Effects of change in hospital treatment payment policy for Palestinian refugees in Lebanon: a health economics analysis.

BACKGROUND: In 2016, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) changed from covering the full cost of secondary care in contracted public and private hospitals in Lebanon, Jordan, to requesting that these hospitals pay 10% of the costs. Meanwhile, services at UNWRA-contracted Palestine Red Crescent Society (PRCS) hospitals remained fully covered. We did a health economics analysis to assess the effects this policy change on the demand for secondary care in UNRWA hospitals. METHODS: We assessed the difference in use of different types of hospital (demand) from January to May, 2016, and June, 2016, to October, 2017, before and after the payment policy change. Data were collected by UNWRA from each hospital's database, including individual-level inpatient information for 22 193 Palestinian refugees in Lebanon who were admitted to secondary care at UNRWA-contracted hospitals (public, private, and PRCS). We used regression analyses to estimate the effects on demand for the different hospital types, length of stay, and total costs of treatment to UNWRA and patients. FINDINGS: Around 64% of patients attended PRCS, 26% private, and 9% public hospitals. According to our econometric estimations, after June, 2016, patients were 16% more likely to choose a PRCS hospital over the other types of hospital. Mean length of stay in PRCS hospitals increased, leading to a 20% chance of patients staying 1 day longer in PRCS hospitals than in public or private hospitals. However, the length of stay in public and private hospitals decreased (by an average of 22% at public and 28% at private hospitals), giving an overall decrease in length of stay of 13%. In terms of bill value (ie, total costs to UNRWA and to patients), we found no difference between before and after the policy change. INTERPRETATION: The introduction of the UNWRA cost-sharing component for secondary care led patients to attend PRCS hospitals more often and for longer periods of time. The finding that no effect was seen on costs for UNRWA or patients suggests that the 10% cut in cover at public and private hospitals did not save any money for UNWRA because patients managed to accommodate the increase by changing their hospital preference The study is limited in that it cannot argue causality between the policy and the results found because there is no control group. Nevertheless, robustness testing, including assessing the year 2017, supports our results. This study contributes to the literature on the impacts of co-payments in health care in a very specific context of poverty and conflict that has rarely been subject to scrutiny and provides feedback to UNRWA on a health-care system measure, relevant for future policy designs. FUNDING: None.

Prevalence and characteristics of Palestine refugee mothers at risk of postpartum depression in Amman, Jordan: a cross-sectional study.

BACKGROUND: Postpartum depression (PPD) is a major public health concern because it adversely affects maternal health and children's physical and mental development. The prevalence of PPD in Arab countries is higher than the worldwide prevalence. Additionally, refugee women are more likely to develop PPD than women in the general population, but little research of refugee women in Arab countries is available. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) have provided primary health care to Palestine refugees since 1950 and began the Mental Health and Psychosocial (MHPSS) programme in Jordan in 2017 to enhance the psychosocial and social wellbeing of Palestine refugees. We assessed the prevalence of PPD and examined associated factors among Palestine refugee women living in Amman, Jordan. METHODS: This cross-sectional descriptive study was done between April 21 and May 21, 2018. Eligible participants were Palestine refugee mothers who had given birth 3-16 weeks previously and were attending any of five UNRWA health centres in Amman that were launching the MHPSS programme. Data were gathered in face-to-face structured interviews that included the Edinburgh Postpartum Depression Scale (EPDS) to assess PPD, the Maternal Social Support Scale to assess levels of perceived social support, and a structured questionnaire about sociodemographic, obstetric or paediatric, psychological, and social factors. Participants with scores greater than 12 in the EPDS were classified as having depressive symptoms. Logistic regression was used to identify factors associated with depressive symptoms. The study protocol was approved by the Department of Health, UNRWA Headquarters, Amman, Jordan, and Nagasaki University. Each participant provided written informed consent. FINDINGS: 251 women participated in the study, with a mean age of 27·2 years (range 18-42, SD 5·43). 123 (49%) women were classified as having PPD. Logistic regression showed that factors associated with PPD were perceived low levels of social support (adjusted odds ratio 3·76, 95% CI 1·92-10·93) and experiencing stressful life events (one event 3·92, 1·51-9·91; two events 5·77, 2·33-14·27; and three or more events 14·8, 5·23-41·89). INTERPRETATION: The prevalence of PPD among Palestine refugee women in Amman was higher than that reported in a previous study of the general childbearing population (women aged 18-45 years) in Irbid in Jordan (22%, Mohammad et al. Midwifery 2011; 27: e238-45) but similar to findings in the West Bank (47%, Quandil et al. BMC Pregnancy Childbirth 2016; 16: 375) and in Syrian refugee women in Jordan (49·6%, Mohammad et al. Res Nurs Health 2011; 41: 519-245). Our findings highlight the need to address this disorder in Palestine refugee mothers. Periodical PPD screening, raising awareness about PPD, providing information to husbands and families, and building a support system for mothers could alleviate the risk of PPD. Future studies should examine whether factors of antenatal depression, which were not assessed in this study, correlate with having PPD to clarify the need for early intervention in mothers. FUNDING: Nagasaki University.

Morbidity patterns among hospitalised Palestine refugees from Syria in Jordan: a population-based study.

BACKGROUND: Palestine refugees from Syria (PRS) are among the most vulnerable refugee groups for adverse health outcomes and require assistance from humanitarian agencies. As the armed conflict in Syria has continued, most Palestinians have been displaced from that country to neighbouring countries, where they have experienced difficulties in accessing essential services. More than 17 000 PRS are in Jordan as of 2018 and have received assistance from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), including free primary care and subsidised secondary and tertiary care through contracted governmental hospitals. In this study, we investigated the morbidity patterns among PRS in Jordan receiving UNRWA-supported hospital care. METHODS: We assessed cross-sectional data extracted from the UNRWA Hospitalization Database in Jordan on Oct 18, 2018, for PRS who used UNRWA hospitalisation support between May 31, 2012, and Dec 9, 2017. The database records demographic and medical characteristics of patients and financial information for the care sought. We used descriptive statistics to reveal morbidity patterns. Analyses were done with Microsoft Excel 2016 and Stata/IC (version 15). No ethics approval was required for this study as it was conducted as a part of routine internal monitoring by UNRWA. FINDINGS: 889 PRS were included in analysis, among whom 637 (72%) were girls or women and 252 (28%) were boys or men. The age range was 1-78 years, with girls and women being younger than boys and men (28·1 years [SD 15·1] vs 31·0 years [SD 21·3], p=0·02). The most common reasons for seeking care were pregnancy, childbirth, and the puerperium (381 [60%] of 637 girls and women). Diseases of the circulatory system, digestive system, and musculoskeletal system and connective tissue were the most common diagnoses among boys and men (34 cases [14%] of 252 for each diagnosis). The mean length of stay for women (1·8 days [SD 2·0]) was slightly shorter than that for men (2·0 days [SD 2·2]) but the difference was not significant. The cost was significantly higher for boys and men (mean US$729·7 [SD 557·4] per person) than for girls and women ($326·0 [SD 1190·4], p<0·001). Of all, 886 (>99%) patients were discharged from hospital, two died, and one was transferred to another hospital. INTERPRETATION: More girls and women than boys and men sought care through the UNRWA support programme during the study period, mostly for pregnancy, childbirth, and the puerperium. However, the conditions seen in boys and men led to longer stays in hospitals and significantly higher costs. Diagnoses based on International Classification of Diseases standards should be investigated further, but this study highlights the demand for health-care services and types of care required by the PRS population. Future research should focus on identifying similarities and differences in hospital admissions for PRS compared with other Palestine refugees to inform future preventive public health efforts by UNRWA. The study examined PRS who accessed to UNRWA services only, thus the findings are not representative of PRS in general. However, this is to our knowledge the first study to present morbidity patters and differences in female and male PRS patients receiving care at UNRWA in Jordan. FUNDING: None.

The impact of e-health system implementation on UNWRA health services: an observational study.

BACKGROUND: The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides primary-health-care services to more than 5 million Palestinian refugees in five operational fields (Jordan, Syria, Lebanon, West Bank, and Gaza) through 144 health centres. UNRWA developed its electronic health records (e-Health) system to improve monitoring and facilitation of health services provided to Palestinian refugees. By the end of 2017, the system had been deployed in 129 health centres, included the health files of 3 million patients, and managed more than 8 million visits per year. We assessed whether preventive-health-care services had improved following implementation of the system. METHODS: This observational study used three key performance indicators to assess preventive-health-care services reported in UNRWA's annual reports in 2012-17: the percentage of targeted people aged 40 years and older screened for diabetes; the percentage of pregnant women with a livebirth who attended at least four antenatal visits; and the prevalence of growth problems (underweight, stunting, wasting, and overweight or obesity) in children younger than 5 years. Simple descriptive analysis was conducted with Microsoft Excel 2010. Ethical approval was obtained from the UNRWA Headquarters Department of Health. FINDINGS: Screening for diabetes significantly increased from 13% in 2012 to 21% in 2017 (p<0·0001) since the e-Health system started sending alerts to clerks at health centres. The percentage of pregnant women with a livebirth who attended at least four antenatal visits, increased from 87% in 2012 to 92% in 2017, when the e-Health System allowed health-care providers to log all pregnant women who missed their appointments to enable follow-up. Additionally, an electronic maternal and child health mobile application, sends regular reminders to mothers about appointments for themselves and their children. The percentages of underweight, stunting, wasting, and overweight or obesity among children younger than 5 years increased respectively from 3%, 4%, 2%, and 2% in 2014 to 5%, 7%, 4%, and 5% in 2017, but this was due to the increased detection of growth problems through the e-Health system. INTERPRETATION: The e-Health system improved detection and monitoring by UNRWA health-care providers and access to health services for Palestinian refugees in all three indicator categories. This study has several limitations. It is an observational study based on assessing health records of children rather than a prospective study over time. The focus of the study was to assess the impact of the eHealth system on health-care delivery and not to assess the changes in health-care delivery itself. The electronic health records that were reviewed are for the Palestine refugees who are registered at UNRWA health clinics and not for other refugees or residents of the five countries. Strengths of the study are that it is based on electronic health records which contain data recorded by the treating staff; the e-health system used by UNRWA clinics staff is centralised and the data are aggregated agency wide; and the growth monitoring indicators used by UNRWA were derived from the WHO Multi-center Growth Reference Study to assess the growth of children from birth up to age 5 years. FUNDING: None.

Classifying caesarean section to understand rising rates among Palestinian refugees: results from 290,047 electronic medical records across five settings.

BACKGROUND: Rising caesarean-section rates worldwide are driven by non-medically indicated caesarean-sections. A systematic review concluded that the ten-group classification system (Robson) is the most appropriate for assessing drivers of caesarean deliveries. Evidence on the drivers of caesarean-section rates from conflict-affected settings is scarce. This study examines caesareans-section rates among Palestinian refugees by seven-group classification, compares to WHO guidelines, and to rates in the host settings, and estimates the costs of high rates. METHODS: Electronic medical records of 290,047 Palestinian refugee women using UNRWA's (United Nations Relief and Works Agency for Palestine Refugees in the Near East) antenatal service from 2017-2020 in five settings (Jordan, Lebanon, Syria, West Bank, Gaza) were used. We modified Robson criteria to compare rates within each group with WHO guidelines. The host setting data were extracted from publicly available reports. Data on costs came from UNRWA's accounts. FINDINGS: Palestinian refugees in Gaza had the lowest caesarean-section rates (22%), followed by those residing in Jordan (28%), West Bank (30%), Lebanon (50%) and Syria (64%). The seven groups caesarean section classification showed women with previous caesarean-sections contributed the most to overall rates. Caesarean-section rates were substantially higher than the WHO guidelines, and excess caesarean-sections (2017-2020) were modelled to cost up to 6.8 million USD. We documented a steady increase in caesarean-section rates in all five settings for refugee and host communities; refugee rates paralleled or were below those in their host country. INTERPRETATION: Caesarean-section rates exceed recommended guidance within most groups. The high rates in the nulliparous groups will drive future increases as they become multiparous women with a previous caesarean-section and in turn, face high caesarean rates. Our analysis helps suggest targeted and tailored strategies to reduce caesarean-section rates in priority groups (among low-risk women) organized by those aimed at national governments, and UNRWA, and those aimed at health-care providers.

Social determinants and mental health needs of Palestine refugees and UNRWA responses in Gaza during the COVID-19 pandemic: a qualitative assessment.

BACKGROUND: Due to pre-existing difficulties, refugees are especially susceptible to the negative effects of the pandemic; nonetheless, the pandemic's effect on this group is still unclear. The purpose of this study was to determine the effects of the COVID-19 pandemic on the mental health of Palestine refugees in Gaza by identifying the role of social determinants. During the pandemic, the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) enacted a number of policies and measures. The purpose of this research was to assess their efficacy and acceptability. METHODS: This qualitative study took place between August and November 2020. Twenty-nine key-informant interviews were conducted remotely with UNRWA Headquarters, field and clinical staff in Gaza and with community members, aged ≥18 years and residing in Rafah and Jabalia camps. We sought informed consent verbally or via email. Data was coded based on the framework for social determinants of mental health. RESULTS: Interview results indicated that the relationship might be unidirectional, with COVID-19 causing the degradation of living conditions and vice versa, with living conditions exacerbating the COVID-19 situation by facilitating virus transmission. In other instances, the association between mental health determinants and COVID-19 might be bidirectional. In terms of experiencing violence and anxieties, women, children, and daily-paid employees were significantly more disadvantaged than other groups in the community. UNRWA modified its service delivery techniques in order to continue providing essential services. In general, UNRWA's strategies throughout the pandemic were deemed beneficial, but insufficient to meet the needs of Gazans. CONCLUSION: The pandemic highlights the need to go beyond disease treatment and prevention to address social determinants to improve refugees' health and reduce their susceptibility to future shocks. UNRWA has rapidly implemented telemedicine and mental telehealth services, making it imperative to assess the efficacy of these novel approaches to provide care at a distance. A long-term option may be to employ a hybrid strategy, which combines online and in-person therapy.

Co-payments and equity in care: enhancing hospitalisation policy for Palestine refugees in Lebanon.

BACKGROUND: This paper measures the impact of introducing a 10% co-payment on secondary care hospitalization costs for Palestine refugees living in Lebanon (PRL) in all UNRWA contracted hospitals, except for the Red Crescent Society. This ex-post analysis provides a detailed insight on the direction and magnitude of the policy impact in terms of demand by hospital type, average length of stay and treatment costs. METHODS: With a complete population episode level dataset, we use multinomial logit, negative binomial, and linear models to estimate impacts on the different dependent variables, controlling for disease, patient and hospital characteristics. RESULTS: After the implementation patients were at least 4 pp (p <0.01) more likely to choose a Red Crescent Society hospital for secondary care, instead of one with co-payment. Average length of stay was not affected in general, despite the increase in control at all UNRWA contracted hospitals. Except for the decrease in UNRWA contribution, did not find a statistically significant impact of the co-payment on costs, nor for the provider or for the patient. Findings suggest that introducing a 10% co-payment for secondary hospital care had an impact on patients' health care budget, leading to demand shifts towards cheaper options - i.e., patients had to chose care based on financial constraints rather than on their treatment preferences. CONCLUSION: Before changing healthcare payment schemes in different types of hospitals, facilities offering free of charge treatment should be assessed and prepared for potential demand shifts to avoid overcapacity and the collapse of health care services for such a fragile population. In addition, exemptions from co-payments should be considered for patients with severe health conditions and financial constraints, who, according to our results, are the most likely to change their pattern of care due to an increase in treatment costs.

Medication adherence by Palestine refugees living in Jordan who have diabetes: a cross-sectional study.

BACKGROUND: The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) estimated that in 2016, 11% of Palestine refugees older than 40 years living in Jordan were diagnosed with diabetes and that the disease is controlled in only 45% of Palestine refugees with diabetes. As medication adherence is one of the most important modifiable self-care behaviours to achieve adequate metabolic control, the aims of this study were to measure medication adherence and to review the factors associated with different levels of medication adherence in patients with diabetes. METHODS: This cross-sectional study was a survey of patients with type 1 and type 2 diabetes who attended medical care at the UNRWA Amman New Camp health centre in Jordan. Medication adherence was measured using the Morisky Medication Adherence Scale (MMAS-8), and results were used as outcome variable. Data on factors associated with adherence were collected using a pre-tested patient questionnaire and patients' electronic records, and these factors were used as explanatory variables. Logistic regression analysis of each explanatory variable against the outcome variable was done to estimate crude odds ratios. Data were analysed using STATA version 13.0. FINDINGS: 763 patients were included in the study. 557 (73%) patients did not adhere to their diabetes drug therapy. Univariate analysis showed that the factors associated with non-adherence were: the use of multiple providers for diabetes care (crude odds ratio 0·51, 95% CI 0·28-0·91) and diabetes drugs (0·22, 0·09-0·56); satisfaction with the quality of UNRWA's diabetes care (4·51, 1·05-19·45) and with the explanation of the disease and treatment presented by UNRWA's health professionals (2·72, 1·24-5·29); and trust in UNRWA's health staff (3·61, 1·4-9·32). INTERPRETATION: Decreased odds of adherence was associated with the use of multiple providers of care and diabetes medication, whereas increased odds of adherence correlated with full satisfaction with the quality of care, explanation of the disease, and treatment and trust in UNRWA health-care staff. These findings show the importance of health-system-related factors in affecting adherence to drug therapy in a population of Palestinian refugees with diabetes who accessed UNRWA health care in Jordan. FUNDING: UNRWA.

Contraceptive use by Palestine refugee mothers of young children attending UNRWA clinics: a cross-sectional follow-up study.

BACKGROUND: UNRWA introduced family planning services in 1994 as an integral part of its expanded maternal and child health-care programme. The main objective of UNRWA's family planning programme is to promote the health of mothers, children, and their families. The aim of this follow-up study was to assess contraceptive practices in the target population 5 years after the 2010 follow-up study and to identify future programme needs. METHODS: This cross-sectional survey was a done by trained nurses from June 1 to Dec 31, 2015. Participants were Palestinian refugee mothers who attended Well Baby Clinics at all UNRWA health centres with their youngest child (aged 2 months to 5 years). A sample size of 10 478 participants was calculated on the basis of contraceptive use in 2010, using Epi Info sample size calculation. Women were interviewed, and retrospective data from health records were used as supplementary data. We did a multiple logistic regression to test if maternal age and parity predicted contraceptive use. We used the χ2 test to analyse the relation between previous contraceptive use and birth interval, birth weight, and gestational age. All participants provided verbal informed consent. The study was approved by the ethical committee in the UNRWA Health Department. FINDINGS: Data were obtained from 9860 mothers (mean age 29·8 years [range 29·4-30·1]). 5849 (59%) women were using modern contraceptives at the time of the survey, 1745 (18%) were using traditional methods, and 2265 (23%) were not using any contraceptive method. The most common modern contraceptive was an intrauterine device (2186 [37%] women), and UNRWA was the main provider for 4827 (83%) women using modern contraceptives. The most common reasons for not using contraceptives were a wish to have a child (873 [22%] women), pregnancy (747 [19%]), and a husband's opposition (775 [20%]). Using women with less than three pregnancies as the reference category, use of contraceptives was most likely in women with three to six pregnancies (adjusted odds ratio 1·58, 95% 1·43-1·73; p<0·0001) and in women with more than six pregnancies (1·6, 1·28-1·99; p<0·0001). Women with at least one male child were more likely to use contraceptives than women with no male child (1·39, 1·24-1·56; p<0·0001). Maternal age over 35 years was not a significant predictor for modern contraceptive use. We found a statistically significant correlation between previous contraceptive use and birthweight [c2=23·88; p<0·0001)] but not with gestational age. INTERPRETATION: It is encouraging that mothers seeking modern contraceptives rely on UNRWA to provide family planning services. We found that mothers with higher parity are more likely to use modern contraceptives that comply with UNRWA recommendations. As expected, modern contraceptives lead to better birth spacing. However, mothers above 35 years of age are not more likely to use modern contraceptives, and these mothers might be at higher risk for negative maternal and infant health outcomes. UNRWA family planning services could focus more on counselling this group of mothers. FUNDING: None.

Health and dignity of Palestine refugees at stake: a need for international response to sustain crucial life services at UNRWA.

The UN Sustainable Development Goals affirm equality and dignity as essential to the enjoyment of basic human rights, including the right to the highest attainable standard of physical and mental health, which promotes global solidarity among all people, including refugees. The UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has provided support to Palestine refugees in Jordan, Lebanon, Syria, the Gaza Strip, and the West Bank since the 1950s. Today, however, conflict and violence, occupation, high levels of poverty, and other social determinants of health jeopardize the wellbeing of Palestine refugees. Health concerns include non-communicable diseases, mental health conditions, and access to hospital care. Additionally, UNRWA is continuing to face a severe funding crisis. Using a historical and health policy perspective, this Health Policy examines UNRWA strategies that facilitate continuous provision of health-care services for Palestine refugees. Given the increasingly volatile environment faced by this population, a multifaceted international response is needed to enable UNRWA to deliver sustainable services to Palestine refugees and avert further loss of life, dignity, and hope, pending a just and lasting solution to their plight in accordance with applicable international law and UN General Assembly resolutions.

Oral health status and caries trend among 12-year old Palestine refugee students: results from the UNRWA's oral health surveys 2011 and 2016.

BACKGROUND: In 2016 the United Nation Relief and Work Agency for Palestine refugees in the Near East (UNRWA) commissioned a survey on oral health among 12-year-old students at UNRWA schools in five fields of operation (Jordan, Lebanon, Syria, Gaza Strip and West Bank), following World Health Organization guidelines. The survey aimed to determine the prevalence of dental caries and periodontal diseases among Palestine students attending UNRWA schools and how this has changed over time. METHODS: A two-stage stratified cluster sample design was used. For each Field of operation, the sample size was calculated based on 95% confidence level, 80% power and margin of error of 4%. Clinical examination was carried out by trained Field Oral Health services Officers (FOHSOs) from the 5 fields. Teeth presence and condition, gingival bleeding and calculus and the presence of dental sealants in occlusal surfaces of permanent molars were recorded. Behavior information of students/parents were collected using a questionnaire that was self-completed by the child/parent under supervision. Results were compared with those from a previous survey carried out in 2011 with the same methodology. RESULTS: In the two surveys the distributions of students who had caries experience in their permanent teeth were similar (73.1% in 2011 vs 72.8% in 2016, p = 0.83). In 2016 a significant increase of missing teeth (p < 0.01) and sealants (p < 0.01) was observed. Both surveys have identified behavioral determinants for dental caries, particularly dietary habits such as soft drinks consumption. Gingival health also showed statistical differences among the fields. CONCLUSIONS: The prevalence of caries experience was very high in all fields and, with regard to main oral health indices, no trend of improvement was observed through 2011 and 2016. Surveys' results advocates the need of a large-scale integrated preventive approach toward oral health and the emerging growth of Noncommunicable Diseases (NCDs), in line with the WHO recommendations.

Assessment of mental health and psycho-social support pilot program's effect on intended stigmatizing behavior at the Saftawi Health Center, Gaza: a cross-sectional study.

Background: In the midst of a global refugee crisis, addressing mental health is critical for refugee health care delivery. Understanding efficacy of mental health interventions is more important than ever. Aims: In this study, we aim to assess the efficacy of comprehensive mental health and psychosocial support services for refugees in Gaza by comparing intended stigmatizing behavior toward mental health disorders between two health centers (HCs)(Saftawi and Nasser). Methods: One year after these services by the United Nations Relief and Works Agency (UNRWA) for Palestine Refugees in the Near East were implemented at Saftawi HC, a randomly selected sample of HC patrons (n = 205) from Saftawi, and a comparable number from a control HC (n = 203 at Nasser) completed the Reported and Intended Behavior Scale (RIBS) regarding stigma towards mental illnesses. Multivariable linear regressions were used to determine the impact of these services in the HC on attitudes against mental health. Results: Saftawi respondents endorsed significantly less intended stigmatizing behavior compared to Nasser respondents (p < 0.001). Multivariable analysis demonstrated significantly less intended stigmatizing behavior at Saftawi compared to Nasser (p < 0.01) while controlling for demographic covariables. Conclusions: UNRWA primary care services and education implemented for refugees in Gaza was associated with reduced stigmatizing behavior toward mental health, which can help guide efficacious mental health care interventions within the Palestine refugee community and in other simiilar communities.

Treatment outcomes in a cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jordan.

OBJECTIVE: The aim of this study was to use E-Health to report on 12-month, 24-month and 36-month outcomes and late-stage complications of a cohort of Palestine refugees with diabetes mellitus (DM) registered in the second quarter of 2010 in a primary healthcare clinic in Amman, Jordan. METHOD: Retrospective cohort study with treatment outcomes censored at 12-month time points using E-Health in UNRWA's Nuzha Primary Health Care Clinic. RESULTS: Of 119 newly registered DM patients, 61% were female, 90% were aged ≥40 years, 92% had type 2 DM with 73% of those having hypertension and one-third of patients were newly diagnosed. In the first 3 years of follow-up, the proportion of clinic attendees decreased from 72% to 64% and then to 61%; the proportion lost to-follow-up increased from 9% to 19% and then to 29%. At the three time points of follow-up, 71-78% had blood glucose ≤180 mg/dl; 63-74% had cholesterol <200 mg/dl; and about 90% had blood pressure <140/90 mmHg. Obesity remained constant at 50%. The proportion of patients with late-stage complications increased from 1% at baseline to 7% at 1 year, 14% at 2 years and 15% at 3 years. CONCLUSION: Nuzha PHC Clinic was able to monitor a cohort of DM patients for 3 years using E-Health and the principles of cohort analysis. This further endorses the use of cohort analysis for managing patients with DM and other non-communicable diseases.

What happens to Palestine refugees with diabetes mellitus in a primary healthcare centre in Jordan who fail to attend a quarterly clinic appointment?

OBJECTIVE: In a primary healthcare clinic in Jordan to determine: (i) treatment outcomes stratified by baseline characteristics of all patients with diabetes mellitus (DM) ever registered as of June 2012 and (ii) in those who failed to attend the clinic in the quarter (April-June 2012), the number who repeatedly did not attend in subsequent quarters up to 1 year later, again stratified by baseline characteristics. METHOD: A retrospective cohort study with treatment outcome data collected and analysed using e-health and the cohort analysis approach in UNRWA Nuzha Primary Health Care Clinic for Palestine refugees, Amman, Jordan. RESULTS: As of June 2012, there were 2974 patients with DM ever registered, of whom 2246 (76%) attended the clinic, 279 (9%) did not attend, 81 (3%) died, 67 (2%) were transferred out and 301 (10%) were lost to follow-up. A higher proportion of males and patients with undetermined or poor disease control failed to attend the clinic compared with those who attended the clinic. Of the 279 patients who did not attend the clinic in quarter 2, 2012, 144 (52%) were never seen for four consecutive quarters and were therefore defined as lost to follow-up. There were a few differences between patients who were lost to follow-up and those who re-attended at another visit that included some variation in age and fewer disease-related complications amongst those who were lost to follow-up. CONCLUSION: This study endorses the value of e-health and cohort analysis for monitoring and managing patients with DM. Just over half of patients who fail to attend a scheduled quarterly appointment are declared lost to follow-up 1 year later, and systems need to be set up to identify and contact such patients so that those who are late for their appointments can be brought back to care and those who might have died or silently transferred out can be correctly recorded.

Leveraging Digital Health Data to Transform the United Nations Systems for Palestine Refugees for the Post Pandemic Time.

The COVID-19 pandemic presented a grave threat to the continuity of health services that UNRWA provides to 5.9 million Palestine Refugees in the Near East. UNRWA runs 140 primary health care clinics, providing approximately nine million medical consultations a year. During the pandemic, UNRWA's e-Health system (and other digital health tools) were crucial in maintaining health services. The e-Health system enabled the identification of at-risk patients and transformed UNRWA's services for sustainability and efficiency. Innovations like telemedicine and two smartphone applications (e-NCD and e-MCH) enhanced service delivery and staff management. To evaluate the effectiveness of digital health integration in UNRWA's services during and after the pandemic, the team analyzed reports, events, and e-Health data from 2019-2022. Results show that digital tools, like e-NCD and e-MCH applications, helped reduce COVID-19 among Palestine Refugees, enabling remote care and continuous access to essential health services. Digital health has now become essential in UNRWA's post-pandemic operations. This paper offers a paradigm for future outbreak responses. By harnessing the power of digital health, UNRWA's e-Health system served as a beacon of hope, demonstrating how innovative approaches can empower patients, enhance health care outcomes, and ensure equitable access to health care services during crisis situations and beyond.

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.