Perceived support, social and marital challenges in the lives of breast cancer survivors after illness: a self-administered cross-sectional survey.

Background: Breast cancer (BC) is a traumatic illness. BC is the leading female cancer in Palestine. Complex socio-political dynamics impact patients' lives, resulting in an increasing need for social support to develop resilience after illness. Methods: Data was collected through a cross-sectional survey targeting women living in the Gaza Strip who had been diagnosed with BC. The survey was self-administered and distributed to 350 women between 1 March and 30 May 2021. Descriptive statistics and multinomial logistic regression analysis (SPSS, version 28.0) were used to explore perceived support, post-illness social and marital changes and the association between these changes and socio-demographic, illness-related and support-related variables. Findings: About four-fifth of the women with BC felt supported after illness, either fully or partially, mainly by family members, non-governmental organisations, spouses, and peers. Nevertheless, nearly half of the women perceived negative social changes after illness, and about 40% of married or formerly married women perceived negative changes in their marital life. Survivors' lived experiences varied by age, marital status, motherhood, prescribed treatment (specifically mastectomy), and the absence of informal support in social life and lack of partner support amongst married or formerly married women. Conclusion: This study shows how BC undermines the social status of women and further exacerbates existing social vulnerabilities. Nevertheless, it is possible to manage and potentially overturn this circumstance by enveloping patients with social support. Guiding partners, families, and friends on providing emotional and instrumental support will help survivors to cope better during recovery.

The influence of socio-demographic factors on the stage at which women's breast cancer is diagnosed and treatment prescribed in the Gaza Strip, occupied Palestinian territory.

Background: One of every three women diagnosed with breast cancer (BC) in Gaza does not live for more than 5 years. They are faced by unreliable treatment plans. Radiotherapy is not available locally and there are chronic shortages in the chemotherapy medications. This paper aims to provide understanding of how socio-demographic factors affect the stage at which the cancer is diagnosed and what treatment is prescribed. Methods: Data were collected through a cross-sectional survey targeting women living in Gaza who had been diagnosed with BC at least once. The survey was self-administered and distributed to 350 women between 1 March 2021 and 30 May 2021. Multinomial logistic regression (SPSS, version 28.0) was used to explore the association between stage of the cancer at diagnosis and socio-demographic characteristics. The relationship between the stage at diagnosis and prescribed treatment was explored using a cluster analysis and crosstabulations. Findings: Socio-demographic inequalities were reflected in stage at diagnosis and varied by age, education, employment, marital status, and refugee status. Breast cancer was less likely to be detected at an advanced stage among educated respondents (women with primary education OR = 0.093, p = 0.008 and women with preparatory education OR = 0.172, p = 0.005), employed women (OR = 0.056, p = 0.022). It was more likely to be detected at an early stage (OR = 3.954, p = 0.011) in women aged 41-50. In widowed and separated/divorced women, it was less likely to be detected at an early stage (OR = 0.217, p = 0.029) and (OR = 0.294, p = 0.028) respectively, than among married women. Among refugee women, it was less likely to be detected at early stage than among non-refugee women (OR = 0.251, p = 0.007). Among the total respondents, only 30% of the full prescribed treatment was available locally. Conclusion: Our research showed various levels of inequalities at the stage of diagnosis by age, marital status, education, employment and refugee status. Most of the survivors needed treatment that was unavailable locally.

Survival analysis for patients with cancer in Gaza applying for Israeli permits to exit the Gaza Strip for health care: a retrospective cohort study of patients from 2008 to 2017.

BACKGROUND: Gaza has been under land, sea, and aerial blockade for more than 13 years, during which time Israel has continued its permit regime to control access for Palestinian patients from Gaza to health facilities in the West Bank (including East Jerusalem), Israel, and Jordan. Specific groups, such as patients with cancer, have a high need for permits owing to a lack of services in Gaza. The approval rate for patient permits to exit Gaza dropped from 94% in 2012 to 54% in 2017. We aimed to assess the effect of access restrictions due to permit denials or delays on all-cause mortality for patients with cancer from Gaza who were referred for chemotherapy, radiotherapy, or both. METHODS: This study matched 17 072 permit applications for 3816 patients referred for chemotherapy, radiotherapy, or both, from Jan 1, 2008, to Dec 31, 2017, with referral data for the same period and mortality data from Jan 1, 2008, to Jun 30, 2018. We stratified survival analysis by period of first application (2008-14, 2015-17), in light of varying access to Egypt during these times. Primary analysis compared survival of patients according to their first referral decision (approved versus denied or delayed) using Kaplan-Meier methods and Cox regression. Consent for the study was granted by the Palestinian Ministry of Health, and ethical approval was granted by the Helsinki Committee of the Palestinian Ministry of Health. FINDINGS: Mortality was significantly higher among patients who were initially unsuccessful in permit applications from 2015 to 2017 (141 events over 493 person-years, corresponding to a rate of 286 per 100 person-years) than among patients who were initially successful in the same period (375 events over 1923 person-years, corresponding to a rate of 195 per 100 person-years) with a hazard ratio of 1·45 (95% CI 1·19-1·78, p=0.0009) after adjusting for age, sex, type of procedure, and type of cancer. There was no significant difference in mortality risk between the two groups in the 2008-14 period, with a hazard ratio of 0·84 (95% CI 0·69-1·01, p=0·071). INTERPRETATION: Barriers to patient access to health care through denied or delayed permit applications had a significant impact on mortality for patients with cancer who applied for chemotherapy, radiotherapy, or both, in the period 2015-17. Relative ease of access through Rafah from 2008 to 2014 may have mitigated the health effects of access restrictions. FUNDING: WHO received funding from the Swiss Agency for Development and Cooperation.

Health attacks and protection strategies during Gaza's Great March of Return: a mixed methods study using data from WHO's Surveillance System for Attacks on Healthcare.

BACKGROUND: WHO defines an attack on health care as "any act of verbal or physical violence or obstruction or threat of violence that interferes with the availability, access and delivery of curative and/or preventive health services during emergencies." Gaza's Great March of Return (GMR) began on Mar 30, 2018, with 322 Palestinians killed and 33 141 injured by December, 2019, and first-response health-care teams exposed to high levels of violence. The aims of this study were threefold: to explore the vulnerabilities of health workers to attacks during the GMR; to understand the effectiveness and comprehensiveness of systems for monitoring health attacks; and to identify potential strategies and interventions to improve protection. METHODS: WHO's Surveillance System for Attacks on Healthcare (SSA) verifies and records health attacks. We analysed SSA data for the Gaza Strip from Mar 30, 2018, to Dec 31, 2019, examining the number and type of attacks, the mechanisms of injury, and the distribution of attacks by gender, time, and location. We analysed the correlation of health worker injuries and deaths with total injuries and deaths of Palestinians during the GMR. We held interviews and focus groups with individuals working for organizations defined as partners contributing to the SSA in the Gaza Strip, to understand data comprehensiveness, the nature and impact of violence, and protection gaps and strategies. FINDINGS: During the study period, there were 567 confirmed incidents, in which three health workers were killed, 845 health workers were injured, and 129 ambulances and vehicles and 7 health facilities were damaged, including one hospital and three medical field stations. Of the total health personnel killed and injured, 166 of 848 (20%) were in the Gaza governorate, 274 (32%) were in the Khan Yunis governorate, 119 (14%) were in the middle governorate, 192 (22%) were in North governorate, and 96 (11%) were in the Rafah governorate. Of 845 injuries, 743 (88%) were in men, 45 (5%) were live ammunition injuries, 62 (7%) were rubber bullet injuries, 151 (18%) were gas canister injuries, 41 (5%) were shrapnel injuries, and 533 (64%) were gas inhalation injuries. Injuries and deaths among health workers correlated moderately (R2=0·54) with and accounted for 2% of the total. Qualitative findings highlighted the incidental and structural nature of violence, normalisation and under-reporting of attacks, the need for improved coordination of protection for health care, and gaps in the availability of protective equipment. INTERPRETATION: Health-care workers function at great personal risk. The correlation of attacks against health care with total injuries and deaths points to the need for alignment of efforts to protect health care with strategies to safeguard civilian populations, including protection of populations living under occupation and those engaged in civil demonstrations. Health-care workers identified the need for systemic measures to improve protection through training, monitoring, and coordination, and through linking of monitoring and documentation of health attacks with stronger accountability measures for prevention. FUNDING: In 2017 and 2018, WHO's Right to Health Advocacy programme received funding from the Swiss Development Cooperation and the oPt Humanitarian Fund.

Comparative survival of cancer patients requiring Israeli permits to exit the Gaza Strip for health care: A retrospective cohort study from 2008 to 2017.

BACKGROUND: Gaza has been under land, sea, and aerial closure for 13 years, during which time Palestinian patients from Gaza have been required to obtain Israeli-issued permits to access health facilities in the West Bank (including east Jerusalem), as well as in Israel and Jordan. Specific groups, like cancer patients, have a high need for permits due to lack of services in Gaza. The approval rate for patient permits to exit Gaza dropped from 94% in 2012 to 54% in 2017. We aimed to assess the impact of access restrictions due to permit denials/delays on all-cause mortality for cancer patients from Gaza referred for chemotherapy and/or radiotherapy. METHODS: This study matched 17,072 permit applications for 3,816 cancer patients referred for chemotherapy and/or radiotherapy from 1 January 2008 to 31 December 2017 with referrals data for the same period and mortality data from 1 January 2008 to 30 June 2018. We carried out separate analyses by period of first application (2008-14; 2015-17), in light of varying access to Egypt during these times. Primary analysis compared survival of patients according to their first referral decision (approved versus denied/delayed) using Kaplan-Meier method and Cox regression. FINDINGS: Mortality in patients unsuccessful in permit applications from 2015-17 was significantly higher than mortality among successful patients, with a hazard ratio of 1·45 (95% CI: 1·19-1·78, p<0.001), after adjusting for age, sex, type of procedure, and type of cancer. There was no significant difference in mortality risk for the two groups in the 2008-2014 period. INTERPRETATION: Limitations to patient access due to unsuccessful applications for permits to exit the Gaza Strip had a significant impact on mortality for cancer patients applying for chemotherapy and/or radiotherapy in the period 2015-17. The substantially higher number of annual unsuccessful permit applications from 2015, combined with severely limited alternatives to access chemotherapy and radiotherapy during these years, may be important factors to explain the difference in the impact of permits delays/denials between the two study periods.