Cumulative War-Related Resource Loss and Multidimensional Quality of Life in Gaza: The Mediating Role of Psychological Distress.

Beyond direct trauma, armed conflicts generate cumulative structural losses, including repeated displacement, housing destruction and economic collapse. Although prior research has linked trauma exposure to impaired quality of life (QoL), the pathways through which cumulative war-related losses affect domain-specific QoL remain underexamined. We conducted a cross-sectional survey in August 2025 among 894 adults across the Gaza Strip. Participants completed the Arabic WHOQOL-BREF and the PHQ-4, and QoL domain scores were transformed to a 0-100 scale. Multivariable linear regression identified independent predictors of overall and domain-specific QoL, and mediation analyses assessed whether psychological distress mediated the associations between cumulative resource loss (housing damage, forced relocations and loss of income source) and QoL outcomes. QoL scores were markedly low across domains, particularly in the environmental (mean: 25.91) and psychological (mean: 35.60) domains, with an overall QoL mean of 37.46. Psychological distress was highly prevalent (mean PHQ-4 = 6.9), with 94.3% scoring above the normal range, 64.9% screening positive for probable anxiety and 65.5% for probable depression. In multivariable models, psychological distress was the strongest and most consistent predictor of reduced QoL across all domains (β range: -1.67 to -2.28 per 1-point increase in PHQ-4; all p < 0.001). Forced relocations were independently associated with lower QoL across all four domains, whereas housing destruction and income loss showed domain-specific effects, particularly on psychological and environmental QoL. Mediation analyses showed that psychological distress partially mediated the association between cumulative resource loss and QoL, accounting for 26% of the association with overall QoL and 29%-41% of the association with domain-specific outcomes, indicating both direct structural and indirect mental health pathways. QoL impairment during the current war in Gaza appears more severe than previously documented in the area and lower than that reported in other recent conflict settings. Cumulative resource loss has both direct and indirect effects on QoL, with psychological distress serving as a key explanatory pathway. Integrated humanitarian responses that address both structural restoration and scalable mental health interventions are urgently needed.