Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 21 / No. 11 November/Novembre ¼¼Ø{L ëíP_UÐíïØn"Ð{dCÐ ©nUÐxP> FeRi2015 V l m 2 1 N m b r 1 1 N m b r 2 0 1 5 Climate change already kills tens of thousands of people a year and air pollution, mostly from the dirty fuel and energy sources driving climate change, claims some 7 million lives. The 21st United Nations Climate Change Conference (COP 21) aims to achieve a universal climate change agreement that will curb greenhouse gas emissions and push countries to develop plans to protect human health from the worst effects of climate change. EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2016 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. 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ISSN 1020-3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean Cover photograph ©World Health Organization ÓnHnhUÐx{bUFfYwí phCn_UÐp[UÐpe^fe=HCÐçPUehdSüÐocCÐLÚ{[>UÐpheH}UÐpdCÐw EQíÔn=úÐsýniíphýn=UÐÓnh]_CÐíhwnaCÐíÊÐÚùÐéØnUíºn4sxíGUÐíph[UÐÓnY{#Ð;Ò{x{!ÐÓÐÚØnCÐí ÓnhdcUÐíºph[UÐgCÐÊn\LÌTOÎpg@Ywí HCÐç hdSl=ngfYd_xnYpÉnBíºÓnYd_CÐYUÙ ØÐ}RúÐíphCn_UÐ p[UÐ pe^fY Ypiín_CÐ ~TÐ}CÐíºphf_CÐ phYc"ÐEQÓ5^fCÐ Ð|Tíºphehd_UÐ {wn_CÐ }ýnHíph]UÐ @ÚnBíhdSüÐ;p[Un=NegCÐ GBÐçOTogZTÐocBÐ Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 21 No. 11 ¼¼Ø{LëíP_UÐíïØn"Ð{dCÐrr Editorial Confronting climate change in the EMR: a win–win public health approach A. Basel Al-Yousfi, Maria Neira and Hamed Bakir......................................................................................................................................................................................................................... 781 Research articles Prevalence of risk factors for noncommunicable diseases in Jalalabad city, Afghanistan, evaluated using the WHO STEPwise approach K.M.I. Saeed, M.H. Rasooly and A. Alkozai..................................................................................................................................................................................................................................... 783 Compliance with and knowledge about diabetes guidelines among physicians and nurses in Palestine N. El Sharif, I. Samara, I. Titi and A. Awartani ............................................................................................................................................................................................................................... 791 Study of prevalence and effects of insulin resistance in patients with chronic hepatitis C genotype 4 A.F. Amer, M.M. Baddour, M.A. Elshazly, G. Fadally, N.F. Hanafi and S.L. Assar ............................................................................................................................................................ Trauma research in Qatar: a literature review and discussion of progress after establishment of a trauma research centre A. El-Menyar, M. Asim, A. Zarour, H. Abdelrahman, R . Peralta, A. Parchani and H. Al-Thani .................................................................................................................................... 811 Socioeconomic inequality and child maltreatment in Iranian schoolchildren Z. Hosseinkhani, S. Nedjat, A. Aflatouni, M. Mahram and R . Majdzadeh............................................................................................................................................................................ 819 Antibiogram of multidrug resistant Acinetobacter baumannii isolated from clinical specimens at King Hussein Medical Centre, Jordan: a retrospective analysis A. Batarseh, A. Al-Sarhan, M. Maayteh, S. Al-Khatirei and M. Alarmouti............................................................................................................................................................................ 828 Review Ageing and intergenerational family ties in Arab countries N.M. Kronfol, A. Rizk and A.M. Sibai ............................................................................................................................................................................................................................................... Report Jordan tobacco dependence treatment guidelines: rationale and development H. Ayub, N. Obeidat, S. Leischow, T. Glynn and F. Hawari ......................................................................................................................................................................................................... 844 WHO events addressing public health priorities Strengthening hospital management in the Region.................................................................................................................................................................................................... Reducing health inequities through actions on the social determinants of health................................................................................................................................ Ala Alwan, Editor-in-chief Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Zuhair Hallaj Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editors Fiona Curlet, Guy Penet (French) Freelance: Alison Bichard, Marie-France Roux Graphics Suhaib Al Asbahi, Diana Tawadros Administration Nadia Abu-Saleh, Yasmeen Sedky, Iman Fawzy HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 781 1Director, World Health Organization Centre for Environmental Health Action, Amman, Jordan. 2Director, Public Health, Environmental and Social Determinants, World Health Organization, Geneva, Switzerland. 3Coordinator, Environmental Health Interventions, World Health Organization Centre for Environmental Health Action, Amman, Jordan. Editorial Confronting climate change in the EMR: a win–win public health approach A. Basel Al-Yousfi,1 Maria Neira2 and Hamed Bakir 3 The effects of climate change are be- ing increasingly felt today and forecasts represent potentially disastrous risk to human health in the future. Policy responses are therefore imperative in countries in order to ensure the protec- tion of the people’s health. “Climate change could be the big- gest global health threat of the 21st cen- tury”, the Lancet XBSOFE JO.BZ (1). Yet in current climate debates, health is still being treated as a periph- eral matter. The WHO Conference on )FBMUI BOE$MJNBUF JO"VHVTU reviewed the strong scientific evidence of the grave impact of climate change on health. Notwithstanding extreme weather disasters, WHO estimates that climate change will cause an additional EFBUITQFSZFBSCFUXFFO BOE.PTUXJMM MJLFMZQFSJTI GSPN malaria, diarrhoea, heat exposure and under-nutrition (2). Children and the elderly will be among the most vul- nerable. Areas with weak health infra- structure will be least able to cope and developing countries will be hardest hit. The health gaps we have been try- ing hard to close may grow even wider. On the brighter side, the latest message from the Lancet report of June BSUJDVMBUFEUIBUi5BDLMJOHDMJNBUF change could be the greatest global health opportunity of the 21st century” (3). In addition, the 21st United Na- tions Climate Change Conference (COP 21) being held in Paris, France GSPN/PWFNCFS UP%FDFNCFS BJNTUPBDIJFWFBOFXBOEVOJWFS- sal climate change agreement from all the nations of the world. COP 21 offers the world an important opportunity to not only reach a strong international climate agreement, but also to save lives and protect the health of current and future generations of humankind (and co-inhabitant species). As such, WHO considers the Paris treaty a significant public health treaty. Although historically Member States of the WHO Eastern Mediter- ranean Region (EMR) have contrib- uted relatively little to the Greenhouse Gases (GHG) emissions and thus to the onset of climate change, EMR is the second worst impacted region after Africa in terms of health conse- quences (4). A systematic review of research evidence from EMR coun- tries (5), documents and predicts ad- verse climate impacts on health, such as increases in: waterborne diseases, under-nutrition, drowning, mortal- ity and morbidity during heat waves, mortality due to cardiovascular and respiratory illnesses, the spread of vec- tor-borne diseases (dengue, malaria, schistosomiasis and zoonotic cutane- ous leishmaniasis), and mental health and allergic reactions and pulmonary diseases across the Region due to dust storms. A systematic review of published research on climate change and health in the EMR (6), however, found that research on the links be- tween climate change and health is still quite limited, and there are many gaps in our awareness and understand- ing of these links that may limit mitiga- tion and adaptation activities. The WHO Regional Centre for En- vironmental Health Action (CEHA) has been providing capacity building and technical support to all EMR Member States to support their public health response to climate change and improve the resilience of their health systems. In that regard, Jordan has de- veloped its national health and climate adaptation action plan and integrated climate change considerations within its national health policy. The health ministries in several countries have developed their National Framework for Action on Health and Climate Change and contributed to the health and climate change chapters of the Na- tional Communication to the United Nations Framework Convention on Cli- mate Change (UNFCCC). However, Member States, still need to take further steps to: r Raise awareness and advocate for protecting health from climate change r Undertake assessment of health vul- nerability to climate change r Develop early warning systems and adaptation and mitigation action plans for health protection and resil- ience from climate change r Support health-promoting climate change policies; and participate in the UNFCCC processes as leaders on health r Identify the health benefits asso- ciated with reducing emissions of greenhouse gases and other climate pollutants. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 782 References 1. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate change. Lancet and University College London Institute for Global Health Commission. Lancet. 2009 May 16;373(9676):1693–733. doi: 10.1016/S0140-6736(09)60935-1 2. Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s. Geneva: World Health Organization; 2014. 3. Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. Lancet. 2015 Jun 24. pii: S0140-6736(15)60854- 6. doi: 10.1016/S0140-6736(15)60854-6. [Epub ahead of print]. 4. Patz J, Campbell-Lendrum D, Gibbs H, Woodruff R. Health Impact Assessment of Global Climate Change: Expanding on Comparative Risk Assessment Approaches for Policy Making. Annu Rev Public Health. 2008;29:27-39. doi: 10.1146/an- nurev.publhealth.29.020907.090750. 5. Khader YS, Abdelrahman M, Abdo N, Al-Sharif M, Elbetieha A, Bakir H, et al. Climate change and health in the Eastern Medi- terranean countries: a systematic review.Rev Environ Health. 2015 Aug;30(3):163–81. doi: 10.1515/reveh-2015-0013.. 6. Climate change and health in the EMR – a systematic review of published research. Amman: WHO Regional Office for the Eastern Mediterranean, Regional Centre for Environmental Health Action (in press). 7. Towards a public health response to climate change and air pollution in the Eastern Mediterranean Region. Paper pre- sented at the 61st Session of the World Health Organization Regional Committee for the Eastern Mediterranean, Tunis, Tunisia, 19–22 October 2014 (http://applications.emro.who. int/docs/Technical_Meeting_Climate_Change_Air_Pollu- tion_2014.pdf, accessed 30 November 2015). This may require a broad public health approach, including not only the preventive and curative functions under direct control of the formal health sector, but also appropriate leadership, guidance and regulatory functions with regard to health-determining sectors, such as water and sanitation, or disaster risk reduction. Given the climate change threats to health and the potential health co-benefits that result from mitiga- tion and adaption actions to confront climate change, Member States need a proactive public health response to support such actions and enhance the resilience of health systems (7). This is win-win public health approach will enable mitigation of climate change and reduction in environmental pol- lution, thus lowering the burden and cost of ill health and generating cost savings that can be re-allocated to strengthen the public health budget in areas such as healthy living pro- motion and disease prevention and control. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 783 1Afghan National Public Health Institute, Ministry of Public Health, Kabul, Afghanistan (Correspondence to K.M.I. Saeed: kmislamsaeed@gmail.com). Received: 22/07/14; accepted: 23/06/15 Prevalence of risk factors for noncommunicable diseases in Jalalabad city, Afghanistan, evaluated using the WHO STEPwise approach K.M.I. Saeed,1 M.H. Rasooly 1 and A. Alkozai 1 ABSTRACT Noncommunicable diseases (NCDs) are a growing public health challenge. This study aimed to estimate the prevalence of common risk factors for NCDs among the adult population an urban setting in the eastern province of Nangarhar, Afghanistan. In a randomized, cluster sample survey of households the WHO STEPwise method was modified and used to collect demographic, behavioural and clinical data from 1200 adults (61% females) in Jalalabad in 2013. Blood samples were collected for biochemical testing. The prevalence of overweight/obesity, diabetes and hypertension were 57.4%, 11.4% and 24.4% respectively. Among respondents, 8.0% reported being current cigarette smokers and 13.7% used mouth snuff; 69.8% and 19.6% had < 3 servings of fruits and of vegetables respectively in a week; and 33.5% and 57.8% reported vigorous and moderate physical activity respectively. Tailored interventions on risk factors of NCDs are needed in urban areas in Afghanistan. oåd]eXÑcåGÌêÐzåGm<oåd¬gaXºëmåhm_Qi<Ømå<Ëé°å?oåewzX9owÚmåTÐDåPßÐ|åXúm<oåÉm#Ð|å\#ÐåXÐKÚmåYhÐ ÕÚzBÐoåågBm^TÐoååZTÐ ïÛcUÐexκ<HÚhaA{e7º{h_HêĆHÎEYp@ÐB }å]#ÐåYÐLÚnåZiÐ}åx{b>OÎpåHÐÚ{UÐì|åwqåR{w{åSí påYn_UÐpå[dUðnåhYnfYðnåx{ĻcåZ>pxÚnåUÐEåQßÐ}åYúÐëÎoåÉ°#Ð yåYåaR ënåin`Rj=på hSPUÐÚnåwninipå^Rn7:påxApåb]fY:Nå`UnUÐëncåUÐNå=pxÚnåUÐEåQßÐ}åY±UpåfUn=p_ýnåZUÐ Ónåinh= åe!ngYÐ{åHÐípå@Ú{CÐpåhCn_UÐpå[UÐpåe^fYpåbx}Jåx{_>å>úÐåYphýÐåZLpåxØbfLpåfh_U 2013ênåLï}å@Ì ëncåR påxhApåhýnhehTÓÐÚnåBÐÊÐ}å@üêØÓnåfhL å+å>í Ønå=ËéĆå@:ÔnåiÎ%61ðnå`Un=1200åYpåx}xíphTdåHíphincåH ååfB{Yåå¹j=NTÚnååZCÐååY%8ØnååRÌí <ÐååUÐDååL%24 4í%11 4í%57 4åå`\UÐânååa>ÚÐíï}cååUÐípfeååUÐ ëÛUÐÒØnååxÛÚnååZiÐ Únå\#ÐíåTÐaUÐåYå[AÔĆå?åYåSÌÐåUínf>{åS19 6%í%69 8ënTíºåaUÐeåZ>ÐY{åHÐågfY%13 7íºëåhUnA}ýnåH ÓĆåB{>OÎpå@nAènåfw <ÐåUÐDåLåHYíïåS©{å=ànåZipåHÚ5e=ågfY%57 8í%33 5ØnåRÌíºâåHÌëå\Q:<ÐåUÐDåL ënåin`RÌ:påx"ÐåJnfCÐ:pxÚnåUÐEåQßÐ}åYúÐ}å]BåYÐLëjåZ=ðnå[h[Båe[> Prévalence des facteurs de risque pour les maladies non transmissibles à Jalalabad (Afghanistan), évaluée à l’aide de l’approche STEPwise de l’Organisation mondiale de la Santé (OMS) RÉSUMÉ Les maladies non transmissibles représentent un défi de santé publique croissant. La présente étude avait pour objectif d’estimer la prévalence des facteurs de risque courants pour les maladies non transmissibles en population adulte en milieu urbain dans la province de l’est de Nangarhar (Afghanistan). Dans une étude randomisée portant sur un échantillon en grappes de ménages, la méthode STEPwise de l’OMS a été modifiée puis utilisée pour recueillir des données démographiques, comportementales et cliniques auprès de 1200 adultes (61 % de femmes) à Jalalabad en 2013. Des échantillons de sang ont été prélevés pour des analyses biochimiques. La prévalence du surpoids/de l’obésité, du diabète et de l’hypertension était de 57,4 %, 11,4 % et 24,4 % respectivement. Parmi les répondants, 8,0 % rapportaient être des fumeurs de cigarettes actuels et 13,7 % utilisaient du tabac à priser ; 69,8 % et 19,6 % indiquaient consommer moins de trois portions de fruits et de légumes respectivement par semaine, et 33,5 % et 57,8 % déclaraient pratiquer une activité physique modérée ou intense, respectivement. Des interventions adaptées sur les facteurs de risque des maladies non transmissibles sont requises dans les zones urbaines d’Afghanistan. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 784 Introduction Morbidity and mortality due to non- communicable diseases (NCDs) continue to rise, in developing as well as developed countries (1,2). The new health goal is to reduce mortality from /$%TCZCZ UIFCZ goal (3). Of the total deaths attributed UP/$%THMPCBMMZ OFBSMZPDDVSJO low- and middle-income countries (4). Furthermore, NCDs kill at a younger age in developing countries, including those of the Eastern Mediterranean Region (EMR). In some EMR coun- USJFTVQ UPPG UIPTFXIPEJF GSPN TVDIEJTFBTFTEJFCFGPSF UIFBHFPG ZFBSTDPNQBSFEXJUI MFTT UIBO JO western Europe (5). The global eco- nomic burden of NCDs is huge (6) and disproportionately affects poorer indi- viduals in low-income countries (7). In Afghanistan, as in other countries of the EMR, most of the costs of health care, particularly for NCDs, are paid directly by patients out-of-pocket, and therefore can be a significant burden on household budgets (8). According to World Health Or- ganization (WHO) estimates the age-standardized death rates in Af- HIBOJTUBO GSPNBMM/$%XFSF QFSQPQVMBUJPOGPSNBMFTBOE QFSGPS GFNBMFT 9). Fur- thermore, the Afghanistan mortality TVSWFZSFWFBMFEUIBUPGBMM deaths in Afghanistan were attributed to NCDs, with cardiovascular diseases, malignant neoplasms, diabetes, res- piratory diseases and digestive diseases BDDPVOUJOHGPS BOEPGUPUBM/$%EFBUITSFTQFD- tively (10). Based on WHO estimates, JO UIFSFXFSF QFPQMF with diabetes in Afghanistan. This OVNCFSJTFYQFDUFEUPSJTFUP JO SFQSFTFOUJOHBOFBSMZGPME JODSFBTF DPNQBSFEXJUI 11). *OB TUVEZBNPOHNFOBHFEZFBST and older in Kabul city the prevalence PG TNPLJOHXBT 12), while in a study to identify the prevalence and risk factors of NCDs among the older BEVMUQPQVMBUJPO BHFEɓZFBST JO ,BCVMDJUZ JO UIFQSFWBMFODFPG diabetes mellitus was reported to be PCFTJUZXBTBOEIZQFS- UFOTJPOXBT 13). Finally, an as- sessment of the air quality of Kabul city showed that the ambient air quality in the city has deteriorated to such extent that it can be ranked among the most polluted cities in the world, a situation which potentially increases the burden of respiratory diseases and different types of cancer among humans (14). It is believed that a large proportion of NCDs can be prevented by reducing the 4 main risk factors: tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol (6). In Af- ghanistan, due to competing priorities and many years of conflict, little infor- mation is available about the prevalence and risk factors for NCDs. However, facts and figures from neighbouring countries such as Pakistan and the Islamic Republic of Iran give cause for concern (15–19). Given that in Afghanistan the risk of mortality due to NCDs has overtaken that due to communicable diseases (10), there is insufficient evidence about the risk factors associated with NCDs in the country. A previous study of risk factors in Kabul city could not be generalizable to all Afghanistan with its variety of dif- ferent geography, risk behaviours and cultural backgrounds. Therefore, to fill this knowledge gap the present study aimed to identify the prevalence of risk factors for chronic NCDs in the ur- ban population of Nangarhar province (Jalalabad city). Methods Study design and setting In this study we adapted and used the WHO STEPwise tool (20) to esti- mate the prevalence of risk factors for NCDs in an urban setting in the east- ern province of Nangarhar. Jalalabad city includes 22 districts of Nangarhar province and is also a vehicle transport hub to neighbouring provinces such as Laghman, Kunar, Nuristan, Kabul and Kapisa. The municipality organizes the city into 6 main districts and the Ex- panded Programme on Immunization (EPI) divides the city into 4 clusters BOE TVCDMVTUFST XIJDIBSF GVSUIFS divided by streets (areas). In this study we approached all EPI clusters and sub- DMVTUFSTJOEJTUSJDUTPGUIFDJUZ Sampling All permanent household members BHFEmZFBST JODMVEJOHNFOBOE women who were residents of the city during the study period and gave con- sent to participate, were included in the study. Temporary residents (resident < 6 months) and those living in insti- tutionalized settings or insecure areas were excluded. Due to the unavailability of previ- ous estimates of risk factor prevalence in this province we assumed the high- est prevalence for sample size calcula- UJPO DPOėEFODF JOUFSWBM $* BOENBSHJOPGFSSPSPG'SPN UIJTXFFTUJNBUFE TVCKFDUT UPCF included in the survey. Taking into consideration the proportion of other risk factors in similar settings, the number of subjects was increased to 5PBMMPX GPSOPOSFTQPOTF DPTU resources and time, without compro- mising the representativeness of the sample, a 2-phase cluster sampling technique was used. Finally, after tak- ing into account the design effect (= 2) of cluster sampling the final sample TJ[FXBTJODSFBTFEUP ¤ which was reasonable for achieving the study objectives with limited resources and funding support. Data were collected from 4 clus- UFST "m% BOE TVCDMVTUFSTPG UIF EPI. The primary sampling unit was subclusters, the secondary sampling unit was streets/areas, the tertiary sampling unit was households and the ultimate sampling unit was respondents HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 785 aged m ZFBST JO UIF IPVTFIPME We could not determine how many households there were from the centre to periphery in each street and so we selected each second household until the sample fraction was completed. The interviewers were instructed to find a well-known fixed landmark or a very populated street within the boundaries of the selected location and, following the bottle rotating method, to proceed to a series of households. A household was defined as a group of people who share the same food pot (not the same roof). In each household the interviewer enumerated all persons who were eligible for our study based on the inclusion criteria. In households with more than one person meeting the eligibility criteria we used a lottery system to select the respondent for this survey. The refusal rate for participation XBTMPX *ODBTFTPGSFGVTBM UIF interviewer approached the next alter- nate household. This method provided an equal chance of each member of the household being selected. Data collection Data on demographic, behavioural and clinical variables were collected from .BZ UP +VOFCZEJSFDU JOUFSWJFX using the WHO STEPwise instrument. For the purpose of the survey imple- mentation, experienced data collectors (males and females) with at least 12th grade level of school education were recruited and trained. At the end of the practical fieldwork, all issues and am- biguity related to data collection were clarified. Definitions Anthropometric measurements (height and weight) were used to calculate body NBTT JOEFY #.* "#.*PGɓLH m2XBTDPOTJEFSFEBTPCFTF mLH m2BTPWFSXFJHIUBOEmLHN2 as normal weight (21). A waist circumfer- FODFPGɓDNGPSNFOBOEɓDN for women was considered as central obesity (22). 4ZTUPMJD CMPPE QSFTTVSF ɓ NN)H BOE EJBTUPMJD QSFTTVSF ɓ mmHg were considered as hyperten- sion (23). Following the interview, blood sam- ples were collected the next morning af- UFSUIFSFTQPOEFOUIBEGBTUFEGPSm hours and were processed by laboratory technicians for serum separation. After- wards they were shipped to the central public health laboratory in Kabul and TUPSFEBUm $-BUFS UIFCJPDIFNJ- cal measurement of blood lipids and sugar were conducted. A fasting blood sugar of ≥ 126 mg/dL was considered as diabetes mellitus (24). The cut-offs for serum total cholesterol, triglycerides and low-density lipoprotein (LDL) DIPMFTUFSPMXFSFNHE- NH E- BOENHE- SFTQFDUJWFMZ BOE for high-density lipoprotein (HDL) DIPMFTUFSPMXFSFNHE- NFO BOE NHE- XPNFO Ethical considerations The study protocol was approved by the institutional review board of the Af- ghan Ministry of Public Health. Before the interviews and sample collection, the provincial public health directorate, the municipality and community lead- ers were briefed about the aims and objective of the study and all agreed with the process of data collection. After an explanation of the survey, in- formed consent was taken from each individual before the interview. All steps were taken to conduct the interviews in privacy and on a voluntary basis. Given the gender sensitivity in the Afghan context, female data collectors inter- viewed only female respondents and male data collectors interviewed only male respondents. Data analysis All collected data, hard and soft, were kept confidential in a locked cupboard and a password-protected computer. Data were entered in Epi-Info, version 7, and analysed descriptively using SPSS, WFSTJPO Results Background demographic " UPUBM PG JOEJWJEVBMTXFSF BQ- proached and interviewed. The propor- UJPOPGNBMFTBOEGFNBMFTXBTBOE SFTQFDUJWFMZ JOPVS TUVEZ TBNQMF DPNQBSFEXJUISBUFTPGBOEJO the general population. In order to bal- ance the sex distribution we weighted the dataset for analysis. The mean and standard deviation (SD) age of the study participants was 4% ZFBST4FMFDUFE TPDJP- economic and demographic character- istics of the participants are shown in Table 1. About two-thirds of females and a third of male participants were JMMJUFSBUFBOEPG UIFQBSUJDJQBOUT IBE BNPOUIMZ JODPNF "G- HIBOJT 64 "NBKPSJUZ of study participants were married. The most common occupation, particularly among men, was farming and manual XPSL XIJMFPGXPNFO were housewives. Prevalence of risk behaviours 0OMZPGQBSUJDJQBOUT SFQPSUFECF- JOHDVSSFOUDJHBSFĨFTNPLFSTBOE reported using mouth snuff (chewing tobacco). Reflecting cultural norms, the prevalence of cigarette smoking and chewing tobacco were very low among women; only 3 women reported us- ing mouth snuff and 1 was a cigarette smoker. "NPOH UIF SFTQPOEFOUTSF- ported consuming < 3 servings of fruits JOBXFFLBOE TFSWJOHTPGWFH- etables in a week (Table 2). Solid oils were used for cooking in the kitchen by PGSFTQPOEFOUTBOEMJRVJEPJMTCZ 7JHPSPVTBOENPEFSBUFMFWFMTPG QIZTJDBMBDUJWJUZXFSFSFQPSUFECZ BOEPGSFTQPOEFOUTSFTQFDUJWFMZ Prevalence of overweight and obesity The mean height, weight and BMI of the sample were 161.4 cm, 69.3 kg and 26.8 kg/m2 respectively. The mean systolic EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 786 blood pressure was 121.8 mmHg and the mean diastolic blood pressure was 78.8 mmHg. "TTIPXOJO5BCMF PWFSBMM of study participants were either overweight or obese. Overweight and obesity were more common among XPNFOBTDPNQBSFEXJUINFO WFSTVT 'VSUIFSNPSF PG respondents had central obesity based on waist circumference (excluding pregnant women). Prevalence of hypertension and diabetes mellitus "NPOH UIF QBSUJDJQBOUT IBE high blood pressure. The prevalence of diabetes mellitus (fasting blood sugar ɓ NHE- XBT BOE XBT IJHIFSBNPOHXPNFOUIBONFO WFSTVT 0WFSBMMPG SFTQPOEFOUTIBE IJHI TFSVN UPUBM DIPMFTUFSPM ɓ NHE- IBE MPX-%-DIPMFT- UFSPM ɒNHE- IBEIJHI )%-DIPMFTUFSPM BOEIBEIJHI USJHMZDFSJEFMFWFM ɓNHE- Discussion In contrast with the attention given to communicable diseases by the govern- ment and its partners in Afghanistan, the current survey focussed on the iden- tification of common risk and protective factors for NCDs (25,26). According to Table 1 Frequency distribution of demographic characteristics of the study participants Variablea Females Males Total No. % No. % No. % Age (years) 25–34 211 39.7 248 43.5 459 41.7 35–44 190 35.8 96 16.8 286 26.0 45–54 95 17.9 117 20.5 212 19.3 55+ 35 6.6 109 19.1 144 13.1 Residence District 1 54 9.2 144 23.6 198 16.6 District 2 118 20.2 21 3.4 139 11.6 District 3 186 31.8 92 15.1 278 23.3 District 4 65 11.1 296 48.6 361 30.2 District 5 162 27.7 56 9.2 218 18.3 Educational level Illiterate 514 88.3 276 45.9 790 66.8 Primary/unofficial education 32 5.5 133 22.1 165 13.9 Secondary school 30 5.2 133 22.1 163 13.8 University and above 6 1.0 59 9.8 65 5.5 Monthly income (Afghanisb) ≤ 10 000 280 47.9 465 76.1 745 62.0 10 000–20 000 18 3.1 25 4.1 43 4.0 ≥ 20 000 34 5.8 1 0.2 35 3.0 Refused 252 43.2 118 19.4 370 31.0 Work status Government employee 18 3.1 113 18.6 131 11.0 Private business 1 0.2 101 16.7 102 8.6 Farmer/manual worker 3 0.5 286 47.2 289 24.3 Working in house 517 88.8 0 0.0 517 43.5 Unable to work/retired 2 0.3 101 16.7 103 8.7 Refused 41 16.7 5 0.8 46 3.9 Marital status Single 32 5.5 66 10.8 98 8.3 Married 514 88.0 534 87.7 1048 88.3 Other 32 5.5 8 0.2 40 3.4 aMissing values in some categories; b$US 1 = 57 Afghanis at the time of the study. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 787 our findings two-thirds of the adults of Jalalabad city were suffering from over- weight or obesity. A study conducted in Kabul city found a higher prevalence of obesity, which might be due to the older age group studied (13). Our findings on obesity are consistent with global and large-scale studies in other parts of the world (27–29). Although no informa- tion from Afghanistan is available to assess the trends of obesity, it is likely that the economic condition of urban citizens is improving. Moreover, cul- tural norms in Afghanistan mean that being overweight and obese is perceived as healthy and people are not generally interested in losing weight. The prevalence of hypertension BOEEJBCFUFTNFMMJUVT in our study suggests that the coun- try has already entered an epidemic of NCDs, which requires strengthening efforts for control and prevention. In an earlier study in Kabul city the prevalence PGIZQFSUFOTJPO BOEEJBCFUFT BOE SFTQFDUJWFMZ XFSFIJHIFS than in the current study, perhaps due to cultural differences and to the older age groups sampled in that study (13). Our findings can be compared with those of a study in the Islamic Republic of Iran, which is a neighbouring county to Afghanistan. A systematic analysis of TUVEJFT GSPN UPFTUJNBUFE that the overall prevalence of hyper- tension in the population age groups Table 2 Frequency distribution of behavioural risk factors for noncommunicable diseases among the study participants Variablea Female Male Total No. % No. % No. % Cigarette smoking status No 541 99.8 515 85.0 1056 92.0 Yes 1 0.2 91 15.0 92 8.0 Duration of smoking: current and ex-smokers (years) < 10 0 0.0 60 44.8 60 43.8 10–20 3 100.0 47 35.1 50 36.5 ≥ 20 0 0.0 27 20.1 27 19.7 Mouth snuff use status No 542 99.4 455 74.6 997 86.3 Yes 3 0.6 155 25.4 158 13.7 Fruit servings (days per week) a < 3 401 73.3 369 66.4 770 69.8 ≥ 3 146 26.7 187 33.6 333 30.2 Vegetable servings (days per week)b < 3 151 26.4 81 13.3 232 19.6 ≥ 3 422 73.6 527 86.7 949 80.4 Type of kitchen oil Liquid 370 68.4 105 17.8 475 42.0 Solid 171 31.6 484 82.2 655 58.0 Vigorous physical activityc No 306 57.5 452 74.5 758 66.5 Yes 226 42.5 155 25.5 381 33.5 Moderate physical activityd No 192 36.8 242 47.8 434 42.2 Yes 330 63.2 264 52.2 594 57.8 Pedal or bicycle for 20 min daily No 502 95.8 246 40.7 748 66.3 Yes 22 4.2 359 59.3 381 33.7 Sitting (h/day) < 3 296 66.7 359 63.3 655 64.8 ≥ 3 148 33.3 208 36.7 356 35.2 aMissing values in some categories; bOne serving is amount of fruits or vegetables taken once; cPhysical activity for 10 min causing high increase in heart rate or respiration; dPhysical activity for 10 min causing moderate increase in heart rate or respiration. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 788 mBOE ZFBSTXFSFBSPVOE BOESFTQFDUJWFMZ 30). The national prevalence of diabetes in the Islamic Re- QVCMJDPG*SBOBNPOHmZFBSPMETJO XBT IJHIFSBNPOH GFNBMFT UIBONBMFT WFSTVT 15). These figures show a lower prevalence of hypertension and diabetes compared with Afghanistan, which is probably due to the Islamic Republic of Iran’s more advanced public health programmes. In Punjab province in Pakistan, another neighbouring country, the prevalence PGEJBCFUFTXBT SFQPSUFE UPCF JONBMFTBOEJOGFNBMFT 16). The overall prevalence of hypertension in ,BSBDIJ 1BLJTUBOXBT XJUIBEJĎFS- FODFCFUXFFONBMFTBOEGFNBMFT WFSTVT "HF BOBMZTJT SFWFBMFE that the prevalence of hypertension in- creased with age and that people with IZQFSUFOTJPOXFSFUJNFTNPSFMJLFMZ UPCFPWFSZFBSTPGBHF 17). Health education campaigns in our country should be tailored to cover the principal risk factors. Vigorous and moderate physical activity are protec- tive factors against obesity as well as other NCDs but are not being practised to recommended levels. Better commu- nity awareness and the establishment of sport centres and jogging areas, which are lacking in urban settings, particularly for women, should be encouraged and discussed with the relevant sectors. Men are at greater risk of NCDs than are women, which is not a modifiable risk factor and could be due to genetic dif- ferences. Sex differences in risk factors Table 3 Frequency distribution of clinical risk factors for noncommunicable diseases among the study participants Variablea Females Males Total No. % No. % No. % BMI (kg/m2)b Underweight 16 3.2 61 10.1 77 7.0 Normal weight 150 30.0 244 40.3 394 35.6 Overweight 155 31.0 205 33.8 360 32.5 Obesity I 102 20.4 69 11.4 171 15.5 Obesity II 47 9.4 18 3.0 65 5.9 Obesity III 30 6.0 9 1.5 39 3.5 Central obesity (missing=133) No 166 34.5 294 50.7 460 43.4 Yes 315 65.5 286 49.3 601 56.6 Blood pressurec Normotensive 143 25.0 252 41.7 738 62.6 Pre-hypertensive 258 45.2 235 38.9 105 8.9 Hypertensive 170 29.8 117 19.4 335 28.4 Elevated blood sugard No 497 86.6 541 90.6 1038 88.6 Yes 77 13.4 56 9.4 133 11.4 Total cholesterol (mg/dL) < 190 256 44.7 296 49.7 552 47.2 ≥ 190 317 55.3 300 50.3 617 52.8 LDL cholesterol (mg/dL) < 100 126 22.0 160 26.8 286 24.5 ≥ 100 446 78.0 437 73.2 883 75.5 HDL cholesterol (mg/dL) < 40 (M); < 50 (F) 518 88.7 420 78.6 938 78.6 ≥ 40 (M); ≥ 50 (F) 66 11.3 190 21.4 256 21.4 Triglycerides (mg/dL) < 150 194 33.9 173 29.0 367 31.4 ≥ 150 378 66.1 424 71.0 802 68.6 aMissing values in some categories; bUnderweight < 18.5 kg/m2, normal weight 18.5–24.9 kg/m2, overweight 25–29.9 kg/m2, obesity I 30–34.9 kg/m2, obesity II 35–40 kg/m2, obesity III > 40 kg/m2; cSystolic/diastolic blood pressures: normotensive 120/80 mmHg, pre-hypertensive 120–140/80–90 mmHg, hypertensive ≥ 140/≥ 90 mmHg; dFasting blood sugar ≥ 126 mg%. LDL = low-density lipoprotein; HDL = high-density lipoprotein; M = males; F = females. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 789 were also demonstrated in Karachi in Pakistan (27). Based on our findings the preva- lence of cigarette smoking and tobacco snuff use was much higher among men than women, probably due to the cul- tural unacceptability of these practices for women. The sex differences in smok- ing patterns are similar to other studies (31,32), but due to a scarcity of previous studies, comparisons of snuff use are not possible. Chronic NCDs such as diabetes, obesity and hypertension tend to occur as a combined syndrome in the adult population. The presence of diabetes and obesity, either central or general, affect blood pressure levels and need to be considered as a comorbidity while managing other problems. These find- ings are supported by another study of the same design in Kabul city on an older population (13). That study hy- pothesized that the population of this urban setting was entering a critical state of NCDs, while little attention was be- ing given to the issue. Interventions are needed to target a group of risk factors rather than just one or two factors. There were some limitations to our study. The first limitation was financial constraints, which prevented listing of the households before the survey and necessitated approaching the community and selecting the house- holds directly. Secondly, the provision of free blood pressure measurements and laboratory tests might have encour- aged more patients with hypertension and diabetes to participate in the study, which might have caused an overes- timation of the prevalence of these diseases. The third limitation, which is common to all studies in Afghanistan is the poor security situation which forced us to exclude a district from our study. Despite these limitations this study has provided some useful baseline in- formation for policy development and the design of interventions. The study demonstrated the impact of NCDs such as diabetes, blood pressure and obesity on a population already bur- dened by communicable and vaccine- preventable diseases. The findings can contribute towards the formulation of more advanced, nationwide studies. Conclusion and Recommendations During the previous decade, the greatest priorities in Afghanistan were commu- nicable diseases, malnutrition, vaccina- tion and maternal and child health care. Therefore, minimal efforts have been carried out to reduce risk factors for NCDs within the population. The NCD unit has recently been established in the Ministry of Public Health and we rec- ommend strengthening the department and preparing for a nationwide survey using the WHO STEPwise approach to surveillance in order to obtain a more complete picture of the risk of NCDs in the country. NCD surveillance should be an integrated part of primary health care, with systems for screening for asymptomatic hypertension and dia- betes and staff training on identification and management of NCD risk factors. Finally, in close collaboration with other sectors such as the ministries of educa- tion, higher education, justice, trade, women’s affairs and media, steps should be taken to promote healthy lifestyles and practices among the population of Afghanistan and to facilitate any neces- sary legislation. Acknowledgements Funding: We would like to thank Afghan National Public Health Insti- tute at the Ministry of Public Health and the WHO Regional Office for the Eastern Mediterranean for supporting the study. In addition the Disease Early Warning System contributed towards completion of the study. Competing interests: None declared. References 1. Wagner KH, Brath H. A global view on the development of NCDs. Prev Med. 2012;54:S38–41. PMID:22178469 2. 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National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants. Lancet. 2011 Feb 12;377(9765):557–67. PMID:21295846 29. Khuwaja AK, Kadir MM. Gender differences and clustering pattern of behavioural risk factors for chronic NCDs: commu- nity-based study from a developing country. Chronic Illn. 2010 Sep;6(3):163–70. PMID:20444764 30. Haghdoost AA, Sadeghirad B, Rezazadehkermani M. Epidemi- ology and heterogeneity of hypertension in Iran: a systematic review. Arch Iran Med. 2008 Jul;11(4):444–52. PMID:18588378 31. WHO STEPS. Chronic disease risk factor surveillance. Data book, I.R. Iran 1388 (2009) [Internet]. Geneva: World Health Organization; 2009 (http://www.who.int/chp/steps/Iran_ DataBook_2009.pdf?ua=1, accessed 29 July 2015). 32. Pan B, Chen X, Wu X, Li J, Li J, Li Y, et al. Prevalence of noncom- municable diseases and their risk factors in Guangzhou, China. Prev Chronic Dis. 2014;11:130091. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 791 1School of Public Health, Al Quds University, Jerusalem (Correspondence to N. El Sharif: nsharif@staff.alquds.edu). 2Ministry of Health, Jenin; 3Ministry of Health, Hebron; 4Ministry of Health, Ramallah, West Bank, Palestine. Received: 07/01/15; accepted: 29/07/15 Compliance with and knowledge about diabetes guidelines among physicians and nurses in Palestine N. El Sharif,1 I. Samara,2 I. Titi 3 and A. Awartani 4 ABSTRACT Guidelines for the care of patients with diabetes mellitus are believed to improve clinical practice and patient care. This study aimed to analyse the pattern of diabetes care by physicians and nurses in primary care clinics in Palestine and their self-reported compliance with the local Palestinian guidelines. Questionnaires were used to collect data from 401 participants in 3 governorates in the West Bank. In total, 46.0% of participants knew about the existence of the Palestinian guidelines and about 60% believed these were partially used; 32.7% had received training on implementation of the guidelines. Multivariate analysis showed that training on the guidelines was the only factor significantly associated with self-reported compliance with guideline use. Respondents reported high commitment to the use of the guidelines, but their attitudes and behaviour varied with time constraints, availability of the guidelines, availability of laboratory tests and training on how to apply the guidelines. M\cQ9Óm|dBÐíÊmIúÐM<m)zgaTÐíï|bTm<oÉm#ÐowØmHÚüÐýøzTÐoQ|^X ©n>ÚLë{Lº]h]UÐên=кÒÚ5HØnxκxPUй qåR{w{åSí }åCÐpåxnLÚípåx}xUÐpåHÚ5CÐå ¬Ļï}cåUn=Nå=n[CÐ}åCÐpåxnL}=påÉn#ÐpxØnåIÚüÐåýø{UÐëÌ{åb_ôx oåÉ°#Ð ådCÐåw{h´b>íºN]ådR:påhUíúÐpåxnL}UÐÓÐØnåhL:Ónå}eCÐíÊnåJúÐåSåYï}cåUn=påxnf_UÐà5åiÌåhdĻOÎpåHÐÚ{UÐì|åw påa\UÐ:Ónå^Rn7ÔĆå?:ðnTÚnåZY401åYÓnåinh= åe!ÓninhåHÐêÐ{åHÐåR påhdCÐphfh]ådaUÐpxØnåIÚüÐåýø{Un=ðnåh>ÐÙåfL nå¹Ìëí{åb_xågfY% 60<ÐåAíºphfh]ådaUÐpxØnåIÚüÐåýø{UÐØå@=ådLDåLNTÚnåZCÐåY% 46 0 åeCÐ: ëncåR påh=}`UÐ ÓÐEå`CÐØ{å_YåhdUÐ}ågKÌ5åT pxØnåIÚüÐåýø{UÐì|åwåh]>DåLðnåxÚ{>Ðåbd>{åS% 32 7ëÌNåA:ºåý~@cåZ=qY{åHÐ åýø{UÐì|åwêÐ{åHn=ðnåh>ÐÙåfLådCÐ{åhbUÐ åY EåTcåZ= å>}CÐ{åhAUÐåYn_UÐënTpxØnåIÚüÐåýø{UÐDåLoåxÚ{UÐëÌ æĆååBn=qååadBÐ*nhTdååHíåågaSÐYååcUíºpxØnååIÚüÐååýø{UÐêÐ{ååHn={x{ååIêÐ~ååUÐØåå@=ënhååHĆUëhååCÐØnååRÌí pxØnåIÚüÐåýø{UÐåh]>påhahTDåLoåxÚ{UÐípåxFCÐÞåaUÐ}åRÐ>ípxØnåIÚüÐåýø{UÐ}åRÐ>ípåhfY~UÐØåhbUÐ Connaissances et respect des recommandations sur le diabète chez des médecins et des infirmières en Palestine RÉSUMÉ Les recommandations pour les soins aux patients atteints de diabète sont réputées améliorer la pratique clinique et les soins aux patients. La présente étude visait à analyser la tendance des soins aux diabétiques dispensés par des médecins et des infirmières en établissements de soins de santé primaires en Palestine ainsi que le respect autodéclaré des recommandations locales palestiniennes. Des questionnaires ont été utilisés pour recueillir les données de 401 participants dans trois gouvernorats de la Cisjordanie. Au total, 46,0 % des participants connaissaient l’existence des recommandations palestiniennes et 60 % pensaient qu’elles étaient appliquées en partie ; 32,7 % avaient reçu une formation sur leur mise en œuvre. Une analyse multivariée a démontré qu’une formation aux recommandations était le seul facteur significativement associé au respect autodéclaré de l’application des recommandations. Les répondants ont déclaré des niveaux d’engagement élevés concernant l’utilisation de ces recommandations, mais leurs attitudes et leur comportement variaient en fonction des contraintes de temps, de la disponibilité des recommandations, de la disponibilité des analyses de laboratoires et de la formation sur l’application des recommandations. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 792 Introduction Several studies have addressed the role of physicians’ compliance with guide- lines for improving the quality of care for patients with diabetes mellitus (1–3), including the awareness, attitudes and behaviour of physicians to such guide- lines (4–6). However, nurses, who are in direct contact with diabetes patients, have been less targeted in research. In the Diabetes Attitudes Wishes and Needs study in the United States of America (USA), greater involvement by nurses, particularly specialist nurses, was shown to be as important as the role of physicians in managing diabetes (7). Another recent study showed the im- portance of the nurse’s role in diabetes care and prevention (8). Diabetes and its associated compli- cations constitute a major health prob- lem in Palestine and are listed as the sixth leading cause of death, accounting GPSPG BMMEFBUIT 9). In the past ZFBST UIFSFIBTCFFOBO JODSFBTFE demand on primary health care (PHC) services for the care of diabetic patients. Nurses play a critical role in the PHC system. The role and scope of nursing in PHC is continually evolving in response to various changes in the health needs of Palestinian communities, including greater demand on health resources coupled with shortages in the PHC workforce. The multidisciplinary role of the nurse as health care provider, educa- tor and advocate lightens the burden on other PHC resources through inte- grated practice involving both general practitioners and nurses. To improve the quality of care of diabetes patients, the Palestinian Min- istry of Health (MOH) and the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), the 2 major stakeholders in Palestine, have developed guidelines for the management of diabetes. The MOH guide is devoted to the man- agement and care of diabetes mellitus, while the UNRWA guide has technical instructions and management proto- cols on the prevention and control of noncommunicable diseases. Both pro- tocols are based on the World Health Organization (WHO) diabetes care HVJEFMJOFTPG XJUI TPNFEJĎFS- ences between the two protocols, and sometimes between them and the WHO guidelines (10). The MOH HVJEFXBTEFWFMPQFE JO JODPPQ- eration with WHO and the Austrian Development Cooperation. The MOH adopted the Quick reference guide for the management and care of diabetes mellitus, which is called the Quick Guide. How- ever, it is not yet known if these diabetes management guidelines are incorpo- rated into the daily practices of PHC staff. Information about physicians’ and nurses’ awareness, attitudes and behav- iour in implementing these guidelines is also not available. Therefore, this study was conducted to analyse the pattern of diabetes mellitus care by physicians and nurses in PHC clinics and their self- reported compliance with the MOH and UNWRA guidelines. The results will assist the main health care stake- holders to determine whether a multi- faceted intervention, such as improving health care staff’s compliance with dia- betes guidelines, is needed to improve the quality of care for patients with dia- betes mellitus. Methods Study design This cross-sectional study was conduct- FEJOPOQIZTJDJBOTBOEOVSTFTJO governorates in the West Bank, Palestine. The study protocol and questionnaires were approved by Al Quds University research ethics committee. Consent was obtained from the various stakeholders to carry out the study in their centres and assess the services in clinics. Sampling "UPUBMPGQIZTJDJBOTBSFSFHJTUFSFE with the Palestinian Medical Association in the West Bank (11). All physicians located in the 3 governorates and dealing with diabetes patients were eligible for inclusion in the study, including general practitioners, internists, endocrinolo- gists, diabetes specialists, nephrologists, ophthalmologists and neurologists. A TBNQMF TJ[F PG QIZTJDJBOT DPOėEFODF MFWFM BOE FSSPSNBS- HJOXJUI DPOUJOHFODJFT SFMBUFE UP non-response or recording error) was calculated. The sample was divided equally among the 3 governorates (Na- blus, Hebron and Ramallah). From each governorate, the main PHC facility of each health care provider was selected, i.e. the central MOH clinic, one of the UNRWA main clinics and the Palestin- ian Medical Relief Society nongovern- mental clinic. All nurses dealing with diabetes patients in the selected centre/ clinic were included in this study. Data collection In each governorate, all physicians and nurses working in the selected partici- pating centres and dealing with diabetes patients were approached and invited to fill in the study questionnaire. Health professionals signed a consent form prior to participation. Two versions of the study question- naire were prepared; the physicians’ questionnaire consisted of 42 questions and the nurses’ questionnaire had 44 questions. Each questionnaire was designed to assess participants’ back- ground characteristics; participants’ awareness of, attitude and behaviour towards the local Palestinian diabetes guidelines; the availability of supportive resources; and referral and continuity of care for patients with diabetes mel- litus. In addition, the health care system arrangements for diabetes patients at these centres were assessed. The ques- tionnaires were based on question- naires used previously in similar studies (4,12), with some modifications and additions as suggested by the research team and the major stakeholders them- selves. The modified questionnaire was HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 793 BOEPGOVSTFT XJUIOPTJHOJėDBOU difference in their ages; more than half of the participants in both groups were JO UIF m ZFBST BHF HSPVQ.PSF than half of nurses and physicians had HSBEVBUFEBěFS CVUPOMZ PGQIZTJDJBOTBOEPGOVSTFTIBE HSBEVBUFEBěFS +VTUPWFSIBMGPG QBSUJDJQBUJOHQIZTJDJBOT XFSF XPSLJOH BU.0) DMJOJDT BOE were practising independently. In con- USBTU PGOVSTFTXFSFXPSLJOHBU UIF.0)DMJOJDT BOEPOMZXFSF nurses in private clinics. Of the physi- DJBOT IBE ZFBST PGXPSL experience with diabetes patients versus PGOVSTFT A majority of physicians in this sam- QMF XFSF HFOFSBM QSBDUJUJPO- ers. Of the specialized physicians, only IBEB TQFDJBMJ[BUJPO JOEJBCFUFT DBSF BOEXFSF FOEPDSJOPMPHJTUT *OUFSFTUJOHMZ PGQIZTJDJBOTIBE obtained their diplomas from the for- mer Soviet Union and eastern Europe, XIJMFIBEPCUBJOFE UIFN GSPN universities in Arab countries. However, NPTUOVSTFT IBEPCUBJOFEUIFJS diplomas from Palestinian or Arab col- leges and universities [data not shown]. Availability of support health staff at health centres Figure 1 shows that fairly low propor- tions of physicians and nurses reported having access to specialized physicians at the centre where they worked, and nurses reported less access to endo- crinologists, ophthalmologists and nutritionists than did physicians. A high proportion of physicians and nurses reported the availability of health edu- cators and educational materials, e.g. posters and brochures, but far fewer had group education facilities in their centre. Knowledge about and use of the diabetes guidelines *OUPUBM PGUIFQBSUJDJQBOUTLOFX about the existence of the local Pales- UJOJBOHVJEFMJOFT PGQIZTJDJBOT BOEPGOVSTFT CVUPOMZ had a copy of the guidelines. Of these, POMZPGQIZTJDJBOTBOEPG nurses knew who had developed these local guidelines. A majority of the par- UJDJQBOUT CFMJFWFE UIBU UIFTF guidelines were used only partially or not at all in physicians’ daily practice. 0WFSBMM PGQIZTJDJBOTBOE PGOVSTFT SFQPSUFEIBWJOHIBE training on the use of these guidelines (Table 2). When asked about their practice of referring patients, physicians were far more likely to refer diabetes patients to an ophthalmologist than to an endocri- OPMPHJTU WFSTVT SFTQFD- tively), and a similar pattern was seen for nurses. The main reason why physicians did not refer their patients to an endo- crinologist was that they did not see the need for it, whereas nurses mostly justified it on the grounds that the spe- cialization was unavailable. However, most physicians and nurses knew that an endocrinologist was available either in the same clinic or in the same city 5BCMF "CPVU PG QIZTJDJBOT had received a report from an ophthal- mologist [data not shown]. The lack of an ophthalmoscope (fundoscope) in the clinic was an obstacle to physicians who wanted to test their patients’ eyes. "MTP PGQIZTJDJBOT SFQPSUFE UIF need for training on how to use the ophthalmoscope. Physicians were more knowledge- able about the use of the glycosylated haemoglobin (HbA1c) test than were OVSTFT CVU POMZ PG QIZTJDJBOT had requested it for their patients. When asked about reason for not ordering the UFTU PGQIZTJDJBOTCFMJFWFE JU UP CFVOOFDFTTBSZ XIJMFCFMJFWFE it to be either expensive or unavailable (Table 2). Self-reported compliance with the diabetes guidelines Table 3 shows the differences between physicians and nurses in their knowl- edge about some tests but not about the examinations prescribed in the UIFOQJMPU UFTUFEPOQBSUJDJQBOUT JO each governorate. These questionnaires were not included in the study. A score of self-reported compliance to the guidelines was calculated for each physician and nurse, depending on how many of the guideline recommenda- UJPOTPG UFTUTBOEFYBNJOBUJPOTIBE been performed in a timely manner (based on their answers to the question- naire). Statistical analysis The responses obtained were entered into a database and were analysed using SPSS GPS8JOEPXT WFSTJPO4UBUJTUJ- cal analysis included the chi-squared test for categorical variables and analysis of variance for the mean continuous variables. All calculated P-values were 2-tailed; PWBMVFT XFSFDPOTJE- ered nonsignificant. For the self-reported compliance score, the t-test was used to determine the association with the bivariate vari- ables, and 1-way ANOVA was done with multivariate variables. A linear regression model was done separately and jointly for the scores of physicians and nurses by age, sex, profession (nurse versus physician), place of employ- ment, work experience, years of work, employed at, years of experience with diabetes patients, graduation period, awareness of the guidelines, familiarity with the guidelines, having a copy of the guidelines, undergone training on use of guidelines, availability of an endocrinol- ogist, availability of an ophthalmologist and availability of a nutritionist. Results In this study the response rate from the QIZTJDJBOTBQQSPBDIFEXBTBOE GSPNUIFOVSTFTXBT Background characteristics of respondents 5BCMF TIPXT UIBUPG SFTQPOE- FOUTXFSFNBMF PG QIZTJDJBOT EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 794 Table 1 Profile of respondents and their experience of care for patients with diabetes mellitus Variable Total (n = 401) Physicians (n = 253) Nurses (n = 148) P-value No. % No. % No. % Sex Male 248 61.8 220 87.0 28 18.9 0.001 Female 153 38.2 33 13.0 120 81.1 Age (years) 25 4 1.0 3 1.2 1 0.7 0.073 25–40 225 56.1 130 51.4 95 63.9 41–55 141 35.2 96 37.9 45 30.6 56–70 31 7.7 24 9.5 7 4.8 Graduation date (years) 1960–1974 14 3.5 6 2.4 8 5.5 0.049 1975–1989 123 30.7 84 33.2 39 26.2 1990–2004 188 46.9 123 48.6 65 44.1 Post 2004 76 19.0 40 15.8 36 24.1 Employed at Ministry of Health 245 61.1 136 53.8 109 73.6 0.001 United Nations Relief and Works Agency 52 13.0 27 10.7 25 16.9 Nongovernmental organization 23 5.7 13 5.1 10 6.8 Private clinic 81 20.2 77 30.4 4 2.7 Years of work experience 1–5 156 38.9 107 42.3 49 33.3 0.269 6–10 98 24.4 55 21.7 43 29.1 11–15 63 15.7 39 15.4 24 16.3 > 15 84 20.9 52 20.6 32 21.3 Year of with diabetic patients < 10 206 51.4 110 43.4 96 65.2 0.002 10–19 112 27.9 83 32.9 29 19.7 ≥ 20 82 20.4 60 23.7 22 15.2 Physician’s location of graduation Western Europe – – 24 9.5 – – Eastern Europe – – 51 20.2 – – Soviet Union – – 101 39.9 – – Arab country – – 75 29.6 – – Eastern Asia – – 1 0.4 – – United States of America – – 1 0.4 – – Type of physician General practitioner – – 154 60.9 – – Specialized physician – – 99 39.1 – – Physician’s field of specialty (n =99) Endocrinology – – 8 8.1 – – Diabetes care – – 12 12.1 – – Internal medicine – – 30 30.3 – – Ophthalmology – – 11 11.1 – – Urology – – 8 8.1 – – Paediatrics – – 17 17.2 – – HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 795 guidelines. According to these guide- lines, which match those of WHO very closely, HbA1c should be performed ei- ther every 3 or every 6 months, depend- ing on patients’ control of their diabetes; PGSFTQPOEFOUTJOUIJTTUVEZDPN- QMJFEXJUI UIF UFTUPO UJNF PG QIZTJDJBOBOEPGOVSTFT 'FXFS respondents examined patients’ feet on FBDIWJTJU PGQIZTJDJBOTWFSTVT PGOVSTFT ĉFFYBNJOBUJPOMFBTU likely to be conducted by physicians BU UIFDMJOJDXBT GVOEPTDPQZ Other blood tests (lipid profile, urinary microalbumin, serum creatinine) and an ECG should be conducted annu- ally and there were no significant differ- ences between physicians and nurses, although physicians tended to conduct the tests more frequently, i.e. according to the guidelines (Table 3). Table 1 Profile of respondents and their experience of care for patients with diabetes mellitus (concluded) Variable Total (n = 401) Physicians (n = 253) Nurses (n = 148) P-value No. % No. % No. % Gynaecology – – 8 8.1 – – Orthopaedics – – 1 1.0 – – Dermatology – – 1 1.0 – – Otorhinolaryngology – – 3 3.0 – – Nursing level of education Nurse by training – – – – 9 6.1 Diploma in nursing – – – – 83 56.1 Bachelor degree in nursing – – – – 49 33.1 Master/PhD degree nursing – – – – 7 4.7 Dashes (–) indicate data not applicable. Physicains Nurses % 90 80 70 60 50 40 30 20 10 0 Po dia tri st Ne ph ro log ist s *E nd or cri no log ist *O ph th alm olo gis t *N utr itio nis t Br oc hu res /p os ter s He alt h e du ca to rs Gr ou p e du ca tio n Figure 1 Availability of support staff and materials in health care centres according to the surveyed physicians (n =253) and nurses (n =148) (*P < 0.05) EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 796 Table 2 Respondents’ self-reported knowledge about the Palestinian guidelines for the care of patients with diabetes mellitus and their practice of continuity of care Variable Total (n =401) Physicians (n =253) Nurses (n =148) P-value No. % No. % No. % Familiar with the guidelines Yes 188 46.9 133 53 55 37.7 0.003 No 209 52.1 118 47 91 62.3 Have copy of the guidelines Yes 144 35.9 106 57.6 38 33.9 0.001 No 152 37.9 78 42.4 74 66.1 Know who developed the guidelines Ministry of Health 107 26.7 61 24.3 46 31.7 < 0.001 United Nations Relief and Works Agency 43 10.7 26 10.4 17 11.7 World Health Organization 74 18.5 42 16.7 32 22.1 Palestinian Medical Relief Society 16 4.0 8 3.2 8 5.5 Not local 11 2.7 9 3.6 2 1.4 Unaware of existence of guidelines 145 36.2 105 41.8 40 27.6 Implement the guidelines in workplace (total n = 219) Widely 61 21.0 43 25.6 18 14.6 0.036 Partially 173 59.5 98 58.3 75 61 No 57 19.6 27 16.1 30 24.4 Trained on use of guidelines Yes 131 32.7 97 42.7 34 23.4 0.001 No 241 60.1 130 57.3 111 76.6 Patient can call physician for counselling Yes 290 72.3 188 75.5 102 70.3 0.263 No 104 25.9 61 24.5 43 29.7 Refer patients to endocrinologist Yes 222 55.4 145 58.0 77 55.8 0.675 No 166 41.4 105 42.0 61 44.2 Reason for not referring to endocrinologist Not available 146 36.4 22 22.4 124 86.1 < 0.001 No need 96 23.9 76 77.6 20 13.9 Distance to endocrinologist’s clinic Same building 52 13.0 43 17.2 9 45.0 0.004 Same city 176 43.9 165 66.0 11 55.0 Another city 42 10.5 42 16.8 – – Refer patients to ophthalmologist Yes 365 91.0 226 89.3 139 96.5 0.012 No 32 8.0 27 10.7 5 3.5 Advise patients on glucose home monitoring Yes 343 85.5 219 86.6 124 83.8 0.445 No 58 14.5 34 13.4 24 16.2 Know about HbA1c test Yes 367 91.5 244 96.4 123 83.1 0.001 No 34 8.5 9 3.6 25 16.9 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 797 According to their self-reports, only 3 participants (1 physician and 2 nurses) were compliant with performance of the SFDPNNFOEFE UFTUT BOE FYBNJOB- tions at the appropriate times. At least half of the tests and examinations were per- GPSNFEPOUJNFCZ QIZTJDJBOT BOEOVSTFT "MTP PGBMM participants did at least 6 tests on time. The t-test and 1-way ANOVA showed no statistically significant differ- ence between physicians and nurses in their compliance with implementation of the guidelines (P ĉFHPWFS- norate location of the clinic (P having training on guidelines use (P BOEQPTTFTTJOHBDPQZPG UIF guidelines (P XFSFUIFPOMZWBS- iables significantly associated with com- pliance scores in the univariate analysis. Linear regression analysis showed that training on use of the guidelines was the only factor significantly associated with self-reported compliance with guide- line use (P BMUIPVHI JU POMZ FYQMBJOFEPGUIFWBSJBCJMJUZPGTFMG reported compliance to the guidelines (adjusted R2 Respondents’ attitudes and behaviour towards the guidelines The respondents reported high com- mitment to the use of guidelines. However, their attitudes and behaviour towards use of the guidelines varied with the time available, the availability of laboratory tests, the availability of the guidelines themselves and training on how to use them. Respondents also cited the financial inability of patients to perform the tests as a factor that hin- dered implementation of the guideline recommendations (Figure 2). Com- mitment to the guidelines was reported CZPGQIZTJDJBOT BOEPG nurses (Figure 2). Discussion Physicians in several countries have expressed differing views on the im- portance of diabetes care guidelines. In this study, only half of the physicians and one-third of nurses were familiar with their local guidelines and had them at their disposal. Therefore, a copy of the diabetes guidelines must be made available to every health staff member dealing with diabetes patients and not simply to physicians. The guidelines may directly or indirectly influence the care given by physicians to patients with diabetes (13). A number of studies have shown that the presence of guidelines is not a factor in determining physicians’ knowledge and behaviour in the follow- up and treatment of diabetes patients and very few physicians report using them (4,6,14). Rätsep et al. justified this by citing doubts held by some physi- cians about the guidelines, while others believed that the guidelines had been developed to save costs and not for the benefit of patients (4). Services provided and referral to specialized services The availability of specialist care ser- WJDFTXBT SFQPSUFECZ MFTT UIBOPG physicians and nurses in this study; the referral of patients to specialized clinics was not, therefore, as high as might be anticipated. This finding is similar to results found in the study comparing Table 2 Respondents’ self-reported knowledge about the Palestinian guidelines for the care of patients with diabetes mellitus and their practice of continuity of care (concluded) Variable Total (n =401) Physicians (n =253) Nurses (n =148) P-value No. % No. % No. % Physician’s reason for not requesting HbA1c test Don’t know what it is – – 1 1.3 – – High cost – – 14 17.9 – – Unnecessary – – 48 61.5 – – Unavailable – – 14 17.9 – – When needed – – 1 1.3 – – Physician’s evaluation of patients by HbA1c test Yes – – 175 69.2 – – No – – 78 30.8 – – Presence of ophthalmoscope in clinic Yes – – 81 32.0 – – No – – 172 68.0 – – Physician needs training on ophthalmoscope Yes – – 195 77.1 – – No – – 58 22.9 – – Dashes (–) indicate data not applicable; HbA1c = glycosylated haemoglobin. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 798 Table 3 Respondents’ self-reported frequency of routine laboratory testing and follow-up examinations based on the Palestinian guidelines for the care of patients with diabetes mellitus Test Total (n =401) Physicians (n =253) Nurses (n =148) P-value Blood sugar test a 1–3 months 94.1 93.2 95.8 0.11 6–12 months 4.6 6.0 2.1 Never 1.3 0.8 2.1 Blood pressure a 1–3 months 95.4 95.1 95.8 0.33 6–12 months 3.3 4.0 2.1 Never 1.3 0.8 2.1 BMI indexa 1–3 months 46.1 45.0 47.8 0.03 6–12 months 38.5 36.0 42.8 Never 15.4 18.9 9.3 Eye examinationa 1–3 months 14.2 14.1 14.3 0.98 6–12 months 69.8 70.1 69.3 Never 16.0 15.7 16.4 Foot examinationa 1–3 months 53.6 60.5 42.0 6–12 months 37.6 33.5 44.8 0.01 Never 8.7 6.0 13.3 HbA1c testing b Monthly 6.8 6.7 6.8 3–6 months 79.0 79.1 78.8 0.28 Yearly 8.6 7.1 11.0 Never 5.8 7.1 3.4 Lipid profile c ≤ 6 months 73.4 73.3 73.5 0.78 Yearly 25.1 25.4 24.5 Never 1.5 1.2 2.1 Urine for microalbuminc ≤ 6 months 73.4 72.7 74.6 Yearly 16.6 16.1 17.6 0.27 Never 10.0 11.2 7.7 Creatinine test c ≤ 6 months 73.4 73.3 73.5 Yearly 23.5 23.4 23.8 0.97 Never 3.1 3.2 2.8 ECG measurement c ≤ 6 months 46.8 44.1 51.4 Yearly 26.1 27.1 24.3 0.38 Never 27.1 28.7 24.3 Recommended frequency: aTo be done every visit (per month or 3 months); bTo be done every 3 to 6 months; cTo be done yearly. HbA1c = glycosylated haemoglobin; BMI = body mass index; ECG = electrocardiograph. Physical examination includes height and weight, vital signs, blood pressure, eye examination, oral examination, cardiovascular including evaluation of pulses and bruits, abdominal examination, foot examination, neurological examination. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 799 01020304050607080 Physicians Nurses Physicians Nurses Physicians Nurses Physicians Nurses Physicians Nurses Physicians Nurses Physicians Nurses Physicians Nurses Physicians Nurses Physicians Nurses Physicians Nurses *C om m itm en t to u se lo ca l gu id el in es A va ila bi lit y C la rit y * Pa tie nt co op er at io n Fi na nc ia l ca pa ci ty o f pa tie nt s * In te re st En ou gh ti m e to fo llo w * Tr ai ni ng o n us e Su pe rv is io n su pp or t Fe ed ba ck fro m sp ec ia lis ts * A va ila bi lit y of a ll la bo ra to ry te st s N ev er /R ar el y U su al ly /M os tly % Fi gu re 2 O bs ta cl es to im pl em en ta ti on o f t he P al es ti ni an g ui de lin es fo r t he c ar e of p at ie nt s w it h di ab et es m el lit us a cc or di ng to th e su rv ey ed p hy si ci an s (n = 25 3) a nd n ur se s (n = 14 8) (* P < 0 .0 5) EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 800 the provision of care for diabetes pa- tients in eastern and western European countries. That comparison showed large inequalities in the use of specialist care services and postgraduate train- ing of physicians and nurses between countries, which ultimately impacts on the provision of services for diabetes patients. These differences were related mainly to poor economic resources and inadequate financial investment in eastern European countries (15,16), a factor that is even more dire in Palestine. This study found a serious lack of eye examinations at clinics; in particular, there was a problem in accessing oph- thalmology services by patients. Only PGQIZTJDJBOT SFQPSUFEIBWJOHB GVOEPTDPQF JO UIFJS DMJOJD BOE reported the need for training on how to perform the test at the clinic. Although PGQIZTJDJBOT TBJE UIBU UIFZ SF- ferred patients for the examination, only BSPVOE SFDFJWFEPQIUIBMNPMPHZ reports from those referred annually. This may be justified by the high cost of an eye examination in the ophthalmol- ogy clinic; despite being partially cov- ered by the public health insurance and recently added to UNRWA services, it is not yet accessible in all clinics in the West Bank. Nevertheless, the coverage of ophthalmology reports was better than in other developing countries such as South Africa (13) and India (17) where there are also problems in self- reported compliance with guidelines, but was worse than in other countries such as Estonia (4) and Saudi Arabia (18). Knowledge about the proper tim- ing for referral of a patient to an endo- crinologist did not vary significantly between physicians and nurses, but re- ferral rates were low. The reasons cited by physicians and nurses varied. A high percentage of physicians believed that there was no need for a patient to con- sult an endocrinologist, even though an endocrinologist was available in the city. However, many of the nurses believed that this specialization was not available. One possible explanation for not re- ferring patients to an endocrinologist was the belief by physicians that they were doing everything necessary to treat their patients. Another reason could be related to the lack of availability of an en- docrinology clinic in the same centre/ clinic, which means there would be no insurance cover and therefore high and needless fees for the patient. Severe foot lesions and foot am- putation are a major complication of diabetes. According to the WHO guide- lines, “health-care professionals, other than physicians, at PHC level should be trained to identify such individuals and recognize early lesions. Patients with suspected or confirmed abnormalities should be sent for medical consulta- tion” (10). In our study, based on to UIF MPDBM EJBCFUFT HVJEFMJOFT PG QIZTJDJBOTBOEPGOVSTFT P cited the correct timing of every 1 to 3 months for a regular foot examination. "SPVOEPGOVSTFTCFMJFWFE UIBUB foot examination should be done yearly or even never. Therefore, nurses require training about foot examinations and the importance of these for ensuring that patients’ feet are not neglected and to prevent any unnecessary foot lesions or amputations from occurring. The most vital test to ascertain the control of diabetes by patients is HbA1c. This study revealed high self- reported compliance to this test by both QIZTJDJBOTBOEOVSTFT FWFSZ to 6 months. This finding is much better than other countries, such as Estonia and the USA (4,19), but very similar to general practitioners’ practice in South Africa (17). Knowledge of and training on use of guidelines The local Palestinian diabetes care guidelines appear to be used less than they should be. Physicians still relied on their own knowledge, views and exper- tise in treating their diabetes patients. Physicians and nurses in this survey had graduated from different countries worldwide and the proportion who had been trained on the local guidelines XBT MPX PG QIZTJDJBOT WFSTVT PGOVSTFT 1BMFTUJOJBOQIZTJDJBOT and nurses who receive training on the guidelines are given a 1- or 2-day work- shop; this training is primarily available to staff in the main health care centres. Postgraduate training on diabetes is well established in many countries and specialist training for nurses is being developed (16), but this is not the case in Palestine. The translation of diabetes guidelines into practice is thought to take place through diffusion and partial dissemination strategies (20). The use of local guidelines is only one small strategy to ensure good quality care, but is still an effective tool to improve treatment. Self-reported compliance with the guidelines This study showed that about half of QIZTJDJBOTBOEOVSTFTBEIFSFEUPPVU of 11 tests and examinations that should be conducted for the continuity of care for diabetes patients. Older physicians BHFEmZFBST BEIFSFENPSF UP the guidelines than younger physicians BHFEmZFBSTPSZPVOHFS *O&TUP- nia, age was not a factor that influenced the use of guidelines (4), but younger physicians in the USA considered diabetes guidelines to be more useful than did older physicians (21). Also, self-reported compliance varied across the 3 governorates studied in the West Bank [data not reported], although the reason for this variation is not clear. Obstacles to implementing the guidelines The dissemination and implementation strategy of the guidelines could influ- ence the extent of their use. In this study, commitment to the guidelines was re- ported by more physicians than nurses WFSTVT 8IFO BTLFE what factors might limit the implemen- tation of guidelines, about half of nurses and physicians cited the availability of HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 801 References 1. Jenssen TG, Tonstad S, Claudi T, Midthjell K, Cooper J. The gap between guidelines and practice in the treatment of type 2 diabetes A nationwide survey in Norway. Diabetes Res Clin Pract. 2008 May;80(2):314–20. PMID:18279994 2. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Ab- boud PA, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458–65. PMID:10535437 3. Bryant W, Greenfield JR, Chisholm DJ, Campbell LV. Diabe- tes guidelines: easier to preach than to practise? Med J Aust. 2006 Sep 18;185(6):305–9. PMID:16999670 4. Rätsep A, Kalda R, Oja I, Lember M. Family doctors’ knowl- edge and self-reported care of type 2 diabetes patients in comparison to the clinical practice guideline: cross-sectional study. BMC Fam Pract. 2006;7:36. PMID:16776847 5. Wens J, Vermeire E, Royen PV, Sabbe B, Denekens J. General practitioners' perspectives of type 2 diabetes patients' adher- ence to treatment: A qualitative analysis of barriers and solu- tions. BMC Fam Pract. 2005;6:20. PMID:15890071 6. Larme AC, Pugh JA. Attitudes of primary care providers to- ward diabetes: barriers to guideline implementation. Diabe- tes Care. 1998 Sep;21(9):1391–6. PMID:9727882 7. Siminerio LM, Funnell MM, Peyrot M, Rubin RR. US nurs- es’ perceptions of their role in diabetes care: results of the cross-national Diabetes Attitudes Wishes and Needs (DAWN) study. Diabetes Educ. 2007 Jan-Feb;33(1):152–62. PMID:17272801 8. Aalaa M, Malazy OT, Sanjari M, Peimani M, Mohajeri-Tehrani M. Nurses’ role in diabetic foot prevention and care; a review. J Diabetes Metab Disord. 2012;11(1):24. PMID:23497582 9. Palestinian Health Information Center. Health status in Pales- tine: 10/14/2011 [Internet]. Ramallah: Palestinian Ministry of Health (http://www.moh.ps, accessed 29 September 2015) [in Arabic]. 10. Guidelines for the management and care of diabetes mellitus. Quick reference guide. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2006 (http:// apps.who.int/iris/bitstream/10665/119807/1/dsa698. pdf?ua=1, accessed 20 August 2015). 11. Physicians lists in the West Bank. Ramallah: Palestinian Medical Association; 2013 ( http://www.jma.ps/en/index. php?page=doctors, accessed 20 September 2015). 12. Lawler FH, Viviani N. Patient and physician perspectives regarding treatment of diabetes: compliance with practice guidelines. J Fam Pract. 1997 Apr;44(4):369–73. PMID:9108834 13. Leslie KG, Nkombua L. Evaluation of general practitioners’ rou- tine assessment of patients with diabetes in Tshwane, South Africa. S Afr Fam Pract 2011;54:68–71. 14. Oja I. Guidelines for type 2 diabetes in Estonia: knowledge, attitudes and self-reported behaviors among general prac- titioners [MPH thesis]. Göteborg: Nordic School of Pub- lic Health; 2005 (http://www.diva-portal.org/smash/get/ diva2:733506/FULLTEXT01.pdf, accessed 29 September 2015). 15. Doničová V, Brož J, Sorin I. Health care provision for people with diabetes and postgraduate training of diabetes specialists in eastern European countries. J Diabetes Sci Technol. 2011 Sep;5(5):1124–36. PMID:22027305 16. Stirbu I, Kunst AE, Mielck A, Mackenbach JP. Inequalities in utilisation of general practitioner and specialist services in 9 European countries. BMC Health Serv Res. 2011;11:288. PMID:22040155 17. Raman R, Paul PG, Padmajakumari R, Sharma T. Knowledge and attitude of general practitioners towards diabetic retin- opathy practice in South India. Community Eye Health. 2006 Mar;19(57):13–4. PMID:17491739 18. Khan AR, Al Abdul Lateef ZN, Khamseen MB, Al Aithan MA, Khan SA, Al Ibrahim I. Knowledge, attitude and practice of ministry of health primary health care physicians in the man- the guidelines followed by their clar- ity as major reasons for non-use. Other obstacles included supervision support and feedback from specialists, training and the organization of care such as the availability of laboratory tests. Nev- ertheless, time constraints and a lack of interest by physicians also played an important role in non-response. Larme and Pugh showed that the attitude of PHC providers towards diabetes was a major limiting factor in diabetes management (6). Moreover, patient cooperation and financial means were seen as another two reasons that could limit the successful use of these guide- lines, especially when a patient requires referral to a specialist. Finally, diabetes guidelines are not the only source of information for phy- sicians or even nurses, but are one of the strategies that can improve the quality of care. Therefore, it is very important to consider them as a tool to support staff involved in diabetes care, albeit not the sole tool. Also, there are uncertainties in clinical practice that are not taken into account in the guidelines and which should be considered when dealing with diabetes patients. Study limitations Although our study revealed important insights into the reasons why health- care professionals fail to adhere to guideline recommendations, some limi- tations must be taken into account. The study participants represented those working in the main centres of the 3 big governorates of the West Bank and who had better access to services. Those working in centres/clinics in villages might have more serious problems with availability of the guidelines and training about them, but they were not included in this study. However, the study still provides valuable information about the compliance and knowledge of both physicians and nurses, particularly the latter, who have more contact with pa- tients and more time to help them. The study highlights the need for improved training of nurses and physicians on the appropriate treatment and follow-up of patients. Acknowledgements Funding: This study was funded by Insulin Dependent Diabetes Trust (IDDT), Northampton, United Kingdom and the authors wish to ex- press their gratitude for this generous support. Competing interests: None declared. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 802 agement of type 2 diabetes mellitus: a cross-sectional study in the Al Hasa District of Saudi Arabia, 2010. Niger J Clin Pract. 2011 Jan-Mar;14(1):52–9. PMID:21493993 19. Deichmann RE, Castello E, Horswell R, Friday KE. Improve- ments in diabetic care as measured by HbA1c after a physician education project. Diabetes Care. 1999 Oct;22(10):1612–6. PMID:10526723 20. Davis DA, Taylor-Vaisey A. Translating guidelines into prac- tice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clini- cal practice guidelines. CMAJ. 1997 Aug 15;157(4):408–16. PMID:9275952 21. Wolff M, Bower DJ, Marbella AM, Casanova JE. US family physicians’ experiences with practice guidelines. Fam Med. 1998 Feb;30(2):117–21. PMID:9494802 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 803 1Department of Medical Microbiology and Immunology, Faculty of Medicine; 2Department of Tropical Medicine, Faculty of Medicine; 3Department of Pathology, Medical Research Institute, University of Alexandria, Alexandria, Egypt (Correspondence to S.L. Assar: sara_asar1@yahoo.com). Received: 02/12/14; accepted: 29/07/15 Study of prevalence and effects of insulin resistance in patients with chronic hepatitis C genotype 4 A.F. Amer,1 M.M. Baddour,1 M.A. Elshazly,2 G. Fadally,3 N.F. Hanafi 1 and S.L. Assar 1 ABSTRACT There is strong epidemiological evidence linking hepatitis C virus (HCV) infection and diabetes. Our aim was to evaluate the prevalence of insulin resistance in Egyptian patients with chronic HCV genotype 4 infection, to assess factors associated with insulin resistance and to test the impact of insulin resistance on outcomes of treatment with pegylated interferon/ribavirin. Insulin resistance [homeostasis model assessment- insulin resistance (HOMA-IR) score > 3.0] was detected in 31 of 100 nondiabetic patients. The relationship between elevated HOMA-IR and baseline viral load and degree of fibrosis was statistically significant (r = 0.218 and r = 0.223). Follow-up of patients with complete early virological response until the end of treatment showed a statistically significant decrease in HOMA-IR score. Out of 29 liver tissue sections examined, 14 had a low level of expression of insulin receptor type 1 by immunohistochemical studies. This study confirms that insulin resistance affects treatment outcome, and thus HOMA-IR testing before initiation of therapy may be a cost–effective tool. fgcKm*ÐD>i=í4eg!ÐdeTÐXCX}BÐïzbTÐÑmfTøm<M<mZBÐ|BÐîzTMThüÐoXímaXÚmYhÐKoGÐÚØ WLa]UÒÚnHºafARxiº<n\RëĆh@º<ÙnZUÐ{1Ì{e7ºÚí{={e7énfYº}YnLRÒEYÌ pYínbYÚnåZiÐ}åx{b>nåfR{wënT{åSí ï}cåUÐNå=íCï{åcUÐÑnågUøÐÜíEåa=îí{å_UÐNå=å=}>påxSpåhýn=íåýøØènåfwoåÉ°#Ð påYínbe=på]>}CÐåYÐ_UÐåhhbUåUÙíº4åfh!ÐåefUÐåYCåY~CÐï{åcUÐÑnågUøn=Nå=n[CÐNåxWCÐ}åCÐî{åUNUåiüÐ NUåi³UpåYínbYØå@íåLåZcUÐåR åxERnx}UÐíëíEåRGiün=på!n_CÐsåýniDåLNUåiüÐpåYínbYEå?j>ÚnåBøíNUåiüÐ EååQååx}Y100ååÉÌååYðnåå\x}Y31î{ååU3.0ååY}ååTÌHOMA-IRëÛÐååUÐÕÙååeiååhhb>oåå=NUååiüÐpååYínbYÜnååhS påhýn[AÎpåUøØÓÐÙåhdUÐpå@ÚØííEåaUÐåedUpåx{LnbUÐpåehbUÐNå=íHOMA-IRânåa>ÚÐNå=påSĆ_UÐqåinTí ï}cåUn=Nå=n[Y ðnånaiÐÓ}ågKÌpå!n_CÐpå xn¹åAÒ}åcYpåYn>phåHíERp=nåHÐå0{Uqå?{Aåx|UÐ}åCÐpå_=nYëÎí (r = 0.223 í r = 0.218) phLnfCÐph@Uåh4ÐpåhýnhehcUÐÓnåHÐÚ{UÐÓ{å=Ìnåg[Rå>ðnåx{Tðnhhåiðnå_]bY29åÉÌåYí HOMA-IRÜnåhS:ðnåKdYðnåhýn[AÎ såýniDåL}å?k>NUåiúÐpåYínbYëÌpåHÐÚ{UÐì|åw{åTk> någfY14î{åU1åefUÐåYNUåiüÐÓĆbåYåYåafYîåYØå@í påadcUÐråhAåYpåUn_RÒÐØÌëåcx{åSpå!n_CÐÊ{å=åSHOMA-IRÚnåBÐÊÐ}å@ÎëlåR<nåUn=íºpå!n_CÐ Étude de la prévalence et des effets de la résistance à l’insuline chez des patients atteints d’hépatite C de génotype-4 RÉSUMÉ Il existe des données factuelles épidémiologiques fortes reliant l’infection par le virus de l’hépatite C et le diabète. Nous avions pour objectif d’évaluer la prévalence de la résistance à l’insuline chez des patients égyptiens atteints d’une infection par le virus de l’hépatite C de génotype-4, d’étudier les facteurs associés à la résistance à l’insuline et de tester l’impact de la résistance à l’insuline sur les résultats du traitement par interféron pégylé/ribavirine. La résistance à l’insuline (score du modèle d’évaluation homéostatique pour l’insulino- résistance [HOMA-IR] > 3,0) a été observée chez 31 des 100 patients non diabétiques. Le lien entre un score HOMA-IR élevé et la charge virale initiale ainsi que le degré de fibrose était statistiquement significatif (r = 0,218 et r = 0,223). Le suivi des patients ayant présenté une réponse virologique précoce et complète jusqu’à la fin du traitement a révélé une diminution statistiquement significative du score HOMA-IR. Sur les 29 coupes de tissu hépatique examinées, 14 présentaient un faible niveau d’expression du récepteur insulinique de type 1 selon les études immunohistochimiques. La présente étude confirme que la résistance insulinique influe sur les résultats du traitement. Par conséquent, le score HOMA-IR avant l’instauration d’un traitement peut être un outil d’un bon rapport coût-efficacité. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 804 Introduction For many years, Egypt has been widely regarded as having an epidemic of hepatitis C virus (HCV) infection, with the highest recorded prevalence in the world. HCV is currently the most sig- nificant health problem in Egypt. The latest published Egyptian Demographic )FBMUI 4VSWFZ JO PG B OBUJPOBM probability sample of the resident popu- lation estimated an overall anti-HCV BOUJCPEZ QSFWBMFODF PG ĉF proportion of Egyptians estimated to be DISPOJDBMMZJOGFDUFEXBT 1). The current standard treatment for chronic HCV infection (CHC) is pe- gylated interferon-alpha (peg IFN-α) combined with ribavirin. Despite significant improvement in treatment efficacy during the past decade, only PGQBUJFOUTDBOCFDVSFEPG)$7 depending on its genotype (2). Besides being unsatisfactory, treatment of HCV is costly, beyond the reach of most pa- tients in Egypt, requires 48 or more weeks to complete and has serious side-effects. New modalities of therapy using directly-acting antiviral drugs, are available in some national treatment units but are not yet fully implemented in all of them. The spectrum of severity of liver dis- ease associated with HCV varies widely and depends on both viral and host factors. Age, male sex, alcohol consump- tion, immune status and co-infections are defined as risk factors for a progres- sive course of CHC (3). One of the co-factors is type 2 diabetes (4). There is strong epidemiological evidence link- ing HCV and diabetes. Patients with CHC are more likely to develop type 2 diabetes (5) and diabetic patients are more likely to be infected with HCV (6). Type 2 diabetes has been recog- nized to worsen the course of hepatitis C. Both are now recognized as being a deadly combination (7). In view of this association, instead of looking only at the occurrence of overt type 2 diabetes, we should also consider prediabetic conditions such as insulin resistance in patients with HCV infection. Insulin resistance is defined as a condition in which higher than normal insulin levels are needed to achieve normal glucose metabolism or alternatively normal insulin levels fail to achieve normal glu- cose metabolism (8). During recent years, basic research, clinical trials and epidemiological stud- ies have provided evidence that HCV can independently contribute to insulin resistance (9–11). Adding to this grow- ing body of evidence, it is now suggested that HCV interferes with the insulin sig- nalling pathway using genotype-specific mechanisms (12). Insulin carries out its biological effects through phospho- rylation of insulin substrate receptors 1 (IRS-1) and 2 (IRS-2) (13). Thus research has focused on IRS-1 and -2 as the loci for insulin resistance. An association between HCV and insu- lin resistance would have significant clinical consequences. Mounting evi- dence indicates that HCV-associated insulin resistance may cause acceler- ated fibrogenesis, reduced response to interferon-based therapy and hepa- tocellular carcinoma (14). These life- threatening complications are different from the well-known complications of lifestyle-associated insulin resistance, namely cardiovascular diseases, renal failure and infections (15). Increased levels of insulin resistance are associated with reduced rates of initial virological response as well as sustained virological response in CHC patients treated with a combination of peg IFN-α and ribavirin (16,17). This negative association has been reported not only in patients infected with geno- type 1 (17), but also in those with the so called “easy to treat” genotypes 2 and 3 (18). Conversely, development of insulin resistance or exacerbation of previously stable glycaemic control have been reported as drug side-effects in CHC patients who are receiving in- terferon treatment (19). To our knowl- edge, studies concerning genotype 4, the most prevalent genotype in Egypt (20), are limited. Information regarding glucose abnormalities in CHC patients with genotype 4 is valuable for deter- mining if strategies to modify insulin resistance before or during combina- tion therapy are a feasible approach for enhancing the likelihood of treatment response. Our aim was to evaluate the preva- lence of insulin resistance in Egyptian patients chronically infected with HCV genotype 4, to assess factors associated with insulin resistance in those patients (viral, metabolic and histopathological, including steatosis, fibrosis and necro- inflammatory changes) and to test the impact of insulin resistance on treat- ment outcomes in patients receiving peg IFN-α and ribavirin treatment. Methods This study was conducted from Janu- BSZ UP +BOVBSZĉF TUVEZ received ethical approval from the local research committee of Alexandria Main University Hospital. All patients and controls were asked to give their in- formed consent before being included in the study. Study sample "UPUBMPGBEVMUQBUJFOUTXJUI$)$ genotype 4 infection were enrolled randomly from the centre for treatment of hepatitis viruses in Sharq El Madina Hospital of Alexandria, Egypt. The hos- pital is one of 23 centres established by the Egyptian Ministry of Health for treating CHC patients as a part of the national viral hepatitis treatment pro- gramme. All patients were eligible for treat- ment and non-diabetic (diabetes was diagnosed using the 1997 American Diabetes Association criterion: fasting HMVDPTF NHE- ĉF GPMMPXJOH patients were excluded from the study by appropriate virological, serological, biochemical and ultrasound data and HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 805 making a total of 71 patients followed for treatment response and insulin re- sistance. Data collection Clinical and demographic data Clinical and demographic data were collected from the patients’ files, in- cluding: age, sex, height, weight, waist circumference and blood pressure. Venous blood samples were collected from both cases and controls after they had fasted overnight for 12 hours, to test their lipid profile and to determine serum levels of glucose and insulin. Body mass index (BMI) was cal- culated. The metabolic syndrome was diagnosed according to the revised World Health Organization (WHO) definition as the presence of 3 or more of the following criteria: central obesity XBJTUDJSDVNGFSFODF DNJONBMFT PS DN JO GFNBMFT IZQFSUFOTJPO CMPPE QSFTTVSF NN)H GBTUJOHQMBTNBHMVDPTF NHE- USJHMZDFSJEFT NHE- IJHIEFO- sity lipoprotein (HDL) cholesterol NHE- NBMFT PS NHE- (females) (21). HOMA method Insulin resistance was assessed using the HOMA method using an immu- noassay analyser (COBAS E insulin kit immunoassay analyser, Roche Di- agnostic) and the following equation: HOMA-IR = fasting insulin (μU/mL) ¤GBTUJOHHMVDPTF NNPM- 22). ")0."*3TDPSF XBTDPOTJE- ered the criterion for insulin resistance (23). Virological assessments Assessment of the HCV viral load of UIFQBUJFOUT JODMVEFE JOPVSTUVEZ was done by quantitative measurement of RNA using real-time PCR (COBAS AmpliprepT/COBAS TaqManT, Roche Molecular Systems). Level of viraemia was classified as high, intermediate and low according to viral MPBECFJOH 6 m6PS IU/ mL respectively (24). Determination of the genotype of the virus was done using a real-time PCR kit (AmpliSens HCV-FRT, InterLabService Ltd). The definition of the on-treatment response was as follows: complete early virological response was defined as HCV-RNA below the limit of detection at week 12. Partial early virological response was defined as positive HCV-RNA at XFFLCVUXJUIBɓ MPHESPQ JO viral load as compared with baseline. End-of-treatment response was defined as serum HCV-RNA below the limit of detection at the end of treatment. We considered non-responders to be: patients with no or minimal change in UIFJS)$73/"UJUSFT MPHESPQ at week 12 as compared with baseline); UIPTFXJUI WJSBM MPBEESPQ MPH at week 12 as compared with baseline and who still had positive HCV-RNA at week 24; those who became HCV- RNA positive after negativization before the end of treatment (breakthrough response); and those who became HCV-RNA positive after negativization at the end of treatment (25). Treatment outcomes 'SPNUIFQBUJFOUTFOSPMMFE JO UIF study, 71 treatment-naive CHC patients (i.e. those who had not had received any form of treatment for HCV by any pri- vate- or government-sector physician) were followed for treatment outcomes associated with various degrees of insu- lin resistance. All patients were started on treatment with a combination of peg INF-α and ribavirin for an intended duration of 48 weeks, as in the protocol of the national HCV programme. Serum HCV-RNA levels were as- sessed in all patients at baseline and then at weeks 12, 24 and 48. After 12 weeks, the early virological response was as- sessed by measuring the viral load and the HOMA-IR score was determined. Patients who did not demonstrate a de- crease in viral load of 2 log or more were considered early non-responders (n = 26). Therapy was discontinued for these patients according to the protocol by clinical history: those with clinical evidence of hepatic decompensation or liver cirrhosis, concomitant hepatitis B infection (defined as HBsAg-positive), patients with CHC of a genotype other than 4, autoimmune hepatitis, hemochromatosis, primary biliary cir- rhosis, Wilson disease, drug-induced liver disease and laboratory values of TFSVNDSFBUJOJOF NHE- BCTPMVUF OFVUSPQIJM DPVOU N- QMBUFMFU DPVOU N-PSIBFNPHMPCJO < 11 g/dL. Randomization was done on the basis of the exclusion and inclusion criteria that were applied to all patients and was performed on the days of data collection for all patients attending the treatment centre on that day. " DPOUSPM HSPVQ DPNQSJTJOH healthy HCV-antibody negative indi- viduals from the general population was included in the study for compar- ing their homeostasis model assess- ment–insulin resistance (HOMA-IR) index with that of the CHC patients. Our controls were individuals entering the laboratory for enzyme-linked im- munosorbent assay (ELISA)-HCV an- tibody test and, when a negative result was obtained, an additional HOMA-IR test was performed to determine their insulin resistance and to compare it with insulin resistance among CHC patients. The sample size calculation for the study was done by an experienced stat- istician. The sampling protocol was as GPMMPXT"UPUBMPGQBUJFOUTBĨFOEJOH the national treatment centre for HCV provided by the national treatment programme were to be included for a cross-sectional study of the prevalence of insulin resistance among CHC pa- UJFOUT'SPNUIFTFQBUJFOUT QB- tients were to be followed for studying the different treatment outcomes and to follow their insulin resistance state. After 12 weeks from starting treatment, QBUJFOUTXFSFOPOSFTQPOEFST BOE their treatment was stopped according to the Ministry of Health protocol. We therefore followed another 11 patients EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 806 approved by the Ministry of Health. Patients showing a ≥ 2 log reduction in viral load continued the antiviral treat- ment regimen until 48 weeks (n = 61). Viral load and insulin resistance were re- assessed again after 48 weeks of therapy. Liver histopathology and immuno- histochemistry All patients underwent an ultrasound- guided percutaneous liver biopsy prior to the start of treatment and patients with hemochromatosis or primary biliary cirrhosis were excluded. The degree of necroinflammatory activ- ity and of fibrosis were scored based on the Metavir system (27). Hepatic steatosis was scored as the percentage of hepatocytes containing macro- vesicular fat droplets and was graded GSPN UP 28). Paraffin-embedded liver sections from selected patients were deparaffinized and subjected to immunohistochemical staining using an anti-human-IRS-1 (Ultravision de- tection system antipolyvalent, HRP/ DAB kit, Thermo Fischer Scientific) to examine the protein expression levels of IRS-1 (29). Statistical analysis The data were analysed using SPSS soft- XBSFQBDLBHF WFSTJPO2VBMJUBUJWF data were described using numbers and percentages. Quantitative data were described using the range (minimum and maximum), mean, standard de- viation (SD) and median. Compari- son between cases and controls was performed using the chi-squared test. The distributions of quantitative variables were tested for normality using Kolmogorov–Smirnov, Shapiro–Wilk and D’Agostino tests. If they revealed normal data distributions, parametric tests were applied. If the data were ab- normally distributed, non-parametric tests were used. For abnormally distrib- uted data, comparison between cases and controls was done using the Mann– Whitney test, while the Kruskal–Wallis test was used to compare between HOMA-IR categories. Correlations between HOMA-IR with different parameters were assessed using Spear- man coefficient. Significance test results were quoted as 2-tailed probabilities. Significance of the obtained results was KVEHFEBUUIFMFWFM Results "NPOHUIF$)$QBUJFOUTJODMVEFE JOUIFTUVEZ XFSFNBMFTBOEXFSF females, with a mean age of 42.8 (SD ZFBSTĉFNFBO#.*XBT (SD 3.4) kg/m2" UPUBMPGQBUJFOUT fulfilled the criteria for the metabolic syndrome. According to the Metavir score, necroinflammation was moder- BUF UP TFWFSF JOPGQBUJFOUT BOE ėCSPTJTXBTTJHOJėDBOUJOPGDBTFT 4UFBUPTJT XBTNPEFSBUF JO PG DBTFTBOETFWFSFJOPGDBTFT Distribution of studied cases according to baseline viral load ĉFEJTUSJCVUJPO PG UIF QBUJFOUT included in this study with respect to their baseline viral load was as follows: IBEMPXMFWFMWJSBFNJB IBE JOUFSNFEJBUF MFWFMWJSBFNJBBOE had high level viraemia. The median WJSBM MPBEXBT¤3 IU/mL with NFBOWBMVFPG 4% ¤3 IU/mL. Results of HOMA-IR Insulin resistance was detected in 31 PG UIFOPOEJBCFUJD$)$QBUJFOUT infected with genotype 4 (HOMA-IR 8IFO)0."*3TDPSFTXFSF categorized into 3 groups (< 2, 2–4 BOE BIJHIMZTJHOJėDBOUEJĎFSFODF was seen between patients and con- USPMT GPS FYBNQMF PG QBUJFOUT WFSTVTPGDPOUSPMTIBE)0.*3 < 2 (P 'JHVSF ĉFNFBO HOMA-IR scores of cases and controls XFSF TJHOJėDBOUMZEJĎFSFOU 4% 2.36) versus 1.61 (SD 1.29) (P (Table 1). Relationship between HOMA- IR and clinical and biological variables Data on the relationship between HOMA-IR and clinical and biological variables are shown in Table 2. HOMA- IR tended to correlate positively with age, baseline viral load, BMI, serum triglycerides, fibrosis and steatosis and negatively with total cholesterol, low- and high-density lipoprotein cholesterol and total lipids. Statistically significant correlations were found be- tween elevated HOMA-IR and both baseline viral load (Spearman r P BOEEFHSFFPGėCSPTJT r = P When the data were analysed by multivariate linear regression, the results showed that viral load remained the only independent factor associated with elevated HOMA-IR levels (P Relationship between insulin resistance and treatment response Patients with a lower baseline HOMA score had more favourable outcomes regarding response to therapy. Patients who reached complete early virological response had statistically significant low- er HOMA scores than non-responders (Table 3). All patients with complete and partial early virological response achieved end-of-treatment response with no breakthrough response. The values of HOMA-IR test at the start of therapy, after 12 weeks and after 48 weeks of therapy in CHC patients who attained complete early virological response showed a considerable decline in HOMA-IR level (P TVH- gesting that insulin resistance improved with successful treatment (Table 4). Relation between immunohistochemistry and HOMA-IR before therapy The expression of IRS-1 was estimated by immunohistochemical staining of 29 liver tissue sections of CHC cases included in the study. The results were HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 807 BT GPMMPXTDBTFTXFSFHSBEF QPTJUJWFDFMMT DBTFTXFSF m QPTJUJWF DFMMTXJUIXFBL TUBJOJOH DBTFTXFSF mQPTJUJWF DFMMT XJUI TUSPOH TUBJOJOH PS QPTJUJWF cells with weak staining) and 4 were DBTFT QPTJUJWFDFMMTXJUITUSPOH staining) (Figure 2) (30). No statisti- cally significant difference was found between any grades of immunohisto- chemistry and HOMA-IR score before therapy (P Discussion This study was conducted to determine the prevalence of insulin resistance in non-diabetic patients with CHC geno- type 4 and its effect on therapy and to reveal whether application of a simple and relatively inexpensive test for as- sessment of insulin resistance (HOMA score) before starting antiviral therapy will lead to better selection of patients who are candidates for successful treat- ment. The mean HOMA-IR score of the QBUJFOUTVOEFSHPJOHUSFBUNFOUXJUI dual therapy (peg-INF-α plus ribavirin) XBT 4% *OTVMJO SFTJTUBODF EFėOFEBT)0."*3TDPSF XBT detected in 31 patients. In a study by Khattab et al., also conducted on CHC patients with genotype 4, the mean pre- treatment HOMA-IR scores (using UIF DVUPĎ XBT 4% (25). Similarly, Ezzat et al. found that among CHC genotype 4 patients 31 IBEJOTVMJOSFTJTUBODF EFėOFE BT)0."*3TDPSF BOEUIFNFBO HOMA-IR was 2.6 (31). Moucari et al. also studied CHC genotype 4 patients and found the HOMA-IR (using the DVUPĎ XBT 4% 23). In Asselah et al.’s study of CHC genotype 4 patients the proportion with HOMA- *3 XBT 32). In the correlational analysis, baseline viral load was a statistically significant factor affecting pre-treatment HOMA- IR (P BOE XBT UIF NBKPS independent factor associated with high HOMA-IR by linear regression analysis (P 4JNJMBSMZ "TTFMBI et al. found that insulin resistance was significantly associated with basal viral load in univariate analysis (P as well as multiple logistic regression analysis (P 32). Moucari et al. also showed that insulin resistance had a statistically significant correlation with Table 1 Comparison of homeostatic model assessment–insulin resistance (HOMA-IR) scores between patients with chronic hepatitis C genotype 4 and control subjects Group HOMA-IR score Mann–Whitney test Mean (SD) Median Min.–Max. Z-value P-value Controls (n = 60) 1.61 (1.29) 1.41 0.03–6.81 3.322 0.001 Cases (n = 100) 2.55 (2.36) 2.05 0.23–15.17 SD = standard deviation. Figure 1 Comparison of homeostatic model assessment–insulin resistance (HOMA-IR) scores in patients with chronic hepatitis C genotype 4 and control subjects at the 3 different cut-off levels (< 2, 2–4, > 4) (χ 2 = 9.168; P = 0.009) 73.3 21.7 5.0 49.0 40.0 11.0 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 < 2 2-4 > 4 HOMA-IR score % o f p ar ti ci p an ts Controls (n = 60) Cases (n = 100) EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 808 serum HCV-RNA in univariate analysis (P BOEBMTPJONVMUJQMFMPHJTUJD regression analysis (P 23). Our finding supports the hypothesis that HCV has a direct effect on insulin resistance progression in CHC patients. In contrast, another study by Ezzat et al. showed that insulin resistance had no impact on early virological response with combined therapy, on viral load or on necroinflammation (31). The contradiction between the findings of the current study and those of Ez- zat et al. may be because they assessed HOMA-IR before therapy and at 12 weeks after therapy only and did not measure HOMA-IR at the end of treat- ment. Concerning the relat ionship between pre-treatment values of HOMA-IR and response to therapy in patients with genotype 4 CHC in- fection, we concluded that having a lower baseline HOMA score led to a favourable therapeutic outcome. There was a statistically significant difference comparing the HOMA-IR of patients achieving complete early virological re- sponse, partial early virological response and non-response (P -JLF- wise, Khattab et al. found a highly and significant relationship between insulin resistance and treatment response (P 25). Similarly, Moucari et al. concluded from their study that HO- MA-IR score < 2 was associated with early virological response (P and also remained an independent pre- dictor of sustained virological response by multiple logistic regression analysis (P 23). This research also studied the effect of successful treatment on the insulin resistance state in the selected CHC patients. Follow-up of the complete early virological responders until the end of treatment showed that they had a statistically significant decrease Table 3 Relationship between pre-treatment values of the homeostatic model assessment–insulin resistance (HOMA-IR) score and response to therapy in patients with chronic hepatitis C genotype 4 Response to therapy HOMA-IR scores Mann–Whitney test Mean (SD) Median Min.–Max. P1 P2 Early non-responders (n = 10) 2.95 (1.14) 3.07 1.10–4.67 – n/a Partial early virological response (n = 7) 3.98 (2.13) 3.66 1.90–8.24 0.435a – Complete early virological response (n = 54) 2.32 (2.35) 1.64 0.37–11.66 0.037a 0.007b Kruskal–Wallis test χ 2 =10.303c; P =0.006 aVersus early non-responders; bVersus partial early virological response; cComparing groups. SD = standard deviation. Table 4 Comparison between homeostatic model assessment–insulin resistance (HOMA-IR) scores at the start of therapy, after 12 weeks and after 48 weeks of therapy in the subgroup of patients with complete early virological response Follow-up interval HOMA-IR scores Wilcoxon signed ranks test Mean (SD) Median Min.–Max. P1 P2 Pre-treatment (n = 54) 2.32 (2.35) 1.64 0.37–11.7 – n/a After 12 weeks therapy (n = 54) 2.20 (2.63) 1.39 0.20–15.1 0.081a – After 48 weeks therapy (n = 52) 1.66 (1.61) 1.20 0.13–10.5 < 0.001a < 0.001b Friedman test χ 2 = 27.038c; P < 0.001 aVersus pre-treatment; bVersus 12 weeks follow-up; cComparing groups. SD = standard deviation. Table 2 Univariate analysis of correlations between homeostatic model assessment–insulin resistance (HOMA-IR) score and different variables in patients with chronic hepatitis C genotype 4 Variable Correlation with HOMA-IR score rs P-value Age 0.101 0.315 Viral load 0.218 0.029 BMI 0.151 0.133 Total cholesterol –0.098 0.338 Triglycerides 0.118 0.246 HDL cholesterol –0.081 0.430 LDL cholesterol –0.120 0.238 Total lipids –0.037 0.716 Fibrosis grade 0.223 0.026 Steatosis grade 0.336 0.075 rs = Spearman correlation coefficient. BMI = body mass index; HDL = high-density lipoprotein; LDL= low-density lipoprotein. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 809 in HOMA-IR (P 4JNJMBSMZ Brandman et al. showed that patients had a substantial decrease in insulin resistance level 6 months after receiving antiviral therapy in comparison with those not receiving treatment (33). In this study, 29 liver tissue sections from selected cases were tested by im- munohistochemistry for expression of IRS-1 to assess viral role in induction of insulin resistance state. Fourteen cases showed a high level of IRS-1 expression HSBEFT BOE BOEDBTFTIBE B MPXMFWFMPGFYQSFTTJPO HSBEFTBOE 1+) and there was no significant differ- ence. Kawaguchi et al. demonstrated a 2- and 3-fold increase in the intensities of IRS-1 and IRS-2 staining respectively after antiviral therapy. They identified mechanisms for HCV-associated in- sulin resistance, postulating that HCV core downregulates hepatic expression of IRS-1/2, and thus decreases the downstream signalling effect of insulin on glucose uptake by cells (34). Almost half of the cases in our study showed a low level of expression of IRS-1, a finding that also supports the hypoth- esis of a direct role of the virus on cells. The limitations in this study may be that a specified cut-off value for HOMA- IR to diagnose insulin resistance in pa- tients was not found. Other studies have used a range of different cut-offs of HO- MA-IR for diagnosis of insulin resistance (2–4). In this study we used the highest possible value to avoid misdiagnosis but this may have given a false low prevalence of insulin resistance among CHC pa- tients. Another limitation was the limited number of tissue sections available for immunohistochemical studies and this may also have affected the analysis of the direct role of the virus in inducing insulin resistance. Also, work-up for studying the effect of the interleukin-28B (IL28B) gene on insulin resistance in our patients was not done, nor was follow-up done for studying sustained virological response in these patients. The possibility that HCV is a cause of insulin resistance in chronically in- fected patients has important impli- cations. From the management point of view, we can ask: Should patients with CHC be monitored regularly for insulin resistance? HOMA-IR is a practical and well-accepted method of measuring insulin resistance and is a non-invasive, inexpensive test that can be implemented easily in routine clinical practice. Our study provides further evidence that insulin resistance affects treatment outcome and that HOMA-IR testing before initiation of therapy may be a cost–effective tool to be considered before treating patients. 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Impact of insulin resistance on HCV treatment response and impact of HCV treatment on insulin sensitivity using direct measure- ments of insulin action. Diabetes Care. 2012 May;35(5):1090–4. PMID:22399695 34. Kawaguchi Y, Mizuta T. Interaction between hepatitis C vi- rus and metabolic factors. World J Gastroenterol. 2014 Mar 21;20(11):2888–901. PMID:24659880 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 811 1Department of Surgery; 4Trauma Surgery Section, Clinical Research, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (Correspondence to A. El-Menyar: Aymanco65@yahoo.com). 2Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar. 3Department of Internal Medicine, Ahmed Maher Teaching Hospital, Cairo, Egypt. Received: 15/10/14; accepted: 28/06/15 Trauma research in Qatar: a literature review and discussion of progress after establishment of a trauma research centre A. El-Menyar,1,2,3 M. Asim,1A. Zarour,4 H. Abdelrahman,4 R. Peralta,4 A. Parchani4 and H. Al-Thani4 ABSTRACT A structured research programme is one of the main pillars of a trauma care system. Despite the high rate of injury-related mortalities, especially road traffic accidents, in Qatar, little consideration has been given to research in trauma. This review aimed to analyse research publications on the subject of trauma published from Qatar and to discuss the progress of clinical research in Qatar and the Gulf Cooperation Council countries with special emphasis on trauma research. A literature search using PubMed and Google Scholar search engines located 757 English-language articles within the fields of internal medicine, surgery and trauma originating from Qatar between the years 1993 and 2013. A steep increase in the number of trauma publications since 2010 could be linked to the setting up of a trauma research centre in Qatar in 2011. We believe that establishing a research unit has made a major impact on research productivity, which ultimately benefits health care. ÓmXzZTÐÔm<Ì}S|XÊmYhÎz^<Û|BÐêzaTÐoYRmeXíÓmg<رTo^?Ð|X|\R9ÓmXzZTm<oac^BÐÔm<úÐ ©n?éËAº©nI}=èI̺nUÐE=N=íÚº1}UÐ{LênZwºÚí}LÛ{1̺ÉnL{e7ºEfCÐexÌ ÓnhRUÐé{å_Yânåa>ÚÐåYåQ}UÐDåLí ÓnåY{[Un=påxnf_UÐênå^fUphåHnHúÐ~åýnT}UÐ{åAÌFå_ôxå^fYå=såYni}=Øå@íëÎoåÉ°#Ð qåR{w{åSí påhªúÐåYåhdbUÐøÎ óå_ô>3ÓnåY{[Un=påbd_CÐÔåUÐëlåR}å]S: påxÚí}CÐÔØÐå"Ð5håHø–Ónå=nÉün=på]>}CÐ }å]SpåUíØ:ï}åxUÐråUÐê{åb>påZSnfYOÎíº}å]SåYÓPåiÓnåY{[UÐâåYåLpåh=ÓÐÚåZfYåhdĻOÎpå_@Ð}CÐì|åw Ónåh=ØúÐ:råUÐéĆåBåeR ÓnåY{[Un=påbd_CÐÔåUÐDåL ÞnåBcåZ= ~åhTGUÐ åYºåhd#Ðëínå_UÐåd6ëÐ{åd=:í :pååx~hdiüÐpåå`dUn=ðønååbY757DååLÚåå_UÐåå>Google Scholaråå@@:ååed_UÐrååAnUÐíPubMedrååUÐ ÷åå óT}7êÐ{ååHn= ÓÐÚåZfCÐØ{åL:ÒØnå"ÐÒØnåx~UÐå=Úåcexí 2013í1993åYnLNå=}å]SåYÒÚØnåÉÓnåY{[UÐípåAÐ}!ÐíåfJnUÐoå]UÐÓønå6 E?j>åUënTÔådUÒ{åAíÊnåZiÎëÌ{åb_inåfiÎ 2011ênåL:}å]S:ÓnåY{[UÐÔnå=Ì~åT}YÊnåZil=2010ênåL|åfYÓnåY{[Un=påbd_CÐ påh[UÐpåxnL}UÐDåL ænå]CÐpåxn¹: Ò{åýnaUn=Øå_>åUÐíºpåhUÐpåh@niüÐDåLEåT Recherche sur les traumatismes au Qatar : analyse de la littérature et discussion sur les progrès après l’établissement d’un centre de recherche sur les traumatismes RÉSUMÉ Un programme de recherche structuré représente l’un des piliers principaux d'un système de soins des traumatismes. En dépit du fort taux de mortalité lié aux traumatismes, notamment consécutif à un accident de la route au Qatar, peu d'attention a été accordé à la recherche sur les traumatismes. La présente analyse visait à étudier les travaux de recherche sur le sujet des traumatismes publiés au Qatar et à discuter des progrès de la recherche clinique au Qatar et dans les pays membres du Conseil de coopération du Golfe en mettant l’accent sur la recherche en la matière. Une recherche de la littérature à l’aide des moteurs de recherche PubMed et Google Scholar a permis d’identifier 757 articles en langue anglaise dans les domaines de la médecine interne, de la chirurgie et des traumatismes, provenant du Qatar entre 1993 et 2013. La forte augmentation du nombre de publications sur les traumatismes depuis 2010 peut être liée à l’établissement d’un centre de recherche sur les traumatismes au Qatar en 2011. Nous pensons que l’établissement d’une unité de recherche a eu un impact important sur la productivité de la recherche, ce qui à la longue est bénéfique pour les soins de santé. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 812 Introduction In the last decade there has been a dramatic increase in the performance and output of medical and scientific research in the Arab region, particularly among stable high-income economies such those of the Gulf Cooperation Council. In the case of Qatar, the DPVOUSZ IBT DPNNJĨFE PG JUT gross domestic product towards higher education, science and technology and academic research (1). Assessment of progress in biomedical research is crucial for developing evidence-based improvement in the health-care sys- tems in the Arab countries and also reflects the prominence of a country in the global scientific community. To date, however, the scientific potential of clinical research in Qatar has not been explored well. Blunt trauma is a serious public health concern in this rapidly devel- oping country and is associated with significant morbidity and mortality among the younger age groups of the population (2 ,3). Road traffic ac- cidents, falls from height and injuries from heavy objects are the frequently observed mechanisms of injury in the country (4,5). Similarly, the incidence of traumatic injuries is rising in Qatar (6). Around two-thirds of all injury- related mortalities in Qatar are due to road traffic accidents, and the younger age population has a higher rate of fatali- ties than other age groups (7). Qatar is the third wealthiest nation in the world, having the 11th highest motorization SBUF NPUPS WFIJDMFT QFS population), which goes some way to- wards explaining its high fatality rates EFBUITQFSNPUPSWFIJDMFT (5,8). Nevertheless, as in many develop- ing countries, little consideration has been given to population-based studies on the incidence, mechanisms of injury, outcomes and prevention of traumatic injuries. Each country has unique socio- economic factors which influence the potential areas for injury prevention and development of trauma services. There- fore there is a need to encourage more trauma research and reporting in Qatar to facilitate evidence-based practice and ultimately to improve patient care. Hamad Medical Corporation is the leading health-care provider in Qatar and offers an array of primary, acute and tertiary care services to all residents of the country. In view of the dispropor- tionately high incidence of uninten- tional injuries in Qatar (2), a trauma care system was established at Hamad (FOFSBM)PTQJUBMJOBOEBUSBVNB SFTFBSDIVOJUXBT TFUVQ JO +VOF Establishing a clinical research unit in trauma could be an appropriate model to demonstrate the improvement in research outcomes with investment in dedicated a trauma research infra- structure in Qatar. This review aimed to analyse trauma research publications that have originated from Qatar and dis- cuss the progress of clinical research in Qatar with special emphasis on trauma research. Methods A literature review was performed to identify all relevant biomedical research publications originating from Qatar in the areas of internal medicine, surgery and trauma. An online search was made using PubMed, Medline and Google Scholar search engines from January UP%FDFNCFSĉFNFEJDBM subject headings (MeSH) used were “Qatar” [MeSH Terms] OR “Qatar”[All 'JFMET> "/% iu<1%"5> iu<1%"5> 8FTFBSDIFE research publications by country name, as we intended to include all relevant articles published from Qatar. We manually reviewed all the obtained abstracts. Although this approach is labour-intensive, it yielded more ac- curate results. All these articles were then included for the review analysis. Articles written in English which were available on electronic databases and specific institutional sites were included in this study. A total of 1781 publications were retrieved from the PubMed database with the keyword “Qatar”, of which 671 articles originated from Qatar, and 86 articles were identified and included from a Google Scholar search. All ar- ticles were studied manually to look for institutional affiliations and were classified according to publication type (research studies, reviews, case reports, clinical trials and editorials) and were categorized as Medline, PubMed and Scholar BSUJDMFT" UPUBMPGBSUJDMFT were not included in the analysis be- cause they presented data from other countries. Non-English language arti- cles and articles with no abstract were excluded. The publications identified through the search were independently screened by two authors for inclusion, XIJDI SFTVMUFE JOBSUJDMFT TFMFDUFE for review. Results 0G UIF BSUJDMFT JEFOUJėFEXJUIJO the 21-year search window nearly two- thirds (n XFSFQVCMJTIFE EVSJOHm UIF MBTUZFBSTPGUIF search period (Table 1). These articles in the fields of internal medicine, surgery and trauma mainly included retrospec- tive (n = 167), prospective (n and cross-sectional (n = 62) research studies and a few case–control (n = 17) studies. There were a high number of case reports/series (n = 244) and review articles (n &EJUPSJBMT n = 17), clinical trials (n = 11) and book chapters (n = 3) were published less frequently. The great majority of clinical medicine publications originated from institutions affiliated to Hamad Medical $PSQPSBUJPO 5BCMF XIFSFBT the other research institutions in Qatar published a relatively low proportion of BSUJDMFT EVSJOHUIFTBNFQFSJPE We made a more detailed review of research articles concerning trauma HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 813 trauma research publications showed a TUFFQSJTF GSPNUIFZFBSPOXBSET (Figure 1). Discussion Clinical research in the GCC The countries of the Gulf Coopera- tion Council (GCC)—Saudi Arabia, United Arab Emirates, Qatar, Bahrain, Kuwait and Oman—are the most rapidly developing countries in the Eastern Mediterranean Region. The discovery of vast oil reserves in these countries has led to a rapid socioeconomic transformation which has stimulated investment in educa- tion quality and research in the region. However, recent reports have suggest- ed that the research output from these countries are lagging behind from a global perspective (9,10). El-Azami- El-Idrissi et al. compared the medical research output of Arab nations with those of more developed countries EVSJOHm 10). The authors found that the research output of Arab OBUJPOTXBT POMZ PG UIF6OJUFE States of America but similar to that of Israel and twice that of the Islamic Republic of Iran. However, the aver- age Hirsch index (11,12) of the Arab researchers, a measure of the quantity and quality of publications (based on the number of publications and cita- tions), was lower compared with other OBUJPOT2BUBSIFME UIFUIQMBDFPVU of the 6 GCC countries both in world ranking (rank = 82) and h-index (h = BWFSBHF 10). Qatar has invested huge resources over the years to improve its health- care facilities and develop the infra- structure for modern educational and research institutions. Hamad Medical Corporation, Qatar Foundation, Weill Cornell Medical College in Qatar and Sidra Medical and Research Centre are the leading health-care and re- search organizations which represent Qatar at the international and regional level. The output of international publications is the primary criterion for the assessment of growth and de- velopment of biomedical research in a country (13), and the scientific activities of individual biomedical re- search institutions (national and inter- national) are evaluated by the quality and quantity of publications (14,15). Yet to date the scientific potential of clinical research in Qatar has not been explored greatly. Currently Qatar is gaining momentum in the field of clin- ical and biomedical research, which is evident from the increasing number of scientific publications. PWFS UIFZFBSTm BT USBVNB related publications from Qatar started UPBQQFBSGSPNPOXBSET"UPUBMPG 128 research publications were identi- fied on the subject of trauma (41 were indexed in Medline JOPubMed and 47 in Google Scholar). The majority of these (n XFSFQVCMJTIFE CFUXFFO BOE%FDFNCFS Among trauma publications, the most frequent types of study were retrospec- UJWFBOBMZTJT GPMMPXFECZDBTFSF- QPSUT BOESFWJFXBSUJDMFT 1SPTQFDUJWF BOEDSPTTTFDUJPOBM TUVEJFTBOEDMJOJDBM USJBMT were less common (Table 3). The Table 1 Details of clinical research publications (medical, surgical and trauma) originating from Qatar, 1993–2013 Variable PubMed (n = 671)a Scholar (n = 86) Total (n = 757) No. No. No. Original research paper Retrospective study 149 18 167 Prospective study 111 4 115 Case series/case report 223 21 244 Cross-sectional study 59 3 62 Clinical trial study 10 1 11 Case–control study 17 0 17 Other publication type Review article 87 20 107 Editorial/ letter to editor 14 3 17 Book chapter 0 3 3 Critique 0 5 5 Published abstract 0 8 8 Year of publication 2013 137 21 158 2012 104 31 135 2011 65 13 78 2010 37 5 42 2009 70 3 73 2008 47 1 48 2007 24 2 26 2006 45 0 45 2005 10 0 10 2004 1 0 1 2003 17 0 17 2002 17 0 17 2001 21 0 21 a452 articles were also Medline. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 814 Trauma research in Qatar Traumatic injuries are one of the lead- ing causes of deaths, affecting nearly 6 million people globally (12). Road traffic accidents account for nearly a quarter of deaths from all injuries and other main causes include falls, drown- ing, burns and poisoning (16). Road traffic accidents currently hold the 8th leading cause of all deaths and, without adequate preventive measures, will be UIFUIMFBEJOHDBVTFPGEFBUICZ (12). Since trauma remains a leading cause of unintentional injuries and deaths in our region, our review focused primarily on progress in trauma research in Qatar, which could be a benchmark for other countries in the region. Local trauma researchers play a central role in the development of innovative trauma programmes and research translation, which eventually can make a contribu- tion to evidence-based patient care and injury prevention strategies. Given the diversity of organizations and the dynamic nature of trauma care systems, it is valuable to conduct re- search which could improve the effec- tiveness of the national trauma system through continuous system develop- ment and performance improvement. Research outcomes provide valuable information for establishing best clinical practices and facilitating system devel- opment for improved patient care. In this review in Qatar, we found an increase in all types of medical, surgical and trauma research publications since ĉFNBKPSJUZPG UIFTFPSJHJOBUFE from institutions affiliated to Hamad .FEJDBM $PSQPSBUJPO 8IFO we analysed only trauma research, we found that publications showed a steep SJTF GSPN UIFZFBSPOXBSET BOE UIFNBKPSJUZPGQBQFST XFSF QVCMJTIFECFUXFFOBOE%FDFN- CFS ZFBST BěFS UIF FTUBCMJTI- ment of the trauma research unit. It was observed that trauma research pub- lications increased nearly 4-fold after JFSFBDIFEQVCMJTIFESFTFBSDI QBQFST JO GSPNBO BWFSBHFPG papers per year across the period from UP5BCMF TIPXTB DPN- parison of the total number of medical research publications among different "SBCDPVOUSJFT GSPNmBOE the number of trauma research papers. Saudi Arabia (n =181) and the United Arab Emirates (n = 122) contributed more than half of the total trauma publi- cations in the GCC region, followed by Kuwait (n = 78) and Qatar (n = 74). The lowest contributions were from Oman (n = 34) and Bahrain (n = 22). Qatar QVCMJTIFE PGUIFUP- tal medical research publications from Table 2 Institutional affiliations of authors of clinical research publications originating from Qatar, 1993–13 (n = 671) Institution No. Hamad Medical Corporation Alone 552 Jointly with Weill Cornell Medical College (Qatar) 18 Jointly with Weill Cornell Medical College (Qatar) and University of Manchester (United Kingdom) 4 Jointly with University of Manchester (United Kingdom) 4 Jointly with University of Bergen (Norway) 1 Other institutions Weill Cornell Medical College (Qatar)r 38 University of Qatar 28 ASPATER Qatar Orthopedic and Sports Medicine Hospital 13 KIMS Qatar Medical Centre 2 University of Calgary (Qatar) 4 Other 7 Table 3 Types of trauma publications originating from Qatar, 2001–2013 Study/publication type PubMed (n = 40) Medline (n = 41) Scholar (n = 47) Total (n = 128) No. No. No. No. % Retrospective study 18 17 11 46 35.9 Prospective study 4 5 0 9 7.0 Case series/case report 12 8 6 26 20.3 Review article 4 7 11 22 17.2 Cross-sectional study 1 2 0 3 2.3 Clinical trial study 0 1 0 1 0.8 Editorial/letter to editor 1 1 3 5 3.9 Book chapter 0 0 3 3 2.3 Critique 0 0 5 5 3.9 Published abstract 0 0 8 8 6.3 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 815 ($$DPVOUSJFTCVU PG the trauma research publications. Thus the trauma research unit can serve as a model to demonstrate the improvement in research outcomes with investment in a dedicated trauma research infrastruc- ture in Qatar. Quality and types of trauma research publications in Qatar Not only is the quantity of published works a concern, but also the quality especially in the light of the low average h-index of articles published by the re- searchers in the Arab region. Although PubMed and Google Scholar are not an indication of the quality of the articles, we utilized these common scientific databases of biomedical information due to their accessibility and compre- hensiveness. PubMed SFUSJFWFEPG the trauma research articles included in our review. PubMed includes Medline, which is the National Library of Medi- cine journal citation database set up in UIFTMedline (PubMed) indexing is advantageous as the database only includes journals that meet the criteria of timely publication, a robust peer review system and adherence to ethical guidelines. Our study found that 1 out of 3 trauma research articles in Qatar published in PubMed was indexed for Medline. Falagas et al. compared the content coverage and practical utility of PubMed, Scopus, Web of Science and Google Scholar and found that Pub- Med remains an important, frequently updated resource for clinicians and researchers (17). Although Google Scholar can retrieve most of the infor- mation, the inadequate and rare up- dating of citations affects the quality of the information retrieved. When we analysed the types of trau- ma research publications, we found that the most frequent types of study were retrospective studies, case reports and review articles, while prospective stud- ies constituted a smaller proportion. The poor representation of prospec- tive studies, including few clinical trials compared with observational studies, highlights the existing gaps in research practice in Qatar. Retrospective study designs are often considered inferior (level III evidence) to prospective study designs (level II evidence). However, in the case of road traffic accidents and traumatic injury in general, retrospective analysis is the only feasible approach, whereas randomized clinical trials could be inapplicable and even unethical in Figure 1 Trend in trauma research publications originating from Qatar, 2001–2013 40 35 30 25 20 15 10 5 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 3 0 0 01 1 2 2 4 7 33 36 38 N o. Table 4 Comparison of number of medical research publications originating from different Arab countries, 1996–2012 Country Population mid- 2013 (millions) No. of medical schools/ hospitals Total no. of publications No. of trauma publications Saudi Arabia 30.1 21/115 16 169 181 United Arab Emirates 9.3 5/120 3 583 122 Bahrain 1.1 3/24 1 310 22 Kuwait 3.5 1/40 3 706 78 Qatar 2.2 1/12 1 748 74 Oman 4.0 2/53 2 107 34 Jordan 7.3 5/105 3 624 72 Egypt 84.7 19/175 15 350 170 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 816 certain trauma-related situations. Hess suggested that a retrospective study de- sign should not be preferred over a pro- spective design, if feasible (18). The high representation of retrospective studies could be related to the inexpensive na- ture, ease of obtaining existing records and lower ethical considerations from institutional review boards as compared with prospective designs. Prospective studies require informed consent from patients, which remains a major chal- lenge in developing countries (19). Other reasons for the poor rep- resentation of prospective designs in Qatar could be the bureaucratic and cultural barriers for conducting human subject research. Although compliance with ethical standards has made re- search safer for research subjects, the working processes of ethics commit- tees and institutional review boards should be explored to understand their impact on health research in Qatar. Alahmad et al. recently explored na- tional research ethics regulations and guidelines in Arab countries including Qatar and demonstrated numerous deficiencies that exist in the systems as compared with international stand- ards (20). Hansson et al. pointed out that although the ethics review process aims to protect all research participants against any potential harm associated with biomedical research, this process, in itself, could produce more harm than good in certain instances, and so it should be reconsidered and modified (21). Hamad Medical Corporation trauma care centre To facilitate evidenced-based practice and improved patient care in Qatar, the Hamad Medical Corporation trauma research unit was set up at Hamad Gen- FSBM)PTQJUBM JO +VOF 'JHVSF summarizes the types of research activi- ties at the trauma research centre. The trauma care centre utilizes the trauma registry database to audit performance based on a comprehensive performance improvement and a patient safety programme. This registry is an active participant of the National Trauma Data Bank and Trauma Quality Im- provement Program of the Committee on Trauma of the American College of Surgeons. As such, it collects standard data in accordance with Trauma Qual- ity Improvement Program standards and these are submitted to them on a quarterly schedule. We have also started a trauma critical care fellowship programme to bridge the postgradu- ate studies such as residency and other programmes to clinical fellowship. 4JODF UIFSFIBTBMTPCFFOBTJH- nificant increase not only in the number of research publications by institutions affiliated to Hamad Medical Corpo- ration, as shown in the results of this review, but also in the dissemination of trauma research results through pres- entations at international congresses by our trauma team (38 presentations JO JOBOE JO Presentation of our findings at leading international trauma conferences facili- tates dissemination of research output and provides a channel for exchange of information, international collaboration and representation of this rapidly devel- oping country to the international com- munity. Our trauma research unit also supports best clinical practice through implementation of clinical practice guidelines, education and training for clinical staff and improvement of quality of care through audit and feedback. It has been observed that evidence-based practice in trauma and critical care helps us to provide better health-care facilities and proper utilization of the hospital. Recently, the Hamad Medical Corporation trauma centre has been BXBSEFEHSBOUTGPSUSBVNBSFTFBSDI projects that tackled important issues, including occupational injuries in Qatar, use of car seats for children, Research activities in trauma section Publications Designing studies Assisting other departments in HMC Abstract presentation at international conferences Conducting research conferences or workshops Inter-institutional research collaboration Journal club Research meetings Writing grants and research proposals Coordinating with Medical Research Center Development of research driven hospital guideline Injury prevention programme Figure 2 Trauma research activities at the Hamad Medical Corporation trauma centre HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 817 organ donation awareness in the com- munity, hypothermia in the early man- agement of head injury and the clinical assessment of thoracolumbar traumatic injury. These projects received grants of around $US 4 million and are carried out in collaboration with United States and Australian institutes. After establish- ing the trauma research unit, the trauma team gained direct contact with all the stakeholders concerned with trauma and its prevention in Qatar, such as the ministries of interior, labour and edu- cation, universities, media and public campaigns. This was strengthened by adding an injury prevention unit to the USBVNBTFSWJDFTJO Benefits and challenges of trauma research Earlier research has highlighted the effectiveness of trauma systems in improving the survival rate of trauma patients through delivering the right care to the right patient at the right time (22). Therefore, research remains an im- portant element of trauma care systems. Research drives the system and provides the foundation for system development and performance improvement. After SFWJFXJOHBCTUSBDUT PGXIJDI referred to a trauma registry from 1998 UP "MĉBOJFU BMEFWFMPQFEB × 3 model to evaluate the impact of the number and quality of registry-based publications in a given country on the delivered trauma care. The authors con- cluded that the quality of publications reflects the efficiency of a trauma system and its maturation (23). Translation of the knowledge gained from research into practice is much needed for strengthening trauma sys- tems, and this eventually helps in preven- tion and management of unintentional injuries and deaths. For instance, a recent study by our team evaluated time-based trauma mortality patterns in the newly established trauma centre in Qatar. We observed a higher rate of mortality at the scene, highlighting the need for advanced pre-hospital trauma care and injury prevention programmes (24). Moreo- ver, even in established trauma systems, the numbers of preventable deaths are comparatively low. Since our trauma care centre is progressing towards the development of a mature trauma system, we believe that the impact of the trauma research centre on trauma prevention, management and reduction in numbers of preventable deaths and improvement in the quality of life of survivors will be evident in the near future. The major constraint for trauma research is the surrounding conditions, which are highly pressured, immediate and emotional and often overburdened for the scope of research (25). It can be slow or inexistent due to time and financial constraints as well as a lack of a research tradition (25). Some investiga- tors suggested that limited resources, lack of experience in designing research and lack of institutional support are oth- er challenges in conducting research in emergency and trauma settings (26). In particular, a lack of qualified researchers in trauma settings hinders the core com- petencies of the interested emergency physicians in addressing critical issues. One of the limitations of this review was the primary focus on the broad spe- cialties of medical, surgical and trauma research in Qatar, which renders other types of research from Qatar unex- plored. Although the trauma research unit is presented as a model to demon- strate the improvement in research out- comes with investment in a dedicated trauma research infrastructure in Qatar, research from other sub-specialties is still in its early stages when compared with that from developed nations and requires huge support for infrastructure, funding and high-quality training. Moreover, trauma research in Qatar is primarily supported by observational studies, which provide lower quality of evidence and so there is a need to encourage more clinical trials and pro- spective studies to improve the quality of research that will improve clinical care for trauma patients in Qatar. The major challenge to conducting prospective studies is the requirement for informed consent from patients, which remains a serious issue attributed to sociocul- tural barriers. To encourage prospective studies, we believe that the informed consent forms, which are often copies of forms used in Western countries, and the alternatives (i.e. deferred and waiver of consent), need to be revised to be more suitable to local culture and reli- gious beliefs. The under-representation of women in clinical research in our region is another challenge which needs a special focus (27). Unfortunately, the lack of dedicated and trained clinical researchers, the complicated process of obtaining informed consent for clini- cal studies and a lack of support for re- search activities are the most common obstacles for trauma research in the developing world. *O DPODMVTJPO BSPVOEPG UIF total trauma research articles from Qatar were published after the establishment PGUIFUSBVNBSFTFBSDIVOJUJO+VOF The increased number of research publi- cations in recent years demonstrates an increased level of participation in trauma research and points to the progressive maturation of the trauma care system in Qatar. We believe that establishing a re- search unit has made a major impact on research productivity, which ultimately benefits health care. To continue im- proving the care of the injured, greater re- search endeavours are crucial and should be encouraged for better understanding and development of an advanced trauma care management system. Acknowledgements We thank the entire trauma team in the section of trauma surgery at Hamad General Hospital. This study was presented in part at the 6th regional conference on Research in Developing $PVOUSJFT m .BZ JO,VXBJU. Funding: None. Competing interests: None declared. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 818 References 1. Qatar National Development Strategy 2011–2016. Towards Qatar National Vision 2030. Doha: Qatar General Secretariat for Development Planning; 2011 (http://www.gsdp.gov.qa/ gsdp_vision/docs/NDS_EN.pdf accessed 6 August 2015). 2. Hofman K, Primack A, Keusch G, Hrynkow S. Addressing the growing burden of trauma and injury in low- and middle- income countries. Am J Public Health. 2005 Jan;95(1):13–7. PMID:15623852 3. Murray CJL, Lopez AD. Quantifying the burden of disease and injury attributable to ten major risk factors. Murray CJL, Lopez AD, editors. 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Tehran, Islamic Republic of Iran (Correspondence to S. Nedjat: nejatsan@tums.ac.ir). 3Department of Educational Research, Faculty of Education and Psychology, University of Tehran, Tehran, Islamic Republic of Iran. Received: 10/08/14; accepted: 20/07/15 Socioeconomic inequality and child maltreatment in Iranian schoolchildren Z. Hosseinkhani,1,2 S. Nedjat,2 A. Aflatouni,3 M. Mahram 1 and R. Majdzadeh 2 ABSTRACT Socioeconomic inequality and child maltreatment have not been studied using the concentration index as an indicator of inequality. The study aimed to assess the association of child maltreatment with socioeconomic status among schoolchildren in Qazvin province, Islamic Republic of Iran. In this cross-sectional study a questionnaire based on the ISPCAN Child Maltreatment Screening Tool–Children’s Version and the Juvenile Victimization Questionnaire was filled by 1028 children aged 9–14 years, selected through multistage stratified random sampling. The concentration indices for economic inequality were –0.086 for any type of child maltreatment and –0.155, –0.098 and –0.139 for the physical, psychological and neglect subtypes of maltreatment respectively. The number of children and the economic status of the family also showed a significant association with child maltreatment in all 3 subtypes. Appropriate planning for effective interventions for at-risk children of lower socioeconomic status should be considered by the relevant decision-makers. oghÐ|wüÐÜÚÐzBÐém`IÌocXm^XÊGíïØmZRøÐ K5?øÐÓím`TÐ ìØÐÛ{6nÚºêÐ}gY}g@fYº©JĆRÌMLºÓniÛni}Hº©nBNAÐ}wÛ {åSí ÓínåaUÐDåLpåUø{dU~å hTGUÐ kåYêÐ{åHn=nåHÚ{ôx3énåaJúÐpådYn_YÊåHíïØnå[SøÐ L5@øÐÓínåaUÐëÎoåÉ°#Ð på^Rn7:ÜÚÐ{åCÐ|åhYĆ>î{åUïØnå[SøÐ L5@øÐ åUÐNå=íénåaJúÐpådYn_YÊåHNå=ànå>ÚøÐåhhb>OÎpåHÐÚ{UÐì|åwqåR{w ååwÚnhBÐåå> pfååH14í9Nåå=ååwÚ5LÌÖíÐGåå>ðĆååaJ1028ênååSpååh_]bCÐpååHÐÚ{UÐì|ååwååaR phYĆååHüÐëÐ}ååxÎpååxÚge=ååxí~S énåaJúÐpådYn_YÊåHï}åUISPCANÒÐØÌOÎ{fåxënhåHÐåYénåaJúÐpåiÊåe= – åAÐ}CÐÒØ{å_YphýÐåZLpåfhLéĆåBåY påådYn_YÊååHà5ååiÌååYååeiïú0.086ïØnåå[SøÐÓínååadUpååfUn=~ååhTGUÐ kååYëncååR ÔÐ{ååAúÐÊÐ|ååxl=Þnåå#ÐënhååHøÐí énåaJÌØ{å_UëÌNå>5åT <ÐåUÐDåLén媳UíphåafUÐípx{å!ÐpådYn_CÐÊåHåYpåhL}aUÐà5åi±U0.139í0.098í0.155íºénåaJúÐ ëÌNåhf_CÐÚÐ}åbUÐânåfÉDåLå`fx på?ĆUÐpåhL}aUÐà5åiúÐ åh+:åa]UÐpådYn_YÊåH åYpåbh?ípåSĆLïØnå[SøÐnåg_ííÒúÐ åiØúÐïØnå[SøÐ L5@øÐ åUÐïíÙåY}å]dUNå}_CÐénåaJúÐå@ÌåYpåUn_RÓĆåB{UpåHnfYå]BåHÚ:Ðí}åcax Inégalités socioéconomiques et maltraitance de l’enfant chez des écoliers iraniens RÉSUMÉ Les inégalités socioéconomiques et la maltraitance chez l’enfant n’ont pas été étudiées à l’aide de l’indice de concentration en tant qu’indicateur d’inégalités. La présente étude visait à évaluer l’association entre la maltraitance chez l’enfant et le statut socioéconomique chez des écoliers de la province de Qazvin (République islamique d’Iran). Dans une étude transversale, un questionnaire reposant sur l’outil de dépistage de la maltraitance envers l'enfant de l'ISPCAN, et sur le questionnaire sur les expérience de victimisation des jeunes (Juvenile Victimization Questionnaire) a été rempli par 1028 enfants âgés de neuf à quatorze ans, sélectionnés dans un échantillon aléatoire stratifié à plusieurs degrés. Les indices de concentration pour les inégalités économiques étaient de – 0,086 pour tout type de maltraitance chez l’enfant et de – 0,155, – 0,098 et – 0,139 pour les sous-types de maltraitance physique, psychologique et par négligence, respectivement. La maltraitance chez l’enfant dans les trois sous-types était aussi fortement associée au nombre d’enfants et à la situation économique de la famille. Une planification appropriée d’interventions efficaces pour les enfants à risque ayant un statut socioéconomique plus faible doit être envisagée par les décideurs concernés. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 820 Introduction The future well-being of a nation hinges on the health of its children because they represent the future. Ignoring children’s needs can compromise their educational preparedness, occupational pursuits, productivity and longevity (1). Child maltreatment is considered a type of violence which affects the health and well-being of many children (2). According to the World Health Organization (WHO) definition, “child maltreatment is all forms of physical and or emotional ill treatment, sexual abuse, neglect or negligent treatment or com- mercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a responsibility, trust or power” (3). In this context, a child is considered any person below the age of 18 years. From the definitions of the National Child Maltreatment and Neglect Data System and the WHO, DIJMENBMUSFBUNFOUJODMVEFTTVCUZQFT physical abuse; emotional abuse; sexual abuse; neglect and negligent treatment; and exploitation (4,5). On the basis of international studies, a quarter of all adults have been physically abused in childhood, while emotional abuse and neglect are reported in many children. ĉFIPNJDJEFEFBUITPG DIJM- ESFOVOEFS ZFBST PG BHF SFQPSUFE annually worldwide are likely to be an underestimate of the true extent of the problem as a significant proportion of the reported deaths due to child abuse is incorrectly attributed to unintentional accidents (6). The risk of aggression, developmental delay, antisocial be- haviour, lack of successful interaction with others, psychiatric disorders and low self-esteem is greater in maltreated children (7). The prevalence of child abuse and neglect has been studied before in the Islamic Republic of Iran. In a study in Qazvin province the proportions of positive cases for each of emotional, QIZTJDBMBCVTFBOEOFHMFDUXFSF BOE SFTQFDUJWFMZ 8). In a similar study in Tehran, the prevalences of mental, mild physical, severe physical and neglect child maltreatment were BOESFTQFD- tively (9). Health inequalities linked to socio- economic status are an issue of growing importance worldwide (7,10–12). In the context of child maltreatment an association between socioeconomic status and child maltreatment has been found in various studies (13–16). For example, a study conducted on 13–16-year-old students in China showed a range of mild to severe child maltreatment which was higher in chil- dren of lower socioeconomic status (14). Studies conducted in the United States of America (USA) and the Unit- ed Kingdom also showed that poverty and parents’ lower levels of education were risk factors for child maltreat- ment (15,16). To our knowledge there have been no previous studies of child maltreatment using the concentration index as an indicator of socioeconomic inequality. Qazvin province is a located in the north-western region of the Islamic 3FQVCMJDPG *SBO IBWJOHDJUJFT BOE 898 rural areas, containing a population PG BCPVU PG WBSJPVT TPDJBM and economic classes. Hence it was considered a suitable region to study the parameters of socioeconomic inequal- ity. The objectives of this study were to assess the association of child maltreat- ment with socioeconomic status and to present the magnitude of the potential socioeconomic inequality of child mal- treatment through the concentration index. Methods Study population and sampling *O UIJTDSPTTTFDUJPOBM TUVEZ TUV- EFOUTPGTDIPPMHSBEFTBOE JFBHFE mZFBST JOQSJNBSZ TDIPPMTPG Qazvin province were selected through multistage, stratified random sampling. 'JSTU DJUJFTXFSFDMBTTJėFEJOUPFDP- nomic classes of poor, middle and rich as the sampling strata. The rural areas were also classified into non-deprived and deprived areas. This stratification was on the basis of expert opinion ses- sions with key persons who worked in the municipality of Qazvin and who were permanent inhabitants of Qaz- vin. The next step was determining the number of students in each group, the sex ratio and the ratio of each group in the total population. Then, schools were randomly chosen from the alphabetical MJTUPGTDIPPMTJOUIFBCPWFNFOUJPOFE economically classified regions and in each selected school we randomly chose some classes in a way that the number of students could reach the minimum estimated sample size for that school. The inclusion criteria were adequate literacy and the absence of visual defects in order for the students to fill the questionnaire properly. Con- sidering P d BOEEFTJHOFĎFDU = 1.2 (in the statistical formula) the FTUJNBUFETBNQMFTJ[FXBTTUVEFOUT For feasibility we choose all the students in one selected class and the final sam- QMF TJ[FXBTĉFRVFTUJPOOBJSF was self-completed by the students. Ethical aspects This study was approved by the eth- ics committees of Qazvin and Tehran Universities of Medical Sciences. Writ- ten consent to participate in the study was obtained from the students and their parents with the cooperation of the school staff. Since parents did not wish their children to be asked questions re- garding sexual maltreatment, this aspect was not assessed in this study. The par- ents were assured that the data would re- main confidential to the parent–teacher meeting. The number of parents who did not cooperate was 8; there was no refusal to participate by students, in fact, they were eager to participate because of their teachers’ encouragement. In the HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 821 A 2-stage pilot test was carried out on 24 students of 2 boys’ and girls’ primary schools through convenience sampling, in which the interval time was 2 weeks. The cases were selected from TDIPPMHSBEFTBOEĉSPVHIQJMPU- ing we made sure of the children’s abil- ity to comprehend and respond to the questions. The intra-class correlations BOEDPOėEFODF JOUFSWBMT $* GPS each question and each domain of child maltreatment, calculated separately, XFSF $*m $* m BOE $*m GPSQIZTJDBM QTZDIPMPHJ- cal and neglect subtypes respectively. $SPOCBDIBMQIBXBT BOE for each of the above-mentioned sub- types respectively. Data were collected on demograph- ic characteristics: the child’s sex, area of residence (urban or rural), parents’ educational level (illiterate, primary school, middle school, high school and diploma, academic education), father’s employment status (employed, unem- ployed), mother’s employment status (employed, housewife) and the number of children in the family (1, 2, 3, 4 or more). Parents filled in a questionnaire at home about their level of education and employment status. The economic situation of the family was assessed by questions about the family’s wealth and property, including ownership of the following: house (and number of rooms in the house), refrigerator, freezer, colour television (LCD/LED), microwave oven, car, washing machine, personal computer (desktop, laptop) and vacuum cleaner. The asset ques- tions were also filled in by students’ parents. From this we calculated the wealth index of the households, which is the most common method of assessing economic status in inequality studies and big surveys. The maltreatment questionnaires were completed in the classrooms by the children under the supervision of the research team; the average time needed to complete the questionnaires was about 37 minutes. The researchers asked the children not to leave any ques- tion blank and they checked that all the questions were answered after the filled questionnaires had been handed in. Data analysis Based on similar studies (17,18) and on the relevant experts’ opinions, the ques- tionnaire’s response options were de- signed as 3 options: “no/never”, “yes but a little/sometimes” and “yes/always”. Child maltreatment was considered if the response to at least one question was “yes” in any of the subtypes of mal- treatment. The socioeconomic status of the children’s families was calculated on the basis their assets using the principal component analysis method (19,20). This variable classifies the community JOUPRVJOUJMFT FBDIPGUIFQPQVMB- UJPO SBOHJOH GSPN UIFTU UP UIFUI groups to indicate the poorest to richest levels in the community respectively. The concentration index (and $*PGUIFJOEFY XBTDBMDVMBUFEUP quantify the degree of socioeconomic inequality in the child maltreatment variable (20). The concentration index is bounded between –1 and 1. In cases where there is no socioeconomic in- FRVBMJUZ UIFDPODFOUSBUJPO JOEFY JT Negative values of the index indicate that there is a disproportionately higher occurrence or presence of a variable in the poorer group and vice versa for positive values of the index. Factors associated with child maltreatment were analysed through chi-squared tests and multiple logis- tic regression. Child maltreatment in each domain was considered as the dependent variable. Children who did not report maltreatment in any of the subtypes were considered not mal- treated, while for each subtype the nega- tive outcome was considered if there was even one question answered “yes”. The independent variables consisted of the number of children in the family, socioeconomic situation of the family, case of the 8 parents, we explained the research finding applications to them again and mentioned that their decision was respected and would not have any effect on the school staff behaviour with their children. According to Iranian law, punish- ment of children by parents with the intention of educating and disciplining a child is not considered a crime. For some years there has been a debate be- tween legal experts, sociologists and so- cial activists on the limits of punishment. Therefore, the law can only intervene in severe cases and we could only report cases of severe physical child maltreat- ment to the legal authority. These cases were those with signs such as bruises and burns on their bodies. However, educational classes on the appropriate behaviour with children were held for all the parents of the chosen schools. Data collection tool Data were collected through a valid and reliable questionnaire in Novem- CFSBOE%FDFNCFSĉFQSJNBSZ draft of the questionnaire was derived from 2 standard screening tools: the International Society for the Preven- tion of Child Abuse and Neglect (ISP- CAN) Child Maltreatment Screening Tool–Children’s Version (ICAST-C) GPSRVFTUJPOT 17), and the Juvenile Victimization Questionnaire (18) for 3 questions. The ICAST-C questionnaire was completely translated into Farsi, but for the Juvenile Victimization Ques- tionnaire we adopted and translated just 3 questions. The extracted questions were finalized after being reviewed by authorized experts. Four questions were added by our experts on the basis of Iranian culture. The final questionnaire had 3 subtypes of child maltreatment: physical, psychological and neglect. To assess the content validity of the questionnaire, we sought the opinions of relevant experts, which yielded rat- JOHTPG BOEGPSSFM- evancy, clarity and comprehensiveness respectively. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 822 mother’s employment status, father’s employment status and parents’ educa- tion. Because of the colinearity between the mother’s and father’s education, a new variable was defined as parent’s education in which the higher educa- tion of one of the parents was registered and analysed. Statistical analysis was done using Stata, version 9, and SPSS WFSTJPOT and 16. Type I error was considered as GPSUIFSFTVMUTBOBMZTJT Results &JHIUPVUPGRVFTUJPOOBJSFTXFSF eliminated because they had more than JODPNQMFUF SFTQPOTFTBOE UIFSFGPSF RVFTUJPOOBJSFT XIJDI IBE MFTT UIBOVOBOTXFSFERVFTUJPOTXFSFBOB- lysed. We removed missing questions from the analysis. The mean and standard deviation 4% PG BHFPG QBSUJDJQBOUTXBT (SD 1.1) years (range 9–14 years). The characteristics of the participants and their families are shown in Table 1. There were slightly more boys than girls among the participants. The most common family size was 2 children "SPVOEIBMGPGUIFQBSFOUTIBE a diploma or a higher degree. Prevalence of child maltreatment The prevalence of child maltreatment XBT BOE JO UIF subtypes of psychological, physical and neglect respectively. The total prevalence (i.e. the prevalence of ex- periencing at least one type of child NBMUSFBUNFOU XBT#BTFEPOPVS results, the family members who most often maltreated the child were his/her CSPUIFSPSTJTUFS GBUIFS BOENPUIFS All the prevalence values have been presented in another article by city, re- gion and demographic variables (8). Table 2 shows the prevalence of chil- dren maltreated in the psychological, physical and neglect domains and any type of maltreatment by the independ- ent variables. The economic status of households was highly significantly associated with the all subtypes of maltreatment (P .PUIFST employment status and parent’s educa- tion were significantly associated with neglect maltreatment, while family size was associated with physical maltreat- ment and neglect. Factors associated with child maltreatment Table 3 shows the crude and adjusted odds ratios (OR) for variables which had significant associations with child maltreatment scores. All the assump- tions of logistic regression were met. As Table 3 shows, economic status had a significant association with all 3 sub- types of child maltreatment in both the bivariate and multiple logistic regres- sion analysis. The number of children in the family had a significant associa- tion only with the physical and neglect subtypes but not with the psychological maltreatment score (P "IJHI- er prevalence of child maltreatment was found in lower socioeconomic status GBNJMJFT 03 $*m and in families with more children (OR $* m JO PUIFS words, the odds of child maltreatment in the poorest quintile was more than 4 times higher than in the richest quintile; and the odds were twice as high for families having the highest number of children compared with families with 1 child. On the other hand, no associa- tion was found with place of residence, father’s employment status or the sex of the child and so these variables are not presented in Table 3. The concentration indices of in- equality for the psychological, physical and neglect subtypes and the index for any type of child maltreatment are shown in Table 4. This shows an index PGm $*mUPm for any type of child maltreatment in families of lower socioeconomic status, and a significantly higher preva- lence of child maltreatment for all 3 Table 1 Demographic characteristics of the study respondents (n = 1028) Variable No. % Sex Female 488 47.5 Male 540 52.5 Father’s employment status Employed 999 97.2 Unemployed 29 2.8 Mother’s employment status Housewife 183 17.8 Employed 845 82.2 Parent’s education Illiterate 40 3.9 Primary school (grades 1–5) 202 19.6 Middle school (grades 6–8) 275 26.8 High school/diploma 264 25.7 University education 243 23.6 No. of children in family 1 113 11.0 2 452 44.0 3 269 26.2 ≥ 4 194 18.8 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 823 Ta bl e 2 Pr ev al en ce o f s ub ty pe s of m al tr ea tm en t a m on g pr im ar y- sc ho ol c hi ld re n in Q az vi n pr ov in ce , I sl am ic R ep ub lic o f I ra n by s oc io ec on om ic v ar ia bl es Va ri ab le Ps yc ho lo gi ca l m al tr ea tm en t Ph ys ic al m al tr ea tm en t N eg le ct m al tr ea tm en t A ny ty pe o f m al tr ea tm en t Ye s N o Ye s N o Ye s N o Ye s N o N o. % N o. % N o. % N o. % N o. % N o. % N o. % N o. % Ec on om ic st at us Ri ch es t 11 2 60 .8 72 39 .2 15 4 83 .7 30 16 .3 14 0 75 .3 46 24 .7 15 0 81 .9 33 18 .1 Ri ch 81 40 .5 11 9 59 .5 13 3 65 .6 70 34 .4 13 8 67 .6 66 32 .4 14 1 76 .2 44 23 .8 M ild 60 33 .3 12 0 66 .7 11 2 58 .4 80 41 .6 13 2 71 .7 52 28 .3 13 1 74 .1 46 25 .9 Po or 56 29 .6 13 3 70 .3 11 1 58 .2 80 41 .8 10 6 55 .5 85 44 .5 13 0 65 .9 67 34 .1 Po or es t 52 27 .5 13 7 72 .5 96 51 .6 90 48 .4 90 46 .9 10 2 53 .1 93 51 .6 87 48 .4 χ2 = 5 7.2 5; P < 0 .0 0 1 χ2 = 4 6. 86 ; P < 0 .0 0 1 χ2 = 3 8. 3; P < 0 .0 0 1 χ2 = 5 8. 0 2; P < 0 .0 0 1 M ot he r’s e m pl oy m en t s ta tu s Em pl oy ed 10 1 55 .8 80 44 .2 60 33 .9 11 7 66 .1 55 30 .2 12 7 69 .8 10 4 59 .7 70 40 .3 H ou se w ife 51 7 62 .7 30 7 37 .3 30 0 36 .1 53 1 63 .9 33 9 40 .4 50 0 59 .6 57 5 71 .2 23 2 28 .8 χ2 = 3 .0 2; P = 0 .0 8 χ2 = 0 .3 0 8; P = 0 .5 7 χ2 = 6 .5 5; P = 0 .0 11 χ2 = 8 .8 5; P = 0 .0 0 3 Pa re nt ’s ed uc at io n Ill ite ra te 25 67 .6 12 32 .4 15 39 .4 23 60 .6 22 55 .0 18 45 .0 29 82 .8 6 17 .2 Pr im ar y sc ho ol 13 7 69 .1 61 29 .9 70 35 .5 12 7 64 .5 85 42 .3 11 6 57 .7 14 5 75 .2 48 24 .8 M id dl e sc ho ol 16 2 61 .8 10 0 38 .2 11 3 42 .6 15 2 57 .3 12 2 45 .7 14 5 54 .3 18 5 71 .7 73 28 .3 H ig h sc ho ol /d ip lo m a 16 0 62 .0 98 38 94 36 .3 16 5 63 .7 97 37 .1 16 5 62 .9 17 9 70 .8 74 29 .2 A ca de m ic e du ca tio n 12 9 53 .9 11 0 46 .1 66 27 .7 17 2 72 .3 66 27 .5 17 4 72 .5 13 6 59 .9 91 40 .1 χ2 = 12 .2 5; P = 0 .0 57 χ2 = 15 .13 ; P = 0 .19 χ2 = 2 6. 88 ; P < 0 .0 0 1 χ2 = 2 0 .3 8; P = 0 .0 0 2 N o. o f c hi ld re n in fa m ily 1 61 54 .4 51 45 .6 25 22 .3 87 77 .7 31 27 .5 82 72 .5 65 58 .6 46 41 .4 2 26 4 59 .6 17 9 40 .4 14 4 33 .2 29 0 66 .8 15 2 33 .7 29 9 66 .3 28 8 66 .5 14 5 33 .5 3 16 6 62 .8 98 37 .2 10 9 41 .4 15 6 58 .6 10 6 40 .2 15 8 59 .8 14 5 56 .9 11 0 43 .1 ≥ 4 12 7 68 .2 59 31 .8 82 47 .7 90 52 .3 10 5 54 .4 88 45 .6 18 1 84 .1 34 15 .9 χ2 = 6 .4 8; P = 0 .0 7 χ2 = 18 .5 2; P < 0 .0 0 1 χ2 = 3 1.1 2; P < 0 .0 0 1 χ2 = 17 .11 ; P < 0 .0 0 1 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 824 Ta bl e 3 M ul ti pl e lo gi st ic re gr es si on a na ly si s of v ar ia bl es a ss oc ia te d w it h su bt yp es o f c hi ld m al tr ea tm en t a m on g pr im ar y- sc ho ol c hi ld re n in Q az vi n pr ov in ce , I sl am ic R ep ub lic o f I ra n Va ri ab le Ps yc ho lo gi ca l m al tr ea tm en t Ph ys ic al m al tr ea tm en t N eg le ct m al tr ea tm en t A ny ty pe o f m al tr ea tm en t C ru de O R (9 5% C I) A dj us te d O R (9 5% C I) C ru de O R (9 5% C I) A dj us te d O R (9 5% C I) C ru de O R (9 5% C I) A dj us te d* O R (9 5% C I) C ru de O R (9 5% C I) A dj us te d O R (9 5% C I) Ec on om ic st at us (q ui nt ile s) Ri ch es t 1 1 1 1 1 1 1 1 Ri ch 2. 28 (1 .5 0 –3 .4 0 ) 2. 33 (1 .5 3– 3. 55 ) 2. 70 (1 .6 0 –4 .4 0 ) 2. 48 (1 .5 0 –4 .0 7) 1.4 5 (0 .9 3– 2. 27 ) 1.2 3 (0 .7 6– 1.9 9) 2. 0 7 (1. 36 -3 .14 ) 1.9 8 (1. 28 -3 .0 2) M ild 3. 10 (2 .0 2– 4. 70 ) 3. 30 (2 .0 8– 5. 25 ) 3. 16 (1 .9 0 –5 .17 ) 2. 84 (1 .6 8– 4. 80 ) 1.9 5 (1. 25 –3 .0 5) 1.6 9 (1. 0 3– 2. 77 ) 3. 0 4 (1. 95 –4 .7 5) 2. 87 (1 .7 7– 4. 63 ) Po or 3. 70 (2 .4 0 –5 .6 0 ) 3. 77 (2 .3 5– 6. 0 4) 3. 70 (2 .2 7– 6. 0 1) 3. 35 (1 .9 8– 5. 67 ) 2. 44 (1 .5 7– 3. 78 ) 1.9 0 (1 .18 –3 .0 7) 3. 42 (2 .19 –5 .3 6) 3. 0 9 (1. 89 –5 .0 3) Po or es t 4. 0 9 (2 .6 5– 6. 30 ) 4. 15 (2 .5 2– 6. 81 ) 4. 81 (2 .9 6– 7.8 0 ) 4. 20 (2 .4 2– 7.2 7) 3. 45 (2 .2 3– 5. 34 ) 2. 36 (1 .4 3– 3. 90 ) 4. 85 (3 .0 1– 7.8 2) 4. 22 (2 .4 6– 7.2 4) M ot he r’s e m pl oy m en t s ta tu s H ou se w ife 1 1 1 –a 1 1 1 1 Em pl oy ed 1.3 3 (0 .9 6– 1.8 5) 0 .9 6 (0 .6 4– 1.4 4) 1.1 0 (0 .7 8– 1.5 5) –a 1.5 7 (1. 11 –2 .2 1) 1.2 0 (0 .7 9– 1.8 2) 1.6 7 (1. 18 –2 .3 4) 1.2 9 (0 .8 4– 1.9 7) Pa re nt ’s ed uc at io n Ill ite ra te 1 1 1 1 1 1 1 1 Pr im ar y sc ho ol 1.0 7 (0 .5 0 –2 .2 8) 1.0 9 (0 .4 7– 2. 51 ) 0 .8 4 (0 .4 1– 1.7 2) 0 .7 4 (0 .3 4– 1.5 9) 0 .5 9 (0 .3 0 –1 .18 ) 0 .7 3 (0 .3 4– 2. 59 ) 0 .6 2 (0 .2 4– 1.5 9) 0 .8 8 (0 .3 2– 2. 41 ) M id dl e sc ho ol 0 .7 7 (0 .3 7– 1.6 1) 0 .8 6 (0 .3 7– 1.9 7) 1.1 3 (0 .5 6– 2. 28 ) 0 .9 9 (0 .4 6– 2. 13 ) 0 .6 8 (0 .3 5– 1.3 4) 0 .9 9 (0 .4 6– 2. 12 ) 0 .5 2 (0 .2 0 –1 .3 1) 0 .8 4 (0 .3 1– 2. 26 ) H ig h sc ho ol / di pl om a 0 .5 6 (0 .3 7– 1.6 3) 1.1 6 (0 .5 0 –2 .7 1) 0 .8 7 (0 .4 3– 1.7 5) 0 .9 0 (0 .4 1– 1.9 6) 0 .4 8 (0 .2 4– 0 .9 4) 0 .9 0 (0 .4 1– 0 .9 7) 0 .5 0 (0 .19 –1 .2 5) 1.1 6 (0 .4 2– 3. 19 ) A ca de m ic e du ca tio n 0 .5 6 (0 .2 7– 1.1 7) 1.2 7 (0 .5 2– 3. 0 8) 0 .5 8 (0 .2 8– 1.1 9) 0 .8 6 (0 .3 8– 1.9 5) 0 .17 (0 .16 –1 .5 3) 0 .9 1 ( 0 .3 9– 2. 0 8) 0 .3 0 (0 .12 –0 .7 4) 1.1 5 (0 .4 0 –3 .2 5) N o. o f c hi ld re n in fa m ily 1 1 1 1 1 1 1 1 1 2 1.3 3 (0 .8 1– 1.8 7) 1.1 7 (0 .7 0 –1 .8 6) 1.6 9 (1. 0 3– 2. 74 ) 1.8 0 (1 .0 7– 3. 0 5) 1.3 4 (0 .8 5– 2. 12 ) 1.3 7 (0 .8 3– 2. 26 ) 1.4 0 (0 .9 1– 2. 15 ) 1.3 7 (0 .8 5– 2. 21 ) 3 1.4 2 (0 .9 0 –2 .2 2) 1.9 7 (0 .6 5– 1.7 8) 2. 43 (1 .4 6– 4. 0 3) 2. 19 (1 .3 6– 3. 80 ) 1.7 7 (1. 0 9– 2. 87 ) 1.4 4 (0 .8 5– 2. 45 ) 1.7 3 (1. 80 –2 .7 5) 1.3 0 (0 .7 7– 2. 19 ) ≥ 4 1.8 0 (1 .10 –2 .9 1) 1.3 5 (0 .7 7– 2. 35 ) 2. 64 (1 .5 6– 4. 49 ) 2. 35 (1 .3 0 –4 .2 3) 3. 16 (1 .9 1– 5. 20 ) 2. 38 (1 .3 8– 4. 12 ) 2. 77 (1 .6 4– 4. 78 ) 1.9 5 (1. 0 9– 3. 49 ) a T hi s v ar ia bl e w as si gn ifi ca nt a t P > 0 .2 in th e bi va ria te a na ly si s a nd th er ef or e w as n ot e nt er ed in th e m ul tiv ar ia te m od el . O R = od ds ra tio ; C I = co nfi de nc e in te rv al . HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 825 studied subtypes of maltreatment in these families. Discussion The results of this study showed that economic inequality was present for all subtypes of child maltreatment; an increasing prevalence of child mal- treatment could be observed from the poorest to the richest groups in the community and the victims of this type of violence were most commonly found among the children of poorer socioeco- nomic classes. A study in the USA also showed a greater prevalence of child maltreatment in the lower economic classes of communities (21), while data from the National Child Abuse and Ne- glect Data System in the USA showed that income inequality had a positive and significant association with child maltreatment rates at the county level (22). Physical violence against children in families with low income and low educational level was also found to be more prevalent in studies from Bangladesh, Colombia, Italy, Sudan, Thailand and England (5). A study on TUVEFOUTPG/PSUI"NFSJDBOBOE&V- ropean countries during the school year mTIPXFENPSFIPNFWJPMFODF among families with an undesirable socioeconomic situation (23). Since the ability to provide even the essential needs of children is impossible or very difficult for parents in poor families, neglect and physical and psychological child maltreatment are seen signifi- cantly more in these families than those with middle and high income, perhaps due to stress and the poor mental health among members of the family (24,25). A distinction, however, should be made between failure to provide for the child because of poverty or because of neglect (i.e. the ability to provide by failure to do so). Fortunately, the results of the cur- rent study did not show any gender associations with any subtype of child maltreatment, although this kind of in- equality can be seen in studies in other countries. For example, the results of the study by Machado et al. in Portugal showed a higher prevalence of maltreat- ment of girls (26). The current study showed a decrease in child maltreatment with an increase in the parents’ educational level, which is in accordance with the findings of other studies (18,25). In a study in the 64"JO DIJMESFOXIPMJWFEJOQPPS families with single parents experienced more maltreatment compared with the children who lived in better educated and richer families (27). The results of our study, however, did not show a significant association between child maltreatment and mothers’ and fathers’ employment status, after adjustment for the effect of other variables. Among other factors that might af- fect child maltreatment, the number of children in the family showed a direct association with child maltreatment in the current study. The family members who most often maltreated the child were brothers or sisters, while fathers and mothers were less likely to be in- volved. In another study in the Islamic Republic of Iran, in Tehran, child mal- treatment was more frequently carried out by mothers of lower socioeconomic classes, which may be due to the greater time spent with the children (28). In a TUVEZJO1BLJTUBOJO HSFBUFSDIJME abuse was reported among children whose mothers were not satisfied with their marital life, were of lower educa- tional level and had a stressful home environment (29). As the phenomenon of child mal- treatment is affected by violence in the home, decision-makers for social af- fairs need to plan special programmes to provide local services for alleviating the problem. Some social critics still believe that punitive measures against parents are ineffective and that more ef- fective and concrete measures should be taken (30). All individuals below the age of 18 years are covered by the Child Protection Law, which was ap- proved by the Iranian parliament in ĉFMBXDPOUBJOTJUFNTPOUIF protection of children and adolescents and prohibits all types of harm leading to physical, psychological and spiritual damage to children and adolescents and threats to their physical or men- tal health. It seems, however, that the laws to protect children’s rights are poorly protected by sanctions. In the cultural context, according to the law PGBOE UIF *TMBNJDQFOBM DPEF punishing children is permissible up to a “customary” extent and the judge- ment about what is customary is as- signed to the public. Hence, the matter becomes a subjective one. People in certain local cultures may allow them- selves to maltreat their children in the name of punishment. As an initial step, this matter should be solved. Some lawmakers attribute this type of child maltreatment to legal uncertainties, which can be scrutinized. This issue oc- curs mostly in the framework of child upbringing, and if a parent maltreats a child it is justified in terms of bet- tering the child’s upbringing. Social organizations need to give appropriate education to the families and plan for the implementation of protection pro- grammes, especially in families with Table 4 Concentration index of child maltreatment by subtype Domain of child abuse Concentration index SD 95% CI Psychological –0.098 0.014 –0.084 to –0.112 Physical –0.155 0.023 –0.116 to –0.162 Neglect –0.139 0.023 –0.132 to –0.178 Any type –0.086 0.010 –0.076 to –0.096 SD = standard deviation of concentration index; CI = confidence interval. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 826 References 1. Hernandez VR, Montana S, Clarke K. Child health inequal- ity: framing a social work response. Health Soc Work. 2010 Nov;35(4):291–301. PMID:21171536 2. Giardino AP. Child abuse/treatment. In: Kris H, editor. Inter- national encyclopedia of public health. Oxford: Academic Press; 2008. pp. 571–83. 3. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organi- zation; 2000. 4. Health topics: child maltreatment [Internet]. Geneva: World Health Organization (http://www.who.int/topics/child_ abuse/en/, accessed 4 August 2015). 5. Gorey KM, Leslie DR. The prevalence of child sexual abuse: integrative review adjustment for potential response and measurement biases. Child Abuse Negl. 1997 Apr;21(4):391–8. PMID:9134267 6. Child maltreatment. Fact sheet No.150. Updated December 2014 [Internet]. Geneva: World Health Organization; 2014 (http://www.who.int/mediacentre/factsheets/fs150/en/, 4 August 2015). 7. Fang P, Dong S, Xiao J, Liu C, Feng X, Wang Y. Regional inequal- ity in health and its determinants: evidence from China. Health Policy. 2010 Jan;94(1):14–25. PMID:19735959 8. Mahram M, Hosseinkhani Z, Nedjat S, Aflatouni A. Epide- miologic evaluation of child abuse and neglect in school- aged children of Qazvin province, Iran. Iran J Pediatr. 2013 Apr;23(2):159–64. PMID:23724176 9. Khoushabi K, Habibi-Asgarabad M, Farzadfard SZ, Moham- madkhani P. Investigating prevalence of child abuse among guidance school students, Tehran: 2009–2010. Soc Welfare (India). 2008;7(27):115–35 [In Persian]. 10. Nedjat S, Hosseinpoor AR, Forouzanfar MH, Golestan B, Ma- jdzadeh R. Decomposing socioeconomic inequality in self- rated health in Tehran. J Epidemiol Community Health. 2012 Jun;66(6):495–500. PMID:21282143 11. Ostlin P, Braveman P, Dachs N, Dahlegren G, Diderichsen F, Harris E, et al.; WHO Task Force on Research Priorities for Equity in Health; WHO Equity Team. Priorities for research to take forward the health equity policy agenda. Bull World Health Organ. 2005 Dec;83(12):948–53. PMID:16462988 12. Starfield B. Equity in health. CMAJ. 2000 Feb 8;162(3):346. PMID:10693592 13. Vallgårda S. Social inequality in health: dichotomy or gradient? A comparative study of problematizations in national public health programmes. Health Policy. 2008 Jan;85(1):71–82. PMID:17706317 14. Wong WCW, Chen WQ, Goggins WB, Tang CS, Leung PW. Individual, familial and community determinants of child physical abuse among high-school students in China. Soc Sci Med. 2009 May;68(10):1819–25. PMID:19344989 15. Sidebotham P, Heron J; ALSPAC Study Team. Child mal- treatment in the “children of the nineties”: a cohort study of risk factors. Child Abuse Negl. 2006 May;30(5):497–522. PMID:16701895 16. Weissman AM, Jogerst GJ, Dawson JD, Jogerst GJ, Daw- son JD. Community characteristics associated with child abuse in Iowa. Child Abuse Negl. 2003 Oct;27(10):1145–59. PMID:14602096 17. Zolotor AJ, Runyan DK, Dunne MP, Jain D, Péturs HR, Ramirez C, et al. ISPCAN Child Abuse Screening Tool Children's Verd- sion (ICAST-C): Instrument development and multi-national pilot testing. Child Abuse &. Neglect. 2009;33(11):833–41. 18. Finkelhor D, Hamby SL, Ormrod R, Turner H. The juvenile victimization questionnaire: reliability, validity, and na- tional norms. Child Abuse Negl. 2005 Apr;29(4):383–412. PMID:15917079 19. Gwatkin DR, Rutstein S, Johnson K, Suliman E, Wagstaff A, Amozou A. Socioeconomic differences in health, nutrition, and population with in developing countries: an over view. JAMA. 2007;298:1943–4. 20. Van de Poel E, Hosseinpoor AR, Speybroeck N, Van Ourti T, Vega J. Socioeconomic inequality in malnutrition in develop- ing countries. Bull World Health Organ. 2008 Apr;86(4):282– 91. PMID:18438517 higher numbers of children and an undesirable economic status. There were some limitations to the study. Due to our inability to ob- tain parents’ permission, sexual child maltreatment was not assessed in this study. Although the questionnaires were anonymous and avoided specific personal characteristics, there was a pos- sibility of under-reporting bias by the victims of child maltreatment due to fear or shame. Over-reporting due to a low level of comprehension by chil- dren or their desire to draw attention to themselves is also possible. However, the scoring approach of the question- naire was sensitive enough to detect the mild type of maltreatment. Further- more, the data were collected in primary schools and since some children with severe forms of child maltreatment may be deprived of education at school, this may also cause underestimation of the prevalence of maltreatment due to this selection bias. Finally, we did not collect data on potential confounders such as family discord, children’s behaviour or parenting style. In conclusion, since socioeconomi- cally deprived groups in the community are at high risk for child maltreatment, appropriate planning for effective in- tervention in these groups should be considered by the relevant decision- makers in social affairs. The effective- ness of these interventions should be evaluated in future research. These find- ings may be useful for decision-makers in the health and education ministries to identify the children at high risk for maltreatment. Acknowledgements The authors offer their thanks to the Department of Education of Qazvin for their cooperation in data collection. This project was the MSc thesis of Zahra Hosseinkhani (proposal number 89- BU 5FISBO6OJWFSTJUZ PG Medical Sciences. Funding: The study was funded by Qazvin University of Medical Sciences and Tehran University of Medical Sciences. Competing interests: None declared. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 827 21. Zielinski DS. Child maltreatment and adult socioeconom- ic well-being. Child Abuse Negl. 2009 Oct;33(10):666–78. PMID:19811826 22. Eckenrode J, Smith EG, McCarthy ME, Dineen M. Income ine- quality and child maltreatment in the United States. Pediatrics. 2014 Mar;133(3):454–61. PMID:24515511 23. Due P, Merlo J, Harel-Fisch Y, Damsgaard MT, Holstein BE, Hetland J, et al. Socioeconomic inequality in exposure to bullying during adolescence: a comparative, cross-sectional, multilevel study in 35 countries. Am J Public Health. 2009 May;99(5):907–14. PMID:19299676 24. Tagikhani SH. Assessment of family characteristics, economic- social, psychological and coping styles of parents with child abuse behaviour [Thesis]. Vanak, Islamic Republic of Iran: Department of Psychology and Educational Sciences, Azzahra University; 2002 [in Persian]. 25. Sahbaei F, Davachi A, Zeraati Najafi Z. The relationship be- tween family factors, social, and psychological abuse of public primary schools for girls in Tehran. Journal of Medical Sciences University. 2006;16(1):43–8 [in Persian]. 26. Machado C, Gonçalves M, Matos M, Dias AR. Child and partner abuse: self-reported prevalence and attitudes in the north of Portugal. Child Abuse Negl. 2007 Jun;31(6):657–70. PMID:17617457 27. Merritt DH. Child abuse potential: correlates with child mal- treatment rates and structural measures of neighborhoods. Child Youth Serv Rev. 2009;31(8):927–34. 28. Rahimi Movaghar A. The prevalence of child abuse in the Teh- ran area. Journal of Social Welfare. 2003;7(1):141 [In Persian]. 29. Ali NS, Ali FN, Khuwaja AK, Nanji K. Magnitude and factors as- sociated with child abuse in a mega city of developing country Pakistan. Iran J Pediatr. 2014 Apr;24(2):140–6. PMID:25535531 30. Humphreys C. A health inequalities perspective on vio- lence against women. Health Soc Care Community. 2007 Mar;15(2):120–7. PMID:17286673 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 828 1Intensive Care Department, Al-Hussein Hospital, King Hussein Medical Centre, Amman, Jordan (Correspondence to A. Batarseh: adelbatarseh@ gmail.com). 2Department of Microbiology, Princess Iman Centre for Research and Laboratory Science, King Hussein Medical Centre, Amman, Jordan. 3Department of Pharmacy, Al-Hussein Hospital, King Hussein Medical Centre, Amman, Jordan. Received: 02/12/14; accepted: 29/07/15 Antibiogram of multidrug resistant Acinetobacter baumannii isolated from clinical specimens at King Hussein Medical Centre, Jordan: a retrospective analysis A. Batarseh,1 A. Al-Sarhan,1 M. Maayteh,2 S. Al-Khatirei 3 and M. Alarmouti 3 ABSTRACT This study was conducted to determine the prevalence and the local antibiogram of multidrug-resistant Acinetobacter baumannii isolates in Al-Hussein Hospital at King Hussein Medical Centre in Amman, Jordan. In a retrospective study from January to December 2013, data on 116 non-repetitive positive clinical samples were retrieved from patients’ laboratory records. The resistance rates of A. baumannii isolates were high for ceftriaxone, cefotaxime and ticarcillin (100%), ceftazidime, cefepime and piperacillin (98.3%), imipenem (97.4%), piperacillin/ tazobactam (96.6%), quinolones (94.8%), ampicillin/sulbactam (89.7%), gentamicin, (87.9%), tobramycin and tetracycline (76.7%) and trimethoprim/sulfamethoxazole (75.9%), but lower for minocycline (26.7%) and colistin (1.7%). A. baumannii in our hospital were highly resistant to all antibiotics, including tigecycline, except for minocycline and colistin which are considered the last resort treatment for multidrug-resistant A. baumannii. M@cBÐ}S|X9o`c8ow|wÓmegKXoTí}^BÐíºÒØz^XowíØúoXímaBÐoghmXTÐÒzSÐ|TÐCKowg"ÐÓØm[BÐD>iT\8 ïØm^GÐgcĵëØÚúm<\TÐ JY}_UÐ{e7{@nYºïE\#Ð3nH}eHºp]xn_Ynx}TÛ{e7ºënAUÐ{1āÐ{LºpHÚn]=3nHéØnL påYínbCÐpåhinYUÐÒ{åTÐ}UÐpåY?}@DåLpåxh"ÐÓÐØnå\CÐEå?jUMåCÐå]CÐíÚnåZiøÐ{åx{UpåHÐÚ{UÐì|åwqåx}@Ì{åbUoåÉ°#Ð åaR ëØÚúnå=ë5åL:påh]UÐNå"Ðpåfx{e=Nå"ÐaåZY:påUí~_CÐpåY?}!Ðì|åwDåLpåxh"ÐÓÐØnå\CÐEå?j>íÒØ{å_YpåxíØú påh=n«Îpåx}xpåfhL116ååUÓnåinh=DåLâĆåJøÐå>2013ênåLåYéíúÐëinT FeåxØOΩnåUÐëåinT }xnfxåYpxØn_åHÐpåHÐÚØ ëåTnxGahdUpåfUn=på hUnLpå hinYUÐÒ{åTÐ}UÐÓøí~å_YpåYínbYÓø{å_YqåincR }åedUpå xFCÐÓĆåUÐåYÒÚ}åcYEåQ NdhååHÐEhUÐíº·97 4ååhfhhexüÐíº·98 3NdhååHÐEhUÐíhhahååUÐíx{xÛnfahååUÐíº·100NdhååHÚnchUÐíhååTn>ahUÐí NdchååHÐGUÐíNååhYÐ}=UÐíº·87 9NååhYnf!Ðíº·89 7êncódåå ôH NdhYúÐíº·94 8ÓnååiUfhcUÐíº·96 6ênååTn=íÛn> qååinT{ååbU ·1 7NååhUcUÐí·26 7NdchååHfhedUpååfUn=ååSÌqååinTnåågfcUº·75 9éíÛnååThYnadH x}=hCÐí·76 7) NdcååHfhCÐÊnfååHn= NdchååhhUÐååUÙ:5åå= pååxh"ÐÓÐØnåå\CÐcååUpååYínbCÐÒ{x{ååI ninaååZY: pååhinYUÐÒ{ååTÐ}UÐ påhinYUÐÒ{åTÐ}UÐpå!n_CEåBúÐÙĆåCÐÐFåLÐåx|dUÐNåhUcUÐí Antibiogramme d’isolats d’Acinetobacter baumannii multirésistants à partir de différents échantillons cliniques au Centre médical Roi Hussein en Jordanie : une analyse rétrospective RÉSUMÉ La présente étude a été menée pour déterminer la prévalence et l’antibiogramme local des isolats d’Acinetobacter baumannii multirésistants à l'hôpital Al-Hussein du Centre médical Roi Hussein à Amman (Jordanie). Dans une étude rétrospective menée de janvier à décembre 2013, les données de 116 échantillons cliniques positifs uniques ont été recueillies à partir des dossiers de laboratoire des patients. Les taux de résistance des isolats d’A. baumannii étaient élevés pour la céftriaxone, la céfotaxime et la ticarcilline (100 %), la ceftazidime, la céfépime et la pipéracilline (98,3 %), l’imipénème (97,4 %), la pipéracilline/le tazobactam (96,6 %), les quinolones (94,8 %), l’ampicilline/le sulbactam (89,7 %), la gentamicine (87,9 %), le tobramycine et la tétracycline (76,7 %) et le triméthoprime/le sulfaméthoxazole (75,9 %), mais étaient moins élevés pour la minocycline (26,7 %) et la colistine (1,7 %). Dans notre hôpital, A. baumannii était très résistant à tous les antibiotiques, notamment à la tigécycline, sauf à la minocycline et à la colistine, qui étaient considérées comme le traitement de dernier recours contre les souches d’A. baumannii multirésistantes. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 829 Introduction Acinetobacter baumannii resistant to multiple antimicrobial agents has been increasing worldwide over recent decades. This resistance pattern usually varies with time, and from one region to another or even within the same region (1). Furthermore, A. baumannii has become one of the most problematic multidrug resistant (MDR) pathogens in the health care environment and is responsible for many nosocomial in- fection outbreaks, especially in critical care areas. These include bloodstream, soft tissue, urinary tract, central nerv- ous system and surgical site infections and ventilator-associated pneumonia (1–3), all of which have been associated with high mortality rates and treatment costs (4). There is limited information in Jordan regarding the epidemiology, prevalence and resistance rates of A. bau- mannii isolates from different sites of infection (5–7). This study was there- fore conducted to determine the current prevalence and the local antibiogram of MDR-AB isolates from different sites of infection in a tertiary teaching hospital at King Hussein Medical Centre, Amman. Methods This was a retrospective study con- ducted in the department of microbiol- ogy, Princess Iman Centre for Research and Laboratory Sciences, King Hus- sein Medical Centre, Amman, over a period of 12 months from January to %FDFNCFSĉF TUVEZQSPUPDPM was approved by the ethics committee of the Royal Medical Services. Sampling From a total of 374 positive cultures of A. baumannii 116 non-repetitive posi- tive clinical samples for A. baumannii from various sources, including blood (n = 24), sputum (n = 28), urine (n = 7) and pus swabs (n GSPNXPVOET tips of catheters and body parts) were retrieved from patients’ laboratory records at Al-Hussein Hospital, King Hussein Medical Centre. Data collection Clinical and Laboratory Standards Institute (CLSI) recommendations for XFSFBEPQUFEGPSDVMUVSF JTPMBUJPO and identification of all A. baumannii isolates and for antibiotic susceptibility testing using the VITEK 2 Compact automated microbiology system (bio- Mérieux), with 2 complementary sets of antibiotic susceptibility testing (AST) DBSET "45/ BOE"459/ (8). Samples that were tested manually or against only one of the AST-cards or to different AST-cards were excluded, i.e. only samples that were tested against both AST cards were included in the study. The minimal inhibitory concen- tration (MIC) interpretive standards for A. baumannii were adopted from the $-4*HVJEFMJOF 8) for the follow- ing groups of antibiotics: r group I: penicillins (ticarcillin and piperacillin), beta-lactames/beta- lactamase-inhibitor combinations (ampicillin/sulbactam and piperacil- lin/tazobactam), 3rd and 4th gen- eration cephalosporins (ceftazidime, cefotaxime ceftriaxone, and cefepime); r group II: carbapenems (imipenem); r group III: fluoroquinolones (cipro- floxacin and levofloxacin); r g r o u p I V : a m i n o g l y c o s i d e s (tobramycin and gentamicin); r group V: tetracyclines (minocycline and tetracycline); r group VI: folate pathway inhibitors (sulfamethoxazole/trimethoprim); r group VII: lipopeptides (colistin), and potential antimicrobial agents; and r tigecycline. Definitions Since there is no agreed single defini- tion for MDR and pan-drug resistance (PDR) for A. baumannii in the literature (9,10) the following definitions were adopted in this study. MDR was defined as resistance to imipenem plus 3 or more different antibiotic classes, including: at least 2 beta-lactames (penicillin, beta- lactames/beta-lactamase-inhibitor combinations, 3rd- and 4th-generation cephalosporins); tobramycin or gen- tamicin; ciprofloxacin or levofloxacin; tetracyclines; or sulfamethoxazole/ trimethoprim. PDR was defined as resistance to all tested antibiotics or only susceptible to colistin. Tigecycline was not included in this definition since no agreed breakpoints for tigecycline IBWFCFFOBQQSPWFECZUIF$-4* guideline (8). Results Over a period of 12 months, a total of 116 A. baumannii isolates were found. The distribution according to their site of infection is shown in Table 1. Isolates XFSF PCUBJOFE GSPN TXBCT CMPPE TQVUVN BOE VSJOF .PSFPGUIFJTPMBUFTXFSF GSPNNBMF UIBO GFNBMF patients. A. baumannii resistance to various antibiotics groups is summarized in Ta- ble 2. The percentage of resistant A. bau- mannii from various sources was highest for ceftriaxone, cefotaxime, and ticarcil- MJO GPMMPXFECZ DFěB[JEJNF DFGFQJNF BOEQJQFSBDJMMJO XIJMF resistance to other tested antibiotics XFSF JNJQFOFN QJQFSBDJMMJO UB[PCBDUBN DJQSPĚPYBDJOBOE MFWPĚPYBDJO BNQJDJMMJOTVM- CBDUBN HFOUBNJDJO UPCSBNZDJOBOE UFUSBDZDMJOF s u l f a m e t h o x a z o l e / t r i m e t h o p r i m 0OUIFPUIFSIBOE UIFSBUFPG resistance of A. baumannii isolates was SFNBSLBCMZ MPXGPSDPMJTUJO BOE NJOPDZDMJOF The resistance pattern differed significantly across samples of differ- ent origins (Pɒ GPSRVJOPMPOFT EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 830 MDR, and also as a result of the overuse of 3rd-generation cephalosporin (13), quinolones or broad-spectrum antibiot- ics (14), and to a lack of proper instru- ment decontamination and personal hygiene (2,13). For these reasons, the A. baumannii resistance patterns differ internationally, regionally and locally in developing and developed countries (1). More of the A. baumannii isolates identified in our study were from NBMF UIBO GFNBMFQBUJFOUT JO agreement with observations in previ- ous studies (11–12). The most com- mon source of A. baumannii isolates XBTTXBCT GPMMPXFECZCMPPE TQVUVN BOE VSJOF ĉFA. baumannii resistance pattern across various sample origins was significantly different for quinolo- nes, tetracyclines, gentamicin and sulfamethoxazole/trimethoprim. The different resistance pattern for A. bau- mannii from different sample sources is in agreement with previous findings from King Hussein Medical Centre in BTUVEZ BOEGVSUIFSJOWFTUJHBUJPOT are needed to elucidate the cause of these differences (6). In the present study, isolates of A. baumannii showed a high resistance SBUF m UP BMM HFOFSBUJPOTPG cephalosporins, penicillins, imipenem and quinolones, findings which are in general similar to the results of studies in Jordan, Islamic Republic of Iran, India and Italy, and a little higher than those from studies in Malaysia, Turkey and the United States of America (USA) m 7,15,16). The high resistance rates of isolates to penicillins and beta-lactamase in- IJCJUPSTJOUIFQSFTFOUTUVEZ m were consistent with the results from other studies obtained from Jordan, Islamic Republic of Iran, India, Turkey and Italy for piperacillin/tazobactam (5,15–19), but were higher than the SFTVMUT GSPN TPVUI *OEJB BOE .BMBZTJB 20,21). At the same time, lower resistance rates for ampicil- lin/sulbactam were found in studies in *UBMZ BOE.BMBZTJB BOE respectively) (18,19). Historically, carbapenems have been considered the best therapeutic option for infections caused by MDR A. baumannii. Recently, carbapenem- resistant A. baumannii have been increasing worldwide, reaching an alarmingly high level in some countries, TVDIBT5VSLFZ *TMBNJD3FQVCMJD PG *SBO BOE *OEJB "U the same time, A. baumannii in Jordan demonstrated high resistance rates to NFSPQFOFN m XIJMF JNJ- penem showed lower resistance rates m JOHFOFSBM CVU UIJT SFTJTU- ance usually varies over time, even at King Hussein Medical Centre, where it XBTPOMZJO 5–7,15,16,18). Nevertheless, carbapenems are still con- sidered one of the treatment options for MDR A. baumannii, which retains sensitivity to carbapenems. However, A. baumannii resistance to imipenem is still low in some studies, even from the same countries that were associated with high resistance rates: Islamic Republic of *SBO BOE*OEJB 20,22). For carbapenem-resistant A. baumannii, tetracyclines, gentamicin and sulfameth- oxazole/trimethoprim. In addition, antibiotic resistance was lowest with urine samples for sulfamethoxazole/ USJNFUIPQSJN BOEXJUI TQV- tum samples for ampicillin/sulbactam GPMMPXFECZCMPPE TBNQMFT especially with ciprofloxacin and levo- ĚPYBDJO HFOUBNJDJO UPCSBNZDJO UFUSBDZDMJOF BOE NJOPDZDMJOF Since there are no agreed breakpoints for tigecycline against A. baumannii in the CLSI guidelines or in the literature (8,11 XFVTFE UIF"459/DBSE MIC breakpoints of susceptibility TVTDFQUJCMFɒNH- SFTJTUBOUɓ NH- 0O UIJTCBTJT JTP- lates were reported to be susceptible to tigecycline (Table 3). "DDPSEJOH UP PVS EFėOJUJPOT A. baumannii isolates were multidrug SFTJTUBOU XIJMFJTPMBUFTXFSF QBOESVHSFTJTUBOU 5BCMF Discussion In the last decades, A. baumannii has been considered as one of the most resistant bacteria within the hospital environment, especially in critical care areas, which are responsible for the most severe nosocomial infections. These in- fections often start locally, then progress to bacteraemia and even septicaemia (1,2,12,13) due to several contribut- ing factors, for example, inappropriate initial antimicrobial therapy, early inter- ruption of treatment, sub-therapeutic doses, minimal tissue penetration and Table 1 Distribution of Acinetobacter baumannii isolates from different specimens, by patient’s sex Specimen Males Females Total No. % No. % No. % Blood 17 14.7 7 6.0 24 20.7 Sputum 16 13.8 12 10.3 28 24.2 Swab 33 28.4 24 20.7 57 49.1 Urine 7 6.0 0 0.0 7 6.0 Total 73 62.9 43 37.1 116 100.0 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 831 tigecycline and colistin are 2 of the most frequently used alternative agents ac- cording to the literature (23). A. baumannii isolates in our hos- pital showed high resistance rates to BNJOPHMZDPTJEFT BOEGPS gentamicin and tobramycin respective- ly). The gentamicin resistance rate was also in line with the results from Islamic Republic of Iran and India (15,17,18). At the same time, the resistance rate XBT GPVOE UPCF MPXFS BSPVOE in other countries such as south India, Malaysia and Italy. On the other hand, SFTJTUBODF SBUFPGBOE GPS tobramycin and gentamicin respec- tively were recorded at King Hussein .FEJDBM$FOUSF JO 6,7,19–21). However, tobramycin resistance from *UBMZ XBTNVDI MPXFS UIBO JO this study and in studies from Malaysia BOE*OEJB 18,19,21). A. baumannii isolates have been found to have a variable degree of resistance to the sulfamethoxazole/ trimethoprim combination, ranging GSPNJOTPVUI*OEJB JO*UBMZ BOEVQUPJO*TMBNJD3FQVCMJDPG Iran (15,19,20). In comparison with UIFTF QSFWJPVT SFQPSUT PG UIF A. baumannii isolates from the present study were found to be resistant to sulfamethoxazole/trimethoprim, while POMZPGUIFJTPMBUFTXFSFSFTJTUBOU BUPVS$FOUSFJO 6). The tetracycline resistance rate in UIJT TUVEZXBT XIJDI JT MPXFS UIBO SBUFT GSPN.BMBZTJB *UBMZ BOE *TMBNJD3FQVCMJDPG *SBO 15,19,21). On the other hand, the minocycline resistance rate was low JO UIFQSFTFOU TUVEZ XIJDI JT similar to what was reported from Italy JOEJDBUJOH UIBUNJOPDZDMJOF is one of the best antibiotics that can be used in combination with the other anti-Acinetobacter antibiotics (19). Tigecycline is a parenteral broad- spectrum bacteriostatic minocy- cline derivative. It has been used alone or in combination with other Ta bl e 2 Re si st an ce p at te rn o f A ci ne to ba ct er b au m an ni i i so la te s fr om d iff er en t c lin ic al s pe ci m en s A nt ib io ti c Sw ab (n = 5 7) Bl oo d (n = 2 4) Sp ut um (n = 2 8) U ri ne (n = 7 ) To ta l (n = 11 6) P- va lu e N o. % N o. % N o. % N o. % N o. % C ef ta zi di m e 56 98 .2 23 95 .8 28 10 0 .0 7 10 0 .0 11 4 98 .3 0 .6 92 C ip ro flo xa ci n 57 10 0 .0 18 75 .0 28 10 0 .0 7 10 0 .0 11 0 94 .8 0 .0 0 0 C ef tr ia xo ne 57 10 0 .0 24 10 0 .0 28 10 0 .0 7 10 0 .0 11 6 10 0 .0 – C ol is tin 1 1.8 1 4. 2 0 0 .0 0 0 .0 2 1.7 0 .6 92 C ef ot ax im e 57 10 0 .0 24 10 0 .0 28 10 0 .0 7 10 0 .0 11 6 10 0 .0 – C ef ep im e 56 98 .2 23 95 .8 28 10 0 .0 7 10 0 .0 11 4 98 .3 0 .6 92 G en ta m ic in 53 93 .0 17 70 .8 26 92 .9 6 85 .7 10 2 87 .9 0 .0 34 Im ip en em 56 98 .2 22 91 .7 28 10 0 .0 7 10 0 .0 11 3 97 .4 0 .2 37 Le vo flo xa ci n 57 10 0 .0 18 75 .0 28 10 0 .0 7 10 0 .0 11 0 94 .8 0 .0 0 0 M in oc yc lin e 12 21 .1 3 12 .5 12 42 .9 4 57 .2 31 26 .7 0 .0 15 Pi pe ra ci lli n 56 98 .2 23 95 .8 28 10 0 .0 7 10 0 .0 11 4 98 .3 0 .6 92 A m pi ci lli n/ su lb ac ta m 51 89 .5 24 10 0 .0 22 78 .6 7 10 0 .0 10 4 89 .7 0 .0 63 Tr im et ho pr im /s ul fa m et ho xa zo le 47 82 .5 20 83 .3 18 64 .3 3 42 .9 88 75 .9 0 .0 40 Te tr ac yc lin e 42 73 .7 14 58 .3 26 92 .9 7 10 0 .0 89 76 .7 0 .0 11 Ti ca rc ill in 57 10 0 .0 24 10 0 .0 28 10 0 .0 7 10 0 .0 11 6 10 0 .0 – To br am yc in 42 73 .7 16 66 .7 25 89 .3 6 85 .7 89 76 .7 0 .2 17 Pi pe ra ci lli n/ ta zo ba ct am 55 96 .5 22 91 .7 28 10 0 .0 7 10 0 .0 11 2 96 .6 0 .3 96 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 832 anti-Acinetobacter drugs for MDR A. bau- mannii, but with varying degrees of suc- cess (15,18,19,23,24). According to the European Committee on Antimicrobial Susceptibility Testing (EUCAST), the United States Food and Drug Admin- istration (FDA) and the CLSI, there are no specific breakpoints for tigecycline as an anti-Acinetobacter agent (21,24,25). On the other hand, the British Soci- ety for Antimicrobial Chemotherapy (BSAC) has previously recommended the ≤ 1 mg/L breakpoint of susceptibil- ity, but recently applied the EUCAST recommendations of “non-species- specific MIC breakpoint of susceptibil- JUZ NH-BOER NH- to interpret susceptibility, while other studies recommended ≤ 2 mg/L break- points” (25–27). However, we consid- FSFEUIF"459/DBSE.*$PGɒ mg/L to be the MIC breakpoint of sus- ceptibility, as shown in Table 3. A study from Jordan showed no resistance to UJHFDZDMJOF FWFOBU.*$m mg/L (7). At the same time, tigecy- cline resistance in the present study was BOEBDDPSEJOH UP UIF.*$CSFBLQPJOUTPGɒNH- ɒ NH-BOEɒNH-SFTQFDUJWFMZ Due to the wide range of resistance to tigecycline, there is a growing need for agreed breakpoints of susceptibility to be declared and accepted by CLSI, EU- CAST, BSAC, FDA and other institu- tions. Tigecycline resistance rates were MPX JO TUVEJFT GSPN +PSEBO BOE *UBMZ NPEFSBUFMZIJHIJO*OEJB BOEIJHIJOUIJTTUVEZ and one from Islamic Republic of Iran 7,5,18,19). Colistin is still considered to be the most effective single antibiotic against MDR A. baumannii, and is always kept as a last resort (23) due to the growing rates of resistance to carbapenems in recent decades (15,16,19). At the same time, resistance and treatment failure rates have been increasing with colistin in some countries lately, and therefore different combinations of colistin with other anti-A. baumannii antibiotics have been tried, with varying success rates (23,24). In the present study the resist- ance rate of isolates to colistin was very MPX XIJDI JT DPOTJTUFOUXJUI EBUB SFQPSUFE GSPN+PSEBO *OEJB *UBMZ BOE*TMBNJD3FQVC- MJDPG*SBO 7,15,18,19). However, resistance rates to colistin were as high BT BOEJO.BMBZTJB Spain and Korea respectively, presum- ably due to the intensive use of colistin recently (7,15,21,23,28,29). Table 4 Antimicrobial susceptibility of multidrug resistant Acinetobacter baumannii isolates (n = 116) to various antibiotics tested Variable No. of isolates Susceptibility (%)c Multidrug resistanta 90 77.6 Colistin + minocycline 37 31.9 Colistin + tobramycin 1 0.9 Colistin + sulfamethoxazole/trimethoprim 12 10.3 Colistin + ampicillin/sulbactam 6 5.2 Colistin + ampicillin/sulbactam + sulfamethoxazole/trimethoprim 2 1.7 Colistin + sulfamethoxazole/trimethoprim + tobramycin 1 0.9 Colistin + minocycline + ampicillin/sulbactam 1 0.9 Colistin + minocycline + sulfamethoxazole/trimethoprim 9 7.8 Colistin + minocycline + tetracycline 10 8.6 Colistin + minocycline + tobramycin 2 1.7 Colistin + minocycline + tetracycline + tobramycin + sulfamethoxazole/trimethoprim 9 7.8 Pandrug resistantb 10 8.6 Not susceptible to any of the tested antibiotics 2 1.7 Susceptible only to colistin 8 6.9 aResistant to imipenem plus 3 or more different antibiotic classes.; bResistant to all tested antibiotics or only susceptible to colistin; cPercentage of total number of isolates tested (n = 116) susceptible to colistin only. Table 3 Minimal inhibitory concentration (MIC) values for tigecycline in the tested Acinetobacter baumannii isolates (n = 116) Tigecycline MIC (mg/L) No. of isolates % ≤ 0.5 20 17.2 1.0 27 23.3 2.0 49 42.2 4.0 15 12.9 ≥ 8.0 5 4.3 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 833 The extensive use of such broad- spectrum antibiotics as 3rd-generation cephalosporins, quinolones and car- bapenems has been associated with emergence of MDR A. baumannii (13–15,18). Moreover, PDR to all available antibiotics has been reported worldwide, even against colistin, minocycline, tigecycline and sulbactam, which dictates the use of combinations of antibiotics, albeit with variable suc- cess rates (30,31). The current study reported high MDR resistance rates of A. baumannii against most antibiot- JDT UFTUFE ĉFIJHIFTU SBUFT IBWFCFFOSFQPSUFE GSPN*TSBFM while lower resistance rates (around XFSF GPVOE JO.BMBZTJB 64" and south India (20,21,32). Finally, the most effective antibiotics against A. baumannii according to the current TUVEZXFSFDPMJTUJO BOENJOP- DZDMJOF GPMMPXFECZTVMGBNFUI- PYB[PMFUSJNFUIPQSJN UIFO UFUSBDZDMJOFBOE UPCSBNZDJO Interestingly, tigecycline showed a IJHI SFTJTUBODF SBUF XIFOXF considered the VITEK 2 system AST- 9/DBSECSFBLQPJOUT ɒNH- )PXFWFS POMZPGPVSA. baumannii isolates were reported to be PDR, which is lower than the south India results 20). In addition, the colistin and minocycline combination seems to be the most effective combination theo- SFUJDBMMZ XJUIBHPPECBDUFSJ- cidal activity, as shown in Table 4. The prescription of colistin and minocycline should therefore be guided by the an- tibiotic protocols and only be ordered by infectious disease specialists in order to minimize the risk of side-effects and rising resistance rates and treatment failure rates (33). The present study had some limi- tations due to the retrospective study design. Patients’ data were missing or in- complete in many cases for data such as age, comorbidity and patient’s location. Future studies with larger sample sizes are necessary to take into account other contributing factors such as irrational use of antibiotics, lack of strict application of infection control instructions, isolation measures, patient and staff hygiene and environmental decontamination. Stud- ies are also needed into the prevalence of MDR and PDR in acute care settings, how to distinguish between coloniza- tion (which does not require antibiotic treatment) and infections (which might require antibiotics), and to assess the associated costs of treatment and the associated mortality rates. Conclusions A. baumannii isolates in Al-Hussein Hospital of Hussein Medical Centre in Amman were found to be highly resistant to almost all tested antibiotics, up to an alarming level, except mainly for colistin and minocycline, which showed relatively low resistance rates. 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Valencia R, Arroyo LA, Conde M, Aldana JM, Torres MJ, Fernández-Cuenca F, et al. Nosocomial outbreak of infection with pan-drug-resistant Acinetobacter baumannii in a tertiary care university hospital. Infect Control Hosp Epidemiol. 2009 Mar;30(3):257–63. PMID:19199531 32. Abbo A, Navon-Venezia S, Hammer-Muntz O, Krichali T, Sieg- man-Igra Y, Carmeli Y. Multidrug-resistant Acinetobacter bau- mannii. Emerg Infect Dis. 2005 Jan;11(1):22–9. PMID:15705318 33. Tan TY, Ng LS, Tan E, Huang G. In vitro effect of minocycline and colistin combinations on imipenem-resistant Acinetobac- ter baumannii clinical isolates. J Antimicrob Chemother. 2007 Aug;60(2):421–3. PMID:17540671 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 835 1Lebanese Health Care Management Association, Beirut, Lebanon. 2Center for Studies on Aging, Beirut, Lebanon. 3Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut (Correspondence to A.M. Sibai: am00@aub.edu.lb). Received: 31/07/14; accepted: 15/09/15 Review Ageing and intergenerational family ties in Arab countries N.M. Kronfol,1,2 A. Rizk3 and A.M. Sibai2,3 ABSTRACT This paper explores the dominant issues in intergenerational ties in Arab countries with a view to highlighting patterns, trends and challenges as well as policy implications. The data were drawn from a review of scholarly work and published literature in Arab countries and from a regional mapping of ageing policies and programmes in 2012. Social and health ageing policies in the region have been set with the premise that the family represents the core safety net for older Arabs. Yet demographic, sociocultural and economic transitions, as well as political conflict in the Arab world, are bringing profound changes to familial structures. This review feeds into efforts to promote health and social reforms that approach intergenerational solidarity from several fronts: providing equitable old-age income security, fostering cross-generational interactions, embracing caregivers and home-based care, promoting age-responsive actions in emergencies and conflicts, and prioritizing context- and country-specific research on the levels, types and trends in intergenerational and familial support. og<|^TÐØ°TÐ9émg?úÐM<owúÐ<Ðí|TÐíoAgYTÐ LnHh7pdLºçÛÚ©]i̺ai}Shi någJ5iÌ DåL Êå\UÐ hdå> æ{å) påh=}_UÐ ëÐ{ådUÐ : énåh@úÐ Nå=påxúÐå=Ðí}dUphåHnHúÐyåYĆCÐ råUÐ Ð|åw d]åxoåÉ°#Ð phexØnTÌ é5åLÌ på_@Ð}Y åYÓnåinhUÐq[dôåHÐ påd[UÐÓÐÙ ÓnåHnhUÐ DåL nåwÚn?Ë OÎ påRnün= ºnågg@Ð> åUÐÓnåx ö{UÐí nå*nwn9Ðí {åbU 2012 ênåL :påb]fCÐ: pBhåZUn= påhf_CÐ såYÐFUÐíÓnåHnhdU påhehdSÎ på]x}BåHÚ åYípåhed_UÐÓĆåCÐ : ÒÚåZfYÓnåHÐÚØí åcUí påh=}_UÐ éí{åUÐ :åUÐ ÚnåcUphåHnHúÐ ënåYúÐ pcåIå/ ÒúÐ ëÌ påöh}RDåL påh[UÐípåhL5@üÐÓnåHnhUÐì|åwåHÚå> pååxÚ|@ÓÐEååh`>OÎÓØÌ{ååS – pååb]fCÐ : phååHnhUÐ ÓnååLÐWUÐ OÎ pååRnÎ pååxØn[SøÐí pååhRnbUÐ pååhL5@øÐíphincååUÐÓøååUÐ pååh[UÐ ÓnååHnhUÐ:ÓnååAĆÉÎÊÐ}åå@ü pååhYÐ}UÐ Øååg!Ð ~ååx~_> :ååecx påå_@Ð}CÐ ì|ååwååYß}åå`UÐ ëÎ pååxúÐ Tnååh4ÐoåådÉ: N=åYn\UÐ ~åx~_>í ºåUÐÚnåcUå[fYï{åLnb>Ýnå_YNåYj>: {åh_ÉåY}åTÌ DåLåUÙípåxúÐå=Ðí}UÐNå/påh`= påhL5@øÐí : åUÐÚnåcUpåÉn#ÐÓnå@nhAüÐÚnåLüÐNå_=|åBj>åUÐ ÓÐÊÐ}å@üÐ ~åx~_>í ºnåghY ¬{bYënå\AÎípåhU~fCÐpåxnL}UÐåLØí ºénåh@úÐ {åd= cå=í çnhåH cå= påÉn#ÐÓnåwn9øÐíà5åiúÐíÓnxåCÐ éínåf>åUÐÔåUÐ ÓnåxUíÌ {åx{Ļí ºÓnåLÐ~fUÐí ÏÚÐå]UÐ ÓønåA énåh@úÐ Nå= å=ÐGUÐíïúÐ åL{UÐ Óønå6 : Vieillissement et liens familiaux intergénérationnels dans les pays arabes RÉSUMÉ Le présent article étudie les questions dominantes concernant les liens intergénérationnels dans les pays arabes afin de dégager les caractéristiques, les tendances et les difficultés ainsi que les implications politiques. Les données sont issues d’un examen des travaux académiques et des publications dans les pays arabes ainsi que d’une cartographie régionale des politiques et programmes sur le vieillissement en 2012. Les politiques sociales et sanitaires sur le vieillissement dans la Région ont été établies à partir du postulat selon lequel la famille représente le filet de sécurité essentiel pour les Arabes plus âgés. Toutefois, les transitions démographiques, socioculturelles et économiques, ainsi que les conflits politiques dans le monde arabe sont sources de profonds changements pour les structures familiales. Cet examen contribue aux actions visant à promouvoir des réformes sanitaires et sociales qui relèvent de la solidarité intergénérationnelle sur plusieurs plans : garantir une pension équitable pour les personnes âgées, favoriser les interactions entre les générations, prendre en compte les aidants et les soins à domicile, promouvoir des actions respectueuses de l’âge dans les situations d’urgence et de conflit, et établir un ordre de priorité pour la recherche propre aux pays et aux contextes sur les niveaux et les types de soutien familial et intergénérationnel ainsi que les tendances en la matière. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 836 Introduction Permeated by a moral code of conduct to honour and respect elders, extended family structures have long played a key role in the care and well-being of older people in the Arab world. To varying degrees, older persons in most Arab societies have traditionally lived in multi-generational households where adult children, spouses and other family members can be relied on for material support and care (1). The constitutions of many Arab states are a testament to the privileged position of the family as the basic unit of society, while religious institutions, in varying settings, con- sider themselves promoters of family integrity (2). These informal family and community-based care systems may have contributed to lessening the pres- sure on Arab governments to establish formal public welfare systems that provide care and safety nets for their older residents. However, demographic transitions, shifts in social norms, and economic pressures, as well as medical advances and the ensuing changes in health patterns in later life, are triggering various forms of estrangement from the traditional family configuration and have resulted in fundamental changes in old-age care. This has come to be problematized as “the fraying in the social cohesion between generations” (3–5). International research has varied in its characterization of intergenerational solidarity. While studies show that support, including financial exchanges, is likely to flow upwards from adult children to older parents (6,7), other findings show that financial support continues to flow from older parents towards adult children, at least until par- ents begin to undergo a decline in health (8,9), with categorically different filial norms across populations (6). Deindl and Brandt noted that when generous provision of government-sponsored social services exists and children have to provide less financial support, other kinds of voluntary or emotional support are encouraged (10). Very l ittle research has been conducted in Arab countries on the levels, types and trends in familial sup- port vis-à-vis the growing economic constraints and limited public health and social services for older persons. Scholarly work has yet to elucidate how intergenerational ties differ within and across Arab countries, in a region where support tends to flow on a reciprocal basis between the young and old (1). Within the changing context of grow- ing economic and political crisis in several settings in the region, this paper explores the shifting dynamics of inter- generational solidarity in Arab countries to shed light on possible future implica- tions and to illustrate, to the extent that the data allow, the plight of caregiving and caregivers in Arab countries. The data and information presented in this paper are drawn from the published lit- erature as well as from a comprehensive region-wide mapping of ageing policies and programmes in Arab countries con- EVDUFECZ UIF BVUIPST JO 4JCBJ AM, Rizk A, Kronfol KM. Ageing in the Arab region: trends, implications and policy options. United Nations Population Fund, Economic and Social Commission of Western Asia and the Center for Studies on Aging, Lebanon, unpublished report). Intergenerational cohesion in Arab countries Kagitcibasi et al., in a comparison of intergenerational relationships in the region and elsewhere, noted that intergenerational relationships and solidarity constitute the core of family dynamics and stated that a key aspect of these relations lies in “the degree of support that is expected, aspired, considered proper, assumed and/or actually provided” (11). Three main indicators are examined below to ap- praise the cohesion between the gen- erations in Arab countries: legislation, policies and programmes related to intergenerational solidarity; living ar- rangements and co-residence patterns; and exchanges between generations. Legislation, policies and programmes ĉF "SBC 1MBO PG "DUJPO PO Ageing endorsed intergenerational solidarity as the cornerstone of social development and urged Member States of the United Nations to de- velop initiatives that bridge the gen- erational gap towards mutual benefit and experience-sharing (12). As such, social and health laws and policies in many countries of the Arab region have been instituted with a vested value in the centrality of familial sup- port, where legislation is intricately connected with councils and directo- rates of family affairs, most notably in Gulf Cooperation Council (GCC) countries. The Permanent Constitu- tion of the State of Qatar, Article 21, for example, explicitly states that “the family founded on religion, morality and patriotism is the basis of the Qatari society” (1). Also, the ministerial body involved with ageing affairs in Mo- rocco is situated in the Office of the Family, Children and the Elderly, and Syria Arab Republic’s National Com- mittee on Ageing is positioned in the Commission for Family Affairs. Like- wise, Jordan’s comprehensive strategy for the welfare of the aged has been prepared in close cooperation with the National Council on Family Affairs. In the same spirit, several countries in the region have instituted policies and programmes that foster intergen- erational solidarity, such as young adults taking care of older persons (as in Bah- rain, Kuwait, Palestine and Sudan) and families hosting older people in need (as in Bahrain and Tunisia). Further- more, laws and policies that hold kin responsible for older relatives exist in HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 837 resulting from industrialization and modernization, this may have translat- ed into a weakening of family ties and changing gender roles (17). However, the extended family in Arab society— whereby strong and highly gendered forms of co-residence and transfers remain between generations—has not yet completely dissolved. In Egypt, for example, older parents have a vested in- terest in continuing to support married daughters, who often live in the same neighbourhoods, village or building as their parents; and upward material transfers are expected from adult sons who remain a form of old-age insur- ance (18). In some countries, such as Qatar, institutional steps have been taken towards ensuring close familial residence, such as providing free hous- ing on condition that extended families live in close proximity (19). Of all the various living arrange- ments, living alone is the most ambiva- lent category with respect to the welfare of older persons. Solitary living may indicate social isolation and exclusion; however, it may also signify financial and psychological independence (20). In Arab countries, very low rates of solitary living are reported from the oil- SJDIDPVOUSZPG,VXBJU BOEUIF poorer communities in Khartoum, Su- EBO #FUXFFOBOEPGPMEFS men and women live alone in Egypt and Jordan (20). By comparison, the proportion of older persons living alone in Lebanon is relatively high (close to 8IJMFUIFESJWFSTGPSUIFTFEJĎFS- ences remain unclear, studies on solitary living are increasingly warranted in this region where older persons living alone defy the customary Arab arrangement of intergenerational co-residence and support. Exchanges between generations While data on material exchanges across generations are scarce in Arab countries, some information is avail- able from the national Pan Arab Project for Family Health studies conducted in Algeria, Lebanon and Palestine and from the Survey of Health, Ageing and Retirement in Saudi Arabia, as well as a number of specialized small-scale studies in Tunisia and Egypt. Data show that older persons are not only recipients of care but also provide sup- QPSUXJUIJO UIF GBNJMZ CFUXFFO BOEPGPMEFSQFSTPOT JO"MHFSJB Lebanon and Palestine provide help in child-rearing and domestic chores) and extend financial support to their children and other family members CFUXFFOBOE 7). Further- more, data from Lebanon show that financial support for older parents is SFDFJWFEGSPNBEVMUDIJMESFO PG PMEFSNFOBOEPGPMEFSXPNFO and that this percentage increases con- TJTUFOUMZXJUI BHF BQQSPBDIJOH PG UIPTFBHFEZFBST BOEPWFS 1). Research from Egypt reveals that older parents and adult children maintain frequent contact, creating expectations of and opportunities for economic exchange by which older fathers are disproportionate givers and older mothers are disproportionate receivers of economic transfers (18). The international literature shows that, although the magnitude of inter- generational financial support from adult children to their elderly parents has declined in some countries, it re- mains significant when the health or disability status of the older person falters (8,9). This may differ greatly, however, by country, depending on the availability of health and social services and pension systems. It may also differ by class—whereby economically-in- dependent older adults would require less financial support—as well as by sex—whereby older women are less able to mobilize resources than older men. Concurrently, and despite chang- ing family patterns, older persons often assume a key role as a social safety net for adult children and their families, and hence should not be seen only as dependent and passive receivers of support and care. Bahrain, Jordan, Kuwait, Libya, Mo- rocco, Palestine, Qatar and Yemen and are under review in Oman (13). In Morocco, articles 484–486 of the penal code heighten the penalties for felonies and misdemeanours committed against older persons, and the Kuwaiti law (Act /PPG QSPWJEFTGPSTFOUFODFT of 1-year imprisonment for negligence towards older family members (14). In Tunisia, social protection for older peo- ple is legally assured through Law 94- 114 (passed in October 1994) which strengthens intergenerational solidarity and family integration through ensuring older people continue to live in their homes, or in the homes of host families, as well as reducing social exclusion and facilitating access to health care and social assistance (15). Living arrangements and co- residence Co-residence is one of the means by which Arab families fulfil the support owed to their older relatives. Popula- tion data from several countries suggest increasing heterogeneity, by place and person, in the norms that drive living arrangements and intergenerational support. Although scholarly studies on Arab households remain sparse, the literature on family systems and liv- ing arrangements cites modernization and urbanization as drivers towards increasing nuclear family structures and the fraying of multi-generational households. Olmsted conducted a historical comparison to elucidate the changes in household formations in Arab countries and concluded that, while patterns had varied considerably across communities, extended family households occurred historically more frequently in the Syrian Arab Republic and Yemen, and shifts in social norms and cultural and economic pressures have contributed towards changing intergenerational living in many coun- tries including Lebanon, Egypt and Yemen (16). Exacerbated by local and regional population movements EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 838 Challenges to intergenerational cohesion Demographic realities The profound demographic transitions that have been taking place in the Arab XPSMEPWFSUIFQBTUEFDBEFT OPUBCMZ the impressive declines in fertility rates, have altered intergenerational cohe- sion on several fronts. While changes in fertility patterns are heralded as indicators of economic development and modernization, the consequences include a shift towards smaller, nuclear families and changes in household structures and intergenerational living arrangements (21–23). This is further exacerbated by a pattern of substantial outwards migration of youth seeking better employment opportunities and safer havens elsewhere. While not well-documented, some countries are currently facing counter-waves of return migration, a flow of older retired workers back to their original homeland, having worked and served in the host country for decades with no prospects of becoming a national (24). Population dynamics and the subsequent changes in dependency ra- tios signify that the responsibility of the adult workforce is increasingly shifting from the support of children to the simultaneous support of children and older persons (25). This is most clearly seen through the old-age dependency ratio, defined as the number of persons BHFEZFBSTBOEBCPWFQFSQFS- TPOTCFUXFFOUIFBHFTPGmZFBST and measures the capacity of a working economy to sustain non-working older persons. Currently, the Arab region includes among the lowest old-age de- pendency ratios worldwide: between 1 in Qatar and the United Arab Emirates (UAE) and 11 in Lebanon. However, CZ UIJT SBUJP JTFYQFDUFE UP SBQ- idly increase in some GCC countries (such as Bahrain, Qatar and the UAE) and more than double in some others (Table 1) (26). Sociocultural transitions Religious moral codes that emphasize honour, respect and affection towards older parents in the Arab region influ- ence, to a large extent, the system of intergenerational ties and facilitate material exchanges. This allows for the pooling and sharing of resources and creates conditions that reinforce emo- tional and psychological support (27). Provision of care to older persons has traditionally fallen on daughters and daughter-in-laws in Arab countries (17) and worldwide (28). However, a shift in these norms has been documented in a number of countries of the region. The traditional nuptial tenets of the Arab countries—generally characterized by early marriage for women, universal marriage for both sexes and large age differences between spouses—have in many respects changed greatly over the past century (29) in a drastic shift that Tabutin and Schoumaker call the “marriage revolution” (30). This, and the increased entry of women in the workforce, may contribute towards un- ravelling the existing multigenerational household pattern and necessitate changes in familial roles, which carry a set of gendered duties and responsibili- ties for family members, including the young and old. Economic and health challenges Economic crises have left several Arab countries struggling to provide work opportunities for their growing labour forces. The proportion of un- employed is particularly high among Table 1 Trends and projections in old-age dependency ratios in Arab countries (1980–2030) Country Dependency ratio (%)a 1980 2010 2030 Algeria 8 7 13 Bahrain 3 3 12 Comoros 6 5 6 Djibouti 4 5 7 Egypt 6 8 13 Iraq 8 6 6 Jordan 7 7 8 Kuwait 3 4 14 Lebanon 10 11 17 Libya 4 7 11 Mauritania 5 5 6 Morocco 8 8 15 Oman 5 4 11 Palestine 5 5 7 Qatar 2 1 5 Saudi Arabia 6 4 9 Somalia 6 5 6 Syria 7 7 11 Sudan 6 6 8 Tunisia 7 10 18 United Arab Emirates 2 1 8 Yemen 5 5 5 Source: United Nations Department of Economic and Social Affairs, 2012 (26), using medium variants aDependency ratios are calculated by the source through the following formula (number of persons aged 65 years and above per 100 persons between the ages of 15–64 years) of the de facto population. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 839 ZPVUI BOE JT FTQFDJBMMZ DSJUJDBM in North African countries and in poor and conflict-ridden areas (31). These economic constraints have made cross- generational and inter-family financial dependency a necessity, especially when augmented by lack of sufficient retirement benefits and inadequate old- age health insurance. However, the ca- pacity of working-age family members to care simultaneously for older persons and younger dependants is becoming increasingly strained, particularly in the context of high unemployment, making more efficient and universal govern- ment-sponsored health and social care policies and programmes an urgent necessity (32). Older persons who are single, widowed or childless (particu- larly women) face an even higher risk of destitution (33,34). At the same time, when social pro- tection nets and universal health sys- tems are either stagnant or regressing in some Arab countries (35), increasing longevity and shifts in disease patterns towards degenerative chronic diseases absorb families’ savings. Hypertension, heart diseases, diabetes, arthritis and chronic back pain appear to be the lead- ing causes of morbidity among older age groups (36) and the percentage of older persons suffering from at least one chronic disease ranges from as low as JO%KJCPVUJUPBIJHIFTUJNBUFPG JO-FCBOPO XJUIBMBSHFOVNCFS PG DPVOUSJFTIBWJOH SBUFT BCPWF (Pan Arab Project for Family Health, League of Arab States. Analysis of TVSWFZEBUB VOQVCMJTIFEEBUB Health care costs in the older age cohorts is much higher than for the younger population, with the average DPTUQFSDBQJUBEPVCMJOHXJUIFBDI year age increase beyond the age of ZFBST 37). These two inextricably related issues—ageing and chronic disease—create challenges for pub- lic health and clinical care in settings already faced with scarce recourses, and necessitate changes in health-care systems and services (38). Pension systems in Arab countries Pension systems were introduced to the Arab world as a sustainable solu- tion for older people’s welfare, and laws regulating social security and pensions were drafted and implemented in the SFHJPOGSPNBTFBSMZBTJO&HZQUUP as late as 1991 in Oman. Despite major economic changes and geopolitical de- velopments, some countries have never made any revisions to their pension laws since their initiation (e.g. Bahrain, Lebanon and Syrian Arab Republic), while others continue to introduce frequent updates, with the latest being JOUSPEVDFE JO +PSEBO JO 5BCMF 2) (39,40). Furthermore, owing to low pension contribution rates and increas- ing life expectancy, some funds suffer from very low reserves and are at risk of using government reserves to pay pension dues (41). Pension systems in the region also tend to be highly fragmented, with wide variations in the level of basic benefits for retirees. Public servants enjoy bet- ter social and health insurance cov- erage as well as better privileges and benefits than those in the private sec- tor (Sibai AM, Rizk A, Kronfol KM, unpublished report). On the other hand, the self-employed and those in the informal sector almost never qualify for old-age pension plans; this adversely affects agricultural workers and many women who fall out of the social secu- rity umbrella (Table 2). It is estimated UIBUPOMZPGUIFMBCPVSGPSDFJOUIF region are enrolled in pension schemes (41). Because of precarious safety nets, economic insecurity becomes a main driver for older people in some Arab countries to continue to work after the legal age of retirement. For example, CFUXFFOBOEPGPMEFSNFO BHFE m ZFBST BOE CFUXFFO BOEPG UIPTFBHFEmZFBST JO Egypt, Jordan, Lebanon, Palestine and Yemen continue to be involved in the workforce (42). In contrast, retirement is the norm in developed countries. Conflicts and political instabilities Owing to a conflagration of internal and external factors, a number of Arab countries are caught up in long-stand- ing wars and conflicts (e.g. Iraq, Leba- non, Palestine, Somalia and Sudan), and some others have more recently been affected by civil disturbances, po- litical crisis or major conflicts (e.g. Tu- nisia, Libya, Egypt, Yemen and Syrian Arab Republic). The consequences of these conflicts permeate almost all seg- ments of society, with adverse effects on populations that include violent deaths and injuries, loss of property and assets, and displacement, as well as damage to essential infrastructure and welfare systems (43). The adverse outcomes of conflicts are especially disruptive to older persons, who may face untimely transitions into widow- hood, solitary living, forced retirement and displacement (44). Tensions and political instabilities also exacerbate social and economic vulnerabilities, pushing youth to emigrate and hence further diminishing opportunities for co-residence and intergenerational exchange. For instance, research from Lebanon has shown that the propor- tion of older women living alone in the Southern governorate, which has been most exposed to recurrent occupations, wars and instabilities, FYDFFET BOE JTBSPVOEUXJDF UIF national average (45). Furthermore, the more recent Syrian crisis, with its huge levels of population displace- ment and transnational migration, is highlighting the perilous health pro- file of older refugees (46) and their heightened vulnerabilities stemming from disruption to the social fabric and the loss of family ties, homes and property (47). In the absence of age- responsive actions by relief agencies and nongovernmental organizations in planning for, responding to, and recovering from emergencies, older persons are easily overlooked during conflicts and disasters. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 840 The plight of caregivers Family members, typically middle-aged daughters as well as daughters-in-law, continue to play the major role of car- egiving to older relatives in Arab socie- ties. With time, caregivers may develop a personal sense of satisfaction for fulfilling their obligations towards the aged. How- ever, caregiving for a cohabiting frail and disabled older person carries significant emotional, physical and financial strains, and lost work and leisure opportunities, that may cause serious health problems for the caregivers themselves (48). A study conducted in Lebanon found that the likelihood of health risks for the caregiver increased as the degree of func- tional impairment and frequency of de- pressive and disruptive behaviour of the cared-for relative increase (49). Some countries in the region have policies and programmes that promote the provi- sion of social support to the caregivers of older persons, including the provision of short-term temporary relief (respite services). Algeria provides financial sup- port for families taking care of older per- sons, and Bahrain, Egypt and Lebanon include initiatives to train caregivers and build the capacities of companions to older persons in home care. Additionally, Jordan’s National Committee for Family Affairs has prepared a booklet geared to caregivers that addresses many of the needed health and social skills. Nevertheless, the difficulties of caring for older persons remain under- researched across Arab countries and require closer investigation. It is no- table, however, that owing to these strains, Arab families in a number of countries are increasingly opting for a new form of in-home care by full-time, live-in foreign domestic workers, mainly from South-East Asian and African countries. This way of ensuring full-time caregiving is highly classed, gendered and racialized and is linked to global and local economic and so- cial inequalities and the “feminization and colorization” of labour in long- term care (50), where the employing families tend to be wealthy nationals and the migrant caregivers tend to be women from Global South countries. Migrant workers play the role of both domestic worker and companion, pro- viding long-term care to older people who are dependent on help in activities of basic daily living (48), as well as maintaining the family orientation for elder care and contributing to lower rates of institutionalization for older people. However, they may also be subject to stringent and discriminatory Table 2 Pensions laws, administrative organizations and pensions exclusions in Arab countries Country Pension laws Administrative organization Pension exclusions Year first drafted Year last updated Bahrain 1976 – Ministry of Finance Household and agricultural workers, casual workers, temporary non-citizen workers Egypt 1950/5 1980 Ministry of Finance – Jordan 1978 2010 Social Security Corporation Civil servants hired before 1995, military staff hired before 2003, casual labourers Kuwait 1976/7 – Ministry of Finance – Lebanon 1963 – Ministry of Labor Temporary agricultural employees, self- employed persons Libya 1957 1980/1 Social security committees – Morocco 1959 2004 Ministry of Employment and Vocational Training Self-employed persons Oman 1991/2 – Ministry of Manpower Foreign workers, household workers, self-employed persons, artisans Saudi Arabia 1969 2001 Ministry of Labour Household and agricultural workers, fishermen, family labour, foreign workers Sudan 1974 1990 Ministry of Welfare and Social Security Household workers, home-based workers, farmers and foresters, unpaid apprentices Syrian Arab Republic 1959 – Ministry of Social Affairs; Labour Temporary workers, household workers, self-employed persons Tunisia 1960 1995 Ministry of Social Affairs; Solidarity Prisoners working in prison workshops Yemen 1980 1991 Separate boards of directors supervise Casual workers, self-employed persons, agricultural workers, seamen, fishermen Source: United States Social Security Administration 2011 (39,40). HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 841 labour practices and sponsorship (ka- fala) systems (51) and lack formal qualifications for elder care. While the Arab region is undergoing a period of economic crisis with high rates of youth unemployment, little is done to make employment in social and health care for older adults appealing to the national workforce. Concluding remarks Demographic, sociocultural and economic transitions, as well as po- litical conflict in the Arab world, have brought about profound changes to intergenerational familial ties. Yet, the family continues to be the main social unit for the care of older Arabs. This review highlights the urgent need for data that are capable of keeping abreast of rapid demographic, socioeconomic and health transitions and informing evidence-based policy. The availability of information does not guarantee suc- cess for policies and programmes; how- ever, an absence of data almost always ensures failure To facilitate the transition into age- ing societies, Arab countries are called upon to approach intergenerational solidarity from several fronts: r providing equitable old-age income security, accessible and affordable health and social services, and im- plementation of poverty-reduction strategies that would contribute to relieving the economic burden from Arab families; r fostering cross-generational interac- tions and exchanges (e.g. promoting close residence between older adults and children, supporting younger families hosting older people); r promoting home-based care services (e.g. mobile units, respite services, financial incentives to caregivers and for home-based palliative care) and embracing caregivers as beneficiaries of care; r promoting age-responsive actions in times of emergencies, conflicts and disasters; and r prioritizing context- and country- specific research on the levels, types and trends in intergenerational and familial support and exchanges in the light of ongoing demographic, social, health and economic transitions. In spite of the challenges presented here, population ageing also presents opportunities. Older people are a re- source for their families and communi- ties, they possess a wealth of knowledge and are a repository of social capital, and many remain active participants in the formal or informal workforce, con- tributing to the socioeconomic devel- opment of their societies. While there is no single policy or measure that is a panacea to all problems, there is a need for a paradigm shift in the approach to the issue of ageing in countries of the Arab region to one that reaps the rewards of this longevity dividend: the additional years lived (52). As such, investing in older persons’ accumulated life experience and capabilities and rec- ognizing the societal and economic opportunities associated with ageing may present untapped opportunities for improving intergenerational solidar- ity and family ties. Funding: None Competing interests: None declared. References 1. Sibai AM, Yamout R. 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Int J Nurs Stud. 2007 Feb;44(2):259–72. PMID:16730728 50. Browne CV, Braun KL. Globalization, women’s migration, and the long-term-care workforce. Gerontologist. 2008 Feb;48(1):16–24. PMID:18381828 51. Reform of the kafala (sponsorship) system. Policy Brief No. 2. Philippines: Migrant Forum in Asia Secretariat; 2012. 52. Beard JR, Biggs S, Bloom DR, Fried LP, Hogan P, Kalache A, et al. Global population ageing: peril or promise? PGDA Working Paper No. 89. Boston (MA): University of Harvard, Program on the Global Demography of Aging; 2012. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 844 1Cancer Control Office; 5Section of Pulmonary and Critical Care, Department of Medicine, King Hussein Cancer Centre, Amman, Jordan (Correspondence to F. Hawari: fhawari@khcc.jo). 2Department of Research, Mayo Clinic, Rochester, Minnesota, United States of America. 3International Cancer Control, American Cancer Society, Washington DC, United States of America. 4Stanford Prevention Research Center, School of Medicine, Stanford University, Palo Alto, California, United States of America. Received: 25/02/15; accepted: 28/06/15 Report Jordan tobacco dependence treatment guidelines: rationale and development H. Ayub,1 N. Obeidat,1 S. Leischow,2 T. Glynn 3,4 and F. Hawari1,5 ABSTRACT Jordan, a high tobacco-burden country, has been working to expand its tobacco dependence treatment services and has completed development of its first customized treatment guidelines. Our paper presents the development process for these guidelines. A group of national and international experts was formed and a national situation analysis for tobacco dependence treatment practices and a detailed review of international evidence were conducted. The guidelines were then drafted and reviewed by national, regional and international experts and were official endorsed by the Jordanian Ministry of Health before being launched. The guidelines comprise concise descriptions and practical supplementary flowcharts covering the major elements of general tobacco dependence treatment. These are the first comprehensive Arabic-language guidelines, including a section focusing on waterpipe use, and we believe they are a reliable and useful resource for neighbouring countries seeking to develop similar guidelines. TÐëmXØÎo!m^BoghØÚúÐowØmHÚüÐýøzTÐØÐzKÎía\eBÐÜmGúÐ ïÚÐwÜÐ}RºNd@ê>ºZxøÓcHºÓÐ{hLÚiºÑxÌpw DååLØ5ååLøÐpåå!n_CnåågY{bxååUÐÓnååY{#Ð hååH>DååLååe_xënT ååa>}Yåå>ÊoååLååx{Uï|ååUÐ{åådUÐ ëØÚúÐëÎoååÉ°#Ð åýø{UÐì|åwØÐ{åLÎpåhde_Uß}å_>Ð|åwnåf=ëÎ på!n_CÐì|å4ðnå[h[Bpåee[CÐpxØnåIÚüÐådýøØOíÌ åíåYågiÐ{åSíºåUÐ DåLØ5åLøÐpå!n_YÓnåHÚ5e=åd_x5åhRåfJUÐ ådUåhdĻï}å@ÌíºNåhUíØíNåhfJíÊÐFåBåYåx}R ¬cå ôI{åbR pxØnåIÚüÐ Ó}åSÌíºëåhUíØíëåhehdSÎíëåhfJíÊÐFåBnåg_@ÐÚípxØnåIÚüÐåýø{UÐpåQnhÉqå/å? påhUí{UÐpåUرUå[aYßÐ}_åHÐíºåUÐ på hdeLpå hdhec>Ónå]]8íÒ~å@YÓnåahÉ>åYpxØnåIÚüÐåýø{UÐåUj>í någSĆJÎåSpå hiØÚúÐpå[UÐÒÚÐÛíåSåYðnheåHÚ åe\>åwíºpåh=}_UÐpå`dUn=pdYnåZUÐpxØnåIÚüÐåýø{UÐOíÌåwì|åw ênåLcåZ=åUÐDåLØ5åLøÐpå!n_Cphåhý}UУnåf_UÐå]`> p)nåZYpxØnåIÚÎåýøØ åíOÎ_å>åUÐÚÐå!Ðéí{åU{åhaYíçå?YÚ{å[Ynå¹Ì{åb_iíºpåZhZUÐåJn_>DåL~åT}x ð5åS Recommandations pour le traitement de la dépendance au tabac en Jordanie : argumentation et développement RÉSUMÉ La Jordanie, un pays ayant une forte charge tabagique, a œuvré pour développer ses services de traitement de la dépendance au tabac et a terminé l’élaboration de ses premières recommandations thérapeutiques personnalisées. Notre article présente le processus de développement de ces recommandations. Un groupe d’experts nationaux et internationaux a été créé et une analyse de la situation nationale en matière de pratiques pour le traitement de la dépendance au tabac ainsi qu’un examen détaillé des preuves internationales ont été menés. Un projet de directives a ensuite été rédigé puis examiné par des experts nationaux, régionaux et internationaux et a été officiellement adopté par le ministère de la Santé jordanien avant son lancement. Les directives incluent des descriptions concises et des schémas pratiques supplémentaires couvrant les principaux éléments du traitement général de la dépendance au tabac. Il s’agit des premières recommandations exhaustives en langue arabe comprenant une partie axée sur l’utilisation de la pipe à eau, et nous pensons qu’elles représentent une ressource fiable et utile pour les pays voisins cherchant à élaborer des recommandations similaires. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 845 Introduction Tobacco dependence treatment plays an essential role in tobacco control (1,2). It is a health-care intervention that, if successfully integrated within health-care systems, will be of great value in managing the growing burden of noncommunicable diseases such as cardiovascular disease, cancer, diabetes and chronic respiratory disease, both globally and in the Arab world (3–5). Jordan, a developing country in the Eastern Mediterranean Region, recently embarked on the process of developing national tobacco dependence treatment guidelines. This has become a pressing need because of the changing landscape of tobacco control issues in the country. Jordan has witnessed an alarming rise in the prevalence of tobacco use over recent years, increasing from JO UP JO 6,7). Furthermore, cardiovascular diseases and cancer are the leading causes PG EFBUI XJUI SBUFT PG BOE SFTQFDUJWFMZ 8), which is not TVSQSJTJOHJOBQPQVMBUJPOXIFSF of adults suffer from chronic disease (9 BOEXIFSFPGDBODFSDBTFTBSF tobacco-related (10). Accordingly, greater efforts are being made to raise awareness about the management of smoking—an important modifiable risk factor c o m m o n t o J o r d a n ’ s p r e v a l e n t noncommunicable diseases—with the aim of emphasizing the chronic nature of tobacco dependence and the possibility of treatment (11). In line with such efforts, the Jordanian Ministry of Health (MoH) and its partners have been working to expand t o b a c c o d e p e n d e n c e t r e a t m e n t services at clinics staffed by health-care professionals (HCPs) educated in tobacco dependence treatment. This is important because the availability of such services is currently limited to only a few clinics. No officially endorsed national t o b a c c o d e p e n d e n c e t r e a t m e n t guidelines previously existed in Jordan. Developing such guidelines was thus seen by concerned parties as a useful step towards achieving multiple objectives: r to compile all information related to tobacco dependence treatment that is relevant to Jordan in a single resource; r to review the international research and guidelines on tobacco dependence treatment and create a comprehensive, standardized, evidence-based, yet locally-customized reference; r to support ongoing educational efforts in the country; r to reinforce the message that a systematic means of tobacco dependence treatment is required for implementation within health care settings; r to provide an officially endorsed guideline to assist decision-makers responding to the call for integration of tobacco dependence treatment services into their systems; and r to reaffirm the Jordanian MoH’s commitment to the World Health O r g a n i z a t i o n ’ s F r a m e w o r k Convention on Tobacco Control (WHO FCTC) (12). Creating standardized, evidence- based (13), locally relevant tobacco dependence treatment guidelines aims to facilitate the successful integration of tobacco dependence treatment into health-care systems. Article 14 of the WHO FCTC confirms the importance of having such guidelines, stating that abiding parties must “develop and disseminate appropriate, c o m p r e h e n s i v e a n d i n t e g r a t e d guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities” (14). Thus, while numerous evidence- based international guidelines exist which may be referred to (15–18), locally developed guidelines make it more likely that knowledge about tobacco dependence treatment is translated into practice by taking into account the characteristics of the audience and the environment within that locality (19), and by communicating scientific content in a manner that is more locally articulate and relevant than international guidelines would be. Furthermore, on the regional level, few Arab countries have developed their own Arabic language tobacco dependence treatment guidelines and none are available publicly. Jordan’s guidelines will therefore be of use to other tobacco dependence treatment experts in the region who are seeking to expand treatment resources (20). This paper aims to describe the process of developing a national tobacco dependence treatment guideline in Jordan. We hope that our paper can provide insights and communicate a learning experience to interested parties in the regional scientific community who are seeking to develop their own guidelines. Methods The guidelines were developed in collaboration with various stakeholders, and over several stages. King Hussein Cancer Centre (KHCC) and the Jordanian MoH were the 2 main parties spearheading the process. KHCC was founded in 1997 and is the only specialized tertiary comprehensive adult and paediatric cancer centre in Jordan. It is a nongovernmental institution which has offered its expertise to the improvement of cancer care throughout the region, and houses a Cancer Control Office which focuses on preventive aspects of cancer control in the country and the region. In developing the guidelines the Cancer Control Office worked closely with the Tobacco Control Department in the Jordanian MoH, acting as the focal point for organizing and developing working EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 846 relevant published literature such as Cochrane and WHO reviews, and successful tobacco dependence treatment models used in other countries. The group also took into consideration the national resources available, the target audience for the guidelines, what actions were expected to be accomplished and the challenges envisioned. Topics to be included in the national guidelines were selected and the content was developed and customized for each topic. 4UBHF %FDFNCFS National review. Following a rigorous review by the Jordan Tobacco Dependence Treatment Guidelines Group, the content of the guidelines was then reviewed by a larger group of invited national stakeholders (HCPs representing major health service providers); and finally by a group of international, regional and national tobacco control experts attending a tobacco dependence treatment workshop in Amman, where the guidelines were presented and discussed (21). After each review, the draft guidelines were modified according to the feedback received. 4UBHF "QSJM &OEPSTFNFOU and launch. After translating the guidelines into Arabic they were approved and official endorsed by the Jordanian MoH. The guidelines were launched via tobacco dependence treatment training workshops for HCPs from the different health providers in Jordan (Jordanian MoH, Royal Medical Services, United Nations Relief and Works Agency for Palestine Refugees in the Near East, university hospitals and the private sector). The guidelines were then uploaded and disseminated electronically on the treatobacco.net website in both Arabic and English (20). Treatobacco.net is an independent body that collates up-to-date evidence- based information (reviewed by SPVHIMZ JOUFSOBUJPOBM FYQFSUT BOE posts international guidelines about the treatment of tobacco dependence. Results Situation analysis The tobacco epidemic Th e n a t i o n a l s i t u a t i o n a n a l y s i s revealed a substantial burden of tobacco use among adults, youth and HCPs in Jordan. The prevalence of regular tobacco use (i.e. cigarettes) BNPOH BEVMUT XBT FTUJNBUFE BU BNPOH NBMFT BOE BNPOH females) (7 BOJODSFBTFGSPNUIF QSFWBMFODF JO 6). Prevalence rates were particularly high in certain demographic groups: for example, BNPOH NFO BQQSPYJNBUFMZ PG mZFBSPMETXFSF SFHVMBS UPCBDDP users (7). Among women, average rates PGXBUFSQJQFVTF BNPOHmZFBS PMET IBE SJTFO GSPN JO UP JO 22,23). Approximately PG BMM +PSEBOJBOIPVTFIPMETIBE at least one smoker (24). The data also indicated that particularly among HCPs (physicians and nurses), smoking rates were higher than the national average PWFSBMM BNPOHQIZTJDJBOT BOEBNPOHOVSTFT 25). Among youth, the Global Youth Tobacco 4VSWFZGPSSFQPSUFESBUFTPG BOE GPS DVSSFOU DJHBSFĨF BOE waterpipe smokers, respectively (26). 'JOBMMZ BNPOHZPVOHHJSMT BHFEm years), rates of cigarette and waterpipe VTFIBE SJTFO GSPN KVTUVOEFSBOE SFTQFDUJWFMZ JO UPBSPVOE BOESFTQFDUJWFMZJO 22,23). Need for and availability of tobacco dependence treatment services Across a country of around 6 million people, the most current published national estimates indicated that only PGBEVMUTNPLFSTIBETVDDFTTGVMMZ quit smoking (27). Adult current TNPLFST SFQSFTFOUFE PG UIF population (7 BSPVOEPGXIPN had received professional advice to quit. A high proportion of current smokers, SPVHIMZ IBEUSJFEUPRVJUBOEGBJMFE Half of current smokers had not heard of smoking cessation services (clinics groups and in ensuring progress over the stages of development. 4UBHF +VOF 'PSNBUJPO of the Jordan Tobacco Dependence Treatment Guidelines Group. The g r o u p c o m p r i s e d i n t e r n a t i o n a l tobacco dependence treatment experts recruited through Global Bridges—a collaborative international project with a network of tobacco dependence treatment professionals—and local experts from the Jordanian MoH and KHCC. A plan was set and approved by the group with regard to the stages through which the guidelines should be developed and reviewed. 4UBHF +VOFm+VMZ $POEVDU of a national situation analysis. A national situation analysis was conducted by KHCC and the Jordanian MoH to generate an overview of the situation in Jordan regarding current tobacco dependence treatment practices. The analysis was important for framing the existing gaps in, and hence the value of, systematic tobacco dependence treatment services, which in turn would benefit from the presence of national guidelines. Specifically, a review of available data in Jordan was conducted, and statistics compiled regarding the burden of tobacco use, the desire to quit among smokers, and the availability of tobacco dependence treatment HCPs and clinics in the country. Because data were not consistently available, some information was based on the expert opinions of those with several years of experience in the field of tobacco control. 4UBHF +VMZm/PWFNCFS Outline and content development. This stage was the most complicated, and involved developing a framework and content for the guidelines and agreeing this among members of the Jordan Tobacco Dependence Treatment Guidelines Group. A review of the most up-to-date information available on tobacco dependence treatment was performed, focusing largely on internationally available guidelines, HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 847 PS IPUMJOFT CVU SPVHIMZ TBJE they would likely contact a clinic or hotline (27 .PSF UIBOIBMG of adolescent current smokers (aged mZFBST IBEUIFEFTJSFUPRVJU BOE IBEUSJFEUPRVJU JOUIFQSFWJPVT year (26). The national situation analysis also revealed a wide gap between the relatively high level of interest in quitting and the limited access or referral to available treatment. It was clear that the tobacco dependence treatment services available in Jordan were insufficient: only 4 cessation clinics in the country provided tobacco dependence treatment (counselling and pharmacotherapy). One of these, at KHCC (Amman), primarily served cancer patients, so there were only 3 free-of-charge MoH clinics serving the general public, one in each geographical region of Jordan: Central (Amman), North and South. Telephone support lines (quitlines) had not yet been established. Very recently, selected pharmacies had begun offering tobacco dependence treatment to smokers (28). There was also evidence that HCPs in the Jordanian MoH primary health- care clinics lacked knowledge about the existence of tobacco dependence treatment clinics and did not routinely practise screening for tobacco use. Thus, referral from the Jordanian MoH’s primary care clinics to its 3 tobacco dependence treatment clinics was limited. Furthermore, on a policy level, although tobacco dependence treatment was mentioned in the country’s National Tobacco Control Plan, there was no clear strategy or programme for it. Rather, tobacco dependence treatment remained a low-grade health priority and did not receive sufficient awareness, promotion, training or funding to sustain it. Tobacco dependence treatment medications The situation analysis noted that first-line medications registered and available in the country included nicotine replacement therapy in the form of patches, gums and lozenges, and varenicline (a nicotinic receptor partial agonist). The antidepressant drug bupropion was not registered at the Jordan Food and Drug Administration but was available at KHCC through a special licence. Unfortunately, it was noted that it was often challenging to sustain the availability of tobacco dependence treatment medication, an issue that further hindered the provision of comprehensive treatment. For example, even with the limited number of patient referrals, MoH tobacco dependence treatment clinics faced budgetary constraints and drug shortages. Drug shortages were also occasionally being faced at KHCC due to deficiencies in drug supplies. Trained specialists Tobacco treatment specialists, another pivotal element in tobacco dependence treatment, were available in Jordan, although this was largely the result of recent efforts in raising awareness about the tobacco epidemic and treatment. In Jordan, in the previous 2 years, BCPVU)$1T QIZTJDJBOT EFOUJTUT pharmacists, nurses) had been trained on advanced tobacco dependence treatment principles, and an additional 3 2 7 h e a l t h e d u c a t o r s ( s c h o o l counsellors and teachers) trained in the basic principles of tobacco control and tobacco dependence treatment. While this was seen a positive step, it was recognized that there was a limit to what these numbers of professionals could achieve on a national scale. Content of the guidelines Forms of treatment The guidelines included the 2 most widely recognized forms of counselling and treatment for tobacco users: brief intervention the AAR [Ask, Advise, 3FGFS> BOE"T <"TL "EWJTF "TTFTT Assist and Arrange] models; and face- to-face support. Any HCP (nurses, physicians, dentists, pharmacists, midwives) can conduct the brief intervention, while the face-to-face support is more likely to be performed by experienced professionals. The AAR model was included to address HCPs and educators with insufficient expertise or time to conduct intensive counselling. This is the situation in most of the public primary care clinics, where HCPs have often not heard of tobacco dependence treatment and where the high workload does not allow much time for long interventions XJUI QBUJFOUT ĉF "T NPEFM XBT included as an option to be used by HCPs with more expertise and time to speak to patients, but insufficient time to provide face-to face-support. Face-to-face support requires more interaction with the smoker through intensive and repeated counselling sessions, possibly accompanied by medication use, rather than referral. In Jordan, only physicians are authorized to prescribe medications, and therefore face-to-face counselling involving pharmacotherapies is anticipated to be performed only by physicians. In the Jordan guidelines face-to-face support was focused on individual-based interventions due to the limited local experience with group therapy. Pharmacotherapy G i v e n t h e i m p o r t a n c e o f p h a r m a c o t h e r a p y i n t o b a c c o dependence treatment, a separate s e c t i o n o f t h e g u i d e l i n e s w a s included to address this topic. Only pharmacotherapies currently available in Jordan were covered, while other p o s s i b l e t o b a c c o d e p e n d e n c e treatment options, such as cytisine (a partial nicotinic receptor agonist) and clonidine (an alpha-2 adrenergic agonist), were described in brief. Support to special groups of tobacco users Other topics addressed in the guidelines were tobacco use in children and EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 848 adolescents, and waterpipe use: two equally concerning public health issues in Jordan. Tobacco use in chi ldren and adolescents The content of this section of the guidelines was developed with both HCPs and school counsellors in mind, given that counselling alone is the recommended line of therapy for tobacco dependence (17). Waterpipe use Use of waterpipes has been increasing in Jordan, but there is currently insufficient evidence to guide the treatment of this form of tobacco use (29). Based on the local experience with treating waterpipe tobacco users, some advice was included in the guidelines on support for waterpipe users who are trying to quit. Appendices A series of appendices to the guidelines provided additional clinical details for HCPs and educators interested in playing an active role in tobacco dependence treatment. Topics in the appendices included the WHO’s MPOWER strategies: the health consequences of tobacco use and benefits of quitting; the nature and assessment of nicotine dependence; assessment of motivation to quit; designing quit plans; tobacco withdrawal symptoms and relapse; using carbon monoxide testing in tobacco dependence treatment; specific instructions on tobacco dependence treatment pharmacotherapy; principles of motivational interviewing; and weight management during smoking cessation. Tobacco dependence treatment interventions of debatable value (self-help material; hypnosis; and electronic cigarettes) were noted briefly. Discussion I n t h i s p a p e r w e d e s c r i b e t h e development of Jordan’s tobacco dependence treatment guidelines, the first comprehensive Arabic-language t o b a c c o d e p e n d e n c e t r e a t m e n t guidelines developed in the region, drafted and reviewed by a team of local and international experts, and endorsed by Jordan’s national health authority. The guidelines were developed to fill some of the gaps observed in Jordan’s tobacco dependence treatment services by promoting the concept of tobacco dependence as a chronic disease and by providing guidance for HCPs and educators on how to help smokers quit. The guidelines are a natural progression for the Jordanian MoH in its continuing efforts to integrate standardized t o b a c c o d e p e n d e n c e t r e a t m e n t services into the national health-care system. By enabling professionals to treat tobacco dependence by referring to these guidelines, it was hoped that treatment services in both the public and private sectors would expand, thereby encouraging pharmaceutical companies and the Jordan Food and Drug Administration to sustain the availability of cessation medications. Based on an updated comprehensive review of medical evidence, the guidelines were also designed to take into account Jordan’s available resources, and, where appropriate, the content was customized to apply to the local situation in Jordan (including a section on the management of waterpipe users). Furthermore, actions and recommendations included in the guidelines could be applied by a variety of HCPs (nurses, physicians, dentists, pharmacists or midwives) and educators (schoolteachers or counsellors). Finally, the guidelines provided information for health care decision-makers and administrators with regard to the necessary tools and resources for treatment and could also serve as a reference for HCPs and educators in the region. The process we used to develop our guidelines was consistent with internationally available standards for guideline development and appraisal (30). The guidelines, however, are a work in progress, requiring substantial follow-up as well as ongoing efforts. For example, it is imperative that the content of our guidelines reflects up-to- date medical evidence and is adapted to the changing local environment (e.g. the availability of additional pharmacotherapies or the inclusion of additional high-risk groups such as pregnant women). The updating of tobacco dependence treatment guidelines varies from country to country (20), and no standards for how often to update guidelines have been recommended. It will therefore be left to the judgement of the involved group of experts who developed Jordan’s tobacco dependence treatment guidelines to decide on this. Furthermore, a clear dissemination and monitoring mechanism is required for the guidelines . With regard to dissemination, a local tobacco d e p e n d e n c e t r e a t m e n t t r a i n i n g workshop was held to coincide with the official endorsement and launching of the guidelines. The workshop aimed to train attendees (HCPs and educators from public and private health-care organizations) in tobacco dependence treatment, while specifically linking the topics in the training course to the contents of the recently launched guidelines. This was valuable for highlighting how the content of the Jordanian guidelines could be used by the participants during their daily practice. Hard and soft copies of the guidelines were distributed to attendees, and are readily available upon request. The national guidelines were also posted on the KHCC’s clinical practice guidelines website and were uploaded onto the treatobacco.net website (20). Given that educational outreach and interactive educational workshops are effective mechanisms to promote clinical practice guidelines (31), Jordan’s tobacco dependence treatment guidelines are currently HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 849 presented and disseminated in all tobacco dependence treatment and tobacco control conferences and workshops conducted nationally, regionally or internationally by KHCC and the Jordanian MoH. A monitoring and evaluation mechanism for our guidelines is currently being planned. Ideally, monitoring of the guidelines will require the design of a rigorous system to assess any emerging barriers to implementation and the extent of implementation of the guidelines and adherence to the recommendations. Also needed are a set of clear process and outcome measures that can be tracked to ensure the guidelines are being implemented and to bring about change in the process of care and patient outcomes, and to highlight where further work and research will be needed (31). In the case of Jordan’s tobacco dependence treatment guidel ines , a feasible monitoring plan will be designed which takes into account the availability of resources as well as the desired scope of guideline implementation (particularly if local decision-makers deem it more practical for guideline implementation to be gradually rolled out across clinics in selected health care sectors). Adoption of these guidelines in Jordan and, ideally, elsewhere in the region, has the potential to make a substantial contribution to public health. As the first comprehensive guideline published in Arabic, and as a means of complying with the requirements of nations who have ratified the WHO FCTC (i.e. most nations in the Arabic- speaking world), these guidelines may be effective in reducing the death, disease and economic disruption caused by all forms of tobacco smoking. Acknowledgements We would like to acknowledge the efforts of Dr Martin Raw (UK Centre for Tobacco Control Studies, University of Nottingham) for his technical advice during the guideline development process and for providing comments during manuscript generation. Funding: KHCC is a grantee of the Mayo Clinic (USA) for conducting Global Bridges work in the Eastern Mediterranean Region. Development of the guidelines was funded in part by this grant. Competing interests: None declared. References 1. WHO report on the global tobacco epidemic, 2011. Warn- ing about the dangers of tobacco. Geneva: World Health Organization; 2011 (http://www.who.int/tobacco/global_re- port/2011/en/, accessed 20 September 2015). 2. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention; 2014 (http://www.surgeon- general.gov/library/reports/50-years-of-progress/, accessed 20 September 2015). 3. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, et al.; Lancet NCD Action Group; NCD Alliance. Priority actions for the non-communicable disease crisis. Lancet. 2011 Apr 23;377(9775):1438–47. PMID:21474174 4. Mokdad AH, Jaber S, Aziz MI, AlBuhairan F, AlGhaithi A, AlHamad NM, et al. The state of health in the Arab world, 1990–2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet. 2014 Jan 25;383(9914):309–20. PMID:24452042 5. Rahim HF, Sibai A, Khader Y, Hwalla N, Fadhil I, Alsiyabi H, et al. Non-communicable diseases in the Arab world. Lancet. 2014 Jan 25;383(9914):356–67. PMID:24452044 6. Al-Nsour M, Zindah M, Belbeisi A, Hadaddin R, Brown DW, Walke H. Prevalence of selected chronic, noncommunica- ble disease risk factors in Jordan: results of the 2007 Jordan Behavioral Risk Factor Surveillance Survey. Prev Chronic Dis. 2012;9:E25. PMID:22172192 7. Jaghbir M, Shreif S, Ahram M. Pattern of cigarette and water- pipe smoking in the adult population of Jordan. East Mediterr Health J. 2014 Sep;20(9):529–37. PMID:25343465 8. Mortality in Jordan 2009 [Internet]. Amman: Ministry of Health Jordan; 2009 (http://moh.gov.jo/MOH/Files/Publication/ al%20seha%20net_1.pdf, accessed 19 January 2015). 9. Prevalence of chronic disease in Jordan 2010 [in Arabic]. Am- man: Department of Statistics; 2010 (http://www.hpcpromise. org.jo/sites/default/files/researches/articles/Amrad%20 mozmena-2010.pdf, accessed 20 September 2015). 10. Jordan cancer registry. Annual incidence of cancer in Jordan 2010. Amman: Ministry of Health; 2010 (http://moh.gov. jo/Documents/Annual%20Incidence%20of%20cancer%20 in%20Jordan%202010.pdf, accessed 19 January 2015). 11. Hawari FI, Bader RK. Advancing tobacco dependence treat- ment services in the Eastern Mediterranean Region: interna- tional collaboration for training and capacity-building. Sultan Qaboos Univ Med J. 2014 Nov;14(4):e442–7. PMID:25364544 12. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003 (http://www.who.int/fctc/ text_download/en/, accessed 20 September 2015). 13. West R, Raw M, McNeill A, Stead L, Aveyard P, Bitton J, et al. Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development. Addiction. 2015 Sep;110(9):1388–403. PMID:26031929 14. Framework Convention on Tobacco Control. Guidelines for implementation of Article 14. Guidelines on demand reduc- tion measures concerning tobacco dependence and cessa- tion. Geneva: World Health Organization; 2010 (http://www. who.int/fctc/guidelines/adopted/article_14/en/, accessed 20 September 2015). 15. European smoking cessation guidelines: The authoritative guide to a comprehensive understanding of the implications and implementation of treatments and strategies to treat to- bacco dependence. 1st ed. Brussels: European Network for Smoking and Tobacco Prevention; 2012 (http://www.ensp. org/sites/default/files/ENSP-ESCG_FINAL.pdf, accessed 20 September 2015). 16. Supporting smoking cessation: a guide for health profes- sionals. Melbourne: The Royal Australian College of General Practitioners; 2011 (www.racgp.org.au/guidelines/smoking- cessation, accessed 20 September 2015). EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 850 17. Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, ET al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville (MD): US Department of Health and Human Services; 2008 (http://www.ahrq.gov/ professionals/clinicians-providers/guidelines-recommenda- tions/tobacco/clinicians/update/index.html, accessed 20 September 2015). 18. Smoking cessation clinical practice guideline. Toronto: Ca- nadian Action Network for the Advancement Dissemination and Adoption of Practice-informed Tobacco Treatment; 2011 (https://www.nicotinedependenceclinic.com/English/ CANADAPTT/Guideline/Introduction.aspx, accessed 20 Sep- tember 2015). 19. Harrison MB, Legare F, Graham ID, Fervers B. Adapting clinical practice guidelines to local context and assessing barriers to their use. CMAJ. 2010 Feb 9;182(2):E78–84. PMID:19969563 20. National cessation guidelines [Internet]. Treatobacco.net. (http://treatobacco.bwa-subway4.co.uk/site/en/page_549. php, accessed 20 September 2015). 21. Jordan hosts a regional conference on strengthening tobacco dependence treatment [Internet]. Rochester (MN): Global Bridges; 2013 (http://www.globalbridges.org/News/Blog/ Jordan-hosts-a-regional-conference-on-strengthening-tobac- co-dependence-treatment, accessed 18 September 2015). 22. Jordan Population and Family Health Survey 2009. Amman: Department of Statistics/ICF Macro; 2009 (www.dos.gov.jo/ sdb_pop/sdb_pop_e/pop_2009.pdf, accessed 20 Septem- ber 2015). 23. Population and family health survey, Jordan 2012. Amman: Department of Statistics/ICF Macro; 2012 (http://microdata. worldbank.org/index.php/catalog/1908, accessed 20 Sep- tember 2015). 24. Smoking in Jordan, 2010 [in Arabic]. Amman: Department of Statistics; 2011 (www.dos.gov.jo/sdb_pop/sdb_pop_a/Smok- ing_2010.pdf, accessed 20 September 2015). 25. Shishani K, Nawafleh H, Jarrah S, Froelicher ES. Smoking patterns among Jordanian health professionals: a study about the impedi- ments to tobacco control in Jordan. Eur J Cardiovasc Nurs. 2011 Dec;10(4):221–7. PMID:20826114 26. Tobacco Free Initiative: Global Youth Tobacco Survey fact sheets and country reports—Jordan, 2009 [Internet]. Geneva: World Health Organization; 2009 (http://www.emro.who.int/to- bacco/gtss-youth-survey/gyts-factsheets-reports.html, accessed 20 September 2015). 27. Jaghbir M, Shareif S, Ahram M. Quitting smoking and utilization of smoking cessation services in Jordan: a population-based survey. East Mediterr Health J. 2014 Sep;20(9):538–46. PMID:25343466 28. Quit smoking [Internet]. Pharmacy 1 (http://www2.pharmacy-1. com/CustomerCenter/SmokingForm.aspx, accessed 20 Sep- tember 2015). 29. Maziak W, Jawad M, Jawad S, Ward KD, Eissenberg T, Asfar T. Interventions for waterpipe smoking cessation. Cochrane Data- base Syst Rev. 2015;7:CD005549. PMID:26228266 30. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Fed- er G, et al.; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010 Dec 14;182(18):E839–42. PMID:20603348 31. SIGN 50. A guideline developer’s handbook. Edinburgh: Scot- tish Intercollegiate Guidelines Network; 2014 (http://www.sign. ac.uk/pdf/sign50.pdf, accessed 20 September 2015). HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 851 WHO events addressing public health priorities Introduction Hospitals are an essential component of the health system; however, they are resource heavy, politically visible and costly. It is important therefore that they are run efficiently while at the same time ensuring quality BOETBGFUZPGDBSFĉFSFDPNNFOEBUJPOTPG UIFUI TFTTJPO PG UIF8)03FHJPOBM$PNNJĨFF BOEPGUIFUITFTTJPOPGUIF8PSME)FBMUI"TTFNCMZ PO8)0SFGPSNIJHIMJHIUFE UIF JNQPSUBODF PGIPTQJUBMNBOBHFNFOUĉFSFTPMVUJPOTPG UIFUI BOETUTFTTJPOTPG UIF3FHJPOBM$PNNJĨFF JO BOEBMTPBEESFTTFEIFBMUITZTUFNTUSFOHUIFOJOH and moving towards universal health coverage through strengthening service provision, including hospitals and hospital management. Most of the countries in the Eastern Mediterranean Region have no established essential hospital service package. The lack of established national or local poli- cies to specify hospital location, size and type of service is also evident. In addition, in many countries there is no balance between the capacity of the hospital system to deliver services and the needs of the population. The absence of hospital management training is par- ticularly noticeable. Thus, the WHO Regional Office for the Eastern Mediterranean organized an expert consultation on regional hospital strategy development and capacity-building of hospital managers in Cairo GSPNUP"QSJMĉF$POTVMUBUJPOXBTBĨFOEFE by professionals and experts in the area of hospital management and training from countries within and outside the Region. The objectives of the meeting were to present a situation analysis of public hospitals; share experi- ences in the area of hospital management; identify key challenges and priorities in the area of hospital management; present experiences on hospital man- agement training from outside the Region; and share the results of the training needs assessment of hospital managers and reach consensus on the outline of a training programme. The expected outcomes included identifying the key challenges and priorities in the area of hospital management in the Region, refining the outline of a training programme for hospital managers and identifying future actions to strengthen hospital management. Proposed hospital care management training programme The great need and demand for training of hospital managers in the countries of the Region through both short- and long-term courses was highlighted. The results of an on-line training needs assessment of 49 NBOBHFSTGSPNDPVOUSJFTTIPXFEUIBUUIFIJHIFTU perceived value for training was given to financial management, operations management, linkage of hospital to the health care system, strategic planning and risk management. Using feedback and data from a number of sources (the results of the assessment, a review of 18 hospital management training courses in various countries, a review of academic peer-reviewed articles and reports and consultation with five experts from both developing and developed countries), the PVUMJOFPG BEBZ USBJOJOHDPVSTF GPSFYQFSJFODFE hospital managers and qualified academic experts was presented and discussed in the meeting. Most of the participants considered that the duration and the content of the course could be reduced: greater emphasis should be paid to issues related to hospital governance and leadership, and virtual facilities could be employed to conduct courses. Other suggestions included collaboration with academic institutions in conducting the course, training of trainers to build capacities at the country level and enable rapid expan- sion of the course across the Region; however, since the training needs of hospital managers in each of the countries could be different, a customized approach should be applied. Recommended actions A number of recommendations for action were pro- posed that would facilitate strengthening hospital management in the Region in line with the challenges identified (Box 1). Strengthening hospital management in the Region This article is abridged from the Report on the expert consultation on regional hospital strategy development and capacity-building of hospital managers, held in Cairo 6–7 April 2015. The complete report is available at: (http://applications.emro.who.int/docs/IC_Meet_Rep_2015_ EN_16428.pdf?ua=1). EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 852 Box 1 Recommended actions strengthening hospital management in the Region To Member States 1. Develop/strengthen the national hospital strategic plan by the formation of a task force and membership of highly quali- fied experts, and integrate it in the national health system policy and plan. The national hospital strategic plan should be in synergy with the regional hospital care management strategy. 2. Assign a high-level task force to develop an essential hospital service package based on capacity, infrastructure and needs of the country and oversee/monitor and support improving hospital care management at national level. 3. Define and ensure essential levels of service delivery for all country hospitals through involvement of all relevant actors and community representatives. 4. Ensure the availability and accessibility of hospital beds and services based on the population needs assessment. Develop hospital service delivery profiles that are culturally appropriate and acceptable and technically feasible based on the country capacity and health system infrastructure. 6. Allocate resources, including funds, human resources and technology, for all hospitals on the basis of defined service levels. 7. Create a responsive hospital networking mechanism, interconnected to primary health care service delivery on the basis of defined services levels. 8. Promote and build the capacities of policy-makers and managers on hospital governance. 9. Support the development of an effective national plan for human resources management at the hospital level. Regulate public and private hospitals through an independent body. 11. 11. Improve hospital financial planning and management and hospital efficiency using macro- and micro-level strategies. 12. Revise the selection criteria and qualifications needed for hospital managers and organize condensed managerial courses to ensure hospital effectiveness and efficiency. 13. Institutionalize quality and safety and scaling-up of people-centred health care services using the WHO Patient Safety Friendly Hospital Initiative assessment tool. 14. Provide resources to seek out, identify and document evidence-based practices. Improve the hospital information system, particularly the medical records system, through the development of relevant tools and guidelines, providing the required supplies and equipment, and capacity-building activities related to data collec- tion, recording, analysis, reporting and feedback. 16. Develop or scale up the national hospital disaster management plan (in particular the hospital preparedness plan). 17. Use the Hospital Safety Index to assess safety and capacity to respond to disasters. 18. Develop strategies for including the voice of patients in quality and safety of care using relevant WHO guidelines and regional experience. 19. Develop a set of core indicators to assess the performance of hospitals. To WHO Create a task force/network of experts for hospital care and management. 21. Continue to enrich hospital situation analysis in the Region. 22. Develop and organize a short capacity development course for hospital managers. 23. Develop better working collaboration among the Regional Office, WHO country offices, and national focal points for hospital care and management. 24. Develop an evidence-informed regional hospital strategy, present it in an intercountry meeting, and have it endorsed by the Regional Committee. Develop tools and undertake an in-depth review of selected public sector hospitals in countries and help develop hospital strategic plans. 26. Develop a set of hospital performance indicators and pilot it in selected countries. 27. Develop policy briefs in key areas such as hospital autonomy, hospital financing and financial management, rational use of technologies in hospitals, etc. 28. Promote more applied research on hospital care and management. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 853 Background Across all countries, the major causes of health inequities arise from the social determinants of health (the conditions in which people are born, grow, live, work, and age). Reduc- ing health inequities is not only a moral imperative but will BMTPEFMJWFSXJEFS TPDJBM BOEFDPOPNJDCFOFėUT *O the WHO Commission on Social Determinants of Health produced an extensive prescription for what is required to iDMPTF UIFHBQuBDSPTTBMM TFDUPSTPGTPDJFUZ BOEBU UIF World Health Assembly Member States resolved to put those recommendations into practice by adopting Resolu- tion 62.14 “Reducing health inequities through action on the social determinants of health”. This was followed by the 8PSME$POGFSFODFPO4PDJBM%FUFSNJOBOUTPG)FBMUI which resulted in the Rio Political Declaration on Social Determinants of Health (1). Closing health equity gaps requires comprehensive, coor- dinated actions to address the social determinants of health across sectors. Nonetheless, evidence and experience from in- side and outside the Region show that it is entirely possible to reduce health inequities, even in the most challenging areas. Country experiences provide excellent examples of successful actions which can be built on and appropriately transferred to other areas. For example, the experiences of Morocco, the Is- lamic Republic of Iran and Tunisia are evidence of successful multisectoral collaboration that can largely be used by other countries of the Region. In this regard, the WHO Urban Health Equity Assess- ment and Response (Urban HEART) (2) approach is recognized as a platform to unify interventions under one umbrella at the city level. The Urban HEART tool has been successfully implemented in the Islamic Republic of Iran and Morocco to operationalize social determinants of health and address inequities in urban settings. Nevertheless, there is evidence to show persistent health inequities related to socioeconomic status, gender and ur- ban/rural differences in the Region and countries need help in implementing the recommendations for social determi- nants of health. Bringing focus on the matter Against this background, the WHO Regional Office for the Eastern Mediterranean organized a regional consultation PO UIF TPDJBMEFUFSNJOBOUTPGIFBMUIPOm"QSJM in Tehran. The meeting was attended by participants from 13 countries of the Region along with experts and staff rep- resenting the UNDP and WHO. Participants were charged with finding ways to: motivate key local policy-makers to support work on the social determinants of health; enhance community empowerment in local health and social devel- opment; design sustainable mechanisms for intersectoral collaboration and partnership for urban health development; and develop strategies to reduce health inequities. The specific objectives were to: r share and review actions being taken to operationalize the Rio Declaration at regional and global levels; r identify data gaps related to inequities; r share experiences from within and outside the Region on social determinants of health in conflict and crisis situations; r introduce options and tools to monitor and reduce health inequities, including Urban HEART. Key issues and challenges Participants discussed the main components of Regional framework for action on social determinants of health and propose interventions in respect to five domains (advocacy and capacity-building, steps towards identifying data gaps, partnership, governance, and integration of social determi- nants of health) in five WHO priority areas (communicable diseases, noncommunicable diseases, maternal and child health, health system development and emergencies). Considering the large number of countries facing conflicts and emergencies in the Eastern Mediterranean Region, a session was entirely devoted to social determinants of health in conflicts and crisis situations. Preparing for crisis – strength- ening response interventions through vulnerability reduction, intersectoral actions, city resilience, restructuring of the health system and protecting public health facilities from damage as a result of crisis – should be seriously considered as an integral part of a country’s social determinants of health plan of action. The main challenges identified were inadequate political commitment by governments and poor recognition of the social determinants of health as a priority. Other problematic areas included: unsustainable leadership; political instability/ security; lack of any mechanism to operationalize a national plan for the social determinants of health through defined roles and responsibilities; the absence of disaggregated data on inequities; inadequate institutional alignment and Reducing health inequities through actions on the social determinants of health This report is based on the report on the Regional consultation on reducing health inequities in the Eastern Mediterranean Region through actions on the social determinants of health, held in Tehran from 21 to 23 April 2015. The complete report is available at: http://applications.emro.who. int/docs/IC_Meet_Rep_2015_EN_16427.pdf?ua=1. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 854 harmonization; lack of communication between different sectors; funding constraints; fragmentation of the health sys- tem infrastructure, especially in conflict areas; weak capacity of human resources to address social determinants of health; and low utilization of public health services. The importance of partnership in tackling the adverse impact of conflicts was highlighted: without sustainable partnership, no development is possible. In this regard, the engagement of the people in priority-setting is the first step in building partnerships. UN agencies can play a key role in building partnerships at national and regional levels in response to the health ineq- uities. Capacity-building in the local community and their active engagement are crucial elements for implementation Box 1 Recommended actions on the social determinants of health Evidence-building, advocacy and capacity-building r Review available economic and social cases from other regions and their impact on social determinants of health and produce an outline and template to promote such undertakings in the Eastern Mediterranean Region. r Develop policy briefs and use these along with advocacy materials to orient high-level policy-makers and parliamentarians and encourage informed policy-making. r Orient media groups on the importance of social determinants of health and their impact on overall devel- opment, including health. Identifying data gaps and the integration of core indicators for social determinants of health in the framework of the health information system r Integrate the proposed core equity indicators in the framework of the health information system. r Engage multiple departments/ministries to identify the data gaps and the sector responsible for collection, analysis and reporting. r Establish national mechanisms for reporting and monitoring equity trends, social determinants of health and actions taken by the relevant sectors. Governance r Engage civil society and other development sectors at the local level in needs assessment, planning and implementation of social determinants of health interventions. r Assess outcomes, expand and institutionalize the social determinants of health approach as part of govern- ment development policies and plans. Partnership and harmonization r Facilitate the exchange of experiences and document good practices in addressing health inequities and social determinants of health. r Introduce and expand health insurance schemes and social protection for the poor to reduce out-of pocket health expenditure. r Engage civil society in policy dialogue and the implementation of local interventions. Integration of social determinants of health in the WHO 5 priority areas r Develop training materials on social determinants of health and their impact on health inequities for mid- level managers and health care providers. r Implement the WHO guide for the integration of social determinants of health in the five priority pro- grammes. r Integrate social determinants of health in health, medical and nursing pre-service education. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ PLïØn"ÐØ{_UÐ 855 References 1. Rio Political Declaration on Social Determinants of Health. World Conference on the Social Determinants of Health. Rio de Janeiro, Brazil, 21 October 2011 (http://www.who.int/sd- hconference/declaration/Rio_political_declaration.pdf?ua=1, accessed 22 November 2015). 2. Urban HEART: Urban Health Equity Assessment and Response Tool. Kobe: World Health Organization, The WHO Centre for Health Development; 2010 (http://www.who.int/kobe_cen- tre/publications/urban_heart.pdf?ua=1, accessed 22 Novem- ber 2015). of social determinants of health. Countries should be assisted in using a refined Urban HEART as an option to address inequities in urban settings. Closing health inequity gaps requires actions across many sectors, including government, civil society, UN agencies and other development organiza- tions, academic institutions, donors and the private sector. Countries of the Region need help in implementing the recommendations for social determinants of health, mainly promoting Health in All Policies; incorporating equity, gender and human rights into public health programmes; enhancing linkages between social and environmental determinants of health; monitoring and evaluating social determinants of health; and removing all barriers that hinder access of all to health and other social services. Choosing simple, practical yet informative indicators for monitoring health inequities is essential to proceed with the implementation of the social determinants of health national plan of action. Monitoring equity indicators is crucial; this comprises five steps: definition of indicators, obtaining data, data analy- sis, reporting (communicating) the results and implementing changes. Countries also need assistance in using the WHO Global Health Observatory and other tools like Urban HEART to monitor health equity and assist in developing responses in filling equity gaps. Actions Member States and WHO agreed to implement a number of components of the proposed regional framework for action on social determinants of health and their related actions, with tech- nical support from WHO. Selected actions are listed in Box 1 Correspondence Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int GBÐçOTogBm^TÐoZTÐod]eBogdgcRüÐoecTÐÊm[KÌëÐzcTÐ phYĆHüÐëÐ}xÎpxÚg+ nhhU i> x}UÐ ënTn= Ò{CÐph=}_UÐÓÐÚnYüÐ ënin`RÌ ëØÚúÐ WY ënfU qxcUÐ }]S N]dR ë5 ôL çÐ}_UÐ énY[UÐ ëÐØUÐ .h@ ehUÐ pxÚUÐph=}_UÐpxÚge!Ð pxØ_UÐph=}_UÐpcdeCÐ Ñ}`CÐ Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen Subscriptions and Permissions Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: emrgoksp@who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: emrgoegp@who.int. Contents Editorial Confronting climate change in the EMR: a win–win public health approach....................................................... 781 Research articles Prevalence of risk factors for noncommunicable diseases in Jalalabad city, Afghanistan, evaluated using the WHO STEPwise approach ................................................................................................................................. 783 Compliance with and knowledge about diabetes guidelines among physicians and nurses in Palestine.......... 791 Study of prevalence and effects of insulin resistance in patients with chronic hepatitis C genotype 4 .............. 803 Trauma research in Qatar: a literature review and discussion of progress after establishment of a trauma research centre ............................................................................................................................................ 811 Socioeconomic inequality and child maltreatment in Iranian schoolchildren..................................................... 819 Antibiogram of multidrug resistant Acinetobacter baumannii isolated from clinical specimens at King Hussein Medical Centre, Jordan: a retrospective analysis............................................................................. 828 Review Ageing and intergenerational family ties in Arab countries ................................................................................... 835 Report Jordan tobacco dependence treatment guidelines: rationale and development................................................ 844 WHO events addressing public health priorities Strengthening hospital management in the Region ............................................................................................... 851 Reducing health inequities through actions on the social determinants of health.............................................. 853
Всемирная организация здравоохранения (ВОЗ / WHO) · Journal articles
Eastern Mediterranean Health Journal [2015; Vol.21, Issue 11]
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