Postpartum depression symptoms: prevalence, risk factors, and childbirth experiences in Palestine.

BACKGROUND: Worldwide mothers are suffering from postpartum depression (PPD) which impairs mothers' well-being, children, and families, and leads to adverse outcomes for mothers and their growing newborns. Low and middle-income countries have a higher prevalence of PPD and limited studies about it. This study assessed the percentage of Palestinian mothers experiencing PPD nationally, identified mothers at a higher risk of PPD, and studied the correlation between PPD and mistreatment during childbirth. METHODS: The study is based on a secondary data analysis from a cross-sectional study in the occupied Palestinian territory (oPt). A total of 745 telephone-based interviews with mothers were done within 2-4 weeks post-childbirth. The Patient Health Questionnaire (PHQ-9) was used as a screening tool for PPD. The Statistical Package for Social Science (SPSS) was used for analyzing the data. RESULTS: In the context of descriptive epidemiology, we observed that 12.6% of the selected Palestinian mothers experienced PPD, with a higher occurrence of PPD among mothers living in the Gaza Strip, a politically and economically unstable region in Palestine, compared to mothers living in the West Bank (Adjusted Odd Ratio (AOD: 2.2, Confidence Interval (CI): 1.4-3.44). Older mothers were two times more likely to develop PPD compared to young mothers (AOR: 2.03, CI: 1.070-3.84). Mothers who experienced disrespectful behaviors represented by any abuse, negligence, abandonment, ineffective communication, or poor pain management in childbirth settings were more likely to report PPD than those who were not exposed to the disrespect. CONCLUSION: A notable percentage of Palestinian mothers were identified as experiencing PPD, especially among mothers who experienced mistreatment in childbirth settings. It is essential to support healthcare providers to improve their practices and attitudes to eliminate mistreatment and abusive behaviors of mothers during childbirth.

The Effect of the COVID-19 Pandemic on Palestinian Patients Attending Selected Governmental Hospitals: An Analysis of Hospital Records.

INTRODUCTION: Confronting the COVID-19 epidemic forced the closure or relocation of the majority of health facilities. It is likely that non-COVID-19 patients suffered collateral effects. METHODS: The clinic and operating room records were analyzed at selected Palestinian government hospitals in the West Bank region. RESULTS: The reduction in patient clinic visits varied from 49% to 90%, with Ear-Nose-Throat (ENT), urology, and pediatric clinics being the most affected. The reduction in operation numbers in the center (which had independent decision-making) ranged from 7.1% to 23.4%, but in the north and south (which followed centralized choices), the reduction ranged from 19.6% to 91.8%. CONCLUSIONS: COVID-19 affected outpatient visits. The pandemic affected some services, but West Bank hospitals were able to provide normal obstetric and gynecological treatments and help patients who needed primary or intermediate surgery.

Factors associated with intentions to quit tobacco use in Lebanon: A cross-sectional survey.

Introduction: The prevalence of tobacco smoking in Lebanon is among the highest globally. This study aims to determine past attempts to quit smoking among adults and identify factors associated with intentions to quit. Methods: A nationally representative telephone survey was conducted between June and August 2022. Eligibility criteria included people aged >=18 years residing in Lebanon. The questionnaire was divided into three components: socio-demographic characteristics, cigarette and waterpipe tobacco use behaviours. Binary logistic regression was used to examine factors associated with intention to quit cigarette and waterpipe tobacco use. Results: A total of 2003 respondents were included in the study. The prevalence of any tobacco product use was 41%, the prevalence of current cigarette smoking was 41% and the prevalence of current waterpipe tobacco use was 20%. Approximately 24% of adults who smoke cigarettes and 26% of those who use waterpipe tobacco had previous quit attempts mainly due to health concerns. Intentions to quit smoking within the next 6 months were reported among 12% of survey respondents. Among adults who smoke, past quit attempts increased the likelihood of intentions to quit cigarette smoking by 5-fold (OR: 5.11; 95% CI: 1.80-14.47, p = 0.002) and waterpipe tobacco use by 7-fold (OR: 6.98, 95% CI: 2.63-18.51, p = <0.001). Age and income were associated with intentions to quit cigarette but not waterpipe tobacco use. Conclusion: Intention to quit smoking was strongly associated with past quitting attempts. Understanding factors associated with intentions to quit can help inform the development of context specific smoking cessation interventions.

From knowledge production to knowledge translation: Waterpipe tobacco control research in the Eastern Mediterranean Region.

Waterpipe tobacco smoking (WTS) rates in the Eastern Mediterranean Region (EMR) are the highest worldwide, particularly among young people. Although fiscal policies to curb tobacco use have been recommended by the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), implementation has been suboptimal. The Eastern Mediterranean Consortium on the Economics of Waterpipe Tobacco Smoking (ECON-WTS) was formed in response to this need to produce knowledge on the economics of WTS in the EMR and apply a comprehensive Knowledge translation (KT) framework. The KT framework comprised priority setting, evidence synthesis, knowledge translation, and knowledge uptake. In this article, we discuss the approaches followed in applying the KT framework to WTS control, providing examples and noting challenges and lessons learned where possible.

Health and economic impacts of introducing specific excise tax to waterpipe tobacco in Egypt: a simulation model of simple and mixed tax policy approaches.

INTRODUCTION: Waterpipe tobacco is taxed at half the rate of cigarettes in Egypt and, unlike cigarettes, does not have a specific excise component. We aimed to simulate the introduction of a specific excise tax on waterpipe tobacco consumption, premature deaths and government waterpipe tobacco revenue in Egypt. METHODS: We took model inputs from the latest available data on consumption, market shares and market share prices, price elasticities of demand, tax structure and from discussions with government officials. We modelled increases to specific excise to produce a 45%, 55%, 65% and 75% tax burden and compared a simple (specific only) structure with a mixed (specific and ad valorem) structure. RESULTS: Under the simple approach, introducing a US$2.1 specific tax would result in a 75% tax burden with 67% fewer waterpipe tobacco units smoked, 1 004 604 averted premature deaths and a 236% increase in government revenue relative to the current tax structure. At the 75% tax burden, the simple approach resulted in 1.5% fewer waterpipe tobacco units consumed, 9000 more averted premature deaths and 12.7% more government revenue compared with the mixed approach. Results for other tax burdens are presented and remained robust to sensitivity analyses. CONCLUSIONS: Introducing a specific excise tax on waterpipe tobacco in Egypt can yield considerable government revenue and public health gains. We recommend the simple approach, in line with the WHO recommendations, which produces greater economic and public health gains than the mixed approach and is easier to administer for the Egyptian government.

Whole-genome sequencing for One Health surveillance of antimicrobial resistance in conflict zones: a case study of Salmonella spp. and Campylobacter spp. in the West Bank, Palestine.

Antimicrobial resistance (AMR) is a critical global concern driven by the overuse, misuse, and/or usage of inadequate antibiotics on humans, animals' agriculture, and as a result of contaminated environments. This study is the first One Health survey in the Middle East that incorporated whole-genome sequencing (WGS) to examine the spread of AMR in Campylobacter spp. and Salmonella spp. This cross-sectional study was conducted to examine the role of AMR at the human-animal-environmental interface and was performed in Ramallah/Al-Bireh and Jerusalem governorates of the central West Bank, Palestine. In 2021 and 2022, a total of 592 samples were collected and analyzed. From a total of 65 Campylobacter jejuni and 19 Salmonella spp. isolates, DNA was extracted for WGS using Oxford Nanopore Technologies MinION platform. We found that the dominant serotypes of C. jejuni and Salmonella enterica were present in chicken manure, chicken meat sold in markets, and feces of asymptomatic farm workers, with high genetic similarities between the isolates regardless of origin. Additionally, our results showed rapid strain turnover in C. jejuni from the same sites between 2021 and 2022. Most of the positive Salmonella spp. samples were multidrug-resistant (MDR) S. enterica serovar Muenchen carrying the plasmid of emerging S. infantis (pESI) megaplasmid, conferring resistance to multiple antibiotics. Our findings highlight the spread of MDR foodborne pathogens from animals to humans through the food chain, emphasizing the importance of a One Health approach that considers the interconnections between human, animal, and environmental health. IMPORTANCE Prior to this study, there existed hardly an integrated human-animal-environmental study of Salmonellosis and Campylobacteriosis and related AMR in Middle Eastern countries. The few existing studies lack robust epidemiological study designs, adequate for a One Health approach, and did not use WGS to determine the circulating serotypes and their AMR profiles. Civil unrest and war in Middle Eastern countries drive AMR because of the breakdown of public health and food security services. This study samples simultaneously humans, animals, and the environment to comprehensively investigate foodborne pathogens in the broiler chicken production chain in Palestine using WGS. We show that identical serotypes of C. jejuni and S. enterica can be found in samples from chicken farms, chicken meat sold in markets, and asymptomatic broiler chicken production workers. The most striking feature is the rapid dynamic of change in the genetic profile of the detected species in the same sampling locations. The majority of positive Salmonella spp. samples are MDR S. enterica serovar Muenchen isolates carrying the pESI megaplasmid. The results demonstrate a close relationship between the S. enterica serovar Muenchen isolates found in our sample collection and those responsible for 40% of all clinical Salmonella spp. isolates in Israel as previously reported, with a sequence identity of over 99.9%. These findings suggest the transboundary spread of MDR S. enterica serovar Muenchen strains from animals to humans through the food chain. The study underscores the importance of combining integrated One Health studies with WGS for detecting environmental-animal-human transmission of foodborne pathogens that could not be detected otherwise. This study showcases the benefits of integrated environmental-animal-human sampling and WGS for monitoring AMR. Environmental samples, which may be more accessible in conflict-torn places where monitoring systems are limited and regulations are weak, can provide an effective AMR surveillance solution. WGS of bacterial isolates provides causal inference of the distribution and spread of bacterial serotypes and AMR in complex social-ecological systems. Consequently, our results point toward the expected benefits of operationalizing a One Health approach through closer cooperation of public and animal health and food safety authorities.

The association between labor companionship and obstetric violence during childbirth in health facilities in five facilities in the occupied Palestinian territory.

BACKGROUND: Studies show that the presence of companionship during childbirth leads to positive outcomes for women. This study investigates the protective effect of having a labor companion on obstetric violence in the health facilities of the Occupied Palestinian Territory. METHODS: A secondary analysis of a cross-sectional study of women who gave birth in five health centers in the occupied Palestinian territory up to 8 weeks following childbirth was performed. The presence of a labor companion was examined in relation to socioeconomic variables and physical abuse, verbal abuse or stigma or discrimination, failure to achieve professional standards, vaginal examinations, and pain relief. RESULTS: According to the findings, the total number of women with a labor partner or a birth companion present at any stage during the labor process was 92% in the West Bank, and 77.4% in the Gaza Strip. According to the timing of support, 23.5% of women had a labor companion present during labor, childbirth, and after childbirth whilst in the hospital. Women who did not have labor companions were more likely than women who did to report at least one sort of mistreatment, such as unconsented procedures. Women with a labor companion were less likely to report abuse (16%) compared to women without labor companion. In terms of informed permission for procedures, 75% of women who did not have a labor companion had unconsented episiotomy. CONCLUSION: Labor companionship assists women by providing them with companions who are less likely to be mistreated during labor. Efforts should be made to best implement the presence of labor companions, including the duration of the labor companionship and women's preferences.

Sexual and reproductive health interventions geared toward adolescent males: A scoping review.

PROBLEM: Male adolescent sexual and reproductive health (SRH) interventions are rare worldwide. The high prevalence of sexually transmitted infections and pregnancies among female and male adolescents worldwide highlights the need for comprehensive interventions that include both genders in the educational process. OBJECTIVE: Our main focus is studying and analysing male-focused SRH interventions globally to include males in evidence-based interventions that improve SRH of adolescent males. ELIGIBILITY CRITERIA: This Review was conducted using the PRISMA extension for scoping reviews. The following databases were searched: PubMed, Embase, Web of science, Scopus, CINAHL and PsycInfo. INCLUSION CRITERIA: 1) No time or date limits; 2)all types of studies; 3)SRH campaign; 4)males; 5)10 to 19 years. SAMPLE: Five thousand and sixty-eight articles were identified and 166 peer-reviewed articles met the inclusion criteria. RESULTS: Family planning was identified as the primary domain covered for adolescents. While interactive activities was the most common method used to deliver information to adolescents about sexual health. SRH interventions for males were most prevalent in America. While in the Eastern Mediterranean region (EMR), no male interventions were found in our review. CONCLUSION: This scoping review emphasizes the need to include adolescent males in sexual and reproductive health interventions, particularly in low- and middle-income countries (LMICs) and the EMR. Policymakers should develop comprehensive programs that address male-specific needs, improve training for intervention providers, and enhance reporting processes to identify gaps and barriers to male inclusion. IMPLICATION: Future research should be directed toward the obstacles that prevent SRH interventions targeting males from being carried out.

A predictive model of waterpipe smoking cessation among women in southern Iran: application of the theory of planned behavior.

BACKGROUND: Today, waterpipe (WT) smoking is a rising issue worldwide, and has taken a significant and growing share of tobacco consumption in the world. Present study aimed to explore the predictors of WT cessation in the light of the theory of planned behavior (TPB). METHODS: This cross-sectional analytical study was conducted in 2021-2022 using a multi-stratified cluster sampling on 1,764 women in Bandar Abbas, southern Iran. Data were collected through a reliable and valid questionnaire. The three-part questionnaire includes demographic information, behavioral information of WT smoking, and the constructs of the TPB along with an additional habit construct. Multivariate logistic regression analysis was run to model the predictor constructs of WT smoking. The data were analyzed statistically in STATA14.2. RESULTS: With an increase in one attitude score, the odds of cessation increased by 31% (p < 0.001). Also, with an increase of one score in knowledge, the odds of cessation are increased by 0.05% (0.008). With an increase of one score for intention, the odds of cessation are 26% (0.000). in social norms, the odds of cessation are 0.02% (0.001). With an increase of one score in perceived control, the odds of cessation increased by 16% (0.000) and inhabit score, the odds of cessation decrease by 37% (0.000). In the model where the habit construct was present, the accuracy, sensitivity, and pseudo R2 indices were 95.69%, 77.31%, and 65%, respectively and after removing the habit construct, the so-called indices changed to 90.7%, 50.38% and 0.44%, respectively. CONCLUSIONS: The present research confirmed the effectiveness of the TPB model in predicting waterpipe cessation behavior. The knowledge obtained from this research can help develop a systematic and effective intervention to facilitate waterpipe cessation. Focusing on the habit variable can play a critical role in waterpipe cessation in women.

Personal data governance and privacy in digital reproductive, maternal, newborn, and child health initiatives in Palestine and Jordan: a mapping exercise.

Introduction: There is a rapid increase in using digital technology for strengthening delivery of reproductive, maternal, newborn, and child health (RMNCH) services. Although digital health has potentially many benefits, utilizing it without taking into consideration the possible risks related to the security and privacy of patients' data, and consequently their rights, would yield negative consequences for potential beneficiaries. Mitigating these risks requires effective governance, especially in humanitarian and low-resourced settings. The issue of governing digital personal data in RMNCH services has to date been inadequately considered in the context of low-and-middle-income countries (LMICs). This paper aimed to understand the ecosystem of digital technology for RMNCH services in Palestine and Jordan, the levels of maturity of them, and the implementation challenges experienced, particularly concerning data governance and human rights. Methods: A mapping exercise was conducted to identify digital RMNCH initiatives in Palestine and Jordan and mapping relevant information from identified initiatives. Information was collected from several resources, including relevant available documents and personal communications with stakeholders. Results: A total of 11 digital health initiatives in Palestine and 9 in Jordan were identified, including: 6 health information systems, 4 registries, 4 health surveillance systems, 3 websites, and 3 mobile-based applications. Most of these initiatives were fully developed and implemented. The initiatives collect patients' personal data, which are managed and controlled by the main owner of the initiative. Privacy policy was not available for many of the initiatives. Discussion: Digital health is becoming a part of the health system in Palestine and Jordan, and there is an increasing use of digital technology in the field of RMNCH services in both countries, particularly expanding in recent years. This increase, however, is not accompanied by clear regulatory policies especially when it comes to privacy and security of personal data, and how this data is governed. Digital RMNCH initiatives have the potential to promote effective and equitable access to services, but stronger regulatory mechanisms are required to ensure the effective realization of this potential in practice.

Deferral of elective surgeries during the COVID-19 pandemic and its impact on Palestinian patients: a cross-sectional study.

BACKGROUND: During the Covid-19 epidemic, the increased number of people seeking medical attention worsened hospital shortages. This shortage required reallocating the workforce, personal protective equipment (PPE), medical equipment, medical disposables, and hospital wards. This reallocation delayed a number of elective surgeries. This study explored the financial, physical, and psychological implications of deferring elective surgeries on Palestinians in three West Bank hospitals during the pandemic. METHODS: This cross-sectional study included 398 patients from tertiary hospitals in Palestine whose elective surgical procedures were deferred due to the COVID-19 pandemic. Between 8/8/2021 and 6/9/2021, data were collected on patients who had elective surgery deferral at three government hospitals in the West Bank of the Palestinian territories. There were five parts to the study tool; personal information, access to the health system, physical affection, financial effect, and psychological effect. Statistical analysis included a univariate, bivariate and multivariate. RESULTS: The healthcare system's response to the COVID-19 epidemic directly affected patients whose surgeries were deferred. The healthcare system's response was the cause of the delay in 91.5% of the cases. Orthopedic and neurological surgeries account for 48.3% of deferred surgery. Other than delayed surgeries, 30.2% of patients were unable to get additional health care services. Physically, 55.5% of patients were impacted, 45% were anxious, and 29.6% were depressed. CONCLUSIONS: Patients who had procedures deferred as a result of the healthcare system's response to the COVID-19 epidemic were impacted physically, financially, and psychologically. There should bea better crisis management strategyto ensure that certain hospitals are able to operate regularly despite the situation.

Monitoring and Combating Waterpipe Tobacco Smoking Through Surveillance and Taxation.

Waterpipe tobacco smoking (WTS) is a traditional tobacco use method that originated in the Eastern Mediterranean Region (EMR) and has resurged in recent decades. WTS rates in the EMR are the highest worldwide, especially among youth, exceeding cigarette-smoking rates in select jurisdictions. Despite its documented harm, the growing prevalence of WTS has been met with a poor regulatory response globally. At the epicenter of the WTS epidemic, countries in the EMR are in urgent need of effective tobacco control strategies that consider the particularities of WTS. A roundtable session, titled "Monitoring and Combating WTS Through Taxation and the Global Tobacco Surveillance System (GTSS)," was held as part of the 7th Eastern Mediterranean Public Health Network's regional conference. The session provided an overview of evidence to date about WTS policy control, the taxation of WTS, volumetric choice experiments for tobacco control research, and monitoring WTS patterns and control policies among adults and youth through the GTSS. The session highlighted the need to update the regulation of WTS in the current global tobacco control policy frameworks and the need for developing tailored, evidence-based, and WTS-specific regulations to complement current tobacco control policy frameworks. Raising taxes to increase the price of tobacco products is the single most effective tobacco control measure, and these taxes can fund expanded government health programs. The effectiveness of taxation can be measured via volumetric choice experiments, which allow for the estimation of a complete set of own-price and cross-price elasticities that are instrumental for fiscal policy simulations. Finally, the surveillance of WTS (for example, through the GTSS) is critical to informing policy and decision makers. The Global Youth Tobacco Survey (GYTS) and Global Adult Tobacco Survey (GATS) are 2 GTSS products that provide nationally representative data among students aged 13-15 years and persons ≥15 years, respectively.

Gender Awareness in Healthcare: Contextualization of an Arabic Version of the Nijmegen Gender Awareness in Medicine Scale (N-GAMS).

Gender is one of the important social determinants of health known to be highly associated with health status. Despite the importance of gender awareness, it has not been addressed and researched in the Arab region, including Palestine. This study aimed to contextualize an Arabic version of the Nijmegen Gender Awareness in Medicine Scale (N-GAMS) and to assess the level of gender awareness and its associated factors among primary health care providers. The N-GAMS tool was translated and adapted through a gender expert consultation and a focus group discussion. Then, it was administered online to a sample of primary health care general physicians and nurses of all health care providing actors in Ramallah and al-Bireh Governorate. The reliability of the N-GAMS subscales using Cronbach's alpha (α) was 0.681 for the gender sensitivity (GS) scale (9 items), 0.658 for the gender role ideology towards co-workers (GRIC) scale (6 items), and α = 0.848 for the gender role ideology towards patients (GRIP) scale (11 items). The results showed that participants had scored near the midpoint of the gender sensitivity subscale (M = 2.84, SD = 0.486). They also expressed moderate gender stereotypes towards patients (M = 3.11, SD = 0.624), where females held lower stereotypical thinking. Participants also expressed low to moderate stereotypes towards co-workers (M = 2.72, SD = 0.660) and females expressed less stereotypical thinking compared to males. Furthermore, the participant's age had some effect on the outcome, specifically on the GRIP subscale, while gender was associated with both GRIP and GRID subscales. The rest of the social and other variables showed no association with the gender awareness subscales. This study adds to our understanding of gender awareness. Further tests are required to confirm the psychometric qualities of the instrument.

Own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco in three Eastern Mediterranean countries: a volumetric choice experiment.

BACKGROUND: Waterpipe tobacco smoking rates in the Eastern Mediterranean region are among the highest worldwide, yet little evidence exists on its economics. Estimates of demand elasticities for tobacco products are largely limited to cigarettes. This study aimed to estimate own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco products in Lebanon, Jordan and Palestine. METHODS: A volumetric choice experiment was conducted using nationally representative household surveys. The choice experiment elicited respondents' stated purchases of eight cigarette and waterpipe tobacco product varieties by hypothetically varying prices. Data were analysed using zero-inflated Poisson models that yielded demand elasticity estimates of cigarette and waterpipe tobacco consumption. RESULTS: The study included 1680 participants in Lebanon (50% female), 1925 in Jordan (44.6% female) and 1679 in Palestine (50% female). We found the demand for premium cigarettes to be price elastic (range, -1.0 to -1.2) across all three countries, whereas the demand for discount cigarettes was less elastic than premium cigarettes in Lebanon (-0.6) and Jordan (-0.7) and more elastic in Palestine (-1.2). The demand for premium waterpipe tobacco was highly elastic in Lebanon (-1.9), moderately elastic in Jordan (-0.6) and inelastic in Palestine (0.2). The cross-price elasticity between cigarettes and waterpipe tobacco was near zero, suggesting that the two products are not considered to be close substitutes by consumers. CONCLUSIONS: These results serve as a strong evidence base for developing and implementing fiscal policies for tobacco control in the Eastern Mediterranean region that address cigarettes and waterpipe tobacco products.

Variation of caesarean section rates in Palestinian governmental hospitals.

BACKGROUND: Globally, the increased use of cesarean sections has become prevalent in high-income and low and middle-income countries. In Palestine, the rate had risen from 20.3% in 2014 to 25.1% in 2018. We have rates as high as 35.8% in some governmental hospitals and some as low as 15%. This study aimed to understand better why there is a variation in cesarean rates in governmental hospitals that use the same guidelines. METHODS: A qualitative and quantitative research approach was used. In-depth interviews were conducted with 27 specialists, obstetrics and gynecologists, and midwives in five government hospitals. The hospitals were selected based on the 2017 Annual Health Report reported cesarean section rates. The interview guide was created with the support of specialists and researchers and was piloted. Questions focused mainly on adherence to the obstetric guidelines and barriers to the use, sources of information, training for healthcare providers, the hospital system, and the factors that affect decision-making. Each hospital's delivery records for one month were analyzed to determine the reason for each cesarean section. RESULTS: The results indicated that each governmental hospital at the system level had a different policy on cesarean sections. The National Guidelines were found to be interpreted differently among hospitals. One obstetrician-gynecologist decided on a cesarean section at high-rate hospitals, while low-rate hospitals used collective decision-making with empowered midwives. At the professional level, all hospitals urged the importance of a continuous training program to refresh the medical team knowledge, in-house training of new members joining the hospital, and discussion of cases subjective to obstetrician-gynecologists interpretations. CONCLUSION: Several institutional factors were identified to strengthen the implementation of the national obstetric guidelines. For example, encouraging collective decision-making between obstetrician-gynecologists and midwives, promoting the use of a second opinion, and mandatory training.

Exploring women's experiences during childbirth in health facilities during COVID-19 pandemic in occupied palestinian territory: a cross-sectional community survey.

INTRODUCTION: This study aims to assess the prevalence of mistreatment during childbirth in the occupied Palestinian territory and to explore factors associated with mistreatment. METHODS: A cross-sectional study of women who gave birth in the West Bank and Gaza Strip health facilities. The survey was administered over the phone to women up to 8 weeks post-partum. Data collection took place between July 2020 and March 2021. RESULTS: A total of 745 women participated in the study, 36·25% were from the Gaza Strip and 63·75% from the West Bank. The prevalence of mistreatment was 18·8% in which women reported any verbal abuse, physical abuse, or stigma or discrimination during childbirth, with verbal abuse as the most common form of mistreatment reported. Physical abuse was more likely to be reported by women with no labour companion with them (OR: 3·11, 95%CI: 1·24 - 7·99). Verbal abuse was more likely to be reported by women with less than three live births (OR: 1·71, 95%CI: 1·06 - 2·76, women with no birth companion (OR: 2·72, 95%CI: 1·36 - 3·80) and more likely to be reported if curtains wre not used (OR: 2·55, 95%CI: 1·33 - 4·88). Women with less education were more likely to report long waiting times or delays in receiving services compared to women with higher education (OR: 1·40, 95%CI: 1·06 - 2·10). CONCLUSION: For the first time using the World Health Organisation (WHO) tool in the Eastern Mediterranean region, the study findings, show the occurrence of mistreatment and identify areas to be strengthened to ensure that all women have a respectful childbirth experience within health facilities.

Maturity Level of Digital Reproductive, Maternal, Newborn, and Child Health Initiatives in Jordan and Palestine.

BACKGROUND: While there is a rapid increase in digital health initiatives focusing on the processing of personal data for strengthening the delivery of reproductive, maternal, newborn, and child health (RMNCH) services in fragile settings, these are often unaccompanied at both the policy and operational levels with adequate legal and regulatory frameworks. OBJECTIVE: The main aim was to understand the maturity level of digital personal data initiatives for RMNCH services within fragile contexts. This aim was performed by choosing digital health initiatives from each country (two in Jordan and three in Palestine) based on RMNCH. METHODS: A qualitative study design was adopted. We developed a digital maturity assessment tool assessing two maturity levels: the information and communications technology digital infrastructure, and data governance and interoperability in place for the five selected RMNCH initiatives in Jordan and Palestine. RESULTS: Overall, the digital infrastructure and technological readiness components are more advanced and show higher maturity levels compared with data governance and interoperability components in Jordan and Palestine. In Jordan, the overall Jordan stillbirths and neonatal deaths surveillance initiative maturity indicators are somehow less advanced than those of the Electronic Maternal and Child Health Handbook-Jordan (EMCH-J) application. In Palestine, the Electronic Maternal and Child Health-registry initiative maturity indicators are more advanced than both Avicenna and EMCH-Palestine initiatives. CONCLUSION: The findings highlighted several challenges and opportunities around the application and implementation of selected digital health initiatives in the provision of RMNCH in Jordan and Palestine. Our findings shed lights on the maturity level of these initiatives within fragile contexts. The maturity level of the five RMNCH initiatives in both countries is inadequate and requires further advancement before they can be scaled up and scaled out. Taking the World Health Organization recommendations into account when developing, implementing, and scaling digital health initiatives in low- and middle-income countries can result in successful and sustainable initiatives, thus meeting health needs and improving the quality of health care received by individuals especially those living in fragile contexts.

The need for standardised methods of data collection, sharing of data and agency coordination in humanitarian settings.

Humanitarian crises and emergencies are prevalent all over the world. With a surge in crises in the last decade, humanitarian agencies have increased their presence in these areas. Initiatives such as the Sphere Project and the Minimum Initial Service Package known as MISP were formed to set standards and priorities for humanitarian assistance agencies. MISP was initiated to coordinate and standardise data and collection methods and involve locals for programme sustainability. Developing policies and programmes based on available data in humanitarian crises is necessary to make evidence-based decisions. Data sharing between humanitarian agencies increases the effectiveness of rapid responses and limits duplication of services and research. In addition, standardising data collection methods helps alleviate the risk of inaccurate information and allows for comparison and estimates among different settings. Big data is a new collection method that can help assemble timely data if resources are available and turn the data into information. Further research on setting priority indicators for humanitarian situations can help guide agencies to collect quality data.

Towards a One Health Food Safety Strategy for Palestine: A Mixed-Method Study.

Introduction: Foodborne diseases, together with increasing antimicrobial resistance (AMR), pose a threat to public health in an era of huge challenges with climate change and the risks of zoonotic epidemics. A One Health approach to foster food safety is a key for improvement, particularly in complex socio-ecological systems such as in Palestine, to examine human-animal-environment interfaces and promote intersectoral action. Objectives: This study aimed to assess food safety from farm to public health toward an operational One Health strategy for Palestine. This study evaluates the food production (broiler production) and monitoring system to better understanding the zoonotic foodborne illnesses transmission and their resistance to antimicrobials. Methods: The transdisciplinary approach included multi-stakeholder discussion groups and field visits to broiler farms, slaughterhouses, and meat stores in the Ramallah and Al-Bireh and Jerusalem districts using a semi-structured observational tool. A survey with 337 poultry producers and workers in slaughterhouses and meat stores was conducted to assess hygiene knowledge, attitudes, and practices during broiler meat production. Results: The stakeholders point out various challenges along the food production chain in Palestine, such as a striking scarcity of public slaughterhouses, insufficient coordination between authorities, a gap between public and private sectors, and inconsistent application of the law. From observations, it appears that, unlike traditional broiler production, the public slaughterhouses and meat markets have effective hygiene, while large-scale farms implement biosecurity measures. Overall, surveyed participants reported that they are aware of zoonotic disease transmission routes and value hygiene standards. Semi-structured observations and survey results are contradictory. Observations indicate poor hygiene practices; however, the vast majority of broiler meat production chain workers claim that hygiene standards are met. Discussion and Conclusions: Our study found that the overuse of antimicrobials, system fragmentation, insufficient infrastructure, a lack of regulations and controls, and poor hygiene practices are among the main obstacles to improving food safety in Palestine. Considering the risk of an important human health burden of food-related illnesses, enhancing food safety in Palestine is required using an integrated One Health approach. It is crucial to develop an integrated quality control system for food production along with promoting on-farm biosecurity and antimicrobial stewardship. Infrastructure, especially slaughterhouses and laboratories, must be built, training and education provided, and consumer awareness raised. As an important added value within a One Health strategy for better food safety in Palestine, research should be reinforced and accompany any future development of the food production monitoring system.

Economic research in waterpipe tobacco smoking: reflections on data, demand, taxes, equity and health modelling.

Economic evaluation of tobacco control policies is common in high-income settings and mainly focuses on cigarette smoking. Evidence suggests that increasing the excise tax of tobacco products is a consistently effective tool for reducing tobacco use and is an efficient mechanism for increasing government revenues. However, less research has been conducted in low/middle-income countries where other tobacco forms are common. This paper presents insights from our work on the economics of waterpipe tobacco smoking conducted in the Eastern Mediterranean Region where waterpipe smoking originated and is highly prevalent. The specific areas related to economics of waterpipe smoking considered herein are: price elasticity, taxation, government revenue, expenditure and healthcare costs. This paper aims to provide practical guidance for researchers investigating the economics of waterpipe tobacco with potential implications for other novel tobacco products. We present lessons learnt across five thematic areas: data, demand, taxes, equity and health modelling. We also highlight knowledge gaps to be addressed in future research. Research implications include designing comprehensive assessment tools that investigate heterogeneity in waterpipe smoking patterns; accounting for cross-price elasticity of demand with other tobacco products; exploring the change in waterpipe tobacco smoking in response to a tax increase and analysing the equity impact of waterpipe tobacco control interventions.