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.

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.

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.

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.

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.

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.

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.

Systematic Review and Meta-Analysis of Integrated Studies on Salmonella and Campylobacter Prevalence, Serovar, and Phenotyping and Genetic of Antimicrobial Resistance in the Middle East-A One Health Perspective.

Background:Campylobacter and Salmonella are the leading causes of foodborne diseases worldwide. Recently, antimicrobial resistance (AMR) has become one of the most critical challenges for public health and food safety. To investigate and detect infections commonly transmitted from animals, food, and the environment to humans, a surveillance-response system integrating human and animal health, the environment, and food production components (iSRS), called a One Health approach, would be optimal. Objective: We aimed to identify existing integrated One Health studies on foodborne illnesses in the Middle East and to determine the prevalence, serovars, and antimicrobial resistance phenotypes and genotypes of Salmonella and Campylobacter strains among humans and food-producing animals. Methods: The databases Web of Science, Scopus, and PubMed were searched for literature published from January 2010 until September 2021. Studies meeting inclusion criteria were included and assessed for risk of bias. To assess the temporal and spatial relationship between resistant strains from humans and animals, a statistical random-effects model meta-analysis was performed. Results: 41 out of 1610 studies that investigated Campylobacter and non-typhoid Salmonella (NTS) in the Middle East were included. The NTS prevalence rates among human and food-producing animals were 9% and 13%, respectively. The Campylobacter prevalence rates were 22% in humans and 30% in food-producing animals. The most-reported NTS serovars were Salmonella Enteritidis and Salmonella Typhimurium, while Campylobacter jejuni and Campylobacter coli were the most prevalent species of Campylobacter. NTS isolates were highly resistant to erythromycin, amoxicillin, tetracycline, and ampicillin. C. jejuni isolates showed high resistance against amoxicillin, trimethoprim-sulfamethoxazole, nalidixic acid, azithromycin, chloramphenicol, ampicillin, tetracycline, and ciprofloxacin. The most prevalent Antimicrobial Resistance Genes (ARGs) in isolates from humans included tetO (85%), Class 1 Integrons (81%), blaOXA-61 (53%), and cmeB (51%), whereas in food-producing animals, the genes were tetO (77%), Class 1 integrons (69%), blaOXA-61 (35%), and cmeB (35%). The One Health approach was not rigorously applied in the Middle East countries. Furthermore, there was an uneven distribution in the reported data between the countries. Conclusion: More studies using a simultaneous approach targeting human, animal health, the environment, and food production components along with a solid epidemiological study design are needed to better understand the drivers for the emergence and spread of foodborne pathogens and AMR in the Middle East.

Prevalence of cigarette and waterpipe tobacco smoking among adults in three Eastern Mediterranean countries: a cross-sectional household survey.

OBJECTIVES: Tobacco smoking is on the rise in the Eastern Mediterranean region. In light of limited surveillance of smoking in the region, this study sought to understand the prevalence of cigarette and waterpipe smoking among adults and the factors associated with smoking in Lebanon, Jordan and Palestine (West Bank only). DESIGN, SETTING AND PARTICIPANTS: Household surveys were conducted with participants over the age of 18 in Lebanon (n=1680), Jordan (n=1925) and Palestine (n=1679) between June and August 2019. A multistage cluster sampling approach with probability-proportional-to-size random selection method was followed in the three countries. PRIMARY AND SECONDARY OUTCOME MEASURES: Gender-specific prevalence rates for cigarette and waterpipe smoking were estimated. Multivariable logistic regression was used to examine factors associated with current cigarette and waterpipe tobacco smoking. RESULTS: The prevalence of cigarette smoking among males and females respectively was 48.6% and 21.5% in Lebanon, 50.4% and 9.1% in Jordan, and 53.4% and 3.1% in Palestine. The prevalence of waterpipe smoking among males and females respectively was 32.7% and 46.2% in Lebanon, 13.4% and 7.8% in Jordan, and 18.0% and 7.9% in Palestine. Cigarette smokers were significantly (p<0.05) more likely to be male, younger and with lower educational attainment across the three countries. Waterpipe smokers were more likely to be young adults across the three countries (p<0.001). They were more likely to be male in Jordan and Palestine, and more likely to be female in Lebanon. CONCLUSIONS: The high prevalence rates of smoking in Lebanon, Jordan and Palestine are concerning. Continued surveillance is key to monitor smoking patterns and inform stronger tobacco control measures.

Women's experiences throughout the birthing process in health facilities in Arab countries: a systematic review.

BACKGROUND: Mistreatment of women during facility-based childbirth has become a significant public health issue globally and is gaining worldwide attention. This systematic review of quantitative studies aimed to estimate the prevalence of mistreatment women may experience throughout the birthing process in health facilities in Arab countries. The review also aimed to identify the types of mistreatment, terminology, tools, and methods used to address this topic. METHODOLOGY: The search was conducted using three electronic databases: "PubMed," "Embase," and "CINAHL" in May 2020. Studies meeting the inclusion criteria were included and assessed for risk of bias. The analysis was conducted based on the evidence-based typology developed by Bohren et al. as a guide to try to estimate the prevalence of mistreatment. RESULTS: Eleven studies out of 174 were included. The included studies belonged to only seven Arab countries out of 22 Arab countries. The mistreatment of women during childbirth is still new in the region. Searching within the included studies yielded diverse and indirect terms that were a proxy for the word mistreatment. These terms were not comprehensive to cover different aspects of the topic. The tools that were used to measure the terms widely varied.. Moreover, it was not possible to estimate the prevalence of mistreatment of women due to high heterogeneity among the 11 studies. CONCLUSION: The topic of mistreatment of women in Arab countries was not adequately addressed in the studies included in this review. More research on this topic is recommended due to its importance in improving maternal health in the region. However, a standardized and comprehensive terminology for mistreatment of women, a standardized tool, and a standardized methodology are recommended to enable comparability between results and allow pooling to estimate the prevalence.

Childbirth is a highly personal and central event in every mother's life. However, several studies have documented unpleasant behaviors that women may face throughout the birthing process in health facilities. These behaviors may affect the whole birthing experience, affecting the women's decision to use health facilities for childbirth in future pregnancies. Therefore, the mistreatment of women during facility-based delivery has become a genuine and global public health issue. There is limited data on this issue in Arab countries. This which triggered the necessity of conducting a systematic review that aimed to estimate the prevalence of mistreatment of women and better understand the burden of this issue regionally, thus reflecting the image on how it might be in Palestine. The search was conducted using three databases and was limited to studies published in English and Arabic, with no restrictions on the publication year. It included all observational studies that reported the prevalence of women's mistreatment throughout the birthing process in Arab countries. Eleven studies were included in this review, and the risk of bias assessed. All were cross-sectional studies. They were done in seven countries out of the 22 Arab countries. It was not possible to estimate the prevalence of mistreatment because the terms, tools, and methodological characteristics varied widely. Further research on the mistreatment of women during childbirth in Arab countries using standardized terminology, tool and methodology is recommended.

The Mental Health Impact of the COVID-19 Pandemic on Healthcare Workers in the Eastern Mediterranean Region: A Scoping Review.

Objectives: This scoping review is to investigate the existing literature on the mental health of Healthcare workers, including stress or distress, anxiety, depression, burnout, insomnia, and fear or phobia within the different countries in the Eastern Mediterranean region (EMR) during the COVID-19 pandemic. Methods: We systematically searched to consolidate studies across EMR countries regarding the mental health morbidity studied, the scales, and the methodology used. The review focused on peer-reviewed academic literature published from March 2020 to November 2021. Results: One hundred sixty-seven articles were included in the review. Most publications came from lower-middle-income countries such as Iran, Pakistan, and Egypt. Most of the literature was specific to Stress/Distress (n = 94), followed by anxiety (n = 93), depression (n = 66), burnout (n = 27), insomnia (n = 20), and fear/phobia (n = 12). Conclusion: Fear, phobia, and insomnia have all been examined extensively worldwide, yet they were among the Eastern Mediterranean region's least explored outcomes. In addition, most underdeveloped countries have a low rate of publication.

Impact of waterpipe tobacco taxation on consumption, government revenue and premature deaths averted in Jordan, Lebanon and Palestine: a simulation study.

INTRODUCTION: Despite the high prevalence of waterpipe tobacco smoking in the Eastern Mediterranean region, evidence supporting its fiscal measures is limited. We modelled the impact of waterpipe tobacco-specific excise taxes on consumption, government revenue and premature deaths averted in Jordan, Lebanon and Palestine. METHODS: We developed a simulation model using country-specific and market share-specific price, consumption and price elasticity data from WHO, UN Comtrade and nationally representative surveys. We modelled increases to specific excise taxes to meet a 35.9% tax burden on 20 g of waterpipe tobacco in Lebanon and Jordan, in line with the global average, and to double government revenues from excise duties in Palestine, which has surpassed this average. RESULTS: Specific excise tax was raised by $1.14 ($0.18-$1.32) in Jordan, $2.41 ($0.03-$2.44) in Lebanon (alongside removal of ad valorem taxes) and $2.39 ($1.72-$4.11) in Palestine per 20 g of waterpipe tobacco. Government revenue increased by $126.3 million in Jordan, $53.8 million in Lebanon and $162.4 million in Palestine while waterpipes smoked decreased by 32.4% in Jordan, 71.0% in Lebanon and 16.3% in Palestine. The corresponding numbers of premature deaths averted annually were approximately 162 000; 1 000 000; and 52 000. DISCUSSION: Increases in waterpipe tobacco-specific excise taxes substantially reduce smoking and increase government revenue and averted premature deaths in Jordan, Lebanon and Palestine. This has positive implications for both public health and financing and should be considered a policy priority.