Barriers faced by primary healthcare providers in addressing emergency situations in the Northern region of Palestine before and during the Gaza war

doi:10.21203/rs.3.rs-4327941/v1

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Research Article

Barriers faced by primary healthcare providers in addressing emergency situations in the Northern region of Palestine before and during the Gaza war

https://doi.org/10.21203/rs.3.rs-4327941/v1

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published 17 Jul, 2024

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Introduction: Physicians working in primary health care (PHC) centers are the first contact for patients and expected to deal with emergencies. Emergency care training in PHC settings has been neglected globally, especially in low to middle income countries. Adequate preparation becomes especially important during periods of conflict. The study objectives are to identify the barriers facing PHC physicians when dealing with emergency cases in the northern region of Palestine.

Methods: A cross-sectional study was conducted with 179 physicians working in the 10 PHC centers distributed among 5 northern governances in Palestine. The study period was from July through December 2023. Data was collected electronically through a self-administered questionnaire adapted from literature review that was internally valid based on the measurement of Cronbach's alpha coefficient.

Results: The physicians’ ages ranged between 25 and 60 years with a mean ± SD of (35.3 ± 8.15) years. Most were not boarded in a specialty (91.6%). The majority attended BLS courses (85.5%), whereas 45.2% and 72% had never attended ACLS or ATLS, respectively. Physicians who reported having work experience in emergency departments (P value = 0.002) and reported attending ACLS courses (P value < 0.001) had a significantly higher perceived level of competence in dealing with emergency cases than others.

Conclusion: Emergency services at PHC in northern Palestine are functioning but have room for improvement. Efforts and resources are needed to increase availability of equipment, supplies, and drugs. Training in emergency management courses like ACLS would enhance the level of competence of physicians to perform emergency skills.

primary health care

emergencies

developing countries

physicians

A medical emergency is defined as a critical and abrupt situation that necessitates quick action due to the potential life-threatening effects. (1) Workers in primary care settings around the world may encounter numerous emergencies such as asthma, anaphylaxis, shock, dyspnea, seizure, and cardiac arrest. (2, 3, 4) Hence, primary care doctors should be prepared to administer basic and advanced life support in situations where there may be a delay in ambulance arrival, or when patients underestimate the urgency of their condition. (5)

With the ongoing war in Gaza and the increased atrocities in the West Bank, it is more crucial than ever for primary care physicians to have the skills to handle emergencies. From October 7th to the end of 2023, there was a 50% increase in lethal attacks in the West Bank compared to the first nine months of the year. (5) As an occupied territory, checkpoints and unexpected road closures make travel difficult. This has grown worse on the West Bank with the Gaza war as the Israeli army attacks cars, storms homes, and Settlers are armed. (5) Ambulances are often obstructed from moving and medics have been wounded. (5) More medical emergencies present to local clinics. Unfortunately, primary care centers and physicians are not well-equipped to handle the emergencies.

Globally, emergency care in primary health care settings has been neglected, especially in countries with low or middle incomes like Palestine (11). Primary health care physicians face many obstacles when dealing with emergency cases including lack of appropriate equipment and medications, unavailability of equipped ambulances to transport cases, and limited competence to respond to emergencies due to limited exposure to cases and the challenges of keeping skills updated (12). Courses like basic life support (BLS) and advanced cardiac life support (ACLS) can assist in better emergency management(13).

To date, no research has been done on the emergency services offered by Palestinian primary health care centers. The study objectives are to identify the barriers facing primary health care physicians when dealing with emergencies in the northern areas of Palestine.

2.1 Study Design and Setting

Using a cross-sectional study design, self-administered online questionnaires, were provided electronically to 150 physicians during their work hours at primary health care clinics in the region. An electronic version of the questionnaire was also distributed to 29 primary health care clinicians at home who had difficulty accessing their clinical setting due to the war.

Data were collected from 10 major PHC centers distributed in 5 geographical areas including: Tulkarem, Nablus, Jenin, Salfit and Qalqilya during a 4-month period.

Target Population, inclusion and exclusion criteria.

Physicians working in primary health care clinics in Northern areas of Palestine were recruited according to the following:

Inclusion criteria: primary health care physicians providing curative, preventative and promotional health care services.
Exclusion criteria: primary health care physicians who do only administrative work and have no contact with patients.

Sample size and sampling technique.

The total number of PHC physicians in Northern areas was 510 (14). Sample size was calculated with Raosoft software. With 95% level of confidence and 5% margin of error and the estimated sample size was 220. A non-probability, convenient sampling technique was used.

Data Tool

The questionnaire structure was based on a similar study conducted in Saudi Arabia (13), and contained the following:

1-Socio-demographic data and questions to identify the level of training in primary health care, experience in primary care, previous working experience in the emergency department (ED) setting, and participation in emergency courses.

2-Questions to determine their perceived level of competence when dealing with emergency cases, self-reported frequency of emergency cases in the last 12 months and their satisfaction with emergency services provided at their primary health care centers (3).

3- The availability in their settings of equipment, drugs, ambulance and other supporting facilities which are needed to deal with emergency cases based on other studies (3, 13).

Validity and Reliability of the tool

We pre-tested the questionnaire to ensure validity and reliability. For internal validity, three experts in the field reviewed the questionnaire. Internal consistency was assessed by measuring Cronbach's alpha coefficient for sections. Section 1 addressed the duration since the last attendance at one of the emergency courses (BLS, ACLS & ATLS) and the result was 0.84. Section 2 examined the frequency of certain emergency cases (eg. asthma, cardiac arrest, etc.) and the result was 0.83. Section 3 assessed at the level of competence to perform certain emergency skills (eg. cardiac compression, bag & mask resuscitation, etc.) and the result was 0.82. Section 4 assessed the availability of emergency equipment, drugs, and facilities and the result was 0.83. Section 5 probed physicians’ satisfaction regarding the management of certain emergency cases and the result was 0.9. All results were between Cronbach alpha 0.8–0.9, showing good reliability.

Data analysis plan

Data entry and analysis was conducted using SPSS software version 25. Mean & standard deviation were used to describe age. Physicians’ characteristics (age, gender, the city where their primary health care centers are located), the frequency of emergency cases, the level of competence to perform emergency skills, the availability of tools, and the physician’s level of satisfaction regarding the management of certain emergency cases were described with frequencies and percentages. A Chi square test was used to indicate statistical significance for attending emergency courses, work experience in emergency department or primary health care clinics, and the perceived level of competence to handle emergency cases. Finally, a multivariable analysis was conducted to track possible confounders of significant associations.

Ethical consideration

All procedures performed in this study, involving human participants, were consistent with the research ethical standards. The An-Najah National University Institutional Review Board (IRB) provided ethical approval (Ref: Med. May.2023/24). The Ministry of Health authorized the study at its primary care centers.

There were 179 physician participants. (Table 1) shows their socio-demographic characteristics. Ages ranged between 25 and 60 years with a mean ± SD of (35.3 ± 8.15) years. Almost half of physicians (58.7%) were between 25 and 35 years. Male physicians comprised 56.4% of the sample. The majority of physicians (91.6%) are general practitioners, which means they completed medical school and a one-year rotating hospital-based internship. Physicians boarded in family medicine comprised 5.6% of the sample.

Table 1

Socio-demographic characteristics of the primary health care physician respondents
Variables	Frequency (%) or median [Q1-Q3] n = 179
Age	33 [29–40]
Gender Male Female	101 (56.4) 78 (43.6)
Marital status Married Single Divorced	125 (69.8) 52 (29.1) 2 (1.1)
Job Title General Practice ^a Family medicine Specialist Gynecologist Pediatrician	164 (91.6) 10 (5.6) 1 (0.6) 4 (2.2)
City Nablus Jenin Tulkarem Qalqilya Salfit	55 (30.7) 46 (25.7) 43 (24) 28 (15.6) 7 (3.9)
^a General Practice are physicians who completed medical school and a one-year hospital-based internship.

(Table 2) shows the perceived level of competence to perform emergency skills. Almost half of primary health care physicians (48%) will perform simple suturing and nebulization and oxygen therapy (44.7%). Over a third of the physicians will attempt bag and mask resuscitation (40.2%), cardiac compression (35.8%) and read ECGs (34.1%). One fifth (20.1%) said that “they don't know where to start” regarding performing defibrillation, whereas (46.9%) said they will intervene if there was no one else available to defibrillate.

Table 2

Physicians’ perceived level of competence to perform emergency skills.
Emergency Skills	Frequency (%) n = 179
Emergency Skills	I do not know where to start	I will do only if no one else is available	I will attempt in most cases	I will attempt in all cases
Cardiac compression	1 (0.6)	40 (22.3)	74 (41.3)	64 (35.8)
Bag & mask resuscitation	2 (1.1)	32 (17.9)	73 (40.8)	72 (40.2)
Nebulization & oxygen therapy	2 (1.1)	24 (13.4)	73 (40.8)	80 (44.7)
Inserting IV cannula	8 (4.5)	61 (34.1)	58 (32.4)	52 (29.1)
Urinary catheter insertion	9 (5)	68 (38)	58 (32.4)	44 (24.6)
Reading ECG	4 (2.2)	33 (18.4)	81 (45.3)	61 (34.1)
Defibrillation	36 (20.1)	84 (46.9)	38 (21.2)	21 (11.7)
Simple suture	5 (2.8)	31 (17.3)	57 (31.8)	86 (48)

(Table 3) compares the perceived level of competence in performing emergency procedures by demographics, experience, and training factors. Males, physicians who had worked in the ED more than one year, and physicians who had taken a BLS and/or ACLS, and/or ATLS course reported significantly more competence. (Table 4 ) shows the frequency of emergency cases seen in primary health care clinics in the last year. Renal colic was the most common, with half of the primary health care physicians (50.3%) having seen three or more cases in the last 12 months. Asthma, angina, and hypoglycemia were reported by a third of the physicians as having seen three or more cases in the last 12 months (38%, 32.4% and 31.9%, respectively). Approximately one quarter (24.6%) have seen three or more cases of acute myocardial infarction, and 8.4% had seen three or more cases of cardiac arrest in the past year.

Table 3

Factors associated with perceived level of competence in performing emergency skill scale among primary health care physicians
Variable	Score of level of competence in performing emergency skill scale (8–32)
Variable	Median [Q1-Q3] n = 179	Mean Rank	P-value ^a
Age 25–34 35–44 ≥ 45	18.5 [14.5-23.25] 23 [13–24] 16 [14.5–19]	86.50 96.32 91.35	0.545 ^c
Gender Male Female	16 [13–20] 15 [13–17]	101.69 74.87	0.001 ^b
Marital status Married Single Divorced	20 [16–24] 18.5 [14–23] -	92.01 90.02 36.75	0.332 ^c
Job Title GP Family medicine Gynecologist Pediatrician	18.5 [14.5–23.5] - - 16.5 [14–19]	88.68 102.00 100.00 111.63	0.709 ^c
Working years in PHC < 1 year 1–5 years > 5 years	23.5 [17.75-24] 20 [14-23.5] 17 [14–21]	101.51 82.34 90.96	0.199 ^c
Working years in ED < 1 year 1–5 years > 5 years	15 [12.75–20.25] 19 [16.25–22.75] 23.5 [16.75-24]	82.33 95.53 127.00	0.008 ^c
BLS Course Yes No	16 [13–19] 14.5 [12.5–17]	93.03 72.17	0.057 ^b
Duration since attending Basic Life Support <1 year 1–2 years > 2 years	16 [14.5–24] 23 [18–24] 17 [13–19]	74.36 79.85 76.11	0.830 ^c
ACLS Yes No	16 [13.75–20.25] 15 [13–17]	101.32 76.30	0.001 ^b
Duration since attending ACLS < 1 year 1–2 years > 2 years	23 [15.25-24] 17 [15–23] 18 [13–21]	59.22 48.67 47.16	0.316 ^c
ATLS Yes No	17 [13-21.25] 15 [13–18]	104.32 84.45	0.021 ^b
Duration since attending ATLS < 1 year 1–2 years > 2 years	16.5 [13–23] 21 [15 -22.5] 16 [13.5–19.5]	25.19 30.61 24.18	0.498 ^c
^a The bold values indicate p < 0.05
^b Statistical significance values calculated using the Kruskal–Wallis test
^c Statistical significance values calculated using the Mann–Whitney U test

Table 4

Frequency of self-reported emergency cases seen by primary health care physicians in the last 12 months
Emergency Cases	Frequency (%) n = 179
Emergency Cases	None	1–2	≥ 3
Acute asthma	30 (16.8)	81 (45.2)	68 (38)
Myocardial infarction	62 (34.6)	73 (40.8)	44 (24.6)
Angina pectoris	47 (26.3)	74 (41.3)	58 (32.4)
Cardiac arrest	116 (64.8)	48 (26.8)	15 (8.4)
Severe dehydration	61 (34.1)	75 (41.9)	43 (24)
Renal colic	13 (7.3)	76 (42.5)	90 (50.3)
Acute GI bleeding	109 (60.9)	48 (26.8)	22 (12.3)
Hypoglycemia	43 (24)	79 (44.1)	57 (31.9)
Diabetic ketoacidosis	75 (41.9)	74 (41.3)	30 (16.8)
Convulsion	70 (39.1)	77 (43)	32 (17.9)
Anaphylaxis	81 (45.3)	68 (38)	30 (16.7)
Acute vaginal bleeding	115 (64.2)	41 (22.9)	23 (12.8)

(Table 5) describes the primary health care centers readiness to manage emergency care. Cannulas, oxygen masks, dressing trays, and scissors were available in almost all primary health care clinics. On the other hand, defibrillators, splints, suction devices, and endotracheal tubes were only available in (20.7%), (22.9%), (34.6%) and (38%) of primary health care clinics, respectively. Laboratories were available in (90.5%) of clinics, whereas x-ray and equipped ambulances were present in (28.5%) and (6.1%), respectively.

Table 5

Availability of equipment, drugs and supporting facilities needed for emergency care at primary health care centers
Item	Frequency (%) n = 179
Equipment
Cannula	177 (98.9)
IV stand	160 (89.4)
Urinary catheter	91 (50.8)
Dressing tray	161 (89.9)
Side lamp with stand	112 (62.6)
Splint	41 (22.9)
Scissors	161 (89.9)
Suture kit	157 (87.7)
Ambu bag	109 (60.9)
Nebulizer	159 (88.8)
O2 cylinder with standard fit	137 (76.5)
Laryngoscope	73 (40.8)
Endotracheal tube	68 (38.0)
O2 mask	162 (90.5)
Defibrillator	37 (20.7)
Suction	62 (34.6)
Drugs and IV fluids
Sublingual Nitrate	85 (47.5)
Glucagon	34 (19)
Aspirin	169 (94.4)
Furosemide	150 (83.8)
Morphine	29 (16.2)
Metoclopramide	147 (82.1)
Diazepam	130 (72.6)
Ventolin	167 (93.3)
Hyoscine	104 (58.1)
Normal saline	172 (96.1)
Ringer lactate	114 (63.7)
Dextrose 5%	126 (70.4)
Adrenaline injection	149 (83.2)
Antihistamine injection	153 (85.5)
Calcium chloride injection	20 (11.2)
Hydrocortisone injection	88 (49.2)
Supporting Facilities
X ray	51 (28.5)
Laboratory	162 (90.5)
Equipped ambulance	11 (6.1)

(Table 6) shows the primary health care physicians’ satisfaction regarding the management of emergency cases in their centers. The highest satisfaction rates were with managing severe dehydration (48%), followed by hypoglycemia (38.5%), anaphylaxis (33%) and acute asthma (30.7%). In contrast, physicians were the least satisfied with the management of cardiac arrest (26.8%), acute vaginal bleeding (21.8%), acute gastrointestinal bleeding (19%), myocardial infarction (18.4%), diabetic ketoacidosis (14.5%) and renal colic (14.5%).

Table 6

Level of satisfaction of primary health care physicians regarding emergency services provided at their primary health care centers
Emergency Cases	Frequency (%) n = 179
Emergency Cases	Not satisfied	Satisfied, but there's a lack in equipment	Satisfied, but there's a lack in medication	Satisfied, but there's a lack in training	Satisfied
Acute asthma	10 (5.6)	45 (25.1)	46 (25.7)	23 (12.8)	55 (30.7)
Myocardial infarction	33 (18.4)	52 (29.1)	37 (20.7)	31 (17.3)	26 (14.5)
Angina pectoris	22 (12.3)	41 (22.9)	46 (25.7)	29 (16.2)	41 (22.9)
Cardiac arrest	48 (26.8)	47 (26.2)	14 (7.8)	47 (26.3)	23 (12.8)
Severe dehydration	11 (6.1)	33 (18.4)	32 (17.9)	17 (9.5)	86 (48)
Renal colic	26 (14.5)	31 (17.3)	43 (24)	32 (17.9)	47 (26.3)
Acute GI bleeding	34 (19)	61 (34.1)	25 (14)	36 (20.1)	23 (12.8)
Hypoglycemia	9 (5)	23 (12.8)	56 (31.3)	22 (12.3)	69 (38.5)
Diabetic ketoacidosis	26 (14.5)	31 (17.3)	43 (24)	32 (17.9)	47 (26.3)
Convulsion	18 (10.1)	24 (13.4)	46 (25.7)	42 (23.5)	49 (27.4)
Anaphylaxis	12 (6.7)	29 (16.2)	44 (24.6)	35 (19.6)	59 (33)
Acute vaginal bleeding	39 (21.8)	51 (28.5)	23 (12.8)	38 (21.2)	28 (15.6)

Concern about the lack of personnel training (physicians and nurses) was the greatest with cases of cardiac arrest (26.3%), convulsion (23.5%), acute vaginal bleeding (21.2%) and acute gastrointestinal bleeding (20.1%). Insufficient medications were a concern for managing hypoglycemia (31.3%), acute asthma (25.7%), angina pectoris (25.7%), diabetic ketoacidosis (24%) and renal colic (24%). Inadequate facilities and equipment were the greatest concern for addressing acute GI bleeding (34.1%), myocardial infarction (29.1%), acute vaginal bleeding (28.5%) and cardiac arrest (26.2%).

(Table 7) presents the barriers to emergency case management. One third of physicians (36.3%) indicated that the nonavailability of appropriate equipment was an issue. Lack of training about emergency management was a barrier for 24%.

Table 7

Barriers that prevent primary health care physicians from managing emergent cases
Cause	Frequency (%)
Patient arrived late and there is no time to transfer it to hospital	34 (19.0%)
Not enough training about managing emergent cases through the studying period	43 (24.0%)
Nonavailability of appropriate equipment required for managing an emergent case	65 (36.3%)
The clinic is crowded with patients making it hard to identify a silent emergency case.	37 (20.7%)

Preparation for emergency care management in the primary care setting is a global problem. (2) It is especially important in regions where travel is delayed or difficult, or hospitals are not easily accessible. (1) Given the current strife in Palestine, assessing the capability and preparedness of primary care centers and physicians to handle emergency situations is timely.

Palestine has been occupied by Israel for decades with periods of increased conflict. (21) Due to years of inadequate investment in health facilities and personnel, (21) it is not surprising that our research shows that the primary healthcare providers and centers in the West Bank are not adequately prepared to handle medical emergencies. The majority of the primary health care centers lacked appropriately furnished ambulances, and almost half of the centers did not have X-ray machines. Availability of supplies and medications was variable. Since the Gaza war has impacted imports and finances, the stock and expense of medications has grown worse since the time of our study.(26)

General practitioners, who have not pursued specialization, provide most of the primary care in the health centers. For the most part, their training has not equipped them with the expertise and skills to handle emergency cases. However, a substantial percentage of them received training in BLS, ACLS or ATLS courses within a one- and two-year time frame. Participation in these courses demonstrates a proactive approach to tackling the specific healthcare difficulties encountered in these high-risk areas, where the prompt and skilled delivery of emergency care is of utmost importance.

The specialty of family medicine started in 2011 in Palestine.( 23) There is only one residency that has graduated 54 practicing family physicians, hardly enough to staff all primary health care centers. Their training includes both BLS and ACLS.

Other studies examining emergency preparedness in primary care echo our findings. Riyadh Saudi Arabia identified the lack of equipment as the main barrier. (13) Studies conducted in Jeddah (3) and Spain (19) identified suboptimal training in managing emergency cases and not attending the emergency courses as the main barriers. Dammam Saudi Arabia found that two thirds of PHC physicians reported good knowledge in the management of emergency cases, but 50–70% wanted further training in one or more of the major and common emergencies (16). Physicians and organizations acknowledge the urgent necessity to improve the emergency abilities of physicians, particularly in high-risk regions (20).

The integration of efficient emergency care management into primary care helps to lessen the burden on hospital emergency rooms (2, 6, 7, 8). It also lowers mortality and disability and can impact the entire health system (9, 10). Preparedness involves equipped facilities, appropriate supplies and medications, and routine health care personnel training.

Improving the emergency preparedness of primary health centers requires resources and a comprehensive plan. In the future, we encourage the Ministry of Health to better equip primary health centers. Our research supports the continued investment in training programs like BLS, ACLS, and ATLS, to provide primary care physicians with the essential skills to effectively handle cardiac and other emergencies. In addition, evidence-based health-care guidelines are not routinely used in Palestine. (25) Including evidence-based guidelines in training or continuing education and adopting them at the ministry or professional association level, may improve the management of cases such as acute asthma, GI bleeding, and convulsions.

Limitations:

As a result of the ongoing conflict, the questionnaire was distributed online to physicians, resulting in a smaller-than-anticipated sample size likely due to unusually busy health center schedules, decreased days in the centers because of budget constraints, and internet disruptions. In addition, we were only able to conduct this study in the northern region of Palestine. Equipment and supplies in the centers were self-reported as was frequency of encountering types of cases. An in-person center assessment and review of the center’s patient visits would have been more accurate, but impossible to do.

The present study showed that emergency services at the primary health care level in northern areas of Palestine are functioning but have room for improvement. The level of training and emergency courses of primary health care physicians are suboptimal particularly in ATLS and ACLS courses. Equipment and services need to be upgraded. Defects revealed by the present study, and made worse by the present conflict, will need to be planned for and addressed when resources become available in order to enhance the quality of the emergency services provided at primary health care centers in Palestine.

Conflicts of interest:

No potential conflict of interest was reported by the author (s).

Funding support:

No funding was received.

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Ethical approval and Consent to participate:

All methods involving human participants in this study were conducted per ethical research standards. The study was conducted in conformity with the ethical norms of An-Najah National University Institutional Review Board (IRB) provided ethical approval (Ref: Med. May.2023/24).The Ministry of Health approved authorization for the study to be conducted in PHC settings, and participants were approached and invited voluntarily to participate. Participants were assured of their confidentiality and anonymity

Acknowledgement:

I am immensely grateful to Therese Zink for her invaluable contributions to the editing of the study , providing feedback, and diligently following the submission process.

Authors contribution :

Suha Hamshari : develop the research questions review and edit the questionnaire, write the manuscript .

Sondos Hamadneh : review and edit the questionnaire, write the manuscript.

Mukaram Ghneem: write the proposal , review and edit the questionnaire, write the manuscript.

Raghad Khalaf : write the proposal , review and edit the questionnaire, write the manuscript.

Sara Daqqa : write the proposal , review and edit the questionnaire, write the manuscript.

Rola Abu Alwafa : Analysis the data , write the manuscript .

Mahfouz Ktaifan: Analysis the data , write the manuscript .

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No competing interests reported.

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published 17 Jul, 2024

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Editorial decision: Revision requested
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Barriers faced by primary healthcare providers in addressing emergency situations in the Northern region of Palestine before and during the Gaza war

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Abstract

BACKGROUND

METHODOLOGY

2.1 Study Design and Setting

Data Tool

Validity and Reliability of the tool

Data analysis plan

Ethical consideration

RESULTS

DISCUSSION

Limitations:

CONCLUSION

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References

Additional Declarations

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Journal Publication

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