Learning Objective #1: Define structural barriers to behavior change in the context of refugee and displaced population settings

Learning Objective #2: List at least one nursing implication for practice, policy, and research based on the findings from this study

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Military and humanitarian relief nurses often find themselves providing health care in refugee and internally displaced persons camps with only rudimentary infrastructure. Residents of these settlements are exposed to disease, pollution, violence, and injury. Multilevel contextual factors may act as structural barriers to nursing interventions. These structural barriers include the social, economic, and political environments that shape individuals and communities.

Effective interventions may be prematurely terminated or ineffective ones continued, proving costly to the individual and the sponsoring organization. Thus, a major aim of this research project was to evaluate a behavior change intervention within the context of the historical and sociopolitical structures of South Africa.

The Ecology of Youth Empowerment Model guided this research study. This conceptual model was derived from ecological or social systems theory. A cross-sectional survey design was employed, and multi-level and cross-level analyses were used to explore the multiple contextual factors that can affect behavior change and the equitable evaluation of nursing interventions.

Using random sampling procedures, survey and demographic data were collected from learners ages 13 through 22 years that attended school in Eldorado Park, a township of Johannesburg, South Africa that is made up of internally displaced peoples and refugees from Lesotho, Mozambique, Tanzania, and Zimbabwe.

The results of the exploratory cross-level analysis suggested that the composite variables Classism, Impoverishment, Racism, and Sexism as conceptualized would provide additional valuable information to the evaluation of nursing interventions that utilize a participatory process.

Nursing implications include the use of measures of change that consider multilevel barriers in order to demonstrate the efficacy of behavior change programs, and to prevent the premature termination of effective programs. Modeling of the multilevel contextual factors that can affect individual change should be encouraged to provide a “real world” evaluation of nursing interventions with and for historically marginalized populations.