Emergency response of the UNRWA health programme to Great March of Return injuries: a descriptive analytic study in Gaza.

BACKGROUND: The United Nations Relief and Work Agency for Palestine Refugees (UNRWA) is one of the main health-care providers in the Gaza Strip. It provides primary health services to approximately 1·3 million Palestine refugees, comprising approximately 76% of the population of the Gaza Strip. UNRWA has well-prepared emergency health plans that are based on previous conflict experiences. However, the Great March of Return (GMR) injuries that UNRWA has faced since Mar 31, 2018, are considered a new experience of emergency. GMR is a protest activity launched by Palestinians in the Gaza Strip to express their right to return to their homes, from which they were expelled in 1948. This study aimed to describe the GMR-related injury patterns in patients and the health services provided as a part of the UNRWA emergency response in Gaza. METHODS: This was a descriptive analysis of medical and data reports of patients who sought care at 22 UNRWA health centres in Gaza for GMR-related injuries between Mar 31 and Sept 30, 2018. Data were collected from each individual on first contact with their health-care provider. We analysed the data using SPSS version 21. The study protocol was approved by the Gaza Field Office, and each participant provided oral informed consent to disclose their medical data for analysis. FINDINGS: 2020 patients attended the 22 UNRWA health centres for GMR-related injuries during the study period. 18·9% (381) were below 18 years of age, and 94·9% (1916) were male. 10·0% (202 of 2020) of injuries were classified as severe, 54·2% (1095) as moderate, and 35·8% (723) as mild. The majority of injuries (86%; 1737 of 2020) were due to gunshots, and 14% (283) were due to other causes (such as gas inhalation, rubber bullets, burns, and falling down). 54% (1090 of 2020) received wound care and dressing, 20% (404), received medical treatment only, and 26% (526) received both medical treatment and wound care. 9% (169 of 2020) developed motor dysfunction or disability as a complication, and received rehabilitation physiotherapy at UNRWA health centres. In addition to injury treatment, all patients received psychological first aid according to UNRWA Mental Health and Psychosocial Support Services guidelines. Individual and group psychosocial support sessions and home visits were provided for injured individuals and their families as needed. The UNRWA Health Programme collaborated with partners (eg, the International Committee of the Red Cross and Médecins Sans Frontières) for hospital referral for patients with severe injuries who needed advanced treatment. INTERPRETATION: Given the unprecedented situation, UNRWA health centres responded positively and comprehensively to the GMR-related injuries, providing care and essential medical and psychosocial support. However, many patients will require long-term care owing to their injuries. Further consideration should be given to developing a more systemised response to such emergencies, and to the human resources that are needed to support health, physiotherapy, and rehabilitation in Gaza. FUNDING: None.

Dietary Inadequacy, Micronutrient Deficiencies, and Approaches to Preventing Poor Nutrition in the Gaza Strip.

Palestine refugees comprise the largest refugee population in the world, most of whom are encamped in Middle Eastern countries. In the Gaza Strip, where ∼1.4 million Palestinians reside, there are high prevalences of anemia and multiple micronutrient deficiencies (MNDs), including those of iron, zinc, vitamins A, B12, D, and E, ranging from 11.4% to 84.7% among pregnant women and 2.9% to 70.9% among preschool children. Dietary diversification and adequate food fortification are framed in policies but remain aspirational goals. Alternative, effective, targeted preventive approaches include, for women, replacement of antenatal iron-folic acid with multiple micronutrient supplementation, and for young children, point-of-use multiple micronutrient powder fortification to prevent anemia, both of which can reduce other MNDs and may bring additional health benefits. These interventions coupled with monitoring of dietary intakes, periodic assessment of MNDs, and implementation research to improve existing nutrition interventions are warranted to protect the health of the Middle East Palestinian diaspora.

Delivering and evaluating a scalable training model for strengthening family medicine in resource-limited environments: the Gaza experience. A mixed-methods evaluation.

BACKGROUND: Since 2007, Gaza Palestine has been subject to blockade affecting over 1.9 million people. This denies health professionals access to continuing professional development (CPD). In Gaza, family physicians are scarce, and their level of training does not meet the needs of United Nations Relief and Works Agency's (UNRWA) Family Health Team (FHT) model for better population health. AIM: This study sought to develop a postgraduate training programme for Gazan doctors via a Diploma in Family Medicine (FM PG), and evaluate its impact on physicians and patients. DESIGN & SETTING: A mixed-methods evaluation of a postgraduate diploma in Gaza Palestine. METHOD: The programme was delivered over 1 year, to 15 primary care doctors. The impact was evaluated through focus group discussions and patient feedback questionnaire survey comparing FM PG graduate doctors and doctors without the FM PG Diploma. RESULTS: All participating doctors graduated successfully and found the experience extremely positive. Trainees felt that the Diploma helped them take more individualised approach to patients; have a better understanding of psychosocial elements affecting patient health; feel more inclined towards team-working and collaborative approaches to health care; and more insight into non-verbal communication such as active listening and tactile gestures. Statistical analysis of patients' feedback showed significantly improved patient-reported outcomes and satisfaction when treated by course diplomates compared to non-diplomates. CONCLUSION: Where there are limited training opportunities, investment in a structured postgraduate diploma training programme can improve quality of health service delivery. UNRWA's experience in Gaza demonstrates the value of a scalable model in resource-limited settings.

Stalled decline in infant mortality among Palestine refugees in the Gaza Strip since 2006.

BACKGROUND: The United Nations Relief and Works Agency for Palestine refugees in the Near East (UNRWA) has periodically estimated infant mortality rates (IMR) among Palestine refugees in the Gaza Strip (Gaza). These surveys have recorded a decline from 127 per 1000 live births in 1960 to 20.2 in 2006. Thereafter, a survey revealed an IMR of 22.4 in 2011. Alerted by these findings, a follow up survey was conducted in 2015 to further assess the trend of IMR. METHODS: We used the same preceding-birth technique as in previous surveys to estimate IMR and neonatal mortality rate (NMR) per 1000 live births. All multiparous mothers who came to the 22 UNRWA health centers to register their last-born child for immunization were asked if their preceding child was alive or dead. We based our target sample size on the previous IMR of 22.4 and we interviewed 3126 mothers from September to November 2015. FINDINGS: The third survey estimated mortality rates in 2013. The IMR was 22.7 (95% CI 17.2-28.1) per 1000 live births. IMR did not decline since the estimated IMR of 20.2 (15.3-25.1) per 1000 live births in 2006 and 22.4 (16.4-28.3) per 1000 live births in 2011. NMR was 16.1 (11.6-20.7) per 1000 live births, which was not statistically significantly different from 2006 (12.1 (8.7-16.4)), and was lower than in 2011 (20.3 (15.3-26.2)). CONCLUSION: The estimated mortality rate in infants of Palestine refugees in Gaza has not declined since 2006. The stagnation of infant mortality rates indicates that further efforts are needed to investigate causes for this stagnation and ways of addressing the potentially preventable causes among Palestine refugee children in Gaza.