Health Care Access Difficulties of Palestinian Patients in the Context of Mental Health: A Literature Review Study

    

    

    Figure 1: PRISMA Flow Diagram.
    

Inclusion and exclusion criteria

Studies were eligible for inclusion if they satisfied the following criteria: the articles discussed the access limitations to health care services either in West Bank or Gaza Strip and mental health consequences.

Health care access conditions in Palestine (oPt) and permission requirements

MOH referral approval procedures can take a long time. It took days to months in some cases. According to are port of a field assessment of health conditions in the oPt in 2017 Security requirements for the Israeli permit process to access health care services in facilities located in Israeli/occupied regions of Palestine: Patient files are checked individually and patients may be required to attend a special security interview as part of the licensing application process. West Bank patients must obtain valid magnetic biometric cards from Israeli military authorities in the West Bank before applying for a health access permit. Even patients with serious conditions, unless there is an emergency, must apply personally. Multiple permits to continue the course of medical treatment, For example, cancer patients who require accurate periods of chemotherapy or radiation therapy must apply for a new permit for each appointment at the hospital with a risk of being rejected or delayed each time, which can have serious health consequences. Patients must walk through barriers and carry their personal belonging sunless they are transported in an ambulance. This process can take a long and tiring time for elderly, seriously ill, and disabled patients who use medical equipment and new mothers with infants.

Patients applying for permits from the Israeli authorities face additional financial burdens, including travel costs, and accommodation costs for their comrades, as well as the emotional stress of a process lacking transparency, unpredictable, and often long, as the process needs time waiting for months. On the other hand male patients aged 16 to 55 years and female patients aged 16 to 45 years face additional, long security clearance processes, while all patients and fellow patients called for security questioning as a prerequisite for allowing treatment [6].

A survey conducted in 2007 and 2008,examined the impact of a lifetime and past 30-day experiences of political violence on the mental and physical health of adult Palestinian women from the West Bank, Professional translators in the West Bank translated the survey from English into Arabic, reported that their access to health care had suffered as a result of the political violence of the occupation forces, 27.5% reported being threatened by Israeli forces and Palestinian mental health affected [16].

The health situation in the oPt remains affected by the Israeli occupation. The long-term blockade and restrictions imposed by the Israeli settlement affect the physical and mental health of the population and the development of quality health services, especially in the Gaza Strip to increased stress levels. In addition, internal Palestinian divisions and financial problems exacerbated the situation [14].

In a descriptive study of the quality of life assessment using a tool from WHOQoL-Bref, conducted by Mataria A, et al, 2008.the design of multi-stage cluster samples for 1,023 adult Palestinians, from the general population living in the conflict zone in the West Bank and Gaza Strip from the end of 2005 to 25 January 2006,concluded that Palestinians suffered from poor quality of neighborhoods due to restrictions on access to health care services due to barriers in the Separation Wall and closures, and in some cases lead to psychological and physical distress and death [17].

Patient referrals process within Palestinian regions including Jerusalem

Patient referral needs many issues to complete the referral process including Medical decision, medical approval, financial approval, the appointment date from the hospital is indicated by patients according to the urgent situation, applying for a license from the Israeli Authority, the process of authorization: Israeli coordination up to the date of the permit according to the patient’s appointment, Gaza patients need to cross the Erez checkpoint to obtain health care in the West Bank, receiving health care and traveling backward. And rearguing Gaza patient’s referral to West Bank health care services they come through the Erez checkpoint and must also cross the Qalandia checkpoint (located between West Bank and East Jerusalem south Ramallah city), which increases the probability of delays and violence [6].

A cohort study conducted by Vitullo A, et al 2012. used quantitative and qualitative approaches aiming to describe and analyze the experiences of Palestinians in the West Bank and Gaza Strip who applied for permits from the Israeli authorities in 2011, either to access health care or for travel to work in Palestinian hospitals in East Jerusalem, data for patient referrals were obtained from the Palestinian MOH; data for permit applications and responses were obtained from the Palestinian General Authority of Civil Affairs, West Bank and Gaza Strip, and hospitals in East Jerusalem. The results conclude that the Palestinians who have been transferred to Jerusalem or from the Gaza Strip to West Bank hospitals need permission to enter and access health care services. However, there are restrictions to granting Palestinians permission from the Israeli government that do not have any standards for it and the clearest denial is for security issues. Patients who are between the ages of 18 and 40 years old had the highest rate of rejected or delayed military permits. Interviews conducted with families of patients in Gaza discovered that six patients whose permits were denied or delayed showed their quality of life negatively affected and lower mental health and they mentioned some patients died while waiting for permits [18].

In 2017, the patient’s permit approval rate reached its lowest level since 2006, with 54% of patient requisitions accepted - that is, nearly half of patients’ requests were rejected or received no final response by the time of the hospital time. Access to emergencies and emergencies can be handled on the same day, although processing time for these applications can take longer for non-urgent patients. The Israeli authorities had previously required Palestinian patients to apply for permits before 10 working days [6]. About 6% of referrals by the MOH in Gaza were to health care facilities in Egypt, requiring exit through Rafah. Access outside Gaza via Rafah remained limited in 2017, limited to humanitarian cases, including patients seeking health care in Egypt [7]. Patients referred to hospitals outside the Gaza Strip are excluded from the general travel prohibition enforced on Palestinians in the Gaza Strip, according to Charara R. et al 2017, allowing them to petition for leave permits for health care. Because the OPt has one of the highest rates of mental illnesses in the eastern Mediterranean area, the occupation of Palestinian territory, notably the closure of the Gaza Strip, has an impact on the socioeconomic determinants of Palestinian health [4].

Ambulances difficulties to access healthcare services for Palestinian patients

Some of the patients need ambulances to access healthcare services according to their condition, the majority (90%) were ambulances transported from back to back (from ambulance to ambulance because the West Bank ambulance can’t cross the barriers) at barriers to East Jerusalem to avoid long- delayed and searches. Ambulances from the West Bank will meet registered ambulances in Jerusalem and transport patients who require transport to hospitals in East Jerusalem. Ambulances can experience time-consuming delays, by being detained by the Israeli military and civilian personnel at barriers, even when the referred hospital and the future hospital have received prior coordination from the Israeli Civil Administration restriction to transport the patient from barriers. To avoid delays in negotiating access to barriers in Jerusalem, the Palestinian Red Crescent Society, the main provider of emergency services to Jerusalem, is using ‘successive’ procedures to transfer 93% of patients from the West Bank to East Jerusalem. This means that an ambulance license painted in the West Bank will transport a patient by stretcher to a Jerusalemplated ambulance waiting for an abyss at the barriers. An operation that takes place in the open, delaying the transfer of the critically ill patients for at least 10 minutes and often longer due to security checks by barriers to staff inspection. In some cases, people need to get out while they are sick to cross the barrier and then another ambulance on the other side is there waiting for them [6].

Besides ambulance delays caused by Israeli barriers and road closures, women during pregnancy and childbirth, children and infants, the elderly, and chronically ill or disabled patients are the most vulnerable groups in Palestine. Knowing that access to health services can be difficult and risky is also additional psychological stress that can directly affect health [19,20].

Health care access limitations regarding obstetric, women, and children

The Palestinian population living in the occupied territories is subjected to ongoing violence as a result of this ongoing crisis. Palestinians, particularly women and children, are suffering from severe psychological distress. Although these patients need immediate and urgent care, usually mental health and social support, access to health care remains difficult because of the settlement policy and the creation of pockets [21]. In a study analyzing data collected from four surveys conducted by the Palestinian Central Bureau of Statistics covering fifteen years (2000-2014) for children (no. 16793) and women (no. 8477) in five areas of the OPt, the conclusion that the location is important with the results shown the negative impact of the severity of the conflict on access to care, particularly in the southern West Bank for maternal health services and the central West Bank vaccination. Also, psychological barriers to access to services are increasing because safety concerns can prevent women and children from trying to access services that increase the psychological stress of patients and adversely affect their quality of life and have fear concerns and unstable living conditions [22].

According to a report of a field assessment of health conditions in the oPt, data collected in November 2015, indicates that some accessibility to some special health services is two to four times more likely to be rejected, 11% of women in the West Bank have unmet family planning needs because the system of permits and barriers adversely affects patients in need of care in the six East Jerusalem hospitals or in Israeli hospitals that provide specialized health services that are not available elsewhere in the oPt. The government’s efforts to address the problem of child labor are also being addressed. Barriers to access to healthcare facilities are a serious, permanent, and well-documented problem including mental health problems of stress, maladaptation, and anxiety [23]. Additionally, a regression analysis by Giacaman et al. established the association between dissatisfaction with the place of birth and selected determinants of 2158 women residing in the West Bank and Gaza Strip. The study reported dissatisfaction with their childbirth location referred to the following reasons: 37.5% of respondents stated that the availability of government health insurance and the low cost with low quality of services in governmental hospitals were among the main reasons; 19.3% stated that they were unable to reach the preferred place of birth due to sudden birth; 13.7% stated that reaching the Israeli army impeded access (closures, blockades, and barriers that prevent the movement of people and goods). 14.1% reported that there was no other place available for them to give birth. And 11.7% of other reasons, Palestinian women are concerned about frustration at the lack of certainty of their ability to access the maternity care center. This means living with constant anxiety during their pregnancy where they will go when labor begins, and how they will return to their families, leading to inducing a severely stressful atmosphere [24].

An example of the unique characteristics of this health conflict is the monitoring of birth rates at Israeli army barriers for those who are unsuccessfully trying to reach a health facility to provide Birth. The well-being of people living in this conflict zone is largely affected due to difficulties in access to health-care services, and mortality and morbidity increase too [25]. Another study conducted in 2007 for 2,158 women living in the West Bank and Gaza Strip by Regression analysis demonstrated the association between dissatisfaction with the place of birth and the selected determinants. Concluded quality of life, well-being, mortality, and morbidity of women were adversely increased by limited access to healthcare services resulting from continued closures and blockades [26].

Additionally, restrictions lead to stress and psychological effects have shown from the story of Halla Shoaibi of the University of Michigan in Ann Arbor in the United States, estimates that in the period studied (2000-2007), 10% of pregnant Palestinian women were delayed at barriers while traveling to the hospital for delivery. One result has been increased dramatically in the number of home births; with women preferring to avoid road trips while in labor due to fear of not being able to arrive at the hospital in time, the fear is reasonable. Shoaibi said 69 babies were born at barriers during the last 7 years. About 35 babies and 5 of the mothers have died an outcome which she considered to amount to a crime against humanity [27]. Barriers continue to have economic, medical, and psycho-social effects on Palestinian pregnant women [28]. By year review of worst abuse against Palestinian children in 2017 twelve Palestinian children died in Gaza due to insufficient access to health care, eight of whom were less than two weeks away due to these pediatric cases prevented from leaving Gaza for medical treatment by rejecting or delaying patients ‘requests and their families suffered [29].

On the other hand, a literature review study in 2017 for Palestinian children explored that 5 million Palestinian refugees currently live in Palestine, Jordan, Syria, and Lebanon, about 40% of whom are children. Palestinian child mortality rates are similar to neighboring Arab states. They are hugely affected by the occupation, which has increased violence against children, mental health problems, and malnutrition, particularly in Gaza, which is suffering from a health crisis, as a result of the restrictions on access to health care in Palestine, children are unable to travel to specialized hospitals in Jerusalem which East Jerusalem hospitals remain the main referral hospitals for Palestinians. The Augusta Victoria Hospital in East Jerusalem is the only hospital that gives treatment to pediatric patients for hematology, oncology, radiation, and kidney diseases. Since there is a permit restriction and limited access to males, most children are cared for by their grandmother or aunt (sometimes the parents are younger than 50), which increases their psychological burden and violates their parents’ rights to care supported by their parents. Also; they feel insecure, had nightmares, and aggressive behaviors lead to mental health problems [8].

Health Care Access limitations for the Political Palestinian Prisoners in Israeli prisons

A Report of a field assessment of health conditions in oPt, in 2015 shows the population of the oPt suffers from threats to their mental health including prisoners. The main issues of concern regarding the physical safety of the detainees and the 6,066 Palestinian security prisoners held in Israeli prisons are lack the access to adequate medical care promptly, whether by diagnosis or treatment, and lack of adequate medical care besides inadequate nutrition, housing conditions, and denial of family visits and contacts. Physical and psychological abuse leads to severe mental health problems and great pain. The use of arbitrary punishments and administrative detention without trial are serious problems for many prisoners. The evaluation team was unable to access Israeli prisons and Palestinian prisoners there and was unable to independently verify the reported conditions to hide the through which some Palestinian patients die in the prison due to preventing them to access their health care needs [14]. Moreover, the prisoners suffer from mental health problems as a result of carelessness, including acute hysterical reactions to interrogation methods involving Israeli interrogators, acute depression and severe introversion from being cut off from their family members, and suicide due to severe psychological stress, as well as insomnia caused by severe psychological stress and anxiety [14].

Health care access difficulties for Palestinians living in West Bank

Palestinians from the West Bank can no longer access specialized health care services in East Jerusalem, and in some cases can’t access hospitals in other West Bank cities due to movement restrictions which reflect the lack of freedom, adversely affecting their quality of life [20]. The over-60 age group accounted for 23.3% of referrals in 2015, although they accounted for only 4.5% of the population, reflecting the burden of non-communicable diseases. For Palestinians from the West Bank-except for East Jerusalem-and the Gaza Strip, medical referral centers in East Jerusalem can only be accessed after a permit from the Israeli authorities, a complex process that can lead to delays and denial of adequate care. In 2015, more than half of the referrals were from the MOH to destinations requiring access permits [18].

Based an analysis of the Geographic Information System (GIS) in 1998 and 2007, shows that low- and middle-income countries have difficulty recording high-quality diseases (such as childhood cancer, leukemia, acute lymphocytic leukemia, lymphomas, brain, and Central Nervous System (CNS) cancers and remaining cancers (excluding leukemia, lymphoma, and CNS tumors)) because of the inadequate health care infrastructure and political and economic instability. This article explored the potential of GIS to add value to understanding childhood cancer patterns in the West Bank, despite a variety of obstacles to disease registration. The result shows that the cancer patient faced many difficulties in receiving cancer care that transports them from hospital to hospital because of the lack of all services established in all areas such as bone marrow transplantation and radiation therapy only at Augusta Victoria Hospital in East Jerusalem besides they need to get permission to cross the Israeli checkpoint and if they have security issues they are not allowed to enter East Jerusalem. The large proportion of cases with death certificates compared to other reports is another indicator of the number of cases that do not reach or exceed major treatment centers in the West Bank [30]. Besides Israel deprives some of the patients’ companions of crossing barriers due to Israeli security issues, causing limited access to medicines and medical equipment. On the other hand, delays at the checkpoints cause the death of Palestinian patients [3].

A review study for 43 articles in Palestine in the West Bank in 2016, aimed to examine the mental health needs of Palestinians and the availability of services and concludes that unstable conditions for Palestinians affected their mental health due to lack of access to basic needs, such as health care services due to geographical difficulties, ‘Separation Wall’, lack of freedom and restrictions on movement and political conflict between Palestinians and ‘Israeli’ Jews. There is a need for mental health care [31], resilience improvement for Palestinians [32], and supporting Sumud culture or steadfastness of Palestinians [33].

Health care access difficulties regarding Palestinian health care workers

In 2011, a qualitative study for the Palestinian Medical Relief Society (PMRS), an NGO that provides health services in the West Bank, was conducted using participant observation, secondary data analysis, and semi-structured interviews with key informants. The study concluded that Palestinians face difficulties in accessing health care services, either by preventing or delaying them due to restrictions on the movement of patients and healthcare workers, who need permission from the Israeli authorities to cross barriers through the Separation Wall [3].

Moreover, health care providers in Palestine face many difficulties accessing their workplace due to barriers as nurses [34]. Also, Doctors, community health workers, and nurses reported that the persistent psychological pressures of the occupation accelerated the deteriorating effects of many chronic diseases. One of the doctors said, “At barriers, they try to humiliate you because you are a doctor. The medical staff faced delays, harassment, torture, and abuse. That occurred primarily at checkpoints elsewhere [8]. In 2017, seven mobile health clinics run by three health providers were denied access to communities in Area C of the West Bank due to health attacks [7].

Health care access difficulties for Palestinians living in Gaza Strip

According to a report on an assessment of health conditions in the oPt in 2017, the Palestinian Coordination Office in Gaza obtained data on Israeli responses to requests for patient permits to travel outside Gaza to receive healthcare services through the Erezb barrier. The Palestinian General Authority for Civil Affairs received data on Israeli responses to all applications for health service permits and classified them by provincial coordination offices. The Gaza Strip has been under land, sea, and air blockade for more than 15 years, with significant consequences for the health sector and access to health services. The majority of referrals in Gaza (77%) require access through the Israeli-controlled Erez crossing to access hospitals in East Jerusalem and some parts of the West Bank and Israel. All these patients must apply to the Israeli security services for permits to leave Gaza to obtain primary health care [6].

In a cohort study done by Vitullo A, et al in 2012, Of the 168 278 applications for health services permits provided to the Israeli authorities, 16.4% (12.8% for patients and 19.5% for companions) were rejected or received no response. For patients in the Gaza Strip, requests for exit through the Erez checkpoint for a referral to medical care increased by 17% over one year to more than 22,000, while the proportion of applications rejected nearly doubled (from 2.89% to 5.72%).The number of referrals from Gaza to Egypt declined in 2015 due to the closure of the Rafah border. The reconstruction of health facilities in Gaza was hampered due to the lack of funds, in addition to restrictions on the import of building materials and medical equipment. October 2015, escalating violence in the OPt has led to new roadblocks and barriers, restricting the movement of ambulances with consequent delays in access to health care [18].

Increased bureaucratic delays in processing patient permit applications in 2017, and 596 patients and 91 companions were under investigation for security questioning as a precondition for access to health services outside Gaza [4]. On the other hand, there is a failure in the health care system in Gaza due to workload, especially in case of fire injury during demonstration events with Israeli Jewish at the Gaza Borderlines with Israel, all of that lead to mental health deterioration [35].

Restrictions on access to health services are one of the main obstacles to the right to health for Palestinians living in the West Bank and Gaza. It affects cancer patients at a weak point in their lives when they need specialized care and services for diagnosis and treatment. Most of the cancer patients from Gaza are referred to West Bank and East Jerusalem due to chronic shortages of medicines and lack of medical equipment in their city. Patients need to wait several months to receive treatment and the process of getting access permission from Israeli authorities to cross the barriers is severely stressful [36]. The following are examples showing patient experiences for Oncology patients from the Gaza Strip with limitations to health care access, which reflect their suffering and that affect mortality and morbidity:

Samira, 64, was diagnosed with uterine cancer in 2016. She underwent surgery but then needed follow-up treatment not available in Gaza. Doctors referred Samira to radiotherapy in East Jerusalem. It takes her more than 6 months and 5 requests for permits to leave Gaza in June 2018. “All this time, I was suffering from abnormal bleeding. It was a matter of life and death. Why was the permit rejected?” She says.

“Khadija, 32, mother of four, noticed something unusual with her breasts in December 2017. Doctors soon confirmed that she had breast cancer. In January 2018, Khadija applied for a permit to go to the Augusta Victoria Hospital in East Jerusalem a plastic surgeon - to see if the cancer had spread and if so, to what extent. She was rejected and started receiving chemotherapy in Gaza, but there was a cosmetic need for optimal treatment surgery. In July, Khadija applied for a permit and was again rejected. She decided to change her medical destination to Egypt. Khadija’s second attempt to leave Gaza into Egypt was finally successful. She underwent surgery in August 2018, 7 months after the diagnosis. These obstacles put her life at risk of death and increased her suffering” [36].

“Mohammed Abu Harbid, 54, was arrested in Erez on July 10 while returning to Gaza with the body of his brother Suleiman Abu Harbid, 58, who died in Tel Aviv’s Akhlilov hospital from stomach cancer. His body was returned to his family in Beit Hanoun, Gaza, while Mohammed was detained for three hours in Erez, and his brother’s funeral was lost. The brothers had traveled together to the hospital on June 16, 2013” [6].

The following are Examples of Gaza patients and patient companions detained at Erez in 2013:

“The risk of being detained while traveling through the Erez checkpoint, or after a security interview faces the patients and their families. The Palestinian Human Rights Organization reported that 5 patients and 5 patient companions were detained in 2013; 3 patients and 4 companions were still in detention in 2014. In the following paragraphs, WHO reports on two patients and 3 of his fellow detainees”.

Detained husband: “A 35-year-old woman from Gaza applied for a permit to cross Erez, after she was asked to attend an Israeli security meeting. When she arrived in Erez with her husband, the Israeli authorities asked her husband to attend a security interview instead. He was arrested, detained, and then got released in 2014 after 6.5 months in prison and after a court appeal. The patient sought local treatment for her eye aches while awaiting her husband’s release and was able to leave Gaza for surgery. At the time of the interview, the family was unsure whether they would risk a new application for access to the Erez crossing. Son of the detained patient: The son of a 48-yearold disabled patient from Gaza was granted permission to accompany his mother to a Jerusalem hospital for bone surgery, but was arrested at the Erezbarrier. His mother’smedical treatment was postponed for 3 months. The son is still awaiting trial in Askelon prison”.

Another example of a patient detained for 12 days in Erez: “Israeli security forces at Erez crossing detained a 24-year-old patient from Rafah suffering from hearing loss in both ears after he came for a security interview to obtain permission to travel to a hospital in East Jerusalem. He was interrogated for 12 days and then released. He had previously been referred for surgery in Egypt but was unable to travel there in August 2013 after the closure of Rafah. He remains untreated and at risk of total hearing loss”.

Finally, a patient was arrested at Erez barrier: “A 33-year-old patient with chronic hepatitis, from Beit Hanoun, was referred for treatment at a West Bank hospital due to an ophthalmology condition. Israeli security forces detained him at the Erez crossing on his way to a hospital in Ramallah. According to his lawyer, he is awaiting trial and is in stable condition, but was not examined by an ophthalmologist and was only a general practitioner in the first days of his interrogation” [37].

The effect of health access limitations of Palestinians on mental health

Palestinians are testing repeated traumas and psychological effects with dire consequences that affect their life quality, such as psychological adaptation and social life, and the restriction of their freedoms and rights, and their bodies [7 p4][11 p][24 p16][33 p19].

In summary, the mental health and well-being of Palestinians are affected. Especially patients in need of health care services through Israeli barriers [17 p13]. Mental health is negatively affected due to the difficulties in accessing healthcare services. and increases the psychological burden, especially among children [2 p3], increases psychological stress [22 p15], emotional stress [7 p4][8 p8], and affects palliative care, especially for cancer patients [2 p3][3 p3][8 p 5] [13p8], patients feel inequality [8 p5], insecure and lack of dignity [38 p23], mortality and morbidity increased [17 p13][26 p17], difficulties face women in childbirth impact women’s psychological status [22 p] [23 p16][24 p16][26], also some of the patients die before accessing health care [4 p4][8 p5][13 p][19 p15][25 p16]. While patients from Gaza face more restrictions than those in West Bank [8 p5].

Discussion

This literature shows the difficulties Palestinian patients have in accessing health care services and their impact on mental health, whereby disparities in health in the Gaza Strip usually characterize lower health outcomes than in the West Bank. The population’s mental health is affected as a result. Almost 312,000 children required psychosocial support in 2018 in Gaza according to Charara R. et al 20017, while patients referred to facilities outside the Gaza Strip are exempt from the general travel ban imposed on Palestinians in the Gaza Strip, allowing them to apply for exit permits for health care. The occupation of the Palestinian territory, particularly the closure of the Gaza Strip, affects the social determinants of Palestinian health, as the OPt bears one of the highest burdens of mental disorders in the eastern Mediterranean region [4]. The WHO report described the chronic mental health situation in the Opt, according to Israeli occupation and violence, although mental illness is one of the most important public health challenges in the OPt. In Gaza, in particular, more than half of children affected by the conflict may be affected by post-traumatic stress disorder, whereas several 210,000 people or more than one in 10 people suffer from severe or moderate mental health disorders in Gaza [10].

In case of no access to free health care services in Palestine due to Israeli checkpoints, the Israeli solders face Palestinian patients in an unreceptive manner while crossing the Israeli barriers patient’s dignity is affected, and his psychological status is affected too as being a pediatric patient without parents [6,9]. And Israeli responses to requests from parents of children in need of specialized medical treatment in outpatient hospitals are unpredictable. Parents are at high risk of arbitrary denial of permits. The health and well-being of children depend on sourcing them with their parents in the hospital. The government’s decision to re-establish a new government in 2008 was essential. Patients are left in uncertainty by not receiving timely responses to permit applications until the date of their appointment at the hospital has passed. The length of time it takes to process Israeli permits unnecessarily delays their medical treatment. They should give priority to the patients, and give them responses before the appointment date at the hospital [6]. Patients in need of companies risk a delay in obtaining their medical care. Israeli authorities refuse or delay approving their permits until they change their companions. Companions are deprived of permissions without reason. Children should not be denied accompaniment by their parents, and should not be delayed medical care due to a request to change companions. Therefore, they become worried and increase their stress levels, anxiety, and depression. Traveling outside of Gaza for medical treatment for a medical condition can be stressful for any patient and physically difficult to negotiate, and all patients need family or social support in the hospital for their psychological well-being [6]. This affects the patient’s emotional state negatively, because the companion supports the patient in the hospital, Children from Gaza are deprived of their parents to stay with them [39], Even with a good prognosis, separation during such a critical time is painful for children: babies must be weaned suddenly to travel with another relative, and older children interact with anxiety, refuse to eat, talk or cure completely. Children who have a parent, on the contrary, have better vital signs and a much better chance of recovery. “Settling for less when it comes to parental accompaniment compromises the child’s recovery prospects and violates their right to health” Majadli says from Augusta Victoria Hospital [40]. As clinical experience and research in human environments from a child’s perspective in 2005, explores the issues facing child and family mental health after traumatized events in conflict zones. The study concludes that children’s mental health needs vary in terms of crisis and complexity. And intimate attachment to their needs for security, food, shelter, education, and family communication, reflecting the difficulty of accessing health-care services that lead to lower quality of life [21]. The delay and denial in a permit application process increase the patient’s concern about the appointment which leads to anxiety and access to health is not fully respected to the extent required for population health and well-being and the functioning of the Palestinian health system, because this causes psychological burden, stress, and development of a mental disorder if no adaptation as mentioned in the literature [4,17,18,22], but oppositely seen in Western countries as high accessibility, continuity, and coordination of care just [41]. As patients in the United States have quick access to specialized healthcare services. In other countries, such as Canada, patients bear little or no financial burden, but they face waiting times for such special services. The Netherlands, the United Kingdom, and Germany provide comprehensive coverage at low pocket costs while maintaining quick access to specialized services [42]. In the other hand the Arab countries are politically unstable as Iraq has difficulties accessing healthcare. Otherwise, the transportation issues may delay access to health care services in Arab countries [43].

As a result of health care access difficulties in Palestine, patients arrived tired, frustrated, anxious, stressed, and in some cases reported depressed emotions and fear from re-experiencing difficulties that increase the psychological burden and affect their mental health. As supported by a descriptive-analytical study conducted in 2017 for cancer patients from Gaza support this. The study indicated that patients suffer from anxiety and depression due to the siege affecting their medical condition and immune system negatively [44]. And according to the second author’s experience as a mental health consultant, most of Gaza patients treated at An Najah National University Hospital had anxiety and depression symptoms due to their suffering while traveling from Gaza strip to west bank to access health care services as cancer treatments, also some of the patients were requested to work with Israeli intelligence services (spy) to get healthcare services.

Additionally west bank patients who are referred to East Jerusalem also have to cross barriers. Palestinians who live in East Jerusalem have differential access to health services compared to Palestinians from the West Bank. Palestinians in East Jerusalem can apply to Israeli authorities for a ‘residency’ status that entitles them to Israeli health services, on the condition that they continue to live or work in East Jerusalem or Israel [12]. That shows there is inequality in accessing health care services for Palestinians, according to living regions, fragmented by Separation Wall. Most suffering is shown in the Gaza Strip followed by the West Bank and East Jerusalem due to military Israeli occupation, which lowers the quality of life and leads to mental health problems. On the other hand, the Palestinian refugee’s dignity and mental health were affected due to inequality to access health care services [6], difficulties in access to health care needs that affect the quality of life as supported by Ibraham Maslow’s theory of the Hierarchy of Needs which is where safety comes first [45]. The minimum basic obligations of the right to health, are the right to access health facilities and services on a non-discriminatory basis, particularly for vulnerable or marginalized groups [38].

Finally the priority needs of Palestinian civilians are to gain their freedom, such as expression, travel, and protection. The unstable environment is constantly causing new mental health problems for civilians. The priority is to establish an effective and supportive mental health system and to stop the occupation as primary prevention [46].

Conclusion

Palestinian patients faced many difficulties geographically and psychologically because of the Israeli occupation. Patients from West Bank need permission to access healthcare services in East Jerusalem or Gaza, Patients who need a permit to access healthcare services either in East Jerusalem or West Bank need to cross barriers through the Separation Wall checkpoint. Many studies and reports supported that there are negative mental health consequences of difficulties in accessing health care services as a result of the Separation Wall, barriers, and closures by the Israeli Authority [6,8,9,14,17,23,25,33,38]. These difficulties represented in the psychological burden, psychological distress, and abuse, emotional stress, negatively affect the dignity and quality of palliative care specifically for cancer patients who feel inequality, insecurity, and their quality of life is affected [2,6,8,17,29,31,34], more seen in Gaza patients affecting socioeconomic determinants and mental health of Palestinian health due to Gaza strip closure [3,4], that to mental illness. On the other hand, there is a negative impact on the work of healthcare providers, who need access to healthcare places through barriers or road closures represented in psychological and moral suffering [2,9,33]. Frustration and dissatisfaction result in women needing to access health care during childbirth [20,21,27,28] and psychological effects on children [6,17,19]. With all the obstacles to accessing health care services, the Palestinians try to cope with their situation and improve their quality of life and mental health depending on the resilience culture [24] and ‘Sumud’ culture [43], which is a Palestinian idea intertwined with ideas of personal and collective resilience [17,23,39]. Reliance on religious support [13].

Recommendations

We recommend the need for more studies and policies to address inequalities in access to health care within these areas. And further study about mental health consequences concerning limitations among Palestinian patients crossing barriers. We also recommend ending up the Israeli occupation which is the main cause of prohibiting Palestinians from free access to health care services.

Limitations

Palestine is an occupied country that is seeking independence with a scarcity of resources. Palestine has been described as “uncharted territories’’ due to a lack of data, resources, and reports. As a result, there is insufficient data regarding access limitations to health services in Palestine.

Funding

There is no source of funding for this research.

Availability of Data and Materials

This is an evidence synthesis study, all data is available from the primary research studies, or can be circulated from the corresponding author.

Ethics Approval and Consent to Participate

Not applicable in this study.

Consent for Publication

Not applicable in this study.

Competing Interests

The authors declare that they have no competing interests in this section.

Authors’ Contributions

Mohammad Marie (MM) conceived the idea for the study from which this article is drawn. Maher Battat (MB) collected the data, analyzed and interpreted the findings and drafted this manuscript. MM supervised the study analysis, interpretation of findings, and made substantive intellectual contributions to the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Special thanks to the Faculty of Postgraduate College - Community Mental Health Nursing Program at AN-Najah National University for their support and offering facilities. In addition to all authors in the field of mental health in Palestine who equipped us with the relevant information for this literature. We would like to thank Miss Hannan Kalbuneh (An-Najah National University Hospital) for proofreading and Zareefa Shaabnah for her review.

References

1. Palestine | History, People, & Religion. Encyclopedia Britannica. 2020.
2. Boulus-Rødje N, Bjørn P, Ghazawneh A. “It’s About Business, not Politics”: Software Development Between Palestinians and Israelis. In: Boulus-Rødje N, Ellingsen G, Bratteteig T, Aanestad M, Bjørn P. (eds) ECSCW 2015: Proceedings of the 14th European Conference on Computer Supported Cooperative Work, 19-23 September 2015, Oslo, Norway. Springer, Cham. 2015.
3. Sousa C, Hagopian A. Conflict, health care, and professional perseverance: A qualitative study in the West Bank. Glob Public Health. 2011; 6: 520-533.
4. Charara R, Forouzanfar M, Naghavi M, Moradi-Lakeh M, Afshin A, Vos T, et al. The Burden of Mental Disorders in the Eastern Mediterranean Region, 1990-2013. PLoS ONE. 2017; 12: e0169575.
5. Over 700 road obstacles control Palestinian movement within the West Bank. United Nations Office for the Coordination of Humanitarian Affairs - occupied Palestinian territory.
6. Manenti A. Report of a field assessment of health conditions in the occupied Palestinian territory. 2017: 29.
7. Ranaweera S. World Health Organization, editors. Current information on use and harm from alcohol in the WHO South-East Asia region. New Delhi: World Health Organization, Regional Office for South-East Asia, 2007; 111.
8. Waterston T, Nasser D. Access to healthcare for children in Palestine. BMJ Paediatr Open. 2017; 1: e000115.
9. Kitamura A, Jimba M, McCahey J, Paolucci G, Shah S, Hababeh M, et al. Health and dignity of Palestine refugees at stake: a need for international response to sustain crucial life services at UNRWA. Lancet. 2018; 392: 2736-2744.
10. Marie M, Shaabna Z, Saleh M. Schizophrenia in the context of mental health services in Palestine: a literature review. International journal of mental health systems. 2020; 14: 44.
11. Marie M, Saad Adeen S, Battat M. Anxiety disorders and PTSD in Palestine: a literature review. BMC Psychiatry. 2020; 20: 509.
12. Zheng Z, Gu S, Lei Y, Lu S, Wang W, Li Y, et al. Safety Needs Mediate Stressful Events Induced Mental Disorders. Neural Plast. 2016; 2016: 1-6.
13. ESCR General Comment No. 12 (1999) on the Right to Adequate Food (Article 11 of the Covenant). Economic, Social, and Cultural Rights.
14. Manenti A. Report of a field assessment of health conditions in the oPt. 2015: 29.
15. Marie M, Saad Adeen S. Mental health consequences of home demolition policy towered Palestinians: Literature review. Int J Ment Health Syst. 2021; 15: 51.
16. Sousa CA. Political violence, health, and coping among Palestinian women in the West Bank. Am J Orthopsychiatry. 2013; 83: 505-519.
17. Mataria A, Giacaman R, Stefanini A, Naidoo N, Kowal P, Chatterji S. The quality of life of Palestinians living in chronic conflict: assessment and determinants. Eur J Health Econ. 2008; 10: 93-101.
18. Vitullo A, Soboh A, Oskarsson J, Atatrah T, Lafi M, Laurance T. Barriers to the access to health services in the occupied Palestinian territory: a cohort study. Lancet. 2012; 380: S18-S9.
19. Funding shortages undermine continuity of mobile health clinics in vulnerable West Bank communities. United Nations Office for the Coordination of Humanitarian Affairs - occupied Palestinian territory. 2018.
20. Crawford R. You are Dangerous to Your Health: The Ideology and Politics of Victim Blaming. International Journal of Health Services. 1977; 7: 663-680.
21. Jones L. Responding to the Needs of Children in Crisis. Int Rev Psychiatry. 2008; 20: 291-303.
22. Leone T, Alburez-Gutierrez D, Ghandour R, Coast E, Giacaman R. Maternal and child access to care and intensity of conflict in the oPt: a pseudolongitudinal analysis (2000-2014). Confl Health. 2019; 13: 36.
23. WHO situation reports. 2015.
24. Giacaman R, Abu-Rmeileh NME, Mataria A, Wick L. Palestinian women’s pregnancy intentions: Analysis and critique of the Demographic and Health Survey 2004. Health Policy. 2008; 85: 83-93.
25. Wick L. Building the Infrastructure, Modeling the Nation: The Case of Birth in Palestine. Cult Med Psychiatry. 2008; 32: 328-357.
26. Giacaman R, Abu-Rmeileh NME, Wick L. The limitations on choice: Palestinian women’s childbirth location, dissatisfaction with the place of birth and determinants. The European Journal of Public Health. 2007; 17: 86-91.
27. Murphy MC. Israeli barriers kill women in childbirth, says new study. The Electronic Intifada. 2011.
28. Palestinian pregnant women giving birth at Israeli checkpoints - HRC seventh session - UNHCHR report. Question of Palestine.
29. Year-in-review: Worst abuses against Palestinian children in 2017. Defense for Children Palestine. 2020.
30. Bailony MR, Hararah MK, Salhab AR, Ghannam I, Abdeen Z, Ghannam J. Cancer registration and healthcare access in West Bank, Palestine: A GIS analysis of childhood cancer, 1998-2007. Int J Cancer. 2011; 129: 1180-1189.
31. Marie M, Hannigan B, Jones A. Mental health needs and services in the West Bank, Palestine. Int J Ment Health Syst. 2016; 10: 23.
32. Marie M, Hannigan B, Jones A. Resilience of nurses who work in community mental health workplaces in Palestine. Int J Ment Health Nurs. 2017; 26: 344- 354.
33. Marie M, Hannigan B, Jones A. Social ecology of resilience and Sumud of Palestinians. Health (London, England: 1997). 2018; 22: 20-35.
34. Marie M, Hannigan B, Jones A. Challenges for nurses who work in community mental health centres in the West Bank, Palestine. Int J Ment Health Syst. 2017; 11: 3-3.
35. Failing Gaza healthcare system after 10-year blockade barely handling 2,000+ live fire injuries. B’Tselem. 2020.
36. WHO EMRO | Gaza patients’ painful journey to cancer treatment | Palestinenews | Palestine.
37. Referral of patients from the Gaza Strip - WHO monthly report. 2014.
38. Report of the Special Rapporteur on the Situation of Human Rights in the Palestinian Territories Occupied since 1967, Richard Falk (Sep. 16, 2013). The Palestine Yearbook of International Law Online 2014;17: 374-402.
39. Segev Z, Arif AA, Rohrer JE. Activity Limitations and Healthcare Access as Correlates of Frequent Mental Distress in Adults 65 Years and Older: A Behavioral Risk Factor Surveillance Study-2008. J Prim Care Community Health. 2012; 3: 17-22.
40. JERUSALEM PG| 27/2/2020. LWF and partners advocate for Palestinian children’s access to health care. The Lutheran World Federation. 2020.
41. WHO details mental health impact for Palestinians under Israeli occupation. Middle East Monitor. 2019.
42. How the U.S. Health Care System Compares Internationally. 2020.
43. Batniji R, Khatib L, Cammett M, Sweet J, Basu S, Jamal A, et al. Governance and health in the Arab world. Lancet. 2014; 383: 343-355.
44. Bseiso RA, Thabet AM. The Relationship between Siege Stressors, Anxiety, and Depression among Patients with Cancer in Gaza Strip. Health Science Journal. 2017; 11: 343-355.
45. Tripathi N. A valuation of Abraham Maslow’s theory of self-actualization for the enhancement of quality of life. Indian Journal of health and wellbeing. 2018; 9: 499-504.
46. Giacaman R, Neil A, Summerfield D. Establishing a mental health system in the occupied Palestinian territories. Int Psychiatry. 2005; 9: 16-8.