Malnutrition is a serious public health problem in the Gaza Strip. We examined both resilient and vulnerable groups to understand how families succeed and how they fail in supporting child nutrition in the face of adversity. This study adds to the body of literature about malnutrition in Palestine by demonstrating how poor maternal mental health, low birth weight, and residential instability contribute to nutritional vulnerability among kindergarten-aged children. It also suggests that children who are assisted with eating by their mothers before the age of 2 are three times more likely to be nutritionally resilient, and that older children are significantly less resilient than younger ones.
In agreement with previous studies undertaken in the Philippines and Tanzania [69
], low birth weight children are less likely to show nutritional resilience than those with normal birth weight and equally more likely to show vulnerability, although the later association was not statistically significant, possibly due to the smaller number of vulnerable children (53 children with stunting). Based on the study sample, older children are less likely to show resilience, which is in line with our previous finding that older children had a poorer quality of life [71
]. This may be explained by more exposures to traumatic events among older children which might have a cumulative effect [72
Based on study findings, child gender is not associated with nutritional status among preschoolers, which is in line with a previous study in Gaza that showed no gender differences in nutritional status or feeding patterns among infants below 18 months of age [73
]. Maternal low level of education is not associated with nutritional vulnerability, a finding that contradicts previous studies in China [29
], Indonesia [36
], Bangladesh [74
], India [26
], Nepal [27
], and Thailand [24
]. Poor maternal mental health is associated with nutritional vulnerability, a finding in agreement with other studies in India and Pakistan that found maternal postpartum depression to be associated with malnutrition in children [48
]. Similarly, a study in Brazil found that poor maternal mental health was associated with a threefold higher risk of nutritional vulnerability [75
]. Another study in rural Chad showed that maternal psychosocial characteristics were among the best predictors of child height-for-age [76
]. Poor maternal involvement in childcare may be one of the explanations for the association between maternal depression and child malnutrition [77
]. Depressed mothers are more likely to be withdrawn, passive, and less responsive to their children, as well as less able to establish and maintain positive interactions [77
]. In addition, higher scores on maternal depression have been found to be associated with persistent food refusal behavior by the child [79
]. However, in this study, the relation between maternal mental health and child nutritional vulnerability was not explained by feeding behaviors including force feeding and helping feed the child when he or she was below 2 years of age, as both variables did not affect the significance of the association between maternal mental health and nutritional vulnerability (data not shown). The association between poor maternal mental health and nutritional vulnerability may also be in part explained by reverse causation, i.e., mothers may have poor mental health because their children are undernourished. However, an evaluation of a five-month psychosocial intervention program for mothers in war-torn Bosnia and Herzegovina showed positive effects on children's weight [80
]. Another study among 221 infants found that infants of mothers with depressive symptoms experience poor linear growth when followed for six months [81
We did not find an association between the absence of forced feeding of the child and nutritional resilience, as had been reported by earlier studies [21
]. This difference in findings may be because food is not always available in the Gaza Strip, thus food refusal may be less of an issue. Following the Uprising in 2000, loss of jobs, assets and incomes sharply reduced economic access to food with real per capita income decreasing by half since 1999 and resulting in six out of ten people falling below the US$ 2.10 per day poverty line in mid-2006 [84
]. We did not find an association between living in direct military confrontation areas and malnutrition. This is in line with the findings of our previous study of health related quality of life of preschoolers where living in direct military confrontation areas was associated with psychosocial health but not with physical health [71
]. However, the study highlights the association between residential instability in the Gaza Strip and the lower prevalence of nutritional resilience.
Contrary to previous studies in developing countries, [22
] our data did not support an association between intake of supplements, birth order, exclusive breast feeding, timely introduction of complementary food, size of the household, and/or economic deprivation and the child's nutritional status. One possible explanation is that other factors such as maternal mental health may be more critical to children's growth when exposed to adversity. Lack of association between intake of dietary supplements and child nutritional status, may be due to reverse causation, as malnourished children were more likely to take dietary supplements when they were younger. In contrast to our expectations, mother's social support was not associated with child nutritional status. This is consistent with our previous study where social support was not associated with child physical health [71
]. This may be explained by the high prevalence of poor mental health among the mothers (60% according to our study results) and thereby the inability to offer or make use of support to help buffer the negative effects of war. Another possible explanation is, again, reverse causation, as children/families with nutritional deficiencies might attract more sympathy from their neighbors/relatives.
We believe that our estimate of 15% vulnerable children may be an underestimate of the true prevalence of malnutrition in the Gaza Strip, as only one third of children 3-6 years old go to kindergarten. Those who fail to enroll do so most often because their families cannot afford it, or because they live in violent areas and their families are worried about their safety [88
]. However, our results are similar to those obtained by the Palestinian Demographic Health Survey (DHS 2006) (data collected Nov 2006-January 2007). In this survey, 4673 children under five were examined in the Gaza Strip yielding a prevalence of vulnerability of 13% [54
In line with earlier findings that some children show nutritional resilience despite adversity [21
], 37% of the children in our study were nutritionally resilient. Although there was insignificant variability in nutritional resilience by locality, there was significant variability in nutritional vulnerability. Beach camp had the highest prevalence of nutritional vulnerability and the lowest prevalence of resilience, while the opposite was noticed in Zwaida village. Beach camp is a refugee camp in Gaza city with high level of unemployment and overcrowding of families in a very small area, with a large number of children [91
]. While Zwaida village is in the middle area of the Gaza Strip and most of the families are landlords and they cultivate their lands and have more income and larger houses than families in the nearby refugee camps. This is evident from the difference in reporting family insufficient food for at least two days in the past month, 70% vs. 14%, respectively. Almost 94% of residents of Beit Hanoun reported living in a direct military confrontation area as this town is only a few hundred metres from the Palestinian-Israeli border and has a high level of confrontation. The relatively low prevalence of nutritional vulnerability in Beit Hanoun can be explained by the highest percentage of households in Beit Hanoun receiving food assistance on a regular basis (at the time of the study) compared to the other localities.
We examined both resilient and vulnerable children to address the causes of malnutrition. Timely interventions may prevent and reverse malnutrition among preschoolers [92
]. Given the results of this study, interventions should target maternal mental health and residential stability. In a previous study, poor maternal mental health was associated with living in a direct military confrontation area [53
]. It is hard to target residential instability and poor maternal mental health by interventions short of ending the violence. Consequently, addressing the root cause of nutritional variability might require the ending of the political violence. Further confirmatory studies should be conducted that include children from the West Bank to see if associations hold, and to examine the effect of the political changes, and the increased intensity of violence in the Gaza Strip on children's nutritional status. We also recommend replicating the study among other deprived populations, and those exposed to domestic and neighborhood violence, to see if the findings are consistent with our findings in the context of political violence.
The cross-sectional design of the study precludes examination of causality. As malnutrition is one of the main factors contributing to child mortality [93
], our estimate of the prevalence of nutritional vulnerability might have been low compared to the true prevalence at a younger age, due to survival bias. Similarly, the estimate of resilience may be overestimated in our study. Another possible limitation of our study is that, as it is not culturally acceptable in Palestine, we were unable to measure mother's weight and height to control for maternal nutritional status, a variable that has been associated with the risk of childhood malnutrition in other studies [43
]. Other limitations are that child birth weight was based on mother's report, and the small number of vulnerable children (53). The latter affected the power to detect significant associations. Finally, the lack of observational or quantitative detail on some of the information collected (e.g., feeding style or habits) limited our ability for more specific and objective analyses.
This study is unique in several respects. First, it examined both nutritional resilience and vulnerability of preschoolers exposed to political violence and deprivation in particular. Second, it accounted for maternal mental health and social support in studying children's nutritional status. Third, it assessed the effect of several risk factors simultaneously, which is important in identifying the combinations of factors that increase nutritional vulnerability of children. Fourth, the study context provided a unique opportunity to examine the impact of both chronic and acute exposure to political violence on children's health. Preschoolers in our study were born and raised following the Uprising in 2000. Since 2006, there has been an escalation in the conflict in the Gaza Strip, compounding with an increase in Palestinian internal violence.