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Review

M. Fehling,¹ Z.M. Jarrah,¹ M.E. Tiernan,¹ S. Albezreh,¹ M.J. VanRooyen,^1,2 A. Alhokair ¹ and B.D. Nelson ^3,4

الشباب في أزمة (الشباب في سياق الأزمات) في الشرق الأوسط وشمال أفريقيا: مراجعة منهجية للأدبيات وتحليل مركَّز للمشهد

مايا فهلنج، زينة الجرّاح، ماجي تيرنان، سعيد البزرة، مايكل فاترويين، عبد المحسن الحكير، بريت نلسون

الخلاصة: إن العوامل السياسية والسكانية الأخيرة كشفت سرعة تأثر الشباب في إقليم الشرق الأوسط وشمال أفريقيا. و قد هدفت هذه الدراسة إلى إلقاء الضوء على الاحتياجات الحالية والأنشطة والأطراف المعنية والحلول المتعلقة بالشباب وصغار البالغين المعرضين للخطر في إقليم الشرق الأوسط وشمال أفريقيا. فأجري استعراض منهجي للأدبيات التي تمت مراجعتها من قبل زملاء (الأدبيات الـمُحكَّمة) وللأدبيات غير الرسمية. وقد استكمِل ذلك بتحليل للمشهد في الإقليم اشتمل على إجراء مقابلات مع المصادر الرئيسية للمعلومات وعلى مناقشات جماعية مركزة، وبعد فحص شامل لـ 1160 مقالة متميزة تم اعتبار 275 مقالة ذاتَ صلة بهذه الدراسة؛ 145 منها (52.7 %) حول الصحة (ارتبطت منها 64.8 % بالصحة النفسية)، بينما ارتبطت 100 مقالة (36.7 %) بسبل كسب الرزق، وتناولت 87 مقالة الوقاية من العنف وناقشت 68 مقالة (24.7 %) التعليم. وكان من جملة المواضيع والتحديات الهامة التي تم التعرف عليها في الأدبيات والمناقشات تزايدُ أعداد الشباب في إقليم الشرق الأوسط وشمال أفريقيا، والبطالة في صفوف الشباب، والفجوات الخطيرة القائمة بين الجنسين، وأثر الصراعات على سبل كسب العيش وعلى التعليم والصحة؛ لا سيما الصحة النفسية.

ABSTRACT Recent political and demographic factors have exposed the vulnerability of the youth in the Middle East and North Africa (MENA) region. This study aimed to elucidate the current needs, activities, stakeholders and solutions related to at-risk youth and young adults in the MENA region. A systematic literature review was conducted of the peer-reviewed and grey literature. This was complemented by an in-region landscape analysis involving key-informant interviews and focus group discussions. After extensive screening of 1160 unique articles, 275 articles were considered relevant to this study. Of these 275, 145 (52.7%) were related to health (64.8% of these related to mental health), 101 (36.7%) to livelihood, 87 (31.6%) to violence prevention and 68 (24.7%) to education. Important themes and challenges identified in the literature and discussions included the MENA region’s growing youth bulge; youth unemployment; critical gender gaps; and the impact of conflict on livelihoods, education and health, especially mental health.

Jeunesse en crise au Moyen-Orient et en Afrique du Nord : examen systématique de la littérature et analyse contextuelle ciblée

RÉSUMÉ Des facteurs politiques et démographiques récents ont révélé la vulnérabilité des jeunes dans la Région du Moyen-Orient et de l’Afrique du Nord. La présente étude visait à connaître les besoins, les activités, les parties prenantes et les solutions liés aux jeunes et aux jeunes adultes à risque actuellement dans la Région du Moyen-Orient et de l’Afrique du Nord. Un examen systématique de la littérature revue par des pairs et de la littérature grise a été mené. Cette démarche a été complétée par une analyse contextuelle intrarégionale impliquant des entretiens avec des informateurs clés et des groupes de discussion thématiques. Après un examen approfondi de 1160 articles uniques, 275 articles ont été considérés comme pertinents pour l'étude. Sur ces 275 articles, 145 (52,7 %) concernaient la santé (64,8 % de ces derniers abordant la santé mentale), 101 (36,7 %) les moyens de subsistance, 87 (31,6 %) la prévention de la violence et 68 (24,7 %) l'éducation. Les difficultés et thèmes importants identifiés dans la littérature et les discussions au niveau de la Région du Moyen-Orient et de l’Afrique du Nord sont les suivants : l'augmentation rapide du nombre de jeunes, le chômage chez les jeunes, les écarts critiques entre les hommes et les femmes, et l’impact des conflits sur les moyens de subsistance, l’éducation et la santé, en particulier la santé mentale.

¹Harvard Humanitarian Initiative, Cambridge, Massachusetts, United States of America. ²Harvard T. H. Chan School of Public Health; ⁴Division of Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America.

³Division of Global Health and Human Rights, Department of Emergency Medicine and Department of Paediatrics, Massachusetts General Hospital, Boston, Massachusetts, United States of America (Correspondence to B.D. Nelson: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Received: 05/04/15; accepted: 28/09/15

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Introduction

Adolescence can be a time of great opportunities, as youth transition from childhood to adulthood and prepare for the responsibilities ahead, including their livelihood, family obligations and productive engagement with their communities. However, among the many communities in the Middle East and North Africa (MENA) that are disrupted by conflict or impoverishment, opportunities for youth can be severely limited. Recent political and demographic factors have exposed the vulnerability of many segments of the civilian population in the MENA region. These vulnerabilities are driven by the expansion of regional conflicts and mass population displacement in urban settings.

The population effects of political crises and disasters will create an increasingly significant impact on youth. Previously, adolescents and young adults have been a neglected population in international programming (1); however, this trend may be changing as youth increasingly become a priority for countries in the MENA region (2). Meanwhile, this population segment is growing more rapidly in the MENA region than almost anywhere else in the world (3). Lack of economic, educational and leadership opportunities curtail adolescent development and limit their full potential for contribution to their families and communities throughout their lifetimes. The results of such conditions during adolescence can lead to a sense of hopelessness and frustration, unnecessary idleness and a propensity for unrest.

In preparation for programmatic development of interventions for youth in the Middle East by the Harvard Humanitarian Initiative, Cambridge, Massachusetts, USA, we discovered no recent overview of the issues faced by youth in the MENA region. Our objective, therefore, was to conduct a multi-method landscape analysis to more fully elucidate the current needs, activities, stakeholders and solutions related to at-risk or conflict-affected youth and young adults in the MENA region.

Methods

To accomplish the study objective, a multi-method approach was used, involving a systematic review of the peer-reviewed literature, a review of the available grey literature, and in-region discussions with stakeholders and key informants in Jordan.

These reviews sought to systematically identify and assess current knowledge, gaps and existing best practices related to the needs of MENA youth in crisis. Jordan was selected for in-region discussions due to its current central position in many of the acute issues facing vulnerable youth and due to its relatively secure access for participants.

This study underwent ethical review and received exemption from the institutional review board of Partners Healthcare (Massachusetts General Hospital, Boston, Massachusetts). In-region visits and discussions in Jordan received permission from the Jordanian Ministry of the Interior.

Systematic literature review

Standardized PRISMA [preferred reporting items for systematic reviews and meta-analyses] guidelines were followed to conduct the systematic literature review (4). This involved surveying the peer-reviewed literature using the PubMed/Medline and Web of Science databases. Identified articles were iteratively screened for relevance regarding youth in crisis by article title, abstract and then full article. The bibliographies of included articles were also reviewed to identify additional relevant references.

Inclusion and exclusion criteria

The inclusion criteria (search terms) used in the literature searches were: (Youth OR adolescence OR adolescent OR teenager) AND ("Middle East" OR MENA OR "North Africa" OR Algeria OR Bahrain OR Egypt OR Iran OR Iraq OR Israel OR Jordan OR Kuwait OR Lebanon OR Yemen OR "United Arab Emirates" OR Libya OR Morocco OR Oman OR Palestine OR Qatar OR "Saudi Arabia" OR Syria OR Tunisia) AND (conflict OR refugee OR crisis OR vulnerable).

The exclusion criteria were articles unrelated to youth population or youth in crisis and articles referring to non-MENA countries. We also excluded articles about immigrants or refugees from MENA countries in non-MENA countries, due to the different context and different opportunities and challenges faced; however, this group needs to be addressed as another vulnerable group of adolescents.

Definitions

For the purpose of these reviews, the terms “adolescents” and “youth” were used interchangeably as their definitions and age ranges overlap among youth-focused organizations. For example, the World Health Organization defines youth as individuals 15–24 years of age, while the United Nations Children’s Fund (UNICEF) defines adolescents as age 10–19 and youth as age 15–24 years. However, in general, the primary focus was on individuals 15–24 years of age.

Grey literature search

In addition to searching the formal peer-reviewed databases, the so-called “grey” literature was surveyed, including online reports and other unpublished documents from nongovernmental organizations (NGOs), United Nations organizations, governments and ministries of health. For this grey literature review, we searched Google, Google Scholar and established humanitarian knowledge databases, such as ReliefWeb, and donor databases, such as the United States Agency for International Development’s Development Experience Clearinghouse. The same search terms were used as for the peer-reviewed literature.

Stakeholder analysis and in-region discussions in Jordan

The in-region research in Jordan took place from November to December 2014. Twelve different organizations were visited and interviewed. To guide the stakeholder discussions, semi-structured key-informant interviews and focus group discussions were used. The questions explored barriers, needs, solutions and priorities for vulnerable youth populations in the MENA.

The participating stakeholders were: United Nations High Commissioner for Refugees, UNICEF, International Youth Foundation, Save the Children, Mercy Corps, Norwegian Refugee Committee, International Rescue Committee, International Medical Corps, Microfund for Women, Jordanian Hashemite Fund for Human Development, Baqaa refugee camp youth centre, Za’atari Syrian refugee camp, Palestinian refugee youth, Syrian refugee youth, and Jordanian youth. These stakeholders and organizations were identified in our literature reviews and through snowball sampling as some of the key groups on the topic of MENA youth.

Synthesis

The selected peer-reviewed and grey literature articles as well as the findings of the in-region analysis were subsequently categorized into one or more of the four topic areas:

livelihoods/economic challenges and opportunities;

educational challenges and opportunities;

health-related issues; and

risk for violence and violence prevention.

Results

Literature review

The peer-reviewed and grey literature reviews initially identified 1160 unique articles (Figure 1). A careful screening of abstracts and full articles resulted in 275 articles that were considered relevant to this study, including 28 key articles with useful inputs for future projects to address youth in crisis (Table 1).

Of the 275 relevant articles, 101 (36.7%) were classified under the category livelihood, 68 (24.7%) under education, 87 (31.6%) under violence prevention and 145 (52.7%) under health; of the latter, 94 (64.8%) were related to mental health issues. Articles contributing to more than one category were accounted for in each.

Geographically, of the 275 included articles, the vast majority (158; 57.5%) referred to Palestine and Palestinian refugees in MENA countries. Peer-reviewed articles examined youth in a group of countries (65; 23.6%) or single countries, such as Lebanon (20; 7.3%), Jordan (15, 5.5%), Islamic Republic of Iran (9; 3.3%) and Iraq (8; 2.9%).

Livelihoods

The youth bulge: business and employment

Assaad and Roudi-Fahimi explained that the increase in the proportion of 15–24-year-olds in the total population in the MENA region—dubbed the “youth bulge”—combined with the sudden expansion in the overall population, has resulted in the most rapid growth in the number of young people in the MENA in history (3). This number is projected to peak at 100 million by 2035 and to decline slowly thereafter. However, the labour market is not expanding to accommodate this demographic shift, risking a negative impact on countries’ economies and societies. The authors argued that the mismatch between quality of labour supply and the requirements of labour markets can largely be tackled by improving the quality of education in the region (3).

In addition to the anticipated demographic shift, there are notable gender dynamics in MENA’s labour markets. Globally, the largest male–female gender gaps in unemployment rates among youth are found in the MENA region, accounting for an estimated 24.5% unemployed young males compared with 42.6% unemployed young females in 2012 (5).

Identity, personality and attitude

Refugee youth in this region have much in common according to Chatty, who included eight different MENA countries in his research (6). The author described how the desire to emigrate, to find work and send remittances back to their families is present among all refugee youth populations. Many young refugees link their refugee status both to a sense of exclusion from their original homelands and to marginality from full legal, social and civil participation in the host communities. Opportunism and agency—seeking an education while also committing to helping the family—was similarly highlighted by refugee youth. Despite economic and political challenges, they looked to the future with optimism (6).

A UNICEF report from 2011 described two common elements that characterize Arab youths identities and influence their vision and priorities: family and religion. In a regional survey, 68% of young respondents said that religion defined them as a person. A survey in Jordan showed that two-thirds of respondents felt that achieving success in life depended on the status of their family in society, rather than on their own efforts (7). Fergus and Zimmerman posited that parental factors such as support, monitoring and communication skills are critical resources for youth to create resilience. Resilience describes the “process of overcoming the negative effects of risk exposure, coping successfully with traumatic experiences, and avoiding the negative trajectories associated with risks” (8).

Migration

A general lack of job opportunities results in a growing number of the youth in Arab countries adopting labour migration as a livelihood strategy. Most Arabs who emigrate are under 35 years of age, and 50% are under 25 years. Fargues described four main factors that contribute to youth emigration from the region: the increasing youth population in the Middle East; the growing number of young well-educated workers facing poor employment conditions; population density; and unresolved political conflicts (9).

The Silatech Index report in 2010 noted that 30% of youth aged 15–29 years would migrate permanently to another country given the opportunity, in particular “those who are the most educated, are already employed, and aspire to start their own businesses” (10).

Education

The importance of education in surmounting barriers in conflict environments is highlighted in various studies (11–14). According to Assad and Roudi-Fahimi, primary education is reaching universal levels of coverage of the population in countries of the Middle East (3). Access to secondary and higher education is limited, however. The educational situation for Syrian youth has changed dramatically in recent years; Syrian refugees in Lebanon face social, economic and bureaucratic obstacles resulting in dropout rates from Lebanese public schools of approximately 70% (15).

Even though new media could play an important role in education, only 62% of Arab youth aged 15–29 years have Internet access in their community and just 22% have access at home (10).

Health

Mental health

The vast majority of health-related articles identified for this review describe an increased prevalence of post-traumatic stress disorder and/or depression through conflict and political violence on youth (16–20). Even if boys are equally, or often more, exposed to trauma—due to boys in the region spending more time outside the house than girls—girls appear to have a higher prevalence of post-traumatic stress disorder, depression, separation anxiety and psychological symptoms than boys. In contrast, boys have more behavioural problems than girls and are more likely to exhibit aggression and hyperactivity (21). Other articles confirm the higher prevalence of mental health issues in female youth in crisis (22–24).

These mental health issues can have further negative impacts on young people’s lives, such as increased risk of substance abuse and use of maladaptive coping mechanisms (self-blame, crying, ignoring the problem, wishful thinking, hiding feelings and anxious anticipation) (25,26).

Thabet et al. described the mental health impact of child labour (< 18 years old) on conflict-affected adolescents who seek early employment to support their family. The findings indicate that these adolescents present with a range of inter-related emotional and behavioural difficulties. The authors recommended human rights-based policies and legislation to tackle the problem, as well as creating incentives for adolescents to return to education (20).

Health in refugee camps and women’s health

Khawaja et al. estimated that 80% of refugee camp populations in Lebanon consist of children, adolescent girls and women. As camps become increasingly militarized, women and girls are particularly at risk of rape and domestic violence. More than a quarter of the women interviewed reported having forced sexual intercourse over the past year (27,28).

Living in an environment of political and social violence also increases the odds of intimate-partner violence occurring (29). In some MENA countries, cultural beliefs and traditions may act as a barrier for women to seek health care, in particular regarding intimate-partner violence. Spencer et al. noted that women in Jordan usually use familial institutions to seek help and would only seek help outside of the family in serious circumstances after the familial help had proven ineffective (30).

The Islamic Republic of Iran has one of the most successful family planning programmes in the developing world and is often considered a potential model for other Muslim countries (31). However, not all family planning programmes are readily accepted throughout the Muslim world. A study on Afghan refugee women who did not use the Iranian programme showed that only after subsidizing general health care did the use of contraceptives increase (32).

Other articles describe the increase of infectious diseases in youth, such as diarrhoeal illness and upper respiratory tract infections, due to the poor living and housing conditions in refugee camps (33–36). War-related injuries of children and youth are also discussed in the literature (37–40). A study on mostly terror-related mass casualty events in Israel between 1998 and 2007 showed that severe injuries were significantly more frequent among children injured in mass-casualty events compared with non-mass-casualty events (39). Another study on injuries from explosive incidents related to terrorism describes the adolescent injury profile as being similar to that of adults but involving fewer internal injuries and more contusions as well as superficial extremity wounds that were more likely to require surgery (40).

Risk of violence and need for violence prevention

According to Urdal, there is an association between youth bulges and the risk of violence in countries (41). The author argued that countries that experience youth bulges are more likely to experience political violence than countries that do not; the higher the dependency burden (i.e. of youth not working), the greater the effect of youth bulges on political violence in terms of riots and violent demonstrations; and the lower the rate of economic growth, the greater the risk of terrorist acts by youth.

Underlining the associated risks of youth unemployment and conflict, Bricker and Foley used countries’ youth population employment statistics to predict the emergence of conflict. They developed the Youth Risk Factor—the ratio of the 17-to-26-year-old age cohort to the size of the total labour force—and showed that countries in the Middle East such as Jordan and Algeria are particularly at risk (42). The authors concluded that a successful transition of youth into the labour force, regardless of their educational backgrounds, is essential to prevent conflict.

Furthermore, the restricted conditions for youth in refugee camps, such as limitations on employment or mobility, can lead to severe consequences, especially when unequal opportunities compared with local youth are perceived. These consequences include illegal activities outside of camps, dropping out of school, physical abuse, child labour and substance abuse (43). While adolescent girls are prone to sexual and gender-based violence, young adolescent boys are particularly vulnerable to being arrested and detained by the authorities in conflict zones (9).

Based on the grey literature review, a number of recommendations and lessons learned for implementing youth-in-conflict programmes in the MENA region were identified (44–49). These are summarized in Table 2 under the following themes:

adopt a holistic approach;

engage policy-makers and regulatory agents for a collaborative, interdisciplinary approach;

emphasize interventions for female youth; and

plan for transition to ensure sustainability.

Coping and resilience

Various articles describe coping mechanisms and the construct of resilience by Palestinian youth, a population that has been at risk of violence and conflict for many years. Nguyen-Gillham et al. confirmed previous studies by showing the value of supportive relationships such as families and friends for coping with conflict. The authors added, “Political participation and education are vital to a sense of identity and political resistance” (50).

Other research has assessed and underlined the increasing importance of participatory educational approaches in school and communities in order to overcome barriers due to conflict, culture and gender (11–14). Morray and Liang pointed out the success of a group intervention for Palestinian and Israeli youth to promote communication and healing and encourage otherwise untenable communication between groups in conflict (51).

Current situation, stakeholder analysis and in-region discussions in Jordan

The in-region discussions revealed multiple challenges for Jordan’s refugees. The stakeholders involved and key points of the discussions, summarized under the four themes of this review, are described in Table 3.

Refugee numbers, particularly from neighbouring Syria, are high and expected to increase in Jordan further by 200, 000 this year to more than one million by December 2015. Approximately 20% of Syrian refugees in Jordan live in two official refugee camps (52). Inside the camps, refugees have access to World Food Programme food, health care and education. Outside of the camps, however, the support for refugees is more precarious, with most refugees relying heavily on the cash transfer programmes of the United Nations High Commissioner for Refugees or other NGOs, as the vast majority of refugees are prohibited from working. Syrian youth articulated their frustration with the lack of economic opportunities matching their educational qualifications. Syrian youth often fled to Jordan without their transcripts and diplomas, making it difficult to prove their educational credentials.

In addition to the barriers to employment, assistance provided to refugees is decreasing or in danger of being cut, with health care outside the camps no longer available free-of-charge and the World Food Programme food assistance programme nearly cancelled in December 2014.

The increasing numbers of refugees could put an even greater pressure on the resources provided by the international community. Several organizations noted the increasing strain that refugees were enduring, stating that refugees were turning towards negative coping mechanisms that specifically affect refugee youth, including child labour, child marriage and survival sex.

Discussion

This multi-method analysis has sought to discern current needs and evidence-based solutions for the challenges faced by youth in crisis in the MENA region. The lack of interdisciplinary, cross-cultural research and policy analysis is one barrier to understanding what factors are associated with increased vulnerability of youth and adolescents and how best to address young peoples’ needs. Few peer-reviewed articles have focussed on programmes providing political, social and economic opportunities to youth in crisis.

Recent worsening of the conflicts in the MENA region and the resulting flows of refugee and internally displaced people make addressing youth in crisis all the more urgent. The present youth bulge, and its expected growth, risks exacerbating challenges such as the general lack of quality education and of employment, which result in high rates of youth unemployment. Guaranteeing better education and stimulating employment not only can help in the short-term but might actually create a platform for entrepreneurship and creation of further employment. Indeed, the discussions with Jordanian, Palestinian and Syrian youth— regardless of gender—revealed both a desire for further education and a frustration with the mismatch between the educational system and the labour market. The literature suggests that a great number of young people in crisis situations are at risk of involvement in violence and conflict. This risk can be mitigated through education and employment opportunities as well as social networks of friends, family and peer groups that help create resilience. Our own programming at the Harvard Humanitarian Initiative will centre on offering educational and livelihood opportunities for MENA youth, while anticipating and evaluating a positive secondary impact on youth health and violence prevention.

The literature review and in-region discussions supported the idea of civic engagement of youth as an important driver for business development in the MENA region, but also noted some barriers, including legal challenges for work permits and accreditation of education as well as limited access to new media and the Internet.

The in-region discussions demonstrated that communities, from the local to the international, are responding to the needs of youth populations through education and livelihood programmes, such as cash transfers and microfinance. However, the impact of these interventions is limited as a result of scarce employment opportunities and the legal restrictions on refugees. This underscores the importance of civil society and local government collaboration in the MENA. Labour migration has become a key livelihood strategy for youth in the region and thus designing educational programmes that can lead to opportunities for subsequent employment is important to consider.

It is often particularly difficult for women in the region to contribute to the economic health of the family, as evidenced by the large employment gender gap. Therefore, families’ investment in education is likely to focus more on the male child when opportunities are more evident. Interventions for youth should therefore reflect these realities and provide opportunities for the most vulnerable and most in need, including young women, while considering religious aspects and understanding the importance and value of the local culture.

The special needs of refugee youth also need to be taken into account, as the inequalities in work opportunities between refugee youth and local youth cause tensions that exacerbate the already higher risk of refugee youth being subject to violence, abuse and detainment.

Health interventions should have a strong focus on mental health issues since they seem to be the predominant health concern for youth in conflict zones, for refugees and for women in particular, a finding supported by the literature search results and the regional stakeholder analysis. However, addressing conflict-related mental diseases requires an interdisciplinary approach with a strong involvement of family and community. This involvement was found to be a key theme for all programmes, whether focusing on livelihood, education, health or violence prevention.

Regarding the limitations of this study, the literature search component only summarized the findings from English-language articles. Additionally, there was a relatively high proportion of health-related articles, likely due to the use of the medical literature database PubMed, and, therefore, the topic of health may be over-represented in the quantification of the literature results. Lastly, in-region discussions were meant to provide additional context, obtain feedback from stakeholders on the initial literature findings and to explore specific issues. The in-region discussions were, by design, limited to Jordan, because it provides a current cross-section of issues related to at-risk youth in the MENA region.

Conclusion

This multi-method analysis has revealed the major challenges in the areas of livelihood, education, health and risk of violence for youth in crisis in MENA countries affected by short- and long-term conflicts. The literature review as well as the in-region research highlights the importance of emphasizing education that leads to employment opportunities for a better and more peaceful future for young people in the MENA and subsequently for the region’s populations in general. In order to create locally accepted and efficient interventions with sustainable impact, it is essential to understand the intentions and barriers for all stakeholders involved, the local political and cultural environments, and, most importantly, the needs of vulnerable youth populations.

Finding: None.

Competing interests: None declared.

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