Introduction
Background
Methods overview
Key-informant interviews
Participants and sampling
Participant category | Eligibility criteria |
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UNRWA staff | a) actors in the Health Programme and in the Relief and Social Services Programme engaged in routine and/or COVID-19 related service delivery at the clinical, area, field, or the headquarter level b) in position for 1 year or more and c) ≥18 years old |
Community members/ leaders | a) Palestine refugees i.e. registered with UNRWA b) residents of either Rafah or Jabalia camps c) ≥18 years old |
Recruitment
Participant category | Participant details | Number |
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UNRWA Headquarters (HQ) staff | Members of the COVID-19 Coordination Body (e.g. representatives from Protection, Planning, Security and Risk Management (SRM) among others) who were responsible for the overarching coordination and core administrative functions | 4 |
Field and area levela | Staff at the health, social work, planning, protection, operations, and emergency departments in Gaza Field Office | 9 |
Health and social care professionals (camp-based) a | Doctors (general or specialist), Nurses, Pharmacists, Head of health centers and coordinators, Social and relief service workers, and Psychosocial counsellors at either Rafah or Jabalia health centers | 12 |
Community members/ leaders | Community leaders (e.g., political, religious or leaders of NGOs) and members | 4 |
Data collection
Analysis
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Becoming familiar with the dataset: This phase involved reading and re-reading the transcripts and sometimes going back to the original audio-recordings. The purpose of this phase was to become immersed and deeply familiar with the information presented in the interviews.
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Coding of the interviews: Interviews were uploaded on Dedoose Version 7.0.23 for coding and subsequent analysis [30]. ZJ coded the interviews, and held several deliberations with KD to finalise coding tree and add new codes when relevant. The codes were developed to cover the elements of the conceptual framework on Social and Cultural determinants of Mental Disorders and the Sustainable Development Goals (Fig. 1). An additional code and subcodes were added to answer the second research question on UNRWA’s strategies. Using an inductive approach, information on UNRWA’s strategies were extracted.
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Generating themes and presenting the analytic narrative: Initially, ZJ started collating related codes and began developing initial themes around them. After that, ZJ started reviewing the generated themes, looking for patterns and overlap and weaving together the narrative so that the final list of identified themes genuinely “tell the story” behind the data. This whole process was iterative as ZJ was going back and forth to the raw data for deeper understanding and reflection and to collate relevant excerpts that illustrate the ideas presented.
Results
Theme 1: determinants which deteriorated as a result of COVID-19
“There were conflicts between people and the police for not complying with the instructions due to COVID… people were fed up and they didn’t abide by the instructions, which caused conflicts with the police. Frankly speaking, unhealthy meals were provided to patients at the governmental isolation areas. Also, if there was an infection, the authorities will quarantine the whole building and keep everyone locked up, without providing them with their food need, so people ran away. People were suffering both ways, whether quarantined at their homes or at the government isolation centres... In short, the pandemic affected three aspects: social, economic and psychological.” Psychosocial counselor_Jabalia 4
“Data indicates that we have an increase in domestic violence related to abuse within the family particularly on females. I think that is also affecting the mental health during the pandemic”. Headquarter staff_1.
“Of course, home quarantine generates a lot of family violence as a result of psychological pressure on people. Home quarantine is not easy especially when it is obligatory”. RSS_Jabalia 3
“Definitely this pandemic has affected food security and as I mentioned before, the majority of the Palestinian people live on an irregular daily work. A person for example, cannot leave his job, stay at home and deprive his family from many basic needs just to abide by the protective measures against coronavirus. The economic situation is very difficult for many people”. RSS-Jabalia 2.
“People stuck at home due to Coronavirus and this in itself has affected people negatively, as they don’t have enough food. I am talking about the majority (almost two-thirds of the community).” Psychologist_Jabalia 4.
“People were quarantined for a week and no one asked about them. They were trying to call the free number, but there was no answer… they [UNRWA staff] answered their calls, but after 10 days, then they brought food and aid. They provide aid to the quarantined, but frankly, irregularly. A large family needs to eat every day and only one meal is not enough. For example, my sister was quarantined, the first day they brought her rice, the second day they brought her cheese and milk, but what about the children? Where is the bread, where is the flour, where is the milk? Third and fourth day they did not bring anything, and so on”. Community member_Jabalia 1
“I was hoping UNRWA would do more, but you know in Gaza, we have limited resources. However, at least, to provide students with school books, how students can study without having textbooks. Okay they are available on the internet, but in Gaza, not all people have mobiles, iPads or laptops. Also, the distant learning curriculum is very difficult and intense and not all parents are educated. UNRWA currently started to distribute school books to parents, as there’s nothing more they can do.” Psycho-social worker_Rafah 5.
“This pandemic has greatly affected children and they were showing very violent behaviours without control. There were no schools, no electricity, no technology, and not all parents are educated to help their children with distance learning”. Psychosocial counselor_Jabalia 4.
“Parents also have noticed negative behaviours among their children as schools and streets were the only breathing space for them. I always recommend people to spend more time with their children, engaging them in doing useful things using simple materials” Psycho-social worker_Rafah 5
“UNRWA is considered as a pillar... our lives depend on UNRWA and the services it provides whether it is health services, coupons for food, education etc. We rely on UNRWA in everything. We fully trust UNRWA even now during the pandemic” Community member- Jabalia 1.
“Working from home is not an easy job and it is a big challenge for me and my family to provide the services required for that, in addition to the many tasks, we were asked to achieve… we serve our people, this is considered a patriotic and religious duty.” Social Worker_Jabalia 3.
“There was coordination between some associations and UNRWA. Some NGOs provided quantities of food parcels and medicines… and this is what I saw in reality”. Community member_ Jabalia 1.
“…We currently work in cooperation with the ministry of health and some NGOs. We have a list of NGOs with their contact details and addresses. If we detect a critical case over phone, we contact the NGOs and give them the case’s address and contact details and explain to them the exact condition of such case in order to make a home visit to them” Physician_Rafah 1.
“We are a conservative society, as family relations are great, but the COVID-19 pandemic was a shock to the Palestinian community. New concepts were introduced to people that were not desirable for them, such as social distancing, not shaking hands, wearing masks and gloves on a daily basis, preventing weddings, condolences and praying in mosques, many things. But we must change our perceptions and behaviours in order to protect ourselves from this disease.” Community members_Rafah 2.
“… neighbours help too. There is a family interdependence among people, even if UNRWA does not afford aid, people help each other.” Community member_Jabalia 1.
“I think there is a stigma in the community due to a number of mistakes made when dealing with cases by local authorities… when someone is tested positive for COVID-19, the local authorities go to pick him/her with an ambulance and a police car, so you can hear the ambulance sirens all the way to them and they also take their family members to be isolated in isolation centres. Accordingly, this caused a very negative reaction from the community and looked like it is a charge to be infected with COVID-19”. Gaza Field Office staff 5.
“Honestly, yes, they’re suffering from stigma, and that’s putting psychological pressure on them. People tend to isolate the infected people with COVID-19 and they are afraid to make any contact with them even after they recover”. Psychosocial counselor_Jabalia 4.
“Previously, people felt stigma to have mental issues or refused to go to psychiatrists, but nowadays people accept the situation and doctors were transferring patients to the psychiatrist clinics without any problems”. RSS_Rafah 5.
“…It [the pandemic] made them [UNRWA staff] closer to each other and they shared their concerns. I did a lot of things to support the staff “you are great“, psychodrama and a breakfast gathering. I think that the relationship between the staff is now way better than before, as they have time to sit and talk to each other. UNRWA’s staff members were also exchanging roles aiming at providing the service.” Psychosocial counselor_Jabalia 4.
“Moral support yes and this support really gave us a big push forward to continue working. Our administration at first announced if anyone of you is sick or afraid of getting sick from this disease, he/she may not work and can simply stay at home. But we insisted on working, since this is a humanitarian act that we cannot leave. The administration was very supportive as the line manager and the director of our department were in contact with us. Especially our department manager who was constantly communicating with us, and this indicates his sincerity at work. Personally, when I spoke to him one day and informed him that my car at work was broken and I could not work in this way, he understood and responded to me in an hour as he lent me his car which he uses for work and gave it to me so that I could continue my work to the fullest.” RSS_Jabalia 3.
Theme 2: determinants which aggravated COVID-19
“It [COVID-19] will be spread in a very fast way because of the highly populated areas, we are talking about the camps. I don’t know if you know how it is in the refugee camps in Gaza, it is very crowded. And if we are talking about physical distancing, it will not be possible at all. Even in the same house, you will find 10- 12 persons living in a small space”. Gaza Field Office staff 3.
“We have an abnormal population density in Gaza Strip. For example, we work in camps, and houses are very narrow, in one house there are ten or eleven people, or more, so imagine how difficult to quarantine people in houses like these. Thus, you find people standing at the doors of their houses. The houses are bad and there is not enough electricity, but anyway this is the bitter reality” RSS- Rafah 3.
“The houses are small and in poor condition, there is no ventilation or electricity”. Gaza Field Office staff 4.
“It greatly affected me to stay at home, because I have small children and sometimes, they are not able to provide me the right atmosphere for work. Just working at home has affected me a lot, and sometimes I get busy with some guests and family, and at the same time my manager calls me asking me for a specific task to fulfill. This affects me and causes a big tension on me. Often when I go to my family house, I take my laptop or my cell phone with me because I might need it to work there. Despite all of this, we were implementing what was asked of us, but at the expense of my time, my children and my home”. RSS_Jabalia 2.
“We were doing our job online via the Internet despite the frequent internet cuts, and it was very difficult for us”. RSS- Rafah 4.
Theme 3: determinants with bi-directional relationship with COVID-19
“Recently, the Director of UNRWA operations in Gaza, said two days ago, that they will give the staff half a salary next month, due to UNRWA’s limited resources. He also requested the support of donors and European countries to enable UNRWA to continue providing its services to citizens.” Nurse_Rafah 7.
“Many people will die of hunger if they do not go to work. For example, if there is closure in Gaza including the markets, people cannot stay at home, as they want to work and gain money for their families. As a result, people break the lockdown measures because it is difficult to stay at home, and people don’t have any other sources of income but their jobs… The economic situation is very difficult, some people do not have the price of the face masks, and there are some people who are taking antidepressants and antipsychotic medications to get through this period” Community member_Jabalia 1.
“Yes, sure, it [employment] was greatly affected, and it is known that unemployment is high. The situation during the pandemic is abnormal, and the general situation got worse, as many factories and shops have closed and suspended the work of their employees. This actually has worsened the psychological wellbeing of people as unemployment rate increased. “RSS_Jabalia 3.
“Gaza was significantly affected by UNRWA’s economic crisis… This also has affected the staff efficiency, in a way or another because there is no job security…. the daily-paid staff was affected in the beginning of the pandemic, as some of them have been laid off”. RSS- Rafah 5.
Theme 4: UNRWA’s response strategies
“…for the treatment of children or adults, there was a free number that they [UNRWA] gave it to everyone. In this regard, we held a meeting in the committee and we took these free numbers and sent them to social media and every other means that can reach patients, so that people know that there is a free number for the clinic, and through this number a person can call UNRWA and tell them about their illness and then provide them with treatment. Names of doctors were also listed to be in contact with people, and each doctor goes to the patient. Of course, this is for emergency cases”. Community member_Jabalia 1.
“At the beginning, the visit to the patient’s house operated for a week after that UNRWA stopped this method. UNRWA was not at the level required. UNRWA is expected to provide support and relief greater than that.” Community member_Jabalia 2.
“Because my work involves communicating with people, I receive several complaints. You know, patients are not limited to NCDs and pregnant women; we have many patients with other diseases who must come to the clinic to get the necessary treatment. In my opinion, I think it would have been better, if we applied work shifts, three shifts instead of two, to enable all patients to come to the clinic to get their treatment or to enable all patients, not just NCDs patients to access the telemedicine service, like patients who need general medications, like ointments and flu medicines. There is also a category requires care, like those who need to change wound or surgical dressings.” Psychosocial counselor_Jabalia4.
“(during community transmission) UNRWA was very flexible with both staff with chronic diseases such as NCDs and elderly staff members. These two groups can stay home, if they want to” Nurse_Rafah 7.
“UNRWA was very supportive during the pandemic. I am only 45 years old and UNRWA started delivering my medication for hypertension ever since the pandemic started. UNRWA staff were putting themselves under risk in order to deliver medicine to us at home. The delivery was prompt and everyone received his medications on time” Community member_ Jabalia 1.
“They [NCD patients] stopped attending the clinic on the 24th of August. Before this period, not all NCD patients can come to the clinic, only those aged 42 or below and who are in a good health. Currently, we do not allow any of them to attend the clinic again, alternatively we are following them up over the phone… Also we are delivering medication packages to NCD patients’ homes in order to reduce the number of patients coming to the clinic.” Psychosocial counselor_Jabalia 4.
“In terms of health, some patients have been affected, like cancer patients who want to get treatment outside Gaza, for example in Jerusalem, and that requires complex coordination with the concerned authorities” Nurse_Rafah 7.
“…In general, we suspended all the regular medical tests for patients with chronic diseases.” Nurse_Rafah 7
“There was also a delay in delivering subsidies (coupons every 3 months) to people for certain reason, as I got to know. Accordingly, this was a problem for people, who depend heavily on such coupons… people live under very difficult circumstances”. RSS- Rafah 5.
“The biggest problem is the food basket (coupon). This assistance has stopped for months, and some people are completely dependent on it…There is a delay in providing health services and food aid.” Community member_ Rafah 2.
“… UNRWA increased the quantities of food parcels and delivered medicines, and any request that people asked for from UNRWA was met. This is what I saw in reality.” Community member_ Jabalia 1
“… at the beginning of the pandemic, Gaza registered a large number of [mental health] cases... we coordinated with doctors and triage nurses that urgent cases, such as suicide and protection cases must come to the clinic because they require direct intervention… Before the pandemic, unfortunately there were only one or two psychiatrists to deal with the cases having mental issues in all of UNRWA’s clinics in Gaza. This psychiatrist will come to the clinic once or twice a month. We receive many cases that require psychiatrist consultation and therefore, we requested to have at least one psychiatrist at the clinic. May be our doctors can prescribe psychotic medications, but some cases require the intervention of a psychiatrist.” Psychosocial counsellor_ Rafah 5.
“The percentage of refugees in Gaza Strip is very huge, and UNRWA represents the main pillar on which they depend on, especially in light of the conditions in which Gaza Strip lives such as: siege, poverty, power cuts, division and many problems.” Community member- Rafah 2.
“We have circulated our numbers, so that refugees can contact us whenever they need a consultation or help in this regard [MHPSS]. We divided Gaza into five areas; North Gaza, city of Gaza, middle of Gaza, old city of Gaza and Rafah and for each area, there is a psychosocial counsellor, so any refugee has any inquiry or concerns can contact them”. Head of Health Center_ Rafah 1.
“We received many protection and violence cases in June and July and we have no time to handle all of them.” Psychosocial counselor_Jabalia 4.
“… You know, during the lockdown, all the family members were staying at home and this definitely had increased family problems, violence, GBV and suicides… The psychosocial workers also started in March to provide support and conduct self-care and stress relieving sessions for all staff members including cleaners and clerks”. Gaza Field Office staff 5.
“… I say we’re relatively limited in what we can do, you’ve got too many people in Gaza with PTSD given what they’ve gone through in the last 20 years, so we have to be realistic about our ability. We weren’t able to meet the needs before this. So we’re less equipped to meet increased needs during it. They are massive needs and we do what we can, but we were under no illusions.” Headquarter staff 3.
“… we have a hotline to provide social support and a hotline for GBV cases; women who are subjected to gender-based violence. We were receiving calls from people who exposed to gender-based violence and such cases were transferred to the protection department. We installed the hotline to enable people to contact us to get our guidance and help, even if we can’t reach them.” Headquarter staff_2.