In this study, 1369 students agreed to participate from seven different schools, two of which were in the northern area, two in the western area, and three in the southern area. It included 723 males and 646 females, of which 244 males and 349 females were from the northern area, 142 males and 205 females from the western area, and 337 males and 92 females from the southern area with a mean age of (16.38 ± 0.79) years. Major characteristics of these children with PTSD, and anger prevalence, HRQL 8 individual questions and PCS, and MCS scores are in (Table 1). Of note here is that the prevalence of PTSD was 53% and problematic anger 62.2%. According to SF8, 46% have moderately to severely affected general health, 30.9% have somewhat limited physical functioning or worse, 30.9% have somewhat or more difficult to work from physical role, 35.3% have moderate to severe bodily pain, 29.4% have some energy or less, 29.1% have limited social functioning, 61% have moderate to severe negative mental health, and 32.5% have negative role-emotional. PTSD and anger prevalence according to gender and school districts are demonstrated in (Figure 1).
- Health-related quality of life (HRQL):
Each individual question: All SF-8 results items were correlated with female gender with body pain, vitality, social functioning, mental-health, and emotional-role (P<0.001), and general health (P=0.002), physical role (P=0.014), and physical functioning (P>0.05). Poorer individual SF-8 question results were also correlated with having a chronic medical condition with (P<0.05). Interestingly, better mental health score was correlated with consanguineous parents (P=0.011) while other SF-8 questions had (P>0.05) with consanguineous parents. All SF-8 results were correlated with having work at (P<0.001) except for social functioning (P=0.018), body pain (P=0.052), physical finding (P=0.388). None of the reported reasons for working were statistical significance with SF-8 results (P>0.05). Declaring that the employer was mean and education being affected from work were correlated with poorer SF-8 results (P<0.01) and (P<0.001), respectively. There was no correlation between the house being rented and SF-8 results (P>0.05).
Poorer SF-8 outcomes were all statistically significantly correlated with high probability of PTSD, higher arousal score, higher DAR-5 anger scores, and weaker family support at (P<0.001). SF-8 single questions had correlations with all social support and DAR-5 (r<±0.3), and for PTSD (r>0.3) except for physical functioning all with (P<0.001). All these results are demonstrated in (Table 2) in more details.
Poorer SF-8 results were found in responders with chronic medical condition (P<0.01 for all SF-8 results). This was particularly in responders with cardiac or urinary medical condition. When comparing having a chronic medical condition or not with SF-8 results, all the results we significantly correlated with having a chronic medical condition (P<0.001).
Frequency of weekly smoking shisha and number of close people lost from war were statistically significant correlated (P<0.05) with worse physical role (r=-0.132, and r=-0.153, respectively) and worse vitality (r=-0.131, and r=-0.153, respectively). Other SF-8 results had correlations (r<±0.1) with number of people living in the house, number of years failed in schools, SES scores, working years, number of cigarettes and shisha smoked, number of residences changed due to war and number of close individuals lost from war.
Cigarette and shisha smoking and being a previous smoker were correlated with all SF-8 results (P<0.001) except for vitality (P=0.086). Being distressed from war and being endangered from war were correlated with poorer SF-8 results with (P<0.01) (except for physical functioning and its relation to being distressed from war which had (P=0.019).
Physical and Mental Components (PCS and MCS): In examining the combination of the items into the PCS and MCS subscales, we observed that both scales were highly corralated (r=0.526 at P<0.001). Different characteristics of PCS and MCS scores in students are demonstrated in (Table 4). Being distressed from war and endangered from war were significantly correlated with higher PCS and MCS scores (P<0.001). Changing place of living was also correlated with higher PCS (P=0.006), and MCS (P=0.012) scores. Having two or more positive of the previous three war variables had the mean PCS score of 15.17 ± 3.193 and the mean MCS score of 14.12 ± 3.478. Being endangered from war had the highest mean PCS and MCS scores. PCS and MCS scores significant differences in regards to PTSD, anger, arousal, social support are demonstrated in (Table 2).
Conducting forward linear regression on PCS scores was significant with these (P<0.05) with DAR 5 anger, having a chronic medical condition, losing someone due to war, family support, being distressed from war noises, working, and gender all contributing significantly with R square values indicating these variables contributed 7.7%, 2.6%, 1.3%, and 0.5%. 0.5%, 0.5%, and 0.5%, respectively to the PCS variance with DAR-5 anger scores recording (P<0.001). When doing forward linear regression on PCS scores with PTSD scores and the previous variables, (P<0.05) for PTSD scores, having a chronic medical condition, losing someone due to war, working, and family support with R square of 8.2%, 2.7%, 1.2%, 1.0%, and 0.4%, respectively with PTSD scores having (P<0.001).
Conducting forward linear regression on MCS scores with DAR 5 scores, DAR 5 anger, gender, family support, being endangered from war, working, having a chronic medical condition, being distressed from war noise, significant other support and friends support all contributed significantly (P<0.05) with R square values indicating these variables contributed 13.2%, 2.3%, 2.3%, 1.3%, 1.1%, 0.5%, 0.4%, 0.3% and 0.3% to the MCS variance respectively with the DAR 5 score recording (P<0.001). When using regression on MCS scores with the PTSD (intrusion + avoidance) score and the other previous variables, (P<0.05) for PTSD scores, family support, having a chronic medical condition, being endangered from war, gender, and working with R square of 19.5%, 2.0%, 0.8%, 0.5%, 0.5%, and 1.2%, respectively with PTSD scores having (P<0.001).
PTSD prevalence was 53% with arousal mean score of 9.46. Correlations between PTSD and SF-8 was discussed in the previous paragraph, and demonstrated in (Table 2). Correlations between CRIES-13 and DAR-5 are demonstrated in (Table 3). PTSD (intrusion + avoidance) and arousal scores correlations with other variables are demonstrated in (Table 4) and (Table 5). Other variables and PTSD were demonstrated in (Table 5).
Forward linear regression on PTSD scores was significant (P<0.001) with DAR 5 anger score, gender, family support, being endangered from war, distressed from war noises, and changing place of living due to war recording R squares indicating contributions of 8.2%, 6.1%, 1.0%, 0.9%, 0.8%, and 0.3% to the variance in PTSD scores respectively. When using forward linear regression on PTSD scores with the same previous variables except for social support, R square value was 8.5% for DAR 5.
Problematic anger was seen in 62.2%. DAR 5 correlation with SF-8 and PTSD were demonstrated in previous paragraphs. More distress from anger was correlated with family support (r=-0.161) and friends support (r=-0.098) (Table 3). Other variables were demonstrated in (Table 4). Dar-5 scores were also correlated with more hours spent on TV and the Internet (Table 5).
Gender and consanguinity: Having parents of fourth degree consanguinity and more distant relatives were correlated with more numbers of people living in the house (P<0.001). However, consanguinity was not correlated with higher family support or any social support. Female gender had higher SES groups than males (P<0.001) while there was no difference in the house being rented or not between gender (P>0.05). Moreover, males worked for more years, and failed more years at school than females (P<0.001 for both). However, males watch TV for less hours while spending more hours on Internet (P=0.007, and P=0.298, respectively). Males smoke cigarette, and cigarette with shisha more than females (P<0.001) with males smoking more cigarettes (mean for females was 8.9 while for males was 13, P=0.041). More females (616 out of 642) did not have a work than males (245 out of 719) (P<0.001). Males failed more years than females [(P<0.001) with mean for males (0.07) years and for females (0.03)]. Females expressed more distress from war noises than males [P<0.001 (OR, 4.632; 95% CI, 3.629-5.912)], but there was no difference in being endangered from war between genders (P>0.05).
School performance: Ninth grade marks were correlated with PTSD (intrusion + avoidance) score (r=0.074 and P=0.009), with family support (r=0.076 and P=0.008) while not significantly correlated with arousal score, DAR-5 anger scores, and other social supports (P>0.05). Living in a rented house, losing someone due to war, or being endangered from war had no statistical significant difference in marks (P>0.05). Interestingly, students being distressed from war had a significantly higher mean of ninth grade mark by 7 (2.6%) points (P=0.002). and females reported higher mean grades than males by 18 (5.8%) points (P<0.001). Having work was correlated with having lower grades (over than 15 points P<0.001). We also found a statistical significant difference when comparing type of work and grades (P<0.001) which is demonstrated in (Figure 2). Smoking cigarette and/or shisha was correlated with lower grades by a mean of 6 (1.94%) points in shisha and 11 (3.5%) points in cigarette (P<0.002). There was a difference in mean grades of different SES groups as the high SES groups had higher marks (P<0.001) and the difference between the mean grade of the lower SES and Upper SES was around 25 points (8.1%). Forward linear Regressing DAR 5 scores, family, friends, and significant other support scores, PTSD scores, gender, working, and all war variables of distress from noises, being endangered, and changing place of living on grades was significant but (P<0.001) only gender and working contributed significantly to the variance in grades recording R squares of 5.9%, and 1.6%, respectively.
Socioeconomic status (SES): In our sample, there was no statistical significant difference in gender and living in a rented house, but there was in SES groups as females were in higher SES groups than males (P<0.001). Moreover, in higher SES groups, students tended not to work more frequently (P<0.001). Working was also correlated with cigarette and/or shisha smoking (P<0.001). Lower SES was found with smoking but (P=0.061). However, living in rented house was correlated with smoking, mainly cigarettes and cigarette with shisha (P=0.019). More students from Southern area schools lived in rented houses (P=0.005) and from Northern area were in higher SES groups (P<0.001).
Other variables: The mean number of people that the students can depend on to provide them with support was 1.02 ± 0.427. Around 17% declared that at least one parent was the main source of the support, 11.5% a sibling, 15% someone they loved, and 39.9% a close friend.