Life under occupation: citizenship and other factors influencing the well-being of university students living in the West Bank

Abstract

There is substantial evidence that individuals affected by conflict suffer poor physical and mental outcomes, particularly in indicators of well-being. This study assesses the health-related quality of life (HRQoL), perceived stress and insecurity of Palestinian young adults in the West Bank. We surveyed 398 university students from Nablus (mean age = 20.1) using the SF-36 to measure HRQoL, the PSS-4 to assess stress and a context-specific insecurity instrument. A third of participants reported Israeli citizenship, and the results indicated better outcomes in these individuals in several outcomes, with the noteworthy exception of insecurity. This study is one of the first to assess citizenship of West Bank Palestinians as a potential covariate to predict measures of well-being. Because citizenship is such a meaningful issue for Palestinians and is related to individual freedom and access to resources, this study suggests that there are complex dynamics outside of typical demographic variables that contribute to well-being.

Keywords:

• Health-related quality of life
• stress
• insecurity
• occupied Palestinian Territory
• citizenship
• conflict

Introduction

While the overall number of conflicts and deaths directly attributed to conflicts has decreased (Human Security Report Project 2013), conflict continues to include practices that irrevocably alter societies. Annexation, occupation, targeting of civilians and civilian infrastructure, denial of humanitarian aid to ailing communities, wide-scale neglect of large populations of refugees and internally displaced people: these consequences of conflict linger long after political settlement may be reached (Weissbecker 2009). Conflict promotes a cycle of poverty, poor health and educational deficits that is perpetuated in future generations, weakening societies and making them more vulnerable to future conflict (Pederson 2002).

As one of the most entrenched conflicts in modern times, the Israeli/Palestinian conflict provides a prime example of the economic, societal and health effects of conflict. The Palestinian territories, made up of the Gaza Strip and the West Bank, have been in some stage of conflict with the Israeli state since its establishment in 1948. Aside from its sheer length, the Palestinian conflict has many unique factors that differentiate it from other modern conflicts, including a prolonged manifestation of ‘structural violence’ (Galtung 1969) such as: a separation wall, a state-supported settlement infrastructure, hundreds of checkpoints, no autonomous control on any borders by the Palestinian governance, a permit system that stifles housing and business development, administrative detention and regular military raids (Burton 2015). The denial of freedom of movement has significantly reduced access to adequate health care, nutrition, clean water, sanitation and other basic services (Stefanini and Ziv 2004). Indeed, the occupation is likely the largest threat to Palestinian health and well-being, with many factors that contribute to a health care system that is inadequate (Bogue et al. 2014).

The youth of a war-afflicted society are often seen as one of the most vulnerable populations. Although youth are in the process of transitioning to adulthood, Palestinian youth can be stuck in a period of ‘waithood’, trying to form their own autonomous lives as they are limited by the physical and mental obstacles that war inherently brings (McEvoy-Levy 2014). The perspective of this age group is vital to understanding how future generations will interpret and deal with societies experiencing some level of conflict. College students who have experienced chronic war-related trauma have shown high levels of psychological distress, such as depression, anxiety and post-traumatic stress disorder (PTSD), in areas such as Iraq (Magruder, Kiliç, and Koryürek 2015), Serbia and Kosovo (Zikic et al. 2015), Lebanon (Abu-Saba 1999) and Darfur (Badri, Van de Borne, and Crutzen 2013).

This study assesses three well-being indicators (health-related quality of life [HRQoL], stress and insecurity) among young adults attending a university in the West Bank, a territory affected by decades of violent conflict and military occupation. It examines factors, such as student demographics, including citizenship, which could be related to these indicators.

We begin by reviewing the relevant literature about well-being and demographic characteristics in the Palestinian territories. Following our methodology and results, we discuss how this study fits into the framework of existing scholarship of psychological distress in Palestine and conflict-affected populations more broadly.

Literature review

This section describes the unique barriers to Palestinian well-being and reviews studies examining factors related to HRQoL, stress and insecurity. The importance of examining citizenship as a factor in Palestinian well-being is introduced. Finally, the distinctive role of university students in Palestinian society is reviewed.

Well-being in the Palestinian territories

Aside from the physical injuries that are specific to populations in war zones, the civilian West Bank population experiences daily trauma that contributes to high levels of psychological distress and disorder in the population, including among youth (Khamis 2012; Pat-Horenczyk et al. 2009). The studies documenting these problems tend to focus on rates of mental disorder, such as anxiety, depression or PTSD (Elbedour et al. 1999; Khamis 2008). A 2016 literature review found that factors such as exposure to violence, rural (as opposed to urban) living and lack of economic resources were most associated with PTSD in Israeli and Palestinian adolescents (Rosshandler, Hall, and Canetti 2016). However, assessing mental health in this population as a mere medical diagnosis outside of the human rights and social justice framework may not wholly capture the lived experience of Palestinians, and thus a ‘quality of life’ approach is called for (Giacaman et al. 2011). A culturally competent approach to understanding Palestinians’ unique mental health challenges and needs is necessary (Marie, Hannigan, and Jones 2016). A multitude of measures can be used to assess the ‘contextualised mental suffering’ of Palestinians – meaning that what the individual is experiencing is expected under extraordinarily stressful circumstances and not merely an expression of mental disorder (Barber et al. 2016). This ‘quality of life’ approach provides the foundation for the current study.

Factors related to HRQoL

Broad measurements of quality of life (QoL), and HRQoL specifically, have been used to assess Palestinians in several settings. In numerous studies focused on the Gaza population, the elderly, women, the infirm, villagers and other rural dwellers, and people who have personally experienced trauma, tend to report lower scores and thus worse feelings of QoL and well-being (Abu-Rmeileh et al. 2011; Baune and Aljeesh 2006; Eljedi et al. 2006; Massad et al. 2011). Indeed, most of the research on Palestinian mental health and well-being focuses on the Gaza Strip, but distinctions between the Gaza Strip and West Bank (such as more direct military action, overcrowding and the siege in the Gaza Strip) make it difficult to generalize any conclusions about well-being in Palestinians. More studies in the West Bank, as well as other groups of Palestinians (such as those in Israel) are necessary to create a fuller picture (Haj-Yahia 2007).

Among the socio-economic factors that could affect Palestinian outcomes, education and employment appear to serve as buffers that can mitigate the impact of volatile environments, even when considering a period of intense political violence (Hammoudeh, Hogan, and Giacaman 2013). In another study, income led to higher QoL in at least some subscales (Baune and Aljeesh 2006).

Factors related to stress in Palestinian society

Individual-level perceived stress has been used to illuminate the relationships between stress and behavioural disorders (Al kalaldeh and Abu Shosha 2012) that have been found in the Palestinian population, such as PSTD, depression and anxiety (Canetti et al. 2010; Khamis 1998, 2005; Sagi-Schwartz 2008). Men are more distressed by direct exposure to political violence, while women are more negatively impacted by the socio-political stressors. However, loss of resources is shown to be the strongest predictor of mental distress in either sex (Canetti et al. 2010).

Lack of social support, poor health and perceived future threats are associated with increased risk for stress reactions such as PTSD (Hall, Murray, et al. 2015). A ‘loss spiral’, where increased stress due to resource loss leads to further resource loss, has also been identified in traumatized Palestinians (Heath et al. 2012). Many studies in this field focus on children, as trauma encountered during development tends to be particularly damaging to a fragile psyche. Increased risk for PTSD, depression and anxiety, and overall stress is elevated in children exposed to political victimization (Khamis 2012). Cumulative exposure to political violence in multiple instances is more likely to contribute to post-traumatic stress in Palestinian children (Dubow et al. 2012). The ‘multitraumatic environment’ that encompasses the daily lived experience of Palestinians is posited to be the primary stressor in Palestinian life (Srour and Srour 2006).

Factors related to insecurity in the Palestinian territories

Human security is a concept that has been a significant addition to the lexicon of international policy. It represents a shift in perspective from state/institutional security to individual security, acknowledging that the state or its actors could be contributors to the insecurity of individuals (Christie 2010). Insecurity may be a more sensitive measure to use under conditions of conflict than QoL instruments, which could be more influenced by individual perceptions of what ‘quality of life’ means (Hammoudeh, Hogan, and Giacaman 2013).

During particular periods of intense political violence, such as the 2008–2009 war in Gaza, insecurity has been shown to increase significantly in the immediate aftermath (Hammoudeh, Hogan, and Giacaman 2013). Insecure Palestinian mothers exposed to higher levels of political violence were shown to be more likely to experience stress, anxiety and depression than mothers with higher security (Guttmann-Steinmetz et al. 2011). A study in Gaza using an expanded version of the insecurity scale used in this study found that men, older persons, those with higher education and full-time employees also reported lower insecurity (Ziadni et al. 2011). These characteristics tend to represent stability and access to resources, both factors that can contribute to higher rates of security.

The importance of citizenship

The Israeli occupation has led to fracturing within the Palestinian community in many aspects. While the geographic barriers are obvious, another means of separation between Palestinians is that of citizenship. The disparity between groups of Palestinians along citizenship lines and their subsequent access to resources indicates that citizenship may be a factor that impacts QoL.

In the West Bank, there are several distinct citizenship categories. The primary group is Palestinian citizens. These residents are issued a passport by the State of Palestine, but must use their Israeli Ministry of Interior-issued Identity card for most official purposes. Another group is those who are eligible for citizenship from neighbouring Arab countries who maintain the citizenship status of that country (most often, Jordan, as many Palestinians were given Jordanian citizenship when the West Bank was under Jordanian occupation from 1948 to 1967).

A number of Palestinians are Israeli citizens. Those who live, work or study in the West Bank are among the one-fifth of Israel’s population that are Arab descendants of pre-1948 villages and towns that remained in what is now Israel, and they have full Israeli citizenship. Also, Palestinians living in East Jerusalem (roughly 300,000 people) may apply to be full Israeli citizens (about 24,000 have since 1967), but until lately they are more likely to be permanent residents with specialized Israeli ID cards, not Israeli passports. While permanent residence allows them to live and work in Israel, and receive some social benefits, they are not full citizens and their residency can be revoked if they leave East Jerusalem. Due to fears of the tenuous nature of permanent residence, some reports suggest that rates of these individuals applying for full Israeli citizenship may be increasing, despite their political and personal opposition to the principle (Lubell 2015). The final group in the West Bank is registered Palestinian refugees, defined as those displaced and expelled during the Nakba in 1948, and their descendants. Although all Palestinians living in the occupied Palestinian territories face challenges, refugees are among the most vulnerable, with those living in camps experiencing high rates of poverty and unemployment (Al-Qudsi 2000).

There is a complex hierarchy regarding access to services, resources and freedom of movement when discussing citizenship for Palestinians. Civic identity is one of the most fundamental personal characteristics of Palestinians throughout the territories. Palestinians with Israeli citizenship living in Israel, as minorities in what Rouhana & Ghanem describe as an ‘ethnic state’, (1998), are generally less affluent and experience more discrimination regarding government services than their Jewish counterparts, resulting in lower social capital (Baron-Epel et al. 2008). However, they are significantly more advantaged than Palestinians with Palestinian citizenship living in the West Bank, who are essentially governed by both a fragile and ineffectual Palestinian Authority and the parameters of the occupation. Without the opportunities that might be afforded by autonomous (but increasingly fleeting) statehood, the Palestinian economy is highly dependent on fluctuating levels of foreign aid that does not allow for meaningful strides in development (Le More 2005). Palestinians living in the West Bank are also severely restricted in their movement. Aside from hundreds of checkpoints and the separation wall, they are essentially barred from entering Israel (including accessing Ben Gurion airport in Tel Aviv) with minor exceptions, it is extremely difficult to travel even to Gaza or East Jerusalem, and the only point of entry/exit for Palestinians in the West Bank is a border crossing with Jordan. These barriers make it difficult to access services (such as health facilities, social services and schools) that are not in their immediate vicinity.

Based on the disparate levels of access to social services and freedom of movement, we pose the question of how citizenship may influence indicators of well-being. Our hypothesis is that Palestinians with Israeli citizenship would have greater HRQoL, less insecurity and less perceived stress than the other groups due to their inherent social, economic and political advantages. While studies investigating the mental status and well-being of Palestinians living in the state of Israel exist (Braun-Lewensohn, Sagy, and Roth 2010; Cohen and Eid 2007; Hall, Saltzman, et al. 2015; Schiff et al. 2010, among others), there appears to be no existing literature about the well-being of Palestinians with Israeli citizenship who live or work/study in the West Bank.

University students in Palestinian society

The population of the West Bank, like much of the Middle East, is very young, with a median age of 22.7 years (CIA Factbook 2015). Thus, most of the people in the West Bank have lived their entire lives under occupation (Barber et al. 2014). The majority of the existing literature on the psychological experience of Palestinians assesses the perspectives of children or teenagers (Khamis 2008, 2013) experiencing circumstances such as house demolition (Shalhoub-Kevorkian 2009), parental detention (Shehadeh et al. 2015), the 1993 peace treaty (Qouta, Punamaki, and El Sarraj 1995) and the first Intifada (Barber 2001). Additionally, the community-level traumas experienced by Palestinians in the Nakba in 1948 and the Nakseh of 1967 may have been passed down through each subsequent Palestinian generation (Baker and Shalhoub-Kevorkian 1999).The age range of the current study (18–26) ensures that the entirety of the sample has grown up in a situation where the occupation is, in a way, normalized; these Palestinians express their own form of agency by purely ‘getting used to’ the circumstances and continuing to live their lives (Allen 2008).

Aside from their age, university students have a special role in Palestinian society that makes them a population worth studying in their own right. In 2011, 11.3% of Palestinians had completed at least an undergraduate degree (Palestinian Central Bureau of Statistics 2012). The Palestinian higher education system, which did not even exist until after the 1967 war (Zelkovitz 2014), is now composed of 14 universities and 20 community colleges throughout the West Bank and Gaza Strip. The occupation of Palestinian lands by the Israeli state motivated Palestinians to establish institutions that could both service the need for movement-restricted youth to attain higher education, as well as maintain a national identity when formation of other types of state institutions were blocked. Universities now serve not only as touchstones for viable Palestinian state institutions, but are a representation of empowerment and resistance to the occupation by educating students despite the physical and political obstacles (Bruhn 2006). Universities may be direct targets of political control and even retribution by the Israeli army, such as expelling and arresting students, preventing them from being able to travel to their campus, or even temporary closure of the entire university (Akesson 2015). Because presidential and legislative elections have been delayed for years, universities are often the only place where young people can voice their political views by voting in campus elections. Universities are thus often also seen as a barometer of general public opinion.

Despite the unique position of university students in the Palestinian environment, surprisingly few studies have been conducted about their health or well-being. Studies of university students in Gaza have reported high levels of stress and anxiety, especially as a result of the consequences of the siege; however, due to the unique circumstances in Gaza, this result cannot be generalized to students in the West Bank (Joma’a and Thabet 2015; Lubbad and Thabet 2009). Studies describing the psychological health of students in the West Bank are scarce: one study of university students from 12 countries using self-administered surveys found higher rates of suicide attempts and psychological distress among Palestinians (Eskin et al. 2016). A 2004 study used university students in focus groups to develop a social/health scale to assess the March 2002 invasion of five West Bank towns, but ultimately the study did not focus on the students (Giacaman et al. 2004). Other health-related studies of West Bank Palestinian university students have looked at reproductive health (Musmar, Afaneh, and Mo’alla 2013), smoking rates (Musmar 2012), use of herbal remedies (Sawalha et al. 2008), dieting behaviours (Bayyari, Henry, and Jones 2013), self-medication practices (Sawalha 2008) and psychological well-being of Internet users (Rayan et al. 2016). To our knowledge, this is the first study to assess the HRQoL, stress or insecurity of university students in the West Bank.

Purpose of this study

This study investigates the following research questions:

(1)	What is the current state of HRQoL, stress and insecurity of young adult university students in the West Bank?
(2)	What demographic and socio-economic factors are associated with these outcomes?
(3)	What role, if any, does citizenship play in the well-being of university students in the West Bank?

Methods

Study location and sample

The research was conducted with both undergraduate and graduate students in classes randomly selected by university administration from those that were in session on the main campus during the data collection period of the study. The survey was distributed at An-Najah University in Nablus, West Bank, in July/August 2014. An-Najah University is one of the largest universities in the territory with a total of 17,807 students in 2014–2015. The Palestinian Central Bureau of Statistics (PCBS) reports that there are over 200,000 students in universities throughout the West Bank (2015), meaning that approximately 8–10% of them attend An-Najah.

Only students above the age of 18 were eligible to participate in the survey. Participants had the option to opt-out of the survey or cease participation at any time, but no students did so (although six surveys were returned blank). The sample that was utilized (university students) was selected primarily for the presence of the target age range (18–26), as young adults in this context tend to be more politically aware and active. The PCBS reports that one-third of the West Bank population are youth between the ages of 15–29, making this an important segment of the population to understand.

Procedure

Ten classrooms with an average of 40–50 students were selected throughout the university, with permission of the appropriate administrators, professors and the Institutional Review Board. Paper surveys were given to the students in each class, and survey completion took about 20 min. No incentive was provided. Overall, 421 surveys were distributed, with 6 surveys returned blank and 17 completed by foreign nationals (primarily from Indonesia). These were excluded from analysis, leaving 398 surveys that were completed and used for investigation, for a usable response rate of 94.5%.

Instruments and measures

Medical Outcomes Study Scale, Short Form (SF-36)

Developed in 1992 by Ware and Sherbourne, the SF-36 has been used for evaluation within clinical practice, as well as in the general population, to assess HRQoL (Obidoa, Reisine, and Cherniack 2010). The standard SF-36 has been translated into Arabic and validated for use in Arab-speaking populations, with a Cronbach α-coefficient of 0.94 (Guermazi et al. 2012). The scale has eight subscales that measure eight constructs: Physical Functioning, Physical Role, Bodily Pain, General Health, Emotional Role, Mental Health, Social Functioning and Vitality (Ware and Sherbourne 1992). Each of these constructs is calculated by an average of the responses to subsets of 36 questions. The SF-36 scoring tool dictates that the responses are recoded into a standardized 1–100 scale for each construct, with higher scores indicating better functioning; a global SF-36 score (an average of all of the constructs) can be calculated for use in analysis as well. Additionally, the eight constructs may also be compiled to represent two broad constructs: the Physical Construct (made up of Physical Functioning, Physical Role, Bodily Pain and General Health) and the Mental Construct (composed of Emotional Role, Mental Health, Social Functioning and Vitality) (Ware and Kosinski 2001).

This scale has been used internationally, not just in populations with health conditions, but also in general populations experiencing personal trauma such as abuse (Alsaker et al. 2006), and members of the military (Smith et al. 2007). In Palestine specifically, the scale has been used to assess populations in Gaza post-war (Ghuneim and Abed 2010). An abbreviated version (the SF-12) was used in a study investigating political violence as a threat to health in Palestinian women in the West Bank (Sousa 2013), and several subscales were adapted in a larger study assessing psychological and physical health for Palestinians in the West Bank, Gaza Strip and East Jerusalem (Hobfoll, Hall, and Canetti 2012).

Perceived Stress Scale-4 (PSS-4)

An abbreviated (four-question) version of the Perceived Stress Scale (PSS), one of the most commonly used in assessing psychological stress, was also used in the survey instrument. Cohen, Kamarck, and Mermelstein (1983) tested the scale for reliability and validity among university students in their original study, and it has since been used widely in university populations (Boals and Banks 2012; Chao 2012). It has also been used in post-war civilian populations (Etwel et al. 2014). Cronbach’s α of the PSS-4 is typically reported as >0.70, including an Arabic translation (Loubir et al. 2014). The score for each question ranges from 0 to 4. The scoring of the instrument includes computing an average score for each survey, with higher values (i.e. closer to 4) indicating higher stress.

Human insecurity scale

Lastly, a 10-question human insecurity scale instrument, adapted from a longer instrument developed by Mataria et al. (2009) and revisions used in Ziadni et al. (2011), was included to assess the level of insecurity felt by each individual (Cronbach’s α = .82). This instrument was developed for use in Palestinian communities, and was based on information developed from focus groups and interviews (Mataria et al. 2009). The survey was pilot tested, modified and validated for use in this setting, taking into account specific aspects of Palestinian life that may lead to insecurity, such as fear of displacement, fear for personal and familial safety, and general fear in daily life (Mataria et al. 2009). Ten questions are examined on a range of 1–5, with 5 indicating higher levels of insecurity. An average of the 10 answers was calculated and used to represent an overall insecurity score ranging from 1 to 5, ranging from least insecurity (1–2) to high insecurity (5) (Ziadni et al., 2011).

Demographic and socio-economic factors

The independent variables that captured demographic and socio-economic information in this study were selected based on the literature review as indicators that are most likely to impact HRQoL, stress and insecurity in this Palestinian sample. These include categorical household income (measured in Jordanian Dinars [JD]), citizenship (Israeli, Palestinian, Jordanian or Palestinian refugee), household size (categorical), religion, city status (urban or rural), sex and age in years. For more detail on each measure, see Table 1.

Table 1. Demographic characteristics of respondents, West Bank 2014.

Characteristic	N	%
Age (mean = 20.1)	n = 385
18	36	9.3
19	86	22.3
20	128	33.2
21	83	21.6
22	35	9.1
23	9	2.3
24+	8	2.1
Citizenship	n = 397
Palestinian	228	57.4
Jordanian	26	6.5
Israeli	132	33.2
Palestinian refugee	11	2.8
City Type	n = 398
Urban	195	49.0
Rural	203	51.0
Sex	n = 394
Male	114	28.9
Female	280	71.0
Household	n = 398
1	2	0.5
2–4	52	13.1
5–7	214	53.8
8–10	112	28.1
11+	18	4.5
Religion	n = 396
Muslim	377	95.2
Christian	14	3.5
Jewish	2	0.5
Other	3	0.8
Household Income (in Jordanian Dinar)	n = 380
<6000 JD	155	40.9
6100–12,000 JD	113	29.7
12,100–18,000 JD	50	13.2
18,100–24,000 JD	33	8.7
>24,100 JD	29	7.6

Data analysis

The data were cleaned and analysed using SPSS Statistics version 22. Descriptive statistics were calculated first to get a full picture of the sample and the variation present in the demographic and socio-economic variables and the three primary outcome variables (global SF-36 score, PSS score and Insecurity score), along with the 10 separate constructs of the SF-36. Further exploration of the data involved calculation of outcome means by sex and citizenship. Using t-tests and ANOVA, the mean differences of outcomes by sex, citizenship, household size and household income, along with levels of significance, were estimated. Lastly, four multiple regressions were performed, one with each outcome (HRQoL, security and stress) as the dependent variable, and one with HRQoL as the dependent variable with stress and insecurity added to the model as predictors of HRQoL. All demographic and socio-economic variables were included as independent variables in the regression analysis but only those with statistical significance were presented. Analysing the impact of citizenship and sex on HRQoL measures increases the likelihood of a Type-1 error due to the multiple comparisons (Pocock, Hughes, and Lee 1987). A sequential Bonferroni adjustment was used to account for multiple hypothesis testing (Holm 1979).

Results

Demographic and socio-economic descriptive statistics

Table 1 presents the demographic and socio-economic characteristics of the respondents. The mean age of the 398 respondents was 20.1. About 70% were female, a proportion that is slightly higher than the general composition of the university population (approximately 60% female). The higher proportion of females corresponds to a post-second Intifada trend of more females than males attending university (61% of total Palestinian university students were female in 2014/2015) (Palestinian Central Bureau of Statistics 2015). Only 57.4% reported having Palestinian citizenship, with the next highest group reporting Israeli citizenship, at 33.2%. Jordanian citizenship and refugees were poorly represented, and thus were removed from bivariate and regression analyses. Urban/rural status was split evenly, with 51% of respondents reporting coming from a rural area. Typical with Palestinian households, which tend to be multigenerational, over half (53.8%) of the sample reported 5–7 people living in their household, with nearly a third (32.6%) reporting 8 or more. The PCBS reports that in a typical housing unit, housing density is an average of 5.78, corresponding with our sample. As expected, an overwhelming majority, 95.2%, reported their religious affiliation as Muslim. Almost half of the participants (41%) reported an annual household income of less than 6000 JD, the lowest available income bracket, with an additional 30% reporting incomes in the next highest bracket, between 6100 and 12,000 JD. Only 7.6% percent of respondents report incomes in the highest available bracket, more than 24,100 JD annually. See Table 1 for more detailed respondent characteristics.

Means of outcome variables: overall, and by citizenship and sex

Mean outcome scores and differences by sex and citizenship status, can be found in Table 2. The first column of Table 2 presents the overall means and standard deviations of the outcome variables. Of the eight constructs captured by the SF-36 scale, the one with the greatest mean for the entire sample was the Physical Functioning construct (mean = 77.4, SD = 24.5), indicating Physical Functioning was the highest scored subscale of HRQoL, while the lowest mean was displayed by the Emotional Role construct (mean = 50.2, SD = 41.72).

Table 2. Means of outcome variables: overall and by citizenship and sex.

Indicator	Overall		Citizenship				Sex
	Mean	SD		Mean	p	SD		Mean	p	SD
SF-36^a
Physical Construct	72.2	17.0	Palestinian	71.6		72.2	Male	70.2		16.9
			Israeli	73.0		60.9	Female	73.0		17.0
Physical Functioning	77.4	24.5	Palestinian	77.5		77.4	Male	70.8		29.1
			Israeli	76.0		62.4	Female	79.9		22.1
Physical Role	68.2	34.7	Palestinian	67.7		68.2	Male	63.5		35.9
			Israeli	69.4		50.5	Female	70.1		34.0
Bodily Pain	77.2	20.7	Palestinian	76.7		77.2	Male	81.6	**	19.0
			Israeli	78.7		73.5	Female	75.4		21.1
General Health	63.2	15.6	Palestinian	62.1		63.2	Male	62.8		16.5
			Israeli	65.0		55.9	Female	63.4		15.2
Mental construct	56.1	20.3	Palestinian	54.8	*	56.1	Male	59.3		21.0
			Israeli	60.4		50.1	Female	54.9		19.8
Emotional role	50.2	41.7	Palestinian	45.7	***	50.2	Male	53.8		39.8
			Israeli	61.8		39.4	Female	48.4		42.3
Mental health	55.3	20.2	Palestinian	54.2		55.3	Male	57.1		20.5
			Israeli	58.0		49.9	Female	54.6		19.8
Social functioning	66.6	23.4	Palestinian	66.2		66.6	Male	68.6		25.2
			Israeli	69.6		60.0	Female	65.9		22.4
Vitality	53.6	18.5	Palestinian	52.6		53.6	Male	58.0	**	19.4
			Israeli	56.3		49.8	Female	51.91		17.7
Global SF-36	64.4	16.2	Palestinian	63.7		64.4	Male	65.0		16.8
			Israeli	66.6		55.8	Female	64.2		15.8
PSS-4
Stress	2.03	0.51	Palestinian	2.04		0.46	Male	1.86		0.60
			Israeli	1.95		0.60	Female	2.09		0.46
Insecurity
Insecurity	3.38	.92	Palestinian	3.28	**	0.92	Male	3.32		0.93
			Israeli	3.58		0.90	Female	3.41		0.91

Notes: p = probability of no difference between categories using t test (adjusted for multiple hypothesis testing). If blank, p > 0.05.

^a In each SF-36 construct, the scale is 1–100, with a score closer to 100 indicating better functioning, including for bodily pain, which will indicate less bodily pain.

* p ≤ 0.05;

** p ≤ 0.01;

*** p ≤ 0.001.

Outcome variables by citizenship

The next two columns present the results by citizenship and sex from the bivariate t-tests. With few exceptions, the individuals with Israeli citizenship reported higher HRQoL and lower stress, but for the most part these were not significantly different from Palestinian citizenship. We found statistically significant mean differences in the Emotional Role (t[348] = −3.539, p < 0.001) and Mental Health (t[318] = −2.354, p = 0.019) constructs, indicating some measure of better mental health for those with Israeli citizenship. In contrast, the Israeli citizenship group did report higher mean insecurity (t[341] = −3.005, p = 0.003),

Outcome variables by sex

Significant differences between males and females existed for Vitality (t[372] = 2.903, p = 0.004) and Bodily Pain (t[385] = 2.705, p = 0.007). In both cases, the mean for males was higher (indicating higher vitality and less bodily pain). Interestingly, these are both indicators that respond to physical perceptions, and no difference was seen in indicators that measured mental outcomes.

Mean differences in outcome variables by household income and size

Table 3 presents ANOVA results for mean differences in global outcome scores by household size and income. Regarding the SF-36, mean differences were found between income groups for the Vitality, F(4357) = 3.0, p = 0.019, and Social Functioning, F(4370) = 2.827, p = 0.025, constructs. Tukey post hoc analysis indicated that within these constructs, scores would increase as income increased, meaning better functioning with higher income. The Insecurity instrument, F(4, 357) = 2.405, p = 0.049, reported statistically significant mean differences between income levels, but there was no conclusion that could be made from Tukey analysis about the direction of significance. No statistically significant mean differences in outcomes were found between household sizes.

Table 3. Comparison of means for outcome variables by household size and income.

Characteristic	SF-36		PSS-4		Insecurity
	Mean	SD	Mean	SD	Mean	SD
Household Size	64.42	16.17	2.03	0.51	3.38	0.92
1 (n = 2)	59.19	24.21	2.12	0.18	2.60	1.27
2–4 (n = 52)	65.55	16.67	1.88	0.63	3.42	0.88
5–7 (n = 207)	64.97	15.63	2.03	0.49	3.37	0.87
8–10 (n = 111)	63.79	17.19	2.07	0.51	3.45	1.02
11+ (n = 17)	59.24	14.15	2.26	0.34	3.07	0.91
	F = 0.576, p = 0.680		F = 2.160, p = 0.073		F = 1.044, p = 0.384
Income	64.36	16.00	2.03	0.52	3.38	0.91
<6000 JD (n = 152)	61.97	16.22	2.04	0.52	3.48	0.88
6100–12,000 JD (n = 110)	65.50	16.73	2.05	0.49	3.26	0.95
12,100–18,000 JD (n = 49)	68.25	12.55	1.92	0.49	3.15	0.88
18,100–24,000 JD (n = 32)	64.39	15.86	2.06	0.50	3.66	0.89
>24,100 JD (n = 29)	64.86	17.30	2.11	0.63	3.44	0.92
	F = 1.487, p = 0.206		F = 0.760, p = 0.552		F = 2.405, p = 0.049*

* p ≤ 0.05.

Multiple regression of demographics, socio-economics and outcome variables

Results from the multiple regressions, with each primary outcome variable (global SF-36 score, PSS and Insecurity score) as the dependent variables, are presented in Table 4. Independent variables included the demographic and socio-economic characteristics (age, gender, income, city type, household size and citizenship, excluding religion since it was overwhelming homogenous). In multiple regression analysis, no variables in the model for global SF-36 score were statistically significant.

Table 4. Predictors of outcome variables^a.

Independent variables	SF-36		PSS-4		Insecurity		SF-36^c
	β	p value	β	p value	β	p value	β	p value
Palestinian Citizenship^b	−0.095	0.151	0.065	0.267	−0.457	***	−0.137	*
Household Size	−0.068	0.302	0.139	*	0.071	0.328	0.021	0.732
City type^d	0.042	0.508	−0.158	**	0.005	0.962	0.030	0.620
Sex^e	−0.034	0.597	0.189	**	0.175	0.127	0.003	0.959
Age	−0.015	0.812	0.134	*	−0.006	0.767	−0.026	658
Insecurity	NA	NA	NA	NA	NA	NA	−0.176	**

^a The following did not significantly predict any of the outcome measures: religion, income.

^b Omitted category = Israeli citizenship.

^c SF-36 model modified with PSS and Insecurity as predictor variables. NA = not applicable. PSS was not significant.

^d 1 = Urban, 2 = Rural.

^e 1 = Male, 2 = Female.

* p ≤ 0.05

** p ≤ 0.01

*** p ≤ 0.001.

The model predicting PSS explained nearly 11% of the variance (R² = 0.106, p < 0.001), and several variables significantly predicted PSS score: household size (β = 0.139, p = 0.016), urban location (β = −0.158, p = 0.005), female sex (β = 0.189, p = 0.001) and age (β = 0.134, p = 0.015). These results indicate that larger household size, urban residency, female sex and older age were associated with a higher perceived stress level. With the exception of urban residency, all of these factors can indicate less ability to access resources.

The Insecurity model (R² = 0.057, p = 0.012) was only significantly predicted by Palestinian citizenship (β = −0.244, p < 0.001), indicating that Palestinian citizenship was associated with a lower level of insecurity than Israeli citizenship.

A final regression examined the relationship between the SF-36 score as the dependent variable, adding the stress and insecurity constructs as additional independent variables to those in the previous models. The model was significant (R² = 0.068, p = 0.023) and insecurity was found to be a significant predictor of SF-36 (b = −0.176, p = 0.006), suggesting that greater insecurity predicts lower HRQoL. Palestinian citizenship was also found to be a significant predictor (b = −0.137, p = 0.046), with the negative coefficient indicating that Israeli citizenship was associated with greater HRQoL when the model controlled for stress and insecurity.

Discussion

This study contributes to the literature by assessing various well-being indicators (HRQoL, stress and insecurity) among young adults in the West Bank, a territory affected by decades of violent conflict and military occupation. It also explores demographic and socio-economic determinants of these indicators. There are several unique aspects of this study: (1) the participants are civilians (not combatants or veterans) and have experienced the effects of conflict for their entire lives (not as a single event or series of individual events) and still live in the conflict-affected area; (2) although many valuable studies have assessed QoL, insecurity and stress in the Palestinian territories, none have assessed all three measures within the same population, particularly university students, within the West Bank; (3) unlike other QoL tools such as the WHOQoL instrument, the SF-36 is underutilized in this specific population; and (4) this is one of the first studies to assess the QoL, insecurity and stress of Palestinians with Israeli citizenship that are living in the West Bank.

Although the SF-36 has been used largely in populations afflicted with chronic disease or disability, it has shown utility in establishing general population health indicators. For example, a study using the SF-36 to assess HRQoL on a population in Shanghai, China found overall high scores in all constructs (Wang et al. 2008). The SF-36 mean scores of their participants are notably higher than those of our group of 18–29 year-olds in the West Bank. We also found the SF-36 scores of four studies from a review article of non-conflict areas (Obidoa, Reisine, and Cherniack 2010) to be higher than the mean scores in this study. However, the mean scores in this West Bank sample were higher than those found another SF-36 study of individuals aged 15–49 from the Gaza Strip (another conflict area) who suffered non-fatal injuries as a result of the 2008 Israeli operation Cast Lead (Ghuneim and Abed 2010), and those of a sample of abused women (Alsaker et al. 2006).

Unlike studies that found socio-economic status to be a protective factor for insecurity (Giacaman et al. 2009; Ziadni et al. 2011), we did not find such a relationship with this data-set. Literature has also suggested that larger household sizes are related to higher levels of insecurity (Ziadni et al. 2011), and while we did not find that to be the case in this study, we did find that larger household size predicted higher perceived stress. These findings support the notion that when resources are stretched, individual well-being measures may decrease.

Existing literature also suggests that living in rural areas is associated with lower HRQoL and higher mental distress (Abu-Rmeileh et al. 2011; Rosshandler, Hall, and Canetti 2016; Shehadeh et al. 2015), another finding that was not reinforced by this study. In fact, the only difference found between urban and rural dwellers in the current analysis was that urban living predicted higher levels of perceived stress. This may be attributed to the fact that villages tend to experience less military intrusion and presence (Veronese et al. 2012).

Female sex predicted higher mean perceived stress than male sex, a finding supported by a study of university students in Jordan, a country that is socially and culturally similar to the West Bank (Hamdan-Mansour and Dawani 2008) and other studies of psychological distress in Palestine (Rosshandler, Hall, and Canetti 2016). The overall status of women in the region, and the greater social restrictions they are subject to as opposed to their male counterparts, may be a potential explanation for this outcome (Abu-Rabia-Queder and Arar 2011).

The predictor with the most significant statistical relationships was citizenship. Palestinians with Israeli citizenship, while not granted the same rights and resources as Jewish Israelis, have greater access to the social services of the state of Israel and also have fewer barriers to travel than their counterparts with Palestinian citizenship. As Israeli citizens, they experience a higher degree of social mobility and more support for entrepreneurship, while being less entangled in the bureaucratic trappings of being a citizen of a quasi-state (Sharabi 2010). Thus, their access to resources and personal freedom is greater, and, as this study suggests, their personal well-being is higher as a consequence. Hobfoll, Hall and Canetti detail how Conservation of Resources theory is relevant to the type of mass trauma experienced by Palestinians and how lack of access to material and economic resources can predict poor mental well-being in distressed populations (2012). In nearly every SF-36 indicator, t-tests indicated that mean scores for those with Israeli citizenship were higher, with statistically significant differences in Emotional Role and the Mental Construct. Mean PSS scores were moderately lower as well. This supports the argument that the resource disparity experienced by Palestinians with different forms of citizenship may play a role in the results of this study; further investigation on this issue is needed.

Arab and Jewish schools within the state of Israel are typically segregated; officially, the reasoning is so that each group can maintain their cultural identity and language (Payes 2013). However, investment in Arab education within the state of Israel is vastly disproportionate to their share of the population, with less funding and more crowded classrooms in Arab schools, less money invested in Arab educational bodies and little representation in the Ministry of Education. Despite being 20% of the Israeli population, only 8% of students accepted to Israeli universities are Arab (Golan-Agnon 2006).

Palestinian citizens of Israel may choose to study in the West Bank because they feel more socially and physically isolated in Israel, and may experience discrimination or prejudice when attending Israeli institutions, particularly if they do not speak Hebrew (Ben-Ari 2004; Moore and Aweiss 2002). Despite their slightly higher status compared to Palestinians without Israeli citizenship, Palestinians have been discriminated against as second class citizens in Israel, with high rates of unemployment and poverty, subpar infrastructure in Palestinian communities in Israel and a decades-long battle for equal rights and resources for social services, such as adequate education (Jabareen 2006). This has led to a ‘growing number of an increasingly frustrated generation of Palestinian college graduates who are well aware of their state of collective relative deprivation as members of a national minority’ (Makkawi 2008). The Palestinian citizens of Israel may also miss the cultural experience and feeling of collective identity that they may experience in Arab schools where they feel less disadvantaged and more socially recognized (Abu-Rabia-Queder and Arar 2011).

The only counter-intuitive result with citizenship was Insecurity score, where Israeli citizenship predicted higher scores (greater insecurity). This is a puzzling finding that should be investigated further. Lavi and Solomon (2005) conducted a study comparing the differences in outcomes as a result of exposure to terror and threat between Palestinian youth living in either the West Bank or Israel. They found that, counter to their expectations, there was no difference in perception of danger between the groups. They suggest that (a) many Palestinian citizens of Israel identify with those in the West Bank, and (b) these citizens may also feel that, as an ethnic minority in the Israeli state, ‘they are part of a community whose social and cultural integrity is under threat’. Another study found that Arabs living in Israel were 2.5 times more likely to meet PTSD criteria than Jews, and proposed that ‘the tensions of dual allegiance’, along with their minority status in Israel, may be potential causes (Bleich et al. 2006). These factors may account for a heightened sense of personal insecurity in Palestinian citizens of Israel, even if other facets of well-being (where access to resources are more significant) are at levels equal to or above their West Bank counterparts.

While these studies are not completely congruent with the current study, they do suggest some complex underlying social, cultural and societal factors that Palestinians with Israeli citizenship may contend with, complicating their sense of well-being. Clearly, more research on the status of Palestinian citizens of Israel who are living, working or studying in the West Bank should be conducted, especially when compared to West Bank Palestinian citizens.

Limitations

It is important to note that the outcomes measured in this study are self-reported and thus rely heavily on the objectivity of the respondent, which may be affected by mood, short-term stress or other issues with mental functioning. This is typical in instruments that assess indicators of QoL and well-being, and indeed, as these measures are based entirely on an individual’s perception of their circumstance, the subjective nature of these types of assessments is unavoidable (Schnurr et al. 2009). Further, the SF-36 does not directly measure health status, and so the results from this study should not be related to clinical or medical outcomes (Reed and Moore 2000). This study purposely selected a sample of young adults by surveying university students, who undoubtedly do not entirely represent their entire age group or the West Bank population as a whole.

Conclusion

This study contributes to the broad, but complex, literature related to well-being outcomes as a result of conflict, particularly in the Palestinian territories. While some of the existing evidence in the field was supported, there were several areas where the data from this study provided additional or divergent information. Results indicate that there remains much to know about the state of population health and well-being for those living in conflicted areas. These populations are often hard to access, particularly for longitudinal data, and context-specific cultural, religious and other societal factors may influence how an individual might self-report their personal well-being.

While it is clear that conflict, especially when coupled with ‘daily stressors’, can cause enduring damage to individuals and communities (Miller and Rasmussen 2010), less is known about what can be done to minimize some of these effects, especially when considering that victims of conflict are often already vulnerable populations with scarce access to resources. Further investigation also needs to define the precise determinants that most significantly reduce (and vice versa, increase) adaptability and resilience, considering the variance of response in different individuals and between different settings (Panter-Brick 2010). While small-scale interventions on select Palestinian populations have shown success in decreasing mental distress and increasing measures such as educational gains (Barron, Abdallah, and Smith 2013), only a lasting political solution can promote long-term gains in community-level development and well-being.

Notes on contributors

Yara M. Asi, PhD, is a lecturer in the Department of Health Management and Informatics in the College of Health and Public Affairs at the University of Central Florida. Her research interests include social determinants of health outcomes in vulnerable populations, global health, QoL and medical anthropology.

Lynn Unruh, PhD, RN, LHRM, is a professor of Health Services Administration in the Department of Health Management and Informatics at the University of Central Florida. A nurse and health economist, Unruh’s research focuses on health care workforce and quality issues at the micro and macro levels.

Xinliang Liu, PhD, is an assistant professor in the Department of Health Management and Informatics at the University of Central Florida. His research focuses on health services utilization, costs, quality of care and performance evaluation of health care organizations.

Disclosure statement

No potential conflict of interest was reported by the authors.