Dec 9, 2012 - Internal consistency using Cronbach's α for the full scale was 0.89 for Group 1 (n=577) and item- ..... receivers. The blockade has ruined both my life and my legs. ..... there were thunder storms, she would panicky. I took her to ...
A-PDF Merger DEMO : Purchasefamilies from www.A-PDF.com to remove the watermark Resilience of Palestinian in the Gaza Strip in the face of stress, trauma and psychological problems due to the ongoing blockade and conflict
Prepared by Abdelaziz Mousa Thabet, M.B.Ch.B, DPM, DCAP, PhD Sana Sabah Thabet, BA, MPH
2014
This study has been conducted with the support of Oxfam and funded by the European Union
Table of contents Name
Page
Table of contents …………………………………………………………………………………………
II
List of tables ……………………………………………… ………………………………………… List of figures……………………………………………………………………………………………
IV V
List of annexes………………………………………………………………………………………
VI
List of abbreviations………………………………………………………………………………………
VII
Acknowledgment…………………………………………………………………………………………
VIII
1. Executive summary…………………………………………………………………………………
1
2. Introduction…………………………………………………………………………………………
8
3. Background and study base ………………………………………………………………
8
4. Study design …………………………………………………………………………………………
14
Aims of the study…………………………………………………………………………………………
14
Study objectives………………………………………………………………… Study questions …………………….………………………
14 15
Methodology…………………………………………………………………………………
16
Measurements…………………………………………………………………………………………
21
5. Statistical analysis ……………………………………………………………………………………
25
6. Results.................................... ………………………………………………………………………
26
6.1 Results of the parents' data………………………………………………………………………
26
Socio-demographic data of parents ............................ ……………………………………………
26
Types and frequency stressful situations due to restriction of movements and siege..............
29
Focus group ……………………………………………………………………………………………
33
Types and severity of traumatic events due to eight days of military escalation……………… Focus groups: Trauma due to eight days of military escalation had affected all the Palestinian society including children and Parents ……………………………………………………………… Psychological symptoms measures by Brief Symptom Inventory-18 items………………………
40
Quality of life of adults…………………………………...................................................…………
57
Resilience of adults …………………………………………………………………………………… Relationship between stress due to the blockade and psychological symptoms and sub scales, quality of life, and resilience ………………………………………………………………………
68
Relationship between trauma due to eight days war, psychological symptoms, quality of life, and resilience factors ………………………………………………………………………
73
I
44 51
71
Focus groups concerning resilience …………………………………………………………
75
6.2 Results of the children' data ………………………………….......................
80
Socio demographic characteristics of the children and adolescents ………………………………
80
Types and severity of traumatic events due to the eight day of military escalation….................
83
Safety and security of children during the eight day war ………………….................................
86
Post-traumatic stress for children ………………………………………………
88
Anxiety problems in children ………………………………………………………………
93
Resilience in children …………………………………………………………………… Relationships between traumatic events, security, anxiety, PTSD symptoms, and total resilience of children ………………………………………………………………………
96
Relationships between stress, traumatic events, mental health problems, quality of life, resilience of parents and traumatic events, security, anxiety, PTSD symptoms, and total resilience of children ……………………………………………………………………… 7. Discussion………………………………………………………………………
100
7.1 Stressful situations due to restriction of movements and the blockade and traumatic events
103
7.2 Psychological symptoms ………………………………………………………………………
103
7.2 Quality of life ………………………………………………………………………………………
104
7.3 Resilience …………………………………………………………………………………
105
7.4 Children……………………………………………………………
106
99
102
i)
Trauma, insecurity, and PTSD …………………………………………………………
106
ii)
Anxiety problems in children……………………………………………………………
107
iii)
Resilience in children ……………………………………………………………………
107
iv)
Relationship between adults and children ………………………………………………
108
Conclusion and Recommendations ……………………………………………………………………
110
References…………………………………………………………………………………… Annex…………………………………………………………………………………………
116
II
123
List of tables No.
Name
Page
Table 1
Research Team…………………………………………………………………………………
18
Table 2
Parents' sample distribution according to the division and area………………………..
19
Table 3
Children' sample distribution according to the division and area………………………
20
Table 4
Socio demographic characteristics of the parents sample (N =502)……………………..
27
Table 5
Types and frequency stressful situations due to restriction of movements and the blockade (N = 502)………… ………………………………………………………………
29
Table 6
Types of traumatic events due to the November 2012 8 days military escalation……..
40
Table 7
Psychological symptoms measures by Brief Symptom Inventory-18 items ………….
52
Table 8
Percentage of quality of life items of parents sample (N= 502)…………………………..
57
Table 9
Percentage of Resilience items of parents sample (N= 502)……………………………..
68
Table 10
Means and standard deviations of resilience factors and sub scales and sex ……
69
Table 11
Relationship between stress, psychological problems, quality of life and resilience ...
72
Table 12 Table 13
Relationship between trauma due to eight days military escalation, psychological symptoms, quality of life, and resilience factors ……………………………………… Socio-demographic information of the children study sample…………………………….
Table 14
Types of traumatic events due to 8 days of military escalation ……………………
83
Table 15
Percentage of security of children during the 8 days war ………………………………
85
Table 16
Post-traumatic distress symptoms in children (N = 502)………………………………
87
Table 17
Means and standard deviations of PTSD and sub scales and sex of children………..
89
Table 18
Percentage of anxiety symptoms in children………………………………………
91
Table 19
Percentage of resilience items of study sample …………………………………………
95
Table 20
Means and standard deviations of resilience factors according to sex of children……
96
Table 21
Relationships between traumatic events, security, anxiety, PTSD symptoms, and total resilience of children…………………………………………………………………
98
Table 22
Relationships between stress, traumatic events, mental health problems, quality of life, resilience of parents and traumatic events, security, anxiety, PTSD symptoms, and total resilience of children…………………………………………………………… …
III
74 81
99
List of Figures Names No. Figure 1
Mean of stressful situations due to the blockade and sex…..
31
Figure 2
Level of traumatic events due to 8 days of military escalation
41
Figure 3
42
Figure 7
Traumatic events and sex…………… ………………… ……. Means and Standard Deviations for Symptom Checklist 18 and sub scales according to sex … Means and Standard Deviations of Quality of life and sub scales according to sex ……………………… Severity of traumatic events in children due to 8 days of military escalation in children ………………………………… Security of children during the 8 days war……………………
Figure 8
Prevalence of PTSD in children ………………………………
88
Figure 9
Prevalence of anxiety disorders in children …………………
92
Figure 4 Figure 5 Figure 6
Page
IV
53 59 83 86
List of Annexes No.
Name
Page
Annex 1
Consent form of parents
121
Annex 2
Socio-demographic information of children
122
Annex 3
Gaza Stressful Situations Checklist due to restriction of movements and the blockade checklist
123
Annex 4
Revised Gaza Traumatic Events Checklist
124
Annex 5
Brief Symptom Inventory 18 (BSI-8)
125
Annex 6 Annex 7
WHOQOL
126
Conner-Davidson Resilience Scale
128
Annex 8
Consent form of children and adolescents
129
Annex 9
Socio-demographic information of children
130
Annex 10
Revised Gaza Traumatic Events Checklist
131
Annex 11
Safety and security of children
132
Annex 12
UCLA PTSD Index for DSM IV - adolescents form
133
Annex 13
Revised Child Manifest Anxiety scale
134
Resilience scale for adolescents (READ)
135
Annex 14
V
LIST OF ABBREVIATIONS ANOVA
Analysis of Variance
CBO
Community-Based Organization
CD-RISC
Connor-Davidson Resilience Scale
CFTCC
Child and Family Training and Counselling Center
BSI
Symptom Checklist (18)
DSM-IV
Diagnostic and Statistical Manual of Mental Disorders-IV
GSI
The global severity index
HR-QOL
Health Related Quality of Life
MoH
Ministry of Health
PCBS
Palestinian Central Bureau of Statistics
PTSD
Post Traumatic Stress Disorder
RCMAS
Revised Children’s Manifest Anxiety Scale
WHO
World Health Organization
WHOQOL-BREF
World Health Organization Quality of life-Brief version
VI
ACKNOWLEDGEMENT The Child and Family Training and Counselling Centre (CFTCC) extend its thanks and appreciation to Oxfam, for the guidance, support and feedback it gave to the research team. Furthermore, CFTCC extends its gratitude and appreciation to the European Union for their financial support of this study as a part of the project “Enhancing respect for human rights and fundamental freedoms in countries and regions where they are most at risk.”
CFTCC would also like to thank the Palestinian families that participated in this study. We would like to give special thanks to the local community and in particular the parents, children and local partner organizations who contributed to the study. Without their opinions, support, and time this study would not have been possible.
VII
1 .Executive summary
The Gaza Strip has been under an Israeli blockade for over seven years, with access and movement of goods and people in and out of Gaza severely restricted and at times forced to a complete halt. The population in Gaza has thus suffered ever-increasing infringements of their economic, social, civil, political and security rights and on their freedom of movement. These measures have not only resulted in a de-development of Gaza’s economy – making over 80 per cent of the population reliant on some form of aid, but has also been a source of stress for the civil population at large. The recurrent exposure to traumatic experience during military escalations and prevalent violence have led to trauma and increased stress levels. As part of the project "Promoting freedom of thought, association and movement in Gaza through support to civil society", the Child and Family Training and Counselling Center (CFTCC) conducted an in-depth study into the mental health of the Gaza population in light of the ongoing blockade and recurrent exposure to wars. The study was conducted over the course of 2013, with the support of Oxfam and funding from the EU. Scope and Methodology A sample consisting of 502 randomly selected parents and 502 children from 16 districts in the Gaza Strip agreed to take part in the study. Both quantitative and qualitative methods of data collection were used as a result of consulting with community-based organizations. They gave their educated opinions on the most important stresses and trauma affecting the people in the community and ways to support data collection. Staff from each organization participating in the study was invited to attend a three days training course in scientific research. Following this initial training, five people were selected to carry out the data collection. Measures for collecting data from adults include Stressful Situations Scale, Traumatic Events Checklist, Symptom Checklist, World Health Organization Quality of Life, and Resilience scale. Data from children was gathered using Traumatic Events Checklist, Security scale, Post traumatic stress disorder scale, Children’s Manifest Anxiety Scale, and Resilience Scale for Adolescents. For qualitative data, five focus groups for adults were conducted in five district areas of the Gaza Strip. In addition to the focal group discussions, a community led research was conducted, aimed at investigating the stress levels incurred by people in their daily lives due to
1
restrictions on freedom of movement, association, and thought, and the impacts of recent wars on the Gaza population’s psychological well-being, resilience and quality of life. After the eight days of military escalation in Gaza in November 2012, CFTCC and Oxfam agreed to include data about the traumatic events linked to the spike of violence as a second dependent variable of the study. Following discussions of the research team with Community Based Organisation’s representatives, a list of eight traumatic events prior to the November 2012 Gaza military escalation was identified and agreed upon. Finally, it was agreed to investigate the effect of the 8 days military escalation on children’s' PTSD, anxiety and resilience levels, and to look into the relationship between children’s mental health and resilience levels and their parents’ stress levels, trauma, psychological symptoms, quality of life and resilience levels. The agreed hypothesis for the overall research was: Stress incurred due to the blockade will lead to more psychological problems, lower quality of life, and decrease resilience in families and children. Results and findings Stress and trauma in parents The study found that there is a direct correlation between the stress generated by the blockade and psychological symptoms found among parents. The most common stressful situations due to blockade identified during the study are: General feeling of living in a big prison The inability to finish construction and repair work in people’s homes due to a chronic shortage in cement and building materials The sharp increase in prices in commodities in recent years The inability to upkeep social and family relationships, including social and religious visits to the West Bank/East Jerusalem The negative impacts on daily life and work due to repeated cut-off of electricity and shortage of gas and fuel The socio-economic background of people was found to significantly determine the impact of those stresses. Most impacted are men, people aged 51 years and older,
2
people living in refugee camps, the unemployed, poor families earning less than $300 /month, and children of less educated parents. The study’s findings indicate that factors protecting people from the negative impacts of stress include a younger age (less than 50 years old), being female, employment and receiving a salary, living in a city or a village, higher monthly incomes and higher education. Traumatic experiences due to the November 2012, eight days military escalation was identified as another risk factor affecting the mental health of people in the Gaza Strip. There were eight main traumatic events reported by parents. The most common traumatic experiences reported were 1) hearing shelling of the nearby area by artillery 2) hearing the sonic sounds of fighter jets 3) hearing loud noises of drones 4) watching mutilated bodies on television The study clearly showed that overall males found these experiences significantly more traumatic than females did. People living in cities reported a higher number of traumatic experiences than people living in villages or refugee camps. Simple workers and less educated mothers were more traumatized by these events than people with better jobs and higher education. Exposure to risk factors Stress and trauma have proven to have a direct impact on people’s mental health, quality of life and resilience factors. The study found that traumatic experiences due to the conflict in Gaza increased psychological problems, with identified problems including depression, somatization, and anxiety in parents. However, the study showed that the short exposure to traumatic events had less impact on people than the effect of long-term stress. Reaction to stress and trauma Palestinian parents reported anxiety symptoms such as nervousness or trembling, feeling tense or locked up. Reported symptoms of depression included general sad feelings and feeling weak in parts of the body. However, people seldom reported feelings of worthlessness and thoughts of ending life. Mothers showed similar signs of anxiety and somatization symptoms as fathers did, but at a lesser degree. In addition, general psychological symptoms, somatization, depression, and anxiety were significantly higher
3
in families with monthly incomes below $300 /month. Similarly, less educated parents were found to experience a higher degree of general psychological symptoms and anxiety. In addition, general psychological and somatisation symptoms were found more frequently in unemployed fathers. Among mothers, these symptoms were found more frequently among those with no formal education, and depression symptoms were found more frequently among housewives, than among employed mothers. Quality of life Only 12.5% of interviewed people would consider their life as good, and only 27.1% said to enjoy their life. Appreciating your own quality of life is an indicator of well-being; the interviewed women were found to have a higher level of quality than the interviewed men. Quality of life varied among the different socio-economic groups. Those 40 years old or younger were found to hold more social and personal relationships, families with an income of over $300 /month rated their quality of life higher, fathers with higher education, being employed and receiving salaries rated their quality of life higher in all aspects of life. Among mothers, those with education beyond elementary school were found to have a better quality of life in general. For resilience factors in general, no clear difference based on gender was identified. However, fathers displayed more personal competences such as high standards and tenacity, while mothers were finding more support in religion.
Spiritual (religious) influences were significantly more used by people living in cities, than by people living in refugee camps or villages. The people surveyed used religion and spirituality as a coping mechanism, where 98% said God is helping them all the time. They were proud of their achievements and had strong sense of purpose. The study found that the religious factor was one of the main factors used by the families to overcome adversities among Palestinian society in Gaza.
Socio-economic variables were found to be mediating factors between stress and resilience. Personal competences such as high standards and tenacity were found more frequently in people living in camps than in people living in cities and villages, while control was a competence found more frequently in people living in a village than in a city or a camp. Resilience, control, and personal competence as coping mechanisms were found more in families with incomes of over $301-$750/month. Also, education was identified as another protective factor for the people in Gaza, with
4
resilience factors such as personal competence, high standards, tenacity, positive acceptance of change and secure relationships identified more frequently in fathers with a university degree. Mothers with higher education were equally found to enjoy more resilience factors such as positive acceptance of change and secure relationships.
Trauma in children Palestinian children in the Gaza Strip had experienced from 3-17 traumatic events with mean of 7.5 traumatic events. The study showed that boys reported more exposure to severe traumatic events than girls; more traumatic events were reported in children living in a city than in a village or in a refugee camp. Traumatic experiences were reported more frequently by children whose mothers are employed as basic workers. Traumatic experiences were found to increase the risk for children to develop feelings of insecurity, decrease their resilience, and negatively affect their relationship with peers and parents. Furthermore, traumatic experiences by children were associated with Post-traumatic Stress Disorder (PTSD) and anxiety. There were eight main traumatic events reported by children. The most common traumatic experiences reported were 1) Hearing loud noises of drones. 2) Hearing shelling of the nearby area by artillery. 3) Hearing the sonic sounds of fighter jets. 4) Watching mutilated bodies on television. Safety and security among children The evaluation of the perception of safety and security among children in Gaza led to the following findings: 65.7% of children said that they did not feel safe in their homes during the 2012 eight days war 71.3% said that they were not able to protect themselves 83.5% said that they were not able to protect their family 45.4% said that others were able to protect themselves The study revealed that 35.9% of the children involved had all the symptoms of both PTSD and re-experiencing trauma (intrusive distressing recollections of the event,
5
including images and thoughts, distressing dreams, acting or feeling as if the traumatic event was recurring, intense psychological distress at exposure to internal or external cues, physiological reactivity on exposure to internal or external cues) were found more frequently in girls. Also, children coming from families with incomes of less than $300 /month, living in a city, whose parents had less than elementary education were found to suffer more frequently from PTSD. 30.9% of children were found to suffer from anxiety disorders, with an equal distribution among boys and girls. Anxiety was more frequently found in children living in camps than in a city or in a village, among children coming from families with monthly incomes of less than $300 /month, and among children whose parents did not have an education. The children used different ways for coping with the stress and trauma. Total resilience in children, personal skills, peer component, and social skills, contextual components facilitating a sense of belonging (spiritual beliefs, culture, and educational items) were found more often in girls than boys. Total resilience and contextual components were found more frequently in children living in a camp or village than in a city. However, there were statistically significant differences in individual factors (personal skills, peer component, and social skills) between children from families with a monthly income between $301 /month till $750 /month, and children from families with a monthly income below $300 /month. Children whose mothers’ education extended to a university degree were found to have significantly higher total resilience and individual factors (personal skills, peer component, and social skills). The results showed that having experienced highly traumatic events –resulting in anxiety symptoms, feeling of insecurity, and a high level of PSTD– significantly decreased the total resilience in children. Finally, the study found that children of parents experiencing a high degree of stress linked to the blockade reported a higher number of traumatic experiences due to the military escalation and increased feelings of insecurity and of feeling unsafe in their homes. In addition, stressors affecting parents were found to decrease the resilience factors in their children and increase their psychological problems due to trauma, in particular post-traumatic stress disorder. The study showed that increasing mental-health problems among parents, including somatization, anxiety, and depression are another risk factor for their children to increasingly develop PTSD or anxiety disorders. The
6
parents' quality of life was one of the most fundamental protective factors identified by the children who took part in this study. Thus for those parents with a higher quality of life, their children feel more secure and safe, leading to an increased resilience among the children. Conclusion and implications This study identified the psychosocial impact of the blockade on civilians in Gaza. Restrictions on movement and access, as well as the worsening humanitarian situation, generate daily stressors that strongly affect the well-being of both adults and children. In addition to those stressors, the November 2012 war in Gaza was found to have led to more psychological symptoms in parents such as anxiety, depression, and somatization, decreasing their quality of life and negatively affecting their resilience. However, the main finding of the research is that the short exposure to traumatic events such as a military escalation has less impact on people’s psychosocial health and well-being than the long-term effect of daily stress caused by the Israeli blockade. There is a clear relationship between socioeconomic conditions and vulnerability to worse psychosocial health, with lower income households or less educated individuals generally showing more psychological symptoms, less quality of life and reduced resilience. Children are in particularly a vulnerable target group. Trauma and on-going stress experienced by parents strongly affects their children’s psychological well-being and their sense of safety, and may lead to PTSD and anxiety. Religion works as a strong coping mechanism, for adults and children alike. Key words: Anxiety, Children, Gaza Strip, Parents, Psychological problems, PTSD , Resilience, Siege, Stress, Trauma
7
Table 1 Research team Dr. Abdelaziz M. Thabet, MD, PhD Principle Investigator Sanaa Thabet, MPH Project coordinator, Co-author- CFTCC Lena Hamid, BA, Assistant researcher, CFTCC Statistician, Emad El Kahlout Data collection team Ibraheem Abu El Feta Eman Ahmad Abu Jarad Tahni Mehana Hanan Abu Mesaad Reda El Masry Najwa Hamid Warda Heles Wesal El Masry Hana Thabet Data Entry Team Mohammed Abu Jarad Mysoun Abu Khousa Belal Emuhtadi
8
2. Introduction
The Gaza Strip is a narrow, elongated piece of land bordering the Mediterranean Sea between Israel and Egypt, and covers 365 km2. It is one of the most densely populated areas in the world. About 17% of the population lives in the north of the Gaza Strip, 51% in the middle, and 32% in the south. There is a high unemployment rate, socio-economic deprivation, overcrowding, and short life expectancy. Nearly two-thirds of the population are refugees, with approximately 55% of refugees living in eight overcrowded refugee camps (PCBS, 2011). Since 2007 the Government of Israel (GoI) was enforcing a blockade on the Gaza Strip. This blockade denies most Palestinians in Gaza the right to freedom of movement, effectively condemning over 1.7 million people to live in 365 km2. Severe restrictions on the movement of goods to, and particularly from, the Gaza Strip has condemned Gaza to a situation of de-development with a collapsed economy and a protracted humanitarian crisis. The population in the Gaza Strip has suffered increasing infringements of their human rights. Not only does the GoI as the occupying power continues to neglect its obligation under the Fourth Geneva Convention to protect the civilian population and ensure their welfare, but it also fails to respect and promote a wide range of civil, political, economic and social rights as per its obligations under the human rights treaties such as Fourth Geneva Convention. Israel’s measures to “ease” the illegal blockade of Gaza in the face of significant international pressure following the flotilla tragedy in June 2010 have done little to address the plight of Gaza’s civilians with the impact of the restrictions on access and movement remaining largely unaltered.
9
3. Background The Israeli blockade of the Gaza Strip enforced since 2007 has provided for a rather unique situation. There are not many studies made on this situation or similar contexts. However, Thabet et al (2008a) completed a study among a random sample of 386 adults from the entire Gaza Strip which showed high dissatisfaction amongst the population, where difficulties acquiring basic food items, variety in the markets and decrease in social visits were reported. In another similar study, Thabet et al (2008b) selected 184 households from the Cohort study II from the entire Gaza Strip. The age ranged from 18 to 64 years with an average age of 41.53 years. The results showed that the most common issues related to the blockade of Gaza were the significant rise in prices, medical staff and supply, fuel shortage, the sense of imprisonment and the lack of variety in the market. The results showed that people with monthly incomes below $350 were more seriously affected by the blockade than other groups. People living in cities were more affected than those who lived in villages and refugee camps. In addition, the results showed that people with a monthly income below $350 showed a higher rate of mental health problems than the other two groups were more affected by the blockade that the other groups. People used different coping strategies to deal
11
with daily life problems. The most common coping strategies used were having faith in God (85.9%) and sharing difficulties with relatives (83.7%), Total psychological problems were negatively affected by the blockade.
Mental health disorders due to traumatic events of war and military violence
Individuals who experience stressors and trauma may or may not develop mental health disorders. There is ample evidence that traumatic events of war and military violence are associated with PTSD and depressive symptoms. An examination of large, fairly representative samples of men and women of age 16 and older living in Algeria, Cambodia, Ethiopia, and Gaza, carried out by de Jong et al (2001) found relatively high rates of PTSD in each sample (37.4%, 28.4%, 15.8%, and 17.8%, respectively). In Algeria and Cambodia, and consistent with findings in the United States, women accounted for 10-14% higher rates of PTSD than men. In contrast, in Ethiopia and Gaza, women possessed similar or lower rates of PTSD in comparison with men (15.2% versus 16.6% and 13.5% versus 22.6%, respectively). In a representative sample of Kosovo Albanians aged 15 or older assessed approximately one year after the end of the 1998– 1999 war in Kosovo, Cardozo et al. (2003) observed a PTSD prevalence rate of 25%, compared with the rate of 17% that was found immediately following the war (Cardozo et al 2000). Parent’s mental health is a serious risk factor for developing mental health problems in their children. Thabet et al (2008c) in a study of 200 families from North Gaza and East Gaza who had been exposed to continuous shelling in 2006 found that the surveyed children had experienced on average eight traumatic events, 138 out of 197 (70.1%) children were likely to present with PTSD, 33.9% were rated as having anxiety symptoms of likely clinical significance, and 42.7% were rated by their parents as having significant mental health morbidity. Parents on average reported 8.5 traumatic events and 60% of parents had symptoms of potential clinical significance. Overall, the study found that children of parents reporting mental health problems presented higher PTSD and anxiety symptoms. In a similar study of 286 Palestinian children of 9–18 years of age and their mothers in the Gaza Strip was carried out in 2001 (Thabet & Vostanis), the traumatic events recollected by children living in areas of conflict, the prevalence of post-traumatic stress
11
reactions and the relationship between children’s and mothers’ mental health were investigated. Children experienced on average four traumatic events; one third reported significant post-traumatic stress reactions. The stress scores were found to be higher among girls and mothers. GHQ scores significantly predicted children’s stress scores. Quality of life Quality of life is defined as physical, mental, and social well-being (World Health Organization, 1948). For the purpose of this paper, we adopt a broader conceptualization of quality of life, according to which quality of life consists of social–material conditions, functioning (role performance), and satisfaction (well-being). The World Health Organization has defined HR-QOL as: [. . .] an individual’s perception of their position in life in the context of the culture and value systems in which they live, in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, and level of independence, social relationships and their relationships to salient features of the environment (WHO QOL-group, 1996).
Other studies have focused on the quality of life of the population under occupation. In a study on Palestinian adolescents in West Bank, Giacaman et al ( 2004) found that the Israeli military occupation/lack of freedom and its consequences on life were clearly top determinants for the quality of life. The political context of military occupation and instability was generally seen as an important cause of daily life problems including mental health states and the loss of dignity (highly valued in the local culture) contributing to a negative impact on life quality. Women from poor backgrounds tended to emphasize unemployment, dependence on Israel, poverty linked to occupation, and inadequate housing as important determinants of life quality. Educational choices affected the social domain and were rated as extremely important and relevant to Palestinian quality of life (Giacaman et al, 2004).
Resilience Resilience is most often considered a personality characteristic that mitigates the negative effects of stress and promotes adaptation. Resilience has been defined as the ability to successfully cope with change or misfortune (Wagnild & Young, 1993). Others such as Hjemdal (2007) have defined resilience as the capacity of individuals to successfully maintain or regain their mental health in the face of significant adversity or
12
risk. Resilience is an interactive dynamic construct that considers protective factors and positive
adaptation
in
adversity,
rather
than
focusing
on
risk
factors
and
psychopathology. Spirituality was commonly reported to be important to resilience and adaptive in illnesses. It was postulated that belief in God or having faith helped individuals make sense of the illness and acted as a source of strength. Participants high in spirituality were reported to have better mental health and adjustment (Chan et al, 2006; Haynes et al, 2008; Costanzo et al, 2009). War and conflict has affected the Palestinians in the Gaza Strip since 1948. Several studies have highlighted the influence of exposure to war trauma on children’s physical health and daily functioning, as well as on their mental health. Thabet et al (2004, 2006, 2008c)in studies of Palestinian children in the Gaza Strip found that children who experienced a variety of traumatic events including witnessing killing of relatives, demolition of homes, bombardments, and arrest of relatives were associated with post traumatic stress disorder, anxiety, and depression. This severely deteriorates children’s sleep and causes uncontrollable fears among babies and children, causing anxiety, panic attacks, and poor concentration.
For the purpose of the present study, psychological resilience is defined as the tendency of a person to overcome multiple factors that place one at risk for psychological dysfunction and to adjust positively in the aftermath of a potentially traumatic event (Lepore & Revenson, 2006).
Moreover, Espié et al (2009) in a study on the experiences of Palestinian children (aged 1–15) residing in the West Bank, witnessing traumatic events such as murder, physical abuse, destruction of property, and threats were associated with PTSD symptoms. Another example is Dubow et al (2010)'s study sample of 600 Palestinian youths (8-14 years old) in West Bank and Gaza Strip which found that children exposed to a variety of political conflict and violence (73%) witnessed actual political violence and (99%) witnessed political violence through media reports. A significant predictor of PTSD symptoms was exposure to political conflict and violence. Gender and age also did not interact with exposure to political violence when predicting PTSD symptoms with other types of exposure.
Studies that have specifically focused on the resilience of children exposed to community violence have identified social support from a child’s family (parent), school, and peer group to be important in resilience from repeated violence exposure (Hill &
13
Madhere, 1996; O’Donnell et al 2002). Family cohesion and positive coping on the part of parents also appear to lessen the negative impact of community violence (Buka et al, 2001; Plybon & Kliewer, 2001). Studies of people living in war zones highlight the significance of interdependent coping, confirming that the level of emotional upset and anxiety displayed by parents, not the war itself, is the most important factor in predicting a child’s response (Garbarino et al, 1992). Ozer and Weinstein (2004) found that specific aspects of social support within the children’s family (e.g. perceived parental helpfulness) and school (e.g. a teacher's helpfulness) provided some level of protection against the deleterious influence of community violence exposure. According to Mowbray et al (2007) the “community resilience emerges from community-level resources that enhance residents’ abilities to adapt in positive ways to risk. Social capital resources, institutional resources, and economic resources are three types of resources that contribute to community resilience”.
14
Four months after the September 11th terrorist attack and seeing a parent cry, parental PTSD or depression was associated with behavioural problems in children (Stuber et al, 2005). Among children living in Afghanistan, mental health problems of the caregiver were found to be a risk factor for children’s emotions, conduct, and hyper kinetic disorders and depression (Panter-Brick et al, 2009). Thus, the parents’ exposure to traumatic events during times of war or acts of terror puts both parents and children at risk for mental health problems. Parental stress may also be expressed in the form of parental control, in the hope of protecting children from danger. Ironically, such attempts may exacerbate children’s stress, putting them at risk of mental health problems.
15
4. Study design The study was descriptive analytic.
Aim of the study The aim of the study was to investigate the impact of stressful daily life events due to restriction of local families’ movement, association, and due to blockage and traumatic events due to eight days of military escalation on November 2012 on psychological symptoms, quality of life, and resilience of parents. In addition, to investigate the effect of traumatic events due to eight days of military escalation on children PTSD, anxiety, resilience, relationship of parents stress, trauma, psychological problems and resilience and children mental health problems and resilience.
Study objectives: Study objectives of parents 1. To identify types and severity of stressful situations due to the blockade among Palestinian parents. 2. To find the types and severity of traumatic experiences due to 8 days of military escalation among Palestinian parents. 3. To find out the most common types and rate of psychological problems in relation to stress due to the blockade and trauma among Palestinian parents. 4. To clarify the level of quality of life of people exposed to long-standing stress due to the blockade. 5. To find the most common psychological resilience factors among Palestinian parents. 6. To explore the relationship between stressful situations due to the blockade, traumatic experiences due to 8 days of military escalation, psychological problems, quality of life, resilience factors and socio demographic variables in Palestinian parents.
Study objectives of Children 7. To find the types and severity of traumatic experiences due to 8 days of military escalation among Palestinian children 8. To estimate the prevalence of anxiety and post-traumatic stress disorder among Palestinian children.
16
9. To find the most common psychological resilience factors among
Palestinian
children. 10. To explore the relationship between exposure to the traumatic experiences, posttraumatic stress disorder,
anxiety, resilience factors, and other socio-
demographic variables in Palestinian children. 11. To investigate the relationship between parental stress due to the blockade, trauma due to 8 days of military escalation, psychological problems, quality of life, and resilience and their children trauma, post-traumatic stress disorder, anxiety, and resilience.
Study questions: The main research questions for this study were as follows:
Study questions for parents 1. What are types and severity of stressful situations due to the blockade of Gaza Strip among Palestinian parents? 2. What are types and severity of traumatic experiences due to eight days of military escalation among Palestinian parents? 3. What are the most common types of psychological problems among Palestinian parents due to stress and trauma? 4. Did the level of quality of life of Palestinian parents decreased due to stress and trauma? 5. Had the stress, trauma, and psychological problems' impact on resilience factors among the Palestinian parents. 6. Did the socio-economic variables such as sex, age, place of residence, type of work, family monthly income associated with stress, trauma, psychological problems and resilience factors?
Study questions for children 1. What are types and severity of traumatic experiences due to eight days of military escalation among Palestinian children? 2. What is prevalence of anxiety and PTSD among Palestinian children? 3. What type of resilience factors Palestinian children use in face of stress and trauma. 4. Is there any relationship between exposure to the stressful situations, traumatic experiences, psychological problems, quality of life, resilience and socio demographic
17
variables (age, sex, place of residence, education and work, and family monthly income) in Palestinian parents? 5.Is there any relationship between exposure to the traumatic experiences and PTSD, anxiety, resilience factors? 6. What are the relationships between socio-demographic variables (age, sex, place of residence, parent's education and work, and family monthly income) and trauma, PTSD, anxiety, and resilience factors in Palestinian children? 7. What are the relationships between parental stress, trauma, psychological problems, quality of life, and resilience and their children trauma, PTSD, anxiety, and resilience factors?
Methodology Setting and Sample The study sample consisted of 502 families living in the Gaza Strip. Families with two children aged from 9-18 years were included. A total number of 502 parents and 502 children agreed to take part in the study. The response rate was 100%. Table 2, 3.
18
Table 2 Parents' sample distribution according to the division and area Area North Gaza
Gaza Area
Middle area
Khan Younis
Rafah area
Division
Male
Female
Total
Beit Hanoun
12
12
24
Jabalia camp
15
13
28
Beit Lahia
19
20
39
Beach camp
12
12
24
El Remal
15
18
33
Shekh Radwan
13
13
26
Nasser
9
11
20
Tel El hawa
10
10
20
Zytoun
10
10
20
Sheijaia
16
16
32
Zawida
7
7
14
Bureij camp
8
7
15
Maghazi
7
7
14
Dear Balah
16
16
32
Qarara
5
5
10
Khouzaha
5
5
10
Khan Younis camp
7
7
14
Khan Younis city
24
24
48
Beny Sohila
5
5
10
Abbasan
5
3
8
Shoka
4
4
8
Yebna camp
6
6
12
Shaboura camp
7
6
13
Tel El sultan camp
8
6
14
Jenina area
7
7
14
252
250
502
Total
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Table 3: Children' sample distribution according to the division and area Area North Gaza
Gaza Area
Middle area
Khan Younis
Rafah area
Boy
Girl
Total
Beit Hanoun
12
12
24
Jabalia camp
15
13
28
Beit Lahia
19
20
39
Beach camp
12
12
24
El Remal
15
18
33
Shekh Radwan
13
13
26
Nasser
9
11
20
Tel El hawa
11
9
20
Zytoun4
10
10
20
Sheijaia
16
16
32
Zawida
7
7
14
Bureij camp
8
7
15
Maghazi
8
6
14
Dear Balah
15
17
32
Qarara
5
5
10
Khouzaha
6
4
10
Khan Younis camp
7
7
14
Khan Younis city
24
24
48
Beny Sohila
4
6
10
Abbasan
5
3
8
Shoka
4
4
8
Yebna camp
5
7
12
Shaboura camp
7
6
13
Tel El sultan camp
7
7
14
Jenina area
7
7
14
252
250
502
Total
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Study procedure
Before starting the research, 15 community-based organizations were invited to attend a workshop on 9th December 2012 to share information about the study. The research objectives, questions, possible difficulties and checklists were jointly reviewed. Fifteen persons were involved in forming the questionnaires of stress due to the blockade and trauma due to eight days of military escalation. Those CBOs were selected according to criteria including the site of the organization, activities in the society, number of employees, and previous experiences in such activities. The representatives of the CBOS were involved in pre-assessment of the families in formulating the scales for stress and trauma. Their contribution was very important, for example, suggesting types of stressors to be studied. They specified that items such as being unable to buy medicine, or to finish building a house due to shortage of materials had to be included. They were thus able to express their voice about the impact of the blockade on them and on the other members of the society. They expected to use the findings of the research to advocate for their freedom of movement and expression and express their feelings and worries for a better future. After this initial workshop, each organization sent a representative to participate in the training course in scientific research for three days on 25, 26, 27 December 2012 which was conducted at Child and Family Training and Counselling Center in Gaza. The focus of the training courses was on different research methodology, types of research, sampling process and collection of data. After three days of training, CBOs representatives together with five trained professionals from CFTCC were selected according to their abilities, previous experiences in data collection and active participation in the training course. Data collectors attended another one-day training provided by the principal investigator regarding the aims of this study, sample, and how to select the families from each area, and questionnaires of the study were introduced to them and they were asked to help the participants in filling the questionnaires. Community-Based Organizations were divided in to five groups according to Gaza Strip demographic distribution and they were given list of the number of the families from 16 districts selected randomly including one child and one parent from each family. Data collection was done between 1st January to 26 January 2013, covering the 502 families and 5 focus groups of parents in the five areas.
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In order to select the families in each district, a street was defined in each area, and every second house was selected. In larger buildings, one flat from each floor was selected randomly. Families were included if they consisted of both parents, with one boy or one girl, aged between 9-16 years, and had been in the area for the last year. Families were approached until 502 agreed to participate. A covering letter was given to each participant explaining the aim of the study and their right not to participate in study and they were asked to sign this letter of consent. Each meeting with the family member lasted 30 minutes. There were some limitations during data collection in which there was bad weather and heavy rain for three days in January 2013. Families complained that the questionnaires were long and they were asking enquiring about financial support.
Measures Measures for quantitative data for Parents 1. Sociodemographic characteristic form This questionnaire includes sex, age, and place of residence, education and job information, number of children, family monthly income. Annex 1. 2. Gaza Stressful Situation due to the siege and blockade Checklist, (Thabet, 2013) Stressful situations experiences were collected using stressful Situation due to the siege and blockade Checklist. This checklist describing the most common stressful experienced during the last 7 years of seize and closure of Gaza Strip. The checklist consisted of 18 items with answer with Yes (1) and no (0). The scoring of the scale is considered by summing all the answers. In this study, the split half reliability of the scale was high (r = .66). Previous version had been used in the area (Thabet et al, 2009). The internal consistency of the scale was calculated using Chronbach’s alpha, and was high ( = .76). Annex 2. 3. The Gaza Traumatic Events Checklist for 8 days war on Gaza (Thabet, 2013) The checklist consisting of 18 items covering three domains of events typical for the 8 days of military escalation: (1) Witnessing personally acts of violence (e.g., killing of relatives, home demolition, bombardment, and injuries), (2) Having experiences of loss, injury and destruction in family and other close persons, and (3) Being personally the target of violence (e.g., being shot, injured, or beaten by the soldiers). In checklist respondent were asked whether they had been exposed to each of these events: (0) no
22
(1) yes. In this study, the split half reliability of the scale was high (r = .57). The internal consistency of the scale was calculated using Chronbach’s alpha, and was high ( = .77). Annex 3. 4. Symptom Checklist (BSI-18) (BSI; Derogatis, 2001). The Brief Symptom Inventory 18 (BSI-18) is a measure of
psychological distress
designed to screen for depressive, anxious, and somatic symptoms. The BSI-18 contains 18 items and employs a 5-point Likert-type scale ranging from 0 (not at all) to 4 (extremely). The global severity index (GSI) score is derived from the sum of all item scores, ranging from 0 to 72, with greater scores suggesting greater psychological distress. Additionally, scores can be obtained for the somatization (6 items; e.g., ‘‘faintness’’), depression (6 items; e.g., ‘‘no interest’’), and anxiety (6 items; e.g., ‘‘nervousness’’) dimensions. The BSI has been shown to be a reliable and valid measure, with an adequate internal consistency (a ¼ .74, .84, .79, and .89, for somatization, depression, anxiety, and GSI, respectively). 27 in the present study, Chronbach’s a of somatization, depression, anxiety, and GSI were .78, .85, .82, and .91, respectively. In this study, the split half reliability of the scale was high (r = .88). The internal consistency of the scale was calculated using Chronbach’s alpha, and was high ( = .90). Annex 4. 5. The Connor-Davidson resilience scale (CD-RISC) The CD-RISC is a 25-item scale that measures one’s ability to cope with adversity. Respondents’ rate items on a scale from 1 (not true at all) to 5 (true nearly all the time). Example items include: “I am able to adapt when changes occur”, “I can deal with whatever
comes my way” and “I tend to bounce back after illness, injury, or other
hardships.” Connor & Davidson (2003) administered the scale to subjects in the following groups: community sample, primary care outpatients, general psychiatric outpatients, clinical trial of generalized anxiety disorder, and two clinical trials of PTSD.Internal consistency using Cronbach’s α for the full scale was 0.89 for Group 1 (n=577) and itemtotal correlations ranged from 0.30 to 0.70. In this study the scale was translated the scale into Arabic by the first author and back translation was done by second author with minimal changes. In this study, the split half reliability of the scale was high (r = .81). The internal consistency of the scale was calculated using Chronbach’s alpha, and was high ( = .88). Annex 5.
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6. World Health Organization Quality of Life (WHOQOL-BREF) The WHOQOL-BREF was developed from the WHOQOL-100, a cross-cultural QOL Instrument developed by the World Health Organization (WHO) for assessing individuals’ subjective perception and feelings of life. Thus, the WHOQOL- 100 was simplified into a brief version, called the WHOQOL-BREF, by selecting 24 items from 24 facets (one item per facet) and two items from the general facet. These 24 items covers four domains, including physical health, psychological state, social relations, and environment. These four domain scores were used to indicate an individual’s QOL. The participants rated each item on a 5-point scale ranging from (1) not at all satisfied to (5) very satisfied. In this study, the split half reliability of the scale was high (r = .75). The internal consistency of the scale was calculated using Chronbach’s alpha, and was also high ( = .88). Annex 6.
Qualitative data for parents For qualitative data collection from parents, a structured interview with a number of questions on the most common stressful condition and common mental health problems, how they overcome such problems in their daily life and expectations for the future. Five parent focus groups were conducted in the five districts areas of the Gaza Strip. Focus groups were conducted in five community based non-governmental organizations which were partners in the project targeting the same group participated in the quantitative data collection. Narratives of the five focus groups were transcript and themes were analysed using theme analysis method.
Measures for quantitative data for children 1. Socio-demographic characteristic questionnaire This questionnaire included sex, age of the children, and place of residence, parental information, and family income. Annex 7. 2. The Gaza Traumatic Events Checklist for 8 days war on Gaza (Thabet, 2013) The checklist consisting of 18 items covering three domains of events typical for the of military escalation: (1) Witnessing personally acts of violence (e.g., killing of relatives, home demolition, bombardment, and injuries); (2) Having experiences of loss, injury and
24
destruction in family and other close persons; and (3) Being personally the target of violence (e.g., being shot, injured, or beaten by the soldiers). In checklist respondent were asked whether they had been exposed to each of these events: (0) no (1) yes. In this study, the split half reliability of the scale was high (r = .59). The internal consistency of the scale was calculated using Chronbach’s alpha, and was high ( = .64). Annex 8. 3. Security during 8 days of military escalation Checklist The checklist consisting of 4 items covering security items convening the child’s feeling secure for themselves or having security for his family. In checklist respondent were asked whether they had been secure during the military escalation with (0) no and (1) yes answers. The scoring of the scale is considered by summing all the answers. In this study, the internal consistency of the scale was calculated using Chronbach’s alpha ( = .71). Annex 9. 4. UCLA PTSD Index for DSM-IV: Adolescent Version (Rodriguez, Steinberg, & Pynoos, 1999) (Arabic version, Thabet, 2008) The items of the UCLA PTSD indices are keyed to DSM-IV criteria and can provide preliminary PTSD diagnostic information. Self-reports for children and adolescents exist, as well as a parent report of PTSD symptoms. The adolescent Version (for adolescent aged 13 years and older) contains a total of 22 questions, have also been administered in school classroom settings. A 5-point Likert scale from 0 (none of the time) to 4 (most all the time) is used to rate PTSD symptoms. Only 17 items were included in the total score because two items were not DSM-IV criteria and three items were repeated symptoms. Although there is limited information about the specific cut-off score for a particular trauma type or population, a cut-off score of 38 has been proposed in the literature (Steinberg et al. 2004).The split-half reliability of this measure was 0.60 and the Cronbach alpha was ( = .71). Annex 10. 4. The Revised Children’s Manifest Anxiety Scale (RCMAS) (RCMAS; Reynolds & Richmond, 1978) The Revised Children’s Manifest Anxiety Scale is designed to measure symptoms of generalized anxiety in children and youth. The 37 scale items are answered yes or no. Nine items comprise a Lie scale, thus symptom severity scores range from 0–28. The clinical cut-off score is ≥ 18. Reliability by Kuder-Richardson- 20 (KR-20) has been found to be high (p.85; Lengua & Sandler, 1996). A high correlation (r = .85) has been found
25
between RC-MAS and other instruments measuring trait anxiety (Reynolds, 1980). In the present population, the KR-20 for the RCMAS was ( = .87). Annex 11. 5. Resilience Scale for Adolescents (Hjemdal et al, 2001, 2007) The scale is a 28-item self-report scale using
positively phrased. Higher scores reflect
higher degree of resilience. This scale was developed using confirmatory factor analysis and has shown adequate psychometric properties (total Chronbach alpha = 0.94) and initial promising validity (Hjemdal et al, 2001, 2007). Results suggest that the Resilience Scale for Adolescents has three sub scales reflecting the major categories of resilience. Furthermore, each sub scale has its own groupings of questions that serve as indicators of the construct’s major categories. The first sub scale reflects an individual factor that includes personal skills (5 items), peer support (2 items), and social skills (4 items). The second sub scale deals with caregiving, as reflected in physical caregiving (2 items) as well as psychological caregiving (5 items). The third sub scale comprises contextual components that facilitate a sense of belonging in youth, components related to spirituality (3 items), culture (5 items), and education (2 items). The split-half reliability of this measure was 0.70 and the Cronbach alpha was ( = .83). Annex 12. 5. Statistical analysis Data entry and analysis were carried out using a statistical software SPSS version 18.0 (SPSS Inc. Chicago Ill, US). Frequency and percent were used to express quantitative data of types of stressful situations, trauma, mental health disorder, quality of life, and resilience of parents and children trauma, PTSD, anxiety, and resilience. For continuous variables means and standard deviations were reported. For differences between means of two groups parametric tests were used such as t-test to compare sex of children and parents and mean of stress, trauma, mental health problems, resilience, and quality of life. While, ANOVA tests were used for measuring differences between more than two groups of continuous variables such place of residence and stress, trauma, resilience, mental health. Pearson’s correlation coefficient was used to test the association between numbers of stressors scores, traumatic experiences, WHOQOL scores, resilience, and mental health problems. The 0.05 alpha levels were accepted as a sign for statistical significance for all the statistical procedures. For qualitative data collected by focus groups with parents were analysed manually by the consultant depending in his previous experiences in similar research.
26
6. Study results In the followings section we presented the main quantitative and qualitative results. Starting by parents findings and including the stress and trauma, psychological problems, quality of life and resilience and differences in socio demographic variables followed by children data concerning trauma, PTSD, anxiety, resilience and socio demographic variables. At the end, we will present the relationships between parents and children variables
6. 1 Parent's results Socio-demographic data The sample consisted of 252 males (50.2%) and 250 females (49.8%) (table 4). According to the selection criteria, the age range was 20-60 years, with a mean age of 42.49 years. Regard age groups, 239 participants age group was less than 40 years (47.6%), 198 age group was ranged from 41-50 years (39.4%), and 65 age group was above 51 years (12.9%). Regard place of residence, 94 live in north Gaza (18.9%), 174 live in Gaza city (34.7%), 84 live in Middle area (16.7%), 96 live in Khan Younis (19.1%), and 54 live in Rafah area (10.8%). For type of residence, 262 live in cities (52.2%), 173 live in refugee camps (34.5%) and 67 live in a villages (13.3%). Regard family size, 22.1% of the participating families had 4 or less children, 49.8% had 5-7 children, and 28.1% had 8 or more children. Almost 67.1% of the families had a monthly income under $300, 25.7% had income between $30 till $751, 5.4% had a monthly income above $751-1000, and 1.8% had monthly income more than $1001. Regard education, 33 of fathers were uneducated (6.6%), 75 had preparatory school education (9.9%), 112 had elementary education (22.3%), 147 had secondary education (29.3%), 47 had diploma education (9.4%), 74 had a university degree (14.7%), and 14 had a postgraduate degree (2.8%). Similarly, 31 of mothers were uneducated (6.2%), 55 had preparatory education (11%), 123 had elementary education (24.5%), 219 had secondary education (43.6%), 39 had a diploma degree (7.8%), 33 a university degree (6.6%), two held a postgraduate degree (0.4%). Regard employment status, 185 of fathers were unemployed (36.9%), 71 were simple workers (14.1%), 45 were skilled workers , 51 were civil employee and working (25.3%), 91 were civil employee not at work and getting salary (6.2%), 24 were merchants (4.8%), 12 were farmers (2.4%), and 23 were working in different jobs (4.6%). The majority of mothers
27
479 (95.4%) were housewives, five were simple workers (1%), 13 were civil employee and working (8.3%), and 5 were civil employee not at work and getting salary and (1%).
Table 4 Sociodemographic characteristics of the parents sample (N =502)
Sex Male Female Age Mean = 42.49 (SD = 7.6) Less than 40 years 41- 50 years old 51 years and above Place of residence North Gaza Gaza Middle area Khan Younis Rafah Type of residence City Village Camp No of siblings Four and less Five to seven siblings Eight and more siblings Family monthly income Less than 300 $ 301-750 $ 751-1000 $ More than 1001$ Father education Not educated Preparatory Elementary Secondary Diploma University Post graduate Mother education Not educated
28
No.
%
252 250
50.2 49.8
239 198 65
47.6 39.4 12.9
94 174 84 96 54
18.7 34.7 16.7 19.1 10.8
262 67 173
52.2 13.3 34.5
111 250 141
22.1 49.8 28.1
337 129 27 9
67.1 25.7 5.4 1.8
33 75 112 147 47 74 14
6.6 14.9 22.3 29.3 9.4 14.7 2.8
31
6.2
Preparatory Elementary Secondary Diploma University Post graduate Father job Unemployed Simple worker Skilled worker Civil employee and working Civil employee not at work and getting salary Merchant Farmer Others Mother job House wife Simple worker Civil employee and working Civil employee not at work and getting salary
29
55 123 219 39 33 2
11 24.5 43.6 7.8 6.6 0.4
185 71 45 51 91 24 12 23
36.9 14.1 9 10.2 18.1 4.8 2.4 4.6
479 5 13 5
95.4 1 2.6 1
Stressful situations due to the siege and blockade on Gaza Strip Types and frequency stressful situations According to Table 5 which reported types of stressors due to siege, 442 of participants (88%) felt that they are living in big prison, 438 (87.3%) said they cannot finish some construction and repairing work in their house due to shortage of building materials, 429 (85.5%) said prices are sharply increased due to closure , 408 (81.3%) said social visits are less than before, and 391 (77.9%) said that their work was affected so much due to cut-off of electricity and shortage of gas. Table 5 Types and frequency stressful situations due to restriction of movements and the blockade (N = 502) Yes
Stressors
No
No.
%
No.
%
1. I feel I am in a big prison
442
88
60
12
2. I can not finish some construction and repair work in my house due to shortage of building materials
438
87.3
64
12.7
3. Prices are sharply increased due to closure
429
85.5
73
14.5
4. Social visits are less than before
408
81.3
94
18.7
5. My work affected so much due to cut-off of electricity and shortage of gas
391
77.9
111
22.1
6. I sold some of my furniture and my wife's gold.
322
64.1
180
35.9
7. I was not able to get specific medicine for me or for one of the family member
320
63.7
182
36.3
8. I need to travel outside the Gaza Strip and can not
301
60
201
40
9. I went to Zakat organizations and other organizations to get the food
282
56.2
220
43.8
10. I cannot get married or help my sons in marriage
267
53.2
235
46.8
11. My monthly income decreased and can not send my children for schools
249
49.6
253
50.4
Yes
No
12. I had suffering of not able to receive proper medical care
249
49.6
253
50.4
13. I stopped completely working due to inability to
243
48.4
259
51.6
31
got to my land and restriction in sea area 14. I thought of immigration
141
28.1
361
71.9
15. I was unable to travel to visit my relatives in West Bank due to siege
135
26.9
367
73.1
16. I stopped sending my children to schools and send them to work to help the family
110
21.9
392
78.1
17. One of the family member died due to prevention of travelling for treatment
97
19.3
405
80.7
18. I was prevented from visiting one of the family members in Israelis jails
55
11
447
89
Differences in Gaza’s stressful situations due to siege In order to find differences in types and severity of stressful situations due to the blockade and other socio demographic variables such as sex, age, place of residence, education, family monthly income a T independent test was conducted. Gaza stressful situations and sex The results showed than mean stressful situations in males were 10.3 (SD =3.67) and 9.13 for females (SD = 3.29). There were statistically significant differences toward males (F= 3.73, p =0.01). Figure 1.
31
Figure 1 Mean of stressful situations due to the blockade and sex (N = 502)
According to the age, the age of the participants was recoded into three categories (less than 40 years, 41-50 years, and above 51 years). Mean stress for participants age was (9.14, 10.27, and 10.17 respectively). One-way ANOVA was conducted in which total stressful situations were entered as dependent variable and other socio demographic variables as independent variables (sex, age, place of residence, education, family monthly income, and employment). The study showed that there were statistically significant differences in stressful situations toward participants age 51 years than the other two groups (F= 6.24, p = 0.01). It means that people aged 51 years and old are experiencing more stress due to the blockade that younger age group. Mean stress for participant's place of residence (city, village, and camp) was (10.01, 11.01, and 8.78 respectively). There were statistically significant differences in stressful situations toward participants living in camps than in city of village groups (F= 12.03, p = 0.01). This finding showed that those refugee people beside the chronic life adversities in the last 60 years, they also another risk group in Palestinian society for stress. Mean stress for participants family monthly income (less than $300, $301-$750, $751$1000, and more than $1001) was (10.90, 7.41. 6.48, 8.22). There were statistically significant differences in stressful situations toward poor families with monthly income below $300 than the other three groups (F= 50.55, p = 0.01).
32
Mean stress for father's education level (less than elementary, secondary, diploma, university and above) was (11.23, 10.86, 9.78, 9.36, and 6.51). There were statistically significant differences in stressful situations toward fathers with lower level of education (less than elementary) (F= 32.87, p = 0.01). The average stress levels in relation to the mother's education (less than elementary, secondary, diploma, university and above) were (11.83, 10.57, 9.04, 9.05, and 6.54). There were statistically significant differences in stressful situations for mothers with lower level of education (less than elementary) (F= 22.11, p = 0.01). These findings showed that educated people are having protective factors in face of stress and adversities than lower educated people. Average stress levels in relation to father's jobs (unemployed, simple worker, civil employee and working, civil employee not at work and getting salary, and others) were (11.23, 10.86, 9.78, 9.36, 6.51 respectively). There were statistically significant differences in stressful situations toward unemployed fathers than simple workers, employee and working, civil employee and getting salary, and others (F= 22.15, p = 0.01). This means that unemployment is another risk factor for people facing stress. Average stress levels in relation to mothers jobs (housewife, simple worker, civil employee and working, civil employee and getting salary and not at work, and others) were (9.86, 9.20, 6.77, 4.40 respectively). There were statistically significant differences in stressful situations toward housewives than women who were employee and working and civil employee not at work and getting salary (F= 7.38, p = 0.01).
33
Focus groups
From the focus groups it was clear that the blockade of the Gaza Strip since 2007 had a devastating effect on Palestinian families’ way of living, quality of life, relationship between families, physical, psychological, financial and environmental situation. In the following narratives of the various people in the focus groups, we are presenting the main themes.
T. A male 45 years unemployed from Gaza said “The Israeli blockade has been present since 2007 and it is still there. I changed more than one job due to the closure of the border to continue in my life, from being a tailor, to electrician, and now I work as a merchant selling TV sets and receivers. The blockade has ruined both my life and my legs. My legs were ruin because they did not allow me to travel beyond Gaza borders for medical treatment, though there are o valid reasons for not allowing me to travel" N. female from Gaza city said “My son was admitted to AL Nasser paediatric hospital. We bought medication from a separate pharmacy at our own expense as there was no medicine available in the hospital due to the blockade. He stayed there for two weeks and they gave him basic medicine. My father then brought an important doctor, Dr Wasta, who prescribed an injection costing $100. Already after the first injection my son’s condition improved. We cannot bring many things for our children. The salaries are always delayed and once received it is only half of it. During the siege, we have been forced not to depend on raw material from Israel and rather bring these materials from Egypt. We built our home during the siege, everything was expensive. No luxurious things at home and until now we have lived without windows or doors". J. A. male from Gaza said "This blockade has deprived me from many things such as food and drink, and luxurious things, I do not even have a refrigerator, I cannot bring anything for my family, I am very stressed due to the blockade and division between Fatah and Hamas. I am fed up".
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R. R. male from Gaza said "The siege brings me back 20 years.. I was earning thousands of dinars from bus driving in Israel, but now life is difficult with no income, and I have had psychological problems due to the siege". F. from Maghazi camp said “The impact of the blockade is too much, we have land in the buffer zone, thus are unable to access and cultivate our land. It is the only source of income in our family”. R. from Maghazi said “The blockade has had a negative impact on all of us, we do not go out anymore. For the youth, there are no jobs. I have suffered from fears and anxiety during this whole time and stressors are accumulated on our shoulders. We are four young people in the house, my father is a civil employee yet he has not received a salary due to the political problems, we cannot fulfil our needs at home, we have many responsibilities and we can not cover them” S. female from Maghazi said “I am a university graduate and I am unable to find a job due to the blockade and siege. My husband was a merchant but he lost his source of income due to the siege, all of this has a negative effect on our socio-economic status. We are living in very small house; we did try to buy bigger house or a land, but due to lack of money we were unable to. The prices of the houses and land slots are high and still increasing, and the same goes for
construction
material. Due to the blockade, we had no money to buy bigger house. I had daughters all sharinga small room and each one wanting to study out loud. I feel psychologically sick and all I can say is that God is the greatest. The girls are bigger now and want separate roomsfor their own privacy, but we are unable to offer that because our house is very small. Nothing makes you happy in this situation, I worry about the girl’s future all the time”. H. female from Maghazi presented her view about the impact of siege “My husband was working inside Israel and due to the blockade he lost his work, all projects in Gaza are stopped and there is no work for anyone. I am graduate and cannot find a job for myself. The situation is worse than ever"
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R. female from Maghazi said "My husband is a simple worker. An impact of the blockade is that construction material is not always available which drives up the prices as well. We moved to a new house, because the rent was very expensive and we could not pay the rent due to lack of money". H. female from Rafah said "The blockade affects all aspects of our life and we are constantly watching the news. My husband is a construction worker who lost his work due to siege and now we do not even have cooking gas. All of the various shortages affects us strongly. I have two daughters who wants to join the university but due to the blockade, our monthly income is very low and I do not have money to face the requirements of life. In addition there is the shortage of electricity. All of these conditions affect our lives and make it harder to live in Gaza. My husband works inside the tunnels. If there was work for people, there would be no need for young people to work inside the tunnels, my husband works there because he has no other source of income. The work inside tunnels is very dangerous and limited, and it is not very well paid. The blockade affects all the people in Gaza, every house is affected, every home has unemployed graduates and their fathers are unemployed. My whole salary is already spent when I receive it. During the military escalation there was no electricity, and my son wet himself in fear". H. S male age from Rafah said "I was affected by the siege. I married at the beginning of the siege. A one bedroom home cost700 dinars before the siege whilst after the blockade it cost 1600 dinars. Previously gold was also cheap, however now it has become very expensive. In the past, a bride would purchase everything she needed for around 2000 dinars, after the siege it costs 4000 dinars. Today 5000 dinars is not enough to buy things for a wedding. Eventually my wedding cost me 1,300 dinars whichdelayed my wedding. Later on I was working on a project, however this project was stopped due to shortage of raw materials as a result of the blockade of Gaza. Now I am just sitting at home. I am responsible for two homes and ask God to change this situation because I cannot bring anything home anymore. The deaths in the tunnels is new kind of death that we did not know before. I worked inside the tunnels for one year. Everyone working in the tunnels are nervous and are unsure if they will make it home every night. Often the tunnels
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are bombarded and in many cases people died because of the collapse of tunnels.” Abu Muhammad male from Rafah said "I was a semi-professional boxer, I earned the second place at the Arab world level, before the crossings were closed. I used to travel a lot to participate in various tournaments, but since the beginning of the the blockade I did not participate in tournaments outside Gaza Strip. This has lead to the destruction of my psyche and destroyed my professional ambitions permanently. related to age and
Sport is
a persons fitness peak is at a young age. Another thing is
when you are buying any new electric instruments such as refrigerator, they only give you five months guarantee, sowhen it is brokenyou need more money to repair it.” N. male from Rafah said" "If we want to talk about the blockade since 2007, there have been signs of economic problems such as lack of resources, as well as the problem of electricity. f someone becomes ill
and we need to take him to the hospital,
there's shortage of medicine The blockade is also preventing social networking among people as they can not afford to buy gifts for visits." Um Yasser from Khan Younis said “The blockade is affecting our lives in many ways. It affects the economic situation in which basic foods become very expensive. The blockade leads to the interruption in the supply of cooking gas and foods from outside Gaza; on the other hand, the lack of money to buy food has had an impact on my kids. For example, my neighbours have money and they can afford to buy what they need for their children, but we cannot afford to meet our children's needs . Our children are looking at other children and want similar things.” S. Female from Beit Lahia said “I feel tired and pain in my body, we are 16 people in our house, my children go near Erez checkpoint with a cart to bring remnants of destroyed homes to sell it later, and every time they are putting their lives in danger. I am always nervous for them not to come back and I thank God for their safety every time they come home. They get 200 -300 shekels for selling the rubbles of the homes they collected.”
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O. female from Rafah said "Now everything is very expensive, in particular when there is a closing of the tunnels, many young people have died working inside these tunnels. They are forced to work there due to the blockade and the lack of job opportunities. My nephew was treated at the hospital, his injury was a result of working inside the tunnel, and our neighbour died because of working inside the tunnels. When my husband receives his salary he goes to the grocery shop to pay down our debt. He is also working as an electrician so he can provide for the basic requirements of the family. During Eid we buy a few pieces of clothing. In the past we were preparing beautiful things for the children. My daughters look at their cousins and become jealous. When my children want something their father would bring them what they want. However, fclothing we only buy for special events because they are expensive and above our spending ability. For my children who attend university I can provide payments for transport only.” F. female from Maghazi said “In the beginning of the school year, our children had many demands such as books, pens, and school supplies. My son wanted a school bag and books, but what was I to do. We had no money. I want to ventilate the daily stressors on my family. Life is a battle.” J. male from Maghazi said “When I was working, I was able to provide my children with school supplies such as notebooks and pens, but when I lost my job I could not do it. We were hitting our young children and ventilate our anger and frustration out on them. My son joined the university for two semesters and then we could not pay the university fees. So he stopped going to the university. All aspects of my life depends on social welfare and support.”
R.K. Male from Beit Lahia said “Of course, during the time of the blockade movement has been restricted which has put us in bad situation. No income due to the blockade, which has lead to fewer employment opportunities and the spread of unemployment. We cannot give our children pocket money and their daily food as usual due to the closure of the borders. Shortage of construction materials and work is resulting in youth
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wanting to die because their parents are unable to provide for their needs such as paying
university fees, because the costs are too high for unemployed
fathers, leading to frustration and wishes of death.” S. female from Khan Younis said “I hope that the blockade will end because we need a variety of things and we cannot buy them because of the high prices and this is all due to the closure of the borders. The blockade has a direct impact on us. We are a family consisting of nine members and no one are working. Before the blockade the cooking gas cost NIS29 per bottle and now the price has increased to NIS80. We need many things, but when I see the house and the economic situation and my parent’s situation, I gave up everything in the hope that the situation becomes better.” Om Mohamed from Rafah said "The electricity shortage is a very big problem. It is harming the entire household. We use candles which is very dangerous because it can cause fires. When we do not have cooking gas, we use wood for cooking our food. Everything is expensive. I accept my faith because there is no other way." N. female from Gaza city said “When my husband turns the generator on and leaves the home, I am very frightened until he comes and turns it off." N. male from Gaza city said “We used to cook two types of foods, but now only we eat salad." M. female from Rafah said “I am divorced and I live with my family and I receive aid from the social affairs department of UNRWA, they give us money every three months. During those three months, my debts accumulate. Needs and requirements of the children are more than what I receive from UNRWA. Thus, I need more money. My parents often help me. Alone, I could not bear this situation but with help of parents, my ability to cope is better. The blockade has made me feel suppressed even when there is joy it is incomplete and the heart is tired."
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A. female from Rafah said “My way of coping was trying to provide my family with basic necessities, and to skip those things that felt like luxury items. When cooking gas was not available I used to replace the gas with fire wood.” G. male from Gaza city said "The situation is insecure. I am tired and became sick after the last war. I had a daughter that was sick and I took here for treatment to one of the religious people (Sheikh) but her condition did not improve."
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Exposure to traumatic events due to eight days of military escalation Types of traumatic events The study showed that Palestinians in the Gaza Strip had experienced from 3-17 traumatic events with mean exposure to 8.8 traumatic events (SD =2.69). The most common traumatic experiences were: hearing shelling of the area by artillery (99.4%), hearing the sonic sounds of the jet fighters (98.8%) hearing the loud sound of drones (98.6%), watching mutilated bodies on television (98%) and witnessing the signs of shelling on the ground (90.2%). Whilst the least common traumatic experiences were witnessing firing by tanks and heavy artillery at own home (7.2%), as well as physical injury due to bombardment of your home (6.2%). Table 6 Types of traumatic events due to the November 2012 - 8 days of military escalation Traumatic Events
Yes
No
No
%
No.
%
1. Hearing shelling of the area by artillery
499
99.4
3
0.6
2. Hearing the sonic sounds of the jet fighters
496
98.8
6
1.2
3. Hearing the loud noise of drones
495
98.6
7
1.4
4. Watching mutilated bodies on television
492
98
10
2
5. Witnessing the signs of shelling on the ground
453
90.2
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9.8
6. Receiving threaten letters by the Israeli army through local Televisions or the Radios 7. Unable to leave you home with family members due to fears of shelling in the street 8. Hearing killing of a friend
341
67.9
161
32.1
323
64.3
179
35.7
322
64.1
180
35.9
9. Witnessing firing by tanks and heavy artillery at neighbours’ homes 10. Receiving pamphlets from Airplane to leave your home at the border and to move to the city centres 11. Forced to leave you home with family members due to shelling 12. Witnessing shooting of a friend
220
43.8
282
56.2
172
34.3
330
65.7
125
24.9
377
75.1
114
22.7
388
77.3
13. Witnessing assassination of people by rockets
100
19.9
402
80.1
14. Threaten by telephoned to evacuate your home before bombardment 15. Hearing killing of a close relative
100
19.9
402
80.1
96
19.1
406
80.9
16. Witnessing shooting of a close relative
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9.2
456
90.8
17. Witnessing firing by tanks and heavy artillery at own home 18. Physical injury due to bombardment of your home
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7.2
466
92.8
31
6.2
471
93.8
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Severity of traumatic events due to 8 days of military escalation In order to find the severity of the traumatic experiences, total traumatic events were recorded in to mild trauma (0-5 events), moderate trauma (6-10 events) and severe trauma (above 11 events). The results showed that 6.6% reported mild, 67.7% reported moderate, and 25.7% reported severe traumatic events. Figure 2 Level of traumatic events due to 8 days of military escalation (N = 502)
Differences in traumatic events according to socio demographic variables In order to find differences in types and severity of traumatic event and other socio demographic variables such as sex, age, place of residence, education, family monthly income a T independent test was conducted.
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Traumatic events and sex The results showed than mean traumatic event were 7.51 (SD =2.28). Mean traumatic experience by males was 9.38 (SD = 2.70) and for females mean was 8.38 (SD = 2.59). There were statistically significant differences toward males (F= 4.26, p =0.001). In order to find the differences in sex according to level trauma, which was recoded into less than 5 traumatic events (mild), 6-10 (moderate), and above 11 severe, chi square test was performed, males were statistically significantly experienced severe traumatic events than females (15.1 vs. 10.6) (2 = 29.86, df = 2, p < 0.001). Figure 3 Percentage of traumatic events and sex (N = 502) 40 33.3
34.5
35 30 25
Male Female
20 15.1 15 10.6 10
6
5 0.6 0 Severe trauma
Moderate trauma
Mild trauma
Differences in traumatic events according to other socio demographic variables (age, place of residence, monthly income, etc.. ) According to the age, the age of the participants was recoded into three categories (less than 40 years, 41-50 years, and above 51 years). One-way ANOVA was conducted in which total traumatic events were entered as dependent variable and other socio demographic variables as independent variables. There were no statistically significant differences in traumatic event according to age (F= 0.30, p = Ns). Mean traumatic events for participant's place of residence (city, village, and camp) was (9.36, 7.69, and 8.63 respectively). There were statistically significant differences in exposure to traumatic
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events toward participants living in city than in village and camp (F=11.99, p=0.01). There were no statistically significant differences in traumatic events according to monthly income families with below $300than the other three groups (F=0.77, p=Ns) and fathers education (F=1.46, p=Ns). There were statistically significant differences in traumatic events according toward mothers less than elementary education (F=1.92, p=0.01). No statistically significant differences in exposure to traumatic events according to fathers type of work (F=0.751, p=Ns). Mean traumatic events for mothers with jobs (housewife, simple worker, civil employee and working, civil employee and getting salary and not at work, and others) was (8.87, 12.40, 8.46, 7.60 respectively). There were statistically significant differences in traumatic event toward simple workers mothers than other three groups (F=3.36, p=0.05).
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Focus groups results Trauma due to eight days of military escalation had affected all the Palestinian society including children and parents. During the eight days of military escalation on November 2012, Palestinian parents reported their experiences during this war and in the previous war in 2008. They also talked about their reaction and the reaction of their children to such traumatic experiences. N. male from Gaza said “This war (Nov 2012) was very hard, worse than the military escalation on 2008. We were expecting bad things to happen. We had feared for our homes and children, and indeed ourselves. We expected that the war would continue to the end of our life and no hope to finish. My thoughts were overwhelming and disturbing as we had bad experiences from the previous war. I do not want to see anything bad happening to my children" R. male from Gaza said “I have no feelings of citizenship inside Gaza. I see the suffering of my cousin and cannot do anything for him. I was not afraid during the eight days of military escalation war and I was sitting in the door of the mosque most of the time. The only thing that changed was that I could not work because I used to work as taxi driver." G. male from Gaza said "During the war, we waited to be killed any second, like the Al Dalou family, who had been exposed to bombardment and 13 people were killed. There was an open field next to our home and we were constantly afraid that this area would be bombed." Om Mohammed female from Gaza city said “During the war, there was no place in Gaza to hide. There was no safe place in Gaza during the war. My older son was dreaming of rockets and wants to be Martyr. He was drawing rockets, airplanes. It was a horrible time when they bombarded the Prime minister office building near our home in Gaza. My husband left our home and my children were awakened from their sleep horrified.
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I asked them about the whereabouts of their father and they told me that he was at the mosque. I was so scared and hugged my children as they continued saying please stay with us and don't leave us. Later on I left the house to see what had happened. I found the street full of smoke and stones from the collapsed building were all over the area and the four story building was levelled to the ground. I was worried about my children and husband, but I accepted the will of God and left everything for God to decide." N. female from Gaza said "During the war we felt a strong fear, that no place were safe and no hope for the war to finish." F. female from Gaza said “After the war in 2008, we did not expect any new war. In the third day of the November 2012 war there was heavy shelling and bombardment of the area. We had escaped to a safe room in the house. We did not expect this to happen, our house was near the mosque and we waited for the F16 airplane bombardment of the area to finish. . As we exited our house you could still smell of the dust because they bombarded my cousin’s land nearby. During the bombardment I was saying to myself at least me and my family are still alive." S. female from Beit Lahia said “During the war we just ate, I had pain in my whole body, I was fearful; my son said that he had seen someone near his head at night (not seen by us). During the war, I told my children not to be scared, the children were telling me that they were going to die, whilst my oldest son used to play cards with his brothers.” E. male from Beit Lahia said “The war had such a strong effect on us, my son was killed, and there was destruction of streets and houses. The word of war is a very big word. I witnessed the bombardment of my neighbour’s house, and I witnessed the removal of bodies from under the rubbles, I lost another son during the previous war. I prefer to die and not seeing the remnants of my children. When I see bodies and remnants of other children on the television, I feel very bad and think about my children as if those children in Television were my own children. My wife had a pain in her legs and cannot walk after learning about the killing of our son. Our children want to sleep with us due to their insecurities and fears.”
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Abu Moh. male from Jabalia camp said “The war started on a Wednesday and we were not prepared. No one expected the war, we had no resources or groceries at home, and our wives started looking for food and other things. All of us gathered under the houses, we were worried what would happen to our children, there was an atmosphere of terror and fears of bombardment of houses. My children started wetting their beds, thank God that the war ended, what do you expect from children in a war torn area, they were scared, feverish, and afraid of the terror.” Abu Muhammad male from Jaballia said ”Jabalia refugee camp differs from Beit Hanoun, after sundown during the war, no one would exit the house, except if there was an emergency , we kept our children at home, the sound of tanks was ever present.” Um Yasser female from Khan Younis said “We had cooked lentils, there were nothing else at home to eatbecause we were not prepared, thank God the war is over. My children were more scared this time around than the previous time. The children started wetting their beds. They refused to go to the bathroom alone during the night. They asked me to come with them. The children wanted to sleep with us in our room and couldn’t sleep in their rooms because they were scared During the war my daughter was leaving for her uncles house. When she returned, she was afraid, anxious and refused to go to the toilet. However, when she is with her brothers and cousins, she plays and forgets the war. I think she feels safer when with other children. Having other people around us helped us during and after the war to overcome the anxiety and fears. Thesame goes for the children, when they were with other children their fears were less than if they were on their own. During the war we kept our children inside worried that they would be exposed to bombardment in the streets. All the while the drones were above our heads and we were afraid that we would be bombarded. We became more worried and scared and by that the children were also very scared.” S. female from Khan Younis said “The war made everyone feel terrified. I felt very fearful when we heard the sound of the bombing repeatedly. On the other hand you feel upset when you watch TV and see injured people and martyrs, and physicians in the hospital that were not
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able to provide treatment for them. I felt an intense fear when someone from my family went out of the house. I was always thinking that that if they left the house, they would not come back again. During the war, we were in the same situation. When there was a shortage of cooking gas, we cooked with fire woods for three months." S. female from Khan Younis said "During the eight days war we were stuck in our house, sometimes we would eat only bread, sometimes I went outside to bring lentils and other things to make lunch.” OM Hind female from Khan Younis said “What can we do. We continued living day by day. When we had money we would buy a sack of potatoes, tomatoes, and beans, we stored them for days so that during war or in time of distress and lack of food, my children were okay and not going hungry. Thank God. There was not even a change in my children’s school achievements." S. female from Khan Younis said “During the war, we experienced a shortage of food, even with the wheat, no bread and everything was expensive. We could not go outside to buy what we needed. So we used to eat anything. Just to survive, sometimes we only ate bread and zaater with olive oil. My little sister started to wet her bed and till now she still has this problem. She told me all the time after the war that the war is coming back and that the Jews' planes will bombard the area again. I can see the fear in her eyes and mind. My little sister and brother developed uncontrollable urination during the war and even now they still suffer from this problem. They talk about Jews returning with planes, that the war will return again and the fear in their hearts and minds is still present."
S. female from Khan Younis said "I've got a brother studying in school, during the period of the war he was drawing pilots and tank and when I asked him what the drawings were, he said 'I killed the Jews'. But after the war he painted ambulances, planes. In addition, when
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anyone tells him go to school he says I want to be martyr, when he sees the Television, he says Jews are traitors and asks us to turn off the television. He is 12 years old. After the war he became very aggressive, when he speaks with any one he hits them. He made a wooden gun and would hold other boys, telling them I want to kill you, you are a Jew. Children are playing violent games such as the game of Jews and Arabs. At the end of the game the Arabs win the game". H. female from Maghazi said “I take pain killers all the time, my parents recently had proven diabetes mellitus from the difficult circumstances in which we are living. My sister, a fourth grader, became violent and very fearful when she heard the sound of airplanes; my cousin is taking pills for her anxiety and fears. No one at home is employed. I get a psychological headache when I am angry. My husband suffers from headaches and anxiety and is taking pills as well.” R. female from Maghazi said “My cousins attend university, no work, they cannot continue due to shortage of money. When they are not attending university, they are making troubles at home. My husband is sleeping all the time and is anxious at night.” J. male from Maghazi said “In response to the war, our children started having nightmares, and they awake screaming at night. There was so much fear during the war, but at least we had faith in God and it gives us strength.” S. female from Maghazi said “I was scaredand also feared the safety of my family, because they witnessed bombardment of homes, they were always afraid and we were counting the days for it to pass. My relative had a sense of humour; during the war, he brought balloons for children and played with them, changing the atmosphere of fear and terror.” H. female for Maghazi said "It was not eight days. It was eight years of fears and anxiety, no sleep and we were very afraid. We expected death each day. The sound of the drones was so loud; we were afraid to be bombarded when we used the car.” R. female from Maghazi said
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“I had a tremble in my body and was afraid, but I showed my children that I am strong. In the first war, I was so scared, but in this second war, I was afraidto be outside our house because our home was exposed to the Jews' army. My son was telling me not to be afraid and yet he became afraid himself.” F. female from Maghazi said “During the war, my mother-in-law came down in the evening because my daughters and I were scared.” R. female from Maghazi said “I worried about my brothers in particular, during the war I was asking about my brothers and my mother was telling us all to stay in one place. So if we die, we die together and if we cannot sleep at night, we sleep during daytime.” H. from Maghazi said “Honestly, I've always watched TV, we used to play with six games, and the children were using colours for drawing. The children were afraid and would not let us leave the house.” R. from Maghazi said “During the war the family was gathering in one room, we were eating and drinking, and preparing the children for next bombardment and asking them clap loudly and laugh.” I. from Maghazi said “I told my children to go and play a game or draw a painting.” Um Mohammed from Gaza "They would play football. They would go on the internet and this is expensive for us, sometimes they would steal and they do not like anything now. They only want to play new video games, not the old games." G. from Gaza said "I used to buy trousers and shirts for the boys and now I cannot, the girls did not stop asking for new clothes - they do not understand our situation.” E. female from Gaza city said "We are still fearful after the war"
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N. female from Gaza city said "We are sure that a war will happen again, that our country is in danger and we are expecting a bombardment
any moment. The children are
fearful and
terrified." E. female from Gaza city said “My son saw an airplane and he asked why the airplane was in the sky. Our thinking is constantly dull, feeling insecure and afraid" T. male from Gaza city said "The first war in 2008 had a strong effect on us because I was injured. My daughter become mad and terrified from any sound and after the war whenever there were thunder storms, she would panicky. I took her to the hospital without any improvement. During the bombardment my son did not wake up and was close to us." N. male from Gaza city said "My sons have become rebels and when I asked them to sleep, they refuse." I. female from Gaza city said “After the war, violence in our home increased and the boys were hitting each other. They imitate what they see on television. They feel
unsafe.”
Um Mohammed from Gaza said “The children have been wetting their beds, becoming more violent and they threw stones on each other. They tell me that they are very afraid and I tell them not be afraid. It is very difficult for children to digest when the mental state of the adults are not good. When there was a bombardment of the Palestine Football Stadium, we felt our home is moving from one place to another. My 16 year old son wet his bed.” N. female from Gaza city said “My son became a savage and very aggressive. Every week they called for me to come to the kindergarten because he was attacking others. He has been verbally abusing others and carries a pillow around and telling people that he will hit them."
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Om Mohammed female from Gaza city said “My daughter awakes telling me that the war is coming again. She has started wetting her bed again. Afraid of anything and trembeling. My other son Bader is very aggressive.” N. male from Rafah said” “For me in particular, I started having fear, confusion, anxiety attacks, nuisance and disturbance when I hear the sounds of air planes. All of this affects our psyche, worries about my children and family. The Israeli army bombarded the areas where I have relatives and friends, so we called them to check on them. I think war has a significant effect on children, more so than adults. We live in a house on the main street next to open land which in every war is bombed once or twice. Sometimes my kids think they will not survive, and young children start to scream and wet their pants. They have such strong fears,
anxiety and their
behaviour has changed drastically. We also had no electricity, which means our lives and the lives of our children become more difficult.” S. Female from Beit Lahia said “During the eight days of military escalation, I felt very fearful and my body was aching. I was feeling depressed, my cousins house was bombarded and my children's condition was getting worse. We stayed close to each other, and this decreased the sadness and fears. My son had nightmares and started bed wetting. My daughter, a fourth grader, sleeps with me all the time now. Before the war she used to sleep with her sisters.” Psychological symptoms measures by Brief Symptom Inventory-18 items
As shown in table 7. The most common psychological symptoms reported by participants were nervousness or shakiness inside (45.4%), feeling tense or keyed up (42.8%), feeling blue (39.4%), and feeling weak in parts of your body (39%). While the least common reported symptoms were Feeling of worthlessness (8%) and thoughts of ending life.
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Table 7 Psychological symptoms measures by Brief Symptom Inventory-18 items Never/
Sometimes
rarely
Most of the time/ Always
1. Faintness or dizziness
40.2
31.7
28.1
2. Feeling no interest in things
63.5
22.3
14.1
3. Nervousness or shakiness inside
30.7
23.9
45.4
4. Pains in your chest
58.2
20.1
21.7
5. Feeling lonely
62.0
18.3
19.7
6. Feeling tense or keyed up
28.3
28.9
42.8
7. Nausea or upset stomach
57.2
24.7
18.1
8. Feeling blue
28.7
31.9
39.4
9. Suddenly scared for no reason
55.2
21.7
23.1
10. Trouble getting your breath
60.0
22.3
17.7
11. Feeling of worthlessness
77.5
14.5
8.0
12. Spells of terror or panic
64.3
18.3
17.3
13. Numbness or tingling in parts of your body
42.2
27.7
30.1
14. Feeling hopeless about future
53.6
18.9
27.5
15. Feeling so restless you couldn’t sit still
41.4
24.7
33.9
16. Feeling weak in parts of your body
33.1
27.9
39.0
17. Thoughts of ending your life
86.1
5.8
8.2
18. Feeling fearful
46.0
28.5
25.5
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Differences in psychological symptoms according to socio-demographic variables In order to find differences in types and severity of psychological symptoms and other socio demographic variables such as sex, age, place of residence, education, family monthly income a T independent for less than 2 variables and One-way ANOVA tests for differences between more than two variables were conducted. The results showed that mean psychological symptoms reported by parents according to BSI-18 in males were 25.88 (SD =14.88) and 28.44 for females (SD = 15.64). There were no statistically significant differences in psychological symptoms according to gender (F= 1.40, p =0.06). Mean somatization symptoms in male were 8.67 and mean in females was 10.24. There were statistically significant differences in somatization symptoms in favour of females (F = 3.04, p = 0.002), mean depression symptoms in males was 7.51 and 6.87 in females There were no statistically significant differences in depression symptoms according to the sex (F= 1.40, p =0.1). Mean anxiety symptoms in male were 9.70 and 11.33 in females. There were significantly differences in anxiety toward females (F= 2.88, p = 0.004). The results showed that mothers were more anxious and had somatization symptoms than fathers.
Figure 4 Means and Standard Deviations of Symptom Checklist 18 sub scales According to sex (N = 502)
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One way ANOVA was conducted in which total psychological symptoms, depression, anxiety, somatization were entered as dependent variable and other socio demographic variables as independent variables. According to the age, the age of the participants was recoded into three categories (Less 40 years, 41-50 years, and above 51 years). Post hoc test showed no statistically significant differences in psychological symptoms and somatization, depression, and anxiety according to age. Post hoc test showed that there were statistically significant differences in total psychological symptoms toward participants living in village than in camp (F= 11.30, p = 0.01) and anxiety was more reported in participants from village than city and camp (F= 5.4, p = 0.01). Total psychological symptoms, somatization, depression, and anxiety were significantly more in families with monthly income below $300than the other three groups. Total score of psychological symptoms in favour of fathers who had less than elementary education than other groups. In addition, symptoms of anxiety were significantly more in fathers with less than elementary education. For job of fathers, total psychological, anxiety, depression, and somatization symptoms were more in unemployed fathers. For mother's education, the results showed were statistically significant differences in total score of total psychological somatization symptoms were significantly more in mothers with less than elementary education. Symptoms of depression were significantly more in house wives than the other groups.
The above-mentioned results were consistent with the themes that emerged from the analysis of the focus group discussions conducted in the five areas of the Gaza Strip: R. female from Maghazi said “There are many stressors, for example, an employed person who then lost his job may become violent at home and vent his anger on his family. We cannot stand our children and we as fathers become more impatient and nervous.” N. female from Beit Lahia said “Due to the blockade, there has been a high demand for construction materials and import and export in the Gaza Strip was stopped, and this has
led to
poverty and rising prices on basic commodities. This has led me to feel increasingly more stressed and under pressure.”
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S. female from Beit Lahia said: “The blockade is preventing us from cultivating our land which is in the buffer zone. This has significantly affected the bread winners at home, because you cannot provide for the needs and demands of the children. We have no longer an income to provide for our family, which has lead to malaise, headache from worrying about what to do, and this again has lead us to be more aggressive toward our children and even beating them. There are some people who are better than others, but life is difficult under a siege.” R. female from Maghazi said “I did not take responsibility. I remained sad all the time whilst my father was the only one focused on the family. My brother was ashamed of himself as he was unable to financially contribute to assist his father in supporting the family. My other brother works in construction and he was very unhappy, always demanding for our father to support him whilst he did nothing to support our family. My third brother is currently completing secondary school and would like to join the university. We all worry about his future. I am worried about my father because he suffers from anxiety and hypertension due to our family demands.” H. female from Maghazi said “I believe that preschool children are not okay under these circumstances, they are hyperactive and showing signs of aggression toward the weaker kindergarten children, as well as more violent than before.” S. female from Maghazi said “I was worried about thefuture and what would happen to us. Our children were hitting each other. My son, who is currently in secondary school, says he loves me when I give him what he wants, however when I am unable to he wonders why I brought him to this world, being unable to take care of him. Frankly, I was seriously worried, not just for me, but for the whole family. I am worried about my cousin, as I always worry every time he leaves the house that something will happen to him. My sister told me that you love him more than me, and I am his mother.”
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E. female from Gaza said “I feel that thinking of life during the blockade is too much for us. It makes us frustrated." H. female from Rafah said "My sons went to work in the tunnels and it really stressed me . I told them I do not need to eat or drink as long as they do not go to the tunnels for work. Now I suffer from high blood pressure. My daughter would come and ask me for things, however if I did not give her what she wanted she would ask why I brought her to life. I have three daughters who are sitting at home doing nothing." S. from Khan Younis said “Everything bothers me and I would like to leave the Gaza Strip, I feel like I am trapped in a prison. The farthest I can go to is to Gaza city and the distance there is one hour. I feel upset when I see our neighbours who needs basics commodities such as food, clothing, and other things, that they are unable to attain. We are 12 members in our family and we cannot cover all our needs despite my father s working as a farmer. His income is not enough to provide for all of us. We buy fruits only once a year, thanks to UNRWA who has helped us a lot. When they (the Israelis) close the crossings, I feel that I am in a big prison.” Om Hend from Khan Younis said “The blockade has had a strong effect on us psychologically. I am a widow and I have three daughters and a son whom I am responsible for. I am unable to provide for and meet all their needs and being unable to meet their ever increasing demands has seriously affected my mental health. My children have been suffering in the absence of their father and when you add food shortage, and the blockade, these all seriously affects my children psychologically.” F. female from Maghazi said “My husband was working in Israel however now he has lost his job. Now we have a small chicken farm thanks to a small generation projects. I feel that those chickens are like my children, because they are the source of income for the family. My husband escapes from the home responsibilities. I supply the family with what it needs.”
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Quality of life for adults The results showed that 12.5% of parents said that they evaluate their life much and very much, 60.2% said they evaluated their life in moderate level, and 27.3% said their evaluate their life as never or little, while 27.1% said they enjoy their life much and very much, 42.8% said they enjoy their life in moderate level, and 30.1% said they never/little enjoy their life. As shown in Table 8, the most common items of quality of life were: 43.3% said that they were much and very much satisfied with personal relationship with others, 40.2% were satisfied about their body image, 34.3% had much/very much satisfied with their self-esteem, 31.3% said they had much/very much negative feelings. However 72.5% said they had no financial resources, 77.9% cannot get recreation and leisure activities, 63.3% said they were not satisfied with their physical environment (pollution / noise / traffic / climate).
Table 8 Percentage of quality of life items of parents sample (N= 502) Scale points/domains and facets
Much/very much
Never/little
Moderate
1. Pain and discomfort
45.8
33.7
20.5
2. Dependence on medicinal substances and medical aids
57.2
22.5
20.3
3. Energy and fatigue
34.7
43.4
21.9
4. Mobility
61.8
29.7
8.6
5. Sleep and rest
50.2
36.3
13.5
6. Activities of daily life
32.5
44.8
22.7
7. Working capacity
31.1
46.2
22.7
8. Positive feelings
45
43
12
9.Thinking, learning, memory and concentration
32.5
43
24.5
10. Body image
19.7
40
40.2
11. Self-esteem
18.9
46.8
34.3
12. Negative feelings
32.3
36.5
31.3
13. Spirituality, religion and personal beliefs
24.7
44.8
30.5
14. Sexual activity
18.7
59
22.3
58
15. Personal relationships
13.5
43
Never/little
Moderate
16. Social support
42.6
37.5
19.9
17. Financial resources
72.5
24.3
3.2
18. Opportunities for acquiring new information and skills
39.2
43
17.7
19. Recreation and leisure
77.9
17.1
5
20. Physical environnement (pollution / noise / trafic / climat)
63.3
31.3
5.4
21. Health and social care: accessibility and quality
49.2
39.4
11.4
22. Transport
54.8
36.1
9.2
23. Home environment
48.8
33.3
17.9
Scale points/domains and facets
43.4 Much/very much
Quality of life and socio-demographic variable Sex differences in quality of life To investigate the sex differences in quality of life, T independent test was done in which sex was the dependent variable, while quality of life and sub scales were the independent variables. The results showed that total scores of Quality of life in males were 65.10 and 68.63 in females. There was significant differences in favour of females in total scores of quality of life (F=3.18, p=0.01). In addition, mean physical health activities of daily life in males were 17.83 and 18.74 in females. There was significant difference in favour of females in physical health activities (F = 3.19, p = 0.01). Psychological bodily image and appearance in males mean was 14.51 and mean in females was 15.28. There was significant difference in favour of females psychological bodily image and appearance (F = 2.15, p = 0.05). Social and personal relationships in males were 8.71 and mean in females was 9.36. There was significant difference in favour of females social and personal relationships (F = 3.4, p = 0.01). Environment and financial resources mean in males was 18.33 and 19.39 females. There was significant difference in favour of females environment and financial resources (F = 3.1 p = 0.01).
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Figure 5 Means and Standard Deviations of Quality of life and sub scales and sex (N = 502)
80
Male
Female
70
68.63
60
65.1
50
40 30 20
10
17.83 18.74
18.33
14.59 15.28
8.71
19.39
9.36
0 Physical health Psychological Social activities of bodily image relationships daily living and appearance personal relationships
Environment Total quality of financial life resources
One way ANOVA was conducted in which total quality of life and sub scales were entered as dependent variable and other socio-demographic variables as independent variables. According to the age, there were no statistically significant differences in total scores of quality of life according to age group. However, there was significant differences in favour of people 40 years and less in social and personal relationships domain (F = 5.24 , p = 0.01) According to the place of residence, Post hoc test showed that there were no statistically significant differences in social and personal relationships and type of residence (city, village, and camp). But, there was significant differences in total quality of life (F=8.21, p=0.01) and environmental and financial resource in favour of people living in city and camp than those live in village (F=19.21, p=0.01) According to the family monthly income, Post hoc test showed that there were statistically significant differences in total scores of quality of life in favour of families with income more than $301 till $750, $751 till $1000 than families with income of $300 (F=
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29.28, p=0.01). Also, there were significant differences in physical health activities of daily life (F=10.52, p=0.01), psychological bodily image and appearance (F= 13.95, p = 0.01) social and personal relationships (F=12.58, p=0.01) and environment and financial resources (F=34.56, p=0.01) in favour of families with income more than $301. This result showed that families with below $300 income per month had less total quality of life and all domains of quality of life. According to the father education, Post hoc test showed that there were
statistically
significant differences in total scores of quality of life in favour of fathers who had university and more education than elementary education than other groups (F= 16.29, p = 0.01). Also, there were significant differences in physical health activities of daily life (F= 8.48, p = 0.01), psychological bodily image and appearance (F= 11.73, p = 0.01), social and personal relationships (F=7.66, p=0.01), and environment and financial resources (F= 13.50, p = 0.01) in favour of fathers who had university and more This result showed that fathers with more education had better quality of life and all domains of quality of life. According to the father job, Post hoc test showed that there were statistically significant differences in total scores of quality of life in favour of fathers who is working and getting salary than the other groups (F=13.49, p=0.01). In addition, there were significant differences in physical health activities of daily life (F=8.95, p=0.01), psychological bodily image and appearance (F=5.76, p=0.01), social and personal relationships (F=4.40, p=0.01), and environment and financial resources (F=14.38, p=0.01) in favour of fathers who is working and getting salary. In addition, fathers had better quality of life and all domains of quality of life. According to the mother education, Post hoc test showed that there were statistically significant differences in total scores of quality of life in favour of mothers who had university and more education than elementary education than other groups (F= 7.50, p = 0.01). In addition, there were significant differences in physical health activities of daily life (F= 5.32, p = 0.01) psychological bodily image and appearance (F= 4.04, p = 0.01), social and personal relationships (F= 3.35, p = 0.01) and environment and financial resources (F= 8.36, p = 0.01) in favour of fathers who had university and more This result showed that mothers with more than elementary education had better quality of life and all domains of quality of life. According to the mother job, Post hoc test showed that there were no statistically significant differences in total scores of quality of life, physical health activities of daily
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life, psychological bodily image and appearance, social and personal relationships according to mother's job. However, there was statistically significant differences in environment and financial resources in favour of working mothers and getting salary (F= 5.80, p = 0.01).
Analysis of themes came from focus groups showed that the blockade had direct effect of increasing physical problems and delayed the improvement of patients due shortage of medicine and lack of care. N. female from Gaza said "I experienced a general tiredness, stitching pain in my heart as though I could not breath. I would try to laugh to get rid of the pain." N. male from Gaza said "I felt a general weakness and got easily tired. My wife suffered of headaches so I consulted a physician. He completed a CT scan on her but found nothing physically wrong.” N. male from Rafah said "We can say that the physical impact of the blockade is to a higher degree affecting adults and less so children. It gives us anxiety attacks and suppress our ambitions, which leads to deeper psychological problems. I was supposed to go to conferences outside the country, but I could not go because of the closure of the crossings. When I was younger I was even unable to get married due to my economic situation." A. female from Rafah said "the blockade has implications on the freedom of movement and freedom of expression as well as an impact on the economic aspects. I have symptoms such as anxiety, because I'm not able to meet the needs of my family, and suffer from stomach aches due to the tension and anxiety". R. female for Maghazi said “Due to excessive thinking of the blockade and impact on us, I' suffer from headaches and have become tense and anxious. I went to the hospital and they
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examined me, but they could not find anything. They said I had to do blood tests, and even those results were okay." R. male from Gaza said "If the blockade is lifted, I want to get a complete health examination including blood tests because I feel sick.” Abu Mohammed male from Rafah said “In the past, high blood pressure was particularly for adults and elderly, now it's a concern for all ages. My wife is 24 years old and she suffers from high blood pressure.” R.K. Male from Beit Lahia said “Thinking of the blockade cause diseases, I myself had to have surgery, and one of my sons tried to commit suicide because of the dire living conditions. The failure to provide for our own needs and the needs of our children (such as napkins and milk) due to unemployment makes you sick. One of our relatives had a stroke due to the stress and pressure of daily life due to the inability to provide for the needs of his children.” H. female from Rafah said “When I think of my circumstances, I get stressed and my blood pressure goes up. I have two children attending university and every day they need money to go to there. I am unemployed and the stress of this has given me high blood pressure due to my concerns about our living costs.” Um Ali female from Rafah said “My husband and I suffer from difficult living conditions, we are both unemployed. We do not have anyone to help us, but sometimes my husband get casual work in an unemployment program, and other times we get a food coupon from UNRWA. I'm tired of this difficult situation and it makes us very stressed. We are unable to provide money to go to the doctor and my husband does not have the opportunity to be treated in the private sector. Myself, I am suffering from pain in my hands and legs and this hinders my performance at home and my family commitments.”
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O. female from Rafah said “Sometime I get chills all over my body, it feels as though my bones turn to ice. I get very nervous when there are difficult circumstances, my white blood cells burns quickly and my immune system fails”
Themes such as social relations and movement is a part of quality of life, especially in Palestinian traditions, which both were affected by the siege. The consequences of the siege such as unemployment and restriction on movement has surfaced in the focus groups. N. male from Gaza said ”I stay at home most of the time and only really go out at night. I feel that I have no life and only live to make money. We never visit our close relatives. Living has become very expensive and we cannot visit others because we cannot afford to buy gifts and sweats. We prefer to stay at home on our own. We only use text messages to communicate with friends." G. male from Gaza said “With regards to visiting other families, we do no longer have the money to go for visits as before. Now we don’t even visit our closest relatives." R. male from Gaza said “Long time ago we used to take flour dishes and sweats during parties, but if we were to do that now people would laugh at our behaviour." I. female from Gaza said "We like to participate in social activities and go visit others, but because we have no money, many events are cancelled. Only the very formal visits are done." N. female from Gaza said "I need money to go visit my cousins and my relatives, thus I cannot go as we have no money to buy gifts and sweats and we prefer that others do not visit us as we fear we would have to revisit and buy things for them." N. female from Gaza said
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“I feel that social relationships exist less than before. We have changed so much, I feel much more stressed and not relaxed like before." F. female from Gaza said “The social relationships are deteriorating as the blockade causes unemployment and poverty, people keep more to themselves." J. male from Maghazi camp said “ “The blockade strongly affects relationships and social bonds prior to the closure I was active and was visiting my friends. Now we are lazy, I am spending most my the time at home. Drugs are also becoming a wide spread problem in Gaza.” E. Male from Beit Lahia said “I am a human being. They stopped my salary for three months, my neighbour fell ill and stayed in hospital but I could not go to visit him. We have a tribal society, my son had to go to the hospital but there were no possibilities of going to a private practice for a specialist. If he had gone to a specialist he would have been better, but we could not afford the medicine.” E. Male from Beit Lahia said: “the blockade seriously affects all aspects of our life, both professionally and privately, with the reduced social relationships among family and friends. There is no space to build relationships between neighbours and friends. With three siblings who all want to attend university, and I cannot provide university fees for my siblings. I am considering not sending them to the university, which just leads to more frustration and pain.” S. from Khan Younis said “The Blockade has absolutely had bad effect on my relationships with my relatives and neighbours. For example: when we had a social occasion at my house, all relatives come to bless us, and when another occasion occurred at the house of a relative and my mom was going to visit them. She wished they had not come to visit us previously as she could not afford to show them the same generosity. The poverty has led our social relations between us and our relatives to deteriorate and it further does not allow formation of new relationships.”
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Om Hind from Khan Younis said “The blockade has a strong effect on our lives; I cannot afford to visit my relatives. Even before my husband past away he would not visit his relatives much. Before the blockade, when I did have some money, I would buy gifts and visit our relatives. But now during the blockade things have become expensive and the situation does not allow me to spend money on presents, as I am responsible for my children, no one works and there is no one to help me with the household expenses.” Om Yasser from Khan Younis said “Before the blockade I used to visit all of my relatives, friends and neighbours for all sorts of occasions. However now I cannot go to anyone, not even to the people close to me, because I cannot afford to buy them a gift and it is because of lack of money.” F. female from Gaza city said “I stopped going outside my house. I am not even visiting close friends and relatives. I am ashamed and my home is not felt sweet like before." N. male from Rafah said" "If we are to talk about the blockade since 2007, there are signs of economic problems such as lack of basic commodities that people need every day, as well as the problem of electricity shortage. Also, the blockade is preventing social networking among people as they do not have the money to buy gifts for visits." A. female from Rafah said "the blockade has implications on the freedom of movement and freedom of expression as well as on the economic aspects. For example, the economic situation has lead to lack of resources and unemployment is high. This has affected social relations, there are no longer visits and we have social diseases and physical problem such as jealousy. My personal, social relations have become strained due to my economic situation. I have symptoms such as anxiety, because I'm not able to meet the needs of my family. I suffer from stomach aches, which causes tension and anxiety."
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T. male from Gaza city said “I tried everything to solve our financial and social problems but nothing is working. We had an electricity problem and we solved it by buying a USB stick to use the computer. The children know when the electricity is off and they leave home to hang out in the streets." N. male from Gaza city said “We have stopped spending money on luxurious things, when the refrigerator was broken we ate only canned food. We try to live. We are suffering from the electricity shortage. Using the generator is another problem. If there is no electricity and the generator is not on we will feel better, because the sounds of the generator and the smell of benzene are terrible. We are sending our boys either to start or shut down the generator all the time. Our daughter asks me where we will get energy from next." R. male from Gaza city said "Our expenses are less now and instead of spending NIS600 we only spend NIS150.” I. female from Rafah said “It happens that I've got a headache and I suffer from high blood pressure. When I’m worried about my children I get a headache. When I was given medicine for high blood pressure I felt better. I also have stomach pains; I sleep with busy mind and wake up in the same situation.” F. female from Maghazi said “I feel nervous. We cope with stress by keeping our faith in God, we ventilate our anger and anxiety on our kids. I was experiencing many stressors, but this does not mean that I am a failure. Our psychological health is not good because when our children asking for money, we could not give them what they want, we cannot fulfil our children’s daily demands due to unemployment and shortage of money. My son is a university graduate and could not find any job. He is married and his father is supporting him and covering his expenses. My daughter is going to graduate soon and I do not think that she will find a job. All of this affects our psyche. I have another son but we could not afford his education. He works for
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one day and stops for three days. We are 13 people in the house and I do not know how we are supposed to manage this situation.” R. female from Maghazi said “We had no problems at our home. I had an uncle with five sons and two daughters. He had a son aged 23 years. They were working as merchants; because of the blockade they lost their work and business. They asked other members of the family to help them, but the general situation due to the blockade is very bad and the family could only offer limited help. They said our grandfather did not help us.” N. male from Rafah said "The blockade is preventing social networking among people due to shortage of money to buy gifts for visits. My aunt lived in Israel within the Green Line.In the past she would visit us every year, however for the past five years we did not see her and I do not expect to see her in the near future. My daughter was travelling to Algeria and then she immigrated to Spain, and now we only have contact with her via internet. She is telling us that she will not come back during the blockade due to shortage of electricity and that life is miserable in Gaza." P. female from Rafah said "For me the blockade has particularly affected me because I have not seen my family for 7 years. I have the kids who have never met their grandparents. The kids have grown up only communicating with them through internet. Though even that is difficult sometimes due to electricity cuts. When my children watch TV, they ask for what they see on TV, but I cannot buy all of those things.” H. female from Maghazi said “During this blockade there have been many social events and obligations for family and friends, but with no income we delay or cancel visits to others because we cannot buy gifts for visits.”
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Resilience factors in adults Despite their many challenges, Palestinians in Gaza are still showing resilience, although it is diminishing. As shown it table, used religious factor in facing the stress and trauma, 98% said God can help 85.1% said they are proud in their achievements, and 71.55% said they had strong sense of purpose. However only 21.1% belief that things happen for a reason and 24.3% said it made unpopular or difficult decisions. Table 9 Percentage of Resilience items of parents sample (N = 502) No/rarely Sometimes
Most of the time/always
1. Able to adapt to change
21.7
33.5
44.8
2. Close and secure relationships
15.1
18.9
65.9
3. God can help
0.6
1.4
98
4. Can deal with whatever comes
9.6
29.1
61.4
5. Past success gives confidence for new challenge
13.3
31.9
54.8
6. See the humorous side of things
33.1
37.6
29.3
7. Coping with stress strengthens
30.5
30.5
39
8. Tend to bounce back after illness or hardship
36.7
25.5
37.8
9. Things happen for a reason
40.2
38.6
21.1
10. Best effort no matter what
20.9
25.9
53.2
11. You can achieve your goals
28.3
36.3
35.5
12. When things look hopeless, I don’t give up
24.7
27.3
48
13. Know where to turn for help
18.9
26.9
54.2
14. Under pressure, focus and think clearly
50.8
22.9
26.3
15. Prefer to take the lead in problem solving
26.7
22.9
50.4
16. Not easily discouraged by failure
33.9
22.5
43.6
17.Think of self as strong person
18.5
20.7
60.8
18. Make unpopular or difficult decisions
46
29.7
24.3
19. Can handle unpleasant feelings
38
28.5
33.5
20. Have to act on a hunch
27.3
27.3
45.4
21. Strong sense of purpose
13.9
14.5
71.5
22. In control of your life
13.1 29.1
17.3 22.5
69.5 48.4
24. You work to attain your goals
10
21.5
68.5
25. Pride of your achievements
4.4
10.6
85.1
23. I like challenges
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Resilience factors and Socio-demographic variables To investigate the sex differences in resilience, T independent test was done in which total scores of resilience, sub scales were entered as independent variables, and sex was entered as dependent variable. The results showed that total scores of resilience in males were 61.20 and 60.5 in females. There was no significant differences in total resilience factor (F = 0.49, p = 0.62). Males significantly showed more personal competence, high standards, tenacity than females (F = 2.18, p = 0.03), females showed significantly more religious factor that male (F = - 4.75, p = 0.01). No significant differences in trust in one’s instincts, tolerance of negative affect, strengthening effects of stress, positive acceptance of change, secure relationships, and control according to sex.
Table 10 Means and standard deviations of resilience factors and sub scales and sex (N = 502)
Resilience factor Total resilience Personal competence, high standards, tenacity Trust in one’s instincts, tolerance of negative affect, strengthening effects of stress Positive acceptance of change, secure relationships Control Spiritual (religious) influences
Sex Male Female Male Female Male Female
Mean 61.20 60.51 21.03 19.88 14.00 13.36
SD 15.91 15.47 6.00 5.82 5.72 5.21
Male Female Male Female Male Female
12.25 12.96 8.58 8.44 5.35 5.86
4.29 4.11 2.88 2.84 1.28 1.16
t .49
p .62
2.18
.03
1.30
.19
-1.91
.06
.53
.60
-4.75
.001
One way ANOVA was conducted in which total resilience and sub scales were entered as dependent variable and other socio-demographic variables as independent variables. According to the age, there were no statistically significant differences in total scores of resilience and sub scales according to age group. According to the place of residence, there were significant differences in total scores of resilience, personal competence, high standards, tenacity in favour of live in camp than the city and village (F =12.51, p = 0.01). Also control was significantly more in people live in village than city or camp (F =7.09, p = 0.01). While spiritual (religious) influences was significantly used by people living in the
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city more than those do live in camp (F =4.05, p = 0.01). According to the family monthly income, Post hoc test showed that there were statistically significant differences in total scores of resilience in favour of families with income more than $301 till $750 than families with monthly income below $300 (F =7.34, p = 0.01). Control scores were statistically significant in favour of families with income more than $301 till $750 than families with monthly income below $300 (F =4.66, p = 0.01). Personal competence, high standards, tenacity was statistically significant in favour of families with income more than $301 till $750 and $751 till $1000 than families with monthly income below $300(F =10.30, p = 0.01). . The results showed there were statistically significant differences in total resilience scores (F =5.11, p = 0.01) personal competence, high standards, tenacity (F =8.26, p = 0.01), and positive acceptance of change, secure relationships (F =2.96, p = 0.01) in favour of fathers who had more than university education than secondary and elementary education. No differences in education level of fathers and Trust in one’s instincts, tolerance of negative affect, strengthening effects of stress (F =2.52, p = ns). The results showed that total resilience (F =5.55, p = 0.01), personal competence, high standards, tenacity (F =4.79, p = 0.01),
and trust in one’s
instincts, tolerance of
negative affect, strengthening effects of stress (F =4.15, p = 0.01) were significantly in favour of fathers not working and getting salary than working and getting salary and simple worker. No differences in father's job and control (F =2.73, p = ns), and spiritual (religious) influences (F =0.80, p = ns). The results showed there were statistically positive significant differences in resilience factors (F =4.12, p = 0.01) and positive acceptance of change, secure relationships (F =7.25, p = 0.01) in favour of mothers who had university and more education than secondary and elementary education. No statistically significant differences in education level and other resilience sub scales such as control, positive acceptance of change, secure relationships, trust in one's instincts, and religious influences. The results showed there were no statistically significant differences in total resilience factor and Personal competence, high standards, tenacity; trust in one’s
instincts, tolerance of negative
affect, strengthening effects of stress; positive acceptance of change, secure relationships; control; and spiritual (religious) influences and mother's type of job. Relationship between stress due to the blockade and psychological symptoms and sub scales, quality of life, and resilience
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Pearson correlation test showed that there were statistically significant positive relationship
between stress due to the blockade and psychological symptoms (r
=0.44, p < 0.01) depression (r =24, p
