mental health service utilization among the arabs in israel

EVALUATING SYSTEM FITWITH NEED

Mental Health Service UtilizationAmong the Arabs in Israel

Alean Al-Krenawi, PhD

SUMMARY. National hospitalization records (1995, 1986, N = 15,698)reveal that Arab women utilize psychiatric services less than Arab men.The exact reverse occurs among Jewish patients. Moreover, Arab pa-tients significantly underutilize mental health services, compared toJewish patients. Possible reasons for these utilization patterns include:Arab health care utilization patterns in general; the availability of mentalhealth services in Arab communities; the influence of the “cultural” overthe “professional” in Arab mental health utilization; the lack of Arabmental health practitioners; Arab attitudes towards mental health; andgendered role constructions within Arab society. Findings emphasize theneed for a policy of developing infrastructure and trained personnel that canprovide services adapted to the special cultural characteristics of the Arabpopulation. [Article copies available for a fee from The Haworth Document DeliveryService: 1-800-HAWORTH. E-mail address: <[email protected]> Website:<http://www.HaworthPress.com>©2002byTheHaworthPress, Inc.All rights reserved.]

Alean Al-Krenawi is Senior Lecturer, Department of Social Work, Ben-GurionUniversity of the Negev, Beer-Sheva 84105, P.O.B. 653, Israel (E-mail: [email protected]).

[Haworth co-indexing entry note]: “Mental Health Service Utilization Among the Arabs in Israel.”Al-Krenawi, Alean. Co-published simultaneously in Social Work in Health Care (The Haworth Social WorkPractice Press, an imprint of The Haworth Press, Inc.) Vol. 35, No. 1/2, 2002, pp. 577-589; and: Social WorkHealth and Mental Health: Practice, Research and Programs (ed: Alun C. Jackson, and Steven P. Segal) TheHaworth Social Work Practice Press, an imprint of The Haworth Press, Inc., 2002, pp. 577-589. Single or mul-tiple copies of this article are available for a fee from The Haworth Document Delivery Service[1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

2002 by The Haworth Press, Inc. All rights reserved. 577

KEYWORDS. Arab, gender differences, mental health utilization, cul-tural gap

Scholars have outlined inequalities in health care services betweenJewish and Arab Israelis (Shuval, 1990), as well as lower standards ofhealth care among Arab Israelis (Hundat, 1988). The following articlecontributes further to this literature in being the first to examine mentalhealth care utilization patterns between these two communities. It doesso on the basis of data from national hospitalization records for January1995 and a survey of patients consulting public mental health servicesin May 1986. Findings reveal that Jewish women utilize services morethan their male counterparts. This pattern is consistent with much of theliterature on gender and mental health care utilization among majoritycommunities within Western societies (D’Arcy and Schmitz, 1979;Leaf, Bruce, and Tischler, 1986; Neighbours and Howard, 1987; Pop-per, 1993; Smead, Smithy-Willis, and Smead, 1982; Russo and Sobel,1981; Wells, Manning, Duan et al., 1986). The findings also reveal thatamong an Israeli Arab population, the gender trend is the exact reverse:Men, more than women, utilize mental health services.

In addition to analysing the above quantitative data, this article pro-vides several frames of interpretation, based on literatures on Arabmental health services and on cross-cultural mental health utilizationpatterns. These factors include: Arab health care utilization patterns ingeneral; the availability of mental health services among the Arabs; theinfluence of the “cultural” over the “professional” in mental health utili-zation; the lack of Arab mental health practitioners; attitudes of theArabs towards mental health; and gendered role constructions withinArab society (Al-Issa, 2000; Al-Krenawi, 1999a; Al-Krenawi, Graham,and Kandah, 2000; Okasha, 1999). As such, then, the article is necessar-ily exploratory, providing some beginning points for thinking about dif-ferent utilization patterns within Jewish and Arab sectors. Thus, manyof the provisional findings should be subject to further evaluative andoutcome research.

BACKGROUND DATA

The Arab population of Israel numbers almost 1 million people, ofwhom over 700,000 are Muslims, about 150,000 are Christians andabout 100,000 are Druze, Circassian or other groups (Israel Statistical

578 SOCIAL WORK HEALTH AND MENTAL HEALTH

Year Book No. 43, 1996). The Arab population lives in about 125 vil-lages and towns, of whom approximately two-thirds are urban and therest are rural. Most of the Arab towns and villages–79 in number–areconcentrated in the north of the country, particularly the Jezreel regionand around Acre; these areas contain about 50% of the Arab population.The Haifa district, claiming the second largest concentration of Arab in-habitants, has about 23 villages and towns consisting of 16% of the totalArab population (Al-Krenawi and Graham, 1998).

The social structure is high context, emphasizing the collective overthe individual, having a slower pace societal change, and a higher senseof social stability (Hall, 1981). The family, therefore, is particularly im-portant to the homologous interrelationship between the individual andgroup, as well as between their social and economic status. There arethree main Arab family units: the Hamula (kinship group extending to awide network of family relations), the extended family (consisting ofparents, siblings, their spouses and children), and the nuclear family(the married couple and children) (Al-Haj, 1989). Arab societies mightbe characterized as authoritarian and group-oriented, rather than egali-tarian and individualistic (Al-Krenawi and Graham, 2000; Dwairy,1998). A hierarchical order is maintained within the family in which thedominance of male over female and older over younger is observed(Al-Krenawi, 1999b). As consequences of such a dynamic individualsin Arab societies may learn that occurrences in life are determined byexternal powers–such as family, social leaders, life experiences, orGod. This perspective may be reinforced by a community or familycontext that is collective. Individual responsibility for behaviour is lessperceived in isolation of others within the community (Al-Krenawi,1999b, 2000; Bazzoui, 1970; West, 1987).

Arab family size is clearly larger than its Jewish counterpart. The aver-age Arab family numbers 5.53, with 3.4 children per family (compared to3.43 people and 2.28 children in the average Jewish family). About onethird (31.8%) of the urban Arab population (compared to 4.7% of the ur-ban Jewish population) and about 40% of the rural Arabs (compared to9.3% among rural Jews) have 7 or more children (Al-Krenawi and Gra-ham, 1998; Dolev, Arnon, Ben-Rabi, Clyman et al., 1996).

The Arab population is also overwhelmingly young: 66.2% of the Mus-lims are aged under 25, while the figures are 58.3% and 62.2% for the Chris-tian and other populations (Druze, Circassian, Bedouin-Arab), respectively,compared to 46.3% among the Jewish population; 2.5% of Muslims areaged over 65, 6% of the Christians and 4% of the other groups, while 11% ofthe Jewish population is aged over 65 (Dolev et al., 1996).

Alean Al-Krenawi 579

METHOD

Data for this study come primarily from two sources. The 1995 figureson hospitalization were taken from the National File on Hospitalization inPsychiatric Hospitals (N = 3,476), run by the Mental Health Service inthe Ministry of Health. The data are comprehensive and taken from psy-chiatric hospitals and psychiatric wards in general hospitals, which senddetails of every patient accepted and released to this file, including demo-graphic, legal and clinical data. The contents of the file are regularly pro-cessed to provide statistical reports (Popper and Horwitz, 1996).

Figures on the utilization of clinics are based on a survey of patientsat public ambulatory mental health services (N = 12,222) randomly se-lected and carried out during one week in May 1986 (Feinson, Popper,and Handelsman, 1992). This is the only source of national data on pa-tients seeking treatment at mental health clinics (the major locus of out-patient psychiatric services in Israel), and contains demographic andclinical information.

Both of the above sources divide data on the basis of religion, accord-ing to the generally accepted population groupings used in publicationsof the Central Bureau of Statistics: “Jews” and “non-Jews (includingChristians, Muslims, Druze and others).” Nearly all of the “non-Jews”category thus may be considered Muslim, Christian, or Druze Arabs, al-though it also could include an extremely small number of individualswho do not belong to the Arab sector. Thus, the data allow researcher todistinguish readily between Arab and Jewish subjects. And for purposesof this paper, the terms “non-Jew” and “Arab” will be synonymous.

FINDINGS

The findings deal with two major categories of services: outpatientand inpatient.

Use of Outpatient Psychiatric Services

The Arab population of Israel constitutes about 19% of the total popu-lation but consumes only about 2.8% of psychiatric services in clinics(Feinson et al., 1992). The 1986 survey found that the rate of mentalhealth clinic utilization among the Arab sector was 0.5 per 1,000 com-pared to a rate of 3.3 per 1,000 in the Jewish sector (Feinson et al., 1992).


An analysis of sources of referral to mental health clinics among pa-tients at public clinics showed that the main referral sources in the Arabsector are general practitioners (49% of cases); 18% were referred bymental health practitioners, 15% were self referrals, 10% were referredby the welfare services and 6% by family members (Ministry of Healthand the Information and Assessment Department, 1994). For the popu-lation as a whole the picture was different: 30% were self referrals, 27%came from general practitioners, 14% from mental health practitioners,12% were referred by family members, 10% from educational services,and 7% from welfare services (Feinson et al., 1992).

An examination of the 1986 data show that Arab men tend to use ser-vices more than Arab women, and yet Jewish women use the servicesmore than Jewish men. Data among all age groups indicates that 62.8%of men utilized the services compared to 37.2% of women (representing0.6 and 0.3 per 1,000 respectively). In the Jewish sector, women use theservices more than men to a certain extent (51.8% compared to 48.2%;or 3.4 and 3.2 per 1,000, respectively) (see Diagram 1).

A comparison of elderly subjects reveals somewhat different pat-terns. In the over-60 age group, the percentage of utilization of servicesby men and women in the Arab sector is equal (50% for both sexes), al-though it should be pointed out that this data are based on very small ab-solute numbers. Among Jewish over-60s, utilization remains higheramong women than among men (Feinson et al., 1992).

The Arab data reveal different utilization patterns based on residen-tial area: In general, communities with high concentrations of Arabpopulation do not necessarily have correspondingly high proportions ofmental health utilization. Arabs in the north, who constitute about 50%of the population of Galilee, consume about 16.2% of the psychiatricclinic services in their region. Arab residents of the Haifa district, whoform about 21% of the population, consume about 4% of the services.But in the central region, members of the Arab sector, who make upabout 8.4% of the population, consume about 1.8%; and for Tel Aviv,where they constitute about 1.9% of the population consume about1.1% of services in their area (Feinson et al., 1992).

Use of In-Patient Psychiatric Services

Psychiatric hospitalisations in the Arab sector account for 7.4% of alladmissions, 8.2% of first time admissions and 7.2% of repeat admis-sions. These are significantly higher proportions than what occursamong Jewish patients. The ratio of first time admissions between Jews


and non-Jews is 1:2 (0.3 versus 0.74 per 1,000); and in the case of repeatadmissions, the ratio is 1:3. The number of non-Jews under the age of 14who were hospitalized tended to be small (Popper and Horwitz, 1996).This is particularly significant, given that the overall Arab population isquite young: Non-Jews under the age of 14 constitute about 41% of thenon-Jewish population, compared to 28% of the Jewish population.Finally, as noted in Diagram 2, the data suggest that a higher proportionof the non-Jew population utilizes services in more acute psychiatricstates. Additionally, many hospitalized Arab patients are in acute psy-chiatric states (Popper and Horwitz, 1996).

DISCUSSION

Two questions bear emphasis. First, is Arab under-utilization of in-and out-patient mental health services the result of a lower rate of men-tal health/distress in the Arab sector, or is it linked to variables that pre-vent utilization? And second, why do Arab men tend to utilize mentalhealth services more than Arab women? While further epidemiologicalresearch on Arab health care utilization is warranted, provisional an-swers to both questions may be attempted. Since rates of mentalhealth/distress are not known, this paper will consider only other issuesrelated to utilization/underutilization, in relation to the first question. Inrelation to the second, the paper examines an equally complex set of


DIAGRAM 1. Gender Differences Between Arab and Jewish Utilization of Ser-vices

psychosocial explanations. Finally, it should be noted that a small bodyof research indicates that findings among Arab patients in the presentstudy are similar to gendered patterns among Hispanics (Russo, Amaro,and Winter, 1987), and medicaid recipients (Temkin and Clark, 1988)in the United States. While trans-national analysis is beyond the scopeof the current paper, future research could be informative.

When a disease emerges, Arab patients typically turn to their familyand friends first, and then go to a general practitioner (GP) within themodern system, then to a traditional healer, follow up with the GP’s re-ferral to a psychiatric system, and then return to the GP (Al-Krenawi,1999b; Al-Krenawi and Graham, 1999a). The influence of the family inthis high context society, however, is particularly vital. Indeed,non-Jewish under-utilization of mental health services may be linked toconsultation with “the cultural canon” (family and/or traditional healerswithin their community) over “the professional” in times of distress: apreference for “folk medicine” over “Western medicine” (Al-Issa,2000; Al-Krenawi and Graham, 1999a, 1996; Al-Krenawi, Graham,and Maoz, 1996; Vega, Kolody, Valle and Hough, 1986). Families actas a natural form of social support, which in some instances may be aproxy for professional intervention. Families, as well, may encouragepatients to consult with traditional healers within Arab communities,rather than with modern practitioners (Al-Krenawi and Graham, 1999b;Dwairy, 1998; Okasha, 1993; Qureshi, Al-Armi, and Abdelgadri,1998). Among women, familial decision making processes are particu-larly strong, compared with the more individualistic processes amongmen.


DIAGRAM 2. Differences Between Arab and Jewish Utilization of Services

Since they have consulted them for generations, traditional healersand spiritual leaders continue to respond to a wide range personal dis-tress (El-Islam, 1982; Gorkin and Othman, 1994; Okasha, 1999). Vari-ous types of healers are able to treat individuals using non-stigmatizingmodes of culturally-acceptable rituals and practices, and are frequentlypreferred over modern mental health practitioners (Al-Krenawi andGraham, 1999b, 1996; E-Islam, 1982; Gorkin and Othman, 1994).Within Arab society, women are more familiar with, and are more fre-quent users of, traditional Arab healing systems (Al-Issa, 1989;Al-Krenawi and Graham, 1999a; Al-Sabaie, 1989; El-Islam, 1982;Morsy, 1993; Nelson, 1973).

Moreover, modern mental health practitioners are not readily avail-able within many Arab communities (Feinson et al., 1992), which re-flects and compounds their low levels of utilization (Hundt, 1988).Geographic mobility among women Arabs is particularly limited, andfew are able to travel outside their home communities; when they do un-dertake such travel, it is invariably with one or several family members(Mass and Al-Krenawi, 1994). Family members often involve them-selves in the treatment process, and so may constrain patient-practitio-ner communication.

At first blush, one might therefore conclude that women do not uti-lize mental health services. But how does one explain nearly equal pat-terns of mental health utilization among Arab men and women over theage of 60? Post-menopausal Arab women, it should be emphasized, tra-ditionally enjoy more freedom and geographic mobility than youngerwomen and can therefore leave their homes and seek modern modes ofhealth care more easily (Al-Krenawi et al., 2000; Maoz et al., 1970).They likewise are able to travel and to make health care decisions withless reliance upon family members. As pointed out in the conclusion ofthis paper, these differences provide a basis for thinking about how toincrease pre-menopausal women’s utilization.

Since there are few Arab mental health practitioners, there are obvi-ous cultural and linguistic gulfs when the psychiatric system works withan Arab population. In general, psychiatrists may not comprehend Arabidioms of distress, nor the familial, tribal, and community contexts inwhich mental health problems are perceived and responded to. Patients,for their part, may not understand the meaning of psychiatric diagnoses;the use of a translator may inhibit patient-psychiatrist communication,particularly if the translator is from the patient’s family. Linguistic bar-riers are particularly prevalent among women patients, who in generalare less educated than men, and have less fluency in Hebrew. This trend


is also consistent with previous research, which correlates higher levelsof education with mental health utilization (McGuire and Weisbord,1981).

Likewise, an additional factor may be the strong tendency for Arabpatients to emphasize the somatic basis of ailments when they aretreated by any modern practitioner (Al-Issa, 1995; Al-Krenawi, 1999a,1999b, 1998; El-Islam, 1994, 1975). Patients do not expect psychiatriststo undertake any form of talking therapy, other than what is related toprescribing medications or giving physical examinations (Al-Krenawiand Graham, 1999a; Al-Krenawi et al., 2000; Ibrahim and Ibrahim, 1993;Kulwicki, 1996; West, 1987). Similarly, patients expect psychiatrists totreat the body somatically and to provide cures for physical symptomswithin a short time, and are consequently disappointed when this doesnot occur (Al-Krenawi et al., 1996; Kulwicki, 1996).

The Arabs, like other non-Western societies, find psychiatric inter-ventions stigmatizing (Al-Krenawi et al., 2000; Brodsky, 1988;Fabrega, 1991; Savaya, 1995). This is especially strong among Arabwomen patients and may be particularly significant in explaining whymale Arabs tend to utilize mental health services more than women.Among non-married women, the stigma could damage their maritalprospects (Okasha and Lotailf, 1979). Among married Muslim women,the label of psychiatric illness could be used, by their husband or hisfamily, as leverage for him to take on a second wife (Al-Krenawi,1999c, 1998; Al-Krenawi and Graham, 1999a; Bazzoui and Al-Issa,1966; Chaleby, 1985).

Arab women, it should be emphasized, utilize primary health careservices more than Arab men (Al-Krenawi, 1999c; Al-Krenawi, Maoz,and Reicher, 1994; Central Bureau of Statistics, 1983). A similar pic-ture emerges with regard to adolescent Arab girls, who form a very highrisk group for mental distress, who rarely consult mental health services(Feinson et al., 1992) but whose presence in the emergency rooms ofgeneral hospitals is higher than average (Hundt, 1988).

CONCLUSION

The above issues point to several lessons that can be drawn regardingIsraeli mental health services. The first is that mental health servicesneed to reflect different needs among Arab Israeli patients, compared totheir Jewish Israeli counterparts. Underutilization patterns, particularlywithin high concentration Arab sectors, certainly confirm recommen-


dations for greater resources towards health institutions for Arabs(Shuval, 1990).

Secondly, services need to reflect differences within Arab societybased on gender: lower utilization rates among Arab women, comparedwith men, and among Arabs under the age of 14. Services might bemore geographically accessible, integrated within current institutionsthat are well utilized by Arab women, and which are not perceived to bestigmatizing. General medical services are frequently used by Arabwomen, and are their main source of referrals to mental health treat-ment. It makes sense, therefore, to more closely align mental health ser-vices with these general medical services. For example, gynecologicaland maternity departments of general hospitals could also employin-house mental health practitioners that would thereby function in anon-stigmatizing locus. These should be located in high concentrationArab areas, where they are most accessible to women, and where as thepresent findings reveal, higher instances of utilization are positivelycorrelated.

Such services could be more culturally sensitive in several respects.They could employ women and male mental health practitioners, andpreferably those who are conversant in Arabic and familiar with the cul-ture. If Arab practitioners are not readily available, cultural consultantscould be utilized in order to assist non-Arab practitioners to delivermore culturally-sensitive services (Budman, Lipson, and Meleis, 1992).These changes could further reduce the possibility of misdiagnosis, in-appropriate treatment, premature termination, and underutilization ofservices (Al-Krenawi et al., 2000; Sue and Zane, 1987). Likewise, theinterventions themselves could be more explicitly integrated with theArabic cultural canon, and if possible aligned with current traditionalhealing systems that are already being widely utilized (Al-Issa, 2000;1995; Al-Krenawi, 1999a, 1999b, 2000; Al-Krenawi et al., 2000;Boddy, 1989; Morsy, 1993). They could also be sensitive to differencesamong Israeli Arabs, particularly along religious lines (Muslim versusChristian versus Druze).

REFERENCES

Al-Haj, M. (1989). Social research on family lifestyles among Arabs in Israel. Journalof Comparative Family Studies, 20(2), 175-195.

Al-Issa, A. (Ed). (2000). Al-Junun: Mental illness in the Islamic world. Madison, CT:International Universities Press.


Al-Issa, I. (Ed). (1995). Handbook of culture and mental illness: An international per-spective. New York: International Universities Press.

Al-Issa, I. (1989). Psychiatry in Algeria. Psychiatric Bulletin, 13, 240-245.Al-Krenawi, A. (2000). Ethno-psychiatry among the Bedouin-Arab of the Negev.

Tel-Aviv: Hakibbuts Hameuchad (in Hebrew).Al-Krenawi, A. (1999a). Explanations of mental health symptoms by the Bed-

ouin-Arabs of the Negev. International Social Psychiatry, 45(1), 56-64.Al-Krenawi, A. (1999b). Culturally-sensitive mental health therapy with Arab people.

In C. Rabin (Ed.), Being different in Israel: Ethnicity, gender and therapy (pp.65-82). Tel-Aviv: Ramot, Tel-Aviv University Press (in Hebrew).

Al-Krenawi, A. (1999c). Women of polygamous marriages in primary health care cen-ters. Contemporary Family Therapy: An International Journal, 21(3), 417-430.

Al-Krenawi, A. (1998). Family therapy with a multiparental/multispousal family.Family Process, 37(1), 65-82.

Al-Krenawi, A., Graham, J. R., & Kandah, J. (2000). Gendered utilization differencesof mental health services in Jordan. Community Mental Health Journal, 36(5),501-511.

Al-Krenawi, A., & Graham, J. R. (2000). Culturally-sensitive social work practicewith Arab clients in mental health settings. Health and Social Work, 25(1), 9-22.

Al-Krenawi, A., & Graham, J. R. (1999a). Gender and biomedical/traditional mentalhealth utilization among the Bedouin-Arabs of the Negev. Culture, Medicine andPsychiatry, 23(2), 219-243.

Al-Krenawi, A., & Graham, J. R. (1999b). Social work and Koranic mental healthhealers. International Social Work 42(12), 53-65.

Al-Krenawi, A., & Graham, J. R. (1998). Divorce among Muslim Arab women in Is-rael. Journal of Divorce & Remarriage, 29 (3/4), 103-119.

Al-Krenawi, A., & Graham. J. R. (1996). Tackling mental illness: Roles for old andnew disciplines. World Health Forum, 17(3), 246-248.

Al-Krenawi, A., Graham, J. R., & Maoz, B. (1996). The healing significance of theNegev’s Bedouin Dervish. Social Science and Medicine, 43(1), 13-21.

Al-Krenawi, A., Maoz, B., & Reicher, B. (1994). Familial and cultural issues in thebrief strategic treatment of Israeli Bedouin. Family Systems Medicine, 12(4),415-425.

Al-Sabaie, A. (1989). Psychiatry in Saudi Arabia: Cultural perspectives. TransculturalPsychiatric Research Review, 26(4), 245-262.

Bazzoui, W. (1970). Affective disorders in Iraq. British Journal of Psychiatry, 117,195-203.

Bazzoui. W., & Al-Issa, I. (1966). Psychiatry in Iraq. British Journal of Psychiatry,112, 827-832.

Boddy, J. (1989). Wombs and alien spirits: Women, men and the zar cult in NorthernSudan. Madsion: University of Wisconson Press.

Brodsky, B. (1988). Mental health attitudes and practices of Soviet Jewish immigrants.Health and Social Work, 13(2), 130-136.

Budman, C. L., Lipson. J. G., & Meleis, A. I. (1992). The cultural consultant and men-tal health care: The case of an Arab adolescent. American Journal ofOrthopsychiatry, 62(3), 359-370.


Central Bureau of Statistics, Israel. (1980, 1983). Utilization of medical services1977-1981, special edition, no. 639T 717. Jerusalem.

Chaleby, K. (1985). Women of polygamous marriages in inpatient psychiatric servicesin Kuwait. Journal of Nervous and Mental Disease, 173(1), 56-58.

D’Arcy, C., & Schmitz, J. A. (1979). Sex differences in the utilization of health ser-vices for psychiatric problems in Saskatchewan. Canadian Journal of Psychiatry,24(1), 19-27.

Dolev, T., Aronin, H., Ben-Rabi, D., Clyman, L., Cohen, L., Trajteberg, S., Levy, J., &Yoal, A. (1996). An overview of children and youth in Israel: Policies, programsand philanthropy. Jerusalem: The Center for Children and Youth, TheJDC-Brookdale Institute (in Hebrew).

Dwairy, M. (1998). Cross-cultural counselling: The Arab Palestinian case. NewYork: The Haworth Press, Inc.

El-Islam, M. F. (1982). Arabic cultural psychiatry. Transcultural Psychiatric ResearchReview, 19(1), 5-24.

El-Islam, M. F. (1994). Cultural aspects of morbid fears in Qatari women. Social Psy-chiatry and Psychiatric Epidemiology, 29(3), 137-140.

El-Islam, M. F. (1975). Culture bound neuroses in Qatari women. Social Psychiatry,10(1), 25-29.

Fabrega, H. (1991). Psychiatric stigma in non-Western societies. Comprehensive Psy-chiatry, 32(6), 534-551.

Feinson, M. C., Popper, M., & Handelsman, M. (1992). Utilization of public ambula-tory mental health services in Israel: A focus on age and gender patterns. Jerusa-lem: Ministry of Health (in Hebrew).

Gorkin, M., & Othman, R. (1994). Traditional psychotherapeutic healing and healersin the Palestinian community. Israel Journal of Psychiatry and Related Sciences,31(3), 221-231.

Hall, E. (1981). Beyond culture. New York: Doubleday.Hundat, G. (1988). Patterns of utilization of health services among the Bedouin. Sde

Boker:The Environmental Education Publishers (in Hebrew).Ibrahim, A. S., & Ibrahim, R. M. (1993). Is psychotherapy really needed in non-West-

ern cultures: The case of Arab countries. Psychological Reports, 72, 881-882.Israel Statistical Yearbook No. 43. (1996). Jerusalem: Central Bureau of Statistics.Kulwicki, A. (1996). Health issues among the Arab Muslim families. In B. C. Aswad &

B. Bilge (Eds.), Family and gender among American Muslims (pp. 187-207). Phila-delphia: Temple University Press.

Leaf, P. J., Bruce, M. L., & Tischler, G. L. (1986). The differential effect of attitudes onthe use of mental health services. Social Psychiatry, 21(4), 187-192.

Maoz, B., Antonovski, A., Datan, N., & Wijsenbeek, H. (1970). Female attitudes tomenopause. Social Psychiatry, 5, 35-40.

Mass, M., & Al-Krenawi, A. (1994). When a man meets a woman, Satan is also pres-ent: Clinical relationships in Bedouin society. American Journal ofOrthopsychiatry, 64(3), 357-367.

McGuire, T. G., & Weisbord, B. A. (Eds). (1981). Economics and mental health.Washington D.C.: National Institute of Mental Health.


Ministry of Health and the Information and Assessment Department. (1994). Unpub-lished Survey. Jerusalem: Ministry of Health (in Hebrew).

Morsy, S. A. (1993). Gender, sickness, and healing in rural Egypt: Ethnography inhistorical context. San Francisco: Westview Press.

Neighbours, H. W., & Howard, C. S. (1987). Sex differences in professional help seek-ing among adult black Americans. American Journal of Community Psychology,15(4), 403-417.

Nelson, C. (Ed). (1974). The desert and sown, nomads in the wider society. Berkeley:University of California Press.

Okasha, A. (1999). Mental health in the Middle East: An Egyptian perspective. Clini-cal Psychology Review, 19(8), 917-933.

Okasha, A. (1993). Psychiatry in Egypt. Psychiatric Bulletin, 17, 621-625.Okasha, A., & Lotailf, F. (1979). Attempted suicide: An Egyptian investigation. Acta

Psychiatric Scandinavica, 60, 69-75.Popper, M. (1993). Trends in psychiatric hospitalization. Jerusalem: Department of In-

formation and Assessment, Mental Health Services, Ministry of Health (in He-brew).

Popper, M., & Horwitz, R. (1996). First Admission to Mental Health Hospitals in Is-rael. Jerusalem: Department of Information and Assessment, Mental Health Ser-vices, Ministry of Health (in Hebrew).

Qureshi, N. A., Al-Armi, A. H., & Abdelgader, H. (1998). Traditional catery amongpsychiatric patients in Saudi Arabia. Transcultural Psychiatry, 35(1), 75-83.

Russo, N. F., Amaro, H., & Winter, M. (1987). The use of inpatient mental health ser-vices by Hispanic women. Psychology of Women Quarterly, 11(4), 427-441.

Russo, N. F., & Sobel, S. B. (1981). Sex differences in the utilization of mental healthfacilities. Professional Psychology, 12(1), 7-19.

Savaya, R. (1995). Attitudes towards family and marital counselling among IsraeliArab women. Journal of Social Service Research, 21(1), 35-51.

Smead, V. S., Smithy-Willis, D., & Smead, R. (1982). Utility of sex, marital status,race, and age in targeting populations for mental health services. Psychological Re-ports, 50(3), 843-855.

Shuval, J. T. (1990). Health in Israel: Patterns of equality and inequality. Social Sci-ence and Medicine, 31, 291-303.

Sue, S., & Zane, N. (1987). The role of culture and cultural techniques in psychother-apy: A critique and reformulation. American Psychologist, 42(1), 34-45.

Temkin, G., & Clark, K. T. (1988). Ethnicity, gender, and utilization of mental healthservices in a Medicaid population. Social Science and Medicine, 26(10), 989-996.

Vega, W. A., Kolody, B., Valle, J. R., & Hough, R. (1986). Depressive symptoms andtheir correlates among immigrant Mexican women in the United States. Social Sci-ence and Medicine, 22(6), 645-652.

Wells, K. B., Manning, W. G., Duan, N., & Newhouse, J. P. (1986). Sociodemographicfactors in the use of out-patient mental health services. Medical Care, 24(1), 75-85.

West, J. (1987). Psychotherapy in the eastern province of Saudi Arabia. Psychother-apy, 24(1), 105-107.


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