key: cord-340993-qb9jlt9f
authors: Kai Hou, Wai; Hall, Brian J.; Canetti, Daphna; Lau, Kam Man; Ng, Sin Man; Hobfoll, Stevan E.
title: Threat to democracy: Physical and mental health impact of democracy movement in Hong Kong
date: 2015-11-01
journal: J Affect Disord
DOI: 10.1016/j.jad.2015.07.005
sha: 
doc_id: 340993
cord_uid: qb9jlt9f

BACKGROUND: This study examined the prevalence and critical predictors of anxiety and depressive symptoms and self-rated health, following the Umbrella Movement in Hong Kong. Methods: Random digit dialing recruited a population-representative sample of 1208 Chinese Hong Kong citizens (mean age=46.89 years; 63% female) in the first two weeks of February 2015. Respondents gave their informed consent and reported personal, social, and economic resource loss since the Umbrella Movement (Conservation of Resources-Evaluation), current anxiety symptoms (State-Trait Anxiety Inventory) and depressive symptoms (Patient Health Questionnaire-9), and self-rated health (1=very good, 4=very bad). RESULTS: A total of 47.35% (95% CI=44.55, 50.17) respondents reported moderate/severe anxiety symptoms and 14.4% (95% CI=12.54, 16.50) reported moderate/severe depressive symptoms; 9.11% (95% CI=7.61, 10.86) reported “poor” or “very poor” health. Multivariable regressions revealed that personal and social resource loss was associated with higher anxiety and depressive symptoms and greater odds of “very poor” health (adjusted odds ratios/incidence rate ratios=5–102%), independent of lower education level and income and being unmarried. LIMITATIONS: This study was cross-sectional in nature and thus could not determine causality from the associations between resource loss and outcome variables. Second, the telephone survey relied on self-reports; response bias and social desirability could influence respondents' answers and discount data validity. Third, potential confounders such as preexisting mental and physical health issues and concurrent predictors like exposure to the Umbrella Movement were not assessed. CONCLUSIONS: This is one of the first studies following any recent political movement (e.g., The Arab Spring) to quantify distress and the associated correlates of distress among affected citizens. Perceived psychosocial resource losses were critical predictors of poor outcomes.

Arab Spring).

The conservation of resources (COR) theory suggests that resource loss is the central mechanism driving adaptation to stress. Resources broadly include those personal, social, and material resources that we centrally value and are often divided between internal and external resources (Hobfoll, 1998; Hou and Wan, 2012) . Internal or personal resources consist of entities that are possessed by the self and can be mobilized on one's own such as sense of self-worth, sense of control over one's life, and optimism (Diener et al., 2003) . External resources consist of entities that are embedded within the physical environment or interpersonal interactions, such as social relationships, money, and employment (House et al., 1988) . A summary of media reports revealed that people supported the Movement because they foresaw threat of resource loss including abolishment of the rule of law and deprivation of freedom (e.g., speech and press) (Bertolini, 2015; Cheung, 2014) . Use of tear gas and pepper spray, physical assaults to suppress the protestors, and cases of selective law enforcement (e.g., non-action to some violence against the protestors by anti-protestors) further heightened people's perceived threat of potential political oppression if there was no universal suffrage in 2017. The Umbrella Movement could be understood as an investment of internal or external resources to create passageways for political resources, i.e., democracy and universal suffrage, among some Hong Kong citizens (Hobfoll, 2012) . A recent study focusing on the Arab Spring in North Africa and the Middle East has shown that the timing of social protest is linked to a particular increase in food prices (Lagi et al., 2011) . This suggests that the inability to provide for oneself and family, the lack of self-sufficiency, and the fear of economic loss and deprivation are also some of the prime drivers of social action. Perhaps the most potent example of the consequences of the depletion of internal and external resources was the actions of Mohammed Bouazizi, a street vendor, in Tunisia on December 17, 2010. He, after having had his wares confiscated by municipal workers, set fire to himself, thus setting in motion the events that led to the Arab Spring (Dupont and Passy, 2011) .

Despite the possibility that social protests could create resource passageways, they also have the power of depleting internal and external resources, which has central impact on the citizens' psychological and physical well-being. Preventing depletion of these resources is key for maintaining healthy functioning (Hobfoll, 1998; Hobfoll et al., 2009; Hou and Lam, 2014; Hou et al., 2010a Hou et al., , 2010b Hou et al., , 2015 . In Cairo, Egypt, citizens who were injured in political demonstrations reported higher levels of psychiatric symptoms than patients who experienced physical trauma from other causes. In both groups (N¼ 120 each), similar levels of perceived external control over life (e.g., other important persons, fate, chance) were reported and predicted higher symptoms, suggesting the adverse impact of possible depletion of personal resources (Papanikolaou et al., 2013) .

There is limited study of the psychological and health impact of political movements with reference to resource loss (de la Sablonnière et al., 2013) . Prior studies reported the association between resource loss and psychological functioning during major social upheaval. Among 145 Russian women in the midst of Russian economic transition, loss of economic resources (e.g., housing, stable employment) predicted depressive symptoms both directly and indirectly through a reduction of a personal sense of mastery over their life situations (Shteyn et al., 2003) . Among Israeli settlers (N¼190) who had faced terrorism and armed conflict and were subsequently evacuated by force from Gaza, a place that provided them with economic compensation and ideological and religious meaning, loss of economic resources (e.g., economic suffering, property damage) predicted clinically significant depressive symptoms, whereas loss of personal and social resources (e.g., confidence in coping with major crises, social intimacy) predicted both depressive and posttraumatic stress symptoms (Hall et al., 2008) . A recent population-representative study conducted among 643 adults living in the Palestinian Authority found that the most salient predictor of new cases of posttraumatic stress disorder was social resource loss (Hall et al., 2015) . A study among 4838 East and West Germans found that loss of social and economic resources (e.g., partner relationships, standard of living) between 1986 and 1996 after the fall of the Berlin Wall predicted lower life satisfaction and higher negative affect (Westerhof and Keyes, 2006) . This is the first study to investigate physical and mental health following social/political movement in the Greater China Region, and one of the first following any recent political movement (e.g., The Arab Spring), to quantify distress and the associated resource loss and correlates of distress. The goals of this study were to describe the prevalence of anxiety and depressive symptoms and self-rated health, and investigate the associations of personal, social, and economic resource loss and preexisting socioeconomic resources with anxiety and depressive symptoms and self-rated health during the immediate period following the Umbrella Movement in Hong Kong. We hypothesize the following: Hypothesis 1. : Following the Umbrella Movement, prevalence of anxiety and depressive symptoms and poor self-rated health will be higher than published population norms and typical of what studies find for populations under significant stress.

Hypothesis 2. : Loss of personal, social, and economic resources will be positively associated with anxiety and depressive symptoms and inversely associated with self-rated health.

Hypothesis 3. : Possessing preexisting socioeconomic resources will be inversely associated with anxiety and depressive symptoms and positively associated with self-rated health.

Upon obtaining the Ethics Committee's approval from The Hong Kong Institute of Education, respondent recruitment and telephone interviews were conducted by the Centre for Communication and Public Opinion Survey of The Chinese University of Hong Kong, an experienced survey institute, during the first two weeks of February 2015. A Computer-Assisted Telephone Interview system was used. A database of the telephone numbers from the latest residential telephone directories was created by erasing the last two digits and appending two random digits to each number. This method allowed new or unlisted telephone numbers to be included. A person was considered eligible if he/she was (1) a Hong Kong Chinese Citizen, (2) 18 years of age or above, and (3) Cantonese-speaking. If multiple household members were eligible after successful contact, the one with the closest birthday to the interview date was selected. Five attempts were made to a number that were "no answer," "busy," or "eligible unavailable" (i.e., willing to participate but unavailable) while no further attempts were made following two refusals. Voluntariness of participation without incentives was emphasized. Oral informed consent was obtained at the onset of interview. All interviews were conducted in Cantonese. Among the total 34,101 telephone numbers attempted, 18,053 (52.9%) of them were ineligible based on the inclusion criteria; 14,168 (41.5%) were unconfirmed eligible, meaning that they were never reached and their status as eligible or not was never evaluated. Among the 1880 (5.5%) eligible numbers, interviews were completed for 1208 (64.3%), whereas 533 (28.4%) indicated refusal and 139 (7.4%) indicated unavailability. The sampling error was within 72.8% at 95% confidence level. A response rate of 38% was recorded along with a cooperation rate of 69.4%.

The 1208 respondents ranged in age between 18 and 95 years (M ¼46.89, SD ¼17.20, median ¼46.01); 633 (52.4%) were female and 756 (62.6%) were married. Forty-nine (4.1%) respondents reported receiving no formal education, 165 (13.7%) primary education, 543 (44.9%) secondary education, and 442 (36.6%) tertiary education or above. One hundred fifty-six (12.9%) reported an average monthly household income less than HK$10,000, 176 (14.5%) reported $10, 000-$19,999, 194 (16.1%) reported $20,000-$29,999, 168 (13.9%) reported $30,000-$39,999, 118 (9.8%) reported $40,000-$49,999, 114 (9.5%) reported $50,000-$59,999, 182 (15.1%) reported an income exceeding $59,999 (US$1 E HK $7.80); 101 (8.3%) did not report income. A total of 615 (50.9%) reported full-time employment, 82 (21.8%) a part-time employment, 24 (2%) being unemployed, and the remainder being students (N ¼81; 6.7%), housewives (N ¼148; 12.2%), or retired (N ¼ 250; 20.7%). Respondents lived in Hong Kong for an average of 39.95 years (SD ¼16.97, range¼ 1-86 years, median ¼39 years). The current sample resembled the population in terms of sex and age group distributions (Census and Statistics Department, 2014).

A standardized proforma was used to obtain demographic information including age in years, sex, marital status (i.e., single, married/cohabited, divorced/separated, widowed), education level, employment status, monthly household income, and years of residence in Hong Kong.

The Chinese version of the 6-item state version of the State-Trait Anxiety Inventory (STAI-6) was used to assess anxiety symptoms (Marteau and Bekker, 1992; Shek, 1988) . Respondents rated the frequency of six emotional states, namely calm, tense, upset, relaxed, content, and worried, during the past two weeks on a 4-point scale (1 ¼ not at all, 2¼somewhat, 3¼ moderately, 4¼very much). Scores on three positive-worded items were reverse coded. The total summed scores were prorated (i.e., multiplied by 20/6), following scale scoring conventions, in order to obtain scores that were comparable with those from the full 20-item STAI (range¼20-80) (Marteau and Bekker, 1992) . A cutoff score of 44 was used to indicate moderate to severe symptoms (Knight et al., 1983; Leung et al., 2005; Spielberger, 1983) . Alpha was .71, for the current administration.

The Chinese version of the 9-item Patient Health Questionnaire (PHQ-9; Yeung et al., 2008) was used to assess depressive symptoms during the past two weeks on a 4-point scale (0 ¼not at all, 1 ¼on several days, 2¼on more than half of the days, 3¼nearly every day). Higher scores indicated higher depressive symptoms (range¼0-27). The Chinese version has demonstrated high internal consistency among Chinese (α 4.80; Yeung et al., 2008; Nan et al., 2013) . To indicate severity of depressive symptoms, the following cutoff scores were adopted based on previous population-based studies among Chinese (Nan et al., 2013) : minimal ¼0-4, mild ¼5-9, moderate¼10-14, moderately severe¼ 15-19, and severe Z20. In this study, alpha was .86.

Self-rated health status was assessed using a commonly used single item indicator scored as 1 ¼very good, 2¼good, 3¼ poor, and 4 ¼very poor. Brief self-reported health assessments are robust and valid predictors of mortality (DeSalvo et al., 2005).

The Conservation of Resources Evaluation (COR-E; Hobfoll and Lilly, 1993) was forward and back-translated into Chinese (Table 3) to assess actual loss of personal, social, and economic resources (three items each) since the start of the Umbrella Movement. Personal resource loss items assessed optimism and personal control over the future: "sense of optimism," "Feeling that my future success depends on me," and "Feeling that I have control over my life." Social resource loss items assessed interpersonal intimacy: "Intimacy with one or more family members," "Intimacy with at least one friend," and "Bonding with at least one family member/friend on social media e.g., Facebook, Twitter, Line, Whatsapp, etc." Economic resource loss items assessed financial status: "Adequate income," "Financial assets (stocks, property, etc.)," and "Financial stability." Respondents rated each item on a 5-point scale (0 ¼not at all/not applicable, 1¼ loss to a small degree, 2¼loss to a moderate degree, 3¼ loss to a considerable degree, 4¼loss to a great degree). Loss of each type of resource was calculated by summing across the three items (range¼ 0-12). Alphas for the personal, social, and economic resource loss subscales were .74, .74, and .83, respectively.

The study data was weighted by sex, age, and education level based on the data of population census in Hong Kong (Census and Statistics Department, 2014). To allow for the best use of the available data, the small portion of missing data (no more than .01% on any study variable) were replaced by multiple imputations. To address Hypothesis 1, the first part of the analyses aimed to report the estimated prevalence of anxiety and depressive symptoms and self-rated health with 95% confidence intervals (95% CI).

To address Hypotheses 2 and 3, the second part of the analyses aimed to investigate the associations of resource loss and preexisting socioeconomic resources with the risk of reporting anxiety and depressive symptoms and poor self-rated health. Different regression models were used for the three outcomes. Multivariable regression was conducted for anxiety symptoms as a continuous outcome; ordinal logistic regression was conducted for self-rated health as an ordinal outcome. To determine whether our data on depressive symptoms best matched a Poisson or negative binomial distribution, an exploratory zero-inflated Poisson regression was conducted, followed by a zero-inflated negative binomial regression without the assumption of equal mean and variance of the depressive symptoms. The negative binomial model would be used if its goodness-of-fit tests indicated smaller values of the Akaike's Information Criterion (AIC) and Bayesian Information Criterion (BIC) fit indices and a ratio of Pearson chisquare and degree of freedom closer to 1.00 compared with Poisson model. Adjusted odds ratios/incidence rate ratios (aOR/ aIRR) with 95% CI were reported to indicate the independent association of each resource loss or demographic with an outcome while adjusting for potential confounders.

In all regression models, loss of resources was recoded into high ( 41 SD of the mean), medium (within 1 SD of the mean), and low (o1 SD of the mean). Education level (1 ¼primary education or below, 2 ¼secondary education, and 3 ¼tertiary education), employment status (1 ¼unemployed, 2 ¼ dependent, and 3¼ employed), and marital status (married ¼1/unmarried ¼0) were also recoded. Based on the median household income of HK $23,800 (Census and Statistics Department, 2015), income level was recoded into 1 ¼ less than HK$20,000, 2 ¼HK$20,000-$29,999, 3¼ HK$30,000-$39,999, 4 ¼HK$40,000-$49,999, and 5 ¼HK $50,000 or above. Years of residence were adjusted by dividing it by age; higher values indicated longer lifetime residence in Hong Kong (range¼0-1). Education level, household income, employment status, and being married were considered proxies for preexisting socioeconomic resources (Hobfoll, 1998) . All analyses were performed using SPSS (Version 21; SPSS Inc., Chicago, IL).

To address Hypothesis 1, using a cutoff score of 44 for STAI, a total of 47.35% (95% CI ¼44.55, 50.17) of the respondents reported moderate to severe levels of anxiety symptoms. Using a cutoff score of 10 for PHQ-9 (Kroenke et al., 2001; Nan et al., 2013) 

The results of the regression analyses are summarized in Table 2 (Hypotheses 2 and 3) . Multivariable regression demonstrated that respondents with medium and high personal resource losses reported 10% and 19% higher in anxiety symptoms, respectively (medium: aOR ¼1.10, 95% CI ¼1.06, 1.14, p o.0001; high: Table 1 Prevalence of anxiety and depressive symptoms and self-rated health.

Depressive symptoms Self-rated health The ordinal logistic regression revealed that respondents with high personal resource loss reported 68% higher in the odds of poorer self-rated health (aOR ¼1.68, 95% CI ¼1.10, 2.56, p ¼.016). Older age, primary education or below, and being unmarried were associated with 1%, 69%, and 55% higher in the odds of poorer selfrated health, respectively (age: aOR ¼1.01, 95% CI ¼1.00, 1.02, p¼ .013; r primary education: aOR ¼1.69, 95% CI ¼ 1.04, 2.75, p¼ .035; unmarried: aOR ¼1.55, 95% CI ¼1.16, 2.08, p ¼.003). The odds of poorer self-rated health were 69% lower among men compared with women (aOR¼.69, 95% CI ¼ .54, .90, p¼ .006), and for one unit increase in lifetime residence in Hong Kong, the odds of poorer self-rated health were 53% lower (aOR¼ .53, 95% CI ¼.29, .94, p ¼.03).

Social or political unrest has the power of depleting internal and external resources and contributes to poorer mental and physical health (Hall et al., 2014; Hobfoll, 1998 Hobfoll, , 2009 , but very few studies to date have reported the psychological and health impact Table 2 Adjusted odds ratios/incidence rate ratios for higher anxiety and depressive symptoms and poorer self-rated health by personal, social, and economic resource loss, socioeconomic resources (education, income, employment status, and marital status), and other demographics. Note. aOR¼ adjusted odds ratio and aIRR ¼ adjusted incidence rate ratio.

of political movements around the world. Two months after the conclusion of the Umbrella Movement in Hong Kong, this study found an alarming 47.30% of moderate to severe levels of anxiety symptoms and almost 15% of moderate to severe depressive symptoms among 1208 respondents, though the majority (4 90%) did not report "poor/very poor" self-rated health (Hypothesis 1). Pertinent to Hypothesis 2, multivariable regressions showed that loss of personal resources was positively associated with the odds of higher anxiety symptoms and poorer self-rated health, whereas loss of both personal and social resources was positively associated Table 3 Chinese version of selected items on Conservation of Resources-Evaluation (COR-E).

with the odds of higher depressive symptoms. Proxies of lower socioeconomic resources including primary education or below, lower household income, and being unmarried were also positively associated with the odds of higher anxiety/depressive symptoms and poorer self-rated health (Hypothesis 3). Age and lifetime residence in Hong Kong (i.e., total years/age), on the other hand, were inversely associated with the odds of higher anxiety and depressive symptoms. The significance of the Umbrella Movement on Hong Kong citizens' mental health became obvious when we compared the present data with those in previous population-based studies among Chinese. The most representative data on self-reported anxiety symptoms to date was obtained from 4481 Hong Kong residents at multiple timepoints following the outbreak of severe acute respiratory syndrome (SARS) in 2003 (Leung et al., 2005) . SARS generated considerable fear and psychological distress among people in the 29 affected regions (Hawryluck et al., 2004; Koh et al., 2005; Leung et al., 2003) . Compared with the data that was obtained among Hong Kong Chinese two to three months after the outbreak of SARS (Leung et al., 2005) , higher anxiety symptoms were reported by almost all age groups in this study (Table 4 ). In a similar vein, compared with the PHQ-9 data on depressive symptoms among a population-based sample of 16,039 Hong Kong Chinese (Nan et al., 2013) , higher percentage of depressive symptoms were observed in mild (N ¼272, 22.5%), moderate (N ¼116, 9.6%), moderately severe (N ¼37, 3.1%), and severe (N ¼21, 1.7%) levels in the present sample (Table 5 ). On the other hand, we found that only 9.11% of the respondents reported "poor/ very poor" self-rated health, which was obviously low compared with population-based data among Chinese in Hong Kong (49.2%, N ¼4553; Wang et al., 2013 Jia et al., 2014), and Singapore (24.3%, N ¼ 3704; Lim et al., 2007) . This could be because Umbrella Movement was short and nonviolent. It is likely that physical health impact is greater in more prolonged and violent cases like Yemen and Syria.

Our findings underscore the impact of resource loss on psychological functioning during a period of social upheaval. Personal resource loss since the start of the Umbrella Movement was associated with higher levels of anxiety and depressive symptoms and the odds of poorer self-rated health by 10-94%. A populationbased survey during the Umbrella Movement (N ¼1050) reported that 38% of the respondents expressed a pessimistic view over the future of Hong Kong, 43% expressed disagreement with the current Chief Executive election proposal (i.e., candidates are selected by a Nomination Committee consisting of 1200 members), and 53% agreed that the government should back down to resolve the situation (The Chinese University of Hong Kong, 2014). The Umbrella Movement did not lead to any concrete political outcomes, while the Hong Kong government has refused to make changes to (Leung et al., 2005) after SARS outbreak in Hong Kong and the scores that were obtained in the present study. Leung et al. (2005) Present study M (95% CI) M (95% CI) Notes. The total summed STAI scores were prorated, following the scale scoring convention, in order to obtain scores that were comparable with those from the full 20-item STAI (range¼ 20-80). M¼ mean; CI ¼ confidence interval.

Scores on PHQ-9 that were obtained in a previous normative study (Nan et al., 2013) and the scores that were obtained in the present study.

Minimal ( the current Chief Executive election proposal. Worries of respondents could have been manifested in lower levels of optimism and a sense of mastery over one's life and future success. If the current election proposal is implemented or Hong Kong citizens do not adjust their expectation, ongoing personal resource loss could demonstrate increased health impact. Social resource loss was associated with increased odds of depressive symptoms by 61%, supplementing previous evidence on its predictive utility in posttraumatic stress disorder (PTSD). Like recovery from PTSD, recovery from depressed mood could depend heavily on prevention of social resource loss or restoration of lost social connections following social-political upheaval (Hall et al., 2014) . Social resource loss could be attributed to everyday political discussions with close social partners. The Umbrella Movement encouraged spirited debate and polarized opinions that may have disrupted social harmony. Discussions could increase the probability of agreement among close social partners (Morey et al., 2012) , but "universal suffrage" was made ambiguous by granting Hong Kong citizens the right to vote and the right to be elected but not the right to nominate candidates. Because of the ambiguity of the issue, the chance of political disagreement increases, while strong ties encourage confrontation of political disagreement that could inadvertently reduce relationship strength and intimacy (Huckfeldt et al., 2004) .

Economic resource loss was not associated with anxiety, depression, and self-rated health, while proxies of lower preexisting socioeconomic resources including lower education level and household income and being unmarried were associated with higher anxiety and depressive symptoms and poorer self-rated health. Age and lifetime residence in Hong Kong were associated with lower anxiety and depressive symptoms, whereas lifetime residence was also associated with better self-rated health. These socioeconomic resources take time to accumulate within the local setting and thus were not easily shaken by the Umbrella Movement. On the other hand, economic resource loss indicates specific loss of adequate income, financial assets, and financial stability since the start of the Movement. The findings extend the wellestablished link between socioeconomic status and physical and mental health to political psychology (Adler et al., 1994) . In milder cases of pro-democracy movements, longstanding socioeconomic resources, not momentary loss of income or financial stability, could have a stronger association with mental and physical health.

A number of limitations warrant attention. First, because this study was cross-sectional in nature, we cannot determine causality from the associations between resource loss and outcome variables. Psychological distress could indeed increase resource loss, which then reciprocally enhances psychological distress, forming a loss spiral during political violence (Heath et al., 2012; Hall et al., 2015) . Second, the telephone survey relied on self-reports. Response bias and social desirability could influence respondents' answers and discount data validity especially on psychiatric symptoms. However, phone-based structured clinical interviews have been found to be a valid method for detecting and monitoring psychiatric symptoms (Hobfoll et al., 2011; Muskens et al., 2014) . Third, potential confounders such as preexisting mental and physical health issues and concurrent predictors like exposure to the Umbrella Movement were not assessed. Unmeasured confounders could dilute the associations between predictors and outcomes, whereas concurrent predictors like exposure to the Movement could accelerate different resource losses.

In conclusion, our findings provide an evidence base for future studies on psychological impact of social uprisings in Arab Spring or elsewhere in the world. One common feature across pro-democracy movements around the world is protestors' willingness to invest internal and external resources in order to resist oppressive rule and create passageways for social and political resources (Hobfoll, 2012; Pearlman, 2013) . In more successful cases of prodemocracy movements, like those of Tunisia, Jordan, and Morocco, protests were relatively shorter and probably caused less psychological and health problems to the peoples. Resource loss among these peoples is down regulated by the positive political outcomes and opportunity of resource gain. Meanwhile, in many places with pro-democracy movements, such as Syria (United Nations, 2015) , protests are on-going and yet to result in political success or stability, bringing about more resource loss than opportunity of gain to the peoples. Depletion of resources could have a more significant negative impact on the peoples' physical and mental health.

Socioeconomic status and health: the challenge of the gradient

Population Census-Summary Results

The Melancholy of Hong Kong

Dramatic social change: a social psychological perspective

Mortality prediction with a single general self-rated health question

Personality, culture, and subjective wellbeing: emotional and cognitive evaluations of life

The Arab Spring or how to explain those revolutionary episodes

A longitudinal investigation of changes in social resources associated with psychological distress among Kurdish torture survivors living in Northern Iraq

The psychological impact of impending forced settler disengagement in Gaza: trauma and posttraumatic growth

Loss of social resources predicts incident posttraumatic stress disorder during ongoing political violence within the Palestinian Authority

SARS control and psychological effects of quarantine

Reciprocal relationships between resource loss and psychological distress following exposure to political violence: an empirical investigation of COR theory's loss spirals

Stress, Culture, and Community: The psychology and philosophy of stress

Conservation of resources and disaster in cultural context: the caravans and passageways for resources

Resource conservation as a strategy for community psychology

Are community studies of trauma's impact exaggerated? A study among Jews and Palestinians

Trajectories of resilience, resistance, and distress during ongoing terrorism: the case of Jews and Arabs in Israel

Resilience in the year after cancer diagnosis: a crosslagged panel analysis of the reciprocity between psychological distress and well-being

Does change in positive affect mediate and/or moderate the impact of symptom distress on psychological adjustment after cancer diagnosis? A prospective analysis

Resource loss, resource gain, and psychological resilience and dysfunction following cancer diagnosis: a growth mixture modeling approach

Changes in positive affect and mindfulness predict changes in cortisol response and psychiatric symptoms: A latent change score modelling approach

Perceived control mediates the prospective impact of relationship quality in the year after colorectal cancer diagnosis

Social relationships and health

Disagreement, ambivalence, and engagement: the political consequences of heterogeneous networks

Difference of the associations between self-rated health and demographic characteristics, lifestyle, and psychosocial work environment between two types of Chinese worksite

Some norms and reliability data for the State-Trait Anxiety Inventory and the Zung Self-Rating Depression scale

Risk perception and impact of Severe Acute Respiratory Syndrome (SARS) on work and personal lives of healthcare workers in Singapore: what can we learn?

The PHQ-9

The Food Crises and Political Instability in North Africa and the Middle East

Longitudinal assessment of community psychobehavioral responses during and after the 2003 outbreak of severe acute respiratory syndrome in Hong Kong

The impact of community psychological responses on outbreak control for severe acute respiratory syndrome in Hong Kong

Gender, ethnicity, health behaviour & self-rated health in Singapore

The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI)

The "who" matters: types of interpersonal relationships and avoidance of political disagreement

Psychiatric diagnosis by telephone: Is it an opportunity

Effects of depressive symptoms and family satisfaction on health related quality of life: the Hong Kong family study

Relationship of locus of control, psychological distress, and trauma exposure in groups impacted by intense political conflict in Egypt

Emotions and the microfoundations of the Arab uprisings

Reliability and factorial structure of the Chinese version of the State-trait anxiety inventory

The impact of the Russian transition on psychosocial resources and psychological distress

Manual for the State-Trait Anxiety Inventory

Public Opinion and Political Development in Hong Kong

Statement by the secretary-general on fulfilling our collective responsibility on Syria

Health information seeking partially mediated the association between socioeconomic status and self-rated health among Hong Kong Chinese

After the fall of the Berlin wall: perceptions and consequences of stability and change among middle aged and older East-and West-Germans

Validation of the Patient Health Questionnaire-9 for depression screening among Chinese Americans

This research was supported by Internal Research Grant, The Hong Kong Institute of Education, Hong Kong (Research Grants Council Direct Allocation; Ref: RG 36/2014 -2015 .

The authors declare that they have no conflict of interest.Author disclosure

Dr. Wai-Kai Hou: formulation of the conceptual framework; statistical analysis; write-up. Dr. Brian J. Hall: comments on the conceptual framework and the discussions of the findings; planning of statistical analysis. Dr. Daphna Canetti: formulation of the conceptual framework; ideas on the discussions of the findings. Miss Kam Man Lau and Miss Sin Man Ng: assistance in statistical analysis and preparation of the manuscript. Prof. Stevan E. Hobfoll: formulation of the conceptual framework; statistical analysis; write-up. All authors have approved the final article.

The funding source was not involved in any stages of the research.