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Abstract Colorectal cancer (CRC) is a frequent cause of cancer-related mortality in the Palestinian population. This cross-sectional study was conducted from July 2019 to March 2020 and examined attitudes toward CRC and colonoscopy, as well as the interplay between both. Participants were recruited using convenience sampling from public spaces, governmental hospitals, and primary healthcare centers across 11 governorates in Palestine. Displaying a positive attitude was defined as agreeing on at least the median number of questions related to CRC (5 of 11 questions) or colonoscopy (6 of 10 questions). A total of 4623 participants were included. Most participants agreed that ‘early detection of CRC increases the possibility of more effective treatment’ (n = 4161, 89.7%). Similarly, the majority of participants agreed on ‘preferring a physician with a gender similar to the participants to perform the colonoscopy’ (n = 3738, 80.9%) and ‘willingness to have colonoscopy even if the participant had to pay for it’ (n = 3727, 80.6%). Furthermore, 3115 participants (67.4%) demonstrated positive attitudes toward CRC, while 2540 participants (55.0%) displayed similar attitudes toward colonoscopy. Participants from the West Bank and Jerusalem were more likely than those from the Gaza Strip to display positive attitudes toward colonoscopy (59.2% vs. 48.9%). Participants with positive attitudes toward CRC were more likely to also display positive attitudes toward colonoscopy and vice versa. About two thirds of study participants exhibited positive attitudes toward CRC, and 55.0% displayed positive attitudes toward colonoscopy. There was a reciprocal relationship between having positive attitudes toward CRC and colonoscopy.

Abstract Background Women’s inability to recognize ovarian cancer (OC) causation myths to be incorrect may lead to behavioral changes that could distract them from actual risk factors and impact their treatment decision making. This study examined Palestinian women’s recognition of OC mythical causes, and explored factors associated with good recognition. Methods A national cross-sectional study was conducted. Adult Palestinian women were recruited from hospitals, primary healthcare facilities, and public areas in 11 governorates. The Cancer Awareness Measure-Mythical Causes Scale was modified and utilized for data collection. Awareness level was determined based on the number of myths around OC causation recognized to be incorrect: poor (0–4), fair (5–9), and good (10–13). Results A total of 5618 participants agreed and completed the questionnaire out of 6095 approached (response rate = 92.1%), and 5411 questionnaires were included in the final analysis. The most recognized food-related myth was ‘drinking from plastic bottles’ (n = 1370, 25.3%) followed by ‘eating burnt food’ (n = 1298, 24.0%). The least recognized food-related myth was ‘eating food containing additives’ (n = 611, 11.3%). The most recognized food-unrelated myth was ‘having a physical trauma’ (n = 2899, 53.6%), whereas the least recognized was ‘using mobile phones’ (n = 1347, 24.9%). Only 273 participants (5.1%) had good awareness of OC causation myths as incorrect. Earning higher monthly incomes as well as visiting governmental healthcare facilities were associated with a decrease in the likelihood of exhibiting good awareness. Conclusion The overall recognition of OC causation myths was low. Addressing mythical beliefs should be included in OC prevention strategies and public health interventions to improve women’s understanding of OC risk factors versus mythical causes.

Abstract Background Lung cancer (LC) has poor survival outcomes mainly due to diagnosis at late stages. This study explored the anticipated time to seek medical advice for possible LC symptoms and barriers to early presentation in Palestine. Methods This cross-sectional study recruited adult participants from hospitals, primary healthcare centers, and public spaces of 11 governorates using convenience sampling. A modified, translated-into-Arabic version of the validated LC awareness measure was used to assess LC symptom awareness, the time needed to seek medical advice and barriers to early presentation. Results A total of 4762 participants were included. The proportion that would immediately seek medical advice for possible LC symptoms varied according to the symptoms’ nature. For respiratory symptoms, this ranged from 15.0% for ‘painful cough’ to 37.0% for ‘coughing up blood’. For non-respiratory symptoms, this ranged from ‘4.2% for ‘unexplained loss of appetite’ to 13.8% for ‘changes in the shape of fingers or nails’. Participants with good LC symptom awareness were more likely to seek medical advice within a week of recognizing most LC symptoms. About 13.0% would delay their visit to see a doctor after recognizing an LC symptom. The most reported barriers were emotional with ‘disliking the visit to healthcare facilities’ (59.8%) as the leading barrier. Conclusion LC respiratory symptoms were more likely to prompt early seeking of medical advice. Good LC symptom awareness was associated with a higher likelihood of help-seeking within a week. Educational interventions are needed to promote LC awareness and address the perceived barriers to early presentation in low-resource settings, such as Palestine.

Abstract Background Cervical cancer (CC) myths and beliefs can negatively impact women's preventive behaviors, including vaccination against human papillomavirus and having regular screening tests. This study aimed to examine awareness of Palestinian women about myths related to CC causation and investigated factors associated with good awareness. Methods A national cross-sectional study was conducted to recruit adult Palestinian women from hospitals, primary healthcare facilities, and public areas in 11 Palestinian governorates. A translated-into-Arabic version of the Cancer Awareness Measure-Mythical Causes Scale was used to collect data. Awareness level was determined based on the number of CC myths around CC causation recognized to be incorrect: poor (0–4), fair (5–9), and good (10–13). Results A total of 7058 questionnaires were included. Myths unrelated to food were more commonly recognized as incorrect compared to those related to food. The most recognized food-unrelated myth was ‘having a physical trauma’ (n = 3714, 52.6%), whereas the least recognized was ‘using mobile phones’ (n = 2238, 31.7%). The most recognized food-related myth was ‘drinking from plastic bottles’ (n = 2708, 38.4%), whereas the least recognized was ‘eating food containing additives’ (n = 1118, 15.8%). Only 575 participants (8.1%) displayed good awareness and promptly recognized at least 10 out of 13 myths around CC causation as incorrect. Factors associated with lower likelihood of displaying good awareness of myths around CC causation included living in the West Bank and Jerusalem, being married, widowed or divorced, knowing someone with cancer, and visiting hospitals or primary healthcare centers. Conclusions A very small proportion of Palestinian women recognized 10 or more myths around CC causes as incorrect. Initiatives addressing CC myths are needed in the Palestinian community.

Abstract Background Several factors contribute to delayed presentation with ovarian cancer (OC) symptoms including poor symptom awareness and barriers to seeking help. This study explored the anticipated time to seek medical advice for possible OC symptoms and its association with OC symptom awareness. In addition, it examined perceived barriers that may delay help-seeking among Palestinian women. Methods A cross-sectional study was conducted among adult women (≥ 18 years) recruited from hospitals, primary healthcare centers, and public spaces in 11 Palestinian governorates. A modified version of the OC awareness measure was used to collect data in face-to-face interviews. The questionnaire comprised three sections: sociodemographic details, awareness of 11 OC symptoms and time to seek medical advice, and barriers to early presentation. Results Of 6095 participants approached, 5618 completed the OCAM (response rate = 92.1%). The proportion of participants who would immediately seek medical advice for a possible OC symptom varied based on the symptom’s nature. For OC symptoms with pain, the proportion that reported immediate seeking of medical advice ranged from 7.9% for ‘persistent low back pain’ to 13.6% for ‘persistent pain in the pelvis’. For non-specific potential OC symptoms, the proportion that reported immediate seeking of medical advice ranged from 2.3% for ‘feeling full persistently’ to 15.8% for ‘increased abdominal size on most days’. Good OC symptom awareness was associated with higher likelihood of seeking medical advice within a week from recognizing 10 out of 11 OC symptoms. Emotional barriers were the most common barriers with ‘feeling scared’ as the most reported barrier (n = 1512, 52.4%). Displaying good OC symptom awareness was associated with a lower likelihood of reporting ≥ 4 emotional barriers (OR = 0.61, 95% CI: 0.38–0.98). Conclusion Participants with good OC symptom awareness were more likely to seek medical advice earlier and to display fewer emotional barriers. Establishing educational interventions to raise OC awareness may help in promoting earlier help-seeking and, thus, facilitate earlier diagnosis and improved prognosis.

Abstract Background Caesarean section rates are rising globally. No specific caesarian section rate at either country-level or hospital-level was recommended. In Palestinian government hospitals, nearly one-fourth of all births were caesarean sections, ranging from 14.5 to 35.6%. Our aim was to assess whether variation in odds for intrapartum caesarean section in six Palestinian government hospitals can be explained by differences in indications. Methods Data on maternal and fetal health were collected prospectively for all women scheduled for vaginal delivery during the period from 1st March 2015 to 30th November 2016 in six government hospitals in Palestine. Comparisons of proportions in sociodemographic, antenatal obstetric characteristics and indications by the hospital were tested by χ2 test and differences in means by one-way ANOVA analysis. The odds for intrapartum caesarean section were estimated by logistic regression. The amount of explained variance was estimated by Nagelkerke R square. Results Out of 51,041 women, 4724 (9.3%) underwent intrapartum caesarean section. The prevalence of intrapartum caesarean section varied across hospitals; from 7.6 to 22.1% in nulliparous, and from 5.8 to 14.1% among parous women. The most common indications were fetal distress and failure to progress in nulliparous, and previous caesarean section with an additional obstetric indication among parous women. Adjusted ORs for intrapartum caesarean section among nulliparous women ranged from 0.42 (95% CI 0.31 to 0.57) to 2.41 (95% CI 1.70 to 3.40) compared to the reference hospital, and from 0.50 (95% CI 0.40–0.63) to 2.07 (95% CI 1.61 to 2.67) among parous women. Indications explained 58 and 66% of the variation in intrapartum caesarean section among nulliparous and parous women, respectively. Conclusion The differences in odds for intrapartum caesarean section among hospitals could not be fully explained by differences in indications. Further investigations on provider related factors as well as maternal and fetal outcomes in different hospitals are necessary.

Abstract Background The majority of lung cancer (LC) cases are diagnosed at an advanced stage. Poor awareness of LC symptoms is a contributor to late diagnosis. This study aimed to assess the awareness of LC symptoms among Palestinians, and to examine the factors associated with displaying good awareness. Methods Participants were recruited from hospitals, primary healthcare centers and public spaces using convenience sampling. A translated-into-Arabic version of the validated LC awareness measure was used to assess recognition of 14 LC symptoms. One point was given for each recognized symptom. The total score was calculated and categorized based on the number of symptoms recognized: poor (0–4), fair (5–9), and good (10–14). Multivariable logistic regression was used to examine the association between participant characteristics and having good awareness. The multivariable analysis adjusted for age-group, gender, education, monthly income, occupation, residence, marital status, any chronic disease, knowing someone with cancer, smoking history, and site of data collection. Results Of 5174 potential participants approached, 4817 completed the questionnaire (response rate = 93.1%) and 4762 were included in the final analysis. Of these, 2742 (56.9%) were from the West Bank and Jerusalem (WBJ) and 2020 (43.1%) were from the Gaza Strip. Participants from the WBJ were older, had higher monthly income but lower education, and suffered from more chronic diseases. The most recognized respiratory LC symptom was ‘worsening in an existing cough’(n = 3884, 81.6%) while the least recognized was ‘a cough that does not go away for two or three weeks’(n = 2951, 62.0%). The most recognized non-respiratory LC symptom was ‘persistent tiredness or lack of energy’(n = 3205, 67.3%) while the least recognized was ‘persistent shoulder pain’(n = 1170, 24.6%). A total of 2466 participants (51.8%) displayed good awareness of LC symptoms. Participants from both the Gaza Strip and the WBJ had similar likelihoods to have good awareness levels. Factors associated with a higher likelihood to display good awareness included female gender, having post-secondary education, being employed, knowing someone with cancer, and visiting hospitals and primary healthcare centers. Conclusion About half of the study participants displayed a good level of awareness of LC symptoms. Further improvement in public awareness of LC symptoms by educational interventions might reduce LC mortality by promoting early diagnosis.

Abstract Background Surgical site infection (SSI) is one of the most common hospital-acquired infections and is associated with serious impact on the rates of morbidity, mortality as well as healthcare costs. This study examined factors influencing the application of several intraoperative preventive measures of SSI by surgeons and surgical residents in the Gaza Strip. Methods A cross-sectional study was conducted from December 2016 to February 2017 at the operation rooms of the three major hospitals located in the Gaza-Strip, Palestine. Inclusion criteria for patients were being adult (aged ≥18 years), no history of wound infection at time of operation and surgical procedure under general anaesthesia with endotracheal intubation. The association between different patient- and procedure-related SSI risk factors and adherence to several intraoperative SSI preventive measures was tested. Results In total, 281 operations were observed. The mean patient age ± standard deviation (SD) was 38.4 ± 14.6 years and the mean duration of surgery ± SD was 58.2 ± 32.1 minutes. A hundred-thirty-two patients (47.0%) were male. Location and time of the operation were found to have significant associations with adherence to all SSI preventive measures except for antibiotic prophylaxis. Type of operation had a significant association with performing all measures except changing surgical instruments. Patient age did not have a statistically significant association with adherence to any measure. Conclusion The results suggest that the surgeon could be a major factor that can lead to a better outcome of surgical procedures by reducing postoperative complications of SSI. Operating department professionals would benefit from clinical guidance and continuous training, highlighting the importance of persistent implementation of SSI preventive measures in everyday practice to improve the quality of care provided to surgical patients.

Objective: To evaluate adherence of clinicians to the European guidelines for management of acute heart failure (AHF). Materials and Methods: This was a medical chart–based review study conducted from January to December 2016, including 200 medical records of patients admitted to two major hospitals in the Gaza Strip, Palestine. The AHF management was compared to the European Society of Cardiology (ESC) Guidelines, 2016. Results: The patients’ mean age was 66.0 ± 13.0 years. A total of 100 patients (50.0%) were women and 192 (96.0%) had comorbidities including hypertension, diabetes, and heart disease. The most notable finding was that of a very poor standard of documentation, especially for vital signs. Patient management showed mostly moderate to good adherence to guidelines with 189 (94.5%) patients undergoing electrocardiogram, 90 (45.0%) echocardiography, 97 (48.5%) chest X-ray, and 79 patients of 167 (47.3%) receiving vasodilators appropriately. Good adherence was found in checking glucose levels, 176 (88.0%), and application of oxygen (100% with SpO2 < 90%). Some aspects of care showed poor adherence, such as overuse of digoxin in 57 patients (28.5%), of which only 30 (53.4%) had atrial fibrillation and inappropriate use of beta-blockers in two patients who were hypotensive. Furthermore, brain natriuretic peptide was not used at all. Conclusion: The results of this study show suboptimal adherence to the ESC guidelines in management of AHF, reflecting the need to improve awareness of evidence-based medicine among clinicians.

Abstract Background In undergraduate medical education, patient safety concepts and understanding of medical errors are under-represented. This problem is more evident in low-income settings. The aim of this study was to explore undergraduate medical students’ attitudes towards patient safety in the low-income setting of the Gaza Strip. Methods A cross-sectional, descriptive study included medical students of the two medical schools in the Gaza Strip with 338 medical students completing the Attitudes to Patient Safety Questionnaire-IV (APSQ-IV), which examines patient attitudes in 29 items over 10 domains. Results are represented as means ± standard deviations for each item and domain as well as percentage of positive responses to specific items. Results Medical students reported slightly positive patient safety attitudes (4.7 ± 0.5 of 7) with the most positive attitudes in the domains of situational awareness, importance of patient safety in the curriculum, error inevitability and team functioning. While no negative attitudes were reported, neutral attitudes were found in the domains of professional incompetence as a cause of error and error reporting confidence. Study year and gender had no significant association with patient safety attitudes, except for disclosure responsibility, where male students displayed significantly more positive attitudes. The study university was significantly associated with three of the 10 examined domains, all of which involved understanding of medical errors, for which students of University 2 (who had undergone limited patient safety training) held significantly more positive attitudes, compared with students of University 1 (who did not have structured patient safety training). Conclusion Medical students’ patient safety attitudes were very similar among students from both universities, except for understanding of medical error, for which students, who had received structured training in this topic, displayed significantly more positive attitudes. This underlines the power of the ‘hidden curriculum’, where students adjust to prevalent cultures in local hospitals, while they do their clinical training. Furthermore, it highlights the need for a systematic inclusion of patient safety content in local undergraduate curricula.

Abstract Background Reliable contraception enables women and men to plan their family sizes and avoid unintended pregnancies, which can cause distress and anxiety, but also increase maternal mortality. This study explored potential barriers to contraceptive use for women in the Gaza Strip, Palestine from user and provider perspectives. Methods A convenient sample was used to recruit women, who were current contraception users, from three healthcare clinics that provide family planning care, two governmental and one non-governmental. A 16-item questionnaire was completed by 204 women, including socio-demographic data, contraceptive use and eight questions exploring user experience. Additionally, 51 women attended focus groups for a deeper insight into their contraceptive use experience and potential barriers. Furthermore, 14 healthcare providers were interviewed about their experience with service provision. Quantitative data are presented as means and frequencies and qualitative data were analysed item by item and are presented in themes jointly with the quantitative data. Results Women reported usage of only three main modern methods of contraception with 35.2% using intrauterine devices, 25.8% combined oral contraception and 16.4% condoms, while only 3.1% used the hormonal implant. Expectations from family planning services were low with most women attending the clinic having already decided their contraceptive method with decisions being made by husbands (41.2%) or women jointly with their partner (33.3%), only 13.7% took advice from service providers. Healthcare providers experienced high prevalence of beliefs that modern contraceptives cause infertility and cancer. Main barriers to effective family planning services were misconceptions of potential harm, poor availability and limited choice of contraceptive methods. Conclusion Women’s contraceptive choices in Gaza are limited by prevalent misconceptions and fears as well as recurring shortages, negatively impacting fertility control. Men are a major factor in choosing a contraceptive method, however, they have limited access to information and therefore, potentially more misconceptions. Therefore, male community members need to be included in the delivery of information on contraceptives to increase women’s choice. Furthermore, greater access to long-acting reversible contraceptives, such as the hormonal implant, and improved availability might be key factors in improving contraceptive uptake in Gaza and, thus, reducing unintended pregnancies.

Abstract Background Providing safe care helps to reduce mortality, morbidity, length of hospital stay and cost. Patient safety is highly linked to attitudes of health care providers, where those with more positive attitudes achieve higher degrees of patient safety. This study aimed to assess attitudes of nurses working in governmental hospitals in the Gaza-Strip toward patient safety and to examine factors impacting their attitudes. Methods This is a cross-sectional, descriptive study with a convenient sample of 424 nurses, working in four governmental hospitals. The Attitudes to Patient Safety Questionnaire III, a validated tool consisting of 29 items that assesses patient safety attitudes across nine main domains, was used. Results Nurses working in governmental hospitals showed overall only slightly positive attitudes toward patient safety with a total score of 3.68 on a 5-point Likert scale, although only 41.9% reported receiving patient safety training previously. The most positive attitudes to patient safety were found in the domains of ‘working hours as a cause of error’ and ‘team functioning’ with scores of 3.94 and 3.93 respectively, whereas the most negative attitudes were found in ‘importance of patient safety in the curriculum’ with a score of 2.92. Most of the study variables, such as age and years of experience, did not impact on nurses’ attitudes. On the other hand, some variables, such as the specialty and the hospital, were found to significantly influence reported patient safety attitudes with nurses working in surgical specialties, showing more positive attitudes. Conclusion Despite the insufficient patient safety training received by the participants in this study, they showed slightly positive attitudes toward patient safety with some variations among different hospitals and departments. A special challenge will be for nursing educators to integrate patient safety in the curriculum, as a large proportion of the participants did not find inclusion of patient safety in the curriculum useful. Therefore, this part of the curriculum in nurses’ training should be targeted and developed to be related to clinical practice. Moreover, hospital management has to develop non-punitive reporting systems for adverse events and use them as an opportunity to learn from them.