Long-Term Health Consequences of Movement Restrictions for Palestinians, 1987-2011.

OBJECTIVES: To estimate the long-term association between Israeli-imposed restrictions on travel for medical care in the occupied Palestinian territory and health status in adulthood. METHODS: Using event history calendar methods, we collected annual data from 1987 to 2011 from a representative sample of 1778 Palestinians aged 32 to 43 years and analyzed the subsample of whomever had a serious medical condition and needed to travel for medical care (n = 246; contributing 1163 person-years). We used ordered logistic regression with person-year data to test the association between movement restrictions from 1987 to 2011 and health status in 2011. RESULTS: Two thirds (65%; n = 161) of participants reported travel restrictions, and 38% (n = 92) reported ever being barred from travel for medical care. Compared with study participants who experienced no travel restrictions in a year (n = 559 person-years), those who were barred from travel in that same year (n = 122 person-years) reported worse self-rated health (57% vs 22% reported bad or very bad self-rated health; P < .05) and greater limits on daily functioning caused by physical health (41% vs 16% reported regular limits; P < .05). CONCLUSIONS: Being barred from travel for medical care was associated with poor health as long as 25 years later.

Mental Suffering in Protracted Political Conflict: Feeling Broken or Destroyed.

PURPOSE: This mixed-methods exploratory study identified and then developed and validated a quantitative measure of a new construct of mental suffering in the occupied Palestinian territory: feeling broken or destroyed. METHODS: Group interviews were conducted in 2011 with 68 Palestinians, most aged 30-40, in the West Bank, East Jerusalem, and the Gaza Strip to discern local definitions of functioning. Interview participants articulated of a type of suffering not captured in existing mental health instruments used in regions of political conflict. In contrast to the specific difficulties measured by depression and PTSD (sleep, appetite, energy, flashbacks, avoidance, etc.), participants elaborated a more existential form of mental suffering: feeling that one's spirit, morale and/or future was broken or destroyed, and emotional and psychological exhaustion. Participants articulated these feelings when describing the rigors of the political and economic contexts in which they live. We wrote survey items to capture these sentiments and administered these items-along with standard survey measures of mental health-to a representative sample of 1,778 32-43 year olds in the occupied Palestinian territory. The same survey questions also were administered to a representative subsample (n = 508) six months earlier, providing repeated measures of the construct. RESULTS: Across samples and time, the feeling broken or destroyed scale: 1) comprised a separate factor in exploratory factor analyses, 2) had high inter-item consistency, 3) was reported by both genders and in all regions, 4) showed discriminate validity via moderate correlations with measures of feelings of depression and trauma-related stress, and 5) was more commonly experienced than either feelings of depression or trauma-related stress. CONCLUSIONS: Feeling broken or destroyed can be reliably measured and distinguished from conventional measures of mental health. Such locally grounded and contextualized measures should be identified and included in assessments of the full impact of protracted political conflict on functioning.

Long-term exposure to political violence: The particular injury of persistent humiliation.

This study assessed the association between exposure to political violence over a 25-year period and adult functioning among a population that has experienced protracted and severe political conflict. Instead of aggregating exposure to political violence across time and type of exposure, as is commonly done, the event history calendar pioneered in this study assessed exposure to five forms of political violence annually from 1987 to 2011 in a representative sample of 1788 adults, aged 37 on average, in the occupied Palestinian territories (West Bank, East Jerusalem, and the Gaza Strip). This method allowed for the identification of trajectories of exposure to political violence from childhood to adulthood using latent profile analysis. We then correlated the trajectories of exposure to measures of economic, political, community, family, psychological, and health functioning. As expected, being shot at, having one's home raided, being hit or kicked, being verbally abused, and witnessing someone close being humiliated were all elevated during periods of heightened political conflict (the first intifada (1987-1993) and, less so, the second intifada (2000-2005)). In addition, 12% of women and men reported high and persistent levels of exposure to humiliation (being verbally abused and/or witnessing someone close being humiliated) across the entire 25-year period. These individuals lived predominantly in neighborhoods with a high Israeli military presence. Compared to those who experienced periodic exposure to political violence, persistently humiliated men and women reported significantly lower health, economic, political, and psychological functioning, as well as higher social cohesion and political expression. Relevant literatures are reviewed when concluding that persistent humiliation is a neglected form of political violence that is best represented as a direct (versus structural), acute (versus chronic), macro (versus micro), and high-grade (versus low-grade) stressor whose particular injury is due to the violation of individual and collective identity, rights, justice and dignity.

Political Imprisonment and Adult Functioning: A Life Event History Analysis of Palestinians.

Political imprisonment is a traumatic event, often accompanied by torture and deprivation. This study explores the association of political imprisonment between 1987 and 2011 with political, economic, community, psychological, physical, and family functioning in a population-based sample of Palestinian men ages 32-43 years (N = 884) derived from a dataset collected in 2011. Twenty-six percent (n = 233) had been politically imprisoned. Men imprisoned between 1987 and 2005 reported functioning as well as never-imprisoned men in most domains, suggesting that men imprisoned as youth have moved forward with their lives in ways similar to their nonimprisoned counterparts. In an exception to this pattern, men imprisoned during the Oslo Accords period (1994-1999) reported higher levels of trauma-related stress (B = 0.24, p = .027) compared to never-imprisoned men. Men imprisoned since 2006 reported lower functioning in multiple domains: human insecurity (B = 0.33, p = .023), freedom of public expression (B = -0.48, p = .017), perceived government stability (B = -0.38, p = .009), feeling broken or destroyed (B = 0.59, p = .001), physical limitations (B = 0.55, p = .002), and community belonging (B = -0.33, p = .048). Findings pointed to the value of examining the effects of imprisonment on functioning in multiple domains.

Politics drives human functioning, dignity, and quality of life.

Too little is known about human functioning amidst chronic adversity. We addressed that need by studying adult Palestinians in the occupied Palestinian territories (oPt), a population that has experienced longstanding economic and political hardships. Fourteen group interviews were conducted in February, 2010 in Arabic by local fieldworkers with 68 participants representing the main stratifications of Palestinian society: gender, region, refugee status, and political affiliation. Interview tasks included each participant: describing someone doing well and not well, free listing domains of functioning, and prioritizing domains to the three most important. Thematic analyses highlighted the dominating role of the political domain of functioning (e.g., political structures, constraints, effects, identity, and activism) and the degree to which political conditions impacted all other realms of functioning (economic, education, family, psychological, etc.). The discussion links the findings to relevant theory and empirical work that has called attention to the need to include the political in frameworks of quality of life. It also emphasized that values, such as justice, rights, dignity and self-determination, that underlie political structures and policies, are key elements of human functioning. This is the case not only in the oPt, but in any society where power imbalances marginalize segments of the population.

Human insecurity, chronic economic constraints and health in the occupied Palestinian territory.

Research on the effects of political conflict has focused predominantly on the association between violence exposure and psychological trauma. This paper expands that focus. We broaden the assessment of health beyond the conventional spotlight on trauma-related stress to include culturally derived measures of health, and we assess the association between a broad array of political and economic conditions and health. Household interviews were conducted in 2011 with a representative sample of 508 30-40 year olds in the occupied Palestinian territory (oPt; response rate = 97%). The four dependent variables were limits on functioning due to health, feeling broken or destroyed (both culturally derived measures of health), feelings of depression and trauma-related stress. Twenty-four predictor variables assessed multiple dimensions of political conflict and background characteristics. All four measures of health and suffering were associated with human insecurity and resource adequacy. Exposure to political violence was associated only with trauma-related stress. These findings support the increasing recognition that human insecurity and chronic economic constraints in the oPt broadly threaten health, perhaps more so than direct exposure to violence. Ultimately, a political solution is required, but in the meantime, efforts to reduce insecurity and improve economic conditions may improve health and reduce suffering in the oPt.

Annual Research Review: The experience of youth with political conflict--challenging notions of resilience and encouraging research refinement.

AIMS AND METHOD: Drawing on empirical studies and literature reviews, this paper aims to clarify and qualify the relevance of resilience to youth experiencing political conflict. It focuses on the discordance between expectations of widespread dysfunction among conflict-affected youth and a body of empirical evidence that does not confirm these expectations. FINDINGS: The expectation for widespread dysfunction appears exaggerated, relying as it does on low correlations and on presumptions of universal response to adversity. Such a position ignores cultural differences in understanding and responding to adversity, and in the specific case of political conflict, it does not account for the critical role of ideologies and meaning systems that underlie the political conflict and shape a young people's interpretation of the conflict, and their exposure, participation, and processing of experiences. With respect to empirical evidence, the findings must be viewed as tentative given the primitive nature of research designs: namely, concentration on violence exposure as the primary risk factor, at the expense of recognizing war's impact on the broader ecology of youth's lives, including disruptions to key economic, social, and political resources; priority given to psychopathology in the assessment of youth functioning, rather than holistic assessments that would include social and institutional functioning and fit with cultural and normative expectations and transitions; and heavy reliance on cross-sectional, rather than longitudinal, studies. CONCLUSIONS: Researchers and practitioners interested in employing resilience as a guiding construct will face such questions: Is resilience predicated on evidence of competent functioning across the breadth of risks associated with political conflict, across most or all domains of functioning, and/or across time? In reality, youth resilience amidst political conflict is likely a complex package of better and poorer functioning that varies over time and in direct relationship to social, economic, and political opportunities. Addressing this complexity will complicate the definition of resilience, but it confronts the ambiguities and limitations of work in cross-cultural contexts.

Feeling disrespected by parents: refining the measurement and understanding of psychological control.

This study investigated parental psychological control of adolescents when construed as disrespect of individuality. First, 120 adolescents from 5 cultures were interviewed and asked to identify specific parental behaviors that communicated to them that they were disrespected as individuals. The interview data were coded and 8 new survey items were constructed to reflect key content. These items were then administered to 2100 adolescents in the same cultures along with a traditional measure of psychological control (PCS). Confirmatory factor analyses indicated that model fit was better when the two scales were kept separate, across culture and sex of parent. In structural equation models, the new scale - labeled Psychological Control - Disrespect - accounted for all and more of the variance in youth depression and antisocial behavior than the PCS did. The discussion centers on the validation the study makes of the construct and offers several suggestions for future research.

Connectedness in the lives of children and adolescents: a call for greater conceptual clarity.

Studies of the role of connectedness in the health and development of children and adolescents are accumulating rapidly. Although findings are uniformly consistent in documenting its correlation with a host of health indicators, the construct is in need of substantial conceptual clarification to maximize its research and applied utility. Current conceptualizations and operationalizations inconsistently span a wide spectrum of varied elements of social experience--including the quality of a relationship, the degree of liking an environment or relationship, the quality of performance in an environment or relationship, the possession of feelings or attitude states, and a combination of states and the behaviors that antecede them--resulting in an ability to adequately understand what the construct is and how, why, and when it is most protective. This paper documents this variability in an effort to sensitize researchers, practitioners, and policy makers to the complexity of the construct. It further describes one ongoing, multicultural research project that is currently informing international health initiatives as an illustration of one approach to addressing the complexity with goals of precision, parsimony, cultural sensitivity, and applied utility.

Family predictors of adolescent substance use: the case of high school students in the Cape Metropolitan Area, Cape Town, South Africa.

Family predictors of tobacco and alcohol use were studied in random samples of school-going Black, Coloured, and White adolescents (total N=1,800) in the Cape Town Metropolitan Area. The subjects ranged in age from 14 to 17 years, with a mean age of 15.95 years. Logistic regression analysis of the data showed invariance across the three racial groups in terms of the specific family variables that were predictive, as well as their direction and magnitude of association with substance use. Essentially, higher rates of substance use for all three groups were predicted by parental behavioural control, parental monitoring/knowledge and limit setting, marital relations and family stress. The findings extend the work on South African adolescent substance use by providing a view into the proximal (family) socialising forces that are related to substance use. The findings also extend the broader work on identifying specialised effects of dimensions of socialization on adolescent functioning. The discussion section includes commentary on the cultural invariance found when measuring socialising forces at this level of generality.

Family predictors of adolescent substance use: the case of high school students in the Cape Metropolitan Area, Cape Town, South Africa

Family predictors of tobacco and alcohol use were studied in random samples of school-going Black; Coloured; and White adolescents (total N=1;800) in the Cape Town Metropolitan Area. The subjects ranged in age from 14 to 17 years; with a mean age of 15.95 years. Logistic regression analysis of the data showed invariance across the three racial groups in terms of the specific family variables that were predictive; as well as their direction and magnitude of association with substance use. Essentially; higher rates of substance use for all three groups were predicted by parental behavioural control; parental monitoring/knowledge and limit setting; marital relations and family stress. The findings extend the work on South African adolescent substance use by providing a view into the proximal (family) socialising forces that are related to substance use. The findings also extend the broader work on identifying specialised effects of dimensions of socialization on adolescent functioning. The discussion section includes commentary on the cultural invariance found when measuring socialising forces at this level of generality