Religiosity: Protective or Risk Factor for Posttraumatic Distress Among Adolescents Who Were Exposed to Different Types of Acts of Political Violence

Abstract

This study examined the potential moderating effects of religiosity on the associations between exposure to acts of political violence and posttraumatic stress symptoms (PTS) among Jewish adolescents in Israel. In addition, it examined whether self-reported physical and interpersonal exposure to acts of political violence predicts PTS symptoms beyond the objective exposure effects (i.e., the proximity of participants’ place of residence to high-, moderate-, or low-intensity political violence). A representative sample of 2,992 Jewish high school students (Grades 10 and 11) was taken. We used self-reporting to measure the level of religiosity and the Impact of Events Scale–Revised (IES-R) to measure PTS symptoms. Results show that self-reported exposure to acts of political violence adds a significant additional amount of variance to the prediction of PTS symptoms after objective exposure is already included in the regression equation. Religiosity was found as a risk factor for PTS symptoms such that the greater the religiosity of the adolescents, the higher their PTS symptoms. Therefore, prevention interventions should target the vulnerable group of religious Jewish adolescents.

Keywords

religiosity political violence mental health and violence PTSD war cultural contexts

Introduction

Exposure to acts of political violence is related to emotional distress and behavioral problems among children and adolescents (Dimitry, 2012; Pfefferbaum, Jacobs, Griffin, & Houston, 2015). Although within the literature there is a wide range of definitions and conceptualizations for the term “exposure to political violence,” we adopted the World Health Organization (WHO) definition that “political violence is the deliberate use of power and force to achieve political goals and is characterized by both physical and psychological acts aimed at injuring or intimidating populations” (Sousa, 2013, p. 169). In the present study, a distinction was made between different types of exposure to political violence. Objective exposure is defined by the distance from the student’s place of residence to the location of the event. This is often referred to in literature as the “conflict zone.” High proximity indicates high exposure and high distance from the events indicates low exposure to acts of political violence. In recent years, there has been an increased interest in the implications of living in conflict zones (Berger, Gelkopf, & Heineberg, 2012; Dubow et al., 2012; Henrich & Shahar, 2013; Pat-Horenczyk, Kenan, Achituv, & Bachar, 2014). For example, Besser, Neria, and Haynes (2009) examined the level of PTS among a representative sample of an adult population exposed to rockets and mortars in southern Israel (high objective exposure) for more than 7 years compared with adults in other regions of Israel who were nominally exposed to acts of political violence (low objective exposure). They discovered significantly higher levels of PTS symptoms among the southern Israel sample.

While the vast majority of the residents of the State of Israel are exposed to acts of political violence, during the period of the research, residents in the north were exposed at a much higher rate due to the Second Lebanon War beginning shortly before the study was conducted. Therefore, during the period of the study, the northern region was considered to be a conflict zone. The southern region was also considered a conflict zone during this period, albeit at a lower level. The central region was not considered a conflict zone.

Self-reported physical and interpersonal exposure was defined in our study similarly to many other studies (Al-Krenawi & Graham, 2012; Sagy & Braun-Lewensohn, 2009) as students reporting on the intensity and frequency of their exposure to various acts of political violence unconnected to their place of residence. This is divided into direct and indirect physical exposure and direct and indirect interpersonal exposure. The students’ reports on events such as being near a place where a missile fell, or on hearing the falling rockets is considered here as indirect physical exposure. Reporting on being in the presence of the event itself, including being wounded from the event, is considered direct physical exposure. Several previous studies also referred to a similar conceptualization of physical exposure to acts of political violence (Lavi & Slone, 2012; Pfefferbaum & Doughty, 2001; Somer, Maguen, Or-Chen, & Litz, 2009).

Interpersonal exposure, similar to physical exposure, is also divided into direct and indirect. Indirect interpersonal exposure refers to harm to an acquaintance who is not a family member. Direct interpersonal exposure refers to harm to a family member. The conceptualizations for direct and indirect interpersonal exposure have already been used in previous studies (e.g., Pfefferbaum & Doughty, 2001). To a large extent, it was found that most children and adolescents in Israel were exposed to all the forms of exposure mentioned here. For example, the meta-analysis of 30 Israeli studies (Dimitry, 2012) found that the rate of familiarity with the wounded or killed (indirect interpersonal exposure) ranged from 13% to 63%, the rate of those reporting a family member wounded or killed (direct interpersonal exposure) ranged from 10% to 20%, and between 23% and 44% heard a bomb explosion, shooting, or suicide bomber (indirect physical exposure). The present study examined the effects of each of the types of exposure on adolescents’ PTS. It also assessed the contribution of self-reported exposure (beyond the objective) to the prediction of their PTS.

Posttraumatic Stress Disorder and Symptoms (PTSD and PTS)

Exposure to acts of political violence may lead to mental, behavioral, and emotional problems among children and adolescents (Cummings et al., 2013; Pfefferbaum et al., 2015; Schiff & Fang, 2016). The most researched psychological responses to acts of political violence are PTS and PTSD (Berger et al., 2012; Contractor et al., 2014; Dubow et al., 2012). Previous studies on political violence found the prevalence of PTSD to range from 4% after the Oklahoma bombing (Pfefferbaum et al., 2000) to 12.6% after the events of September 11 (Pfefferbaum, Stuber, Galea, & Fairbrother, 2006). Similarly, the prevalence of PTSD among Israeli children and adolescents ranged between 5% and 14% (Dimitry, 2012; Rosshandler, Hall, & Canetti, 2016; Schiff et al., 2012; Slone & Mann, 2016), depending on the type of events and the way PTSD was measured (i.e., with or without functional disorders).

As the level of PTS symptoms, even if they are not sufficient for a diagnosis of PTSD, points to major psychological distress, often no less than those of the diagnosis of PTSD, it is also common to measure the level of PTS and symptoms severity rather than PTSD (Pine & Cohen, 2002; Tang et al., 2017).

Protective Factors From PTS in the Context of Acts of Political Violence

The literature is inconsistent regarding the negative consequences of exposure to acts of political violence. Some find significant negative consequences, others report only mild negative consequences (Bleich, Gelkopf, & Solomon, 2003), and some find high resilience (Fayyad et al., 2017; Klingman, 2001; Masten, 2014; Pat-Horenczyk, Yeh, Cohen, & Schramm, 2014). These mixed results beg the question, “What explains the emotional distress some adolescents develop as a result of exposure to acts of political violence in contrast to others who report a positive adaptation?” A potential explanation may be related to the variables that moderate the association between exposure and psychological distress, which may also explain the large variance in people’s responses to stressful events (Chrisman & Dougherty, 2014; Govender & Killian, 2001; Pat-Horenczyk, Kenan, et al., 2014). Religiosity is one of the variables that might moderate the associations between exposure to acts of political violence and psychological distress although the literature is inconsistent about it. This study addresses religiosity as a potential moderator between exposure to acts of political violence and PTS.

Religiosity

Religiosity might serve a protective factor, such that the association between exposure to acts of political violence and PTS will be lower among students with higher levels of religiosity and higher for students with lower levels of religiosity. Laufer and Solomon (2010) claim that religiosity includes three different dimensions: (a) Religiosity as a major component in the individual’s life—the extent the individual conducts his life according to religious values; (b) religiosity as a societal component—to what extent the individual is committed to religion as part of his social life; and (c) religiosity as the primary identity—to what extent religion serves as the main component in the individual’s identity. The present study partly adopts this typology and seeks to examine religiosity as the primary identity.

There are conflicting findings on the contribution of religiosity to the individual’s well-being in the context of trauma. Results of a study conducted in the United States after 9/11 showed adult participants indicated that they sought out assistance from a higher power to cope with the fear and stress. Attributing spiritual significance to the events was related to lower levels of symptoms such as anxiety and depression (Amy, Cascio, & Santangelo, 2005). Similarly, a study conducted among African refugees in the United States (Adedoyin et al., 2016) found that religious activity and membership in religious communities were associated with the ability to better overcome the traumas they experienced in their native countries, whether natural disasters or living in conflict zones. In Israel, a study conducted among volunteers in ZAKA, Israel’s primary rescue and recovery volunteer organization, found that ultraorthodox volunteers in that organization reported a low rate of likelihood PTSD (measured on a self-report scale based on Diagnostic and Statistical Manual of Mental Disorders [4th ed.; DSM-IV]; American Psychiatric Association [APA], 1994 criteria) even in the presence of repeated exposure to traumatic events (Solomon, Berger, & Ginzburg, 2008). Another study among 770 students learning in an area repeatedly exposed to acts of political violence found that religiosity was associated with fewer avoidance behaviors (Korn & Zukerman, 2011).

The contribution of religiosity to coping with acts of political violence was also examined among adolescents. In a review article which included 71 articles on psychological distress among children and adolescents in Middle East conflict zones (Israel, Palestinian Authority, Lebanon, and Iraq), it was found that religiosity served as a protective factor in the face of PTS symptoms related to exposure to political violence (Dimitry, 2012). Similar findings were noted by Laufer and Solomon (2011) among high school students in Israel. In contrast to these studies, a study conducted among 600 adolescents from the Gaza Strip and Southern Lebanon found that different levels of religiosity did not explain the variability in the participants’ stress reactions. However, higher levels of religiosity were associated with higher levels of depression and anxiety among adolescents in the Gaza Strip but not among adolescents in Southern Lebanon (Khamis, 2012). Similarly, a study conducted among Jewish adolescents found that while greater religious commitment was associated with lower levels of PTS among girls, it was associated with higher levels of PTS among boys (Laufer & Solomon, 2006).

As can be seen throughout the review, the literature is inconsistent with regard to the protective role of religiosity. Although several studies find it to be a protective factor, others find religiosity serves as a risk factor for PTS in the context of political violence. The conflicting findings may derive primarily from the complexity of the concept of religiosity and from the possibility that the studies examined religiosity from different angles (Kroll & Erickson, 2002). For example, religiosity in the context of exposure to acts of political violence was examined through its place and role in social structures (McIntosh, Poulin, Silver, & Holman, 2011), as religious motivation (Heyman, Brennan, & Colarossi, 2010), as religious orientation (Laufer & Solomon, 2011), as religious beliefs (Korn & Zukerman, 2011), and as religious coping, that is, relying on religious beliefs and traditions (Zukerman & Korn, 2014). In the present study, we defined religiosity as the participant’s identity based on their self-definition.

Research Hypotheses

Hypothesis 1: The greater the adolescents’ objective exposure to acts of political violence, the higher their PTS symptoms.

Hypothesis 2: The greater the adolescents’ self-reported exposure (direct and indirect physical exposure and direct and indirect interpersonal exposure) to acts of political violence, the higher their PTS symptoms.

Research Questions

Research Question 1: Does self-reported exposure (in all its forms) to acts of political violence predict PTS symptoms beyond the objective exposure effects?

Research Question 2: Does the level of religiosity moderate the associations between exposure (objective and self-reported) to acts of political violence and PTS symptoms?

Method

Study Population and Sample

The present study was conducted in 2007, almost 7 years after the outbreak of the second Intifada (uprising) and 8 months after the Second Lebanon War. The population for this study consisted of Grade 10 and 11 high school students attending Jewish secular and religious schools during the 2006-2007 school year. A stratified cluster sampling strategy was developed for this study. The data represented three strata: (a) Students living in the south of Israel, close to the Gaza strip; (b) students living in the north of Israel, in an area that had been exposed to rocket attacks during the Second Lebanon war; and (c) students from other areas in Israel (excluding settlements in the West Bank). Within each stratum, schools were randomly selected, and within each school, two Grade 10 and 11 classes were randomly selected.

The sample included 2,992 students from 31 Jewish schools (120 classes). More than half of the students (54%) were females and 55.2% were in the 10th grade. 85.3% of the students were born in Israel, 9.1% were born in the Former Soviet Union, and 5.6% were born in other countries. When asked about religiosity, 53.6% defined themselves as secular, 39.5% traditional, 6.3% religious/orthodox, and 0.8% ultraorthodox. In case of objective exposure, at the time of the study, 38.8% of the students resided in a highly exposed area, that is northern Israel; 23.5% of the students resided in a moderately exposed area (southern Israel); and 37.7% resided in a low-exposed area (central Israel). The self-reported exposure to different types of acts of political violence was associated with the objective exposure. The average self-reported exposure to all types of acts of political violence in northern Israel (highly exposed area) was 5.91 (SD = 3.98), 4.32 (SD = 4.47) in southern Israel (moderately exposed area), and 2.20 (SD = 2.92) in low-exposed area (central Israel). The response rate among the participating students was 79%. The response rate among students who were present in classrooms during the data collection was 98%.

Measures

The present study was part of a larger survey conducted by the first author and a colleague. Only measurements of the variables utilized in this study are described.

Types of self-reported exposure to acts of political violence

The respondents were asked about their exposure to acts of political violence. This measure was used in previous studies in similar contexts of political violence (Pat-Horenczyk, 2005; Schiff, 2006; Schiff & Fang, 2014). The measure included 14 statements assessed on a three-level scale ranging from 0 (never happened) to 2 (happened more than once). Five items assessed direct physical exposure: “You were present in a political violence event without getting hurt”; “You were present at the scene and got hurt”; “You felt the blast of an explosion, shooting of rockets”; “You heard the whistle of the rockets”; and “Your house was damaged by a missile.” Two items assessed indirect physical exposure: “You were near a place of political violence events” and “You saw people getting hurt in a political violence event (in reality, not television).” Direct interpersonal exposure was assessed by two items: “A family member was injured in a political violence event” and “A family member was killed in a political violence event.” Indirect interpersonal exposure was assessed by five items: “Someone you know (not a family member) was present during a political violence event and were not hurt”; “Someone you know (not a family member) was injured or killed during a political violence event”; “Your friend was present at the scene but was not hurt”; “Your friend was injured or killed at a political violence event”; and “The house of someone you know was damaged in a political violence event.” A composite score for each type of exposure was built summing the scores on all items included in that type of exposure.

Objective exposure to acts of political violence was defined according to the intensity of the event that occurred in the adolescent’s residential area. The study was conducted a few months after the Second Lebanon war of July 2006. During the war, civilians in northern Israel, including the major city of Haifa, experienced severe rocket attacks from Lebanon. The intense war lasted 34 days, with a total of 4,000 rockets falling almost entirely on civilians, who suffered 44 deaths and 2,000 wounded. Therefore, living in northern Israel at that time was defined as high objective exposure. Living in southern Israel was defined as moderate exposure because although people residing in this area, which is close to the border of the Gaza Strip, had been suffering for years from rockets from Gaza (Nuttman-Shwartz & Shoval-Zuckerman, 2016), at the time of the study, the intensity of events was relatively low. Living in other areas in Israel (central Israel) was defined as low exposure.

PTS

PTS was measured using the Revised Impact of Event Scale (Weiss & Marmar, 1997). This 22-item questionnaire consists of three subscales assessing hyperarousal, intrusive, and avoidance symptoms associated with PTS on a 5-point scale, ranging from 0 = not at all to 4 = extremely. This questionnaire does not assess functional impairment (F criteria) for PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000). A study using confirmatory factor analysis showed that the three subscales do not provide a good fit and that a single measure using all items or two factors (intrusion–hyperarousal and avoidance) was preferable (Creamer, Bell, & Failla, 2003). Thus, the Revised Impact of Event Scale is widely used (Asukai et al., 2002) and shows good reliability and validity for measuring PTS symptoms, but not for the likelihood of a PTSD diagnosis (Creamer et al., 2003). Interitem reliability (Cronbach’s α) in our study was .94. Summed scores based on the 22 scale items were used for the regression analyses, with a theoretical maximum score of 88. A common cutoff for probable PTSD in this scale is 46 and above (Murphy, Ross, Ashwick, Armour, & Busuttil, 2017). In our sample, 4.4% of religious adolescents, 4.3% of traditional adolescents, and 2.2% of secular adolescents reported on symptoms that matched the cutoff for potential PTSD.

Religiosity

Participants were asked to define themselves as either ultraorthodox, orthodox, traditional, or secular (Schiff, 2006). As only 18 students defined themselves as ultraorthodox, the two categories of ultraorthodox and orthodox were combined into one category titled “Religious.”

Background variables

Students reported on their age, gender, and grade.

Data Collection

After we received the approval from the Israel Ministry of Education and the University ethics committee, data collection took place between February and May 2007. Anonymous questionnaires were available in both Arabic and Hebrew. In this study, we used only the Hebrew version of the questionnaire. Answers were scanned by a computer.

Analytical Plan

We used descriptive statistics (ANOVA) to examine differences in PTS symptoms by objective exposure and level of religiosity (see Table 1). We then used Pearson’s correlations and hierarchical regression approach to test our hypotheses. In hierarchical regression analysis, several steps are defined in which additional effects are tested by means of an increase in percent variance explained (∆R²). In this analysis, five steps were built to introduce background effects, objective exposure, types of self-reported exposure, religiosity, and interactions effect. Results are presented in Table 3 and Figure 1.

Table 1.

ANOVA Results and Descriptive Statistics for PTS Symptoms, by Objective Exposure to Acts of Political Violence and Level of Religiosity.

Variable		M	SD	n
Secular
High objective exposure (North Israel)		13.14	12.83	788
Moderate objective exposure (South Israel)		11.40	11.87	297
Low objective exposure (Center Israel)		8.51	8.34	540
Traditional
High objective exposure (North Israel)		16.90	15.86	343
Moderate objective exposure (South Israel)		12.54	14.19	314
Low objective exposure (Center Israel)		9.07	13.21	491
Religious (orthodox and ultraorthodox)
High objective exposure (North Israel)		19.16	17.28	70
Moderate objective exposure (South Israel)		12.49	14.48	53
Low objective exposure (Center Israel)		14.30	13.26	47
Source	SS	df	MS	F
Objective exposure	7,699.36	2	3,849.68	23.39***
Religiosity	3,931.33	2	1,965.67	11.95***
Objective exposure × Religiosity	2,056.43	4	514.11	3.12*
Error	482,809.62

Note. R² = .048, adjusted R² = .045. PTS = posttraumatic stress symptoms; SS = Sum of Squares; MS = Mean Squares.

p < .05. **p < .01. ***p < .001.

Figure 1.

Interactions of types of self-reported exposure to acts of political violence and religiosity decomposed: (a) Indirect Physical Exposure × Religiosity, (b) Direct Interpersonal Exposure × Religiosity, (c) Indirect Interpersonal Exposure × Religiosity.

Results

PTS Symptoms: Differences by Objective Exposure and Level of Religiosity

A two-way ANOVA was conducted to explore levels of PTS symptoms by objective exposure and religiosity. Results are presented in Table 1. We found the main effect for objective exposure, F(2, 2934) = 23.39, p < .001. Post hoc contrast with Bonferroni criteria revealed that students residing in an area with high objective exposure (i.e., northern Israel) reported higher levels of PTS symptoms than students residing in moderately exposed areas (southern Israel; estimated mean difference = 2.54, confidence interval [CI] = [1.05, 4.02], p < .001) and low-exposed areas (central Israel; estimated mean difference = 5.50, CI = [4.26, 6.84], p < .001). Students residing in moderately exposed areas also reported higher levels of PTS symptoms than those residing in low-exposed area (estimated mean difference = 3.01, CI = [1.50, 4.53], p < .001).

Religiosity

We found the main effect for religiosity, F(2, 2934) = 11.95, p < .001. Bonferroni criteria revealed that religious students reported higher levels of PTS symptoms than traditional students (estimated mean difference = 3.38, CI = [0.85, 5.90], p < .01) and secular students (estimated mean difference = 4.45, CI = [1.98, 6.93], p < .001). Traditional students did not differ from secular students in the level of their PTS (estimated mean difference = 1.08, CI = [–0.11, 2.26], p = .09). We also found significant interaction effects between objective exposure to acts of political violence and religiosity, F(4, 2934) = 3.12, p < .05. Further analysis found that in the more highly exposed area, significant differences in PTS symptoms were found by religiosity, F(2, 1136) = 9.60, p < .01. Bonferroni criteria revealed that both religious and traditional students reported a higher level of PTS symptoms than secular students (estimated mean difference = 6.02, CI = [1.82, 10.22], p < .01) and (estimated mean difference = 3.77, CI = [1.59, 5.94], p < .001), respectively, but no differences were found between traditional and religious students (estimated mean difference = 2.25, CI = [–2.16, 6.67], p = .66. In the low-exposed area, we also found significant differences in PTS symptoms by religiosity, F(2, 1071) = 6.76, p < .005. Bonferroni criteria revealed that religious students reported higher levels of PTS symptoms than traditional students (estimated mean difference = 5.23, CI = [1.19, 9.27], p < .01), and secular students (estimated mean difference = 5.79, CI = [1.77, 9.82], p < .01) but traditional and secular students did not differ in their PTS symptoms (estimated mean difference = 0.56, CI = [–1.09, 2.21], p = 1). Finally, no significant differences in PTS symptoms by religiosity were found among students residing in the moderately exposed area, F(2, 661) = 0.60, p = .549.

Correlational analyses are presented in Table 2. It shows that all types of exposure to acts of political violence were significantly associated with PTS symptoms except for moderate versus low objective exposure. Religiosity (religious vs. secular students) was significantly associated with self-reported direct physical exposure and with PTS symptoms.

Table 2.

Summary of Pearson’s Correlations of Exposure to Acts of Political Violence, PTS Symptoms, and Religiosity.

Variables	1	2	3	4	5	6	7	8	9
1. Objective exposure: moderate vs. low	—	—	—	—	—	—	—	—	—
2. Objective exposure: high vs. low	.45***	—	—	—	—	—	—	—	—
3. Self-reported direct physical exposure	.04	.46***	—	—	—	—	—	—	—
4. Self-reported indirect physical exposure	.01	.20***	.52***	—	—	—	—	—	—
5. Self-reported direct interpersonal exposure	−.02	.01	.10***	.15***	—	—	—	—	—
6. Self-reported indirect interpersonal exposure	−.02	.23***	.46***	.48***	.19***	—	—	—	—
7. PTS symptoms	.03	.24***	.38***	.29***	.16**	.30***	—	—	—
8. Religiosity: traditional vs. secular (dummy variable)	.08^**	−.16***	−.07**	−.08**	.12***	−.04	−.02	—	—
9. Religiosity: religious vs. secular (dummy variable)	.00	.05	.08**	.03	.01	.02	.08***	−.21***	—

Note. PTS = posttraumatic stress symptoms.

p < .05. **p < .01. ***p < .001.

Hypothesis Testing: The Contribution of Self-Reported Physical and Interpersonal Exposure and Moderation of Religiosity

The results of the five steps of hierarchical regression analysis (background effects, objective exposure, types of self-reported exposure, religiosity, and interactions effect), presented in Table 3, reveal that the model shows a gradual increase in R², which means the additional variables significantly improved the model. Note that for the fifth step, we did not calculate the additional explained variance as this was not the goal of the step. The first step shows female adolescents experienced higher levels of PTS symptoms (β = .16, p < .001) compared with males. In the second step, low objective exposure to acts of political violence was compared with moderate and high objective exposure. Results show that adolescents residing in areas that were highly or moderately exposed to acts of political violence experience higher levels of PTS symptoms than adolescents residing in low-exposed areas (moderate compared with low exposure: β = .10, p < .001; high compared with low exposure: β = .20, p < .001). As the coefficients were standardized, the effects in the highly exposed area were twice as large as in the moderately exposed area. The self-reported physical and interpersonal exposure effects on PTS symptoms beyond the objective exposure effects were estimated in Step 3. Direct physical exposure was positively associated with PTS symptoms. Higher exposure explained higher levels of PTS symptoms (β = .16, p < .001). A small yet significant effect was found in indirect physical exposure: higher indirect exposure was positively associated with higher levels of PTS symptoms (β = .06, p < .05). Similarly, interpersonal exposure was also associated with PTS symptom levels (direct: β = .07, p < .001; indirect: β = .12, p < .001). In Step 4, ordinal religiosity ranking was broken into two groups for which secular was the reference category. Results show that higher levels of religiosity were associated with higher levels of PTS symptoms (traditional: β = .07, p < .001; religious: β = .06, p < .001). Next, in Step 5, we ran interactions between types of self-reported exposure to acts of political violence and religiosity. Out of eight interactions, three were found significant (indirect physical by religiosity: β = .05, p < .05; direct interpersonal by religiosity: β = .04, p < .05; indirect interpersonal by religiosity: β = .07, p < .01). These interactions were further broken down to explore their sources (Preacher, Curran, & Bauer, 2006). The decomposition analyses are presented in Figure 1a, 1b, and 1c. In these interactions, we tested whether the association between exposure and PTS symptoms varied by religiosity. We analyzed all three categories of religiosity. Note that due to the nature of the religiosity factor, we decomposed interactions into three levels of religiosity, although only the religious versus secular interactions with exposure were found significant. In the first interaction, Figure 1a shows that the higher the indirect physical exposure, the higher the PTS symptoms among religious adolescents (b = 2.99, p = .002), and slightly lower among traditional adolescents (b = 0.78, p = .05), but insignificant among secular adolescents. In the second and third interactions, secular adolescents reported higher levels of PTS symptoms in response to direct and indirect interpersonal exposure to acts of political violence as shown in Figure 1b and 1c (direct interpersonal exposure: b = 1.01, p = .006; indirect interpersonal exposure: b = 1.43, p < .001). Traditional adolescents showed an indifference to different levels of direct interpersonal exposure, while they showed higher levels of PTS symptoms in response to indirect interpersonal exposure (b = 1.14, p = .004). Yet, similar to indirect physical exposure, the highest positive associations between exposure and PTS symptoms were found among religious adolescents (direct psychological: b = 2.73, p < .001; indirect psychological: b = 4.56, p < .001).

Table 3.

Hierarchical Regression Results for PTS Symptoms as the Dependent Variable, Standardized Coefficients.

	Step 1	Step 2	Step 3	Step 4	Step 5
Step 1: Background characteristics
Class (Grade 11 vs. Grade 10)	−.03	−.02	−.02	−.02	−.01
Gender (0 = males, 1 = females)	.16***	.16***	.15***	.16***	.16***
Step 2: Objective exposure
Moderate vs. low		.10***	.04	.04	.04
High vs. low		.20***	.07**	.08**	.08***
Step 3: Type of self-reported exposure
Direct physical			.16***	.15***	.15***
Indirect physical			.06*	.06**	.04
Direct interpersonal			.07***	.06**	.06**
Indirect interpersonal			.12***	.12***	.12***
Step 4: Religiosity
Traditional vs. secular				.07***	.07***
Religious vs. secular				.06***	.06**
∆R²	—	.03***	.07***	.01***	—
R ²	.03***	.06***	.13***	.14***	—
F	36.41***	43.03***	51.37***	43.41***	—
df	2, 2787	4, 2789	8, 2781	10, 2779
Step 5: Interactions between self-reported exposure and religiosity
Step 5a: Direct Physical × Religiosity
Direct Physical × Traditional vs. Secular					.04
Direct Physical × Religious vs. Secular					.03
Step 5b: Indirect Physical × Religiosity
Indirect Physical × Traditional vs. Secular					.01
Indirect Physical × Religious vs. Secular					.05*
Step 5c: Direct Interpersonal × Religiosity
Direct Interpersonal × Traditional vs. Secular					−.04
Direct Interpersonal × Religious vs. Secular					.04*
Step 5d: Indirect Interpersonal × Religiosity
Indirect Interpersonal × Traditional vs. Secular					−.01
Indirect Interpersonal × Religious vs. Secular					.07**

Note. PTS = posttraumatic stress symptoms.

p < .05. **p < .01. ***p < .001.

Discussion

The objectives of this study were to examine the associations between physical and interpersonal exposure (objective and self-reported) and PTS symptoms, as well as identify the potential moderating role of religiosity in the associations between exposure and PTS symptoms. The findings of the study indicate that residing in an area of high exposure to acts of political violence (during the period of the study this was northern Israel) is indeed related to higher levels of PTS symptoms compared with residing in areas with lower exposure. These findings are supported by findings from previous studies, showing direct relationships between residing in places that are in close proximity to acts of political violence and greater psychological distress than that of places of residence farther away. For example, one study compared two communities exposed to shelling during the Second Lebanon War. One community was directly exposed (Kiryat Shemona) and the second was indirectly exposed (Kfar Yonah). The results of the study demonstrated that the residents of Kiryat Shemona reported higher levels of PTS symptoms than reported by the residents of Kfar Yonah (Somer, Zrihan-Weitzman, et al., 2009).

Students from southern Israel, who, as noted, also live in a conflict zone and are exposed to ongoing acts of political violence, reported lower levels of PTS symptoms than those of northern Israel. How can this be explained? One explanation is the span of time in which the events occurred. Meaning, while the students in the north who participated in the present study were exposed to acute but temporary acts of political violence (the Second Lebanon War), the students in the south were, and still are, exposed to ongoing political violence. Previous studies revealed conflicting findings regarding the associations between the duration of exposure to acts of political violence and PTS symptoms. Although some studies found that ongoing exposure increased the levels of PTS symptoms (Lahad & Leykin, 2010), others showed that the longer the exposure, the lower the rates of PTS symptoms, a phenomenon called habituation (Solomon, Laufer, & Lavi, 2005). Similarly, a study conducted among Israeli adolescents exposed to ongoing acts of political violence found that the majority of adolescents showed high levels of adjustment without noted emotional symptoms (Sagy & Braun-Lewensohn, 2009). In our study, students residing in southern Israel might have experienced a certain degree of habituation to exposure to these events, which reduced their levels of PTS symptoms to lower than that of the students from northern Israel.

Furthermore, the present study found that self-reported physical and interpersonal exposure to acts of political violence contributed to predicting PTS symptoms beyond the predictability of objective exposure. Thus, although residing in a conflict zone has negative consequences on the students’ emotional well-being, the way these events are experienced has an additional contribution to their distress. We are reluctant to compare these findings with the findings from other studies because the way exposure was measured differed among the various studies.

The present study also examined whether religiosity serves as a protective role in the associations between exposure to acts of political violence and PTS. Similar to previous studies (Galili & Sagy, 2010; Laufer & Solomon, 2006), in the present study, the students who defined themselves as religious reported higher levels of PTS symptoms than the students self-described as traditional or secular. In addition, our findings (interactions analysis with regression equations) indicate that religiosity has a moderating role; at high levels of religiosity (religious students compared with secular), the levels of PTS symptoms are higher when students are exposed to indirect self-reported physical exposure and direct or indirect interpersonal exposure. Thus, in our study, religiosity served as a risk factor for PTSD in the context of political violence. Our findings are supported by several previous studies (Adedoyin et al., 2016; Galea et al., 2002; Galili & Sagy, 2010) and are in contrast with others (Laufer & Solomon, 2011; McIntosh et al., 2011). The latter argue that religion may provide a powerful cognitive schema that can moderate the shattering of previous beliefs (e.g., the just world theory) when a stressful and overwhelming event occurs.

It is possible to understand these findings when observing the complexity and unique ethnopolitical background of violence in Israel. Political violence occurs within the broader ideological context connected to the Israeli–Palestinian conflict, which defines who are “good” and who are “bad” and accords the fighting meaning and purpose (Laufer & Solomon, 2006). In Israel, religiosity is related to an ideological commitment (Schiff, 2006), and a large portion of the Israeli population sees the conflict not just as a conflict between two fighting sides, but rather as a war with religious characteristics: the Jewish commandment of redemption of the Land and the holiness of the Land of Israel on one side, against the Islamic Jihad on the other (Laufer & Solomon, 2006). Therefore, religious ideology, as mentioned above, may be related to the manner in which the exposure to the act of political violence is processed and the way a threat to life is perceived. Meaning, against the background of exposure to acts of political violence, whose purpose is to threaten the integrity of the body and mind, it seems that for whoever holds an ideology that itself is the subject of the conflict, the psychological distress may be higher than for those who do not. In addition, our findings show that religious students experienced higher psychological distress even if the area that they currently live in could objectively be considered to be a low exposure environment. Given the linkage between religiosity and ideology, and the high associations found between perceived life threat and psychological distress (Heir, Blix, & Knatten, 2016), religious students might feel to be in greater psychological distress due to their higher perceived life threat. This interpretation should be examined in future research studies. Furthermore, previous studies suggest that ideology can constitute a stressor at the time of crises. For example, a study examining associations between political ideology (but not religiosity) and the level of psychological distress among youth exposed to terror attacks found that a higher commitment to a position, without regard to the position itself, is associated with greater mental distress (Laufer & Solomon, 2010). Similarly, another study conducted among Jewish evacuees from Gaza found that political ideology not only did not constitute a resource to help the evacuees cope with their trauma but actually served as a risk factor (Oren & Possick, 2010). The authors’ explanation for these findings is that when there is a clash between ideology and the political reality, it can lead to a presenting of psychological symptoms among the ideology holder (Oren & Possick, 2010). It seems that, in the same way, religiosity, which in Israel is highly related to political ideology, is also linked to greater levels of distress in the context of political violence.

Another explanation for the findings of religiosity as a risk factor for PTS is connected to the term “religious coping,” which in recent years has aroused interest among researchers (e.g., Pirutinsky, Rosmarin, Pargament, & Midlarsky, 2011; Rosmarin et al., 2011; Zukerman & Korn, 2014). Researchers identified two kinds of religious coping: positive and negative (Rosmarin, Pargament, Krumrei, & Flannelly, 2009). Positive religious coping implies searching out spiritual support and a spiritual connection to God, whereas negative religious coping includes religious dissatisfaction regarding the religious beliefs of the individual and overall belief and tradition (Zukerman & Korn, 2014). In response to negative life events, people may become angry at God, to wonder whether God cares about them, and to doubt whether God even has any power (Pargament, 1997). Rosmarin et al. (2011) offered a cognitive model of worry, which proposes that the associations between religious coping and psychological distress may be mediated through cognitive variables. They assert that negative religious coping may increase lack of faith in God, increase intolerance for uncertainty, and increase worry. Such negative religious coping may predict greater psychological distress expressed through depression, anxiety (Pirutinsky et al., 2011), and symptoms of PTS (Harris et al., 2008). In the present study, although we did not directly examine religious coping, it is possible that the religious adolescents adopted “negative religious coping” methods and therefore experienced greater distress in comparison with the secular and traditional adolescents, who did not utilize any religious coping methods at all.

In conclusion, religiosity served as a risk factor for PTS symptoms in the context of political violence, because exposure to political violence is associated with religious students’ spheres of meaning and ideology, which they believe in and rely on.

Up against these violent acts, the religious adolescents are prone to use negative religious coping methods and to experience PTS symptoms at a higher level than adolescents who do not hold religious beliefs and do not experience the political violence as an ideological trauma.

Limitations of the Study

This study contributed to the existing literature by examining the implications of exposure to acts of political violence about 1 year after the exposure of adolescents to an acute event (the Second Lebanon War) in a representative national sample. However, it has a number of limitations that are important to note. First, the present study did not examine different dimensions of religiosity, except for self-definition. In light of the inconsistencies in the literature and the present findings regarding the role of religiosity in adolescents’ psychological distress, it is important to examine the role of religiosity in this context using a more comprehensive measure which will also include relating to other elements such as religious coping methods and religious ideology. Second, we addressed only the potential negative consequences of exposure to acts of political violence and did not include resilience factors such as posttraumatic growth (Laufer, Solomon, & Levine, 2010). Third, self-reported physical and interpersonal exposure to acts of political violence may reflect the severity of the event for the student rather than his or her subjective experience of the exposure. If this were the interpretation of the students, it would have been expected, similarly to findings from literature on perceived threat (Heir et al., 2016) that higher levels of self-reported exposure would predict higher PTS symptoms, over and above objective exposure. This potential interpretation should be further examined in future studies. Fourth, the current study did not examine grief which could confound results. Is it possible that students, who experienced an extensive loss, might vary in terms of their sense of religiosity. Fifth, the present study is not a longitudinal study, meaning we were unable to track the implications of the war over time or to deduce from it a causal relationship between exposure, religiosity, and PTS symptoms. Finally, only Jewish religiosity was examined, in the present study. It should be noted other religious views may have different relationships to PTS symptoms. Therefore, the findings of the study can be generalized only to the Jewish adolescent population.

Implications to Practice

The literature emphasizes the importance of early identification of psychological distress (Pat-Horenczyk, 2005; Pat-Horenczyk et al., 2011). The present study indicates that even after relatively long period of time since the exposure, the level of PTS is not negligible, which brings up the need for treatment programs across the long term, especially against the backdrop of the constant threat of exposure to acts of political violence in Israel.

Furthermore, the findings of the study show that students who self-identify as religious are at greater risk for PTS in the context of exposure to acts of political violence. Therefore, it is important to consider the development of culturally sensitive intervention programs that target the needs of this vulnerable population.

Footnotes

Acknowledgments

We thank Prof. Rami Benbenishty who took a leading role in the larger survey.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Israel Anti Drug and Alcohol Authority.

Author Biographies

Efrat Sakat, MSW is a doctoral student at Paul Baerwald School of Social Work and Social Welfare, Hebrew University of Jerusalem, Israel. She is a licensed social worker. Her research areas focused on (a) political violence and the way religiosity assist or impede coping with this type of violence and (b) rehabilitation among soldiers in the Israeli army.

Miriam Schiff, PhD, MSW, MA is associate professor and Zena Harman chair in social work at Paul Baerwald School of Social Work and Social Welfare, Hebrew University of Jerusalem, Israel. She is also the chair of the Teaching, Policy and Procedures Committee at the university. She is a social worker, a licensed school psychologist, and family therapist. Her research interests are in (a) the moderators and mediator factors explaining the associations between man-made trauma and substance use as well as mental health in general among children and adolescents, (b) grief and bereavement, and (c) translational research from academic research to the field of social work, and from practice wisdom to theories and research in the areas of social work in health and mental health care.

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