Study protocol

This project provides real-time information on the nutritional status of humanitarian staff in Gaza. Our aim is to inform humanitarian decision-making, advocacy, and diplomatic action to improve the lives of the affected population. We are developing this project during a rapidly changing situation: please interpret results with caution. Find out more

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Version: 31 July 2025

Authors: Francesco Checchi, Zeina Jamaluddine (LSHTM)

Aim and objectives

This information system is being set up by organisations providing humanitarian services inside the Gaza Strip, with the technical and scientific support of the London School of Hygiene and Tropical Medicine (LSHTM). Its aim is to inform humanitarian decision-making, advocacy and diplomatic action to improve the lives of the affected population by providing real-time information on the nutritional status of humanitarian staff in Gaza.

While it is recognised that this sub-population may not be representative of the overall population (and may in fact have relatively higher socio-economic status), the system is intended to at least track the evolution of nutritional status within a well-defined and accessible group inside Gaza and thereby offer additional evidence for nutritional and food insecurity monitoring.

The system’s specific objectives are to:

  1. Estimate average weight and body-mass index (BMI) change since pre-war (7 October 2023) levels;

  2. Monitor the relative and absolute evolution of weight and BMI over time;

  3. Describe differences in weight and BMI change by sex, age, governorate of residence, professional role and number of children dependents.

Data collection and analysis

Eligibility

All individuals working for the organisation in some capacity are eligible to take part in data collection. Depending on the organisation, this may include expatriates, national staff, consultants, casual (e.g. daily) workers and others. The term staff throughout this document implies any of the above categories and should not be interpreted as signifying any specific employment relationship between the individual and the organisation.

It is recommended that expatriate staff also join data collection, partly to monitor their own nutritional status, but also to attenuate Palestinian staff’s potential concerns about data confidentiality and other harms.

Data structure

The dataset will be longitudinal, meaning that multiple weight measures will be collected for the same individuals, with a unique ID linking sequential observations to each individual (staff member). This is far preferable in terms of statistical analysis to collecting observations that cannot be linked over time.

Requirements

The LSHTM has prepared a generic ODK/Kobo data collection platform that any organisation can adopt. This should work on any mobile phone, tablet or computer. Staff can enter data using two forms accessible from separate URLs on a web browser (see below). They are able to toggle between identical Arabic and English versions of the data collection instruments. It is also possible to enter data on a desktop or mobile ODK/Kobo app, which however needs to be downloaded first. The LSHTM can provide instructions for this alternative option if staff prefer it, or if staff prefer designating a few individuals who will enter data on their device on behalf of many people, which would be easier to do via a desktop app.

When they first join the system, staff members read the information sheet and provide consent (see Appendix); if they consent, they will be prompted to create a user ID (see below) and fill a brief baseline questionnaire: staff members will use a URL linking to the data collection screen for this one-off data collection. Staff need to be online when accessing this first URL on their browser. Even if they lose connectivity, the platform will allow them to complete the consent process and questionnaire and click submit: their submission will be queued and will be uploaded by their device when next connected to the internet.

Staff are also be provided with a separate URL that they will need to use each time they wish to record new weight observations for themselves or a colleague. Again, the first time they use the URL on their device, they will need to be online. Subsequently, they can be offline, and the data will be uploaded when the device next has an internet connection; it is also possible to close the browser tab after submitting data.

If staff delete their cookies or browsing history, it may be that they will once again need to be online when accessing either URL. However, they should not worry about losing data: this can only happen if the device is lost or breaks before uploading the latest weight observation. Even in these cases, data previously uploaded will be safe.

Variables collected

Baseline data collection:

  • Unique ID, specified once by each new participant: participants are given two options for this: (i) specify their 9-digit Palestinian national ID; (ii) specify the first initials of their name, last name, father’s name and mother’s name (e.g. Fatima Abdelwahab Salman Yasmeen), their date of birth (dd/mm/yy, e.g. 03/11/1978) and the first initial of their favourite Palestinian artist (e.g. Sliman Mansour; if none, use any letter of the alphabet), which in the above example will generate the following ID: FASY031178S. Whichever option they choose, they are reminded by the system to remember their ID.

    • Once an ID is selected, staff have to use the same ID every time they add a new observation.

  • Date [today by default, but with option to select a different date in the past]

  • Age [16-99y]

  • Sex [M, F, other/prefer not to say]

  • Governorate where you currently live [North Gaza, Gaza City, Deir al Balah, Rafah, Khan Younis]

  • Role [expatriate staff, national staff, consultant/contractor, casual/daily worker, other, prefer not to say]

  • Number of children aged below 10 years within Gaza that you are currently responsible for feeding on a daily basis [0 to 20]

  • Estimated height in cm [100-230]

  • Estimated weight before the war started in Kg, to nearest decimal [30.0 to 180.0]

  • Weight today in Kg, to nearest decimal [30.0 to 180.0]

Ongoing data collection:

  • Unique ID, as above

  • Date [today by default, but with option to select a different date in the past]

  • Weight on the above date in Kg, to nearest decimal [30.0 to 180.0]

Analysis and publication

An automated data pipeline automatically captures data from the server at daily intervals, pre-processes the date to remove implausible variables, and analyses them to generate the following aggregate visualisations:

  • Mean, median and inter-quartile range absolute and percent reduction in weight and body mass index (BMI) from pre-war baseline.

  • Proportion of staff with BMI in different WHO categories: underweight <18.5, normal 18.50 – 24.99, overweight ≥ 25, obese ≥

  • Trends in the mean, median and inter-quartile range weight, BMI and percent weight change, by date.

  • Modelled percent change in individual weight, based on an additive growth model.

Visualisations are available for the entire group of staff being monitored, but also according to the following stratifications: (i) by organisation, (ii) by sex, (iii) by age group (<30yo, 30-44yo, 45+yo), (iv) by governorate of current residence, (v) by staff role (any categories available), (vi) by number of children <10years old the staff member is responsible for feeding (0, 1, 2, ≥ 3).

All visualisations are automatically updated on a publicly available website.

Confidentiality provisions

The following confidentiality provisions are built into the system:

  • Data are uploaded onto a secure server that is compliant with UK Data Protection legislation and is being used for other sensitive studies, including storage of non-anonymised data;

  • The unique ID specified by each participant, whichever option they choose, is encrypted at source, meaning that the variable as uploaded will not be either the Palestinian ID or the initials-date of birth composite ID, but rather an encrypted code that researchers receiving the dataset will not be able to decrypt;

  • As no names or other uniquely identifiable variables are requested, data are therefore entirely anonymised;

  • The public website enables members of the public to download graphs/tables but does not enable any access to the original source data.

Ethics

The system may be considered part of routine monitoring for the purpose of occupational health and humanitarian advocacy: as such, we believe it is exempt from institutional ethics review. However, the LSHTM has applied for ethics approval so as to cover the likely eventuality that data from the system are subjected to additional statistical analyses and submitted for scientific publication. Once this approval is granted, the LSHTM can provide details of it to participating organisations that also wish to apply for internal ethics approvals.

Procedures

Before system launch

The following need to be in place:

  • a calibrated adult weight scale set to kilograms in a visible, relatively secluded location (e.g. tea room, bathroom) within each office or building to which staff typically report at least once a day. It is recommended where possible that separate scales for women and men be made available, with a chair or stool for people to place any bags and take off or put on shoes.

  • a designated staff member in each of the above locations, trained to calibrate the scale (if not electronic).

  • one or more designated member(s) of staff who can answer questions by staff on the system, including data protection aspects.

Procedures for system launch

When the system is launched, the following procedures should be followed:

  • all staff should be informed about the system through suitable means (e.g. at morning briefings; through email, Whatsapp groups etc.); this information should be reiterated at least twice over the subsequent week; the links to the two ODK data collection screens (consent + baseline questionnaire; ongoing weight observations) should be shared at this stage.

  • key information to emphasise to staff (see also Information Sheet below) includes the following:

    • this initiative is meant to give a voice to the lived experience of staff who are facing severe food insecurity, and make this information available publicly for advocacy purposes.

    • the data are not collected for the purpose of food aid registration: there is no immediate direct benefit to staff participating.

    • taking part in data collection is completely up to each staff member; there will be no monitoring of who is providing data or not, and not providing data will not change anything for staff.

    • staff can enter data on their mobile, their computer, or even someone else’s mobile/computer; they can use a different device on any given day; they just need the same URLs; the first time they use either the first or second URL, they will need to be online; thereafter, they can also be offline.

    • data entry should only take a few seconds; it would be great if staff enter their weight every day, but as often as possible would be good too. As soon as the device has an internet connection, the data will be automatically uploaded. Therefore, staff should take their weight and make sure to enter the information straight away, rather than trying to remember the number for later.

      • Before taking their weight, staff must take their shoes off and remove any heavy items (bags, coats) they may be holding or wearing, consistent with privacy and cultural preferences.

    • all the information will be anonymised and encrypted at the point of data entry, so that it will not be possible for anyone to identify staff from the data they provide.

    • we will generate analyses from everyone’s data and publish them automatically online, but also share these with the staff, so that you can also monitoring the evolution of the situation.

    • weight scales have been provided at each workplace [specify where / who can direct staff at each workplace]. If you have any questions about the system, please contact [specify whom].

Procedures after system launch

After the system is launched:

  • check regularly (at least once daily) that the weight balances are functional and (if manual) well-calibrated.

  • remind staff once a week to enter their data and encourage any new employees to join the system.

  • make sure that, for those who don’t have internet access, at least some of the key graphs showing trends are printed or otherwise shared. Make some time for feeding back information to staff.

  • any staff who leave Gaza (e.g. for annual leave in the case of expatriates) should stop entering weight information until they return to Gaza.

  • if there are any concerns from staff or other problems with the system, please email cc in English or Arabic.