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.
•Explores how quality of life is understood by a population under chronic constraint.•Employs an interview method that facilitates a holistic view of functioning.•Reveals how essentially political structures, policies, and actions impact quality of life.•Constructs a conceptual model with political functioning as the core that impacts other domains.•Highlights the role of justice, rights, political identity and dignity in wellbeing.
Background Although much is known about wellbeing and quality of life generally, there is insufficient understanding and measurement of human functioning during chronic constraint. This difficulty is ...especially true for populations whose constraints extend beyond economic disadvantage to include persistent political conflict and its associated constraints, as is the case for Palestinians living in the occupied Palestinian territory (oPt). In this study, the first phase of a project designed to assess the wellbeing of adult Palestinians, we sought to answer some fundamental questions about wellbeing and quality of life. This population cohort is of particular interest in terms of wellbeing because of its high political activism during the first intifada, and because it has endured a steady economic decline, increasing political constraints, and protracted political violence since then. Methods In February, 2010, trained local fieldworkers from the Palestinian Center for Policy and Survey Research, Ramallah, West Bank, interviewed in Arabic 68 adults (33 men, mean age 34·8 years, range 21–53; 35 women, mean age 32·2 years, range 20–49) in the West Bank, East Jerusalem, and the Gaza Strip in 14 groups of five same-sex individuals (apart from two absentees). Participants were selected with purposive sampling to represent sex, region, refugee or non-refugee status, and (in the Gaza Strip) the main political factions of Fateh and Hamas. The focus of the interviews was on participants' perceptions of what constitutes quality of life and wellbeing in their society. Various methods were used to elicit this information during the interview, including the description of close associates who were doing fairly and less well, and ad-hoc listing and prioritisation of domains of wellbeing. The interviews of the 14 groups (including 68 individuals), each one lasting 60–90 min, were transcribed in Arabic and translated into and transcribed in English. Content analyses of the English transcripts were done with Atlas.ti (version 6.2.27) by three project staff, with several Palestinian key informants checking the coding of the transcripts. The study was approved by the institutional review boards of the University of Tennessee, Knoxville, TN, USA, and the Palestinian Centre for Policy and Survey Research. Interviewees provided written informed consent. Findings In the analyses, we identified expected domains of wellbeing and quality of life—ie, economics, education, employment, family relations, personal characteristics, social relations, health, and religion. Examples of the prevalence of some of these conventional domains of wellbeing and quality of life include economic issues (n=65 96%), family relations (62 91%), and education (52 76%). Additionally, however, consistent with hypotheses about the central role of the political domain in the lives of Palestinians, most participants (27 82% men, 29 83% women) also mentioned political factors. Types of issues coded as being in the political domain included experience of occupation, perceived effects of occupation, political conflict, solidarity between political factions, freedom of expression, mobility constraints, safety or security, stability, and expectations of government provisions. Of these, safety or security and solidarity between political factions were more frequently discussed by the Gazan participants (n=40) than by the non-Gazan participants (n=28). 31 (78%) Gazans mentioned safety or security as an element of wellbeing compared with six (21%) non-Gazans. Similarly, 24 (60%) Gazans mentioned solidarity in the factions as an element of wellbeing compared with seven (25%) non-Gazans. Interpretation The findings of this study contribute valuable and detailed insights into how wellbeing and quality of life are viewed under lifelong political conflict and constraints. The findings reinforce and expand the increasing recognition of the important role of the political domain in the definition of wellbeing in populations such as the Palestinians in the oPt. The substantial, refined elaboration of this domain by the participants we interviewed is especially valuable for the creation of methods for measuring political wellbeing and quality of life. Funding Jacobs Foundation.
We sought to examine the relationship between perceived and stated parental expectations regarding adolescents' use of violence, parental use of physical punishment as discipline, and young ...adolescents' violence-related attitudes and involvement.
Surveys were completed by 134 youth and their parents attending 8 pediatric practices. All youth were 10 to 15 years of age and had scored positive on a psychosocial screening test.
Multivariate analyses revealed that perceived parental disapproval of the use of violence was associated with a more prosocial attitude toward interpersonal peer violence and a decreased likelihood of physical fighting by the youth. Parental report of whether they would advise their child to use violence in a conflict situation (stated parental expectations) was not associated with the adolescents' attitudes toward interpersonal peer violence, intentions to fight, physical fighting, bullying, or violence victimization. Parental use of corporal punishment as a disciplining method was inversely associated with a prosocial attitude toward interpersonal peer violence among the youth and positively correlated with youths' intentions to fight and fighting, bullying, and violence victimization.
Perceived parental disapproval of the use of violence may be an important protective factor against youth involvement in violence, and parental use of physical punishment is associated with both violence perpetration and victimization among youth. Parents should be encouraged to clearly communicate to their children how to resolve conflicts without resorting to violence and to model these skills themselves by avoiding the use of physical punishment.
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.
Background Investigation of the long-term effects of political violence is needed. Patterns of past exposure to political violence since the first intifada were identified in a large sample of adults ...in the occupied Palestinian territory (oPt) and assessed for associations with current adult functioning. Methods In 2011, fieldworkers from the Palestinian Center for Policy and Survey Research, Ramallah, West Bank, oPt, undertook household interviews in Arabic of a representative sample of 1800 individuals (aged 30–40 years; 50% men) in the oPt. The interviews consisted of a culturally-grounded inventory of current wellbeing or quality of life along with an event-history calendar, which through its design and mode of administration has been shown to enhance memory. For every year from 1987 to 2011, participants indicated the degree from 0 (never) to 3 (frequently) to which they had been shot at, hit or kicked, verbally abused, saw other individuals humiliated, and had their homes raided. Latent profile (MPlus, version 7.0) and general linear regression analyses (SPSS, 21.0) were used for the statistical analyses. All participants provided written informed consent. The Palestinian Center for Policy and Survey Research and the University of Tennessee, Knoxville, TN, USA, provided institutional review board approval for the study. Findings Data were evaluable for 1758 people. For analyses, yearly scores for violence exposure were averaged within four periods: first intifada, Oslo period, second intifada, and post-second intifada. For men, there were three patterns of past exposure to political violence: 519 (60%) of 872 men reported moderate exposure during the first and second intifadas and very little or no exposure between the intifadas and after the second intifada (group 1); 250 (29%) had the same periodic pattern but with higher exposure during the intifadas (group 2) than did group 1; and 103 (12%) indicated chronic exposure to humiliation (verbal abuse and observing others being humiliated) for all the periods (group 3). For women, there were two patterns of exposure: 745 (84%) of 886 women had the same pattern of low, periodic exposure as did the men in group 1; and 141 (16%) reported high exposure to observing others being humiliated for all the periods, similar to that reported by the men in group 3. Results from the general linear regression models showed that chronically humiliated men and women, compared with other patterns of exposure, had less access to basic resources; higher insecurity or fear; higher feelings of depression; higher feelings of being broken or destroyed; higher trauma-related stress; higher community belonging; and higher marital quality. Chronically humiliated women also reported less personal freedom and poorer health. Post-hoc analyses showed that most of the chronically humiliated participants (85 83% of 103 men and 93 66% of 141 women) were living in distinct neighbourhoods in East Jerusalem and Hebron—two oPt cities that have a particularly strong presence of Israeli forces, and have frequent and several constraints (including checkpoints and barriers) on the Palestinian population's mobility. Interpretation The results of this study show that, methodologically, the assessment of the patterns of exposure over time (instead of commonly aggregating exposure) is a useful way to capture the long-term effect of political violence exposure. Substantively, they show the particular risks to long-term wellbeing of individuals with chronic exposure to humiliation. Funding Jacobs Foundation, Zurich, Switzerland.
Long-term effects of political imprisonment on functioning are unknown. This retrospective study explored the association between economic, political, psychological, physical, community, and family ...functioning and political imprisonment during a span of 25 years in a population-based sample of Palestinian men aged 32–43 years in the West Bank, East Jerusalem, and the Gaza Strip.
Event-history calendars and surveys of present level of functioning were given by the Palestinian Center for Policy and Survey Research to a representative sample of 884 men who completed it. Informed consent was obtained from all participants. Latent class models were used to identify patterns of imprisonment across 25 years (1987–2011). We compared mean scores of 13 measures of functioning across five latent classes of political imprisonment representing the main trajectories of imprisonment during the 25 years. To assess these 13 measures, we used previously established and validated scales for four measures, whereas others we assessed with scales we had developed and validated ourselves.
The overall response rate was 97%. Of the 884 men who completed the study, 26% (233 men) had been politically imprisoned at some point. Men imprisoned mainly during the first Intifada (1987–93; 87 men) or the Oslo period (1994–99; 78 men) did not significantly differ from men who had never been imprisoned (651 men) with respect to 12 indicators of functioning. Men who had been politically imprisoned reported higher trauma-related stress: during first Intifada mean stress was scored 1·32 (95% CI 1·05–1·58), and Oslo mean of 1·54 (95% CI 1·29–1·80), compared with men not imprisoned mean of 1·04 (95% CI 0·96–1·13; range score of 0–3; p=0·030 and p<0·001, respectively). Men imprisoned during 2006–11 (21 men), reported lower functioning than never-imprisoned men on six measures: work insecurity (mean 2·06 95% CI 1·70–2·42 vs 2·52 95% CI 2·40–2·65, p=0·017, range 1–5), ability to pay for their children's education (mean 2·88 95% CI 2·31–3·44 vs 3·47 95% CI 3·35–3·59, p=0·05, range 1–5), community belonging (mean 3·08 95% CI 2·77–3·38 vs 3·42 95% CI 3·34–3·51, p=0·036, range 1–5), feelings of depression (mean 1·25 95% CI 1·03–1·47 vs 0·96 95% CI 0·90–1·03, p=0·015, range 0–3), feeling broken or destroyed (a locally defined measure of suffering suggesting that their morale is damaged; mean 3·71 95% CI 3·27–4·14 vs 2·99 95% CI 2·60–3·38, p=0·035, range 1–5), and functional limitations (mean 2·84 95% CI 2·39–3·30 vs 2·28 95% CI 2·19–2·38, p=0·015, range 1–5).
Findings suggest long-term resilience of these men after political imprisonment. Efforts to support previous political prisoners in the occupied Palestinian territory should provide support to those recently released from political imprisonment to promote long-term recovery.
The Jacobs Foundation, Switzerland.
Most studies of political conflict rely on imported measures of mental health. We identified and tested a local definition of suffering in the occupied Palestinian territory that we labelled “Feeling ...Broken or Destroyed”.
The construct was identified in group interviews completed in Arabic in 2010, with 68 residents as the total sample size from the West Bank, East Jerusalem, and the Gaza Strip aged 30–40 years. Survey items were then written and given to a representative sample of people (same age group in the same territories) in June 2011 (n=508; study 1), and November 2011 (n=1778; study 2). All data were collected with written consent by the Palestinian Center for Policy and Survey Research, who purposively selected participants to represent key elements of diversity in Palestinian society.
Participants referred in Arabic to a type of suffering not included in standard instruments, which the participants typically associated with economic and political hardships. Descriptions from the participants included being or feeling: broken, crushed (muḥaṭṭima), destroyed, (mudammira), exhausted, and tired (ta'bāna). Aspects of the participants were described as the self or spirit (an-nafs), morale (al-ma'naūiyyat), and hopes or ambition for the future (amālak aū ṭamūḥatak ban-nisba lil-mustaqbil). The following survey items were then written in English, translated to Arabic, and back-translated. The survey was administered in Arabic, asking the respondents to rate how often during the past 2 weeks they “felt that your spirit or morale is broken or destroyed?” (Kam murra aḥsast ba'n nasfiyyatak wa ma'naūiyyatak muḥaṭṭima?); ”felt that your ambitions and hopes for the future are destroyed?” (Kam murra aḥsast ba'n amālak aū ṭamūḥatak ban-nisba lil-mustaqbil muḥaṭṭima?); and “felt emotionally or psychologically exhausted?” (Kam murra aḥsast ba'nak murhaq ‘āṭafiyyan aū nafsiyyan?). Internal consistency of these items across subgroups in studies 1 and 2 ranged from 0·80 to 0·87. Discriminant validity was evident in that these items factored separately from standard mental health items in principal components analysis. The scale correlated moderately in both data sets with: feelings of depression (study 1: r=0·46; p<0·0001; study 2: r=0·55; p<0·0001) and trauma-related stress (study 1: r=0·21; p<0·001; study 2: r=0·21; p<0·001).
Contextualised suffering can be discerned through careful interviewing, and can be efficiently and reliably measured, tested, and quantitatively distinguished from traditional mental health measures.
The Jacobs Foundation, Switzerland.
Chronically humiliated participants were distinguished from the other participants in the study because they reported humiliation not only during the two intifadas, but also throughout the 12 years ...without intifada.
Background Research into the effects of political conflict has focused predominantly on the association between exposure to violence and psychological trauma. This focus was expanded by investigation ...of the association of a broad array of political and economic factors with four health outcomes in the occupied Palestinian territory (oPt). Methods The Palestinian Center for Policy and Survey Research, Ramallah, West Bank, oPt, undertook household interviews in 2011 with a representative sample of 508 people aged 30–40 years. Interviews included culturally-informed questions about current wellbeing and past political and economic experiences. Health outcomes were assessed as limitations on functioning due to health (one item, 1 never to 5 regularly); feeling broken or destroyed (six items, α=0·81, range 1–5) such as the extent to which respondents felt emotionally exhausted or their spirits broken; feelings of depression (eight items, α=0·84, 0–3); and trauma-related stress (17 items on the Post-Traumatic Stress Disorder Checklist, α=0·92, 0–3). Political and economic conditions were assessed as 34 outcomes, including human insecurity (five items, α=0·80, 1–5) such as the extent to which respondents felt fear for themselves or their family in their daily life and the extent to which they worry or fear for their and their family's future; resource inadequacy (six items, α=0·84, 1–5); heard or felt effects of a bomb (one item, 0–1); or was hit, kicked, shot at, or verbally abused (three items, α=0·83, 1–5). Data were analysed with ordered logit and ordinary least-squares regression models using Stata (version 12.1). The study was approved by the institutional review board of the University of Tennessee, Knoxville, TN, USA. All participants provided written informed consent. Findings 508 (97%) of 524 households took part in the interviews. When other covariates were controlled for, human insecurity and inadequacy of economic resources were positively associated with all four health outcomes: functional limitations (odds ratio 1·29, p=0·029, and 1·43, p<0·001, respectively), feeling broken or destroyed (β=0·29, p<0·001; and β=0·24, p<0·001, respectively), feelings of depression (β=0·11, p=0·001, and β=0·18, p<0·001, respectively), and trauma-related stress (β=0·18, p<0·001, and β=0·09, p=0·003, respectively). Direct personal exposure to political violence was related only to trauma-related stress (heard or felt effects of a bomb β=0·13, p=0·049); ever hit, kicked, shot at, or verbally abused by the Israeli Defense Forces (β=0·07, p=0·008). Interpretation These findings support the increasing recognition that human insecurity and chronic economic constraints in the oPt threaten health, perhaps more so than does direct exposure to violence. Funding Jacobs Foundation.
PDF