Residential segregation, neighborhood violence and disorder, and inequalities in anxiety among Jewish and Palestinian-Arab perinatal women in Israel.

BACKGROUND: Residential segregation can foster health inequality mechanisms by increasing stress related to neighborhood violence and disorder. AIMS: We studied the association between neighborhood violence and disorder and inequalities in anxiety between two groups of perinatal Israeli women (Jewish, Palestinian-Arab) living in ethno-nationally segregated neighborhoods, and explored the influence of neighborhood characteristics; social support and chronic stress to this inequality. METHODS: We linked survey data on neighborhood violence and disorder, neighborhood social characteristics (collective efficacy, social capital and social support) and aggregate discrimination to neighborhood SES census data. The survey data was obtained from the "Family Relations, Violence and Health" study (2014-2015) and included a stratified national sample of women (Palestinian-Arab = 436, Jewish = 965) residing in 63 segregated neighborhoods. We conducted multi-variable logistic regression analysis for anxiety (measured based on State-trait Anxiety Inventory) using generalized estimating equation (GEE) to estimate odds ratios of the association with neighborhood violence and disorder (total score for 10 problems) while considering neighborhood characteristics (SES; social characteristics; aggregate discrimination), social support and chronic stress in different models for the total sample, and separately for Palestinian-Arab and Jewish women. RESULTS: Palestinian-Arab women had higher anxiety (60.5% vs. 42.1%, respectively) and higher severity of neighborhood violence and disorder (49.5% vs. 16.2%, respectively) compared to Jewish women. After considering individual and neighborhood variables, adjusted odds ratio (AOR) and 95% confidence intervals (CI) = 1.63, 1.04-2.56. The association between neighborhood violence and disorder and anxiety was significant for low vs. no problems in the final model for the total sample (AOR, 95%CI = 1.28, 1.00-1.64). Similarly, significant association was found only for low severity vs. no problems for Jewish women (1.40, 1.07-1.86). While among Palestinian-Arab women the association between neighborhood violence and disorder and anxiety rendered insignificant in the final model. Neighborhood social cohesion and social support were protective factors from anxiety in both groups, high neighborhood SES was protective factor only among Jewish women, and neighborhood aggregate discrimination was a risk factor only in Palestinian-Arab women. CONCLUSIONS: Inequalities in anxiety related to neighborhood violence and disorder in ethno-national perinatal groups of women likely reflect residential segregation. Policies entrenching segregation might have affected neighborhood mechanisms (SES inequalities, aggregate discrimination and low social cohesion) that lead to higher stress and ethno-national inequalities in anxiety among perinatal women.

Multiple forms of discrimination and postpartum depression among indigenous Palestinian-Arab, Jewish immigrants and non-immigrant Jewish mothers.

BACKGROUND: While discrimination takes multiple forms, racial or ethnic discrimination is a root cause of this health-damaging social phenomenon. We drew on intersectionality theory, which offers an account of discrimination's multiple effects, to consider associations between women's experiences of discrimination and postpartum depression (PPD) using four measures: single forms of discrimination (SFD); multiple forms of discrimination (MFD); ethnic discrimination combined with MFD (E-MFD); and a composite MFD that interacted with women's identity (C-MFD). METHODS: We interviewed a stratified sample of 1128 mothers face to face in 2014-2015 during mothers' visits to maternal and child health clinics. The mothers belonged to three groups in Israel: Palestinian-Arab minority, Jewish immigrant, and non-immigrant Jewish. We conducted unadjusted and adjusted logistic regressions for PPD, measured on the Edinburgh Postnatal Depression Scale, in associations with SFD (experiencing discrimination based on any of the following: age, sex, class, ethno-national identity, religiosity level and skin color); MFD (experiencing 0,1, 2 or ≥ 3 of SFD); E-MFD (ethnic discrimination combined with other MFD); and finally, C-MFD (interaction between MFD and women's identity). RESULTS: Palestinian-Arab mothers had higher PPD and reported higher SFD (based on ethnicity, religiosity level, and socioeconomic status), as well as higher MFD and E-MFD. This was followed by Jewish immigrant mothers, and lastly by non-immigrant Jewish mothers. However, both MFD and E-MFD had a strong association with PPD among non-immigrant Jewish mothers reporting 2MFD and ≥ 3MFD, and Palestinian-Arab mothers reporting ≥3MFD, but no significant association among immigrant Jewish mothers. When we used C-MFD, we found a dose-response association in which Palestinian-Arab mothers experiencing more MFD (2MFD and ≥ 3MFD) were more likely to experience PPD. This was followed by immigrant Jewish mothers (reporting 2MFD and ≥ 3MFD), and lastly by non-immigrant Jewish mothers. CONCLUSIONS: MFD should be considered in relation to women's identity (being part of a minority, immigrant, or non-immigrant majority group) in maternal mental health research and practice. Otherwise, we risk underestimating the effects of MFD on PPD, especially in minority and immigrant mothers, who are more likely to face interlocking forms of discrimination.

Suicidal behavior among Muslim Arabs in Israel.

PURPOSE: Countries with Muslim populations report relatively lower rates of suicide. However, authors have noted methodological flaws in the data. This study examined reliable rates of completed suicide, suicide ideation, planning and attempts among Muslims as compared to Jews in Israel. METHODS: For completed suicide, information was extracted from death certificates (2003-2007); the National Emergency Room Admissions Database (NERAD) provided data on suicide attempts (2003-2007); and the Israel National Health Survey (INHS) (2003-2004) was used for self reports on lifetime suicide ideation, planning and attempts. RESULTS: Completed suicide rates among Muslim-Israelis (3.0 per 100,000) were lower compared to Jewish-Israelis (8.2 per 100,000). Based on NERAD, attempted suicide rates among men were lower for Muslims compared to Jews, while among women aged 15-44 no differences were found. In the INHS, the rate of self-reported lifetime suicide attempts was significantly higher among Muslims (2.8%) compared to Jews (1.2%), while lifetime prevalence rates of suicide ideation (6.6%) and planning (2.1%) in Muslims did not differ from Jews (5.2 and 1.9%, respectively). CONCLUSIONS: Conceivably, the lower rate of completed suicide among Muslim-Israelis might be explained by the strenuous proscription of suicide by the Koran. However, its extension to suicide attempts is equivocal: attempts were higher among Muslims than among Jews according to self-reports but lower in the NERAD records. Social pressures exerted on the reporting agents may bias the diagnosis of self-harm in both the latter data source and in the death certificates.

Service use for mental disorders and unmet need: results from the Israel Survey on Mental Health Among Adolescents.

OBJECTIVE: The first nationwide Israel Survey of Mental Health Among Adolescents was conducted in 2004-2005 with a representative sample of 957 adolescents aged 14-17 and their mothers to assess 12-month mental health service use, unmet needs, and associated factors. METHODS: Need for services was assessed by presence of a psychiatric disorder diagnosed with the Development and Well-Being Assessment inventory, plus clinicians' verification and additional questions on service use. RESULTS: In the past year, 22% of adolescents and 11% of their mothers consulted a service provider. Adolescents' help seeking in school was associated with residing in an Arab locality (odds ratio [OR]=1.6, 95% confidence interval [CI]=1.1-2.4) and with having single, divorced, or widowed parents (OR=2.9, CI=1.8-4.8); an employed father (OR=1.7, CI=1.0-2.8); and an internalizing disorder (OR=2.2, CI=1.2-3.9). Mothers' consultation was associated with residing in a Jewish or mixed locality (OR=18.1, CI=3.4-96.1); being single, divorced, or widowed (OR=3.1, CI=1.6-6.0); and having a child with an internalizing disorder (OR=6.4, CI=3.2-13.0), an externalizing disorder (OR=8.2, CI=2.9-23.0), or a learning disability (OR=4.5, CI=2.4-8.4). Overall, unmet needs were 66% and 60%, according to adolescents' and mothers' reports, respectively. According to mothers' reports, unmet needs were higher in Arab (91%) than in Jewish or mixed localities (54%). CONCLUSIONS: Adolescents and their mothers reported distinct service use patterns with particular implications for policy makers and health service providers. High rates of unmet needs, particularly among Arab-Israeli adolescents, need to be addressed.

Treatment lag on the way to the mental health clinic among Arab- and Jewish-Israeli patients.

BACKGROUND: The early recognition and timely treatment of psychiatric disorders helps reduce suffering, prevents mental disabilities and makes interventions more cost-effective. OBJECTIVE: To examine treatment lag among Arab- and Jewish-Israelis applying to psychiatric clinics for the first time, and the association of this lag with selected socio-demographic and mental health-related variables. METHODS: 251 adult outpatients making their first-ever visit to a psychiatric clinic completed a self-administered questionnaire, including questions on the time elapsed since the onset of the current disorder, reasons for the treatment lag, source of referral, main complaints, current psychiatric problems (self-diagnosis), attitudes to psychiatric disorders and treatment, pathways to care, and standard sociodemographic information. Univariate and multivariate analyses were performed to compare Arab- and Jewish-Israelis on parameters of interest. RESULTS: Compared with their Jewish counterparts, Arab-Israeli patients showed a two-fold delay in initial treatment contact (X2 = 4.00, df = 1, p < 0.05). Logistic regression analysis showed that this delay was associated with lower schooling, other-than-psychiatric attribution of mental symptoms, and a more pessimistic attitude to the successful treatment of mental disorders in general and for oneself in particular. CONCLUSIONS: Since longer treatment delay was mostly associated with potentially modifiable knowledge and attitudes on mental disorders and treatment, educational programs targeting specific community sectors and community agents should be promoted to shorten this lag.

Common mental disorders among Arab-Israelis: findings from the Israel National Health Survey.

OBJECTIVES: Psychiatric epidemiological data on Arab populations are generally scanty. This community-based survey, a component of the World Health Organization's 27-country study, explored the prevalence rates of anxiety and mood disorders, emotional distress and help-seeking practices among Arab-Israelis, and compared them with those found among Jewish-Israelis. METHODS: Close to 5,000 non-institutionalized individuals were interviewed with the WHO/Composite International Diagnostic Interview (CIDI) to determine the prevalence rates of selected psychiatric diagnoses, and with the 12-item General Health Questionnaire (GHQ) to measure emotional distress. The schedule included other items, e.g., socio-demographic variables and help-seeking practices. RESULTS: Arab-Israelis, in contrast to Jewish-Israelis, had higher mean GHQ-12 scores and lower self-appraisal of mental health. Twelve-month prevalence rates for any anxiety or affective disorder were not significantly higher among Arab-Israelis. Among respondents with diagnosed disorders, rates of help-seeking from specialized health services were lower among Arab-Israelis than among Jewish-Israelis. Intention to consult was elicited from both groups when the disorders were accompanied by higher distress scores. CONCLUSIONS: Despite major health gains, the social stresses impacting the Arab-Israeli minority may explain both the higher emotional distress and lower self-appraisal of mental health. However, no impact was observed of social causation factors on the rates of common mental disorders in the Arab-Israeli group. Cultural factors, including the definition of disorders and stigma and a lesser availability of culturally-tailored services, could account for the marked treatment gap.

Emotional distress among first-time patients attending outpatient mental health clinics in Israel: an Arab-Jewish comparative study.

BACKGROUND: Few studies have focused specifically on the role of ethnicity in emotional distress and symptoms among first-time psychiatric outpatients. METHODS: 251 first-time patients, aged 18-72 years, attending three outpatient mental health clinics in Israel, were surveyed. Three methods of case detection were used: a GHQ-12 score (equal or >3), self-reported symptoms (using a checklist) and a psychiatrist's provisional ICD-10 diagnosis. In addition, self-efficacy and perceived social support were measured using standardized self-report questionnaires. Univariate and multivariate analyses compared the two ethnic groups: Israeli Arabs and Israeli Jews. RESULTS: Compared to Jewish patients, Israeli Arab patients had a higher "distress caseness" rate based on GHQ-12 score (70.8% versus 41.2%) and a higher rate of psychiatrist-detected ICD-10 stress-related disorders (46.7% versus 23.3%), but a lower rate of self-reported emotional distress (36% versus 54.3%) and symptoms of mood disturbances (38.7% versus 64.7%). The Israeli Arabs also had lower mean scores on measures of self-efficacy (2.0 versus 2.4) and perceived social support from friends (12.2 versus 17.6) and significant others (16.7 versus 20.0). In a parsimonious regression model, the best predictors of emotional distress had low self-efficacy and social support from significant others, and, being Arab, these variables accounted for 27.1%, 7.2% and 8.8%, respectively, of the total variance in GHQ distress scores. CONCLUSION: The results suggest that the detection of emotional distress and symptoms varies markedly by patients' ethnic background. These variations can be predicted by a lower sense of self-efficacy and social support among Israeli Arabs as compared to Israeli Jews.

Comparative study of eating-related attitudes and psychological traits between Israeli-Arab and -Jewish schoolgirls.

OBJECTIVE: The aims of the study were to examine weight concerns, dieting and eating behaviours in a group of Israeli-Arab schoolgirls as compared with Israeli-Jewish schoolgirls, as well as to investigate the reliability of the Arabic (Palestinian) version of the eating disorder inventory-2 (EDI-2). METHOD: The sample consisted of 2548 Israeli schoolgirls, including 1885 Jewish and 663 Arab adolescents ranging in age from 12 to 18. The study was conducted in 1998-2003 from urban and rural residential settings in the northern part of Israel. The (EDI-2) was the assessment tool used, yielding scores on 11 sub-scales. RESULTS: The Israeli-Arab schoolgirls scored significantly higher than the Israeli-Jewish schoolgirls in most EDI-2 sub-scales. In addition, the sub-scale inter-item consistency of the translated Arabic (Palestinian version) of the EDI-2 was found to be reliable. DISCUSSION: The drive to be thin found among Israeli Arab schoolgirls is not reflected in their small number of ED clinic referrals. These discrepancies are discussed in light of the socio-cultural changes currently taking place in the Israeli Arab population due to the influence of Western-oriented life in Israel.

Suicidal attempts admitted to a general hospital in the Western Galilee: an inter-ethnic comparison study.

BACKGROUND: Deliberate self-harm is a relatively frequent cause of consultation in the emergency room of general hospitals. Despite its importance, few epidemiological studies of self-injury in Israel have been carried out, and of these, they mostly covered selected population groups. OBJECTIVES: To provide epidemiological data on self-harm in patients examined in the emergency room of a general hospital in the Western Galilee, with special emphasis on differential sociodemographic and clinical characteristics of the Arab and Jewish subjects. METHODS: Demographic, clinical, and self-harm characteristics were extracted from hospital files for people aged 18 years and older admitted to the general hospital in Nahariya, Western Galilee, over a 24-month period (January 1996 to December 1997) following a suicidal attempt. Chi-square statistics, two-tailed t-tests, and logistic regression analyses were used to test the significance of inter-ethnic differences in risk factors. RESULTS: The overall incidence rate of suicidal attempts was 16.7 per 100,000 population of Northern District in 1996 (Arabs, 24.4 and Jews, 11.0); or 37.6 per 10,000 admissions (Arabs, 44.2 and Jews, 30.3). Among the Jewish male subjects, attempts rose markedly after the age of 40, while among their Arab counterparts the age distribution was even throughout all age groups. Among Jewish females, admissions for self-harm rose gradually with age, while among the Arab women there was a peak at the 20-29 year age group. Both ethnic groups differed significantly in their sociodemographic and clinical profiles, but they shared common characteristics with regard to the attempt. CONCLUSIONS: Our findings suggest differential ethnic patterns of risk factors for self-harm. Further in-depth investigation of deliberate self-harm is warranted to better explore these factors.

A community study on emotional distress among Arab and Jewish Israelis over the age of 60.

BACKGROUND: The elderly constitute a vulnerable group for psychopathology, yet research on their mental health among both Arab and Jews in Israel remains limited. The same is the case in Arab countries. This paper reports on the contrasting distribution of the mean emotional distress (ED) scores and rates of suspected clinical cases, and their related risk factors, among community residents over the age of 60. METHODS: Several national agencies conducted a survey on 5,055 elderly individuals to investigate their health status, including ED. The interview included socio-demographic and behavioral health items, as well as a modified 12 item-GHQ as a measure of ED. Total ED scores and prevalence rates for suspected psychopathology were calculated. Their respective risk factors were examined using univariate and multivariate methods. RESULTS: The ED scores were highest among Muslim Arabs (4.9), followed by Christian Arabs (4.2), Jews (3.1) and Druzes (2.8). Their estimated prevalence rates were 43.4%, 37.0%, 21.4%, and 17.0%, respectively. The gradient of these results remained unchanged in the multivariate analysis for ED scores adjusting for confounding variables. In contrast, logistic regression analysis controlling for confounding variables did not find a differential risk for suspected psychopathology between Arabs and Jews. CONCLUSION: Conceivably, the higher demoralization scores among elderly Arabs are associated with their minority status affiliation, as well as with the rapid social changes that have taken place in their midst. A cultural response style may be entertained as a possible explanation. However, these factors do not impact the risk for suspected psychopathology where no differential risk was noted after adjustments for confounders.