'Nowhere and no one is safe': spatial analysis of damage to critical civilian infrastructure in the Gaza Strip during the first phase of the Israeli military campaign, 7 October to 22 November 2023

BACKGROUND

Since the Hamas attacks in Israel on 7 October 2023, the Israeli military has launched an assault in the Gaza Strip, which included over 12,000 targets struck and over 25,000 tons of incendiary munitions used by 2 November 2023. The objectives of this study include: (1) the descriptive and inferential spatial analysis of damage to critical civilian infrastructure (health, education, and water facilities) across the Gaza Strip during the first phase of the military campaign, defined as 7 October to 22 November 2023 and (2) the analysis of damage clustering around critical civilian infrastructure to explore broader questions about Israel's adherence to International Humanitarian Law (IHL).

METHODS

We applied multi-temporal coherent change detection on Copernicus Sentinel 1-A Synthetic Aperture Radar (SAR) imagery to detect signals indicative of damage to the built environment through 22 November 2023. Specific locations of health, education, and water facilities were delineated using open-source building footprint and cross-checked with geocoded data from OCHA, OpenStreetMap, and Humanitarian OpenStreetMap Team. We then assessed the retrieval of damage at and with close proximity to sites of health, education, and water infrastructure in addition to designated evacuation corridors and civilian protection zones. The Global Moran's I autocorrelation inference statistic was used to determine whether health, education, and water facility infrastructure damage was spatially random or clustered.

RESULTS

During the period under investigation, in the entire Gaza Strip, 60.8% (n = 59) of health, 68.2% (n = 324) of education, and 42.1% (n = 64) of water facilities sustained infrastructure damage. Furthermore, 35.1% (n = 34) of health, 40.2% (n = 191) of education, and 36.8% (n = 56) of water facilities were functionally destroyed. Applying the Global Moran's I spatial inference statistic to facilities demonstrated a high degree of damage clustering for all three types of critical civilian infrastructure, with Z-scores indicating < 1% likelihood of cluster damage occurring by random chance.

CONCLUSION

Spatial statistical analysis suggests widespread damage to critical civilian infrastructure that should have been provided protection under IHL. These findings raise serious allegations about the violation of IHL, especially in light of Israeli officials' statements explicitly inciting violence and displacement and multiple widely reported acts of collective punishment.

The hidden burden of dysmenorrhea among adolescent girls in Palestine refugee camps: a focus on well-being and academic performance

BACKGROUND

Dysmenorrhea (painful menstruation) is a condition that may have a profound effect on adolescent girls' health status and well-being. It can impede their engagement in daily activities and hamper their regular school attendance. This study aims to explore the relationship between dysmenorrhea, well-being, and academic performance among adolescent girls living in Palestine refugee camps in the West Bank and Jordan.

METHODS

We conducted a household survey between June and September 2019, with a total sample of 2737 adolescent girls 15 to 18 years old. Dysmenorrhea severity was assessed using the Working Ability, Location, Intensity, Duration of pain Dysmenorrhea scale (WaLIDD). The WHO-5 scale was used to evaluate the girls' overall well-being. Menstrual academic disruption (MAD) was measured using a self-reported scale. Multiple linear regression models were employed to evaluate the association between dysmenorrhea, well-being, and academic performance. Directed Acyclic Graphs (DAGs) were employed to identify variables for control in regression models.

RESULTS

The mean dysmenorrhea score was 6.6 ± 2.6, with 37.9% and 41.2% expressing moderate and severe symptoms, respectively. The mean WHO-5 score was 58.7 ± 25.1, and 34.9% reported a low well-being status. The mean MAD score was 3.1 ± 3.3. 26% reported missing school due to dysmenorrhea, 36% said dysmenorrhea impacted their ability to concentrate, and 39% were unable to study for tests, and complete homework. The first regression analysis showed a reduction of 1.45 units in WHO-5 score for each unit increase in dysmenorrhea. The second regression analysis showed a non-linear increase in MAD score for increasing dysmenorrhea. For each dysmenorrhea score less than 4 (mild) there was a modest increase in MAD scores (coefficient 0.08, p-value = 0.006), and for each dysmenorrhea score above 4 there was a stronger increase in MAD scores (coefficient 0.95, p < 0.001).

CONCLUSION

Dysmenorrhea poses significant challenges to the well-being and academic performance of adolescent girls living in Palestine refugee camps. Collaborative efforts and multifaceted approaches are crucial to address dysmenorrhea effectively. This involves research, targeted interventions, culturally sensitive strategies, and fostering a supportive environment that empowers girls to thrive academically and beyond.

Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa

Global mental health [GMH] scholarship and practice has typically focused on the unmet needs and barriers to mental health in communities, developing biomedical and psychosocial interventions for integration into formal health care platforms in response. In this article, we analyse four diverse settings to disrupt the emphasises on health system weaknesses, treatment gaps and barriers which can perpetuate harmful hierarchies and colonial and medical assumptions, or a 'deficit model'. We draw on the experiential knowledge of community mental health practitioners and researchers working in Ghana, India, the Occupied Palestinian Territory and South Africa to describe key assets existing in 'informal' community mental health care systems and how these are shaped by socio-political contexts. These qualitative case studies emerged from an online mutual learning process convened between 39 academic and community-based collaborators working in 24 countries who interrogated key tenets to inform a social paradigm for global mental health. Bringing together diverse expertise gained from professional practice and research, our sub-group explored the role of Community Mental Health Systems in GMH through comparative country case studies describing the features of community care beyond the health and social care system. We found that the socio-political health determinants of global economic structures in all four countries exert significant influence on local community health systems. We identified that key assets across sites included: family and community care, and support from non-profit organisations and religious and faith-based organisations. Strengthening community assets may promote reciprocal relationships between the formal and informal sectors, providing resources for support and training for communities while communities collaborate in the design and delivery of interventions rooted in localised expertise. This paper highlights the value of informal care, the unique social structures of each local context, and resources within local communities as key existing assets for mental health.

Because its power remains naturalized: introducing the settler colonial determinants of health

Indigenous people suffer earlier death and more frequent and severe disease than their settler counterparts, a remarkably persistent reality over time, across settler colonized geographies, and despite their ongoing resistance to elimination. Although these health inequities are well-known, they have been impervious to comprehensive and convincing explication, let alone remediation. Settler colonial studies, a fast-growing multidisciplinary and interdisciplinary field, is a promising candidate to rectify this impasse. Settler colonialism's relationship to health inequity is at once obvious and incompletely described, a paradox arising from epistemic coloniality and perceived analytic challenges that we address here in three parts. First, in considering settler colonialism an enduring structure rather than a past event, and by wedding this fundamental insight to the ascendant structural paradigm for understanding health inequities, a picture emerges in which this system of power serves as a foundational and ongoing configuration determining social and political mechanisms that impose on human health. Second, because modern racialization has served to solidify and maintain the hierarchies of colonial relations, settler colonialism adds explanatory power to racism's health impacts and potential amelioration by historicizing this process for differentially racialized groups. Finally, advances in structural racism methodologies and the work of a few visionary scholars have already begun to elucidate the possibilities for a body of literature linking settler colonialism and health, illuminating future research opportunities and pathways toward the decolonization required for health equity.

Menstrual characteristics and dysmenorrhea among Palestinian adolescent refugee camp dwellers in the West Bank and Jordan: a cross-sectional study

BACKGROUND

Women and girls experience menstruation throughout their reproductive years. Normal adolescent menstrual cycles gauge current and future reproductive health. Dysmenorrhea (painful menstruation) is the most prevalent menstrual disturbance in adolescents that can be debilitating. This study examines the menstrual characteristics of adolescent girls living in Palestinian refugee camps in the West Bank of the Israeli-occupied Palestinian territory and Jordan, including estimates of dysmenorrhea levels and associated factors.

METHODS

A household survey of 15 to 18-year-old adolescent girls was conducted. Trained field workers collected data on general menstrual characteristics and dysmenorrhea level using Working ability, Location, Intensity, Days of pain Dysmenorrhea scale (WaLIDD), in addition to demographic, socio-economic, and health characteristics. The link between dysmenorrhea and other participant characteristics was assessed using a multiple linear regression model. Additionally, data on how adolescent girls cope with their menstrual pain was collected.

RESULTS

2737 girls participated in the study. Mean age was 16.8 ± 1.1 years. Mean age-at-menarche was 13.1 ± 1.2; mean bleeding duration was 5.3 ± 1.5 days, and mean cycle length was 28.1 ± 6.2 days. Around 6% of participating girls reported heavy menstrual bleeding. High dysmenorrhea levels were reported (96%), with 41% reporting severe symptoms. Higher dysmenorrhea levels were associated with older age, earlier age-at-menarche, longer bleeding durations, heavier menstrual flow, skipping breakfast regularly, and limited physical activity patterns. Eighty nine percent used non-pharmacological approaches to ease menstrual pain and 25% used medications.

CONCLUSION

The study indicates regular menstrual patterns in terms of length, duration, and intensity of bleeding and a slightly higher age-at-menarche than the global average. However, an alarmingly high prevalence of dysmenorrhea among participants was found that tends to vary with different population characteristics, some of which are modifiable and can be targeted for better menstrual health.This research emphasizes the need for integrated efforts to assist adolescents with menstrual challenges such as dysmenorrhea and irregular periods to achieve informed recommendations and effective actions.

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.

Structural racism and the health of Palestinian citizens of Israel

Palestinian citizens of Israel (PCI) constitute almost 20% of the Israeli population. Despite having access to one of the most efficient healthcare systems in the world, PCI have shorter life expectancy and significantly worse health outcomes compared to the Jewish Israeli population. While several studies have analysed the social and policy determinants driving these health inequities, direct discussion of structural racism as their overarching etiology has been limited. This article situates the social determinants of health of PCI and their health outcomes as stemming from settler colonialism and resultant structural racism by exploring how Palestinians came to be a racialized minority in their homeland. In utilising critical race theory and a settler colonial analysis, we provide a structural and historically responsible reading of the health of PCI and suggest that dismantling legally codified racial discrimination is the first step to achieving health equity.

Coming of age: a qualitative study of adolescent girls’ menstrual preparedness in Palestinian refugee camps in the West Bank and Jordan

Menstrual health is important for adolescent girls and is particularly compromised in displaced communities due to restricted access to information and lack of private spaces to manage menstruation. Menarche is the biological and social milestone of girls’ adolescence, marking the onset of puberty and confirming womanhood in many communities. It also marks a difficult transitional period influenced by socio-cultural beliefs and expectations. Menstrual preparedness is critical for this transition, and the lack of accurate, timely, age-appropriate information might impact current, and future reproductive health and well-being. This paper investigates the menstrual preparedness status of adolescents living in Palestinian refugee camps in the West Bank and Jordan. These are long-term refugee camps characterised by a variety of social, economic, and political constraints affecting the health of women and girls. We conducted 39 in-depth interviews and 23 focus-group discussions with adolescent girls. The study reveals inadequate menstrual preparedness among the participants, especially in pre-menarche. Among the barriers to adequate menstrual preparedness is a predominance of practical concerns, such as the use of sanitary pads and hygienic practices, socio-cultural norms that promote secrecy and taboo around menstruation, and divergent notions of timeliness of information among girls, their mothers, and teachers. The study contends that addressing the taboo around menstruation requires joint efforts by the family, school, and social services. Menstrual preparedness should begin early and encompass biological, practical, emotional, and psychological components. The paper advocates for Comprehensive, Contextually Relevant, Timely Menstrual Preparedness (CCTMP) policies and initiatives, empowering adolescent girls, their mothers, and educators.

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.

Pathways to food insecurity in the context of conflict: the case of the occupied Palestinian territory

BACKGROUND

Conflict reduces availability of production input and income, increases the number of days households had to rely on less preferred foods, and limits the variety of foods eaten and the portion size of meals consumed. While existing studies examine the impact of conflict on different food security measures (e.g., Food Consumption Score, Food Insecurity Experience Scale), the relationship between these measures as well as their relationship with political, economic, and agricultural factors remain under explored. Food insecurity may not only be an externality of conflict but also food deprivation may be utilized as a weapon to discourage residency in contested territories or to incentivize rebellions.

METHODOLOGY

This paper examines the association between political factors (e.g., violence, policies that require permit for passage in one's own hometown), economic factors (e.g., loss of assets, unemployment), agricultural factors (e.g., shortage of water, poor weather conditions), and food insecurity experience and dietary diversity in a conflict setting-that of the occupied Palestinian territory (oPt). The study employs generalized structural equation models to analyze the 'Survey on socio-economic conditions for Palestinian households 2014' dataset compiled by the Palestinian Central Bureau of Statistics-which contains a representative sample of the population in the oPt at governorate and locality levels.

RESULTS

We find that in the West Bank, residence in Area C-administered by Israel in both civil and security issues and contains illegal Israeli settlements and outposts-is associated with a higher level of agricultural hardship (p < 0.01) but lower economic hardship (p < 0.01) and a higher dietary diversity (p < 0.001), as compared to those living outside of Area C. In the Gaza Strip, living within one kilometer to a buffer zone is associated with lower dietary diversity (p < 0.01), higher level of political hardship (p < 0.01), and higher level food insecurity experience (p < 0.01) compared to not living in close proximity to a buffer zone. Concomitantly, in the Gaza Strip, food insecurity experience is associated with approximately a one-point reduction in dietary diversity as measured by the food consumption score (p < 0.01).

CONCLUSIONS

The results suggest that broader socio-political conditions in the oPt impact different aspects of food security through augmenting the economic and agricultural hardships that are experienced by the residents. As such, it is important to address these broader political and economic structures in order to have more sustainable interventions in reducing food insecurity.

Strategies and interventions for healthy adolescent growth, nutrition, and development

Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.

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.

The psychological impact of deprivation in regions affected by conflict: a multilevel analysis of a cross-sectional survey in the occupied Palestinian territory

BACKGROUND

Deprivation is an important determinant of poor health. Locality can be key in understanding variation in deprivation across a population. This study aimed to analyse how different forms of deprivation affect mental health among Palestinians, and how they account for locality effects in the occupied Palestinian territory.

METHODS

We used multilevel modelling to analyse data from the Socio-Economic & Food Security Survey 2014 conducted by the Palestinian Central Bureau of Statistics, which had a sample size of 7827 adults representing the same number of households. The main outcome is a General Health Questionnaire (GHQ) score, in which a higher score signifies worse mental health. Deprivation variables include subjective deprivation, material deprivation, food deprivation, and political deprivation (which was measured by use of the human insecurity scale). For the analysis, we included data on experience of different stressors (economic, political, health-related, and weather-related stress) reported at the household level in the 6 months preceding the survey, and we controlled for demographic characteristics, including age, gender, education, wealth, and region. We also conducted a two-level random effects multilevel regression, with locality as a proxy for neighbourhood.

FINDINGS

The model indicates significant variance at the locality (neighbourhood) level. There is a significant association between poor mental health and subjective, economic, political, and food deprivation; health, economic, and political stressors; age, and being a woman. Education beyond secondary school level and wealth have a significant inverse association with poor mental health. Individuals who indicated that they felt somewhat or very deprived have significantly higher GHQ scores than individuals who indicated that they did not feel deprived (β=1·73 and 4·33 for those who felt deprived and who did not feel deprived, respectively, p<0·0001). Food consumption was inversely associated with GHQ score (β=-0·01, p<0·0001) and food insecurity was positively associated with GHQ score (β=0·19, p<0·0001). Political deprivation, and health-related, political, and economic stressors were significantly positively associated with GHQ scores (β=0·043, 0·23, 0·35, and 0·19 respectively, p<0·0001). Age (β=0·079, p<0·0001) and being a woman were positively associated with GHQ score (β=0·26, p=0·0040), whereas education beyond secondary school level was inversely associated with GHQ score (β=-0·54, p<0·0001).

INTERPRETATION

The findings that the mental health of Palestinians is associated with various forms of deprivation and stressors, provide further evidence that political and social factors are determinants of health. Correlated factors include both subjective and objective measures, and suggest that although material conditions are important, people's subjective experiences are also important. Feeling deprived is an important correlate of mental health. The community effect suggests that services (or lack thereof), checkpoints and blockades, political situations, and other factors that vary across localities, may influence mental health issues at the neighbourhood level.

FUNDING

This project is part of the study "Re-conceptualising health in wars and conflicts: a new focus on deprivation and suffering" funded by the Middle East Centre at the London School of Economics and Political Science.

Food insecurity in the context of conflict: analysis of survey data in the occupied Palestinian territory

BACKGROUND

Conflict impacts food security and decreases household dietary diversity. However, few studies have explored the routes by which prolonged conflict and social stressors affect food insecurity experience and food diversity. This study examines the influence of political, economic, and agricultural stressors on food insecurity and food diversity, and evaluates variations in food insecurity and food diversity with location of residence for households in the occupied Palestinian territory.

METHODS

A secondary data analysis with structural equation modelling was carried out on data from the Socio-Economic & Food Security Survey 2014 of the Palestinian Central Bureau of Statistics. The survey was completed by a representative sample of the Palestinian population in the occupied Palestinian territory at governorate and locality levels, and consisted of 4215 households in the West Bank and 2916 households in the Gaza Strip. The primary outcomes were food diversity (measured with a food consumption score) and food insecurity (assessed with a composite experience-based measure of food security). We used structural equation models to examine the relationships between location of residence (in the West Bank, living in Area C versus not Area C; in the Gaza Strip, proximity of residence to the buffer zone), the number of political stressors, economic stressors, and agricultural stressors (eg, restricted access to land), and the primary outcomes. We controlled for demographic characteristics, including education, governorate, and wealth.

FINDINGS

In the West Bank, there was no statistically significant direct association between living in Area C and food insecurity. Living in Area C is associated with a higher number of agricultural stressors than not Area C (p=0·032), and a higher number of agricultural stressors is in turn associated with lower food diversity (p=0·0080) and higher food insecurity (p=0·040). In the Gaza Strip, proximity to the buffer zone is directly associated with higher food insecurity (p=0.041) and lower food diversity (p=0·019) and a higher number of political stressors (p=0·057). A higher number of political stressors is associated with a higher number of economic stressors (p=0·026) and higher food insecurity (p=0·034).

INTERPRETATION

The findings suggest that political, economic, and agricultural factors contribute to food insecurity and food diversity, and that their interactions are complex. Conflict and occupation affect food availability through both direct and indirect channels. In the Gaza Strip, living in close proximity to the buffer zone is associated with lower food diversity and higher food insecurity. In the West Bank, although residing in Area C may not directly increase food insecurity, the hardship generated by the conditions in Area C contributes to higher food insecurity.

FUNDING

The Emirates Foundation.

Life conditions and quality of life of Palestinians living in the Biddu Enclave: a qualitative study

BACKGROUND

Palestinians have been exposed to long-term violence, displacement, and conflict since the 1940s. Continued expropriation and fragmentation of the region has affected people's quality of life. The Biddu Enclave communities, located northwest of Jerusalem, are behind a barrier wall that detaches them from Jerusalem and the rest of the West Bank other than by access through a tunnel controlled by the Israeli authorities. The enclave is fully or partially under Israeli administration. We explored the effects of socioeconomic and geographical transformations and isolation on the quality of life of these communities, specifically on daily uncertainty, stress, and overall wellbeing of residents.

METHODS

We included four communities-Beit Iksa, Qatanna, Biddu, and Beit A'nan-that have varied characteristics and circumstances. Between early October, 2018, and the end of November, 2019, we did in-depth interviews with 20 key informants, such as mayors, village council members, municipality employees, and teachers, and 16 residents older than 20 years and from a range backgrounds, including activists, retirees, and housewives. We also did two focus groups involving young adults from all four communities. Questions were asked about living conditions and consequences of the socioeconomic and geographic transformations in the study area. We analysed the data by repeated readings to identify patterns and themes.

FINDINGS

We found poor overall quality of life, characterised by chronic daily uncertainty, insecurity and heightened vulnerability, leading to stress and reduced wellbeing. The main negative determinants of quality of life were poor infrastructure, dependence on work in the Israeli labour market, a precarious permit system, increasing land expropriation and expansion of Israeli settlements, separation from Jerusalem, and marginalisation by the Palestinian National Authority. Community characteristics, such as social solidarity and active community organisations were important in mediating some of these effects. Other variations in the characteristics of the communities, such as topography, having relatives living in the USA, levels of education, unemployment rate, and proximity to Israeli settlements seemed to play a role in the abilities of residents to endure conditions.

INTERPRETATION

Our findings highlight the importance of political and socioeconomic transformations in the wellbeing of residents in the Biddu Enclave. Sustained insecurity and uncertainty, marginalisation, and isolation of the communities have negative effects on quality of life. More research focusing on these communities is needed to better understand the mechanisms by which these factors affect health and how they may lead to ill health and disease in the long term.

FUNDING

Arab Council for Social Sciences.

From a Death Sentence to a Disrupted Life: Palestinian Women's Experiences and Coping With Breast Cancer

This study explores women's experiences of breast cancer in the occupied Palestinian territory. We use an inductive qualitative design with a thematic analytical approach for conducting and analyzing 35 semi-structured interviews with breast cancer patients. The interviews focused on diagnosis, experiences and coping with breast cancer, social support and care needs, and the impact of illness on their families and social relationships. Three themes emerged: (a) the transition from initial shock to the daily struggles with disruptions caused by illness, (b) the role of social support in helping women cope with the burden of disease, and the importance of (c) faith and reliance on God (tawakkul). In the Palestinian context, women's narratives highlighted the disruptive nature of breast cancer. Our findings underline the importance of social support provided by extended family members. Finally, faith is an important overarching theme that influences how women make sense of and cope with breast cancer.

Quality of life, human insecurity, and distress among Palestinians in the Gaza Strip before and after the Winter 2008-2009 Israeli war

PURPOSE

This study investigates changes in the quality of life (QoL) of Gaza Palestinians before and after the Israeli winter 2008-2009 war using the World Health Organization's WHOQOL-Bref; the extent to which this instrument adequately measures changing situations; and its responsiveness to locally developed human insecurity and distress measures appropriate for context.

METHODS

Ordinary least squares regression analysis was performed to detect how demographic and socioeconomic variables usually associated with QoL were associated with human insecurity and distress. We estimated the usual baseline model for the three QoL domains, and a second set of models including these standard variables and human insecurity and distress to assess how personal exposure to political violence affects QoL.

RESULTS

No difference between the quality of life scores in 2005 and 2009 was found, with results suggesting lack of sensitivity of WHOQOL-Bref in capturing changes resulting from intensification of preexisting political violence. Results show that human insecurity and individual distress significantly increased in 2009 compared to 2005.

CONCLUSION

Results indicate that a political domain may provide further understanding of and possibly increase the sensitivity of the instrument to detect changes in the Qol of Palestinians and possibly other populations experiencing intensified political violence.

Health-related quality of life of Gaza Palestinians in the aftermath of the winter 2008-09 Israeli attack on the Strip

BACKGROUND

We document the health-related quality of life (HRQoL) of people living in the Gaza Strip 6 months after 27 December 2008 to 18 January 2009, Israeli attack.

METHODS

Cross-sectional survey 6 months after the Israeli attack. Households were selected by cluster sampling in two stages: a random sample of enumeration areas (EAs) and a random sample of households within each chosen EA. One randomly chosen adult from each of 3017 households included in the survey completed the World Health Organization Quality of Life instrument, in addition to reported information on distress, insecurities and threats.

RESULTS

Mean HRQoL score (range 0-100) for the physical domain was 69.7, followed by the psychological (59.8) and the environmental domain score (48.4). Predictors of lower (worse) scores for all three domains were: lower educational levels, residence in rural areas, destruction to one's private property or high levels of distress and suffering. Worse physical and psychological domain scores were reported by people who were older and those living in North Gaza governorate. Worse physical and environmental domain scores were reported by people with no one working at home, and those with worse standard of living levels. Respondents who reported suffering stated that the main causes were the ongoing siege, the latest war on the Strip and internal Palestinian factional violence.

CONCLUSION

Results reveal poor HRQoL of adult Gazans compared with the results of WHO multi-country field trials and significant associations between low HRQoL and war-related factors, especially reports of distress, insecurity and suffering.

Sources of Human Insecurity in Post-War Situations: The Case of Gaza

This paper explores classical and war-related factors associated with human insecurity reports in the Gaza Strip following the winter 2008-09 Israeli attack. A cross-sectional survey was conducted six months after the Israeli attack with adults from 3017 households. Results demonstrate that persons with greater human capital and socioeconomic resources were somewhat protected from human insecurity associated with the attack and siege. Results also underscore the significance of including both classical and war-related factors in assessing human insecurity in conflict, and the link between individual and communal/national security. While it is important to intervene by supporting Gazans with food and aid, interventions should also address the violence of war and ongoing siege as one of the causes of human insecurity.