Inequalities in Wellbeing in Lebanese Children and Different Refugee Subpopulations: A Multidimensional Child Deprivation Analysis.

Background and Objectives: This study constitutes the first attempt to describe the overlapping deprivations faced by Lebanese children (Lebanese) and that of the three sub-populations of refugees living in Lebanon: Palestinian refugees living in Lebanon, Palestinian refugees from Syria and Syrian refugees. Methods: Using data from the United Nations International Children's Emergency Fund (UNICEF) Household Survey 2016 (n = 10,555 Lebanese; 7,106 Palestinian refugees living in Lebanon; 2,768 Palestinian refugees from Syria and 5,891 Syrian refugee children aged 2 to 17 years old), we report on single and overlapping deprivations (at least two concurrent deprivations) using indicators related to survival (nutrition, health, water, sanitation and overcrowding), development (education) and protection (labor, exposure to violence and early marriage). Maternal education and geographical correlates of deprivation were explored using multivariable logistic regression models clustering for children in the same households. Main Results: In terms of co-occurrence of deprivations, Syrian refugees had the highest prevalence in all age groups (68.5%, 2-4y and 65.7%, 6-17y), followed by Palestinian refugees from Syria (46.2%, 2-4y and 45.5%, 6-17y), Palestinian refugees living in Lebanon (28.9%, 2-4y and 23.7%, 6-17y), with Lebanese children having the lowest prevalence (13.2%, 2-4y and 15.3, 6-17y). About half of Palestinian refugees from Syria and Syrian refugees (6-17y) were deprived in protection and housing. Education deprivation is of primary concern for Syrian children. Higher maternal education was consistently associated with lower odds of co-occurrence of deprivations among children aged 6-17y. Conclusion: This study highlights the importance of including refugee populations in reporting frameworks. This analysis additionally generates geographical and socio-economic profiles of the deprived children and identifies key deprivation areas of the affected sub-groups to inform effective policy design especially in light of the prevailing economic crisis. Supplementary Information: The online version contains supplementary material available at 10.1007/s12187-023-10040-2.

Effects of size at birth on health, growth and developmental outcomes in children up to age 18: an umbrella review.

BACKGROUND: Size at birth, an indicator of intrauterine growth, has been studied extensively in relation to subsequent health, growth and developmental outcomes. Our umbrella review synthesises evidence from systematic reviews and meta-analyses on the effects of size at birth on subsequent health, growth and development in children and adolescents up to age 18, and identifies gaps. METHODS: We searched five databases from inception to mid-July 2021 to identify eligible systematic reviews and meta-analyses. For each meta-analysis, we extracted data on the exposures and outcomes measured and the strength of the association. FINDINGS: We screened 16 641 articles and identified 302 systematic reviews. The literature operationalised size at birth (birth weight and/or gestation) in 12 ways. There were 1041 meta-analyses of associations between size at birth and 67 outcomes. Thirteen outcomes had no meta-analysis.Small size at birth was examined for 50 outcomes and was associated with over half of these (32 of 50); continuous/post-term/large size at birth was examined for 35 outcomes and was consistently associated with 11 of the 35 outcomes. Seventy-three meta-analyses (in 11 reviews) compared risks by size for gestational age (GA), stratified by preterm and term. Prematurity mechanisms were the key aetiologies linked to mortality and cognitive development, while intrauterine growth restriction (IUGR), manifesting as small for GA, was primarily linked to underweight and stunting. INTERPRETATION: Future reviews should use methodologically sound comparators to further understand aetiological mechanisms linking IUGR and prematurity to subsequent outcomes. Future research should focus on understudied exposures (large size at birth and size at birth stratified by gestation), gaps in outcomes (specifically those without reviews or meta-analysis and stratified by age group of children) and neglected populations. PROSPERO REGISTRATION NUMBER: CRD42021268843.

Maternal and infant outcomes of Syrian and Palestinian refugees, Lebanese and migrant women giving birth in a tertiary public hospital in Lebanon: a secondary analysis of an obstetric database.

OBJECTIVES: This study aims to assess whether the characteristics, management and outcomes of women varied between Syrian and Palestinian refugees, migrant women of other nationalities and Lebanese women giving birth at a public tertiary centre in Beirut, Lebanon. METHODS: This was a secondary data analysis of routinely collected data from the public Rafik Hariri University Hospital (RHUH) between January 2011 and July 2018. Data were extracted from medical notes using text mining machine learning methods. Nationality was categorised into Lebanese, Syrian, Palestinian and migrant women of other nationalities. The main outcomes were diabetes, pre-eclampsia, placenta accreta spectrum, hysterectomy, uterine rupture, blood transfusion, preterm birth and intrauterine fetal death. Logistic regression models estimated the association between nationality and maternal and infant outcomes, and these were presented using ORs and 95% CIs. RESULTS: 17 624 women gave birth at RHUH of whom 54.3% were Syrian, 39% Lebanese, 2.5% Palestinian and 4.2% migrant women of other nationalities. The majority of women had a caesarean section (73%) and 11% had a serious obstetric complication. Between 2011 and 2018, there was a decline in the use of primary caesarean section (caesarean section performed for the first time) from 7% to 4% of births (p<0.001). The odds of preeclampsia, placenta abruption and serious complications were significantly higher for Palestinian and migrant women of other nationalities compared to Lebanese women, but not for Syrian women. Very preterm birth was higher for Syrians (OR: 1.23, 95% CI: 1.08 to 1.40) and migrant women of other nationalities (OR: 1.51, 95% CI: 1.13 to 2.03) compared to Lebanese women. CONCLUSION: Syrian refugees in Lebanon had similar obstetric outcomes compared to the host population, except for very preterm birth. However, Palestinian women and migrant women of other nationalities appeared to have worse pregnancy complications than the Lebanese women. There should be better healthcare access and support for migrant populations to avoid severe complications of pregnancy.

The hypertension cascade of care in the midst of conflict: the case of the Gaza Strip.

Although hypertension constitutes a substantial burden in conflict-affected areas, little is known about its prevalence, control, and management in Gaza. This study aims to estimate the prevalence and correlates of hypertension, its diagnosis and control among adults in Gaza. We conducted a representative, cross-sectional, anonymous, household survey of 4576 persons older than 40 years in Gaza in mid-2020. Data were collected through face-to-face interviews, anthropometric, and blood pressure measurements. Hypertension was defined in anyone with an average systolic blood pressure ≥140 mmHg or average diastolic blood pressure ≥90 mmHg from two consecutive readings or a hypertension diagnosis. The mean age of participants was 56.9 ± 10.5 years, 54.0% were female and 68.5% were Palestinian refugees. The prevalence of hypertension was 56.5%, of whom 71.5% had been diagnosed. Hypertension was significantly higher among older participants, refugees, ex-smokers, those who were overweight or obese, and had other co-morbidities including mental illnesses. Two-thirds (68.3%) of those with hypertension were on treatment with one in three (35.6%) having their hypertension controlled. Having controlled hypertension was significantly higher in females, those receiving all medications for high blood pressure and those who never or rarely added salt to food. Investing in comprehensive but cost-effective initiatives that strengthen the prevention, early detection and timely treatment of hypertension in conflict settings is critical. It is essential to better understand the underlying barriers behind the lack of control and develop multi-sectoral programs to address these barriers.

Establishment of a birth-to-education cohort of 1 million Palestinian refugees using electronic medical records and electronic education records.

Introduction: By linking datasets, electronic records can be used to build large birth-cohorts, enabling researchers to cost-effectively answer questions relevant to populations over the life-course. Currently, around 5.8 million Palestinian refugees live in five settings: Jordan, Lebanon, Syria, West Bank, and Gaza Strip. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides them with free primary health and elementary-school services. It maintains electronic records to do so.We aimed to establish a birth cohort of Palestinian refugees born between 1st January 2010 and 31st December 2020 living in five settings by linking mother obstetric records with child health and education records and to describe some of the cohort characteristics. In future, we plan to assess effects of size-at-birth on growth, health and educational attainment, among other questions. Methods: We extracted all available data from 140 health centres and 702 schools across five settings, i.e. all UNRWA service users. Creating the cohort involved examining IDs and other data, preparing data, de-duplicating records, and identifying live-births, linking the mothers' and children's data using different deterministic linking algorithms, and understanding reasons for non-linkage. Results: We established a birth cohort of Palestinian refugees using electronic records of 972,743 live births. We found high levels of linkage to health records overall (83%), which improved over time (from 73% to 86%), and variations in linkage rates by setting: these averaged 93% in Gaza, 89% in Lebanon, 75% in Jordan, 73% in West Bank and 68% in Syria. Of the 423,580 children age-eligible to go to school, 47% went to UNRWA schools and comprised of 197,479 children with both health and education records, and 2,447 children with only education records. In addition to year and setting, other factors associated with non-linkage included mortality and having a non-refugee mother. Misclassification errors were minimal. Conclusion: This linked open birth-cohort is unique for refugees and the Arab region and forms the basis for many future studies, including to elucidate pathways for improved health and education in this vulnerable, understudied population. Our characterization of the cohort leads us to recommend using different sub-sets of the cohort depending on the research question and analytic purposes.

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.

School and community drivers of child diets in two Arab cities: The SCALE protocol and innovative tools to assess children's food environments.

BACKGROUND: In the context of the rapid nutrition transition experienced by middle-income countries of the Arab region, children and adolescent's food choices and dietary behaviors are early risk factors for the development of non-communicable diseases. Assessment of factors influencing food choices among this age group is challenging and is usually based on self-reported data, which are prone to information and recall bias. As the popularity of technologies and video gaming platforms increases, opportunities arise to use these tools to collect data on variables that affect food choice, dietary intake, and associated outcomes. This protocol paper describes the SCALE study (School and community drivers of child diets in Arab cities; identifying levers for intervention) which aims to explore the environments at the level of households, schools and communities in which children's food choices are made and consequently identify barriers and enablers to healthy food choices within these environments. METHODS: Field studies are being conducted in primary schools, among children aged 9-12 years, in Greater Beirut, Lebanon and Greater Tunis, Tunisia. A stratified random sample of 50 primary schools (public and private) are selected and 50 children are randomly selected from grades 4-5-6 in each school. The study includes surveys with children, parents/caregivers, school directors, teachers, and nutrition/health educators to assess individual diets and the contextual factors that influence children's food choices. Innovative locally adapted tools and methods such as game-based choice experiments, wearable cameras and neighborhood mapping are used to describe the environments in which children's food choices are made. DISCUSSION: The SCALE study will generate contextual knowledge on factors in school and neighborhood environments that influence child dietary behaviors and will inform multi-level interventions and policies to address childhood malnutrition (under-and over-nutrition). By integrating methods from various disciplines, including economics, data science, nutrition, and public health and by considering factors at various levels (home, school, and neighborhood), the study will identify levers for intervention with the potential to improve children's dietary behaviors. This will help fill existing gaps in research on food systems and consequently guide positive change in Lebanon and Tunisia, with the potential for replicability in other contexts.

Pathways to food insecurity in the context of conflict: the case of the occupied Palestinian territory.

BACKGROUND: Conflict reduces availability of production input and income, increases the number of days households had to rely on less preferred foods, and limits the variety of foods eaten and the portion size of meals consumed. While existing studies examine the impact of conflict on different food security measures (e.g., Food Consumption Score, Food Insecurity Experience Scale), the relationship between these measures as well as their relationship with political, economic, and agricultural factors remain under explored. Food insecurity may not only be an externality of conflict but also food deprivation may be utilized as a weapon to discourage residency in contested territories or to incentivize rebellions. METHODOLOGY: This paper examines the association between political factors (e.g., violence, policies that require permit for passage in one's own hometown), economic factors (e.g., loss of assets, unemployment), agricultural factors (e.g., shortage of water, poor weather conditions), and food insecurity experience and dietary diversity in a conflict setting-that of the occupied Palestinian territory (oPt). The study employs generalized structural equation models to analyze the 'Survey on socio-economic conditions for Palestinian households 2014' dataset compiled by the Palestinian Central Bureau of Statistics-which contains a representative sample of the population in the oPt at governorate and locality levels. RESULTS: We find that in the West Bank, residence in Area C-administered by Israel in both civil and security issues and contains illegal Israeli settlements and outposts-is associated with a higher level of agricultural hardship (p < 0.01) but lower economic hardship (p < 0.01) and a higher dietary diversity (p < 0.001), as compared to those living outside of Area C. In the Gaza Strip, living within one kilometer to a buffer zone is associated with lower dietary diversity (p < 0.01), higher level of political hardship (p < 0.01), and higher level food insecurity experience (p < 0.01) compared to not living in close proximity to a buffer zone. Concomitantly, in the Gaza Strip, food insecurity experience is associated with approximately a one-point reduction in dietary diversity as measured by the food consumption score (p < 0.01). CONCLUSIONS: The results suggest that broader socio-political conditions in the oPt impact different aspects of food security through augmenting the economic and agricultural hardships that are experienced by the residents. As such, it is important to address these broader political and economic structures in order to have more sustainable interventions in reducing food insecurity.

Development, Validity, and Cross-Context Equivalence of the Child Food Insecurity Experiences Scale for Assessing Food Insecurity of School-Age Children and Adolescents.

BACKGROUND: Children ages 6 to 17 years can accurately assess their own food insecurity, whereas parents are inaccurate reporters of their children's experiences of food insecurity. No globally applicable scale to assess the food insecurity of children has been developed and validated. OBJECTIVES: We aimed to develop a globally applicable, experience-based measure of child and adolescent food insecurity and establish the validity and cross-contextual equivalence of the measure. METHODS: The 10-item Child Food Insecurity Experiences Scale (CFIES) was based on items previously validated from questionnaires from the United States, Venezuela, and Lebanon. Cognitive interviews were conducted to check understanding of the items. The questionnaire then was administered in 15 surveys in 13 countries. Other items in each survey that assessed the household socioeconomic status, household food security, or child psychological functioning were selected as criterion variables to compare to the scores from the CFIES. To investigate accuracy (i.e., criterion validity), linear regression estimated the associations of the CFIES scores with the criterion variables. To investigate the cross-contextual equivalence (i.e., measurement invariance), the alignment method was used based on classical measurement theory. RESULTS: Across the 15 surveys, the mean scale scores for the CFIES ranged from 1.65 to 5.86 (possible range of 0 to 20) and the Cronbach alpha ranged from 0.88 to 0.94. The variance explained by a 1-factor model ranged from 0.92 to 0.99. Accuracy was demonstrated by expected associations with criterion variables. The percentages of equivalent thresholds and loadings across the 15 surveys were 28.0 and 5.33, respectively, for a total percentage of nonequivalent thresholds and loadings of 16.7, well below the guideline of <25%. That is, 83.3% of thresholds and loadings were equivalent across these surveys. CONCLUSIONS: The CFIES provides a globally applicable, valid, and cross-contextually equivalent measure of the experiences of food insecurity of school-aged children and adolescents, as reported by them.

Measuring and monitoring child health and wellbeing: recommendations for tracking progress with a core set of indicators in the Sustainable Development Goals era.

Although great improvements in child survival were achieved in the past two decades, progress has been uneven within and across countries, and the COVID-19 pandemic threatens to reverse previous advances. Demographic and epidemiological transitions around the world have resulted in shifts in the causes and distribution of child death and diseases, and many children are living with short-term and long-term chronic illnesses and disabilities. These changes, plus global threats such as pandemics, transnational and national security issues, and climate change, mean that regular monitoring of child health and wellbeing is essential if we are to achieve the Sustainable Development Goals. This Health Policy describes the three-phased process undertaken by the Child Health Accountability Tracking technical advisory group (CHAT) to develop a core set of indicators on child health and wellbeing for global monitoring purposes, and presents CHAT's research recommendations to address data gaps. CHAT reached consensus on 20 core indicators specific to the health sector, which include 11 impact-level indicators and nine outcome-level indicators that cover the topics of: acute conditions and prevention; health promotion and child development; and chronic conditions, disabilities, injuries, and violence against children. An additional six indicators (three impact and three outcome) that capture information on child health issues such as malaria and HIV are recommended; however, these indicators are only relevant to high-burden regions. CHAT's four research priorities will require investments in health information systems and measurement activities. These investments will help to increase data on children aged 5-9 years; develop standard metadata and data collection processes to enable cross-country comparisons and progress assessments over time; reach a global consensus on essential interventions and associated indicators for monitoring emerging priority areas such as child development, chronic conditions, disabilities, and injuries; and implement strategies to increase the uptake of data on child health to improve evidence-based planning, programming, and advocacy efforts.

Does a school snack make a difference? An evaluation of the World Food Programme emergency school feeding programme in Lebanon among Lebanese and Syrian refugee children.

OBJECTIVE: To investigate the effects of providing a daily healthy school snack on children's nutritional, social and educational outcomes and explore stakeholders' perceptions of an emergency school feeding programme (SFP). DESIGN: Convergence triangulation mixed-methods study design. Associations were examined between receiving the school feeding intervention and children's outcomes using multivariable regression models. Quantitative data were complemented with interviews and focus group discussions with parents and staff. SETTING: In vulnerable communities in Lebanon, the World Food Programme has implemented an emergency SFP targeting Lebanese (attending morning sessions) and Syrian refugee children (attending afternoon sessions) in public schools. PARTICIPANTS: Children from ten intervention schools (morning n 403; afternoon n 379) and ten matched control schools (morning n 399; afternoon n 401), as well as twenty-nine parents and twenty-two school staff members. RESULTS: Diet diversity was higher in intervention schools as compared with control with a significantly higher consumption of dairy products, nuts and fruit in both sessions. Child-reported food insecurity experience was lower in children attending the afternoon session of intervention v. control schools. The SFP intervention was associated with higher school engagement and sense of school community in the morning session only. While the SFP was significantly associated with higher attendance for children in afternoon sessions only, it was significantly associated with school retention of children in both sessions. CONCLUSIONS: A daily healthy snack potentially acts as an incentive to improve children's nutritional outcomes, school engagement, sense of belonging, equality between students and improvement in children's attendance and retention in public schools.

Child deprivation among Palestinian refugees in Lebanon and Palestinian refugees from Syria living in Lebanon: a cross-sectional analysis of co-occurrence of deprivation indicators.

BACKGROUND: Palestinian refugees in Lebanon (PRL) and Palestinian refugees from Syria (PRS) living in Lebanon have high poverty rates. As the social, economic, and physical environment in which a child develops is a strong determinant of health and wellbeing, a comprehensive approach that recognises the influence of multidimensional deprivation on child wellbeing is needed. This study investigates overlaps (co-occurrences) in deprivation indicators experienced by Palestinian children compared to those experienced by other vulnerable children living alongside them in Lebanon; children who are Syrian refugees (SYR) and children who are Lebanese nationals (LBN). METHODS: This analysis adopted a life-cycle approach using data from the UNICEF 2016 Lebanon Household Survey, and included data on children aged 2-17 years (PRL, n=7106; PRS, n=2768; LBN, n=10555; SYR n=5891). We report on indicators relating to early childhood (24-59 months) and school age (6-17 years), including child survival (nutrition, health, water, sanitation, and overcrowding), child development (education), and child protection (labour, exposure to violence, and early marriage), as well as the co-occurrence of these deprivation indicators. Socio-demographic and geographical correlates of child deprivation were explored using univariate and multivariable logistic regression analysis, a using sampling weights and clustering for children in the same households. Analyses were conducted using Stata 15. FINDINGS: Among children aged 24-59 months, 28·9% (347 of 1202) of PRL and 46·2% (260 of 563) of PRS children were deprived in at least two dimensions, compared with 13·2% (67 of 508) of LBN and 68·5% (915 of 1335) of SYR children. Co-occurring deprivations were highest across the protection and overcrowding dimensions in Palestinian refugee children aged 6-17 years (PRL, 14·2% [769 of 5421]; PRS, 26·7% [531 of 1985]). Across all ages, PRS children were more likely to be deprived in two dimensions than PRL children. However, indicators of health and education deprivation were lower in PRL and PRS children than in SYR children. Geographical disparities in deprivation existed within all four populations, with the highest disparity among those living in North Lebanon and the Bekaa. Higher maternal education (completed intermediate education) was consistently associated with lower odds of having at least two concurrent deprivations among children aged 6-17 years (LBN odds ratio [OR] 0·1, 95% CI 0·1-0·2, p<0·0001; PRL OR 0·3, 95% CI 0·3-0·5, p<0·0001; PRS OR 0·5, 95% CI 0·3-0·7, p=0·0002; SYR OR 0·4, 95% CI 0·2-0·7, p=0·0004). INTERPRETATION: The most common overlaps in deprivation indicators were in housing (overcrowding) and protection (exposure to violence) among PRL and PRS children, highlighting the need to focus simultaneously on housing improvements and protection programmes. Deprivation in health and education were relatively low as PRS children have been included in the well-established UNRWA health and education systems, largely protecting them from poor health and education outcomes. FUNDING: UNICEF Lebanon. The findings, interpretations, and conclusions do not necessarily reflect the view of UNICEF.

Food insecurity in the context of conflict: analysis of survey data in the occupied Palestinian territory.

BACKGROUND: Conflict impacts food security and decreases household dietary diversity. However, few studies have explored the routes by which prolonged conflict and social stressors affect food insecurity experience and food diversity. This study examines the influence of political, economic, and agricultural stressors on food insecurity and food diversity, and evaluates variations in food insecurity and food diversity with location of residence for households in the occupied Palestinian territory. METHODS: A secondary data analysis with structural equation modelling was carried out on data from the Socio-Economic & Food Security Survey 2014 of the Palestinian Central Bureau of Statistics. The survey was completed by a representative sample of the Palestinian population in the occupied Palestinian territory at governorate and locality levels, and consisted of 4215 households in the West Bank and 2916 households in the Gaza Strip. The primary outcomes were food diversity (measured with a food consumption score) and food insecurity (assessed with a composite experience-based measure of food security). We used structural equation models to examine the relationships between location of residence (in the West Bank, living in Area C versus not Area C; in the Gaza Strip, proximity of residence to the buffer zone), the number of political stressors, economic stressors, and agricultural stressors (eg, restricted access to land), and the primary outcomes. We controlled for demographic characteristics, including education, governorate, and wealth. FINDINGS: In the West Bank, there was no statistically significant direct association between living in Area C and food insecurity. Living in Area C is associated with a higher number of agricultural stressors than not Area C (p=0·032), and a higher number of agricultural stressors is in turn associated with lower food diversity (p=0·0080) and higher food insecurity (p=0·040). In the Gaza Strip, proximity to the buffer zone is directly associated with higher food insecurity (p=0.041) and lower food diversity (p=0·019) and a higher number of political stressors (p=0·057). A higher number of political stressors is associated with a higher number of economic stressors (p=0·026) and higher food insecurity (p=0·034). INTERPRETATION: The findings suggest that political, economic, and agricultural factors contribute to food insecurity and food diversity, and that their interactions are complex. Conflict and occupation affect food availability through both direct and indirect channels. In the Gaza Strip, living in close proximity to the buffer zone is associated with lower food diversity and higher food insecurity. In the West Bank, although residing in Area C may not directly increase food insecurity, the hardship generated by the conditions in Area C contributes to higher food insecurity. FUNDING: The Emirates Foundation.

Revitalizing child health: lessons from the past.

Essential health, education and other service disruptions arising from the COVID-19 pandemic risk reversing some of the hard-won gains in improving child survival over the past 40 years. Although children have milder symptoms of COVID-19 disease than adults, pandemic control measures in many countries have disrupted health, education and other services for children, often leaving them without access to birth and postnatal care, vaccinations and early childhood preventive and treatment services. These disruptions mean that the SARS-CoV-2 virus, along with climate change and shifting epidemiological and demographic patterns, are challenging the survival gains that we have seen over the past 40 years. We revisit the initiatives and actions of the past that catalyzed survival improvements in an effort to learn how to maintain these gains even in the face of today's global challenges.

Predictors of complementary feeding practices among children aged 6-23 months in five countries in the Middle East and North Africa region.

Ensuring diets of children aged 6-23 months meet recommended guidance is crucial for growth and development and for the prevention of malnutrition including stunting, wasting and micronutrient deficiencies. Despite some improvement, indicators related to undernutrition and overnutrition fall short of global targets in the Middle East and North Africa (MENA) region that consist of low- and middle-income countries witnessing political and social changes and a nutrition transition. This research aims at reviewing the situation related to the diets of children aged 6-23 months in five selected countries in the MENA region, examining factors affecting complementary feeding and providing recommendations for guiding effective strategies to improve it. The study triangulated data on complementary feeding status and predictors from semistructured interviews with 30 key informants, and multivariable analysis of household surveys in Egypt, Jordan, Lebanon, State of Palestine and Sudan including data on refugees in Lebanon and Jordan. There remain considerable gaps in complementary feeding differing noticeably among geographic areas. Findings from qualitative and quantitative analyses showed that maternal factors, including maternal education and age, household level factors such as paternal education and wealth, community-level factors (culture and geographic location), and utilization of health services, were associated with minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD) at varied levels in the five countries. Interventions to improve complementary feeding practices should include actions tailored to the needs of the population at multiple levels including at the caregiver's level, household, service use, community and policy level.