Direct and indirect exposure to violence is common among children in Palestine, and especially among those living in the Gaza Strip [1–3]. Political violence has resulted in the imposition of restrictions on the movement of Palestinian goods and people across borders and within Palestine. These restrictions have seriously compromised household welfare, resulting in loss of income, decreased quantity and quality of food, and impeded access to health care . Since this time, poverty has risen dramatically, with more than 57% of the Palestinians (47% in the West Bank, 77% in the Gaza Strip) currently living below the poverty line (less than $2/person/day) .
Current knowledge about children's responses to wartime trauma is limited mostly to Post Traumatic Stress Disorder (PTSD) . PTSD is defined as an anxiety disorder developed as a result of exposure to a terrifying event or ordeal . However, PTSD is only one extreme aspect of a complex set of responses . Health-Related Quality of Life (HRQOL) is another important measure of the health costs of war. We are not aware of studies measuring HRQOL among children in conflict areas. Most studies of HRQOL were among children with chronic diseases [7–11]. Traditional measures of morbidity and mortality may be too narrow in focus to capture the range of health issues in children , especially among those in situations of severe adversity. Child health outcomes also include broader health concerns, such as physical, emotional, social, and school functioning , which is measured in health-related quality of life. Availability of data on HRQOL in children will not only help identify subgroups at risk, but may also assist in the evaluation of health care needs and in the allocation of resources .
Research on the effects of war on children found that exposure to war leads to severe stress reactions and anxiety in a significant number of children . Child witnesses of violence show an increased incidence of internalizing behaviors, such as depression, and externalizing behaviors, such as aggressiveness and noncompliance . In 2001, a national survey of the impact of political violence on the well-being of Palestinian children age 5-17 years found that 44% had crying attacks, 41% had fear of blood color, 28% thought too much about death, and 22% had anger and nervous breakdown . In 2003, Qouta investigated the prevalence of mental health problems of 121 Palestinian children (aged 6-16 years) and found that 54% suffered from severe levels of PTSD . Similarly, in a study of Kuwaiti children following the Persian Gulf War, more than 70% of the children reported moderate or severe PTSD . The reactions to being exposed to violence intensify with increasing level and duration of violence [14, 17–19]. In 2003, Thabet examined the behavioral and emotional problems of 309 Palestinian preschoolers and found that direct and indirect exposure to war trauma increases the risk of poor mental health .
Most previous research examined the impact of exposure to violence as the only stressor affecting the mental health of children in war [6, 20–24]. In addition to traumatic events, however, it is equally important to examine secondary stressors such as deprivation  and forced relocation [26, 27]. Moreover, as we have demonstrated elsewhere , studying predictors of resilience may offer complementary insights. Parental social support, for example, predicts resilience in poor families ; social support may improve access to cash loans and food, esteem, status, motivation, information, companionship, emotional empathy, and understanding [30, 31]. Far less studied has been the influence of maternal mental health on child mental health . The few studies that have examined the effect of maternal mental health on the mental health of children exposed to political violence examined it as having a direct [14, 33], mediating [14, 32, 34–37], or a moderating effect (buffering effect) . Our previous study of the mental health of preschoolers in Gaza found that factors associated with resilience were maternal rated good health, higher maternal level of education, and less child exposure to traumatic events. Factors associated with vulnerability in child's mental health were poor maternal mental health, and male gender .
Because so far no published studies have addressed HRQOL of children in war, we used this measuring scheme to examine how violence and deprivation affect quality of life of preschoolers in the Gaza Strip, who have experienced longstanding military conflict throughout their lives. We used the PedsQL 4.0 to conceptualize the effects of war on children beyond PTSD. While there is no reference data for quality of life for children in war, we expect that the quality of life of Palestinian preschoolers is much worse than that of the American reference population, and similar to that of American children with chronic diseases. Based on review of factors associated with mental health of children exposed to war [14, 17–20, 25, 30–32, 38], we postulate that the health-related quality of life declines with both direct and indirect exposures to violence, and with increased number of exposures to traumatic events. Beit Hanoun, one of the districts we sampled from, lies in the borders and has high level of confrontation, so we expect that health-related quality of life of preschoolers in Beit Hanoun to be lower than the rest of the study sample. In addition to exposures to violence, we hypothesize that other factors are negatively associated with health-related quality of life and physical health and psychosocial health subscales: deprivation, low maternal education, inadequate social support, and male gender. In addition, we expected that HRQOL would correlate with other measures of health such as stunting and the child's mental health as well as with mental and self-reported overall health of the mother. As a secondary aim, we explored the feasibility, reliability and content validity of PedsQL in the study sample to document its relevance for the study of children exposed to political violence.