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The Experience and Prevalence of PTSD in Palestinian Adults Living in the Gaza Strip Talal El ... PDF

333 Pages·2017·3.23 MB·English
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Running Head: PTSD IN PALESTINIAN ADULTS The Experience and Prevalence of PTSD in Palestinian Adults Living in the Gaza Strip Talal El-Deeb Thesis submitted for the degree of Doctor of Philosophy College of Health and Life Sciences Brunel University June 2017 Running Head: PTSD IN PALESTINIAN ADULTS DECLARATION I hereby declare that this thesis has not been and will not be submitted in whole or in part to another University for the award of any other degree. Chapter 4 (Study 1) presented in this thesis have been submitted for publication under review in the PLOS Journals. i Running Head: PTSD IN PALESTINIAN ADULTS ACKNOWLEDGEMENTS This thesis would not have been possible without the guidance, support, encouragement, and inspiration from the following people. First, I would like to thank my supervisor Dr.Terence Dovey (Terry) I am grateful for his tireless and unending support and guidance. I would also like to extend my thanks to my supervisory team, Professor Taeko Wydell, Dr. Michel Price, Dr.Tara Marshall. I am grateful for their support, guidance, discussions, encouragement to try new ideas of research, and most of all, their belief in me and this work when I was short of it myself. Their advice and teachings have shaped me into a better researcher, academic, psychologist and writer. I have the utmost gratitude for Professor Abu Hein and his team for their efforts in collecting the data from Gaza on my behalf. Without him and his great team, this research would not have been possible. I would also like to thank all the participants in this research, for their participations. On a personal note: This thesis is dedicated to the memory of my father who passed away in Gaza in 2004, without seeing him. At this point of my life, I would say: father, your dream became a reality; I have achieved your wish. Great thanks to my family. I am grateful to my mother, brothers and sisters who are living in Gaza. I am especially grateful to my lovely wife Naila, and to my dearest and beloved sons Mohammed, Ahmed, Mahmoud and to my wonderful and lovely two daughters Lana and Dina, for their support and belief in me during this challenging period. I am deeply grateful to all the friends who have heartily stuck with me through many difficult years of research. I am especially profoundly indebted to my friend Clive Hambidge for his unequivocal friendship, kindness and support during proofreading sessions. I am Running Head: PTSD IN PALESTINIAN ADULTS also grateful to Soraya Boyd for her wonderful encouragement during this testing time and for her great donation. I would also like to express my deepest gratitude to Samir and Lena Lojain and Khalid Salah, Dr. Mohammed Hassona for his unequivocal friendship, Kindness, great efforts, help and support. Big thanks for those how helped and donated money towards my tuition fees, especially Um Ali (Ghada Hammad); Fawzia Badass; Hafez (Um Ahmed), Najeeb Abu Nahil (Abu Ghazi) Dr. Iyad Bardaweel, Dr. Myssara Bahja, Rajab shamlak and my dear brother Mohammed Ghazal and Naima Ghazal and last but not the least, brother Zejad Mehanovic. God bless you all. Finally, I would like to thank the many unnamed individuals for their assistance and encouragement in completing this research. Running Head: PTSD IN PALESTINIAN ADULTS Abstract Objective: This study aims to explore the traumatic experiences and to estimate prevalence and predictor factors for PTSD, depression and general psychiatric morbidity amongst Palestinian adults living in the Gaza Strip. Method: A total of 500 Palestinian adults were recruited from four areas of the Gaza Strip using a snowball sampling. The same sample was used for both quantitative studies. Four scales were employed to identify predictors for trauma, PTSD, depression and general mental health. Participants were divided into three age groups: young adults (18 to 25 years), adults (26 to 49 years) and older adults (50 to 65 years). The third qualitative study was aimed at exploring the traumatic experiences of adults living in the Gaza Strip to expand upon the outcomes from the quantitative studies. Results: For Studies 1 and 2, the prevalence rate of PTSD symptoms was 90% and 36.7% met the criteria of DSM-IV for PTSD. Study 2 found depression was 38.4%, and general mental health comorbidity was 67.1%. Study 2 revealed significant differences in PTSD between age groups. Novel results were found amongst adults and older adults on the re- experiencing subscale for PTSD. Participants who lived in Gaza City scored significantly higher on the PTSD subscale for hyperarousal compared to those living in the middle Gaza region. Study 3 expanded on the psychometric data through interviewing members of the Gaza community. When analysed five main themes were identified: Siege related stressors; war related trauma; psychological negative effects; re-experiencing initial event and coping strategies. Conclusions: The findings indicated that blockade was the predominant cause of the increased prevalence rate of PTSD. These studies found that the Palestinian adult participants in Gaza had been exposed to a variety of traumatic events on an ongoing basis that was having a detrimental impact on their mental health. Running Head: PTSD IN PALESTINIAN ADULTS Contents Chapter 1: General Introduction ............................................................ 1 1.1 Children and adolescent studies in the Palestinian territories ....... 6 1.2 Adults studies in the Palestinian territories ................................... 6 1.3 Quantitative studies (Study 1 and Study 2) ................................... 8 1.4 Qualitative study (Study 3) .......................................................... 11 1.5 General Aims of the Current Research ....................................... 13 1.6 Research Questions ................................................................... 14 1.7 Overview of the Current Research .............................................. 14 1.8 Outline of the content of the thesis ............................................. 16 Chapter 2: Literature Review ............................................................... 19 2.1 Introduction ................................................................................. 19 2.2 Definitions of trauma and PTSD ................................................. 20 - Trauma Definitions .................................................................. 20 - PTSD Definition ....................................................................... 22 - Definition of Complex PTSD................................................…...22 - Definition of ChronicPTSD………………….………………..…..23 - Etiology of Complex PTSD and Depression ............................ 23 2.3 Development of Trauma and PTSD in the DSMs ........................ 29 - DSM-5 (2013) ............................................................... 29 - DSM-IV-TR (2000) ........................................................ 30 2.4 Alteration and Comparison between DSM-5 and DSM-IV .......... 31 2.5 Depression .................................................................................. 35 - The Definition of Depression in DSM-IVTR (2000)………………………………………………………………….35 Running Head: PTSD IN PALESTINIAN ADULTS 2.6 Types of Depression……………………………………………… ..36 - Comorbidities of depression…………………………….……..37 2.7 Post – Conflict Environments in Different Countries ................... 45 - Comparative Studies in Four Post-Conflict Countries ...... 48 - Comparative Studies of PTSD in Gaza ............................ 50 2.8 Risk Factors Leading to Complex PTSD – Gaza ........................ 51 - Exposure to War-Related Traumatic Events ........................ 57 - Political Conflict and Mental Disorders in Gaza .................... 58 2.9 Lifetime Prevalence Rates of PTSD in Gaza and Israel.............. 60 - Palestinian Epidemiological Studies in Gaza ....................... 63 - Sociodemographic factors ................................................ …68 2.10 Summary .................................................................................... 71 Chapter 3: Methodology ....................................................................... 73 3.1 Introduction ................................................................................. 73 3.2 Quantitative studies (Study 1 and 2) ........................................... 74 3.2.1 General Research Hypotheses ........................................ 75 - Cognitive Theory of Trauma and PTSD ................................ 75 - The Cognitive Theory of Depression: Arabic version ............ 77 - Rationale of using DSM-IV TR (2000) ................................... 77 - Justification of the quantitative studies’ variables .................. 79 - Ethical Considerations ............................................................ 81 3.2.2 Methods ........................................................................... 81 3.2.3 Materials ......................................................................... 83 3.2.4 Procedure ........................................................................ 91 Running Head: PTSD IN PALESTINIAN ADULTS 3.2.5 Data Analysis ................................................................... 93 3.3 Qualitative study (Study 3) .......................................................... 94 3.3.1 Justification of Qualitative approach ................................ 94 - Justification of Transactional model of stress and coping.…..95 - Justification of the thematic analysis model…….…………..…96 - Justification for the Qualitative Variables…………….……………………………………………..…98 - The validity in thematic analysis …….……………………….…99 - Ethical Issues………….…….………………………...…….101 3.3.2 Methods. ....................................................................... .101 3.2.6 Material and Procedure ................................................. 102 Data Collection ………………………..………………………..…….102 - Questionnaire translation and back-translation………………103 - Transcription, Translation and Back-translation …………..…103 3.2.7 Data Analysis ................................................................. 104 3.4 Summary .................................................................................. 105 Chapter 4: Young Adults, Adults and Older Adults assessment of trauma and prevalence of PTSD ........................................................ 107 4.1 Introduction ............................................................................... 107 4.2 Methods and Participants ......................................................... 110 4.3 Materials ................................................................................... 111 - The Gaza PTSD Checklist (PTSDC) for adults ........ 111 4.4 Procedure ................................................................................. 113 - Statistical Analysis .................................................... 114 4.5 Results ...................................................................................... 114 4.6 Discussion ................................................................................ 117 Running Head: PTSD IN PALESTINIAN ADULTS 4.7 Limitations and Strengths ......................................................... 120 4.8 Summary .................................................................................. 121 Chapter 5: Prevalence and predictor factors for PTSD, depression and general psychiatric morbidity amongst the adult population in Gaza ..................................................................................................... 124 5.1 Introduction ............................................................................... 124 5.2 Hypotheses ............................................................................... 127 5.3 Methods .................................................................................... 128 5.4 Materials……………………………………………….……………128 5.4.1 The Gaza Siege Checklist .............................................. 128 5.4.2 The Gaza PTSD Checklist (PTSDC) for adults .............. 129 5.4.3 General Health Questionnaire-28 (GHQ-28) ................ 130 5.4.4 Beck Depression Inventory-II (BDI-II) (Arabic version) .. 131 5.4 Procedure ................................................................................. 132 5.5 Statistical Analysis .................................................................... 133 5.7 Descriptive statistics……………………………..……….…..134 5.8 Results ...................................................................................... 136 5.8.1 Exposure to traumatic events ........................................ 136 5.8.2 Prevalence rate and severity of PTSD among Palestinian adults in Gaza….………………………….…………………..…….137 5.8.3 Factors predicting PTSD among the three groups of Palestinian adults ....................................................................... 140 5.8.4 General Health Questionnaire-28 (GHQ-28) ................. 143 5.8.5 Prevalence rates of general psychiatric morbidity among Palestinian adults in Gaza .................................................... ....144 5.8.6 Prevalence rate and severity of depression ................... 149 Running Head: PTSD IN PALESTINIAN ADULTS 5.8.7 Testing the hypotheses……………………………….……151 - Psychological variables by age……......…….…………….........153 - war and siege……………………………………..……....……..153 - Location of residence……………………………...……….………….153 - Educational levels………………..………………………….…….…..156 - Marital status ....…...……………………………..….….………..…...157 5.9 Discussion………………………………………………..………... 158 - The implications of the study……………….……….…..…..…156 - Limitations and strengths……….……………………….......... 156 - Directions for Future Research……………………...…....……166 5.10 Conclusion…………………………………………………....…....167 Chapter 6: Exploring the Experiences of Adults Living in the Gaza Strip………………………………………………………………………….169 6.1 Introduction…………………………………………………………169 6.2 Cultural considerations of war-trauma and PTSD………..…....171 6.3 Anthropological contributions to discourses on war-trauma and PTSD ................ …………………………………………………………173 - Justification for the qualitative study……………….…….…..174 - Aim……………………………………………………….………174 - Research question………………………………….….………174 - Ethical approval……………………………………….….…….174 6.4 Methods……………………………...…………………….….......…174 6.5 Results.. ............................................................................ ..…..176 6.6 Discussion ................................................................................ 200 6.7 Strengths and limitations ........................................................... 206 6.8 Reflexivity ................................................................................. 208

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