Ongoing Deterioration Of The Nutritional Status Of .
EMHJ Vol. 19Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientaleNo. 3 2013Ongoing deterioration of the nutritional status ofPalestinian preschool children in Gaza under theIsraeli siegeS.M. Radi,1 N.A. El-Sayed,2 L.M. Nofal 3 and Z.A. Abdeen 4 التدهور املتواصل يف احلالة التغذوية لدى األطفال الفلسطينيني ما قبل سن املدرسة يف غزة حتت احلصار اإلرسائييل زياد عبد املحسن عابدين ، ليىل حممد نوفل ، نوال عبد الرحيم السيد ، سمري حممد عبد اهلل رايض 2009 أجرى الباحثون هذا املسح السكاين املستعرض املرتكز عىل املجتمع يف مدينة غزة يف دولة فلسطني خالل النصف األول من عام : اخلالصـة يف ع ّينة %95.2 وكان معدل االستجابة . سنوات ممّن هم حتت احلصار 5-2 لدراسة الوضع التغذوي لألطفال الفلسطينيني ما قبل سن املدرسة بعمر وأن السبب الرئييس هو احلصار املفروض عىل قطاع ، يواجهون صعوبات يف الوصول إىل الطعام %94.4 واتضح أن معظم السكان . نسمة 770 بلغت ً وأن ما يزيد قلي ،)%85.5( وأن معظم السكان يعانون من عدم األمن الغذائي ، غزة ونقص منتجات الطعام من األطفال قبل سن املدرسة %50 ال عىل ولقد كان انعدام األمن . منهم يعانون من التقزُّ م %15 وأن ، ممن أجري هلم اختبار الرباز لدهيم عدوى بالطفيليات %26.8 وأن ، يعانون من فقر الدم . وأوضحت مؤرشات سوء التغذية أهنا كانت األسوأ يف قطاع غزة منذ عقود عديدة ، الغذائي هو املنبئ األول للتقزم ولنقص الوزن ABSTRACT This cross-sectional, community-based, household survey was carried out in Gaza City, Palestineduring the first half of 2009 to study the nutritional status of Palestinian preschool children aged 2–5 years underblockade. The response rate was 95.2% from a total sample of 770. The majority (94.4%) of households faceddifficulties accessing food, the main cause was the siege and the shortage of food products; and the majority(85.5%) were food insecure households. Just over 50% of the preschoolers were anaemic, 26.8% of those whohad a stool test had parasitic infections, and 15.0 were stunted. Food insecurity was the first predictor of stuntingand underweight, and malnutrition indicators indicate the worst situation in the Gaza Strip for several decades.Détérioration continue de l'état nutritionnel des enfants d'âge préscolaire palestiniens à Gaza sous siègeisraélienRÉSUMÉ La présente enquête auprès des ménages, transversale et communautaire, a été menée dans la ville deGaza (Palestine) sous blocus pendant la première moitié de l'année 2009 afin d'évaluer l'état nutritionnel desenfants palestiniens âgés de 2 à 5 ans non scolarisés. Le taux de réponse était de 95,2 % sur un échantillon total de770 enfants. La majorité des ménages (94,4 %) était confrontée à des difficultés pour se procurer de la nourriture.Le siège et la pénurie de produits alimentaires en étaient les causes principales. La majorité des ménages (85,5 %)souffrait d'insécurité alimentaire. Un peu plus de 50 % des enfants d'âge préscolaire étaient anémiques, 26,8 %de ceux qui ont passé une analyse de selles souffraient d'infections parasitaires et 15,0 % étaient atteints d'unretard de croissance. L'insécurité alimentaire était le premier facteur prédictif d'un retard de croissance et d'uneinsuffisance pondérale. Les indicateurs de malnutrition signalent la pire situation dans la Bande de Gaza depuisplusieurs décennies.Planning and Policy Making Unit, Ministry of Health, Gaza, Palestine (Correspondence to S.M. Radi: samir radi@hotmail.com).Department of Nutrition; 3Department of Biostatistics, High Institute of Public Health, University of Alexandria, Alexandria, Egypt.4Al-Quds Nutrition and Health Research Institute, Faculty of Medicine, Al-Quds University, Jerusalem, Palestine.12Received: 06/08/11; accepted: 01/11/11234
املجلد التاسع عرش العدد الثالث IntroductionThe Gaza Strip is a narrow piece of landlying on the coast of the MediterraneanSea on the crossroads of Africa and Asia.The total area of the Gaza Strip is 378km2 and it has a population of about 1.6million [1,2].In children, the preschool period isa time of significant growth in the social, cognitive, and emotional areas [3].Undernutrition contributes to morethan one-third of all deaths in childrenunder the age of 5 years [4], yet theinternational community and most developing countries have failed to tacklemalnutrition and nearly one-third ofchildren in the developing world remainunderweight or stunted [5].Anaemia is a widespread publichealth problem in the countries of theWorld Health Organization (WHO)Eastern Mediterranean Region: prevalence varies from a low of 17% to a highof over 70% among preschool children[6]. It is generally assumed that 50% ofthe cases of anaemia are due to iron deficiency [7]. Children’s nutritional statusdepends on 3 necessary components,food security, access to adequate healthcare, and adequate feeding practices [8].The United Nations Children’s Fund(UNICEF) reported that there is athreat of increasing undernutrition andrisk of dying from malnutrition in theGaza Strip since the rapid nutritionalassessment of children aged under 5years revealed steadily increasing trendsin recent years [9].The cause of unprecedented poverty in the Occupied Palestinian territory is the socioeconomic crisis thatbegan with the almost total siege ofGaza and the isolation of the Gaza Stripand the West Bank from each other andfrom the outside world by the Government of Israel [10]. The main driver ofPalestinian food insecurity is political,through the military and administrativemeasures imposed by the Israeli occupation, such as closures, and destructionof assets [11]. The nutritional status of املجلة الصحية لرشق املتوسط vulnerable groups in the Gaza Strip maybe adversely affected by these measures.This study was conducted to assessthe nutritional status of Palestinian preschool children aged 2–5 years in GazaCity under blockade. Our objectiveswere to identify household food security levels; to assess the prevalence ofanaemia among the targeted children;to assess the anthropometric indicatorsof nutritional status; and to investigatethe factors affecting nutritional status.MethodsThis community-based, cross-sectionalstudy was conducted during 2009, inGaza City. The sample included urban,rural and refugee camp children aged2–5 years.We used a multistage, stratified, cluster sampling technique with probabilityproportionate to size of population in thefirst stage and a constant number of children per cluster at the second stage. Thesampling frame was Gaza City; it wasdivided into 12 primary sampling units.Seven (7) of the primary samplingunits (Al-Shati Refugee Camp, AlMoghraga, Al-Sheikh Radwan, Al-Shagaia, Al-Sabra, Al-Zitoon and Al-Twfah)were randomly selected for this study;110 households were selected in eachunit giving a total of 770 children. Froma random starting point in each cluster,selection of households was startedand then a search was made door-todoor until the required sample size wasreached. Response rate was 95.2%: 37of selected households refused to participate. The final number of childrenparticipating in the study was therefore733 preschoolers aged 2–5 years.Data collection was carried out overa period of 6 months from January toJune 2009. Two days of training wereconducted, and a pilot study on 30 preschoolers from Gaza city was carriedout for validation and verification of thequestionnaires. These 30 children werenot included in the study sample.A structured questionnaire was designed by the researchers and checkedfor completeness and accuracy. Threeresearch teams conducted the interviews with the mothers of the childrenin their homes and collected the required data and measurements over2 days per week. Height and weightwere recorded. Height was measuredusing a measuring rod to the nearest0.1 cm. The Tanita Baby/Adult DigitalScale 1582 was used for weight measurements; weight was recorded to thenearest 0.1 kg [12,13]. Measurementswere collected according to criteria ofJelliffe et al. [14]. The nutritional indiceswere compared with reference values(WHO/National Centre for HealthStatistics standards) [15].Some of the mothers refused permission for their children to participatein the laboratory investigations. Only528 of the 733 in our sample had ahaemoglobin (Hb) test, and 485 gavea stool sample. Hb concentration wasmeasured using the most widely usedmethod (cyanmethaemoglobin) [16]and the stool samples for were tested forparasitic infection at the main Ministryof Health laboratory (El-Remal HealthCentre). We used the WHO cut-offpoint for anaemia for this age group,haemoglobin level 11 g/dL blood [17].Socioeconomic status of households was determined using factoranalysis. The appropriateness of thefactor analysis for the 18 variables usedin analysis was examined. Firstly, 10 ofthe 18 variables correlated at least 0.3with at least 1 other variable, suggestingappropriateness of factor analysis. Secondly, KMO (the Kaiser-Meyer-Olkingstatistic) was 0.553, above the recom mended value of 0.5, and Bartlett’s testof sphericity was significant (χ2 636.57,P 0.05). None of the variables demonstrated complex structure and none ofthe components had only one variablein it. Factor analysis was thus completedwith the remaining 12 variables. Internalconsistency was examined using Cronbach alpha for each of the extracted235
EMHJ Vol. 19factors. Principal components analysisdemonstrated the existence of 3 ei genvalues greater than 1.0, explaining73.82% of the variance. The Scree testprovides a graphic representation ofeigenvalues and was used to furtherclarify the number of components torotate. Cronbach alpha was 0.73 for fac tor 1, 0.63 for factor 2 and 0.87 for factor3. Composite scores were created, withhigher scores indicating higher socioeconomic status, which were then classified into groups using cluster analysis.Cluster analysis identified 2 groups, alow socioeconomic group and a highsocioeconomic group. The relative pov erty line was computed based on thePalestinian household expenditure andconsumption survey [18]. The officialpoverty line was estimated at 2362 newIsraeli shekels (about US 569.1 at thetime of the study) monthly consump tion expenditure for a representative6-person household. The per capitapoverty line was, therefore, estimatedat US 94.8 monthly consumption,around US 3.1 daily per capita consumption expenditure [19].Food security was categorized asfood secure (includes high and marginalfood secure) and food insecure (includeslow and very low food secure) [20].Data entry, management and analysis were carried out using SPSS, version16.0. Epi-Info, version 2002, was usedto calculate the nutritional indicators.Statistical significance was establishedat P 0.05. Frequency distributionswere generated for all variables and theunivariate analysis applied; those factors found to be statistically significantwere included in stepwise multivariatelogistic regression analysis.ResultsThe total sample was 733 children, 401(55%) boys and 332 (45%) girls. Thesample was collected from 7 districtsin Gaza City: these covered 3 types oflocality.236Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientaleNo. 3 2013Mean age was 42.4 [standard deviation (SD) 10.2] months. About 8% ofthe sample had been low-birth-weightbabies; 33.8% were the first in birthorder. The majority (95.8%) of the children had been breast-fed; 51.2% hadreceived mixed feeding and 44.6% wereexclusively breast-fed during the first 6months. The mean duration of breastfeeding was 15.0 (SD 6.7) months.About half (51.1%) of the childrenbelonged to families with 7 or moremembers and 25.1% belonged to families with 9 or more members. For 56.2%of the families, crowding index was 3per room: mean crowding index was3.29 (SD 1.52) per room.All of the households we studiedwere connected to the sewerage system;78% had a garbage container. Almost allhouseholds (99.9%) had a access to water: 92.0% purchased their drinking waterfrom a truck with tanks of filtered water,only 4.0% of households used tap waterfrom the municipality for drinking use.Most of the households (97.5%)we studied suffered from power privation and electricity shortages. Half(50.5%) the households used candles tocompensate the electricity shortage and43.0% used kerosene lamps. The majority (84.7%) of the households did nothave gas available for cooking on a dailybasis. Accordingly, they used alternativemethods: 28.4% used electricity, 41.4%used kerosene and 14.9% used wood.For 72.7% of the households monthly income was stated (by the mothers)to be insufficient. The distribution ofthe sample according to socioeconomicstatus was heavily skewed, the majority(93.5%) of households being classifiedinto the low socioeconomic group andthe rest as high socioeconomic group.The total proportion of householdsclassed as below the poverty line was92.1%. The majority of households(94.4%) faced difficulties with accessto food products in the previous year;only 1.1% did not face any difficultiesat all. The predominant causes (97.3%)of difficulty in accessing food identifiedby the mothers were the siege and theshortage of food products on the market, followed by increases in food prices(94.0%) and loss of income (63.0%).The majority (85.5%) of the households we studied were food insecureand 73.3% were considered very lowfood secure (Table 1). In Al-Zitoonand Al-Moghraga areas 95.5% of households were food insecure, followedby Al-Twfah and Al-Shagaaia areas at90.6%. The lowest level of food insecurity area in Gaza City was Al-Shataarefugee camp, but even here 68.6% ofhouseholds were classed as food insecure. These differences were statistically significant (χ2 58.09; P 0.001).In the rural area 95.4% of householdswere food insecure; in the urban areait was 86.9%. The differences betweenlocalities were statistically significant (χ2 33.8; P 0.001).The most common insecure fooditem was poultry (73.4%), followedby fruits and meats (67.9%) and fish(64.0%). Other items mentionedwere eggs (53.3%), yogurt and cheese(50.5%), and flour and bread (40.8%).Table 1 Distribution of households (n 733) in Gaza City according to food securitylevel, 2009Food security levelNo.%Secure10614.5HighMarginalInsecureLowVery low111.59513.062785.59012.253773.3
املجلد التاسع عرش العدد الثالث املجلة الصحية لرشق املتوسط Approximately two-thirds (70.3%) ofthe households had to borrow or usecredit to purchase food products in order to cope with food insecurity, while42.3% relied on aid and donations. Onethird (35.1%) of households reportedhaving to sell gold and 9.4% to sell assetsin order to cope with food insecurity.Approximately half (50.6%) of thepreschool children in our sample wereanaemic: mean haemoglobin level was10.98 (SD 1.00) g/dL. There was astatistically significant difference between the districts for prevalence ofanaemia (χ2 39.49, P 0.001). AlZitoon district had the highest prevalence (70.5%) followed by Al-Sabra(59.5%); Al-Shagaaia had the lowestprevalence (25.9%). The prevalence ofanaemia was greater (53.6%) in ruralareas than urban (50.8%) and refugeecamp (45.3%) areas, but the differencewas not statistically significant.Just over a quarter of the 485 children who had a stool analysis (26.8%)had parasitic infections, mostly withEntamoeba histolytica (15.7%) andGiardia lamblia (11.1%). There was asignificant difference according to age.Significantly more children in the olderage group (48–60 months) were in fected with G. lamblia (15.2%) and E.histolytica. (20.6%) than the younger agegroup (9.1%) and (13.1%) respectively(χ2 10.25; P 0.006).The overall prevalence of wasting,stunting and underweight was 3.5%,15,0%, and 6.1% respectively (Table 2),while the prevalence of overweight was2.9%. The prevalence of underweightamong the children was statistically significantly different between the districts(χ2 19.9, P 0.003), with the highestprevalence in Al-Moghraga (11.9%)followed by Al-Twfah (9.4%) and AlSheikh Radwan (8.8%). No significantdifference was found in the prevalenceof stunting between districts, the highestprevalence (17.6%) was in Al-SheikhRadwan followed by Al-Moghraga(16.5%). The highest prevalence ofwasting (7.3%) was in Al-Twfah followed by Al-Sheikh Radwan (4.9%)and Al-Moghraga (4.6%).The children who lived in the ruralareas had a higher prevalence of underweight (11.9%), stunting (16.5%) andanaemia (53.6%) than other localities(Table 2), but the difference was onlystatistically significant for underweight(χ2 8.6; P 0.014).Determinants of nutritionalstatusUnivariate analysis by using simplelogistic regressionStunting was significantly associated with poverty, food security andbirth weight. The prevalence of stuntingwas greater (15.9%) among the childrenfrom households below the poverty linewith a significantly higher risk than thosefrom households above the poverty line(5.2%) [odds ratio (OR) 3.45, 95%confidence interval (CI): 1.06–11.24;P 0.04] (Table 3). The prevalence ofstunting was greater (16.4%) among theTable 2 Indicators of malnutrition among 733 preschool children aged 2–5 years in3 types of locality in Gaza City, 2009IndicatorLocalityAll(n 733)AnaemiaaaUrban(n 519)Rural(n 109)Refugee camp(n g15.014.616.515.2Underweight6.14.611.96.7Hb 11 g/dL blood. Only 485 children had a blood test for anaemia.children from food insecure householdswith significantly higher risk comparedwith those belonging to the food securehouseholds (6.6%) (OR 2.78, 95% CI:1.25–6.15; P 0.012). The prevalenceof stunting was higher (29.3%) amongstudied preschool children with lowbirth weight, with significantly higher risk(OR 2.59, P 0.002) compared withthe children with normal birth weight.Underweight was significantlyassociated with food insecurity andartificial feeding. The prevalence ofunderweight was statistically greater(7%) among preschool children fromfood insecure households with the riskincreased about 8-fold (OR 7.92; 95%CI: 1.08–58.14; P 0.042) comparedwith those from food secure households(0.9%). Children who had had artificialfeeding had a significantly greater risk ofbeing underweight than those who hadbeen breastfed (OR 3.73; 95% CI:1.26–11.01; P 0.017).Wasting was apparently affected bycertain factors but the differences werenot significant, e.g. anaemic children hadmore than 2-fold risk of wasting compared with those who were not anaemic(OR 2.16, P 0.099). Children whohad had artificial feeding and those fromlow socioeconomic level householdshad an almost 2-fold greater risk ofwasting compared with those from highsocioeconomic level households andthose who had been breastfed.Factors showing an apparent butnot statistically significant associationwith anaemia included having Giardiainfection and being from non-refugeelocalities. No association was observedas regards the remaining variables.Multivariate analysisFood insecurity was the most significantfactor in stunting followed by low birthweight. The preschool children from thefood insecure households had an almost3 times greater risk of being stunted relative to those from food secure households (OR 2.86; 95% CI: 1.24–6.12;P 0.017) (Table 4). Children who had237
EMHJ Vol. 19Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientaleNo. 3 2013Table 3 Simple logistic regression analysis of factors associated with stuntingVariableTotalStuntingNo.OR (95% CI)P-value1.25 (0.51–3.02)0.6163.45 (1.06–11.24)0.040*2.78 (1.25–6.15)0.012*0.509%Socioeconomic levelHigh48612.5Low68510415.2PovertyAbove poverty line5835.2Below poverty 015714.2Female3325316.01.14 (0.76–1.72)24–4877515.41.09 714.4315375Not anaemicAnaemicNegative (Ref.)Giardia lambliaEntamoeba histolyticaFood securitySex0.675Age group (months)Weight at birthNormal BWLow BW2.59 (1.41–4.75)0.002*16.11.14 (0.41–3.13)0.7915815.51.09 (0.71–1.65)0.6852613814.62674115.41.06 (0.66–1.71)0.7983555615.85459.30.545 (0.20–1.42)0.217761114.50.904 (0.44–1.81)0.776Type of breastfeedingBreastfeeding (Ref.)Artificial feedingMixed feedingAnaemia (n 528)Stool analysis (n 485)*Significant at P 0.05.OR odds ratio; CI confidence interval; Ref. reference category.been low-birth-weight babies had a 2.66times greater risk of being stunted relative to preschoolers with normal birthweight (OR 2.66; 95% CI: 1.39–4.73;P 0.002).Food insecurity was the most significant factor in underweight, followedby locality (Table 4). The childrenfrom the food insecure householdshad 9 times the risk of being underweight compared with the childrenfrom the food secure households (OR 8.98; 95% CI: 1.20–7.28; P 0.033).Those living in rural areas had 2.5 timesthe risk of being underweight relative238to those who were resident in urbanareas (OR 2.40; 95% CI: 1.17–4.94;P 0.017).DiscussionThe ongoing complex emergencies inthe Gaza Strip over the past few years,with severe shortages of life basics,the extensive siege and the semipermanent border closures, have hada severe impact on the poorest andmost vulnerable people in the GazaStrip.The rate for exclusive breastfeedingin the present study was 44.6%, higherthan the 2004 rate (25.4%) in the studyby Palestinian Central Bureau of Statistics [21]. The higher figure in ourstudy may indicate an improvement inbreastfeeding practices over the last fewyears as well as a means of coping withthe recurrent shortage of infant formulaon the market in Gaza due to the siege.All the households we studied hadaccess to a water supply and to thesewerage system, although only a smallminority (4%) used tap water for drinking. These findings were supported by
املجلد التاسع عرش العدد الثالث املجلة الصحية لرشق املتوسط Table 4 Stepwise logistic regression analysis of factors associated with stuntingand underweightVariableBSEPOR (95% CI)0.4420.017*2.86 (1.24–6.12)0.3170.002*2.66 (1.39–4.73)StuntingFood securitySecure (Ref.)Insecure1.054Weight at birthNormal (Ref.)Low0.981UnderweightFood securitySecure (Ref.)Insecure2.1961.0270.033*8.98 (1.20–7.28)Rural0.8780.3680.017*2.40 (1.17–4.94)Refugee camp0.0030.4830.9961.00 (0.38–2.58)LocalityUrban (Ref.)*Significant at P 0.05.SE standard error; OR odds ratio; CI confidence interval; Ref reference category.recent reports from United Nations(UN) agencies [22,23]. Most of thehouseholds experienced a shortageof gas for food preparation. This alsosupports the findings of recent studies conducted by the United NationsPopulation Fund (UNPF) [24] andthe Food and Agriculture Organization(FAO) [23].Most of the households in thepresent study confronted difficultiesaccessing food during the year preceding the survey. The most often citedprevailing causes of difficulties were theongoing siege of Gaza and shortage offood commodities, followed by highprice of food products and the loss ofincome source. These findings did notdiffer from those of previous studies[13,21] and are in agreement with arecent report of the UN DevelopmentProgramme [25].The majority of studied householdswere food insecure, and although a different methodology was used by FAO/World Food Programme in their foodsecurity assessments, their recent reports revealed the deterioration in foodsecurity in the Gaza Strip [11,26].The rural locality had the greatestproportion of food insecure householdsand food insecure districts. These areas experience clashes along the borderwith Israel and are exposed to recurrentmilitary invasions and attacks, in addition to being very highly populated. Ourfindings are in agreement with those ofprevious studies [13,25].One out of two of our preschoolers was anaemic, a noticeably higherprevalence than in previous studiesconducted in Palestinian [27–29]. Thisindicates that the prevalence of anaemiaamong preschoolers in the Gaza Striphas been deteriorating since 2002 andthus anaemia is considered a severepublic health problem in the Palestinian's community. Not surprisingly, theGaza Strip, being subjected to on-going,blockade has one of the highest rates ofanaemia in the Middle East region, similar to the figure in Iraq, 56% [30]. Thelowest prevalence was in Israel (11.8%).Three consecutive main surveys document the nutritional status of preschoolchildren in Palestine were PalestinianCentral Bureau of Statistics [21,31], andUSAID [27] in addition to other considerable related surveys [32,33].The prevalence of underweight andstunting among the Gazan preschoolersin our study were the highest for severalyears, and is expected to be the highestsince the occupation in 1967 [31] (Table 5). The overall prevalence of wastingamong our preschoolers was markedlyhigher than in previous studies carriedout in the Gaza Strip since 2004 [21](Table 5).The prevalence of stunting and underweight among preschoolers in Gazaworsened considerably between 1996and 2010 [31] (Table 5). This is in lineTable 5 Comparison of anthropometric measurements among preschoolers in the Gaza Strip in different studies since 1996Publisher, year [reference number]Underweight (%)Stunting (%)Wasting (%)PCBS, 1996 [33]3.983.8USAID, 2003[29]NA12.73.9PCBS, 2004 [21]4111.4UNICEF, 2005 [34]5101WHO, 2006 [35]3103Current study (Radi et al.), 20136.1153.5PCBS Palestinian Central Bureau of Statistics.UNICEF United Nations Children’s Fund.WHO World Health Organization.239
EMHJ Vol. 19Eastern Mediterranean Health JournalLa Revue de Santé de la Méditerranée orientaleNo. 3 2013with the increasing prevalence of foodinsecurity and poverty among households in the Gaza Strip. Food insecurity was the most significant predictorof underweight and stunting among thepreschoolers in our sample.Taking into consideration that themain reported cause of food insecuritywas the prolonged siege on Gaza andthe shortage of food commodities since2006, it is reasonable to assume that thedeterioration in nutritional status in theGaza Strip was political in nature andman-made via the Israeli blockade andtightening of restrictions on the freemovement of people and goods in theGaza Strip and the unprecedented andprolonged closure of the Gaza Stripas confirmed by previous surveys byinternational agencies [11,34].Deterioration of the nutritional status among Gazan preschool childrenand the malnutrition indicators showsthe situation in the Gaza Strip is theworst for several decades. The ruralarea was the worst locality in the nutritional status of preschoolers; it also hasmore food insecure households anda higher prevalence of anaemia thanother localities.References1.Desk study on the environment in the occupied Palestinian territories. Geneva, United Nations Environment Programme; 2003.2.Population, Housing and Establishment Census, 2007. Censussemi-final results in Gaza Strip. Summary (Population and Housing). Ramallah, Palestinian Central Bureau of Statistics, 2008.Iron deficiency anaemia. Assessment, prevention and control. Aguide for programme managers. Geneva, World Health Organization, 2001 (WHO/NHD/01.3).18.Survey on the household expenditure and consumption. Ramallah, Palestine, Palestinian Central Bureau of Statistics, 2006.Poverty in the occupied Palestinian territory, 2007. Geneva,United Nations Relief and Works Agency, 2009 (Briefing paperMay 2009).3.Lucas BL, Feucht SA, Ogata BN. Nutrition in childhood. In:Mahan LK, Escott-Stump S. Krause's food, nutrition, and diettherapy. 12th ed. St Louis, Elsevier Science, 2008:222–242.19.4.Tracking progress on child and maternal nutrition: a survival anddevelopment priority. New York, United Nations Children’sFund, 2009.20. Boyle AM, Holben HD. Community nutrition in action: an entrepreneurial approach, 5th ed. Belmont, California, Wadsworth,Cengage Learning, 2010.5.Repositioning nutrition as central to development. A strategy forlarge-scale action. Washington DC, International Bank for Reconstruction and Development: World Bank, 2006.21.6.Bagchi K. Iron deficiency anaemia-an old enemy. Eastern Mediterranean Health Journal, 2004, 10(6):754–760.22. Gaza health assessment July 2009. Geneva, World Health Organization, 2009.7.Benoist B et al. Worldwide prevalence of anaemia 1993–2005.World Health Organization global databases on anaemia.Geneva, World Health Organization and Centers for DiseaseControl and Prevention, 2008.23. Emergency operation occupied Palestinian territory. Emergencyfood assistance for operation Lifeline Gaza. Rome, Food andAgriculture Organization of the United Nations, 2010.8.Emergency nutrition intervention guidelines consensus building workshop. Addis Ababa, Ethiopia, UNICEF, 2004 (Pressrelease: speech by United Nations Children’s Fund NutritionOfficer Sylvie Chamois).9.Feedback on the Rapid Nutritional Assessment of Children 6–59months in the Gaza Strip. Geneva, United Nations Children’sFund, 2008.10.Poverty in the occupied Palestinian territory 2007. Geneva, United Nations Relief and Works Agency, 2009 (Briefing paper).11.FAO, World Food Programme, United Nations Relief andWorks Agency. Joint rapid food security survey in the occupiedPalestinian Territory, 2008. Rome, Food and Agriculture Organization of the United Nations, 2008.12.Hammond K. Assessment: dietary and clinical data. In: MahanLK, Escott-Stump S. Krause’s food, nutrition, and diet therapy,12th ed. St Louis, Elsevier Science, 2008:383–409.13.Abdeen Z et al. Nutritional assessment of the West Bank andGaza Strip. Jerusalem: CARE International, 2002.14.Jelliffe DB et al. Community nutritional assessment. New York,Oxford University Press, 1989:68–105.15.WHO Multicentre Growth Reference Study Group. WHO childgrowth standards: length/height-for-age, weight for age, weightfor-length, weight-for-height and body mass index-for-age: methodsand development. Geneva, World Health Organization, 2006.16.24017.Anemia detection in health services. Guidelines for program managers. Seattle, Washington, Program for Appropriate Technology in Health (PATH), 1996:37.Demographic and Health Survey 2004. Press conference on theinitial survey results. Ramallah, Pales
78% had a garbage container. Almost all households (99.9%) had a access to wa-ter: 92.0% purchased their drinking water from a truck with tanks of filtered water, only 4.0% of households used tap water from the municipality for drinking use. Most of the households (97.5%) we studied suffe
May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)
Silat is a combative art of self-defense and survival rooted from Matay archipelago. It was traced at thé early of Langkasuka Kingdom (2nd century CE) till thé reign of Melaka (Malaysia) Sultanate era (13th century). Silat has now evolved to become part of social culture and tradition with thé appearance of a fine physical and spiritual .
On an exceptional basis, Member States may request UNESCO to provide thé candidates with access to thé platform so they can complète thé form by themselves. Thèse requests must be addressed to esd rize unesco. or by 15 A ril 2021 UNESCO will provide thé nomineewith accessto thé platform via their émail address.
̶The leading indicator of employee engagement is based on the quality of the relationship between employee and supervisor Empower your managers! ̶Help them understand the impact on the organization ̶Share important changes, plan options, tasks, and deadlines ̶Provide key messages and talking points ̶Prepare them to answer employee questions
Dr. Sunita Bharatwal** Dr. Pawan Garga*** Abstract Customer satisfaction is derived from thè functionalities and values, a product or Service can provide. The current study aims to segregate thè dimensions of ordine Service quality and gather insights on its impact on web shopping. The trends of purchases have
Chính Văn.- Còn đức Thế tôn thì tuệ giác cực kỳ trong sạch 8: hiện hành bất nhị 9, đạt đến vô tướng 10, đứng vào chỗ đứng của các đức Thế tôn 11, thể hiện tính bình đẳng của các Ngài, đến chỗ không còn chướng ngại 12, giáo pháp không thể khuynh đảo, tâm thức không bị cản trở, cái được
Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. Crawford M., Marsh D. The driving force : food in human evolution and the future.
Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. 3 Crawford M., Marsh D. The driving force : food in human evolution and the future.
