'Nowhere and no one is safe': spatial analysis of damage to critical civilian infrastructure in the Gaza Strip during the first phase of the Israeli military campaign, 7 October to 22 November 2023

BACKGROUND

Since the Hamas attacks in Israel on 7 October 2023, the Israeli military has launched an assault in the Gaza Strip, which included over 12,000 targets struck and over 25,000 tons of incendiary munitions used by 2 November 2023. The objectives of this study include: (1) the descriptive and inferential spatial analysis of damage to critical civilian infrastructure (health, education, and water facilities) across the Gaza Strip during the first phase of the military campaign, defined as 7 October to 22 November 2023 and (2) the analysis of damage clustering around critical civilian infrastructure to explore broader questions about Israel's adherence to International Humanitarian Law (IHL).

METHODS

We applied multi-temporal coherent change detection on Copernicus Sentinel 1-A Synthetic Aperture Radar (SAR) imagery to detect signals indicative of damage to the built environment through 22 November 2023. Specific locations of health, education, and water facilities were delineated using open-source building footprint and cross-checked with geocoded data from OCHA, OpenStreetMap, and Humanitarian OpenStreetMap Team. We then assessed the retrieval of damage at and with close proximity to sites of health, education, and water infrastructure in addition to designated evacuation corridors and civilian protection zones. The Global Moran's I autocorrelation inference statistic was used to determine whether health, education, and water facility infrastructure damage was spatially random or clustered.

RESULTS

During the period under investigation, in the entire Gaza Strip, 60.8% (n = 59) of health, 68.2% (n = 324) of education, and 42.1% (n = 64) of water facilities sustained infrastructure damage. Furthermore, 35.1% (n = 34) of health, 40.2% (n = 191) of education, and 36.8% (n = 56) of water facilities were functionally destroyed. Applying the Global Moran's I spatial inference statistic to facilities demonstrated a high degree of damage clustering for all three types of critical civilian infrastructure, with Z-scores indicating < 1% likelihood of cluster damage occurring by random chance.

CONCLUSION

Spatial statistical analysis suggests widespread damage to critical civilian infrastructure that should have been provided protection under IHL. These findings raise serious allegations about the violation of IHL, especially in light of Israeli officials' statements explicitly inciting violence and displacement and multiple widely reported acts of collective punishment.

Fecal carriage of extended-spectrum β-lactamase-producing enterobacterales from hospitals and community settings in Gaza Strip, Palestine

BACKGROUND

The fecal carriage of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) is a major driver of the global spread of these antibiotic resistance determinants. Here we determined the rate of fecal ESBL-PE carriage in pediatric hospitals and community-serving healthcare centers serving adults and children in the Gaza Strip, Palestine.

METHODS

A total of 373 fecal and rectal samples were collected from different hospitals and clinics in Gaza. The antibiotic susceptibility was determined using the disk diffusion method and interpreted according to CLSI guidelines. The bacterial isolates were tested for ESBL production using phenotypic methods (double disk synergy test and growth on selective chromogenic media). BlaCTX-M, blaSHV, and blaTEM genes were sought by PCR.

RESULTS

Out of the 373 isolates tested, 138 (37%) were considered ESBL positive as revealed by phenotypic tests. The prevalence of ESBLs among hospitalized patients was 39.1% (hospital setting) whereas, among outpatients attending community healthcare centers, it was 35.1% (community setting). ESBL production among Escherichia coli, Klebsiella pneumoniae, Citrobacter freundii, Proteus mirabilis, and Klebsiella aerogenes isolates was 52.8%, 39.1%, 26.7%, 2.8%, and 2.1% respectively. Meropenem and amikacin were the most effective antibiotics against ESBL producers (68.9% and 73.6% susceptibility, respectively), while only 15.2%, 22.5%, and 24.6% remained susceptible to ceftazidime, cefotaxime, and ceftriaxone, respectively. Out of 138 phenotypically ESBL-positive isolates, 98 randomly chosen were screened for blaCTX-M, blaTEM, and blaSHV genes. The prevalence rate of blaCTX-M was 45.9%, while blaTEM and blaSHV genes were detected in 16.8% and 5.2% of CTX-M-negative isolates (corresponding mostly for K. pneumoniae isolates in the case of SHV-PCR), respectively.

CONCLUSIONS

The study revealed an alarmingly high prevalence of fecal carriage of ESBL-producing Enterobacterales among hospitalized children but also in the community of the Gaza Strip. In addition, 30% of ESBL-producers were already resistant to carbapenems, the treatment of choice of infections with ESBL-producers.

Computer-aided diagnostic accuracy of pulmonary tuberculosis on chest radiography among lower respiratory tract symptoms patients

Even though the Gaza Strip is a low pulmonary tuberculosis (TB) burden region, it is well-known that TB is primarily a socioeconomic problem associated with overcrowding, poor hygiene, a lack of fresh water, and limited access to healthcare, which is the typical case in the Gaza Strip. Therefore, this study aimed at assessing the accuracy of the automatic software computer-aided detection for tuberculosis (CAD4TB) in diagnosing pulmonary TB on chest radiography and compare the CAD4TB software reading with the results of geneXpert. Using a census sampling method, the study was conducted in radiology departments in the Gaza Strip hospitals between 1 December 2022 and 31 March 2023. A digital X-ray, printer, and online X-ray system backed by CAD4TBv6 software were used to screen patients with lower respiratory tract symptoms. GeneXpert analysis was performed for all patients having a score > 40. A total of 1,237 patients presenting with lower respiratory tract symptoms participated in this current study. Chest X-ray readings showed that 7.8% (n = 96) were presumptive for TB. The CAD4TBv6 scores showed that 11.8% (n = 146) of recruited patients were presumptive for TB. GeneXpert testing on sputum samples showed that 6.2% (n = 77) of those with a score > 40 on CAD4TB were positive for pulmonary TB. Significant differences were found in chest X-ray readings, CAD4TBv6 scores, and GeneXpert results among sociodemographic and health status variables (P-value < 0.05). The study showed that the incidence rate of TB in the Gaza Strip is 3.5 per 100,000 population in the Gaza strip. The sensitivity of the CAD4TBv6 score and the symptomatic review for tuberculosis with a threshold score of >40 is 80.2%, and the specificity is 94.0%. The positive Likelihood Ratio is 13.3%, Negative Likelihood Ratio is 0.2 with 7.8% prevalence. Positive Predictive Value is 52.7%, Negative Predictive Value is 98.3%, and accuracy is 92.9%. In a resource-limited country with a high burden of neglected disease, combining chest X-ray readings by CAD4TB and symptomatology is extremely valuable for screening a population at risk. CAD4TB is noticeably more efficient than other methods for TB screening and early diagnosis in people who would otherwise go undetected.

First report of mobile colistin resistance gene mcr-1 in avian pathogenic Escherichia coli isolated from turkeys in the Gaza Strip, Palestine

Background and Aim

Colistin is used to treat avian pathogenic Escherichia coli (APEC), a microorganism that affects turkey meat production in the Gaza Strip and worldwide. However, the recent emergence of plasmid-borne mobile colistin resistance (mcr) genes in pathogenic E. coli strains is a serious antimicrobial resistance (AMR) challenge for both human and animal health. In December 2018, colistin was banned as a veterinary antimicrobial in the Gaza Strip. This study aimed to detect and track the prevalence of colistin-resistant APEC isolated from turkey flocks in the Gaza Strip.

Materials and Methods

This study investigated 239 APEC isolates from turkey flocks in the Gaza Strip between October 2018 and December 2021 (at 6-month intervals). The colistin-resistant APEC strains were detected using the broth microdilution method. The mcr-1 gene was identified using a polymerase chain reaction.

Results

The overall colistin resistance among the isolated APECs was 32.2% during the study period. The average resistance in the first interval was 37.5%, which significantly decreased to 9.3% in the last interval. Among the 77 phenotypically resistant isolates, 32.4% were positive for mcr-1. The average abundance of mcr-1 in the first interval was 66.6%, which decreased to 25% in the last interval.

Conclusion

To the best of our knowledge, this is the first study reporting the presence of the mcr-1 gene among the APEC isolates from turkeys in the Gaza Strip. Banned veterinary use of colistin significantly decreased the percentage of resistant APEC isolates from turkeys in Gaza Strip. Further studies are needed to investigate other colistin resistance genes and track the emergence of AMR.

Hospital-based case-control study of risk factors for early neonatal mortality in the Gaza Strip

Background

Early neonatal death is an essential epidemiological indicator of maternal and child health.

Aims

To identify risk factors for early neonatal deaths in the Gaza Strip.

Methods

This hospital-based case-control study included 132 women who experienced neonatal deaths from January to September 2018. The control group comprised 264 women who were selected using systematic random sampling and gave birth to live newborns at the time of data collection.

Results

The controls who had no history of neonatal death or stillbirth were less likely to have an early neonatal death than women who had such history. The controls who did not have meconium aspiration syndrome or amniotic fluid complications were less likely to have an early neonatal death than women who experienced these complications during delivery. The controls who had a singleton birth outcome were less likely to have an early neonatal death than women who had multiple births.

Conclusion

Interventions are needed to provide preconception care, improve the quality of intrapartum and postnatal care, provide high-quality health education, and improve the quality of care provided by neonatal intensive care units in the Gaza Strip.

Prevalence of mecA and Panton-Valentine Leukocidin Genes in Staphylococcus aureus Clinical Isolates from Gaza Strip Hospitals

Methicillin-resistant Staphylococcus aureus (MRSA) are spreading worldwide in hospital and community settings, thus posing a serious public health problem. Panton-Valentine Leukocidin (PVL), an important virulence factor of S. aureus, is a marker of community-acquired MRSA. Here we determined the prevalence of pvl genes among S. aureus isolates from different hospitals in the Gaza Strip, Palestine. A total of 285 S. aureus isolates were collected from five different hospitals in the Gaza Strip. All isolates were characterized for their susceptibility patterns to available antimicrobial agents and by using multiplex PCR for the detection of mecA and pvl genes. The overall prevalence of MRSA in Gaza hospitals was 70.2% (range: 76.3% to 65.5%) and that of pvl among S. aureus isolates was 29.8% (range: 32.9% to 26.2%). The pvl gene was equally prevalent among MRSA isolates (30.5%) and MSSA isolates (28.2%). The most effective antibiotics were rifampicin, vancomycin, and clindamycin, with susceptibility rates of 91.2%, 88.7%, and 84.6%, respectively. The highest percentage of strains were observed to be resistant to penicillin and amoxicillin with clavulanic acid-96.1% and 73.6%, respectively. Our results showed a high prevalence of MRSA and pvl-positive isolates in Gaza Strip hospitals, which likely reflects the situation in the community. It is mandatory to implement systematic surveillance of both hospital and community isolates, together with interventions (such as increased hand hygiene, use of hydroalcoholic solutions, and isolation of carriers) to limit their spread.

The Association Between the Serum Level of IGF-1 and IGFBP-3 and the Risk of Breast Cancer among Women in the Gaza Strip

OBJECTIVE

The purpose of this research was to look at the relationship between insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3) levels and the risk for breast cancer (BC) among women in the Gaza Strip.

METHODS

This case-control study, which included 334 participants (112 women with BC as cases, and 222 women without BC as control), was conducted between January 2021 and August 2022. Research data for the cases were gathered at the Oncology Departments of the Gaza Strip's two hospitals, "Al- Shifa Hospital and Turkish Palestinian Friendship Hospital," as well as from the electronic records of the Screening Mammogram Unit at Al- Remal Clinic for controls. The information about the participants was gathered using a standardized questionnaire. The key variables related to BC were identified using multivariate logistic regression.

RESULTS

According to multivariate logistic regression, participants' age was associated with an increase in the risk of BC (OR= 1.03; 95%CI, 1.007-1.060). There was an association between serum concentrations of fasting blood glucose (FBG) (OR= 1.027; 95% CI, 1.013-1.042), IGF-1 (OR= 1.010; 95% CI, 1.006-1.015), and the risk of BC, while there was no link between IGFBP-3 and the risk of BC. In an analysis of the risk according to menopausal status, premenopausal women were associated with an approximate 0.5 time decrease in risk of BC compared to women in post-menopause (OR= 0.428, 95% CI, 0.258, 0.710). Dairy product was also related to a decreased risk of BC.

CONCLUSION

The results suggest that age, lower physical activity, increased levels of FBG, and IGF- 1 increase the BC risk among females in the Gaza Strip. Meanwhile, premenopausal women and dairy products are linked to a reduction in the risk of BC. Furthermore, no link was found between IGFBP-3 and BC risk. Improving early BC detection rates in the Gaza Strip necessitates preventative interventions and screening for BC in the public and healthcare sectors.

Assessment of preparedness for response to COVID-19 by two hospitals in the Gaza Strip

Background

Hospital preparedness enables the healthcare delivery system to save lives during emergencies that surpass the day-to-day capacity of existing response systems. The COVID-19 pandemic negatively affected all aspects of life worldwide, and in the Gaza Strip particularly.

Aims

We assessed the preparedness of 2 hospitals in the Gaza Strip for response to COVID-19.

Methods

An observational, analytical, cross-sectional study was conducted among 160 nurses and physicians between July 2020 and October 2021 at the European Gaza Hospital and the Turkish-Palestinian Friendship Hospital, 2 hospitals dedicated to the reception and care of COVID-19 patients in the Gaza Strip. Data were collected using a structured, self-administered questionnaire and a checklist. The data were analysed using SPSS, version 23. Frequencies and descriptive data were used to assess the variables. Inferential statistics such as ANOVA and t-test were used to determine the significance and differences between the variables. Cronbach's alpha was 0.903.

Results

The majority of the participants were nurses (77.5%) and they showed a high level of knowledge and training regarding the response to COVID-19 pandemic (73.4 %). Their perception of the preparedness of their hospitals in terms of work environment and availability of resources was average (63.6%). Around 70% perceived COVID-19 to have had a negative effect on their personal lives and work.

Conclusion

The preparedness level at the 2 hospitals was unsatisfactory (55.75%). Further research is recommended to assess the level of hospital preparedness from the viewpoint of other healthcare workers.

Knowledge, Attitudes, and Practice towards Occupational Health and Safety among Nursing Students in Gaza Strip, Palestine

Background

Health and safety in the workplace are critical components in healthcare institutions. Unsafe working conditions are among the causes of poor quality of care and burnout. This study aims to assess the knowledge, attitudes, and practice of occupational health and safety among nursing students at Al-Israa University.

Methods

In this cross-sectional study, a structured online questionnaire was distributed from March to May 2021. Of the 350 eligible students, 219 students answered the questionnaire (Response rate=62.6). Data were analyzed using the statistical software IBM-SPSS version 22. Descriptive statistic, Independentsamples T-Test, and ANOVA tests were used.

Results

The majority of participants were female (81.7%) and studying in a diploma program. 21% of nursing students have experienced a needle stick injury. The mean scores for knowledge, attitudes, and practice were (M±SD:78.2% ±12.9, M±SD:80.6% ±7.1, and M±SD:81.2% ±7.6) respectively. In terms of knowledge, attitudes, and practice the mean scores were statistically significant between nursing students who attended a safety precautions course and those who didn not (P-value <.05). In terms of attitudes, the mean scores were statistically significant between diploma and bachelor students (P-value =.026). In terms of practice, the means scores were statistically significant between males and females (Pvalue =.017), nursing students who had experience with needle sticks and those who didn't (P-value =.015).

Conclusions

The authors recommend that clinical training departments and universities continue to offer occupational health and safety courses and training for health science students. Since the training had a positive impact on the students' practices.

Pathways to food insecurity in the context of conflict: the case of the occupied Palestinian territory

BACKGROUND

Conflict reduces availability of production input and income, increases the number of days households had to rely on less preferred foods, and limits the variety of foods eaten and the portion size of meals consumed. While existing studies examine the impact of conflict on different food security measures (e.g., Food Consumption Score, Food Insecurity Experience Scale), the relationship between these measures as well as their relationship with political, economic, and agricultural factors remain under explored. Food insecurity may not only be an externality of conflict but also food deprivation may be utilized as a weapon to discourage residency in contested territories or to incentivize rebellions.

METHODOLOGY

This paper examines the association between political factors (e.g., violence, policies that require permit for passage in one's own hometown), economic factors (e.g., loss of assets, unemployment), agricultural factors (e.g., shortage of water, poor weather conditions), and food insecurity experience and dietary diversity in a conflict setting-that of the occupied Palestinian territory (oPt). The study employs generalized structural equation models to analyze the 'Survey on socio-economic conditions for Palestinian households 2014' dataset compiled by the Palestinian Central Bureau of Statistics-which contains a representative sample of the population in the oPt at governorate and locality levels.

RESULTS

We find that in the West Bank, residence in Area C-administered by Israel in both civil and security issues and contains illegal Israeli settlements and outposts-is associated with a higher level of agricultural hardship (p < 0.01) but lower economic hardship (p < 0.01) and a higher dietary diversity (p < 0.001), as compared to those living outside of Area C. In the Gaza Strip, living within one kilometer to a buffer zone is associated with lower dietary diversity (p < 0.01), higher level of political hardship (p < 0.01), and higher level food insecurity experience (p < 0.01) compared to not living in close proximity to a buffer zone. Concomitantly, in the Gaza Strip, food insecurity experience is associated with approximately a one-point reduction in dietary diversity as measured by the food consumption score (p < 0.01).

CONCLUSIONS

The results suggest that broader socio-political conditions in the oPt impact different aspects of food security through augmenting the economic and agricultural hardships that are experienced by the residents. As such, it is important to address these broader political and economic structures in order to have more sustainable interventions in reducing food insecurity.

Post-traumatic stress disorder among victims of great march of return in the Gaza Strip, Palestine: A need for policy intervention

This study aimed to assess the level of Post-Traumatic Stress Disorder (PSTD) and to examine the relationship between exposure to war stress and posttraumatic symptoms among people who were injured during the Great March of Return (GMR) in the Gaza Strip, Palestine. A sample of 264 adults who were injured during participation in the events of GMR completed the Impact Event Scale-Revised (IES-R). IES-R has three sub-scales; intrusion, avoidance, and hyper-arousal. Only 27.3% of the participants had two or more injuries and 38.4% of participants reported having disability due to their injuries. The results showed that 95.4% of the participants had severe posttraumatic symptoms. Total score of IES-R ranged between 29 and 88 (mean = 61.28). The most frequent symptoms of trauma subscales was "Intrusion" (mean = 2.90), followed by "Avoidance" (mean = 2.73), and then "Hyper-arousal" (mean = 2.70). Level of PTSD was affected by working status, need for hospitalization, need for a referral for treatment outside the Gaza Strip, disability and severity of injury. Such high level of PSTD will have negative consequences on participants' physical and mental status. Therefore, a need for special counseling programs is required to help them to survive with least consequences of PTSD on their wellbeing.

Preparedness and Readiness Strategies for Addressing the COVID-19 Pandemic in Fragile and Conflict Settings: Experiences of the Gaza Strip

The COVID-19 pandemic is a global public health threat of serious concern, especially in conflict settings that face fragility and lack adequate resources and capacities. Gaza suffers from a blockade imposed by the Israeli occupation, environmental deterioration, confiscation of lands, demolition of houses and hospitals, restrictions on movement, lack of control over natural resources, and financial constraints. Gaza's population is consequently living in a poor humanitarian situation with high unemployment rates, poverty, over-crowdedness, and a weak health system. This makes Gaza incredibly fragile and affects its ability to respond to the COVID-19 pandemic effectively. The pandemic is expected to deepen Gaza's systems' fragility, which is already overstretched beyond their limits. This will hinder its capacity to deal with the pandemic, and other pre-existing pressing humanitarian needs. Therefore, in this review, we comprehensively explored Gaza's policy failures and successes related to the COVID-19 preparedness and response by state and non-state actors and recommend potential solutions and alternatives. We have addressed critical issues including the health system, water, sanitation, hygiene, socio-economic, education, food security, and others. In Gaza, effectiveness in combating the COVID-19 pandemic can only come from committed political will, transparency from all regulators, strategic dialogue, comprehensive planning, and active international support.

Prevalence of depression, anxiety and stress during the COVID-19 pandemic: a cross-sectional study among Palestinian students (10-18 years)

BACKGROUND

The COVID-19 pandemic considers a threat to students' well-being and mental health. The current descriptive cross-sectional study aims to identify psychological distress among school students during the lockdown period.

METHODS

This study was carried out in a sample of 420 primary and secondary school students from June 10 to July 13, 2020, in the Gaza Strip in Palestine. Data was collected using an online questionnaire that included informed consent, socio-demographic questions, and a psychometric scale (DASS-21).

RESULTS

The results revealed that most students experienced moderate to severe levels of anxiety (89.1%) and depression (72.1%), whereas less than half of them (35.7%) experienced moderate to severe stress. Stress, anxiety and depression scores were significantly different across gender, age groups, family size, and family's economic status. The results showed that gender (β = -0.174, p < 0.001), age (β = -0.155, p = 0.001) and economic level of family (β = -0.147, p = 0.002) were negative predictors correlated with stress. Family size (β = 0.156, p = 0.001) played a positive role in stress. It was found that gender (β = -0.105, p = 0.031), age (β = -0.135, p = 0.006) and economic level of family (β = -0.136, p = 0.005) were negative predictors correlated with anxiety, whereas family size (β = 0.139, p = 0.004) played a positive role in anxiety. For depression, gender (β = -0.162, p = 0.001), age (β = -0.160, p = 0.001) and economic level of family (β = -0.131, p = 0.007) were negative predictors correlated with depression, whereas family size (β = -0.133, p = 0.006) was found to be a positive predictor. Concerns about the influence of COVID-19 on economic, education, and daily life were positively correlated to the levels of depression, anxiety and stress, whereas the availability of social support was negatively correlated.

CONCLUSION

The development of a health protocol for influenced students is urgently needed to maintain them remain resilient during dangerous times.

Refractive amblyopia among children aged 4-12 years in a hospital-based setting in Gaza Strip, Palestine

Background

Refractive amblyopia is the most common cause of amblyopia in the Gaza Strip. However, the pattern of this condition has not yet been studied in this region. This study aimed to determine the pattern of refractive amblyopia in Gazan children aged 4‒12 years.

Methods

This was a hospital-based cross-sectional study using a purposive sampling method. Children aged 4‒12 years who attended the Children's Unit at Gaza Ophthalmic Hospital, Gaza Strip, Palestine from September 2019 to July 2020, were examined. A comprehensive eye test was conducted for all participants. Those who failed the eye examinations and were diagnosed with refractive amblyopia were included in the study. Demographic data and amblyopic refractive error patterns were analyzed accordingly.

Results

Of the 107 children, 72.9% were newly diagnosed with refractive amblyopia. The mean (standard deviation [SD]) of age of the children who participated was 7.85 (1.55) years. Approimately two-thirds of the patients were female (57.9%). Unilateral amblyopia was predominant in 60.7% of the cases. Moderate amblyopia was common (81.9%). A total of 149 amblyopic eyes were examined in total, with a mean (SD) (range) of best-corrected distance visual acuity and spherical equivalent of 0.45 (0.19) (0.2 to 1.3) logarithm of the minimum angle of resolution and + 0.76 (4.51) diopters (- 10.25 to + 11.50). Astigmatism was the most common amblyogenic factor (53.7%) among children with amblyopia.

Conclusions

The frequency of refractive amblyopia was 72.9%, and meridional amblyopia accounted for the highest percentage. Girls were more commonly affected than boys. The majority were in the 7-year-old age group. Most cases were unilateral with moderate refractive amblyopia. Our study yields insights into the patterns of refractive amblyopia among children in the Gaza Strip.

Towards decolonising research methods training: the development of a locally responsive online learning course on research methods for mental health in war and conflict for researchers and practitioners in the Gaza Strip

BACKGROUND

Concerns exist that online learning directed at non-Western settings to strengthen research capacity imposes Western-centric epistemology, provides unidirectional transfer of knowledge, and neglects local paradigms and expertise. We argue that a plurality of voices, histories and epistemologies are essential to strengthen research capacity. We share our experience developing and teaching an online course for mental health professionals and researchers in the Gaza Strip.

METHODS

Birzeit University and King's College London developed and delivered the course equally, focusing on the intersection between qualitative research methods, mental health and conflict, and addressing local research needs. We incorporated local case studies and expertise, encouraged interaction in English and Arabic, and stimulated critique of Western theories. Seventeen participated, 12 completed the pre-course questionnaire, 15 completed the post-course questionnaire and four undertook semi-structured interviews.

RESULTS

Our pre-course survey showed participants most needed coding and qualitative data analysis skills. Post-course findings showed improved qualitative research skills. Most agreed the course was comprehensive and well delivered, with relevant case studies. Three themes were identified: (1) the course was locally contextualised and met students' needs; (2) the course fostered dialogic and multi-directional learning and (3) suggestions for improvements. Several participants wanted some topics in greater depth and further specialised training. A few suggested the course be in Arabic.

CONCLUSION

Fostering multi-directional learning is key for non-Western knowledge, epistemologies, and languages to gain prominence in Western academia. A social transformation would see local researchers and educators engage with and use local methods and paradigms in mental health in war and conflict.

Variations in COVID-19 Spread and Control Measures in the Palestinian Territories

Palestinians are facing the epidemic while they are the only occupied country globally, with around 2 million inhabitants under siege in the Gaza Strip (GS) for the last 14 years and have no control over the health of the Palestinians in East-Jerusalem (EJ). Such catastrophic situations created a variety in the spread of the COVID-19 pandemic in different territories. This study aimed to explore variation in COVID-19 spread, risk factors, and intervention activities in the three Palestinian territories: West Bank (WB), EJ, and GS to learn from the current gaps to overcome this pandemic and be prepared for future emergencies. Epidemiological data regarding COVID-19 were obtained from online websites, Palestinian national reports, WHO reports, and scientific publications. Morbidity and mortality indicators in Palestine are higher than the global level with rate variation in the three territories. COVID-19 incidence and mortality rates are higher in EJ and lowest in GS, while case fatalities are around 1% all over the country. Social gathering and lack of readiness of the fragmented health systems (there are two systems; Palestinian serves the WB and GS and Israeli serves the EJ) are risk factors in the three Palestinian territories. The most prominent risk in GS is overcrowding, while the movement of the workers inside Israel and travel are more prevalent in the WB and EJ. The WHO and international organizations play an active role in responding to a community spread, mainly national coordination, risk communication and community engagement, laboratory support, surveillance and procurement, and supply management. Recommendations include restructuring the national committees, reviewing and standardization of the national protocols, expanding infections prevention training, supporting and developing the capacity of laboratories, and setting the role of NGOs besides community engagement and participation.

Conflict exposure and health: Evidence from the Gaza Strip

We study the impact of conflict exposure on health in the Gaza Strip using individual-level longitudinal data and geo-localized information on conflict-related violent events. Results show that individuals living in localities exposed to more conflict events have a higher probability of suffering from a physical impairment and a chronic disease. Two mechanisms contribute to explain why living in conflict-affected area increases the incidence of physical impairment: conflict increases the difficulty to reach health facilities and it decreases individual income. The conflict-induced increase in the probability of having high blood pressure is instead consistent with the development of Post-Traumatic Stress Disorder (PTSD) due to the exposure to conflict-related violent events.

Impact of a mobile phone app on adherence to treatment regimens among hypertensive patients: A randomised clinical trial study

BACKGROUND

Hypertension is one of the most prevalent long-term diseases seen in many countries, including Palestine. Patients with poorly controlled blood pressure are more likely to develop several complications. Therefore; it is imperative to control their blood pressure by improving their adherence to the treatment regimen.

AIM

The objective of this study was to evaluate the impact of using a mobile phone app on the level of adherence to treatment regimens among hypertensive patients in the Gaza Strip.

METHODS AND RESULTS

This study used an experimental design with a pre and post-intervention assessment. Using the Hill-Bone compliance to high blood pressure therapy scale, 191 participants completed the study: 94 in the control group and 97 in the intervention group. The intervention group used a phone app which reminds participants to take their medication, reminding them about their follow-up appointments and sending educational information about hypertension management. After 3 months of intervention, the level of adherence to treatment was reassessed. Results showed that participants in both groups showed a significant improvement in adherence levels, with higher improvements in the intervention group in the total score as well as all three domain scores: adherence to medication, diet and keeping appointments.

CONCLUSION

The use of a mobile phone app resulted in improvements in adherence to hypertension treatment. Thus, this study confirms the potential effectiveness of mobile technology in improving treatment adherence in hypertension and an opportunity to reduce cardiovascular mortality and morbidity. However, wider adoption has to be accompanied by ongoing evaluation and integration in public health systems.

Intersectionality and Femicide: Palestinian Women's Experiences With the Murders of Their Beloved Female Relatives

This article examines how the intersectionality between political, socio-cultural, and demographic factors influences femicide events and women's experiences in Gaza. Based on the testimonies of 13 female first-degree relatives of murdered women and 7 professionals, the article suggests the "politicological" logic of femicide to highlight the interrelationship between Israel's political and Palestinians' patriarchal control of the killed, the bereaved, and women's lives in Gaza. The article reveals that while all murderers are free and some have even fled Gaza, all women remain trapped in an immense political and patriarchal prison, lacking basic feelings of safety and the right to live.

Emergency management to avoid the spread of the COVID-19 pandemic in Gaza Strip

Gaza Strip is exposed to the danger of the novel coronavirus pandemic ‘nCOVID‐19’ spread, which exacerbates the crises severity on this besieged area since 2007. This study aims to identify the preventive actions during the action effectiveness implemented by the Central Emergency Committee and the Ministry of Health to reduce the coronavirus spread in Gaza Strip. The researchers have followed the descriptive and the analytical methodology of the purposive sample responses data from the preventive medicine workers, the security team, and the members of the Central Emergency Committee.The most important results of the study showed that targeted peoples have been reexamined several times to ensure that they are recovered from the disease with an average of 81.0%. The reliability and accuracy of the detection tests of the coronavirus disease were of an average of 79.33%. In addition, the results demonstrate the existence of a strong correlation between the preventive action taken by the Central Emergency Committee and the effectiveness of the procedures to prevent the coronavirus pandemic. Also, the study shows a statistical significance effect at the level of significance (α ≤ 0.05) regarding the prevention procedures from the coronavirus pandemic and the effectiveness of the procedures.

Assessment of organizational culture types, leadership styles and their relationships within governmental and non-governmental hospitals in Gaza Strip of Palestine

Background

The subjects of organizational culture and leadership have been studied several times in various fields. However, studies have tried to determine the relationship between corporate culture and leadership as it is still indistinguishable, or more evidence is needed. The paper describes the perceptions of the staffs about the hospitals’ organizational culture types and their managers’ leadership styles in these hospitals and the relationships that may exist between these domains.

Method

This is a cross-sectional descriptive study involving 400 participants from three governmental and two non-governmental hospitals during the period from June to December 2018. The target population included all categories of staff working at hospitals as physicians, nurses, paramedics and administrators.

Results

The largest number of participants was 82.5 % from government hospitals while 17.5 % were from non-governmental hospitals. Clan and hierarchy-driven cultures were the top-defined forms of organizational culture at hospitals in the Gaza Strip. In all types of organizational culture, the non-governmental hospitals which all are small size hospitals have higher perceptions’ means than the governmental ones that have different sizes. Managers’ styles in the investigated hospitals were transformational and transactional. The study’s results showed significant positive associations by Pearson’s Correlations and effect by linear multiple regression analysis between styles of transformation and transactional leaderships and types of organizational cultures.

Discussion and conclusion

The study addressing the main concepts showed positive relations and also impacts between two of the leadership styles and organizational culture types, apart from the Laissez-faire style. This paper has been successful in contributing to the research on this topic and providing indications for understanding certain domains of the hospital industry in Palestine.

Barriers of Occupational Safety Implementation in Infrastructure Projects: Gaza Strip Case

Infrastructure projects are the foundation for essential public services and have an influential position in societal development. Although the role of infrastructure projects is substantial, they can involve complexities and safety issues that lead to an unsafe environment, and which impacts the project key stakeholders. Therefore, this study aimed to evaluate the barriers to implementing occupational safety in infrastructure projects in the Gaza Strip, which cause serious threats and reduce project performance. To evaluate the barriers, 39 items were highlighted and modified as per the construction context and environment, and which later were distributed in the form of a questionnaire, to get feedback from consultants and contractors. The analysis shows that in the safety policy barriers group, consultants and contractors both ranked the item “a contractor committed to an occupational safety program is not rewarded” first. In the management barriers group, consultants and contractors both ranked the item “safety engineer does not have significant powers, such as stopping work when needed” in the first place. In the behavior and culture barriers group, consultants and contractors both ranked the item “workers who are not committed to occupational safety are not excluded” in the first place. Overall, both consultants and contractors shared the same viewpoint in classifying the barriers in the working environment. The outcome of this study is beneficial for Palestinian construction industry policymakers, so they can monitor the highlighted barriers in on-going infrastructure projects and can modify the safety guidelines accordingly.

Assessment of awareness and hygiene practices regarding COVID-19 among adults in Gaza, Palestine

Coronavirus disease 2019 (COVID-19) has spread worldwide and become an emerging life-threatening pandemic disease since 2019. This study aimed to evaluate the basic knowledge, awareness, personal hygiene and healthy practices regarding COVID-19 during its outbreak among the Palestinian population in the Gaza Strip. It is a cross-sectional survey carried out between July and August 2020 and included 458 participants, aged 18 years or older, belonging to the five Gaza Strip governorates, Palestine, with a variety of socio-economic status. Sociodemographic data and data on COVID-19 knowledge, awareness, personal hygiene and healthy practices were collected via email and social media applications (WhatsApp and Facebook) from the study participants. Statistical analyses were performed using Vr 22 of the SPSS software. Overall, the mean ± SD age of the participants was 26.5 ± 4.2 years. Our findings showed that most of the Gazan adults had very good knowledge regarding COVID-19 in terms of host sources, causative agents, incubation period, symptoms, transmission, treatment and prevention. Additionally, most of the participants had a high level of personal hygiene and healthy practices during the COVID-19 outbreak, where personal hygiene and healthy practices against COVID-19 was 77.4%. Furthermore, a higher educational level did not affect the quality of personal hygiene and healthy practice behaviours during the COVID-19 outbreak. Although most of the Gazans had good knowledge regarding the healthy practices, a significant percentage of the population did not practice the hygiene protocol. Despite the majority of the Gazan population having very good knowledge regarding COVID-19 and a high level of personal hygiene and healthy practices during the COVID-19 outbreak, a small proportion require education about avoiding physical contact and maintaining social distancing with others during the pandemic.

COVID-19 Pandemic in Hong Kong and Gaza Strip: Lessons Learned from Two Densely Populated Locations in the World

The emergence of the coronavirus pandemic led to the implementation of several precautionary measures across the globe. For densely populated regions in the world, this may have been challenging given the proximity of people to one other. Thus, this brief report sought to compare the measures across 2 densely populated locations, Hong Kong and Gaza. Epidemiological data was obtained from governmental online repositories and was compared with the data presented by the Johns Hopkins coronavirus map to ensure consistency. Descriptive statistics were used to interpret the data obtained over the period of the study. The data suggested that although Hong Kong and Gaza implemented similar strategies, Gaza recorded marginally higher cases compared with Hong Kong in the same timeframe. The strategies implemented in both settings included border closures, social distancing, proper hand hygiene, and mask usage. Cultural and socio-demographic differences may have played a part in this variation in case numbers, in addition to lessons Hong Kong had previously learned from a similar outbreak. As the pandemic is ongoing it is essential that public sensitization to adherence to precautionary measures at the personal/family level does not occur.

Prevalence of Type 2 Diabetes and Its Association with Added Sugar Intake in Citizens and Refugees Aged 40 or Older in the Gaza Strip, Palestine

BACKGROUND

Little is known about the prevalence and risk factors of diabetes among Gaza Palestinians, 64% of whom are refugees with exceeded sugar intake. We aimed to estimate the prevalence of type 2 diabetes (T2D) and its association with added sugar intake among residents, with regular visits to primary healthcare centers (PHCs) across Gaza.

METHODS

From October to December of 2019, a cross-sectional survey was conducted among 1000 citizens and refugees in nine PHCs selected from the five governorates of the Gaza Strip. Information on dietary intake, medical history, and other risk factors was collected by trained health workers, using structured questionnaires. Anthropometry and biochemical data were extracted from the PHC medical record system.

RESULTS

Overall, the prevalence of diagnosed T2D and undiagnosed T2D were 45.2% and 16.8%, respectively, in adults aged 42 to 74 years, with the differences among citizens and refugees (diagnosed: 46.2% vs. 43.8%; undiagnosed: 15.7% vs. 18.2%). The uncontrolled glycaemic rate was 41.9% and 36.8% for diagnosed patients in citizens and refugees, respectively. Among those without a clinical diagnosis of T2D, after multivariable adjustment, daily added sugar intake was positively associated with fasting glucose and the risk of undiagnosed T2D (odds ratio, 95% CI, highest vs. lowest intake, was 2.71 (1.12-6.54) (pfor trend < 0.001). In stratified analysis, the associations between added sugar intake and the risk of undiagnosed T2D tend to be stronger among refugees or those with higher body mass index.

CONCLUSIONS

Among Palestinian adults, both citizens and refugees are affected by T2D. Added sugar intake is associated with the risk of undiagnosed T2D.

Undergraduate medical students' attitudes towards medical errors and patient safety: a multi-center cross-sectional study in the Gaza Strip, Palestine

BACKGROUND

In undergraduate medical education, patient safety concepts and understanding of medical errors are under-represented. This problem is more evident in low-income settings. The aim of this study was to explore undergraduate medical students' attitudes towards patient safety in the low-income setting of the Gaza Strip.

METHODS

A cross-sectional, descriptive study included medical students of the two medical schools in the Gaza Strip with 338 medical students completing the Attitudes to Patient Safety Questionnaire-IV (APSQ-IV), which examines patient attitudes in 29 items over 10 domains. Results are represented as means ± standard deviations for each item and domain as well as percentage of positive responses to specific items.

RESULTS

Medical students reported slightly positive patient safety attitudes (4.7 ± 0.5 of 7) with the most positive attitudes in the domains of situational awareness, importance of patient safety in the curriculum, error inevitability and team functioning. While no negative attitudes were reported, neutral attitudes were found in the domains of professional incompetence as a cause of error and error reporting confidence. Study year and gender had no significant association with patient safety attitudes, except for disclosure responsibility, where male students displayed significantly more positive attitudes. The study university was significantly associated with three of the 10 examined domains, all of which involved understanding of medical errors, for which students of University 2 (who had undergone limited patient safety training) held significantly more positive attitudes, compared with students of University 1 (who did not have structured patient safety training).

CONCLUSION

Medical students' patient safety attitudes were very similar among students from both universities, except for understanding of medical error, for which students, who had received structured training in this topic, displayed significantly more positive attitudes. This underlines the power of the 'hidden curriculum', where students adjust to prevalent cultures in local hospitals, while they do their clinical training. Furthermore, it highlights the need for a systematic inclusion of patient safety content in local undergraduate curricula.

The pandemic under siege: A view from the Gaza Strip

In this article I argue that while the COVID-19 outbreak is at its early stages in the Gaza Strip, the Palestinian coastal enclave is particularly vulnerable to its effects - not least due to the multiplicity of existing development challenges that have resulted from an ongoing Israeli and Egyptian-imposed blockade. With the economy at a standstill, the Palestinian governing authority has limited financial resources to (re)build key sanitation, hygiene, waste treatment and water supply infrastructure. These (infrastructural) inadequacies, while already a public health concern before the onset of the pandemic, now renders Gaza particularly vulnerable to the spread of viruses and diseases. Additionally, the limited movement of goods because of the siege has led to an acute shortage of medical supplies and equipment that are essential for combating a pandemic. Nonetheless, the COVID-19 outbreak is also "unique" in that it presents Gaza with a crisis that has little to do with the hostilities that define the politics of Israel-Palestine. Yet, the potential of a widespread outbreak also lays bare to the development challenges that Gaza faces as a result of the conflict. This, I conclude, provides an opportunity for the donor community to, under pretext of combating the pandemic, remedy some of the consequences of the conflict and siege without having to contend with the (political) stigma of doing so.

Intimate partner violence against Palestinian women in Gaza strip: Prevalence and correlates

Context:

Intimate partner violence (IPV) affects gravely the victims and is resulting in negative physical and psychological consequences.

Aims:

This paper aimed to determine the prevalence of IPV against women in Gaza strip and associated factors. Moreover, to explore women's seeking behaviors to help.

Settings and Design:

Cross-sectional study.

Methods and Materials:

Community internet-based survey was conducted using the Heart Insult Threat Scout questionnaire and the reporting behavior of respondent to violence act.

Statistical Analysis Used:

A number of 517 ever married women responded and data were entered and analyzed using SPSS software version 23.

Results:

About 517 women participated. Of which, 23% (119/517) reported exposure to any types of IPV. Multivariate logistic regression showed factors associated with IPV were as follows: husbands who are drug user (OR = 27.577, CI95%: 5.153–147.591; P < 0.001), husband exposure to violence in childhood (OR = 9.174, CI95%: 4.753–7.727; P > 0.001), and family with a special needs child (OR = 2.956, CI95%: 1.131–8.607; P < 0.05). Approximately, two-thirds of the victims tended to keep silent toward violence and dealt with it as a private and family issue; hence, they hesitated to communicate with others or seek any help to protect themselves.

Conclusions:

About 23% from the study participants experience violence in their life time. Factors associated with IPV are husband's drug abuse, having a child with special needs, and husband's childhood experience of violence. Qualitative researches are needed to understand the women experience to violence and sociocultural barrier for disclosure.

Does gender influence food intake and physical activity pattern among Palestinian adolescents in the Gaza Strip?

Background

One of the most important parameters that affect the development of adolescents is nutrition. Eating practices among adolescents may have long-term impact on their health.

Aims

This study aimed to assess whether there is a difference in food intake and physical activity patterns among male and female adolescents (12-19 years old) in the Gaza Strip.

Methods

The cross-sectional study was conducted in April 2016 among 378 adolescent students, 205 males, 173 females. Researchers utilized quantitative and qualitative measures by incorporating a face-to-face interview questionnaire with the adolescents and focus group discussions with parents.

Results

Over 55% of participants were eating healthy foods with high frequency; the proportion of boys was greater than that of girls (P < 0.05). Around 45% were eating unhealthy foods with high frequency; here the proportion of girls was greater, but the difference was not statistically significant (P > 0.05). In terms of physical activity pattern, more than half of the adolescents were practicing a sedentary lifestyle, girls statistically significantly more than boys (P < 0.001). No statistically significant sex-based association was found between food intake habits and physical activity pattern.

Conclusions

Palestinian adolescents of both sexes in the Gaza Strip are practising unhealthy feeding habits coupled with an apparently highly sedentary lifestyle.

HIV/AIDS in Palestine: A growing concern

According to the United Nations AIDS reports in 2018, the Middle East and North Africa region is considered an area of increasing concern for HIV infection due to high mortality associated with AIDS. The incidence of HIV/AIDS in Palestine between 1988 and 2017 as reported by the Palestinian Ministry of Health was analyzed. A total of 98 cases were reported (79 AIDS patients and 19 HIV positives). A nationwide surveillance is needed to understand the epidemiology of HIV infection in the country. Identification of the HIV risk factors and health outreach directed to the public are essentially crucial prevention measures that should be implemented by the Palestinian Ministry of Health.

Serum vitamin D status in type 2 diabetic patients from Gaza Strip

OBJECTIVE

To assess serum vitamin D status and its relations to other biochemical parameters in type 2 diabetic patients from Gaza Strip.

MATERIALS AND METHODS

This case-control study included 58 type 2 diabetic patients as well as 58 non-diabetic controls. Patients and controls were matched for age and gender. Data were obtained from questionnaire interview, and biochemical analysis of blood samples.

RESULTS

Serum vitamin D was significantly lower in diabetic patients compared to non-diabetic controls (25.9 ± 11.0 versus 34.6 ± 13.8 ng/dl, % difference = 28.8%, P < 0.001). The number of patients having vitamin D deficient, insufficient and sufficient were 6 (10.4%), 35 (60.3%) and 17 (29.3%) compared to controls of 3 (5.2%), 16 (27.6%) and 39 (67.2%), respectively (χ² = 14.672, P < 0.001). Serum glucose, glycated hemoglobin (HbA1c), serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and triglycerides were significantly higher in patients than in controls whereas serum insulin, high density lipoprotein cholesterol (HDL-C) and calcium were significantly lower in patients. Serum vitamin D showed significant negative correlations with HbA1c (r = - 0.186, P = 0.046), ALT (r = - 192, P = 0.040) and AST (r = - 0.188, P = 0.044) whereas significant positive correlations were found with HDL-C (r = 0.188, P = 0.044) and calcium (r = 0.239, P = 0.010).

CONCLUSION

The significant negative and positive correlations of vitamin D with HbA1c and calcium, respectively suggests that vitamin D supplementation would be of potential therapeutic value in clinical settings for controlling of type 2 diabetes and more importantly its complications. However, a well-designed clinical trials are needed to define the contribution of vitamin D status and therapy in the global diabetes problem.

The Public Health Impacts of Gaza's Water Crisis: Analysis and Policy Options

Gaza has long had water and sanitation challenges, but today it is in a state of emergency. Its dual water crisis combines a shortage of potable water for drinking, cooking, and hygiene with a lack of wastewater sanitation. As a result, over 108,000 cubic meters of untreated sewage flow daily from Gaza into the Mediterranean Sea, creating extreme public health hazards in Gaza, Israel, and Egypt. While these problems are not new, rapidly deteriorating infrastructure, strict limitations on the import of construction materials and water pumps, and a diminished and unreliable energy supply have accelerated the water crisis and exacerbated the water-related health risks. Three wars between Israel and Hamas since 2009 and intra-Palestinian rivalry between Hamas and Fatah have further hindered the rehabilitation of Gaza's water and sanitation sectors. This study describes the relationship between Gaza's water problems and its energy challenges and examines the implications of this water crisis for public health. It reviews the current state of water supply and water sanitation in Gaza, analyzes water-related risks to public health in Gaza, and explains potential regional public health risks for Israel and Egypt. The authors recommend a number of steps to ameliorate the crisis and decrease the potential for a regional public health disaster that take into consideration current political constraints. The audience for this study includes stakeholders involved in Gaza, including the Palestinian, Israeli, and Egyptian governments, various international organizations and nongovernmental organizations working on the ground in Gaza, and the donor community seeking to rehabilitate Gaza.

Development of reconstructive surgery services in the Gaza Strip, Palestine

Plastic surgery involves the restoration, alteration or reconstruction of the human body. It includes reconstructive and aesthetic surgery. This paper discusses the authors' experience introducing new reconstructive, microsurgical and aesthetic surgeries in the Gaza Strip. We analyzed 192 cases of reconstruction carried out in the Al-Alamy Burns Center in Al-Shifa Hospital from August 2017 to July 2018 and at the European Gaza Hospital during a one-month delegation, as well as 38 aesthetic surgeries performed in the author's private clinic. We highlight challenges hindering the development of reconstructive and plastic practices in the Gaza Strip and propose solutions. Plastic surgeries have greatly evolved at Al-Shifa Hospital. Despite obstacles limiting the development of reconstructive surgery, we were able to treat complicated cases requiring microsurgical procedures. In one year we performed 192 reconstructive surgeries, in addition to 38 hair transplants. Overall success rate was 97.8%, with five failed flaps documented. Wound infection was the main cause of failure. However, the failed flaps were repaired by various approaches. The hair transplant patients went home the same day with no complications. Plastic surgeries have improved significantly and staff competencies have increased with frequent exposure to different cases. Moreover, the physicians' skills and knowledge have been imbedded in practice following the educational development of the authors. Establishing specialized training programs in plastic and reconstructive surgery is crucial to enhancing and reinforcing the physicians' skills and knowledge and guaranteeing high quality care.

Causes and consequences of unintended pregnancies in the Gaza Strip: a qualitative study

BACKGROUND

Little is known about unintended pregnancies in the Gaza Strip. This study explored causes and consequences of unintended pregnancies among women in the Gaza Strip.

METHODS

This was a qualitative study, and included 21 women who had experienced unintended pregnancies previously. Data collection took place in three focus groups of 5-12 participants, which were facilitated by one female researcher. Structured questions on reasons for, causes and impact of unintended pregnancies were answered by all participants. Sessions were audiotaped and responses were transcribed and read by all the researchers to extract themes.

RESULTS

The mean age of participants was 34.2±6.0 years, parity was 2.7±0.6 and 16 participants (76.2%) had benefitted from secondary level education or above.Five main themes were identified: (1) economic hardship was the main reason for pregnancies to be unwanted; (2) high pressure was exerted on women for male babies, exposing women to gender-based violence; (3) advanced maternal age was perceived as a social stigma; (4) complete lack of support for women facing unintended pregnancy led to self-management of terminations including attempts of unsafe methods; and (5) changes of methods and incorrect use leading to contraceptive failure was the most frequent cause.

CONCLUSIONS

Unintended pregnancies in the Gaza Strip are a common cause of distress for women. The most effective way of preventing unintended pregnancies remains access to reliable contraception. However, a service designated to support women facing unintended pregnancies is needed in the Gaza Strip. Local policymakers have to address this when planning healthcare services.

The burden of war-injury in the Palestinian health care sector in Gaza Strip

Background

War-related injury is a major public health concern, and a leading cause of mortality, morbidity, and disability globally, particularly in low and middle-income countries such as Palestine. Little is known about the burden of war-related injury in the Palestinian context. The objective of this study was to characterize the incidence and pattern of injuries, associated with war in Gaza Strip, from July 8 to August 26, 2014.

Methods

This was a descriptive study based on an injury registry at hospital facilities in the Gaza Strip. A total of 420 victims records from 2014 Gaza war injuries were randomly selected, proportionate to the size of the study population estimated across five Gaza governorates. Simple descriptive statistics were calculated to explore the frequency and percentage distribution of study variables and injury data. A chi-square test (X²) was used. The significance level was derived at p < 0.05. The data were analyzed by IBM SPSS software, version 23.

Results

Males (75.5%) have experienced more war-related injuries than females (24.5%), constituting a male: female ratio of 3.1:1. Almost half (49.5%) of the injured victims were of the age group 20–39, followed by children and adolescents (< 20 years), accounting for 31.4%. More than half of victims were single (53.6%), 44.3% were married and the rest were widowed or divorced. The overall number of injuries was 6.4 per 1000 population, though it varied among regions. North Gaza reported the highest number of injuries (9.0) and Rafah the lowest (4.7) per 1000 population. Blast and explosion were found to be the most common causes of war injuries (72.9%). The highest proportion of injuries were reported in the upper body. Multiple body shrapnel wounds and burns (39.3%) were most frequent. Other types of injuries were multiple organ injury (24.3%), fractures (13.6%), internal organ injury and bleeding (9.8%), amputation (4.5%), abrasions/lacerations and contusions (4.8%), vision or hearing loss or both (1.9%) and respiratory problems (1.9%). The highest percentage of injuries were classified as mild (46.9%), and the rest ranged from moderate-to-severe. Almost 26% of individuals had sustained disability, and most of them had physical/motor impairment.

Conclusion

War-related injuries constitute a major problem to public health discipline and clinical medicine as well. A better surveillance system using ICD codes, and development of a comprehensive electronic data network are necessary to make future research easier and more timely.

Survival after the diagnosis of breast or colorectal cancer in the GAZA Strip from 2005 to 2014

Background

Within a dramatic socio-political context, cancer represents a growing health burden in the Gaza Strip. We investigated the survival experience of people diagnosed with breast (BC) or colorectal (CRC) cancer from 2005 to 2014.

Methods

Data included 1360 BC cases (median age 55.1 years) and 722 CRC cases (median age: 59.5 years; 52.5% men) recorded by the Gaza Cancer Registry according to a standard protocol. Clinical information was available for cases diagnosed in 2005–2006 only. Survival probabilities were estimated by Kaplan-Meyer method, while hazard ratios (HRs) and 95% confidence intervals (CI), adjusted for age and sex, were computed to assess factors associated with the risk of death.

Results

Five-year survival was 65.1% for women with BC and 50.2% for patients with CRC. Advanced age (> 65 years), stage, and grade increased the death risk. Full access to therapies was associated with a reduced risk of death as compared with patients who had limited access (HR = 0.26, 95% CI:0.13–0.51 for BC; and HR = 0.11, 95% CI:0.04–0.31 for CRC).

Conclusion(s)

The 5-year survival after BC or CRC in the Gaza Strip was in line with estimates from surrounding Arab countries, but it was much lower than in developed Mediterranean countries (e.g., in Italy or in Jewish people in Israel).

Glycemic control among primary care patients with type 2 diabetes mellitus in the Gaza Strip, Palestine

AIM

In this study, we aimed to assess the level of good glycemic control, to determine association between adherence to antidiabetic medications and glycosylated hemoglobin (HbA1c) and to examine factors influencing good glycemic control.

MATERIALS AND METHODS

A cross-sectional design was employed among 369 patients with type 2 diabetes mellitus (T2DM) from four Ministry of Health health centers in 2016. A sample of 3 ml blood was taken to measure the HbA1c, and patients were asked to fill out a pretested questionnaire. Univariate and multivariate logistic regressions, to identify independent factors associated with good glycemic control, were conducted using SPSS software version 22 (IBM Corp, Armonk, NY, USA).

RESULTS

Mean [±standard deviation (SD)] of HbA1c was 8.97 (2.02) and one fifth of patients had good glycemic control (HbA1c ⩽ 7%). Factors associated with good glycemic control were: older age [odds ratio (OR) = 0.96, 95% confidence interval (CI): 0.933-0.988), high medication adherence (OR: 2.757, 95% CI: 1.308-4.693), and better health literacy (OR= 2.124, 95% CI: 1.917-4.921). Duration of diabetes mellitus (DM > 7 years) was inversely related to good glycemic control (OR = 2.255, 95% CI: 1.189-4.276).

CONCLUSION

Our study showed that glycemic control was suboptimal, and factors associated with that were: older age, high medication adherence, and better health literacy. Knowledge of these factors could be an entry toward helping patients and targeting interventions to improve glycemic control and prevent diabetes-related complications.

Psychometric Properties of an Arabic Safety Attitude Questionnaire (Short Form 2006)

OBJECTIVES

There is a widespread interest in exploring healthcare providers' attitudes and perceptions about patient safety culture. This study was done to determine the reliability and validity of the Arabic version of Safety Attitude Questionnaire (SAQ) in Palestinian hospitals.

METHODS

This was a methodological study and the SAQ was translated into Arabic using the forward-backward translation technique. Four Ministry of Health hospitals in the Gaza Strip were randomly selected, and proportionate systematic sampling was followed to select the participants. Questionnaires were distributed to 370 physicians and nurses. Face and content validity were tested, and the content validity index was determined using the average approach. Internal consistency was assessed with Cronbach's alpha, split-half reliability, and intercorrelation between the questionnaire scales. Construct validity was assessed through exploratory and confirmatory factor analysis.

RESULTS

A total of 339 questionnaires were received, giving a response rate of 91.6%. Questionnaire acceptability was good and relevant to the study purpose. Cronbach's alpha value was 77.7 (74.7-82.2). Goodness of fit indices from the confirmatory factor analysis showed a satisfactory model fit: comparative fit of indices (CFI = 0.797), root mean square error of approximation (RMSEA = 0.085), and standardized root square residual (SRMR = 0.074). Factor analysis with varimax rotation revealed that six factors explained 62.3% of the variance.

CONCLUSIONS

The Arabic version of SAQ (short form 2006) is valid and reliable, and shows a satisfactory model of fit. This instrument shows promise to be a sound tool to assess the safety culture in Palestinian hospitals.

Nursing perceptions of patient safety climate in the Gaza Strip, Palestine

AIMS

This study was undertaken to assess the perception of nurses about patient safety culture and to test whether it is significantly affected by the nurses' position, age, experience and working hours.

BACKGROUND

Patient safety has sparked the interest of healthcare mangers, yet there is limited knowledge about the current patient safety culture among nurses in the Gaza Strip.

METHODS

This was a descriptive cross-sectional study, administering the Arabic Safety Attitude Questionnaire (Short Form 2006) to 210 nurses in four public general hospitals.

RESULTS

Job Satisfaction was the most highly perceived factor affecting patient safety, followed by Perception of Management. Safety culture varied across nursing position, age, work experience and working hours. Nurse Managers had more positive attitudes towards patients than frontline clinicians did. The more experience nurses had, the better their attitudes towards patient safety. Nurses who worked the minimum weekly required hours and who were 35 years and older had better attitudes towards all patient safety dimensions except for Stress Recognition. Nurses with a positive attitude had better collaboration with healthcare professionals than those without a positive attitude.

LIMITATION

Generalization is limited, as nurses who worked in private and specialized hospitals were excluded.

CONCLUSION

Evaluation of the safety culture is the essential starting point to identify hindrances or drivers for safe patient care. Job Satisfaction, Perception of Management and Teamwork necessitate reinforcement, while Working Conditions, Stress Recognition and Safety Climate require improvement.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Ensuring job satisfaction through adequate staffing levels, providing incentives and maintaining a collegial environment require both strategic planning and institutional policies at the higher administrative level. Creation of a non-punitive and learning environment, promoting open communication and fostering continuous education should be fundamental aspects of hospital management. A policy of mixing experienced nurses with inexperienced nurses should be considered.

Nasal carriage of methicillin resistant Staphylococcus aureus among health care workers at Al Shifa hospital in Gaza Strip

Background

Nasal carriage of Staphylococcus aureus among hospital personnel is a common cause of hospital acquired infections. Emergence of drug resistant strains especially methicillin resistant S. aureus (MRSA) is a serious problem in hospital environment. Therefore, the aim of this study was to determine the nasal carriage rate of S. aureus and MRSA among Health Care Workers (HCWs) at Al Shifa Hospital, the major hospital in Gaza Strip.

Methods

A cross sectional study was conducted on 200 HCWs. Nasal swabs were collected during February — April 2015, and cultured on blood and mannitol salt agar. The isolates were identified as S. aureus based on morphology, coagulase test, DNase test and mannitol salt agar fermentation. Disk diffusion antibiotic susceptibility tests were performed according to the guidelines of the Clinical and Laboratory Standards Institute. MRSA were confirmed by detection of the mecA gene by PCR.

Results

Out of the 200 healthcare workers, 62 (31%) carried S. aureus, of which 51 (82.3%) were MRSA. Therefore, 25.5% of all HCWs were identified as MRSA carriers. MRSA carriage rate was highest among nurses (30.4%) whereas the carriage rate among doctors was (16%). The majority of MRSA carriers were workers of internal medicine department and surgical wards (41.3 and 35% respectively). Out of the 51 MRSA isolates identified by oxacillin disc resistance, 40 were confirmed by PCR targeting the mecA gene. Penicillin showed the highest rate of resistance among MRSA and MSSA isolates (100%).

Conclusions

The high rate of nasal MRSA carriage among healthcare workers found in this study is alarming and highlights the need for adjusted infection control measures to prevent MRSA transmission from HCWs to the vulnerable patient.

Clinical and Biochemical Associations with Diabetic Retinopathy in Male Patients in the Gaza Strip

BACKGROUND

There are limited data on the prevalence and risk factors for diabetic retinopathy (DR) in the Gaza Strip.

OBJECTIVE

To assesses clinical and biochemical associated with DR in males with type 2 diabetes mellitus (T2DM) in the Gaza Strip.

METHODS

One hundred and fifty males with T2DM from the Gaza Strip underwent a questionnaire interview, serum biochemical analysis, and assessment of their previous urine and blood results.

RESULTS

The prevalence of DR was 24.7%. The duration of diabetes and prevalence of neuropathy, nephropathy, cardiovascular disease, and recurrent infections were significantly higher among patients with DR compared with those without DR (p < 0.05). Serum urea, creatinine, glucose, cholesterol, and low-density lipoprotein cholesterol were significantly elevated, whilst eGFR and high-density lipoprotein cholesterol were significantly lower in patients with DR compared with patients without DR (p < 0.05). Urinary albumin concentration and albumin creatinine ratio (ACR) was higher in patients with DR. ACR correlated significantly with the duration of T2DM (r = 0.311, p < 0.001), glucose (r = 0.479, p < 0.001), urea (r = 0.337, p < 0.001), creatinine (r = 0.275, p = 0.001), and GFR (r = -0.275, p < 0.001).

CONCLUSION

These data show a high prevalence of DR in an unselected cohort of patients with T2DM and relationships to modifiable risk factors in Gaza.

Assessment of health-care waste management in a humanitarian crisis: A case study of the Gaza Strip

Health-care waste management requires technical, financial and human resources, and it is a challenge for low- and middle income countries, while it is often neglected in protracted crisis or emergency situations. Indeed, when health, safety, security or wellbeing of a community is threatened, solid waste management usually receives limited attention. Using the Gaza Strip as the case study region, this manuscript reports on health-care waste management within the context of a humanitarian crisis. The study employed a range of methods including content analyses of policies and legislation, audits of waste arisings, field visits, stakeholder interviews and evaluation of treatment systems. The study estimated a production from clinics and hospitals of 683kg/day of hazardous waste in the Gaza Strip, while the total health-care waste production was 3357 kg/day. A number of challenges was identified including lack of clear definitions and regulations, limited accurate data on which to base decisions and strategies and poor coordination amongst key stakeholders. Hazardous and non-hazardous waste was partially segregated and treatment facilities hardly used, and 75% of the hazardous waste was left untreated. Recommendations for mitigating these challenges posed to patients, staff and the community in general are suggested. The outputs are particularly useful to support decision makers, and re-organize the system according to reliable data and sound assumptions. The methodology can be replicated in other humanitarian settings, also to other waste flows, and other sectors of environmental sanitation.

Prevalence and perception of smoking habits among the Palestinian population in the Gaza Strip

BACKGROUND

The Gaza Strip is a densely populated place with ~2 million inhabitants in an area of 365 km(2). The aim of this study was to determine the smoking prevalence in the Gaza Strip and to identify the perception of the Palestinian population on smoking.

METHOD

A cross-sectional study was conducted in the Gaza Strip, Palestinian territories, during the period from June to September 2014. Convenient sampling method was adopted. A structured pretested questionnaire was used.

RESULTS

A total of 600 adults aged 15 years or older completed the questionnaires with a response rate of 83.3%. The prevalence rate of smoking was 26.3%, with a significantly higher rate among males (31%) than females (6.9%) (P<0.001). The mean starting age was 17.4±3.9 years. The study revealed that influence of friends is the major reason for initiation of smoking and the most influential factor in convincing smokers to quit was the family. Smokers' knowledge about smoking risks motivates them to try stop smoking (64.9%) or desire to stop smoking (65.2%).

CONCLUSION

The study revealed that tobacco use is significantly prevalent in the Gaza Strip. The author recommends rapid antismoking campaigns with stress on the family role and massive intervention programs to encourage young people to change their behavior toward smoking.

National G6PD neonatal screening program in Gaza Strip of Palestine: rationale, challenges and recommendations

Congenital genetic disorders affecting neonates or young children can have serious clinical consequences if undiagnosed and left untreated. Early detection and an accurate diagnosis are, therefore, of major importance for preventing negative patient outcomes. Even though the occurrence of each specific metabolic disorder may be rare, their collective impact of preventable complications may be of considerable importance to the public health. Our previous studies showed that glucose-6-phosphate dehydrogenase (G6PD) deficiency is a problem of public health importance that has been shown to be a predominant cause of acute hemolytic anemia requiring hospitalization in Palestinian young children in Gaza Strip. Intriguingly, the majority of these children had one of the three variants, Mediterranean(c.) (563T) , African G6PD A-(c.) (202A) (/c.) (376G) and heretofore unrecognized as a common G6PD-deficient variant G6PD Cairo(c.) (404C) . The high prevalence of G6PD deficiency, as well as dietary factors in the region that precipitate anemia, argues for a need to protect the Palestinian children from a treatable and manageable genetic and metabolic disorder. This work reviews and discusses rationales and challenges of G6PD screening program in Gaza Strip. We advocate adopting a national neonatal G6PD screening program in Gaza Strip to identify children at risk and promote wellness and health for Palestine.

ICU Nurses’ Perceptions and Practice of Spiritual Care at the End of Life: Implications for Policy Change

Nurses strive to provide holistic care, including spiritual care, for all patients. However, in busy critical care environments, nurses often feel driven to focus on patients’ physical care, possibly at the expense of emotional and spiritual care. This study examined how Palestinian nurses working in intensive care units (ICUs) understand spirituality and the provision of spiritual care at the end of life. In this article, the author presents background studies, encouraging an increased emphasis on spiritual care, and describes the qualitative method used to study 13 ICU Gaza Strip nurses’ understanding of spiritual care. Findings identified the following themes: meaning of spirituality and spiritual care; identifying spiritual needs; and taking actions to meet spiritual needs. The author discusses the difficulty nurses had in differentiating spiritual and religious needs, notes the study limitations, and concludes by recommending increased emphasis on the provision of spiritual care for all patients.

How to assess solid waste management in armed conflicts? A new methodology applied to the Gaza Strip, Palestine

We have developed a new methodology for assessing solid waste management in a situation of armed conflict. This methodology is composed of six phases with specific activities, and suggested methods and tools. The collection, haulage, and disposal of waste in low- and middle-income countries is so complicated and expensive task for municipalities, owing to several challenges involved, that some waste is left in illegal dumps. Armed conflicts bring further constraints, such as instability, the sudden increase in violence, and difficulty in supplying equipment and spare parts: planning is very difficult and several projects aimed at improving the situation have failed. The methodology was validated in the Gaza Strip, where the geopolitical situation heavily affects natural resources. We collected information in a holistic way, crosschecked, and discussed it with local experts, practitioners, and authorities. We estimated that in 2011 only 1300 tonne day(-1) were transported to the three disposal sites, out of a production exceeding 1700. Recycling was very limited, while the composting capacity was 3.5 tonnes day(-1), but increasing. We carefully assessed system elements and their interaction. We identified the challenges, and developed possible solutions to increase system effectiveness and robustness. The case study demonstrated that our methodology is flexible and adaptable to the context, thus it could be applied in other areas to improve the humanitarian response in similar situations.

Anti-mullerian hormone as a predictor of ovarian reserve and ovarian response in IVF women from Gaza strip

Back ground: Careful evaluation of patients and proper treatment with right techniques are essential for successful outcome of assisted reproduction. To obtain satisfactory results, it is necessary to assess ovarian reserve before planning treatment.

OBJECTIVE

To evaluate anti-mullerian hormone as a predictor of fertility potential in terms of ovarian reserve and ovarian response reflected by antral follicles and mature oocyte counts in response to menotrophin stimulation in in vitro fertilization (IVF) women from Gaza Strip.

MATERIALS AND METHODS

This prospective cohort study consisted of 81 women (mean age 28.7 years) attending IVF at Al-Basma Fertility Center in Gaza City. Blood withdrawal for antimullerian hormone measurement was performed in all the patients and the number of oocytes and embryos were recorded.

RESULTS

The total number of retrieved oocytes was inversely associated with age (12.5±4.5, 11.0±5.4 and 6.9±4.7 at age ≤25, 26-35 and >35 years, respectively (F=4.793 and p=0.011). The ovarian response to Menotrophin (FSH 75IU, LH 75 IU) stimulation was better for younger age. There was a significant positive association between ovarian response in terms of total number of oocytes and antimullerian hormone levels. The maximum level of antimullerian hormone was observed in females who achieved positive pregnancies (4.5±2.5 ng/mL) followed by negative pregnancies (2.9±1.8 ng/mL) with significant differences (F=6.862 and p=0.002). Correlation coefficient revealed that the number of mature oocytes showed strong positive correlation with the antimullerian hormone levels (r=0.469, p=0.001).

CONCLUSION

Anti-mullerian hormone can be used in IVF programs as a good predictor of ovarian reserve and ovarian response.

Human rights violations during Israel's attack on the Gaza Strip: 27 December 2008 to 19 January 2009

The Israeli attack on the Gaza Strip from 27 December 2008 to 19 January 2009 was characterised by gross, unprecedented human rights violations, which were the result of a deliberate political decision to overlook the loss of civilian lives in order to save those of Israeli soldiers. These violations included attacking medical personnel and civilians, impeding emergency medical evacuations, restricting health care for the civilian population, preventing referral to care outside the Gaza Strip and jeopardising distribution of medical supplies and food. This article will focus on the right to health of Palestinians under Israeli occupation by presenting case studies that have been collected by Physicians for Human Rights-Israel. It will emphasise how the Palestinian medical system has been stretched to its breaking point, severely and negatively affecting the provision of medical services; the consequences of denying patients referral to care outside the Gaza Strip; and other severe violations of human rights. It will conclude by reiterating that only the withdrawal of Israeli occupation from Palestinian land can guarantee the right to health of Palestinians.