Multiple micronutrient supplementation improves growth and reduces the risk of anemia among infants in Gaza Strip, Palestine: a prospective randomized community trial.

BACKGROUND: Infants and young children 6-24 months of age are the most nutritionally vulnerable groups, as their needs for vitamins and minerals are high relative to the amount of food they consume. This study determines the effect of Micronutrient Powder Supplementation (MNP) on growth and hemoglobin of infants in Gaza Strip, Palestine. METHOD: This was a two-arm parallel-group randomized controlled trial conducted in two health care clinics of the United Nations Relief and Work Agency (UNRWA) at the Middle Area governorate of Gaza Strip, Palestine. A total of 200 healthy infants aged 6-month-old were recruited and randomized to receive 3 sachets/week of MNP for 12 months alongside with the National Micronutrient Supplement (NMS) (n = 100) or NMS alone (n = 100). Weight, length, blood hemoglobin, and dietary intakes were measured at 6, 9, 12, 15, 18, and 21 (3 months after the end of intervention) months of age. Analysis was by intention to treat. RESULTS: The experimental group had a higher concentration of hemoglobin at 12 and 15 months than did the control group, and a significant difference (p <  0.05) was observed at 15 months only. Significantly greater weight, length, weight-for-age, length-for-age, and weight-for-length z-scores were observed in the experimental group than that in the control group at 12 and 15 months (p <  0.05). The prevalence of anemia (18% vs. 52%) and stunting (1% vs. 11%) were higher in the control than the experimental group, respectively. After controlling for sex, similar findings were reported. CONCLUSIONS: Addition of MNP to the existing NMS program improved the nutritional status of young children. The potential benefits of MNP supplementation on physical growth and hemoglobin should be considered in the existing NMS program. TRIAL REGISTRATION: ISRCTN57594793 ; Date of registration: 20-03-2018 (Retrospectively registered).

Prevalence and predictors of overweight and obesity among women in the Gaza strip-Palestine: a cross-sectional study.

BACKGROUND: The prevalence of overweight and obesity among women of childbearing age is considered a public health concern. Few studies have been conducted in the Gaza Strip to determine the magnitude of overweight and obesity. This study aimed to determine the prevalence of overweight and obesity along with their associated factors among women in the Gaza Strip. METHODS: A cross-sectional study was conducted to recruit a total of 357 mothers aged 18-50 years. Interviews were carried out among mothers to collect sociodemographic information, nutritional information, and physical activity. Anthropometric measurements [height, weight and waist circumference (WC)] were conducted with the mothers. Body Mass Index (BMI) was computed to determine the prevalence of overweight and obesity. Multinomial logistic regression was used to examine the associated factors of overweight and obesity. RESULTS: The combined prevalence of overweight and obesity among mothers was (64.1%). The results of multinomial logistic regression showed the risk of overweight and obesity increased with age, the highest risk being in mothers aged > 33.0 years (OR = 2.7, 95% CI: (1.06,6.86)), and (OR = 5.72, 95% CI: (2.07,15.78)), respectively, compared to mothers aged < 33.0 years. Moreover, mothers with medium and high educational levels had a slightly higher risk of obesity (OR = 0.31, 95% CI: (0.15,0.64)), and (OR = 0.32, 95% CI: (0.12,0.82)) respectively than mothers with low educational level. Household income was positively associated with overweight and obesity. Mothers exposed to higher monthly income were more likely to be overweight or obese (OR = 2.64, 95% CI: (1.20, 5.83)), and (OR = 3.06, 95% CI: (1.28,7.29)), respectively. Nutrition knowledge was significantly associated with a high prevalence of obesity (OR = 1.20, 95% CI: (1.03,1.38)). CONCLUSIONS: This study showed a higher prevalence of overweight and obesity among Palestinian women than previous studies. Age, educational level, monthly income, and nutrition knowledge were associated with the prevalence of overweight and obesity, compared to other variables that were not associated with overweight and obesity such as location, work status, physical activity, and sitting hours. Urgent action is needed to tackle overweight and obesity among women. Effective intervention is required to increase nutrition knowledge among women to improve their eating behaviors.

Assessing policy-makers', academics' and experts' satisfaction with the performance of the Palestinian health research system: a qualitative study.

BACKGROUND: There is a growing demand within international health agencies to ensure health research systems (HRSs) are strengthened and well-functioning to support healthcare systems (HCSs). Understanding HRS performance through system actors is an indispensable move in analysing this system. This study aims to examine policy-makers', academics' and experts' satisfaction with overall HRS performance, while also investigating their perceptions about political will and attention towards health research. Ultimately, we want to identify gaps related to performance and generate insights on how to move forward for HRS performance strengthening. METHODS: This study was carried out in Palestine, targeting three sectors, namely government institutions, public health universities, and major local and international health non-governmental organisations (NGOs). Semi-structured, in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted with participants. The institutions from the three sectors were selected based on stated criteria and peer reviews. Data were translated from Arabic into English, transcribed, content checked by the principal investigator, imported to a software programme (MAXQDA 12), and then coded. Thematic content analysis was used. RESULTS: A total of 104 experts participated in 52 IDIs and 52 experts participated in 6 FGDs. Findings revealed three principal domains. First, the HRS in Palestine is remarkably underperforming, and the majority of experts were unsatisfied. Participants perceived the system as ineffective and inefficient, poorly managed and lacking systematic assessment. Second, the factors behind system underperformance were (1) an unstructured system and the lack of a research culture as well as of a governing body or policies; (2) health research was seen as individualistic, non-development driven and unutilised in policy decisions; and (3) considerably deficient coordination and essential resources. The third finding showed inadequate political support and engagement, which then also related to system underperformance. CONCLUSIONS: The Palestinian HRS is perceived as underperforming by health experts at different levels, where research is not on the leadership agendas. Potential actions should be taken to actively engage the state health decision-makers and inform them of the importance, uses and impacts of performance assessment. Findings urge policy-makers and legislators to build an inclusive and national body of governance with agreed strategies including fundamentally hybrid and aligned performance assessment mechanisms, such as a research observatory platform. In addition, it is recommended to establish a strategic plan to expand professionals' research awareness and abilities, as well as empower the institution's research monitoring and evaluation capacities.

Understanding the concept and importance of the health research system in Palestine: a qualitative study.

BACKGROUND: The importance of a health research system (HRS), namely an instrument for developing and enabling health systems, is increasing, particularly in developing countries. Assessing the perceptions of system performers is a necessary part of system analysis, which seeks to recognize a system's strengths and limitations aiming towards improvement. This study assesses the perceptions of policy-makers, academicians and experts regarding the HRS concept and its importance to generate insights for system strengthening. In Palestine, HRS is just emerging, helping to address the many public health-related challenges faced by the country. METHODS: The study was implemented from January until July 2016, targeting three sectors, namely relevant government institutions, schools of public health, and major local and international health agencies. Data was collected through 52 in-depth interviews and six focus group discussions (FGDs) with policy-makers, academics, directors and experts. Participants and institutions were selected based on stated criteria and peer review. Data were translated, transcribed, checked and then imported to a software program (MAXQDA 12) for thematic and content analysis. RESULTS: A total of 104 experts participated, wherein 52 were interviewed and 52 participated in the six FGDs. The HRS concept, as defined by WHO, was conceptualized differently among participants with unclear delineations between various components. Inconsistencies appeared when participants attempted to conceptualize HRS in broader contexts, though HRS goals and functions were sufficiently delineated. The majority of participants agreed that HRS correlates with notions of 'improvement' and recognized HRS 'as a significant gain'. Neglect of HRS was perceived as a big loss. CONCLUSIONS: The study revealed that the level of understanding of HRS among health experts in Palestine is inadequate and not sufficiently conceptualized for its application. Findings also underlined the need to establish a central governance coordination body that promotes HRS understanding, awareness and culture as an enabler for HRS strengthening.

The Palestinian health research system: who orchestrates the system, how and based on what? A qualitative assessment.

BACKGROUND: In 2011, the WHO Eastern Mediterranean Region committee launched a strategy for scaling up research in the region to address the countries' health needs through formulating and analysing the National Health Research System (HRS). Stewardship comprises three functions, namely governance, policy and priorities, and is a central pillar of this system to ensure a well-organised and functioning HRS. This study aims to examine the perceptions of the HRS performers to understand these functions and to generate insights for system strengthening. METHODS: The study was carried out in Palestine, targetting three sectors in the health field, including relevant governmental health institutions, schools of public health, and major local and international health agencies. The data were collected through 52 in-depth interviews (IDIs) and 6 focus group discussions (FGDs) with policy-makers, academics, directors, and experts. Participants and institutions were selected purposively based on a set of criteria and peer review. RESULTS: A total of 104 experts participated in the IDIs (52 participants) and FGDs (52 participants in 6 FGDs), highlighting that stewardship functions remain problematic and insufficiently performed, mainly due to a missing health research structural and regulatory framework and dispersed health research work. Despite the limited good practices, the majority of the participants described the Ethical Review and Clearance as weak due to the lack of an agreed-upon national committee and procedural quality and ethics guidelines for non-compliance. A policy or strategy dedicated to health research is lacking. The exercises of research priority-setting appear to be evolving despite the lack of consensus and the low levels of knowledge and experience in research prioritisation. Common gaps, such as weak political will and capacity support, the absence of a national unified regulating body, and the indirect effects of political conditions on strengthening the HRS as well as other sectors, also emerged. CONCLUSIONS: The stewardship functions of the Palestinian HRS remain weak along with substantial political, structural, and resources and capacity gaps. The study emphasises the imperative need to initiate strategic efforts led by the MOH and the Palestinian National Institute of Public Health alongside with other players to strengthen a national HRS through improving the stewardship functions. To achieve this, attention and support of decision-makers, involvement, mobilisation and strategic dialogue are indispensable, in order to embark on building a well-regulated and coordinated structure, operational research policy, and prioritisation of essential research.

Growth patterns of Palestinian children from birth to 24 months.

BACKGROUND: Growth faltering in early life can adversely affect health in later childhood and adulthood. Growth monitoring of children can provide evidence to help formulate effective strategies to address growth problems but such information on Palestinian children is lacking. OBJECTIVES: This study aimed to determine the growth patterns of children under 2 years in Gaza, Palestine. METHODS: This retrospective cohort study was conducted in 2014 in 10 randomly selected primary health care clinics in 5 governorates of Gaza. Weight and length data were obtained from the health cards of children born in 2012, and z-scores were calculated and compared with the WHO Growth Standard (2006). RESULTS: A total of 2 632 children's cards were included at the beginning of the study. Weight-for-age and weight-forlength decreased from birth to 6 months to about -0.40 SD but increased afterwards to -0.11 SD and 0.34 SD at 24 months respectively. Length-for-age declined after 6 months, reaching -0.85 SD at 24 months. At 6 months, the prevalence of underweight and stunting were 5% and 9% but at 24 months, the prevalence was 4% and 20% respectively. Wasting was highest at 6 months (10%) but decreased to 3% at 24 months. Significantly more girls were stunted at 9, 12 and 18 months (P < 0.001), underweight at 24 months (P < 0.05) and wasted at 12 months (P < 0.05). Early life faltering in length was more pronounced than weight, with stunting occurring in one fifth of boys and girls by 2 years of age. CONCLUSIONS: Preventive strategies are urgently needed to address early life causes of undernutrition, particularly stunting, in Palestinian children in Gaza.

Prevalence and associated factors influencing stunting in children aged 2-5 years in the Gaza Strip-Palestine: a cross-sectional study.

BACKGROUND: Stunting continues to be a major public health problem in developing countries. It is one of the most important risk factors for morbidity and mortality during childhood. In Palestine, it is another health problem, which adds to the catastrophic issues in the region. This study aimed to determine the prevalence of stunting and its associated factors among preschool children in the Gaza Strip. METHODS: A cross-sectional study design was conducted in the Gaza Strip. A total of 357 children aged 2-5 years and their mothers aged 18-50 years were recruited. A multistage cluster sampling was used in the selection of the study participants from three geographical areas in the Gaza Strip: Jabalia refugee camp, El Remal urban area, and Al Qarara rural area. A structured questionnaire was used for face- to -face interviews with the respective child's mother to collect sociodemographic information and feeding practice. Anthropometric measurements for children were taken to classify height-for-age (HAZ), while maternal height was measured as well. Descriptive and binary logistic regression analyses were applied to determine the prevalence and associated factors with stunting. RESULTS: The total prevalence of stunting in this study was 19.6%, with the highest prevalence being (22.6%) in Jabalia refugee camp. It turns out that shorter mothers had increased the odds of stunting in preschool children in the Gaza Strip. Children born to mothers whose height was 1.55-1.60 m or <1.55 m were more likely to be stunted (p = 0. 008), or (p < 0.001), respectively, than children born to mothers whose height was >1.60 m. Moreover, parental consanguinity increased the risk of stunted children (p = 0. 015). CONCLUSIONS: This study showed the prevalence of stunting was of alarming magnitude in the Gaza Strip. Our results also demonstrated that parental consanguinity and short maternal stature were associated with stunting. Culturally appropriate interventions and appropriate strategies should be implemented to discourage these types of marriages. Policy makers must also raise awareness of the importance of the prevention and control of nutritional problems to combat stunting among children in the Gaza Strip.

Atherosclerotic cardiovascular disease: a review of initiators and protective factors.

Atherosclerotic cardiovascular disease (CVD) is a collective term comprising of a group of disorders of the heart and blood vessels. These diseases are the largest cause of morbidity and premature death worldwide. Coronary heart disease and cerebrovascular disease (stroke) are the most frequently occurring diseases. The two major initiators involved in the development of atherosclerotic CVD are vascular production of reactive oxygen species (ROS) and lipid oxidation. In atherosclerosis development, ROS is associated with rapid loss of anti-inflammatory and anti-atherogenic activities of the endothelium-derived nitric oxide (NO(·)) resulting in endothelial dysfunction. In part involving activation of the transcription factor NF-κB, ROS have been involved in signaling cascades leading to vascular pro-inflammatory and pro-thrombotic gene expression. ROS is also a potent activator of matrix metalloproteinases (MMPs), which indicate plaque destabilization and rupture. The second initiator involved in atherosclerotic CVD is the oxidation of low-density lipoproteins (LDL). Oxidation of LDL in vessel wall leads to an inflammatory cascade that activates atherogenic pathway leading to foam cell formation. The accumulation of foam cells leads to fatty streak formation, which is the earliest visible atherosclerotic lesion. In contrast, the cardiac sarco/endoplasmic reticulum Ca(2+)-ATPase (SERCA2a) and hepatic apolipoprotein E (apoE) expression can improve cardiovascular function. SERCA2a regulates the cardiac contractile function by lowering cytoplasmic calcium levels during relaxation, and affecting NO(·) action in vascular cells, while apoE is a critical ligand in the plasma clearance of triglyceride- and cholesterol-rich lipoproteins.

Anemia among children aged 2-5 years in the Gaza Strip- Palestinian: a cross sectional study.

BACKGROUND: Anemia is a major public health problem worldwide, with adverse consequences on child growth, development, and survival. This deficiency has affected approximately a quarter of the world population. This study aimed to determine the prevalence of anemia and the associated factors among preschool children in the Gaza Strip. METHODS: A cross-sectional study was conducted between May and September 2012. A total of 357 preschool children were selected using multistage sampling method from Jabalya refugee camp, El Remal urban area, and Al Qarara rural area. Hemoglobin level was measured, and anemia diagnosis was confirmed at a level <11.0 g/dL. In this study, we utilized a pretested questionnaire for face to face interview with mothers. Anthropometric indicators for children were measured using the WHO guideline. Descriptive and multivariate analyses were conducted to determine the prevalence and associated factors of anemia. RESULTS: The overall prevalence of anemia was 59.7% among preschool children in the Gaza Strip, 46.5% and 13.5% of which are mild and moderate, respectively. The mean hemoglobin level was 10.83 ± 0.86 g/dl. Children living in Jabalya refugee camp have a high risk of anemia [adjusted b= -0.55; 95% confidence interval (CI;-0.72,-0.39); p < 0.001]. Boys were more susceptible to this deficiency than girls [adjusted b = 0.17; 95% CI (0.0.01, 0.33); p = 0.031]. Hemoglobin level increased with age [adjusted b = 0.02; 95% CI (0.01, 0.03); p < 0.001]. Hemoglobin level decreased in children living in poor households [adjusted b = -0.24; 95%CI (-0.41,-0.06); p = 0.006]. Underweight children were more susceptible to anemia than normal weight children [adjusted b = - 0.22; 95% CI (-0.41, -0.03); p = 0.025]. CONCLUSIONS: The prevalence of anemia among preschool children in the Gaza Strip was higher than those reported in previous local studies, indicating that anemia is a major public health problem. In this study, we also observed mild and moderate cases among children, whereas severe anemia was not observed. Independent predictors of anemia were geographic location, sex, age, monthly income, and malnutrition. Results provided the baseline information on anemia, therefore, especial attention should be given on intervention of anemia.

Role of fish oil in human health and possible mechanism to reduce the inflammation.

The roles of Omega-3 FAs are inflammation antagonists, while Omega-6 FAs are precursors for inflammation. The plant form of Omega-3 FAs is the short-chain α-linolenic acid, and the marine forms are the long-chain fatty acids: docosahexaenoic acid and eicosapentaenoic acid. Omega-3 FAs have unlimited usages, and they are considered as omnipotent since they may benefit heart health, improve brain function, reduce cancer risks and improve people's moods. Omega-3 FAs also have several important biological effects on a range of cellular functions that may decrease the onset of heart diseases and reduce mortality among patients with coronary heart disease, possibly by stabilizing the heart's rhythm and by reducing blood clotting. Some review studies have described the beneficial roles of Omega-3 FAs in cardiovascular diseases (CVDs), cancer, diabetes, and other conditions, including inflammation. Studies of the effect of Omega-3 FAs gathered from studies in diseased and healthy population. CVDs including atherosclerosis, coronary heart diseases, hypertension, and metabolic syndrome were the major fields of investigation. In studies of obesity, as the central obesity increased, the level of adipocyte synthesis of pro-inflammatory cytokines like tumor necrosis factor alpha (TNF-α) and interleukin 6 (IL-6) were increased and the level of anti-inflammatory adiponectin was decreased indicating a state of inflammation. The level of C reactive protein (CRP) synthesized from hepatocyte is increased by the influence of IL-6. CRP can be considered as a marker of systemic inflammation associated with increased risks of CVDs. In molecular studies, Omega-3 FAs have direct effects on reducing the inflammatory state by reducing IL-6, TNF-α, CRP and many other factors. While the appropriate dosage along with the administrative duration is not known, the scientific evidence-based recommendations for daily intake are not modified.

Understanding coverage of antenatal care in Palestine: Cross-sectional analysis of Palestinian Multiple Indicator Cluster Survey, 2019-2020.

INTRODUCTION: Antenatal care is an essential component of primary healthcare, providing opportunities to screen, prevent, and treat morbidity to preserve the health of mothers and offspring. The World Health Organization now recommends a minimum of eight antenatal care contacts, instead of four, which is challenging in countries exposed to political violence and structural disparities in access to social, economic and healthcare resources as exist in Palestine. This study examines the compliance of the recommend standard of antenatal care in Palestine. METHODS: We analyzed data from the UNICEF's Palestinian Multiple Indicator Cluster Survey (MICS) 2019-2020. The eligible sample consisted of 2,028 women, 15-49 years of age, living in Palestine, on whom data were available on reported antenatal care services received during the most recent pregnancy within the last two years. Outcome variables of interest were the reported frequencies of antenatal care visits, gestational timing of 1st visit, and services received. Potential risk factors were assessed in women attending less than eight versus eight or more antenatal contacts, as recommended by WHO, by estimating prevalence ratios with 95% Confidence Intervals. RESULTS: Overall, 28% of women did not meet the WHO's recommendation of eight or more antenatal contacts, varying from 18% in Central West Bank to 33% in South West Bank across the four areas of Palestine (North, Central, and South West Bank and Gaza Strip). Twelve percent of women reported having had no antenatal contacts in the 1st trimester, and these women were two- to three-folds more unlikely to meet WHO recommendation of antenatal contacts than mothers who initiated the antenatal contact in the 1st trimester. Women who had less than eight antenatal contacts were generally poorer, higher in parity, lived in North and South West Bank, sought ANC from either doctor or nurse/midwife only, and initiated antenatal contact in 2nd-to-3rd trimesters. CONCLUSION: There were considerable socioeconomic and geographic inequalities in the prevalence of not meeting WHO recommended number of antenatal contacts in Palestine, offering the opportunity to inform, improve and continuously reassess coverage of antenatal care.

Food insecurity, dietary inadequacy, and malnutrition in the Gaza Strip: a cross-sectional nutritional assessment of refugee children entering the first grade of UNRWA schools and their households before the conflict of 2023-24.

BACKGROUND: Gaza has long been subjected to food insecurity; however, little was known about the influence of food insecurity on the nutritional wellbeing of schoolchildren. To fill this gap, the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), which provides humanitarian relief to Palestine refugees, assessed the nutritional status, diet, and food security of refugee children about to enter first grade (aged 4-10 years, mean age 72·1 months) in mid-2023 during a required health examination. METHODS: As part of an annual School Entrance Health Examinations that began in May, a cross-sectional food security and nutritional assessment was added from July 8, to Sept 7, 2023, during which children being examined at six study-designated UNRWA clinics across Gaza were systematically sampled (in a 1:4 ratio) and parental or guardian consent sought for their participation. Household food security was assessed by a seven-point Arab Family food Security Scale score, and respondents were asked about family receipt of food assistance. The 1-week meal patterns of the children were probed, and intake frequencies of 49 foods in the past month categorised into ten nutritious food groups to assess diet diversity. The weight, height, and haemoglobin concentrations (assessed with a photometric analyser) of the children were measured. The UNRWA Research Review Board approved all study procedures. FINDINGS: Approximately 34 000 children underwent the annual School Entrance Health Examination in Gaza in May, 2023 and approximately 16 000 children were estimated to have completed the additional food security and nutritional assessments from July 8, to early Sept 7, 2023, of whom 3814 were systematically sampled at six UNRWA clinics across Gaza, with 3229 (84·7%) parents or guardians consenting for their children to participate. 3155 were interviewed about household food security with a seven-point Arab Family Food Security Score, and 3212 were asked about food assistance receipt. 2694 (83·9%) of 3212 households were on food assistance, 787 (24·9%) of 3155 were classified as food secure (0-2 points), 1025 (32·5%) were classified as moderately (3-5 points) food insecure, and 1343 (42·6%) as severely food insecure (6-7 points). 219 (28·5%) of 768 children reported missing breakfast and 213 (28·4%) of 750 reported missing dinner in the food-secure group, 438 (47·2%) of 928 reported missing breakfast and 426 (45·6%) of 934 reported missing dinner in the moderately food-insecure group, and 956 (75·5%) of 1267 reported missing breakfast and 951 (74·8%) of 1272 reported missing dinner in the severely food-insecure group. Lunch was missed daily by 30 (3·8%) of 786 children in the food-secure group, 54 (5·3%) of 1023 in the moderately food-insecure group, and 193 (14·5%) of 1334 in the severely food-insecure group. Diets were poor in dairy items, meat, poultry, fish, pulses, eggs, and vitamin A-rich vegetables and fruit, and 2225 (68·9%) of 3229 children did not consume a minimally diverse diet every day (≥5 nutritious food groups). 72 (2·5%) of 2913 children had stunting and 129 (4·4%) of 2913 had wasting (less than -2 Z scores), and 963 (29·8%) of 3229 had anaemia (haemoglobin <11·5 g/dL). Boys and girls were similar in their diets, anthropometric Z scores, and prevalence of anaemia. INTERPRETATION: Gazan families with children about to enter first grade were food insecure and reliant on food assistance, possibly protecting the anthropometric status of the children, whose diets however lacked diversity. FUNDING: Japan Ministry of Foreign Affairs and the Vitamin Angels Alliance, USA. TRANSLATION: For the Arabic translation of the abstract see Supplementary Materials section.

Irrational use of medicine in Arab countries: findings from a systematic review of literature (2000-2019).

OBJECTIVE: This study aimed to analyse the patterns of the irrational use of medicines in Arab countries and to determine the factors contributing to these patterns. METHODS: A systematic literature review was conducted using two major databases: PubMed and Scopus. The systematic search targeted original studies conducted in Arab countries from 2000 to 2019. A conceptual framework was adopted from a previous study and was utilized to assess the irrational use of medicines and its influencing factors. RESULTS: A total of 136 studies from 16 Arab countries were included. Almost all were cross-sectional studies. Most focused on evaluating the irrational use of medicines rather than investigating the cause. The number of medications per encounter was 2.3 which is within the limits of developed countries (2.7). The percentage of antibiotics per 100 encounter was 50.1% and the percentage of injections prescribed per 100 encounter was 15.2%. The consumption of antibiotic and injections was much higher than that recommended by WHO. At the same time, the review identified that one fourth of all medications were unnecessarily prescribed. SUMMARY: The literature review revealed that the irrational use of medicine is prevalent in most Arab countries. Excessive use of antibiotics was the most commonly observed pattern. Therefore, there is a need to conduct further research to identify the factors that drive the irrational use of medicines in Arab countries and then to make recommendations to mitigate this issue.

Policymakers' and patients' perspectives on breast cancer management in the Gaza Strip-Palestine: A qualitative study.

PURPOSE: This study aimed to explore the perspectives of policymakers and patients on breast cancer (BC) management in the Gaza Strip. METHODS: A descriptive qualitative study design was employed using semi-structured in-depth interviews with 13 policymakers and focus group discussions with 19 BC patients. The four criteria presented by Lincoln and Guba were used to evaluate the validity and reliability. Data were analysed using conventional content analysis approach. RESULTS: Three categories were generated from the qualitative data analysis: (1) limited human resources in the BC management, (2) inadequate institutional level service provision in the BC management, and (3) a lack of policy level support for the BC management. The current health services provided to Gazan BC patients are either fragmented or partially unavailable. The roles and responsibilities at the policy, system and individual levels were ambiguous. Policymakers attributed the fragmented BC services to the shortage of qualified healthcare professionals, inadequate training programmes for the staff, and lack of coordination among health institutions. Some patients expressed an insufficient knowledge about cancer screening tests, while others ignored screening for cultural reasons. CONCLUSION: Gaza's BC services are fragmented and not well-organised and they have received inadequate attention at the leadership and governance levels. The government in the Gaza Strip should strengthen its leadership to upgrade and develop the policies and strategies necessary for proper BC management, including an improved information system and cooperation with national and international institutions to secure funding for developing BC services and ensure medication availability.

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.

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.

The association of types, intensities and frequencies of physical activity with primary infertility among females in Gaza Strip, Palestine: A case-control study.

INTRODUCTION: Physical activity and energy state balance have fundamentally been related to reproductive system and health. This study explored the relationship between different types, intensities and frequencies of physical activity with primary infertility among women in Gaza Strip, Palestine. METHODS: A case-control study was conducted in Gaza Strip with the participation of 320 married couples. 160 infertile couples were chosen from five fertility centers registries from 2016 to 2018 and matched residentially with 160 fertile couples. Cases were selected through systematic stratified sampling of five lists categorized according to residency and the determined percentage selected from each list was proportional. Data were collected through a self-administered questionnaire extended by the short form of international physical activity questionnaire and analyzed through SPSS program version 22 by using descriptive analysis, independent T-test, cross-tabulation, and binary logistic regression. RESULTS: Low frequency, intensity and duration of physical activity were associated with 3.1 risk of primary infertility (95% CI, 1.60-5.99, P < 0.001). Adjustment for age, marital age, age of menarche, refugee status and monthly income provided 3.2 risk (95% CI, 1.55-6.60, P = 0.002). Women spending more than 300 minutes a day sedentarily were 2.3 times more likely to have fertility problems than physically active females. Measuring energy expenditure in MET-min/w (Metabolic Equivalent) showed vigorous MET-min/w as negatively associated with the infertility status of females (Interquartile range IQR: 480 for cases and 720 for controls, P = 0.010). On the basis of energy expended in kilocalories in relation to weight, results showed the same association (IQR: 564 for case and 864 for controls, P = 0.011). No associations were found between moderate activity levels and primary infertility. CONCLUSION: Low levels of physical activity and sedentary lifestyle endanger the fertility status of females in Gaza Strip. This may offer the need for endorsing and formalizing adequate physical activity education and awareness protocols in the national reproductive health guidelines and empowering environmental capacity building to alter physical activity-related cultural norms.

A vision to strengthen resources and capacity of the Palestinian health research system: a qualitative assessment.

BACKGROUND: The World Health Organization has proposed a global strategy to build a robust Health Research System Resources and Infrastructural Capacity (HRSRIC). Despite the growing research productivity, HRSRIC in Palestine has rarely been investigated. AIMS: To analyse perceptions of health research system performers to understand the status of HRSRIC, identify its gaps, and propose policy solutions to strengthen HRSRIC. METHODS: This qualitative study targeted 3 health sectors: government, academia, and local and international organizations. Fifty-two in-depth interviews and 6 focus group discussions were conducted with key informants who were selected purposively. Data were analysed using MAXQDA 12. RESULTS: Despite the availability of competent personnel, the overall HRSRIC, such as human and financial resources, and facilities, forms a central challenge. HR financing is limited, unsustainable, and flows from external and individual sources. The public and private funds are largely in shortage with resources misallocation and donors' conditionality. HR quality is moderate while knowledge transfer and translation are not well conceptualized and inappropriately performed. Lack of governance, coordination, HRSRIC strategy, resource allocation, systematic and reliable data, evidence-informed culture, and environmental impacts are the main common gaps. CONCLUSIONS: The overall status of HRSRIC in Palestine is still lacking and major challenges persist where the pace of strengthening efforts is steady. There is an emphasis that strengthening HRSRIC is an imperative step and real investment opportunity for building a successful health research system. Political commitment, consolidated leadership structure, operational capacity building strengthening strategy, resources mobilization, and sovereignty are key requirements.

Mapping stakeholders of the Palestinian Health Research System: a qualitative study.

BACKGROUND: There is a growing international and regional interest in Health Research Systems (HRSs) in light of a global strategy for HRS stakeholders' (HRSSHs) active involvement. HRSSHs in Palestine have rarely been investigated with regard to uncertainties. AIMS: This study aimed to analyse perceptions of HRSSHs in order to understand their roles and involvement, identify gaps, and offer policy solutions for stakeholders' engagement in the Palestinian HRS. METHODS: This qualitative study targeted three local Palestinian health sectors, government, academia, and local and international agencies. Data were collected through 52 in-depth interviews (IDIs) and 6 focus group discussions (FGDs) and then analysed using MAXQDA 12 software. Participants and institutions were selected purposively based on a set of criteria and peer review. RESULTS: The overall HRS stakeholders' roles were unsatisfactory, with low involvement from society, the private sector, local and international sectors. The role of academia and the Ministry of Health is vital but observed moderate in health research while that of international agencies is weak due to conflicting agendas and lack of a guiding body. Most universities have poor representation in public decision-making and scarcity in health research potential and capacity. Interest-power imbalance among stakeholders is reported where political, organizational, and technical shortfalls were indicative of weak roles and low involvement, along with a lack of health research culture, structure, resources, defined roles, and network. CONCLUSIONS: Tackling the inadequate roles, interests' disparity, and poor involvement of HRSSHs is imperative for HRS strengthening. Redefining HRSSHs' roles and involving all stakeholders is key through strategic dialogue, consolidated leadership, and resource mobilization.

Sociodemographic correlates of food habits among school adolescents (12-15 year) in North Gaza Strip.

BACKGROUND: There is little information about meal patterns and food consumption of adolescents in Palestine. The objective of this study was to describe the association between sociodemographic factors and food intake, and meal patterns among Palestinian school adolescents (12-15 year) in North Gaza Strip. METHODS: A cross-sectional study was conducted in 2002 comprising 944 subjects in 10 schools in Gaza city, Jabalia village and Jabalia refugee camp. Self-administered questionnaires were filled in by students and parents to obtain data on frequency of meals, food intake and sociodemographic characteristics. RESULTS: High household socioeconomic status (SES) was associated with the increased number of meals and the increased intakes of many nutritious foods such as; animal food items, fruits and vegetables and dairy foods. The percentage of adolescents having breakfast daily of high and low SES was 74.5% vs 55% in boys and 65.6% vs 45% in girls. The percentage of girls with refugee status who had lunch was higher (90.2%) compared to the local citizen girls (83.9%), (p = 0.03). Girls were less likely to skip daily lunch (OR = 0.55, 95% CI = 0.36-0.87, p = 0.01) compared to boys. Risk of skipping lunch was three times higher among adolescents living in the village compared to Gaza well-off area (OR = 3.3, 95% CI = 1.72-6.31, p < 0.001). Adolescents who were having lunch daily were less likely to skip breakfast or dinner. Only 11.6% of boys and 16.2% of girls consumed fruits daily. In multivariate analysis, SES was positively associated with food frequency intake scores in both genders. Boys from the refugee camp and the village had a significant higher consumption of fruits and vegetables than boys from high and low income area in Gaza City, while it was the opposite in girls. CONCLUSION: Meal skipping is common, particularly among those of low SES and the intakes of many nutritious foods such as animal food items, fruits and vegetables and dairy foods seem to be low among adolescents of low SES. The results of this study could be used as an important base-line for future monitoring of the nutritional situation of adolescents.