Background Exposure to ongoing political violence and stressful conditions increases the risk of posttraumatic stress disorder (PTSD) in low-resource contexts. However, much of our understanding of the determinants of PTSD in these contexts comes from cross-sectional data. Longitudinal studies that examine factors associated with incident PTSD may be useful to the development of effective prevention interventions and the identification of those who may be most at-risk for the disorder.
Methods A 3-stage cluster random stratified sampling methodology was used to obtain a representative sample of 1,196 Palestinian adults living in Gaza, the West Bank and East Jerusalem. Face-to-face interviews were conducted at two time points 6-months apart. Logistic regression analyses were conducted on a restricted sample of 643 people who did not have PTSD at baseline and who completed both interviews.
Results The incidence of PTSD was 15.0 % over a 6-month period. Results of adjusted logistic regression models demonstrated that talking to friends and family about political circumstances (aOR = 0.78, p = 0.01) was protective, and female sex (aOR = 1.76, p = 0.025), threat perception of future violence (aOR = 1.50, p = 0.002), poor general health (aOR = 1.39, p = 0.005), exposure to media (aOR = 1.37, p = 0.002), and loss of social resources (aOR = 1.71, p = 0.006) were predictive of incident cases of PTSD.
Conclusions A high incidence of PTSD was documented during a 6-month follow-up period among Palestinian residents of Gaza, the West Bank, and East Jerusalem. Interventions that promote health and increase and forestall loss to social resources could potentially reduce the onset of PTSD in communities affected by violence.
Identifying key risk and resiliency factors for posttraumatic stress disorder (PTSD) in contexts of political violence and instability is an important public health priority. Within the Palestinian Authority, loss of life and freedoms due to political conflict is extreme. During the first and second Intifadas, over 6,200 Palestinians were killed and more than 65,000 were detained. Palestinians are also exposed to internecine violence from within factious Palestinian groups. These exposures are associated with ratings of poor general health, loss of valued economic and social resources, and prevalence estimates of PTSD in the West Bank, Gaza and East Jerusalem range from 6.6 to 25.4 %.
Direct exposure to conflict and violence are important potentially traumatic events (PTEs), but Palestinians are also exposed to the downstream consequences of political violence and military occupation. Stressors associated with poverty, lack of resources and marginalization may modify, and potentiate, the effect of PTEs on PTSD in conflictaffected populations. Within the Palestinian Authority, detainment, harassment, and the punitive destruction of homes by the Israeli military create another category of stresses that may contribute to PTSD incidence.
It is critical to understand the role of potentially modifiable exposures that contribute to psychiatric morbidity in conflict-affected regions. Utilizing the framework provided by Hobfoll’s conservation of resources theory, the present study extends prior research by evaluating the central role of psychosocial resources and losses to these resources, while also considering potentially traumatic event (PTE) exposures, stressors, and candidate individuallevel characteristics for PTSD onset.
Conservation of resource theory (COR) posits that one consequence of PTEs is the actual or threatened loss of psychosocial resources, which in turn creates stress that can lead to poor mental health outcomes. Studies in Israel and the Palestinian Authority repeatedly demonstrated the relationship between psychosocial resource loss and poor mental health. Losses of economic resources are also associated with poorer functioning and worse PTSD-related outcomes. COR theory posits that psychosocial resource loss begets further losses via a ‘loss spiral’ whereby declining psychosocial resources lead to mental health problems, which in turn, lead to greater psychosocial resource loss, indicating the need to intervene before losses accrue. Our previous longitudinal analyses of the current study population showed that social resource loss was related to worse trajectories of PTSD symptoms. We, therefore, expect that resource loss will contribute to PTSD incidence.
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