Parámetros biofísicos de la cubierta vegetal 46

The participants in Study II were school-aged children from North Gaza and Gaza City in the Gaza Strip in Palestine. Our study was carried out in the aftermath of the 2008–2009 Gaza War, known by the different parties as Operation Cast Lead ( ע ָצ ְב ִמ

ה ָקוּצְי ת ֶר ֶפוֹע), the Battle of Al-Furqan (نﺎﻗﺮﻔﻟا ﺔﻛﺮﻌﻣ), or the Gaza Massacre. The war

resulted in around 1,400 deaths, of which nine were Israeli soldiers and four Israeli civilians, the remainder being Gazans, including 240 police officers and hundreds of civilians (United Nations Human Rights Council [UNHRC], 2009). Of those killed, 431 were Palestinian children under the age of 18. At least 5,400 Palestinians were injured, including over 1,800 children (WHO, 2009). Around 100,000 people were newly displaced in Gaza, with half of them housed in United Nations Relief and Works Agency shelters at the start of 2009. North Gaza and Gaza City were among the areas hardest hit by the war (Abu-Rmeileh et al., 2012).

The war featured probable war crimes by Israeli forces such as deliberate attacks including the use of white phosphorus against the Al-Quds and Al-Wafa hospitals as well as the United Nations Relief and Works Agency field office sheltering hundreds of civilians, and deliberate destruction of farmland and food production facilities (UNHRC, 2009). In total, fifteen hospitals were damaged and access to healthcare severely affected (WHO, 2009). At the same time, Palestinian armed

groups also committed probable war crimes prior to and during the conflict by indiscriminately launching rockets and mortars into Southern Israel and by using civilians and civilian areas to shield themselves (UNHRC, 2009).

Most children living in Gaza in 2009 had been exposed to traumatic events, whether in connection to the war of 2008–2009, before that, or both. Qouta and El Sarraj (2004) reported that over 60% of children and adolescents 10–19 years of age living in Gaza had witnessed the injury or death of a family member and more than 80% had witnessed shooting, fighting or explosions. According to a self-report scale, close to a third suffered from severe PTSS as a result. In an intervention study carried out in 2005–2006 by Peltonen, Qouta, El Sarraj, and Punamäki (2012), around half of school-aged children in randomly selected classes suffered from probable PTSD. In the sample Study II is based on, there was likewise high exposure to war trauma with over 60% of children having witnessed violent deaths, around a quarter having been injured or hurt themselves, and more than half having feared for their life (Palosaari, Punamäki, Qouta, & Diab, 2013). As a result, around half of participating children suffered from probable PTSD (Qouta et al., 2012).

As regards the adults in Gaza, already immediately preceding the war, in 2007– 2008, Canetti et al. (2010) found that slightly under a quarter of adults suffered from PTSD and slightly over a quarter from major depression. With so many of their parents suffering from serious disorders themselves even prior to the war, adequate parental support to cope with trauma-related problems was likely to be lacking for many of the children in our study in the aftermath of the war, too.

Apart from direct experiences of war, the difficult living conditions in the Gaza Strip, exacerbated by the Israeli blockade and international economic boycott since 2007, are an additional source of stress for adults and children alike. As an example, the United Nations Conference on Trade and Development (2015) noted that the three military operations against Gaza from 2007–2015 and the blockade “ravaged the already debilitated infrastructure of Gaza, shattered its productive base, left no time for meaningful reconstruction or economic recovery and impoverished the Palestinian population in Gaza” (p. 7). In a quality of life survey six months after the war, 49% of adult Gazans reported moderate or high levels of individual distress, while 88% suffered from moderate or high levels of human insecurity, 74% reported crucial needs related to livelihood and 42% to rebuilding their homes (Abu-Rmeileh et al., 2012). More than half had problems with basic needs such electricity, clean water and cooking gas. The on-going siege and the latest war were cited as primary sources of suffering by around 90% of respondents. Meanwhile in 2009, unemployment stood at around 40% (United Nations, 2017), and the war had also

exacerbated opioid abuse especially among teenage and young adult males (Progler, 2010).

The population of the Gaza Strip was around 1.5 million at the time of the study, of whom slightly more than half were under the age of 18 (Association of International Development Agencies [AIDA], 2009; WHO, 2009). With around 4,000–5,000 people / km2_{, Gaza was among the most densely populated areas on}

the planet, with high fertility rates and overcrowding becoming serious issues. Importantly for the children in our study, the war of 2008–2009 also devastated parts of Gaza’s education system with at least 280 schools or kindergartens damaged and 18 schools fully destroyed. This worsened the already existing overcrowding in schools and decline in academic achievements (AIDA, 2009).

The psychological effects of the enduring isolation and blockade of Gaza should not be under-estimated, either. Gazans were and are to a large extent prisoners in their own country, unable to go abroad except in specific circumstances after grappling with Israeli or Egyptian authorities. Most will never travel outside the 5– 10 km wide strip of land.

With such high levels of PTSS among children in Gaza, the need for mental health treatment and support was and remains obvious and acute. At the same time, economic hardship, an over-stretched and repeatedly devastated healthcare sector, and lack of trained therapists mean that provision of individual trauma-focused treatment to all those that would need it appears impossible. Thus, exploring the possibility of helping children in Gaza cope with their PTSS with group-based psychosocial interventions that could be easily implemented is an important area of research with immediate practical implications. As findings on the results of such interventions in Palestine have been mixed (Barron et al., 2013; 2016; Qouta et al., 2012), understanding how and why interventions succeed or fail to affect children’s PTSS is a particularly pressing concern.