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Under-Five Malnutrition Among Palestine Refugee Children Living in Camps in Jordan: a Mixed-Methods Study

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Under-Five Malnutrition Among Palestine Refugee Children Living in Camps in Jordan: a Mixed-Methods Study Under-Five Malnutrition Among Palestine Refugee Children Living in Camps in Jordan: A Mixed-Methods Study The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Abu Kishk, Nada. 2020. Under-Five Malnutrition Among Palestine Refugee Children Living in Camps in Jordan: A Mixed-Methods Study. Master's thesis, Harvard Medical School. Citable link https://nrs.harvard.edu/URN-3:HUL.INSTREPOS:37365195 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA This thesis Under-Five Malnutrition Among Palestine Refugee Children Living in Palestine Refugee Camps in Jordan: A Mixed-Methods Study, presented by Nada AbuKishk and Submitted to the Faculty of The Harvard Medical School in Partial Fulfillment of the Requirements for the Master of Medical Sciences in Global Health Delivery in the Department of Global Health and Social Medicine has been read and approved by: Peter Rohloff, MD, PhD Joia Mukherjee, MD, MPH Mary C. Smith-Fawzi, ScD May 1, 2020 Under-Five Malnutrition Among Palestine Refugee Children Living in Camps in Jordan: A Mixed-Methods Study Nada Abu Kishk A Thesis Submitted to the Faculty of The Harvard Medical School in Partial Fulfillment of the Requirements for the Degree of Master of Medical Sciences in Global Health Delivery in the Department of Global Health and Social Medicine Harvard University Boston, Massachusetts. May 15, 2020 Thesis Advisor: Dr. Peter Rohloff Nada Abu Kishk Under-Five Malnutrition Among Palestine Refugee Children Living in Camps in Jordan: A Mixed-Methods Study Abstract Background The first part illustrates the historical dispossession of Palestine refugees and data scarcity for the nutritional status of their children. The second part demonstrates the study results of malnutrition among Palestine refugee children under-five years in Jordan. It also investigated the children's family's facilitators and structural barriers to food security. Methods In 2019, a household mixed-methods study was conducted in Jerash and Souf Palestine refugees' camps in Jordan. A random sample of 407 households, 20 in-depth interviews with the children's mothers, and two focus groups for UNRWA staff, were used. Demographic, socioeconomics, food insecurity scores, diet quality, and anthropometric data were recorded using REDCap, with written consents. Descriptive analysis, bivariate, and multivariate analysis was performed for the quantitative data and deductive thematic coding for qualitative data. Approved IRB by Harvard Medical School and UNRWA, were obtained. The World Health Organization software (WHO- Anthro-Plus), was used to calculate the prevalence of stunting (Height-for-Age <-2SD) and overweight (Weight/Height-for-Age >+2SD). Written consents were obtained from the parents. Results Out of 405 household participants approached, 367 were eligible, children age was (2.74±1.15yrs), 182(49.6%) were female. No significant differences in the prevalence of stunting between Jerash and Souf camp were found (23.6% vs. 20%, respectively). However, overweight was significantly higher in Jerash compared to Souf (18% vs. 7%, respectively). Food insecurity ii (scores>8) in both camps was 72.7% (276). Souf camp had less food insecurity, (OR 0.61 [0.35- 1.05], p=0.07), and the less number of months with an income, in the last six months, was significant with food insecurity (OR 0.60 [0.51-0.71], p<0.001). Three thematic groups emerged from qualitative data, including (a) strategies for obtaining food or food aid, (b) factors impacting children's nutritional status and diet quality, and (c) the central role of mothers as strategists and household managers. Conclusion We found a moderate-to-high prevalence of stunting and overweight levels among Palestine refugee children in both camps, high food insecurity levels related to income. We believe that these findings are associated with the lack of meaningful livelihood among Palestine refugees living in both camps. This study constitutes an initial step for future studies among Palestine Refugee children in other camps. iii Table of Contents Part 1: Political Economy/Background ........................................................................................... 1 Preface............................................................................................................................................. 1 Road map of background paper .................................................................................................. 2 Child health as a refugee ............................................................................................................. 2 Child malnutrition ....................................................................................................................... 5 Child malnutrition among Palestine refugee children ................................................................. 6 The story of Palestine and Palestine refugee ............................................................................... 7 Palestine refugee current status ................................................................................................. 13 Part 2: Publishable Paper .............................................................................................................. 18 Introduction ................................................................................................................................... 18 Methods......................................................................................................................................... 21 Setting: ...................................................................................................................................... 21 Study design .............................................................................................................................. 22 Study population ....................................................................................................................... 22 Quantitative Sampling and data collection................................................................................ 22 Quantitative Measures ............................................................................................................... 23 Quantitative Data analysis ......................................................................................................... 25 Sample size calculation ............................................................................................................. 25 Qualitative sampling and data collection .................................................................................. 26 Qualitative Data Analysis.......................................................................................................... 27 Ethical considerations ............................................................................................................... 27 Results ........................................................................................................................................... 28 Quantitative results .................................................................................................................... 28 Qualitative analysis ................................................................................................................... 37 Discussion ..................................................................................................................................... 49 Conclusion and Recommendations ............................................................................................... 55 Appendices .................................................................................................................................... 62 Appendix 1 GIS maps for Jerash and Souf camps .................................................................... 62 Appendix 2 Household questionnaire for the children’s Parent/LAR ...................................... 62 Appendix 3 Child questionnaire ................................................................................................ 65 iv Appendices 4 Semi-structured interview guide for the children’s Parent/LAR in-depth interviews .................................................................................................................................. 66 Appendix 5 Interview guide for the UNRWA’s focus group ................................................... 67 Appendix 6 Multivariate analysis for the outcome of child stunting and overweight .............. 68 v Figures Figure 1: UN partition plan for Palestine in 1947 and occupation by Israeli forces in 1949 ....... 10 Figure 2: Palestine loss of land from 1946 to 2000 ...................................................................... 12 Figure 3: Maps of Jordan with Palestine refugee camps of Jerash and Souf ................................ 21 Figure 4: Flow diagram of the study participants ......................................................................... 28 Figure 5: The percentage of responses for food insecurity questions among Palestine refugee parents in both camps.................................................................................................................... 34 vi Tables Table 1: Descriptive
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