Development and Validation of the Arab Youth Mental Health Scale

ORIGINAL PAPER

Development and Validation of the Arab Youth Mental HealthScale

Jihad Makhoul • Rima T. Nakkash •

Taghreed El Hajj • Sawsan Abdulrahim •

Mayada Kanj • Ziyad Mahfoud • Rema A. Afifi

Received: 6 September 2009 / Accepted: 12 April 2010 / Published online: 6 May 2010

� Springer Science+Business Media, LLC 2010

Abstract 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 iden-

tification 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 the-

oretical or conceptual constructs. The process of soliciting

feedback from youth groups, the community and profes-

sionals; 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 meth-

odology to construct a relevant, culturally and contextually

sensitive measure.

Keywords Mental health � Validation � Arab �Youth

Introduction

Approximately 1 in 4 or 5 adolescents will suffer from a

mental health problem in any year (Patel et al. 2007). A

variety of risk and protective factors have been linked to

the probability of mental health problems, with refugee

status a definite risk. (Patel et al. 2007). A variety of

measures of mental health have been used with youth

generally (Harpham et al. 2003; Myers and Winters 2002b;

Winters et al. 2002; Costello and Angold 1998), and spe-

cifically with refugee youth (Keyes 2000; Mollica et al.

1997; Nese et al. 2005; Rousseau and Drapeau 1998; Savin

et al. 1996; Slodniak 2002). However, most current mea-

sures of mental health are used for clinical diagnosis at the

individual level rather than for assessing prevalence at the

J. Makhoul � R. T. Nakkash � T. El Hajj � S. Abdulrahim �M. Kanj � R. A. Afifi (&)

Department of Health Behavior and Education, Faculty of Health

Sciences, American University of Beirut, P.O. Box 11-0236,

Riad El Solh, 1107 2020 Beirut, Lebanon

e-mail: [email protected]

Z. Mahfoud

Department of Epidemiology and Population Health,

Faculty of Health Sciences, American University of Beirut,

P.O. Box 11-0236, Riad El Solh, 1107 2020 Beirut, Lebanon

123

Community Ment Health J (2011) 47:331–340

DOI 10.1007/s10597-010-9312-6

population level (Myers and Winters 2002b). Additionally,

despite the abundance of youth mental health scales in the

literature, 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 prior to

utilizing any measure of mental health with a certain

population, due to possible cultural variations in inter-

preting meaning (Moreau et al. 2009; Hundt et al. 2004;

Ommeren 2003).

Palestinians were displaced beginning in 1948 and

became refugees residing in Lebanon, Syria, and Jordan.

An estimated 422,000 Palestinian registered refugees

reside in Lebanon (UNRWA 2009). Palestinian refugees in

Lebanon live under dire environmental and social condi-

tions. These conditions are commonly perceived to be the

worst of Palestinian refugees in the region, due to limited

employment opportunities, scarce economic resources, and

limited access to basic health and social services—exac-

erbated as a result of state imposed restrictions on

employment and opportunities to seek education (Jacobsen

2000). Health and social services are provided by a variety

of international as well as governmental and non-govern-

mental organizations. The United Nations Refugee and

Works Agency (UNRWA) was set up in 1948 specifically

to provide educational and health services to the Palestin-

ian refugees. However, services are fragmented and

insufficient.

Palestinian refugees in Lebanon have the highest prev-

alence of mental distress when compared with other such

refugees in the region (Jacobsen 2000). Using an abbrevi-

ated version of the Hopkins Symptoms Checklist, refugees

aged 15 years and older in Lebanon were found to have a

mean score over 3 (on a scale of 0–7), the highest mean

score as compared to refugees in Syria and Jordan (Jac-

obsen 2000). A particular study of relevance to this pop-

ulation involved 590 never married 13–19 year old

Palestinian refugees (mean age: 15.84, SD: 2.02) living in

Burj El Barajneh camp (BBC) in Beirut (Makhoul and

Nakkash 2009). BBC—located in the southern suburbs of

Beirut, is the 6th largest of the 12 official camps estab-

lished in Lebanon to house Palestinian refugees after 1948.

BBC houses approximately 14,000–18,000 residents over

an area of 1.6 square kilometers (Statistics UNRWA 2009;

Makhoul 2003). Though mental health was not specifically

measured, several potential indicators were evident. For

example, youth surveyed lived in households where the

mean annual income of the household was 4,854,000L.L.

(LL1500 = $1.00). Forty five percent of the youth sur-

veyed were out of any educational institution (school,

university, technical). Over a quarter (27%) of the youth

were working. Of those who worked, 67% worked more

than 40 h per week, and 90% earned less than 75,000L.L.

per week. In addition, 63% contributed at least part of their

income to household expenses. Approximately 15% of the

youth surveyed reported they had never been to see a

doctor, and 24.1% had seen a doctor over 1 year ago. The

youth had been exposed to a variety of stressful life events:

42% had had a death in the family in the past year, 67%

had a family member hospitalized, and 48% had a parent

who had taken a loan and had to repay it. When asked to

compare themselves to others their age in Lebanon, 68%

stated that they have fewer opportunities compared to

others. In addition, only 13% stated that they felt their life

would improve a lot in the future. With respect to social

capital, 94% of those surveyed trusted few people or no one

in their neighborhood and 67% stated that one needed to be

vigilant and cautious when dealing with neighbors. Finally,

59% had not exchanged a favor with a family member,

76% had not done so with a friend, and 80% with a

neighbor (Afifi et al. 2010).

With specific relevance to Arab youth, a variety of

mental health scales have been used among Arab refugee

youth (Bean et al. 2007; Foldspang and Montgomery

2000), and Arab youth generally, (Baker and Kanan 2003;

Elbedour et al. 2007; Giacaman et al. 2004; Hundt et al.

2004; Punamaki et al. 2005; Thabet et al. 2000, 2002;

Thabet and Vostanis 1998, 1999, 2001). These include the

Hopkins Symptoms 37 (Bean et al. 2007), the Child Post

Traumatic Stress Reaction Index (CPTSD-RI; Baker and

Kanan 2003; Thabet et al. 2002; Thabet and Vostanis

1999), the Revised Child Manifest anxiety scale (RCMAS;

Thabet et al. 2002; Thabet and Vostanis 1998), the Rutter

scale (completed by teachers about children; Thabet and

Vostanis 1998, 1999, 2001), the Gaza traumatic events

checklist (Thabet and Vostanis 1999), and the Children’s

Depression Index (Arabic version; Baker and Kanan 2003)

among others. However, despite the abundance of mea-

sures used to measure Arab youth mental health, psycho-

metric properties of these instruments are rarely measured

(Moreau et al. 2009; Abdel-Khalek 2002; Foldspang and

Montgomery 2000).

In an effort to address the dearth of robust analysis of

scales used with Arab adolescents, this paper describes the

process of development and psychometric testing of the

Arab Youth Mental Health (AYMH) Scale. The AYMH

scale was developed to measure the impact of an interven-

tion planned as a follow-up to the survey conducted in BBC

and described above. The results of that survey were dis-

seminated at a meeting of stakeholders (NGOs, UNRWA,

and adult and youth residents of BBC). At this meeting, a

decision was taken to move towards intervention to promote

mental health of youth in BBC, and a Community Youth

Committee (CYC) was established to guide the develop-

ment, implementation and evaluation of an intervention

using Community Based Participatory Research as a con-

ceptual framework (Viswanathan et al. 2004).

332 Community Ment Health J (2011) 47:331–340

123

Methods

The process of developing the Arab Youth Mental Health

(AYMH) Scale included 5 phases (Fig. 1): (1) reviewing

existing scales; (2) rating the scales by the researchers and

community members; (3) soliciting youth input; (4) seek-

ing expert opinion; and (5) testing for psychometric prop-

erties. Each is described separately below. The phased

approach to development and validation of instruments is

supported by previous research on childhood autism

(Schopler et al. 1980), job stress (Spector and Jex 1998,

2003), and mental well being (Tennant et al. 2007).

Reviewing Existing Scales

The researchers conducted a review of existing mental

health scales used with youth from the published literature

using medline, pubmed, PsycINFO, academic search pre-

mier and Google scholar. Additional scales were identified

through an iterative process of reading published articles

Fig. 1 The 5 phases of

development and validation of

the Arab Youth Mental Health

Scale

Community Ment Health J (2011) 47:331–340 333

123

and reports on mental health measurement, mental health

interventions, and refugee health. Throughout the search

process, the researchers sought to review scales that were

non-diagnostic and relatively short, keeping in mind that

these will be used with youth in community settings.

Search terms included mental health, anxiety, depression,

and quality of life—paired with adolescent or youth. The

inclusion criteria comprised scales measuring depression

and anxiety as well as other scales measuring quality of life

pertinent to mental health. Exclusion criteria included

scales used for diagnosis only (never used in a community

sample or for screening) and that were long (over 60 items

unless used specifically for screening and in refugee pop-

ulations). Most of the scales identified had been used either

in clinical settings for screening or in population-wide

surveys to assess prevalence of mental health while a

smaller number of scales had been used specifically to

evaluate impact of interventions.

The search yielded 14 scales for review. These were: the

Self Report Questionnaire (SRQ20; Harpham et al. 2003;

Harding et al. 1980), the Hopkins Symptoms Checklist 25

(HSC; Mattsson et al. 1969), the WHO Quality of life-Bref

(WHO QOL; WHOQOL 1998), the Harvard Trauma

Questionnaire (HTQ; Mollica et al. 1992), the Short Form

36 Question (SF36; Ware and Sherbourne 1992), the

Mental Health Inventory-5 (MHI-5; Veit and Ware 1983),

the Community-based psycho social support survey ques-

tionnaire used by Birzeit University Institute of Commu-

nity and Public Health (CPSSQ; Giacaman 2004), the Duke

Health Profile (DHP; Parkerson et al. 1990), the Affect

Balance scale (ABS; Bradburn 1969), the Center of Epi-

demiological Studies-Depression score (CES-D; Radloff

1977), the General Health Questionnaire (GHQ-12; Gold-

berg and Hiller 1979), the Kessler-6&10 (K-6 or K-10;

Kessler and Mroczek 1994), the Mental Health Inventory

from the Medical Outcomes Study (MHI-MOS; Ware et al.

1992) and the Strength and Difficulties Questionnaire

(SDQ; Vostanis 2006).

Rating of the Scales by the Researchers

and Community Members

To select the scales which were most relevant to the local

context, the researchers sought input from members of the

Community Youth Committee (CYC). As mentioned

above, the CYC was established to guide all phases of the

intervention project, and included 17 different NGOs that

work with youth in the camp, camp residents including

youth, UNRWA, as well as academicians from the Amer-

ican University of Beirut. Usually each NGO sent one

representative that consistently attended the meetings. For

the purpose of reviewing the scales, a subcommittee was

formed, since a smaller group was thought to facilitate

discussion and make the process more efficient. The sub-

committee consisted of two members from the academic

research team and three volunteer members from the CYC

(non academic). The process was very time consuming.

The subcommittee met on average 5 times to review the

selected 14 scales and each meeting lasted up to 2 h. At the

end of each meeting, the research team members summa-

rised discussions to inform the next meeting. The scales

were rated according to set criteria as described below.

Each member of the committee discussed why they thought

a certain scale fit the criteria for selection or not and a

discussion ensued. Some scales took more time for dis-

cussion than others to reach a consensus. The purpose of

this phase was only to select those scales most relevant to

our context rather than adapt them—which was the purpose

of phases that followed.

Members of the subcommittee looked over the 14

scales and rated each using a set of criteria based on the

reviewed literature (Bowling 2001, 2005; Boyle and

Jones 1985; Myers and Winters 2002a). The criteria

included: Suitability, the extent to which the instrument

items were culturally relevant for use within the camp;

Applicability, the extent to which the youth would

understand the questions; Structure, the extent to which

the recall period, the number of items in the question-

naire and type of responses (Likert or dichotomous)

matched the norms of the context; and Appropriateness,

or relevance to the developmental stage of youth. Since

none of these particular scales had been tested for

validity and reliability in this specific context and with

the population in question, we discounted this as a

relevant criterion in the selection process. Table 1

summarizes the ratings for each scale.

Structure was considered first as it was the most

straightforward to assess. Based on their previous research

experience with this age group in comparable contexts, the

researchers thought that measures with long recall periods

were harder to use with 10–14 year olds because of diffi-

culty with recall. Although Myers and Winters (2002a)

maintains that a dichotomous response format is better for

use with youth, it was apparent from prior experience that a

yes/no option did not work very well with youth in this

context. Dichotomous response options were felt to result

in underestimation of mental health issues as the youth

would tend to answer in the negative to avoid being

‘labeled’. Also based on prior experience with this age

group in a comparable context, a short Likert type format

was found to be more comprehensible. Consequently, the

SRQ20, GHQ12, MHI-MOS, CPSSQ, ABS, Kessler, HTQ,

DHP, WHO-Quality of Life, WHO MHI-5 and SF36 were

all excluded (see Table 1 for details). Once the list of 14

scales had been shortened to 3, the researchers and coali-

tion members reviewed the remaining scales using the


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other three criteria (applicability, suitability, and appro-

priateness) which were considered in tandem.

The three remaining scales were: the SDQ, the Hopkins

and the CESD. The SDQ has non-dichotomous response

items that were similar for all the survey items (except for

8 clinical items included in the SDQ but not considered for

our purposes). Although it has a long recall period

(6 months), it was found otherwise suitable, applicable,

and appropriate. The Hopkins checklist has non-dichoto-

mous response options, only 25 items, and a recall period

of 1 week. One question related to sexual pleasure seemed

inappropriate, but with this item disregarded, the Hopkins

checklist was appropriate, applicable, and suitable. The

CES-D has a 1 week recall period, is not dichotomous, has

scale options that were thought to be easy and compre-

hensible by youth and has only 20 questions in total. The

CES-D was also found to be appropriate, applicable, and

suitable for our population. These three scales were sub-

sequently translated into formal Arabic to be used in sub-

sequent phases.

Soliciting Youth Input

To check for comprehension and the appropriateness of

terms used in the scales to express mental health and

related symptoms, the researchers asked the opinions of a

sample of out-of-school youth (drop-outs) in the camp

through two focus groups. Participatory research particu-

larly involving youth suggests that by listening to young

people’s stories and collaborating with them in designing

interventions to address their concerns, research questions

and interventions are more effective (McIntyre 2000). This

is because the youth are particularly well aware of issues

that affect them and they will benefit more from programs

they participate in setting up (O’Donnell et al. 1997). The

researchers were committed to hearing youth voices.

Thirteen youth aged 13–17 years accessed through Pales-

tinian NGOs in the camp serving out-of-school youth were

invited to participate in focus group discussions conducted

in the camp by two of the authors (JM, RN). The youth

found the items in formal Arabic difficult to understand.

The researchers felt this would also apply to youth still in

school as well. Thus, the scale needed to be re-edited into

colloquial Arabic which all children 10–14 years old could

understand.

Further FGD were conducted at the University by 4 of the

authors (JM, RN, RA, MK) with 44 youth in grades 5 and 6

from UNRWA1 schools in the camp. The focus groups

checked for: (1) comprehension (2) relevance (3) response

options, and (4) context specific feelings, thoughts, and

expressions. The findings revealed that several of the ques-

tions were conceptually meaningless to the young persons

and many terms were ambiguous to them. The double bar-

reled items containing two questions in one, such as ‘‘I fight a

Table 1 Rating of scales according to set criteria

Scale Structure Suitable Applicable Appropriate

SRQ 20 No (Dichotomous; Recall: 1 month; 20 Q) No Yes No

Hopkins checklist Yes (Not dichotomous; Recall: 1 week; 25 Q) Yes Yes Yes

WHO Quality of life-Bref No (Not dichotomous; Response categories too wide;

Recall: 1 month; 26 Q)

Yes Yes No

Harvard Trauma Q No (Dichotomous; Many open ended Q’s; Recall: Ever; 92 Q) No Yes No

SF 36 Maybe (Some dichotomous; Response Options vary

across Q’s; Recall: *1 month; 36 Q)

Yes No No

WHO MHI-5 No (Not dichotomous; Recall: 1 month; 5 Q) Yes Yes Yes

Community-based psychosocial

support survey

No (Some open ended q; Response Options vary

across Q’s; Recall: 2 weeks–6 months; 43 Q)

Yes Yes Yes

Duke health profile Maybe (Some dichotomous; Response Options vary

across Q’s; Recall: 1 week; 17Q)

Yes No Yes

Affect balance scale No (Dichotomous; Recall: past few weeks; 10 Q) No Yes No

CES-D Yes (Not dichotomous; Recall: 1 week; 20 Q) Yes Yes Yes

GHQ-12 No (Not dichotomous; Categories difficult for youth;

Recall: past few weeks; 12 Q)

Yes No No

Kessler 6 or 10 No (Not dichotomous; Response categories too wide;

Recall: 1 month; 6–10 Q)

No Yes No

Mental health inventory from

the medical outcomes study

No (Not dichotomous; Response categories too wide;

Recall: 1 month, 57 Q)

No Yes No

Strengths and difficulties Yes (Not dichotomous; Recall: 6 months; 33 Q Yes Yes Yes

1 UNRWA is the United Nations agency established for the sole

purpose of providing educational and health services to Palestinian

refugees.


123

lot. I can make other people do what I want’’ appearing in the

Strength and Difficulties Questionnaire is one such example.

Also, youth found difficulty with the recall period of ‘during

the past 6 months’. Instead, they found it easier to recall

seasons (winter or summer) as most of their year is spent

either in or out of school; or significant events (the summer

war), or the number of the month (‘‘month 6’’ meaning June).

In addition, the young people stated that they remembered

events most clearly in the last week. They also seemed to

have difficulty understanding the slight difference between

the 4 response options of the CES-D (rarely or none of the

time, some or little of the time, occasionally or a moderate

amount of the time, and most or all of the time), and the 4

response options of the Hopkins Symptom Checklist (Not at

all, a little, quite a bit, extremely), and the 3 response options

of the SDQ (not true, somewhat true, certainly true). Using

stars to indicate increasing intensity of feeling (or frequency)

was the preferred alternate option among the participants.

The youth used specific Arabic terms to express how they

felt about recent incidents that affected them the most, such

as the Israeli attack on Lebanon in the summer of 2006 and

other matters which continue to affect them, such as having

no place to play, confinement to the camp, crowding, noise

and violence. The rich information from these group dis-

cussions provided the researchers with a list of terms that

were sure to capture the youth’s experiences. The most

recurring terms the boys used were: ‘was sad’, ‘was afraid’,

‘cried’. Examples of other terms mentioned at least once to

express their feelings were: ‘devastated’, ‘felt sorry’, felt

lonely’, ‘was bored’, ‘couldn’t eat’, ‘lost my temper’. A

number of them spoke of nightmares and thoughts of death

and dying. Similarly, terms such as ‘afraid’, ‘irritated’,

‘agitated’, ‘upset’, ‘depressed’, recurred in the focus groups

with girls and other terms that were mentioned at least once

included: ‘pressured’, ‘couldn’t concentrate’, ‘dizzy’, ‘lost

hope in life’, ‘started to shake’, ‘sadness’, ‘worn out emo-

tional state’. They, too, spoke about death and dying,

nightmares and being disturbed by the war and the violence

in their neighborhoods. They also expressed their fear for

their loved ones, but let out their feelings by screaming and

talking to their friends about their problems.

The researchers then formulated statements using these

terms or chose statements that were part of the three short

listed translated questionnaires. A new scale of 40 items; a

shorter Likert scale with three options: always, sometimes

and rarely; and a shorter recall period (1 week) was

formulated.

Seeking Expert Opinion

To contextualize the resulting scale further and to point out

the questions which were the most relevant to use in

screening for common mental disorders, the researchers

sought the input of four local mental health specialists, two

psychologists and two psychiatrists. This constituted the

content validation aspect of the scale. They each responded

with suggestions about questions to keep and to delete. The

items which they all agreed to keep remained in and those

which they all deleted were removed. The remaining items

were then reviewed and kept if two out of four experts

suggested including them. This round of expert comments

resulted in a scale of 28 items.

Testing Psychometric Properties

To test for construct validity of the latest draft of the

mental health scale (28 items), the researchers adminis-

tered the questionnaire to a total of 288 students in fifth and

sixth grades in UNRWA schools. The data were entered

into SPSS version 15 for analysis. First, an exploratory

factor analysis was carried out on the 28 items utilizing the

principal components extraction (PCA) method. We used

PCA to identify a more parsimonious set of items, or the

smallest number of factors, that could explain most of the

variance in the data (Bryant and Yarnold 2000). We used

PCA because our intent was to carry out exploratory, as

opposed to confirmatory, factor analysis. Secondly, we

followed the factor analytic step with ANOVA tests for the

purpose of construct validity. It was hypothesized that

youth who score low on the mental health scale (i.e.,

express a higher level of psychological/mental distress)

will also report poor general self-rated health (GSRH) and

poor self-rated mental health (SRMH).

Results

Based on the exploratory factor analysis using the principal

components analysis (PCA), we got 7 possible factors with

total eigenvalues over 1 (Table 2). Factor 1 explained

28.319% of the total variance in the data. None of the other

factors contributed substantially to explaining more

variance.

Three of these seven factors (factors 1, 2, 7) had items

with loadings of 0.5 or above (Table 3). The cut-off point of

0.5 was chosen because our intent was exploratory and in

order to include as many items as possible. However, upon

closer examination, most of the items either loaded or did

not load on factor 1. There were two items that loaded only

on factor 2 (feeling comfortable and secure wherever I

went; feeling happy), one that loaded only on factor 7

(feeling that nothing mattered, not caring about anything),

and four that did not load well on any of the factors (feeling

bothered by things that usually do not bother me; shivering

without being cold; losing appetite; and wanting to

hit someone). The three items that loaded on factors 2 and


123

Table 2 Results of the principal components analysis—factors and variance explained

Total variance explained

Component Initial eigenvalues Extraction sums of squared loadings

Total % Of variance Cumulative % Total % Of variance Cumulative %

1 7.929 28.319 28.319 7.929 28.319 28.319

2 1.727 6.168 34.487 1.727 6.168 34.487

3 1.436 5.128 39.615 1.436 5.128 39.615

4 1.267 4.525 44.140 1.267 4.525 44.140

5 1.191 4.252 48.392 1.191 4.252 48.392

6 1.046 3.737 52.129 1.046 3.737 52.129

7 1.027 3.669 55.798 1.027 3.669 55.798

Extraction method: principal component analysis

Table 3 Results of the principal component analysis—factor loadings for each item within identified components

Component matrixa

Component

1 2 3 4 5 6 7

During the last week I was upset .562 .228 -.003 -.373 -.072 .354 -.119

During the last week I burst into tears several times .520 .370 -.085 -.101 -.167 .032 .057

During the last week I was bothered by things that usually do not bother me** .432 -.142 .235 -.140 -.400 -.043 -.219

During the last week I was feeling scared and frightened .520 .206 -.342 .289 -.153 .086 -.132

During the last week I felt suffocated .663 .120 .137 -.015 -.100 -.160 .091

During the last week my sleep was interrupted because I was thinking of so many things .641 .057 -.101 .099 -.209 -.092 -.124

During the last week I was shivering without really being cold** .398 .225 -.453 .015 .170 -.429 .148

During the last week I was tense/nervous .608 -.239 .116 -.007 -.185 -.175 -.090

During the last week I felt lonely .561 -.009 .168 -.369 -.068 -.350 -.112

During the last week I lost my appetite** .448 -.024 .059 -.467 .043 .238 .335

During the last week I was sad .618 .175 -.071 -.245 .066 -.067 .096

During the last week I was worried .644 .155 -.063 .216 -.173 .049 -.044

During the last week I was having difficulty concentrating on what I was doing .526 .105 --.041 .374 -.137 .078 .093

During the last week I felt dizzy/light headed .554 -.318 -.208 -.160 .316 .019 -.073

During the last week I didn’t feel like talking .621 -.020 -.047 -.191 .014 -.320 .301

During the last week I was bored and I hated my life .654 .023 .196 .109 -.052 -.124 .060

During the last week I didn’t have any hope for the future .512 .164 .182 -.018 -.291 .106 .013

During the last week I was fighting for no particular reason .533 -.392 .354 .261 .128 -.024 -.011

During the last week I was feeling comfortable and secure wherever I went** .086 .529 .494 .130 .283 .082 -.041

During the last week I was bored and I had nothing to do .531 -.213 -.233 -.061 .159 .073 -.366

During the last week I felt like hitting someone** .384 -.408 .423 .192 .184 -.207 -.062

During the last week I was having thoughts of death .502 .074 .053 .279 -.160 .267 .095

During the last week I was feeling emotionally drained .633 .040 -.198 .218 .188 -.071 -.181

During the last week my heart was beating fast even without doing any type of sports .515 -.039 -.253 .199 .259 .128 .232

During the last week nothing mattered for me/I didn’t care for anything** .323 -.383 -.020 .120 -.039 .139 .575

During the last week I was happy** .257 .540 .325 .040 .469 -.059 .027

During the last week I was feeling fidgety, and moving a lot. I couldn’t sit still for a long

time without any particular reason (for example without having an exam)

.566 -.189 .138 -.105 .116 .353 .030

During the last week I was having a lot of headaches, stomachaches and nausea .637 -.160 -.128 -.105 .304 .214 -.282

Extraction method: principal component analysisa 7 components extracted

** excluded from final scale


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7—‘‘feeling secure,’’ ‘‘feeling happy,’’ and ‘‘not caring

about anything’’—could not be theoretically/substantively

described in a coherent theme. Therefore, all 7 items were

excluded and only the 21 items that loaded well on factor 1

were kept in the scale. As such, factor analysis was an

important data reduction step and served to condense the

mental health scale to a linear combination of 21 items that

loaded relatively well on one factor. The internal validity of

the scale was high with a cronbach’s alpha of 0.901.

As to the construct validity of the scale, results of

ANOVA tests of unequal means clearly revealed that

adolescents in the sample who rated their GSRH and

SRMH (these two questions were added to the question-

naire) poorly scored low on the mental health scale. Fig-

ure 2 shows that the means were different from each other,

and this difference was significant at the P \ 0.001 for

both GSRH and SRMH. Furthermore, the figure shows a

clear gradient in mean differences. In sum, the internal and

construct validation tests revealed that the mental health

scale of 21 items generated through an iterative process

was valid in measuring mental health among Palestinian

refugee adolescents. It can be used as an evaluation

instrument in future research with this group.

Discussion

The authors engaged in the process described herein

because of the scarcity of critical analysis and research on

mental health scales that are culturally relevant and psy-

chometrically robust in the Arab context generally and for

Palestinian youth specifically. We recognize that there is

not one single perfect scale, however, the objective was to

find one which most closely matched the research

objectives, all the while being structurally acceptable,

appropriate, suitable, and applicable to the target group. A

similar process of identifying a scale conducted by a dif-

ferent research group for different research objectives and a

different target population could lead to the selection of a

different scale. This critical analysis process, however,

ensures that a more relevant and meaningful assessment

instrument is selected. Researchers and practitioners

working with youth should be sensitive to the particulari-

ties of the specific context and population they work within

in order to avoid utilizing an assessment tool that is not

pertinent to their purposes.

The interactive process of translating, soliciting feed-

back from youth groups, the community coalition and

professionals, and meticulous field testing proved to

require much attention to detail, group work and decision

making. However, the outcome was a contextually sensi-

tive and culturally appropriate reliable scale to measure

mental health of young Palestinian refugees. The research

team members were familiar with the target group, the

planned intervention, and the community context where the

intervention would be conducted, all of which are neces-

sary criteria for such a process to succeed. As a result of

this process of validation, the Arab Youth Mental Health

scale is grounded in community yet meets professional

criteria for measuring common mental disorders. We

believe that a final step in the validation of this scale should

be to clinically validate it against a psychiatric interview

using diagnostic criteria. Since the factor analysis descri-

bed herein was exploratory, we also recommend further

analysis to confirm the findings.

There are several limitations to the work described in

this manuscript. All the work leading to the development

and validation of this scale was conducted in one refugee

camp as part of a larger intervention research project. The

youth who provided their understanding of scale items (in

the focus groups) as well as descriptions of their feeling

and actions when distressed were between the ages of 10

and 14 years. We engaged both out of school youth

(13–19 years) and youth in schools (10–14 years) of both

genders. The age groups were different, and the current

AYMH scale is for use with the younger age group

(10–14 year olds). The scale was not correlated against

another mental health scale. We could not find any scales

that were similar and had been tested for psychometric

properties in Arabic.

However, despite the fact that this scale was developed

for use with Palestinian youth, we believe it has relevance

and applicability to most Arab youth. Although the context

of a refugee camp may be different than that of non-refugee

communities or neighborhoods, many of the political and

social factors influencing youth of the camp also influence

Arab youth in general to a different degree. The scale also

Fig. 2 Results of the construct validity correlating self rated general

health and self rated mental health with the AYMH scale


123

uses very simple language and uses Arabic terms that are

understandable; therefore it can be used with youth in or

out of school.

We suggest that researchers or practitioners working in

other developing world contexts consider whether the

AYMH scale or other scales are appropriate to the pecu-

liarities of their cultural situations. If not, then we recom-

mend that they engage in a similar process to develop and

validate a mental health measure, using quantitative and

qualitative data as well as community and professional

feedback.

Acknowledgments This paper was produced in the framework of a

larger, inter-disciplinary research project on Urban Health, coordi-

nated by the Center for Research on Population and Health at the

Faculty of Health Sciences, American University of Beirut, Lebanon,

with generous support from the Wellcome Trust, Mellon Foundation,

and Ford Foundation.

The authors would like to thank Dr. Trudy Harpham for her

valuable guidance in reviewing earlier drafts of this paper, and Tanya

Salem for her help with the development of the diagram.

The authors would also like to thank the community and youth of

Burj El Barajneh Palestinian refugee camp in Beirut as well as Drs.

Hassen El Amin, Brigitte Khoury, Tima El Jamil, and Madeleine

Badaro.

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Development and Validation of the Arab Youth Mental Health Scale

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