Conducting a health technology assessment in the West Bank, occupied Palestinian territory: lessons from a feasibility project.

OBJECTIVES: To achieve universal health coverage (UHC), countries must make difficult choices to optimize the use of scarce resources. There is a growing interest in using evidence-based priority setting processes, such as Health Technology Assessment (HTA), to inform these decisions. In 2020, the Palestinian Institute of Public Health (PNIPH) and the Norwegian Institute of Public Health (NIPH) initiated a pilot to test the feasibility of coproducing an HTA on breast cancer screening in the West Bank, occupied Palestinian Territory. Additionally, a secondary aim was to test whether using an adaptive HTA (aHTA) approach that searched and transferred published evidence syntheses could increase the speed of HTA production. METHODS: The applied stepwise approach to the HTA is described in detail and can be summarized as defining a core team, topic selection, and prioritization; undertaking the HTA including adaptation using tools from the European Network for HTA (EUnetHTA) and stakeholder engagement; and concluding with dissemination. RESULTS: The aHTA approach was faster but not as quick as anticipated, which is attributed to (i) the lack of availability of local evidence for contextualizing findings and (ii) the necessity to build trust between the team and stakeholders. Some delays followed from the COVID-19 pandemic, which showed the importance of good risk anticipation and mitigation. Lastly, other important lessons included the ability of virtual collaborations, the value of capacity strengthening initiatives within low- and middle-income countries (LMICs), and the need for early stakeholder engagement. Overall, the pilot was successfully completed. CONCLUSION: This was the first HTA of its kind produced in Palestine, and despite the challenges, it shows that HTA analysis is feasible in this setting.

Gestational age recorded at delivery versus estimations using antenatal care data from the Electronic Maternal and Child Health Registry in the West Bank: a comparative analysis.

BACKGROUND: Estimated dates of delivery have important consequences for clinical decisions during pregnancy and labour. The Electronic Maternal and Child Health Registry (MCH eRegistry) in Palestine includes antenatal care data and birth data from hospitals. Our objective was to compare computed best estimates of gestational age in the MCH eRegistry with the gestational ages recorded by health-care providers in hospital delivery units. METHODS: We obtained data for pregnant women in the West Bank registered in the MCH eRegistry from Jan 1, 2017 to March 31, 2017. Best estimates of gestational age in the registry are automated and based on a standard pregnancy duration of 280 days and ultrasound-based pregnancy dating before 20 weeks' gestation or the woman's last menstrual period date. Hospital recorded gestational ages are reported by care providers in delivery units and are rounded to the nearest week. We calculated proportions of gestational ages (with 95% CIs) from both sources that fell into the categories of term, very preterm (24-32 weeks' gestation), preterm (33-37 weeks), or post-term (>42 weeks). FINDINGS: 1924 women were included in the study. The median hospital recorded gestational age was 39 weeks (IQR 38-40 weeks) and according to MCH eRegistry estimates was 39 weeks and 5 days (IQR 38 weeks and 1 day to 40 weeks and 5 days). Proportions of very preterm, preterm, and post-term deliveries were higher based on MCH eRegistry estimates than on hospital recorded gestational ages (very preterm 3%, 95% CI 2-4 vs 2%, 1-2; preterm 6%, 5-7 vs 5%, 3-6 ; post-term 6%, 5-7 vs 1%, 1-2). INTERPRETATION: In addition to clinical care, the proportions of term, very preterm, preterm, and post-term births can have implications for public health monitoring. The proportion of deliveries within the normal range of term gestation was calculated to be higher by care providers in delivery units than by MCH eRegistry estimates. Extending the access of hospitals to information from antenatal care in the MCH e-Registry could improve continuity of data and better care for pregnant women. FUNDING: European Research Council, Research Council of Norway.

Improving newborn health in countries exposed to political violence: An assessment of the availability, accessibility, and distribution of neonatal health services at Palestinian hospitals.

INTRODUCTION: Geopolitical segregation of Palestine has left a fragile healthcare system with an unequal distribution of services. Data from the Gaza Strip reflect an increase in infant mortality that coincided with a significant increase in neonatal mortality (12.0 to 20.3 per 1,000 live births). OBJECTIVE: A baseline study was carried out to evaluate available resources in neonatal units throughout Palestine. STUDY DESIGN: A cross-sectional, hospital-based study was conducted in 2017 using the World Health Organization's "Hospital care for mothers and newborn babies: quality assessment and improvement tool." Data on the main indicators were updated in 2018. RESULTS: There were 38 neonatal units in Palestine: 27 in the West Bank, 3 in East Jerusalem, and 8 in the Gaza Strip. There was an uneven geographic distribution of incubators in relation to population and births that was more marked in the Gaza Strip; 79% of neonatal units and 75% of incubators were in the West Bank. While almost all hospitals with neonatal units accepted very and extremely low birth weight and admitted out-born neonatal cases, there was a shortage in the availability of incubators with humidifiers, high-frequency oscillatory ventilation, mechanical ventilators with humidifiers and isolation wards. There was also a considerable shortage in neonatologists, neonatal nurses, and pediatric subspecialties. CONCLUSION: Almost all the neonatal units accepted extremely low birth weight neonatal cases despite not being ready to receive these newborns due to considerable shortages in human resources, equipment, drugs, and essential blood tests, as well as frequent disruptions in the availability of based amenities. Together, these factors contribute to the burden of providing quality care to newborns, which is further exacerbated by the lack of referral guidelines and challenges to timely referrals resulting from Israeli measures. Ultimately, this contributes to suboptimal care for neonates and negatively impacts future health outcomes.

Accuracy of mortality statistics in Palestine: a retrospective cohort study.

OBJECTIVE: To examine the accuracy of mortality statistics in Palestine, to identify gaps and to provide evidence-based recommendations to improve mortality statistics in Palestine. STUDY DESIGN AND SETTING: A retrospective death registry-based study that examined a stratified random sample of death notification forms (DNFs) of patients who died in hospitals in Palestine was reported in 2012. We randomly selected 600 deceased from the Cause of Death Registry: 400 from the West Bank and 200 from the Gaza Strip. Analysis was based on the randomly selected deaths that we were able to retrieve the medical records for; 371 deaths in the West Bank and 199 deaths in the Gaza Strip. RESULTS: Data in the Palestinian Health Information Centre (PHIC) registry had a low degree of accuracy: less than half of the underlying causes stated the correct cause of death. In general, deaths due to malignant neoplasms were more accurately reported on DNFs than other causes of death, and metabolic diseases (including diabetes) were the most problematic. Issues with coding and classification at the PHIC were most apparent for perinatal conditions and congenital anomalies. CONCLUSION: Procedures for coding and classification at the PHIC deviate considerably from the international norms defined in the International Statistical Classification of Diseases and Related Health Problems (ICD) and account to a considerable extent for the discrepancies between the cause of death determined on the medical data on the death extracted from the deceased patient's hospital records and the cause of death coded by the PHIC. We recommend the introduction of international coding software for coding and classification, and a review to improve data handling in hospitals, especially those with electronic patient records.

Factors associated with depression in patients with type 2 diabetes in the Gaza Strip: a cross sectional study.

BACKGROUND: About 9% of the world's population has diabetes. Most people with diabetes live in developing countries. Diabetes is the fourth leading cause of death in the occupied Palestinian territory. The likelihood of diabetes complications increases with depression. Worldwide, about half of patients with diabetes have severe depression that has been misidentified by health providers. The aim of this study was to examine factors associated with depression in patients with type 2 diabetes in the Gaza governorate. METHODS: This cross-sectional study included patients attending three primary health centres in 2016. A convenient purposive approach to sampling was used to select three centres from the 15 centres in the Gaza governorate, covering the east (border), middle, and west areas. Since 2014, all patients with type 2 diabetes have been screened for depression using the Patient Health Questionnaire 9. Data on demographic, socioeconomic, and health status and on patients' beliefs were collected during interviews with structured questionnaires, and medical data were collected from patient records. χ2 tests and logistic regression were used to test associations between dependent and independent variables. FINDINGS: 380 patients were included in the study. 255 participants were women with type 2 diabetes and older than 40 years. The median age of participants was 59 years (IQR 13). 285 (75%) participants were married, and 221 (58%) had not completed high school. 103 (27%) participants screened positive for depression. Factors positively associated with depression were age (people younger than 50 years were at greater risk than people aged 50 years and older [odds ratio 2·25, 95% CI 1·2-4·2]), being single (2·04, 1·68-3·55), not believing that they can manage the disease (2·9, 1·6-5·6), and living in border areas (3·6, 2·0-6·2). INTERPRETATION: More attention should be given to young, single patients and to those living in border areas. Treatment options and care for patients with depression should be strengthened with counselling and medications. FUNDING: Palestinian National Institute of Public Health.

Predicted efficacy of the Palestinian wheat flour fortification programme: complementary analysis of biochemical and dietary data.

OBJECTIVE: To utilize complementary biochemical and dietary data collected before the initiation of national flour fortification to (i) identify micronutrient insufficiencies or deficiencies and dietary inadequacies in Palestinian women and children in vulnerable communities and (ii) assess the suitability of the current wheat flour fortification formula. DESIGN: Quantitative dietary intake questionnaires were administered and fasting venous blood samples collected in randomly selected households in Gaza City and Hebron. The impact of fortification was simulated by estimating the additional micronutrient content of fortified wheat flour. SETTING: Households in Gaza City and Hebron that were not receiving food aid from social programmes. SUBJECTS: Non-pregnant women (18-49 years) and children aged 36-83 months. RESULTS: The micronutrients with highest prevalence of insufficiency were vitamin D in women (84-97 % with serum 25-hydroxyvitamin D <50 nmol/l) and vitamin B12 in women and children (43-82 % with serum B12 <221 pmol/l). Deficiencies of vitamin A, Fe and Zn were also of public health concern. Current levels of wheat flour fortificants were predicted to improve, but not eliminate, micronutrient intake inadequacies. Modification of fortificant concentrations of vitamin D, thiamin, vitamin B12, Zn and folic acid may be indicated. CONCLUSIONS: Micronutrient insufficiencies or deficiencies and intake inadequacies were prevalent based on either biochemical or dietary intake criteria. Adjustments to the current fortification formula for wheat flour are necessary to better meet the nutrient needs of Palestinian women and children.

Water quality and improving hygienic practices of the rural community in the vicinity of Ramallah, West Bank, Palestine.

The study aims to increase community awareness at the household level about certain hygienic practices and water quality in order to develop an effective program that will target improving specific hygiene-related behavior. The study was carried out in two Palestinian villages and applies a quasi-experimental design where chemical and biological water quality analysis as well as residential behavioral aspects related to some hygiene practices were assessed before and after envisaged intervention applications. A questionnaire was used to evaluate the housewives' knowledge, and practices in regard to hygienic practices and water use, followed by face-to-face health education and awareness sessions to the selected housewives. After 3 months, another assessment was conducted using the same questionnaire to measure improvement in their knowledge and practices. On the first visit, in addition to collecting data related to the questionnaire, the water quality in the selected houses was tested to ensure the quality aspects of the hygiene practices. Based on these findings, the chosen methodology was able to promote a real change in improving the water quality on household taps and in improving hygienic practices and knowledge.