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(2022)
Compounding inequalities: Adolescent psychosocial wellbeing and resilience among refugee and host communities in Jordan during the COVID-19 pandemicPLoS ONE, 17
F. Samuels, N. Jones, B. Hamad (2017)
Psychosocial support for adolescent girls in post-conflict settings: beyond a health systems approachHealth Policy and Planning, 32
(2021)
The State of the World's Children 2021State of the World's Children
Catherine Porter, M. Favara, A. Hittmeyer, D. Scott, A. Jiménez, Revathi Ellanki, T. Woldehanna, Le Duc, M. Craske, A. Stein (2021)
Impact of the COVID-19 pandemic on anxiety and depression symptoms of young people in the global south: evidence from a four-country cohort studyBMJ Open, 11
Anushka Ataullahjan, M. Samara, T. Betancourt, Z. Bhutta (2020)
Mitigating toxic stress in children affected by conflict and displacementThe BMJ, 371
B. Hamad, N. Jones, Ingrid Gercama (2020)
Adolescent access to health services in fragile and conflict-affected contexts: The case of the Gaza StripConflict and Health, 15
S. Blakemore (2019)
Adolescence and mental healthThe Lancet, 393
M. Kamali, Mariella Munyuzangabo, F. Siddiqui, M. Gaffey, Sarah Meteke, D. Als, Reena Jain, A. Radhakrishnan, Shailja Shah, Anushka Ataullahjan, Z. Bhutta (2020)
Delivering mental health and psychosocial support interventions to women and children in conflict settings: a systematic reviewBMJ Global Health, 5
M. Favara, R. Freund, Catherine Porter, Alan Sánchez, D. Scott (2022)
Young Lives, Interrupted: Short-Term Effects of the COVID-19 Pandemic on Adolescents in Low- and Middle-Income CountriesThe Journal of Development Studies, 58
Sarah Baird, Z. Bhutta, B. Hamad, Joan Hamory, N. Jones, Jennifer Muz (2019)
Do restrictive gender attitudes and norms influence physical and mental health during very young Adolescence? Evidence from Bangladesh and EthiopiaSSM - Population Health, 9
Lisa Croke (2018)
Depression in Adolescents: AAP Updates Guidelines on Diagnosis and Treatment.American family physician, 98 7
‘Occupied Palestinian Territory. Emergency Type: Chronic Conflict and Outbreak’
G. Veronese, F. Mahamid, Dana Bdier, Rachel Pancake (2021)
Stress of COVID-19 and mental health outcomes in Palestine: the mediating role of well-being and resilienceHealth Psychology Report, 9
Shakuntala Banaji, S. Livingstone, Anulekha Nandi, Mariya Stoilova (2018)
Instrumentalising the digital: adolescents’ engagement with ICTs in low- and middle-income countriesDevelopment in Practice, 28
Abu Hamad BA, et al. 2022. Exploring the gendered mental health experiences of adolescents in Gaza during the Covid-19 pandemic. Adv Glob Health, 1: 1. DOI: https://doi.org/10.1525/agh.2022.1730691 RESEARCH ARTICLE Exploring the gendered mental health experiences of adolescents in Gaza during the Covid-19 pandemic 1, 2 3 4 Bassam A. Abu Hamad *, Nicola A. Jones , Sarah J. Baird , Shoroq H. Abuhamad , 4 3 5 Riyad A. Diab , Erin M. Oakley , and Agnieszka M. Małachowska Adolescent mental health is increasingly recognized as a critical concern. Globally, suicide is among the top 5 causes of death for 15–19-year-olds (girls and boys). In the Middle East and North Africa, the prevalence of mental disorders (17.3% for girls and 16.8% for boys) is the second highest in the world. The Covid-19 pandemic has exacerbated adolescents’ vulnerabilities, particularly through the impacts of lockdowns and school closures. This article explores adolescent experiences in Gaza, drawing on mixed-methods research carried out in late 2020 in refugee camps (29%) and urban settings (71%). The sample involved phone surveys with 505 adolescent girls and boys (12–19 years) and their caregivers, in-depth interviews with a subsample of 77 adolescents, and 9 key informant interviews with service providers. Using the Patient Health Questionnaire-8, 9% of adolescents show signs of moderate-to-severe depression, and 19% reported moderate-to-severe anxiety, according to the Generalized Anxiety Disorder-7, with older adolescents (15– 19 years) more vulnerable overall, and older girls more prone to self-harm ideation. However, older boys were significantly more likely to turn to substance use as a coping mechanism than older girls (18% vs. 6%). The drivers of these negative mental health impacts during the pandemic include deepening household economic vulnerabilities, heightened intra-family tensions (boys and men spending more time at home, increasing domestic work burdens on girls and women), and isolation from peer networks, especially for girls. We conclude by discussing implications for policy and programming, in line with Sustainable Development Goal 3, to promote mental health and well-being for all. Measures include investing in age- and gender- responsive interventions (including social protection) to support positive coping repertoires among adolescents, mitigating risks of substance abuse, investing in counseling services (online and in-person), and paying particular attention to the most disadvantaged adolescents, especially those out of formal education. Keywords: Adolescent, Gaza, Covid-19, Mental, Health Introduction vulnerabilities in the Middle East and North Africa (MENA) Adolescent mental health is increasingly recognized as region are more pressing still: the prevalence of mental a critical concern globally, with recent data indicating that disorders (17.3% for girls and 16.8% for boys) is the sec- suicide is one of the top 5 causes of death for boys and ond highest in the world [1]. The Covid-19 pandemic, with girls aged 15–19 years [1]. Adolescent psychosocial associated lockdowns and school closures, has exacerbated the situation. There is, however, limited available evidence around the psychosocial and mental health of adolescents School of Public Health, Al-Quds University, Gaza, State of Palestine in conflict affected contexts particularly during Covid-19 Gender and Adolescence: Global Evidence (GAGE), and ODI, pandemic [2, 3]. London, UK To explore this issue in the MENA context, this article Department of Global Health, Milken Institute School of focuses on the experiences of adolescents in the Gaza Public Health, George Washington University, Washington, DC, Strip, drawing on mixed-methods research carried out USA in late 2020 in refugee camp and noncamp settings. The Gender and Adolescence: Global Evidence (GAGE), Gaza, State sample involved phone surveys with 505 adolescent girls of Palestine and boys (aged 12–19 years) and their caregivers, in- Gender and Adolescence: Global Evidence (GAGE), GAGE MENA Operations Advisor, Warsaw, Poland depthqualitative interviewswithasubsampleof77ado- lescents, and 9 key informant interviews with service * Corresponding author: Email: ghsrcb@gmail.com providers. Art. 1(1) page 2 of 12 Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza Drawing on self-reported measures of anxiety (using found rates of depression, anxiety, and post-traumatic the Generalized Anxiety Disorder, GAD-7 ) and depression stress disorder (PTSD) as high as 70% [8, 9]—with poverty (using the Patient Health Questionnaire, PHQ-8 ), as well and war being the main drivers (for girls and boys alike). as modules related to whether adolescents had received Some studies have found that while girls and young support during the pandemic and their access to peer women are less stressed by economic hardship than their networks and trusted adults, we explore the patterning male peers [10], they are considerably more disadvantaged of adolescent mental health. We pay particular attention by mobility constraints—which also preclude access to to gender differences and educational status. We also dis- social support—and by the need to uphold family honor cuss the key drivers of the mental health toll of the pan- [8]. When asked to identify the most important health demic, including deepening household economic issue they faced, 26.1% of young women reported psycho- vulnerabilities due to pandemic-related lockdowns; logical problems [11]. heightened intra-family tensions and isolation from peer Before the Covid-19 pandemic, there were a large num- networks due to the closure of schools and recreational ber of mainly nongovernmental and community-based centers. organizations providing psychosocial services in Gaza, but The article concludes by discussing the implications of only two—the Ministry of Health and the Gaza Community our findings for policy and programming, and making Mental Health Programme—provide specialist services progress toward the Sustainable Development Goals [12]. The Ministry (the main service provider and regula- (SDGs), particularly SDG targets 3.4, “to promote mental tor) operates 6 community mental health centers and health and well-being for all,” SDG 1.5 on “promoting provides inpatient care (psychiatry) at Gaza’s only mental resilience among the poor and people in vulnerable health hospital, while the United Nations Relief and Works situations,” and SDG 10, “ensuring equal opportunity and Agency for Palestine Refugees in the Near East (UNRWA) is reducing inequalities of outcome”—recognizing, as the the second major provider, delivering preventive services World Health Organization (WHO) has powerfully argued, at its health and relief centers. UNRWA and the Ministry that “mental ill-health is both a consequence and a cause both also run a large-scale school counseling program. of inequalities” [4]. Despite the range of services available, organizational, cul- tural, and psychological barriers often prevent young peo- ple accessing them, and services for adolescents are rarely Background tailored to their age or gender [12]. Sociopolitical and economic context as determinants of mental health Covid-19 context in Gaza Adolescence is a time of heightened psychosocial vulner- Following the first reported cases of Covid-19 in the West ability; half of all mental illnesses begin by age 14, and Bank in March 2020, the President of the State of Pales- neuropsychiatric disorders are the leading cause of disabil- tine declared a state of emergency, closing schools and ity in adolescence (1.6%). Girls are more likely (than both places of worship. Lockdown measures included curfews, younger girls and their male peers) to show signs of men- restrictions on movement within and across governorates, tal disorders, especially anxiety and depression [5]. As and strict penalties for noncompliance with social distanc- demands on their time grow, girls have fewer opportuni- ing policies [13]. Some primary health care centers were ties to pursue their own interests and identities; they are closed as resources were redeployed to combat the pan- increasingly isolated socially as their bodies mature, often demic [14]. Notwithstanding, serious concerns about how being pulled out of school, deprived of contact with their quickly Covid-19 would spread in Gaza (a very densely friends, and confined to the home—especially upon mar- populated area), the consequences of the Israeli blockade riage. In conflict-affected contexts in particular, girls are and the limited number of entry points to the Gaza Strip often at greater risk of sexual and gender-based violence (just two) have played a somewhat protective role in lim- and the resulting psychosocial trauma [6]. There are also iting the rapid transmission of the virus. emerging challenges linked to the rapidly expanding As of December 2021, there were 457,950 cases of exposure to digital spaces, in the absence of adequate Covid-19 reported in Palestine, including 186,125 in Gaza guidance on how to stay safe online [7]. [15]. The total number of deaths was 4,770, with 1,627 in Gaza (case fatality rate of 1%) [15]. At the time of writing Overview of adolescent mental health (February 2022), there were 2,758 active cases, with 1,783 vulnerabilities and mental health services in Gaza in Gaza [15]. Palestine started a vaccination program in The evidence on psychosocial well-being and mental late February 2021 in Gaza, and by December 2021, health of adolescents in Gaza is complex. Studies have almost 1.4 million people had been fully vaccinated, including 378,487 in Gaza (representing approximately 26% of the population overall but just 18% of the Gazan 1. Anxiety was assessed using the Generalized Anxiety Disorder 7 (GAD-7) scale, a screening tool routinely used to population) [15]. test for various anxiety disorders. A score of 10 or higher indicates the presence of moderate-to-severe anxiety. Materials and methods 2. The Patient Health Questionnaire (PHQ-8) is a short Study population and sampling approach screening tool for depression, which scores patients on a scale This article draws on the findings of mixed-method of 1–24. A PHQ-8 score of 10 or higher indicates the presence of moderate-to-severe depression. research carried out between October 2020 and January Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza Art. 1(1) page 3 of 12 Table 1. Characteristics of surveyed adolescents Table 2. Characteristics of total qualitative (n ¼ 505) adolescents’ sample (n ¼ 77) Variable Number Percentage Variable Number Male 251 49.7 Male 32 Female 254 50.3 Female 45 Age 12–14 201 39.8 Age 12–14 22 Age 15–19 304 60.2 Age 15–19 55 Living in a refugee camp 147 29.1 Registered refugee 61 Living outside refugee camp 358 70.9 Non-refugee 16 Registered refugee 327 64.8 Having a functional disability 15 Non-refugee 178 35.2 Not having disability 62 Having a functional disability 54 17.8 Ever married 8 Not having disability 250 82.2 Never married 69 Ever married 50 9.9 Out-of-school boys 5 Never married 455 90.1 Out-of-school girls 4 Married adolescent lives with in- 29 58.0 Out-of-school (boys and girls) 9 laws/extended family Total 77 Out-of-school boys 59 23.5 Out-of-school girls 49 19.3 were conducted using tablets and computer-assisted Out-of-school adolescents in total 108 21.4 telephone interviewing software. The response rate was (boys and girls) high (90%). The survey collected data on education, health and nutrition, mobility and social opportunities, paid work, 2021 in 5 governorates of the Gaza Strip. Quantitative and community impacts of Covid-19, as well as household data was collected through phone surveys with 505 girls income, health and food security, and pandemic impacts and boys aged 12–19 years and their caregivers. Partici- (see the Gender and Adolescence: Global Evidence [GAGE] pants were selected randomly using a sampling frame website for the survey instruments) [16]. It also asked provided by the Palestinian Central Bureau of Statistics about participants’ psychosocial well-being during the (PCBS). Subsamples of vulnerable and disadvantaged ado- pandemic and what challenges they faced. It included lescents were drawn from camps and urban settings in all self-reported measures of anxiety (using the Generalized 5 governorates through a snowballing sampling tech- Anxiety Disorder, GAD-7) and depression (using the nique, including girls and boys who had dropped out of Patient Health Questionnaire, PHQ-8), and asked about school (see Table 1 for more details). ability to seek help through support networks and trusted Quantitative data were complemented by 77 qualita- persons. Coping was measured using the Brief Resilient tive virtual interviews with a purposively selected sample Coping Scale (BRCS) , and aseparateBRCSscale that of adolescent boys and girls to complement the survey, includes items on coping during Covid-19. including those in and out of school. In-person interviews were conducted with adolescents with a hearing impair- ment, in a convenient and safe location, facilitated by Qualitative data a sign language translator. There were also 9 virtual key A one-day training session was conducted virtually to ori- informant interviews conducted with selected community ent 4 qualitative researchers on the data collection process leaders, education and health providers, and health and and tools, which were refined after piloting. The average social workers (see Table 2 for more details). duration of each interview was 60 min, and for key infor- mant interviews, 45 min. A debriefing session was con- ducted virtually immediately after data collection to Data collection and analysis discuss the emerging findings. Quantitative data Following a 3-day training course to orient 12 female data collectors from the localities surveyed and 3 female super- visors on the quantitative data collection process and sur- 3. BRCS is a 4-item scale (0–16) that measures tendencies to cope with stress in a highly adaptive manner. A score of 0–9 vey administration, the survey (piloted with 38 indicates low resilient coping and a score of 13–16 indicates households) and the written protocol developed for the high resilient coping. We adapted BRCS by adding Covid-19 data collection process were translated into Arabic. Phone specific 5 items (0–20). A score of 0–11 indicates low resilient surveys (60 min for adolescents; 20 min for caregivers) coping and a score of 16–20 indicates high resilient coping. Art. 1(1) page 4 of 12 Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza Data analysis according to the intersecting disadvantages they face. Cleaning and analysis of the quantitative data was con- Here we discuss the multidimensional effects on their ducted using the Statistical Package for the Social Sciences capabilities—health and nutrition, education and learning, (SPSS) 25. Descriptive analysis was conducted first fol- bodily integrity and freedom from violence, connected- lowed by inferential analysis to explore the relationships ness, livelihoods, and voice and agency—and the toll that between the study variables. P value was considered as this has had on their psychosocial well-being and mental statistically significant when it equals or falls under health. We discuss each of these in turn below (see also 0.05. The qualitative interviews were recorded, tran- Table S1). scribed, translated, and thematically coded using a coding book informed by the GAGE conceptual framework [17]. Health and nutrition-related challenges Coding was completed using MAXQDA 12 software. When asked about their overall health status, 90% of adolescents perceived their health as “good” or “very Ethics good”; however, 19% of girls and 17% of boys said they The international code of ethics was followed, and permis- felt their health had worsened since the onset of the pan- sions for the study were sought and granted from Gaza’s demic. Among those who reported needing to see Helsinki Committee and the Ministry of Interior in Gaza. a health-care provider, 28% of boys and 33% of girls had Research ethics approvals were also obtained from Al- not been able to due to pandemic-related restrictions; Quds University and George Washington University. Verbal 16% of girls and 9% of boys were unable to get necessary consent was obtained from participants aged 18 years and medications, though gender differences were not statisti- above, and verbal assent was sought for those under 18 cally significant (see Table S1). Only 80% of adolescents years, as well as verbal consent from their caregiver (typ- who had dropped out of school perceived their health as ically the primary female caregiver). Enumerators were “good” or “very good” compared to 92% of those enrolled oriented on how to interact with adolescents in an age- in school. To the best of the authors’ knowledge, no evi- and gender-responsive way. dence exists that shows the differences in perceptions about health status between adolescents who were Limitations of the study enrolled versus those who were not enrolled in education As with other cross-sectional surveys, this study takes prior to Covid-19 in Gaza. a snapshot of the situation at a point in time. Self- Our survey results suggest that the pandemic has had reported measures may contribute to recall bias as parti- a major impact on adolescent food security, with 42.6% of cipants are sometimes unable to describe their experi- boys and 38.2% of girls reporting having been hungry due ences, feelings, and attitudes accurately. The phone to lack of food at least once during the past 4 weeks. survey was also a major barrier to engaging in more par- Furthermore, 30% of boys and 24% of girls said they had ticipatory interactive qualitative methods. Participants been hungry more often during the pandemic. Adoles- may also have had limited privacy during the phone calls, cents also reported consuming less diverse diets as a result particularly girls living in camps. However, the research of the pandemic; 42% of boys and 31% of girls said they team had received training to address such challenges. consumed less protein and 38% ate less fruit and vitamin A-rich vegetables. More adolescents who were out of Key findings school reported experiencing hunger (61%) in the past We now turn to our findings. The characteristics of the month than their counterparts who were enrolled (35%). adolescents surveyed can be seen in Table 1 and Table 2. Our findings also suggest that Covid-19 has visible We begin with a discussion of adolescent experiences dur- impacts on physical health, including sleeping fewer ing Covid-19 and the multiple and intersecting challenges hours (18% of boys and 19% of girls) (Table 4). The that they faced across a range of domains: health and food impact of the pandemic on levels of physical activity was security, education, age- and gender-based risks of vio- particularly striking: 45% of boys and 18% of girls lence, social connectedness, voice and agency, and eco- reported a reduction in the number of days on which they nomic security and livelihood opportunities. After did physical activity for at least 30 min (girls’ participation discussing adolescent coping responses, we then present in physical activities was limited even before the our findings on adolescent outcomes from 3 psychosocial pandemic) [18]. well-being and mental health scales, to assess the mental Our survey also found some gender and age differences health toll of the pandemic on adolescent girls and boys. in other coping responses, with significant health implica- We note that while the qualitative findings inform the tions. Perhaps not surprisingly, cigarette smoking was far narrative discussion below, due to space constraints, we more common among boys: 15% of those aged 15 and present only a limited number of illustrative quotes in older reported ever having smoked cigarettes, and 17% Table 3 and refer to these in our presentation of the had ever smoked shisha pipe (the figure for girls the same findings. age was just 2%). Moreover, among boys who were regular smokers, 35% reported an increase in smoking during the Adolescent experiences during Covid-19 pandemic. However, 57% of regular smokers said they had Our findings suggest that the pandemic and associated either reduced the number of cigarettes smoked or public health measures have impacted adolescents’ psy- stopped smoking altogether; qualitative data suggests this chosocial well-being and mental health differently is probably due to financial constraints. One striking Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza Art. 1(1) page 5 of 12 Table 3. Adolescent voices on the psychosocial experiences of the Covid-19 pandemic Quote 1: I know a girl who is 21 years old, and she died because she faces violence from her dad. There are also a lot of people who face depression. Psychiatric therapy sessions are urgently needed as there are many girls who face violence during the corona crisis and we need to protect them. Also, there needs to be a special helpline for girls to call for help whenever they are in danger as there are a lot of girls who suffer. (16-year-old adolescent girl, Gaza) Quote 2: There is more connection in my family than before Corona; we become closer than before. So, I try as much as I can to enjoy the family atmosphere. Additionally, I try to contact my friends usually; I contact them every day. Furthermore, I try to be active on the social media as an active girl who shares in the youth groups; we talk about several youth issues and the issues which the youth suffer from. Additionally, I read novels and I participate in online volunteer activities. (18-year-old adolescent girl, Gaza) Quote 3: The corona situation has affected relationships and friendships. For example, now no one visits us or enters our house! They’re scared, and we don’t want them to come because we might God forbids but we might have something and infect them, and of course, they don’t want to visit because they’re scared for their lives and everyone is afraid and wants to secure themselves. (19-year-old adolescent girl, Gaza) Quote 4: The area is dead economically, there is no movement at all, neither cars nor anything else, the police are present all the time, and I provide my greetings to them and for the white army [nurses] because of their effort in Gaza to prevent the spread of the virus, and at the level of movement, generally it’s a slow death economically ... the economic situation is so bad honestly! (17-year-old adolescent boy, Gaza, out-of-school) Quote 5: During the pandemic the males say that are watching TV serials continuously while the females say that they have tons of household chores, like washing dishes, sweeping, cleaning, and laundry. (19-year-old adolescent boy, Gaza) Quote 6: I feel bored and hate life ... No one can help, nobody was able to help me with this .. . . For example, when you tell someone that you feel bored, they would say I feel more bored and lonely than you! I mean no one cares about this, everyone feels bored and lonely and that’s it. (17-year-old adolescent boy, Gaza) Quote 7: This situation [coronavirus pandemic] made a ring of the negative energy around me because of the external conditions and the worries regarding the situation in the Gaza Strip because we don’t have in Gaza the capabilities to fight this virus. So, the negative feeling which I have passed is the fear; I feel worried and afraid if the situation evolves more than this and the virus becomes widespread. (18-year-old adolescent girl, Gaza, out of school) Quote 8: A close friend of mine from school tried to commit suicide during the coronavirus period. I asked her why she said that she has a difficult life and that she can’t tell anyone about it .... I told her it was wrong, and that she will die an infidel .. .. I think it was both violence and the financial situation .... She is the only daughter ... And she is under a lot of pressure at home. (15-year- old adolescent girl, Gaza) difference is that 28% of adolescents who are out of problems, resource deficits, and/or time constraints; school reported ever smoking, compared to 9% of their 24% of boys and 34% of girls reported a lack of (or peers still in school. unreliable) Internet connections, with statically signifi- Among adolescents aged 15 and older, 22% of boys cant gender differences (Table S1). and 8% of girls thought that marijuana consumption had increased among adolescents of the same age and gender Bodily integrity and violence-related challenges as them, while 17% of boys and 8% of girls thought that When asked to think about their own community, older young people of the same age and gender had increased adolescents (aged 15–19) reported that household vio- their use of other illicit drugs (see Table 4). lence had increased since the pandemic began, against boys (69%) and girls (67%), with no statistically significant Education and learning-related challenges difference by gender (see Table S1). However, they also Our survey suggests that the school enrollment rate observed that there was increased household violence before Covid-19 favored girls (77% for boys, 81% for against women by male family members (reported by girls). The vast majority (83%) of in-school girls and 65% of boys and 73% of girls). When asked about chal- boys (76%) received some form of family support to lenges that other adolescents might be experiencing, 49% enable them to continue their studies during Covid- of both boys and girls noted that being “yelled at” by related school closures, ranging from help with school- parents had increased. Almost two-thirds of adolescents work (53%), giving them a space to study (80%) or (64%) who had dropped out of school reported that par- reducing their time spent on chores (31%). Among ents yelling was a challenge for them during the pan- those enrolled, 68% of girls and 57% of boys reported demic; 47% of enrolled adolescents reported the same. having had some form of contact with their teacher in Furthermore, 20% responded that fathers were more vio- the 7 days prior to the survey; however, only 45% of lent physically toward mothers, 24% said parents hitting boys and 58% of girls had received feedback from adolescents had increased (reported by 25% of boys and a teacher in the same period (see Table S1). Gender 23% of girls), and 30% of boys and 39% of girls reported differences in each case were statistically significant. A that bullying by siblings had increased. sizable number of respondents said that their ability to The mean score for adolescent girls in the combined access distance learning was impaired by connectivity violence index (calculated from responses to the vignette Art. 1(1) page 6 of 12 Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza Table 4. Distribution of responses related to adolescent coping and residence Male Female Variable Number Percentage Number Percentage Sig. People in the community are smoking and using shisha more (þ15), 124 81.6 125 84.5 0.507 n ¼ 300 Adolescent experienced disrupted sleep 51 20.3 64 25.2 0.191 Comparing the time right before Covid to now, adolescent is 44 17.5 48 18.9 0.594 sleeping less Adolescent slept less than 8 h in past 24 h 55 21.9 59 23.2 0.724 Adolescent reports fewer days of physical activity (30þ min) than 112 44.6 46 18.1 0.001 before pandemic Adolescent ever smoked cigarettes 23 15.0 0 0.0 0.001 Adolescent ever smoked shisha pipe 26 17 3 2 0.001 Adolescent increased smoking cigarettes since pandemic (among 8 34.8 smokers) Adolescent decreased/stopped smoking cigarettes since pandemic 13 56.5 (among smokers) Adolescent increased smoking shisha since pandemic (among 3 12 2 66.7 0.019 smokers) Adolescent decreased/stopped shisha since pandemic (among 17 68 1 33.3 0.236 smokers) Respondent thinks adolescents of own gender smoke marijuana in 60 43.5 27 20 0.001 community Respondent thinks adolescents smoking marijuana in community 30 21.7 11 8.1 0.002 has increased Respondent thinks adolescents of own gender use drugs in 44 32.4 21 15.8 0.002 community Respondent thinks adolescent drug use in community has increased 23 16.9 10 7.5 0.019 Brief Resilient Coping Scale (BRCS) Low Resilient Coping (BRCS 0–9) Low Resilient Coping (BRCS Covid-19 Specific 0–11) Characteristics of Number Percentage P Value Number Percentage P Value Adolescents Boys 71 28.5 0.087 90 35.9 0.694 Girls 63 24.9 82 32.3 Younger cohort 54 27.3 0.558 68 33.8 0.112 Older cohort 80 26.3 104 34.2 Living outside camp 79 22.1 0.001 116 32.4 0.334 Living in camp 55 38.2 56 38.1 Non-refugee 40 22.5 0.220 55 30.9 0.480 Refugee 94 29.0 117 35.8 Without disability 61 24.4 0.101 89 35.6 0.545 With disability 19 35.2 15 27.8 Never-married girls 53 26.1 0.058 59 28.9 0.055 Ever-married girls 10 20.0 23 46.0 In school pre-pandemic 107 27.2 0.355 115 29.0 0.001 Out of school pre- 27 25.0 57 52.8 pandemic Statistically significant. Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza Art. 1(1) page 7 of 12 exercise [16] about household violence being a challenge unable to buy enough food or had to change what they for adolescents in their community; 1.22 on a scale from eat, and many families were forced into debt. Most house- 0–4) is similar to that of boys (1.28), with no statistically holds (80%) reported worrying that they could not meet significant differences by gender. The qualitative findings, daily needs, 45% were unable to buy essential food items however, pointed to high levels of vulnerability among in the past 7 days, and 46% were unable to buy essential adolescent girls to gender-based violence that had been hygiene items in the past 7 days. Similarly, 93% reported exacerbated during the pandemic on account of house- that many households are selling assets, while 75.3% hold stress (see Table 3, Quote 1). reported an increase in begging. When adolescents were asked about particular stressors facing people the same Connectedness-related challenges age and gender as them, respondents most often identi- Nearly two-thirds of all adolescents (boys 68%; girls 65%) fied difficulties obtaining household items, which was agreed that household stress had increased since the onset a source of increased tension. Only 34% of caregivers of the pandemic. Our survey findings suggest that within reported receiving any cash assistance from any households, aggravated stress levels manifested in mem- organization. bers getting angry more quickly or arguing more often than before the pandemic (reported by 58% of boys and Voice and agency-related challenges 58% of girls). To learn more about adolescents’ supportive Girls, particularly older girls, were more likely to rely on networks during the pandemic, we asked whether the virtual methods to connect with friends. Among boys and level of support they received from friends and family had girls, 25% reported “hanging out” or playing with friends changed. Findings were mixed: 30% of boys and 37% of in person in the past week; this percentage rose to 44% girls reported receiving more support, while 19% of boys among boys and dropped to 6% among girls, with sta- and 11% of girls reported receiving less support, and the tistically significant gender differences. Nearly two-thirds gender differences were statistically significant. Similarly, of boys and three-quarters of girls reported spending there were mixed responses about giving support to more time on household chores and sibling care since others: 33.5% reported giving more support and 13% the start of the pandemic (see Table S1 and Table 3, reported giving less support, with no statistically signifi- Quote 5 which underscores the disproportionate domes- cant differences by gender. For those young people who tic and care work burden shouldered by girls during lock- reported that family support had been instrumental in downs). More girls (84%) than boys (78%) reported that their ability to cope with the stresses of the pandemic, their mobility had been moderately or completely closer bonds were family members were identified as restricted by the pandemic. Most notably, 48% of girls a positive spillover effect (see Table 3, Quote 2), although reported not having left the house in the past 7 days, these adolescents were in the minority. compared with 17% of boys, with statistically significant Our findings suggest that peer support was more lim- differences by gender. Only 9% of boys and 2% of girls ited. Only 57% of boys and 54% of girls said they had reported volunteering in community activities during the a friend they could trust, while 69% of both boys and girls pandemic. said they had an adult they could trust. Despite the impor- tance of peer interactions for adolescents, 21% of boys Adolescent coping and resilience and 34% of girls reported having no interaction with To measure coping, we used the BRCS and the BRCS Covid- friends, in-person or online, and the gender difference was 19 specific scale. Table 4 illustrates adolescent coping statistically significant. Young people in the qualitative strategies, both overall and in response to the pandemic. research underscored that friendships were being nega- The findings show a clear dichotomy in our sample, with tively affected by the pandemic-related social distancing 27% of all adolescents considered to have low resilience messages (see Table 3, Quote 3). More than half of boys and only 9% high resilience. (53%) and around two-thirds of girls (63%) had interacted On the Covid-19 specific scale, the proportion of ado- with friends virtually in the past week, either by text mes- lescents showing low levels of resilience was even higher saging, through social media, or playing online games; (34%); only 11% showed high resilience. Although in the gender differences were statistically significant. quantitative data boys were not significantly more likely to score low on resilience than girls, this was a pattern that Livelihoods-related challenges emerged starkly in the qualitative findings (Table 3, The already chronic financial hardship experienced by Quote 6). Similarly, age did not make a difference. households in Gaza has been exacerbated by the pan- On the Covid-19 specific BRCS (see Table 4), the pro- demic and associated measures. Our survey indicates that portions of boys and girls scoring high on resilience were more than a quarter of households in Gaza (28%) reported similar (10% for boys and 11% for girls). More worryingly, having lost employment due to Covid-19, permanently or 36% of boys and 32% of girls scored low on resilience, temporarily, and 58% lost some income. Our qualitative although gender differences were not statistically signifi- work underscored that adolescent boys were particularly cant (see Table 4). affected by the mobility restrictions as their predomi- In line with the broader disadvantages faced by adoles- nantly informal livelihoods are dependent on regular con- cents out of school, on the Covid-19 specific scale, adoles- tact with customers (Table 3, Quote 4). Similarly, more cents who had dropped out of school (53%) also exhibited than 95% of caregivers reported that their families were much lower levels of resilience than their counterparts Art. 1(1) page 8 of 12 Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza Table 5. Psychosocial and mental health challenges facing adolescents in Gaza during Covid-19 Boys Girls Variable Number Percentage Number Percentage Sig. More people are becoming very anxious or depressed 145 94.8 141 94.7 0.957 (þ15), n ¼ 302 There is an increase in thoughts about self-harm, or 80 53 87 58.4 0.346 people harming themselves (þ15), n ¼ 300 PHQ-8 Score 10 (Moderate-to-Severe If GAD-7 Score 10 Depression) (Moderate-to-Severe Anxiety) Differences in Mental Health Challenges by Number Percentage P Value Number Percentage P Value Characteristics Variables Boys 21 8.4 0.478 43 17.1 0.275 Girls 26 10.2 53 20.9 a a Younger cohort 10 5.0 0.006 21 10.4 0.001 Older cohort 37 12.2 75 24.8 Living outside camp 29 8.1 0.139 73 20.4 0.212 Living in camp 18 12.3 23 15.6 Non-refugee 20 11.2 0.276 50 22.5 0.148 Refugee 27 8.3 56 17.2 Without disability 30 12 0.852 62 24.9 0.899 With disability 7 13 13 24.1 Never-married girls 20 9.8 0.646 38 18.6 0.064 Ever-married girls 6 12 15 30.6 a a In school pre-pandemic 26 6.5 0.001 61 15.4 0.001 Out of school pre-pandemic 21 19.6 35 32.7 GAD-7 ¼ Generalized Anxiety Disorder 7; PHQ-8 ¼ Patient Health Questionnaire 8. Statistically significant. still in school (29%), with strong statistically significant Our findings also indicate that up to 9% of young differences. Similar inequalities in coping capabilities Gazans may be experiencing moderate-to-severe depres- were also reflected in the qualitative findings (see Table sion, with around 19% experiencing moderate-to-severe anxiety. Depression was assessed using the PHQ-8; results 3, Quote 7). showed that around 1 in every 10 adolescent participants had a score indicative of moderate-to-severe depression Psychosocial and mental health outcomes during (10). Girls reported higher PHQ-8 scores than boys Covid-19 (10% of girls scored 10 or higher, compared with 8% of Our findings suggest that Covid-19 has had devastating boys), though differences were not statistically significant. effects on the psychosocial well-being of adolescent in There were, however, significant differences by age: 12% Gaza. More than half of boys (53%) and girls (58%) aged of the older cohort scored 10 or higher, compared with 15 and older believed that there was an increase in 5% among the younger cohort. thoughts about self-harm or in the numbers of people Our survey also revealed a relatively high prevalence of harming themselves since the pandemic started. Height- moderate-to-severe anxiety. Around 19% of adolescents ened risk of suicidal ideation among adolescents was also were assessed as having moderate-to-severe anxiety, scor- echoed in the qualitative findings (see Table 3, Quote 8). ing 10 or higher on the GAD-7 scale. Rates were higher When asked about the mental health of people in their among girls (21%) than boys (17%) but differences were community, 95% of both boys and girls said they felt that not statistically significant (see Table 5). However, age was people were becoming more anxious and/or depressed an important factor: more of the older cohort (25%) (see Table 5). scored 10 or above on GAD-7 compared with the younger Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza Art. 1(1) page 9 of 12 cohort (10%), and there were strong statistically signifi- The response to Covid-19 has a catastrophic impact on cant differences. Findings also suggest that being in households and the national economy in Gaza. According school is a protective factor against developing anxiety; to the PCBS [25], in 2020, gross domestic product per 33% of adolescents who had left school scored 10 or capita declined by 14% and public debts increased by above on the GAD-7 anxiety scale, compared with 15% 24% (compared to 2019), putting further pressure on of their peers still in education, and the differences were households already struggling to meet basic needs, who strongly statistically significant. suffered an immediate drop in their income due to Covid- Interestingly, our findings affirm the reported links 19 [26]. Our findings are consistent with the literature between anxiety and depression and suggest that when around the effects of the pandemic in low- and middle- it comes to mental health challenges, one problem accent- income countries on adolescent [27, 28] and underscored uates the other [19]. We found strong correlations that the pandemic negatively impacted adolescent psy- between depression and anxiety (r ¼ 0.699), with strong chosocial well-being in multiple aspects especially for girls statistically significant associations between the two who suffer from compounded psychosocial vulnerabilities (P value ¼ 0.001). not only due to economic hardship but also violence at The poorest PHQ-8 scores were reported by children the household and community levels, decreased access to who left school before the onset of the pandemic; they basic livelihoods, limited access to education, inadequate scored 3 times higher than their peers who were still in interactions and connectedness to the people outside school, and differences between the two subgroups were their families, limited voice and agency, restrictive cultural statistically significant (see Table 5). norms, and discriminatory gender norms and practices, which exist all the time, but are often increased during crises [1, 2, 20]. Discussion Resilience and coping strategies are partly shaped by Our findings suggest that the pandemic has negatively gender roles and norms, but also underpinned by pre- impacted the key determinants of mental health among Covid vulnerabilities, especially in the case of young peo- adolescents in Gaza. It has increased poverty and unem- ple out of formal education, and adolescents’ access (or ployment, and food insecurity, and made it more difficult lack of) to formal and informal psychosocial support [2, for household to secure basic needs and earn their liveli- 20]. Adolescents are clearly struggling to be resilient in hood. Furthermore, it has reinforced restrictive gender thefaceofthe pandemic,withonlysmall proportions norms experienced by adolescent girls. All these factors scoring high on resilience on both scales. One-quarter of have worsened the already compromised psychosocial respondents scored low for resilience on the BRCS scale, well-being of adolescents in Gaza, manifested in high rates and one-third scored low on the Covid-19 specific scale. of depression, chronic anxiety, PTSD, psychosomatic reac- Despite their exposure to higher levels of stressors, girls tions, attention deficit disorder, loss of hope, chronic frus- maintained a resilience level similar to boys or even tration, and conduct disorders [2, 20–22]. This situation slightly better. This is probably due in part to girls and requires urgent attentionfrompolicymakers and boys facing similar socioeconomic and age-related chal- programmers. lenges [2, 20, 23], and to the more constructive coping Our study confirms that Covid-19 has put adolescent approaches they develop, such as investing in education boys and girls in Gaza at greater risk of anxiety, depression, and communicating on social media with peers, which and exacerbated chronic frustration. Despite adolescents’ helped them to counteract the consequences of those tendency to internalize problems [1, 19], a considerable daily stressors. As such, and as we discuss in the conclu- proportion of boys and girls scored more than 10 on the sions, our findings suggest a need to promote more pos- PHQ-8 depression and GAD-7 anxiety scales, indicating itive coping strategies among boys such as providing moderate-to-severe depression and anxiety (and note that training on resilience, conflict resolution and dealing with there may be some underreporting). It is worth noting stress, building basic life skills, investing in education, that credible evidence around the prevalence of depres- promoting adolescent access to psychosocial support, and sion and anxiety levels among adolescents in Gaza based strengthening ties and nurturing relationships between on PHQ-8 and GAD-7 scales (consecutively) during the pre- boys and their families. Covid-19 era is lacking. Although girls tend to adopt pos- itive coping approaches more so than boys [21–23], girls (especially older girls) had higher scores on the anxiety Conclusions Not only has the pandemic exacerbated preexisting vul- and depression scales, which reflects the greater multifac- nerabilities among adolescents, but it has brought new eted stressors they face, a phenomenon that has also been reported in other conflict-affected settings [24]. vulnerabilities, which risk leaving young people even fur- Our findings, consistent with the literature, also sug- ther behind. Our findings underscore the importance of gest that certain subgroups of adolescents are facing developing robust age- and gender-responsive psychoso- greater psychosocial stressors [24]. Girls (especially older cial and mental health interventions for adolescents as girls) and adolescents from poorer households are more part of any emergency response, targeting particular at- vulnerable, and again, in line with other studies [24], our risk groups, including adolescents who have dropped out findings indicate that children are least resilient when of school. The latter are more likely to lack access to sup- they are out of school. port and services, essential livelihoods, and opportunities Art. 1(1) page 10 of 12 Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza for socializing and interaction; therefore, they need to be of quantitative data is not ready yet for public sharing as it reached first. requires processing and measures to ensure data confiden- In line with the SDG 3 commitment to promote mental tiality and protecting rights of participants. Potential users health and well-being for all, this article reinforces the can contact the GAGE program hub office to enquire need to reconceptualize how we address psychosocial about use ahead of public archiving (gage@odi.org.uk). challenges facing adolescents during crises. Our findings underscore that mental health services and support Supplemental files should not be seen just as an “optional extra” but rather The supplemental files for this article can be found as as a critical component of life-course health promotion, follows: and to avoid longer term mental illnesses that can have Table S1. Adolescent experiences during Covid-19, and dramatic lifelong consequences. Our findings further sug- pre-existing vulnerabilities gest that adolescent mental health services should be incorporated into public health response plans to ensure Acknowledgments adolescent girls and boys can access the services, The World Health Organization’s child and adolescent resources, and information they need, and twinned with health team in the Eastern Mediterranean Region (EMRO) increasing social support through peer-to-peer interac- along with WHO Headquarters (HQ) team provided invalu- tions, school-based interventions, and the use of able support for the development of this publication. Spe- adolescent-friendly approaches such as online platforms. cial thanks also go for Eman Abu Hamra, Ahmed Qandeel, In this regard, it is vital to engage young people—girls and and Nadeen Al Redaisy for their contribution to data col- boys and from diverse social backgrounds—in emergency lection. The authors would like to sincerely thank the and recovery responses, allocating resources to them and adolescent girls and boys, their caregivers, and key infor- enabling them to meaningfully contribute to policy dia- mants in the State of Palestine for sharing their invaluable logue and program design and evaluation. perspectives and insights. The authors also wish to thank In keeping with the SDG 10 target on reducing inequal- Kathryn O’Neill for the editorial support. ity, gender inequalities that have resulted in greater vul- nerabilities for girls, and older girls should be addressed Funding by progressively developing more gender-equitable poli- The WHO Regional Office for the Eastern Mediterranean cies and programs, and engaging in their implementation and The Bill and Melinda Gates Foundation (# INV- with men and women, schools, youth and women’s 003527), awarded through the NBER, provided funds to groups, community leaders, religious leaders, and policy- carry out this research. makers. Our findings indicate that many adolescents (especially girls) experience loneliness, are home-bound, Competing interests and have limited access to support (from trusted adults or The authors declare that they have no competing friends); this calls for greater investments in psychosocial interests. counseling as well as informal support through peer-to- peer support groups at schools, in the community, or Author contributions online [29, 30]. Conceptualization: BAH, NJ, SB, EO, AM. Finally, in line with SDG target 1.5 which aims to build Data curation: SB, EO, AM, SAH, RD. the resilience of people living in poverty and in vulnerable Formal analysis: SB, EO, AM, SAH, RD, BAH, NJ. situations, strategies and policies at the national level Funding acquisition: NJ, SB, EO, AM, BAH. should address the key determinants of psychosocial and Investigation: BAH, NJ, SB, EO, AM, RD, SA. mental well-being to induce positive change, including Methodology: SAH, NJ, BAH, SB, EO. economic growth and access to livelihood opportunities Project administration: SB, EO, AM, BAH. for youth, especially those out of formal education as our Supervision and validation: SB, EO, AM, BAH. findings underscored. Greater efforts are also needed to Writing—original draft: BAH, SAH, RD, NJ. enhance resilience, educate adolescents and the commu- Writing—review and editing: BAH, NJ, AM, SB, SAH, nity at large about the consequences of negative coping approaches such as substance abuse and smoking (espe- RD, EO. Read and approved the submission of this manuscript cially among boys), and encourage positive coping strate- for publication: All authors. gies, such as building life skills, enhancing access to recreational and voluntary activities, and seeking formal and informal support. Improving educational quality, References investing in interventions to strengthen community cohe- 1. United Nations Children’s Fund. The state of the sion, and ultimately political resolution of the Palestinian world’s children 2021: on my mind—promoting, pro- case are also critical as they underpin the chronic psycho- tecting and caring for children’s mental health. New social vulnerabilities that young people in Gaza experience. York (NY): United Nations Children’s Fund; 2021. 2. Samuels F, Jones N, Abu Hamad B. Psychosocial sup- Data accessibility statement port for adolescent girls in post-conflict settings: The data collected in this study is subject for sharing beyond a health systems approach. Health Policy Plan. according to GAGE data sharing policy. Currently, the set 2017;32(5):40-51. Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza Art. 1(1) page 11 of 12 3. Veronese G, Mahamid F, Bdier D, Pancake R. Stress of ID¼07E7BFC52EF3C95D2540EF23F30FEDED& COVID-19 and mental health outcomes in Palestine: temp¼False&tx¼0&source¼Report. the mediating role of well-being and resilience. 16. Baird S, Abu Hamad B, Jones N, Małachowska A, Oak- Health Psychol Rep. 2021;9(4):398-410. doi:10.5114/ ley E. Covid-19 phone survey (round 2) in Jordan and Palestine. Core respondent module. London (UK): hpr.2021.104490. Gender and Adolescence: Global Evidence; 2020. 4. World Health Organization. Fact Sheets on Sustainable 17. GAGE consortium. Gender and Adolescence. Why Development Goals: Health Targets, Mental Health. understanding adolescent capabilities, change strate- Copenhagen (Denmark): WHO Regional Office for Eur- gies and contexts matters. 2nd ed. London (UK): ope; 2018 [cited 2022 Jan 16]. Available from: https:// Gender and Adolescence: Global Evidence; 2019. www.euro.who.int/__data/assets/pdf_file/0017/ 18. Abu Hamad B, Jones N, Gercama I. Adolescent access 348011/Fact-sheet-SDG-Mental-health-UPDATE-02-05- to health services in fragile and conflict-affected con- 2018.pdf. texts: the case of the Gaza Strip. Confl Health. 2021; 5. Blakemore SJ. Adolescence and mental health. Lancet. 15(1):40. doi:10.1186/s13031-021-00379-0. 2019;393(10185):2030-1. doi:10.1016/S0140-6736 19. American Academy of Pediatrics. Depression in ado- (19)31013-X. PMID:31106741. lescents: AAP updates guidelines on diagnosis and 6. Abu Hamad B, Jones N, Pincock K. “It’s the fear that is treatment. Pediatrics. 2018;141(3):e20174081-2. killing us, not the actual disease!” Covid-19: an 20. Abu Hamad B, Jones N, Samuels F. Mental health and unfolding crisis for adolescents in humanitarian set- psychosocial challenges facing adolescent girls in tings. In: Jones N, Pincock K, Abu Hamad B, editors. conflict-affected settings: the case of the Gaza Strip. Adolescents in humanitarian crisis: displacement, Arab J Psychiatr. 2020;31(2):169-80. doi:10.12816/ gender and social inequality. London: Routledge; 2021. p. 182-97. 21. Baird B, Bhutta Z, Abu Hamad B, Hicks J, Jones N, Muz 7. Banaji S, Livingstone S, Nandi A, Stoilova M. Instru- J. Do restrictive gender attitudes and norms influence mentalizing the digital: adolescents’ engagement with physical and mental health during very young adoles- ICTs in low- and middle-income countries. Dev Pract. cence? Evidence from Bangladesh and Ethiopia. SSM 2018;28(3):432-43. Popul Health. 2019;9:100480. 8. Abu Hamad B, Jones N, Al Bayoumi N, Samuels F. 22. Jones N, Abu Hamad B. The hidden costs of the Mental health and psychosocial support service pro- Gaza-Israeli conflict: adolescent girls’ psycho-social vision for adolescent girls in post-conflict settings: the wellbeing. London (UK): ODI; 2015. case of the Gaza strip. London (UK): Overseas Devel- 23. Samuels F, Jones N, Abu Hamad B. Psychosocial sup- opment Institute; 2015. port for adolescent girls in post-conflict settings: 9. Ministry of Health. Mental Health Directorate Human a social and gendered norms approach. Humanitarian Resource Plan 2014-2024. Ramallah (Palestine): Min- Exchange Number. 2018;72:26-9. istry of Health; 2014. 24. Jones N, Baird S, Abu Hamad B, Bhutta ZA, Oakley E, 10. United Nations Population Fund. Palestine 2030: Shah M, et al. Compounding inequalities: adolescent demographic transition in Palestine and what it psychosocial wellbeing and resilience among refugee means for development. Ramallah (Palestine): United and host communities in Jordan during the COVID-19 Nations Population Fund; 2016. pandemic. PLoS One. 2022;17(2):e0261773. doi:10. 11. Palestinian Central Bureau of Statistics. Palestinian 1371/journal.pone.0261773. youth survey, 2015: main findings. Ramallah (Pales- 25. Palestinian Central Bureau of Statistics. Statistical tine): Palestinian Central Bureau of Statistics; 2016. Yearbook of Palestine 2020. Ramallah (Palestine): 12. Abu Hamad B, Gercama I, Jones N, Al Bayoumi N. Palestinian Central Bureau of Statistics; 2020 [cited “I prefer to stay silent”. Exploring opportunities for 2022 Feb 10]. Available from: https://www.pcbs.gov. and challenges to adolescents’ psychosocial and men- ps/Downloads/book2545.pdf. tal health in Gaza. London (UK): Gender and Adoles- 26. Gavi, the Vaccine Alliance. How does COVID-19 com- cence: Global Evidence; 2018. pare to past pandemics? Gavi, The Vaccine Alliance. 13. United Nations Health Cluster. ‘Occupied Palestinian 2020 June 1 [cited 2022 Jan 5]. Available from: www. Territory. Emergency Type: Chronic Conflict and Out- gavi.org/vaccineswork/how-does-covid-19-compare- break’. Health Cluster Bulletin, 2020 April, 1 April–30 past-pandemics. April. 27. Favara M, Freund R, Porter C, Sa´nchez A, Scott D. Young 14. UNFPA. Assessment report: impact of COVID-19 lives, interrupted: short-term effects of the COVID-19 counter measures on SRHR sector in Palestine. Pales- pandemic on adolescents in low- and middle-income tine: UNFPA; 2020. countries. COVID Economics: Vetted and Real-Time 15. World Health Organization. Coronavirus Disease 2021 Papers. 2021;67(4) [cited 2022 Jan 13]. Available from: (COVID-19) Situation Report 85. Geneva (Switzerland): https://cepr.org/sites/default/files/ World Health Organization; 2021 [cited 2022 Mar 02]. CovidEconomics67.pdf. Available from: https://who18.createsend.com/ 28. Porter C, Favara M, Hittmeyer A, Scott D, Sanchez campaigns/reports/viewCampaign.aspx?d¼j& Jime´nez A, Ellanki R, et al. Impact of the COVID-19 c¼99FA4938D049E3A8& pandemic on anxiety and depression symptoms of Art. 1(1) page 12 of 12 Abu Hamad et al: Exploring the gendered mental health experiences of adolescents in Gaza young people in the global south: evidence from children in conflict settings: a systematic review. BMJ a four-country cohort study. BMJ Open. 2021;11(4): Glob Health. 2020;5(3):e002014. doi:10.1136/bmjgh- e049653. doi:10.1136/bmjopen-2021-049653. PMID: 2019-002014. PMID:32201624107. 33858874. 30. Ataullahjan A, Samara M, Betancourt T, Bhutta Z. Miti- 29. Kamali M, Munyuzangabo M, Siddiqui FJ, Gaffey MF, gating toxic stress in children affected by conflict and Meteke S, Als D, et al. Delivering mental health and displacement. BMJ (Clinical Research Ed.). 2020;371: psychosocial support interventions to women and m2876. doi:10.1136/bmj.m2876. PMID:33214156. How to cite this article: Abu Hamad BA, Jones NA, Baird SJ, Abuhamad SH, Diab RA, Oakley EM, et al. Exploring the gendered mental health experiences of adolescents in Gaza during the Covid-19 pandemic. Adv Glob Health. 2022;1(1). https://doi.org/ 10.1525/agh.2022.1730691 Editor-in-Chief: Craig R. Cohen, University of California, San Francisco, CA, USA Senior Editor: Sarah Ssali, Makerere University, Kampala, Uganda Section: Achieving Gender Equality Published: November 01, 2022 Accepted: August 30, 2022 Submitted: March 7, 2022 Copyright: © 2022 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/. Adv Glob Health is a peer-reviewed open access journal published by University of California Press.
Advances in Global Health – University of California Press
Published: Nov 1, 2022
Keywords: Adolescent; Gaza; Covid-19; Mental; Health
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