Health as human security in the occupied Palestinian territory

Navigating health challenges: the interplay between occupation-imposed movement restrictions, healthcare access, and community resilience

BACKGROUND

Transportation plays a significant role in health, community resilience, and access to basic needs such as healthcare, social services, education, and job opportunities. Health and community resilience are, however, impacted by a multitude of complex and unequal factors, such as transportation restrictions exacerbated by the Israeli occupation. The goal of the research was to examine the intricate relationships that exist in Palestine between movement restrictions imposed by occupation, health outcomes, and community resilience.

METHOD

A self-structured questionnaire, devised based on expert conversations and previous literature, was used in this descriptive, quantitative study to explore health and resilience outcomes. Age, gender, marital status, place of residence, and means of transportation were among the various factors that were utilized to describe the socio-demographics of the study sample (n = 202). The researchers employed stepwise multiple regression and descriptive statistics for the data analysis.

RESULTS

Study findings indicated that transportation restrictions have significant direct and indirect health consequences. A significant direct effect is observed, signifying a negative correlation between restrictions and health; increased transportation restrictions are consistently correlated with a decline in health. The study emphasized how place of residence affects health outcomes, with higher scores for campers and people living in green line areas. It also underscores that public means of transportation are found to be better for health outcomes than private cars.

CONCLUSION

This study emphasized that roadblocks, checkpoints, and military incursions make it difficult for Palestinians to receive medical care, which has a detrimental impact on their health and well-being. It also underscores the need for significant reforms in Palestinian health and transportation systems to enhance infrastructure and healthcare access. The Palestinian Authority should invest in public transportation and community resilience programs to address transportation-related health issues, especially in villages, due to frequent settler attacks.

Psychosocial concerns in a context of prolonged political oppression: Gaza mental health providers' perceptions

In this qualitative exploratory study, we investigated the perspectives of mental health providers in Gaza, Palestine, regarding the primary concerns of their clients who are exposed to low-intensity warfare and structural violence. We conducted qualitative interviews with 30 psychologists, social workers, psychiatric nurses, and psychiatrists providing services to communities in Gaza. Participants were asked to discuss their clients' most commonly occurring mental health problems, diagnoses, and psychosocial conditions. Thematic analysis identified one superordinate theme (Impact of the Blockade on Mental Health and Quality of Life) and four second-order themes (Concerns about Social Problems, General Concerns about Quality of Life, Concerns about the Mental Health of the Community, and Concerns Related to Children's Mental Health). Participants indicated that the social and political dimensions of mental health and the economic, educational, and health-related consequences of the ongoing blockade of Gaza were the main determinants of psychological burden among their clients. Findings demonstrated the importance of adopting an approach to mental health that includes understanding psychological indicators in a broader framework informed by human rights and social justice. Implications for research and clinical work are discussed, including the role of investments in social capital that may provide individuals with access to resources such as social support, which may in turn promote overall mental health.

A Developmental Psychopathology Perspective on Political Violence and Youth Adjustment

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Access to advanced cancer care services in the West Bank-occupied Palestinian territory

Introduction

Universal Health Coverage (UHC) identifies the provision of palliative care for people with advanced disease as an essential health service. Palliative care is also stipulated as a human right under existing covenants. Oncology services provided by the Palestinian Authority under Israeli military occupation are limited to surgery and chemotherapy treatment. Our study aimed to describe the experiences of patients with advanced-stage cancer in the West Bank in accessing oncology services and meeting their health care needs.

Methodology

We conducted a qualitative study among adult patients diagnosed with advanced lung, colon, or breast cancer in three Palestinian governmental hospitals, and with oncologists. Thematic analysis was conducted on the verbatim interview transcripts.

Results

The sample consisted of 22 Palestinian patients (10 men and 12 women) and 3 practicing oncologists. The findings reveal that cancer care is fragmented, with limited access to the services needed. Patients face referral delays in accessing treatment which worsen their health condition in some cases. Some patients reported difficulties in getting Israeli permits to access radiotherapy treatment in East-Jerusalem, and others experienced interruptions of their chemotherapy treatment sessions due to the unavailability of chemotherapy medications caused by Israeli-side delays. Other reported problems were related to the Palestinian health system and service delivery and quality, including fragmentation of services, infrastructure issues, and unavailability of medications. Advanced diagnostic services and palliative care are almost absent at Palestinian governmental hospitals, and patients need to seek these services in the private sector.

Conclusion

The data demonstrate specific access restrictions to cancer care in the West Bank due to Israeli military occupation of Palestinian land. This affects all stages of the care pathway, from restricted diagnosis services, to limited treatment and then poor availability of palliative care. Cancer patients will continue to suffer if the root causes of these structural constraints are not addressed.

Life and Health Under Israeli Military Occupation During COVID-19: Report from the West Bank, Occupied Palestinian Territory

This qualitative study explores lived experiences of Palestinians in the West Bank during the COVID-19 pandemic intersecting with life under Israeli military occupation, structural violence, and racism. Insight is provided into the pandemic's effect on daily life and health and into coping and support mechanisms employed under apartheid conditions. Forty-three semi-structured interviews were conducted among a stratified sample of Palestinian adults. Interviews were digitally recorded, transcribed, and analyzed using thematic analysis. During the pandemic, Palestinian social lives were interrupted, jobs were lost, and incomes declined. Families fell into social and financial crises, with strife, insecurity, uncertainty, and fear negatively affecting physical and mental health. Pandemic effects were compounded by the Palestinian Authority's shortcomings and policies not taking into account citizens' rights and social protection and by Israel's continued colonization of Palestinian land and violation of Palestinian human rights. Social solidarity was instrumental for coping during the pandemic just as it was during intensified political violence. One key feature that helped Palestinians survive promoting their cause for freedom, sovereignty, and self-determination is their social solidarity in times of strife. This has proven to be a crucial component in overcoming threats to the survival of a people during the twentieth century and into the twenty-first century.

The double burden of COVID-19 and Israeli military rule on persons with disabilities in the West Bank of the occupied Palestinian territory

Background

The COVID-19 pandemic has enormous negative effects on people’s lives. People with disabilities (PWDs) who have been made vulnerable and who tend to face significant barriers in accessing public services are likely to be affected even more. This study aims to shed light on the impact of the COVID-19 pandemic on PWDs with special attention to their ability to access public services in the West Bank region of the occupied Palestinian territory.

Methods

This qualitative study was conducted between March 2021 and October 2021. The study was divided into two phases. The first phase consisted of interviews with people with different disabilities, while the second phase targeted policymakers and stakeholders in discussion of the results of the first phase. A total of 16 interviews with people with different types of disabilities (7 males, 9 females) were conducted via telephone. For the second phase, a total of 6 interviews were conducted with stakeholders most responsible for addressing the issue of disability and the needs of PWDs in the West Bank. Analytical memos were prepared for all interviews. Main themes and subthemes were identified by reading and re-reading memos and transcripts until themes and subthemes emerged.

Results

All participants agreed that the COVID-19 pandemic had affected all aspects of life for all groups of people, including PWDs. The effects of the pandemic exacerbated the overall living conditions and access to basic services for PWDs. The results show that access to public transportation, public services, and to health services was all interrupted during the pandemic. This was compounded by deterioration of the financial situation for PWDs which further worsened their access. The stakeholders’ interviews confirmed and explained the findings as mainly due to lack of prioritization of PWD’s rights and needs.

Conclusion

The study emphasized that most of the reported barriers to accessing essential services were intensified during the pandemic. Furthermore, the results show that PWDs and their needs are not considered a priority by the Palestinian Authority, exacerbated by the Israeli occupation. Our findings underline the importance of including PWDs in any future crisis planning.

The mental health impact of multiple deprivations under protracted conflict: A multi-level study in the occupied Palestinian territory

Building on the literatures examining the impacts of deprivation and war and conflict on mental health, in this study, we investigate the impact of different forms of deprivation on mental health within a context of prolonged conflict in the occupied Palestinian territory(oPt). We expand the operationalization go deprivation while accounting for more acute exposures to conflict and political violence and spatial variations. We use multilevel modelling of data from the Socio-Economic & Food Security Survey 2014 conducted by the Palestinian Central Bureau of Statistics, which included a sample size of 7827 households in the West Bank(WB) and Gaza Strip(GS). We conduct the analysis for the combined sample, as for the WB and GS separately. We use a General Health Questionnaire-12 (GHQ12) score as our main outcome measure of poor health. We used various measures of deprivation including subjective deprivation, material deprivation, food deprivation, and political deprivation. In addition to the different measures of deprivation, we included acute political, health, and economic shocks in our analysis along with background socio-demographic characteristics. The results indicate significant variance at the locality level. We find a significant association between poor mental health and subjective, economic, political, and food deprivation; health, economic, and political stressors; age, and being a woman. Post-secondary education and wealth have a significant inverse association with poor mental health. Subjective deprivation is the strongest predictor of GHQ12 score in the models whereby people who feel very deprived have GHQ12 scores that are almost 4-points higher than people who do not feel deprived. Economic conditions, particularly subjective measures, are significant predictors of mental health status. Our findings confirm that political and social factors are determinants of health. Feeling deprived is an important determinant of mental health. The community effect suggests that spatial characteristics are influencing mental health, and warrant further investigation.

Human (in)security and psychological well-being in Palestinian children living amidst military violence: A qualitative participatory research using interactive maps

BACKGROUND

Research has widely evidenced the effects of war and political violence on the functioning of children, with a great accord in diagnosing children's psychological burdens related to their exposure to violence. Yet, within this literature, the influence of the chronic sense of insecurity on their psychological functioning during and after hostilities remains unexplored.

METHODS

The present study aimed at exploring interrelated relationships between the perceived insecurity and the children's psychological well-being and their adjustment to trauma. Based on drawings and walk-along interviews with 75 Palestinian children, residents of both the West Bank and Gaza Strip, we offer an analysis of human security-related risks and protective factors that contribute to either promoting or undermining the child's psychological functioning in a context characterized by chronic instability and political violence.

RESULTS

A complex network of sources of security and insecurity emerged from the narratives depicting an ecological portrait encompassing the determinants of children's mental health and psychological functioning. The TCA led to the identification of eight main themes: school and associativism; social relations and house as a source of security/insecurity; military occupation as a source of insecurity; national and political identity as a source of safety; mosque and spirituality as a source of safety/unsafety; environment as a source of security/insecurity; and mental health.

DISCUSSION

An approach encompassing human security as an explicative model can help in exhaustively portraying the complexity of the Palestinian children's suffering and their competence in adjusting to their traumatic reality. The study draws attention to social, political, environmental and economic determinants of children psychological well-being.

Exploring health literacy and its associated factors among Palestinian university students: a cross-sectional study

Health literacy plays an important role in personal and community health. Since university is a turning point when young adults begin to take responsibility for their own health, understanding university students’ health literacy levels is crucial. To this end, we aimed to explore health literacy and its associated factors among Palestinian university students. We conducted a cross-sectional study at Birzeit University in the Ramallah district. We recruited 472 students using convenience sampling at six on-campus cafeterias. The 44-item Arabic version of the Health Literacy Questionnaire was used to measure students’ health literacy levels, while a locally developed distress scale was used to measure students’ distress levels. We stratified the multiple regression model for the health literacy score by gender. Students’ average total health literacy score was 135.3 (SD 20.9), with male students scoring significantly higher than female students. A higher health literacy score was significantly associated with having a father with a higher level of education, a higher frequency of medical checkups, higher self-reported health status, and consulting a higher number of sources for health-related information. High distress levels were associated with lower levels of health literacy, especially among female students. This study provides the first evidence on Palestinian university students’ health literacy levels. Tailored health education and promotion are required for students with low parental education and moderate to high distress. Future research is required to explain the gender differences in health literacy and distress among university students.

Rethinking sense of coherence: Perceptions of comprehensibility, manageability, and meaningfulness in a group of Palestinian health care providers operating in the West Bank and Israel

Drawing on a salutogenic perspective, we explored sense of coherence (SOC) in a group of Palestinian mental health care providers living and working in Israel and the occupied Palestinian territories (West Bank). Specifically, we conducted a qualitative exploration of the cultural characteristics of SOC and its components (comprehensibility, manageability, and meaningfulness) in two groups of Palestinian Muslim helpers. We found that context-specific features of SOC can mobilize generalized resistance resources for coping with traumatic and stressful experiences, even in an environment characterized by political instability, military violence, and social trauma. Ten main themes emerged from the thematic content analysis: acceptance, reacting to adversity, acknowledging human insecurity (comprehensibility), self-control, talking to family, education as a resource for survival, connecting to the severity of the event, responsibility as a source of control (manageability), religiosity, and sense of belonging (meaningfulness). The Islamic faith, as expressed through the concepts of Sumud and Taslim, seemed to permeate individuals' ability to attribute meaning to historical and transgenerational trauma, as well as to their ongoing traumatic conditions, thus acting as their ultimate source of health and wellbeing. A holistic, spiritual, and collectivist outlook helped respondents to approach their lives with optimism. We discuss the implications for mental health care providers and future research directions.

Constraints to liberty of movement and attachment styles significantly account for well-being in three Palestinian samples

BACKGROUND

Political violence and constraints on liberty of movement can have consequences for health and well-being but affect individuals differently.

OBJECTIVE

In three Palestinian samples, we sought to examine the relationship between key environmental and psychological factors and general and mental health, including the previously unexplored roles of constraints to liberty of movement and attachment orientation.

METHOD

Participants (N = 519) in the Occupied Palestinian Territories and Jordan completed questionnaires on constraints to liberty of movement, attachment insecurity, resource loss, experience of political violence , demographics, general healthdepression, and anxiety. All measures were translated from English to Arabic and back-translated into English.

RESULTS

Findings from regression and mediation analyses indicated that (1) differences in general and mental health among Palestinians in the Occupied Palestinian Territories and the diaspora in Jordan can be explained by the assessed constructs; (2) constraints to liberty of movement, attachment avoidance, and resource loss significantly accounted for poor general health; (3) constraints to liberty of movement, attachment anxiety, and resource loss significantly explained general anxiety symptoms; and (4) attachment anxiety, resource loss, and experience of political violence significantly explained depression symptoms.

CONCLUSION

The findings have theory-building implications for psychological models of human flourishing and suffering, suggesting that they are incomplete without consideration of liberty as a context, as well as implications for policymakers and champions of global health initiatives, as they highlight the psychological effects of constraints to liberty of movement on health.

Associations between exposures to occupation-related events, depression and intimate partner violence among women in the occupied Palestinian Territories

War and conflict impact on women's mental health and experiences of intimate partner violence (IPV), including in the occupied Palestinian Territories (oPT). Drawing on a cross-sectional population representative sample (n=534) collected in February 2017 in the oPT, we sought to (i) characterise the patterning of occupation-related events among women (18+) living in the oPT, (ii) to descriptively assess factors associated with this patterning, (iii) to assess the health impacts of occupation-related events by this patterning, specifically experience of IPV and poor mental health, and (iv) to assess the pathways through which occupation-related events are associated with IPV experience. Using Latent Class Analysis we identified three 'classes' of exposure to occupation-related events: 1 in 20 experienced multiple forms directed at themselves, their families and homes, 42.3% reported experiences against family members and their homes, and half reported relatively few direct experiences of occupation-related violence. Group membership was associated with increased past year IPV experience, and depressive symptoms. Using structural equation modelling we demonstrate that experiences of occupation-related events increased IPV experience via two mediated pathways; increased gender inequitable attitudes, and increased depressive symptoms and quarrelling with their husband. Preventing IPV requires addressing occupation-related events as well as transforming gender norms.

Youth in Northern Ireland: Linking Violence Exposure, Emotional Insecurity, and the Political Macrosystem

Growing up in the aftermath of armed conflict puts youth at a higher risk for psychopathology—particularly in societies like Northern Ireland which continue to be characterized by intergroup tension and cyclical violence. This risk may be heightened during adolescence, when youth are beginning to explore their identities and are becoming more aware of intergroup dynamics in both their immediate communities and the broader society. It is also during this stage when youth increasingly witness or engage in antisocial behavior and sectarian activities. A series of studies in Belfast conducted by Cummings et al. (2014, Child Dev Perspect, 12(1), 16–38; 2019, J Clin Child Adolesc Psychol, 48(2), 296–305) showed that adolescents’ exposure to sectarian violence resulted in heightened emotional insecurity about the community and subsequent adjustment problems. Though the impact of direct exposure to violence is well documented, few studies have accounted for the influence of sectarianism that occurs outside of one's immediate environment. These influences may include the general climate surrounding events that are not experienced firsthand but are nonetheless salient, such as the overarching levels of tension between groups or societal discourse that is threatening to one's identity. These higher‐level influences, often referred to collectively as the macrosystem, are a necessary component to consider for adequately assessing one's socio‐developmental environment. Yet, measurement at this level of the social ecology has proven elusive in past work. The current study advances research in this area by using newspaper coding as a method of measuring the political macrosystem in Northern Ireland and assessing whether a tense or threatening climate serves as an added risk factor for youth living in Belfast.

In the current study, we measured sectarian violence at the level of the macrosystem by systematically collecting and coding newspaper articles from Northern Ireland that were published between 2006 and 2011 (N = 2,797). Each article was coded according to its level of overall political tension between Catholics and Protestants, threat to Catholics, and threat to Protestants. When aggregated, these assessments reflected the overarching trends in Catholic–Protestant relations during this period. In order to assess the association between these sociopolitical trends and the direct experiences of adolescents, the newspaper coding was linked with five waves of survey data from families (N = 999) in socioeconomically disadvantaged areas of Belfast. Using a series of multilevel moderation analyses, we then tested whether intergroup tension and ingroup threat moderated the relation between adolescents’ direct exposure to violence and their emotional insecurity. These analyses were followed by a thematic analysis of the coded newspaper articles in order to provide further context to the findings.

The results indicated that adolescents’ response to direct exposure to sectarian violence varied based on the political climate at the time of their interview. Overall, the adolescents’ emotional insecurity about the community increased with exposure to sectarian violence. During periods when the sociopolitical climate was characterized by high levels of intergroup political tension, this relation was slightly weaker—regardless of the adolescents’ ingroup (i.e., Protestant vs. Catholic). During periods when the sociopolitical climate was coded as threatening, this relation was weaker for Catholic adolescents. That is, high levels of macro‐level threat—particularly events coded as threatening for Protestants—seemed to be a protective factor for Catholic adolescents. Group differences were also found based on the adolescents’ cumulative amount of exposure to sectarian violence. As threat in the macrosystem increased, Catholic adolescents who were directly exposed to higher than average levels of sectarian violence became more emotionally secure, while Catholics with little to no exposure to violence became more insecure. Contrastingly, Protestant adolescents directly exposed to higher than average levels of sectarian violence were more insecure than Protestants with little to no violence exposure.

A thematic analysis of the newspaper articles revealed the categories of events that were viewed by coders as politically tense and threatening. Five primary themes emerged: ineffective policing and justice, family and community unrest, memories of violence, destabilized leadership, and organized paramilitary activity. Many of the articles coded as most threatening reported on a spike in attacks organized by dissident republican groups—that is, members of the Catholic community with, particularly hardline views. This may be pertinent to the finding that associations between sectarian violence exposure and emotional insecurity were exacerbated during this time for Protestants but not for Catholics. Findings from the thematic analysis provide a deeper examination of the context of events taking place during the study period, as well as their potential bearing on interpretation of the macro‐level effects.

In conclusion, these findings illustrate how one's response to the immediate environment can vary based on shifts in the political macrosystem. The current study thus contributes conceptually, empirically, and methodologically to the understanding of process relations between multiple levels of the social ecology and adolescent functioning. These results may further inform the design of future interventions and policies meant to lessen the impact of political violence. The methods used here may also be useful for the study of other contexts in which macrosystem effects are likely to have a salient impact on individual wellbeing.

Service utilization patterns for childbirth and neonatal mortality in the occupied Palestinian territory during conflict

BACKGROUND

The global incidence of man-made crises has increased in the last decade. Evidence on deviations in service uptake during conflict is needed to better understand the link between conflict and adverse neonatal outcomes. We assessed the association between conflict intensity in the occupied Palestinian territory (oPt) at time of birth and (i) utilization patterns for childbirth across different providers; and (ii) neonatal mortality.

METHODS

We combined data on conflict intensity with four demographic and health surveys (2004, 2006, 2010 and 2014) that included nationally representative samples of women of childbearing age. Our exposure variable was casualties per 100 000 population in defined sub-regions of the oPt. Our outcome specifications were a binary variable for neonatal deaths and a categorical variable for childbirth location. We used multivariate logistic and multinomial regressions to assess the associations.

RESULTS

High conflict intensity was associated with fewer childbirths in the private sector (RR=0.97, P=0.04), and non-governmental organizations (RR=0.95, P=0.03) compared to public facilities. Conflict intensity was not associated with higher neonatal mortality beyond 2004.

CONCLUSIONS

Policy implications include better preparedness in the public sector for childbirth during conflict and exploring reasons for the slow decline in neonatal mortality in the territory beyond conflict at time of birth.

Child abuse in the West Bank of the occupied Palestinian territory (WB/oPt): social and political determinants

BACKGROUND

Child maltreatment is a global epidemic. It affects morbidity, mortality, social behavior, wellbeing, and quality of life of children. This study aims to assess prevalence of child abuse in the West Bank (WB) of the occupied Palestinian territory (oPt) and to determine some of its social and political associated factors.

METHODS

We analyzed secondary data obtained from a cross sectional study conducted on a sample representing Palestinian children on the West Bank and using the International Society for the Prevention of Child Abuse and Neglect (ISPCAN) tool. The ISPCAN Child Abuse Screening Tool for parents (ICAST-P) questionnaire was completed by 1107 Palestinian mothers to estimate physical and emotional child abusive practices at home for children aged 0-12 years. Univariate, bivariate, and multivariate binary logistic regression analyses were performed using the SPSS® version 20 to assess prevalence and predictors of child abuse.

RESULTS

Overall, around 34% of the West Bank-children were abused by their mothers. Results of the logistic regression analysis indicated that male children, children of younger mothers, children whose fathers were with low levels of education, children whose mothers reported low levels of parental warmth, and children whose parents were exposed to political violence were at greater risk of being abused.

CONCLUSIONS

Child abuse is highly prevalent among children of the Palestinian society in the West Bank. Policy makers need to pay more attention to this epidemic. The association between child abuse and political violence found in this study makes a just solution for Palestinians essential for improving the welfare of children and families.

Trauma in the Kashmir Valley and the mediating effect of stressors of daily life on symptoms of posttraumatic stress disorder, depression and anxiety

BACKGROUND

The negative psychological impact of living in a setting of protracted conflict has been well studied, however there is a recognized need to understand the role that non-conflict related factors have on mediating exposure to trauma and signs of psychological distress.

METHODS

We used data from the 2015 Kashmir Mental Health Survey and conducted mediation analysis to assess the extent to which daily stressors mediated the effect of traumatic experiences on poor mental health outcomes. Outcomes of interest were probable diagnosis of anxiety, depression, or PTSD; measured using the pre-validated Hopkins Symptoms Checklist (HSCL-25) and the Harvard Trauma Questionnaire (HTQ).

RESULTS

Total effect mediated were statistically significant but the proportions of effect mediated were found to be small in practical terms. Financial stress mediated 6.8% [95% Confidence Interval (CI) 6∙0-8∙4], 6.7% [CI 6.2-7∙7] and 3.6% [CI 3∙4-4∙0] of the effect of experiencing multiple traumaticogenic events on symptoms of anxiety, depression and PTSD, respectively. Family stress mediated 11.3% [CI 10.3-13.8], 10.3% [CI 9.5-11.9] and 6.1% [CI 5.7-6.7] of the effect of experiencing multiple traumatogenic events on symptoms of anxiety, depression and PTSD, respectively. Poor physical health mediated 10.0% [CI 9.1-12∙0], 7.2% [CI 6.6-8.2] and 4.0% [CI 3.8,4.4] of the effect of experiencing more than seven traumatic events on symptoms of anxiety, depression and PTSD, respectively.

CONCLUSION

Our findings highlight that not only do we need to move beyond a trauma-focussed approach to addressing psychological distress in populations affected by protracted conflict but we must also move beyond focussing on daily stressors as explanatory mediators.

Fathers detained, contact restrained: Experiences of Palestinian children visiting their fathers in Israeli detention

BACKGROUND

Very little is known about the experiences of children of political prisoners internationally, because of the challenges of researching within politically oppressive contexts.

OBJECTIVE

The aim of this secondary analysis was to explore and understand Palestinian children's experiences visiting their fathers in Israeli detention.

PARTICIPANTS, SETTING AND METHODS

Qualitative data from sixteen in-depth interviews with thirty-one children were analyzed. Structural and longitudinal coding cycles were employed and focused upon the timeline of the visitation process.

RESULTS

Three overarching themes emerged, which included: Children's experiences 'before the visit', 'during the visit', and 'after the visit'. Subthemes related to the distressing and at times traumatic experiences the children suffered throughout the process of preparation for, going through, and the aftermath of the visit. This included reports of experiencing punitive measures at checkpoints and waiting areas and humiliation and maltreatment by the Israeli authorities during the visitation process. These findings are discussed with reference to the United Nations Convention on the Rights of the Child. It was clear that the children's best interests were denied and contact and interaction with their fathers was restrained under the Israeli visitation scheme. Despite the arduous visitation process that children often hated, they loved to see their fathers.

CONCLUSIONS

Even though the children's rights were infringed upon, they still endured hardships to maintain whatever contact was possible. International advocacy for the realization of the 'rights of the child' for Palestinian children, as well as other children of political detainees is warranted.

Maternal and child access to care and intensity of conflict in the occupied Palestinian territory: a pseudo longitudinal analysis (2000-2014)

Background

In the occupied Palestinian territory (oPt), access to maternal and child healthcare (MCH) services are constrained due to the prolonged Israeli military occupation, the Separation Wall, army checkpoints, and restrictions on the movement of people and goods. This study assesses the relationship between conflict intensity and access to Maternal and Child Health care in occupied Palestinian territory (oPt). To the best of our knowledge, the impact of conflict on access to health care has not been measured due to the lack of data.

Methods

We analyse pooled data from household surveys covering a fifteen-year period (2000–2014) of children (n = 16,793) and women (n = 8477) in five regions of the oPt. Conflict intensity was used as a continuous variable defined as the square root of non-combatant conflict mortality taken from monthly death rates of non-combatants by region. We use multilevel logistic models to explain four outputs: child vaccination schedules, antenatal care, caesarean sections, and complications during pregnancy.

Results

Locality is important with results showing the negative impact of conflict intensity on access to care, especially in the South West Bank for maternal health services and Central West Bank for vaccination (B − 0.161 p = 0.000 for DPT). Wealth is only significant for DPT vaccinations with poorest (B − 0.098 p = 0.005) and poor (B − 0.148 p = 0.002) individuals less likely to access services. Otherwise conflict does not show a differential effect across socio-economic conditions.

Conclusions

This study shows how locality is the strongest factor when looking at the impact of conflict in the oPt. Preventative services (ANC and vaccinations) are the most affected by conflict. We recommend a greater use of community health care to improve access to maternal and child care when barriers impede access to health facilities during times of conflict.

"And I'm in another world". A qualitative examination of the experience of participating in creative arts groups in Palestine

Background: We examine the experience of participating in creative arts groups for Palestinians living under the shadow of military conflict. Methods: 14 men and women aged 17-50 were recruited from community creative arts groups to participate in one of three semi-structured group interviews. Interviews explored participants' perceptions of the creative arts groups, including how they came to participate in the group and how they felt about their involvement. Results: An inductive thematic analysis identified three central themes: "An emptying", "Growth in the face of challenge", and "A rare freedom". The themes capture the extreme challenges participants faced and the protective effects of the creative arts groups on wellbeing. Participating in creative arts activities, such as writing, drawing, and music, encourages self-expression and release, personal exploration and escapism. Conclusions: In the face of traumatic experiences, restrictions, and poverty associated with living in an occupied land, creative arts groups can be liberating and support wellbeing.

Are public hospitals reforming efficiently in West Bank?

BACKGROUND

The structure, function, and capacity of the health care system in the Occupied Palestinian Territories (OPT) had been largely shaped by the complex political history of the country. Since the establishment of the Palestinian Authority in 1994, the reform efforts were subsidized much by the international aids to rebuild the country's institutional capacity. No previous studies have provided a realistic evaluation of Palestinian achievements in the conduct of public healthcare, we examine the relative productive efficiency of public hospitals (their managers' success in the usage of resources) during 2010-2015 within West Bank and Jordan. Then, we estimate the efficiency of policies within which managers operate (the program efficiency) across the two countries.

METHODS

We employ the Data Envelopment Analysis (DEA) models to distinguish between within-country managerial efficiencies and public policy "program" efficiencies across the two countries. The study follows two key steps, the first step evaluates managerial efficiencies and explores trends in performance within each country. Then, we examine the program efficiencies across the two countries.

RESULTS

Public hospitals improved their year-specific overall efficiency from 75 to 80% in the West Bank and from 78 to 86% in Jordan in 2010 and 2015 respectively. Changes in efficiency are driven by scale effects in West Bank and by managerial enhancements in Jordan. Program efficiency in West Bank outperformed Jordan during 2010-2012, there was no significant difference in mean program efficiencies between the two countries during 2013-2015.

CONCLUSIONS

This work addresses a gap in the DEA literature by empirically investigating the efficiency of public hospitals as distinct from program efficiency in a developing country, namely, Palestine. Findings stimulate hospital managers to enhance potential improvements, policymakers to allocate resources, and international donors to focus on the right adoption of new technology to get better benefits from their considerable investments in public hospitals.

Life after conflict-related amputation trauma: a clinical study from the Gaza Strip

Background

More than 17.000 Palestinians were injured during different Israeli military incursions on the Gaza Strip from 2006 to 2014. Many suffered traumatic extremity amputations. We describe the injuries, complications, living conditions and health among a selection of traumatic amputees in the Gaza Strip.

Methods

We included 254 civilian Palestinians who had survived, but lost one or more limb(s) during military incursions from 2006 to 2016. All patients were receiving follow-up treatment at a physical rehabilitation center in Gaza at the time of inclusion. We measured and photographed anatomical location and length of extremity amputations and interviewed the amputees using standard questionnaires on self-reported health, socioeconomic status, mechanism of injury, physical status and medical history.

Results

The amputees were young (median age 25,6 years at the time of trauma), well educated (37% above graduate level), males (92%), but also 43 children (17% ≤ 18 years). The greater part suffered major amputations (85% above wrist or ankle). Limb losses were unilateral (35% above-, 29·5% below knee), and bilateral (17%) lower extremity amputations. Pain was the most frequent long-term complaint (in joints; 34%, back; 33% or phantom pain; 40·6%). Sixty-three percent of amputees were their family’s sole breadwinner, 75·2% were unemployed and 46% had lost their home. Only one in ten (11·6%) of the destroyed homes had been rebuilt.

Conclusions

The most frequently observed amputees in our study were young, well-educated male breadwinners and almost one in five were children. Conflict-related traumatic amputations have wide-ranging, serious consequences for the amputees and their families.

Coping with trauma and adversity among Palestinians in the Gaza Strip: A qualitative, culture-informed analysis

In this article, we propose that coping is not only an individual property but also a structural feature. Coping shapes what is referred to in social network theory as multiplex networks, which are based on relations with multiple functions, values and meanings. Focus groups with adult Palestinians were held and content analysed. Five main coping strategies were identified: (a) creating cultural and religious meaning; (b) individualism to collectivism; (c) normalization and habituation; (d) belonging, acceptance, expectation and readiness; and (e) social support. Participants also reported culture-specific expressions for indicating psychological distress. Implications for cultural informed clinical work are then discussed.

Health research in a turbulent region: the Reproductive Health Working Group

The Reproductive Health Working Group (RHWG) was established in 1988 in Cairo to advance research in the Arab countries and Turkey on the health of women, broadly defined. The paper considers the ways in which the group contributed to global health conversations through three examples of interdisciplinary research that, in privileging local contexts, modified or even challenged prevailing approaches to health and often raised entirely new issues for consideration. The three examples cited in the paper are: (i) the network's early research on reproductive morbidity; (ii) a broad set of ongoing studies on childbirth/maternal health; and (iii) emerging research on health and conflict. The paper discusses how the RHWG has strengthened research capability in the region, and explores the reasons for the longevity of this research network.

Well-being and pressures of daily life in two West Bank villages-Exploring context and history

Interest in the well-being of people exposed to long-term violence and conflict has tended to focus on measurable effects of acute traumatic events, while attention to the pressures of their daily living context is relatively new. Using qualitative and quantitative data from a 2005 survey of all female family caretakers in 2 neighbouring Israeli-occupied West Bank villages (n = 820), we explored the associations of demographic, health-related and contextual factors with reported pressures and WHO-5 well-being index scores. The final model explained 17.8% of the variance with negative associations between health-related factors ("back-aches," "stomach aches" "psychological illness in the family") and family-related factors ("male head of household aggressive", "male head of household physically violent") and the WHO-5 well-being index scores. We found positive associations between socio-economic factors ("standard of living"; "number of rooms") and village-related factors ("residency in village A/B") and the WHO-5 well-being index score. Exploring the daily living context of villages A and B illuminated how the impact of historical and political events differed, even in villages that are geographically close. The paper lends support to calls for including politics and history in research on well-being in contexts of long-term violence and conflict.

The impact of smoking on expected lifetime with and without chronic disease among Palestinian men in the West Bank

Background

The purpose of the study was to estimate life expectancy and the average lifetime with and without chronic disease among male never smokers, ex-smokers and smokers living in the West Bank of the occupied Palestinian territory.

Methods

The study used a life table for the West Bank male population and Danish relative risk estimates for death for smokers and ex-smokers vs. never smokers and utilized data from the Palestinian Family Survey 2010. Expected lifetime with and without chronic disease was estimated and the contributions from the mortality and the morbidity effect to smoking related difference in average lifetime with and without chronic disease were assessed by decomposition.

Results

In the West bank 40% of the male population are smokers. Life expectancy of 15-year-old Palestinian men who would never start smoking was 59.5 years, 41.1 of which were expected to be without chronic disease. Ex-smokers could expect 57.9 years of remaining lifetime, 37.7 years of which without disease. For lifelong heavy smokers (> 20 cigarettes per day), the expected lifetime was reduced to 52.6 years, of which 38.5 years were without chronic disease. Of the total loss of 6.9 years of life expectancy among heavy smokers, the mortality effect accounted for 2.5 years without and 4.4 years with disease, whereas the morbidity effect was negligible.

Conclusions

The high prevalence of smoking causes a considerable loss of life years and lifetime without chronic disease. We recommend the Palestinian health authorities to enforce the anti-smoking law.

Measuring the efficiency of Palestinian public hospitals during 2010-2015: an application of a two-stage DEA method

Background

While health needs and expenditure in the Occupied Palestinian Territories (OPT) are growing, the international donations are declining and the economic situation is worsening. The purpose of this paper is twofold, to evaluate the productive efficiency of public hospitals in West Bank and to study contextual factors contributing to efficiency differences.

Methods

This study examined technical efficiency among 11 public hospitals in West Bank from 2010 through 2015 targeting a total of 66 observations. Nationally representative data were extracted from the official annual health reports. We applied input-oriented Data Envelopment Analysis (DEA) models to estimate efficiency scores. To elaborate further on performance, we used Tobit regression to identify contextual factors whose impact on inefficient performance is statistically significant.

Results

Despite the increase in efficiency mean scores by 4% from 2010 to 2015, findings show potential savings of 14.5% of resource consumption without reducing the volume of the provided services. The significant Tobit model showed four predictors explaining the inefficient performance of a hospital (p <  0.01) are: bed occupancy rate (BOR); the outpatient-inpatient ratio (OPIPR); hospital’s size (SIZE); and the availability of primary healthcare centers within the hospital’s catchment area (PRC). There is a strong effect of OPIPR on efficiency differences between hospitals: A one unit increase in OPIPR will lead a decrease of 19.7% in the predicted inefficiency level holding all other factors constant.

Conclusion

To date, no previous studies have examined the efficiency of public hospitals in the OPT. Our work identified their efficiency levels for potential improvements and the determinants of efficient performance. Based on the measurement of efficiency, the generated information may guide hospitals’ managers, policymakers, and international donors improving the performance of the main national healthcare provider. The scope of this study is limited to public hospitals in West Bank. For a better understanding of the Palestinian market, further research on private hospitals and hospitals in Gaza Strip will be useful.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3228-1) contains supplementary material, which is available to authorized users.

The land of no milk and no honey: force feeding in Israel

In 2015, the Israeli Knesset passed the force-feeding act that permits the director of the Israeli prison authority to appeal to the district court with a request to force-feed a prisoner against his expressed will. A recent position paper by top Israeli clinicians and bioethicists, published in Hebrew, advocates for force-feeding by medical professionals and presents several arguments that this would be appropriate. Here, we first posit three interrelated questions: 1. Do prisoners have a right to hunger-strike? 2. Should governing institutions force-feed prisoners and/or is it ethical to force-feed prisoners? 3. Should healthcare professionals force-feed prisoners? We then focus on the first and third questions. We first briefly provide several arguments to support the right of prisoners to refuse treatment. Next, we critically review the arguments presented in the Israeli position paper, demonstrating that they are all misguided at best. Lastly, we briefly present arguments against force-feeding by medical professionals. We conclude that healthcare providers should not participate in the force-feeding of prisoners.

"We must cooperate with one another against the Enemy": Agency and activism in school-aged children as protective factors against ongoing war trauma and political violence in the Gaza Strip

This exploratory qualitative study investigated self-perceived risk and protection factors that may reinforce the ability of children living in refugee camps on the Gaza Strip to adjust to a traumatic and risky life context characterized by loss and dispossession. The sample comprised 200 Palestinian children recruited at primary schools in four refugee camps in the Gaza Strip following the Israeli military operation "Pillar of Defence" in 2012. Thematic content analysis was applied to written materials and narratives produced by the children. Environment, friends, emotions, family, play, self, sociality, health, school, and spirituality were the dimensions that emerged from the narrative texts. Palestinian children's psychological adaptability and ability to reposition themselves along the continuum between ease and disease is underpinned by constant political agency and activism - a dimension that guides sense-making activities in a traumatizing environment marked by continuous uncertainty, loss and bereavement. We therefore recommend a politically-informed focus, both when assessing children and when designing intervention for them in contexts of chronic political violence and war.

Psychological Aspects of the Israeli-Palestinian Conflict: A Systematic Review

Despite ongoing local and international peace efforts, the Jews, Arabs, and other residents of Israel and the Palestinian territories (i.e., the West Bank and Gaza) have endured decades of political, social, and physical upheaval, with periodic eruptions of violence. It has been theorized that the psychological impact of the Israeli-Palestinian conflict extends beyond the bounds of psychiatric disorders such as posttraumatic stress disorder (PTSD). Exposure to the ongoing conflict may lead to changes in the way Israelis and Palestinians think, feel, and act; while these changes may not meet the thresholds of PTSD or depression, they nonetheless could have a strong public health impact. It is unclear whether existing studies have found associations between exposure to the conflict and nonclinical psychological outcomes. We conducted a systematic review to synthesize the empirical research on the Israeli-Palestinian conflict and its psychological consequences. As a whole, the body of literature we reviewed suggests that exposure to regional political conflict and violence may have detrimental effects on psychological well-being and that these effects likely extend beyond the psychiatric disorders and symptoms most commonly studied. We found evidence that exposure to the conflict informs not only the way Israelis and Palestinians think, feel, and act but also their attitudes toward different religious and ethnic groups and their degree of support for peace or war. We also found that Palestinians may be at particularly high risk of experiencing psychological distress as a result of the conflict, though more research is needed to determine the extent to which this is due to socioeconomic stress. Our review suggests the need for more studies on the nonclinical psychological aspects of the Israeli-Palestinian conflict as well as for longitudinal studies on the impact of the conflict on both Israelis and Palestinians.

Age of despair or age of hope? Palestinian women's perspectives on midlife health

There is limited evidence about women's experiences of the midlife, beyond a narrow - frequently biomedical - focus on the menopause. The broader (physical, social, cultural, political) dimensions of women's midlife health are poorly understood, particularly in low and middle-income countries. Our study seeks to understand how women in the West Bank (occupied Palestinian territories) conceptualise, experience and manage their health in the midlife. We generated qualitative evidence using in-depth life history interviews in 2015 with women (n = 35) living in the West Bank, analysed thematically. Women's understandings of good health draw on indigenous and biomedical knowledge and include a calm psychological state, ease of movement, as well as physical appearance and complexion. Exposure to political violence was understood as impacting mental and physical well-being. Most women articulated a positive view about midlife and ageing as a natural process. A range of terms and expressions were suggested by women experiencing this transition, internalised differently according to marital and motherhood status. For many women, the menopause was merely one - often relatively unimportant - aspect of changes associated with ageing. In dealing with midlife health issues women used multiple strategies, or health pluralism, sequentially or simultaneously; drawing on multiple sets of accrued resources. For never-married or childless women, formal healthcare services represented a site of social exclusion. Our evidence highlights the importance of considering the broader dimensions related to midlife health for understanding women's health maintaining and care-seeking behaviours as they age.

Challenges to conducting epidemiology research in chronic conflict areas: examples from PURE- Palestine

Little has been written on the challenges of conducting research in regions or countries with chronic conflict and strife. In this paper we share our experiences in conducting a population based study of chronic diseases in the occupied Palestinian territory and describe the challenges faced, some of which were unique to a conflict zone area, while others were common to low- and middle- income countries. After a short description of the situation in the occupied Palestinian territory at the time of data collection, and a brief overview of the design of the study, the challenges encountered in working within a fragmented health care system are discussed. These challenges include difficulties in planning for data collection in a fragmented healthcare system, standardizing data collection when resources are limited, working in communities with access restricted by the military, and considerations related to the study setting. Ways of overcoming these challenges are discussed. Conducting epidemiological research can be very difficult in some parts of our turbulent world, but data collected from such regions may contrast with those solely from politically and economically more stable regions. Therefore, special efforts to collect epidemiologic data from regions engulfed by strife, while challenging are essential.

Well-being and associated factors among adults in the occupied Palestinian territory (oPt)

BACKGROUND

The World Health Organization (WHO) incorporated well-being into its definition of health in 1948. The significance given to this concept is due to its role in the assessment of people's quality of life and health.

METHODS

Using the WHO Well-being Index, we estimated well-being among adults and identified selected associated factors in the occupied Palestinian territory (oPt) using data obtained from the National Time Use Survey conducted by the Palestinian Central Bureau of Statistics (PCBS) 2012-2013 on a representative sample of persons living in the West Bank and Gaza Strip. Univariate and bivariate analyses were conducted among participants 18 years old and above. Multivariate analysis (Regression) was performed with factors found significant in cross-tabulations, using SPSS® version 20.

RESULTS

Overall, 33.8 % (2395) of respondents reported low levels of well-being (ill-being). Neither age, nor sex, nor region were found significant in regression analysis. People who were married, working 15 h or more, with a higher standard of living, who reported participating in community, cultural, and social events, or in religious activities reported high levels of well-being. Those who reported regularly following the mass media, or living in Palestinian refugee camps reported low levels of wellbeing.

CONCLUSIONS

Overall, about one-third of adult Palestinians reported low levels of well-being (ill-being), a finding which in itself requires attention. Marriage, employment, high living standards, community participation, and religious activities were found to be protective against ill-being. Further investigations are required to determine additional causes of ill-being in the oPt, taking into consideration the possible effects of chronic exposure to political violence on subjective well-being.

The mortality in Gaza in July-September 2014: a retrospective chart-review study

BACKGROUND

The majority of Gazans who were killed or injured in the 2014 Israel-Gaza war were civilians, and one-fourth of the population were internally displaced. As the Gaza Strip is a small territory, the whole population was exposed to the war and its effects on the health care system, supplies and infrastructure. Our aim was to assess the overall, sex and age-group mortality in Gaza for the period July-September 2014 that was not caused by war injuries, and the proportion of non-trauma deaths among adults that occurred outside hospital wards. A comparison was made with the mortality for the same period in 2013.

METHOD

Date, sex, age, cause and place of each death that was not attributed to war-related physical trauma were collected from death notification forms or death records in Gaza hospitals for the period 01 July to 30 September 2014. The same information was extracted from the local death register for all deaths in the same period in 2013.

RESULTS

The mean age at death was 52.4 years in 2014 and 49.7 in 2013, and about 50 % were older than 60 years in both years. The crude non-trauma death rates among adults were 11.6 per 10,000 population in 2014 and 11.3 in 2013, and the age standardised 13.2 and 12.4, respectively. Higher death rates in 2014 were observed among elderly and women. Cardiovascular disease was the most common cause of death among adults of both sexes, and infectious diseases caused less than 10 % in both periods. Three maternal deaths were observed in 2013 and six in 2014 (p = 0.17). The proportion of deaths that occurred in a hospital ward was 71.5 % in 2013 and 51.2 % in 2014.

CONCLUSIONS

The mortality from communicable diseases was low in Gaza. We did not detect a higher overall background mortality in the 2014 period compared to 2013, but the observed age and sex distribution differed. The proportion of non-trauma deaths among adults that occurred in a hospital ward was markedly lower during the war. The living conditions and health care situation in Gaza point to the need for close monitoring of mortality.

Emotional insecurity in the family and community and youth delinquency in Northern Ireland: a person-oriented analysis across five waves

BACKGROUND

Over one billion children are exposed worldwide to political violence and armed conflict. Currently, conclusions about bases for adjustment problems are qualified by limited longitudinal research from a process-oriented, social-ecological perspective. In this study, we examined a theoretically-based model for the impact of multiple levels of the social ecology (family, community) on adolescent delinquency. Specifically, this study explored the impact of children's emotional insecurity about both the family and community on youth delinquency in Northern Ireland.

METHODS

In the context of a five-wave longitudinal research design, participants included 999 mother-child dyads in Belfast (482 boys, 517 girls), drawn from socially-deprived, ethnically-homogenous areas that had experienced political violence. Youth ranged in age from 10 to 20 and were 12.18 (SD = 1.82) years old on average at Time 1.

FINDINGS

The longitudinal analyses were conducted in hierarchical linear modeling (HLM), allowing for the modeling of interindividual differences in intraindividual change. Intraindividual trajectories of emotional insecurity about the family related to children's delinquency. Greater insecurity about the community worsened the impact of family conflict on youth's insecurity about the family, consistent with the notion that youth's insecurity about the community sensitizes them to exposure to family conflict in the home.

CONCLUSIONS

The results suggest that ameliorating children's insecurity about family and community in contexts of political violence is an important goal toward improving adolescents' well-being, including reduced risk for delinquency.

Increasing disability-free life expectancy among older adults in Palestine from 2006 to 2010

BACKGROUND

The population of Palestine comprises almost 200 000 Palestinians aged 60 or older. The purpose of the study was to estimate disability-free life expectancy for Palestinians living in the West Bank and Gaza Strip and to evaluate changes from 2006 to 2010.

METHODS

The study combined mortality data and prevalence of activity limitation derived from the Palestinian Family Health Surveys carried out in 2006 and 2010. Based on questions about the ability to perform five basic daily activities, disability-free life expectancy was estimated. Changes between 2006 and 2010 were decomposed into contributions from changes in mortality and disability.

RESULTS

Life expectancy at age 60 increased from 17.1 years in 2006 to 17.3 years in 2010 for men and from 18.7 years to 19.0 years for women. Disability-free life expectancy increased significantly, by 1.3 years for 60-year-old men (from 12.8 years to 14.1 years) and 1.8 years for 60-year-old women (from 12.6 years to 14.4 years). This increase was seen in the Gaza Strip as well as in the West Bank. While the modest contribution of the mortality effect did not differ between gender and regions, the strong contributions from the disability effects varied, being greatest for women in the Gaza Strip.

CONCLUSION

The significant increase in disability-free life expectancy for both genders is remarkable and, to our knowledge, not seen in other low-income countries. This change may be due to decreasing incidence of disability and greater recovery from disability as a result of better prevention, care and rehabilitation of chronic diseases.

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.

Health and ecological sustainability in the Arab world: a matter of survival

Discussions leading to the Rio+20 UN conference have emphasised the importance of sustainable development and the protection of the environment for future generations. The Arab world faces large-scale threats to its sustainable development and, most of all, to the viability and existence of the ecological systems for its human settlements. The dynamics of population change, ecological degradation, and resource scarcity, and development policies and practices, all occurring in complex and highly unstable geopolitical and economic environments, are fostering the poor prospects. In this report, we discuss the most pertinent population-environment-development dynamics in the Arab world, and the two-way interactions between these dynamics and health, on the basis of current data. We draw attention to trends that are relevant to health professionals and researchers, but emphasise that the dynamics generating these trends have implications that go well beyond health. We argue that the current discourse on health, population, and development in the Arab world has largely failed to convey a sense of urgency, when the survival of whole communities is at stake. The dismal ecological and development records of Arab countries over the past two decades call for new directions. We suggest that regional ecological integration around exchange of water, energy, food, and labour, though politically difficult to achieve, offers the best hope to improve the adaptive capacity of individual Arab nations. The transformative political changes taking place in the Arab world offer promise, indeed an imperative, for such renewal. We call on policy makers, researchers, practitioners, and international agencies to emphasise the urgency and take action.

Governance and health in the Arab world

Since late 2010, the Arab world has entered a tumultuous period of change, with populations demanding more inclusive and accountable government. The region is characterised by weak political institutions, which exclude large proportions of their populations from political representation and government services. Building on work in political science and economics, we assess the extent to which the quality of governance, or the extent of electoral democracy, relates to adult, infant, and maternal mortality, and to the perceived accessibility and improvement of health services. We compiled a dataset from the World Bank, WHO, Institute for Health Metrics and Evaluation, Arab Barometer Survey, and other sources to measure changes in demographics, health status, and governance in the Arab World from 1980 to 2010. We suggest an association between more effective government and average reductions in mortality in this period; however, there does not seem to be any relation between the extent of democracy and mortality reductions. The movements for changing governance in the region threaten access to services in the short term, forcing migration and increasing the vulnerability of some populations. In view of the patterns observed in the available data, and the published literature, we suggest that efforts to improve government effectiveness and to reduce corruption are more plausibly linked to population health improvements than are efforts to democratise. However, these patterns are based on restricted mortality data, leaving out subjective health metrics, quality of life, and disease-specific data. To better guide efforts to transform political and economic institutions, more data are needed for health-care access, health-care quality, health status, and access to services of marginalised groups.

Relations between political violence and child adjustment: a four-wave test of the role of emotional insecurity about community

This study further explored the impact of sectarian violence and children's emotional insecurity about community on child maladjustment using a 4-wave longitudinal design. The study included 999 mother-child dyads in Belfast, Northern Ireland (482 boys, 517 girls). Across the 4 waves, child mean age was 12.19 (SD = 1.82), 13.24 (SD = 1.83), 13.61 (SD = 1.99), and 14.66 years (SD = 1.96), respectively. Building on previous studies of the role of emotional insecurity in child adjustment, the current study examines within-person change in emotional insecurity using latent growth curve analyses. The results showed that children's trajectories of emotional insecurity about community were related to risk for developing conduct and emotion problems. These findings controlled for earlier adjustment problems, age, and gender, and took into account the time-varying nature of experience with sectarian violence. Discussion considers the implications for children's emotional insecurity about community for relations between political violence and children's adjustment, including the significance of trajectories of emotional insecurity over time.

"It's not easy to acknowledge that I'm ill": a qualitative investigation into the health seeking behavior of rural Palestinian women

BACKGROUND

This qualitative study sets to fill a gap in knowledge by exploring the health seeking behaviour of rural women living in the occupied Palestinian territories (oPt). The existing literature on the oPt has so far focused on unravelling the country's epidemiological and health system profile, but has largely neglected the assessment of factors shaping people's decisions on health care use.

METHODS

Based on a conceptual framework rooted in the Anderson behavioural model, we conducted 30 semi-structured interviews with purposely selected women and seven key informant interviews in three purposely selected villages in Ramallah district.

RESULTS

Our findings indicate that women delay seeking professional care, use self-prescribed medications and home treatment, and do not use preventive and educational health services. Their health seeking behaviour is the result of the interplay of several factors: their gendered socio-cultural role; their health beliefs; financial affordability and geographical accessibility; their perceptions of the quality of care; and their perceived health needs.

CONCLUSIONS

Findings are discussed in the light of their policy implications, suggesting that adequate health policy planning ought to take into considerations socio-cultural dimensions beyond those directly pertinent to the health care system.

The Arab Spring and Health: Two Years on

The “Arab Spring” has touched almost all countries in the Middle East and North Africa. While most attention has focused on security and political developments, there are significant consequences for population health. These include immediate problems, such as violent deaths and injuries, population displacement, and damage to essential infrastructure, but also longer term vulnerabilities not yet addressed by the political changes, including high unemployment, the low status of women, erosion of already weak welfare systems, and rising food prices. It will be important to tackle these underlying issues while not repeating the mistakes made in other countries that have undergone rapid political transition.

Short and longer-term psychological consequences of Operation Cast Lead: documentation from a mental health program in the Gaza Strip

BACKGROUND

There is growing recognition of the psychological impact of adversity associated with armed conflict on exposed civilian populations. Yet there is a paucity of evidence on the value of mental health programs in these contexts, and of the chronology of psychological sequelae, especially in prolonged conflicts with repeated cycles of extreme violence. Here, we describe changes in the psychological profile of new patients in a mental health program after the military offensive Cast Lead, in the context of the prolonged armed conflict involving the Gaza Strip.

METHODS

This study analyses routinely collected program data from a Médecins Sans Frontières mental health program in the Gaza Strip spanning 2007-2011. Data consist of socio-demographic as well as clinical baseline and follow-up data on new patients entering the program. Comparisons were made through Chi square and Fisher's exact tests, univariate and multivariate logistic and linear regression.

RESULTS

PTSD, depression and other anxiety disorders were the most frequent psychopathologies, with 21% having multiple diagnoses. With a median of nine sessions, clinical improvement was recorded for 83% (1122/1357), and more common for those with separation anxiety, acute and posttraumatic disorders as principal diagnosis (855/1005), compared to depression (141/183, p<0.01). Noted changes proximal to Operation Cast Lead were: a doubling in patient case load with a broader socio-economic background, shorter interval from an identified traumatic event to seeking care, and a rise in diagnoses of acute and posttraumatic stress disorders. Sustained changes included: high case load, more distal triggering events, and increase in diagnoses of other anxiety disorders (especially for children 15 years and younger) and depression (especially for patients 16 years and older).

CONCLUSION

Evolving changes in patient volume, diagnoses and recall period to triggering events suggest a lengthy and durable effect of an intensified exposure to violence in a context of prolonged conflict. Our findings suggest that mental health related humanitarian relief in protracted conflicts might need to prepare for an increase in patients with changing profiles over an extended period following an acute flare-up in violence.

Self-perceptions of well-being in professional helpers and volunteers operating in war contexts

We carried out qualitative research with 61 health professionals and volunteer workers to explore their perceptions of their own and their clients’ well-being in a context of political violence. We applied content analysis to identify the themes emerging from 8 focus group and 11 individual interviews. Participants were found to define the concept of well-being in terms of three key areas: security, participation, and development. Palestinian health providers see promotion of economic development and professional growth, involvement in political and social life, and resistance to the occupation as factors required to enhance well-being and quality of life for themselves and their clients.

Nutritional status of Palestinian preschoolers in the Gaza Strip: a cross-sectional study

BACKGROUND

The authors examined factors associated with nutritional resilience/vulnerability among preschoolers in the Gaza Strip in 2007, where political violence and deprivation are widespread.

METHODS

This cross-sectional study was carried out in 2007 using random sampling of kindergartens in order to select 350 preschoolers. Binary logistic regression was used to compare resilient (adequate nutrition) and vulnerable (stunted) groups with those with moderate nutrition.

RESULTS

Approximately 37% of the subjects demonstrated nutritional resilience and 15% were vulnerable. Factors associated with nutritional resilience were child younger age, normal birth weight, actively hand- or spoon-feeding when the child was below two years, and residential stability in the past two years. The only factor associated with nutritional vulnerability was lower total score on the mother's General Health Questionnaire, which we interpret as a marker of maternal mental health.

CONCLUSIONS

Children with low-birth weight and older children had worse nutritional resiliency outcomes. Further, poorer outcomes for children were associated with lower maternal mental health status, as well as increased family residential instability. Our results add to the large literature on the pervasive effects of violence and instability on children and underscore the need for resources for early intervention and for the urgent resolution of the Palestinian and other armed conflicts.