Experiencing stress and exposure to terrorism may have an adverse effect on health risk behaviors. Few studies have examined alcohol use among adults living in Israel under chronic, stressful terrorism-related conditions. In this study, we examined the relationships of demographics, past stressful events, and terrorism exposure to the frequency of alcohol use and the mediating roles of depressive and post-traumatic stress disorder (PTSD) symptoms. We used three waves of data from a 2007–2008 nationally representative sample of Jewish and Palestinian adults in Israel. We assessed past stressful events, in addition to direct and indirect exposures to terrorism. Results indicated that past stressful events and exposure to terrorism were not directly associated with alcohol use, but were indirectly associated and mediated by depressive and PTSD symptomology. Mental health symptoms were differentially associated with alcohol use. More frequent drinking was mediated by higher levels of depression, including for women and Palestinians; however, PTSD symptom severity was related to less frequent drinking. Mental health may play a prominent role in the frequency of alcohol use among adults exposed to terrorism in Israel. Alcohol use, as a coping mechanism, may differ by demographic characteristics (gender and ethnicity) and psychological symptomology for adults living in a conflict zone in Israel.
Living in a conflict zone and being directly and indirectly exposed to ongoing conflict can have detrimental effects on mental health (Canetti, Hall, Rapaport, & Wayne, 2013; Gelkopf, Solomon, Berger, & Bleich, 2008; Soskolne, Baras, Palti, & Epstein, 1996), physical health (Palmieri, Chipman, Canetti, Johnson, & Hobfoll, 2010; Soskolne et al., 1996), and health behaviors (Ben-Zur & Zeidner, 2009; Soskolne et al., 1996). Populations that live under the conditions of ongoing conflict may experience chronic stress from repeated overt and imperceptible exposures, which can lead to increased vulnerability for developing unhealthy risk behaviors (Soskolne et al., 1996).
The Israeli and Palestinian populations in Israel contend with the impact of ongoing political violence and are continuously exposed to terrorism. For example, in 2007, during the 2007–2008 study period, there was a total of 2946 terrorist attacks (Israeli Security Agency, 2007), of which 1263 were rocket launches and 1511 were mortar attacks — an increase from 55 mortar attacks in the previous year in 2006 (Israeli Security Agency, 2010a, 2010b). While the mental health consequences (e.g., depression and post-traumatic stress disorder (PTSD)) of exposure to ongoing conflict has been examined among adult populations in Israel and the Middle East (Canetti et al., 2010; Hobfoll, Hall, & Canetti, 2012; Hobfoll et al., 2008), few studies have examined the relationship between exposure to terrorism and alcohol consumption in the context of mental health symptom severity (Kane et al., 2014). Research indicates that both Israeli and Palestinian women (Gelkopf et al., 2008; Hobfoll et al., 2012; Kaplan et al., 2010; Somer, Maguen, Or-Chen, & Litz, 2009) and Palestinians, regardless of gender, (Canetti et al., 2010; Gelkopf et al., 2008; Hobfoll et al., 2008; Somer et al., 2009) who have experienced terrorism-related events in Israel endorsed higher levels of depressive and PTSD symptoms compared to men and Jews, respectively, and in the general population (Kaplan et al., 2010; Somer et al., 2009). One study found increased risk for alcohol use disorders among the general, civilian adult population in Israel following exposure to ongoing terrorism (Bleich, Gelkopf, Melamed, & Solomon, 2005).
The social and health consequences of increased alcohol use can include injury, violence, pregnancy-related risks, as well as long-term health consequences — liver and heart diseases (Centers for Disease Control and Prevention, 2014). Several demographic and social factors have been linked to alcohol use among Palestinians and Jews in Israel. Neumark, Rahav, and Jaffe (2003) reported correlations between alcohol consumption and various socio-economic status factors, indicating that more years of education were associated with less alcohol use and lower occupational status was correlated with more alcohol use among Jews; these socio-demographic relationships were more varied among the sample of Palestinians in this study. In addition, gender and ethnicity were associated with drinking in Israel. Based on data from the National Israeli Health Interview Survey (Israel Center for Disease Control Ministry of Health, 2012), drinking rates were higher in men and Jews relative to women and Palestinians, respectively (men: 69.6% for Jews, 31.1% for Palestinians; and women: 34.4% for Jews, 10.9% for Palestinians). Individuals who immigrated to Israel from the former Soviet Union (FSU) were identified as a high risk group for increased alcohol use and related problems (Schiff, Rahav, & Teichman, 2005). Additionally, increased religiosity was shown to be protective against alcohol use among Jewish and Palestinian adults (Neumark, Rahav, Teichman, & Hasin, 2001).
Hence, the objective of the present study was to identify factors associated with the frequency of alcohol use in adults living in Israel. In addition to terrorism exposure, we evaluated several other factors, including demographic characteristics, past stressful life events, and depressive and PTSD symptoms, to give context to the experience of living under the constant threat of terrorism-related violence. We hypothesized that experiences of terrorism and other stressful life events would be associated with greater frequency of alcohol use, and demographic characteristics, such as gender and ethnicity, would be associated with drinking frequency, with women and Palestinians having a decreased frequency of alcohol use than men and Jews, respectively. We also expected that higher levels of depressive and PTSD symptoms would mediate these factors in predicting greater drinking frequency. Thus, we hypothesized that the associations of demographics, past stressful events, and terrorism exposure on the frequency of alcohol use would be mediated by higher levels of depressive and PTSD symptoms in the midst of ongoing conflict (Canetti et al., 2010; Hobfoll et al., 2006; Palmieri, Canetti-Nisim, Galea, Johnson, & Hobfoll, 2008). To our knowledge, scant evidence exists exploring these relationships among a nationally representative sample of Israeli adults.
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