Challenges to conducting epidemiology research in chronic conflict areas : examples from PURE- Palestine

Challenges encountered in working within a fragmented health care system include: difficulties in planning for data collection; standardizing data collection when resources are limited; working in communities with access restricted by the military; and other considerations related to the study setting in the occupied Palestinian territory. Data collected from conflict regions may contrast with those solely from politically and economically stable regions. Special efforts to collect epidemiologic data from regions engulfed by strife are essential. This paper describes issues encountered in designing and conducting the Prospective Urban Rural Epidemiology (PURE) study in the occupied Palestinian territory (oPt).Population Health Research Institut

Evaluation of Glycated Hemoglobin (HbA1c) for Diagnosing Type 2 Diabetes and Prediabetes among Palestinian Arab Population

The purpose of the study is to compare the potential of HbA1c to diagnose diabetes among Palestinian Arabs compared to fasting plasma glucose (FPG). A cross-sectional sample of 1370 Palestinian men (468) and women (902) without known diabetes and above the age of 30 years were recruited. Whole blood was used to estimate HbA1c and plasma for FPG and total lipid profile. Fasting plasma glucose was used as a reference to diagnose diabetes ($126 mg/dL) and prediabetes (100–125 mg/dL). The area under the receiver operating characteristic curve (AUC) for HbA1c was 81.9diabetes and 63.90.498) and low with prediabetes (K = 0.142). The optimal cut-off value for HbA1c to diagnose diabetes was$ 6.3% (45 mmol/mol). The sensitivity, specificity and the discriminant ability were 65.6% (53.1–76.3%), 94.5% (93.1–95.6%), 80.0% (72.8–87.3%), respectively. However, using cut-off value of $6.5the sensitivity, specificity and the discriminant ability were 57.4For diagnosing prediabetes with HbA1c between 5.7–6.4discriminant ability were 62.7value of$ 6.5% (48 mmol/mol) by itself diagnosed 5.3% and 48.3% as having diabetes and prediabetes compared to 4.5% and 24.2% using FPG, respectively. Mean HbA1c and FPG increase significantly with increasing body mass index. In conclusion, the ROC curves showed HbA1c could be used for diagnosing diabetes when compared to FPG but not for prediabetes in Palestinians Arabs even though only about 50% of the diabetic subjects were identified by the both HbA1c and FPG.This project was partially supported by United Nation Relief and Working Agency (UNRWA. No additional external funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors thank Fida Zeidan from UNRWA for organizing the teams at different UNRWA clinics. Also, the authors thank the staff of UNRWA clinics for their cooperation in the study. Thanks to Dr. Khaldoun Bader from Al-Quds University for his assistance in statistical analysis.Guarantor: Akram T. Kharroubi

Substance use among Palestinian youth in the West Bank, Palestine: a qualitative investigation

Abstract Background Youth health risk behaviors, including substance use (psychoactive substances including alcohol and illicit drugs), have been the subject of relatively limited study to date in Middle Eastern countries. This study provides insights into the perceived prevalence and patterns of alcohol and drug use among Palestinian youth. Methods The study was based on ten focus groups and 17 individual interviews with youth aged 16–24 years (n = 83), collected as part of the formative phase of a cross-sectional, population representative study of risk taking behaviors among Palestinian youth in the West Bank in 2012. Qualitative analysis was used to code detailed notes of focus groups and interviews. Results Most participants reported that substance use exists, even in socially conservative communities. Almost all participants agreed that alcohol consumption is common and that alcohol is easily available. The top alcoholic drinks referred to by the study participants were vodka, whisky, beer, and wine. Most participants claimed that they drink alcohol to cope with stress, for fun, out of curiosity, to challenge society, and due to the influence of the media. Participants were familiar with illicit drugs and knew of youth who engaged in drug use: marijuana, cocaine, and heroin were mentioned most frequently. Study participants believed that youth use drugs as a result of stress, the Israeli occupation, inadequate parental control, lack of awareness, unhappiness, curiosity, and for entertainment. Many participants were unaware of any local institutions to support youth with substance use problems. Others expressed their distrust of any such institution as they assumed them to be inefficient, profit-driven, and posing the risk of potential breaches of confidentiality. Conclusions Although this study uses a purposive sample, the results suggest that substance use exists among Palestinian youth. Risk behaviors are a concern given inadequate youth-friendly counseling services and the strong cultural constraints on open discussion or education about the impact of high risk behaviors. These barriers to treatment and counseling can exacerbate the health and social consequences of alcohol abuse and illicit drug use

Perceived peer norms, health risk behaviors, and clustering of risk behaviors among Palestinian youth.

Relatively little is known about patterns of health risk behaviors among Middle Eastern youth, including how these behaviors are related to perceived peer norms. In a sample of approximately 2,500 15-24 year old Palestinian youth, perceived engagement of general peers in alcohol consumption, drug use and sexual activity was substantially greater than youths' own (self-reported) engagement in these activities, suggesting a tendency to overestimate the prevalence of risk-taking behavior among peers. Individual participation in a risk behavior strongly covaries with the perceived levels of both friends' and peers' engagement in that behavior (p = 0.00 in each case). In addition, significant clustering of risk behaviors is found: youth who participate in one risk behavior are more likely to participate in others. These findings for a rare representative sample of Middle Eastern youth are strikingly similar to those in the US and Europe. The clustering of behaviors suggests that prevention programs should be structured to deal with a range of connected risk behaviors for which certain youth may be at risk. The findings also suggest that adjusting expectations about peers' behavior may reduce young Palestinians' engagement in risk taking

Metabolic Syndrome among Refugee Women from the West Bank, Palestine : A Cross-Sectional Study

This study was carried out among Palestinian refugee women in the West Bank to provide data on the prevalence of metabolic syndrome (MetS) and its correlates. Data were obtained from a cross-sectional study of 1694 randomly selected refugee women from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) health centers throughout the West Bank during June and July 2010. In this cohort, 30% of the refugee women were overweight, 39% were obese, and 7% were extremely obese. Based on World Health Organization (WHO) criteria, the age-adjusted prevalence of MetS was 19.8%. The results of the binary logistic regression analysis indicated that older age and younger marital age were significantly associated with an increased likelihood of MetS in the women. The high prevalence of obesity and MetS mandates the implementation of national policies for its prevention, notably by initiating large-scale community intervention programs for 5.2 million refugees in Palestine, Jordan, Lebanon, and Syria, to tackle obesity and increase the age at marriage

HbA_1c receiver operating characteristic (ROC) curves for diabetes (A) and prediabetes (B) using FPG as a reference.

<p>AUC: area under the receiver operating characteristic curve.</p

The difference between mean values of measured parameters between subjects with diabetes vs. normal subjects according to FPG and HbA_1c criteria.

<p>Diagnosed by FPG (cut-off value ≥126 mg/dL): N for diabetes  =  61, N for normal  =  1309</p><p>Diagnosed by HbA_1c (cut-off value ≥6.5%), N for diabetes  =  73, N for normal  =  1297</p><p>t test was used to compare means of diabetes vs. control.</p

Micronutrient status of Palestinian school children following salt and flour fortification : a cross-sectional study

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

Venn Diagrams for Diabetes, ADA standards.

<p>Diabetes diagnosed by HbA_1c ≥ 6.5% (48 mmol/mol, n = 73) or FPG ≥ 126 mg/dL (n = 61). Prediabetes diagnosed by HbA_1c 5.7–6.4% (39–46 mmol/mol, n = 628) or FPG 100–125 mg/dL (n = 337). Normal diagnosed by HbA_1c < 5.7% (39 mmol/mol, n = 669) or FPG <100 mg/dL (n = 972).</p