Micronutrient status of Palestinian school children following salt and flour fortification: a cross-sectional study.

BACKGROUND: In 1996 and in 2006, Palestine initiated salt iodization and multiple micronutrient fortification of wheat flour, respectively as a strategy to prevent deficiencies of these nutrients. In 2009, we assessed the impact of these interventions on the health and nutritional status of schoolchildren residing in the West Bank. METHODS: We surveyed a sample of 22 schools run by the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the Palestinian Government. We randomly selected students from the first (mean age 6.7 years [SD 0.5]), sixth (11.8 years [0.6]), and ninth grades (14.8 years [0.6]). Data were obtained from 1484 (99%) of 1500 students planned for enrollment. RESULTS: Our results suggest that iodine intake appears adequate and there was essentially no iodine deficiency. As to the status of other micronutrients, the main nutritional micronutrient risks for schoolchildren in the West Bank continue to be low serum levels of iron, zinc, and vitamin B-12; folate levels were seemingly high. The overall prevalence of anemia was 9.6%, but there were pockets of anemia in certain districts. Almost 42% of the anemia in our sample was explained by iron deficiency. There were significant differences in iron deficiency between girls and boys, 29.5% vs. 15.7%, respectively (p = 0.0001). There were no cases of lead toxicity in the studied sample. CONCLUSIONS: Wheat flour and salt fortification has had a major influence on improving the micronutrient status of Palestinian children, for some but not all micronutrients. The recommended key blood and biochemical parameters to be incorporated in the surveillance system are iron, zinc, and vitamin B12.

Exposure to violence and its relationship to mental health among young people in Palestine.

BACKGROUND: Exposure to violence is a significant risk factor for the development of psychopathology in young people. Research on the mental health consequences of violence exposure in youth has focused mostly on post-traumatic stress disorder, however, the association with depression and anxiety has also been established. As a result of the longstanding Israeli-Palestinian conflict, young Palestinians are vulnerable to exposure to various types of violence. AIMS: We examined psychiatric symptomatology and its relationship to direct and indirect forms of violence exposure. METHODS: A representative household survey of 2481 Palestinian youth was conducted in 2014. Self-report measures included psychiatric symptomatology (global distress, depression, anxiety) and violence exposure (personal victimization, witnessed, vicariously heard about). RESULTS: The proportion of elevated symptoms of global distress (46%), depression (55%), and (37%) anxiety was high; 47% had been a personal victim, 71% had witnessed violence, and 69% had heard about violence experienced by someone close to them. In logistic regression analysis, controlling for other bivariate correlates, exposure to any violence event, as well as any of the 3 types of violence exposure, were independently associated with each of the 3 measures of elevated psychiatric symptomatology. Females were 4 times more likely to report elevated psychopathology, despite being less likely to experience each type of violence. CONCLUSIONS: These findings suggest the need for services that cater to the mental health needs of youth in settings of high violence exposure, and that gender-specific strategies may be useful.

Metabolic Syndrome among Refugee Women from the West Bank, Palestine: A Cross-Sectional Study.

This study was carried out among Palestinian refugee women in the West Bank to provide data on the prevalence of metabolic syndrome (MetS) and its correlates. Data were obtained from a cross-sectional study of 1694 randomly selected refugee women from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) health centers throughout the West Bank during June and July 2010. In this cohort, 30% of the refugee women were overweight, 39% were obese, and 7% were extremely obese. Based on World Health Organization (WHO) criteria, the age-adjusted prevalence of MetS was 19.8%. The results of the binary logistic regression analysis indicated that older age and younger marital age were significantly associated with an increased likelihood of MetS in the women. The high prevalence of obesity and MetS mandates the implementation of national policies for its prevention, notably by initiating large-scale community intervention programs for 5.2 million refugees in Palestine, Jordan, Lebanon, and Syria, to tackle obesity and increase the age at marriage.

Perceived peer norms, health risk behaviors, and clustering of risk behaviors among Palestinian youth.

Relatively little is known about patterns of health risk behaviors among Middle Eastern youth, including how these behaviors are related to perceived peer norms. In a sample of approximately 2,500 15-24 year old Palestinian youth, perceived engagement of general peers in alcohol consumption, drug use and sexual activity was substantially greater than youths' own (self-reported) engagement in these activities, suggesting a tendency to overestimate the prevalence of risk-taking behavior among peers. Individual participation in a risk behavior strongly covaries with the perceived levels of both friends' and peers' engagement in that behavior (p = 0.00 in each case). In addition, significant clustering of risk behaviors is found: youth who participate in one risk behavior are more likely to participate in others. These findings for a rare representative sample of Middle Eastern youth are strikingly similar to those in the US and Europe. The clustering of behaviors suggests that prevention programs should be structured to deal with a range of connected risk behaviors for which certain youth may be at risk. The findings also suggest that adjusting expectations about peers' behavior may reduce young Palestinians' engagement in risk taking.

Health risk behaviours of Palestinian youth: findings from a representative survey.

BACKGROUND: There is little systematic information about health risk behaviours among youth in Middle Eastern countries, leaving public health authorities unprepared to deal with emerging public health threats at a time of major social change. AIM: The Palestinian Youth Health Risk study investigates patterns of risk behaviours among Palestinian youth, their perceptions of the risks and benefits of such behaviours, and the relationship of exposure to violence with mental health and engagement in risk behaviours. METHODS: We conducted a representative survey among 2500 individuals aged 15-24 years in the West Bank and East Jerusalem, permitting reliable comparison across sex and rural-urban divisions. A stratified 2-stage random sample was drawn from the 2007 population census, with strata formed by crossing the 12 governorates with urban, rural and refugee camp locations. Within strata, 208 survey clusters were sampled with probability proportional to size. Within each cluster, 14 households with youth of the appropriate age were sampled. RESULTS: Among youth aged 20-24 years, 22.4% of males and 11.6% of females reported trying alcohol; 10.5% of males and 4.3% of females reported trying drugs. Almost one quarter of unmarried youth aged 20-24 years reported any sexual experience. Tobacco use is high, even among younger youth (45.4% of males and 21.2% of females aged 15-19 smoke). Risk behaviours are higher among males, older youth and in urban areas and refugee camps. CONCLUSION: While smoking is of particular concern, prevention outreach for all behaviours should be directed at subgroups and areas identified as highest risk.

Health risk behaviours of Palestinian youth: findings from a representative survey

Background: There is little systematic information about health risk behaviours among youth in Middle Eastern countries, leaving public health authorities unprepared to deal with emerging public health threats at a time of major social change. Aim: The Palestinian Youth Health Risk study investigates patterns of risk behaviours among Palestinian youth, their perceptions of the risks and benefits of such behaviours, and the relationship of exposure to violence with mental health and engagement in risk behaviours. Methods: We conducted a representative survey among 2500 individuals aged 15–24 years in the West Bank and East Jerusalem, permitting reliable comparison across sex and rural–urban divisions. A stratified 2-stage random sample was drawn from the 2007 population census, with strata formed by crossing the 12 governorates with urban, rural and refugee camp locations. Within strata, 208 survey clusters were sampled with probability proportional to size. Within each cluster, 14 households with youth of the appropriate age were sampled. Results: Among youth aged 20–24 years, 22.4% of males and 11.6% of females reported trying alcohol; 10.5% of males and 4.3% of females reported trying drugs. Almost one quarter of unmarried youth aged 20–24 years reported any sexual experience. Tobacco use is high, even among younger youth [45.4% of males and 21.2% of females aged 15–19 smoke]. Risk behaviours are higher among males, older youth and in urban areas and refugee camps. Conclusion: While smoking is of particular concern, prevention outreach for all behaviours should be directed at subgroups and areas identified as highest risk

Contexte : Il existe peu de données systématiques sur les comportements à risque pour la santé chez les jeunes au Moyen-Orient. Les autorités de santé publique ne sont donc pas préparées aux menaces de santé publique émergentes en période de changement social majeur. Objectif : L'Étude des risques sanitaires chez les jeunes palestiniens examine les schémas comportementaux à risque parmi les jeunes palestiniens, leurs perceptions des risques et des bénéfices tirés de tels comportements, la relation entre l'exposition à la violence et la santé mentale, et l'adoption de comportements à risque. Méthodes : Nous avons réalisé une enquête représentative auprès de 2500 individus âgés de 15 à 24 ans en Cisjordanie et à Jérusalem-Est, ce qui nous a permis de procéder à une comparaison fiable en fonction du sexe ainsi qu'entre zones rurale et zones urbaines. Un échantillon aléatoire stratifié à deux niveaux a été prélevé dans le recensement de population de 2007, avec des strates formées en sélectionnant les zones urbaines, rurales, et les camps de réfugiés au sein des 12 gouvernorats. Dans les strates, 208 foyers d'étude ont été échantillonnés, avec une probabilité proportionnelle à la taille. Au sein de chaque foyer, 14 ménages comptant des jeunes ayant l'âge approprié ont été échantillonnés. Résultats : Parmi les jeunes âgés de 20 à 24 ans, 22,4 % des garçons et 11,6 % des filles ont rapporté avoir déjà essayé l'alcool, et 10,5 % des garçons et 4,3 % des filles ont signalé avoir déjà essayé les drogues. Près d'un quart des jeunes célibataires âgés de 20 à 24 ans ont rapporté n'avoir eu aucune expérience sexuelle. Le tabagisme est très élevé, même chez les plus jeunes [45,4 % des garçons et 21,2 % des jeunes filles âgés de 15 à 19 ans fument]. Les comportements à risque sont plus élevés parmi les garçons, chez les jeunes plus âgés, dans les zones urbaines et dans les camps de réfugiés. Conclusion : Si le tabagisme est particulièrement préoccupant, des activités de prévention pour l'ensemble des comportements devraient être menées dans les sous-groupes et les zones identifiés à haut risque

الخلفية: لا تتوفر سوى معلومات منهجية ضئيلة عن كثير من السلوكيات التي تنطوي على مخاطر صحية بين شباب الشرق الأوسط. الهدف: توفير هذه الدراسة تقديرات لمستويات وأنماط السلوكيات الخطرة بين الشباب الفلسطينيين استناداّ إلى مسح ذو طابع تمثيلي واسع النطاق. طرق البحث: استُهدفت عينة من 2500 فرداً في الفئة العمرية 15-24 عاماً في الضفة الغربية والقدس الشرقية لإجراء مسح ذي طابع تمثيلي.النتائج: أفاد 22.4 % من الشبان الذكور في الفئة العمرية20-24 عاما و 11.6% من الشابات بتجربة المشروبات الكحولية - 8.1% و 3.6% - بالنسبة للشبان و الشابات فى الفئة العمرية 15-19 عاماوافاد 10.5% من الشبان فى الفئة العمرية 20-24 عاما 4.3% من الشابات بتجربة المخدرات 3.8% و 1.6% بالنسبة للشبان و الشابات فى الفئة 15-19 عاما كما افاد 9.3% من الشبان غير المتزوجين و 6.7% من الشابات غير المتزوجات فى الفئة العمرية 20-24 عاما بممارسة الجنس و لئن افاد نحو ربع هذه النسبة من كلا الجنسين بعدم وجود خبرة جنسية لديهموتبين ارتفاع مستوى تعاطي التبغ بصورة بالغة، حتى بين الشباب الأصغر سناً ) 45.5 % من الذكور و 21.2 % من الإناث في الفئة العمرية19-15 عاماً هم من المدخنين(، كما تبيّ انتشار العنف المتبادل بين الأفراد )الشجار( بصورة كبيرة. وتبيّ ارتفاع مستوى السلوكيات الخطرة فيما بينالشبان والشباب الأكبر سناً وفي المناطق الحضرية )لا سيَّما القدس( وفي مخيمات اللاجئين مقارنة بالمناطق الريفية. كما تبدو مستويات انخراط الشبابالفلسطينيين من المناطق الأخرى في تعاطي الكحوليات والمخدرات وممارسة الأنشطة الجنسية، بما في ذلك الجماع، أقل من غيرهم في جميع النتائج،ولكن ينقلب الوضع فيما يتعلق بالتدخين والعنف المتبادل بين الأفراد.الاستنتاجات: يمثل التدخين شاغلاً مهماً، إلا أنه ينبغي توجيه أنشطة التوعية على الوقاية من جميع السلوكيات الخطرة إلى المجموعات الفرعيةوالمناطق التي يتم تحديدها باعتبارها عالية المخاطر

Political violence and mental health of Bedouin children in the West Bank, Palestine: a cross-sectional study.

The Bedouin population is among the most vulnerable in Palestine, subject to forced relocation and lacking basic necessities, including water and electricity. To our knowledge, there are no studies on the mental health of Palestinian Bedouin children. A cross-sectional household survey was conducted examining exposures to traumatic events and mental health among 455 refugee children between the ages of 5-16 years old, and randomly selected from 18 Bedouin communities throughout the West Bank, including East Jerusalem. Mental health status was measured using the Strength and Difficulties Questionnaire. Based on reports by mothers, teachers and children, 44% of the participants in the study had a probable psychiatric disorder. Exposure to traumatic events, fair/poor maternal self-rated mental health, and younger age were positively associated with child mental health problems. The findings highlight the importance of maternal mental health as a contributing factor affecting children's vulnerability. Bedouin mothers and their children need immediate psychosocial intervention, as well as the protection of their basic human rights.

Prevalence, awareness, treatment and control of hypertension in four Middle East countries.

OBJECTIVE: We report the prevalence, awareness, treatment, and control of hypertension across four Middle Eastern countries (Iran, Occupied Palestinian Territory, Saudi Arabia, and United Arab Emirates), using a standardized and uniform method. METHODS: The Prospective Urban Rural Epidemiology study enrolled participants from 52 urban and 35 rural communities from four countries in the Middle East. We report results using definitions of hypertension, prevalence, awareness, treatment, and control, and the standards for uniform reporting of hypertension in adults as recently recommended by the World Hypertension League expert committee. RESULTS: Data for analyses were available on 10 516 participants, of whom 5082 (48%) were men. The mean age was 49 (±9.4) years for men and 48 (±9.3) years among women. A total of 3270 participants had hypertension (age-standardized rates, 33%), and n = 1807 (49%) of these participants were aware of their diagnosis. Of those with hypertension, n = 1754, (47%) were treated and only n = 673, (19%) had controlled blood pressure levels. Only 17% (n = 541) of those treated for hypertension received two or more blood pressure-lowering medications and 15% (n = 499) received statins. The prevalence, awareness, treatment, and control of blood pressure were higher among women and older (50-69 years) participants compared with men and younger individuals (30-49 years) (P < 0.0001 for all). The prevalence was higher in rural communities; however, awareness, treatment, and control were significantly higher among urban dwellers. CONCLUSION: Findings from this study indicate the need for improvements in hypertension diagnosis and treatment in the Middle East, especially in rural communities, men and younger individuals.

Substance use among Palestinian youth in the West Bank, Palestine: a qualitative investigation.

BACKGROUND: Youth health risk behaviors, including substance use (psychoactive substances including alcohol and illicit drugs), have been the subject of relatively limited study to date in Middle Eastern countries. This study provides insights into the perceived prevalence and patterns of alcohol and drug use among Palestinian youth. METHODS: The study was based on ten focus groups and 17 individual interviews with youth aged 16-24 years (n = 83), collected as part of the formative phase of a cross-sectional, population representative study of risk taking behaviors among Palestinian youth in the West Bank in 2012. Qualitative analysis was used to code detailed notes of focus groups and interviews. RESULTS: Most participants reported that substance use exists, even in socially conservative communities. Almost all participants agreed that alcohol consumption is common and that alcohol is easily available. The top alcoholic drinks referred to by the study participants were vodka, whisky, beer, and wine. Most participants claimed that they drink alcohol to cope with stress, for fun, out of curiosity, to challenge society, and due to the influence of the media. Participants were familiar with illicit drugs and knew of youth who engaged in drug use: marijuana, cocaine, and heroin were mentioned most frequently. Study participants believed that youth use drugs as a result of stress, the Israeli occupation, inadequate parental control, lack of awareness, unhappiness, curiosity, and for entertainment. Many participants were unaware of any local institutions to support youth with substance use problems. Others expressed their distrust of any such institution as they assumed them to be inefficient, profit-driven, and posing the risk of potential breaches of confidentiality. CONCLUSIONS: Although this study uses a purposive sample, the results suggest that substance use exists among Palestinian youth. Risk behaviors are a concern given inadequate youth-friendly counseling services and the strong cultural constraints on open discussion or education about the impact of high risk behaviors. These barriers to treatment and counseling can exacerbate the health and social consequences of alcohol abuse and illicit drug use.

Double Burden of Undernutrition and Obesity in Palestinian Schoolchildren: A Cross-Sectional Study.

BACKGROUND: The coexistence of underweight and overweight (double burden) remains a major problem in many developing countries. Little is known about the factors associated with the double burden of malnutrition in Palestinian children. OBJECTIVE: To assess factors associated with undernutrition and overnutrition in 1500 schoolchildren aged 5 to 16 years, in the West Bank. METHODS: We surveyed a sample of 22 schools run by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the Palestinian government. Binary logistic regression was used to examine the factors associated with malnutrition. The hunger index, a composite score from 8 questions, was used to measure food insecurity. RESULTS: In the 1484 children enrolled in UNRWA and government schools in the West Bank, the prevalence of stunting was 7% and underweight 3%. Around 12% of students were overweight and 6% obese. The hunger index was negatively associated with height for age. Factors associated with being underweight were male sex, mother being unemployed, and households not having enough food to eat for at least 2 days in the previous month. Factors associated with obesity were older age and time spent watching television. When overweight and obesity were combined in the analysis, they were inversely associated with increasing number of days spent playing sports. CONCLUSION: Our results show that the important nutritional risks for school-age children in the West Bank would seem to be the simultaneous occurrence of undernutrition and obesity. The study highlights the need to balance obesity management and prevention with interventions to tackle undernutrition.

Challenges to conducting epidemiology research in chronic conflict areas: examples from PURE- Palestine.

Little has been written on the challenges of conducting research in regions or countries with chronic conflict and strife. In this paper we share our experiences in conducting a population based study of chronic diseases in the occupied Palestinian territory and describe the challenges faced, some of which were unique to a conflict zone area, while others were common to low- and middle- income countries. After a short description of the situation in the occupied Palestinian territory at the time of data collection, and a brief overview of the design of the study, the challenges encountered in working within a fragmented health care system are discussed. These challenges include difficulties in planning for data collection in a fragmented healthcare system, standardizing data collection when resources are limited, working in communities with access restricted by the military, and considerations related to the study setting. Ways of overcoming these challenges are discussed. Conducting epidemiological research can be very difficult in some parts of our turbulent world, but data collected from such regions may contrast with those solely from politically and economically more stable regions. Therefore, special efforts to collect epidemiologic data from regions engulfed by strife, while challenging are essential.

Total Antioxidant Status in Type 2 Diabetic Patients in Palestine.

The objective of this study was to compare the level of total antioxidant status (TAS) in type 2 diabetic and normal Palestinian subjects as well as the major factors influencing TAS levels. A sample of convenience composed of 212 type 2 diabetic and 208 normal subjects above the age of 40 were recruited. Only 9.8% of the subjects had normal body mass index (BMI) levels (<25), 29% were overweight (≥25 to <30), and 61.2% were obese (≥30). The mean levels of TAS were significantly higher in diabetic compared to control subjects (2.18 versus 1.84 mM Trolox, P = 0.001) and in hypertensive subjects compared to subjects with normal blood pressure (BP). Mean TAS levels were higher in obese compared to nonobese subjects (2.12 versus 1.85 mM Trolox, P = 0.001). Mean TAS levels were similarly higher in subjects with high fasting plasma glucose (FPG) compared to normal FPG (2.19 versus 1.90 mM Trolox) and high HbA1c (≥6.5%) compared to HbA1c < 6.5% (2.14 versus 1.91 mM Trolox). Multivariate analysis revealed that only diabetic status (P = 0.032) and the level of education (P = 0.036) were significantly associated with TAS. In conclusion diabetic patients had 18.5% increase in TAS levels compared to control subjects.

Perceptions of sexual risk behavior among Palestinian youth in the West Bank: a qualitative investigation.

BACKGROUND: Young people in the Middle East and North Africa (MENA) are profoundly affected by violence, high unemployment, and economic hardship. Experiences of community-level violence and personal trauma increase the likelihood that young people will engage in risky behaviors that include smoking, drug use, and unsafe sex. Little is known about the sexual behavior of young people in the region, particularly in the occupied Palestinian territory (oPt). Our aim in this study was to gain an insight into the perceived prevalence and patterns of sexual behavior among Palestinian youth. METHODS: The study was based on ten focus groups and 17 in-depth interviews with young people aged 16-24 years as part of the formative phase of a cross-sectional representative study of risk behaviors in the West Bank, including Jerusalem, in 2012. The sample was selected using a combination of purposive and convenience sampling. Qualitative analysis was used to code detailed notes of focus groups and interviews. RESULTS: Based on participants' reports, different types of sexual activity outside marriage were not uncommon, even in conservative communities. The most reported sexual activity was non-penetrative sex: oral and anal intercourse, and virtual sex. Some young people had sexual intercourse with sex workers; they went to brothels in Israel and to brothels operating clandestinely in the West Bank, including East Jerusalem. Most respondents were of the opinion that young people did not usually use protection during sexual intercourse. Many reported that youth engage in different types of sexual activity outside marriage for several reasons: to challenge the culture, financial constraints and inability to marry, basic human need, personal pleasure, suppression, to kill boredom, and to prove manhood. CONCLUSIONS: In contrast with the conservative social context of the occupied Palestinian territory (oPt), the findings suggest that sexual activities outside marriage may be more common than is currently assumed. Sexual behavior in the oPt is a concern because of the low awareness of the potential health consequences. The results draw attention to the need to incorporate sexual reproductive health into the national agenda and ensure that it is included in the programs of national institutions.

Evaluation of glycated hemoglobin (HbA1c) for diagnosing type 2 diabetes and prediabetes among Palestinian Arab population.

The purpose of the study is to compare the potential of HbA1c to diagnose diabetes among Palestinian Arabs compared to fasting plasma glucose (FPG). A cross-sectional sample of 1370 Palestinian men (468) and women (902) without known diabetes and above the age of 30 years were recruited. Whole blood was used to estimate HbA(1c) and plasma for FPG and total lipid profile. Fasting plasma glucose was used as a reference to diagnose diabetes (≥ 126 mg/dL) and prediabetes (100-125 mg/dL). The area under the receiver operating characteristic curve (AUC) for HbA(1c) was 81.9% to diagnose diabetes and 63.9% for prediabetes. The agreement between HbA(1c) and diabetes as diagnosed by FPG was moderate (ĸ  =  0.498) and low with prediabetes (ĸ = 0.142). The optimal cut-off value for HbA1c to diagnose diabetes was ≥ 6.3% (45 mmol/mol). The sensitivity, specificity and the discriminant ability were 65.6% (53.1-76.3%), 94.5% (93.1-95.6%), 80.0% (72.8-87.3%), respectively. However, using cut-off value of ≥ 6.5% (48 mmol/mol) improved specificity. At this cut-off value, the sensitivity, specificity and the discriminant ability were 57.4% (44.9-69.0%), 97.1% (96.0-97.9%) and 77.3% (71.0-83.5%). For diagnosing prediabetes with HbA1c between 5.7-6.4% (39-46 mmol/mol), the sensitivity, specificity and the discriminant ability were 62.7% (57.1-67.9%), 56.3% (53.1-59.4%) and 59.5% (56.3-62.5%), respectively. HbA(1c) at cut-off value of ≥ 6.5% (48 mmol/mol) by itself diagnosed 5.3% and 48.3% as having diabetes and prediabetes compared to 4.5% and 24.2% using FPG, respectively. Mean HbA(1c) and FPG increase significantly with increasing body mass index. In conclusion, the ROC curves showed HbA1c could be used for diagnosing diabetes when compared to FPG but not for prediabetes in Palestinians Arabs even though only about 50% of the diabetic subjects were identified by the both HbA1c and FPG.

Palestinian women's sexual and reproductive health rights in a longstanding humanitarian crisis.

This paper results from a study conducted in the Occupied Palestinian Territory in September 2002 to test the usefulness of a guide for a comprehensive approach to sexual and reproductive health rights and needs of refugee women. In-depth interviews with key informants from 19 organisations and two focus group discussions were carried out in the West Bank and Gaza. Three refugee camps were visited as well as five health facilities. The findings revealed that severe restrictions on mobility had reduced access to health facilities for both staff and patients in a significant way. For pregnant women, this had resulted in decreased access to antenatal and post-natal care and an increasing number of home deliveries, induced deliveries and deliveries at military checkpoints. Lack of donor interest and withdrawal of donor support were mentioned as hampering the implementation of the National Reproductive Health Guidelines, and the sustainability and quality of existing sexual and reproductive health services. Family planning had become a politically sensitive issue, and there were indications of increased gender-based violence. Lack of access to reproductive health services was the most visible aspect of the impact of the conflict on women's sexual and reproductive health. Little attention is paid to the less visible evidence that women's reproductive rights have been subordinated to the political situation.