Adolescent mental health is increasingly recognized as a critical concern. Globally, suicide is among the top 5 causes of death for 15–19-year-olds (girls and boys). In the Middle East and North Africa, the prevalence of mental disorders (17.3% for girls and 16.8% for boys) is the second highest in the world. The Covid-19 pandemic has exacerbated adolescents’ vulnerabilities, particularly through the impacts of lockdowns and school closures. This article explores adolescent experiences in Gaza, drawing on mixed-methods research carried out in late 2020 in refugee camps (29%) and urban settings (71%). The sample involved phone surveys with 505 adolescent girls and boys (12–19 years) and their caregivers, in-depth interviews with a subsample of 77 adolescents, and 9 key informant interviews with service providers. Using the Patient Health Questionnaire-8, 9% of adolescents show signs of moderate-to-severe depression, and 19% reported moderate-to-severe anxiety, according to the Generalized Anxiety Disorder-7, with older adolescents (15–19 years) more vulnerable overall, and older girls more prone to self-harm ideation. However, older boys were significantly more likely to turn to substance use as a coping mechanism than older girls (18% vs. 6%). The drivers of these negative mental health impacts during the pandemic include deepening household economic vulnerabilities, heightened intra-family tensions (boys and men spending more time at home, increasing domestic work burdens on girls and women), and isolation from peer networks, especially for girls. We conclude by discussing implications for policy and programming, in line with Sustainable Development Goal 3, to promote mental health and well-being for all. Measures include investing in age- and gender-responsive interventions (including social protection) to support positive coping repertoires among adolescents, mitigating risks of substance abuse, investing in counseling services (online and in-person), and paying particular attention to the most disadvantaged adolescents, especially those out of formal education.

Purpose The COVID-19 pandemic and associated risk-mitigation strategies have altered the social contexts in which adolescents in low- and middle-income countries live. Little is known, however, about the impacts of the pandemic on displaced populations, and how those impacts differ by gender and life stage. We investigate the extent to which the pandemic has compounded pre-existing social inequalities among adolescents in Jordan, and the role support structures play in promoting resilience. Methods Our analysis leverages longitudinal quantitative survey data and in-depth qualitative interviews, collected before and after the onset of COVID-19, with over 3,000 Syrian refugees, stateless Palestinians and vulnerable Jordanians, living in camps, host communities and informal tented settlements. We utilize mixed-methods analysis combining multivariate regression with deductive qualitative tools to evaluate pandemic impacts and associated policy responses on adolescent wellbeing and mental health, at three and nine months after the pandemic onset. We also explore the role of support systems at individual, household, community, and policy levels. Findings We find the pandemic has resulted in severe economic and service disruptions with far-reaching and heterogenous effects on adolescent wellbeing. Nine months into the pandemic, 19.3% of adolescents in the sample presented with symptoms of moderate-to severe depression, with small signs of improvement (3.2 percentage points [pp], p<0.001). Two thirds of adolescents reported household stress had increased during the pandemic, especially for Syrian adolescents in host communities (10.7pp higher than any other group, p<0.001). Social connectedness was particularly low for girls, who were 13.4 percentage points (p<0.001) more likely than boys to have had no interaction with friends in the past 7 days. Adolescent programming shows signs of being protective, particularly for girls, who were 8.8 percentage points (p<0.01) more likely to have a trusted friend than their peers who were not participating in programming. Conclusions Pre-existing social inequalities among refugee adolescents affected by forced displacement have been compounded during the COVID-19 pandemic, with related disruptions to services and social networks. To achieve Sustainable Development Goal targets to support healthy and empowered development in adolescence and early adulthood requires interventions that target the urgent needs of the most vulnerable adolescents while addressing population-level root causes and determinants of psychosocial wellbeing and resilience for all adolescent girls and boys.

Adaptive and adequately resourced health systems are necessary to achieve good health outcomes in post-conflict settings, however domains beyond the health system are also critical to ensure broader wellbeing. This paper focuses on the importance of psychosocial support services for adolescent girls in fragile contexts. Its starting point is that adolescence is a pivotal time in the life course but given the physical, cognitive and emotional changes triggered by the onset of puberty, it can also be a period of heightened sensitivity and vulnerability to trauma, social isolation, bullying by peers, a lack of supportive adults and gender-based and sexual violence. Our findings highlight why humanitarian and biomedical approaches in their current form are inadequate to address these complexities. Drawing on qualitative fieldwork (consisting of in-depth and key informant interviews as well as group discussions in Gaza, Liberia and Sri Lanka involving a total of 386 respondents across the three countries), we argue that going beyond biomedical approaches and considering the social determinants of health, including approaches to tackle discriminatory gendered norms and barriers to service access, are critical for achieving broader health and wellbeing. While all three case study countries are classified as post-conflict, the political economy dynamics vary with associated implications for experiences of psychosocial vulnerabilities and the service environment. The study concludes by reflecting on actions to address psychosocial vulnerabilities facing adolescent girls. These include: tailoring services to ensure gender and age-sensitivity; investing in capacity building of service providers to promote service uptake; and enhancing strategies to regulate and coordinate actors providing mental health and psychosocial support services.

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A descriptive cross-sectional study evaluated the compliance of physicians with the Palestinian essential drug list (EDL) in all the government primary care clinics in the Gaza Strip. While 67.4% reported currently using the EDL 51.2% of these physicians reported problems in using it. The mean number of drugs per prescription was 1.92, the percentage of drugs prescribed from the EDL was 97.9% but the percentage of drugs prescribed by generic name was only 5.5%. A copy of the EDL was available in 28.3% of clinics and the availability of key drugs was 82.6%. The compliance of physicians with the EDL was generally good, but more efforts are needed to encourage prescribing by generic name and to ensure the supply of key drugs. 1School of Public Health, Gaza, Palestine (Correspondence to R. Fattouh: r_m_11@hotmail.com). Impact de l'utilisation de la liste des médicaments essentiels : analyse des indicateurs d'utilisation des médicaments dans la Bande de GazaRÉSUMÉ Une étude transversale descriptive a évalué la manière dont les médecins respectaient la liste de médicaments essentiels palestinienne dans l'ensemble des centres de soins de santé primaires publics de la Bande de Gaza. Si 67,4 % des médecins ont affirmé recourir à cette liste, 51,2 % d'entre eux ont déclaré rencontrer des problèmes lors de son utilisation. Le nombre moyen de médicaments par prescription était de 1,92 ; le pourcentage de médicaments prescrits à partir de la liste était de 97,9 %, mais le pourcentage de médicaments prescrits par nom générique atteignait seulement 5,5 %. Un exemplaire de la liste était disponible dans 28,3 % des centres et les principaux médicaments étaient disponibles à 82,6 %. En général, les médecins se conformaient bien à la liste des médicaments essentiels, mais des efforts supplémentaires pour encourager la prescription de médicaments par leur nom générique et pour assurer l'approvisionnement en principaux médicaments essentiels doivent être réalisés.‫املتوسط‬ ‫لرشق‬ ‫الصحية‬ ‫املجلة‬ ‫عرش‬ ‫السادس‬ ‫املجلد‬ ‫الثامن‬ ‫العدد‬ 887

Implementing an appropriate drug dispensing system in hospitals is essential to ensure the safe and rational use of drugs. This study aimed to assess the unit-dose drug dispensing system (DDS) and the ward-stock DDS utilized in Gaza hospitals to ascertain which system is more beneficial. The quantitative, comparative cross-sectional design utilized structured interviews with pharmacists and head nurses, missing drug registration sheets and drug administration observation checklists. The number of missing units per drug item dispensed (mean 3.4 and 1.8 respectively) and medication administration errors per patient (mean 1.8 and 0.9 respectively) were statistically significantly lower in the hospital using the unit-dose DDS than the ward-stock DDS. The unitdose DDS appeared to be safer, with fewer missing drugs, was more positively perceived by staff and was more supportive of good clinical pharmacy practice. Its use in other hospitals in the Gaza Strip is recommended. 1Ministry of Health, Ramallah, Palestine (Correspondence to M. Al Adham: mokhlis78@gmail.com

Background: The World Health Organization recommends postnatal home visits (PNHVs) to improve maternal and newborn health. Evidence of PNHV effectiveness in humanitarian settings is limited. Aims: To evaluate PNHVs implemented in the constrained humanitarian context of Gaza. Methods: Qualitative data were obtained through key informant interviews, in-depth interviews and/or focus group discussions with women targeted by the programme, nontargeted women, husbands, and home visitors. These data were complemented by a secondary analysis of quantitative data from existing household surveys and project monitoring data. Qualitative data were analysed using thematic analysis, and quantitative data were analysed to describe trends over time. Results: Women in the programme demonstrated improved breastfeeding practices and increased uptake of breastfeeding, and behavioural changes reduced harmful traditional norms and practices. The programme increased mutual understanding and respect between health providers and women, allowed for a more personalized approach and increased self-esteem among the women. To improve postnatal care throughout the population, interventions should focus not only on home visits but also address immediate postnatal care in maternity, postnatal follow-up in clinics, and improvements in the coordination and communication between the different levels of care. Conclusion: Implementation of PNHVs in a constrained humanitarian context such as Gaza is feasible and positively contributes to breastfeeding and newborn care practices, as well as to improved interactions between health providers and their clients. Positive effects could be leveraged if postnatal care were strengthened throughout the continuum of care.

During counselling mothers, nurses should focus on promoting gradual weaning practices and abstain from using traditional methods. Also, nurses should receive training and supervision on the appropriate weaning practices.