Four Years After the 2014 War Against Gaza Strip, Post-Traumatic Stress Disorder Among People Who were Forced to Leave their Homes During the War: A Cross-Sectional Study

Introduction: Post-Traumatic Stress Disorder (PTSD) is a common, disabling disorder that appears after the exposure to a traumatic experience. Post-traumatic stress leads to a pattern of symptoms that include a delayed response to an acute stressful and a life-threatening event or situation, such as combat exposure during war time. Individuals exposed to combat exposure in a war zone are not only at risk to experience trauma but typically they may experience multiple traumatic experiences. Gaza Strip was a target for several Israeli aggressions in the last decade. The last and the worst was the offensive of the summer of 2014. People who live in the war zone and were forced to leave their homes have encountered several stressors during the war time that included personal threats to their lives, their families and partial or complete destruction of their homes.


Introduction
In the last decade, Israel waged three wars against Gaza Strip.
The last war of August 2014 was the worst and the most devastating.
It continued for 51 days during July and August 2014. According to a report issued by OCHA (United Nations Office for Coordination of Humanitarian Affairs) which was issued about one week after ceasefire, the war left 2131 deaths (1,473 have been identified as civilians, including 501 children, according to preliminary assessments). About 18,000 housing units were either destroyed or severely damaged, leaving approximately 108,000 people homeless. Moreover, there were approximately 110,000 internally displaced persons who stayed in UNRWA emergency shelters and with host families. Exposure to traumatic events, such as war and displacement from own houses, leads to stress and mental problems [1][2][3]. According to (Andreasen 2011), such stressors can induce a final common pathway that is expressed by a variety of autonomic/ physiologic, cognitive, and emotional symptoms that occur in response to a severe stressor. Such stressors may lead to a variety of several mental disorders such as depression, anxiety, somatoform disorders, psychosis, substance use disorders, impairment in social functioning, work impairments, and Post-Traumatic Stress Disorder (PTSD) [4][5][6][7][8].
Post-traumatic stress disorder is a common, disabling disorder that appears after the exposure to a traumatic experience [9]. It was defined by (Andreasen 2011) as "a syndrome, defined by a characteristic set of physiological (autonomic) and cognitive and emotional symptoms, that occurs after exposure to severe physical and emotional stress." Post-traumatic stress leads to a pattern of symptoms that include a delayed response to an acute stressful and a life-threatening event or situation, such as combat exposure during war time [10,11]. These symptoms may appear either during or immediately after the occurrence of the event, or several days later. The symptoms include initially intense fear, helplessness, or horror. Later, the individual develops a response to the stressful event that is characterized by persistently re-experiencing the event, with resultant symptoms of numbness, avoidance and hyperarousal [12]. After exposure to a stressful or a traumatic event, one usually experiences agitation, anxiety and sleep disturbance [13]. Half of those who experience posttraumatic nightmares may have dreams that exactly replicate the traumatic event [13][14][15][16].
Moreover, they may have trouble in concentration, and they try to avoid reminders of the event. In the last two decades, research revealed that traumatic events occur far more often than what it was previously assumed [17,18] and that PTSD is a highly prevalent condition with great impact on human and society well-being and costs [19].
PTSD is characterized by three main clusters of symptoms: Re-experiencing, Avoidance, and Hyperarousal symptoms. Reexperiencing symptoms are characterized by intrusive memories, nightmares, flashbacks, and psychological and physiological reactivity when encountering traumatic events. Avoidance symptoms include avoiding thoughts and activities associated with traumatic experiences, inability to recall aspects of the traumatic event, diminished interest, emotional detachment, restricted affect, and a sense of foreshortened future. Hyperarousal symptoms of PTSD include consist of disturbance, irritability/anger, difficulty concentrating, hypervigilance, and an exaggerated startle response [5]. Individuals exposed to combat exposure in a war zone are not only at risk to experience trauma but typically they may experience multiple traumatic experiences [20,21]. Research conducted after various military conflicts has shown that military personnel were subject to considerable risk for mental health problems, including, major depression, substance abuse, impairment in social functioning, work impairments, PTSD and increased use of health care services [22]. Studies within the Palestinian context related to trauma are limited. They were limited to studying PTSD among children and adolescents [23][24][25][26][27][28][29][30] health care providers [31][32][33][34]] and a few numbers of studies about adults [36][37][38][39][40]. Despite the abundant studies about PTSD, only a few numbers of them have systematically examined the effect of health care providers and hospital personnel's exposure to extreme stress [38,39]. In a previous study, we aimed to assess the level of PTSD and to examine the relationship between exposure to war stress and posttraumatic symptoms among health care providers following Israeli offensives against Gaza Strip in 2014. Data were collected three months after the offensives. Results revealed that 89.8% of participants suffered from PTSD. In this study, we aimed to examine if there were any changes of our previous results after two years of the war. People who live in the war zone and were forced to leave their homes have encountered several stressors during the war time that included personal threats to their lives, their families and partial or complete destruction of their homes. people including negative health outcomes, social and family relationship, and adverse psychological disorders such as acute depression, anxiety, and psychosocial disorders. This level of trauma warrants intervention programs, including counselling, to reduce stress and trauma among this vulnerable group.
Purpose: This study aimed to assess the level of PSTD and to examine the relationship between exposure to war stress and posttraumatic symptoms among people who were forced to leave their homes during/following Israeli offensives against Gaza Strip in 2014.

Materials and Methods
A cross-sectional design was used to conduct this study. The target population for the study was all adult individuals who were forced to leave their homes during/following the war of August 2014 against Gaza Strip. A snow-ball technique was used to recruit participants. Organizations that take care of war victims were contacted to recruit participants. Nursing students, friends, and colleagues were asked to recruit participants. The result was a convenience sample of 190 participants. Data were collected in the period between August and December 2018.

Instrument
The Impact Event Scale-Revised (IES-R) [41] was used in this study. The original Impact Event Scale (IES) predated the introduction of the diagnosis of PTSD. It is comprised of 15 items that measure two symptom clusters of PTSDs; seven items measure intrusions and eight items measure avoidance related to a negative event [42][43][44][45]. The revision of the original IES was done by Weiss and Marmar to better match the DSM-IV criteria for PTSD. As a result, a third cluster of symptoms that consists of seven items (hyperarousal subscale) was added to the original IES and its now known as IES-R.The IES-R is a self-report questionnaire that consists of 22 items measuring post-traumatic stress symptoms in three clusters: intrusion (seven items), avoidance (eight items) and hyperarousal (seven items). Participants were asked to rate how frequently each symptom was distressing for each participant during the past seven days with respect to the specified potentially stressful event on a 5-point Likert scale (where 0 -not at all, 1= a little bit, 2 = moderately, 3 = quite a bit, and 4 = extremely).
The IES-R has demonstrated good psychometric properties [46]. Briere reported that the internal consistency of the three subscales were found to be very high, with intrusion Cronbach's alphas ranging from 0.87 to 0.92, avoidance Cronbach's alphas ranging from 0.84 to 0.86, and hyperarousal Cronbach's alphas ranging from 0.79 to 0.90. Currently, IES-R is considered one of the most widely used measures to assess posttraumatic stress symptoms [47]. The cut-off score for IES-R varies between 22 and 44 with a score above the cut-off indicating a person at a high risk for psychological problems [48][49][50].  [51].
The instrument was translated into the Arabic language by two independent bilingual researchers and was used in two previous studies aimed to measure PTSD among health care providers following the 2014 war [52][53][54][55][56][57]. Then the two Arabic versions were compared, and double checked for accuracy until common agreement about a final translation was agreed upon. Conceptual rather the literal meaning was the goal of the translation. The final Arabic version was then back translated into the English language by a third bilingual researcher. Back-translation is a standard procedure for translating a research questionnaire from English to other languages [58]. Reliability Coefficients (Cronbach's Alpha) of the Arabic IES-R subscales were: 0.817, 0.779, 0.713 respectively, and 0.892 for total IES-R [59,60].

Statistical Analysis
The Statistical Package for Social Science (SPSS) version 22 was used to analyze data. Data were cleaned and checked for meeting statistical assumptions for normal distribution and homogeneity.
Data analysis procedures included basic descriptive statistics (mean, range, standard deviation, and percentage) and frequency distribution tables. ANOVA and t test were used to compare means.
Pearson's correlation was used to test correlations among study variables.

Ethical Considerations
Prior to conducting this research study, approval of the research committee at the Palestinian Ministry of Health was obtained. After explaining the purpose of the study and reassuring participants about confidentiality of data, each participant was asked to sign a consent paper prior to participation.

Analysis of IES-R Scale
The results of our study revealed that the great majority of the participants (N=174, 91.6%) had scores more than 35 (threshold cut-off) on IES-R scale. The mean for the total score of IES-R scale was 53.12 (±10.92) and values ranged between 25.03 and 78.0. Table 2 summarizes the results of the IES-R scale and its subscales. The highest mean of the subscales belongs to "Intrusion" (mean=20.95) followed by "Avoidance" (mean=17.66) while the least frequently reported symptoms were related to hyper-arousal subscale (mean=14.54). Table 3 shows the results for each item of the IES-R scale. The highest scores for the most stressful symptoms of trauma, as ranked by the participants, were "I had waves of strong feelings about it" (mean=3.24), followed by "I felt watchful or on-guard" (mean=3.03), and "Pictures about it popped up into my mind" (mean=3.03). The least frequent symptoms of trauma were "Reminders of it caused me to have physical reactions, such as sweating, trouble breathing, nausea or a pounding heart" (mean=1.70) and "My feelings about it were kind of numb" (mean=1.72).    In a different cross-sectional study that was conduct in the town of Juba, (2 years after the end of the civil conflict in Sudan), results revealed that over one third (36%) of respondents met symptom criteria for PTSD. Another study that assessed level of PTSD of residents from South Sudan revealed 48% of residents in southern Sudan and 46% of refugees from southern Sudan living in Uganda had PTSD. Although that our study reported the highest level of PTSD, other several studies had reported similarly high rates of PTSD among civilians forced to leave their homes and areas of conflict. In their study, Roberts et al. found that more than 54% of participants who were forced to leave their area of living in Uganda during armed conflict met the criteria for PTSD and more than 67%  The study did not find significant associations of all independent variables, such as gender, marital status, etc. (Table 4)  Based on that, the researchers recommend the implementation of such supportive programs to buffer PTSD and limit its impact on mental health of people living on war zones.