Salwa Massad

Introduction: Cancer care in humanitarian settings is very challenging, and patients may face significant barriers to accessing the care they need. This study explored access to advanced diagnostic and treatment services for children with cancer in humanitarian settings, taking Gaza as a case study. Methods: The study was based on 51 key informant interviews and two focus group discussions with close relatives of children with cancer, healthcare providers and Ministry of Health officials between November 2021 and January 2022. We also analysed referral data for paediatric oncology care outside Gaza in 2021. Results: Among the structural barriers to cancer care are complex and lengthy referral mechanisms, along with an unclear permit system. These challenges contribute to significant delays in both diagnosis and the initiation of treatment. The referral pathway involves multiple administrative and logistical steps to secure approval for treatment outside Gaza. It begins with a physician-initiated referral, approval of the Ministry of Health Service Purchasing Unit, and concludes with exit permit requests for the child and a companion, which must be approved by the Israeli Gaza Coordination and Liaison Administration. Analysis of 2021 referral data reveals that 25% of children with cancer experienced permit delays of over 1 month, and 8% died while waiting for an exit permit. Conclusions: The urgent need to scale up cancer care in Gaza is critical, particularly for children who face severe challenges due to ongoing conflict, the Israeli blockade since 2006 and the closure of the only paediatric oncology department. Immediate, coordinated national and global efforts are essential to overcome political, medical and financial barriers. Improving health outcomes and survival for children with cancer in Gaza requires addressing the root causes of late diagnosis, as well as the complex referral and unclear permit processes that delay timely access to specialised care.

Noncommunicable diseases (NCDs) are the leading causes of mortality and morbidity among Palestinians, accounting for 71.8% of all deaths in 2023. Following the initial STEPS survey conducted in 2010/2011 and in accordance with WHO recommendations, a second STEPS survey was carried out for the occupied Palestinian territory (oPt) between August and October 2022. The target population for the survey included all Palestinian individuals between 18 and 69 years of age residing in the West Bank and Gaza. A three-stage stratified cluster sampling method was used to randomly select a sample of 5,775 adults from 525 enumeration areas, comprising 3,135 individuals from the West Bank and 2,640 from the Gaza Strip. Of the target sample, 5503 adults participated in the survey. The prevalence of smoking, obesity, and insufficient physical activity among Palestinians was notably high, with rates of 33.5%, 31.6%, and 21.1%. The prevalence of smoking among men in the West Bank was alarmingly high and was the highest in the world. In terms of diet, 84.3% of the participants reported an insufficient intake of fruits and vegetables, and 26.5% always or often added salt to their food before eating. Among the Palestinian population aged 18–69 years, 7.6% had raised fasting blood glucose (≥ 126 mg/dl) or were currently on medication for raised blood glucose; and 17.1% of adults between the ages of 40–69 years had a 10-year cardiovascular disease risk (CVD) risk ≥ 20% or had existing CVD. More than 55% of men and women aged 45–69 had three or more risk factors for NCDs. The prevalence of risk factors for NCDs was notably high in oPt. These results underscore the urgent need for interventions to reduce the imminent burden of NCDs within this vulnerable population. The worsening crisis in Gaza demands immediate action. Unified and decisive global efforts are essential to halt the war in Gaza, secure a permanent ceasefire, and ensure access to humanitarian aid. While rebuilding the healthcare system will be a long-term undertaking, empowering local professionals, investing in essential infrastructure, and providing sustained support can offer renewed hope to patients with NCDs. The online version contains supplementary material available at 10.1186/s12889-025-23880-0.

Raised blood sugar (hyperglycemia) is considered a strong indicator of prediabetes or diabetes mellitus. Diabetes mellitus is one of the most common non-communicable diseases (NCDs) affecting the adult population. Recently, the prevalence of diabetes has been increasing at a faster rate, especially in developing countries. The primary concern associated with diabetes is the potential for serious health complications to occur if it is not diagnosed early. Therefore, timely detection and screening of diabetes is considered a crucial factor in treating and controlling the disease. Population screening for raised blood sugar aims to identify individuals at risk before symptoms appear, enabling timely intervention and potentially improved health outcomes. However, implementing large-scale screening programs can be expensive, requiring testing, follow-up, and management resources, potentially straining healthcare systems. Given the above facts, this paper presents supervised machine-learning models to detect and predict raised blood sugar. The proposed raised blood sugar models utilize diabetes-related risk factors including age, body mass index (BMI), eating habits, physical activity, prevalence of other diseases, and fasting blood sugar obtained from the dataset of the STEPwise approach to NCD risk factor study collected from adults in the Palestinian community. The diabetes risk factor obtained from the STEPS dataset was used as input for building the prediction model that was trained using various types of supervised learning classification algorithms including random forest, decision tree, Adaboost, XGBoost, bagging decision trees, and multi-layer perceptron (MLP). Based on the experimental results, the raised blood sugar models demonstrated optimal performance when implemented with a random forest classifier, yielding an accuracy of 98.4%. Followed by the bagging decision trees, XGBoost, MLP, AdaBoost, and decision tree with an accuracy of 97.4%, 96.4%, 96.3%, 95.2%, and 94.8%, respectively.

Introduction: Antenatal care is an essential component of primary healthcare, providing opportunities to screen, prevent, and treat morbidity to preserve the health of mothers and offspring. The World Health Organization now recommends a minimum of eight antenatal care contacts, instead of four, which is challenging in countries exposed to political violence and structural disparities in access to social, economic and healthcare resources as exist in Palestine. This study examines the compliance of the recommend standard of antenatal care in Palestine. Methods: We analyzed data from the UNICEF’s Palestinian Multiple Indicator Cluster Survey (MICS) 2019–2020. The eligible sample consisted of 2,028 women, 15–49 years of age, living in Palestine, on whom data were available on reported antenatal care services received during the most recent pregnancy within the last two years. Outcome variables of interest were the reported frequencies of antenatal care visits, gestational timing of 1^st visit, and services received. Potential risk factors were assessed in women attending less than eight versus eight or more antenatal contacts, as recommended by WHO, by estimating prevalence ratios with 95% Confidence Intervals. Results: Overall, 28% of women did not meet the WHO’s recommendation of eight or more antenatal contacts, varying from 18% in Central West Bank to 33% in South West Bank across the four areas of Palestine (North, Central, and South West Bank and Gaza Strip). Twelve percent of women reported having had no antenatal contacts in the 1^st trimester, and these women were two- to three-folds more unlikely to meet WHO recommendation of antenatal contacts than mothers who initiated the antenatal contact in the 1^st trimester. Women who had less than eight antenatal contacts were generally poorer, higher in parity, lived in North and South West Bank, sought ANC from either doctor or nurse/midwife only, and initiated antenatal contact in 2^nd-to-3^rd trimesters. Conclusion: There were considerable socioeconomic and geographic inequalities in the prevalence of not meeting WHO recommended number of antenatal contacts in Palestine, offering the opportunity to inform, improve and continuously reassess coverage of antenatal care.

The unique socioeconomic context in Palestine, characterized by political and economic tensions, creates conditions that facilitate the spread of illicit drug use among Palestinians. This paper presents findings from a 2017 survey of high-risk drug use (HRDU) among males in four regions in Palestine: the West Bank (north, middle, and south) and the Gaza Strip. These findings are essential for developing effective policies to respond to the increasing use of drugs among Palestinians. Eligible participants were males aged 15 years and above who used at least one drug other than non-synthetic hashish or marijuana during the previous week. Participants underwent a face-to-face interview and had their drug use verified by urinalysis. Data were collected using respondent-driven sampling and data were analyzed using the successive sampling estimator. Multivariate regression analysis was conducted to examine factors associated with ever seeking rehabilitation services for illicit drug use in the West Bank and the Gaza Strip. A total of 400 males who use drugs were sampled in Gaza, plus 299 in the south, 300 in the north, and 299 in the middle region of the West Bank. It is estimated that there are 26,500 male HRDUs in Palestine comprising 1.8% of the male population aged 15 and above. Findings indicate that polydrug use is a serious issue in Palestine, especially in the West Bank, and that synthetic marijuana is prevalent among teenagers and young adults. Palestine must strengthen its national efforts to scale up harm reduction and treatment and care options for people suffering from drug use disorders, especially those involved in polydrug use. Additional measures are needed to prevent substance use among children and youth, support the families of people who use drugs, and ensure the continuity of HRDU services during emergencies.

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 1000 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 the neonatal units and 75% of the 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.

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

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

Background In 1996 and in 2006, Palestine initiated salt iodization and multiple micronutrient fortification of wheat flour, respectively as a strategy to prevent deficiencies of these nutrients. In 2009, we assessed the impact of these interventions on the health and nutritional status of schoolchildren residing in the West Bank.Methods We surveyed a sample of 22 schools run by the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the Palestinian Government. We randomly selected students from the first (mean age 6.7 years [SD 0.5]), sixth (11.8 years [0.6]), and ninth grades (14.8 years [0.6]). Data were obtained from 1484 (99%) of 1500 students planned for enrollment.Results Our results suggest that iodine intake appears adequate; there was essentially no iodine deficiency. As to the status of other micronutrients, the main nutritional micronutrient risks for schoolchildren in the West Bank continue to be low serum levels of iron, zinc and vitamin B-12; folate levels were seemingly high.Conclusions Wheat flour and salt fortification has had a major influence on improving the micronutrient status of Palestinian children, for some but not all micronutrients. The recommended key blood and biochemical parameters to be incorporated in the surveillance system are iron, zinc, and vitamin B12.

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.