WORKING PAPER

Prevalence and Patterns of Health Risk Behaviors of Palestinian Youth Findings from a Representative Survey Peter Glick, Umaiyeh Kammash, Mohammed Shaheen, Ryan Andrew Brown, Prodyumna Goutam, Rita Karam, Sebastian Linnemayr, and Salwa Massad

RAND Labor & Population

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PREVALENCE AND PATTERNS OF HEALTH RISK BEHAVIORS OF PALESTINIAN YOUTH: FINDINGS FROM A REPRESENTATIVE SURVEY PeterGlick1,UmaiyehKammash2,3,MohammedShaheen4,RyanBrown1,ProdyumnaGoutam1, RitaKaram1,SebastianLinnemayr1,SalwaMassad3,5              1

RANDCorporation,Santa.Monica,California,USA. JuzoorforHealthandSocialDevelopment,Ramallah,Palestine. 3  United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), Jerusalem,Palestine. 4 AlQudsUniversity,AbuͲDis,Palestine 5 PalestinianNationalInstituteofPublicHealth,Ramallah,Palestine. 2

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SUMMARY Verylittleisknownaboutyouthhealthriskbehaviorssuchasdrugandalcoholuseandsexual activityintheMiddleEastandNorthAfrica,andintheOccupiedPalestinianTerritories(OPT) specifically. This lack of information, together with a lack of open discussion of these topics, leavespublichealthauthoritiesintheregionunpreparedtodealwithemergingpublichealth threatsatatimewhenmajorsocialandeconomicchangesareincreasingtherisksthatyoung menandwomenface.ThePalestinianYouthHealthRiskStudywasdesignedtoaddressthese gapsinknowledge.Itisthefirstintheregiontocollectlargescale,representativesurveydata fromyouthonkeyriskbehaviors(smoking,alcoholanddruguse,andsexualactivityaswellas interpersonal violence). The study investigates the prevalence and patterns of these risk behaviors as well as of mental health, perceptions of the risks of such behaviors, and the factorsincreasingvulnerabilitytoaswellasprotectionfromengagementinthem.Thestudy, conducted by researchers at the RAND Corporation, based in Santa Monica, CA, USA, and Juzoor Foundation, based in Ramallah, West Bank, Occupied Palestinian Territories, implementedarepresentativesurveyofabout2,500maleandfemaleyouthage15Ͳ24livingin theWestBankandEastJerusalem.Themainconclusionswithrespecttoprevalenceare: Withtheexceptionsoftobaccouseandinterpersonalviolence(fighting),youthengagement inhealthriskactivitiesoverallisrelativelylow,butsubstantiallyhigherformaleyouththan female youth. Consistent with earlier studies, tobacco use among Palestinian youth is very high.Evenamongyoungeryouthinthesample(age15Ͳ19)45%ofmalesand22%offemales report current smoking; for older youth (20Ͳ24) the shares are 72% and 31% for males and females, respectively. As these shares indicate, prevalence is substantially higher for male youththoughbynomeanstrivialforfemales. With regard to alcohol use, slightly less than one quarter of older (19Ͳ24) male youth report havingtriedalcohol.Ratesamongfemaleyouthinthisagegroupareabouthalfthatformale youth(12%).Experienceofalcoholamongyoungeryouthage15Ͳ19islower(8%ofmalesand 3.6%offemales). Relatively few youth report having tried any of a range of drugs asked about in the survey, including marijuana or hashish, pills, inhalants, and cocaine or heroin. 10% of males 20Ͳ24 reporthavingtriedanykindofdrugscomparedwith4%foryoungermaleyouth.Only4%of older female youth and 1.6% of younger female youth report ever using drugs. Less than a thirdofthoseyouthwhosaytheyevertrieddrugssaytheycurrentlytakedrugs. 2

QuestionsonsexualactivitywereaskedonlyofnonͲminors(over17years)duetothecultural sensitivityofthesubject.25%ofolder(19Ͳ24)unmarriedmaleyouthand22%ofyounger(17Ͳ 18) male youth report having had any sexual experience. Rates for females are generally similar. Experience specifically of sexual intercourse among unmarried youth is substantially lowerthanforexperienceofanysexualactivity:9.5%ofolderunmarriedmaleyouthand5.6% ofyoungerunmarriedmaleyouthreporthavinghadsexualintercourse,comparedwith7%for older females and 4% for younger females.  Phone sex (sexting) and internet sex involving anotherpersonarerelativelycommonamongunmarriedyouthofbothgenders:amongmale youth, 38% of older and 33% of younger (age 18 and 19) report having ever engaged in this activity;30%ofolderfemaleyouthand23%ofthose18and19reporthavingdoneso. Finally, in line with what was suggested by earlier studies of the OPT, engaging in physical fighting is relatively common, especially among younger male youth 15Ͳ19.  56% of males in thisagegroupand29.3%offemalesreportedengaginginoneormorefightsintheyearprior tothesurvey. Forallyouth,thefindingspointtotobaccouse(especially)andengagementininterpersonal violentbehavioraskeybehaviorsdeservingoffocusedattention.Smokinghasobviousdirect healthimplications,especiallyinthelongterm.Levelsofinterpersonalviolencearequitehigh thoughbroadlyinlinewithfindingsfromseveralothermiddleincomecountries.Fightingmay have direct health implications through injury but also may lead to significant negative emotional outcomes among young people. The causes and implications of violence among Palestinian youth (including the role of conflict and economic stress) should be carefully studiedtoformulateappropriateinterventions.Otherriskbehaviorssuchasalcoholanddrug useandsexualactivityappearlowrelativetocountriesoutsidetheregion,butremainasource ofconcern,especiallyforsomesubgroupsandlocations.  There are important patterns in behaviors by location that should inform outreach efforts. For almost all health risk behaviors, there is a pattern of substantially higher prevalence in urbanareasandrefugeecampscomparedwithruralareas.Forexample,inbothurbanareas andcamps,26%ofmaleyouthage19Ͳ24saytheyhaveusedalcohol,doubletheshareinrural areas (13.2%). For the same group of older male youth, 13% of urban residents and 16% of camp residents say they have tried drugs, compared with 3% in rural areas. Similar patterns across areas are found for females and for younger youth age 15Ͳ19. These differences may reflect easier access to alcohol and drugs in urban areas andcamps (many of which are also urban), different cultural attitudes in urban vs. rural areas, or a greater ability to engage in these behaviors discretely in urban settings. SelfͲreported sexual activity exhibits a similar patternbyarea. 3

Thesizeofsampledidnotpermitsystematiccomparisonsacrossgovernorates.However,the data do show significantly elevated levels of risk behaviors in Jerusalem. Jerusalem Governorate,whichismostlyurban,isdividedinto‘J1’and‘J2’areas,correspondingtoEastern areasofthecitythatwereannexedbyIsraelandinsidetheSeparationWallontheonehand, andotherareas,ontheother.Amongmaleyouth15Ͳ24inJerusalemGovernorate(J1plusJ2), rates of current alcohol use, having tried drugs, and sexual activity outside of marriage (age over 17) are 13.8%, 15.5%, and 27.5%, respectively. For urban areas in Jerusalem alone they are16.1%,18.4%,and31.0%.Theseratesaresubstantiallyhigherthanforotherurbanareas combined(5.1%,5.5%,and5.5%forcurrentalcoholuse,trieddrugs,andsexualactivity;p=0.00 forJerusalemvs.otherurbanforeachbehavior).Asimilarpatternprevailsforfemaleyouthin Jerusalemvisavistheothergovernorates. While refusals to participate in the survey and nonͲresponses to individual questions were low, the accuracy of selfͲreports of behavior remains a concern. Great effort was made to develop protocols to ensure that youth were comfortable discussing sensitive topics. Youth werealsoaskedlessdirectlypersonalquestionsaboutengagementindifferentriskbehaviors bytheirgeneralpeersinthecommunity(individualsofthesameageandgender)aswellasby their close friends.  Responses to questions about close friends (asked before any questions about therespondent’sown behavior) suggest moderately higher levels of engagement than the youths’ responses about their own behavior would suggest. On the other hand, the perceivedengagementofpeersingeneralinthecommunityissubstantiallyhigherthanthat reportedbytherespondentsaboutthemselvesonaverage.Whileitisoftenarguedthatyouth tendtosignificantlyoverestimatepeernormsofengagementinriskbehaviors,thisdiscrepancy mayalsopointtounderreportingofownriskbehaviors.Moreresearchneedstobedonein theregion,usingalternativeinterviewapproaches,toexplorepotentialbiasesinresponsesto questionsaboutsensitiveorstigmatizedbehaviors.  Withrespecttoanumberofpatterns,thestudyfindingsdisplayastrikingsimilaritytoyouth or adolescent surveys carried out in other regions. The disparity noted above between selfͲ reportedlevelsofyouths’ownparticipationinriskbehaviorsandtheirperceptionsofthelevel ofengagementofotheryouthisobservedinmanystudiesofyouthintheU.S.andelsewhere; as noted, it is typically thought to reflect a tendency of youth to overestimate the extent to which others participate in such behaviors. Wealso find, similar to studies elsewhere, that a youth’sselfͲreportedengagementinriskbehaviorsisstronglycorrelatedwithhisorperception of the level of engagement of peers in their community. This suggests that youth are influencedbyperceivednormsofbehavior,thoughthiscannotbeestablishedconclusivelywith thedata.Finally,inkeepingwithstudiesofyouthoradolescentsinotherregions,youthwho engage in one risk behavior (e.g., smoking) are more likely to engage in other risk behaviors (e.g.,alcohol). 4

 Interventions for Palestinian youth should be informed by these patterns. As indicated, the findingsprovideguidanceastowhereandforwhompreventioneducationprogramsaremost needed. Not surprisingly, young men, especially older male youth, are the most likely to engage in health risk activities. Programs should therefore make particular efforts to engage maleyouth,butalsoshouldnotignorefemaleyouth,whowhileapparentlylesspronetodoso, also engage in these behaviors.  With regard to location, urban areas and camps have the highest prevalence and should also be targeted. In addition, the fact that behaviors are ‘clustered’—with youth who participating in risk behavior tending to participate in multiple such behaviors—means that prevention education programs need to deal with a range of connectedriskbehaviorsforwhichcertainyouthmaybeatrisk,notjustsinglebehaviorssuch as drug use. Finally, the correlation of an individual’s behavior with perceived level of local peers’ behaviors suggests that influencing what youth think about peers may reduce their likelihood of engaging in risk behaviors, though additional work is needed to better assess whetherthisrelationshipiscausalassuchinterventionswouldassume.  TheexperienceofthePalestinianYouthHealthRiskstudyshowsthatitispossibletocarry out populationͲbased surveys of youth on highly sensitive behaviors in conservative social contextsoftheMiddleEast.Giventhelackofinformationonthesebehaviorselsewhereinthe region,itwouldbehighlybeneficialforpublichealthauthoritiesandresearcherstocarryout similar surveys across the region, both to understand current prevalence and to be able to monitorchangesovertime. Futureworkisplannedwiththesurveydatatoexaminethecorrelatesanddeterminantsof thesebehaviors,includingfamilysituation,exposuretoviolence,mentalhealth,expectations forthefutureandassessmentofrisksofbehaviors,andpersonalitytraitssuchasimpulsiveness and fatalism. These findings will provide more refined guidance to the development of preventionprogramsforPalestinianyouth.

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CONTENTS SUMMARY............................................................................................................................... ..............2 INTRODUCTION............................................................................................................................... ......7 METHODS............................................................................................................................... .............10 Studypopulation,sampling,andsurveydevelopment...................................................................10 Dataanalysis............................................................................................................................... .....12 RESULTS............................................................................................................................... ................13 Samplecompositionandcharacteristics.........................................................................................13 Healthriskbehaviors....................................................................................................................... 14 Furtherpatternsbyarea.................................................................................................................18 Peers’andfriends’behavior............................................................................................................19 Covarianceofindividualriskbehaviors...........................................................................................21 DISCUSSION............................................................................................................................... ..........22 Levelsandvariationinriskbehaviors.............................................................................................22 RiskBehaviorslevelsinInternationalPerspective......................................................................22 Patternsacrosssubgroups..........................................................................................................24 PerceptionsofpeerbehaviorandtheaccuracyofselfͲreportedbehavior....................................25 Relationofownandperceivedbehaviorofpeers..........................................................................27 Covarianceamongmultipleriskbehaviors.....................................................................................27 Implicationsofthefindings.............................................................................................................28 REFERENCES............................................................................................................................... .........30 TABLES............................................................................................................................... ..................35

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INTRODUCTION Health risk behaviors among adolescents and youth, such as smoking, drug and alcohol use, and sexual activity, are a global concern. Smoking, drug and alcohol use during adolescence havelongbeenrecognizedashavingdirecthealthimplicationsandmayincreasetherisksof developingchronicdependenceandillnessinadulthood(VinerandBarker2005;WHO1993). Research in the U.S. and other contexts has also shown that young people’s likelihood to engageinsuchbehaviorsispositivelyrelatedtotheirbeliefsregardingpeers’engagementin them (Rimal and Real 2005; SimonsͲMorton and Farhat 2010; Perkins and Wechsler 1996). Further, youth who engage in one risk behavior tends to engage in others, that is, the behaviorsareclustered,withimplicationsforthedesignofpreventionprograms. Thereislittlesystematicinformationaboutthelevelsorpatternsofmosthealthriskbehaviors amongyouthintheMiddleEastandNorthAfricaincludingsexualactivityanddrugandalcohol use. This lack of information, together with a lack of open discussion of these topics, leaves publichealthauthoritiesintheregionunpreparedtodealwithemergingpublichealththreats atatimewhenmajorsocialandeconomicchangesareincreasingtherisksthatyoungmenand women face. For example, rates of preͲmarital sexual activity are apparently rising as young menandwomenstayinschoollongerandmarryatolderages(Shepardetal2005).Illicitdrug useamongyouth,includinginjectingdruguse,hasemergedasaseriouspublichealthissuein several countries in the region (Shepard et al 2005; RoudiͲFahimi 2007). Tobacco use among youngpeopleintheregion,aboutwhichmoreisknown,isveryhighinanumberofcountries (UsmanovaandMokdad2013). There is therefore a strong need, recognized by international agencies (UNAIDS 2008, World Bank2005)andagrowingnumberofgovernmentsoftheregion,foranunderstandingofthe patternsandcausesofyouthriskbehaviors,includingthoseassociatedwithincreasedHIVrisk. Such information will both reveal the epidemiology of these behaviors and provide policymakers with the ability to target appropriate prevention programs to those at highest risk. YouthintheOccupiedPalestinianTerritories(OPT)oftheWestBank,EastJerusalem,andGaza areexperiencingthesamerisksandtrendsastheircounterpartselsewhereintheregion.Rates of tobacco use are very high for both genders (Ghrayeb et al. 2013; Husseini et al. 2010; Musmar 2012). Drug use is a growing concern, although systematic data have been lacking. Therewereabout10,000and15,000registereddrugabusersintheWestBank/GazaandEast Jerusalem,respectivelyin2008(INCB2008).Youthunemployment,consideredariskfactorfor drug use (Morell et al. 1998, Peck and Plant 1986), is very high in the OPT (26% and 55% in WestBankandGaza,respectively,forthoseage20Ͳ24)duetoconflict,Israelirestrictionson travel from the West Bank to Israel, and embargo in Gaza (Palestinian Central Bureau of 7

Statistics 2010). A further risk factor that is very pronounced in the OPT is exposure to long termconflictandhardship;inothercontextssuchastheU.S.,exposuretoviolence(thoughnot political violence) is linked to youth engagement in unsafe sex or having multiple partners, smokinganddruguseBenͲZurH,ZeidnerM.2009,PatͲHorenczyketal.2007)aswellasearly pregnancy(WilsonandDaly1997). ExistingstudiesoftheOPTandoftheregionhaveseriousdrawbacksthatlimittheconclusions wecandrawfromthemabouttheactualprevalenceandpatternsofthesebehaviors,whichis critical for effective policy responses. First, prior studies of youth risk behaviors as well as mental health in the OPT and the region mostly use convenience samples of students in classroomsratherthanrepresentative,randomsamplesthatincludeoutofschoolyouthwho maybeatgreatestrisk.Second,giventheschoolsetting,theyfocusonyoungeradolescents, notolderyouth,whoaremorelikelytoengageinriskbehaviors.Third,theydonotaskabout mostriskbehaviorsoriftheydo,theydonotaskabouttherespondents’ownengagementin thembutonlyabouttheirperceptionsregardingpeers. In order to address these gaps in knowledge, we designed and implemented the Palestinian Youth Health Risk Study, which is the first in the region to collect large scale, representative survey data from youth on key risk behaviors (smoking, alcohol and drug use, and sexual activity).Thestudywasdesignedtoinvestigate(1)theprevalenceandpatternsofhealthrisk behaviorsaswellasmentalhealthamongPalestinianyouth,(2)youths’perceptionsoftherisks and benefits of potentially harmful behaviors, and their subjective expectations about future life chances; (3) the relationship of exposure to violence (a significant consequence of occupation and political strife in the OPT) to mental health, future orientation, and engagement in high risk behaviors; (4) the effects of other factors including education, socioeconomicstatus,andlocationonriskbehaviors. To achieve these aims the survey also gathered detailed information on mental health, risk perceptions,exposuretoviolenceandotherfactorswhichmaybedriversofriskbehaviors.It also collected information on youth’s perceptions about the extent of risk behaviors among both general peers, defined as youth in the community the same age and sex as the respondent, and proximate peers, defined as the three peers closest to the respondent. The purpose of collecting this information was twoͲfold. First, because peer norms (perceived behaviorofpeers)itselfmaybeanimportantdriverofayouth’sownengagementinbehaviors, and second, because responses about peers may be less subject to bias from respondents’ concerns over stigma or inclination to provide socially desirable answers than responses to questions about their own behavior. The study was conducted by researchers at the RAND

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Corporation(basedinSantaMonica,CA,USA,andJuzoorFoundation,basedinRamallah,West Bank,OPT.1 The objective of the present paper is to present findings on the prevalence of risk behaviors among youth 15Ͳ24, considering variations by gender, age, and location. Location is a potentiallyimportantfactorforriskbehaviorsgiventhedifferencesbetweenruralandurban areasoftheOPT—andbetweenthemandrefugeecampsͲͲwithrespecttocommunitycultural attitudes,accesstoalcoholanddrugs,andeconomicpressuresandpoliticaltensions(thelatter being especially severe in camps and in East Jerusalem). The paper also provides the first systematic investigation of whether patterns in risk behaviors found among youth in other contextsarealsofoundintheenvironmentoftheMiddleEastandtheparticularenvironment of the OPT. For example, we examine whether multiple risk behaviors occur together (for example,ifayouth’suseoftobaccoisrelatedtohisorheralcoholuse),andwhetherperceived peernormsofbehaviorarerelatedtoayouth’sownlikelihoodofengaginginthatbehavior. Thefindingsofthisanalysiswillbeimportantinputsintothedevelopmentofpoliciestotarget vulnerableyouth.

1

ThisresearchwasfundedbytheU.S.NationalInstitutesofHealthunderawardnumberR01HD067115.The contentissolelytheresponsibilityoftheauthorsanddoesnotnecessarilyrepresenttheofficialviewsofthe NationalInstitutesofHealth. 9

METHODS Study population, sampling, and survey development The survey aimed to achieve a representative sample of youth age 15Ͳ24 living in the West Bank and East Jerusalem. Initially it was planned to include Gaza in the survey, but logistical andcostconsiderationsmadethisinfeasible.Atargetsamplesizeof2,500youth,splitequally between males and females, was selected to enable meaningful statistical comparisons by gender for younger and older youth (15Ͳ19 and 20Ͳ24), by urban and rural areas, and for Jerusalemvs.othergovernorates.2AstratifiedtwoͲstagerandomsamplewasdrawnbasedon the 2007 Population Census, with the strata formed by crossing the 12 governorates with urban, rural, and refugee camp location. Within each of these strata, survey clusters (census enumerationareas)wererandomlysampledwithprobabilityproportionaltosizeforatotalof 208clusters.3 Withineachcluster(essentially,community),amodifiedrandomwalkprocedurewasfollowed to locate 14 households with youth in the appropriate age range. Implicit stratification was usedtoensureequalnumbersofmaleandfemaleyouths(duringtherandomwalk,theteams first looked for a household with a male youth, then one with a female youth, and so on). Wherehouseholdshadmorethanoneindividualage15Ͳ24ofthetargetedgender,Kishtables were used to randomly select the youth for interview. Both the household head or a parent and the youth were interviewed; the latter was the key respondent. In some urban areas, it proveddifficulttofindhouseholdswithyouth.InRamallah,forexample,whichisthedefacto Palestinian capital, many apartments are inhabited part time by families that usually reside elsewhere.Thereforeinsomeclustersaconsiderablenumberofresidenceshadtobevisited beforehouseholdswithyouthwereidentified. Extensive formative research, including focus groups and interviews with youth followed by repeated cognitive testing of survey questions, was carried out to determine the optimal culturallyappropriateapproachestointerviewingaswellasquestionwording,sequence,and responseformats.Thequestionnaireandfieldprocedureswerepilotedinoneurbanareaand oneruralarea,afterwhichfinalrefinementsweremade.

2

JerusalemGovernorateisdividedinto‘J1’and‘J2’areas,correspondingtoEasternareasofthecitythat wereannexedbyIsraelandinsidetheSeparationWallontheonehand,andotherareasofJerusalem Governorate,ontheother. 3 ThesamplingandclusterselectionwascarriedoutforthestudybythePalestinianCentralBureauof Statistics.WegreatlyappreciatetheworkofNayefAbedofPCBSonthesampling.

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Consentand interviewing approach:For minors (under 18) parental consent was obtained to interviewtheyouth.Parentswereinformedofthepurposeandnatureofthestudy.Separate consent was obtained from all youth. In view of the highly sensitive nature of the subject matter in this culturally conservative environment, interviewers were strictly instructed to ensure that the youth interview was carried out in a private room or other private area (in somecasesthiswasontheflatroofofthehome).Youthwerealsogiventheoptionofmeeting separately at a local youth center or other location for the interview, though in practice relatively few did so, and almost no girls did so, reflecting greater constraints on their movement. Male youth were interviewed by male interviewers and female youth by female interviewers. Also reflecting perceived sensitivities of parents and the youth, questions on sexualactivity—consideredthemostsensitiveofthebehaviorsͲͲwerenotaskedofminors.The studywasapprovedbyRAND’sHumansubjectsProtectionCommittee.Refusalratesbyyouth werealmostuniformlylow—11%forthesurveyoverall—butsignificantlyhigher(about30%)in theareaofEastJerusalem(discussedfurtherbelow). InterviewswereconductedfaceͲtoͲface,withonepartialexception.Initiallyitwasplannedto usecomputerassistedselfͲinterview(ACASI)forsensitivequestions,wherebytherespondent indicates on a small notebook computer or other device (out of view of the interviewer) the answertoquestionsreadaloudbytheinterviewer.StudieshaveshownthatACASIyieldsmore honest responses about highly stigmatized behaviors in some settings (Hewett et al. 2004; Mensch et al. 2008). However, extensive formative research revealed a strong general bias amongyouthagainstusingcomputersforinterviewinginthisway,andapreferenceforbeing asked(andrespondingto)thesequestionsinafacetofaceformat. Nonetheless, youth respondents were given the option of using a selfͲadministered (paper) questionnaire (SAQ) for questions on sexual activity, which were deemed to be the most sensitive.Thisapproachretainsthefacetofaceformat,withthequestionsreadaloudbythe interviewer, but the answers are written by the youth and placed in a sealed envelope that couldnotbeopenedwithoutdetection,andwasdelivereddirectlytotheteamsupervisorby theinterviewer.Norespondentorfamilynamesoraddressesappearedonanyquestionnaire forms used by the survey; only ID numbers, which were linked to names on crosswalk lists maintainedbythesupervisorsforthedurationofthesurvey,appearedonthequestionnaires AfterinitialfieldworkrevealedthatveryfewyouthchosetheSAQ,possiblyreflectingalackof understanding of the method, it was decided to randomly allocate youth to SAQ or FTF for sexual activity questions to ascertain if the mode mattered for responses, an important question for future surveys on these topics. This analysis will form the focus of a separate study.

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Data analysis Theanalysisinthispaperisalargelydescriptiveportrayaloftheprevalenceandpatternsofa range of health risk behaviors covered in the survey. Analysis of differences in behavior by subgroupswasdoneprimarilyusingPearsonchiͲsquaretests.Toexaminetherelationshipof friends’ and peers’ behaviors with own behavior, we conducted regressions of perceived friends or peers shares engaging in the behavior on the respondent's own selfͲreported engagement in the behavior, with controls for age and location (urban, rural, camp). To examinetherelationshipsofindividualriskbehaviors,weuselogisticmodelstoestimateodds ratios of engaging in one behavior conditional on engaging in another, with controls for age andlocation.Giventhelargeanticipateddifferencesbygenderinhealthriskbehaviorsinthis environment,separateanalysesareperformedforyoungmenandyoungwomen.Theanalysis wasdoneusingSTATAversion13,applyingthe‘Survey’routine,whichincorporatesthesurvey design,inparticularthecorrelationsofstandarderrorswithinsampleclusters.

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RESULTS Sample composition and characteristics Reflecting the sampling approach, the overall sample of 2,481 youth is evenly split between males and females (Table 1). There are more individuals in the younger age group (15Ͳ19): 1,419(57%ofthetotal)vs.1,062age20Ͳ24(43%),apatternthatfitstheoveralldemographic profileofPalestiniansintheOPT.(belowweusetheterm‘olderyouth’torefertothe20Ͳ24 agegroupand‘youngeryouth’toreferto15Ͳ19yearolds).However,whilethestratificationby gender assured equal shares of males and females, the balance between younger and older youthdiffersbygender.Malesage20Ͳ24makeup40%ofallthemaleyouth,whiletheolder female group accounts for 45.7% of all females.This is likelyexplainedby older maleyouths being more likely to be living away from home, or if living at home, being unavailable for interviewevenaftermultipleattemptsatcontact.4 About one quarter of the sample are refugees (Table 2). ‘Refugee’ is an official designation referringtosomeonewholostlandorlivelihoodduringthe1948or1967conflictsorwhois the descendent of such a person, and is eligible for services provided by the United Nations ReliefandWorksAgency(UNRWA)andotheragencies.Itshouldbenotedthatmostrefugees are not actually living in refugee camps, which account directly for only a small share of the refugeepopulation. As Table 2 indicates, the majority of younger youth 15Ͳ19 are still in school (79% males and 85%females)whiletheoppositeisthecasefortheoldergroup(33%malesand40%females). Thesubstantiallyhighereducationalenrollmentoffemalerelativetomaleyouthisnoteworthy (p=0.001 for age 15Ͳ19, p=0.011 for age 20Ͳ24) and consistent with other data sources; for example, published data from the Palestine Central Bureau of Statistics indicates that some 60%ofuniversitystudentsarefemale(PCBS2014). Differences in education by location are important, with youth in camps being markedly less likely to still be in school and having lower grade attainment. Among male youth (all ages), while60.4%ofurbanrespondentsand64%ofruralreportbeinginschool,only45%ofthosein camps do (p=0.019 and 0.006 for comparison of camps with urban and rural areas, respectively). For female youth, about 65% of both urban and rural youth are in school comparedwith58%forcampsbutthedifferencesarenotstatisticallysignificant(p=0.253and

4

Incaseswherethetargetedyouth(selectedfromamongthoselivinginthehousehold)wasnotinitially available,interviewerswereinstructedtomakeuptotwosubsequentvisitstotheresidencetoconnectwith theindividual.

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0.200). It should be kept in mind (for here and for findings below) that power for detecting differences between camps and rural or urban areas is low because of the relatively small numberofsampledyouthincamps. Marital status differs very strongly by gender, with only 6.5% of older male youth married comparedwith43%ofolderfemaleyouth(whoobviously,giventhisimbalance,tendtomarry older males). Reflecting this, a substantial share (35%) of older female youth live away from theirparentsintheirnewhouseholds,whilealmostallyoungmeninthatagegrouparestill livingathomewiththeirparents.Thesharesoffemaleyouthwhoaremarrieddoesnotvary greatlybylocation.Slightlylessthanathirdofallmaleyoutharecurrentlyworkingcompared withonly6%offemales;forboth,ratesarehigherforolderthanyoungeryouth,asexpected. Thesefiguresforlevelsofeconomicactivity,includinginparticularthedifferencesbygender, are in line with other data from the OPT and are similar to findings from across the Middle East.5 Differencesinfamilysocioeconomicstatusbyareaarenoteworthy.Informationonownership ofvariousconsumerdurableslikecars,TVs,andmicrowaveswasusedinafactoranalysisto create a household wealth index.  By construction, the mean of the index for the overall sampleiszerowithastandarddeviationof1.0.Ruralrespondentsarelesswelloffthanurban residents: for both males and females, the difference is about 0.3 s.d. of the index (p=0.001 and0.00,formalesandfemales,respectively).Thepointestimatessuggestthatwealthamong camp residents is even lower than for rural areas but these differences are not statistically significantforeithergender.Valuesoftheassetindexforfemalesareconsistentlylowerthan formales,likelyreflectingthatasignificantshareoffemaleslivewiththeirspousesinrecently formedhouseholdsratherthanwithparentswhohavemoreaccumulatedwealth.Withregard to parental schooling, mother’s education (share having attained secondary level) is also highestinurbanareas,thougheducationoffathersseemshighestinruralareas.

Health risk behaviors Before discussing prevalence findings we present the shares of respondents who did not respondtoquestionsabouttheirengagementinhealthriskbehaviors.Togetherwithrefusalto participate in the survey (which as discussed above was low) and underreporting (discussed below),lowlevelsofresponsetospecificquestionsisapotentialsourceofbiasinprevalence estimates of behaviors. For sensitive questions, there was a coded ‘No Answer’ response for the interviewer to mark if the youth was not willing to respond; for some questions, for

5

The2013PalestineLaborForceSurvey(PCBS2014)indicatesalaborforceparticipationrateof49%for males15Ͳ24and8.8%forfemales(figuresincludeGaza).Notethatparticipationincludesboththose employedandthosesearchingforwork.

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exampleonpeers’behavior,a‘Don’tKnow’wasalsoallowed.Formostquestionsaboutthe respondent’sownhealthriskbehaviorsdiscussedinthispaper,nonͲresponserateswerevery low—under1%oftherelevantsampleforthequestion(thatis,respondentswho,givenfilter patterns in the questionnaire, were asked the question).  NonͲresponse rates for these questionsareshowninAppendixTable1.RatesofnonͲresponseor‘NoAnswer’aresomewhat higher(thoughunder5%)forquestionsoncurrentdruguse,whichwereaskedofthosewho indicatedintheprecedingquestionsthattheyhadevertrieddrugs. WealsoreportinAppendixTable1thesharesofmissingvaluesforthesamequestions,where noresponseatallwascodedbytheinterviewer.Byandlargethesealsoarenotsignificant— under 1% of the relevant sample.  One significant exception is the nonͲtrivial number of missing values for thequestion about current drug use, which shouldhave been asked of all respondentsreportingthattheyhadeveruseddrugs:thecurrentusequestionismissingfor 17% of thisgroup.  Thisis, presumably, not a matter ofnonͲresponse since ‘No answer’ was explicitlycodedasresponseaswiththeotherbehaviorquestions.Instead,itappearsthatthe followͲupquestionwasinadvertentlyskippedinsomecasesofindividualshavingreportedever usingdrugs. Smoking:Turningtotheprevalencesofriskbehaviors,thesurveymoduleontherespondent’s health behaviors asked first about smoking, as this is the least stigmatized of health risk activities. Smoking (including both cigarettes and narghila or water pipe) is very common amongPalestinianyouth,inlinewithotherstudiesofadolescentsoryouthintheOPT(Husseini et. al. 2010, Ghrayeb et al. 2013). As shown in Table 3, almost threeͲfourths of older male youth smoke while almost half of younger male youth do. Rates are substantially lower for femalesbutstillsignificant:31%forolderfemaleyouthand22%foryoungerfemales(p=0.00 formaleͲfemaledifferenceforbotholderandyoungergroups,respectively).Reportedtobacco use is lower in rural areas, especially for female youth: among older females, 37% of urban respondentsreportsmokingcomparedwith16%ofruralrespondents(p=0.00). Alcoholuse:Slightlylessthanonequarterofmaleyouthage20Ͳ24reporthavingtriedalcohol; rates in urban areas and camps (26% in each case) are double that in rural areas (13.2%; p=0.002and0.039,forcomparisonorruralwithurbanareasandcamps,respectively).Rates among female youth 20Ͳ24 are substantially lower, but with a similar pattern by area: 12% overall reported having tried alcohol (15% in urban areas, 12.8% in camps, and 3.5% in rural areas). Among younger youth, 8% of males and 3.6% of females report ever trying alcohol, againwithhighersharesinurbanareasandcamps(p