Long-Term Exposure to Political Violence: The Particular Injury of Persistent Humiliation
This study assessed the association between exposure to political violence over a 25-year period and adult functioning among a population that has experienced protracted and severe political conflict. Instead of aggregating exposure to political violence across time and type of exposure, as is commonly done, the event history calendar pioneered in this study assessed exposure to five forms of political violence annually from 1987 to 2011 in a representative sample of 1,788 adults, aged 37 on average, in the occupied Palestinian territories (West Bank, East Jerusalem, and the Gaza Strip). This method allowed for the identification of trajectories of exposure to political violence from childhood to adulthood using latent profile analysis. We then correlated the trajectories of exposure to measures of economic, political, community, family, psychological, and health functioning. As expected, being shot at, having one’s home raided, being hit or kicked, being verbally abused, and witnessing someone close being humiliated were all elevated during periods of heightened political conflict (the first intifada (1987-1993) and, less so, the second intifada (2000-2005)). In addition, 12% of women and men reported high and persistent levels of exposure to humiliation (being verbally abused and/or witnessing someone close being humiliated) across the entire 25-year period. These individuals lived predominantly in neighborhoods with a high Israeli military presence. Compared to those who experienced periodic exposure to political violence, persistently humiliated men and women reported significantly lower health, economic, political, and psychological functioning, as well as higher social cohesion and political expression. Relevant literatures are reviewed when concluding that persistent humiliation is a neglected form of political violence that is best represented as a direct (versus structural), acute (versus chronic), macro (versus micro), and high-grade (versus low-grade) stressor whose particular injury is due to the violation of individual and collective identity, rights, justice and dignity.
Long-term exposure to political violence: The particular injury of
Brian K. Barber
, Clea McNeely
, Joseph A. Olsen
, Robert F. Belli
Samuel Benjamin Doty
University of Tennessee, USA
New America, USA
Brigham Young University, USA
University of Nebraska, USA
Johns Hopkins University, USA
Received 14 July 2015
Received in revised form
7 March 2016
Accepted 10 March 2016
Available online 11 March 2016
Event history calendar
This study assessed the association between exposure to political violence over a 25-year period and
adult functioning among a population that has experienced protracted and severe political conﬂict.
Instead of aggregating exposure to political violence across time and type of exposure, as is commonly
done, the event history calendar pioneered in this study assessed exposure to ﬁve forms of political
violence annually from 1987 to 2011 in a representative sample of 1788 adults, aged 37 on average, in the
occupied Palestinian territories (West Bank, East Jerusalem, and the Gaza Strip). This method allowed for
the identiﬁcation of trajectories of exposure to political violence from childhood to adulthood using
latent proﬁle analysis. We then correlated the trajectories of exposure to measures of economic, political,
community, family, psychological, and health functioning. As expected, being shot at, having one's home
raided, being hit or kicked, being verbally abused, and witnessing someone close being humiliated were
all elevated during periods of heightened political conﬂict (the ﬁrst intifada (1987e1993) and, less so, the
second intifada (2000e2005)). In addition, 12% of women and men reported high and persistent levels of
exposure to humiliation (being verbally abused and/or witnessing someone close being humiliated)
across the entire 25-year period. These individuals lived predominantly in neighborhoods with a high
Israeli military presence. Compared to those who experienced periodic exposure to political violence,
persistently humiliated men and women reported signiﬁcantly lower health, economic, political, and
psychological functioning, as well as higher social cohesion and political expression. Relevant literatures
are reviewed when concluding that persistent humiliation is a neglected form of political violence that is
best represented as a direct (versus structural), acute (versus chronic), macro (versus micro), and high-
grade (versus low-grade) stressor whose particular injury is due to the violation of individual and col-
lective identity, rights, justice and dignity.
© 2016 Elsev ier Ltd. All rights reserved.
“… but our shudders are all for the ‘horrors’ of the minor Terror,
the momentary Terror, so to speak; whereas, what is the horror
of swift death by the axe, compared with lifelong death from
hunger, cold, insult, cruelty, and heart-break?”
d Mark Twain, A Connecticut Yankee in King Arthur's Court
Research on youth and political conﬂict has become an estab-
lished ﬁeld of scholarly work over the past two decades. One area
that is particularly undeveloped, however, is the long-term func-
tioning of people who spend their childhood and youth amidst
political conﬂict and its violence (Barber, 2013, 2014; Betancourt
et al., 2013; Fernando et al., 2010; Panter-Brick, 2010; Pedersen
et al., 2008). This paper addresses that limitation directly by
charting exposure to political violence over a 25-year period since
childhood and adolescence, and assessing how patterns of expo-
sure to that political violence predict adult functioning.
* Corresponding author. Center for the Study of Youth and Political Conﬂict, 2110
Terrace Ave., Knoxville, TN 37916, USA.
E-mail address: firstname.lastname@example.org (B.K. Barber).
Contents lists available at ScienceDirect
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journal homepage: www.elsevier.com/locate/socscimed
0277-9536/© 2016 Elsevier Ltd. All rights reserved.
Social Science & Medicine 156 (2016) 154e166
We pursued this innovation in a large, representative sample of
adults living in the occupied Palestinian territories (oPt; West Bank,
East Jerusalem, Gaza Strip). Now in their 30s, they were the storied
generation of stone-throwing youth of the ﬁrst intifada
(1987e1993). They are a particularly interesting population among
which to study the long-term impact of exposure to political
violence given that they came of age with unprecedented
involvement in the 6-year long ﬁrst intifada (Barber, 2001). More-
over, they have experienced continual economic decline and po-
litical adversities ever since.
This project has developed in several phases, including intensive
interviews (Barber et al., 2014a), item construction and pilot testing
(McNeely et al., 2014), as elaborated below. The present paper
builds in part on some partial analyses of the variables studied here
(Barber et al., 2013, 2014b, 2016; McNeely et al., 2015). In addition
to addressing the lack of assessment of long-term functioning after
exposure to political conﬂict, this study addressed two further
limitations of extant research. First, we assessed and analyzed
multiple types of political violence exposure so as to detect unique
effects of discrete types of violencedas opposed to the common
method of creating aggregate scores across types of political
violence. Second, adult functioning was assessed holi-
sticallydincluding psychological, social, community, family, health,
economic, and political domainsdin contrast to the preoccupation
with psychological trauma and behavioral problems characteristic
of the bulk of the studies in this area.
1.1. Long-term exposure to political violence
Although studies of the effects of exposure to political violence
are still predominantly cross-sectional, the number of longitudinal
studies is increasing, including studies of Palestinians (e.g., Akello
et al., 2010; Betancourt et al., 2010; Cummings et al., 2013; Boxer
et al., 2013; Dubow et al., 2012; Hobfoll et al., 2011; Panter-Brick
et al., 2011).
Findings from these studies of relatively short time lags gener-
ally conﬁrm those of the scores of cross-sectional studies: exposure
to political violence correlates signiﬁcantlydmildly to moder-
atelydwith mental and behavioral problems. The few longer-term
studies conﬁrm the same correlation (Pedersen et al., 2008; Suarez,
The data analyzed here allowed us to make another advance in
studying the long-term impact of exposure to political violence.
When measuring political violence exposure over time, prior work
has used a count of the number of traumatic events or violence-
related stressors ever experienced (i.e., aggregated exposure); or,
they have used the number of years violence or stress was expe-
rienced (Pedersen et al., 20 08; Suarez, 2013). Given that political
conﬂicts evolve over time, as do the individuals experiencing and
interpreting them, it is not immediately clear that aggregating
across time is the best way to capture the risk of exposure to po-
litical violence. In contrast to these cumulative assessments, we
measured the exposure to ﬁve discrete forms of political violence in
each year of the event history calendar, which allowed us to explore
both the patterning and the timing of political violence exposure
across a 25-year period.
This inspection of patterns of exposure across the life course is
consistent with lifespan psychology (Baltes et al., 1999
) and life
course theory (Elder et al., 2003), in which the relative timing and
patterning of events shape adult functioning. Such an approach
avoids the linear presumption underlying the study of cumulative
exposure (i.e., the more exposure the worse the functioning) and
allows for the possibility that the type of political violence expo-
sure, it's timing and patterning during the life course, and it's
timing and persistence relative to other types of political violence
exposure might offer unique insight into how histories of exposure
to political violence impacts adult wellbeing. (See Pynoos et al.,
2014 for alternative analytic approaches from developmental psy-
chopathology and developmental epidemiology orientations.)
This life course approach is particularly apt for regions of the
world in which political conﬂ ict resurfaces over time, as for current
Palestinian adults, whose life course has been punctuated by
alternating, well-demarcated, multi-year periods of: (a) frequent
and high intensity political violence (the ﬁrst intifada [1987e1993]
and the second intifada [2000e2005]), and (b) periods of sub-
stantially less political violence (the interim “Oslo” period between
the two intifadas [1994e1999] and after the second intifada
[2006e2011]). (The exception to this are Gazans who have expe-
rienced internecine political conﬂict and multiple wars with Israel
Except for the self-evident expectation that violence exposure
(of any type) would be highest during the two intifadas and among
males among this generation of Palestinians, available theory or
ﬁndings do not justify ﬁrm expectations or hypotheses regarding
which patterns of exposure to political violence might have
unfolded in this population. Other possibilities include either
consistently low or high levels of exposure to political violence
based on location, whether for geographic or strategic reasons. As
to whether adult functioning would vary according to patterns of
exposure, there is equally little information to guide expectations,
especially when considering the discrete forms of exposure that we
1.2. The speciﬁcity of political violence exposure
Despite often measuring discrete forms of direct exposure to
political violence, researchers have commonly aggregated speciﬁc
forms of exposure into one or more trauma or violence-exposure
indexes, including studies on Palestinians (e.g., Boxer et al., 2013;
Khamis, 2012; Pedersen et al., 2008; Slone, 2009; Suarez, 2013).
This aggregation of across type of violence exposure is done either
because of psychometric reasons or because accumulated stress is
theoretically viewed as the better way to capture risk (e.g., the
resilience literature; Canavan, 2008; Masten and Reed, 2002).
Consistent with some others (e.g., Layne et al., 2010), our position is
that political violence exposure in contexts of long-term political
conﬂict is so varieddin terms of proximity, intensity, meaning,
etc.dthat studying the unique effects of exposure types is
In this study, we focused on ﬁve speciﬁc forms of direct expo-
sure: two involved assault on the person's body (hit or kicked, shot
at), two related to humiliation (verbally abused, witnessing the
humiliation of a close person), and one indexed home raids (which
frequently involve both personal assault and humiliation). All ﬁve
are forms of violence common to many instances of political con-
ﬂict and have been well-documented in studies of Palestinians
(Boxer et al., 2013; Khamis, 2012; Giacaman et al., 2007), and
speciﬁcally so in the cohort under study here when they were
youth during the ﬁrst intifada (Barber, 2000; Barber and Olsen,
1.3. The breadth of impact of political violence exposure
Despite recommendations decades ago to move past a focus on
psychopathology when searching for the impact of political
violence (Cairns and Dawes, 1996), the large majority of studies
continue to focus on mental, and to some degree, behavioral
problems as outcomes (Barber, 2014; Pedersen et al., 2008). There
are numerous problems with this narrow focus, including the
importation of Western concepts and measures of mental health,
B.K. Barber et al. / Social Science & Medicine 156 (2016) 154e166 155
artiﬁcially isolating the individual from her/his context, and pa-
thologizing normative stress and suffering (Bracken et al., 1995;
Honwana, 2006; Summerﬁeld, 1999).
In addition, the narrow focus of conventional models on mental
and behavioral problems ignores the ecological realities of lived
experience. Speciﬁcally, as is articulated in frameworks from an-
thropology (Das et al., 2001; Eggerman & Panter-Brick, 2010;
Panter-Brick, 2010), community psychology (Prilleltensky, 2012),
and public health (Krieger, 2001), humans function, and suffer, in
an array of domains. Any one or more of these domainsdeconomic,
political, community, psychological, religious, family, etc.dcould
logically be impacted by high levels of exposure to political
Therefore, consistent with calls from others to broaden the
scope of inquiry (Fernando et al., 2010; Panter-Brick and Leckman,
2013; Pedersen et al., 2008), we included measures of several as-
pects of adult functioning in the current study. We were guided
directly by an earlier phase of this project that explicitly sought
through intensive group interviews to identify the complexity of
functioning in this generation of Palestinians (Barber et al., 2014a).
Our general expectation was that assessing functioning holistically
across a spectrum of domains including, but not limited to the
psychological, would facilitate the detection of any lasting effects of
patterns of exposure to political violence.
2.1. Sampling procedure
In September and October 2011, local ﬁeld workers from the
Palestinian Center for Policy and Survey Research (PSR; Ramallah,
West Bank) conducted household interviews with a representative
sample of 1778 32e43 year olds in the West Bank, East Jerusalem,
and the Gaza Strip. The clustered 3-stage probability sample was
drawn from all Palestinian Central Bureau of Statistics (PCBS)
enumeration areas from updated 2007 PCBS census maps. Kish
tables were used to select one eligible adult per household. Two
local ﬁeldworkersda male and a femaledwith extensive experi-
ence doing household surveys and with rigorous training by the
research team in how to conduct event history calendar inter-
viewsdvisited every household in order to maximize entry to all of
the homes in the sample (i.e., avoiding having only a male inter-
viewing a female, and vice versa). The response rate was 97%.
Sample characteristics are reported in Table 1. The study was
approved by the Institutional Review Boards of PSR and the Uni-
versity of Tennessee. Questions about exposure to political violence
and personal loss such as those included in this study are common
across investigations of political conﬂict and have not been found to
pose particular risk. In our case, ﬁeld workers commonly expressed
that participants enjoyed reviewing their life histories.
Interviewers administered an event history calendar covering
the years from 1987 (beginning of the ﬁrst intifada, when the
average age of the sample was 12 years) to 2011 (year of interview),
and a multi-domain functioning inventory that had been developed
and reﬁned in previous qualitative (Barber et al., 2014a) and
McNeely et al., 2014) phases of the project.
2.3. Event history calendar
Event history calendaring has become a highly respected and
credible method of assessing an individual's biographical history
(Belli et al., 2009, 2001). The EHC approach differs notably from
other life event work in that it emphasizes timing and patterns of
life events rather than just incidence (Tenant, 2002; Zimmerman,
1983). Moreover, the researcher can use EHC data to examine the
timing and sequencing of events or statuses in different domains,
thereby providing a richer picture of potential causal mechanisms
in the development of an individual's well-being (Freedman et al.,
1998; Roberts and Mulvey, 2009).
Brieﬂy put, an event history calendar is a calendar or matrix
with time periods across the top (in our case, years) and events or
activities listed down the side (in our case, education, employment,
violence exposure, etc.). The respondent then ﬁlls in the calendar
with the help of the interviewer, indicating for every year whether
an event or activity took place or not.
The EHC method is effective at overcoming the subjective and
often elusive nature of memory, particularly regarding post-event
trauma recall. It does so by facilitating the reconstruction of
memory through increasing the respondent's ability to place
different activities, experiences, or events within the same time
frame during the interview process (Freedman et al., 1988). A re-
view of seven studies that simultaneously implemented calendar
methods and conventional survey methods concluded that use of a
calendar outperforms conventional methods in terms of data
quality (Belli, 2014).
Sociodemographic characteristics of the sample (n ¼ 1778).
(n ¼ 884)
(n ¼ 894)
Age 36.8 (3.5)
Refugee 43.6 43.7
Number of children 4.0 (2.2)
Greater than high school education 26.1
Employment status during last year
Did not work, did not want to work 7.2
Employed part of the year 35.6 6.1
Employed entire year 47.5 9.7
Other (asked not to work, pension) 9.8 1.9
Inadequate food in the last year 22.6 23.7
Inadequate water in the last year 42.6
Inadequate income in the last year 38.4 40.4
Family income less or much less than poverty level 45.6
p < 0.05;
p < 0.01;
p < 0.001.
test of difference.
B.K. Barber et al. / Social Science & Medicine 156 (2016) 154e166156
Speciﬁcally, certain events are readily remembered, such as
marriages, births, and changes in residence. They provide impor-
tant reference points for recalling less salient events or extended
life circumstances such as school enrollment, details of employ-
ment and living arrangements. Researchers have found that when
individuals attempt to recall a past event they typically align their
memories spatially as well as temporally, and visually connect
seemingly unrelated events to one another (Barsalou, 1988; Neisser
and Winograd, 1988). Thus, a particular advantage of the EHC
method is that it allows respondents (and interviewers) to visualize
in the calendar the interconnectedness of past events and deter-
mine whether they have accurately reported the co-occurrence or
ordering of various events (Axinn et al., 1999).
In conﬂict environments, episodes of conﬂict can serve as key
anchoring events. This is particularly the case for Palestinians
whose lives have included regular and numerous marker periods or
events. Some examples are: the 1987e1993 ﬁrst Intifada; the
1994e2000 Oslo period; the speciﬁc day of the 2000 onset of the
second, Al Aqsa Intifada; the 2005 withdrawal of Israeli settlers and
soldiers from Gaza; the 2006 election of Hamas; and the 2007
military takeover of the Gaza Strip by Hamas.
The list of events and experiences that made up the EHC for the
current project was developed from previous phases of the project
and in consultation with several key informants. It was written in
English and back-translated to Arabic, and an initial version was
piloted with 26 participants in the Gaza Strip and the West Bank in
2010. Each draft of the EHC was shared regularly with key in-
formants during multiple trips to the region between May 2010 and
July 2011. The ﬁnal EHC included information on 15 domains (with
multiple questions within each domain) across 25 years
(1987e2011). Domains included: education, employment, family
formation, signiﬁcant separations, etc. For the current study, we
analyzed only the political violence exposure items, described
In July and September 2011, we conducted four, 3-day training
sessions (2 each in the West Bank and the Gaza Strip) with 47 PSR
ﬁeldworker staff on how to administer the EHC. Training included
role-playing EHC interviews, proper recording of responses, and
when and how to utilize the various methods of cross-checking the
data. The actual EHC interviews lasted approximately 40 min, with
the total interviewdincluding the adult functioning asses-
smentdaveraging 60 min. Fieldwork supervisors conducted
informal evaluations of ﬁeldworker interviews and provided
feedback on EHC interview techniques and recording responses
throughout the data collection period.
To assess the ﬁeld utility of the EHC, after all interviews were
completed we surveyed the ﬁeldworkers and supervisors as to their
perceptions of the EHC method. The large majority of interviewers
agreed or strongly agreed with statements regarding: conﬁdence in
the respondents’ ability to answer both major (95.7%) as well as
detailed (85.1%) events and that the method of recording responses
on the EHC was easy to understand and master (91.4%). The fact
that the rates of reported exposure to these same types of political
violence concord well with rates reported by this same generation
of individuals in 1998, 5 years after the end of the ﬁrst intifada
provides support for the convergent validity of the EHC method
further (Barber, 2000; Barber and Olsen, 2009). In addition, the
large majority of ﬁ
eld workers (95.7%) agreed or strongly agreed
that they had conﬁdence in the accuracy of the data, suggesting
2.4. Measures: political violence exposure
For each of the 25 years of the calendar (1987e2011), re-
spondents were asked about their exposure to ﬁve types of political
violence: whether they were shot at (directly or with a group), hit
or kicked, verbally abused, witnessed someone close to them hu-
miliated, and had their home raided. Response options were
“never” (0), “once” (1), “several times” (2) and “frequently” (3).
These speciﬁc variables were chosen because of their high preva-
lence in many studies of Palestinians, including of this same gen-
eration when studied shortly after the ﬁrst intifada (Barber, 2000;
Barber and Olsen, 2009).
2.5. Measures: adult functioning
In the ﬁrst, qualitative phase of this project, numerous domains
of functioning (e.g., quality of life, wellbeing) were identiﬁed by the
interview sample. Interviewees placed particular emphasis on the
economic and political aspects of their lives as indicators of well-
being (Barber et al., 2014a). Quantitative items and scales were
then identiﬁed or created to tap those domains during the second
phase of the project (McNeely et al., 2014). Below, we present the
selection of those items/scales used for the present study, orga-
nized by functioning domain.
2.5.1. Economic domain
Resource adequacy consisted of three items (
¼ 0.82). With
reference to the past 6 months, respondents were asked to rate how
true the following statements were: “I have had adequate food,”“I
have had adequate clothing,” and “I have had adequate housing.”
Response categories ranged from “never” (1) to “regularly” (5).
2.5.2. Political domain
Restrictions at checkpoints was a summary measure of three
dichotomous items as to the whether participants had experienced
the following within the past month: “I was delayed for a long
period of time at an Israeli checkpoint,”“I was refused to pass
through an Israeli checkpoint,” or “I was humiliated when stopped
at an Israeli checkpoint.” Responses ranged from “N/A e I was not in
Palestine during the past month” (1) to “daily” (7). Freedom of
expression was assessed as the mean of two items (r ¼ 0.57) asking
respondents (without reference to a time period) to what extent
they feel freedom “To express your ideas and opinions outside of
your home” and “To express your political opinions.” Responses
ranged from “ not at all” (1) to “completely” (5).
2.5.3. Community domain
Community belonging was measured as the mean of three items
¼ 0.74). Respondents were asked to rate their satisfaction with:
“The extent you feel like you belong in your community,”“The
extent you are involved in your community,” and “The social sup-
port you receive from your community.” Responses ranged from
“very dissatisﬁed” (1) to “very satisﬁed” (5). Personal freedom was
assessed as the mean of two-items (r ¼ 0.60) asking respondents
about the extent to which they feel freedom: “To dress or groom
yourself as you wish” and “To have the type of social relations you
would like.” Responses ranged from “not at all” (1) to “completely”
2.5.4. Family domain
Positive marital functioning was the mean of three locally deﬁned
¼ 0.94) asking respondents to rate their agreement with
the following statements: “Our marriage is happy and harmo-
nious,”“I feel that I have enough freedom and independence in our
relationship,” and “My spouse and I understand each other well.”
Responses ranged from “strongly disagree” (1) to “strongly agree”
(5). Family satisfaction was the mean of two items (r ¼ 0.56) asking
respondents how satisﬁed they are with: “your relationship with
your children” and “your relationships with your family members.”
B.K. Barber et al. / Social Science & Medicine 156 (2016) 154e166 157
Responses ranged from “very dissatisﬁed” (1) to “very satisﬁed” (5)
2.5.5. Psychological domain
Feeling broken or destroyed was a locally deﬁned measure of
mental suffering that was discerned in interview data in the ﬁrst
phase of this project (mean of three items:
¼ 0.84). The interview
narratives repeated references to Palestinians of this generation
feeling “broken” or “destroyed” (translated from the Arabic). We
subsequently wrote these three items and pilot tested them.
Further, we demonstrated their discriminant validity with respect
to feelings of depression and trauma-related stress (see below) and
have argued that the construct differs importantly from other
renditions of mental suffering, such as despair, demoralization,
mental defeat, and emotional exhaustion (Barber et al., 2015a,b).
With reference to the past two weeks, respondents were asked how
regularly they felt: “That your spirit or morale is broken or
destroyed?”“That your ambitions and hopes for the future are
destroyed?” and “Emotionally or psychologically exhausted?” Re-
sponses ranged from “never” (1) to “regularly” (5).
Feelings of depression consisted of ﬁve items of the 8-item Pa-
tient Health Questionnaire (PHQ-8;
¼ 0.84; Kroenke and Spitzer,
2002), selected via factor analysis of the full item set. With refer-
ence to the past two weeks, participants were asked how often they
had been bothered by the primarily somatic symptoms of: trouble
falling asleep, feeling tired or having little energy, poor appetite or
overeating, trouble concentrating, and moving or speaking slowly/
being ﬁdgety or restless. Responses ranged from “not at all” (0) to
“nearly every day” (3). In a pilot survey conducted in June 2011 of
508 of the respondents also included in the larger sample being
analyzed for the current study, the correlation between this
reduced set of items and the full PHQ-8 was r ¼ 0.95 (McNeely et al.,
2014). The item set was reduced for this study due to space limi-
tations in the survey that included the extensive event history
Trauma-related stress was measured with 5 items of the 17-item
PTSD Symptom Scale (PSS;
¼ 0.91; Foa et al., 1993). These items
were selected via factor analysis of the full item set. To adapt the
measure to the context under study, participants were ﬁrst asked to
think about any harsh events they may have experienced during
the political conﬂict over the course of their lives. Then, with
reference to the past month, to indicate whether they had experi-
enced recurrent or intrusive thoughts, experienced sudden reliving
of the event(s), experienced being emotionally upset when
reminded of the event(s), persistently made efforts to avoid
thought or feelings associated with the event(s), and persistently
made efforts to avoid activities, situations, or places that reminded
them of the event(s). Responses ranged from “not at all” (0) to
“nearly every day” (3). In the pilot sample, the correlation between
the reduced set of items and the full 17-item PSS scale was r ¼ 0.88
(McNeely et al., 2014).
Human Insecurity was the mean of ﬁve items of the Human
Insecurity Scale (
¼ 0.83 [this study]; Giacaman et al., 2011). With
no reference to a speciﬁc time period, respondents were asked, “To
what extent do you fear for yourself or your family in your daily
life?”“Do you worry/fear that you will be displaced or lose your
home or land?”“Do you worry/fear for your future and your fam-
ily's future?”“Do you worry/fear the chaos in Palestinian society?”
and “Do the events in Palestine make the children in your family
feel frightened?” Responses ranged from “ not at all” (1) to “an
extreme amount” (5).
2.5.6. Health domain
We used a single item to measure functional limits due to health
(McNeely et al., 2014):“How often does your physical health limit
your ability to meet the other demands in your life such as ﬁnancial,
education, or family responsibilities?” Responses ranged from
“never” (1) to “regularly” (5).
We identiﬁed patterns of exposure to political violence over
time using latent proﬁle analysis (LPA). To reduce the number of
variables for the latent proﬁle analysis, we ﬁrst calculated the mean
score of each of the exposure variables for each of the four main,
politically demarcated, time periods covered by the EHC, as follows:
1987e1993 (ﬁrst intifada), 1994e1999 (Oslo period), 2000e2005
(second intifada), and 2006e2011 (post-second intifada, or recent
period). Thus, we had four time scores for every exposure type. This
data reduction decision was made after determining that the
variability in exposure to each of the forms of political violence
varied much more between political periods than within political
LPA assumes that the overall population is made up of a ﬁnite
number of latent and substantively meaningful subpopulations
(i.e., classes), each of which has a different pattern of exposure to
political violence. The means of the political violence exposure
variables were allowed to vary across classes, as is traditional.
Models were estimated with within-class variances and co-
variances constrained to be equal across classes. We attempted to
relax this assumption and allow within-class variances to vary, but
there were not enough degrees of freedom for those models to be
For men, we ﬁt latent proﬁle models using all ﬁve measures of
violence exposure. For women, we excluded being hit or kicked and
shot at due to the low prevalence of these variables in all periods.
Following recommendations by Masyn (2013), we determined the
optimal number of latent proﬁles or classes by assessing relative ﬁt
using the adjusted Lo-Mendell-Rubin likelihood ratio chi-square
goodness-of-ﬁt statistic, the model Bayesian Information Criterion
(BIC), the Consistent Akaiake’s information criterion (CAIC), the
approximate weight of evidence criterion (AWE), and the bootstrap
likelihood ratio chi-square goodness-of-ﬁt statistic (BLRT).
We examined indices of ﬁt comparing models with one to four
latent proﬁles. In terms of the ﬁt indices, we looked for low BIC,
CAIC, and AWE and for the p-value from the LMS and bootstrap
likelihood ratio test to indicate a signiﬁcant improvement in model
ﬁt when compared to the previous model and no improvement in
model ﬁt when compared to the model with an additional class
(Masyn, 2013 ).
In addition, several classiﬁcation diagnostics were used to assess
the extent to which the latent proﬁle analysis produced highly-
differentiated groups whose members had a high degree of ho-
mogeneity in their responses on the indicator variables. We
calculated the relative entropy (E), the average posterior class
probability (AvePP), the odds of correct classiﬁcation ratio (OCC),
and the modal class assignment proportion (mcaP). Good classiﬁ-
cation is indicated by high values of E, an AvePP above 0.7 (Nagin,
2005), large values of OCC (Nagin, 2005), and close agreement
between the modal class assignment (mcaP) and the model-
estimated proportion to class k (Masyn, 2013).
The associations between the latent categorical variable
measuring class membership and the observed variables that
assessed the multiple domains of adult functioning were estimated
following the recommendation of Lanza et al. (2013) and
Asparouhov and Muth
en (2013). Speciﬁcally, after the latent proﬁle
model was estimated, we estimated an auxiliary model where the
distal outcome(s) (the adult functioning measures) was used as a
latent class predictor within a multinomial logistic regression
model. An advantage of this approach is that the addition of distal
outcomes does not change the class structure that would be
B.K. Barber et al. / Social Science & Medicine 156 (2016) 154e166158
obtained from the measurement model alone. Descriptive statistics
were estimated using the svy suite of commands in Stata 12.0. All
other analyses were conducted using Mplus version 7.1.
3.1. Latent proﬁles of political conﬂict exposure
Results indicated that for both men and women a three-proﬁle
model provided the optimal representation of patterns of exposure
to political violence over the 25-year period (see Table 2). In Table 3,
the classiﬁcation indices are listed, which indicate the precision of
the latent class assignment. These are useful for assessing the de-
gree of class separation. Based on the four indicators (entropy,
mcaP, AvePP and OCC), there was high classiﬁcation accuracy for
both men and women.
The three proﬁles for men are presented in Panel A of Fig. 1. The
largest proﬁle (n ¼ 549; 63%) contains men who had a pattern that
can be described as Lower Periodic Exposure. This proﬁle is charac-
terized by somewhat elevated exposure to political violence during
the ﬁrst intifadadparticularly to having one's home raideddfol-
lowed by somewhat elevated exposure during the second intifada,
and low exposure during the other two periods. A second proﬁle of
men (n ¼ 218; 25%) can be described as having a pattern of Higher
Periodic Exposure. This proﬁle is characterized by higher exposure
to political violence during the ﬁrst intifada, somewhat elevated
exposure during the second intifada, and low exposure during the
other two periods. The third proﬁle of men (n ¼ 105; 12%) had a
trajectory of exposure to political violence that can be described as
Persistent Humiliation. This group is distinguished by high levels of
exposure to verbal abuse and witnessing someone close to them
being humiliated throughout the 25-year period. Their exposure to
other types of political violence is indistinguishable from the other
For women, three latent proﬁles also were identiﬁed: Lower
Periodic Exposure (n ¼ 780; 88%), Witnessing Humiliation (n ¼ 80;
9%) and Persistent Humiliation (n ¼ 22; 2.5%) (See Panel B of Fig. 1).
The patterns of exposure to political violence in the Lower Periodic
Exposure group and the Persistent Humiliation group were similar to
those of the men in the proﬁles with these same labels. The women
in the Witnessing Humiliation group differed in that they reported
less regular exposure to verbal abuse and to having their home
raided during the two intifadas, but reported high levels of wit-
nessing humiliation recurrently throughout the 25-year period.
Consistent with this pattern, the indicators of homogeneity and
separation suggest that the three proﬁles for women were distin-
guished by patterns of witnessing others being humiliated and
verbal abuse. There is not good separation or within-class homo-
geneity for the home raided variable. The means of the political
violence exposure measures in each of the latent proﬁles are
presented in Table 4.
Finally, we conducted post-hoc analyses to assure the appro-
priateness of characterizing classes as persistently exposed. That is,
because we estimated the models using the mean values of expo-
sure in each of the four main historical periods, rather than the
annual exposure data, it would be possible that the high levels of
exposure to witnessing humiliation and verbal abuse in each period
do not reﬂect persistent exposure (i.e., every year) but rather
extremely high exposure during just one or two years within a
period. To test for this possibility, we performed LPA of the expo-
sure variables separately for each of the four periods, using annual
data within each period. While some variability occurred depend-
ing on speciﬁc exposure type, generally it was evident that sub-
stantial proportions of those in the persistent exposure classes
identiﬁed above did report exposure to humiliation with some
3.2. Associations between latent proﬁles of political violence
exposure and functioning
The association between the latent proﬁle membership and the
twelve measures of functioning are presented in Tables 5 and 6. The
main pattern of ﬁndings is clear, and applies to both men and
women. With few exceptions, those who reported persistent
humiliationdcompared to those who experienced political
violence periodicallydalso reported signiﬁcantly poorer func-
tioning across a range of domains.
For women, means for the functioning variables did not differ
signiﬁcantly between the two humiliation proﬁles (persistent hu-
miliation and witnessing close ones humiliated), but the means for
both of those groups were signiﬁcantly different than for the
women in the low periodic exposure group across the majority of
the domains of functioning. This is particularly noteworthy given
the small number of women respondents in the persistent humil-
iation group (n ¼ 22) and thus the limited statistical power to
detect a difference. This suggests that the driving feature of these
two classes may be witnessing humiliation, the type of persistent
exposure that they reported in common (i.e., and not verbal abuse).
Women who have persistently witnessed humiliation reported
widespread poorer functioning: economically (lower resource ad-
equacy), politically (recent problems at a checkpoint), psycholog-
ically (higher feelings of depression, trauma-related stress, feeling
broken or destroyed, and human insecurity), and relative to
(higher functional limitations).
For men, the ﬁndings were very much the same. Uniformly,
compared to their counterparts who experienced low periodic
exposure, persistently humiliated men reported signiﬁcantly
poorer functioning across the same sets of variables as for women.
One interesting difference between men and women is evident in
the locally deﬁned mental suffering variable “feeling broken or
Model ﬁt indices for exploratory latent proﬁle analysis, within-class variances and covariances constrained to be equal across classes.
# of classes
LL # free
BIC CAIC AWE Adj. LMR-LRT
(k, k þ 1)
(k, k þ 1)
(n ¼ 872)
1 16936.152 40 34143.14 34183.14 34533.97
2 14364.957 61 29142.93 29203.93 29738.95 0.00 <0.001 <0.10 <0.01
3 13646.755 82 27848.71 27930.71 28649.92 0.29 <0.001 <0.10 1
4 Not well identiﬁed
(n ¼ 886)
1 10438.955 24 21040.79 21344.98 21275.56
2 8258.89 37 16768.89 16984.85 17130.83 0.00 <0.001 <0.10 <0.01
3 7243.56 50 14826.46 14954.19 15315.57 0.65 <0.001 <0.10 <0.01
4 Not well identiﬁed
B.K. Barber et al. / Social Science & Medicine 156 (2016) 154e166 159
destroyed.” For men, the means for all groups were relatively
highdapproximately 3 on a 1e5 scale, corresponding to feeling
broken or destroyed “sometimes” over the past two weeksdbut
they did not vary across exposure groups. In contrast, this form of
mental suffering among women was sensitive to patterns of
exposure to political violence.
A second pattern of ﬁndings is equally as clear as the ﬁrst, and it
illustrates just how complex functioning is. In contrast to the broad
Classiﬁcation indices for exploratory latent proﬁle analysis, within-class variances and covariances constrained to be equal across classes.
Estimated class proportions mcaP AvePP OCC
Entropy ¼ 0.966
Men Class 1 0.63 0.63 0.99 48.98
Class 2 0.12 0.12 1.00 7057.45
Class 3 0.25 0.25 0.98 119.54
Entropy ¼ 0.998
Women Class 1 0.89 0.89 1.00 30.78
Class 2 0.02 0.02 1.00 48951.00
Class 3 0.09 0.09 0.99 1675.07
Fig. 1. Political violence latent proﬁles for men and women.
B.K. Barber et al. / Social Science & Medicine 156 (2016) 154e166160
evidence of poorer functioning among the persistently humiliated,
there were also elements of functioning for which they reported
higher levels compared to those who experienced political violence
periodically. Interestingly, these elements of functioning appear to
share a social component. Speciﬁcally, persistently humiliated men
and women reported better functioning in the family (higher
positive marital functioning), community (higher sense of
belonging), and politically (freedom of expression). Persistently
humiliated women also reported greater personal freedom (i.e., to
groom as they wish and to relate socially as they wish).
Most of what we know about youth's experience with political
violence comes from cross-sectional or relatively short-term lon-
gitudinal studies. Very little attention has been paid to the long-
term impact of exposure to political violence; that is, if, how, and
to what extent their experiences with political violence shape their
lives from childhood into mid-adulthood. This is an important line
of inquiry because the large majority of young people survive the
intense episodes or periods of political conﬂict. Therefore, insight
into how their experiences with political violence shape their on-
ward functioning as adults is needed.
We addressed this need by tracking exposure to political
violence over a 25-year period spanning youth to adulthood. We
did so in a particularly apt population: Palestinians who came of
age during the intense ﬁrst intifada (1987e1993), and who have
experienced deteriorating economic and political conditions since
then. In pursuing this long-term view, we incorporated two further
research reﬁnements. Rather than aggregating across exposure
types as is commonly done, we gave independent attention to
discrete forms of violence exposure in order to detect any unique or
specialized effects of exposure type. Further, we extended past the
preoccupation in the relevant literature with psychopathology and
aggression, instead assessing functioning broadly across economic,
political, community, family, and as well as psychological, domains.
These innovations allowed us to pose new questions relative to
the impact of exposure to political violence. Speciﬁcally, instead of
the conventional concern about the risk of accumulated exposure,
we were able to consider whether the patterning of exposure
across time yields insight into its effects. Further, we were able to
ask how distinct types of exposure to political violence clustered
together over time and if those exposure patterns were signiﬁ-
cantly associated with adult functioning. Posing such questions was
enabled by the utilization of an event history calendar, a particu-
larly rigorous method of achieving reliable retrospective data.
Means of violence exposure variables in each political period by latent proﬁle membership.
1st 2nd 1st 2nd 1st 2nd
Intifada Oslo Intifada Recent Intifada Oslo Intifada Recent Intifada Oslo Intifada Recent
Men Class 1: Lower periodic exposure (n ¼ 548) Class 2: Higher periodic exposure (n ¼ 216) Class 3: Persistent humiliation (n ¼ 108)
Shot at 0.40 0.04 0.23 0.06 1.51 0.07 0.38 0.08 0.60 0.08 0.60 0.08
Hit kicked 0.23 0.05 0.12 0.05 1.38 0.08 0.16 0.02 0.90 0.37 0.63 0.22
Verbally abused 0.23 0.07 0.34 0.13 2.24 0.16 0.58 0.15 2.32 2.09 2.32 1.83
Saw others humiliated 0.46 0.06 0.33 0.15 1.99 0.07 0.55 0.18 2.62 2.52 2.64 2.50
Home raided 0.66 0.06 0.26 0.08 1.75 0.07 0.27 0.06 0.66 0.06 0.26 0.08
Women Class 1: Lower periodic exposure (n ¼ 785) Class 2: Witness humiliation (n ¼ 79) Class 3: Persistent humiliation (n ¼ 22)
Verbally abused 0.37 0.01 0.13 0.06 0.76 0.02 0.73 0.15 2.31 2.44 2.39 2.00
Saw others humiliated 0.75 0.03 0.25 0.14 2.52 2.59 2.61 2.34 2.47 2.36 2.49 2.46
Home raided 0.78 0.03 0.19 0.06 0.67 0.19 0.44 0.14 0.77 0.43 1.02 0.34
Associations between latent proﬁle membership and measures of adult functioning: Women (n ¼ 894).
LPE proﬁle (89%)
WH proﬁle (9%)
PH proﬁle (2%)
LPE vs WH
LPE vs PH
WH vs PH
Broken or destroyed 3.14 (0.04) 3.49 (0.12) 3.62 (0.26) 7.94
3.21 0.20 10.41
Feelings of depression 1.09 (0.03) 1.53 (0.08) 1.74 (0.19) 24.72
Trauma-related stress 1.02 (0.03) 1.94 (0.08) 2.04 (0.13) 113.12
Human insecurity 3.74 (0.03) 4.33 (0.09) 4.33 (0.15) 35.83
Functional limits due to health 2.41 (0.04) 2.99 (0.09) 2.91 (0.11) 34.72
Resource adequacy 3.98 (0.04) 3.65 (0.10) 3.70 (0.17) 10.42
2.65 0.05 12.20
Positive marital functioning (n ¼ 763) 3.89 (0.03) 4.22 (0.10) 4.33 (0.22) 9.88
Satisfaction with family 4.07 (0.02) 4.13 (0.06) 4.20 (0.10) 0.88 1.68 0.31 2.38
Community belonging 3.24 (0.03) 3.60 (0.09) 3.53 (0.19) 14.47
2.30 0.12 16.14
Personal freedom 3.55 (0.04) 3.70 (0.11) 3.98 (0.17) 1.45 6.09
Freedom of expression 2.73 (0.04) 3.03 (0.11) 3.25 (0.18) 6.89
Problem at checkpoint past month 0.08 (0.01) 0.16 (0.04) 0.50 (0.11) 3.78 15.28
LPE ¼ Lower periodic exposure proﬁle.
WH ¼ Witnessing humiliation proﬁle.
PH ¼ Persistent humiliation proﬁle.
*p < 0.05; **p < 0.01; ***p < 0.001.
B.K. Barber et al. / Social Science & Medicine 156 (2016) 154e166 161
4.1. Patterns of exposure to political violence
The ﬁrst ﬁnding was that exposure to political violence across
this lengthy period for this representative sample could in fact be
characterized by a limited set of patterns of exposure (three each
for men and women). That these patterns of exposure are clearly
interpretable is important validation for this novel method of data
collection in this ﬁeld. Speciﬁcally, it is sensible that most of the
sample had their highest and broadest level of political violence
exposure during the ﬁrst intifada: years of unusually frequent,
widespread, and intense involvement in the conﬂict.
It is further sensible that exposure to political violence during
the second intifada, while elevated compared to the non-conﬂict
periods, was lower compared to the ﬁrst intifada. The second in-
tifada was a more localized, albeit more lethal, conﬂict in which the
general population was less broadly involved. It is also sensible that
among men, there were differences in the amount of periodic
exposure to political violence. This likely reﬂects the reality that
some males were more politically active during the intifadas than
other males, which put them in closer contact with Israeli military
forces or to be targeted by them.
The event history calendar method was fruitful also in identi-
fying a pattern of exposure (one for men, and two related patterns
for women) that differed signiﬁcantly from the periodic exposure
trajectories discussed above. In this regard, the study's inclusion of
distinct forms of exposure to political violence proved crucial. This
patternd12% of men and women who reported persistent expo-
sure to forms of humiliationdwas unanticipated, but it appears
nevertheless to be interpretable. First, it is sensible that these men
and women did not report persisting experience with the other
types of exposure (being hit/kicked, shot at, and having their homes
raided) because those forms of political violence occurred more
systematically during the two conﬂict periods. (Also sensible, the
rates of being hit/kicked and shot at were low enough for women as
to remove them from the analyses.)
The interpretability of this pattern of persistent humiliation was
enhanced through post-hoc inspection of where these individuals
live. Those who reported being persistently humiliated were largely
concentrated in speciﬁc neighborhoods in Hebron, Jerusalem, and
the Jordan River Valley. All of these areas have a high presence of
Israeli military or security installations (e.g., checkpoints, turn-
stiles) and no presence of Palestinian police or security. There is
abundant documentation of the presence of these movement bar-
riers, their use, and the humiliating tactics employed at them, via
personal anecdotes, documentaries, and press, policy, academic,
and human rights organization reports (e.g., B'Tselem, 2015; OCHA,
2015; Kershner, 2014; Longo et al., 2014; Paliwal, 2013). This
pattern of concentration further validates (e.g., criterion-referenced
validity) the data and ﬁndings of the study.
It is reasonable, therefore, to consider that the humiliation these
men and women reported experiencing persistently has occurred
at or because of these movement barriers (Barber et al., 2014b).
Such a position is supported in part in the data analyzed here in
that signiﬁcantly more persistently humiliated men and women
reported recent problems at a checkpoint than those of the other
4.2. Correlates of patterned exposure to political violence
The identiﬁcation of this group became all the more valuable in
the face of the second main ﬁnding of the study; namely, that the
persistently humiliated reported signi
ﬁcantly different functioning
than those who experienced periodic exposure to political violence.
This ﬁnding was robust in the sense that poorer functioning was
evident across the breadth of domains we assessed.
In appreciating the meaning of the broadly negative effect of
persistent humiliation, it is ﬁrstly important to make clear what the
ﬁnding does not imply. The ﬁnding does not mean that the risk of
exposure to political violence is embodied fully by persistent
exposure to humiliationdthat, somehow, other types or patterns of
exposure are innocuous. What the ﬁnding does say is that when
considering exposure to political violence across two and one-half
decades from youth to adulthood, those who have faced humili-
ating treatment multiple times every year, function differently in
adulthood than those whose exposure was periodic (even when the
periodic exposure included more types of violence exposure).
An important additional ﬁnding was that persistently humili-
ated men and women also reported elevated levels of social
cohesion and expression. This ﬁnding is important at various levels.
Basically, it suggests evidence of the centrality of family functioning
Associations between latent proﬁle membership and measures of adult functioning: Men (n ¼ 884).
LPE proﬁle (63%)
HPE proﬁle (25%)
PH proﬁle (12%)
LPE vs HPE
LPE vs PH
HPE vs PH
Broken or destroyed 2.93 (0.05) 3.07 (0.08) 2.97 (0.11) 2.20 0.09 0.58 2.25
Feelings of depression 0.94 (0.03) 1.03 (0.05) 1.22 (0.09) 2.52 10.12
Trauma-related stress 1.00 (0.04) 1.13 (0.06) 1.72 (0.08) 3.48 62.74
Human insecurity 3.51 (0.04) 3.68 (0.06) 3.97 (0.10) 5.95
Functional limits due to health 2.21 (0.05) 2.38 (0.08) 2.46 (0.09) 2.94 6.02
Resource adequacy 4.13 (0.04) 3.87 (0.07) 3.68 (0.08) 10.28
Positive marital functioning (n ¼ 838) 4.26 (0.03) 4.17 (0.05) 4.47 (0.06) 2.68 10.95
Satisfaction with family 4.23 (0.02) 4.10 (0.04) 4.18 (0.05) 6.96
0.63 1.34 7.26
Community belonging 3.34 (0.04) 3.41 (0.06) 3.63 (0.09) 1.06 9.31
Personal freedom 3.95 (0.04) 4.06 (0.06) 4.00 (0.09) 2.16 0.21 0.33 2.18
Freedom of expression 3.09 (0.05) 3.11 (0.08) 3.38 (0.10) 0.04 6.28
Problem at checkpoint past month 0.20 (0.02) 0.18 (0.03) 0.51 (0.05) 0.36 36.34
LPE ¼ Low periodic exposure proﬁle.
HPE ¼ High periodic exposure proﬁle.
PH ¼ Persistent humiliation proﬁle.
*p < 0.05; **p < 0.01; ***p < 0.00.
B.K. Barber et al. / Social Science & Medicine 156 (2016) 154e166162
in this population (Giacaman and Johnson, 2002) as well as Arab
cultures more broadly (Barakat, 1985). That family strengths are
visible in the face of widespread diversity also may evidence no-
tions that Palestinians prioritize family relations as a safety net
(Farsoun, 2004) or even as an expression of resistance against the
occupation (Taraki, 2006). More broadly, the ﬁnding supports no-
tions of individual and family resilience in the face of adversity
(Nguyen-Gillham et al., 2008; Ungar, 2008) and that perceptions of
inequality can be a source of both social capital and demoralization
4.3. Characterizing and situating persistent humiliation
Several literature come to mind when considering this ﬁnding of
persistent humiliation. Three that overlap substantially are chronic
(versus acute) stress (including its sub-domain of daily hassles/
stressors), and structural (versus direct) violence. We think that
prevailing applications of these frames to understanding political
violence are not adequate to interpret this study's ﬁndings, and
elaborate here to caution against any tendency to use them when
evaluating the ﬁndings.
4.4. Acute (versus chronic) stress
When we ﬁ rst presented these ﬁndings, we used the label
“chronic humiliation” because of the regularity with which par-
ticipants reported experiencing humiliation across the decades
covered in this study (Barber et al., 2013). However, after more
carefully reviewing how it is used in relevant literature, we now
prefer to explicitly avoid using the word chronic. Speciﬁcally,
chronic stress is often deﬁned explicitly as a contrast to acute stress,
the former being continuous (i.e., insidious, nebulous, unchanging,
low grade) and the latter discrete (i.e., event-like, with a clear onset
and offset; higher grade) (Miller and Rasmussen, 2010a,b; Pearlin
et al., 1981; Wheaton, 1997).
Accordingly, persistent humiliation actually appears more like
acute stress than chronic stress becausedunlike poverty, for
exampledit is event-like and episodic. Moreover, despite an in-
crease in attention to chronic stress in the literature, many see it as
insufﬁcient in and of itself to cause negative health outcomes
(Aldwin, 2011). In contrast, our ﬁndings relative to persistent hu-
miliation show broad and signiﬁcant negative associations with
adult functioning, such that it would better be viewed as repeated
exposures to an acute, high grade stressor.
Persistent humiliation also should not be characterized as a
daily hassle/stressorda popular subset of the chronic stress liter-
atureddue to the explicit distinction made in that literature be-
tween daily hassles and direct
exposure to violence, and, more
speciﬁcally, with direct exposure to political violence (Miller and
Rasmussen, 2010a,b; Neuner, 2010). While the term “daily” has-
sles or stressors (otherwise referred to as “microstressors”; Aldwin,
2007) has been acknowledged as overly broaddwith some prog-
ress at reﬁnement being made by distinguishing between more and
less traumatic typesdthe literature nevertheless explicitly differ-
entiates daily hassles/stressors from direct, acute exposure to po-
litical violence. This is evident, for example, in models that situate
daily hassles as mediators of the effect of episodes of political
violence on well-being (Miller and Rasmussen, 2010b). There is no
question that there are “lower level” stressors of varying intensity
in regions of political conﬂict that may mediate the impact of po-
litical conﬂict on health. However, according to prevailing deﬁni-
tions, being humiliated by military or security forces cannot be
considered as such because it is a direct, acute, and deliberate form
of political violence (Giacaman et al., 2007).
4.5. Direct (versus structural) violence
At a superﬁcial level, the humiliation that our participants re-
ported could be considered structural violence. It is structural in the
sense that it is embedded in political systems that interfere with
people meeting their needs; and, it is violent in that it injures
people in ways that implicate social justice (Farmer et al., 200 6;
Galtung, 1990). However, being verbally abused or witnessing hu-
miliation by military and security forces is discordant with many
elaborations included in classic deﬁnitions of structural violence. As
examples, persistent humiliationdunlike structural violencedis
not: invisible, difﬁcult to witness, or distant (Galtung, 1990). It is not
imposed indirectly (Kent, 2006), and it is not slow or subtle, nor are
its perpetrators difﬁcult to identify (Farmer et al., 2006; Galtung,
In fact, persistent humiliation appears more like direct violence
against which structural violence is often distinguished. Direct
violence is thought to be distinct from the more nebulous structural
violence, such as unequal access to goods and services, unequal
distribution of power and wealth, poverty, unjust institutions,
systems and structures (Farmer, 2004; Kohler and Alcock, 1976;
Schwebel and Christie, 2001). Ratherd
like acute versus chronic
stressddirect violence reﬂects events, rather than processes, that
are physical and thus easily visible and measurable and often
involve gross injustice (Opotow, 1990). For its part, notions of direct
violence have been criticized for not acknowledging that its effects
can be psychological and not only physical (Audi, 1971). Our ﬁnd-
ings assist in clarifying that there can indeed be such psychological
effects, even for witnessing this type of violence.
4.6. The particular injury of humiliation
“Humiliation is worse than death; in times of war words of
humiliation hurt more than bullets.”
(Somali proverb, as cited in Lindner, 2006)
An important reason for the elaborations above is to avoid any
tendency to under-represent the severity of this form of political
violence as being a low grade, indirect, chronic stressor. To the
contrary, as Giacaman et al. (2007) has argued and demonstrated in
work on Palestinians, humiliationdwhether experienced person-
ally or witnesseddhas been a neglected, “invisible” trauma of war
that merits explicit focus as a unique dimension of political
violence. This is so both because of its prevalence and its risk to
wellbeing. Our ﬁndings are fully consistent with that assessment,
and extend it meaningfully through the particular innovations of
the methods we employed: a representative sample, annual as-
sessments over a 25-year period of discrete forms of exposure, and
demonstration of risk to multiple domains of functioning.
The call for attention to humiliation is consistent with broader
literature well beyond the oPt. Thus, while discrimination,
oppression, dehumanization, maltreatment/abuse, and humiliation
have been shown to be linked with poor physical and mental health
across a variety of patient, minority, immigrant, and refugee pop-
ulations, scholars have noted that such intentional, complex,
“macro-aggressive traumas” have received relatively little attention
in health, stress, and political conﬂict literature (Haslam and
Loughnan, 2014; Helms et al., 2010; Kira et al., 2013; Pascoe and
Smart Richman, 2009; Spinazzola et al., 2014).
Future efforts to emphasize humiliation in studies of political
violence should build directly off a dynamic literature on humili-
ation across several disciplines. The “humiliation dynamic” (Klein,
1991) has been speciﬁcally measured (Hartling and Luchetta,
1999) and is distinguished conceptually as an objective, public,
and intentionaleoften forceful and violent (Lindner, 2006) e ex-
ercise of power (Leidner et al., 2012; Leask, 2013) that dehumanizes
B.K. Barber et al. / Social Science & Medicine 156 (2016) 154e166 163
and assaults personal and collective identity, dignity, honor and
justice (Haslam and Loughnan, 2014; Giacaman et al., 2007; Kira
et al., 2013). The associated emotionsethat include senses of
injustice, outrage, and powerlessness (Ginges and Atran, 2008) e
have been shown to be different than other emotions (e.g., shame,
anger, sadness; Leidner et al., 2012).
For these reasons, the effects are considered to be substantial,
life-changing (Leask, 2013), and cognitively more intense (i.e., than
anger or sadness; Otten and Jonas, 2014). Humiliation has been
linked either conceptually or empirically to a range of psychological
and social difﬁculties, as well as intergroup conﬂict and violence
(Giacaman et al., 2007; Kira et al., 2013; Leidner et al., 2012). We
have no current data with which to test such mechanisms of effect.
Nevertheless the ﬁ ndings of this study do underscore the unique
salience of this form of political violence in that it was more broadly
associated with the long-term functioning of this sample than were
the more conventionally assessed forms of political violence,
including being physically assaulted or shot at. As such, it counters
some recent ﬁndings that political violence per se is not a risk factor
to wellbeing in conﬂict zones, but that rather its related chronic
hassles or stressors are (Miller and Rasmussen, 2010b; Thabet and
Vostanis, 2000). It may be that such studies did not concentrate on
particularly acute forms of political violence or their persistence
The ﬁndings of this study demonstrate that long-term exposure
to political violence can be reliably assessed retrospectively, and
that doing so can be done via an event history calendar. Further,
exposure to multiple types of political violence can be summarized
by a limited set of interpretable patterns of periodic and persistent
exposure, at least for the population studied here. The ﬁnding that
persistent humiliation was widely associated with suffering, but
also with social cohesion, recommends more explicit attention to
humiliation as a form of political violence and in so doing en-
courages the careful inspection and integration of several theo-
retical and conceptual approaches in distinguishing it from other
forms of political violence. Most importantly, the ﬁndings
encourage a conceptualization of humiliation as a direct, acute, and
high-grade stressor because of its intentional, power-centric
violation of justice and dignity. The ﬁndings have relevance for
health and social policy, as well as practice, in pinpointing a
uniquely consequential form of adversity warranting intervention.
5.1. Limitations and future research
A signiﬁcant limitation of this study was its narrow focus on
historical exposure to political violence as a predictor of adult
functioning. Numerous other events and experiences during and
after periods of political conﬂict are highly relevant, including,
especially, access to economic, social, community, health, and po-
litical resources. Given the predominant attention in several
literatures to exposure to political violence, however, we felt that a
precise focus on that realm of experience would add a meaningful
increment of understanding of how political violence evolves over
time and what its long-term impact is. Future efforts will elaborate
on this model systematically by incorporating patterns of SES,
employment, education, family formation, access to resources and
medical services, movement restrictions, political activism, etc.
While the EHC has proven to be effective on this topic among
this population, it still has several limitations. Although it anchors
events in the past in reliable ways, the method is nevertheless still
cross-sectional in that all data were collected simultaneously. This
limits the ability to assert causal direction, although it seems
unlikely that assessments of current functioning would determine
the patterns with which participants identiﬁed their violence
exposure. Substantively, it is also possible that memory of humili-
ation may be more salient, and thus remembered more easily, than
other forms of political violence, resulting in biased reports of
relative prevalence of violence exposure. This would not neces-
sarily impact the heightened predictive ability of humiliation,
however, relative to other violence exposures that the study found.
Further regarding humiliation, the study is also limited by two,
rather direct, temporally-bound forms of humiliation (witnessing a
close person humiliated and experiencing verbal abuse). There are
certainly other ways in which humiliation can be experienced (e.g.,
identity denial, movement restrictions) and further work should
attempt to distinguish among multiple forms and levels of humil-
This research was funded by the Jacobs Foundation, Switzerland
(2009-828) for which we are sincerely grateful. Sincere apprecia-
tion is expressed to key advisors: Rita Giacaman, Mahmoud Daher,
Khalil Shikaki, Olfat Hammad, Cairo Arafat, Eyad El Sarraj
(deceased), Waleed Ladadweh, and Mohammed Abu Mallouh. Most
importantly, deep appreciation is expressed to the PSR ﬁeld work
staff and, especially, to the participants in this study who gave
much time and effort.
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