some conditions were seen to be specific to certain places. The most common sub-themes were ‘restrictions on mobility’, ‘money’ and ‘aid’.

Restrictions on mobility was the most commonly coded sub-theme, and a major problem for girls of different nationalities and Syrian boys. Restrictions on mobility were associated with broader social, economic and political conditions that affected boys, girls, Syrians and differently abled people, in different ways. Girls faced restrictions on their mobility due to the risk of danger, socialised expectations and norms about honour and how girls “should behave”, and significant caring responsibilities towards the family (discussed in Section 3.1). In some cases, girls were able to spend time outside with their siblings or friends under supervision from an older family member. Syrian boys are subject to military and police checkpoints and spot checks that restrict freedom of mobility and discourage leaving the house. Maintaining a consistent job is complicated by barriers to transport and the looming possibility of detainment and dismissal.

Hussein: Recently, every Syrian man is being taken away. They are only allowed to hire Lebanese people. There are restrictions on us now. They are sending us home, they are planning on killing us.

Syrian boy (no age given)

Problems with moving around the town were rarely mentioned by adolescents with severe cognitive or physical disabilities. However, we were increasingly made aware of the restrictions when we attempted to organise meetings and events. The project paid for transport to ensure they could participate in all of the activities. Restrictions on mobility affected the kinds of activities young people described themselves participating in (see Section 3.4).

‘Money’ and ‘aid’ were the second most common themes. A lack of money and financial support was a major contributor to school dropout. Of the 17 interviewees not in school, their education was normally interrupted by displacement or by the costs of education. For those whose education had been disrupted by displacement, costs were named as a reason for not returning. Costs for transportation, supplies and sometimes school fees place severe stress on students and families. Specialised schools for differently abled adolescents are quite rare and those that are available are often costly.

Marwa [mother of Ibrahim]: What made things worse is that there is a private school that gave us hope that we can register them […] The second day they called me and said that they wanted me to find a funder. In one month, they needed 500,000 LPB for each child, so in one month they need a million including transportation and school. I asked them why didn't you tell us from the beginning, you put a lot of hope especially for Ibrahim. Ibrahim was […] excited to learn regardless of his disability he wanted to learn and become like the other kids.

Mother of Lebanese boy with cognitive disability, age 17

Adolescents expressed hopelessness, apathy, and great frustration when discussing these circumstances out of their control.

3.2. Risk and protective factors

The most common overarching themes for risk and protective factors were ‘people, social groups or figures’ and ‘nature of relationships’ (e.g. supportive relationships and abusive relationships).

3.2.1. People, social groups and figures

This theme describes the people, communities, groups, including organizations, and non-human figures, who affect adolescent mental health. It included family and friends, aid agencies and God. Mothers and friends were the most common sub-themes. Mothers and friends (and occasionally fathers and siblings) were associated with improving or good mental health, particularly with the feeling that they were able to go through hard times. For boys and girls, the most trusting and supportive relationship was with their mother or close siblings (22 out of 30 associate ‘trust’ and ‘honesty’ with mother, 17 associate ‘support’ with mother).

Interviewer: Do you talk to your mother about everything?

Huda: Yes I don't hide anything from her. For example, when I'm feeling sad or something made me happy, directly I would go and tell her.

Palestinian girl, age 16

Aid agencies were rarely mentioned, except in a negative light. This is especially true of the UN, which tended to be mentioned when funding had been withdrawn. This was most common amongst Syrians.

Hussein: There is injustice, some people are treated unjustly, like the UN, they eliminated us [from the list of aid recipients] and we're a big family. Our neighbour has two cars and two pick-up trucks […], and he's alone with his family. He grows fruits and vegetables, he receives aid from UNHCR, gasoline, everything.

Syrian boy, no age given

3.2.2. Nature of relationships

This theme describes adolescents’ characterisation of a relationship between themselves and others. The most common sub-themes for ‘nature of relationships’, were ‘supportive relationships’ and ‘abusive relationships’.

Almost all of the young people had someone they could trust and who supported them. Young women of all nationalities mentioned experiencing abuse or being afraid of abuse by unknown men (see Section 3.1). Boys also spoke about abuse at work or on the streets. Syrian boys were subject to abuse on the basis of their nationality.

Akif: Lebanese sometimes they are intrusive when we walk on the streets […] They tell us bad words when we walk on the streets, I don't answer them, if I reply back there will be a fight, right? […] Sometimes we want to play together, and Lebanese people come and they want to play with us, by force and they are older than [us], we don't have the same level of fighting skills. I wish I have fighting skills, so I can defend myself.

Syrian boy, age 15

Being off the street does not necessarily mean being free from abuse – school and home were places where adolescents experienced abuse. In relation to public school, Syrians mentioned abuse from teachers and from students. Differently abled adolescents who had been to school faced a lot of abuse in school from other students.

Yamina: Because I have a birth abnormality in my leg […] from the eldest to the smallest kid in school, they would mock my walk and say look at how she is walking. So, I told my mother that I am tired, I told her that it's easier for me to register in an institute than to register in the school and children from kindergarten to mock me.

Lebanese girl, age 17

Direct experiences of interpersonal violence, witnessing the abuse of close family members, and hearing others’ stories about interpersonal violence impacted adolescents’ mental health. Young people who had experienced interpersonal violence in Lebanon described feeling on the brink of despair. Adolescents described how experiences of abuse forced them to change the way they related to other people, and to themselves. Some described becoming ‘more aware’ or learning an important life lesson.

Yamina: Until we grew up we didn't understand. Then we started knowing what is life. Then after my mother left my father, she started studying and getting certificates until she became a doctor for diabetes and gangrene so she could afford our living. And thank God we are living.

Lebanese girl, age 17

3.3. Behaviours and states

3.3.1. Behaviours

This theme is defined as how young people said they act in Bar Elias. The most commonly coded subthemes for ‘behaviour’ were ‘withdrawal’ and ‘participating in activities’.

Withdrawal was a key coping strategy for adolescents of different genders and nationalities (21 out of 30 coded for ‘withdrawal). This included withdrawal from family and friends, and withdrawal from places where they had unpleasant experiences. ‘Withdrawal’ describes temporary solitude, where adolescents gathered their thoughts and calmed their feelings, and a more permanent withdrawal from undesirable places such as school or public spaces.

Maha: I prefer to be on my own when I feel annoyed because I'm the angry type of girl and I start shouting and I won't be aware of what I'm doing, so I prefer to be alone in my room to calm down.

Palestinian girl, age 18

The second, more permanent kind of withdrawal was associated with regret and frustration.

Omar: The curriculum in Lebanon is with a foreign language and not Arabic so this is why I didn't learn. This is why I didn't continue [my education]. […] I didn't learn anything and I didn't benefit from anything. I sit doing nothing and I'm not happy with that and I'm not happy with the whole world. You know I regret everything, I regret not continuing my education, I regret.

Syrian boy, age 17

‘Participating in activities’ was another common sub-theme for ‘behaviours’. We distinguished ‘play and entertainment’ from ‘passing time’, where the former has a specific game or programme as a focus, and the latter is more general. The relative (im)mobility of young people affected their activities. Overall, boys had more freedom to move from place to place, and to meet in public spaces. This is less true of differently abled boys, but some still did leave the house independently to meet friends. Hence, sports and outdoor activities are significantly more a part of their lives than girls’. Girls mentioned being driven around, being allowed to visit restaurants and others’ homes – often in the company of parents, older brothers or married siblings. ‘Passing time’ described not doing anything in particular with one's time, but simply waiting.

Hussein: I get exhausted, I stay at home contemplating the walls. I get bored, I have nothing [to do]. When I have an outing, I get super excited. […] So that I can forget the past, I won't forget, but I want to get over this phase.’

Syrian boy, (no age)

Another behaviour linked to mental health was mobile phone and social media use. Phones and social media were important for connecting young people with distant family members and friends who lived elsewhere (particularly for Syrian boys and girls). They were rarely mentioned in a negative way, and in some cases made up for not having close family or friends in the area.

Interviewer: Is there someone close to you that you feel you can speak to when you're frustrated or going through a tough time?

Nader: There is my cousin.

Interviewer: Is he in Lebanon or Syria?

Nader: No Lebanon, in Beirut […] I speak to him, like 2–3 h. I put my headphones on, talk to him on the phone, and speak to him for a while. He'll ask me “Are you still having nightmares?” and he'll say “It's wrong that you got into such a thing”.

Syrian boy, (no age)

Girls’ phone-usage seemed more limited. Some were allowed to use family members’ phones, and one mentioned her father checking her phone messages.

3.3.2. States

This theme describes researchers’ interpretation of adolescents’ ways of relating to the situation they described living in. It is closely linked to behaviours, in that it describes a collection of related behaviours. The most common sub-theme for ‘states’ was ‘endurance’. When asked what piece of advice young people would give to friends if they were having a hard time, they talked about enduring hardship. Endurance was an important coping strategy. Very few expressed anger or opposition towards whatever was upsetting them. Some spoke about this experience as something which made them more knowledgeable about the world, but others talked about feeling resignation. This was not particular to different nationalities.

Fadi: I run, I swim, I dive in the water and let go of everything that bothers me. I don't let anyone know what I am feeling. I used to be a very sad person and people saw this sadness on my face. When I grew up I changed a lot, I learned about life, who are the good people by looking, [I can distinguish] the good friend from the fake friend.

Lebanese boy, age 17

Endurance is central to stories about transitions, awareness, and growth. Young people talked about realising something about the world which is unjust or destabilising, and how they learned to simply carry on. Two young women mentioned positively reshaping their coping strategies away from self-medication.

Farah: The thing I would change about my life [is] to get out of the environment I am living in. As I told you I used to take sleeping pills, thank God, now I have stopped it, I am not drinking it now and wasting my whole day.

Syrian girl, age 15

3.4. Mental health and wellbeing

The themes for mental health were derived from the interviewees’ descriptions of their own mental health and wellbeing. The mental health and wellbeing codes roughly divided into ‘futures’ (meaning ways of talking about the future) and ‘feelings’. There was some overlap between these.

3.4.1. Futures

This theme is defined as the way adolescents relate to the future. There was an equal split between positive and negative orientations towards the future, and ‘hope’ and ‘wish’ were by far the most common sub-themes.

For young people, hope for the future was grounded in a sense of what was possible in the short-term, for example, the possibility of returning to school next year was associated with the hope of getting a job. Young people who had hope for the future tended to have found a subject area which they were doing well in, or knew someone who had taken a similar path. This person acted as a kind of role model, which suggests the relevance of family class-background and income to young people's hope for the future. Generally, hope was spoken about in reference to future professions, but it was sometimes related to being reunited with certain people (friends and family), and sometimes with travel. Many girls and boys had hopes of entering a profession or opening a business. Some, particularly those with different physical and cognitive abilities, focused on being employed in a stable and respectable job.

Hayat: I have the ambition to travel, I like travelling a lot. My uncle is in Spain he's a doctor, I want to fix my papers and go there during this summer for vacation, and maybe next year I will go study there.

Palestinian girl, age 17

On the other hand, ‘wish’ was expressed as something desirable but unlikely. This was often about something over which they had little control. This was a common expression for differently abled people and for adolescents in families with very low income.

Omar: I wish, I wish…

Interviewer: What do you wish for?

Omar: To own a shop [laughing], may God help me’

Syrian boy, age 17

3.4.2. Feeling

This theme describes adolescents’ emotional state. The most common codes under the theme of ‘feeling’ were ‘wishful’ and ‘restricted’. These echo the points above (see Section 3.5 and 3.1).

Interviewer: Is there any place in the area you like to go to? Like a place from your childhood or a specific place where you like to spend your time alone?

Aashif: […] There are some places I visit in my dreams, no more than this.

Being ‘traumatised’ was not common but is important to mention. Syrian boys were most likely to talk about trauma: their traumas were related to experiences of war in Syria and of travelling to Lebanon. But trauma was not only experienced by Syrian boys or differently abled people: traumatic experiences included interpersonal violence within the family and divorce, as well as violence in war, and this was experienced by Lebanese as well as Syrians. A young man with a cognitive disability had experienced major trauma due to bullying.

4. Discussion

This study has shown that young people's mental health in Bar Elias is related to place-specific social, cultural and economic factors, such as gender norms and housing costs, as well as individual-level factors like interpersonal relationships or the experience of traumatic events. The study has demonstrated how broad social, economic and political conditions in Bar Elias play out in the specific environments which young people say affect them. It has also highlighted how young people respond to those environments, to relieve stress and avoid negative encounters.

The results show that the same shared conditions can affect Syrian, Lebanese and Palestinian adolescents’ mental health, but also indicate their effect is different for different people. The results from this study have demonstrated that gender and different physical and cognitive abilities play an important role in determining how a young person is affected by their environment, and how a young person feels they are able to respond to their environment. Intersectional identities are therefore important to consider, as well as nationality or citizenship status, when thinking about mental health.

Intersecting dimensions

Sawyer et al. (2012)’s framework for adolescent health shows that dimensions of adolescent health interact with one another. In the Results section, we associated themes with different dimensions of adolescent mental health. In this section, we describe how these themes and their associated dimensions interact with one another to create three social and cultural conditions of adolescent mental health in Bar Elias.

4.1. Unsafe public spaces

Public spaces, including public schools, work spaces and the street, are places young people associate with negative encounters. For young women of all nationalities, indirect and direct experience of abuse in public space led to their withdrawal. Dina suggested that traditional cultural norms had a similar effect on adolescents’ mental health as experience of abuse in public spaces, by forcing adolescents to withdraw into the home away from gossip and judgement. Whilst withdrawal is a means of protection from a hostile environment, it also introduces its own challenges to adolescent mental health by creating a ‘limited activity space’ (Vallée et al., 2011). Hussain suggested that limited mobility has practical consequences for young people, such as preventing them from attending school or working. Akif suggests that limited mobility complicates meeting others and creating supportive relationships and friendships within their community. Those who withdrew from public spaces and/or lacked the ability to move around their neighbourhoods suggested they ‘did nothing’ and that they had fewer friends as a result. Place (a social determinant), people (a risk and protective factor) and withdrawal (a behaviour) interact with one another to contribute to a worsened mental health, particularly feeling restricted and contributing to a lack of hope for the future.

4.2. Unhealthy homes

Housing provides a sense of stability and safety, or it can do the opposite in more difficult living environments. Both Syrian and Lebanese adolescents living in overcrowded and substandard housing associated their homes with a loss of pride, a feeling of neglect and a lack of privacy. This accords with Groot et al.’s finding that poor housing conditions such as high-density households were associated with the onset of Low Quality of Life score amongst adolescents (Groot et al., 2022). Maha and other adolescents in this study valued solitary space for self-reflection and contemplation, which they said was important for their mental health. Again, place (a social determinant) and withdrawal (a behaviour) directly interact to affect mental health.

4.3. Interpersonal relationships

To achieve good mental health, adolescents described the importance of supportive, trusting relationships which are free from violence and abuse and which stand up to incidents of violence and abuse without reducing their personal freedom. Adolescents’ supportive relationships were found in the home, and created at schools and by chance in public spaces. Supportive relationships can be foundations of stability for adolescents going through the transition of growth and displacement, and to many participants, enabled them to adapt to their environment and circumstances (Nagi et al., 2021) (Kirby et al., 2020). They provide a stable foundation for understanding oneself, finding comfort with the present situation, and a purpose for building towards a future.

In this study, the family home is also a place of potential violence; between siblings, parents, and their children. Situations like that of Yamina are extremely difficult to navigate and young people never said that they felt they were able to stand up to this abuse. However, parents who stood up to abusive partners or in-laws were highly regarded and young people talked about learning a lot from them. These narratives of interpersonal violence were shared amongst young people of different nationalities and complicate our views of trauma in contexts of displacement. Other studies have shown that exposure to domestic violence is a risk factor for internalising and externalising outcomes in adolescence (Moylan et al., 2010). As well as war-related trauma, the trauma of interpersonal violence is an area of concern which demands more attention in refugee and non-refugee contexts (Vu et al., 2014). People, particularly family members, were therefore potential risk and protective factors which impacted on adolescent mental health.

5. Policy recommendations

Policy-makers have expressed concern about recently displaced young people and young Lebanese and Palestinians. Given the importance of shared living conditions to different young people's mental health, policy-makers and funders ought to consider the value of shared infrastructures and public space interventions to adolescent mental health outcomes. Improving the safety of public spaces and access to affordable and appropriate transportation could support adolescents to develop supportive relationships outside of the family, and to access organisations and places which facilitate education and employment opportunities. Improving access to housing, particularly for mothers wanting to leave abusive relationships or fighting families, would also improve adolescent mental health by providing a safe space to withdraw to.

6. Strengths and limitations

Due to limited funding and resources, and our endeavour to include adolescents from different communities in Bar Elias, the sample size for this study was small. Saturation was nonetheless reached with the sample size of 30 adolescents. The study would benefit from a comparative perspective with another similar-sized town, to understand which factors were unique to Bar Elias. We did not ask questions about family income, and could not identify this as an intersectional identity which plays a role in mental health outcomes. Given our focus on the shared lived environment, we have not devoted much discussion to war-related trauma. Of the four young people we referred for psychosocial support, all four had experienced war-related trauma.

The strength of our study was the place-based approach to researching adolescent mental health. Using data generated by this approach, we are able to show that lived environments, including the material and social aspects of lived environments, can mitigate or compound the effects of trauma for both forced migrant and Lebanese adolescents. Despite the small sample size, the participants’ different backgrounds and experiences offer a wide range of data to understand the factors affecting mental health of adolescents in Bar Elias. Differently-abled participants were included in the study, widening the scope of understanding regarding how social and cultural conditions affect mental health of all of Bar Elias’ residents. By including both groups of adolescents in our study, we were able to show that intersectional identities, including nationality, gender, neurodiversity and different physical abilities interact to mitigate or compound the effect of mental ill-health factors. The study explored how factors related to community shape the mental health of participants, and demonstrated that mental health can be seen as an individual and a communal experience.

7. Conclusions

In contexts of displacement, particularly urban and protracted displacement, mental health of recently displaced and host community adolescents can be seen to be affected by shared conditions. These shared conditions include social relations, cultural norms, economic challenges and access to safe public and private spaces. Gender and being differently-abled are important intersectional identities which cut across nationality, which affect how young people are affected by these shared conditions, and how they can respond to them.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.