Identifying a package of cost-effective interventions to address non-communicable diseases in Gaza
Lead Research Organisation:
Imperial College London
Department Name: School of Public Health
Abstract
Long term diseases are increasing worldwide, including in developing countries, resulting in a huge economic and health burden to society. While there are known policies and interventions to prevent and control long term diseases, these may not be applicable in settings exposed to prolonged armed conflict, such as Gaza. It is therefore important to understand which policies could best work in these situations to minimise the harm long term diseases cause to societies.
This research will involve conducting a household survey of the population in Gaza in order to understand the types of long term diseases experienced (e.g. diabetes, heart disease) as well as their risk factors (e.g. smoking, unhealthy diet). The data from this household survey will inform a statistical model, which will predict how long term diseases and their risk factors will change over time depending on the policies that governments and other agencies implement in Gaza. This modelling component will test different scenarios under different conditions, such as siege, blockage, armed conflict, and restrictions to farming and imports, and will aim to identify set of value for money and feasible interventions best suited to the population of Gaza.
This research will involve conducting a household survey of the population in Gaza in order to understand the types of long term diseases experienced (e.g. diabetes, heart disease) as well as their risk factors (e.g. smoking, unhealthy diet). The data from this household survey will inform a statistical model, which will predict how long term diseases and their risk factors will change over time depending on the policies that governments and other agencies implement in Gaza. This modelling component will test different scenarios under different conditions, such as siege, blockage, armed conflict, and restrictions to farming and imports, and will aim to identify set of value for money and feasible interventions best suited to the population of Gaza.
Technical Summary
Non-communicable diseases (NCDs) are increasingly prevalent in low- and middle-income countries (LMICs), and pose a substantial economic and health burden. "Best buy" interventions to prevent and control NCDs in LMICs may not be applicable in settings with intense resource constraints, political instability and conflict, such as Gaza. Better understanding of interventions to prevent and control NCDs in such settings are important to minimise the NCD burden.
This research will conduct a cross-sectional household survey among adults in Gaza, to capture detailed sociodemographic, NCD, and NCD risk factor data in a representative manner. These data will inform a microsimulation model which will test cost-effective interventions known to prevent and control NCDs, under different scenarios, to produce an optimal package for Gaza. This model will incorporate the unique political and economic constraints in Gaza, such as armed conflict, dwindling resource for healthcare providers, restrictions on farming, etc., and incorporate a number of sensitivity analyses to increase robustness.
This research will conduct a cross-sectional household survey among adults in Gaza, to capture detailed sociodemographic, NCD, and NCD risk factor data in a representative manner. These data will inform a microsimulation model which will test cost-effective interventions known to prevent and control NCDs, under different scenarios, to produce an optimal package for Gaza. This model will incorporate the unique political and economic constraints in Gaza, such as armed conflict, dwindling resource for healthcare providers, restrictions on farming, etc., and incorporate a number of sensitivity analyses to increase robustness.
Planned Impact
This research will provide the basis for a wider programme of work evaluating changes to NCD policies in Gaza, part of which will form the basis of a Full Research Proposal to HSRI. For example we have undertaken some preliminary discussions about UNRWA's plan to modify how they deliver food aid to Palestine refugees in Gaza which may form the basis for a future application. The Foundation grant will form the baseline data collection in a research project that includes a pre-post study design, which is critical for a more robust evaluation of a variety of NCD policies in Gaza.
The main beneficiaries of this research will be policymakers in UNRWA and the Palestinian Ministry of Health and in other countries doubly affected by protracted armed conflict and growing burden of non-communicable diseases (NCDs). This research will provide the evidence needed to make changes to policies targeting the prevention and control of NCDs while being mindful of the political and economic constraints imposed on the country.
Researchers from the Al-Quds University, the American University of Beirut, and Imperial College London involved in this project also stand to benefit tremendously. Researchers will be able to share learning across institutions based on past experiences, expose junior researchers on the team to sound research and wider research networks. All of these facets will help develop capacity for NCD research locally and regionally.
One final beneficiary is the people of Gaza. Already at a socioeconomic disadvantage given the protracted armed conflict in the region, living with NCDs can worsen quality of life and reduce life expectancy. Policies that better support NCDs can promote healthier choices and a better standard of living, which may make some small contribution to the dire situation there.
More details on how these beneficiaries will be engaged are given in the Pathways to Impact document.
The main beneficiaries of this research will be policymakers in UNRWA and the Palestinian Ministry of Health and in other countries doubly affected by protracted armed conflict and growing burden of non-communicable diseases (NCDs). This research will provide the evidence needed to make changes to policies targeting the prevention and control of NCDs while being mindful of the political and economic constraints imposed on the country.
Researchers from the Al-Quds University, the American University of Beirut, and Imperial College London involved in this project also stand to benefit tremendously. Researchers will be able to share learning across institutions based on past experiences, expose junior researchers on the team to sound research and wider research networks. All of these facets will help develop capacity for NCD research locally and regionally.
One final beneficiary is the people of Gaza. Already at a socioeconomic disadvantage given the protracted armed conflict in the region, living with NCDs can worsen quality of life and reduce life expectancy. Policies that better support NCDs can promote healthier choices and a better standard of living, which may make some small contribution to the dire situation there.
More details on how these beneficiaries will be engaged are given in the Pathways to Impact document.
Organisations
Publications
Abu Hamad BA
(2023)
The hypertension cascade of care in the midst of conflict: the case of the Gaza Strip.
in Journal of human hypertension
Description | NIHR Global Health Research Group - National Institute for Health Research. Physical Trauma from Injury & POsT Conflict iPROTECT |
Amount | £2,999,987 (GBP) |
Organisation | National Institute for Health Research |
Sector | Public |
Country | United Kingdom |
Start | 09/2022 |
End | 08/2027 |
Title | Development of a survey questionnaire in Gaza |
Description | Development of a survey questionnaire For the purposes of this project, we have conducted an interviewer administered, face-to-face household survey of 4,576 adults aged 40 years or above living in Gaza. Randomly selected households have been approached during culturally convenient times of the day using a random multistage, stratified cluster sampling approach to produce representative data of the Gazan population. A survey questionnaire was developed by the research team. Questions in the survey have been taken from commonly used household surveys in the Gaza Strip (e.g. Demographic and Health Survey, Multiple Indicator Cluster Survey, WHO STEPS, etc). More specifically, the survey has 16 modules including (1) Participant identification; (2) Demographics, (3) Food security (using the Food and Agriculture Organization's food insecurity experience scale (FIES) and Arab Family Food Security Scale (AFFSS)), (4) Assistance (using Expenditure and Consumption Survey, Palestine 2011, UNICEF Cash Transfer Surveys, UNRWA Household Form Socio-economic Survey of Palestine Refugees in Lebanon); (5) Psychosocial Health (using the 12-item General Health Questionnaire); (6-9) History of diabetes mellitus, Raised Blood Pressure, Raised Total Cholesterol Cardiovascular diseases, Chronic Respiratory Diseases and Cancer (using the Non-communicable diseases and behavioral risk factor survey, Lebanon 2009 WHO STEPS, Palestine); (10) Physical Activity (Adopted from International Physical Activity Questionnaire (IPAQ)); (11) Dietary Salt (using WHO STEPS, Palestine); (12-14) Tobacco Use, Nargila Use and Lifestyle Change (using the Non-communicable diseases and behavioral risk factor survey, Lebanon 2009 and WHO STEPS, Palestine); (15) Physical measurements (blood pressure, waist circumference, and height and weight); (16) Nutrition (using a validated nutritional questionnaire for the Palestine population; Hamdan et al Public Health Nutrition, 17(11), 2512-2518). The survey has been translated from English language into Arabic. Both English and Arabic versions of the survey will be uploaded onto an online survey program (called KoBoToolbox). Data from this household survey provide information on the burden and distribution of cardio-metabolic risk factors and non-communicable diseases in a representative sample of the Gazan population over the age of 40 years. |
Type Of Material | Physiological assessment or outcome measure |
Year Produced | 2021 |
Provided To Others? | No |
Impact | During the current reporting period (2023-2024), we undertook the assessment of the effectiveness and cost-effectiveness of potential new public health and healthcare NCD risk reduction efforts among Palestinians in Gaza. We created a microsimulation model using: (i) a cross-sectional household survey of NCD risk factors among 4,576 Palestinian adults aged >40 years old in Gaza (please see the details above in the Research Tools section)); (ii) a modified Delphi process among local public health experts to identify potentially feasible new interventions (please see above in the Research Tools Section); and (iii) reviews of intervention cost and effectiveness, modified to the Gazan and refugee contexts. We computed disability-adjusted life-years (DALYs) lost to NCDs without and with the selected interventions, and the costs of the interventions, over a 10-year policy time horizon from a societal perspective. We then estimated the individual risk of each of the five major NCDs in the Palestinian population in Gaza (cardiovascular disease consisting of coronary heart disease or stroke, type 2 diabetes mellitus, asthma/COPD, breast cancer, and colorectal cancer). The paper reporting the results from these analyses has been finalised. The household survey has been completed in Gaza. Data from this household survey will provide information on the burden and distribution of cardio-metabolic risk factors and non-communicable diseases in a representative sample of the Gazan population over the age of 40 years. Data from this survey will inform a statistical model, which will predict how chronic non-communicable diseases and their risk factors will change over time depending on the policies that governments and other agencies implement in Gaza. This modelling component will test different hypothetical scenarios under different conditions, such as siege, blockage, armed conflict, and restrictions to farming and imports. This research will identify a set of cost-effective and feasible interventions to prevent and control non-communicable diseases in Gaza, implemented in the context of political and economic instability and conflict to inform policy and future research. The questionnaire will be published as an online appendix with our first publication. |
Title | Gaza household survey questionnaire |
Description | Development of a survey questionnaire For the purposes of this project, we have conducted an interviewer administered, face-to-face household survey of 4,576 adults aged 40 years or above living in Gaza. Randomly selected households have been approached during culturally convenient times of the day using a random multistage, stratified cluster sampling approach to produce representative data of the Gazan population. A survey questionnaire was developed by the research team. Questions in the survey have been taken from commonly used household surveys in the Gaza Strip (e.g. Demographic and Health Survey, Multiple Indicator Cluster Survey, WHO STEPS, etc). More specifically, the survey has 16 modules including (1) Participant identification; (2) Demographics, (3) Food security (using the Food and Agriculture Organization's food insecurity experience scale (FIES) and Arab Family Food Security Scale (AFFSS)), (4) Assistance (using Expenditure and Consumption Survey, Palestine 2011, UNICEF Cash Transfer Surveys, UNRWA Household Form Socio-economic Survey of Palestine Refugees in Lebanon); (5) Psychosocial Health (using the 12-item General Health Questionnaire); (6-9) History of diabetes mellitus, Raised Blood Pressure, Raised Total Cholesterol Cardiovascular diseases, Chronic Respiratory Diseases and Cancer (using the Non-communicable diseases and behavioral risk factor survey, Lebanon 2009 WHO STEPS, Palestine); (10) Physical Activity (Adopted from International Physical Activity Questionnaire (IPAQ)); (11) Dietary Salt (using WHO STEPS, Palestine); (12-14) Tobacco Use, Nargila Use and Lifestyle Change (using the Non-communicable diseases and behavioral risk factor survey, Lebanon 2009 and WHO STEPS, Palestine); (15) Physical measurements (blood pressure, waist circumference, and height and weight); (16) Nutrition (using a validated nutritional questionnaire for the Palestine population; Hamdan et al Public Health Nutrition, 17(11), 2512-2518). The survey has been translated from English language into Arabic. Both English and Arabic versions of the survey will be uploaded onto an online survey program (called KoBoToolbox). Data from this household survey provide information on the burden and distribution of cardio-metabolic risk factors and non-communicable diseases in a representative sample of the Gazan population over the age of 40 years. |
Type Of Material | Database/Collection of data |
Year Produced | 2020 |
Provided To Others? | No |
Impact | Data from this survey will inform a statistical model, which will predict how chronic non-communicable diseases and their risk factors will change over time depending on the policies that governments and other agencies implement in Gaza. This modelling component will test different hypothetical scenarios under different conditions, such as siege, blockage, armed conflict, and restrictions to farming and imports. This research will identify a set of cost-effective and feasible interventions to prevent and control non-communicable diseases in Gaza, implemented in the context of political and economic instability and conflict to inform policy and future research. |
Title | Microsimulation modelling to assess the effectiveness and cost-effectiveness of potential NCD risk reduction efforts among Palestinians in Gaza |
Description | This modelling work is currently under review with a journal. "We created and applied a microsimulation model using three sources of data: (i) a cross-sectional household survey providing information about baseline characteristics and NCD risk factors among the Palestinian population in Gaza; (ii) a modified Delphi process for local public health experts to identify potentially feasible interventions for modelling NCD risk reduction strategies in Gaza, including associated costs; and (iii) reviews and meta-analyses of intervention effectiveness, with modifications for the Gazan and refugee contexts. We utilized the model to compare the effectiveness and cost-effectiveness of the studied interventions." The sources of data (i) and (ii) have been described earlier. The paper describing the modelling that seeks to assess the effectiveness and cost-effectiveness of potential new public health and healthcare NCD risk reduction efforts among Palestinians in Gaza is currently under peer review. |
Type Of Material | Data analysis technique |
Year Produced | 2024 |
Provided To Others? | No |
Impact | The paper describing the modelling that seeks to assess the effectiveness and cost-effectiveness of potential new public health and healthcare NCD risk reduction efforts among Palestinians in Gaza is currently under peer review. |
Title | Workshop on prioritising WHO 'best-buy' interventions for NCD prevention in the Gaza context |
Description | Engagement with policy makers, government officials, clinicians and public health professionals to achieve research objectives and develop locally feasible and acceptable evidence-based interventions in the Gaza setting is central to this research. To this end, a large workshop series was organised in July 2021 to prioritize WHO 'best-buy' interventions for NCD prevention. The purpose of this stakeholders' consultative exercise is to develop a consensus on a shortlist of policy interventions (ideally less than 8 scenarios) to prevent and control NCDs, based on the World Health Organisation "best buys", which are contextually relevant, cost-effective and feasible in the Gaza context. Context specificity, limited available resources and the needed to have a strategic focus "intent focus", necessitate identifying few possible intervention strategies and focusing on them (Pareto Principle 20/80) to combat the NCD epidemic. There is a growing evidence in the literature that implementing contextually relevant multi-sectoral interventions strategies can effectively address root causes of NCDs and their underlying risk factors. WHO extensive list of best buys options is valid for controlling NCDs, but still not adequately utilized in LMIC. The identified best buys options will be further investigated and modelled across different sub-populations. These can be further tested in future to ascertain its effectiveness in controlling NCDs in Gaza. Overall, there 46 participants including 10 delegates from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA); 14 delegates from the Ministry of Health (MOH); 2 delegates from the WHO; 9 delegates from NGOs and Community Leaders and 11 academics from across the Islamic University, Al Azhar Univeristy, American University of Beirut and Al Qundus University. All delegates were senior officials, heads of services or high-ranking members of their organisation. Further details on this activity, and how it informs the research are described in the Research Tools and Methods section. |
Type Of Material | Database/Collection of data |
Year Produced | 2021 |
Provided To Others? | No |
Impact | Among the 88 potential best buy interventions, we focused on those which are related to CVD and diabetes and remove alcohol related interventions, this will reduce the list of best buys. Also, we removed some interventions that are not contextually relevant like those related to cancer cervix. Additionally, we added around 10 interventions related to the prevailing protracted context in Gaza in relation to food assistance, availability of drugs, use of standards and guidelines, governance, regulation and coordination of NCDs services. Participants were given the opportunity to suggest other possible interventions other than the provided list of best buys. However, among this list, we came up with a shortlist of less than 10 priority interventions which are feasible for statistical modelling. Data from the consultation event with government officials, health professionals and other key stakeholders (please see the details above) • A shortlist of best buys resulted from the in-country consultations, agreed by the relevant stakeholders, outputs of in country consultations • A final peer-reviewed shortlist of best buys for further investigation and modelling, an output of review of the list emerged from the in-country consultations by the research partners (ICL, UCL, AUB, Standford university) • Documentation of the processes and steps followed during the prioritization and consensus building. The final shortlist will be shared with Stanford University for statistical modelling as described in the objectives. |
Description | Engagement with policy makers, government officials, clinicians and public health professionals |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Policymakers/politicians |
Results and Impact | The following section describes policy and wider stakeholder engagement activities carried out in the previous reporting period that informed the development of the modelling component of the project: Engagement with policy makers, government officials, clinicians and public health professionals to achieve research objectives and develop locally feasible and acceptable evidence-based interventions in the Gaza setting is central to this research. To this end, a large workshop series was organised in July 2021 to prioritize WHO 'best-buy' interventions for NCD prevention. The purpose of this stakeholders' consultative exercise is to develop a consensus on a shortlist of policy interventions (ideally less than 8 scenarios) to prevent and control NCDs, based on the World Health Organisation "best buys", which are contextually relevant, cost-effective and feasible in the Gaza context. Context specificity, limited available resources and the needed to have a strategic focus "intent focus", necessitate identifying few possible intervention strategies and focusing on them (Pareto Principle 20/80) to combat the NCD epidemic. There is a growing evidence in the literature that implementing contextually relevant multi-sectoral interventions strategies can effectively address root causes of NCDs and their underlying risk factors. WHO extensive list of best buys options is valid for controlling NCDs, but still not adequately utilized in LMIC. The identified best buys options will be further investigated and modelled across different sub-populations. These can be further tested in future to ascertain its effectiveness in controlling NCDs in Gaza. Overall, there 46 participants including 10 delegates from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA); 14 delegates from the Ministry of Health (MOH); 2 delegates from the WHO; 9 delegates from NGOs and Community Leaders and 11 academics from across the Islamic University, Al Azhar Univeristy, American University of Beirut and Al Qundus University. All delegates were senior officials, heads of services or high-ranking members of their organisation. Further details on this activity, and how it informs the research are described in the Research Tools and Methods section. |
Year(s) Of Engagement Activity | 2021 |