Public Health (2004) 118, 131–142

Palestinian refugee conditions associated

with intestinal parasites and diarrhoea: Nuseirat
refugee camp as a case study
T.A. Abu Mourada,b,*

a
Consultant, Palestine Save the Children Foundation (PSCF), P.O.Box 1386, Al-Rimal, Gaza City, Palestine
b
Ph. D. Researcher, Department of Social Medicine, School of Medicine, University of Crete, P.O.Box 2208,
Heraklion, Crete, Greece

Received 21 January 2003; received in revised form 8 May 2003; accepted 11 September 2003

KEYWORDS Summary Objective. To assess the socioeconomic-demographic, environmental

Environmental health;
Hygiene conditions;
Diarrhoea; Intestinal
parasites; Refugee Camp;
Crowding index
health and hygiene conditions associated with intestinal parasites and diarrhoea in
Nuseirat Refugee Camp of Gaza Strip.
Methods. A cross-section of 1625 households were surveyed. A stratified sample was
used and drawn from the eight Blocks. Face-to-face Interviews were administered for
data collection. Piloted and validated questionnaires along with specific checklists
were used as instruments.
Results. A total of 485 women interviewed (29.8%) reported intestinal parasites
among their household members; 223 (13.7%) admitted cases of diarrhoea. The highest
prevalence of intestinal parasites (24.1%) was found among children aged 1– 4 years;
the highest prevalence of diarrhoea (10.6%) was found among children younger than 1
year. Intestinal parasites were strongly associated with crowding, source of drinking
water and the cleaning of water tanks, and were significantly higher among families
with unclean homes. Diarrhoea was strongly associated with source of drinking water,
a full-day water supply and cleaning of water tanks, and was significantly higher among
families with a presence of mosquitoes and garbage around their homes.
Conclusions. Poor socioeconomic-demographic, environmental health and hygiene
conditions play a major role in the occurrence of intestinal parasites and diarrhoea.
Children younger than 5 years are at high risk. Real interventions, such as health
education, environmental awareness, community involvement and raising funds for
infrastructural development are urgently needed.
Q 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights
reserved.

Introduction
Gaza Strip is an elongated area located in an arid to
semi-arid region. It is bordered by Egypt from
*Tel: þ972-8-2848705 (Gaza) Fax: 302-810-394-606 (Greece).
E-mail address: tayserm@med.uoc.gr; pscf@palnet.com
the South, the green line from the North, Nagev
desert from the East and the Mediterranean Sea
from the West. The total surface area of the Gaza
Strip is 360 km2, and its population has been
estimated to be 1,261,909 for the year 2002, two-
thirds of them mainly concentrated in eight refugee
camps.1 The Palestinian refugee problem came

0033-3506/$ - see front matter Q 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.puhe.2003.09.002
132
into being in 1948 as a result of the disturbances
before and after the occupation of Palestine and
the creation of the state of Israel in Palestine.
About three-quarters of a million men, women and
children were uprooted from their homes and land,
and forced to take refuge in Gaza Strip, the West
Bank, Jordan, Lebanon and Syria. Others were
dispersed within and without the Arab World.2
Since 1950, the World Health Organization (WHO)
has provided technical supervision of the United
Nations Relief and Works Agency (UNRWA) health-
care programme. UNRWA has since been the main
healthcare provider for the Palestinian refugee
populations.3,4 Palestinian refugees have a high
rate of unemployment and higher incidences of
arrests and work stoppage compared with non-
refugee Palestinians; they also earn less than non-
refugees. High fertility among refugees imposes a
further challenge for policy makers in terms of
resources required for the provision of appropriate
health facilities.5 Nuseirat Refugee Camp (NRC) is
named after a local Bedouin tribe. About 16,000
refugees settled in the camp after 1948, most
having fled from the Beersheva area in the Negav,
southern Palestine, many housed initially in a
former British military prison (Kallaboush) and
others were sheltered in tents. NRC was established
in 1949 on a 0.588 km2 (58.8 hectare) site, is
located 8 km south of Gaza City and its population
is registered to be 44,425 in 1997, 64,233 in 2002
and estimated to be 83,033 people in 2010, all of
them living in overcrowded conditions.6,7 NRC
includes eight Blocks named Block ‘B’, Block ‘D’,
Block ‘F’, Block ‘G’, Block ‘H’, Block ‘J’, Block ‘L’
and Block ‘M’. Many of these Blocks have a poor
sewage network; sewage and wastewater flow in
open channels along roads and pathways, and
through agricultural lands towards Wadi Gaza,
thus posing serious environmental health hazards.
Water supply to the NRC is mainly from wells in
which chloride concentration reaches 1200 mg/l in
summer. UNRWA’s health centre, which was built in
1963, provides outpatient medical care and other
specialized health services.7,8 The prevalence of
intestinal parasites, particularly among children
living in some Palestinian refugee camps, has been
investigated; Giardia Lamblia, Ascaris lumbricoides
and Entamoeba histolytica are the most prevalent
intestinal parasites.9,10 Intestinal parasites, bac-
terial and viral infections are the main common
causes of diarrhoea. Diarrhoea results in dehy-
dration, particularly in children and elderly
people.11 It was the main water-related disease in
the medical records of all districts in Northern
Senegal,12 and considered a dilemma in Mexico.13
The endemic pattern of diarrhoea, however,
T.A. Abu Mourad
reflects mostly inadequate housing, sanitation and
water-related practices,14 and is likely to have
measures of socioeconomic deprivation, such as
household crowding.15 Diarrhoeal disease in
younger children demonstrated that Salmonella
spp., Cryptospordium, Campylobacter spp. and
rotavirus were the major pathogens in Gaza Strip,
and overcrowding was linked with an increased risk
of diarrhoea.16 Diarrhoea is one of the leading
causes of death among the population in Gaza
Strip.17
This is the first study conducted in NRC aimed at
assessing socioeconomic-demographic, environ-
mental health and hygiene conditions associated
with intestinal parasites and diarrhoea. The objec-
tives of this study were to answer the following
research questions
1. What are the general characteristics of refugees
living in NRC?
2. What is the incidence of intestinal parasites and
diarrhoea and in which age groups do they occur?
3. Is there an association between intestinal para-
sites and the socioeconomic-demographic,
environmental health and hygiene conditions
among refugees living in NRC?
4. Is there an association between diarrhoea and
the socioeconomic-demographic, environmental
health and hygiene conditions among refugees
living in NRC?
Methods
The Palestine Save the Children Foundation (PSCF)
designed and implemented a base-line, cross-
sectional survey in co-operation with Nuseirat
municipality. The survey was carried out from
June to September 2001. The investigation was a
base-line house-to-house survey. The target popu-
lation was the residents of NRC. The sample size
was determined in order to have 98% confidence
limit ðZ ¼ 2:33Þ of 3% maximum allowable error and
conservative estimate of proportion ðP ¼ 50%Þ: This
led to the required sample size of 1508 house-
holds.18 To allow for a no-response expectation, the
sample size was increased to 1655 households. All
eight Blocks were selected and included in the
study. A stratified sample was used, based on the
number of households in each Block. The pro-
portional sample was selected randomly from each
block, using the municipality registration of houses
as a sampling frame. The number of households
investigated was selected from each Block as
follows: Block ‘B’ ðn ¼ 376Þ; Block ‘D’ ðn ¼ 251Þ;
Block ‘G’ ðn ¼ 220Þ; Block ‘F’ ðn ¼ 197Þ; Block ‘L’
Palestinian refugee conditions associated with intestinal parasites and diarrhoea:
Nuseirat refugee camp as a case study
ðn ¼ 186Þ; Block ‘J’ ðn ¼ 169Þ; Block ‘H’ ðn ¼ 161Þ
and Block ‘M’ ðn ¼ 95Þ: The guardian (i.e. mother or
‘woman’ in this study) was interviewed face-to-
face, and the questionnaire was completed during
the interview. The mother also provided infor-
mation on household characteristics (e.g. water
supply, sanitation, socioeconomic, environmental
health and demographic variables). In the absence
of the mother during the interview period, the field
workers were invited to attend the interview. All
interviews were conducted face-to-face by three
well-trained and qualified staff. Interview and
questionnaire training was provided by the author.
The questionnaire was administrated by PSCF
qualified staff and validated by five experts in the
fields of public health, epidemiology, statistics and
environmental health. Most of the questions were
one of two types: the yes/no question, which offers
a dichotomous choice; and the multiple choice
question, which offers several fixed alternatives.19
A questionnaire was piloted with 10 households not
included in the sample from the study area, and
modified as necessary for improving reliability. The
questionnaire included questions relating to the
following: background information, such as age and
level of education of the woman and her spouse;
number of rooms per house; total number of
household members and their ages; economic
questions, such as the monthly income of each
household; classification of jobs for male and
female workers; and public health questions focus-
ing on intestinal parasite infection and diarrhoea,
the ages of those infected and the manifestation of
these diseases. The questions of intestinal parasites
and diarrhoea were limited to 2 weeks before the
interview took place to minimize the recall bias.
There were also questions relating to environmen-
tal health (e.g. the household’s method of sewage
disposal, existence of flush-toilet or shower,
sources of drinking water, cleaning of water
containers, the fate of household solid waste and
who in the household disposed of it. The mother
was asked how frequently she washed her hands and
that of her children, and how frequently each child
was bathed each week. The interviewers also used a
check-list for reporting their observations on
environmental health and hygiene among the
investigated households. The check-list was
designed with a three-point observation scale such
as ‘poor’, ‘moderate’ and ‘good’. The check-list
included the following items: cleanliness of home;
personal cleanliness of household adults; personal
cleanliness of household children; flies inside the
house; ventilation of home, presence of garbage
and mosquitoes inside and outside the house.
133
Data analysis
Data were analysed by computer using the following
two statistical packages: Statistical Package for the
Social Sciences ‘SPSS’20 and Epidemiological Infor-
mation ‘EPI-INFO’.21 Simple distribution of the
study variables, the cross-tabulation and normal
x2-tests were applied. The x2 -test for trend with
one degree of freedom (DF), which is a more
sensitive test that looks for an increasing (or
decreasing) trend in the proportions over the
columns having natural order, was used. One-
sample t-test was used to test if the mean of
crowding index differs from the specific standard or
optimal mean.22,23 The optimal mean of crowding
index is considered as one individual per room.24
Results
Response distribution in different Blocks
A total of 1655 households were investigated. The
total response for questionnaire interview was
found to be high (1625/1655 (98.2%)). The highest
response was found in Block ‘G’ (197/197 (100%)),
whereas the lowest response was in Block ‘J’
(162/169 (95.9%)). The response of the remaining
Blocks is as follows: Block ‘B’ (373/376 (99.2%));
Block ‘L’ (159/161 (98.8%)); Block ‘H’ (182/186
(97.8%)); Block ‘F’ (215/220 (97.7%)); Block ‘D’
(245/251 (97.6%)); Block ‘M’ (92/95 (96.8%)).
Household characteristics as reported by the
study sample
Most of the interviewed women were between 18 –
49 years of age (1171/1625 (72.0%)). The age and
educational levels of women and their husbands
(who represent the men in this study) are shown in
Table 1. The number of family members of
investigated households, including the intervie-
wees, totalled 13,051. The ages are broken down
as follows: younger than 1 year 376 (2.9%); 1 – 4
years 1318 (10.1%); 5 – 14 years 3665 (28.1%) and
older than 14 years 7692 (58.9%). This study showed
that, out of 1625, 716 women (44.1%) completed
their secondary education, whereas 106 (6.5%)
were university graduates; 196 women (12.0%)
were found to be illiterate and the remaining
women had finished either primary or preparatory
school.
Out of 1527 men, 500 (32.7%) completed their
secondary school; 83 (5.4%) were illiterate. The
age of the youngest mother was 18 years. As
indicated in Table 2, most of the study sample
134 T.A. Abu Mourad

as 2.7 individuals per room, was significantly higher

Table 1 Distribution of women and their husbands according
to age and education. than the optimal mean of one individual per room
(T(one-sample t-test) ¼ 50.9; P , 0:001). Out of 1625
The study sample women interviewed, 1183 (72.8%) reported that at
Variable Women Men ðn ¼ 1527Þ least one of their family members had some form of
ðn ¼ 1625Þ employment, whereas 442 (27.2%) family members
were unemployed. Twenty-four percent of women
Frequency % Frequency %
(242/1007) reported that their spouses were
Age-group (year) employed as police and general security, whereas
18–33 504 31.0 461 30.2 a high proportion of female family members worked
34–49 667 41.0 709 46.4 in the educational sector (110/176 (62.5%)). Job
^ 50 454 28.0 357 23.4 classifications for male and female household
Education members are listed in Table 3. The monthly income
Illiterate 196 12.0 83 5.4 of the investigated households ranged form US$ 0 –
Primary school 137 8.4 188 12.3 1100, with a median of US$ 230 and mode of US$
Preparatory school 300 18.5 306 20.1
Secondary school 716 44.1 500 32.7
230. Out of 1625, a total of 1294 (79.6%) households
Diploma degree 170 10.5 178 11.7 reported their income to be US$ 368; 276 (17.0%)
University degree 106 6.5 272 17.8 households reported their income to range from
US$369 to US$736; and 55 (3.4%) households
reported their income to range from US$737 to
(631/1625 (38.8%)) lived in houses consisting of US$1100.
three rooms, whereas a minority (17/1625 (1.1%)) This study, which was carried out during the Al-
lived in houses with seven rooms. The number of AQSA Intifada, showed that 18.6% (302/1625) of the
family members living together in the same house study sample reported that at least one of their
ranged from 1 to 21 (median 8 and mode 7). The family members had lost their job in Israel as a
highest percentage of investigated households result of sealing and closure of the Gaza Strip during
95.1% (1546/1625) reported family members up to the study period. Those who lost their job in Israel
14 individuals. Most of the investigated house- represent 68.3% (302/442) of the total number of
holds (1239/1625 (76.2%)) had up to 3.45 indivi- the interviewees who reported unemployed family
duals per room. This study showed that the
members.
mean of the crowding index, which was calculated

Table 2 Household characteristics as reported by women of Environmental health status as reported by

investigated households. women of the investigated households
Variable The study sample ðn ¼ 1625) Table 4 lists the environmental health issues as
reported by women of investigated households.
Frequency %
Out of 1625 investigated households, the most
Number of rooms per house prominent environmental issues were as follows:
One room 74 4.6 common drainage of sewage disposal 67.8% ðn ¼
Two rooms 337 20.7 1102Þ; not-having a flush-toilet 59.4% ðn ¼ 965Þ;
Three rooms 631 38.8 existence of a shower 90.9% ðn ¼ 1477Þ; munici-
Four rooms 365 22.4
Five rooms 151 9.3
pality is the main source of drinking water supply
Six rooms 50 3.1 99.0% ðn ¼ 1608Þ; the source of drinking water is
Seven rooms 17 1.1 directly from the tap 82.2% ðn ¼ 1336Þ; cleaning
Number of family members periodically of water-storage tanks 63.2% ðn ¼
1–7 774 47.6 1027Þ; availability of full-day water supply inside
8–14 772 47.5 the house 54.9% ðn ¼ 892Þ; and dumping the
15–21 79 4.9 garbage in the garbage containers 63.6% ðn ¼
Crowding index (individual/room)* 1034Þ: Also, among those households who did not
0.17–3.45 1239 76.2 have a full-day supply of drinking water, the
3.46–6.74 362 22.3 highest percentage 75.9% (556/733) had avail-
6.75–10.03 24 1.5
ability of drinking water up to 8.25 h a day.
*The mean crowding index of 2.7 individuals per room is Children older than 9 years represented the
significantly higher than the optimal mean of one individual highest percentage to transfer the household
per room ðTðone-sample t-testÞ ¼ 50:9; P , 0:001Þ:
garbage 41.3% ðn ¼ 671Þ:
Palestinian refugee conditions associated with intestinal parasites and diarrhoea:
Nuseirat refugee camp as a case study
Table 3 Distribution of the study sample according to the occupation of male and female household members.
Job type The study sample ðn ¼ 1183Þ
Maleðn ¼ 1007Þ
Frequency
Police and general security 242
Business 222
Education sector 117
Car driver 80
Health sector 54
Tailor 69
Governmental employee 111
Building sector 56
Non-governmental sector 31
Unemployment projects 25
Total 1007
Women’s attitude and practice toward washing
their hands and the hands of their children
Table 5 shows the attitude of women towards
washing their hands and the hands of their children.
Of the interviewed women, 995/1625 (61.2%)
reported that their hands should always be washed,
whereas most of the interviewees (1149/1625
(70.7%)) reported that their children’s hands had
to be washed just ‘before and after eating’. Most of
the women interviewed who had children (1045/
1393 (75.0%)) said that they bathed their children
7 – 13 times per week.
Hygiene conditions observed by interviewers
Table 6 summarizes the observations of the inter-
viewers on personal hygiene and the environmental
situation inside and around the house.
Prevalence of intestinal parasites and diarrhoea
among the study sample
A total of 29.8% (485/1625) of the investigated
households reported parasitic cases, whereas 13.7%
(223/1625) of the interviewed women reported
cases of diarrhoea among family members 2 weeks
preceding the interview. Among the investigated
households, four types of parasites were reported in
addition to double infections: Enterobius vermicu-
laris, Giardia lamblia, Enlamoeba histolytica and
Ascaris lumbricoids; the main non-doubled domi-
nant parasites were 50.1% (243/485), 17.6%
(85/485), 10.1 (49/485) and 4.7% (14/485) for
each of them, respectively. It is clear that the
most reported manifestation associated with diar-
rhoea was the fever (Table 7).
135
Femaleðn ¼ 176Þ
% Frequency %
24.0 3 1.7
22.0 16 9.1
11.6 110 62.5
7.9 0 0.0
5.4 22 12.5
6.9 7 4.0
11.0 8 4.5
5.6 0 0.0
3.1 10 5.7
2.5 0 0.0
100 176 100
Distribution of intestinal parasites and diarrhoea
according to socioeconomic-demographic
conditions
The association between socioeconomic-demo-
graphic conditions and household prevalence of
intestinal parasites and diarrhoea are evaluated
in Table 8. The prevalence of intestinal para-
sites was found to be associated with crowding
level (x2trends ¼ 31.9, DF ¼ 1; P , 0:001) and
female work ( x2 ¼ 6.4, P , 0:05Þ: The age-
specific infected rate indicated that the highest
prevalence of parasitic infection 24.1% (318/
1318) was found to be statistically significant
higher among children aged 1 – 4 years
(x2 ¼ 1324; P , 0:0001). In contrast, household
prevalence of intestinal parasites were indepen-
dent of income and Block type. The study shows
that the prevalence of diarrheoa was associated
with Block type (x2 ¼ 23.9; P , 0:01) and the
crowding level (x2 trend ¼ 5.2, DF ¼ 1, P , 0:05Þ:
This study shows that the highest prevalence of
diarrhoea 10.6% (40/376) was found to be
statistically significantly higher among children
aged younger than one year ðx2 ¼ 554;
P , 0:0001Þ: In contrast, it was independent of
female work and income.
Distribution of intestinal parasites and diarrhoea
according to environmental health conditions
The association between environmental health
conditions with the household prevalence of
intestinal parasites and diarrhoea was investigated
(Table 9). The prevalence of intestinal parasites
was linked with the following: sewage disposal
ðx2 ¼ 8:6; P , 0:05Þ; flush-toilet ðx2 ¼ 7; P , 0:01Þ;
source of drinking water ðx2 ¼ 260; P , 0:001Þ;
full-day water supply ðx2 ¼ 4:4; P , 0:05Þ;
136 T.A. Abu Mourad

Table 4 Environmental health status as reported by women Table 5 Women’s attitude and practice towards washing
of investigated households. their hands and the hands of their children.

Variable The study sample Variable The study

sample
Frequency %
Frequency %
Sewage disposal
Barrel 506 31.1 Washing of women’s hands ðn ¼ 1625Þ
Socking pits 17 1.1 Always 995 61.2
Common drainage 1102 67.8 Before suckling 61 3.7
Before and after eating or preparing food 966 59.4
Existence of flush-toilet Before and after toilet 776 47.8
Yes 660 40.6 Before going to the bed 71 4.4
No 965 59.4
After walking up at the morning 118 7.3
Existence of a shower After transferring solid waste 114 7.0
Yes 1477 90.9
For washing children hands ðn ¼ 1625Þ
No 148 9.1 Always 380 23.4
Source of drinking water Before and after eating 1149 70.7
Municipalities 1608 99.0 Before and after toilet 947 58.3
UNRWA 2 0.1 After playing 850 52.3
Purchasing 15 0.9 Before going to the bed 165 10.2
After waking up in the morning 294 18.1
The source of drinking water is After transferring solid waste 32 1.9
Direct from tap 1336 82.2
Indirect from storage tank 289 17.8 Washing of children per week ðn ¼ 1393Þ
Households wtih no children 232 14.2
Storage of water in 0–6 336 24.1
Metallic tank 793 48.8 7–13 1045 75.0
Plastic tank 741 45.6 $14 12 0.9
Both 40 2.5
Non-existent 51 3.1
Storage tank was
Distribution of intestinal parasites and diarrhoea
Cleaned periodically 1027 63.2
Not cleaned 508 31.3 according to hygiene conditions
Non-existent 90 5.5 The association between intestinal parasites and
hygiene conditions and between diarrhoea and
Full-day drinking water supply
Yes 892 54.9 hygiene conditions is summarized in Table 10. It
No 733 45.1 is clear that the parasite infection was signifi-
In case of not full-day water supply, the availability of
cantly higher among families with the following
drinking water ðn ¼ 733Þ hygiene conditions: poor cleanliness of households
0.25–8.25 h/day 556 75.9 39.0% ðx2 ¼ 12:6; P , 0:01Þ; poor cleanliness of
8.26–16.26 h/day 167 22.8 children 42.3% ðx2 ¼ 8:1; P , 0:05Þ; much pre-
.16.26 h/day 10 1.3 sence of mosquitoes 37.8% ðx2 ¼ 8:3; P , 0:05Þ;
Solid waste disposed much garbage inside the house 37.4% ðx2 ¼ 6:4;
In garbage containers (dumpsters) 1034 63.6 P , 0:05Þ; and poor status of kitchen 35.5%
In the street 591 36.4 ðx2 ¼ 6:3; P , 0:05Þ: This study shows that the
The house solid waste transferred by prevalence of diarrhoea is significantly higher
Men 273 16.8 among families with the following hygiene con-
Women 538 33.1 ditions: much presence of mosquitoes 20.3%
Boys and girls aged .9 years 671 41.3
Boys and girls aged , 9 years 143 8.8
ðx2 ¼ 9:6; P , 0:01Þ; many flies inside the house
17.1% ðx2 ¼ 7:1; P , 0:05Þ; poor household venti-
lation 17.6% ðx2 ¼ 8:2; P , 0:05Þ; and much
garbage around the house 19.0% ðx2 ¼ 13:5;
and cleaning of water tanks ðx2 ¼ 863; P , 0:001Þ: P , 0:01Þ:
The study shows that the prevalence of diarrhoea
was associated with the following: sewage dis- Discussion
posal ðx2 ¼ 8:0; P , 0:05Þ; source of drinking water
ðx2 ¼ 793; P , 0:001Þ; full-day water supply The sanitation deficiencies represent a growing
ðx2 ¼ 8:7; P , 0:01Þ and the cleaning of water environmental health challenge in several regions
tanks ðx2 ¼ 27:3; P , 0:001Þ: around the globe. Unsafe sewage disposal and
Palestinian refugee conditions associated with intestinal parasites and diarrhoea: 137
Nuseirat refugee camp as a case study

Table 6 Hygiene conditions observed by interviewers. Table 7 Prevalence of intestinal parasites and diarrhoea
among investigated households.
Variables The study sample ðn ¼ 1625Þ
Variable Investigated
Frequency % households that
reported
Cleanliness of the home intestinal
Poor 267 16.4 parasites and
Moderate 964 59.3 diarrhoea
Good 394 24.3
Frequency %
Personal cleanliness of the household adults
Poor 129 8.0 Households reporting intestinal parasites 485 29.8
Moderate 1018 62.6 ðn ¼ 1625Þ
Good 478 29.4
Type of intestinal parasites ðn ¼ 485 households)
Personal cleanliness of the household children Enterobius vermicularis 243 50.1
Poor 241 14.8
Giardia lamblia 85 17.6
Moderate 860 52.9 Entamoeba histolytica 49 10.1
Good 292 18.0 Ascaris lumbricoides 23 4.7
No children 232 14.3 Giardia lamblia and Enterobius vermicularis 14 2.9
Flies inside the house Entamoeba histolytica and Giardia lamblia 4 0.8
Many 263 16.2 Unknown 67 13.8
Few 935 57.5 Households reported diarrhoea ðn ¼ 1625Þ 223 13.7
None 427 26.3 Symptoms associated with diarrhoea
Household ventilation (n ¼ 223 households)
Poor 433 26.6 Mucus 51 22.9
Moderate 859 52.9 Blood 4 1.8
Good 333 20.5 Vomiting 19 8.5
Fever 142 63.7
Garbage inside the house All above 7 3.1
Much 203 12.5
Moderate 948 58.3
Little 474 29.2
Garbage around the house with a strong record in community development.
Much 347 21.3 Block ‘J’ had the lowest response rate (95.9%),
Moderate 828 51.0
possibly because it was the poorest section of the
Little 450 27.7
camp; interviewers concluded that residents
Status of the kitchen needed practical intervention rather than ques-
Poor 327 20.1
tionnaires to fill in.
Moderate 1032 63.5
Good 266 16.4

Status of the washroom and other sanitary facilities Household characteristics as reported by the
Poor 310 19.1 study sample
Moderate 980 60.3
Most of the interviewed women were aged between
Good 335 20.6
18 – 49 years (72%), indicating a minimum marital
Presence of mosquitoes inside and outside the house age of 18 years. This concords with another study,
Much 222 13.7
Little 1095 67.3
which showed that early marriage of girls is a
None 308 19.0 widespread practice in Arab countries.25 Also, this
early marriage has a negative impact, as poor
health outcomes for children are associated with
having a young mother.26 Illiteracy among women
fecal-oral transmission of pathogens are respon- (12.0%) is higher than their husbands (5.4%); this
sible for many preventable enteric diseases, such concords with a previous study27 and may reflect
as intestinal parasites and diarrhoea. This study’s the emphasis on the male rather than female in
high response rate (98.0%) reflects the quality of such communities. The crowding index is an
the fieldwork and the good reputation of the important measurement to assess the social and
PSCF, which is principally concerned with the economic situation of the residents, and has been
long-term development needs of Palestinian refu- calculated in this study. The mean crowding index
gees and communities through its clear policy and (2.7 individuals per room) was found to be
working principals, as well as experienced staff significantly higher than the optimal mean of one
138 T.A. Abu Mourad

Table 8 Distribution of intestinal parasites and diarrhoea according to socioeconomic-demographic conditions.

Variable Number Intestinal parasites Diarrhoea

Frequency % Frequency %

Block type
Block ‘B’ 215 77 35.8 44 20.5
Block ‘D’ 159 49 30.8 29 18.2
Block ‘F’ 162 49 30.2 25 15.4
Block ‘G’ 245 64 26.1 36 14.7
Block ‘H’ 197 60 30.5 29 14.7
Block ‘J’ 92 31 33.7 12 13.0
Block ‘L’ 182 40 21.9 16 8.8
Block ‘M’ 373 115 30.8 32 8.6
Total 1625 485 29.8 223 13.7
x2 ¼ 11:6; P ¼ 0:11 x2 ¼ 23:9; P , 0:01
Crowding index (individual/room)
0.17–3.45 1239 330 26.6 158 12.8
3.46–6.74 362 139 38.4 59 16.3
6.75–10.03 24 16 66.7 6 25.0
Total 1625 485 29.8 223 13.7
x2 ¼ 31:9; P , 0:001‡ x2 ¼ 5:2; P , 0:05‡
Female work
Yes 176 38 21.6 16 9.1
No 1449 447 30.8 207 14.3
Total 1625 485 29.8 223 13.7
x2¼ 6:4; P , 0:05 x2¼ 3:6; P ¼ 0:05
The income (US$)
0–368 1294 395 30.5 173 13.4
369–736 276 80 28.9 40 14.5
737–1100 55 10 18.1 10 18.1
Total 1625 485 29.8 223 13.7
x2 ¼ 2:7; P ¼ 0:09‡ x2¼ 1:03; P ¼ 0:31‡
Age-group (year)
,1 376 22 5.9 40 10.6
1–4 1318 318 24.1 131 9.9
5–14 3665 516 14.1 72 1.9
.14 7692 62 0.8 54 0.7
Total 13051 918 7.0 297 2.3
x2 ¼ 1324; P , 0:0001 x2 ¼ 554; P , 0:0001
‡
P value for x2 of trend, with DF ¼ 1.

individual per room, and this reflects the problem
of refugees. The world community should be urged
to take real action in finding a fair solution for
Palestinian refugees.
Twenty-seven percent (442/1625) of the study
sample reported unemployment; 68 of those lost
their jobs in Israel. This indicates how Israeli siege
and closure has had a devastating impact on the
economic situation of the Palestinians in general
and the refugees in particular. A total of 1294
households (79.6%) reported a monthly income
equal to or less than US$ 368, with a median income
of US$ 230; this income is insufficient to cover the
most essential needs on the basis of an estimated
income poverty line of US$ 394 per month for a
household of two adults and four children.28
The environmental health status
Periodic cleaning of water storage tanks is an
observed practice that needs to be improved.
Contaminated drinking water as a potential source
of infection cannot be ignored, as water for drinking
and other uses is often stored in tanks and other
containers.29 Furthermore, the practice of dumping
solid waste in the street (36.4%) should be mini-
mized, as it is common to see children playing in and
around disposal sites in Gaza Strip, which can
certainly cause serious health problems.30 Also,
flies and rats spread infection from rotting and
contaminated waste.31 Gaza Strip currently suffers
from enormous environmental problems, such as
uncontrolled dumping of solid waste; the composting
Palestinian refugee conditions associated with intestinal parasites and diarrhoea: 139
Nuseirat refugee camp as a case study

Table 9 Distribution of intestinal parasites and diarrhoea according to environmental health conditions.

Variable Number Intestinal parasites Diarrhoea

Frequency % Frequency %

Sewage disposal
Barrel 506 176 34.8 87 17.2
Socking pits 17 5 29.4 1 5.9
Sewers 1102 304 27.6 135 12.3
Total 1625 485 29.8 223 13.7
x2 ¼ 8:6; P , 0:05 x2 ¼ 8:0; P , 0:05
Flush-toilet
Yes 660 173 26.2 91 13.8
No 965 312 32.3 132 13.7
Total 1625 485 29.8 223 13.7
x2 ¼ 7; P , 0:01 x2¼ 0:004; P ¼ 0:95
Source of drinking water is
Direct from the tape 1336 285 21.3 34 2.5
Indirect from storage tank 289 200 69.2 189 65.4
Total 1625 485 29.8 223 13.7
x2 ¼ 260; P , 0:001 x2¼ 793; P , 0:001
Full-day water supply
Yes 892 247 27.7 102 11.4
No 733 238 32.5 121 16.6
Total 1625 485 29.8 223 13.7
x2 ¼ 4:4; P , 0:05 x2¼ 8:7; P , 0:01
Storage tank was
Cleaned periodically 1027 60 5.8 108 10.5
Not cleaned 508 400 78.7 103 20.3
Not exist 90 25 27.7 12 13.3
Total 1625 485 29.8 223 13.7
x2 ¼ 863; P , 0:001 x2¼ 27:3; P , 0:001

process, which reduces the amount of solid waste,
has been recommended.32
The mother’s attitude to and practice of personal
hygiene
Most women (61.2%) reported that ‘their hands
have to be washed always’. Also, most women
(70.7%) mentioned that their children’s hands
should be washed ‘before and after eating’, an
attitude which needs to be improved. Most mothers
(75.1%) said that their children took a shower
between 7 and 13 times a week, which is probably
aspiration rather than reality. Children should
always be encouraged to wash their hands because
contamination of children’s hands is significantly
correlated with the incidence of diarrhoea, and this
relationship strongly supports the promotion of
hand washing as a method of controlling diarrhoeal
diseases.33 Also, hands of care-givers contaminated
directly or indirectly with fecal matter are con-
sidered important in the transmission of rotavirus
infections.34
Intestinal parasites and the socioeconomic-
demographic, environmental and hygiene
conditions
This study shows that the highest prevalence of
intestinal parasites (24.1%) is in children younger
than 5 years. Children of this age tend to play in
contaminated outdoor environments and can lack
fecal hygiene. Parasitic infection can result in
anaemia.35 The highest prevalence of diarrhoea
was statistically higher among children aged less
than 1 year; this concords with a study from Jordan,36
which points to poor environmental health con-
ditions. Despite breast feeding, the high levels of
rotavirus antibodies in mothers may not protect
infants.37 The real association between diarrhoea,
crowding, type of sewage disposal and full-day water
supply reflects the socioeconomic and environmen-
tal conditions as shown in a previous study.38 Female
members of the household who had a job was
associated with a lower percentage of parasitic
infection and diarrhoea. This reflects the importance
of the woman as worker, and the positive affect this
140 T.A. Abu Mourad

Table 10 Distribution of intestinal parasites and diarrhoea according to hygiene conditions observed by interviewers.

Variable Number Intestinal parasites Diarrheoa

Frequency % Frequency %

Cleanliness of the house

Poor 267 104 39.0 41 15.4
Moderate 964 271 28.1 140 14.5
Good 394 110 27.9 42 10.7
x2 ¼ 12:6; P , 0:01 x2 ¼ 4:2; P ¼ 0:12
Cleanliness of adults
Poor 129 46 35.7 22 17.1
Moderate 1018 303 29.8 148 14.5
Good 478 136 28.5 53 11.1
x2 ¼ 2:5; P ¼ 0:28 x2 ¼ 4:6; P ¼ 0:10
Cleanliness of children (n ¼ 1393)
Poor 241 102 42.3 41 17.0
Moderate 860 280 32.6 133 15.5
Good 292 98 33.6 37 12.7
x2 ¼ 8:1; P , 0:05 x2 ¼ 2:1; P ¼ 0:34
Presence of mosquitoes
Much 222 84 37.8 45 20.3
Little 1095 318 29.0 136 12.4
None 308 83 26.9 42 13.6
x2 ¼ 8:3; P , 0:05 x2 ¼ 9:6; P , 0:01
Flies inside the house
Many 263 88 33.5 45 17.1
Few 935 274 29.3 134 14.3
None 427 123 28.8 44 10.3
x2 ¼ 1:9; P ¼ 0:40 x2 ¼ 7:1; P , 0:05
House ventilation
Poor 433 145 33.5 76 17.6
Moderate 859 244 28.5 111 12.9
Good 333 96 28.8 36 10.8
x2 ¼ 3:8; P ¼ 0:15 x2 ¼ 8:2; P , 0:05
Garbage inside house
Much 203 76 37.4 33 16.3
Moderate 948 271 28.6 137 14.5
Little 474 138 29.1 53 11.2
x2 ¼ 6:4; P , 0:05 x2 ¼ 4:1; P ¼ 0:13
Garbage around house
Much 347 119 34.3 66 19.0
Moderate 828 230 27.8 112 13.5
Little 450 136 30.2 45 10.0
x2 ¼ 5; P ¼ 0:08 x2 ¼ 13:5; P , 0:01
Status of the kitchen
Poor 327 116 35.5 54 16.5
Moderate 1032 291 28.2 135 13.1
Good 266 78 29.3 34 12.8
x2 ¼ 6:3; P , 0:05 x2 ¼ 2:7; P ¼ 0:26

has on the health of the family. The negative
association between parasitic infections with flush-
toilet, shows the importance of its use. The
association between parasitic infection with crowd-
ing and sewage disposal requires rapid intervention
to improve living and environmental conditions of
Palestinian refugees. The percentage of intestinal
parasites and diarrhoea is significantly higher in
households with an indirect source of drinking water
(storage tanks) and uncleaned water tanks resulting
in contamination. The source of water was found to
be significantly associated with a high prevalence of
infection from water-borne parasites, including
intestinal parasites and diarrhoea.38,39 Prevalence
Palestinian refugee conditions associated with intestinal parasites and diarrhoea:
Nuseirat refugee camp as a case study
of both intestinal parasites and diarrhoea was found
to be independent of household income; this may be
due to the poor environmental situation that is not
within the power of the individual to control, but
rather should be based on a special budget for
improving the infrastructure and raising environ-
mental health standards.
Also, the economic circumstances cannot be
viewed in isolation of other health determinants,
such as individual characteristics, lifestyle factors,
the physical environment, social environment and
access to health services. An increased risk of
intestinal parasites and diarrhoea in unclean
houses, poor hygiene of children, much presence
of mosquitoes and flies, much garbage inside or
outside the house reflects poor environmental and
hygiene conditions. Our finding of an association
between sociodemographic and environmental con-
ditions and the prevalence of intestinal parasites is
confirmed by a previous study.40 Finally, infectious
diseases, including intestinal parasites, exist among
the refugees, regardless of whether or not they are
the in Palestine,41,42 and will continue to exist
unless they return back to their cities and villages.
Strengths and limitations
Despite a good response rate, there were several
limitations to this study. Recall bias may have
occurred in assessing the prevalence of intestinal
parasites and diarrhoea. An attempt was made to
reduce this by asking for only a 2-week recall period.
Because of the high sample size, the data were
collected by more than one person. Inter-observer
error may have occurred, and an attempt was made
to reduce this bias by limiting the number of data
collectors/observers to three university-graduated
and well-trained people. Also, there may possibly
have been an underestimation or overestimation of
the number of intestinal parasites and diarrhoea
cases, as the data were collected by interview rather
than using clinical and biomedical analysis, which are
recommended to confirm findings. Intra and inter-
personal variation may have occurred during the use
of three-point observation scale of the check-list, but
we attempted to reduce this by conducting intensive
field-work training for the data collectors in order to
unify their assessment and to minimize the intra- and
inter-observer variations as much as possible.
Conclusions
Overcrowding and low income are predominant
characteristics of NRC. Female effort in Palestine
141
has a positive impact on reducing the intestinal
parasites and diarrhoea infection. Intestinal para-
sites and diarrhoea is dependant on socioeconomic-
demographic, environmental health and hygiene
conditions. Children younger than 5 years are at an
increased risk of intestinal parasites and diarrhoea,
which is attributed to poor hygiene conditions.
Recommendations
This study, which highlights the adverse affect on
health of poor living conditions and environmental
situation, urges real interventions. Therefore,
effort should be focused on the following interven-
tions
1. Promote health-education programmes to over-
come the problems of disease prevalence and its
impact on the residents in NRC.
2. Urgent introduction of awareness and edu-
cational programmes to improve the environ-
mental health awareness of the residents in NRC.
3. Establish a multidisciplinary approach among all
related sectors to overcome environmental and
health-related problems.
4. Support the concept of community involvement
for solving the above mentioned problems.
5. Co-operation and fund-raising for improving and
reconstructing the infrastructure.
Acknowledgements
Special thanks to Nuseirat Municipality and the
environmental health workers who participated in
data collection and other activities. Great thanks to
TAMKEEN-USAID for funding this work.
References
1. Palestinian Central Bureau of Statistics (PCBS), Population,
housing and establishment census, Palestine: PCBS; 1997.
2. World Health Organization, Manual on water and sanitation
for health in refugee camps. Jordan: WHO/EMRO/CEHA and
UNEP/ROWA; 1993.
3. World Health Organization, Health conditions of, and
assistance to, the Arab population in the occupied Arab
territories including Palestine. Fifty-third world health
assembly: provisional agenda item 16: WHO; 2001.
4. Lilienfield LS, Rose JC, Corn M. UNRWA and the health of
Palestine refugees. United Nations Relief and Works Agency.
N Engl J Med 1986;315:595—600.
5. Al-qudsi SS. Profiles of refugee and non-refugee Palestinians
from the West Bank and Gaza. Int Migr 2000;38:79—107.
6. Palestinian Central Bureau of Statistics (PCBS), Small area
population 1997—2010; 1999.
142
7. United Nation Relief and Work Agency (UNRWA). Public
Information Office, UNRWA Headquarter-Gaza. UNRWA
[updated online] 2002. Available from: URL: http://www.
unrwa.org
8. Environmental profile, interactions between man and
environment: towards a sustainable use of resources. The
Netherlands: Euroconsult/Iwaco; 1995.
9. Al-Wahaidi A. Effect of different sanitation conditions on the
prevalence of infection with three types of intestinal
parasite among children in two localities in the Gaza Strip
[masters dissertation]. University College London; 1997.
10. Yassin M, Shubair M, Al-Hindi A, Jadalh S. Prevalence of
intestinal parasites among school children in Gaza Strip.
J Egypt Soc Parasitol 1999;29:365—73.
11. US National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK). US Department of Health and Human
Services. Digestive diseases. NIDDK-NIH [updated online];
2001. Available from: http://www.niddk.nih.gov/health/
digest/pubs/diarrhea.htm
12. Sow S, de Vlas SJ, Engels D, Gryseels B. Water related disease
patterns before and after the construction of the Diama dam
in northern Senegal. Ann Trop Med Parasitol 2002;96:
575—86.
13. Weinhold B. The diarrhea dilemma. Managing illness in
Mexico. Environ Health Perspect 2002;110:A590.
14. Cifuentes E, Suarez L, Solano M, Santos R. Diarrheal diseases
in children from a water reclamation site in Mexico city.
Environ Health Perspect 2002;110:619—24.
15. Kotloff KL, Wasserman SS, Steciak JY, et al. Acute diarrhea
in Baltimore children attending an outpatient clinic. Pediatr
Infect Dis J 1988;7:753—9.
16. Sallon S, el-Shawwa R, Khalil M, et al. Diarrhoeal disease in
children in Gaza. Ann Trop Med Parasitol 1994;88:175—82.
17. Awad R, Abu Arquob O. The status of health in Palestine:
HMIS-MOH 2000;2001.
18. Hogg RV, Tanis EA, 5th ed. Probability and Statistical
Inference, New Jersy: Prentice Hall; 1997. pp. 326—35.
19. Backestrom C, Hursh-Cesar G, 2nd ed. Survey Research,
London: Macmillan; 1981. pp. 128—40.
20. Statistical Package for the Social Sciences (SPSS, Version
7.0). Chicago IL-USA; 1999.
21. Epidemiological Program Office (EPI-INFO, Version 6.04).
WHO-CDC, Atlanta, Georgia, USA; 2001.
22. Kuzma WJ, Basic Statistics for Health Science; 1992. pp.
171—91. Mountain view, CA: Mayfield publishing.
23. Kirkwood BR. Essential for Medical Statistics. London:
Blackwell Scientific Ltd; 1988. pp. 94—105.
24. Salha R. Gaza Strip: Study in the Geology of Cities, 1st ed.
Islamic University of Gaza; 1997, pp. 320—24.
25. Shawky S, Milaat W. Cumulative impact of early maternal
marital age during the childbearing period. Paediatr Perinat
Epidemiol 2001;15:27—33.
26. Lester C, Griffiths S, Smith K, Lowe G. Priority setting with
health inequality impact assessment. Public Health 2001;
115:272—6.
T.A. Abu Mourad
27. Donati S, Hamam R, Medda E. Family planning KAP survey in
Gaza. Soc Sci Med 2000;50:841—9.
28. UNRWA Organization (Gaza-Headquarters). UNRWA Emer-
gency Appeal. Eighth progress report. Department External
Relation. UNRWA; 2001. Available from: URL: http://www.
badil.org/Resources/Intifada/update8.pdf
29. Nimri L, Hijazi S. Rotavirus associated diarrhea in children in
refugee camp in Jordan. J Diarrhoeal Dis Res 1996;14:1—4.
30. Al-Agha M. Environmental management in the Gaza Strip.
Environ Impact Assess Rev 1997;17:65—76.
31. Dialogue on diarrhoea (UK). Refugees and Displaced com-
munities. Issue 45. London: The Institute; 1991. Available
from: URL: http://myindia.net/pdf/su45.pdf.
32. Kaschl A, EL Nahhal Y, Abu Mourad T, Römheld V. Long-term
field experiment to examine the agricultural application of
municipal solid waste compost in the Gaza Strip. VDLUFA-
Schriftenreihe 1998;49:271—3.
33. Henry FJ, Rahim Z. Transmission of diarrhoea in two
crowded areas with different sanitary facilities in Dhaka
Bangladesh. J Trop Med Hyg 1990;93:121—6.
34. Pickering LK, Bartlett AV, Woodward WE. Acute infectious
diarrhea among children in day care: epidemiology and
control. Rev Infect Dis 1986;8:539—47.
35. al-Agha R, Teodorescu I. Intestinal parasites infestation
and anemia in primary school children in Gaza Governor-
ates-Palestine. Roum Arch Microbiol Immunol 2000;59:
131—43.
36. Nazer H, al-Jobeh I, Qubain H, Abdul Latif D. Diarrhoea: a
continuing health problem in Jordanian infants. J Trop
Pediatr 1993;39:95—6.
37. Widdowson MA, van Doornum GJ, van der Poel WH, et al. An
outbreak of diarrhea in a neonatal medium care unit caused
by a novel strain of rotavirus: investigation using both
epidemiologic and microbiological methods. Infect Control
Hosp Epidemiol 2002;23:665—70.
38. Omar MS, Mahfouz AA, Abdel Moneim M. The relationship of
water sources and other determinants to prevalence of
intestinal protozoal infections in a rural community of Saudi
Arabia. J Commun Health 1995;20:433—40.
39. Chunge RN, Simwa JM, Karumba PN, et al. Comparative
aetiology of childhood diarrhea in Kakamega and Kiambu
Districts Kenya. East Afr Med J 1992;69:437—41.
40. Al-Shammari S, Khoja T, El-Khwasky F, Gad A. Intestinal
parasitic diseases in Riyadh Saudi Arabia: prevalence,
sociodemographic and environmental associates. Trop Med
Int Health 2001;6:184—9.
41. Yaman H, Kut A, Yaman A, Ungan M. Health problems among
UN-refugees at a family medical center in Ankara (Turkey).
Scand J Prim Health Care 2002;20:85—7.
42. Peterson MH, Konczyk MR, Ambrosino K, Capenter DF,
Wilhelm J, Kocka FE. Parasitic screening of a refugee
population in Illinois. Diagn Microbiol Infect Dis 2001;40:
75—6.