Self-reported health complaints in a primary care population living under stressful conditions in the Gaza Strip, Palestine

Abstract

Background: The population in the Gaza Strip has been living under chronically stressful conditions as a result of the ongoing Israeli–Palestinian conflict.

Objectives: To identify health complaints reported by attendants consulting primary care physicians in the Gaza Strip.

Methods: The study took place in 10 governmental primary health care centres and 5 clinics of the United Nations Relief and Works Agency in the Gaza Strip, during autumn 2005. Self-reported health complaints were recorded through face-to-face interviews with 956 respondents using a validated and reliable questionnaire.

Results: Abdominal pain and headache were the most frequent complaints reported among patients aged 18 to 44 years, accounting for 23.3% and 22.7% of total complaints in males and females, respectively. Fatigue and joint pain were the most common complaints among patients aged 45 years and above, accounting for 26% and 33.9% of total complaints in males and females, respectively.

Conclusions: The most common complaints, as reported by patients attending PHC facilities were stress-related and could be attributed to the ongoing conflict and high level of violence and uncertainty in the area. These complaints present a challenge to primary care providers in their efforts to improve the everyday quality of life of Palestinian residents with scarce means and resources.

Keywords:

• self-reported complaints
• abdominal pain
• headache
• fatigue
• joint pain
• primary health care

Introduction

The Palestinian National Authority consists of two separate provinces, the Gaza Strip and the West Bank. As of mid-2005, the Palestinian population was estimated at a total of 3.762 million, of which 2.372 million lived in the West Bank and 1.390 million in the Gaza Strip1. In 1994, Palestinians were given control over their own health services with the challenge of reorganizing disordered health services into a cohesive, regulated and sustainable health care system2. Since then, the primary health care (PHC) system in the Gaza Strip has consisted of two main public service providers: the Palestinian Ministry of Health (MOH) and the United Nations Relief and Works Agency (UNRWA), in addition to private sector services. Its main purpose has been the provision of comprehensive PHC services to all Palestinians to improve the population's health status3.

The Israeli–Palestinian conflict, ongoing for more than half a century, has influenced all aspects of Palestinian people's lives, having a direct effect on their health1 ^, 2 ^, 4. War and conflict does not only lead to increasing numbers of death, injury and disability, but also affects physical and mental health in a variety of cumulative ways, including stress5-7. People who are in stressful conditions often complain of vague somatic/psychosomatic symptoms and conditions and the Palestinian people manifest a prime example. Personal stress caused by unemployment, the destruction of homes, the daily shortage of food and medications, and the overall hardships that Palestinians experience, has been implicated in the development and exhibition of various psychosomatic symptoms5 ^, 8 ^, 9. However, due to the ongoing conflict, most research and health reports have focused on the mental health of Palestinian children10-14 and on describing the nature of fatal and non-fatal injuries15 ^, 16, while little attention has been paid to examining the common complaints or symptoms reported by adults.

Thus, in order to investigate demand and utilization for PHC services in the Gaza Strip, a collaborative project between the University of Crete, Al-Quds University and the Palestinian MOH was initiated in 2003. The project's objectives included an exploration of PHC strategy, utilization of PHC services, patients' satisfaction with services provided17-20 and health complaints among PHC population. This paper reports on the five most common self-reported health complaints among adults attending PHC services in the Gaza Strip, and discusses these complaints in light of the stressful conditions encountered by Gaza Strip inhabitants.

Methodology

Setting and target population

A cross-sectional study took place during autumn 2005 in 10 PHC centres administered by MOH and 5 clinics supervised by UNRWA, located in the Southern Governorates of Palestine (Northern, Gaza, Middle Zone, Khan Younis and Rafah). Targeted patients were consulting General Practitioners (GPs) in the above centres. The sample size of 1,067 was based on power calculation prior to study implementation. Severely ill patients, and those less than 18-years-old, were excluded. A more detailed description of sample size, sampling and data collection has been reported in a previous article19. The study sample was categorized into two age groups (18–44 and >45), similarly to the methodology followed in an earlier study18.

Response rate

A total of 974 patients agreed to answer the questionnaire (response rate 91.3%). Since the health condition of 18 patients deteriorated during the interview and the sessions were interrupted, these patients were subsequently excluded from further analysis. Therefore, analysis was carried out on 956 patients.

Validation

Information about health complaints of patients was obtained through the question ‘Why are you coming to the PHC Centre?’ which was part of an extensive questionnaire designed to measure the demand for PHC in Palestine. It was translated to Arabic by standardized methods, and its content validity was rated excellent by a panel of 12 Palestinian experts in the field of Public Health. The Arabic version of the questionnaire was pilot-tested using a cognitive debriefing method with 10 patients who were not included in the actual study21.

Ethics

The Helsinki Committee of the Palestinian MOH and UNRWA Headquarters granted approval for carrying out this research study. In addition, approval to carry out fieldwork was obtained from the general directorate of governorates in the selected areas. Prior to interviews, a consent letter was read to patients who in return gave their approval to participate in the study.

Data quality management and analysis

Interviews were conducted by the first author and a well-trained researcher prior to the patient's consultation with the GP. Health complaints were entered, as they were reported by attendants, into the SPSS software program (version 15) for data analysis.

Results

General characteristics of subjects

Table 1 summarizes the general characteristics of the study sample. Patients aged 18–44 constituted a larger proportion of PHC respondents than those aged 45 and above. There were also more female patients than male (51.5% versus 48.5%). Patients' individual characteristics regarding physician consultations were not dependent on type of health providers, i.e. MOH versus UNRWA setting (P = 0.08).

Table 1. General characteristics of study sample (n = 956).

Variables	Total (n = 956)
Age group (year)
18–44	661 (69.1%)
≥45	295 (30.9%)
Total	956 (100%)
Sex
Male	464 (48.5%)
Female	492 (51.5%)
Total	956 (100%)
Male
18–44	314 (67.7%)
≥45	150 (32.3%)
Total	464 (100%)
Female
18–44	347 (70.5%)
≥45	145 (29.5%)
Total	492 (100%)

Self-reported complaints

Distributions of the five most common complaints reported by patients according to age, sex and providers are listed in Table 2. Abdominal pain, headache, fever, cough and back pain accounted for most complaints among male patients aged between 18–44 years. These complaints accounted for 48.7% of the total complaints in this category. Fatigue, joint pain, prescription for anti-diabetic drugs, headache and chest pain were the most common complaints among male patients aged 45 years and above. These complaints accounted for 50% of the total complaints in this category.

Table 2. The five most common complaints distributed by provider, age and sex (n = 956).

	MOH1		UNRWA2		Total
Complaints	Freq.	%	Freq.	%	Freq.	%
Male (aged 18–44)	n = 208		n = 106		n = 314
Abdominal pain	29	13.9	14	13.2	43	13.7
Headache	21	10.1	9	8.5	30	9.6
Fever	21	10.1	8	7.5	29	9.2
Cough	20	9.6	8	7.5	28	8.9
Back pain	14	6.7	9	8.5	23	7.3
Male (aged ≥45)	n = 96		n = 54		n = 150
Fatigue	16	16.7	9	16.7	25	16.7
Joint pain	10	10.4	4	7.4	14	9.3
Prescription diabetic drugs	10	10.4	4	7.4	14	9.3
Headache	6	6.3	6	11.1	12	8.0
Chest pain	7	7.3	3	5.6	10	6.7
Female (aged 18–44)	n = 254		n = 93		n = 347
Abdominal pain	40	15.7	8	8.6	48	13.8
Headache	22	8.7	9	9.7	31	8.9
Cough	18	7.1	5	5.4	23	6.6
Gynaecological complaints	12	4.7	11	11.8	23	6.6
Fever	12	4.7	8	8.6	20	5.8
Female (aged ≥ 45)	n = 95		n = 50		n = 145
Fatigue	17	17.9	13	26	30	20.7
Joint pain	14	14.7	6	12	20	13.2
Prescription diabetic drugs	12	12.6	5	10	17	11.7
Headache	6	6.3	6	12	12	8.3
Prescription antihypertensive drugs	10	10.5	0	0	10	6.9
Notes: 1Ministry of Health; 2United Nations Relief and Works Agency.

Among female patients aged between 18 and 44 years, abdominal pain, headache, cough, gynaecological complaints and fever were the most frequent complaints, accounting for 41.7% of the total complaints in this category. Fatigue, joint pain, prescription for anti-diabetic and anti-hypertensive drugs and headache were the most common complaints among female patients aged 45 years and above. These complaints accounted for 60.8% of the total complaints in this category. Finally, there was significant difference in the category of gynaecological complaints, with women aged 18–44 attending UNRWA clinics reporting a higher percentage (11.8%) than those attending MOH clinics (4.7%) (P < 0.05), as indicated in Table 2.

Discussion

Identification of the most common types of complaints reported by patients visiting primary care physicians in the Gaza Strip highlights a problem that presents a serious financial and human resource burden on the Palestinian health care system. Despite experiencing conditions of conflict, Palestinians had their first contact with physicians through PHC services, similar to patients in other countries22-23. However, findings from a previous study in the same sample revealed that the more educated Palestinian patients were, the less likely they were to use PHC services, as they tended to visit specialists more frequently than GPs18.

Our results showed that a larger number of patients aged 18–44 years consulted physicians, compared to patients 45 years old and above. This finding might be explained by the fact that the Palestinian population is predominantly young, composed of 30% in the 18–44 years old category, whereas only 10% are 45 years and above24. Despite the larger number of patients in the age category of 18–44, an earlier publication based on the same study sample showed that the frequency of visits and utilization of services was higher among those ≥45 years of age18. This outcome is consistent with that from a Canadian study showing overall health care utilization increasing significantly with age25 and could be attributed to older people being more likely to suffer from chronic diseases, therefore, requiring more frequent monitoring and care23 ^, 26.

Palestinian women, similar to women in several studies from developed and developing countries, were more frequent users of health services than Palestinian males25 ^, 27-30. This could be explained by epidemiological evidence that the prevalence of most pain conditions is higher among women than men31 ^, 32. In regards to provider differences, women attending the UNRWA clinics reported a significantly higher percentage of gynaecological complaints, compared to those attending PHC centres. This outcome could be attributed to the higher emphasis placed on women's and children's health at the UNRWA facilities.

In terms of the most frequent self-reported complaints, abdominal pain had the highest prevalence in the age group 18–44 years for both males and females, followed by headache. Both complaints are also listed among the most common health problems in a Swedish study33 and could be attributed to either somatic disease or stress. Particularly headache, one of the most common reasons for visiting a primary care physician in privileged countries34-36, has also been reported as a main complaint in areas experiencing conflict and unrest37. Evidence of co-morbidity between headache and depression, bipolar disorder, simple and social phobia and generalized anxiety disorder indicates the importance of mental health screening and early detection38-41.

The finding that back pain was the fifth most common complaint among male patients aged 18–44 years is in line with several other studies33 ^, 36 ^, 42 ^, 43. This can be explained by the fact that people in this age group are at the peak of their productivity and engage in arduous physical activities during their daily work. Elderly Palestinian patients complaining of joint pain and fatigue, felt pain in all of their body parts, as they explained during interviews. Both complaints are commonly reported symptoms among the elderly, having a powerful adverse effect on quality of life44. There is growing evidence that stressful life events are implicated in the development, exacerbation and maintenance of chronic pain syndromes, including abdominal45 ^, 46 and low back pain47 ^, 48, while headache is acknowledged as a multi-factorial disease49. This vulnerability to pain could be attributed to abnormal individual reactivity to normal stimuli or to increased environmental pressure.

The above findings are in accordance with studies from other areas under conflict, such as Kashmir37, Iraq50 and Afghanistan51 that have shown nervousness, tiredness, headaches, psychological distress and post-traumatic stress disorder (PTSD) as the main complaints of the population. Moreover, it has been argued that mental and psychological problems encountered in areas under turmoil are frequently ‘translated’ into psychosomatic symptoms such as muscle pain, tiredness, depression, fatigue, headaches and sleep disturbances in order to conform with acceptable cultural values and practices52. Thus, previous findings from the Gaza Strip showing that primary health care professionals were able to detect only 11.6% of mental health problems, with the remaining 88.4% cases going undetected53, are of particular concern.

Since fever and cough were placed among the frequent self-reported complaints, it is important to discuss to what extent those complaints might be associated with stressful living conditions. Fever needs an objective assessment and it is uncertain whether our finding represents a feeling or a clinical sign. On the other hand, chronic cough is often perceived as a trivial problem but can be a disabling symptom associated with significantly impaired quality of life54. Since cough was one of the most common symptoms for Palestinian patients, in consistence with a global health survey42 and a study carried out in Africa27, GPs in the Gaza Strip should be in a position to comprehend its importance and offer effective management by making referrals to specialized respiratory physicians55. Understanding and controlling the risk factors of coughs could contribute to the reduction of such complaints.

Finally, prescription writing for diabetic and hypertensive patients was another common reason for visiting PHC clinics among the older ages. This result reflects the significant prevalence of diabetes and hypertension among PHC patients and is in line with findings from other countries56 ^, 57.

Strengths and limitations

Inter-observer error may have occurred and an attempt to reduce this bias was made through limiting the number of data collectors to two. Sampling bias was minimized by including PHC centres from different geographic areas. The large number of patients, selected randomly, was representative of all patients consulting GPs in PHC settings in the Gaza Strip, while the reported health complaints did not reflect seasonal variation since it was carried out only during autumn. Since health complaints were self-reported, reporting biases could not be ruled out. There also might be an under-reporting of women's health problems and complaints because male researchers administered the interviews. Furthermore, since the Palestinian National Authority has not yet adopted the standardized coding methods in PHC, it was difficult to compare the reported complaints with those from other countries. Finally, although this study revealed several health complaints, it concentrated only on the main five.

Implications for policy and recommendations

Certain actions should be taken by both primary care professionals and policy makers in relation to physical health complaints encountered in the Gaza Strip PHC settings and the potentially hidden psychological morbidity. Firstly, to recognize and address the most prevalent self-reported complaints, such as pain, fatigue and chronic cough that can have debilitating effects on a person's ability to function and be a productive community member. Secondly, to more effectively manage chronic diseases such as diabetes and hypertension through the use of clinical guidelines and an interdisciplinary approach. Finally, to improve Palestinian GPs' capacity to deal with their patients' psychological symptoms and needs. All of the identified complaints should be urgently addressed by local health authorities through an integrated on-the-job training program for PHC physicians and other health professionals, targeting cost-effective and culturally appropriate interventions with a special emphasis on mental health screening, diagnosis and early intervention. Furthermore, the commissioning of studies to investigate the potential cause and effect association between the identified physical complaints and psychological morbidity is highly recommended.

Conclusions

The most common complaints reported by patients attending PHC facilities in the Gaza Strip were stress-related and could be attributed to the ongoing conflict and high level of violence and uncertainty in the area. These complaints present a challenge to primary care providers in their efforts to improve the every-day quality of life of Palestinian residents with scarce means and resources.

Current situation in Gaza

As of early January 2009, the latest Israeli military operations (28 days war: 27 December 2008 to 23 January 2009) on the Gaza Strip have considerably worsened the situation since the time our study was carried out, and has led to the destruction of infrastructure and buildings, including homes, universities, schools, clinics, hospitals, mosques, and welfare organizations. Hundreds of civilians were killed and thousands more injured, intensifying Gaza's humanitarian crisis. Eight hospitals were targeted and 40 primary health centres (33 MOH, 5 UNRWA and 2 NGOs) were targeted by Israeli forces. The Ministry of Health reported that more than 16 members from medical teams were killed in their course of duty and another 36 were injured during the 28 days of war. Israeli forces also targeted and destroyed 15 ambulances. In their efforts to deal with a death toll of more than 1455 people, along with over 5503 casualties, health care providers have been overburdened and are exhausted, and facilities have suffered the physical consequences of military attacks. Out of the 56 PHC centres owned by the MOH and the 18 owned by the UNRWA, 28 facilities functioned as emergency centres58. Therefore it can be anticipated that in the near future, stress-induced psychosomatic complaints, such as those reported in our study, will be far more prevalent and severe than previously studied.

Evidence from recent studies

Ten weeks after the end of the recent crisis, the WHO carried out a survey to measure the prevalence of psychological distress among 500 adult patients visiting five Primary Health Care (PHC) centres in the Gaza Strip, as well as to identify the ability of General Practitioners (GPs) to identify patients with psychiatric problems. The results of the study reveal that 37% of adult patients that sought PHC services showed psychological distress. Older patients showed higher rates of prevalence (70%). The prevalence of psychological distress was higher among:

1.	Patients with severe somatic symptoms (53.8%) as compared to those with mild somatic symptoms (27.4%);
2.	Patients with chronic conditions (51.8%) as compared to patients with no chronic conditions (32.3%).

The results of this survey also showed that the ability of the GPs in PHC centres to identify psychiatric problems was very limited59. In addition to this study, the Ministry of Health (General Directorate of Mental Health) reported an increase of psychological disorders in the Gaza Strip by 134% for the period from February to March 2009 (253 cases), compared with the same period of the year 2008 (108 cases), and an increase of Post Traumatic Symptoms Disorder (PTSD) by 486%60.

Acknowledgements

Scholarship funding for Tayser Abu-Mourad was provided by the Palestinian American Research Center (PARC). Special thanks to Dr Yehia Al Taweel, Dr Aymen Hamdan and Dr Samir Radi.