The development and validation of the Palestinian children's traumatic events checklist in a war-torn environment.

Traumatic experiences in childhood can lead to trauma symptoms and impaired mental health, especially when children are exposed to war and political violence. Despite significant attention to child's exposure to traumas, few instruments to detect potentially traumatic events have been validated psychometrically. Our study aimed to develop, adapt and validate a user-friendly traumatic events checklist in Palestinian children living in three areas affected by low-intensity war and ongoing political and military violence. 965 Palestinian children (494 males and 471 females) living in the Gaza Strip, West Bank and East Jerusalem were administered with a tailor-made Traumatic Events checklist, Children Impact of Events scale, and Strengths and Difficulties Scale. Exploratory and Confirmatory factor analysis was run to detect the factorial structure of the checklist. Furthermore, ANOVA was performed to identify statistically significant demographic differences among participants. A three factors structure emerged with Political violence-related traumatic experiences (PVTE), military violence against individuals (MVI), and military violence against individuals and families (MVF). Gaza children and adolescents resulted in being the most exposed to potentially traumatic events. The instrument can clearly portray potentially traumatic experiences in children exposed to violent events and adverse childhood experiences.

Positive and negative effects of child's agency on trauma symptoms and psychological difficulties in war-like conditions. The mediating role of hope and life satisfaction.

BACKGROUND: Children affected by war and political violence deploy agentic competencies to cope with trauma symptoms and psychological difficulties. However, it does not always act as a protective factor to help them adjust to potentially traumatic events. AIMS: We expected to explore the association between agency, trauma symptoms and psychological difficulties and the mediating role of hope and life satisfaction in a group of child victims of military violence in Palestine. METHODS: 965 children aged 8 to 14 were assessed with self-reported measures, War Child Agency Assessment Scale, Children Revised Impact of events scale, Strengths and difficulties scale, Child Hope Scale and Brief Multidimensional Students Life Satisfaction Scale. Structural Equation Modelling was performed having Agency as a predictor, trauma symptoms, psychological difficulties as an outcome variable and life satisfaction and hope as a mediator. RESULTS: We found a direct and positive effect of agency on trauma symptoms, psychological difficulties, and life satisfaction and hope on the two dependent variables. Life satisfaction and hope mediated the association between agency and the outcome variables. CONCLUSION: Agency can help defend children from trauma and psychological maladaptation when it acts on life satisfaction and hope. At the same time, it might worsen psychological dysfunctions when working directly on trauma symptoms and difficulties. Clinical interventions must help children to foster agentic resources in activating hope and life satisfaction.

Concerns, perceived risk, and hesitancy on COVID-19 vaccine: a qualitative exploration among university students living in the West Bank.

The current study aimed to explore Palestinian university students' perceptions and concerns about COVID-19 vaccination hesitancy. Our sample comprised 50 university students selected using snowball sampling techniques from Palestinian universities in the West Bank, Palestine. Thematic content analysis was conducted to identify the main themes of semi-structured interviews with students. The results of the thematic content analysis yielded four main themes: Students' perceptions and concerns on COVID-19 vaccinations, perceived risks of vaccination, experiences related to vaccination, and causes of vaccination hesitancy. Participants expressed concerns and doubts about the vaccine's safety, showing high hesitancy and scepticism; they also reported different causes for COVID-19 vaccination hesitancy in the Palestinian context, such as the lack of confidence in vaccines, false beliefs about vaccines, and peculiar political instability and conflict of the Palestinian territories enduring a military occupation undermining the health system's capacity to respond to the COVID-19 outbreak appropriately. Health authorities and policymakers are urgently called to invest in and potentiate awareness campaigns to change the diffuse people's stereotypes related to the COVID-19 vaccine in the Palestinian territories.

Quality of life is associated with vaccine reluctance via mental health and fear of covid-19: an exploratory investigation on a Palestinian sample.

Quality of life (QoL) has been studied as an antecedent of good mental health in contexts characterized by extreme poverty and acute conflict. The covid-19 crisis exacerbated the risks of health-related consequences in such contexts. Vaccination campaigns have been started worldwide to contain the virus outbreak with high rates of hesitancy and refusal. Our exploratory study sheds light on the relationship between QoL and vaccine reluctance via mental health and fear of covid-19 in a Palestinian population affected by military occupation or socioeconomic marginalization. Who-QolBref, Fcov-19, and Dass were administered to 1122 Palestinian adults living in the occupied territories and Israel. Structural equation modelling was applied to test the relations between variables. Results showed that fear of COVID-19, stress, anxiety and depression mediated the association between QoL and vaccination reluctance with a good model fit (χ2 (5) = 828.37; p = .001; GFI=.93; AGFI=.94; RMSEA=.046; NFI=.94; CFI=.95). QoL and mental health were negatively associated with stress (ßX, Y = - .35; p < .001), depression (ßX, Y = -.37; p < .001), and anxiety (ßX, Y = -.36; p < .001). QoL and fear of COVID- 19 (ßX, Y = -.16; p < .001) were inversely correlated. A positive effects was found between stress (ßM, Y = .17; p < .001), anxiety (ßM, Y = .18; p < .001), and depression (ßM, Y = .17; p < .001), fear of COVID-19 and vaccination reluctance (ßX, Y = .23; p < .001). According to our findings, Public health measures to ease the social suffering of people with low QoL due to conflict and social marginality might favour the acceptance of the vaccine.

Political violence and posttraumatic stress symptoms among Palestinians: The mediating roles of sense of belongingness and loneliness.

The current study investigated the correlation between political violence and posttraumatic stress symptoms (PTSS) and whether the sense of belongingness (SOB) and loneliness mediate the correlation between the two variables among Palestinians living in a society characterised by high political violence and prolonged traumatic events. The study sample consisted of 590 Palestinian adults, consisting of 360 men and 230 women, and were recruited using non-probabilistic convenience sampling methods from a village in the northern region of the occupied Palestinian territories. This study suggests a positive correlation between political violence and PTSS, a positive correlation between loneliness and PTSS, and a negative correlation between SOB and PTSS. SOB and loneliness mediated the correlation between political violence and trauma-related symptoms.

Fear of coronavirus (COVID-19) and mental health outcomes in Palestine: The mediating role of social support.

The current investigation was conducted to test the correlation between fear due to coronavirus (COVID-19) and mental health outcomes (stress, depression, and anxiety) and the mediating role of social support during the Covid-19 Pandemic in Palestine. Structural equation modeling (SEM) was performed to test the conceptual model, where fear of Covid-19 was considered as a predictor, social support as a mediating variable, and mental health (stress, depression, and anxiety) as outcomes. The participants involved were 370 Palestinians, 266 females, and the remaining were males. Participants were recruited through online methods; Facebook advertising, Network email, and Twitter during the COVID-19 in Palestine. Results of the study showed that fear related to COVID-19 was positively and significantly correlated with mental health outcomes (anxiety; r = .29, p < .01, depression; r = .25, p < .01, and stress; r = .36, p < .01), while negatively correlated to perceived emotional support (r = -.30, p < .01), support seeking (r = -.29, p < .01), and received support (r = -.31, p < .01). Results of SEM indicated a standardized total effect of social support on mental health outcomes (ßX, M = -.57; p < .001), and an indirect but statistically significant effect (via social support, ßX, M, Y = -. 286; p < .01). These results indicate that social support fully mediated the relationship between fear associated with COVID-19 and mental health distress (stress, depression, and anxiety). The current study supported previous findings demonstrating that fear related to COVID-19 positively correlated with mental health distress (depression, anxiety, and stress). In addition, social support mediated the relationship between fear of COVID19 and mental health outcomes. However, further investigations are needed to test the correlation between current study variables and other associated factors and develop intervention programs targeting affected populations during crises to enhance mental health outcomes.

Spatial agency among children living in the Dheisheh refugee camp in the West Bank: a qualitative investigation of space and place as risk and protection factors from political and military violence.

BACKGROUND: In Palestine, the ongoing Israeli occupation shapes and endangers all spaces that are used by children in their everyday lives. In this study, Palestinian children were considered active agents in their lives, both affecting and being affected by the world around them. Our research aimed to explore the role of resources, competencies, and attitudes of spatial agency in the lives of children in the occupied Palestinian territory. Specifically, we investigated how children use domestic and social spaces to actively maintain positive function and wellbeing despite an environmental backdrop of military violence. METHODS: A convenience sample of 29 children aged 7-13 years (mean 9·66, SD 1·63) attending the primary school in Dheisheh refugee camp, West Bank, was selected. 17% (5 of 29) were boys and 83% (24) were girls. All children were asked to draw and describe a map of safe and unsafe places in the camp. Ten children were asked to continue the conversation outdoors using a "walk-along" technique, showing familiar places and narrating their experiences. Data were collected in April, 2018. All of the children's narratives were audiotaped, transcribed, and translated by a local bilingual researcher. Thematic content analysis was applied. Children who have been diagnosed with a physical or psychological disease were excluded from the sample. The study was approved by the ethical board of the University of Milano-Bicocca. Written informed consent was obtained from children and their families, who were informed of the scope of the research. FINDINGS: Five themes emerged: using the mosque and the school to access spiritual and educational resources for subjective wellbeing; internal spaces as a safe place for growth and development (including domestic spaces to experience a sense of protection and security); community spaces to have fun and play an active part in the social and political life of the camp; enjoying the outdoor spaces of the camp despite environmental dangers and the violence of the occupation. Some children perceived risks and lack of safety in their lives. Children's narratives made plain the ways in which their ability to mobilise functioning resources (such as playing and socialising) were constrained by military and community violence, and environmental degradation. Overall, social and external places as spaces to restore a sense of normality and happiness were valorised more by boys than by girls, and girls were more active in internal spaces than in external spaces. INTERPRETATION: Spatial agency is a key factor that potentiates wellbeing in children. Psychosocial interventions should aim to promote children's participation in transforming and reshaping spaces and places for their own protection and to improve the psychological wellbeing of the community. FUNDING: None.

Daily experiences and strategies for psychological survival during the 2014 assaults in Gaza: a retrospective analysis of chronological diaries.

BACKGROUND: Public health research suggests that multiple factors contribute to the mental health sequalae of political violence, but the daily experiences and ongoing strategies of psychological survival during active warfare are not clearly understood. We analysed retrospective chronological diaries from Palestinian women in Gaza, occupied Palestinian territory, to explore their lives during Operation Protective Edge in 2014, when a series of aerial bombardments killed over 2000 Palestinians and left around 500 000 displaced from their homes. METHODS: 20 Palestinian female teachers in Gaza were recruited via an intervention for trauma recovery 1 month after the end of Operation Protective Edge, in September, 2014. Following the experience sampling method, women were asked to chronicle specific memories and affective responses associated with their experiences. Data were imported into qualitative data analysis software, coded line by line, and analysed using content analysis, with special attention to the causes of mental distress associated with political violence. FINDINGS: The women's narratives included memories of exposure to bombings, injuries, death, and destruction of vital infrastructure and systems. Their experiences of flight were described as exhausting and demoralising. Their temporary shelters lacked their basic needs for sanitation, food, and privacy. These experiences resulted in intense terror, grief, exhaustion, hopelessness, and isolation. Strategies of psychological survival included reframing; trying to appreciate "being able to escape death", a sense of solidarity within families and neighbourhoods, and pride and satisfaction found in a context of resistance and global attention to the suffering in Gaza. INTERPRETATION: Our results reveal the importance of tracing the events of warfare, its psychosocial consequences, and the distinct patterns of emotional and logistical survival in Gaza. This study was limited by the representativeness of our study population and the small sample size. Future studies should explore this topic in larger populations. Limitations notwithstanding, in drawing out the unique contribution of reflective narratives of women survivors of war, our study highlights the need to solicit and analyse reflective and chronologically grounded narratives within global mental health epidemiology. FUNDING: None.

Wellbeing, symptoms of trauma, and personal resources in Palestinian professional helpers: a cross-sectional quantitative survey.

BACKGROUND: Professional helpers working in adverse circumstances are at risk of developing psychosocial stress and signs of primary and secondary trauma (eg, anxiety and hyperarousal). We used modelling to investigate whether and to what extent personal resources (ie, post-traumatic growth, sense of coherence, and wellbeing) of Palestinian helpers affected their experience of psychological distress and trauma symptoms. METHODS: Eligible participants were professional health-care providers working in Gaza and the West Bank, occupied Palestinian territory, between June and October, 2018. We used the following quantitative measures: WHO Well Being Index (WHO-5), General Health Questionnaire (GHQ-12), Impact of Event Scale (IES-13), Sense of Coherence Scale (SOC-3), and Post-traumatic Growth Index (PTGI-10). Data were analysed by multivariate structural equation modelling with latent and empirical indicators to test the fit of these constructs to the empirical data. The model was specified to evaluate whether and to what extent mental resources may be interpreted as a set of protective factors mitigating risk factors. The study was approved by the ethics board of the University of Milano-Bicocca, Milan, Italy. Written consent was obtained from participants. FINDINGS: 181 participants were enrolled, ranging in age from 18 to 65 years (mean 31·1, SD 8·7). 135 (75%) were men. The mean GHQ-12 score was 17·7 (SD 7·5), revealing a medium to high degree of psychological trauma. 60 (33%) participants reported low mood (although not necessarily depression) on WHO-5. The structural model showed an excellent fit (χ2 [24] 31·8, p=0·132, root mean square error of approximation 0·043, 90% CI 0·019-0·077). Stronger personal resources were associated with lower levels of both psychological distress (ß=-0·25, p<0·01) and trauma (ß=-0·16, p<0·01). Personal resources were especially associated with reduced levels of anxiety (ß=-0·23, p<0·01) and intrusion symptoms (ß=-0·22, p<0·01). INTERPRETATION: Our integrated model showed that, despite heavy psychological burden, perceptions of post-traumatic growth, coherence, and wellbeing are associated with reduced psychological distress. Targeted training of health-care providers focused on self-awareness of their personal skills and survival resources could improve their psychological health. The study was limited by the cross-sectional research design, and the outcomes of the structural model should be read in terms of probabilistic associations rather than cause-effect relationships. A second limitation concerns the kind of data collected. All the research instruments yielded self-reported quantitative scores, meaning that the standardised ß weights in the model could potentially be an artifact of common method variance (ie, attributable to the measurement method rather than to the constructs themselves. FUNDING: None.

The psychometric properties and the factorial structure of COVID-19 Vaccines Acceptance scale (VAC-COVID-19) within the Arabic language in a Palestinian contex.

BACKGROUND: The COVID-19 Vaccines Acceptance scale (VAC-COVID-19) is an international measure designed to evaluate vaccination acceptance against the COVID-19 virus. The current scale was translated from English to Arabic and validated within the Palestinian context. AIMS: Our study aimed to test the factorial structure and the psychotic properties of the VAC-COVID-19 within the Palestinian context using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) through 484 participants selected using online method techniques. FINDINGS: The VAC-COVID-19 was a reliable and valid method in assessing COVID-19 vaccine acceptance among Palestinians. Results of CFA indicated a stable construct of a two-factor solution in assessing COVID-19 vaccination acceptance in a Palestinian context. (1) Reasons for not receiving the vaccination, and (2) for receiving the vaccination. CONCLUSION: The VAC-COVID-19 was a valid method to assess vaccination acceptance in the Arabic language within the Palestinian context. Therefore, it is recommended to conduct similar studies with diverse samples in Palestinian society; it would be prudent to target at-risk populations needed to develop the scale and its factorial structure. The VAC-COVID-19 can be a useful measure to assess vaccination acceptance among Palestinians, enabling health providers to implement interventions to modify negative attitudes toward not receiving vaccinations.

Human (in)security and psychological well-being in Palestinian children living amidst military violence: A qualitative participatory research using interactive maps.

BACKGROUND: Research has widely evidenced the effects of war and political violence on the functioning of children, with a great accord in diagnosing children's psychological burdens related to their exposure to violence. Yet, within this literature, the influence of the chronic sense of insecurity on their psychological functioning during and after hostilities remains unexplored. METHODS: The present study aimed at exploring interrelated relationships between the perceived insecurity and the children's psychological well-being and their adjustment to trauma. Based on drawings and walk-along interviews with 75 Palestinian children, residents of both the West Bank and Gaza Strip, we offer an analysis of human security-related risks and protective factors that contribute to either promoting or undermining the child's psychological functioning in a context characterized by chronic instability and political violence. RESULTS: A complex network of sources of security and insecurity emerged from the narratives depicting an ecological portrait encompassing the determinants of children's mental health and psychological functioning. The TCA led to the identification of eight main themes: school and associativism; social relations and house as a source of security/insecurity; military occupation as a source of insecurity; national and political identity as a source of safety; mosque and spirituality as a source of safety/unsafety; environment as a source of security/insecurity; and mental health. DISCUSSION: An approach encompassing human security as an explicative model can help in exhaustively portraying the complexity of the Palestinian children's suffering and their competence in adjusting to their traumatic reality. The study draws attention to social, political, environmental and economic determinants of children psychological well-being.

Measuring Traumatic Reactions in Palestinian Children: A Psychometric Assessment of the Children Revised Impact of Event Scale-Arabic Version (CRIES-13A).

The aim of the present study was to test the measurement model and measurement invariance of the Impact of Event Scale (Arabic version) in a large sample of Palestinian children. We estimated (Study 1; n = 610) the measurement model using confirmatory factor analysis. In Study 2 (n = 864), we conducted multigroup (girls and boys) tests of measurement invariance. We pooled the data collected from the participants in the first two studies (Study 3, N = 1474) to assess overall score reliability, as well as the IES' convergent and divergent validity vis-à-vis other measures of child wellbeing and mental health. The outcomes of the statistical analyses supported an invariant 13-item measurement model (intrusion, avoidance, and hyperarousal) for CRIES-13A. Intrusion and hyper-arousal together made up a first-order domain of symptoms (re-experiencing). The combined findings of these studies suggest that the CRIES-13A displays robust psychometric properties and may be used in contexts of military violence.

Social support, resilience, and mental health in a low-intensity warfare context: the effects of siege on university students in Gaza.

BACKGROUND: Gaza has long been enduring a quasi-total siege that significantly undermines quality of life in the region. Gazan youth are particularly affected by the ongoing economic recession, a disrupted environment, and health and food insecurity. These critical circumstances are worsened by the ongoing conflict between Palestine and Israel, which is a cause of death and destruction. AIMS: This cross-sectional study investigated the effects of living under protracted siege conditions on mental distress, resilience, and social support among a sample of Palestinian university students living on the Gaza Strip. METHODS: Five hundred fifty Palestinian university students were recruited at four universities in Gaza. They completed a battery of instruments, including the Gaza Siege Checklist, Depression, Anxiety and Stress Scale (DASS), Resilience Scale (RS), and Berlin Social Support Scales (BSSS). We used structural equation modelling (SEM) to test a conceptual model of social support and resilience as protective factors against the impact on mental distress of living under siege. RESULTS: Our findings indicate that living under siege has direct adverse effects, leading to increased mental distress in the form of anxiety, depression, and acute stress. Enduring siege conditions compromises resilience and sources of social support, thereby increasing subjects' risk of developing psychological distress.

Factor structure and psychometric proprieties of the COVID-19 prevention behaviours (COV19-PB) scale.

We sought to test the COVID19-PB scale's psychometric properties and its dimensionality in a sample composed of 1107 Italian adults aged from 18 to 80 years (M = 39.59; SD = 16.36), 75% (n = 830) females, and 25% (n = 277) males. Exploratory, Confirmatory factor analysis and parallel analysis were used to validate the instrument that resulted from the Ebola Virus protective behaviours scale adaptation. Fear of covid-19 and a 1-item level of adherence to the Covid-19 protection scale were used to test the measure's convergent validity. A four-factor structure emerged from exploratory and confirmatory factor analysis: direct avoidance, avoidance of public spaces, avoidance of social interaction, and talking about the virus as protection. COVID-19 PB was a valuable measure to assess individuals' competencies in assuming correct behaviours during the pandemic.

Psychometric properties of the COVID stress scales (CSS) within Arabic language in a Palestinian context.

The main goal of this study was to examine the psychometric properties of the COVID Stress Scales (CSS) in the Palestinian context and the factorial structure of the instrument. The CSS, a newly emerging internationally standardized measure of stress related to being exposed to or contracting COVID-19, was translated and validated for a Palestinian context to ensure that it can be used to measure COVID-19 stress. The sample of the study consisted of 860 Palestinian adults living in the West Bank of Palestine. Participants' age ranged from 20 to 48 years old (M = 34.7, SD =13.46). They were all recruited from online advertisements, e-mail campaigns, blogs, social media, and SMS campaigns. The CSS was found to be valid in the Arabic language within a Palestinian context. The confirmatory factor analysis yielded six factors: (1) Fears about the dangerousness of COVID-19, (2) fears about the personal social, and economic consequences of COVID-19, fears of disruption in the supply chain, fears of looting or rioting, (3) COVID-19-xenophobia, fears that foreigners are sources of COVID-19, (4) fears about sources of COVID-19-related contamination,(5) traumatic stress symptoms related to COVID-19, and (6) COVID-19-related checking which is consisting with the ordinal structure the scale. The CSS demonstrated a high level of validity and reliability in a Palestinian context and therefore can be considered for future studies as the COVID-19 pandemic persists. Further investigations using the Arabic Language of CSS may have far-reaching implications for measuring and combating the stress of COVID-19 at a personal and societal level for uniquely at-risk populations such as in the occupied territories of Palestine.

Measuring agency in children: The development and validation of the War Child Agency Assessment Scale - Palestinian version (WCAAS-Pal).

In the present article, we aimed at construing a new quantitative measure of children's agency in Palestine. Within a socio-ecological and culturally and contextually informed perspective, the study introduces the development of a new instrument to investigate and evaluate children's agentic practices within their living contexts and their daily lives. First, we evaluated the model of measurement of WCAAS-Pal using a sequential exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Following the principles of testing a quantitative measure in the context of the dual-frame sampling method, the process of validating the quantitative measure was conducted on a group of 1166 Palestinian children aged 9 to 14 years (m = 11.58, sd = 1.54). Second, a sample of 251 Palestinian children aged between 9 and 14 years (m = 11.82, sd = 1.53) was used to compute the reliability of the instrument along with both convergent and divergent validity using the Children Hope Scale and the Children Revised Impact of Event Scale-Arabic Version measures, respectively. The results of the EFA suggested a baseline seven-factor structure to be further assessed via CFA. a complex web of agency domains that might contribute to the child psychological functioning when forced to leave in conditions of ongoing threat and military violence emerged from the analysis.

Quality of life, primary traumatisation, and positive and negative affects in primary school students in the Gaza Strip.

BACKGROUND: Many researchers have reported that exposure to war and ongoing political violence increases mental health problems in children. Results of studies have also shown a high prevalence (58-80%) of post-traumatic stress disorder in war-affected children living in the occupied Palestinian territory. The aim of this study was to estimate the direct and indirect effects of perceived life satisfaction on the consequences of children's exposure to trauma and the balance of positive and negative affect. METHODS: Palestinian children were recruited from primary schools in four refugee camps in the Gaza Strip (Bureij, Gaza Beach Camp, Jabalia, Rafah). All children had been involved in or witnessed one or more episodes of violence involving other people in the 2 months prior to the study (the 2012 Gaza War). We used the Multidimensional Students Life Satisfaction Scale (peers, self, living environment, school, family), the Positive and Negative Affect Scale for Children, and the revised Children Impact of Events scale (intrusion and avoidance symptoms) to test (through structural equation modelling) the moderation effect of life satisfaction on war trauma via positive emotions. FINDINGS: 1276 Palestinian children were enrolled in this study. The model tested with structural equation modelling was robust. Children's life satisfaction influenced both the intrusion (ß=-0·48; p=0.003) and avoidance (ß=-11; p=0·021) effects of primary traumatisation. The consequences of primary traumatisation by intrusion (ß=0·34; p=0·008) and avoidance (ß=0·27; p=0.011) contributed to increasing negative affect. Finally, perceived life satisfaction had direct effects on affective experience, specifically increasing positive affect and diminishing negative affect. INTERPRETATION: Perceived quality of life in children has a role in controlling war-related traumas. Life satisfaction contributes both directly and indirectly to change affectivity. When children perceive themselves to be highly satisfied with their home and school environment, living conditions, and relationships with peers and parents, the effects of trauma are less severe. FUNDING: None.

Integrating a public health and human rights approach into mental health services for Palestinians in the Gaza Strip.

BACKGROUND: In the context of violations of human rights and insecurity, the Gaza Community Mental Health Programme (GCMHP) provides mental health services and psychosocial interventions that match local cultural and social norms. The GCMHP uses a community mental health approach to promote the psychological wellbeing of the people living in the Gaza Strip and advocate on mental health issues. METHODS: The GCMHP provides preventive and therapeutic care to a broad public health spectrum of Gazan society. Services are provided in terms of preventative public health at the primary, secondary, and tertiary levels. Data reported here are from 2014-16. FINDINGS: For primary prevention, our services include advocacy, public awareness, and media campaigns aimed at raising awareness about and preventing common mental disorders and behavioural difficulties in children. 35 878 people are estimated to have benefited from these programmes. The GCMHP also provides psychological first aid and crisis intervention to vulnerable persons and a free telephone counselling service. About 12 943 persons have received individual sessions, and 2590 persons have received telephone counselling. The GCMHP also provides training to enhance the skills of professionals of local organisations working in mental health and psychosocial services. 3557 people have attended these programmes. As secondary prevention, the GCMHP offers individual and group psychotherapy, and routine home visits are provided for torture survivors and individuals and families exposed to cumulative trauma. 11 713 individuals have received such services. As tertiary prevention, rehabilitation services including physiotherapy and occupational therapy are provided to help patients regain their role as active members of the community. 398 people have received these services. INTERPRETATION: A public health-oriented approach to mental health services fits the socioecological model that locates individuals and families within the context of their community, religious-cultural context, and social, economic, and political systems. With social responsibility embedded as a core value, the GCMHP seeks to restore psychological wellbeing in citizens of the Gaza Strip. FUNDING: None.

Teaching in conflict contexts: dimensions of subjective wellbeing in Palestinian teachers living in Israel and the occupied Palestinian territory.

BACKGROUND: Subjective wellbeing can be defined in terms of good mental state, including positive and negative evaluations that people make of their affect and lives. The aim of this study was to identify specific domains of wellbeing that are salient to Palestinian teachers living in three different contexts (West Bank, Gaza Strip, and Israel) and to map how components of subjective wellbeing vary between the three cohorts. METHODS: Data were gathered from interviews of teachers participating in 16 focus groups and from 36 key informants (including psychologists, counsellors, school principals, lawyers). Participants were divided into three groups according to their working locations. Data were analysed by using a mixed-method approach. We used thematic textual analysis, and data were cross-validated with results of statistical significance of lexical specificities (ie, domain-specific terms extracted from specific participants' lexicon) and semantic network analysis. FINDINGS: We interviewed 104 teachers. First-order hierarchical categorisation of thematic analysis revealed four dimensions of subjective wellbeing: psychosocial, professional-related, economic issues, and contextual factors. Some second-order subcategories were quality of teaching work, personality aspects, emotional dimensions, political dimensions, and psychological dimensions. Analysis of lexical specificities and results of semantic network analysis revealed that the importance of different components of subjective wellbeing varied across geographical cohorts. Overall, the results of qualitative and quantitative data analysis showed a clear relationship between the teachers' subjective wellbeing and the places they lived. INTERPRETATION: General themes were common in all populations, but the three cohorts differed in terms of the relative salience of each theme. The prominent themes for the Gazan group were quality of teaching, social dimensions, and religion. The key themes for the West Bank group were economic, social dimensions, and recognition. Salient themes for the Arab-Israeli group were professional, emotional, and social dimensions. Despite some differences between the diasporic Palestinian populations in the occupied Palestinian territories and Israel, the categories of wellbeing are supported in all cohorts. FUNDING: None.

Narrating hope and resistance: A critical analysis of sources of agency among Palestinian children living under military violence.

BACKGROUND: In light of critical and socioconstructionist theories, the aim of our research was to analyze source of agency, psychological adjustment to trauma as protective factors against political violence in children living in three different refugee camps in Palestine, as well as exploring the risks to which these children are exposed. METHODS: Thematic content analysis was applied to children's written and drawn productions in order to extract the main categories and themes. RESULTS: Four main domains of agency emerged from the analysis: personal growth, political well-being, social relationships, and geographical context. For each domain, specific dimensions are discussed. CONCLUSIONS: The results of this preliminary exploration of children's agency suggest that the children's living environment plays a key role in shaping their suffering and reactions to war and ongoing violence. Furthermore, the social nature of the children affected by war-related suffering forces practitioners and policymakers to question the effectiveness of intervention programs that are predominantly focused on symptoms.