A cross-sectional survey of the prevalence and determinants of comorbid psychological distress in attendees at two general hospitals in Gaza.

BACKGROUND: There is an absence of mental health services within general hospitals in Gaza. As part of the Ministry of Health plan to develop mental health liaison services, a cross-sectional survey of the prevalence of and risk factors for psychological distress in attendees at two general hospitals was undertaken to estimate and highlight the need for establishing such services. METHODS: 20 volunteers aged 24-30 years with a degree in psychological or social science from a university accredited by the Palestinian Ministry of Education and Higher Education, and with experience in field data collection for studies in mental health, were selected and trained in the use of the Arabic version of the 12-item General Health Questionnaire (GHQ-12), an internationally and well validated tool for measuring psychological distress in adults. The volunteers were supervised as they screened adult attendees at emergency rooms, inpatient wards and outpatient departments, and women attending the maternity units at two of the largest general hospitals in Gaza (Nasser and Indonesian) over seven consecutive days (March 18-23, 2018). Attendees at emergency and outpatient departments were included if they were on repeat visits with medically unexplained somatic complaints, if they attended with complaints resulting from any kind of social problem, physical or sexual violence, or had a history of any kind of chronic disease. All patients from the internal medicine and inpatient departments were included. The data from the questionnaires were collated and analysed with descriptive and inferential statistics. FINDINGS: 1789 attendees (791 men and 998 women) were screened using the GHQ-12. Of these attendees, 23·8% (426 of 1789) had a GHQ-12 score of 6 or 7, indicating the presence of significant psychological distress with a high possibility of caseness (ie, meeting the diagnostic threshold for clinical depression). 36·2% (648 of 1789) scored 8 or above, indicating the presence of moderate to severe depression or anxiety disorders that require immediate clinical intervention. For all of the hospital departments surveyed, individuals with scores of 6 or greater made up a large proportion of the attendees (385 of 660 [58·3%] in emergency rooms, 197 of 306 [64·4%] in inpatient wards, 430 of 711 [60·5%] in outpatient departments, and 62 of 112 [55·4%] in maternity units), in both hospitals. In addition, a set of risk factors were found to be significantly associated with GHQ-12 scores of 6 or greater. These were being a woman (p=0·020), living in villages adjoining the most conflict prone areas (p<0·0001), no or low formal education (p<0·0001), being divorced (p<0·001) or widowed (p<0·0001), being unemployed (p<0·0001), and low family income (monthly income of <1000 ILS; p<0·0001). On further stepwise regression analysis, unemployment and low family income were found to be the most important risk factors associated with GHQ-12 scores of 6 or greater. INTERPRETATION: In general hospital attendees there was a very high rate of significant psychological distress. Given the absence of mental health services within general hospitals in Gaza, the findings indicate an urgent need to make mental health interventions routinely available through general hospital liaison units in Gaza. The risk factors that were identified indicate that psychosocial interventions and access to developmental support are key components of such clinical services, and will be required to reduce the very large, and mostly unmet, population burden of mental health problems in Gaza. FUNDING: WHO, occupied Palestinian territory, as part of the EU project "Building Palestinian resilience: improving psychosocial and mental health responses in emergency".

Integration of mental health and psychosocial support services into primary health care in Gaza: a cross-sectional evaluation.

BACKGROUND: Integration of mental health and psychosocial support (MHPSS) into primary health care in the Gaza Strip involves the delivery of mental health services within the essential service package provided by UNRWA, as recommended by WHO to fill the treatment gap. In early 2016, a successful pilot demonstrated that the integration is achievable in limited resource settings, and resulted in the adoption of a stepped care model to screen, identify, support, and treat patients. This study aimed to evaluate the MHPSS integration process and outcomes at UNRWA health centres in the Gaza Strip. METHODS: We used a descriptive analytical study design, with quantitative and qualitative data collected from records, and individual feedback from patients and health care providers (HCPs). The study was performed in the 22 UNRWA health centres of the Gaza Strip and all participants agreed to participate either verbally or by written consent. Approval was also obtained from the UNRWA Health Program Gaza Field Office. FINDINGS: The integration process started with the comprehensive training of 460 medical and nursing HCPs, in accordance with the Mental Health Gap Action Programme (mhGAP) Intervention Guide. On completion of training, the HCPs put into practice their learning, under close supervision for the first month and with only technical support thereafter. During the period of technical support, MHPSS activities, referral pathways, and proper reporting were ensured and standardised in all health centres. Overall, the integration process achieved success in training, implementation, and supervision. The success of training was assessed with an evaluation form and participants' feedback, the success of implementation by the numbers of people who benefitted, their response to the intervention, and their feedback, and the success of supervision by the standardisation of the process and the technical validity of the intervention. By the end of September, 2018, 80 857 high-risk patients were screened using the General Health Questionnaire 12 (GHQ-12) and 9·0% (7327) were identified as requiring intervention and support, and were assisted using the UNRWA stepped care approach. Of the individuals who were assisted, 30·2% (2212 of 7327) showed significant improvement and 38·9% (2849) were identified as having mental health issues according to the mhGAP. In the same period, 1020 patients benefited from 113 support groups, with excellent effects on their physical and mental health as assessed with qualitative data, patients' testimonies and, in some cases, laboratory investigations. The challenges that were faced were due to manual documentation and reporting, sociopolitical uncertainty, an increase in the number and needs of patients, and the imposed burden on HCPs. In addition, during implementation many individuals who were screened and identified required an urgent response: individuals who were suicidal and individuals whose mental health had been affected by the Great March of Return. INTERPRETATION: The integration showed remarkable success in a short time as a result of the collective effort of all participants. However, there are challenges to overcome, and observation, further evaluation, and refinement of the process are needed to stabilise and sustain the integration of MHPSS services into primary health care for maximum benefit. FUNDING: WHO, and UNRWA resources.

The mortality in Gaza in July-September 2014: a retrospective chart-review study.

BACKGROUND: The majority of Gazans who were killed or injured in the 2014 Israel-Gaza war were civilians, and one-fourth of the population were internally displaced. As the Gaza Strip is a small territory, the whole population was exposed to the war and its effects on the health care system, supplies and infrastructure. Our aim was to assess the overall, sex and age-group mortality in Gaza for the period July-September 2014 that was not caused by war injuries, and the proportion of non-trauma deaths among adults that occurred outside hospital wards. A comparison was made with the mortality for the same period in 2013. METHOD: Date, sex, age, cause and place of each death that was not attributed to war-related physical trauma were collected from death notification forms or death records in Gaza hospitals for the period 01 July to 30 September 2014. The same information was extracted from the local death register for all deaths in the same period in 2013. RESULTS: The mean age at death was 52.4 years in 2014 and 49.7 in 2013, and about 50 % were older than 60 years in both years. The crude non-trauma death rates among adults were 11.6 per 10,000 population in 2014 and 11.3 in 2013, and the age standardised 13.2 and 12.4, respectively. Higher death rates in 2014 were observed among elderly and women. Cardiovascular disease was the most common cause of death among adults of both sexes, and infectious diseases caused less than 10 % in both periods. Three maternal deaths were observed in 2013 and six in 2014 (p = 0.17). The proportion of deaths that occurred in a hospital ward was 71.5 % in 2013 and 51.2 % in 2014. CONCLUSIONS: The mortality from communicable diseases was low in Gaza. We did not detect a higher overall background mortality in the 2014 period compared to 2013, but the observed age and sex distribution differed. The proportion of non-trauma deaths among adults that occurred in a hospital ward was markedly lower during the war. The living conditions and health care situation in Gaza point to the need for close monitoring of mortality.