Political Violence, Psychological Distress, and Perceived Health:A Longitudinal Investigation in the Palestinian Authority

Stevan E. HobfollRush Medical College

Brian J. HallRush Medical College and Kent State University

Daphna CanettiUniversity of Haifa

A total of 1,196 Palestinian adults living in the West Bank, Gaza Strip, and East Jerusalem wereinterviewed beginning in September 2007 and again at 6- and 12-month intervals. Using structuralequation modeling, we focused on the effects of exposure to political violence, psychosocial andeconomic resource loss, and social support on psychological distress and the association of each of thesevariables on subjective health. Our proposed mediation model was partially supported. Exposure topolitical violence, psychosocial resource loss, and social support were related to subjective health, fullymediated by their relationship with psychological distress. Female gender and being older were alsodirectly related to poorer subjective health and partially mediated via psychological distress. Greatereconomic resource loss, lower income, and poorer education were directly related to poor subjectivehealth. An alternative model exploring subjective health as a mediator of psychological distress revealedthat subjective health partially mediated the relationship between resource loss and psychologicaldistress. The associate between female gender, education, income, and age on psychological distress werefully mediated by subjective health. Social support and exposure to political violence were directlyrelated to psychological distress. These results were discussed in terms of the importance of resource losson both mental and physical health in regions of chronic political violence and potential interventionstrategies.

Keywords: PTSD, resource loss, trauma, political violence, occupation, war, health

Political–military occupation, conflict, and violence may havesubstantial public health implications, affecting both mental andphysical health. In low-income regions of the world, politicalviolence may also result in a critical deterioration in economicconditions, educational and social services, availability of food andgoods, and the availability of employment and income (Ai Al,Person, & Ubelhor, 2002; Cardozo, Vergara, Agani, & Gotway,2000; de Jong et al., 2001; Johnson & Thompson, 2008). The littleresearch in this field has mainly focused on mental health out-comes of political violence, especially examining symptoms ofposttraumatic stress (PTS) and depression. In general, war andongoing political violence are associated with higher levels ofposttraumatic stress disorder (PTSD) and symptoms of PTS(Bleich, Gelkopf, & Solomon, 2003; de Jong et al., 2001; Hall etal., in press; Hobfoll, Canetti-Nisim, & Johnson, 2006; Hobfoll etal., 2008, 2009; 2007; Johnson & Thompson, 2008; Shalev &

Freedman, 2005). To a lesser extent, studies have shown thatdepression is also elevated during and after such events (Basogluet al., 2005; Hall et al., 2008; Hobfoll et al., 2006; Miguel-Tobalet al., 2006; Tracy, Hobfoll, Canetti-Nisim, & Galea, 2008). Fewstudies, however, have examined the impact of war and politicalturmoil in low-income countries or the predictors of symptoms ofPTS and depression in such contexts (Basoglu et al., 2005; Car-dozo et al., 2000; de Jong et al., 2001; Pham, Weinstein, &Longman, 2004; Vinck, Pham, Stover, & Weinstein, 2007). More-over, there has been little attempt to examine how physical healthis affected in these circumstances and how physical health mightbe related to psychological distress (Caspi, Saroff, Suleimani, &Klein, 2008).

Palestinians have experienced years of political–military occu-pation and military attack in the Israeli–Arab conflict. During thefirst and second Intifadas (uprisings), more than 6,200 Palestinianswere killed (B’Tselem, 2008a, b), more than 60,000 wounded(JMCC, 2008; PCHR, 2008), and more than 65,000 have beendetained (B’Tselem, 2008a, c; JMCC, 2008). Palestinians havealso experienced a virtual civil war, as Palestinian factions fight forthe leadership of Palestine with very different visions of what theyhope to accomplish and how they hope the Palestinian State will begoverned. These internal political tensions have led to gun battles,assassinations, and a division of the Palestinian Authority, withseparate governing authorities in Gaza and the West Bank. Over150 Palestinians are reportedly arrested by Palestinian Authoritysecurity forces in the West Bank each month and in Gaza over 250people are being detained each month by the security forces of the

This article was published Online First October 4, 2010.Stevan E. Hobfoll, Department of Behavioral Sciences, Rush Medical

College; Brian J. Hall, Department of Behavioral Sciences, Rush MedicalCollege, and Department of Psychology, Kent State University; DaphnaCanetti, Department of Political Science, University of Haifa.

This research was made possible in part by a grant from the NationalInstitute of Mental Health (RO1MH073687).

Correspondence concerning this article should be addressed to Stevan E.Hobfoll, Department of Behavioral Sciences, Rush Medical College, 600S. Paulina Street, Suite 202, Chicago, IL 60612. E-mail: Stevan_Hobfoll@rush.edu

Psychological Trauma: Theory, Research, Practice, and Policy © 2010 American Psychological Association2012, Vol. 4, No. 1, 9–21 1942-9681/10/$12.00 DOI: 10.1037/a0018743

9

de facto Hamas government. Over 590 individuals have beenkilled in internecine warfare between Palestinian political factions(B’Tselem, 2008a, b). The period prior to and during this studywas a period of appreciable conflict, deaths because of politicalviolence, as well as major economic distress.

The Association Between Trauma, PsychologicalDistress, and Health

Trauma history is associated with both psychological distressand physical health problems (Dennis et al., 2009; Golding, 1994;Kimerling & Calhoun, 1994). Among those who report trauma,both PTS and depression are related to health impairment when thetrauma exposure is long-term and chronic (Zoellner, Goodwin, &Foa, 2000). It has also been noted that both depression and PTSmediate the impact of trauma exposure on physical health (Eadie,Runtz, & Spencer-Rodgers, 2008). For example, a study of Cana-dian bus drivers found that only those with trauma exposure andPTSD differed from nonexposed individuals on reports of morehealth treatment and poorer subjective health ratings (Vedanthamet al., 2001). This appears to extend to a wide array of healthproblems, including subjective health, anemia, arthritis, asthma,back pain, diabetes, kidney and lung disease, and ulcer (Weisberget al., 2002).

The Role of Resource Loss in Contributing toPsychological Distress

One of the major factors linking trauma exposure to psycholog-ical distress is loss of material and psychosocial resources (Hob-foll, 1989, 1998). Conservation of Resources (COR) theory hasbeen adopted to explain the impact of mass casualty trauma onindividuals (Benight et al., 2000; Freedy, Shaw, Jarrell, & Masters,1992; Hobfoll et al., 2006; Ironson et al., 1997; Kaiser, Sattler,Bellack, & Dersin, 1996). Disaster, war, and terrorism are majortraumatic events that share the important quality of being outsideof people’s control, occurring to large groups of people that sharea social space (e.g., school, city, nation) and have the potential tocause great harm psychologically, socially, and physically (Hob-foll, 1989, 1998). Inherent in COR theory is the prediction thatstress occurs primarily as a consequence of threat of resource lossor actual loss of resources that are highly valued by people (Hob-foll, 1989, 1998). Resources include both material resources (e.g.,transportation, housing) and psychosocial resources (e.g., self-efficacy, social support). Several studies of disaster and masscasualty events have found that resource loss is a critical predictorof psychological distress following disaster (Freedy et al., 1992;Ironson et al., 1997). Likewise, studies of terrorism, war, andpolitical violence have found that the loss of interpersonal, intrap-ersonal, and economic and material resources were key predictorsof psychological distress (Galea et al., 2002; Hobfoll et al., 2009;Schlenger et al., 2002). Ironson et al. (1997) found that resourceloss following disaster was the best single predictor of downregulation of victims’ immune response.

Political violence and upheaval such that occurs in the Pales-tinian Authority threatens interpersonal resources such as socialsupport. Nevertheless, those who sustain supportive social rela-tionships in disaster and traumatic circumstances have been foundto be more resilient (Benight et al., 2000; Galea et al., 2002; Norris

& Kaniasty, 1996). Past research has found that perceived socialsupport is especially important in the face of political violence,even in circumstances where personal resources appear to beoutstripped (Bleich et al., 2003; Galea et al., 2002; Hobfoll et al.,2006; Palmieri, Galea, Canetti-Nisim, Johnson, & Hobfoll, 2008).Perhaps because people fear for both themselves and loved oneswhen they face war and political violence, studies of terrorismhave found that contacting loved ones is one of the most commonforms of coping following such circumstances (Bleich et al.,2003).

It is, of course, also possible that those who experience physicalhealth problems will become more psychologically distressed.This path has not been previously considered in trauma research,but does fall within several trauma theories. First, one basic aspectof what is traumatic is that the person feels that they are unsafe(e.g., Punamaki, Komproe, Qouta, Elmasri, & de Jong, 2005). Ifpeople feel ill as a consequence of traumatic stressors, they aremore likely to feel that their world has become unsafe as illnesscues insecurity. Second, COR theory (Hobfoll, 1998) suggests thattraumatic stress results, in part, from a rapid loss of resources, andhere too, with illness, people may often feel that they are losingstrength, capacity to cope, and vigor. Indeed, this pathway betweenpoor physical health and psychological distress may be more rapidthan the opposite pathway as psychological distress is a moreimmediate reaction to stressful circumstances, and physical healthdeclines are typically seen as occurring following slower movingpathways such as immunological compromise and increased in-flammatory processes (Dirkzwager, van der Velden, Grievink, &Yzermans, 2007).

Based on this prior work, we proposed two possible models(Figures 1 and 2). In the first model, it was predicted that traumaexposure and resource loss will together contribute to psycholog-ical distress as measured by PTS and depression symptoms. Thesesymptoms, in turn, were predicted to mediate the impact of traumaexposure and resource loss on health outcomes. The model alsosuggested that to the extent people can nevertheless sustain socialsupport, this should in part offset the impact of trauma exposureand resource loss on psychological distress, and through psycho-logical distress on health outcomes. Finally, it was predicted thatexposure to trauma and resource loss might have more minordirect impact on subjective health because stressors might impactsubjective health directly and resource loss might make access tohealth care, medication, and rehabilitation more difficult to access.

In the second, alternative model, we predicted that subjectivehealth might mediate the impact of trauma exposure, resource loss,and social support on psychological distress. As people respondsomatically because of stress they are likely to be more vulnerableto negative cognitions and feel weaker. This, in turn, could betranslated to greater distress. That physical symptoms may precedeor exacerbate PTSD and depression was illustrated in a recentstudy of battle-injured soldiers by Grieger and colleagues (2006).They noted that severity of physical problems was more stronglyassociated with later PTSD and depression than 1-month PTSDand depression.

We examined these models in a longitudinal three-wave panelstudy of a representative random sample of Palestinian citizens ofthe West Bank, East Jerusalem, and Gaza. In addition to allowingan examination of these models, this study represents one of the

10 HOBFOLL, HALL, AND CANETTI

only multiwave studies of a region of such substantive conflictanywhere in the world.

Method

We employed a stratified 3-stage cluster random samplingstrategy for Palestinian adults living in the West Bank, GazaStrip, and East Jerusalem. First, 60 clusters were selected with

populations of 1,000 or more individuals (after stratification bydistrict and type of community— urban, rural, and refugeecamp) with probabilities proportional to size. Next, 20 house-holds in each of the chosen clusters were selected. The thirdstage involved selecting one individual in each household usingKish Tables (these tables provide within-household randomiza-tion of participants). We visited each sampled household atleast 3 times to complete the interview. After complete descrip-

Baseline Interview 6-Month Follow-up 12-Month Follow-up

Trauma Exposure

Poor Subjective Health

PsychologicalDistress

PsychosocialResource

Loss

EconomicResource

Loss

Support

+

++

+

-

-

+

+

+

Figure 1. Hypothesized structural model for psychological distress as a mediator. Support � social support.Exposure � exposure to political violence. Psychosocial resource loss � intrapersonal and interpersonal resource loss.Psychological distress � posttraumatic stress symptom severity and depressive symptom severity. Poor subjectivehealth � number of days that health has been poor in past 30 days and participant’s overall health rating.

Baseline Interview 6-Month Follow-up 12-Month Follow-up

Trauma Exposure

Psychological distress

Poor SubjectiveHealth

PsychosocialResource

Loss

EconomicResource

Loss

Support

+

++

+

-

-

+

+

+

Figure 2. Hypothesized structural model for poor subjective health as a mediator. Support � social support.Exposure � exposure to political violence. Psychosocial resource loss � intrapersonal and interpersonal resource loss.Psychological distress � posttraumatic stress symptom severity and depressive symptom severity. Poor subjectivehealth � number of days that health has been poor in past 30 days and participant’s overall health rating.

11SPECIAL SECTION: VIOLENCE, DISTRESS, AND HEALTH

tion of the study to the participants, written informed consentwas obtained and they were paid the equivalent of about $5(U.S.).

Three face-to-face interviews were conducted by same-genderinterviewers. Interviewers were from the local area where theyconducted interviews, were themselves Palestinian, and fluent inArabic. They were trained in interview techniques, and most heldcollege degrees or their equivalent. Baseline interviews were con-ducted from September 16, 2007, to October 16, 2007; 6-monthfollow-up interviews from April 24, 2008, to May 17, 2008; and12-month follow-up interviews were conducted from October 15,2008, to November 1, 2008. A structured interview comprisingseveral self-report instruments was administered that has previ-ously been translated and back-translated into Arabic for priorresearch and found to have sound psychometric properties in thispopulation (Hobfoll et al., 2006; Hobfoll et al., 2008). The inter-view lasted approximately 45-min.

Of the 1,902 people approached for the first study wave, 702refused to participate and 4 terminated the interview early, yieldinga sample of 1,196 people (a response rate of 63%). Of the originalsample, an attempt was made to reach the 999 people who agreedto be contacted at 6-month follow-up. Of this sample, 110 wereconsidered “noncontact” owing to change in address (18), refusal(52), unavailability for interview (36), being in prison (2), or being“martyred,” (2), yielding a response rate of 89%. For 12-monthfollow-up, 890 people were approached who agreed to be con-tacted again. Of this sample 98 were considered “noncontact”owing to change of address (15), refusal (32), unavailability (48),or sickness (3), yielding a final interview sample of 792, and aresponse rate of 89%. The rate of attrition in the overall study was33.78%, which is excellent for a study of this size and the socio-political climate of the region. The institutional review boards ofKent State University, the University of Miami, Rush Universityand Medical College, and the University of Haifa approved thisstudy.

Instruments

Demographic variables included: gender (coded 1 � male, 2 �female), education (less than high school, high school graduate,some college, college graduate), age, marital status (single, di-vorced/separated/widowed, married), and income. For income,participants were asked to report their income in relation to theaverage monthly household income in the Palestinian Authority(2,500 New Israeli Shekel; low: much lower than average or a littlelower than average; medium: average; high: a little higher thanaverage or much higher than average).

Exposure to political violence occurring in the past year wasassessed by four open-ended items that were summed to indicatethe total number of times the following occurred as a result ofexposure to political violence: a death of a family member or afriend, an injury to a family member or a friend, an injury tothemselves, or whether they had witnessed Israeli attacks or vio-lence among Palestinian factions. An internal consistency reliabil-ity estimate was not calculated for this scale, as one exposure doesnot portend another.

Loss of interpersonal and intrapersonal resources related toexposure to political violence was assessed using a 9-item scale(5-items measured intrapersonal loss and 4-items measured inter-

personal loss) from the Conservation of Resources Evaluation(COR-E; Hall et al., 2008; Hobfoll et al., 2006; Hobfoll & Lilly,1993; Palmieri et al., 2008). Participants were asked “To whatextent have you lost any of the following things in the past year asa result of the occupation or violence among factions?” Sampleitems for interpersonal loss include: “Feeling that you are a personof great value to other people,” “stability of your family,” and“intimacy with at least one friend.” Examples of intrapersonallosses are: “the feeling that you are a successful person,” “Sense ofcontrol in your life,” and “Hope.” Participants indicated the degreeof their resource loss on a 4-point scale with item responsesranging from 1 (did not lose at all) to 4 (lost very much). Itemswere summed to create an interpersonal loss and intrapersonal lossscore. Internal consistency reliability estimates was not calculatedfor these scales, as one loss does not portend another.

Economic resource loss was assessed by asking participantswhether they suffered significant financial losses (e.g., to money orproperty) as a result of their exposure to political violence. Re-sponses were coded 0 � no, 1 � yes.

Social support satisfaction was measured by two items ofWeiss’ (1974) social support provisions scale and were rated from0 (not at all satisfied) to 3 (very satisfied). “How satisfied are youwith the social support you receive from your. . . . ‘family’ and‘friends.’” The items were summed to indicate overall supportsatisfaction. An internal reliability estimate for this scale was notcalculated as one type of support may not relate to another.

PTS symptoms occurring within the past month that respondentsassociated with exposure to political violence were assessed withthe 17-item PTSD Symptom Scale Interview format (PSS-I; Foa,Riggs, Dancu, & Rothbaum, 1993). This scale has been usedpreviously in non-Western, low-income regions (Johnson &Thompson, 2008) and within the Israeli population (including bothPalestinians and Jews) (Hall et al., 2008; Hobfoll et al., 2006;Hobfoll et al., 2008; Palmieri et al., 2008). Responses to itemswere given on a 4-point Likert scale from 0 (not at all) to 3 (verymuch). The internal consistency reliability estimate was .87 atbaseline interview, .86 at 6-month follow-up, and .89 at 12-monthfollow-up in the current study.

Depression symptom severity was assessed using the 9-itemPatient Health Questionnaire, a well-validated, highly sensitiveinstrument for identifying symptoms of depression (Kroenke,Spitzer, & Williams, 2001) consistent with the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition, Text Re-vision (DSM–IV–TR; American Psychiatric Association, 2000). Ithas been used previously in Israeli Palestinian populations (Hob-foll et al., 2008). Participants responded on a 4-point Likert scale,0 (not at all), 1 (several days), 2 (more than half the days), 3(nearly every day). Sample items include “Little interest or plea-sure in doing things,” “feeling down, depressed, or hopeless,”“feeling tired or having little energy.” The internal consistencyreliability estimate was .88 at baseline interview, .89 at 6-monthfollow-up, and .90 at 12-month follow-up, in the current study.

Subjective health was assessed by two items derived from theMedical Outcomes Survey Short Form-36 (Ware & Sherbourne,1992). The first item inquired about physical health-related func-tional impairment, “How many days in the past 30 days did yourhealth prevent you from doing your usual activities?” For the nextitem, participants provided an overall rating of their health (“How

12 HOBFOLL, HALL, AND CANETTI

would you rate your overall health during the past 30 days”), from1 (very good) to 5 (poor).

Data Analyses

Estimated zero-order correlations were examined to assess thebivariate relationships among study variables. Two hypothesizedmediation models were tested using structural equation modeling(SEM). Figure 1 displays our simplified hypothesized mediationmodel (i.e., demographic manifest indicators are omitted for easeof presentation). To evaluate the adequacy of this model to theobserved data, a measurement model was first specified. Demo-graphic variables (i.e., gender, age, income, education, maritalstatus) that were potentially related to the outcomes were added tothe model, and their pathways among all study variables werefreely estimated. An initial partial structural model was then spec-ified to evaluate the hypothesized relationships of exposure topolitical violence, psychological resource loss, economic resourceloss, and social support (measured at baseline interview), predict-ing subjective health (measured at 12-month follow-up), and thehypothesized mediating role of psychological distress (measured at6-month follow-up). The second alternative mediation modeltested the hypothesized relationship of exposure to political vio-lence, psychological resource loss, economic resource loss, andsocial support (measured at baseline interview), predicting psy-chological distress (measured at 12-month follow-up), and thehypothesized mediating role of subjective health (measured at6-month follow-up). To increase model parsimony, nonsignificantcorrelations among variables in the measurement model wereexcluded from the initial models. We further trimmed nonsignif-icant structural model pathways after testing the initial models, andexamined direct and indirect effects in final, respecified models.All paths in the models were tested and their direct and indirecteffects on 12-month subjective health or 12-month psychologicaldistress were simultaneously estimated (MacKinnon, Lockwood,Hoffman, West, & Sheets, 2002; Shrout & Bolger, 2002).

Many methods for estimating the significance of indirect effectshave been proposed in the literature. MacKinnon and colleagues(2002) compared the Type I error rates and power of 14 of theseprocedures. It was noted that the commonly used method describedby Baron and Kenny (1986) actually yielded the lowest statisticalpower. Shrout and Bolger (2002) described a bootstrap procedureto estimate indirect effects that is superior to other options. Fol-lowing the recommendations by Shrout and Bolger (2002) a boot-strap procedure was utilized to evaluate the significance of thestudy indirect effects (Shrout & Bolger, 2002). The 95% confi-dence intervals (CIs) about the mean of the indirect effect are usedto determine whether the effect is significant. If the CI does notinclude zero, the indirect effect is significant at the .05 level. Thefinal, trimmed structural models were tested 1,000 times in orderto produce 1,000 estimates for each path coefficient in the models,one for each of the 1,000 bootstrapped samples of the original dataset (N � 1197). The 1,000 estimates were then combined in orderto calculate the indirect effects. This procedure is automated in theAMOS program (Version 7; Arbuckle, 2006).

For all analyses missing data was imputed using the EstimationMaximization (EM) algorithm in the NORM software program(Schafer, 1999). This technique imputes missing data following aniterative maximum likelihood procedure, which utilizes all avail-

able participant data, making EM an efficient missing data han-dling technique (cf., listwise deletion). EM model based estimatesof conditional means and the variance-covariance matrix take intoaccount random error (Little & Rubin, 1987; Schafer, 1997).Simulation studies have demonstrated the clear advantage of usingthe EM algorithm versus pairwise or listwise deletion in caseswhere data is assumed to be missing completely at random, or theless stringent missing at random (Enders & Bandalos, 2001).Furthermore, EM is an excellent modern method for missing datahandling given that it produces identical variance-covariance ma-trices as full information maximum likelihood estimation (Gra-ham, 2003; Graham, Hofer, Donaldson, MacKinnon, & Schafer,1997) and yields highly similar estimates as multiple imputation(Graham, 2003). The covariance coverage values, which reflect theproportion of data present to estimate each pairwise relationship,ranged from 66% to 100% in the current study. These valuesexceeded the recommended minimum of 10% for imputing miss-ing data (Muthen & Muthen, 2002).

All measured continuous variables were examined for departurefrom normality. Exposure to political violence and the number ofdays of health-related impairment at each measurement wave hadvalues indicating non-normal distributions. Following transforma-tion, the univariate skewness and kurtosis values of the studyvariables indicated that all variables were normally distributed(West, Finch, & Curran, 1995). Model goodness of fit was as-sessed using the residual mean squared error of approximation(RMSEA), with values below.08 and a lower bound of the 90% CIless than .05, indicating adequate fit (Browne & Cudeck, 1993)and the Comparative Fit Index (CFI; Bentler, 1990), with valuesgreater than .95 indicating good fit. All data analyses were con-ducted using the AMOS program (Version 7; Arbuckle, 2006).

Results

The means, SDs, and percentages of study variables are pre-sented in Table 1. The mean age of the sample was 35.03 years(SD � 12.67). In terms of reported highest level of education,34.3% finished elementary school, 32.0% finished high school,10.9% completed some college, and 22.9% had a college degree.Annual household income was 51.7% below average 25.7% aver-age, and 22.6% above average. In terms of marital status, 31.5%reported being single/divorced/separated/widowed and 68.5% re-ported being married. Our sample mirrored the known PalestinianAuthority population demographics in age, economic status, region(the West Bank, Gaza, and East Jerusalem), type of locality (cities,villages and refugee camps), and gender (ICBS, 2007; PCBS, 1999,2008) suggesting that we were successful in contacting a representa-tive sample of the target population (Vinck et al., 2007).

The estimated zero-order correlations among all study variablesincluded in either SEM model are displayed in Table 2. For themediation models, significant associations among exogenous vari-ables and the outcome variables were included in the model ascovariates.

SEM Analyses

Mediation model evaluating the role of psychological dis-tress in subjective health. We first evaluated the hypothesizedmeasurement model (Anderson & Gerbing, 1988). The model

13SPECIAL SECTION: VIOLENCE, DISTRESS, AND HEALTH

included eight manifest variables that were identified by theirobserved scores, and three latent variables that represented psy-chosocial resource loss, psychological distress, and subjectivehealth. Psychosocial resource loss was specified by two manifestindicators measuring interpersonal and intrapersonal resource loss.Psychological distress was specified by the PTS symptom severity

and depression symptom severity manifest indicators. Subjectivehealth was specified by two observed health items: number of dayswith health-related impairment, and the participant’s rating of theircurrent health. All observed variables and latent variables wereallowed to freely intercorrelate in the measurement model. Thestandardized loadings for the two psychosocial resource loss indi-

Table 1Percentages, Means, and SDs for Study Variables

Variable % M (SD) Range

GenderFemale 48.0

Education 2.22 (1.15) 1–4Age 35.03 (12.67) 18–80Marital status

Single 31.5Married 68.5

Yearly household income 1.70 (0.81) 1–3Exposure to political violence 3.10 (6.29) 1–62Intrapersonal resource loss 4.72 (3.75) 0–15Interpersonal resource loss 2.85 (2.82) 0–12Economic resource loss 0.33 (0.47) 0–1Social support 4.33 (1.58) 0–6PTS symptom severity

T1 21.66 (9.40) 0–51T2 20.63 (8.96) 0–49T3 18.31 (9.62) 0–47

Depression symptom severityT1 10.41 (6.06) 0–27T2 9.64 (6.28) 0–27T3 8.47 (6.24) 0–27

Number of days of health-related impairmentT1 2.16 (5.73) 0–30T2 3.60 (6.43) 0–30T3 3.12 (6.09) 0–30

Overall health ratingT1 2.11 (1.01) 1–5T2 2.15 (1.05) 1–5T3 2.03 (1.05) 1–5

Note. T1 � baseline interview. T2 � 6-month follow-up. T3 � 12-month follow-up.

Table 2Estimated Correlation Matrix of Latent Study Variables

Variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14

1. Gender (female) —2. Education �.07� —3. Age �.02 �.23��� —4. Marital status .04 �.17��� .37��� —5. Income �.01 .27��� .03 �.01 —6. Exposure �.20��� �.07� �.01 .01 �.10��� —7. Resource loss �.06 �.13��� .08� .04 �.08� .14��� —8. Economic loss �.06� �.04 .05 .06� �.05 .24��� .09�� —9. Social support .03 .02 �.03 .04 .01 .02 �.15��� .02 —

10. T1 Distress .07� �.11��� .10�� �.00 �.08�� .19��� .63��� .10�� �.09�� —11. T2 Distress .12��� �.13��� .11��� .00 �.06 .14��� .35��� .06 �.16��� .56��� —12. T3 Distress .06 �.14��� .18��� .08� �.08�� .19��� .37��� .05 �.14��� .46��� .67��� —13. T1 Subjective health .10�� �.25��� .36��� .11��� �.12��� .16��� .29��� .03 �.11�� .39��� .38��� .40��� —14. T2 Subjective health .11�� �.27��� .42��� .15��� �.20��� .03 .18��� .08� �.06 .29��� .46��� .47��� .59��� —15. T3 Subjective health .12�� �.27��� .41��� .14��� �.11��� .06 .14��� .08� �.09� .22��� .40��� .64��� .61��� .77���

Note. Exposure � exposure to political violence. Resource loss � psychosocial resource loss. T1 � baseline interview. T2 � 6-month follow-up. T3 �12-month follow-up.� p � .05. �� p � .01. ��� p � .001.

14 HOBFOLL, HALL, AND CANETTI

cators were .88 and .84; .79 for PTS symptom severity and .86 fordepression symptom severity on the latent psychological distressfactor; and, overall health rating loaded .95 and days of health-related impairment loaded at .60 on the subjective health factor.These factor loadings and the fit indices for the measurementmodel indicated an adequate model fit to the underlying datastructure, �2(30, N � 1197) � 100.37, CFI � .978; RMSEA �.044, 90% CI � .035–.054.

Next, an initial structural model was specified to test the rela-tionships of exposure to political violence, psychosocial and eco-nomic resource loss, social support and psychological distress onsubjective health. Although allowed to freely correlate in themeasurement model, nonsignificant associations among study pre-dictors were omitted from the model to achieve a more parsimo-nious initial structural model. The initial model fit the data ade-quately well, �2(54, N � 1,197) � 161.66, CFI � .966;RMSEA � .041, 90% CI � .034–.048 (figure available on re-quest). To assess the direct and indirect relationships between thestudy predictors and subjective health, nonsignificant model pathswere trimmed. The final trimmed model accounted for the dataquite well, �2(58, N � 1,197) � 165.88, CFI � .966; RMSEA �.039, 90% CI � .032–.047 (Figure 3). Results of �2 differencetesting indicated that omitting these model paths did not lead to asignificant decrement in overall model fit, �2(4, N � 1,197) �4.22, p � .38). As would be expected, the structural relationshipsfound in the initial model were replicated in the final, trimmedmodel. The following significant pathways were observed in pre-dicting psychological distress: social support (� � �.10), expo-

sure to political violence (� � .15), resource loss (� � .35), femalegender (� � .17), and age (� � .10), explaining a total of 21% ofthe variance. In the prediction of subjective health, significantpathways were observed for economic resource loss (� � .06),education (� � �.12), female gender (� � .07), age (� � .31),income (� � �.07), and psychological distress (� � .29), explain-ing a total of 26% of the variance.

The indirect effects of study variables were next examined todetermine the extent to which psychological distress mediated therelationship between the study predictors and subjective health.Significant indirect and direct effects were observed for femalegender and age, indicating that psychological distress partiallymediated the relationship between each of these exogenous vari-ables and overall health. Social support, exposure to politicalviolence, and psychosocial resource loss did not have a directeffect on subjective health in the final model, and demonstrated anindirect relationship to this outcome. The effect of social support,exposure to political violence, and psychosocial resource loss onsubjective health was fully mediated by psychological distress(Table 3).

Evaluating subjective health as a mediator between exposure,resource loss and social support, and psychological distress. Asdiscussed earlier, we first evaluated the measurement model,which included eight manifest variables and three latent variables.Regarding the latent variables, the standardized loadings for thetwo psychosocial resource loss indicators were .89 and .83; .73 forPTS symptom severity and .85 for depression symptom severity onthe latent psychological distress factor; and, overall health rating

Baseline Interview 6-Month Follow-up 12-Month Follow-up

Trauma Exposure

Poor Subjective

Health

PsychologicalDistress

PsychosocialResource

Loss

EconomicResource

Loss

Support

PTS.79

Depress

Days

Rating

Inter

.83

intra

.89

R2 = .21

R2 = .26

.95

.60

.06

.29

.35

.15

-.10

.89

-.15

.23

.13

.08

Figure 3. Standardized structural equation modeling results of final trimmed model with psychological distressas a mediator, demonstrating the relationship of social support, political violence exposure, economic andpsychosocial resource loss, and psychological distress predicting subjective health. Support � social support.Exposure � exposure to political violence. Intra � intrapersonal resource loss. Inter � interpersonal resourceloss. PTS � posttraumatic stress symptom severity. Depress � depressive symptom severity. Days � numberof days that health has been poor in past 30 days. Rating � overall health rating. All coefficients at or above .10are significant at p � .001, all others are p � .05.

15SPECIAL SECTION: VIOLENCE, DISTRESS, AND HEALTH

loaded .89 and days of health-related impairment loaded at .60 onthe subjective health factor. These factor loadings and the fitindices for the measurement model indicated an adequate model fitto the underlying data structure, �2(30, N � 1197) � 95.21, CFI �.979; RMSEA � .043, 90% CI � .33–.052.

Next, an initial structural model was specified to test the rela-tionships of exposure to political violence, psychosocial and eco-nomic resource loss, social support and subjective health on psy-chological distress. As above, nonsignificant associations amongstudy predictors were omitted from the model to achieve a moreparsimonious initial structural model. The initial model fit the datawell, �2(52, N � 1197) � 126.21, CFI � .976; RMSEA � .035,90% CI � .027–.042. To assess the direct and indirect relation-ships between the study predictors and psychological distress,nonsignificant model paths were trimmed. The final trimmedmodel accounted for the data quite well, �2(59, N � 1197) �131.98, CFI � .976; RMSEA � .032, 90% CI � .025–.040(Figure 4). Results of chi-square difference testing indicated thatomitting these model paths did not lead to a significant decrementin overall model fit, �2(4, N � 1197) � 5.77, p � .38). Thefollowing significant pathways were observed in predicting sub-jective health: female gender (� � .11), education (� � �.11), age(� � .38), income (� � �.16), and resource loss (� � .13),explaining a total of 26% of the variance. In the prediction ofpsychological distress, significant pathways were observed forresource loss (� � .30), social support (� � �.07), politicalviolence (� � .08), and subjective health (� � .42), explaining atotal of 34% of the variance.

We next examined the indirect effects of study variables todetermine the extent to which subjective health mediated therelationship between the study predictors and psychological dis-tress. Significant indirect and direct effects were observed forresource loss indicating that subjective health partially mediatedthe relationship between resource loss and psychological distress.Female gender education, income, and age did not have directeffects on psychological distress in the final model, and demon-strated an indirect relationship to this outcome, and therefore theireffects on psychological distress were fully mediated by subjectivehealth (Table 4).

Discussion

Our proposed model examining the role of psychological dis-tress as a mediator was partially supported; the effect of economicloss on subjective health was not mediated by psychological dis-tress. Trauma exposure, psychosocial resource loss, and socialsupport were related to subjective health as mediated by theirrelationship with trauma-related psychological distress. The stron-gest path in this model was, as predicted, between psychosocialresource loss and subjective health, mediated by psychologicaldistress. Only economic resource loss directly impacted subjectivehealth ratings, with greater economic loss being related to poorsubjective health. The alternative model, in which subjective phys-ical health was modeled as a mediator of the impact of otherpredictors on psychological distress was only partially supportedby the findings. Indeed, this model demonstrated that subjectivehealth served only as a mediator of resource loss and psychologicaldistress, but nevertheless suggested that subjective health is rea-sonably modeled as a mediator between the stressful aspects ofT

able

3B

oots

trap

Ana

lysi

sof

the

Mag

nitu

dean

dSt

atis

tica

lSi

gnif

ican

ceof

Indi

rect

Eff

ects

for

Med

iati

onM

odel

Inde

pend

ent

vari

able

Med

iato

rva

riab

leD

epen

dent

vari

able

�st

anda

rdiz

edin

dire

ctef

fect

Bm

ean

indi

rect

effe

cta

SEof

mea

na95

%C

Im

ean

indi

rect

effe

ct(l

ower

and

uppe

r)a

Soci

alsu

ppor

t3

Psyc

holo

gica

ldi

stre

ss3

Subj

ectiv

ehe

alth

(�.1

03)

�(.

286)

��

.030

�.0

19.0

06�

.034

,�.0

09R

esou

rce

loss3

Psyc

holo

gica

ldi

stre

ss3

Subj

ectiv

ehe

alth

(.34

5)�

(.28

6)�

.099

.030

.004

.022

,.03

9E

xpos

ure3

Psyc

holo

gica

ldi

stre

ss3

Subj

ectiv

ehe

alth

(.14

8)�

(.28

6)�

.042

.120

.029

.066

,.18

2G

ende

r(f

emal

e)3

Psyc

holo

gica

ldi

stre

ss3

Subj

ectiv

ehe

alth

(.17

0)�

(.28

6)�

.049

.099

.022

.058

,.14

4A

ge3

Psyc

holo

gica

ldi

stre

ss3

Subj

ectiv

ehe

alth

(.09

5)�

(.28

6)�

.027

.002

.001

.001

,.00

4

Not

e.C

I�

conf

iden

cein

terv

al;

expo

sure

�ex

posu

reto

polit

ical

viol

ence

.R

esou

rce

loss

�ps

ycho

soci

alre

sour

celo

ss.

All

indi

rect

effe

cts

are

sign

ific

ant

atp

�.0

1.a

The

seva

lues

are

base

don

unst

anda

rdiz

edpa

thco

effi

cien

ts.

16 HOBFOLL, HALL, AND CANETTI

community trauma, and the psychological distress people in suchcircumstances experience. This model further demonstrated thatthe direct association between subjective health and psychologicaldistress was stronger than what was found the first model wetested, modeling psychological distress as a predictor of subjectivehealth. Overall, these relationships predicted a sizable proportionof the variance in the outcome variables in each of the two testedmodels, which clearly indicates that the circumstances associatedwith occupation and the accompanying political violence have amajor impact on health perceptions and psychological well-being,and that these two outcomes are transactional, affecting one an-other.

These relationships are further clarified by the fact that theywere independent of the influence of demographic factors. Theyalso contribute to our knowledge of the impact of political violenceand political occupation on physical health, as most studies havebeen descriptive or qualitative and lack theoretical bases (Holli-field et al., 2002). Our results also coincide with those of Caspi etal. (2008), who found that among Bedouin veterans of the Israelidefense forces, that it was the combination of trauma exposure andpsychological distress that was associated with physical healthdisorder. Caspi et al.’s (2008) study is especially informative asthey included health impairments in daily functioning, physician-diagnosed medical conditions, and health visits. Similarly,O’Toole, and Catts (2008) found that it was through trauma’sinfluence on psychological distress that veterans’ health was foundto be impaired. This latter work suggested that the chronic natureof psychological distress that follows trauma is consistent withaltered inflammatory responsiveness that, in turn, results in a widevariety of health disorders.

Although subjective health ratings and psychological distressare not one in the same, it is not possible to fully disentangle howthey are affecting each other. Even given our multiwave data, theassociation between health status and psychological distress maywell precede our initial assessment, setting a cycle in motion thatcannot be exactly estimated. This said, our analyses suggest that assubjective health declines it results in increases in psychologicaldistress, and that the inverse is also true, albeit to a lesser degree.Hence, our findings suggest that subjective health ratings actuallyhad greater multiwave influence on psychological distress, thandid psychological distress on subjective health ratings. We mustemphasize, however, that even with three waves we have studieda limited time frame and what we may have found in regard topsychological distress and physical health is that physical healthrather quickly affects psychological distress, but that if psycholog-ical distress affects physical health we would expect that thiswould take more time to germinate and evolve.

Among demographic factors (Tables 3 and 4), it is notable thatgender had both direct and indirect impact on subjective health andpsychological distress. In this regard, women were found to reportpoorer subjective health and greater psychological distress bothdirectly and through their greater psychological distress or poorsubjective heath compared with men. Older individuals also re-ported poorer subjective health and greater psychological distress,and educated individuals reported better subjective health than lesseducated individuals. These findings are similar to those foundfollowing Katrina, where women, older individuals, and lowerSES individuals both had greater sleep impairment, anxiety, anddepression (Adeola, 2009). Likewise, following hurricane expo-sure, older individuals were both more likely to be depressed and

Baseline Interview 6-Month Follow-up 12-Month Follow-up

Trauma Exposure

PsychologicalDistress

Poor SubjectiveHealth

PsychosocialResource

Loss

EconomicResource

Loss

Support

Days.60

Ratings

PTS

Depress

Inter

.83

intra

.89

R2 = .26

R2 = .34

.95

.60

.42

.13

.89

-.15

.23

.13

.08

.08

-.07

.30

Figure 4. Standardized structural equation modeling results of final trimmed model with poor subjective healthas a mediator, demonstrating the relationship of social support, political violence exposure, economic andpsychosocial resource loss, and subjective health predicting psychological distress. Support � social support.Exposure � exposure to political violence. Intra � intrapersonal resource loss. Inter � interpersonal resourceloss. PTS � posttraumatic stress symptom severity. Depress � depressive symptom severity. Days � numberof days that health has been poor in past 30 days. Rating � overall health rating. All coefficients at or above .10are significant at p � .001, all others are p � .05.

17SPECIAL SECTION: VIOLENCE, DISTRESS, AND HEALTH

to report poorer subjective health (Ruggiero et al., 2009), andamong Lebanese citizens exposed to chronic war conditions, olderand less educated individuals were more likely to report greaterpsychological distress (Roberto, Chaaya, Fares, & Khirs, 2006).These findings further support that those with fewer resources aremore vulnerable to the negative impact of chronically stressfulenvironmental conditions.

The question arises as to whether subjective health assessment ismore about health or a reflection of psychological states influencedby trauma-related psychological distress. First, much research in-dicates that subjective and objective health reports are substan-tively related (McCullough & Laurenceau, 2004; Singh-Manoux etal., 2006). Furthermore, subjective health assessment has beenfound to be important in its own right as it predicts both function-ing and mortality, over and above the influence of objective healthfactors (Idler & Benyamini, 1997; Wolinsky, & Johnson, 1992)Moreover, subjective health ratings are a good indicator of healthbehavior and how individuals will respond to their health circum-stances in terms of exercise, smoking, adherence to medical care,and health care visits (Fylkesnes, 1993; Jakupcak, Luterek, Hunt,Conybeare, & McFall, 2008).

Perceived health may be particularly important for Palestiniansas the chronic nature of the environmental stressors, overcrowdingand poor health services have been emblematic of Palestinianrefugee camps. There is nowhere else in the world where 60 yearsafter being created that refugees are still in “temporary” camps. Itis at this juncture that health meets politics, as the “temporary”refugee camps owe their longevity to the political process andPalestinian aspirations to return these refugees to Israel, with bothsides blaming the other for the camp’s continued existence. In-deed, this may link psychological distress to health perceptions, asthe never-ending nature of the conflict undermines hope and maykeep individuals from seeking to build their lives. This situationhas been found to lead to what has been termed a “fragmented andincoherent” health care system, with as many as 10% of Palestin-ian children having stunted growth (Mataria et al., 2009). It is alsolikely that these health problems are related to the chronic natureof the stressors in this situation, as multiple trauma exposures overtime is a major predictor of physical health problems (Sledjeski,Speisman, & Dierker, 2008).

Strengths and Limitations

This study had both limitations and strengths. A major limitationin making any causal interpretation of the data is that participantshave long-term exposure to this conflict. Hence, the processesunder study capture one period in time, but are interacting with along prior history. Second, some respondents may have refused toparticipate out of political fears, and we cannot estimate how thismight have affected our results. Also, at least some overlap be-tween subjective health ratings and degree of psychological dis-tress can be assumed, and to the extent that these constructs sharevariance, ratings of subjective health may be an artifact of distressrather than an accurate reflection of current healthfulness. Severalof the measures of key constructs in the current study werenecessarily short owing to the space limitations inherent in con-ducting a large scale longitudinal study such as this one. Given thislimitation, this is still one of the few investigations into the role oftrauma on subjective health and the relationship between healthT

able

4B

oots

trap

Ana

lysi

sof

the

Mag

nitu

dean

dSt

atis

tica

lSi

gnif

ican

ceof

Indi

rect

Eff

ects

for

Alt

erna

tive

Med

iati

onM

odel

Inde

pend

ent

vari

able

Med

iato

rva

riab

leD

epen

dent

vari

able

�st

anda

rdiz

edin

dire

ctef

fect

Bm

ean

indi

rect

effe

cta

SEof

mea

na95

%C

Im

ean

indi

rect

effe

ct(l

ower

and

uppe

r)a

Res

ourc

elo

ss3

Subj

ectiv

ehe

alth3

Psyc

holo

gica

ldi

stre

ss(.

133)

�(.

415)

�.0

55.1

14.7

43.0

55,.

178

Gen

der

(fem

ale)3

Subj

ectiv

ehe

alth3

Psyc

holo

gica

ldi

stre

ss(.

114)

�(.

415)

�.0

47.6

56.6

56.2

90,1

.115

Edu

catio

n3

Subj

ectiv

ehe

alth3

Psyc

holo

gica

ldi

stre

ss(�

.107

)�

(.41

5)�

�.0

44�

.268

�.2

68�

.446

,�.1

14In

com

e3

Subj

ectiv

ehe

alth3

Psyc

holo

gica

ldi

stre

ss(�

.161

)�

(.41

5)�

�.0

67�

.570

�.5

70�

.812

,�.3

64A

ge3

Subj

ectiv

ehe

alth3

Psyc

holo

gica

ldi

stre

ss(.

381)

�(.

415)

�.1

58.0

87.0

87.0

67,.

114

Not

e.C

I�

conf

iden

cein

terv

al;

expo

sure

�ex

posu

reto

polit

ical

viol

ence

.R

esou

rce

loss

�ps

ycho

soci

alre

sour

celo

ss.

All

indi

rect

effe

cts

are

sign

ific

ant

atp

�.0

1.a

The

seva

lues

are

base

don

unst

anda

rdiz

edpa

thco

effi

cien

ts.

18 HOBFOLL, HALL, AND CANETTI

and trauma-related psychological distress. Strengths of the studyinclude this being one of the only 3-wave studies of an area of suchhigh level conflict ever studied with such large, random samplingon a national level. In particular, it is rare to have such carefulinterviews outside of Western contexts, although these have beenincreasing (Ai et al., 2002; Cardozo et al., 2000; ; de Jong et al.,2001; Goenjian et al., 2000; Johnson & Thompson, 2008). Byrandom sampling, we also are able to analyze models includedemographic variables that are themselves important.

Conclusions

This study provides critical insight into the process of chronictraumatic stress exposure of political violence and occupationwhich is unfortunately common in many regions of the world. Italso provides valuable knowledge about how trauma exposureimpacts mental and physical health and to the important resiliencyvalue of social support. As prior studies have found major healthproblems for citizens of the Palestinian Authority (Mataria et al.,2009), our results yield information for potential intervention.Although we might not be able to reduce trauma exposure, inter-vention could aim at reducing secondary resource loss, supportingpeople’s and communities’ resource reservoirs, and buttressingsocial support. These processes have been referred to as the fiveprinciples of mass casualty intervention (Hobfoll et al., 2007), andinclude promoting: (1) sense of safety, (2) calming, (3) a sense ofself-and-community efficacy, (4) connectedness, and (5) hope.Intervention along these lines would both have the likely effect ofreducing psychopathology and health problems.

References

Adeola, F. O. (2009). Mental health and psychosocial distress sequelae ofKatrina: An empirical study of survivors. Human Ecology Review, 16,195–210.

Ai, A. L., Peterson, C., & Ubelhor, D. (2002). War-related trauma andsymptoms of posttraumatic stress disorder among adult Kosovar refu-gees. Journal of Traumatic Stress, 15, 157–160.

American Psychiatric Association. (2000). Diagnostic and statistical man-ual of mental disorders (4th ed., text rev.) Washington, DC: Author.

Anderson, J. C., & Gerbing, D. W. (1988). Structural equation modeling inpractice: A review and recommended two-step approach. PsychologicalBulletin, 103, 411–423.

Arbuckle, J. (2006). Amos 7.0 User’s Guide. Amos Development Corpo-ration: Spring House, PA.

Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variabledistinction in social psychological research: Conceptual, strategic, andstatistical considerations. Journal of Personality and Social Psychology,51, 1173–1182.

Basoglu, M., Livanou, M., Crnobaric, C., Franciskovic, T., Suljic, E.,Duric, D., et al. (2005). Psychiatric and cognitive effects of war informer Yugoslavia: Association of lack of redress for trauma and post-traumatic stress reactions. Journal of the American Medical Association:Journal of the American Medical Association, 294, 580–590.

Benight, C. C., Freyaldenhoven, R. W., Hughes, J., Ruiz, J. M., Zoschke,T. A., & Lovallo, W. R. (2000). Coping self-efficacy and psychologicaldistress following the Oklahoma City bombing. Journal of AppliedSocial Psychology, 30, 1331–1344.

Bentler, P. M. (1990). Comparative fit indexes in structural models. Psy-chological Bulletin, 107, 238–246.

Bleich, A., Gelkopf, M., & Solomon, Z. (2003). Exposure to terrorism,stress-related mental health symptoms, and coping behaviors among a

nationally representative sample in Israel. Journal of the AmericanMedical Association: Journal of the American Medical Association, 290,612–620.

Browne, M. W., & Cudeck, R. (1993). Alternative ways of assessing modelfit. In K. A. Bollen & J. S. Long (Eds.), Testing structural equationmodels (pp. 136–162). Newbury Park, CA: Sage.

B’Tselem. (2008a). Fatalities in the first Intifada. Retrieved from http://www.btselem.org/english/statistics/First_Intifada_Tables.asp

B’Tselem. (2008b). Intifada fatalities. Retrieved from http://www.btselem.org/english/statistics/Casualties.asp

B’Tselem. (2008c). Statistics on Palestinians in the custody of the Israelisecurity forces. Retrieved from http://www.btselem.org/english/statistics/Detainees_and_Prisoners.asp

Cardozo, B. L., Vergara, A., Agani, F., & Gotway, C. A. (2000). Mentalhealth, social functioning, and attitudes of Kosovar Albanians followingthe war in Kosovo. Journal of the American Medical Association:Journal of the American Medical Association, 284, 569–577.

Caspi, Y., Saroff, O., Suleimani, N., & Klein, E. (2008). Trauma exposureand posttraumatic reactions in a community sample of Bedouin membersof the Israel Defense Forces. Depression and Anxiety, 25, 700–707.

de Jong, J. T. V. M., Komproe, I. H., Van Ommeren, M., El Masri, M.,Araya, M., Khaled, N., et al. (2001). Lifetime events and posttraumaticstress disorder in 4 postconflict settings. Journal of the American Med-ical Association: Journal of the American Medical Association, 286,555–562.

Dennis, M. F., Flood, A. M., Reynolds, V., Araujo, G., Clancy, C. P.,Barefoot, J. C., et al. (2009). Evaluation of lifetime trauma exposure andphysical health in women with posttraumatic stress disorder or majordepressive disorder. Violence Against Women, 15, 618–627.

Dirkzwager, A. J., van der Velden, P. G., Grievink, L., & Yzermans, C. J.(2007). Disaster- related posttraumatic stress disorder and physicalhealth. Psychosomatic Medicine, 69, 435-440.

Eadie, E. M., Runtz, M. G., & Spencer-Rodgers, J. (2008). Posttraumaticstress symptoms as a mediator between sexual assault and adverse healthoutcomes in undergraduate women. Journal of Traumatic Stress, 21,540–547.

Enders, C. K., & Bandalos, D. L. (2001). The relative performance of fullinformation maximum likelihood estimation for missing data in struc-tural equation models. Structural Equation Modeling, 8, 430–457.

Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993).Reliability and validity of a brief instrument for assessing post-traumaticstress disorder. Journal of Traumatic Stress, 6, 459–473.

Freedy, J. R., Shaw, D. L., Jarrell, M. P., & Masters, C. R. (1992). Towardsan understanding of the psychological impact of natural disasters: Anapplication of the conservation resources stress model. Journal of Trau-matic Stress, 5, 441–454.

Fylkesnes, K. (1993). Determinants of health care utilization: Visits andreferral. Scandinavian Journal of Social Medicine, 21, 40–50.

Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J.,et al. (2002). Psychological sequelae of the September 11 terroristattacks in New York City. New England Journal of Medicine, 346,982–987.

Goenjian, A. K., Steinberg, A. M., Najarian, L. M., Fairbanks, L. A.,Tashjian, M., & Pynoos, R. S. (2000). Prospective study of posttraumaticstress, anxiety, and depressive reactions after earthquake and politicalviolence. American Journal of Psychiatry, 157, 911–916.

Golding, J. M. (1994). Sexual assault history and physical health inrandomly selected Los Angeles women. Health Psychology, 13, 130–138.

Graham, J. W. (2003). Adding missing-data relevant variables to FIML-based structural equation models. Structural Equation Modeling: AMultidisciplinary Journal, 10, 80–100.

Graham, J. W., Hofer, S. M., Donaldson, S. I., MacKinnon, D. P., &Schafer, J. L. (1997). Analysis with missing data in prevention research.

19SPECIAL SECTION: VIOLENCE, DISTRESS, AND HEALTH

In K. Bryant, M. Windle & S. West (Eds.), The science of prevention:Methodological advances from alcohol and substance abuse research(pp. 325–366). Washington, DC: American Psychological Association.

Grieger, T. A., Cozza, S. J., Ursano, R. J., Hoge, C., Martinez, P. E., Engel,C. C., et al. (2006). Postraumatic stress disorder and depression inbattle-injured soldiers. American Journal of Psychiatry, 163, 1777–1783.

Hall, B. J., Hobfoll, S. E., Canetti-Nisim, D., Johnson, R., Palmieri, P., &Galea, S. (in press). Exploring the association between posttraumaticgrowth and PTSD: A national study of Jews and Arabs during the 2006Israeli-Hezbollah War. Journal of Nervous and Mental Disease.

Hall, B. J., Hobfoll, S. E., Palmieri, P. A., Canetti-Nisim, D., Shapira, O.,Johnson, R. J., et al. (2008). The psychological impact of impendingforced settler disengagement in Gaza: Trauma and posttraumatic growth.Journal of Traumatic Stress, 21, 22–29.

Hobfoll, S. E. (1989). Conservation of resources: A new attempt at con-ceptualizing stress. American Psychologist, 44, 513–524.

Hobfoll, S. E. (1998). Stress, culture, and community: The psychology andphilosophy of stress. New York: Plenum Press.

Hobfoll, S. E., Canetti-Nisim, D., & Johnson, R. J. (2006). Exposure toterrorism, stress-related mental health symptoms, and defensive copingamong Jews and Arabs in Israel. Journal of Consulting and ClinicalPsychology, 74, 207–218.

Hobfoll, S. E., Canetti-Nisim, D., Johnson, R. J., Palmieri, P. A., Varley,J. D., & Galea, S. (2008). The association of exposure, risk, andresiliency factors with PTSD among Jews and Arabs exposed to repeatedacts of terrorism in Israel. Journal of Traumatic Stress, 21, 9–21.

Hobfoll, S. E., & Lilly, R. S. (1993). Resource conservation as a strategyfor community psychology. Journal of Community Psychology, 21,128–148.

Hobfoll, S. E., Palmieri, P. A., Johnson, R. J., Canetti-Nisim, D., Hall,B. J., & Galea, S. (2009). Trajectories of resilience, resistance anddistress during ongoing terrorism: The case of Jews and Arabs in Israel.Journal of Consulting and Clinical Psychology, 77, 138–148.

Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J.,Friedman, M. J., et al. (2007). Five essential elements of immediate andmid-term mass trauma intervention: Empirical evidence. Psychiatry:Interpersonal and Biological Processes, 70, 283–315.

Hollifield, M., Warner, T. D., Lian, N., Krakow, B., Jenkins, J. H., Kesler,J., et al. (2002). Measuring trauma and health status in refugees: Acritical review. Journal of the American Medical Association: Journal ofthe American Medical Association, 288, 611–621.

Idler, E., & Benyamini, Y. (1997). Self-rated health and mortality: Areview of twenty-seven community studies. Journal of Health and socialbehavior, 38, 21–37.

Israeli Central Bureau of Statistics (ICBS). (2007). Statistical abstract ofIsrael 2007 - no. 58 subject 2 table no. 7: Localities (1) and population,by district, sub-district, religion and population group.

Ironson, G., Wynings, C., Schneiderman, N., Baum, A., Rodriguez, M.,Greenwood, D., et al. (1997). Posttraumatic stress symptoms, intrusivethoughts, loss, and immune function after Hurricane Andrew. Psycho-somatic Medicine, 59, 128–141.

Jakupcak, M., Luterek, J., Hunt, S., Conybeare, D., & McFall, M. (2008,May). Posttraumatic stress and its relationship to physical health func-tioning in a sample of Iraq and Afghanistan war veterans seeking postdeployment VA health care. Journal of Nervous and Mental Disease,196, 425–428.

Jerusalem Media and Communication Centre (JMCC). (2008). The Inti-fada: An overview, the first two years. Retrieved from http://www.jmcc.org/research/reports/intifada.htm#statist

Johnson, H., & Thompson, A. (2008). The development and maintenanceof post-traumatic stress disorder (PTSD) in civilian adult survivors ofwar trauma and torture: A review. Clinical Psychology Review, 28,36–47.

Kaiser, C. F., Sattler, D. N., Bellack, D. R., & Dersin, J. (1996). Aconservation of resources approach to a natural disaster: Sense of co-herence and psychological distress. Journal of Social Behavior & Per-sonality, 11, 459–476.

Kimerling, R., & Calhoun, K. S. (1994). Somatic symptoms, social sup-port, and treatment seeking among sexual assault victims. Journal ofConsulting and Clinical Psychology, 62, 333–340.

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9:Validity of a brief depression severity measure. Journal of GeneralInternal Medicine, 16, 606–613.

Little, R. J. A., & Rubin, D. B. (1987). Statistical analysis with missingdata. New York: Wiley.

MacKinnon, D. P., Lockwood, C. M., Hoffman, J. M., West, S. G., &Sheets, V. (2002). A comparison of methods to test mediation and otherintervening variable effects. Psychological Methods, 7, 83–104.

Mataria, A., Khatib, R., Donaldson, C., Bossert, T., Hunter, D., Alsayed,F., et al. (2009). The health-care system: An assessment and reformagenda. The Lancet, 373, 783–784.

McCullough, M. E., & Laurenceau, J. P. (2004). Gender and the naturalhistory of self-rated health: A 59-year longitudinal study. Health Psy-chology, 23, 651–655.

Miguel-Tobal, J. J., Cano-Vindel, A., Gonzalez-Ordi, H., Iruarrizaga, I.,Rudenstine, S., Vlahov, D., et al. (2006). PTSD and depression after theMadrid March 11 train bombings. Journal of Traumatic Stress, 19,69–80.

Muthen, L. K., & Muthen, B. O. (2002). Mplus: The comprehensivemodeling program for applied researchers [Computer program]. LosAngeles: Muthen & Muthen.

Norris, F. H., & Kaniasty, K. (1996). Received and perceived socialsupport in times of stress: A test of the social support deteriorationdeterrence model. Journal of Personality and Social Psychology, 71,498–511.

O’Toole, B. I., & Catts, S. V. (2008). Trauma, PTSD, and physical health:An epidemiological study of Australian Vietnam veterans. Journal ofPsychosomatic Research, 64, 33–40.

Palmieri, P. A., Galea, S., Canetti-Nisim, D., Johnson, R. J., & Hobfoll,S. E. (2008). The psychological impact of the Israel-Hezbollah War onJews and Arabs in Israel: The impact of risk and resilience factors.Social Science & Medicine, 67, 1208–1216.

Palestinian Central Bureau of Statistics. (PCBS; 1999). Population, hous-ing, and establishment Census, 1997; Locality type booklet. Ramallah,Palestine: Palestinian Central Bureau of Statistics.

Palestinian Center for Human Rights (PCHR). (2008). Palestinian Centerfor Human Rights. Statistics related to Al Aqsa Intifada: 29 September,2000, updated 27 August, 2008. Retrieved from http://www.pchrgaza.org/alaqsaintifada.html

PCBS. (2008). Palestine in figures, 2007. Ramallah, Palestine: PalestinianCentral Bureau of Statistics.

Pham, P. N., Weinstein, H. M., & Longman, T. (2004). Trauma and PTSDsymptoms in Rwanda: Implications for attitudes toward justice andreconciliation. Journal of the American Medical Association: Journal ofthe American Medical Association, 292, 602–612.

Punamaki, R., Komproe, I., Qouta, S., Elmasri, M., & de Jong, J. (2005).The role of peritraumatic dissociation and gender in the associationbetween trauma and mental health in a Palestinian community sample.American Journal of Psychiatry, 162, 545–551.

Roberto, S. B., Chaaya, M., Fares, J. E., & Khirs, J. A. (2006). Psycho-logical distress after occupation: A community cross-sectional surveyfrom Lebanon. British Journal of Health Psychology, 11, 695–702.

Ruggiero, K. J., Amstadter, A. B., Acierno, R., Kilpatrick, D. G., Resnick,H. S., Tracy, M., et al. (2009). Social and psychological resourcesassociated with health status in a representative sample of adults affectedby the 2004 Florida hurricanes. Psychiatry, 72, 195–210.

20 HOBFOLL, HALL, AND CANETTI

Schafer, J. L. (1997). Analysis of incomplete multivariate data. New York:Chapman and Hall.

Schafer, J. L. (1999). NORM: Multiple imputation of incomplete multivar-iate data under a normal model. University Park, PA: Department ofStatistics, Pennsylvania State University.

Schlenger, W. E., Caddell, J. M., Ebert, L., Jordan, B. K., Rourke, K. M.,Wilson, D., et al. (2002). Psychological reactions to terrorist attacks:Findings from the national study of Americans’ reactions to September11. Journal of the American Medical Association: Journal of the Amer-ican Medical Association, 288, 581–588.

Shalev, A. Y., & Freedman, S. (2005). PTSD Following terrorist attacks:A prospective evaluation. American Journal of Psychiatry, 162, 1188–1191.

Shrout, P. E., & Bolger, N. (2002). Mediation in experimental and non-experimental studies: New procedures and recommendations. Psycho-logical Methods, 7, 422–445.

Singh-Manoux, A., Martikainen, P., Ferrie, J., Zins, M., Marmot, M., &Goldberg, M. (2006). What does self rated health measure? Results fromthe British Whitehall II and French Gazel cohort studies. Journal ofEpidemiology & Community Health, 60, 364–372.

Sledjeski, E. M., Speisman, B., & Dierker, L. C. (2008). Does number oflifetime traumas explain the relationship between PTSD and chronicmedical conditions? Answers from the National Comorbidity Survey-Replication (NCS-R). Journal of Behavioral Medicine, 31, 341–349.

Tracy, M., Hobfoll, S. E., Canetti-Nisim, D., & Galea, S. (2008). Predictorsof depressive symptoms among Israeli Jews and Arabs during the AlAqsa Intifada: A population-based cohort study. Annals of Epidemiol-ogy, 18, 447–457.

Vedantham, K., Brunet, A., Boyer, R., Weiss, D. S., Metzler, T. J., &Marmar, C. R. (2001). Posttraumatic stress disorder, trauma exposure,

and the current health of Canadian bus drivers. The Canadian Journal ofPsychiatry/La Revue canadienne de psychiatrie, 46, 149–155.

Vinck, P., Pham, P. N., Stover, E., & Weinstein, H. M. (2007). Exposureto war crimes and implications for peace building in Northern Uganda.Journal of the American Medical Association: Journal of the AmericanMedical Association, 298, 543–554.

Ware, J., & Sherbourne, C. (1992). The MOS 36-item short form health-survey (SF-36): Conceptual framework and item selection. MedicalCare, 30, 473–483.

Weisberg, R. B., Bruce, S. E., Machan, J. T., Kessler, R. C., Culpepper, L.,& Keller, M. B. (2002). Nonpsychiatric illness among primary carepatients with trauma histories and posttraumatic stress disorder. Psychi-atric Services, 53, 848–854.

Weiss, R. S. (1974). The provisions of social relationships. In Z. Rubin(Ed.), Doing unto others (pp. 17–26). Englewood Cliffs, NJ: PrenticeHall.

West, S. G., Finch, J. F., & Curran, P. J. (1995). Structural equation modelswith nonnormal variables: Problems and remedies. In R. H. Hoyle (Ed.),Structural equation modeling: Concepts, issues, and applications. (pp.56–75). Thousand Oaks, CA: Sage.

Wolinsky, F., & Johnson, R. (1992). Perceived health status and mortalityamong older men and women. Journals of Gerontology, 47, S304–S312.

Zoellner, L. A., Goodwin, M. L., & Foa, E. B. (2000). PTSD severity andhealth perceptions in female victims of sexual assault. Journal of Trau-matic Stress, 13, 635–649.

Received June 3, 2009Revision received November 5, 2009

Accepted November 18, 2009 �

E-Mail Notification of Your Latest Issue Online!

Would you like to know when the next issue of your favorite APA journal will be availableonline? This service is now available to you. Sign up at http://notify.apa.org/ and you will benotified by e-mail when issues of interest to you become available!

21SPECIAL SECTION: VIOLENCE, DISTRESS, AND HEALTH