Our study aimed to assess the prevalence of PTSD among civilians living in southern Israel. To our knowledge, this is the first study to compare the mental health state of the adult Jewish and Bedouin sub-populations in the face of past missile attacks and the ongoing threat of future missile attacks.
Overall, 20.3% of the respondents exhibited PTSD symptoms during a period of relative calm. Israel’s Operation Breaking Dawn, during which 1,1175 were launched at southern Israel from Gaza, injuring 70 Israelis and damaging homes and factories, occurred August 5–7, 2022, almost six months before the study period. (The Meir Amit Intelligence and Terrorism Information Center, 2022). These findings align with the results of the Green, et al (2018) systematic review of studies conducted in Israel, which reported PTSD rates ranging from 5.6–35.2% during periods of relative calm (Greene et al., 2018). In the present sample, 8.1% of the Jewish participants reported symptoms characteristic of PTSD during the previous month. A study conducted using a sample of 764 Jewish residents of central and southern Israel, four months after Israel’s 2014 Operation Protective Edge, revealed similar results, in that 8.2% of the participants exhibited symptoms of PTSD (Ben-Tzur et al., 2021). Studies conducted during times of active military conflict consistently found higher prevalence rates (Besser & Neria, 2012; Neria et al., 2010). For example, a cross-sectional study among Jewish students from a college near Sderot during active conflict reported a PTSD rate of 20% (Besser & Neria, 2012).
The present study revealed that the odds for PTSD were significantly higher – by almost seven-fold – for Bedouins compared to Jews, after taking into account possible confounders. This finding is in line with previous Israeli studies which have consistently shown that Israeli Arabs exhibit higher levels of PTSD following traumatic events compared to their Jewish counterparts (Hobfoll et al., 2008; Ron, 2014; Yahav & Cohen, 2007).
There are several plausible explanations for the increased prevalence of PTSD within the Bedouin population. The Jewish population has experienced several wars and periods of domestic terrorism. For most Israeli Jews, mandatory military service for men and women is an accepted part of life. In contrast, it was not until after 2005 that Bedouin communities in southern Israel began to find themselves subject to life-threatening missile attacks. Most Bedouin citizens, for whom Israeli Army service is optional, have not been deliberately targeted by Israel’s enemies during wars or periods of domestic terrorism, and thus have had less exposure to them and less experience in coping with them. Only 300–500 Bedouins per year decide to enlist in the army, and only one-third of the enlistees are residents of southern Israel (Toth Stub, 2016). Most Bedouin enlistees come from northern Israel, where they are more integrated into Israeli society than are Bedouins in southern Israel (Toth Stub, 2016). Reportedly, Bedouins from southern Israel who enlist in the army face criticism and even threats of violence from their communities (Toth Stub, 2016).
Studies suggest increased prevalence of PTSD among Bedouins may be related to the “conflict of belonging” (Ron, 2014, 2019; Yahav & Cohen, 2007). An Israeli study about the level of perceived distress in university medical students during a prolonged period of terror attacks reported an association between greater sense of national belonging and lower level of distress (Kovatz et al., 2006). The close familial connections between Bedouin residents of Gaza and Bedouin residents in southern Israel may render the latter susceptible to secondary traumatization. Furthermore, although Bedouins are Israeli citizens, a growing number of Bedouins identify themselves as Palestinians (Ron, 2014), leading to the stressful dilemma of dual allegiance on both familial and community levels. Another possible contributing factor is that some Israeli Bedouins report feelings of discrimination (Alhuzail & Segev, 2023), which may increase the likelihood of adverse mental health reactions (Brooks Holliday et al., 2020).
By history and culture, Bedouins feel bound to their living places and their tribes. In contrast, Jewish citizens feel they have alternative housing options throughout Israel. While remaining in southern Israel is a choice for Jewish citizens, Bedouins do not feel free to leave their living places or violate tribal obligations (Alhuzail & Segev, 2023).
A significant difference between unemployment rate and SES among Bedouin and Jewish participants raises the possibility that these factors must be addressed to a greater extent than other factors that may be impacted by policy makers. Undeniably, the Bedouin population in Israel is one of the most economically disadvantaged groups (Yahel & Abu-Ajaj, 2021), which may be attributed to a combination of a high fertility rate and higher unemployment. The shift in Bedouin economic activity from animal husbandry to wage labor places Bedouin workers in stressful competition for non-professional jobs (Tubi & Feitelson, 2019). The unemployment rate is especially high among Bedouin women. According to Knesset Israel (2022), in 2019, 77% of Bedouin women of prime employable age were not part of the workforce, compared with 62% among Arab women in general, and 14% among Jewish women. Those Bedouin women who are employed earn, on average, 45% less than their Jewish counterparts (Knesset Israel, 2022). One of the main factors behind the relatively low employment rates for Arab men and women is low education level. With regard to higher education, the rate of eligibility for a matriculation certificate among Bedouin high school students is significantly lower compared to Arabs in general, and compared to the Jewish population (48.1%, 63.9%, and 73.1% respectively) (Haj-Yahya et al., 2022).
This study used self-reported SES, which was found significantly associated with increased odds for PTSD with a dose-response relationship independent of other participant characteristics. Individuals in low socio-economic positions may experience a higher prevalence of adverse events, such as poverty, discrimination, violence, and crime. These chronic stressors can contribute to the development of PTSD, as they expose individuals to traumatic situations more frequently (Nurius et al., 2013). Studies reveal that individuals with lower SES often face barriers in accessing healthcare and mental health services (Kim et al., 2018; McMaughan et al., 2020; Yip et al., 2002). This barriers can impede ability to receive timely and appropriate treatment for traumatic experiences, thereby elevating the risk of developing PTSD (Greene et al., 2018; McMaughan et al., 2020). Apart from the influence of low SES, and limited access to overall healthcare, there appears to be under-utilization of mental health services among minority groups (Norris & Alegria, 2005; Roberts et al., 2011). Thus, studies indicate low utilization of mental health services among Bedouin citizens of Israel, which can be attributed to language barriers, mistrust in the quality of treatments, fear of psychological intervention, and concerns about social stigma associated with mental illness (Al-Krenawi & Graham, 2006; Fahoum & Al-Krenawi, 2023; Shorer et al., 2021). Moreover, within Arab and Bedouin culture, there is a prevailing belief that problems should be resolved within the family rather than through outside professional assistance (Al-Krenawi & Graham, 2011; Fahoum & Al-Krenawi, 2023).
Certain household characteristics can play a role in influencing anxiety level during exposure to a missile attack, including the availability of a shelter and the presence of an alarm system. In comparison to Jews, Bedouin citizens had limited access to shelters and siren systems. This discrepancy may be attributable to the fact that 17% of the Bedouins in the sample resided in unrecognized vilages lacking municipal infrastructure and services. Before Bedouin villages were subject to missile attacks, there was no need for shelters and alarm systems. When the possibility of missile attack increased, the need for such infrastructure increased. While the univariate analysis revealed that a lack of accessibility to shelter and a siren system were significantly associated with PTSD, in the multivariable analysis no association was detected.
Our study revealed that citizens residing in urban areas vs. rural areas, had a two-fold significant likelihood of developing PTSD. This observation also aligns with the results of the systematic review cited above (Greene et al., 2018). The potential explanation for this phenomenon may lie in the distinctive nature of small Israeli villages and communities. These “kibbutzim” and “moshavim” were initially established to farm and settle the land, driven by ideals of economic and social equality, mutual support, and individual responsibility. Nuttman-Shwartz et al. (2015) proposed that the sense of belonging to such communities serves as a valuable resource, strong enough to reduce posttraumatic distress and increase resilience (Nuttman-Shwartz et al., 2015).
Finally, having a disability was associated with almost three-fold higher odds of PTSD, after considering other characteristics. Shpigelman & Gelkopf (2017) investigated the experiences and obstacles faced by Israelis with lifelong disabilities during periods of conflict escalation (Shpigelman & Gelkopf, 2017). The findings revealed that participants with physical and sensory disabilities encountered challenges in reaching shelters within the limited time-frame between the sounding of the siren and an actual attack, and challenges in obtaining adequate safety information. Additionally, increased reliance on others, and the perceived overprotectiveness imposed by family members during war, contributed to the distress and anxiety of disabled persons during emergency situations (Shpigelman & Gelkopf, 2017).
Importantly, the research was conducted during a peaceful interval, free from conflict. However, the outbreak of war on October 7, 2023, had widespread ramifications, impacting various sectors, including the Bedouin community. Civilian Bedouins endured injuries, fatalities, and even abductions. The findings of this study underscore the imperative to allocate resources and focus on aiding this population in coping with the mental challenges they face.
Policy implications and recommendations
Healthcare professionals must proactively address the mental impacts of missile attacks on all civilians. This includes screening for the condition and providing tailored treatment and support, considering individuals’ language, cultural background, and other characteristics that may be associated with PTSD. To enhance service acceptance, healthcare providers and authorities should seek to eliminate barriers, including geographical distance, inadequate availability of mental health services, especially in unrecognized villages, cost, stigma, and mistrust. This may be aided by avoiding psychopathology labels, providing free-of-charge treatment, and ensuring easy accessibility by delivering services within Bedouin communities. Authorities should address the disparity in bomb shelter access and siren warning coverage between Bedouin and Jewish communities.
Our findings are relevant to other war-stricken areas around the world. Conducting thorough mental health assessments, along with evaluating the awareness of available mental health services, is of utmost importance, particularly within disadvantaged populations in communities subject to missile attack or other elements of warfare. Moreover, establishing easily accessible, community-based, culturally competent mental health services that are affordable or free-of-charge is crucial for effectively addressing the specific needs of disadvantaged individuals. Effective programs must employ practitioners who actively engage within the community beyond the clinic setting. Representatives from disadvantaged communities should be involved from the planning and implementation of the interventions to the evaluation of their efficacy. It is also essential to employ ethnic minority practitioners to enhance recruitment, retention in care, and recovery efforts.