Effect of a 12- year siege on the mental health among university students in the Gaza Strip

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This affected the general mental health and quality of life of the population significantly. In this study, we aimed at assessing the impact of siege on the mental health among university students in the Gaza Strip. Method The study is a cross sectional study in which we have collected the data from 600 participants from four universities. We have collected demographic data, the impact of siege using Gaza Siege Checklist, and mental health status using the symptoms checklist. Data was entered, cleared and analyzed using SPSS version 23 to assess the relationship between the impact of siege and mental health. Results A total of 600 university students participated (mean age 20.5 ± 1.7 years; 54.4% female). Overall, the impact of the siege was substantial, with a mean impact score of 51.2% ± 21.8. The most frequently reported stressors were disruption of study due to electricity shortages (82.9%), difficulty traveling abroad for education (82.1%), and inability to pay university fees because of low family income (71.2%). Male students reported significantly higher siege impact scores than females (58.3% vs. 45.1%, p < 0.05). High prevalences of mental health symptoms were observed, including dysthymic (54.9%), depressive (51.1%), mistrust (53.3%), and sociophobic symptoms (44.4%). Agoraphobic symptoms were significantly higher among females than males (42.1% vs. 37.8%, p < 0.05). Pearson correlation analysis demonstrated significant positive associations between siege impact and all mental health domains, including depressive (r = 0.363), dysthymic (r = 0.173), vegetative (r = 0.201), agoraphobic (r = 0.155), sociophobic (r = 0.239), and mistrust symptoms (r = 0.331), with all correlations reaching statistical significance (p < 0.05). Conclusion It is concluded that the siege has impacted the mental health situation of the participants badly, as it raised the risk to develop several mental health problems including; depression, dysthymia, vegetation, agoraphobia, sociophobia, and mistrust. Gaza Strip Siege Impact University Students Mental Health Psychological Distress Introduction The Gaza Strip is a narrow coastal territory located along the Mediterranean Sea, covering an area of approximately 360 km² and characterized by one of the highest population densities in the world, with most residents concentrated in urban areas and refugee camps [ 1 ]. According to the Palestinian Central Bureau of Statistics, the estimated population of Palestine in 2017 was 4,780,978, of whom 2,881,687 resided in the West Bank (5,655 km²) and 1,899,291 lived in the Gaza Strip (365 km²) [ 2 ]. The population structure in Gaza is notably young, with 44.1% aged under 14 years and 21.3% aged between 15 and 24 years, reflecting a demographic profile that places substantial pressure on educational, economic, and health systems [ 2 ]. The humanitarian situation in the Gaza Strip has progressively deteriorated since 2007, following the imposition of a comprehensive siege that has severely restricted the movement of people and goods [ 3 ]. The blockade has been accompanied by widespread political, economic, and social constraints, as well as ongoing human rights violations, which have collectively undermined living conditions and access to essential services. This situation was further exacerbated by successive military offensives in 2008–2009, 2012, and 2014, which resulted in extensive loss of life, widespread injuries, and large-scale destruction of infrastructure, placing an additional burden on an already fragile healthcare system [ 4 ]. The prolonged siege has significantly affected all aspects of daily life in Gaza, including access to basic necessities, employment opportunities, education, and healthcare. Severe restrictions on travel have further intensified feelings of isolation and confinement among the population. In addition, internal political division has disrupted traditional social support networks, thereby compounding psychosocial stressors. Collectively, these chronic stressors create conditions conducive to the development of mental health disorders, including depression, anxiety, post-traumatic stress disorder (PTSD), and substance use disorders [ 5 ]. As a consequence of sustained political instability, economic hardship, and repeated exposure to traumatic events, mental health disorders have become one of the most prevalent yet under-recognized public health challenges in the occupied Palestinian territory. It is estimated that approximately one-third of Palestinians are in need of psychosocial or mental health interventions [ 6 ]. Reports from United Nations agencies indicate that both individuals and institutions in Gaza continue to struggle with the long-term consequences of the 2014 military offensive, compounded by the ongoing blockade and unresolved internal political divisions [ 7 ]. These conditions place the population at heightened risk of continuous psychological trauma, characterized by chronic stress, despair, hopelessness, helplessness, and a persistent sense of insecurity. Consistent with this context, previous studies conducted in Gaza have documented high prevalence rates of mental health disorders, including PTSD, generalized anxiety disorder, depressive disorders, and substance use disorders [ 8 – 11 ]. Psychosocial distress has been particularly evident among children and adolescents. For example, a study of 358 adolescents aged 14–18 years in the Gaza Strip reported high levels of anxiety-related symptoms, with a mean total anxiety score of 41.18%, alongside elevated rates of obsessive–compulsive symptoms, social phobia, separation anxiety, and panic/agoraphobia [ 12 ]. These findings underscore the pervasive psychological impact of prolonged exposure to siege and conflict across different age groups. University students represent a particularly vulnerable subgroup within this context, as they face the combined pressures of academic demands, economic uncertainty, restricted future prospects, and ongoing exposure to siege-related stressors. Despite this vulnerability, research focusing specifically on the mental health of university students in Gaza remains limited. Therefore, the present study aimed to assess the impact of the prolonged siege on mental health among university students in the Gaza Strip and to examine the relationship between siege-related stressors and mental health outcomes. Methodology Study Design This study employed a cross-sectional analytical design using quantitative methods to examine the effect of the prolonged siege on mental health outcomes among university students in the Gaza Strip. The cross-sectional approach was selected to allow for the assessment of exposure to siege-related stressors and their association with mental health symptoms at a single point in time. Study Setting The study was conducted in the Gaza Strip, a densely populated area subjected to an ongoing siege since 2007, which has significantly affected socioeconomic conditions, access to services, and overall quality of life. Data were collected from four major universities representing different geographical areas of Gaza: Islamic University of Gaza Al-Azhar University Al-Quds Open University Al-Aqsa University These institutions collectively enroll a large and diverse student population, making them appropriate settings for examining the mental health impact of the prolonged siege. Study Population The target population consisted of undergraduate university students enrolled in the selected universities during the data collection period. University students were chosen due to their heightened vulnerability to psychological distress resulting from chronic political violence, economic instability, and uncertainty regarding future employment and academic opportunities. Sample and Sampling Technique A convenience sampling technique was used to recruit participants from the four universities. A total of 800 students who met the sampling criteria were approached and invited to participate in the study. Of these, 600 students completed the questionnaires adequately and were included in the final analysis, yielding a response rate of 75%. The final sample comprised 274 males (45.6%) and 326 females (54.4%), with a mean age of 20.54 years. Participants were recruited from various academic disciplines and educational levels to enhance sample heterogeneity. Eligibility Criteria Inclusion criteria: Enrolled as a university student in one of the selected institutions Aged 18 years or older Resident of the Gaza Strip during the period of the siege Willing to participate and able to provide informed consent Exclusion criteria: Incomplete or poorly filled questionnaires Students with self-reported severe cognitive or psychiatric conditions that could impair questionnaire completion Instruments Socio-demographic Questionnaire A structured socio-demographic questionnaire was used to collect data on participants’ background characteristics, including age, gender, marital status, area of residence, type of housing, residency status, monthly household income, family size, parental education and occupation, student employment status, university, college, and academic level. Gaza Siege Checklist (GSC) The Gaza Siege Checklist (GSC) is a 21-item instrument designed to assess daily life stressors related to the ongoing siege. The checklist covers multiple domains, including family life, health, education, social relationships, and economic conditions. The GSC was developed based on focus group discussions with 20 mental health professionals and has been previously used in Gaza (Thabet & Thabet, 2015) on a community-based sample of 400 adults selected through a random sampling technique. The scale demonstrated good internal consistency, with a Cronbach’s alpha of 0.802 in previous applications. Symptom Checklist-27 (SCL-27) Mental health symptoms were assessed using the Symptom Checklist-27 (SCL-27), a validated short multidimensional screening instrument for psychological distress. The scale measures six symptom domains: depressive symptoms, dysthymic symptoms, vegetative symptoms, agoraphobic symptoms, sociophobic symptoms, and symptoms of mistrust (Hardt et al., 2011). The SCL-27 has shown strong psychometric properties, with a Cronbach’s alpha of 0.895, indicating high internal consistency. Data Collection Procedures Data collection was carried out between October 2018 and April 2019. Prior to data collection, official permissions were obtained from the administrations of the participating universities. Ethical approval was granted from research committee at the Faculty of Medicine – Islamic University of Gaza. Participants were informed about the study objectives, procedures, voluntary nature of participation, and confidentiality of their responses. Written informed consent was obtained from all participants before questionnaire administration. Questionnaires were self-administered in a classroom or university setting under the supervision of trained research assistants. Statistical Analysis Data were coded, entered, and analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to describe socio-demographic characteristics, siege-related stressors, and mental health outcomes. Inferential statistical analyses were conducted to examine associations between exposure to siege-related stressors and mental health symptoms. Pearson’s correlation coefficient was used to assess the relationship between Gaza Siege Checklist scores and SCL-27 mental health symptom scores. Statistical significance was set at p < 0.05. Ethical Considerations Ethical approval for the study was obtained from the research committee at the Faculty of Medicine – Islamic University of Gaza. Participation was entirely voluntary, and participants had the right to withdraw at any time without penalty. Written informed consent was obtained from all participants. Data were collected anonymously, and confidentiality was strictly maintained throughout the study. All procedures were conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Results Demographics A total of 600 participants completed the questionnaires, comprising 274 (45.6%) men and 326 (54.4%) women, with a mean age of 20.54 ± 1.69 years (range 17–32). Most participants were single (90.2%), and the majority had completed the literary track in secondary education (70.9%). Participants were recruited from four universities in the Gaza Strip, with the highest representation from Al Azhar University (34.1%). Most students (93.5%) did not work during their studies. Participants predominantly lived in towns (69%), with family sizes typically exceeding eight members (49.8%), and 65.3% were refugees. Regarding parental education, 30.9% of fathers and 23.8% of mothers had completed university, while 12.6% of fathers and 1.7% of mothers had postgraduate education. Fathers’ occupations varied, with 24.5% unemployed, and most mothers (82.6%) were housewives. Family income was below 2000 NIS for 67.4% of participants. Table 1 presents demographic characteristics of study participants Table 1 Demographic Characteristics of Participants (n = 600) Characteristic Category n (%) Gender Male 274 (45.6) Female 326 (54.4) Age (years) Mean ± SD 20.54 ± 1.69 Marital Status Single 541 (90.2) Married 52 (8.6) Divorced 4 (0.7) Widow 3 (0.5) Secondary Education Track Literary 425 (70.9) Scientific 172 (28.7) University Al Azhar 205 (34.1) Al Aqsa 158 (26.4) Islamic University 143 (23.8) Al Quds 94 (15.6) University Level 1st 89 (14.9) 2nd 131 (21.9) 3rd 185 (30.8) 4th 169 (28.2) 5th 13 (2.1) 6th 13 (2.1) Faculty Education 352 (58.7) Science 34 (5.6) Medicine 55 (9.1) Engineering 29 (4.9) Pharmacy 1 (0.2) Islamic Studies 38 (6.3) Law 14 (2.3) Economics & Political Science 77 (12.8) Employment Employed 29 (4.9) Not employed 561 (93.5) Residence Town 414 (69) Camp 130 (21.7) Village 56 (9.3) Family Members > 8 299 (49.8) 5–7 223 (37.1) < 4 78 (13.1) Family Type Nuclear 260 (43.4) Extended 179 (29.8) Nuclear in extended 161 (26.8) Refugee Status Refugee 392 (65.3) Citizen 208 (34.7) Father Education Primary 29 (4.9) Preparatory 82 (13.6) Secondary 157 (26.2) University 185 (30.9) Postgraduate 75 (12.6) Diploma 45 (7.7) Uneducated 24 (4) Mother Education Primary 27 (4.5) Preparatory 78 (13) Secondary 245 (40.8) University 143 (23.8) Postgraduate 10 (1.7) Diploma 65 (10.8) Uneducated 33 (5.4) Father Occupation Unemployed 147 (24.5) Employee (active) 115 (19.1) Employee (inactive) 97 (16.1) Worker 73 (12.1) Dealer 62 (10.3) Other 68 (11.4) Mother Occupation Housewife 496 (82.6) Employee 86 (14.3) Other 18 (3.1) Family Income (NIS) 4000 60 (9.9) Impact of Siege Nearly half of the participants (51.24%, SD = 21.81) have been impacted negatively by the siege (Table 2 ). Of them, 82.9% have reported that their study was affected by the lack of electricity due to the lack of fuel due to the siege, and 82.1% have reported that they found it difficult to travel abroad to study due to siege. In addition, 71.2% have reported that they find it difficult to pay university fees because of low family income. Furthermore, 67.8% have reported that they feel like they live in a big prison. Moreover, 67.5% have indicated that they find it difficult to get medical care outside Gaza Strip due to the difficulty of movement at the crossings. The differences between women and men was statistically significant as p < 0.05. The mean among men was 58.34% (SD = 20.59), while the mean among women was 45.11% (SD = 19.76). Table 2 Participants’ response to impact of siege items NO Item (Yes) Number (Yes) Percentage 1 I feel that I live in a big prison 407 67.8% 2 We find it difficult to complete the construction of the house for the lack of building materials 330 55% 3 I find it difficult to buy my educational needs due to lack of income and increasing prices 392 65.4% 4 We find it difficult to visit friends and relatives for lack of money as a result of the siege 318 53% 5 My daily income from my family is not enough for my transportation and my day at the university 313 52.1% 6 My study was affected by the lack of electricity due to the lack of fuel due to the siege 497 82.9% 7 I find it difficult to find transportation to go to university 274 45.7% 8 I find it difficult to study abroad because of the siege 493 82.1% 9 I find it difficult to get medical care outside Gaza Strip due to the difficulty of movement at the crossings 405 67.5% 10 I went to associations, institutions and zakat committees that provide assistance to university students 172 28.6% 11 I find it difficult to pay university fees because of low family income 427 71.2% 12 I have difficulty getting medical care for me or for one of my family members due to the inability to provide health insurance 212 35.3% 13 I feel stressed due to my father’s loss of his job due to siege and closure 301 50.1% 14 I am thinking and looking for another country to emigrate from Gaza 350 58.3% 15 I find it difficult to travel to visit my family members in the West Bank as a result of the siege 322 53.6% 16 I am thinking of leaving university to be able to work and save money for myself and my family 200 33.4% 17 One member of my family members died for not being able to travel for treatment due to the siege and to determination of movement 120 20% 18 I have been prevented from visiting a member of the family in prison as a result of the closure 79 13.1% 19 I cannot find the things I need in the market as a result of the blockade 402 67% 20 I began to work on immigration procedures from Gaza 137 22.6% Mental symptoms among the participants The results showed that 51.11% of the participants suffered from depressive symptoms, while 54.90% suffered from dysthymic symptoms (Table 3 ). Furthermore, 39% indicated that they had vegetative symptoms, and 40.21% had agoraphobic symptoms. In addition, 44.37% and 53.3% showed sociophobia and mistrust feelings respectively. The differences between women and men were not statistically significant except in the agoraphobic domain in which the percentage among women (42.11%) is statistically higher than the mean among men (37.8%) (P = 0.02). Table 3 Participants’ response to mental health problems items No Mental Health Problems % 1 Depressive symptoms 51.11% 2 Dysthymic symptoms 54.9% 3 Vegetative symptoms 39% 4 Agoraphobic symptoms 40.21% 5 Sociophobic symptoms 44.37% 6 Mistrust feelings 53.3% Relationship between siege and mental health We have conducted Pearson correlation test between the impact of siege variable and the six domains of the mental health scale. The results showed that there was a statistically significant positive relationship between the impact of siege and the six domains of mental health scale that includes the depressive symptoms, dysthymic symptoms, vegetative symptoms, agoraphobic symptoms, Sociophobic symptoms and mistrust feelings as p < .05 in all relations and the Pearson correlation coefficients were 0.363, 0.173, 0.201, 0.155, 0.239 and 0.331 respectively. Discussion The findings of this study indicate that prolonged exposure to siege-related stressors is strongly associated with poor mental health outcomes among university students in the Gaza Strip. The high prevalence of depressive and dysthymic symptoms, alongside substantial levels of anxiety-related manifestations such as agoraphobia and sociophobe, reflects the cumulative psychological burden of chronic restrictions on mobility, education, economic stability, and access to healthcare. The reported disruption of academic activities due to electricity shortages, financial hardship in paying university fees, and limited opportunities for travel and medical treatment highlights how structural constraints translate into daily stressors that negatively affect students’ psychological well-being. The significant positive correlations between siege impact and all mental health domains further support the notion that sustained political and economic adversity functions as a continuous traumatic stressor rather than an acute event. Gender differences, particularly higher agoraphobic symptoms among female students, may be explained by sociocultural factors and heightened safety concerns in constrained environments. Overall, these results are consistent with previous research from conflict-affected settings, underscoring the vulnerability of young adults to long-term mental health consequences of prolonged siege and emphasizing the necessity of integrating mental health services within university and community-based support systems. The findings of the present study provide important evidence on the mental health consequences of prolonged siege conditions among university students in the Gaza Strip and are highly consistent with, and complementary to, recent longitudinal evidence documenting escalating psychological distress in the general adult population. Our results reveal a substantial burden of mental health symptoms, with more than half of participants reporting depressive and dysthymic symptoms and considerable proportions experiencing anxiety-related manifestations, sociophobia, and mistrust. These findings reinforce earlier cross-sectional studies conducted in Gaza prior to the most recent war escalation, which consistently demonstrated elevated levels of psychological distress associated with chronic exposure to political violence, economic hardship, and restricted mobility [ 13 – 17 ]. The high prevalence of mental health symptoms observed in our student sample suggests that young adults in Gaza were already experiencing significant psychological vulnerability even before the escalation to full-scale war in October 2023. The strong association identified in this study between siege-related stressors and all domains of mental health symptoms supports the conceptualization of the siege as a form of continuous traumatic stress. Unlike acute traumatic events, the prolonged blockade has imposed persistent stressors that permeate daily life, including disrupted education due to electricity shortages, financial strain related to tuition fees, barriers to travel and medical care, and a pervasive sense of confinement. These stressors were widely reported by participants and were significantly correlated with depressive, anxiety-related, and mistrust symptoms. This pattern mirrors findings from conflict and post-conflict settings, where chronic socioeconomic deprivation, uncertainty about the future, and repeated exposure to stressors are strongly linked to poor mental health outcomes [ 18 ]. The perception among a large proportion of students that they “live in a big prison” further highlights the psychological toll of long-term restrictions on movement and autonomy. When placed in the context of recent longitudinal evidence from Gaza, our findings appear to represent an earlier point along a deteriorating mental health trajectory. The longitudinal cohort study conducted between 2020 and 2025 demonstrated that even before the escalation to war, nearly one in five adults met criteria for severe psychological distress, a figure already exceeding what is commonly reported in many post-conflict settings [ 13 ]. Following the outbreak of war in October 2023, this proportion increased dramatically, with nearly 70% of adults experiencing high psychological distress by early 2025 and a twelvefold increase in odds compared with 2020. While our study focuses on university students and uses different instruments, the consistency in overall patterns—high baseline distress followed by further escalation during intensified conflict—suggests that the mental health burden observed during the war did not emerge in isolation but rather evolved from a prolonged period of siege-related psychological strain. Notably, the similarities in symptom profiles across age groups strengthen this interpretation. The adult cohort study reported widespread distress across all socio-demographic subgroups, indicating near-universal exposure to psychological stressors during the war [ 13 ]. Similarly, our study found high prevalence rates of depressive and anxiety-related symptoms among students from diverse backgrounds, with only limited gender differences. The higher agoraphobic symptoms observed among female students may reflect gender-specific vulnerabilities, such as heightened safety concerns and social constraints in a highly restrictive environment. However, the overall burden of distress across both men and women underscores that the siege exerts a broad and largely indiscriminate psychological impact. Comparison with other conflict-affected populations further emphasizes the severity of the mental health burden in Gaza. Meta-analytic evidence suggests that approximately 22% of individuals in post-conflict settings experience mental health disorders, with lower proportions suffering from moderate to severe conditions [ 13 ]. In contrast, both our findings and recent studies conducted during the current war report substantially higher prevalence rates of psychological distress, anxiety, and depression in Gaza [ 18 – 21 ]. This discrepancy likely reflects the unique context of Gaza, where prolonged blockade, repeated military escalations, high unemployment, and limited access to basic services have compounded over decades. The longitudinal evidence showing a tripling of severe distress during the war highlights how acute conflict escalation can dramatically amplify pre-existing vulnerabilities created by long-term siege conditions. The implications of these findings are profound, particularly given the young age of our study population. University students represent a critical segment of society, poised to contribute to future social and economic recovery. Persistent mental health problems during this formative stage may undermine academic performance, career prospects, and long-term well-being. Moreover, the adult cohort study underscores the potential for intergenerational consequences, as sustained psychological distress among caregivers is associated with adverse developmental, emotional, and behavioral outcomes in children [ 22 – 23 ]. Although intergenerational effects were not directly assessed in our study, the high levels of distress observed among students—many of whom will become future parents—raise concerns about the long-term transmission of trauma if adequate mental health support is not provided. Together, the findings from this study and recent longitudinal evidence highlight the urgent need for comprehensive, sustained, and context-sensitive mental health and psychosocial interventions in Gaza. Short-term or crisis-driven responses are unlikely to address the cumulative effects of prolonged siege and repeated conflict escalation. Instead, interventions should integrate clinical mental health services with community-based psychosocial support, educational accommodations, and efforts to strengthen resilience and coping strategies. Recent evidence suggests that despite extreme adversity, certain protective factors—such as social support, adaptive problem-solving, religious faith, and culturally rooted concepts like Sumud (steadfastness)—may help buffer psychological decline in some individuals [ 18 , 24 – 26 ]. Understanding and strengthening these protective mechanisms may be crucial for mitigating long-term mental health consequences. One of the important strength of this study that it is a leading study in assessing the relationship between the impact of siege and mental health problems among a crucial category of the community; the university students. In addition, the sample size added a value to our study as it represents relatively the university students’ population in four main universities in the Gaza Strip. One of the limitations of our study is the potential mistrust of researchers in Gaza, as it is a conflict zone that is characterized by mistrust and suspicion of persons seeking information in the event that they are informants for the various political and military factions. We believe that the researchers have considerable respect in the community to offset any of such concerns. Moreover, our study was based on the quantitative measures only, so we recommend conducting future studies adopting the mixed method approach. Conclusion This study demonstrates that the prolonged 12-year siege has had a substantial and pervasive negative impact on the mental health of university students in the Gaza Strip. A considerable proportion of students reported significant siege-related stressors affecting their education, mobility, economic security, and access to healthcare, alongside high prevalence rates of depressive, dysthymic, anxiety-related, and mistrust symptoms. The observed gender differences in perceived siege impact, with males reporting higher exposure, and in agoraphobic symptoms, with higher levels among females, highlight differential vulnerabilities within the student population. Importantly, the significant positive correlations between siege-related stressors and all assessed mental health domains underscore a clear association between chronic exposure to siege conditions and psychological distress. Collectively, these findings emphasize the urgent need for targeted mental health interventions, psychosocial support programs, and policy-level actions aimed at mitigating the long-term psychological consequences of prolonged political and economic restrictions on young adults in Gaza. Abbreviations Full Term GSC Gaza Siege Checklist SCL-27 Symptom Checklist-27 PTSD Post-Traumatic Stress Disorder SPSS Statistical Package for the Social Sciences NIS New Israeli Shekel SD Standard Deviation r Pearson Correlation Coefficient p Probability Value (Significance Level) Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Research Committee of the Faculty of Medicine, Islamic University of Gaza. Participation was voluntary, and all participants had the right to withdraw at any time without penalty. Written informed consent was obtained from all participants prior to data collection. Data were collected anonymously, and confidentiality was strictly maintained. All procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki. Consent for publication Not applicable Competing Interest Authors have no conflict of interest Funding None Author Contribution Khamis Elessi conceptualized and supervised the study. Tayseer Afifi analyzed the data and drafted the manuscript. Both authors reviewed and approved the final version of the manuscript. Acknowledgment Not applicable Data Availability Data are available upon reasonable request References Afana A. The assessment of mental disorders in primary health care clinics in the Gaza Strip. Prim Health Care Res Dev; 2003. Afana A, Qouta S, Sarraj E. Mental health needs in Palestine. Humanitarian Practice Network. 2004. Castellino J, Cavanaugh K. Minority rights in the Middle East. Oxford: Oxford University Press; 2013. p. 150. Dunning T, Hamas. Jihad and popular legitimacy: Reinterpreting resistance in Palestine. London: Routledge; 2016. Hardt J, Dragan M, Kappis B. A short screening instrument for mental health problems: the Symptom Checklist-27 (SCL-27) in Poland and Germany. Int J Psychiatry Clin Pract. 2011;15(1):42–9. 10.3109/13651501.2010.523791 . Jomaa A, Thabet A. Relationship between stressors due to siege of Gaza Strip on anxiety, depression and coping strategies among university students. Arab J Psychiatry. 2015;26(1):39–48. Khamis V. Coping with war trauma and psychological distress among school-age Palestinian children. Am J Orthopsychiatry. 2015;85(1):72–9. Palestinian Central Bureau of Statistics (PCBS). Population of Palestine. Ramallah: PCBS; 2017. Thabet A, El-Buhaisi O, Vostanis P. Trauma, PTSD, anxiety and coping strategies among Palestinian adolescents exposed to war in Gaza. Arab J Psychiatry. 2014;25:71–82. 10.12816/0004117 . Thabet A, Thabet S, Vostanis P. Impact of trauma on Palestinian children and the role of coping strategies. Br J Med Med Res. 2015;5(3):330–40. Thabet A, Thabet S. Stress, trauma, psychological problems, quality of life and resilience of Palestinian families in the Gaza Strip. J Clin Psychiatry. 2015;1(1):1–16. Tol WA, Song S, Jordans MJD. Annual research review: resilience and mental health in children and adolescents living in areas of armed conflict – a systematic review of findings in low- and middle-income countries. J Child Psychol Psychiatry. 2013;54(4):445–60. Charlson F, van Ommeren M, Flaxman A, et al. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. Lancet. 2019;394:240–8. AbuQamar M, Eltayyan D, Kuznetsova I, et al. The impact of access to electricity on mental health in conflict-affected territories: an exploratory study in Gaza. Int J Soc Psychiatry. 2023;69:2148–56. Zughbur MR, Hamam Y, Kagee A, et al. Prevalence and correlates of anxiety, depression, and symptoms of trauma among Palestinian adults in Gaza after a year of war: a cross-sectional study. Confl Health. 2025;19:43. Miller KE, Rasmussen A. War exposure, daily stressors, and mental health 15 years on: implications of an ecological framework for addressing the mental health of conflict-affected populations. Epidemiol Psychiatr Sci. 2024;33:e78. Restrepo MT, Padilla-Medina D. Armed conflict exposure and mental health: examining the role of imperceptible violence. Med Confl Surviv. 2023;39:199–221. Brugger C, Hamad BA, Hattendorf J, Winkler MS, Probst-Hensch N. Changes in psychological distress during conflict escalation in an adult population-based cohort in the Gaza Strip (2020–2025): a longitudinal analysis. eClinicalMedicine. 2025;90. Aldabbour B, El-Jamal M, Abuabada A, et al. The psychological toll of war and forced displacement in Gaza: a study on anxiety, PTSD, and depression. Chronic Stress (Thousand Oaks). 2025;9:24705470251334943. Albelbeisi AH, Hajizadeh A, Al-Zeer AM, et al. Prevalence and associated factors of mental health disorders among internally displaced persons in Gaza. East Mediterr Health J. 2025;31:81–8. Aldabbour B, Abuabada A, Lahlouh A, et al. Psychological impacts of the Gaza war on Palestinian young adults: a cross-sectional study of depression, anxiety, stress, and PTSD symptoms. BMC Psychol. 2024;12:696. Hamdan-Mansour AM, Albalishi IZ, Rayani A et al. The moderation effect of resilience on the relationship between PTSD, depression, and life satisfaction among on-duty healthcare professionals in Gaza. Psychiatr Q. 2025. Dashorst P, Mooren TM, Kleber RJ, et al. Intergenerational consequences of the holocaust on offspring mental health: a systematic review of associated factors and mechanisms. Eur J Psychotraumatol. 2019;10:1654065. Javanbakht A. Gaza's hidden crisis: adults, children, and generations of psychological torment to come. Eur J Psychotraumatol. 2024;15:2416824. Abuelaish I, Yousufzai S. Resilience under protracted conflict and siege: a new paradigm shift. Med Confl Surviv. 2023;39:369–88. Hammad J, Tribe R. Culturally informed resilience in conflict settings: a literature review of sumud in the occupied Palestinian territories. Int Rev Psychiatry. 2021;33:132–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8598990","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":580321670,"identity":"2bac691f-1413-4e59-81ec-6eb7f68f96ae","order_by":0,"name":"Khamis Elessi","email":"","orcid":"","institution":"Islamic University of Gaza","correspondingAuthor":false,"prefix":"","firstName":"Khamis","middleName":"","lastName":"Elessi","suffix":""},{"id":580321671,"identity":"9d7a8e89-3da8-4be0-9a09-46835013e76a","order_by":1,"name":"Tayseer Afifi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYBACNuaDDR8S4NwKIGZmbsCrhZ8tsXFGAoMBlHsGpIURvxbJtgTGGQwwLYxtYBK/FoNjzI0NDxj+yBucP3zwceW82mj+dqCWHxXb8GhhbGwAOsxww420ZMOz247nzjjM2MDYc+Y2bi33G9sfALUwbrjBYybZuO1YbgNQCzNjG24t9lBb7DecP//9Z+OcY7nzCWmBOSxxw4EcNiCzJncDcVoMjJNn3kgzlmw4diB3I1DLQbx+Ocb+sPFHhZxt3/nDDz821NTlzgMG3YMfFbi1QDUyMCgcALMOg8kDBNRDgHwDmKojSvEoGAWjYBSMLAAAwaFkhq5E3XkAAAAASUVORK5CYII=","orcid":"","institution":"Islamic University of Gaza","correspondingAuthor":true,"prefix":"","firstName":"Tayseer","middleName":"","lastName":"Afifi","suffix":""}],"badges":[],"createdAt":"2026-01-14 07:53:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8598990/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8598990/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105845280,"identity":"a1ce381d-fd51-45e5-8469-09164619b6fb","added_by":"auto","created_at":"2026-03-31 17:40:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":723874,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8598990/v1/31b495df-e214-4786-ae66-e6a717bf6b28.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of a 12- year siege on the mental health among university students in the Gaza Strip","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe Gaza Strip is a narrow coastal territory located along the Mediterranean Sea, covering an area of approximately 360 km\u0026sup2; and characterized by one of the highest population densities in the world, with most residents concentrated in urban areas and refugee camps [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. According to the Palestinian Central Bureau of Statistics, the estimated population of Palestine in 2017 was 4,780,978, of whom 2,881,687 resided in the West Bank (5,655 km\u0026sup2;) and 1,899,291 lived in the Gaza Strip (365 km\u0026sup2;) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The population structure in Gaza is notably young, with 44.1% aged under 14 years and 21.3% aged between 15 and 24 years, reflecting a demographic profile that places substantial pressure on educational, economic, and health systems [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe humanitarian situation in the Gaza Strip has progressively deteriorated since 2007, following the imposition of a comprehensive siege that has severely restricted the movement of people and goods [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The blockade has been accompanied by widespread political, economic, and social constraints, as well as ongoing human rights violations, which have collectively undermined living conditions and access to essential services. This situation was further exacerbated by successive military offensives in 2008\u0026ndash;2009, 2012, and 2014, which resulted in extensive loss of life, widespread injuries, and large-scale destruction of infrastructure, placing an additional burden on an already fragile healthcare system [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe prolonged siege has significantly affected all aspects of daily life in Gaza, including access to basic necessities, employment opportunities, education, and healthcare. Severe restrictions on travel have further intensified feelings of isolation and confinement among the population. In addition, internal political division has disrupted traditional social support networks, thereby compounding psychosocial stressors. Collectively, these chronic stressors create conditions conducive to the development of mental health disorders, including depression, anxiety, post-traumatic stress disorder (PTSD), and substance use disorders [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs a consequence of sustained political instability, economic hardship, and repeated exposure to traumatic events, mental health disorders have become one of the most prevalent yet under-recognized public health challenges in the occupied Palestinian territory. It is estimated that approximately one-third of Palestinians are in need of psychosocial or mental health interventions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Reports from United Nations agencies indicate that both individuals and institutions in Gaza continue to struggle with the long-term consequences of the 2014 military offensive, compounded by the ongoing blockade and unresolved internal political divisions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These conditions place the population at heightened risk of continuous psychological trauma, characterized by chronic stress, despair, hopelessness, helplessness, and a persistent sense of insecurity.\u003c/p\u003e \u003cp\u003eConsistent with this context, previous studies conducted in Gaza have documented high prevalence rates of mental health disorders, including PTSD, generalized anxiety disorder, depressive disorders, and substance use disorders [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Psychosocial distress has been particularly evident among children and adolescents. For example, a study of 358 adolescents aged 14\u0026ndash;18 years in the Gaza Strip reported high levels of anxiety-related symptoms, with a mean total anxiety score of 41.18%, alongside elevated rates of obsessive\u0026ndash;compulsive symptoms, social phobia, separation anxiety, and panic/agoraphobia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These findings underscore the pervasive psychological impact of prolonged exposure to siege and conflict across different age groups.\u003c/p\u003e \u003cp\u003eUniversity students represent a particularly vulnerable subgroup within this context, as they face the combined pressures of academic demands, economic uncertainty, restricted future prospects, and ongoing exposure to siege-related stressors. Despite this vulnerability, research focusing specifically on the mental health of university students in Gaza remains limited. Therefore, the present study aimed to assess the impact of the prolonged siege on mental health among university students in the Gaza Strip and to examine the relationship between siege-related stressors and mental health outcomes.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eStudy Design\u003c/p\u003e \u003cp\u003eThis study employed a cross-sectional analytical design using quantitative methods to examine the effect of the prolonged siege on mental health outcomes among university students in the Gaza Strip. The cross-sectional approach was selected to allow for the assessment of exposure to siege-related stressors and their association with mental health symptoms at a single point in time.\u003c/p\u003e \u003cp\u003eStudy Setting\u003c/p\u003e \u003cp\u003eThe study was conducted in the Gaza Strip, a densely populated area subjected to an ongoing siege since 2007, which has significantly affected socioeconomic conditions, access to services, and overall quality of life. Data were collected from four major universities representing different geographical areas of Gaza:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIslamic University of Gaza\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAl-Azhar University\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAl-Quds Open University\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAl-Aqsa University\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese institutions collectively enroll a large and diverse student population, making them appropriate settings for examining the mental health impact of the prolonged siege.\u003c/p\u003e \u003cp\u003eStudy Population\u003c/p\u003e \u003cp\u003eThe target population consisted of undergraduate university students enrolled in the selected universities during the data collection period. University students were chosen due to their heightened vulnerability to psychological distress resulting from chronic political violence, economic instability, and uncertainty regarding future employment and academic opportunities.\u003c/p\u003e \u003cp\u003eSample and Sampling Technique\u003c/p\u003e \u003cp\u003e A convenience sampling technique was used to recruit participants from the four universities. A total of 800 students who met the sampling criteria were approached and invited to participate in the study. Of these, 600 students completed the questionnaires adequately and were included in the final analysis, yielding a response rate of 75%.\u003c/p\u003e \u003cp\u003eThe final sample comprised 274 males (45.6%) and 326 females (54.4%), with a mean age of 20.54 years. Participants were recruited from various academic disciplines and educational levels to enhance sample heterogeneity.\u003c/p\u003e \u003cp\u003eEligibility Criteria\u003c/p\u003e \u003cp\u003eInclusion criteria:\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eEnrolled as a university student in one of the selected institutions\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAged 18 years or older\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eResident of the Gaza Strip during the period of the siege\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e Willing to participate and able to provide informed consent\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003cp\u003eExclusion criteria:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIncomplete or poorly filled questionnaires\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStudents with self-reported severe cognitive or psychiatric conditions that could impair questionnaire completion\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eInstruments\u003c/p\u003e \u003cp\u003eSocio-demographic Questionnaire\u003c/p\u003e \u003cp\u003eA structured socio-demographic questionnaire was used to collect data on participants\u0026rsquo; background characteristics, including age, gender, marital status, area of residence, type of housing, residency status, monthly household income, family size, parental education and occupation, student employment status, university, college, and academic level.\u003c/p\u003e \u003cp\u003eGaza Siege Checklist (GSC)\u003c/p\u003e \u003cp\u003eThe Gaza Siege Checklist (GSC) is a 21-item instrument designed to assess daily life stressors related to the ongoing siege. The checklist covers multiple domains, including family life, health, education, social relationships, and economic conditions. The GSC was developed based on focus group discussions with 20 mental health professionals and has been previously used in Gaza (Thabet \u0026amp; Thabet, 2015) on a community-based sample of 400 adults selected through a random sampling technique. The scale demonstrated good internal consistency, with a Cronbach\u0026rsquo;s alpha of 0.802 in previous applications.\u003c/p\u003e \u003cp\u003eSymptom Checklist-27 (SCL-27)\u003c/p\u003e \u003cp\u003eMental health symptoms were assessed using the Symptom Checklist-27 (SCL-27), a validated short multidimensional screening instrument for psychological distress. The scale measures six symptom domains: depressive symptoms, dysthymic symptoms, vegetative symptoms, agoraphobic symptoms, sociophobic symptoms, and symptoms of mistrust (Hardt et al., 2011).\u003c/p\u003e \u003cp\u003eThe SCL-27 has shown strong psychometric properties, with a Cronbach\u0026rsquo;s alpha of 0.895, indicating high internal consistency.\u003c/p\u003e \u003cp\u003eData Collection Procedures\u003c/p\u003e \u003cp\u003eData collection was carried out between October 2018 and April 2019. Prior to data collection, official permissions were obtained from the administrations of the participating universities. Ethical approval was granted from research committee at the Faculty of Medicine \u0026ndash; Islamic University of Gaza. Participants were informed about the study objectives, procedures, voluntary nature of participation, and confidentiality of their responses. Written informed consent was obtained from all participants before questionnaire administration. Questionnaires were self-administered in a classroom or university setting under the supervision of trained research assistants.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were coded, entered, and analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to describe socio-demographic characteristics, siege-related stressors, and mental health outcomes. Inferential statistical analyses were conducted to examine associations between exposure to siege-related stressors and mental health symptoms. Pearson\u0026rsquo;s correlation coefficient was used to assess the relationship between Gaza Siege Checklist scores and SCL-27 mental health symptom scores. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eEthical Considerations\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e for the study was obtained from the research committee at the Faculty of Medicine \u0026ndash; Islamic University of Gaza. Participation was entirely voluntary, and participants had the right to withdraw at any time without penalty. Written informed consent was obtained from all participants. Data were collected anonymously, and confidentiality was strictly maintained throughout the study. All procedures were conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDemographics\u003c/h2\u003e \u003cp\u003eA total of 600 participants completed the questionnaires, comprising 274 (45.6%) men and 326 (54.4%) women, with a mean age of 20.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69 years (range 17\u0026ndash;32). Most participants were single (90.2%), and the majority had completed the literary track in secondary education (70.9%). Participants were recruited from four universities in the Gaza Strip, with the highest representation from Al Azhar University (34.1%). Most students (93.5%) did not work during their studies. Participants predominantly lived in towns (69%), with family sizes typically exceeding eight members (49.8%), and 65.3% were refugees. Regarding parental education, 30.9% of fathers and 23.8% of mothers had completed university, while 12.6% of fathers and 1.7% of mothers had postgraduate education. Fathers\u0026rsquo; occupations varied, with 24.5% unemployed, and most mothers (82.6%) were housewives. Family income was below 2000 NIS for 67.4% of participants. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents demographic characteristics of study participants\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of Participants (n\u0026thinsp;=\u0026thinsp;600)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e274 (45.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e326 (54.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e541 (90.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (8.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary Education Track\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiterary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e425 (70.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScientific\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e172 (28.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAl Azhar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e205 (34.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAl Aqsa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e158 (26.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIslamic University\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e143 (23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAl Quds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (15.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (14.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131 (21.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e185 (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e169 (28.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFaculty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e352 (58.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (5.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEngineering\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePharmacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIslamic Studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (6.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEconomics \u0026amp; Political Science\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (12.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e561 (93.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e414 (69)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCamp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130 (21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily Members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e299 (49.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e223 (37.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (13.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e260 (43.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e179 (29.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNuclear in extended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e161 (26.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRefugee Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRefugee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e392 (65.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCitizen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e208 (34.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFather Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreparatory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82 (13.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e157 (26.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e185 (30.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (12.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUneducated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (4.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreparatory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e245 (40.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e143 (23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (10.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUneducated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFather Occupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e147 (24.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployee (active)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115 (19.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployee (inactive)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 (16.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (12.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDealer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (10.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (11.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother Occupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e496 (82.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily Income (NIS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e224 (37.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1100\u0026ndash;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e180 (30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2100\u0026ndash;3000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108 (18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3100\u0026ndash;4000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (4.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;4000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (9.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImpact of Siege\u003c/h3\u003e\n\u003cp\u003eNearly half of the participants (51.24%, SD\u0026thinsp;=\u0026thinsp;21.81) have been impacted negatively by the siege (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Of them, 82.9% have reported that their study was affected by the lack of electricity due to the lack of fuel due to the siege, and 82.1% have reported that they found it difficult to travel abroad to study due to siege. In addition, 71.2% have reported that they find it difficult to pay university fees because of low family income. Furthermore, 67.8% have reported that they feel like they live in a big prison. Moreover, 67.5% have indicated that they find it difficult to get medical care outside Gaza Strip due to the difficulty of movement at the crossings. The differences between women and men was statistically significant as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The mean among men was 58.34% (SD\u0026thinsp;=\u0026thinsp;20.59), while the mean among women was 45.11% (SD\u0026thinsp;=\u0026thinsp;19.76).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants\u0026rsquo; response to impact of siege items\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNO\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(Yes) Number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(Yes) Percentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI feel that I live in a big prison\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWe find it difficult to complete the construction of the house for the lack of building materials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI find it difficult to buy my educational needs due to lack of income and increasing prices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWe find it difficult to visit friends and relatives for lack of money as a result of the siege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMy daily income from my family is not enough for my transportation and my day at the university\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMy study was affected by the lack of electricity due to the lack of fuel due to the siege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e497\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI find it difficult to find transportation to go to university\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI find it difficult to study abroad because of the siege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI find it difficult to get medical care outside Gaza Strip due to the difficulty of movement at the crossings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e405\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI went to associations, institutions and zakat committees that provide assistance to university students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI find it difficult to pay university fees because of low family income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e427\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI have difficulty getting medical care for me or for one of my family members due to the inability to provide health insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI feel stressed due to my father\u0026rsquo;s loss of his job due to siege and closure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI am thinking and looking for another country to emigrate from Gaza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI find it difficult to travel to visit my family members in the West Bank as a result of the siege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e322\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI am thinking of leaving university to be able to work and save money for myself and my family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne member of my family members died for not being able to travel for treatment due to the siege and to determination of movement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI have been prevented from visiting a member of the family in prison as a result of the closure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI cannot find the things I need in the market as a result of the blockade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI began to work on immigration procedures from Gaza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eMental symptoms among the participants\u003c/h3\u003e\n\u003cp\u003eThe results showed that 51.11% of the participants suffered from depressive symptoms, while 54.90% suffered from dysthymic symptoms (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Furthermore, 39% indicated that they had vegetative symptoms, and 40.21% had agoraphobic symptoms. In addition, 44.37% and 53.3% showed sociophobia and mistrust feelings respectively. The differences between women and men were not statistically significant except in the agoraphobic domain in which the percentage among women (42.11%) is statistically higher than the mean among men (37.8%) (P\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants\u0026rsquo; response to mental health problems items\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental Health Problems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.11%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDysthymic symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVegetative symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgoraphobic symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.21%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSociophobic symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.37%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMistrust feelings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRelationship between siege and mental health\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWe have conducted Pearson correlation test between the impact of siege variable and the six domains of the mental health scale. The results showed that there was a statistically significant positive relationship between the impact of siege and the six domains of mental health scale that includes the depressive symptoms, dysthymic symptoms, vegetative symptoms, agoraphobic symptoms, Sociophobic symptoms and mistrust feelings as p\u0026thinsp;\u0026lt;\u0026thinsp;.05 in all relations and the Pearson correlation coefficients were 0.363, 0.173, 0.201, 0.155, 0.239 and 0.331 respectively.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe findings of this study indicate that prolonged exposure to siege-related stressors is strongly associated with poor mental health outcomes among university students in the Gaza Strip. The high prevalence of depressive and dysthymic symptoms, alongside substantial levels of anxiety-related manifestations such as agoraphobia and sociophobe, reflects the cumulative psychological burden of chronic restrictions on mobility, education, economic stability, and access to healthcare. The reported disruption of academic activities due to electricity shortages, financial hardship in paying university fees, and limited opportunities for travel and medical treatment highlights how structural constraints translate into daily stressors that negatively affect students\u0026rsquo; psychological well-being. The significant positive correlations between siege impact and all mental health domains further support the notion that sustained political and economic adversity functions as a continuous traumatic stressor rather than an acute event. Gender differences, particularly higher agoraphobic symptoms among female students, may be explained by sociocultural factors and heightened safety concerns in constrained environments. Overall, these results are consistent with previous research from conflict-affected settings, underscoring the vulnerability of young adults to long-term mental health consequences of prolonged siege and emphasizing the necessity of integrating mental health services within university and community-based support systems.\u003c/p\u003e\u003cp\u003eThe findings of the present study provide important evidence on the mental health consequences of prolonged siege conditions among university students in the Gaza Strip and are highly consistent with, and complementary to, recent longitudinal evidence documenting escalating psychological distress in the general adult population. Our results reveal a substantial burden of mental health symptoms, with more than half of participants reporting depressive and dysthymic symptoms and considerable proportions experiencing anxiety-related manifestations, sociophobia, and mistrust. These findings reinforce earlier cross-sectional studies conducted in Gaza prior to the most recent war escalation, which consistently demonstrated elevated levels of psychological distress associated with chronic exposure to political violence, economic hardship, and restricted mobility [\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The high prevalence of mental health symptoms observed in our student sample suggests that young adults in Gaza were already experiencing significant psychological vulnerability even before the escalation to full-scale war in October 2023.\u003c/p\u003e\u003cp\u003eThe strong association identified in this study between siege-related stressors and all domains of mental health symptoms supports the conceptualization of the siege as a form of continuous traumatic stress. Unlike acute traumatic events, the prolonged blockade has imposed persistent stressors that permeate daily life, including disrupted education due to electricity shortages, financial strain related to tuition fees, barriers to travel and medical care, and a pervasive sense of confinement. These stressors were widely reported by participants and were significantly correlated with depressive, anxiety-related, and mistrust symptoms. This pattern mirrors findings from conflict and post-conflict settings, where chronic socioeconomic deprivation, uncertainty about the future, and repeated exposure to stressors are strongly linked to poor mental health outcomes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The perception among a large proportion of students that they \u0026ldquo;live in a big prison\u0026rdquo; further highlights the psychological toll of long-term restrictions on movement and autonomy.\u003c/p\u003e\u003cp\u003eWhen placed in the context of recent longitudinal evidence from Gaza, our findings appear to represent an earlier point along a deteriorating mental health trajectory. The longitudinal cohort study conducted between 2020 and 2025 demonstrated that even before the escalation to war, nearly one in five adults met criteria for severe psychological distress, a figure already exceeding what is commonly reported in many post-conflict settings [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Following the outbreak of war in October 2023, this proportion increased dramatically, with nearly 70% of adults experiencing high psychological distress by early 2025 and a twelvefold increase in odds compared with 2020. While our study focuses on university students and uses different instruments, the consistency in overall patterns\u0026mdash;high baseline distress followed by further escalation during intensified conflict\u0026mdash;suggests that the mental health burden observed during the war did not emerge in isolation but rather evolved from a prolonged period of siege-related psychological strain.\u003c/p\u003e\u003cp\u003eNotably, the similarities in symptom profiles across age groups strengthen this interpretation. The adult cohort study reported widespread distress across all socio-demographic subgroups, indicating near-universal exposure to psychological stressors during the war [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Similarly, our study found high prevalence rates of depressive and anxiety-related symptoms among students from diverse backgrounds, with only limited gender differences. The higher agoraphobic symptoms observed among female students may reflect gender-specific vulnerabilities, such as heightened safety concerns and social constraints in a highly restrictive environment. However, the overall burden of distress across both men and women underscores that the siege exerts a broad and largely indiscriminate psychological impact.\u003c/p\u003e\u003cp\u003eComparison with other conflict-affected populations further emphasizes the severity of the mental health burden in Gaza. Meta-analytic evidence suggests that approximately 22% of individuals in post-conflict settings experience mental health disorders, with lower proportions suffering from moderate to severe conditions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In contrast, both our findings and recent studies conducted during the current war report substantially higher prevalence rates of psychological distress, anxiety, and depression in Gaza [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This discrepancy likely reflects the unique context of Gaza, where prolonged blockade, repeated military escalations, high unemployment, and limited access to basic services have compounded over decades. The longitudinal evidence showing a tripling of severe distress during the war highlights how acute conflict escalation can dramatically amplify pre-existing vulnerabilities created by long-term siege conditions.\u003c/p\u003e\u003cp\u003eThe implications of these findings are profound, particularly given the young age of our study population. University students represent a critical segment of society, poised to contribute to future social and economic recovery. Persistent mental health problems during this formative stage may undermine academic performance, career prospects, and long-term well-being. Moreover, the adult cohort study underscores the potential for intergenerational consequences, as sustained psychological distress among caregivers is associated with adverse developmental, emotional, and behavioral outcomes in children [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Although intergenerational effects were not directly assessed in our study, the high levels of distress observed among students\u0026mdash;many of whom will become future parents\u0026mdash;raise concerns about the long-term transmission of trauma if adequate mental health support is not provided.\u003c/p\u003e\u003cp\u003eTogether, the findings from this study and recent longitudinal evidence highlight the urgent need for comprehensive, sustained, and context-sensitive mental health and psychosocial interventions in Gaza. Short-term or crisis-driven responses are unlikely to address the cumulative effects of prolonged siege and repeated conflict escalation. Instead, interventions should integrate clinical mental health services with community-based psychosocial support, educational accommodations, and efforts to strengthen resilience and coping strategies. Recent evidence suggests that despite extreme adversity, certain protective factors\u0026mdash;such as social support, adaptive problem-solving, religious faith, and culturally rooted concepts like Sumud (steadfastness)\u0026mdash;may help buffer psychological decline in some individuals [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Understanding and strengthening these protective mechanisms may be crucial for mitigating long-term mental health consequences.\u003c/p\u003e\u003cp\u003eOne of the important strength of this study that it is a leading study in assessing the relationship between the impact of siege and mental health problems among a crucial category of the community; the university students. In addition, the sample size added a value to our study as it represents relatively the university students\u0026rsquo; population in four main universities in the Gaza Strip. One of the limitations of our study is the potential mistrust of researchers in Gaza, as it is a conflict zone that is characterized by mistrust and suspicion of persons seeking information in the event that they are informants for the various political and military factions. We believe that the researchers have considerable respect in the community to offset any of such concerns. Moreover, our study was based on the quantitative measures only, so we recommend conducting future studies adopting the mixed method approach.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study demonstrates that the prolonged 12-year siege has had a substantial and pervasive negative impact on the mental health of university students in the Gaza Strip. A considerable proportion of students reported significant siege-related stressors affecting their education, mobility, economic security, and access to healthcare, alongside high prevalence rates of depressive, dysthymic, anxiety-related, and mistrust symptoms. The observed gender differences in perceived siege impact, with males reporting higher exposure, and in agoraphobic symptoms, with higher levels among females, highlight differential vulnerabilities within the student population. Importantly, the significant positive correlations between siege-related stressors and all assessed mental health domains underscore a clear association between chronic exposure to siege conditions and psychological distress. Collectively, these findings emphasize the urgent need for targeted mental health interventions, psychosocial support programs, and policy-level actions aimed at mitigating the long-term psychological consequences of prolonged political and economic restrictions on young adults in Gaza.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cb\u003eFull Term\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGSC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGaza Siege Checklist\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCL-27\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSymptom Checklist-27\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePost-Traumatic Stress Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNew Israeli Shekel\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003er\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePearson Correlation Coefficient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ep\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProbability Value (Significance Level)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e Ethical approval for this study was obtained from the Research Committee of the Faculty of Medicine, Islamic University of Gaza. Participation was voluntary, and all participants had the right to withdraw at any time without penalty. Written informed consent was obtained from all participants prior to data collection. Data were collected anonymously, and confidentiality was strictly maintained. All procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interest\u003c/h2\u003e \u003cp\u003eAuthors have no conflict of interest\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKhamis Elessi conceptualized and supervised the study. Tayseer Afifi analyzed the data and drafted the manuscript. Both authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgment\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData are available upon reasonable request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAfana A. The assessment of mental disorders in primary health care clinics in the Gaza Strip. Prim Health Care Res Dev; 2003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfana A, Qouta S, Sarraj E. Mental health needs in Palestine. Humanitarian Practice Network. 2004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastellino J, Cavanaugh K. Minority rights in the Middle East. Oxford: Oxford University Press; 2013. p. 150.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunning T, Hamas. Jihad and popular legitimacy: Reinterpreting resistance in Palestine. London: Routledge; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHardt J, Dragan M, Kappis B. A short screening instrument for mental health problems: the Symptom Checklist-27 (SCL-27) in Poland and Germany. Int J Psychiatry Clin Pract. 2011;15(1):42\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/13651501.2010.523791\u003c/span\u003e\u003cspan address=\"10.3109/13651501.2010.523791\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJomaa A, Thabet A. Relationship between stressors due to siege of Gaza Strip on anxiety, depression and coping strategies among university students. Arab J Psychiatry. 2015;26(1):39\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhamis V. Coping with war trauma and psychological distress among school-age Palestinian children. Am J Orthopsychiatry. 2015;85(1):72\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalestinian Central Bureau of Statistics (PCBS). Population of Palestine. Ramallah: PCBS; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThabet A, El-Buhaisi O, Vostanis P. Trauma, PTSD, anxiety and coping strategies among Palestinian adolescents exposed to war in Gaza. Arab J Psychiatry. 2014;25:71\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12816/0004117\u003c/span\u003e\u003cspan address=\"10.12816/0004117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThabet A, Thabet S, Vostanis P. Impact of trauma on Palestinian children and the role of coping strategies. Br J Med Med Res. 2015;5(3):330\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThabet A, Thabet S. Stress, trauma, psychological problems, quality of life and resilience of Palestinian families in the Gaza Strip. J Clin Psychiatry. 2015;1(1):1\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTol WA, Song S, Jordans MJD. Annual research review: resilience and mental health in children and adolescents living in areas of armed conflict \u0026ndash; a systematic review of findings in low- and middle-income countries. J Child Psychol Psychiatry. 2013;54(4):445\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharlson F, van Ommeren M, Flaxman A, et al. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. Lancet. 2019;394:240\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbuQamar M, Eltayyan D, Kuznetsova I, et al. The impact of access to electricity on mental health in conflict-affected territories: an exploratory study in Gaza. Int J Soc Psychiatry. 2023;69:2148\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZughbur MR, Hamam Y, Kagee A, et al. Prevalence and correlates of anxiety, depression, and symptoms of trauma among Palestinian adults in Gaza after a year of war: a cross-sectional study. Confl Health. 2025;19:43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller KE, Rasmussen A. War exposure, daily stressors, and mental health 15 years on: implications of an ecological framework for addressing the mental health of conflict-affected populations. Epidemiol Psychiatr Sci. 2024;33:e78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRestrepo MT, Padilla-Medina D. Armed conflict exposure and mental health: examining the role of imperceptible violence. Med Confl Surviv. 2023;39:199\u0026ndash;221.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrugger C, Hamad BA, Hattendorf J, Winkler MS, Probst-Hensch N. Changes in psychological distress during conflict escalation in an adult population-based cohort in the Gaza Strip (2020\u0026ndash;2025): a longitudinal analysis. eClinicalMedicine. 2025;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAldabbour B, El-Jamal M, Abuabada A, et al. The psychological toll of war and forced displacement in Gaza: a study on anxiety, PTSD, and depression. Chronic Stress (Thousand Oaks). 2025;9:24705470251334943.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlbelbeisi AH, Hajizadeh A, Al-Zeer AM, et al. Prevalence and associated factors of mental health disorders among internally displaced persons in Gaza. East Mediterr Health J. 2025;31:81\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAldabbour B, Abuabada A, Lahlouh A, et al. Psychological impacts of the Gaza war on Palestinian young adults: a cross-sectional study of depression, anxiety, stress, and PTSD symptoms. BMC Psychol. 2024;12:696.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamdan-Mansour AM, Albalishi IZ, Rayani A et al. The moderation effect of resilience on the relationship between PTSD, depression, and life satisfaction among on-duty healthcare professionals in Gaza. Psychiatr Q. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDashorst P, Mooren TM, Kleber RJ, et al. Intergenerational consequences of the holocaust on offspring mental health: a systematic review of associated factors and mechanisms. Eur J Psychotraumatol. 2019;10:1654065.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJavanbakht A. Gaza's hidden crisis: adults, children, and generations of psychological torment to come. Eur J Psychotraumatol. 2024;15:2416824.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbuelaish I, Yousufzai S. Resilience under protracted conflict and siege: a new paradigm shift. Med Confl Surviv. 2023;39:369\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHammad J, Tribe R. Culturally informed resilience in conflict settings: a literature review of sumud in the occupied Palestinian territories. Int Rev Psychiatry. 2021;33:132\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Gaza Strip, Siege Impact, University Students, Mental Health, Psychological Distress","lastPublishedDoi":"10.21203/rs.3.rs-8598990/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8598990/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSince the siege was imposed on the Gaza strip, the humanitarian situation was deteriorated to reach unprecedented level of poverty, economic hardship and social problems. This affected the general mental health and quality of life of the population significantly. In this study, we aimed at assessing the impact of siege on the mental health among university students in the Gaza Strip.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003e The study is a cross sectional study in which we have collected the data from 600 participants from four universities. We have collected demographic data, the impact of siege using Gaza Siege Checklist, and mental health status using the symptoms checklist. Data was entered, cleared and analyzed using SPSS version 23 to assess the relationship between the impact of siege and mental health.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 600 university students participated (mean age 20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 years; 54.4% female). Overall, the impact of the siege was substantial, with a mean impact score of 51.2% \u0026plusmn; 21.8. The most frequently reported stressors were disruption of study due to electricity shortages (82.9%), difficulty traveling abroad for education (82.1%), and inability to pay university fees because of low family income (71.2%). Male students reported significantly higher siege impact scores than females (58.3% vs. 45.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). High prevalences of mental health symptoms were observed, including dysthymic (54.9%), depressive (51.1%), mistrust (53.3%), and sociophobic symptoms (44.4%). Agoraphobic symptoms were significantly higher among females than males (42.1% vs. 37.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Pearson correlation analysis demonstrated significant positive associations between siege impact and all mental health domains, including depressive (r\u0026thinsp;=\u0026thinsp;0.363), dysthymic (r\u0026thinsp;=\u0026thinsp;0.173), vegetative (r\u0026thinsp;=\u0026thinsp;0.201), agoraphobic (r\u0026thinsp;=\u0026thinsp;0.155), sociophobic (r\u0026thinsp;=\u0026thinsp;0.239), and mistrust symptoms (r\u0026thinsp;=\u0026thinsp;0.331), with all correlations reaching statistical significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIt is concluded that the siege has impacted the mental health situation of the participants badly, as it raised the risk to develop several mental health problems including; depression, dysthymia, vegetation, agoraphobia, sociophobia, and mistrust.\u003c/p\u003e","manuscriptTitle":"Effect of a 12- year siege on the mental health among university students in the Gaza Strip","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 20:17:09","doi":"10.21203/rs.3.rs-8598990/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e1487583-2d26-4ede-a5c3-2d336af6f27d","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-31T17:39:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-27 20:17:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8598990","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8598990","identity":"rs-8598990","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}