Eastern Mediterranean Health Journal | All issues | Volume 31 2025 | Volume 31, issue 4 | Psychosocial experiences of refugee Gaza children who received cancer treatment in Jordan

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Psychosocial experiences of refugee Gaza children who received cancer treatment in Jordan

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Omar Shamieh1,2,3, Ghadeer Alarjeh1,2, Waleed Alrjoob1,2, Dua Al Habahbeh3, Farah Hashem3, Leen Aldabbas3, Mohanad Absi3, Abdulrahman Shamieh4, Rawad Rihani5 and Asem Mansour6

1Department of Palliative Care, King Hussein Cancer Center, Amman, Jordan (Correspondence to Omar Shamieh: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ). 2Center for Palliative and Cancer Care in Conflict, King Hussein Cancer Centre, Amman, Jordan. 3Psychosocial Oncology Program, King Hussein Cancer Center, Amman, Jordan. 4School of medicine, University of Jordan, Amman, Jordan. 5Department of Paediatrics, King Hussein Cancer Center, Amman, Jordan. 6Office of Director General, King Hussein Cancer Center, Amman, Jordan.

Abstract

Background: Due to war, paediatric cancer patients from Gaza face several healthcare challenges, including frequent treatment disruptions, limited medication supplies, poor infrastructure, psychosocial burden, and war-related trauma.

Aim: To assess the psychosocial status of paediatric cancer patients from Gaza treated at King Hussein Cancer Center (KHCC), Jordan.

Methods: Using the psychosocial assessment tool, psychologist observations and caregiver reports, we collected data from 23 paediatric cancer patients aged 1–18 years, from Gaza, who received treatment at KHCC between November 2023 and April 2024. We conducted a retrospective thematic analysis of the data using Braun and Clarke's six-step process.

Results: About half (52%) of the children had leukaemia, while others presented with sarcomas, lymphoma and other tumours. The patients reported emotional stress and sadness due to the war, separation from family, loss, or displacement, reflecting significant mental health challenges. They exhibited symptoms such as fatigue and poor appetite and expressed heightened fear and anxiety regarding their hospital stay and medical treatment. Strong family support was key in helping the children cope, for those who had immediate family members with them.

Conclusion: This study highlights the complex health challenges that paediatric cancer patients from Gaza face and the need for integrated care to improve their physical and psychosocial wellbeing.

Keywords: cancer, paediatric, psychosocial wellbeing, conflict, war, mental health, Jordan, Gaza

Citation: Shamieh O, Alarjeh G, Alrjoob W, Al Habahbeh D, Hashem F, Aldabbas L, et al. Psychosocial experiences of refugee Gaza children who received cancer treatment in Jordan. East Mediterr Health J. 2025;31(4):235–242. https://doi.org/10.26719/2025.31.4.235.

Received: 22/10/2024; Accepted: 04/03/2025

Copyright © Authors 2025; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Background

Over 400 000 children and adolescents are estimated to be diagnosed with cancer globally every year, and this number is expected to increase especially in low- and middle-income countries (LMICs) (1). Cancer accounts for 16.5% of total deaths in Jordan, an LMIC, and is among the leading causes of death (2). King Hussein Cancer Center (KGCC), Jordan's leading tertiary cancer facility, offers an integrated approach, which combines advanced medical care with psychosocial support, to address the holistic needs of adult and paediatric cancer patients and their families (3). These services are critical in Jordan, a resource-limited country accommodating local patients and refugees from neighbouring countries (4).

For children, the physical, emotional and social toll due to cancer disrupts normal development and daily life, causing psychological distress such as anxiety and depression, further worsened by prolonged hospitalization and separation from family. Research shows that low quality-of-life during treatment affects long-term outcomes (5). War adds to these challenges, creating chronic stress, post-traumatic stress disorder (PTSD) and developmental delays due to violence, displacement and instability (6).

A study highlighted several challenges that displaced paediatric Ukrainian cancer patients and their families face, including psychological distress, uncertainty about the future and the financial burden of treatment. Obtaining medical records from Ukraine proved difficult, constituting a barrier to the continuity of care, as is typical in conflict zones (7).

The Gaza Strip has faced continuous Israeli aggression and political instability for decades and these conditions have severely impacted healthcare delivery, particularly for paediatric cancer patients (8). In 2021, the cancer incidence rate in Gaza was 91.3 per 100 000 people, with 1952 new cases and 610 deaths (8). The October 2023 war has had detrimental effects on healthcare, with almost total destruction of the health infrastructure and loss of many health care staff. The Turkish-Palestinian Friendship Hospital, Gaza's largest and only specialized cancer centre, was severely damaged by Israeli airstrikes, critically impairing its ability to provide essential cancer care (8,9).

Children with cancer in Gaza face the physical and emotional toll of their illness and additional stress from living in a war zone with little or no access to basic needs such as water, food, electricity, and health care services. Treatment disruptions due to border closures, shortage of medical supplies and an overburdened healthcare system are common, further complicating cancer care (10).

The constant threat of Israeli attacks and precarious living conditions in Gaza contribute to elevated levels of anxiety, fear and trauma among paediatric cancer patients. The uncertainty about consistent access to treatment exacerbates these feelings, often leading to higher level psychological distress. Prolonged conflict and lack of access to comprehensive cancer care can cause hopelessness and depression, which affects the patients and their families (11). Many children in Gaza are at high risk of developing PTSD, with symptoms such as nightmares, flashbacks and heightened anxiety becoming common (12).

The frequent border closures and blockades severely limit access to essential medical treatments, often necessitating travel outside of Gaza to neighbouring countries, if allowed, for advanced care, and resulting in significant delays and disruptions to treatment. Gaza’s healthcare system lacks the required specialized paediatric oncology services due to prolonged blockade, restrictions, funding limitations, and reliance on external support, leaving patients dependent on external aid, which affects the quality and continuity of care (8). Because of the overwhelming focus on basic survival needs, psychosocial support is often overlooked (8,13). Mental health services are scarce and the stigma surrounding mental health issues further complicates access to care when needed (14).

Illness and frequent hospital visits often disrupt children’s education and social development and affect their academic progress (10), although some paediatric cancer patients in Gaza exhibit remarkable resilience, drawing strength from family support, community solidarity and faith (15).

Addressing the complex healthcare needs of paediatric cancer patients and improving their overall care requires an understanding of their suffering and the broader socio-political context. Only few studies have explored the experiences of paediatric cancer patients in Gaza, particularly the dual burden of war trauma and chronic illness. This dual burden manifests as heightened physical and psychological symptoms, exacerbated by constrained resources, disrupted healthcare systems and the psychosocial impact of protracted conflict (10,16). This study aimed to explore, collate and analyse the subjective psychosocial experience of paediatric cancer patients from Gaza who were treated at KHCC in Jordan.

Methods

Study design and data collection

This retrospective qualitative study used a phenomenological theoretical framework and thematic analysis to examine available psychosocial assessment data. Data sources included tailored assessment interviews conducted by psychologists through face-to-face semi-structured interviews using the validated psychosocial assessment tool, as well as observational reports from psychologists and caregiver feedback. Thematic analysis of these interviews continued retrospectively until no new themes or insights emerged, indicating conceptual saturation. The results of the interviews and reports were compiled by 3 experienced paediatric clinical psychologists at KHCC. We used the mixed-method approach to ensure comprehensive and holistic data collection and to get more in-depth insight into the experiences of the targeted participants.

The study included preexisting data of paediatric cancer patients from Gaza, aged 1–18 years, who received treatment at KHCC between November 2023 and April 2024. All patients met the inclusion criteria. They had been displaced from Gaza and diagnosed with cancer regardless of their cancer stage, type or treatment modality. Reports from eligible participants were thematically analysed by 2 independent researchers.

The psychosocial assessment tool is a validated instrument designed to screen for psychosocial risks in paediatric patients, particularly those with chronic illnesses like cancer. It is a family-centred tool that assesses various domains, including family structure, social support, patient stress reactions, and overall family functioning. Psychosocial assessment tool was selected because of its reliability and validity in assessing psychosocial needs (17).

The psychological assessment interviews were conducted by experienced and highly trained paediatric clinical psychologists at KHCC. The interviews were conducted either in private rooms at the psychologist’s clinic or at inpatient rooms in KHCC to ensure confidentiality and provide a comfortable setting for participants. The interviews covered various aspects of the patient’s health, including demographics, presenting issues, mental health assessment, developmental and psychiatric history, psychosocial history, and risk assessment (e.g. suicide risk or harm to others). They also included observations regarding family dynamics, barriers to treatment and the role of caregivers. For each patient, a detailed observational report was prepared, including notes on their attitude, activity levels, behavioural changes and observed psychosocial issues.

Caregiver reports for the patients were also reviewed to provide critical insight into the mental health and psychosocial status of the children. These reports offered valuable information about the child’s home environment, family structure and the emotional challenges faced by both the patient and the family due to war trauma and illness.

Data analysis

The data were transcribed verbatim and anonymised at the point of transcription, and translated from Arabic to English by 2 professional translators and then compared with the original Arabic version 2 bilingual experts to ensure accuracy. We interpreted interview transcripts using a critical realist approach, enabling us to explore the subjective experiences of participants while acknowledging the impact of the broader social and structural contexts. Thematic analysis was conducted using Braun and Clarke's six-step process (18), which included repeated reading of the data, initial coding, theme identification, refinement, theme naming, and generation of the final report. The 2 data analysts were not known to the participants and were not part of the clinical team that conducted the interviews. Both of them used an iterative process involving rearrangement, addition and removal of codes and themes. Codes were crystallized into themes by grouping related codes, refining categories and aligning them with the research questions. Both researchers collaborated to review patterns, merge overlapping codes and ensure thematic coherence, to make sure that the themes accurately reflected the underlying meanings of the data. They conducted independent coding to enhance the reliability of the findings (15,19–21). Following the independent coding, the data analysts and the research team engaged in multiple discussions to reach consensus. The final themes were collaboratively reviewed, approved and used for comprehensive analysis.

Ethics considerations

This study was conducted in accordance with the Declaration of Helsinki, taking into consideration the ethics guidelines for research involving vulnerable groups, including UNICEF's Guidelines on Research Involving Children and the UNHCR’s ethics standards for research with refugees, adhering to all ethics guidelines for research involving data of vulnerable populations (22,23). The data were coded to protect patient confidentiality. Ethics approval was obtained from KHCC (Study Reference: 24 KHCC 149) before conducting the study.

Results

Demographic characteristics

We collected and analysed data on 23 paediatric patients from Gaza. Out of those, we interviewed 3 caregivers because their children were less than 2 years old. The mean age of the participants was 9 years, 65% of them were male, and about half (52%) had leukaemia, while others presented with sarcomas, lymphoma and other tumours (Table 1). Nearly half of the children were diagnosed at an advanced stage due to delays in accessing treatment, primarily caused by limited access to specialized medical care in Gaza.

Psychosocial experiences

Six major themes emerged from the study (Table 2), providing insight to the experiences of the patients. These include: (1) traumatic events and their impact on the children, (2) separation and loss, (3) physical symptoms and wellbeing, (4) fear and distress related to medical procedures, (5) emotional and psychological symptoms, and (6) family dynamics and support systems.

1. Traumatic events and their impact on the children

The children experienced emotional and psychological distress due to their illness and the war in Gaza, including aggression, anger, nightmares, anxiety, and social separation. Trauma became an unavoidable part of the daily lives of the children. For instance, one child, wounded with no surviving immediate family member, who came to the treatment centre with his maternal grandmother, recounted the recurring nightmares and anxiety caused by the destruction he witnessed.

“I keep having bad dreams and still feel the ground shaking.” (7-year-old male child)

“I keep remembering how my school was bombed and I fainted from fear.” (14-year-old female child)

“I can’t imagine myself getting old because everyone is dying.” (8-year-old male child)

“The sound of the toilet flushing reminds me of the bombs, so I get scared.” (8-year-old female child)

2. Separation and loss

Children described the emotional toll of being separated from their families. Many of them had lost at least one family member during the war (killed or detained by the Israeli forces), and many were forced to leave their surviving relatives in Gaza to seek treatment in Jordan. This separation added to their emotional distress.

“I miss my mother and siblings who are still in Gaza so much.” (10-year-old female child)

“I wish my mother was here with me and not just my father.” (14-year-old female child).

“I really wish my brother could come play with me.” (8-year-old male child).

“I’m always worried about my father who is stranded due to the war.” (14-year-old male child).

This longing for family connection, which was often not possible due to logistic or safety reasons, exacerbated feelings of grief and isolation among the children.

3. Physical symptoms and wellbeing

Many of the children reported a range of physical symptoms, including poor appetite, fatigue and lethargy, due to a combination of their underlying illness, cancer treatments and the overwhelming stress of living through the war. The complex effects of physical illness and emotional trauma posed significant challenges to their overall wellbeing.

“I have pain in my right shoulder after the liver biopsy, I wish that I could eat my favourite food, but I can’t.” (9-year-old male child).

“I have loss of appetite because I’m worried about the upcoming procedure.” (13-year-old male child)

“I can’t play or do anything I want because of what I look like and I’m sleeping a lot because of pain.” (7-year-old male child)

4. Fear and distress related to the war and medical procedures

Fear of the medical procedures was another recurring theme. Hospitalization, biopsies and other invasive procedures caused considerable distress in many of the children. The fear of pain, combined with the unfamiliar environment of the hospital, contributed to heightened anxiety levels. Fear, which is common among paediatric oncology patients, was further intensified by the war and the psychological distress.

“I feel distressed in the hospital and scared of the biopsy.” (11-year-old male child)

“I’m afraid of being alone in the dark, I still hear the sound of planes.” (8-year-old male child)

“I’m afraid that the enemy followed us here to Jordan to kill us.” (5-year-old female child)

“He keeps crying and looks traumatized whenever he sees someone walk in with a white coat or when he hears loud noises.” (caregiver of a 2-year-old paediatric patient)

5. Emotional and psychological symptoms

The children exhibited a wide range of emotional and psychological symptoms; anxiety, sadness, irritability and social withdrawal were the most common. These symptoms reflected the complex interplay between their illness, the trauma of war and their separation from family members.

“I constantly feel fearful and anxious but don’t know exactly what I’m afraid of; it often feels like someone is behind me.” (13-year-old male child)

“I keep seeing my grandmother who died in my dreams, and I hate waking up because I still want to be with her.” (14-year-old female child)

“I hate watching the news because I don’t want to see more corpses.” (8-year-old male child)

6. Family dynamics and support systems

Family support, or the lack of it, emerged as a key factor in the psychological wellbeing of the children. Strong family ties provided an emotional buffer against stress due to illness and trauma, offering children a sense of stability. However, many of the children lacked direct family support due to the death of first-degree relatives during the war. Some of them were accompanied by second-degree relatives, such as grandparents, who struggled to provide the same level of care and support as their parents. Children who had lost immediate family members or were separated from their families exhibited higher levels of emotional distress and a greater need for psychosocial support. Children who still had strong family support coped better and were more resilient.

“The patient has been playful, energetic and in high spirit because his immediate family members have been around during the treatment.” (caregiver for a 13-year-old male paediatric patient)

“I’m glad others who came here live near us because we play together all the time.” (14-year-old female child)

“I feel better now that my father and sister are with me, and I can video-call my mom who is in Turkey.” (8-year-old male child)

Discussion

Our study has revealed the impact of war and illness on Gaza children. We used qualitative method for the study so we could explore their experiences with cancer and war trauma and understand their perceptions and emotions. Abuzied et al used a phenomenological approach to explore the experiences of male Arab spinal cord injury patients, highlighting the importance of culturally sensitive, patient-centred care for improving health care outcomes (24). The trauma of war had exacerbated the suffering of the patients and their families. We observed the incidence of PTSD in many of them. Altawil had reported chronic traumatic stress disorder among children and their families in Gaza due to the war and long-term aggression (25).

Family support plays a crucial role in the mental health of paediatric cancer patients. Separation from family members often contributes significantly to stress and emotional burden of young patients. Guo et al found that isolation from social support networks was a major source of distress, particularly for refugee patients, who experienced a more pronounced impact of separation and isolation (20).

Our study highlights numerous physical complaints related to cancer and its treatment, and the potential influence of mental wellbeing on physical health. Anxiety, sadness and emotional distress were prominent among the patients. In a review of 24 studies from West Bank and Gaza among children, adolescents and women, Marie et al found that anxiety disorders and PTSD were highly prevalent due to inconsistent access to medication, resource constraints, fragmented mental health system, and Israeli occupation (26).

In addition to the profound psychosocial impact on paediatric cancer patients from conflict zones such as Gaza, it is important to recognize the broader public health implications for Jordan. The chronic exposure to traumatic events, combined with the burden of cancer and its treatment, places significant demand on Jordan's healthcare system. Specialized centres like the KHCC, which serve local patients and those referred from conflict-affected areas, play a critical role in providing care and addressing these complex needs.

Paediatric cancer patients from conflict-affected regions often present with more advanced disease stages, likely due to delayed diagnosis and restricted access to healthcare services (27). A retrospective study of 268 adult and paediatric Syrian refugees with cancer in Turkey found approximately 40% diagnosed at advanced stages of the disease (28). This underscores the need for early screening, timely intervention and a multidisciplinary approach to care, which can help reduce the physical burden on patients and improve outcomes. The integration of palliative care and psychosocial support services, tailored to the unique experiences of these children, is crucial for enhancing the quality of care and life of the patients.

Another challenge is the inability to ensure continuity of care for children with cancer in conflict situation. The fragile health care access for patients in Gaza, the border crossing difficulties and the need for complex treatment regimens, make it imperative to establish cross-border collaborations and adopt telemedicine (29). However, irregular supply of electricity and internet services and the destruction of houses make the use of telemedicine for follow-up care, psychosocial counselling and education to families and caregivers very difficult in conflict-affected regions. Although telemedicine complements in-person care and can improve care in humanitarian situations, it cannot replace in-person care, and it poses certain risks such as data breaches, ethics concerns, malpractice liability, and inequitable access (30). Collaborative interventions that strengthen regional health care networks and provide sustainable solutions for paediatric oncology patients in conflict zones are urgently needed to mitigate the lasting impact of war and illness in Gaza.

Strength and limitations of this study

This study provides an overview of the challenges faced by paediatric cancer patients in conflict zones. It highlights the mental and physical distress they and their families experience. However, because this was a retrospective study, it could not obtain more detailed insights or make further inquiries, which is possible with semi-structured face-to-face interviews.

Recommendations

The most urgent priority for improving care for paediatric cancer patients in Gaza is to end the war and mass destruction because continuous violence and destruction of health care infrastructure severely hinders access to treatment. Peace and stability are essential for delivering care and rebuilding health facilities. Lifting the siege on Gaza is vital to ensure the delivery of medical supplies and allow patient referral for specialized care outside Gaza. Establishing post-conflict collaborations between Gaza and the neighbouring countries will help improve patient referral, ensure smoother transfers and continuity of care. Integrating specialized care that addresses emotional and psychological needs is crucial for comprehensive care of paediatric patients. Continued research on the effects of war on paediatric cancer patients and evaluations of medical and psychosocial interventions will provide evidence for strategies to improve outcomes for this vulnerable population.

Conclusion

This study highlights the impact of war and cancer on paediatric patients. The trauma experienced by these children due to cancer and the challenges of living in a conflict zone have impacted their emotional, psychological and physical health, leading to long-term effects like PTSD and chronic anxiety. Integrating psychosocial interventions with medical treatment can help reduce trauma, improve coping skills and enhance the quality-of-life of paediatric cancer patients. Interventions that address medical and emotional needs will help improve health outcome and ensure holistic care.

Acknowledgment

We extend our gratitude to the study participants and their families, and to the Psychosocial Oncology Program, the Paediatric Department and KHCC staff for their collaboration and support throughout this research.

Funding: None.

Conflict of interest: None declared.

Expériences psychosociales des enfants réfugiés de Gaza ayant reçu un traitement contre le cancer en Jordanie

Résumé

Contexte : En raison de la guerre, les patients pédiatriques atteints de cancer originaires de Gaza sont confrontés à plusieurs défis en matière de soins de santé, notamment de fréquentes perturbations des traitements, un approvisionnement limité en médicaments, une infrastructure défaillante, une charge psychosociale et des traumatismes liés à la guerre.

Objectif : Évaluer le statut psychosocial des patients pédiatriques atteints de cancer originaires de Gaza et traités au Centre du cancer Roi Hussein en Jordanie.

Méthodes : À l'aide de l'outil d'évaluation psychosociale, d'observations de psychologues et de rapports d'aidants, nous avons collecté des données auprès de 23 patients pédiatriques atteints de cancer âgés de 1 à 18 ans, originaires de Gaza, qui ont reçu un traitement au Centre du cancer Roi Hussein entre novembre 2023 et avril 2024. Nous avons effectué une analyse thématique rétrospective des données en utilisant le processus en six étapes de Braun et Clarke.

Résultats : Près de la moitié des enfants (52 %) étaient atteints de leucémie, tandis que les autres présentaient des sarcomes, des lymphomes et d'autres tumeurs. Les patients ont signalé un stress émotionnel et de la tristesse en raison de la guerre, de la séparation d'avec leur famille, des pertes, ou des déplacements, ce qui révèle des défis majeurs en matière de santé mentale. Ils présentaient des symptômes tels que la fatigue et une perte d'appétit, et exprimaient une peur et une anxiété accrues concernant leur séjour à l'hôpital et leur traitement médical. Un soutien familial solide a été essentiel pour aider les enfants à affronter la situation, pour ceux qui étaient accompagnés de membres de leur famille proche.

Conclusion : La présente étude met en évidence les problèmes de santé complexes auxquels sont confrontés les patients pédiatriques atteints de cancer, originaires de Gaza, ainsi que la nécessité de soins intégrés pour améliorer leur bien-être physique et psychosocial.

التجارب النفسية والاجتماعية لأطفال لاجئين من غزة مصابين بالسرطان في الأردن

عمر شامية، غدير العرجة، وليد الرجوب، دعاء الهباهبة، فرح هاشم، لين الدباس، مهند عبسي، عبد الرحمن شامية، رود ريحاني، عاصم منصور

الخلاصة

الخلفية: بسبب الحرب، يواجه الأطفالُ مرضى السرطان في غزة العديدَ من تحديات الرعاية الصحية، ولا سيما الانقطاعات المتكررة في العلاج، ونقص الأدوية، وضعف البنية التحتية، والعبء النفسي الاجتماعي، والصدمات المرتبطة بالحرب.

الأهداف: هدفت هذه الدراسة الى تقييم الحالة النفسية الاجتماعية للأطفال مرضى سرطان من غزة الذين يتلقّون العلاج في مؤسسة ومركز الحسين للسرطان بالأردن.

طرق البحث: باستخدام أداة التقييم النفسي الاجتماعي، والملاحظات النفسية، وتقارير مقدمي الرعاية، جمعنا بيانات من 23 طفلا مريضًا مصابًا بالسرطان من غزة تتراوح أعمارهم بين عامٍ و18 عامًا، ممن تلقوا العلاج في مؤسسة ومركز الحسين للسرطان في الفترة بين نوفمبر/ تشرين الثاني 2023 وأبريل/ نيسان 2024. وأجرينا تحليلًا مواضيعيًّا استرجاعيًّا للبيانات باستخدام عملية براون وكلارك المكونة من ست خطوات.

النتائج: كان قرابة نصف الأطفال (52%) مصابين بسرطان الدم، في حين كان آخرون مصابين بالساركوما والغدد الليمفاوية وأورام أخرى. وأبلغ المرضى عن معاناتهم ضغوطًا عاطفية وتوترًا وجدانيًّا وحزنًا بسبب الحرب أو الانفصال عن العائلة أو الخسارة أو النزوح، ما يعكس تحديات كبيرة في مجال الصحة النفسية. وظهرت عليهم أعراض مثل الإرهاق وضعف الشهية، كما أعربوا عن خوف وقلق متزايدين بشأن إقامتهم في المستشفى وعلاجهم الطبي. ولقد مثل الدعم الأسري القوي عاملًا أساسيًّا في مساعدة الأطفال على التأقلم، لا سيما لمن كانوا يرافقهم أفراد من عائلاتهم.

الاستنتاجات: تسلط هذه الدراسةُ الضوءَ على التحديات الصحية المعقدة التي يواجهها الأطفال مرضى السرطان من غزة، وتؤكد على الحاجة إلى الرعاية المتكاملة لتحسين سلامتهم البدنية والنفسية والاجتماعية.

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