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Objectives The objective of this study is to map cardiovascular disease (CVD) research productivity in Arab countries and identify gaps and opportunities that would inform future research agenda. Study design This is a scoping review. Methods A review of research output between January 2000 and December 2018 in seven Arab countries, selected to represent various economies and epidemiological transitions, was conducted. Data on quantity and quality, study design, setting and focus were extracted and analysed for trends by time and place. Results Over the study period, a total of 794 articles were published, with an average of 7.3 publications per million population. While time trends showed a 6-fold increase in the number of publications over the study period, a decreasing trend in mean journal impact factor was noted (from 2.3 in 2000 to 1.5 in 2018). Most studies (71%) were observational, 56% were conducted in medical facilities (hospitals or clinics) and most of the experimental studies (10%) were based in laboratory settings. Behavioural risk factors were addressed in 52% of the studies, and there was a dearth of studies examining associations with diet, physical inactivity or family history. Conclusions Findings from this review indicate gaps in robust methods and pertinent themes in CVD research in the Arab region. Greater attention should be paid to high-quality evidence and implementation research. Also, there is a need for a more targeted CVD research agenda that is responsive to local and regional health burden and needs.

Background In the occupied Palestinian territory (oPt), access to maternal and child healthcare (MCH) services are constrained due to the prolonged Israeli military occupation, the Separation Wall, army checkpoints, and restrictions on the movement of people and goods. This study assesses the relationship between conflict intensity and access to Maternal and Child Health care in occupied Palestinian territory (oPt). To the best of our knowledge, the impact of conflict on access to health care has not been measured due to the lack of data. Methods We analyse pooled data from household surveys covering a fifteen-year period (2000–2014) of children (n = 16,793) and women (n = 8477) in five regions of the oPt. Conflict intensity was used as a continuous variable defined as the square root of non-combatant conflict mortality taken from monthly death rates of non-combatants by region. We use multilevel logistic models to explain four outputs: child vaccination schedules, antenatal care, caesarean sections, and complications during pregnancy. Results Locality is important with results showing the negative impact of conflict intensity on access to care, especially in the South West Bank for maternal health services and Central West Bank for vaccination (B − 0.161 p = 0.000 for DPT). Wealth is only significant for DPT vaccinations with poorest (B − 0.098 p = 0.005) and poor (B − 0.148 p = 0.002) individuals less likely to access services. Otherwise conflict does not show a differential effect across socio-economic conditions. Conclusions This study shows how locality is the strongest factor when looking at the impact of conflict in the oPt. Preventative services (ANC and vaccinations) are the most affected by conflict. We recommend a greater use of community health care to improve access to maternal and child care when barriers impede access to health facilities during times of conflict.

Background In order to set research priorities for reproductive health in the occupied Palestinian territory, it is vital to know what current research has been done in the field of reproductive health. The purpose of this scoping review is to examine the range and nature of reproductive health research in the occupied Palestinian territory and to identify research gaps in the existing literature. Methods We searched four databases: EMBASE, PubMed, CINAHL, and Popline. We included studies that: (i) are published (with an abstract); (ii) relevant to reproductive health; (iii) Palestinians living in Palestine; (iv) participants over the age of 15 years; and (v) restricted to human research. Three independent reviewers screened title and abstracts, and extracted data from included articles. We conducted quantitative and qualitative analyses. Results Of 1025 titles and abstracts screened, 145 articles were included. 52 (36%) articles were conducted in community setting and 34 (24%) were conducted in hospitals. There were 5 (3%) experimental studies. 15 articles had more than one main theme; 160 subthemes overall were identified. The most frequently studied theme was labor and delivery (n = 19; 12%). One article discussed adolescent reproductive health and menopause while no articles discussed men’s reproductive health. Conclusions 91% of the research conducted is observational. The focus of reproductive health research was to understand the topic, community and providers’ perceptions and knowledge. Articles related to the quality of services were limited. It is also important to research the reproductive health of women outside of reproductive age, men, and adolescents. Electronic supplementary material The online version of this article (10.1186/s12978-019-0699-4) contains supplementary material, which is available to authorized users.

Type 2 diabetes mellitus (T2DM) is a growing pandemic that will lead, if not managed and controlled, to frequent complications, poor quality of life, and high rates of disability and death. Little is known about T2DM complications in Palestine. The aim of this study is to estimate the prevalence of T2DM complications in Ramallah and al-Bireh governorate of Palestine.The study was conducted in eleven primary healthcare clinics offering services for persons with T2DM. Macrovascular complications were assessed using the Diabetes complication index. Microvascular complications were measured by physical examinations and laboratory tests. Questionnaires, laboratory tests, and physical examinations were used to assess socio-demographic characteristics, co-morbidities and other risk factors.517 adult men and nonpregnant women participated in the study (166 men, 351 women). The response rate was 84%. Mean age and mean duration of diabetes were 58.1 and 9.4 years respectively. Prevalence of diagnosed microvascular and macrovascular complications was 67.2% and 28.6% respectively. 78.2% of the participants had poor glycemic control (HbA1c≥7.0%).Significant proportions of persons with T2DM had macro- and microvascular complications and poor metabolic control. These findings are important for policy development and the planning of health services.

We examine the relationship between national health expenditure and its drivers to help inform resource allocation policy decisions in Palestine. We forecast health expenditures from the financing agency perspective, and examine Granger-Causality relationships to assess implied causality between health spending and exogenous variables, using estimates of vector autoregressions. We forecast national health expenditure to be US$1.45 billion in 2015 and grow at 7% annually through 2020. This is due to expected increases in government health expenditure, and household spending, at 5% and 7%, respectively, compared to 2014. The proportion of household spending on health services is expected to increase, while the government proportion is expected to decrease over the long run due to budget constraints. Population growth, ageing and changes in chronic disease patterns contribute significantly as drivers of the increase in healthcare costs. Our results suggest a need to review and modify the current health insurance scheme.

Purpose Type 2 diabetes mellitus (T2DM) is a considerable impact on physical health as well as on emotional and social wellbeing. This study aimed to investigate the quality of life and its associated factors among Palestinians with T2DM. Methods A cross-sectional study including 517 patients (68% female) was conducted in eleven primary health care clinics located in Ramallah and al-Bireh governorate of the West Bank. To assess socio-demographic data, risk factors and diabetes control, interviews, physical examinations, anthropometric measurements, and blood and urine tests were performed. The validated Arabic version of the Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaire was carried out on all patients to measure Quality of Life (QoL). A multivariable regression analysis was performed. Results The average weighted impact (AWI) score was −3.38 (95% CI: −3.55 to −3.21, range: −9.00 to 0.12). This indicates that diabetes was perceived as having a considerable negative impact on the quality of life. The life domains ‘freedom to eat’, ‘physical activities’, and ‘work-life’ were the most negatively impacted. Males and individuals living with diabetes for a prolonged time were associated with a more significant negative impact on quality of life. Conclusion The study showed that diabetes generally had a negative impact on QoL and identified the demand for diabetes management programs tailored to patient needs and different patient groups, as well as health policies that put patients in the center of diabetes care.

Background: The Covid-19 pandemic created major global health crises, with serious effects on all aspects of life. The pandemic reached the Israeli occupied West Bank of Palestine in early March 2020, and lockdown immediately ensued. Objectives: To assess the prevalence and predictors of distress and insecurity among Birzeit University’s community during the COVID-19 pandemic and lockdown. Methods: An online survey completed in March-April 2020 using standardized and previously validated distress and insecurity scales. The survey was placed on the University portal accessed by students, faculty and employees, and was sent by email to faculty and employees. Data were weighted to reflect the University community’s distribution. Findings: There were 1,851 participants in the study: 84% were undergraduate students, 10% graduate students, and 6% faculty and employees. Sixty two percent were women. Ages ranged from 17 to 70 years (mean 24 ± 9.7). Prevalence of moderate/high distress and insecurity were 40% and 48% respectively. Multiple logistic regression revealed that women, those under 35 years old and those with worse reported income, had significantly higher odds of distress and insecurity compared to their counterparts. Undergraduate students or living with a person at home with high risk of illness with COVID-19 were associated with higher odds of distress compared to their counterparts (OR = 1.56, 95%CI[1.13–2.15]) and (OR = 1.34, 95%CI[1.11–1.62]) respectively. A COVID-19 worry score was significantly associated with higher odds of distress and insecurity (OR = 1.77, 95%CI[1.46–2.14]) and (OR = 4.3, 95%CI[3.53–5.23]) respectively. Conclusion: This study emphasizes the need to pay attention not only to physical health but also to mental health during the COVID-19 pandemic, especially among young people, women, those with lower economic status, and those living with high risk persons during the pandemic. We hope that this study will inform the policies and interventions of the Palestinian Authority, local non-governmental organization, international groups working in the occupied Palestinian territory, and beyond.

Background Overweight and obesity are multifactorial conditions that are spreading fast in both developing and developed countries. They are emerging as a major public health threat among children and adolescents, and present a serious morbidity and mortality burden. Adolescence is a critical period in which lifestyle and dietary behaviours are shaped that persist into adulthood. Therefore, adolescents are an ideal study target in terms of estimating the magnitude of the problem, understanding its risk factors and investigating potential effective intervention programmes. This study assesses the prevalence of overweight, obesity, and associated factors among adolescents in Palestinian schools. Methods Weighted analysis was conducted on data from the Palestinian Micronutrient Survey, a national cross-sectional study carried out in 2013 by the Palestinian Ministry of Health in collaboration with UNICEF. For sample selection, stratified cluster random sampling was used. This school-based survey involved 2400 male and female adolescents aged 15–18 years in government schools in the West Bank and Gaza Strip. Data were analysed at univariate, bivariate, and multivariate levels, by the use of proportions, confidence intervals, and logistic regression. In the original survey, written informed consent was obtained from parents and guardians of the participants. A letter of approval to use the study data was obtained from the Ministry of Health (who own the data). The study was also approved by the Ethics Committee of the Institute of Community and Public Health. Findings The analysis indicates a prevalence of 23·6% (95% CI 20·6–26·5) for overweight and obesity, with a prevalence of 26·1% in the West Bank and 19·5% in the Gaza Strip. The multivariate analysis revealed that the likelihood of overweight and obesity was significantly higher for adolescents from the West Bank than from the Gaza Strip, for those eating two main meals or less than for those eating three meals, for those who reported a high frequency of vegetable intake, and those who observed a diet for weight loss. Interpretation The data suggest that one in every four adolescents is overweight or obese, which is an alarming statistic and calls for attention. The high prevalence can be attributed to different lifestyles, eating behaviours, and dietary intake, which affect energy balance. These factors should be investigated within social, political, and economic contexts, and addressed comprehensively, first at the level of individuals and family, and then at the level of schools and the community. It should be noted that the original study included students in the 10th grade and 11th grade only, whereas adolescence covers a wider age group (10–19 years). Funding None.

For parents, how to manage child discipline is a difficult question in the task of raising a socially, emotionally, and physically mature adult. Negative discipline can be physical or psychological, and can negatively affect child development, mental health, and wellbeing. This study aimed to assess the prevalence of negative disciplinary methods (NDMs) and their associated factors in the West Bank, occupied Palestinian territory, as reported by mothers.The survey was conducted in November and December, 2014, to explore the disciplinary methods that mothers used for one of their children (aged 0-12 years) during the previous 12 months. 1195 Palestinian mothers were studied based on a stratified multistage cluster sampling method and using the International Society for Prevention of Child Abuse and Neglect (ISPCAN) Child Abuse and Screening Tool for Parents (ICAST-P). A scale was built from mothers' reports on the use of NDMs, with good internal consistency (Cronbach's α=0·75). The dataset was split according to whether the mother used 0-6 NDMs or 7-20 NDMs in the previous 12 months. Bivariate analyses were performed using the chi squared test to compare these two categories in terms of demographic and socioeconomic variables, and exposure to Israeli political violence. Binary logistic regression was performed to check for confounders. The Institute of Community and Public Health and Birzeit University approved the use of the data.The mothers were aged between 15 and 55 years. 11·3% of mothers (135 of 1195) were 15-25 years old, 45·4% (541) were 26-35 years old, and 43·2% (515) were 36-55 years old. 52·5% of children (627 of 1195) were male, 34·0% (406) were 0-3 years old, and 66·0% (789) were 4-12 years old. 5·2% of children (62) were the only child, 4·4% of children (53) were the first child, 27·6% (330) were the middle child (a child that is not the first or the last child), and 62·8% (750) were the last child. 45·8% of the mothers and children (547) lived in the north of the West Bank, 23·3% (278) lived in the middle of the West Bank, and 31·0% (370) lived in the south of the West Bank. 5·3% of mothers (63) reported that their homes were bombed or shelled by the Israeli army. 83·8% of mothers (1002) reported using 0-6 NDMs and 16·2% (193) used 7-20 methods. Other demographic and socioeconomic variables collected were not significantly associated with NDMs. Binary logistic regression revealed that females were less likely to be exposed to NDMs than males (OR 0·63, 95% CI 0·45-0·88, p=0·0074), and that children aged 0-3 years were less likely to be exposed to NDMs than children aged 4-12 years (0·50, 0·33-0·76, p=0·0014). Compared with last children, first children (2·84, 1·46-5·51, p=0·0020) and middle children (1·49, 1·02-2·17, p=0·0375) were more likely to be exposed to NDMs. Compared with mothers aged 36-55 years, mothers aged 15-25 years (2·67, 1·47-4·85, p=0·0010) and 26-35 years (1·54, 1·05-2·26, p=0·0289) used more NDMs. Compared with children in the north of the West Bank, children in the south of the West Bank (2·46, 1·66-3·64, p0·0001) and middle of the West Bank (1·90, 1·24-2·93, p=0·0034) were more likely to be exposed to NDMs. Compared with mothers whose houses were not bombed or shelled by the Israeli army, mothers whose houses were bombed or shelled were more likely to use a higher number of NDMs (2·71, 1·84-1·95, p=0·0012).Negative child discipline is prevalent in Palestine and is associated with factors such as the child's gender, their age, their index in the family (whether they are the only child, first, middle, or last child), the mother's age, the district, and the political conditions in Palestine. Effort should be made to help families to understand alternative methods to address child discipline, through education, discussion, and parenting programmes.This study is part of a larger study of child discipline in Qatar and the occupied Palestinian territory. The study was conceptualised and planned with the funding of Qatar National Research.

Aims To estimate current and future direct cost of diabetes and its complications for the period 2010 and 2030. Methods This study is a prevalence-based approach that combines model-based forecasts of diabetes prevalence rates from the validated OPT IMPACT Diabetes forecast model, diabetes complications prevalence rates and health care costs and economic data. We use a societal and health care perspective and a time horizon to 2030, and costs were estimated as international US dollar adjusted for Purchasing Power Parity (PPP). Results The estimated direct costs for diabetes per person in 2012 was 1087 PPP dollars (281-1895 PPP dollar) and the direct costs of diabetes and its complications was 2156 PPP dollar (981-4508 PPP dollar). The estimated diabetes direct cost for the year 2012 was 184 million PPP dollar (47–320 million PPP dollar). The cost is expected to increase to 209 million PPP dollar (54–364 million PPP dollar) in 2015, 248 million PPP dollar (64–432 million PPP dollar) in 2020 and 300 million PPP dollar (77–523 million PPP dollar) in 3030 with 3% discounting rate assumption. The estimated direct cost of diabetes complications is 365 million PPP dollar in 2012, 491 million PPP dollar in 2020 and 595 million PPP dollar in 2030. Conclusions The burden of diabetes and its complications on the Palestinian health system is huge and actions are needed to address the increasing prevalence of obesity on one hand and providing proper diabetes management on the other hand.

This report was made possible by UREP grant # UREP19-013-3-001 from the Qatar National Research Fund (a member of Qatar Foundation). The statements made herein are solely the responsibility of the author(s). The authors declare no conflict of interest.

To compare the nature and determinants of child discipline in Qatar and Palestine among young adults through retrospective survey to develop legislation, policies and interventions for effective prevention of child maltreatment, and educational materials to promote positive discipline among parents and caregivers. Cross-sectional random household surveys were conducted in each country (Qataris N=697, Palestinians N=2064) using ISPCAN Child Abuse Screening Tool-Retrospective (ICAST-R) for young adults (18-24 years), to investigate child discipline methods into the maltreatment range. Qatari young adults were more educated (p0.001) and had more full-time employment (p=0.004) than Palestinian young adults. Qatar reported lower physical and emotional abuse compared to their counterparts in Palestine, e.g. Hit/Punch, Kick (p0.001) and Insult/Criticize, Threaten to be hurt/killed (p0.001). Qatari participants found any harsh discipline they received in childhood was not reasonable and not justified compared to Palestinian participants. The more advantaged Qatari population was less likely to experience disciplinary methods that experts developing the ICAST-R defined as abuse compared to Palestinians where the higher incidence of child abuse could be attributed to lower economic advantage, lower level of education and greater exposure to violence. Suggestions are made for future studies in Qatar and Palestine to develop survey methodology with a more culturally appropriate level of intrusion, such as indirect yet meaningful child maltreatment questions.

The burden of type 2 diabetes is increasing rapidly in the occupied Palestinian territory. Different counselling interventions have been applied worldwide to reduce HbAThe scientific literature was reviewed to identify relevant interventions that can reduce HbAWe identified three main effective counselling interventions at the primary health-care level: (1) individual counselling intervention by multidisciplinary teams of health-care professionals, which provided individual counselling sessions depending on the patients' glycaemic control status; (2) the community health-worker intervention, which provided a set of home counselling visits for patients with uncontrolled type 2 diabetes; and (3) short message service (SMS)-based intervention (sending patients a number of counselling SMS weekly). All interventions were effective in reducing mean HbAWe compared the effectiveness of a set of interventions that are considered relativity low cost and applicable at the level of primary health care (the "Best Buys"). Implementing at least one of these effective interventions within the Palestinian health-care system could help improve glycaemic control and eventually reduce the prevalence of complications associated with type 2 diabetes. Controlling HbAEastern Mediterranean Regional office of WHO.

Background Occupied Palestinian territory (oPt) is an authority with limited resources. Therefore, research conducted in such a setting should be prioritized and coordinated to follow a national research agenda. This study aims to produce a research agenda for reproductive health in the oPt that can be utilized by reproductive health stakeholders and contribute to the development of policy-based evidence to guide health practice. Methods In the current study, we followed research prioritization methods developed by the World Health Organization-Child Health and Nutrition Research Initiative. Research questions were obtained from reproductive health experts in the oPt. The questions were then grouped into thematic areas which were prioritized by the reproductive health experts. Scores were calculated and sorted to define the top priority research areas. Results A total of 232 research questions were prioritized by 30 reproductive health experts. Health system issues were the most addressed in the top 50 research questions. They included questions on the quality of services and health professionals’ knowledge and continuous professional training. Adolescents’ sexual and reproductive health and gender-based violence were rarely mentioned in the top 50 questions. The number of questions related to safe motherhood was around 50% followed by questions related to health system. Questions related to elderly women and menopause as well as reproductive system cancers were also within the top 50 ranked questions. Conclusions Priority research areas in reproductive health were identified for the oPt, which should be utilized by researchers with a focus on the high priority areas. Policy makers and funders should coordinate their efforts to ensure the production of research with value to the Palestinian context, in the most efficient way possible.

The links between two commonly used measures of health – self-rated health (SRH) and self-reported illness (SRI) – and socio-economic and contextual factors are poorly understood in Low and Middle Income Countries (LMICs) and more specifically among women in conflict areas. This study assesses the socioeconomic determinants of three self-reported measures of health among women in the occupied Palestinian territories; self-reported self-rated health (SRH) and two self-reported illness indicators (acute and chronic diseases). Data were obtained from the 2010 Palestinian Family Health Survey (PFHS), providing a sample of 14,819 women aged 15-54. Data were used to construct three binary dependent variable – SRH (poor or otherwise), and reporting two SRI indicators – general illness and chronic illness (yes or otherwise). Multilevel logistic regression models for each dependent variable were estimated, with individual level socioeconomic and sociodemographic predictors and random intercepts at the governorate and community level included, to explore the determinants of inequalities in health. Consistent socioeconomic inequalities in women’s reports of both SRH and SRI are found. Better educated, wealthier women are significantly less likely to report an SRI and poor SRH. However, intra-oPt regional disparities are not consistent across SRH and SRI. Women from the Gaza Strip are less likely to report poor SRH compared to women from all other regions in the West Bank. Geographic and residential factors, together with socioeconomic status, are key to understanding differences between women’s reports of SRI and SRH in the oPt. More evidence is needed on the health of women in the oPt beyond the ages currently included in surveys. The results for SRH show discrepancies which can often occur in conflict affected settings where a combination of ill-health and poor access to health services impact on women’s health. These results indicate that future policies should be developed in a holistic manner by targeting physical and mental health and well-being in programmes addressing the health needs of women, especially those in conflict affected zones.

Hepatitis E virus (HEV) is an RNA virus transmitted mainly through zoonotic transmission or fecal-oral route. More than 80% of Qatar's population are expatriates, including many coming from hyperendemic countries; thus, it is important to estimate the seroprevalence and to compare between different nationalities. The results can be useful in alerting blood banks to the importance of HEV screening.Samples from 5854 blood donations provided by Hamad Medical Corporation were tested in the period between June 2013 to June 2016. Samples were tested for the presence of anti-HEV immunoglobulin (Ig)G and IgM antibodies and viral RNA using real-time polymerase chain reaction (PCR). Descriptive statistics, bivariate analysis, and multivariate logistic regression were used.Anti-HEV seroprevalence was 20.7%. A total of 1198 and 38 donations tested positive for IgG and IgM antibodies, respectively. Of the IgM-positive donations four tested positive by PCR. A significant association was detected between HEV seroprevalence with age and nationality.The seroprevalence of anti-HEV was high in Qatar. Since HEV IgM and RNA were detected, this suggests the possibility of HEV transmission by transfusion. Blood banks in Qatar and the region should consider screening for HEV, especially when transfusion is intended to pregnant women or immunocompromised patients.

Background: This paper examines one EC-funded multinational project (RESCAP-MED), with a focus on research capacity building (RCB) concerning non-communicable diseases (NCDs) in the Mediterranean Middle East and North Africa. By the project’s end (2015), the entire region was engulfed in crisis.\ud \ud Objective: Designed before this crisis developed in 2011, the primary purpose of RESCAP-MED was to foster methodological skills needed to conduct multi-disciplinary research on NCDs and their social determinants. RESCAP-MED also sought to consolidate regional networks for future collaboration, and to boost existing regional policy engagement in the region on the NCD challenge. This analysis examines the scope and sustainability of RCB conducted in a context of intensifying political turmoil.\ud \ud Methods: RESCAP-MED linked two sets of activities. The first was a framework for training early- and mid-career researchers through discipline-based and writing workshops, plus short fellowships for sustained mentoring. The second integrated public-facing activities designed to raise the profile of the NCD burden in the region, and its implications for policymakers at national level. Key to this were two conferences to showcase regional research on NCDs, and the development of an e-learning resource (NETPH).\ud \ud Results: Seven discipline-based workshops (with 113 participants) and 6 workshops to develop writing skills (84 participants) were held, with 18 fellowship visits. The 2 symposia in Istanbul and Beirut attracted 280 participants. Yet the developing political crisis tagged each activity with a series of logistical challenges, none of which was initially envisaged. The immediacy of the crisis inevitably deflected from policy attention to the challenges of NCDs.\ud \ud Conclusions: This programme to strengthen research capacity for one priority area of global public health took place as a narrow window of political opportunity was closing. The key lessons concern issues of sustainability and the paramount importance of responsively shaping a context-driven RCB.

Background The burden of type 2 diabetes is increasing rapidly in the occupied Palestinian territory. Different counselling interventions have been applied worldwide to reduce HbA 1c concentrations in patients with type 2 diabetes. Achieving good glycaemic control is important for prevention of complications of type 2 diabetes. The aim of this modelling study was to assess the effectiveness of different counselling interventions in improving glycaemic control in patients with type 2 diabetes. Methods The scientific literature was reviewed to identify relevant interventions that can reduce HbA 1c concentrations in patients with type 2 diabetes. We included articles describing interventions tested at the primary health-care level and targeting patients with type 2 diabetes. Based on WHO's "Best Buys", and taking into consideration their feasibility, acceptability, and potential effectiveness, we identified different forms of counselling interventions at the primary health-care level. The effect of each identified intervention on HbA 1c concentrations and the duration of this effect were collected in predefined tables. A regression line was plotted to find an estimate of the effect of each intervention through calculating the correlation between the changes in HbA 1c from each intervention versus the duration of the intervention. The unstandardised β-coefficient was identified for each intervention to predict its effectiveness in reducing HbA 1c concentrations. Findings We identified three main effective counselling interventions at the primary health-care level: (1) individual counselling intervention by multidisciplinary teams of health-care professionals, which provided individual counselling sessions depending on the patients' glycaemic control status; (2) the community health-worker intervention, which provided a set of home counselling visits for patients with uncontrolled type 2 diabetes; and (3) short message service (SMS)-based intervention (sending patients a number of counselling SMS weekly). All interventions were effective in reducing mean HbA 1c concentrations in patients with type 2 diabetes. The SMS-based intervention was the most effective (β=0·65, R 2 =0·10), followed by the community health-worker intervention (β=0·27, R 2 =0·28) and the individual counselling intervention (β=0·14, R 2 =0·01). Interpretation We compared the effectiveness of a set of interventions that are considered relativity low cost and applicable at the level of primary health care (the "Best Buys"). Implementing at least one of these effective interventions within the Palestinian health-care system could help improve glycaemic control and eventually reduce the prevalence of complications associated with type 2 diabetes. Controlling HbA 1c concentration will not only reduce the epidemiological burden of type 2 diabetes and its complications but it will also reduce the economic burden within Palestinian health-care system. Funding Eastern Mediterranean Regional office of WHO.

Background Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a validated CHD mortality model (IMPACT) to explain recent trends in Tunisia, Syria, the occupied Palestinian territory (oPt) and Turkey. Methods Data on populations, mortality, patient numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points (1995-97; 2006-09); integrated and analysed using the IMPACT model. Results Risk factor trends: Smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, oPt and Turkey. BMI rose by 1-2 kg/m2 and diabetes prevalence increased by 40%-50%. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria. Mortality trends: Age-standardised CHD mortality rates rose by 20% in Tunisia and 62% in Syria. Much of this increase (79% and 72% respectively) was attributed to adverse trends in major risk factors, occurring despite some improvements in treatment uptake. CHD mortality rates fell by 17% in oPt and by 25% in Turkey, with risk factor changes accounting for around 46% and 30% of this reduction respectively. Increased uptake of community treatments (drug treatments for chronic angina, heart failure, hypertension and secondary prevention after a cardiac event) accounted for most of the remainder. Discussion CHD death rates are rising in Tunisia and Syria, whilst oPt and Turkey demonstrate clear falls, reflecting improvements in major risk factors with contributions from medical treatments. However, smoking prevalence remains very high in men; obesity and diabetes levels are rising dramatically. The MedCHAMPS project and data collection were funded by EC FP7 grant no. 223705 . JC and SC are supported by the UK Higher Education Funding Council . MOF was partly funded by the European Union and the UK Medical Research Council ( NPR3, Project 45 ). This study was funded by the European Community's Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 223075 - the MedCHAMPS project. MOF was also supported by the UK MRC . Scopus

Background From the 2011 Palestinian Center Bureau of Statistics, disability is defined as long-term physical, mental, intellectual, or sensory impairment that can hinder full and effective participation in society; disability among elderly people has become a major public health concern in recent years. More than 1 billion people live with disability worldwide. In the occupied Palestinian territory, disability in elderly people is still not well understood. This study aims to assess the prevalence of disability among Palestinians aged 50 years or older and associated factors. Methods Data were obtained from the Palestinian Central Bureau of Statistics Disability-Survey of 2011, representing the Palestinian population. People aged 50 years or older were selected. We gathered descriptive statistics and used multivariate binary logistic regression to check for confounders. Data were analysed with SPSS17 software. Findings The total sample size was 8747 people aged 50 years or older. 71% of those had no disability and the remaining 29% reportedly had at least one disability, of which 53% represented problems with mobility, 26% vision, 11% hearing, 7% memory, 1% mental health, 1% communication, and 1% intellectual. Men were less likely to be disabled than women (odds ratio [OR] 0·75, 95% CI 0·64–0·89, p=0·001). The level of disability increased at age 70 and older (OR 1·96, 95% CI 1·67–2·31). The percentage of disabled elderly people increased among those who could not read compared with those educated (OR 2·93, 95% CI 2·36–3·63); decreased in those with large families compared with families of fewer than three people (for families of three to six people, OR 0·73, 95% CI 0·63–0·84; for families of seven to 27 people, 0·59, 0·50–0·70); increased in refugees compared with non-refugees (OR 1·26, 95% CI 1·07–1·47, p=0·005); increased in non-workers compared with workers (OR 2·96, 95% CI 2·50–3·49); and increased in those widowed and divorced compared with people who were married (OR 1·25, 95% CI 1·07–1·47, p=0·005). Compared with the centre of the West Bank, the number of people with disability was highest in the Gaza Strip (OR 2·23, 95% CI 1·89–2·63), followed by north West Bank (OR 2·60, 95% CI 2·22–3·05), and south West Bank (OR 1·95, 95% CI 1·63–2·33). Interpretation Disability is more prevalent in women, those not educated, refugees, non-workers, widowed and divorced individuals, and people in Gaza. Further investigations are needed to establish the main causes of disability in the occupied Palestinian territory, and associated factors. Funding None.

Background Disabilities are impairments or limitations that can vary between groups, localities, and family financial status. These restrictions could range from mental and intellectual to sensory and physical, and could be either congenital or acquired. In the occupied Palestinian territory, little attention is given to people with a disability, reasons behind their disabilities, and the prevalence of different disabilities in communities. This research focuses on the prevalence of disabilities among Palestinian children aged 0–17 years in 2011, in the occupied Palestinian territory and also the associated factors. Methods We used data from the Disability Survey in 2011 by the Palestinian Central Bureau of Statistics in this analysis. 42 176 children were included, representing all children in the occupied Palestinian territory. We analysed data with frequencies, cross tabs with significance testing, and regression analysis to test for confounders using SPSS version 17. Age was dealt with as a continuous variable and household size was dealt with as a categorical variable. No written consent was required for this study. Findings Prevalence of disability was 1586 (3·7%), including intellectual disabilities in 521 (33%) children, communication disabilities in 488 (31%), vision disabilities in 437 (28%), memory disabilities in 389 (25%), mobility disabilities in 384 (24%), hearing disabilities in 261 (16%), and mental disabilities in 144 (9%). More disability was reported in boys than in girls (odds ratio [OR] 1·37, 95% CI 1·24–1·52). Disability increased with increasing age groups (OR 1·07, 95% CI 1·06–1·08) and increasing household size (OR 1·02, 95% CI 1·00–1·04). Disability was higher in the south West Bank and Gaza Strip than in the centre West Bank region (OR 1·32, 95% CI 1·11–1·57 for south West Bank; vs 1·20, 1·03–1·42 for Gaza) and higher disability numbers were recorded in refugees than in non-refugees (OR 1·17, 95% CI 1·05–1·31). 520 (33%) children with a disability had more than one disability. Interpretation Disability prevalence was increased in south West Bank and the Gaza strip, and in older children. We could not analyse data by locale (eg, urban, rural, or refugee camp) or socioeconomic status because these variables were not found in the dataset, therefore the prevalence of disability in refugees could not be assessed. Further studies are recommended to identify the factors that account for these findings, with special attention given to children with a disability and refugees. Funding None.

Background Available evidence suggests that women in the occupied Palestinian territory are served by an overburdened health system that prioritises family planning and reproductive services above provision for other health care that women may need. To address this gap, we investigated ill-health and disparities in the health of all women across the life course, not just those who are married with children, in the occupied Palestinian territories. Methods Cross-sectional data for women aged 15–54 years from the Palestinian Family Health Survey 2010 were used (n=15 734). Determinants of binary health outcomes were analysed (self-reported chronic illness, self-reported acute illness, self-rated health) using separate weighted logistic regression models with region, locality, sociodemographic, and socioeconomic explanatory variables (n=14 819). Findings 11% of women reported a chronic illness (n=2176), 22% reported an acute illness (n=3811) and 21% rated their health as poor (n=3708). Parity did not increase the odds of reporting a chronic or acute illness. Highly parous women (4–7 and ≥8 children) rated their health as poorer compared with nulliparous women (odds ratio 1·65, 95% CI 1·01–2·69 and 1·73, 1·06–2·81, respectively). Pregnant women rate their health as poorer (1·29, 1·10–1·52), but are no more likely to report an acute illness and less likely to report chronic illness than non-pregnant women (0·706, 0·51–0·98). Compared with being married, being divorced was associated with poorer self-rated health (3·97, 1·53–10·30), whereas being single was associated with less acute illness (0·59, 0·39–0·88). Women from Gaza reported lower levels of illness and better self-rated health than women in the West Bank, despite poorer health infrastructure and similar burdens of illness. Interpretation Despite the focus of the health system on family planning and reproductive services, we found little evidence that married women with children have increased ill-health in the occupied Palestinian territory. A broader range of health services for women is needed. Funding Emirates Foundation, LSE Middle East Centre.

Background In 2010, diabetes mellitus was the fourth cause of death in West Bank, causing 9% of deaths. Few reliable data on diabetes complications exist. We aimed to estimate prevalence of diabetic retinopathy and determinants in a clinic-based sample in Ramallah Governorate, West Bank. Methods The study was done in 11 clinics (four United Nations Relief and Works Agency [UNRWA], five Ministry of Health, two joint Ministry of Health and non-governmental organizations). It was approved by ethics committee at Institute of Community and Public Health (Birzeit University), Ministry of Health, and UNRWA and oral witnessed consent was obtained from patients. Patients with type 2 diabetes older than 25 years were identified in clinics or from clinic databases and were invited to participate in a slit lamp eye exam by a licensed ophthalmologist. Questionnaire, physical examination, and lab tests (glycated haemoglobin [Hb A1c ], lipid profile) were done. We classified retinopathy using International Clinical Diabetic Retinopathy Disease Severity Scale. Data were collected between Feb 28, 2012, and June 7, 2012, and analysed using the statistical package for social sciences (SPSS) version 22. Findings Most eligible patients (517) consented to participate and were referred for eye exam; 376 (73%) underwent eye exam (127 men and 249 women). Mean age was 57·8 years (SD 9·0) and mean duration of diabetes was 8·9 years (SD 7·0). Only 21% (77) of patients had controlled diabetes (Hb A1c A1c , diabetes duration, and systolic blood pressure were associated with retinopathy (p A1c >7%) were four times more likely to have retinopathy compared with patients with controlled disease (odds ratio [OR] 4·16, 95% CI 1·76–9·85). Patients with diabetes duration more than 7 years were eight times more likely to have retinopathy than were patients whose diabetes duration was 7 years or less (OR 7·7, 95% CI 4·30–13·79). There was a 2% increase in risk of retinopathy per 1 mm Hg increase in systolic blood pressure (OR 1·02, 95% CI 1·01–1·04). Interpretation A third of patients with diabetes had retinopathy. Early regular screening might help early diagnosis and control of diabetic retinopathy, especially among high-risk patients (ie, those with uncontrolled diabetes, high systolic blood pressure, and long diabetes duration). Funding Swedish International Development Agency (SIDA); Umea Centre for Global Health Research, Umea University, Sweden.

Background Population health surveys play a vital part in enabling the planning, implementation, and monitoring of national health programmes and policies. However, the construction of these surveys is often determined by international stakeholders' agendas and implementation is restricted by availability of local resources. We used the Palestinian Family Survey (PFS) 2010 as a case study to inform the discussion on health surveys in the Arab region. Methods We used qualitative research methods involving a detailed document review of all PFS materials (eg, questionnaires, interviewer instructions and training manuals, reports) to assess the construction and implementation of the PFS in the occupied Palestinian territories. We compared the of the PFS 2010 survey instruments with contemporary health policies and practices. Findings We found a mismatch between the PFS content and data requirements at the national level. Some PFS content appeared to reflect international agendas rather than local health needs–for example, detailed questions about HIV/AIDS in a context with fewer than 100 reported cases since 1988. By contrast, health issues that were important in the context, such as mental health or exposure to violence, were not included in the PFS. There were inconsistencies in data collection by age and sex. For example, women aged 54–59 years were excluded from all survey modules except for the household roster, and there were few questions on the health of women who had never married. Interpretation Although population surveys are an important source of evidence in resource-poor settings, these findings suggests a need to re-evaluate health surveys, taking into account the necessity of addressing health concerns within their specific national context, while retaining the ability to monitor international health targets. Funding Emirates Foundation, London School of Economics Middle East Centre.

Objectives To explore the feasibility of using a simple multi-criteria decision analysis method with policy makers/key stakeholders to prioritize cardiovascular disease (CVD) policies in four Mediterranean countries: Palestine, Syria, Tunisia and Turkey. Methods A simple multi-criteria decision analysis (MCDA) method was piloted. A mixed methods study was used to identify a preliminary list of policy options in each country. These policies were rated by different policymakers/stakeholders against pre-identified criteria to generate a priority score for each policy and then rank the policies. Results Twenty-five different policies were rated in the four countries to create a country-specific list of CVD prevention and control policies. The response rate was 100 % in each country. The top policies were mostly population level interventions and health systems’ level policies. Conclusions Successful collaboration between policy makers/stakeholders and researchers was established in this small pilot study. MCDA appeared to be feasible and effective. Future applications should aim to engage a larger, representative sample of policy makers, especially from outside the health sector. Weighting the selected criteria might also be assessed. European Community's Seventh Framework Programme (FP7/2007-2013) under Grant Agreement No. 223075 the MedCHAMPS project. Scopus

Background Negative disciplinary methods (NDMs), including corporal and verbal punishment, are often used in the occupied Palestinian territory (oPt) and are reported to be used on 94·5% of children aged 2–14 years. Because such practices can negatively affect the psychological and physical development of children, the factors associated with the use of NDMs by parents in the oPt were investigated. Methods Nationally representative data from the Pan Arab Project for Family Health (PAPFAM) Survey 2006, which had a section on child discipline, were obtained from the Palestinian Central Bureau of Statistics. For this survey, data was gathered from a representative sample of households in the oPt by random-cluster sampling. A questionnaire had been used to obtain information from mothers or other female members of the household about the disciplinary methods used, including types of verbal and physical abuse. Our analysis for this cross-sectional study focused on questions about child rearing and discipline. The relation between sociodemographic variables (child's age and sex, parents' education, and family's wealth status) and NDMs was assessed with bivariate analysis in SPSS (version 17.0), and regression analysis of the significant associations. Findings The 2006 PAPFAM survey included 13 238 households, with a response rate of 88% (11 661 households). One child aged 2–14 years was selected from each household having children in this age group (4552 households). 2578 (57%) of 4552 children were exposed to the use of fewer than three NDMs, whereas 1974 (43%) to three or four (this split in the NDMs was used in the initial data analysis). Results from the regression analysis showed that girls were less likely to be exposed to NDMs than were boys (three or four NDMs: 916 [40%] of 2276 girls vs 1057 [47%] of 2271 boys; odds ratio 0·79, 95% CI 0·70–0·90) and children in the economically and politically unstable Gaza Strip were more likely to be exposed to NDMs than were those in the West Bank, oPt (1·42, 1·25–1·62). Families who were financially better off (0·69, 0·57–0·83) and mothers (0·77, 0·61–0·96) and fathers (0·76, 0·63–0·91) who were more educated were less likely to use NDMs than were those who were not. Interpretation Poverty seems to be a strong factor for the use of NDMs by parents. The findings of this study draw attention to the importance of engaging boys and their families who have a low income in interventions to prevent the use of NDMs and to help individuals to cope with the consequences of these practices. Funding None.

Background Diabetes mellitus type 2 is a leading cause of morbidity and mortality in the occupied Palestinian territory (oPt), with a prevalence of 12·5% in adults aged 25–64 years in 2010–11. Studies of the management and control of diabetes mellitus in the oPt are lacking. The association between diabetes self-care, provider recommendations, and glycaemic control was investigated in a sample of adults with diabetes mellitus type 2 in Ramallah, West Bank, oPt. Methods A sample of 517 individuals with diabetes mellitus type 2 (166 men and 351 women who were not pregnant) was selected from 11 diabetes clinics owned by the Palestinian Ministry of Health (MoH; n=5), UN Relief and Works Agency for Palestine Refugees in the Near East (n=4), and jointly by non-governmental organisations and MoH (n=2). The number of individuals selected from each clinic was proportional to the number of patients being treated for diabetes at the clinic. Patients were identified from the clinics' databases; 62 (11%) of 579 refused to participate. All participants provided verbal informed consent. The Summary of Diabetes Self-Care Activities questionnaire was used to assess self-care behaviour and providers' recommendations. The glycated haemoglobin A 1c (HbA 1c ) test was done to assess glycaemic control. Data were gathered during March to June, 2012, and analysed with SPSS (version 18.0). Logistic regression analysis was used to ascertain factors associated with poor glycaemic control. Approval to undertake the study was obtained from the Institute of Community and Public Health, Birzeit University, Ramallah, West Bank, oPt. Findings The mean HbA 1c was 8·8% (73 mmol/mol [SD 2·0 and 2, respectively]). One in five patients had glycaemic control (HbA 1c Interpretation The results of this study show that although patients in the West Bank are provided medication, health education and monitoring are insufficient and support is non-existent—these would help patients to control their diabetes mellitus. Further research is needed to confirm these findings. Funding Swedish International Development Cooperation Agency (SIDA), and Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden.

Background Postnatal care is an important component of maternal health, especially for the treatment of complications after delivery. However, only a third of women receive postnatal care in the occupied Palestinian territory (oPt). The aim in this study was to assess the factors that contributed to women not receiving postnatal care despite the manifestation of symptoms. Methods Data were obtained from a nationally representative household survey (Pan-Arab Project for Family Health [PAPFAM] 2006) by the Palestinian Central Bureau of Statistics, West Bank, oPt, and analysed. Women (aged 15–54 years) who were married and reported one or more postnatal symptoms with fever—severe vaginal bleeding, swelling and pain in the legs, foul-smelling vaginal discharge, lower abdominal pain, severe lower back pain, severe upper back pain, painful micturation, or breast swelling and pain—were selected from 3334 women in the postnatal period. For the analysis, responses about these eight symptoms were converted into a scale (Cronbach's α=0·82). Descriptive analysis, Pearson's χ 2 , and binary logistic regression were done with postnatal care as the dependent variable and selected demographic and socioeconomic variables as possible associated factors. SPSS (version 17.0) was used for the statistical analysis. Findings 267 (46%) of 584 women had one postnatal symptom, 217 (37%) had two or three postnatal symptoms, and 100 (17%) had four to seven. 245 (42%) women received postnatal care and 339 (58%) did not. 251 (74%) of 339 women who did not receive postnatal care reported that symptoms were not a problem. Logistic regression analysis showed that women who were poorer were more likely to not receive postnatal care than were those who were better off (odds ratio 2·1, 95% CI 1·1–4·0]. Women reporting normal delivery were four times less likely to use postnatal care than were those who reported having a caesarean (4·0, 2·5–6·2). Women married to younger men (aged ≤29 years) and women living in the West Bank were almost half as likely to receive postnatal care than were women married to older men (aged ≥30 years; 1·9, 1·1–3·3) and women in the Gaza strip (2·4, 1·5–3·6). Interpretation Poverty is an important barrier to postnatal care for women and contributes to the inequity in the provision of services to these women. Better accessibility of postnatal care for women in the Gaza Strip might be due to the presence of several international humanitarian agencies that provide services to people living in this region, and the small size of the Gaza Strip increasing accessibility to clinics for women. More efforts are needed to address women's health needs in the postnatal period. Funding None.

Background The burden of coronary heart diseases is increasing at an alarming rate in most low-income and middle-income countries. The findings of evidence-based studies suggest that this burden can be prevented through health policies. Various methods to define and select policies have been developed including evidence-based prioritisation, which is important in view of the scarce resources in and data for low-income and middle-income countries. The aim of this study was to assess and prioritise context-specific policies for the prevention and control of coronary heart diseases in the occupied Palestinian territory (oPt). Methods In this mixed-methods pilot study, a set of policy options was developed and shortlisted on the basis of integrated findings from country-specific qualitative situational analysis inputs and quantitative modelling of related risk factors and treatments with the IMPACT Excel-based model. A simple Excel sheet was used to calculate a priority score for each policy and then the policies were ranked in terms of their importance. Criteria from WHO's prioritised research agenda and stepwise framework were used to rate the policies. The specific policies were scored and prioritised by five key informants (mid-level health managers, health practitioners, and academics) from the oPt and then ranked in terms of importance. Ethics approval to undertake the study was obtained from the Institute of Community and Public Health, Birzeit University, Ramallah, West Bank, oPt. All participants provided verbal informed consent. Findings Key informants shortlisted and rated 19 polices. The top five policies were population-level primary prevention with focus on blood pressure (n=2), health-system level with focus on collaboration and capacity building of health-care providers (n=2), and treatment for high-risk patient groups (n=1). Interpretation Policies with focus on primary prevention and health systems indicate a good understanding of the epidemiology of diseases and the needs of the community. However, the small number and scope of the policy makers (directly related to health) who rated the policies in this study were limitations for improved identification of evidence-based policies. This approach of ranking pre-identified policies might be important for engaging policy makers and, when there are few resources, prioritising policies. Funding European Community's Seventh Framework Programme.

Background Children younger than 5 years represent 14·7% of the Palestinian society. Parenting is important for child development, so various organisations have focused on identifying protective and risk factors related to parenting and child development. The cognitive caregiving behaviour of Palestinian parents with children younger than 5 years in the occupied Palestinian territory (oPt) was assessed. Methods The Palestinian Family Health Survey 2006, Palestinian Central Bureau of Statistics, Ramallah, West Bank, oPt, included three questions about whether family members had read books or stories to or helped children with drawing during the 3 days preceding the survey. A cognitive caregiving scale was constructed from questions used to identify whether either of the parents had engaged in such activities with good internal consistency (α 0·76). The scale was recoded as no activity and at least one activity. χ 2 testing was used to check for significant associations of cognitive caregiving with each variable—region, locality, mother's age, parent's education and relation to labour forces, child's sex, and family's wealth status. Binary logistic regression was done to identify confounders. Data were analysed with SPSS (version 17.0). Findings 5352 households were visited for the survey: 3051 (57%) from the West Bank and 2301 (43%) from the Gaza Strip, oPt. Mothers in 1869 (35%) households had greater than high-school education. 2298 (43%) households were classified as poor, 2224 (42%) middle class, and 830 (16%) better off financially. 2962 (55%) parents did not practice cognitive caregiving. Logistic regression analysis showed that children in better-off (odds ratio 1·29, 95% CI 1·08–1·52) and middle-class families (1·20, 1·06–1·35) were more likely to receive cognitive caregiving from their parents than were children from other families. Children with educated mothers (>12 years of education) were more likely to receive cognitive caregiving than were those whose mothers had less education (1·45, 1·28—1·64). Parents in the Gaza Strip were less likely to engage in cognitive caregiving than were those from the West Bank (0·85, 0·76–0·95). Interpretation The findings suggest that children from the Gaza strip, from poor families, or with less educated mothers need more cognitive caregiving. Training, support, and awareness programmes are needed for parents of these children to improve cognitive caregiving for them in the oPt. Funding None.

Background The incidence of coronary heart diseases is increasing in the occupied Palestinian territory (oPt) and hence poses a growing challenge for treatment. Reduction in the intake of dietary salt is a potentially cost-effective approach to reduce the burden of coronary heart diseases. Here, we report the results of an economic assessment of three interventions of salt reduction in the oPt. Methods We did the analysis from a societal perspective of three salt-reduction interventions—population-wide health promotion campaigns, mandatory labelling of food packaging, and mandatory reduction of salt content of processed food. These interventions were assessed individually, and in combinations of two and all three together. We estimated the costs of policies using past experiences, expert opinion, and hospital records, and costs of health care with a standardised unit cost for treatments. We considered the financial implications for the food industry and public sectors. The total cost of implementation of each policy was compared with the do-nothing scenario. We used data reported in reviews of epidemiological studies as estimates of the expected reduction of the current sodium salt consumption attributable to each policy. The expected change in salt intake was then converted into a change in mean population blood pressure based on estimates reported in a meta-analysis. The change in blood pressure was used to estimate the number of deaths prevented or postponed in 10 years, using the Palestinian IMPACT policy model for coronary heart disease. The estimates were compared with the number of deaths from coronary heart disease that would have been expected in relation to the number in the baseline year. This policy model is an epidemiological model that was used to analyse mortality associated with coronary heart disease and risk factor trends in the West Bank, oPt, between 1998 and 2009, and project mortality trends for the future. We used Microsoft Excel 2010 for our analyses. Findings All policies resulted in a reduction in salt intake of 5–30%, leading to changes of 1–20 mm Hg in systolic blood pressure. All scenarios were cost effective compared with the do-nothing scenario. The cost-effectiveness of the scenarios for per life-year gained was $134·57–1430·62 (purchasing power parity at 2010 exchange rates). Policies for the labelling of food and use of the three interventions together were the most cost effective. These two scenarios were estimated to save costs ($9 million and $6 million) and resulted in 945 life-years gained and 2682 life-years gained, respectively. Interpretation Reduction of salt intake reduces the long-term burden of coronary heart diseases. In the oPt, population-based interventions to reduce salt intake are not only cost effective but also cost saving. We recommend a population-wide health promotion campaign, mandatory labelling of food packaging, and mandatory reduction of salt content of processed food. Funding European Community's Seventh Framework Programme.

Background The World Health Organization (WHO) incorporated well-being into its definition of health in 1948. The significance given to this concept is due to its role in the assessment of people’s quality of life and health. Methods Using the WHO Well-being Index, we estimated well-being among adults and identified selected associated factors in the occupied Palestinian territory (oPt) using data obtained from the National Time Use Survey conducted by the Palestinian Central Bureau of Statistics (PCBS) 2012–2013 on a representative sample of persons living in the West Bank and Gaza Strip. Univariate and bivariate analyses were conducted among participants 18 years old and above. Multivariate analysis (Regression) was performed with factors found significant in cross-tabulations, using SPSS® version 20. Results Overall, 33.8 % (2395) of respondents reported low levels of well-being (ill-being). Neither age, nor sex, nor region were found significant in regression analysis. People who were married, working 15 h or more, with a higher standard of living, who reported participating in community, cultural, and social events, or in religious activities reported high levels of well-being. Those who reported regularly following the mass media, or living in Palestinian refugee camps reported low levels of wellbeing. Conclusions Overall, about one-third of adult Palestinians reported low levels of well-being (ill-being), a finding which in itself requires attention. Marriage, employment, high living standards, community participation, and religious activities were found to be protective against ill-being. Further investigations are required to determine additional causes of ill-being in the oPt, taking into consideration the possible effects of chronic exposure to political violence on subjective well-being.