Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. MethodsWe did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. FindingsWe included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58•0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2•8 kg (2•3-3•3). Mortality among all patients was 37 (39•8%) of 93 in low-income countries, 583 (20•4%) of 2860 in middle-income countries, and 50 (5•6%) of 896 in high-income countries (p<0•0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90•0%] of ten in lowincome countries, 97 [31•9%] of 304 in middle-income countries, and two [1•4%] of 139 in high-income countries; p≤0•0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2•78 [95% CI 1•88-4•11], p<0•0001; middle-income vs high-income countries, 2•11 [1•59-2•79], p<0•0001), sepsis at presentation (1•20 [1•04-1•40], p=0•016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1•82 [1•40-2•35], p<0•0001; ASA 3 vs ASA 1-2, 1•58, [1•30-1•92], p<0•0001]), surgical safety checklist not used (1•39 [1•02-1•90], p=0•035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1•96, [1•4...

Background In low-resource settings, the awareness level of colorectal cancer (CRC) signs and symptoms plays a crucial role in early detection and treatment. This study examined the public awareness level of CRC signs and symptoms in Palestine and investigated the factors associated with good awareness. Methods This was a national cross-sectional study conducted at hospitals, primary healthcare centers, and public spaces in 11 governorates across Palestine between July 2019 and March 2020. A translated-into-Arabic version of the validated bowel cancer awareness measure (BoCAM) was utilized to assess the awareness level of CRC signs and symptoms. For each correctly identified CRC sign/symptom, one point was given. The total score (ranging from 0 to 12) was calculated and categorized into three categories based on the number of symptoms recognized: poor (0 to 4), fair (5 to 8), and good awareness (9 to 12). Results Of 5254 approached, 4877 participants completed the questionnaire (response rate = 92.3%). A total of 4623 questionnaires were included in the analysis; 1923 were from the Gaza Strip and 2700 from the West Bank and Jerusalem (WBJ). Participants from the Gaza Strip were younger, gained lower monthly income, and had less chronic diseases than participants in the WBJ. The most frequently identified CRC sign/symptom was ‘lump in the abdomen’ while the least was ‘pain in the back passage’. Only 1849 participants (40.0%, 95% CI: 39.0%-41.0%) had a good awareness level of CRC signs/symptoms. Participants living in the WBJ were more likely to have good awareness than participants living in the Gaza Strip (42.2% vs. 37.0%; p = 0.002). Knowing someone with cancer (OR = 1.37, 95% CI: 1.21–1.55; p < 0.001) and visiting hospitals (OR = 1.46, 95% CI: 1.25–1.70; p < 0.001) were both associated with higher likelihood of having good awareness. However, male gender (OR = 0.80, 95% CI: 0.68–0.94; p = 0.006) and following a vegetarian diet (OR = 0.59, 95% CI: 0.48–0.73; p < 0.001) were both associated with lower likelihood of having good awareness. Conclusion Less than half of the study participants had a good awareness level of CRC signs and symptoms. Future education interventions are needed to improve public awareness of CRC in Palestine.

PURPOSE To assess the public awareness level of colorectal cancer (CRC) risk factors in Palestine and identify factors associated with the good awareness level. MATERIALS AND METHODS Adult Palestinians were recruited using convenience sampling from hospitals, primary health care centers, and public locations in 11 governorates. The recognition of 11 CRC risk factors was evaluated using a translated-into-Arabic version of the validated bowel cancer awareness measure. Participants were given one point for each correctly recognized risk factor. The awareness level was determined by the number of CRC risk factors recognized: poor (0-3), fair (4-7), and good awareness (8-11). RESULTS A total of 4,877 participants, of 5,254 approached, completed the questionnaire (response rate = 92.3%). The final analysis included 4,623 questionnaires, 2,700 from the West Bank and Jerusalem (WBJ) and 1,923 from the Gaza Strip. Participants from the WBJ were older, gained higher monthly income, and had more chronic diseases than participants from the Gaza Strip. The most recognized modifiable CRC risk factor was not doing 30 minutes of moderate physical activity five times a week (n = 3,846, 83.2%), whereas the least recognized was having a diet low in fiber (n = 1,985, 42.9%). The most recognized nonmodifiable CRC risk factor was having a bowel disease (n = 3,320, 71.8%), whereas the least recognized was having diabetes (n = 1,581, 34.2%). Only 1,840 participants (39.8%) demonstrated good awareness of CRC risk factors. Participants from the Gaza Strip were more likely than participants from the WBJ to have good awareness (46.5.0% v 35.0%). Female sex, knowing someone with cancer, and completing postsecondary education were all associated with good awareness. CONCLUSION Awareness of CRC risk factors was found to be low in Palestine. There is a substantial need to raise awareness of CRC risk factors through educational campaigns and programs.

This study explored the anticipated time to seek medical advice for possible colorectal cancer (CRC) signs/symptoms and its association with CRC symptom awareness. In addition, it examined perceived barriers that may delay seeking medical advice. Palestinian adults were recruited from hospitals, primary healthcare centers, and public spaces in 11 governorates. A modified, translated-into-Arabic version of the validated Bowel Cancer Awareness Measure was used. The questionnaire comprised three sections: sociodemographics, assessment of CRC symptom awareness and time to seek medical advice, and barriers to early presentation. A total of 4623 participants were included. The proportion that reported seeking immediate medical advice for possible CRC signs/symptoms with blood or mass ranged from 47.1% for ‘blood in stools’ to 59.5% for ‘bleeding from back passage’. Less than half of the participants reported immediate seeking of medical advice for non-specific symptoms (ranging from 5.4% for ‘loss of appetite’ to 42.0% for ‘anemia’) and other gastrointestinal symptoms (ranging from 7.7% for ‘feeling persistently full’ to 35.7% for ‘change in bowel habits’). Good CRC symptom awareness was associated with higher likelihood of seeking medical advice within a week from recognizing a CRC symptom. About 13.0% reported a delay to visit their doctor after recognizing a CRC symptom. The most reported barriers were practical with ‘would try some herbs first’ (50.9%) as the leading barrier. CRC symptoms with blood or mass prompted earlier help seeking. Participants with good CRC awareness were more likely to seek medical advice within a week.

COVID-19 is an emerging respiratory disease caused by a novel coronavirus accompanied by a tsunami of misinformation and fake news. This can weaken the public health responses by affecting the COVID-19-related knowledge, attitudes, and practices (KAP) of the public. Therefore, this cross-sectional study was designed during the early stage of the pandemic to evaluate the KAP of Palestinian university students and their commonly used information sources. We found that the most trusted information source among students was the World Health Organization (WHO), followed by the Palestinian Ministry of Health (MoH) briefings and healthcare workers, whereas social media was the most frequently used source of information. The participants exhibited a high level of COVID-19-related knowledge, having an average score of 8.65 (range: 0–10). In total, 76% avoided going to crowded places, and only 33% wore a mask while being outdoors. The vast majority (93%) checked the accuracy of COVID-19-related information before publishing it, 56% used the WHO and MoH briefings for fact-checking, and only 8% relied on healthcare workers. This was particularly the case for those who lived in refugee camps. This study provides an insight into the information sources used by Palestinian university students, the sources they trust, and the information formats they prefer. These results may help public health authorities to locate the information sources through which university students should be targeted. Efforts should be made to recommend healthcare workers as credible information sources. In this way, they will be able to prevent the spread of misleading information and provide high-quality information, especially within unconventional settings such as refugee camps.