Eastern Mediterranean Health Journal [2012; Vol.18, Issue 5]

Contents V olum e 18 N um ber 5 M ay 2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 18 / No. 5 May / Mai 2012 5 ددع / شرع نماثلا دلجلما ويام / رايأ Tobacco control Tobacco use kills nearly 6 million people yearly, 600 000 of whom were exposed to second-hand smoke. Children are vulnerable both to the adverse effects of second-hand smoke and to enticement to smoke in the future. They need to be protected from both by ensuring smoke-free environments and educating them about smoking. World No Tobacco Day on 31 May 2012 focuses on the tactics of the tobacco industry to undermine tobacco control efforts, including the WHO Framework Convention on Tobacco Control. Letter from the Editor ....................................................................................................................................................... 409 Research articles Promoting public–private mix for TB-DOTS: a multi-country study from the WHO Eastern Mediterranean Region .......................................................................................................................410 Reproductive and non-reproductive health status of women aged 15 years and above in southern Jordan ...... 417 Maternal mortality in Jordan: role of substandard care and delays ....................................................................... 426 Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors .............432 Predictors of fetal demise after trauma in pregnant Saudi Arabian women ...........................................................439 General practitioners’ awareness and management of common psychiatric disorders: a community-based survey from Karachi, Pakistan ................................................................................................ 446 Smoking habits and attitudes among university students in Palestine: a cross-sectional study ............................454 Low adherence of Kuwaiti adults to fruit and vegetable dietary guidelines S. Zaghloul, C. Waslien, M. Al Somaie and P. Prakash ............................................................................................. 461 Feasibility of a peer-led, school-based asthma education programme for adolescents in Jordan...................... 468 Study of the relation between quality of inpatient care and early readmission for diabetic patients at a hospital in the Eastern province of Saudi Arabia ...............................................................................................474 Relationship between consultation length and rational prescribing of drugs in Gorgan city, Islamic Republic of Iran ............................................................................................................................................ 480 Social and behavioural HIV/AIDS research in Jordan: a systematic review .......................................................... 487 Aspects actuels des infections nosocomiales au Centre Hospitalier Libanais de Beyrouth .................................495 Evaluation of specific biochemical indicators of Helicobacter pylori-associated gastric cancer in Egypt ............ 501 نانسلأا بط ةنهم مهرايتخا بابسأ لوح قشمد ةعماج في نانسلأا بط ةيلك في بلاطلا ءارآ ............................................................................ 508 Review Appraisal of the research grant schemes of the World Health Organization Regional Office for the Eastern Mediterranean: the way forward ............................................................................................................515 Short communications Crimean–Congo haemorrhagic fever outbreak investigation in the Western Region of Afghanistan in 2008 ....522 Sanjad Sakati syndrome: a case series from Jordan .................................................................................................527 Profil étiologique des pancytopénies chez l’adulte à Marrakech (Maroc) .............................................................532 Case report Jessner lymphocytic infiltrate presenting on a cutaneous leishmaniasis scar: case report ...................................537 Translation Quality of life of Iranian β-thalassaemia major patients living on the southern coast of the Caspian Sea ...........539 Cover 18-5.indd 1 5/15/2012 9:06:51 AM Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Correspondence Editor-in-chief EMHJ 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: khayat@emro.who.int/emhj@emro.who.int 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 is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed‑Full text on CD‑ROM, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2012 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. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. 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 ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نادوسلا بونج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما 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 . South Sudan 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 . Soudan du Sud . Tunisie . Yémen Cover 18-12.indd 2 11/26/2012 2:25:16 PM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 18 No. 5 5 ددع شرع نماثلا دلجلما•  2012  • Letter from the Editor ..............................................................................................................................................................................................................................................................................................................................409 Research articles Promoting public–private mix for TB-DOTS: a multi-country study from the WHO Eastern Mediterranean Region Z. Haq, W. Khan and A. Seita ................................................................................................................................................................................................................................................................410 Reproductive and non-reproductive health status of women aged 15 years and above in southern Jordan F.A. Abu-Moghli, I.A. Khalaf, S. Tokiko, I. Atsuko, M.M. Nabolsi and B.A. Al-Sharairi ..................................................................................................................................................................417 Maternal mortality in Jordan: role of substandard care and delays A.M. Okour, Y. Khader, Z. Amarin, H. Jaddou and M. Gharaibeh ...............................................................................................................................................................................................................426 Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors F.H. Al Dallal and I.N. Grant ..............................................................................................................................................................................................................................................................................................432 Predictors of fetal demise after trauma in pregnant Saudi Arabian women A.S. Al Mulhim, M.H. Balaha and F. Tudiver............................................................................................................................................................................................................................................................439 General practitioners’ awareness and management of common psychiatric disorders: a community-based survey from Karachi, Pakistan H.A. Naqvi, S. Sabzwari, S. Hussain, M. Islam and M. Zaman ......................................................................................................................................................................................................................446 Smoking habits and attitudes among university students in Palestine: a cross-sectional study S.G. Musmar ................................................................................................................................................................................................................................................................................................................................. 454 Low adherence of Kuwaiti adults to fruit and vegetable dietary guidelines S. Zaghloul, C. Waslien, M. Al Somaie and P. Prakash ..........................................................................................................................................................................................................................................461 Feasibility of a peer-led, school-based asthma education programme for adolescents in Jordan N.A. Al-Sheyab, R . Gallagher, J.K. Roydhouse, J. Crisp and S. Shah .............................................................................................................................................................................................................468 Study of the relation between quality of inpatient care and early readmission for diabetic patients at a hospital in the Eastern province of Saudi Arabia S.A.Mokhtar, A.A. El.Mahalli, S. Al-Mulla and R . Al-Hussaini ..................................................................................................................................................................................................................... 474 Relationship between consultation length and rational prescribing of drugs in Gorgan city, Islamic Republic of Iran V. Khori, S. Changizi, Biuckians, A. Keshtkar, A.M. Alizadeh, A.M. Mohaghgheghi and M.R Rabie ........................................................................................................................................480 Social and behavioural HIV/AIDS research in Jordan: a systematic review E. Alkhasawneh, L. Ismayilova, H. Olimat and N. El-Bassel .............................................................................................................................................................................................................................. 487 Aspects actuels des infections nosocomiales au Centre Hospitalier Libanais de Beyrouth A. Al-Hajje, M. Ezedine, H. Hammoud, S. Awada, S. Rachidi, S. Zein et P. Salameh ...........................................................................................................................................................................495 Evaluation of specific biochemical indicators of Helicobacter pylori-associated gastric cancer in Egypt M.M. Anwar, A.I. Youssef, M.I. Sheta, A. Zaki, N.R. Bernaba and M.A. El-Toukhi .............................................................................................................................................................................501 نانسلأا بط ةنهم مهرايتخا بابسأ لوح قشمد ةعماج في نانسلأا بط ةيلك في بلاطلا ءارآ حلشم دوممح رماع ..........................................................................................................................................................................................................................................................................................................................508 Review Appraisal of the research grant schemes of the World Health Organization Regional Office for the Eastern Mediterranean: the way forward O. Shideed and N. Al-Gasseer ............................................................................................................................................................................................................................................................................................... 515 Short communications Crimean–Congo haemorrhagic fever outbreak investigation in the Western Region of Afghanistan in 2008 J. Moflehand A.Z. Ahmad .....................................................................................................................................................................................................................................................................................................522 Sanjad Sakati syndrome: a case series from Jordan J. Albaramki, K. Akl, A. Al- Muhtaseb, M. Al-Shboul, T. Mahmoud, M. El-Khateeb and H. Hamamy ....................................................................................................................................527 Profil étiologique des pancytopénies chez l’adulte à Marrakech (Maroc) H. Nafil, I. Tazi, M. Sifsalam, M. Bouchtia et L. Mahmal ...................................................................................................................................................................................................................................532 Case report Jessner lymphocytic infiltrate presenting on a cutaneous leishmaniasis scar: case report G. Sadeghian and H. Ziaei ................................................................................................................................................................................................................................................................................................................... 537 Translation Quality of life of Iranian β-thalassaemia major patients living on the southern coast of the Caspian Sea H. Khani, M.R. Majdi, E. Azad Marzabadi, A. Montazeri, A. Ghorbani and M. Ramezani ........................................................................................................................................................539 M. Haytham Khayat MD, PhD, FRSPH, Editor-in-chief Editorial Board Ahmad Ezzat Abdou BSc, DPH, PhD, (Secretary) Naeema Al Gasseer MSc, PhD Ahmad Bassel Al-Yousfi PhD, PE, DEE Mohamed M. Ali BSc, MSc, PhD, DTMH Abdulla S. Assaedi MBBS, MPH Mounir Farag MD, DGS, DEmS, DHP Zuheir Hallaj MD, DPH, DrPH Nahla Khamis Ibrahim MD, MPH, Dr.PH (Epidemiology), DHPE (Medical Education) Mamunur Rahman Malik MBBS, Dip(Health Economics), MSc, MPhil Ezzedine Mohsni PhD Abdulaziz Saleh Dip(Hosp Pharm), Dip(Indus Pharm), PHD Kassem Sara MD, MAM Joanna Vogel MScHS, MScPH Mohamed Helmy Wahdan MD, DPH, PhD International Advisory Panel Dr S. Aboulazm. Professor of Orthodontics. Egypt Dr Abdul Rahman Al-Awadi BSc, MD, MPH, Honorary FRCM, Ireland Dr Law, Korea, Honorary FRCS & P, Glasgow, FRCP, Edinbugh. Kuwait Dr Fariba Al-Darazi RN, MSc, PhD. Bahrain Dr M. Al-Nozha, MD, FRCP, FACC, FESC. Professor of Medicine and Consultant Cardiologist. Saudi Arabia Dr Ala’din Alwan MD, FRCP, FFPHM. Iraq Dr F. Azizi. Professor of Internal Medicine and Endocrinology. Islamic Republic of Iran Dr K. Bagchi BSc, MD, PhD. India Professor K. Dawson BA, MD, PhD, FRCP, FRACP, FRCPCH, DObst, RCOG. New Zealand Professor Kaussay Dellagi MD. Tunisia Dr R. Dybkaer MD. Denmark Dr M. Aziz El-Matri. Professor of Medicine. Tunisia Professor F. El-Sabban BSc, MS, PhD. United States of America Dr A.H. El-Shaarawi MSc (Stat), PhD (Stat). Canada Professor N. Fikri-Benbrahim PhD (Pub health) (SocSci). Morocco Professor A.T. Florence BSc (Pharm), PhD, DSc, FRSC, FRPharmS, FRSE. United Kingdom Professor Cheherezade M.K. Ghazi BS (Nursing), MS (Nursing), DPH, MPA. Egypt Professor M.A. Ghoneim MD, MD (Hons). Egypt Dr J.A. Hashmi DTM&H, FRCP. Pakistan Professor J. Jervell MD, PhD. Norway Professor G.J. Johnson MA, MD, BChir, FRCS (C), FRCOphth, DCEH. United Kingdom Dr M. Kassas. Emeritus Professor of Plant Ecology. Egypt Professor M.M. Legnain MBBS, MRCOG, FRCOG. Libyan Arab Jamahiriya Professor El-Sheikh Mahgoub DipBact, PhD, MD, FRCPath. Sudan Professor A.M.A. Mandil MSc (Paediatr), MPH, DrPH. Egypt Professor A.B. Miller MB, FRCP. Canada Professor S.S. Najjar MD. Lebanon Dr Abubaker A. Qirbi BSc, MD (Edin), FRCPC (Can), FRCP FRCPath (UK). Republic of Yemen Professor O.S.E. Rasslan MD, PhD. Egypt Professor W.A. Reinké MBA, PhD. United States of America Professor I.A. Sallam, MD, Dip High Surgery Cairo, Honorary FRCS, PhD (Glasgow), LRCP, MRCS, FRCS (London), ECFMG. Egypt Dr C.Th.S. Sibinga FRCP (Edin), FRCPath. The Netherlands Mr Taoufik Zeribi Eng BSc, MSc. Tunisia Editors Fiona Curlet, Eva Abdin, Alison Bichard, Guy Penet Graphics Suhaib Al Asbahi, Hany Mahrous, Diana Tawadros Administration Nadia Abu-Saleh, Yasmine El Sakhawy المجلة الصحية لشرق المتوسط المجلد الثامن عشر العدد الخامس 904 رسالة من المحرر rotidE eht morf retteL مع أن تقدمًا هائًلا قد تحقق في التصدِّ ي لتعاطي التبغ، من خلال اتفاقية منظمة الصحة العالمية الإطارية بشأن مكافحة التبغ واستراتيجية REWOPM، التي تقوم على رصد تعاطي التبغ؛ وحماية الناس من الدخان، وتقديم المساعدة لهم للإقلاع عن التدخين، والتحذير من أخطاره، وإنفاذ الحظر على الإعلان عن منتجات التبغ، وزيادة الضرائب. إلا أن تعاطي التبغ مازال مشكلة صحية عمومية كبرى. والعامل الرئيسي وراء ذلك هو شركات صناعة التبغ التي عقدت العزم على التحايل، وعلى استغلال جميع السُبل المتاحة كي تقّوض الجهود المبذولة للحد من استهلاك التبغ والقضاء عليها. ولذلك اختير موضوع يوم مكافحة التبغ العالمي في 13 أيار/مايو 2102 حول «تدخل شركات صناعة التبغ». والهدف هو إطلاع صانعي السياسات وعامة الناس على السُبل التي تنتهجها شركات صناعة التبغ، ضاربًة بالمبادئ عرض الحائط، وعلى ضرورة مواجهتها والحفاظ على اليقظة والالتزام. ويشكل الشباب قطاعًا من المهم الوصول إليه لتقليص استهلاك التبغ. ويضم هذا العدد من المجلة الصحية لشرق المتوسط دراسة عن عادات واتجاهات التدخين بين طلبة الجامعة في فلسطين، وقد أبلغت عن استخدام التبغ بين 53% من الطلبة، وهذا أعلى بكثير من استخدام التبغ بين عامة السكان، مما يوضح الحاجة إلى استهداف طلبة الجامعة في ما يخص مخاطر التبغ. ستعقد الدورة الخامسة والستون لجمعية الصحة العالمية في جنيف خلال الفترة من 12 حتى 62 أيار/مايو 2102، وسيناقش خلالها مواضيع الصحة العمومية الرئيسية، وتعد تقارير عنها. وتتعلق عديد من الأوراق العلمية المنشورة في هذا العدد من المجلة الصحية لشرق المتوسط بالمواضيع التي توليها جمعية الصحة العالمية الاهتمام، بما في ذلك الأمراض غير السارية، والاضطرابات النفسية، والصحة الإنجابية، والبحوث الصحية. وعلى سبيل المثال، فقد اكتشف دراسة أجريت في الأردن أن البرنامج التثقيفي الذي يرتكز على المدرسة حول الربو والذي يقوده الزملاء، قد زاد من معارف ووعي الطلبة عن الربو، وأدى إلى المزيد من الدعم المقدَّ م من الزملاء للمصابين بالربو. وأبلغت دراسة عن مرضى السكري المعالجين في المستشفى في المملكة العربية السعودية عن أن إعادة إدخال المرضى للمستشفى مبكرًا (خلال 82 يومًا من خروجهم من المستشفى) كان شائعًا، وقد تأثر ذلك تأثرًا يعتد به بجودة الرعاية التي يتلقاها المرضى الداخليون في المستشفى. وفي ما يخص الصحة الإنجابية، اكتشفت دراسة أجريت عن وفيات الأمهات في الأردن أن تدني مستوى الرعاية ساهم في حدوث 6.25% من وفيات الأمهات، بينما ساهم التأخير في السعي لطلب الرعاية في 3.55% منها، في حين أبلغت دراسة أخرى أن النساء في جنوبي الأردن قد شهدن قدرًا هائًلا من المراضة المتعلقة بالإنجاب وأمور أخرى، ولاسيَّما اللاتي يعشن في مناطق محرومة. ووجد أن سابقة الإصابة بأعراض الاكتئاب والإحساس بعدم وجود دعم من الزوج هما عاملان هامَّ ان لخطر الإصابة بالاكتئاب التالي للولادة بين النساء في البحرين، في حين أبلغ عن وجود ثغرات في معارف الممارسين العامين حول التدبير العلاجي للاضطرابات النفسية الشائعة في باكستان، مما يؤثر على الاستخدام الرشيد للأدوية النفسية التأثير. dna lortnoC occaboT no noitnevnoC krowemarF OHW eht hguorht esu occabot 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-si htlaeh cilbup yek hcihw gnirud ,2102 yaM 62 ot 12 morf aveneG ni ecalp sekat ylbmessA htlaeH dlroW eht fo noisses ht56 eTh eht ta desserdda gnieb scipot eht ot etaler JHME fo eussi siht ni dehsilbup srepap eht fo ynaM .no detroper dna dessucsid eb lliw seus ni yduts a ,elpmaxe roF .hcraeser htlaeh dna htlaeh evitcudorper ,sredrosid latnem ,sesaesid elbacinummocnon gnidulcni ,ylbmessA dna ,ssenerawa dna egdelwonk amhtsa ’stneduts desaercni emmargorp noitacude amhtsa desab-loohcs ,del-reep a taht dnuof nadroJ -simdaer ylrae taht detroper aibarA iduaS ni stneitap citebaid dezilatipsoh fo yduts A .amhtsa htiw esoht rof troppus reep erom ot del .deviecer erac tneitapni fo ytilauq eht yb decneuflni yltnacfiingis saw siht dna nommoc saw )egrahcsid fo syad 82 nihtiw( nois  lanretam fo %6.25 rof detnuocca erac dradnatsbus taht dnuof nadroJ ni ytilatrom lanretam no yduts a ,htlaeh evitcudorper sdrager sA elbaredisnoc decneirepxe nadroJ nrehtuos ni nemow taht detroper yduts rehtona elihw ,%3.55 rof erac gnikees ni yaled dna shtaed dna smotpmys evisserped fo yrotsih A .saera degatnavdasid ni gnivil esoht ylralucitrap ,seitidibrom rehto dna detaler-evitcudorper ,nemow iniarhaB ni noisserped latantsop rof srotcaf ksir tnacfiingis eb ot dnuof erew dnabsuh eht morf troppus fo kcal deviecrep -ikaP ni srenoititcarp lareneg gnoma sredrosid cirtaihcysp nommoc fo tnemeganam eht fo egdelwonk eht ni detroper era spag elihw .snoitacidem ciportohcysp fo esu lanoitar eht detceffa hcihw nats EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 410 Promoting public–private mix for TB-DOTS: a multi- country study from the WHO Eastern Mediterranean Region Z. Haq,1 W. Khan 2 and A. Seita 2 ABSTRACT This study was carried out to document the implementation status of public–private mix (PPM) in 6 member countries of the World Health Organization Eastern Mediterranean Region, with a particular focus on advocacy, communication and social mobilization (ACSM) specific to PPM. Interviews and focus group discussions were held with staff of national tuberculosis control programmes and partners. Four PPM models were being practised. For all models, ACSM specific to PPM was at the elementary stage. Participants perceived that promoting private partners was difficult, specific policy guidelines were deficient and human resources and capacity for both initiatives were lacking across the region. Building ACSM capacity is required along with the development of guidelines and the implementation of country-specific communication plans to carry out local-level advocacy, strategic communication and effective social mobilization to maximize the benefits of PPM. 1Arnold School of Public Health, University of South Carolina, Columbia-SC, United States of America (Correspondence to: drzaeem@hotmail.com). 2Stop Tuberculosis, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. Received: 06/03/11; accepted: 04/05/11 ةددعتم ةسارد :شرابلما فاشرلإا تتح دملأا ةيرصقلا لسلا ةلجاعم ةيجيتاترسا في صالخاو ماعلا ينعاطقلا ينب نواعتلا زيزعت طسوتلما قشر ميلقإ ،ةيلماعلا ةحصلا ةمظنم نم نادلبلا اتيس ويرهيكأ ،ناخ قثاو ،قلحا ميعز ةيلماعلا ةحصلا ةمظنلم يميلقلإا بتكلماب ةطبترم نادلب 6 في صالخاو ماعلا ينعاطقلا ينب نواعتلا ذيفنت تلااح قيثوتل ةساردلا هذه تَيرجأ :ةصلالخا نوثحابلا ىرجأ دقو .صالخاو ماعلا ينعاطقلا ينب نواعتلاب صالخا يعمتجلما دشلحاو ،ملاعلإاو ،ةيعوتلا تلاحم لىع زيكترلا عم ،طسوتلما قشرل ماعلا ينعاطقلا ينب نواعتلل جذمان ةعبرأ قيبطت ظحولو .مهئاكشرو لسلا ةحفاكلم ةينطولا جمابرلا في ينلماعلا عم تاعوممج في تاراوحو تاءاقل جمابرلا تَكردأ دقو .ينعاطقلا ينب نواعتلا اذله لىولأا ةلحرلما يه يعمتجلما دشلحاو ملاعلإاو ةيعوتلا تلاحم تناك جذمانلا عيجم في هنأو ،صالخاو لكل تاردقلاو ةيشربلا دراولما في ًاصقنو ،تاسايسلا ضعبل ةيداشرلإا لئلادلا في ًاصقن كانه نأو ،ًابعص ناك صالخا عاطقلا نم ءاكشرلا زيزعت نأ نواعتلاب صالخا يعمتجلما دشلحاو ملاعلإاو ةيعوتلا تلاحم لامج في تاردقلا ءانب وه بولطلما نأو ،ميلقلإا ءاجرأ رئاس في ينعاطقلا في تاردابلما ديعصلا لىع ةيعوتلا ذيفنت لجأ نم ،ةدح لىع دلب لكب ةصالخا ملاعلإا ططخ ذيفنتو ةيداشرإ لئلاد دادعإ بناج لىإ ،صالخاو ماعلا ينعاطقلا ينب .ينعاطقلا ينب نواعتلا دئاوف ميظعتل لا َّعفلا يعمتجلما دشلحاو ،يجيتاترسلاا ملاعلإا لجأ نمو ،ليحلما Promotion d'un partenariat public-privé pour le traitement de la tuberculose de brève durée sous observation directe (DOTS) : une étude multipays dans la Région OMS de la Méditerranée orientale RÉSUMÉ La présente étude a été menée pour documenter le statut de mise en œuvre du partenariat public-privé dans six pays membres de la Région OMS de la Méditerranée orientale, avec une attention particulière pour la sensibilisation, la communication et la mobilisation sociale (SCMS) propres au partenariat. Des entretiens et des groupes de discussion thématiques ont été organisés avec le personnel des programmes nationaux de lutte contre la tuberculose et les partenaires. Quatre modèles de partenariat public-privé ont été mis en pratique. Pour tous les modèles, les activités de SCMS spécifiques au partenariat étaient à un stade élémentaire. Les participants percevaient la promotion des partenariats privés comme difficile, les directives politiques spécifiques comme déficientes et les ressources humaines et les capacités pour les deux initiatives comme insuffisantes dans l'ensemble de la Région. Le renforcement des capacités en matière de SCMS est requis ainsi que l'élaboration de directives et la mise en œuvre de plans de communication spécifiques aux pays pour mener à bien la sensibilisation, la communication stratégique et une mobilisation sociale efficace au niveau local et optimiser les bénéfices du partenariat public-privé. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 411 Introduction Global incidence, prevalence and mortality due to tuberculosis (TB) are falling, albeit slowly [1]. This reduction has been achieved following the imple- mentation of many strategic steps, one of which is engaging all forms of health- care providers in TB control. According to the most recent report by the World Health Organization (WHO) [1], this engagement, termed public-private mix (PPM), resulted in around one fifth to one third of case notifications in 2009 in 15 countries where PPM was implemented. To achieve the target of halving the 1990 prevalence rate by 2015, further intensification of efforts including implementation of PPM in many other countries has been recom- mended in the WHO report. The innovation of PPM aims at maximizing the implementation of di- rectly observed treatment short course (DOTS), a revolutionary step intro- duced in 1991, which helped achieve the targets of global TB control. Build- ing on the successful implementation of DOTS over 15 years, a new strategy was formulated in 2006 with PPM included as component 4 of this revised strategy [2]. PPM was introduced following the recognition that DOTS services pro- vided by the public sector national TB programmes (NTPs) were not enough, and many patients with symptoms of TB were receiving care from outside the network of NTP services. It was envisaged that involving all stakeholders belonging to various segment of the public and private sectors would expand diagnostic as well as treatment services for TB [3]. Envisioning a TB-free world, the new strategy also aimed at empower- ing people and communities with TB (component 5) through advocacy, communication and social mobiliza- tion (ACSM) [4]. Advocacy is ensur- ing political and financial commitment to place TB high on the development agenda and to involve the people affected and their communities. Com- munication aims at facilitating dialogue and information sharing, helping people to understand and to influence positive- ly their health-related behaviour, while social mobilization is promotion of the active involvement of people with TB and communities in health initiatives [5]. Combined, ACSM aims at rais- ing awareness among individuals and communities, and promoting DOTS services to facilitate the implementation of all 6 components of the Stop-TB strategy [6]. The WHO provided guidelines on PPM and ACSM, following which member countries were expected to develop and implement their national plans and strategies [3,6]. While experi- ences have been shared from imple- mentation and evaluation of PPM [7,8], fewer published studies are available on ACSM [9], and virtually none on ACSM specific to PPM. We carried out a study to document the overall imple- mentation status of PPM in 6 countries associated with the Eastern Mediter- ranean Regional Office (EMRO) of the WHO, with a particular focus on ACSM specific to PPM. An effort was made to identify the linkages and complemen- tarities between the 2 components and how countries were using these inter- linkages. This paper describes the status of ACSM with reference to PPM, chal- lenges faced by these components and suggestions to address these challenges. Methods Study design The study aimed at exploring the status of PPM and ACSM in 6 countries of the region, and how countries were dealing with combination of the 2 innovative ideas. A qualitative study design was adopted to capture the naturally oc- curring events in a programme setting, a method that effectively uncovers the significance that participants ascribe to programme structures, processes, events, and outcomes [10]. Prospective respondents were busy professionals; therefore individual interview was se- lected as the main method for recording participants’ experiences, perceptions and views about the issues under discus- sion. Focus group discussions were also planned; the objective of these was to brainstorm potential ideas about the role of ACSM specific to PPM. Population and sampling We purposively selected 6 countries that had a combination of higher inci- dence of TB, a considerable role of the private sector in overall healthcare, and reported ACSM activities by the NTP. Potential participants who could bring diversity of experience and opinion to this study were contacted through email; these included NTP managers, deputy managers, PPM and ACSM focal persons, other senior NTP mem- bers, representatives of partner non- governmental organizations (NGOs), and relevant staff at WHO Country Offices. The contacts were jointly fa- cilitated by the Stop-TB Department at WHO/EMRO and the WHO office in the respective country. Consent- ing countries and programmes were visited for meetings and discussions. During meetings, the NTPs proposed and arranged meetings with officials of various public departments e.g. prison, the health insurance organization and health providers belonging to both the public and private sectors in the respec- tive country. Instruments and data collection Guidelines for in-depth interviews and focus group discussions were devel- oped in the light of the sample ques- tions provided in the WHO-ACSM document [6]. Open-ended questions about various PPM models in the country, how this innovation was being promoted through ACSM activities, and what could be done to improve it in future, were included. The interview EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 412 and discussion guides were validated through a pilot test with officials of NTP Pakistan in Islamabad. We conducted in-depth interviews and focus group discussions with key informants in major cities of all the 6 countries under study. All participants were interviewed to ensure attainment of maximum information. The number of focus group discussions per country was dictated by the availability of a suf- ficient number of participants (5–8), and feasibility within the available time. English was the main medium of com- munication during the discussions. Representative from the NTP acted as interpreters to facilitate 2-way com- munication when participants could not speak English. Manual note-taking was done at the time of interview or discussion. Participant anonymity and confidentiality was discussed before the interview/focus group discussion, and ensured at every stage. Analysis The analysis began on the same evening by perusing notes of the interview or discussion held that day and summariz- ing it in the form of a table to show the highlights of each interview or dis- cussion. Guidance or clarification was sought from the participants for any ambiguities while the researcher was present in the country for the study. Detailed notes and transcripts were sub- jected to inductive analysis by reading and re-reading notes, manual coding, grouping ideas together as categories, identifying patterns within and between categories and final interpretation of emergent themes [10,11]. The findings of this stage of analysis were matched with the tables developed earlier to remove misconceptions or chances of misreporting. The findings were shared with the relevant NTP for their com- ments, questions and clarifications. The findings were reviewed by another expert to ensure congruence among the research questions, responses and their analysis. Improvements were made by addressing discrepancies and clarifying questions raised. The guiding documents published by the WHO, including guidance on PPM [3], and the guidebooks on com- munity involvement in TB care and ACSM [5,6] were perused. Relevant documents available from the countries under study were also reviewed. These included draft PPM guidelines from Afghanistan and, the ACSM strategy document from Egypt and the PPM guidelines and ACSM strategy docu- ment from Pakistan [12,13]. This part of the exercise focused on knowing whether these guiding documents pro- vided some direction on ACSM specific to PPM. The latest relevant data from WHO reports were used to compile a TB-PPM profile of participant coun- tries for this paper. This study was commissioned by WHO EMRO and conducted by a Regional consultant with experience on implementation and evaluation of health communication campaigns. The study was carried out from 2 March 2009 to 24 June 2009. Results All 6 invited countries agreed to par- ticipate in the study; these were Af- ghanistan, Egypt, the Islamic Republic of Iran, Pakistan, Tunisia and Yemen. Background data from participant countries is presented in Table 1. The countries had a range of population size (10 million in Tunisia to 181 million in Pakistan) coupled with high incidence of TB and a relatively greater contribu- tion to healthcare by the private sector. Table 1 Background data from 6 countries of the Eastern Mediterranean Region Indicator Pakistan Egypt Islamic Republic of Iran Afghanistan Yemen Tunisia Population (millions)a 181 83 74 28 24 10 Urban population (%)a 36 43 68 24 31 67 Private expenditure on health (% of total health expenditure)a 70.0 61.9 53.2 76.4 60.4 49.5 Incidence of TB (all forms)b 231 19 19 189 54 24 Case detection rate (all forms)b 76 63 73 49 67 86 Treatment success (%)b 90 89 83 88 85 86 Notification rateb 175 12 14 93 36 21 TB mortality rate (per 100 000 population)b 33.0 1.1 2.4 37.0 8.2 1.8 Average delay in diagnosis (days)c 101 57 127 NA 59 NA aWorld Health Statistics 2010 (WHO). bGlobal Tuberculosis Control 2010 (WHO). cDiagnostic and Treatment Delay in Tuberculosis 2006 (WHO-EMRO). TB = tuberculosis. NA = not available. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 413 We carried out in-depth interviews with 27 key informants in 8 major cities of the 6 countries under study. We also conducted 6 focus group discussions with a total of 36 participants (range 5–10) in 5 countries under study: no focus group discussion could be ar- ranged in Afghanistan because of time constraints. Eleven respondents in the 27 in-depth interviews and 10 par- ticipants in the focus group discussions were female. The participants dealt with policy and implementation is- sues of TB care and came from various tiers, including the national (central or federal), intermediate (provincial, directorate or university) and local (district or sub-district) administrative or implementation level. The various PPM models being practiced in each country and issues re- lated to ACSM within each model were discussed. A summary of these models and ACSM performance within each model is provided in Table 2. In most of the countries the NTP was carrying out training of health professionals on TB care and providing TB drugs free of cost to the partners. Sporadic ACSM activi- ties that mostly comprised distributing information, education, communica- tion materials were being carried out. A notable social mobilization activity spe- cific to PPM was the free chest camps by an NGO under the social franchising model in Pakistan. These were camps where the patients could get basic di- agnostic and treatment services free of charge for 1 day at the clinic of a private provider; they publicized the private provider’s involvement, and promoted TB-DOTS services in the area. The issues and challenges faced by the programmes and possible solutions to these challenges in implementing ACSM specific to PPM emerged from the discussions are described here. Elementary stage Participants described both ACSM and PPM as relatively newer areas for them in TB care. The programmes were in the phase of understanding both con- cepts and implementing the initial steps. Some countries were still developing the broader strategy or guidelines for ACSM/PPM. Therefore the interlink- ages that could be developed were yet to be fully comprehended. According to NTP officials from Afghanistan, “Our department of new initiatives is resource- and capacity-constrained. We are in the phase of developing the broader ACSM framework, which has taken a lot of time. Once the broad framework is available, only then we can think of specific activities to pro- mote PPM.” In countries like Pakistan, where the for-profit PPM partners were especially promoted to some extent, the task was being done independently by the NGOs responsible for provision of curative services as well. In Yemen, the ACSM was mainly confined to advo- cacy meetings with departments and private providers. The participants also stated that minimal guidance was avail- able on using various communication channels to promote PPM, and coun- tries were dealing with this aspect in a piecemeal fashion. Perceived difficulties The participants felt that engaging and promoting private providers was difficult because the “disease of poor” did not seem to offer profits. The pro- grammes thought that selling TB (the disease of the poor) was difficult, and innovative thinking was required to develop logical arguments to market TB to private providers as a disease that can bring profits. How to sell the idea to private providers and promote their services was a challenge. The NTP officials from Afghanistan, Egypt and Pakistan shared the additional dif- ficulty that many health providers in their country fell in “grey areas” because they served as public sector providers in the morning and private providers in the evening. According to the NTPs in Egypt and Pakistan “The difficulty is that the private practice of a doctor serving in the public sector is not officially ac- knowledged. Promoting them as private providers becomes a little difficult for a public sector programme.” Another difficult area was ensuring effective counselling by the busy private provider. Effective counselling by pro- viders is seen as the most powerful tool in identifying suspects, convincing them on sputum microscopy and ensuring compliance of treatment. Yet according to participants, the busy private provid- ers did not impart counselling because Table 2 Status of public–private mix (PPM) and advocacy, communication and social mobilization (ACSM) in 6 countries of Eastern Mediterranean Region Mix Partners ACSM status Public–public NTP with department of prisons, police, military, etc. Sporadic production and usage of PPM-specific information, education, communication materials Public–semi public NTP with insurance and parastatal organizations ACSM limited to distribution of materials, no emphasis on ACSM specific to the partnership Public–private (non-profit) NTP with NGOs managing DOTS Partner NGOs carrying out independent ACSM activities according to their understanding and capacity Public–private (for profit) NTP with private providers, directly, or through NGO Local level ACSM only where the private provider is engaged by the NGO NTP = National TB programme; DOTS = directly observed treatment, short-course; NGO = nongovernmental organization. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 414 of time constraints and there seemed no way to work around this constraint. Policy issues Participants mentioned the lack of policy direction on whether and how to use mass media for ACSM specific to PPM. Programmes had been using mass media for the promotion of public sector services in the past and felt ap- prehensive while making commitments on behalf of the partners, especially the for-profit private sector. Representa- tives of NTP and partner organizations in Pakistan stated, “The private sector is not regulated and includes unqualified, unregistered practitioners commonly called quacks. En-bloc promotion of such a sector can be misconstrued as promotion of the illegal practitioners as well.” The participants also shared that there were larger policy issues in play. The PPM partnerships were yet to integrate within the larger system, i.e. at inter-ministerial level or sometimes within various programmes under the ministry of health. According to NTP Pakistan, “Lady Health Workers of (another) national programme can be effective in promoting PPM in rural areas, but a decision to engage them to promote private providers (where required) needs deliberation and direc- tion from the health ministry.” National TB Programme capacity and additional issues Lack of human resources and relevant capacity for both PPM and ACSM were reported throughout the Region. Pakistan had a team while Egypt and Afghanistan had 1 person at central level for ACSM. The rest of the coun- tries relied on delegating ACSM to officials primarily responsible for other programme activities. Some countries were yet to produce strategy documents and action plans for PPM and ACSM. Among those who had developed some, Pakistan had finalized both docu- ments while Afghanistan and Egypt had produced the draft versions of these strategy documents. Additionally, a vari- ation was found across countries in the felt need for ACSM specific to PPM. Countries having a significant private sector role (Afghanistan, Pakistan and Yemen) felt a stronger need for cam- paigns that could help promote PPM partners, especially the for-profit private providers. Addressing the challenges The participants felt a strong need for developing a clear road map on ACSM in the area of PPM-DOTS. The senti- ment was profound in countries where involvement of the private sector in the overall health care was consider- ably greater as compared to the other countries. These countries expressed the need for more assistance in terms of guidelines and training on the complementarities of these 2 impor- tant components of TB-DOTS. The participants also shared their views on how the issues and challenges facing this important component could be addressed in accordance with the local context (Table 3). The ideas included developing a clear thinking and action plan; the strategic use of mass media and on-the-ground communication; involving journalists to alleviate pub- lic apprehensions about the costs of obtaining treatment from the private sector; effective social mobilization events like holding free medical camps at private providers' clinics; and giving more representation to all PPM part- ners in events like World TB Day. Discussion To our knowledge, this is the first study that looked into the interlinkages be- tween PPM and ACSM, 2 important components of the new Stop-TB strat- egy. PPM is an innovative approach that can play a significant role in countries where a large segment of the popula- tion seeks health care from the private sector. Our study has highlighted the need for developing a comprehensive ACSM strategy specific to PPM, and provided direction on how PPM could be promoted and strengthened through strategic advocacy and communication. Global TB control is facing many practical challenges, including weak health systems and services, deficient human resources and demand for increasing access to quality care [2]. Maximum efforts are required to meet these challenges and approaches like PPM can help achieve the global TB control targets [14,15]. In this context, the health care provided by the private sector has special significance in re- source-poor countries because much of the population in these countries seeks health care from individual or institu- tional private health care providers [8]. Yet it is also true that the management practices of these private providers are often not satisfactory [8,16]. Formal involvement and better communica- tion skills of private providers can im- prove uneven TB management and advance people’s access to quality TB care [8,17]. ACSM can help in effective involvement of these private providers, and ensure mutual benefits. Effective advocacy to involve pri- vate providers in TB care and delivery of client-centred health education messages has been successfully im- plemented in small-scale projects [9] and can be scaled up by the larger programmes. Promoting the engage- ment of all partners, especially the for-profit, however, is a bold step and embedded within it are some conten- tious issues. Advertising the for-profit private sector through the mass me- dia, asking community health workers from the public sector to refer cases to private providers, making choices of partnering between regulated or unregulated, and formal or informal private providers as partners, and making decisions on how to promote them are a few examples. Country programmes shared their thoughts on طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 415 how to address these issues. There is a need for policy directions and guide- lines from ministries of health and the WHO on this particular aspect of the Stop-TB strategy. Lack of capacity to develop, imple- ment and evaluate action plans on stra- tegic communication was omnipresent in this study. More important was the lack of leadership skills to deal with the Table 3 Suggestions to address challenges faced by advocacy, communication and social mobilization (ACSM) specific to public–private mix (PPM) Suggestion Explanation Improve planning Improved policy directions Technical assistance agencies should help develop ACSM guidelines specific to PPM. Country programmes should crystallize their thinking on dos and don’ts of ACSM for PPM and disseminate it. Communication plan to promote PPM and enhance private provider’s interest A well-thought, PPM-specific communication plan catering to local context should be developed by involving stakeholders, especially the private providers. It should: • have clear communication objectives e.g. raising awareness among people about availability of DOTS at local general practitioners clinic; • outline appropriate channels to be used for promoting PPM; • allocate the roles and responsibilities; • complement the broad ACSM. Market TB to private providers One-on-one sensitization meetings with private providers The meeting should highlight what each partner could bring to the table: • PPs: provide service to poor TB patients and help NTP achieve its targets; • NTP: enhance number of overall patients for the private provider and promote services provided at his/her clinic. Free health/chest camps at/ around the PP’s facility as part of social mobilization NTP through SM partners can hold free health/chest camps at PP’s facility. The event publicized at the local level can increase number of patients for the PP, while NTP captures more suspects in the area Focus on local-level advocacy Seminars for local level advocacy and social mobilization In the initial phase the seminar should introduce the team to make the area TB free. Teams include health department officials, NTP, the private sector and the citizenry. Later, the events should celebrate the progress, and honour the partners, especially leadership and the private providers with some rewards. Involving private sector in world TB day activities The day is celebrated with enthusiasm but PPs are usually ignored. They should be on board during the planning as well as execution of activities of the day. Use a media-mix Suggestions for using the mass media The message should not promote public facility but “health facility”. Some media products (e.g. television drama, television or radio spot, newspaper advertisement) should present DOTS being administered at private clinics. Discourse on TB (e.g. talk shows) should engage PPs and present them as part of the team. Effective client provider interaction Picking up suspects, convincing them about sputum testing and ensuring treatment compliance are the main pillars of TB care, all needing effective interaction by the provider. This requires a comprehensive training and monitoring system that enables the busy PP to effectively communicate in a short time and involving paramedics when the PP is busy and cannot give adequate time and emphasis to counselling Involving CHWs Where available, the CHW should educate the household and community on TB. The CHWs employed by the public sector may be allowed to refer suspects to a PP in case the public facility is not available/accessible. Build relevant capacity Capacity of NTP There should be conceptual clarity on PPM and specific ACSM initiatives. PPM and ACSM trainings should be organized for relevant staff. Operations research Process of development, implementation and evaluation along with its findings should be documented Countries at relatively advanced levels of ACSM implementation should share their lessons for the benefit of other countries. DOTS = directly observed treatment, short-course; PP = private provider; TB = tuberculosis; NTP = National TB Programme; SM = social mobilization; CHW = community health worker. contentious issues inherent in all kinds of partnerships. The public sector has traditionally worked on a track sepa- rate from the private sector—many times in a supervisory or regulatory EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 416 References 1. Global tuberculosis control. WHO report 2010. Geneva, World Health Organization, 2010 (WHO/HTM/TB/2010.7). 2. Raviglione M, Uplekar M. WHO’s new Stop TB strategy. Lancet, 2006, 367:952–955. 3. Engaging all health care providers in TB control: guidance on implementing public-private mix approaches. Geneva, World Health Organization, 2006 (WHO/HTM/TB/2006.360). 4. Stop TB Partnership and WHO. Global Plan to Stop TB 2006– 2015. Geneva, World Health Organization, 2006 (WHO/ HTM/STB/2006.35). 5. Community involvement in tuberculosis care and prevention: towards partnership for health. Geneva, World Health Organi- zation, 2008 (WHO/HTM/TB/2008.397). 6. Stop TB Partnership. Advocacy, Communication & Social Mobilization (ACSM) for tuberculosis control: a handbook for country programmes. Geneva, World Health Organization, 2007. 7. Dewan P et al. Improving tuberculosis control through pub- lic–private partnership in India. British Medical Journal, 2006, 14(8):1066–1068. 8. Lonnroth K et al. Public–private mix for DOTS implementa- tion: what makes it work? Bulletin of the World Health Organi- zation, 2004, 82:580–586. 9. Krishnan N et al. Impact of advocacy on tuberculosis manage- ment practices of private practitioners in Chennai City, India. International Journal of Tuberculosis & Lung Disease, 2009, 13(1):112–118. 10. Miles M, Huberman A. Qualitative Data Analysis an Expanded Sourcebook, 2nd ed. Thousand Oaks, California, Sage Publica- tions, 1994. 11. Pope C, Zieblan S, Mays N. Qualitative research in health care: analyzing qualitative data. British Medical Journal, 2000, 320:114–116. 12. Ahmed N, Mann G. Situation analysis, Public–private partner- ship models, operational and monitoring & evaluation guidelines for National TB Control Programme Pakistan. Pakistan, Techni- cal Assistance Management Agency to the National Health & Population Welfare Facility, 2006. 13. Advocacy, communication and social mobilization: national strat- egy and operational guidelines: National Tuberculosis Programme. Islamabad, Ministry of Health, Government of Pakistan, 2008. 14. Ahmed J et al. Public private mix model in enhancing tubercu- losis case detection in District Thatta, Sindh, Pakistan. Journal of the Pakistan Medical Association, 2009, 59:82–86. 15. Saw S et al. Public and/or private health care: Tuberculosis patients’ perspectives in Myanmar. Health Research Policy and Systems, 2009, 7:19. 16. Hussain A et al. Adherence of private practitioners with the National Tuberculosis Treatment Guidelines in Pakistan: a survey report. Journal of the Pakistan Medical Association, 2005, 55(1):17–19. 17. Lewis C, Newell J. Improving tuberculosis care in low income countries–a qualitative study of patients’ understanding of “patient support” in Nepal. BMC Public Health, 2009, 9:190. 18. Hurtig A et al. Linking private and public sector in tuberculosis treatment in Kathmandu Valley, Nepal. Health Policy and Plan- ning, 2002, 17 (1):78–89. 19. Rangan S et al. Tuberculosis control in rural India: lessons from public-private collaboration. International Journal of Tubercu- losis and Lung Disease, 2004, 8(5):552–559. role. Dealing with the same private pro- viders as partners and accepting that they could also add value needs leader- ship, advocacy and communication re- sources that were found to be deficient. Similar programme challenges like lack of human resources, frequent transfers and apathy at the lower level of DOTS implementation have been reported in the past [18,19]. Building the ACSM capacity of the programmes is impor- tant as ACSM provides the opportunity to public and private partners to open up, overcome the barriers and work in a closely knit environment where all the stakeholders can achieve their targets. Our study was constrained by fre- quent travels within short periods of time, language issues, small number of interviews with private providers and lack of contact with patients. We did not look into the impact of specific ACSM activi- ties on PPM and their outputs as this was not within the scope of this study. These limitations notwithstanding, the study highlights an important issue in the current TB control efforts and suggests ways to address these issues. More research on the topic can further illuminate this area. More importantly, development of clear policy guidelines and improved capacity can help PPM in making significant contribution to TB- control efforts during the next decade. Conflict of interest None declared. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 417 Reproductive and non-reproductive health status of women aged 15 years and above in southern Jordan F.A. Abu-Moghli,1 I.A. Khalaf,1 S. Tokiko,2 I. Atsuko,2 M.M. Nabolsi 1 and B.A. Al-Sharairi 3 ABSTRACT Failure to address women’s health, including their reproductive health needs, increases health care costs and social inequity. This descriptive study assessed the reproductive and non-reproductive health status of women over 15 years old in poverty pockets in the southern region of Jordan. Two villages were selected using purposive sampling and all women in the villages were invited to participate in a “healthy family week”: 259 responded to the invitation. Although 49.4% of the surveyed women were overweight or obese, only 8.5% had high blood pressure. Reproductive health concerns included the high proportions of women married at an early age (15–20 years) (76.8%), having 5+ children (43.1%) and with haemoglobin level < 12 g/dL, indicating anaemia (55.5%). Urinary tract infection was the most common health problem (29.0%). Health care providers should be sensitized to the health needs of Jordanian women in general and those living in disadvantaged areas in particular. 1Faculty of Nursing, University of Jordan, Amman, Jordan (Correspondence to F.A. Abu-Moghli: fathieh@ju.edu.jo). 2Integrating Health and Empowerment of Women in the South Region Project, Japan International Cooperation Agency, Amman, Jordan. 3Amman Airport Health Centre, Ministry of Health, Amman, Jordan. Received: 29/07/10; accepted: 24/01/11 ندرلأا بونج بركأف ةنس 15 رمعب تايتفلل ةيباجنلإا يرغو ةيباجنلإا ةيحصلا ةلالحا يرياشرلا ماسب ،سيلبان رانم ،وكوستأ وتوميإ ،وكيكوت وتاس ،فلخ ماعنإ ،ليغم وبأ ةيحتف مقافيو ،ةيحصلا ةياعرلا ةفلكت نم ،نيهدل ةيباجنلإا ةحصلا تاجايتحا ةيبلت كلذ في ماب ،ءاسنلا ةحصب مماتهلاا ءلايإ في لشفلا ديزي :ةصلالخا يتلا بويلجا في ةنس 15 رمع نم بركأ تايتفلل ةيباجنلإا يرغو ةيباجنلإا ةيحصلا ةلالحا ةيفصولا ةساردلا هذه تمَّيق دقو .يعماتجلاا فاحجلإا ةحص عوبسأ" في ةكراشملل ينتيرقلا في ءاسنلا عيجم تَيعُدو ،ةفدهتسم نايتعا ةقيرطب ينتيرق نوثحابلا راتخا دقو .ندرلأا بيونج في رقفلا اهيف شرتني %8.5 نإف ،ةنمسلا وأ نزولا طرف نم ينناعي َّنك حسلما ةسارد في نكترشا تيلالا ءاسنلا نم %49.4 نأ عمو .ةوعدلل نهنم 259 باجتسا دقو :"ةسرلأا رمع في نجوزتي تيلالا تايتفلا ةبسن عافترا لىع ةيباجنلإا ةحصلل ةبسنلاب قلقلل ةيرثلما لماوعلا لمتشتو .مدلا طغض عافترا نم ينناعي نك طقف نهنم لىإ يرشي امم ،ترلسيدلا في مارغ 12 نع ينبولغوميلها ىوتسم ضافخناو ،)%43.1( لافطأ 5 نم رثكأ ةدلاوو ،)%76.8( تغلب ثيح )ةنس 20-15( ركبم ةياعرلا وم ِّدقم نوكي نأ بيج ،انه نمو .)%29.0( ًاعويش ةيحصلا لكاشلما رثكأ يه ةيلوبلا ىوادعلاب ةباصلإا تناكو .)%55.5( مدلا رقفب نهتباصإ .ةمورحلما قطانلما في نشعي تيلالا ءاسنلل ديدحتلابو ،ماع وحن لىع ،ندرلأا في ءاسنلل ةيحصلا تاجايتحلااب ًايعو رثكأ ةيحصلا État de santé génésique et non génésique des femmes âgées de 15 ans et plus au sud de la Jordanie RÉSUMÉ L'absence de prise en compte de la santé des femmes, et notamment de leurs besoins en santé génésique, augmente le coût des soins de santé et l'inégalité sociale. La présente étude descriptive a évalué l'état de santé génésique et non génésique de femmes de plus de 15 ans dans des poches de pauvreté de la région méridionale de Jordanie. Deux villages ont été sélectionnés selon un échantillonnage dirigé et toutes les femmes des villages ont été invitées à participer à une « semaine de la santé de la famille » : 259 ont répondu à l'invitation. Bien que 49,4 % des femmes interrogées étaient en surpoids ou obèses, seules 8,5 % présentaient une hypertension artérielle. Une forte proportion (76,8 %) de femmes mariées jeunes (entre 15 et 20 ans), le fait d'avoir cinq enfants ou plus (43,1 %) et un taux d'hémoglobine inférieur à 12 g/dl, indiquant une anémie (55,5 %) comptaient parmi les préoccupations de santé génésique. Les infections urinaires étaient le problème de santé le plus fréquent (29,0 %). Les prestataires de soins de santé devraient être sensibilisés aux besoins sanitaires des femmes jordaniennes en général et des femmes vivant dans des zones défavorisées en particulier. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 418 Introduction Women’s reproductive health prob- lems and illnesses, which are often preventable, harm not only the women but also their children and families and consequently the quality of life in a region. The health of many women in developing countries has been traumatized by difficult environmental conditions, excessive workload at home and outside, repeated child bearing and inadequate diet and health care [1]. Yet the health status of women has only recently been addressed [2,3]. Failure to address women’s health care needs throughout their lifespan, including their reproductive health needs, increases both health care costs and social inequity in the Eastern Mediterranean region [4]. In view of this, the content of the 2007 Jordanian Family Health Survey was expanded to include additional data on ever-married women’s reproductive health, knowl- edge of sexually-transmitted infections, domestic violence and early childhood development [5]. Previous studies in Jordan indicated that women suffer from an appreciable level of morbidity as they approach menopause, includ- ing urinary incontinence, urinary tract infections (UTI), reproductive tract in- fections (RTI) and genital prolapse [1]. The health awareness of these women lagged behind the identified prevalence of the studied conditions. Similar results were reported by a study of women aged 50–65 years in underprivileged areas of southern Jordan [6]. Women were reported to have multiple menopause- related symptoms and morbidities. The majority of them did not receive any health education about this phase of their life, and preventive health practices and health-promoting behaviours were relatively uncommon. Another 2-phase community based study in Belqa gov- ernorate indicated that three-quarters of women suffered from one or more reproductive and/or non-reproductive disease [3]. It also indicated that women generally tended to underestimate the degree to which they were affected by these morbidities. The present study aimed to assess the reproductive and non-reproductive health status of women aged over 15 years in the southern region of Jordan. The results might provide data that can be used by health care administrators and providers in establishing new, more effective national guidelines and proce- dures for health care services tailored to the health needs of women in disadvan- taged regions. Methods Data for this study were derived from a project entitled “Integrating Health and Empowerment of Women in the South Region”. The study utilized a 2-phase survey design to assess the reproductive and non-reproductive health status of women in 2 target areas in the southern region of Jordan. Setting and sample Southern Jordan is a disadvantaged re- gion compared with other regions of the country, containing 6 of the country’s 20 poverty pockets according to the 2004 report Jordan poverty assessment [7]. The project chose its focal areas from these poverty pockets, where an intensive effort was to be made to im- prove the situation of women’s health as well as enhancing their empower- ment by taking an integrated and multi- sector approach. Using a purposive sampling procedure, a village from Aqaba governorate and another from Ma’an governorate, which fulfilled the criteria for inclusion, were selected to represent the southern region of Jor- dan. Criteria for the selection of the communities for this study included: being a focal area; existence of strong leadership with a community leader (sheikh); community members’ willing- ness to carry out collective voluntary work for the community; and existence of a community-based organization (jamaieh). All women aged 15 years and above in the selected villages were invited to participate in a healthy family week by visiting the nearest primary health care centre where health examinations and treatments were carried out. The sample included 259 women who responded to the invitation; 113 from Aqaba gov- ernorate and 146 from Ma’an governo- rate The overall response rate was 56.4% (71.5% in Aqaba and 48.5% in Ma’an) based on 2006 census data. Study tool A data collection tool to assess the health condition of women was developed by the researchers with the assistance of a representative from the Jordanian Ministry of Health (MOH) and the physicians who were part of the data collection team. Development of the tool was based on a thorough review of the literature and a review of the health assessment tools available at the MOH and other health care sectors that had been tested for validity and reliability. The tool comprised 2 parts. Part 1 col- lected data on: demographic variables; reproductive health history; and physi- cal and physiological measurements (including height, weight and blood pressure). Part 2 was the results of a current health assessment (including measurement of haemoglobin level and a reproductive health examination). Several meetings were conducted between the consultants, the project managers from Japan International Cooperation Agency and the MOH and the physicians (data collectors) to validate the data collection instru- ment, to ensure that ethical issues were considered and to agree on the data collection method to be followed in order to ensure inter-rater reliability. Data collection The study proposal and data collection tool were approved by the Directorate of Research and Technical Office at the طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 419 MOH that was assigned the responsi- bility as an institutional review board. The tribal leaders of the 2 villages were contacted, informed about the purpose of the study and asked for assistance in distributing the invitations for participa- tion. The tribal leader of the selected villages encouraged the population to participate. Men who support the tribal leader visited and talked to the heads of the household and handed over the invitation cards directly to them. They also encouraged the heads of the house- holds to let target women participate in the event by ensuring health checkups would be done free and that medicines would be provided free according to need. Moreover, since the communities consisted of the same family (tribe), there was a strong network within the community where information could spread easily. Transport was arranged by the project for one of the 2 com- munities where the members could not reach to the event venue on foot. Two consecutive healthy family weeks (1 in each village) were set up for data collection purposes. Each healthy family week extended over 6 days (from 9–14 June and from 23–28 June 2007). Five professional nurses, 3 midwives, 6 female physicians (2 gynaecologists, 2 family physicians and 2 paediatricians) and 3 laboratory technicians collected the data. All members of the data collec- tion team were MOH staff. They were trained prior to the data collection on the methods of conducting interviews and performing health assessments. Data collection in each village was designed as a 2-phase process. The first phase was conducted by nurses and midwives and consisted of a structured personal interview to collect demo- graphic data and data related to the women’s general and reproductive health history and an measurements of body temperature, blood pressure, height and weight. Three successive measurements each of vital signs, weight and height were taken to assure the reli- ability of the measures. The successive measurements agreed within 0.1 cm for height and 0.1 kg for weight and were used for the calculation of body mass index (BMI) (weight in kg/height in m2). During this phase, the women were familiarized with the purpose of the study and their verbal consent to participate in the second phase was ob- tained. They were informed that their participation was voluntary and that they could withdraw at any time. The second phase was conducted by the physicians and involved a follow- up physical examination, including a pelvic examination, and blood sample for haemoglobin testing. All women (100%) were interviewed and con- sented to the physical examination. Single women and those suspected or confirmed pregnant were not eligible for the pelvic examination, leaving 196 eligible of whom 131 consented. Ethical considerations including pri- vacy and confidentiality were ensured throughout the survey to protect hu- man rights. Additionally medical inter- ventions were provided when needed. Ethical approval for the study was sought through the Jordanian MOH ethics committee. Definitions BMI was classified as underweight (< 20 kg/m2), normal (20–25 kg/m2), overweight or obese (> 25 kg/m2) [8,9]. Hypertension was defined as systolic blood pressure ≥ 140 and/or diastolic blood pressure and ≥ 90 mmHg [10]. Hb levels were classified as: low (< 12 g/dL), critically low (< 5.0 g/dL) or normal (> 15 g/dL) [11], Data analysis Statistical analysis was performed using the statistical software package SPSS, version 11.5. Cross tabulation of the frequencies and percentages was done for all items under investigation. The chi-squared test was used to measure the relationship between the 2 villages in terms of all items and the null hypothesis was rejected at the 5% level (P ≤ 0.05). Results Demographic characteristics The majority of the women in the sam- ple were married (64.3%) and 38.2% were illiterate (Table 1). The great ma- jority of participants from both Aqaba and Ma’an governorates were not working at the time of the study (96.4% and 91.8% respectively). There were no significant differences between the women in the 2 villages in terms of age distribution, marital status or employ- ment status. However, the educational level was significantly higher in Ma’an than Aqaba (P < 0.001). Physiological and physical measurements Table 2 shows selected physiological and clinical measurements. Half of sur- veyed women (49.4%) had high BMI. Participants from Ma’an governorate had significantly higher BMI than those from Aqaba governorate (61.5% versus 33.9% respectively) (P < 0.001). The majority of the women had normal blood pressure levels (91.5%), with a highly significant difference between the 2 villages (P < 0.001). Of the 216 (83.4%) women whose Hb concentration was checked more than half (55.5%) had abnormally low levels (< 12 g/dL), with no significant difference between Aqaba and Ma’an (61.8% and 51.2% respectively) (P = 0.12). None of the women in either village had Hb > 15 g/dL and none of the women approached the critically low limit of Hb < 5.0 g/dL [11]. Only 2 women (from Ma’an governorate) (1.6%) had Hg 8–< 9 g/dL. The oth- ers had Hb between 9–< 12 g/dL (Table 2). Reproductive health history Table 3 shows that the majority of the survey sample (76.8%) were married at an early age (15–20 years). Around half of the sample (58.5%) has been pregnant 5+ times while 43.1% had 5+ children and 2% had 5+ dead children. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 420 There were no significant differences between women from the 2 villages in any of the variables, except for age at marriage. A higher percentage of wom- en from Aqaba governorate (86.4%) were married when they were ≤ 20 years old compared with women from Ma’an governorate (69.1%) (P < 0.001). Only 25.9% of the women used a family planning method. Although there was no significant difference between Aqaba and Ma’an governorates in the proportions using family planning there were significant differences regarding the methods used (P < 0.001). The most commonly used family planning method in Aqaba was the intrauterine device (IUD) (30.8%), while in Ma’an it was breastfeeding (50.0%). Few of the sample women (11.6%) had a history of infertility. More than one-third of the sample (37.9%) had a history of spontaneous or induced abortion. The difference between par- ticipants from the 2 villages were not statistically significant Current health problems The top 12 most common health prob- lems (experienced by more than 3% of the sample), as reported by the women and confirmed by physicians, in the 2 villages are presented in Table 4. UTI was the most common health problem overall (29.0%), followed by congested throat, gastric problems, atrophic va- gina and RTI (bacterial vaginitis and candida). Anaemia ranked 7th and was diagnosed for only 6.6% of women. There were differences in the pattern of health problems between the 2 villages; e.g. the most common health problem in Aqaba governorate was UTI (29.0%), while in Ma’an it was congested throat (25.3%). Discussion Demographic characteristics The 2 selected villages in the present study are from poverty pockets in Jordan, and this was reflected by an il- literacy rate of 38.2% which is much higher than the illiteracy rate of women in the general population of Jordan (12%) [5]. This may explain the high Table 1 Demographic characteristics of the sample of women in 2 governorates of south Jordan Demographic characteristic Aqaba (n = 113)a Ma’an (n = 146)a Total (n = 259)a P-value No. % No. % No. % Age (years) 15–20 23 20.4 21 14.4 44 17.0 0.14 21–25 21 18.6 18 12.3 39 15.1 26–30 14 12.4 32 21.9 46 17.8 31–35 8 7.1 15 10.3 23 8.9 36–40 17 15.0 16 11.0 33 12.7 41–45 3 2.7 11 7.5 14 5.4 46–50 7 6.2 9 6.2 16 6.2 ≥ 51 20 17.7 24 16.4 44 17.0 Marital status Single 26 23.0 36 24.8 62 24.0 0.80 Married 76 67.3 90 62.1 166 64.3 Divorced 1 0.9 2 1.4 3 1.2 Widowed 10 8.8 17 11.7 27 10.5 Educational level Illiterate 50 44.2 49 33.6 99 38.2 < 0.001 Elementary 23 20.4 17 11.6 40 15.4 Preparatory 24 21.2 29 19.9 53 20.5 High school 11 9.7 35 24.0 46 17.8 Diploma 1 0.9 8 5.5 9 3.5 Bachelor degree 3 2.7 8 5.5 11 4.2 Postgraduate degree 1 0.9 0 0.0 1 0.4 Employment status Working 4 3.6 12 8.2 16 6.2 0.10 Not working 107 96.4 134 91.8 241 93.8 aData were missing in some categories. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 421 level of unemployment (93.8%), al- though the unemployment rate in the present study did not agree with the results of a community-based survey of women in southern Jordan conducted in 2005 in which only 4.6% of women were working[12]. Physiological and clinical measurements BMI has been widely used and accepted as a simple method to determine the risk of developing health problems by weight status [8,9,13]. Half of surveyed women were overweight or obese and this finding agrees with several other studies conducted in Jordan [2,6,14]. The rate of obesity/overweight is a health concern in the Jordanian com- munity [15]. It has been linked to dys- lipidaemia and type 2 diabetes, which in turn, elevate the risk of cardiovascular disease (CVD) [6]. Moreover, obesity causes serious medical complications and impairs quality of life and, in older persons, it can exacerbate the age-relat- ed decline in physical function and lead to frailty [9]. Only 8.5% of the women surveyed had high blood pressure levels. This contradicts a WHO report in 2005 in- dicating that 21% of Jordanian women had high blood pressure [15] and 2 other studies that reported higher percentages of women with elevated blood pressure in southern [6] and in northern Jordan [16]. The statistical significant difference between women from the 2 villages is consistent with the differences in the rate of obesity. A relationship has been shown between obesity and elevated blood pressure. A high rate of hypertension has been linked to increased CVD mortality among overweight individuals [17]. In addition to BMI, high blood pressure is positively associated with illiteracy [18]. However, this disagrees with the results of this survey as women from Ma’an governorate had higher BMI but lower illiteracy rates than women from Aqaba. Although no statistics about anae- mia have been published for Jordan since 1991, anecdotal evidence and discussions between health care clini- cians indicate that it is prevalent among the Jordanian population [19] and this was confirmed by other studies [1,16] and by the situation analysis conducted by the Communication Partnership Program in Jordan [20]. In the present study none of the women in either vil- lage whose Hb level was checked had Table 2 Selected physiological and physical measurements of the sample of women in 2 governorates of south Jordan Measurement Aqaba (n = 113) Ma’an (n = 146) Total (n = 259) P-value No %a No %a No %a Temperature (°C) < 37.5 110 97.3 136 93.2 246 95.0 0.10 BMI Underweight 27 24.1 10 7.0 37 14.5 < 0.001 Normal weight 47 42.0 45 31.5 92 36.1 Overweight/obese 38 33.9 88 61.5 126 49.4 (Missing data) 3 2.7 10 6.8 13 5.0 Blood pressure Normal 111 98.2 126 86.3 237 91.5 < 0.001 Hypertension 2 1.8 20 13.7 22 8.5 Haemoglobin Normal 34 38.2 62 48.8 96 44.4 0.12 Anaemic 55 61.8 65 51.2 120 55.5 (Missing data) 24 – 19 – 43 – Haemoglobin level (g/dL) (n = 89) (n = 127) (n =216) 08–< 9 0 0.0 2 1.6 2 0.9 0.12 09–< 10 2 2.2 2 1.6 4 1.9 10–< 11 20 22.5 18 14.2 38 17.6 11–< 12 33 37.1 43 33.9 76 35.2 12–< 13 22 24.6 37 29.1 59 27.4 13–< 14 12 13.5 19 15.0 31 14.4 14–< 15 0 0.0 6 4.7 6 2.8 aPercentages were calculated based on the total number of women with data recorded in each category. BMI = body mass index. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 422 Table 3 Reproductive health indicators of women in 2 governorates of south Jordan Indicator Aqaba Ma’an Total P-value No. %a No. %a No. %a Age at marriage (years) 15–20 76 86.4 76 69.1 152 76.8 < 0.001 21–25 6 6.8 28 25.5 34 17.2 26–30 3 3.4 5 4.5 8 4.0 31–35 3 3.4 1 0.9 4 1.0 No. of pregnancies 0 4 4.7 4 3.7 8 4.1 0.99 1 6 7.0 7 6.4 13 6.7 2–3 16 18.6 19 17.4 35 17.9 4–5 10 11.6 15 13.8 25 12.8 > 5 50 58.1 64 58.7 114 58.5 No. of children 0 7 8.0 7 6.5 14 7.2 0. 95 1 10 11.5 10 9.3 20 10.3 2–3 17 19.5 24 22.2 41 21.0 4–5 15 17.2 21 19.4 36 18.5 > 5 38 43.7 46 42.6 84 43.1 No. of dead children 0 55 63.2 80 72.7 135 68.5 0.46 1 19 21.8 17 15.5 36 18.3 2–3 7 8.0 7 6.4 14 7.1 4–5 3 3.4 5 4.5 8 4.1 > 5 3 3.4 1 0.9 4 2 History of abortion 0 49 55.7 74 67.3 132 62.1 0.39 1 17 19.3 15 13.6 32 16.2 2–3 18 20.5 15 13.6 33 16.7 ≥ 4 4 4.5 6 5.4 10 5.0 Infertility No 80 92.0 95 85.6 175 88.4 0.26 Primary 3 3.4 4 3.6 7 3.5 Secondary 4 4.6 12 10.8 16 8.1 Family member first degree relative with breast cancer Yes 1 1.0 – – 1 0.4 0.41 No 102 99.0 145 100.0 247 99.6 Delivered in the last 40 days Yes 3 3.4 6 5.5 9 4.6 0.37 No 85 96.6 103 94.5 188 95.4 Current pregnancy status Pregnant 12 14.0 20 18.9 32 16.7 0.55 Not pregnant 70 81.4 83 78.3 153 79.7 Don’t know 4 4.7 3 2.8 7 3.6 Use of family planning Yes 21 24.4 29 27.1 50 25.9 0.40 No 65 75.6 78 72.9 143 74.1 Type of family planning method Intrauterine device 8 30.8 10 29.4 18 30.0 < 0.001 Breastfeeding – – 17 50.0 17 28.3 Oral contraceptive pill 7 26.9 3 8.8 10 16.7 Lactational amenorrhea method 5 19.2 2 5.9 7 11.7 Condom 2 7.7 – – 2 3.3 Progesterone implant (Implanon®) 2 7.7 – – 2 3.3 Periodic abstinence or withdrawal – – 1 2.9 1 1.7 aPercentages were calculated based on the total number of women with data recorded in each category. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 423 normal Hb levels and more than half had levels < 12 g/dL, with no signifi- cant difference between the 2 villages. According to international criteria this classifies the women as having anaemia [10,21,22]. Khader et al. argued that in developing countries anaemia prob- ably reflects a nutritional deficiency due to poor economic status. They questioned the role of menorrhagia and hyper menorrhoea in causing anae- mia among women of child-bearing age [16]. Anaemia lowers women’s tolerance of blood loss and resistance to infection, contributing to maternal illness and death [4]. Fortunately, none of the women approached the critically low Hb level of < 5.0 g/dL [21]. Reproductive health history The mean age at first marriage in Jor- dan has risen significantly during the period 1979–2004 (from 21.0 years in 1979 to 25.6 years in 2004) and this has contributed to lowering the number of expected births to Jordanian woman during this shortened reproductive period [11]. However, the results of the present survey show that a majority of the survey women were married at an early age. The rate of early marriage reported in this study was much higher than those reported by other stud- ies of Jordanian women [11,12,19]. This may be related to differences in educational level and literacy which were lower for this sample of women in rural areas than the general popula- tion. According to the Department of Statistics education had a tangible impact on delaying the marriage time for females and correlates inversely with child deaths [11]. According to Youssef a steady in- crease in contraception use has been reported among Jordanian women in the last 12 years, with considerable variation between different regions [6]. The prevalence of current con- traception use among women in the central region (58%) was higher than among women in the northern region (54%) and reached its lowest level (48%) among women in the southern region. The differentials in the use of modern contraceptives followed the same pattern [9]. Similar results were reported by the Atlas of Health Indica- tors in 2004 [23] by Shakhatreh et al. in 2006 [6]. The present survey found even lower rates, with only one-quarter of the participants using a family plan- ning method, most commonly IUD and breastfeeding. Current health problems The results showed that UTI was the most common health problem among women overall, followed by congested throat and gastric problems. There were also variations in health problems be- tween the 2 villages. Previous findings indicated hypertension was the main problem in southern Jordan, followed by hyperglycaemia, RTI, anaemia, vari- cose veins, bronchial asthma and peptic ulcer [6]. In the present survey, hyper- tension was not ranked among the most common problems, which agrees with the relatively low percentage of women with high blood pressure. Anaemia only ranked 7th while diabetes mellitus was ranked 12th. According to the WHO list of noncommunicable diseases and risk factors among women in Jordan, physical inactivity is ranked first fol- lowed by obesity, high blood pressure and high cholesterol at the same level, then diabetes and finally smoking [24]. Data on risk factors associated with nutrition-related noncommunicable diseases indicate a high prevalence of these risk factors in this population [14]. Southern Jordan is a disadvantaged re- gion and economic and health-related indicators lag far behind those of other parts of the country [6]. Table 4 Most common health problems as reported by the survey sample of women in 2 governorates of south Jordan Health problem Aqaba (n = 113) Ma’an (n = 146) Total (n = 259) % % % Urinary tract infection 39.8 20.6 29.0 Congested throat 17.7 25.3 22.0 Gastric problema 23.9 15.8 19.3 Atrophic vagina 24.8 11.0 17.0 Bacterial vaginitis 15.9 12.3 13.9 Vaginal candidiasis 13.3 13.0 13.1 Anaemia 4.4 8.2 6.6 Cystocele 6.2 4.1 5.0 Bronchial asthma 6.2 2.7 4.3 Otitis media 5.3 2.7 3.9 Cardiac problemb 6.2 1.4 3.5 Diabetes mellitus 0.9 4.8 3.1 aStomach ache and burning sensation; bValvitis. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 424 References 1. Al-Qutob R. Menopause-associated problems: types and magnitude; A study in the Ain Al-Basha area, Jordan. Journal of Advanced Nursing, 2001, 33:613–620. 2. Al Ma’Aitah R, Haddad L, Umlauf M. Health promotion behav- iors of Jordanian women. Health Care for Women International, 1999, 20:533–546. 3. Casterline JB, Sinding SW. Unmet need for family planning in developing countries and implications for population policy. Population and Development Review, 2000, 26:691–723. 4. Roudi-Fahimi F. Women’s reproductive health in the Middle East and North Africa. Washington DC, Population Reference Bureau, 2003. 5. Jordan population and family health survey 2007. Amman, Department of Statistics and Calverton, Maryland, Macro International, 2008. 6. Youssef R. Contraception use and probability of continuation: community-based survey of women in southern Jordan. East- ern Mediterranean Health Journal, 2005, 11:545–558. 7. The Hashemite Kingdom of Jordan. Poverty assessment. Amman, World Bank, 2004 (http://www.espp.gov.jo/Vol1June1_re- vised3%20_2_.pdf, accessed 12 March 2012). 8. World health statistics. Geneva, World Health Organization, 2007. 9. Villareal D, Apovian C, Kushner R. Obesity in older adults: technical review and position statement of the American So- ciety for Nutrition and NAASO, The Obesity Society. Obesity Research, 2005, 13:1849–1863. 10. High blood pressure. Medlineplus [online factsheet] (http:// www.nlm.nih.gov/medlineplus/highbloodpressure.html, ac- cessed 12 March 2012). 11. Jordanian mothers, facts and figures. Department of Statistics, The Hashemite Kingdom of Jordan [online factsheet] (http:// www.dos.gov.jo/dos_home_e/mother.htm, accessed 12 March 2012). 12. Annual report year 2007. Amman, Health Communication Partnership, 2007. 13. World development indicators database. The World Bank Group [online database] (http://data.worldbank.org/sites/default/ files/wdi07fulltext.pdf, accessed 8 April 2012). 14. Madanat H, Brown R, Hawks S. The impact of body mass index and Western advertising and media on eating style, body im- age and nutrition transition among Jordanian women. Public Health Nutrition, 2007, 10:1039–1046. 15. Global status report on noncommunicable diseases 2010. Ge- neva, World Health Organization, 2011. 16. Khader YS et al. Prevalence of medical conditions among patients attending dental teaching clinics in Northern Jordan. Journal of Contemporary Dental Practice, 2007, 8(1):60–67. 17. Hu FB. Overweight and increased cardiovascular mortality: no French paradox. Hypertension, 2005, 46:645–646. 18. Jaddou HY, Bateiha AM, Ajlouni KM. Prevalence, awareness and management of hypertension in recently urbanized com- munity, eastern Jordan. Journal of Human Hypertension, 2000, 14:497–501. 19. Jarrah S et al. Iron deficiency anemia (IDA) perceptions and di- etary iron intake among young women and pregnant women in Jordan. Journal of Transcultural Nursing, 2007, 18:19–27. 20. Health communication. Jordanian Ministry of Health [website]. (http://www.healthcomm.gov.jo/Default.aspx?tabid=79, ac- cessed 8 April 2012). Another study in the south of Jordan found results that were relatively similar to our results. It indicated that 39% out of 117 women who agreed to a vaginal examination had signs of a RTI and 31% reported symptoms of UTI, including dysuria, frequency of micturition or both. Yet that study was conducted on women over 50 years of age and was fo- cused mainly on menopause-associated problems [1]. Another study reported that RTI were diagnosed in 55% of the women, anaemia in 40%, genital pro- lapse in 22% and UTI in 14%. This comparison reveals some kind of consensus on at least 4 main health problems: UTI, RTI, anaemia and obesity (with all its associated risks). This finding is congruent with that of the MOH Communication Partnership Program that emphasized that the so- called lifestyle diseases, such as diabetes, obesity and CVD, have begun to replace infectious diseases as the leading causes of morbidity and mortality in Jordan [20]. More importantly, many women did not realize they had a treatable health problem such as anaemia. According to Roudi-Fahimi, although anaemia is common throughout the Middle East and North Africa (regardless of a coun- try’s income level), few women with anaemia recognize the symptoms and seek treatment [4]. Al Ma’Aitah et al. called for increasing women’s awareness of the relationship between lifestyle and healthy behaviours as an important issue for health professionals in promoting women’s health in Jordan [2]. Limitations of the study Since the participation in the study was on voluntary basis, and since the re- searchers made no attempts to examine whether the participants differed from those who did not attend, the generaliz- ability of the results may be limited. Conclusion The study results support the idea that women in southern Jordan experience considerable reproductive-related and other morbidities. Health care providers should be sensitized to the health needs of women in general and those living in disadvantaged areas in particular. Provision of the necessary information related to healthy lifestyles and abnormal signs and symptoms is an essential element for women’s em- powerment. Acknowledgements This study was funded by the Gov- ernment of Jordan Ministry of Health and the General Secretariat of Higher Population Council, and the Japan International Cooperation Agency. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 425 21. DeMoranville VE, Best MA. Hemoglobin test. In: Senagore AJ, ed. Gale encyclopedia of surgery: a guide for patients and caregiv- ers. Farmington Hills, Michigan, The Gale Group, 2007 (http:// www.encyclopedia.com/topic/Hemoglobin_test.aspx, ac- cessed 12 March 2012). 22. Lab Tests Online®. American Association for Clinical Chemistry [website] (http://www.aacc.org/resourcecenters/LTOPres- ence/Pages/default.aspx accessed 14 March 2012). 23. Jordan: atlas of health indicators. Calverton, Maryland, ORC Macro, 2004. 24. Markovic N et al. Adequacy of a single visit for classification of hypertensive status in a Nigerian civil servant population. Inter- national Journal of Epidemiology, 1994, 23:723–729. WHO research shows effective simplified approach to preventing postpartum haemorrhage Between 2009 and 2010, UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction coordinated a randomized controlled trial in 8 countries that studied a simplified approach to management of the third stage of labour without controlled cord traction. The study, in which more than 24 000 women participated, showed that omitting controlled cord traction has little effect on the risk of severe bleeding and indicates that effective prevention of postpartum haemorrhage could be accomplished with just a uterotonic agent (primarily oxytocin). The findings have important implications for expanding access to effective care and could have a substantial impact on maternal survival in places where access to skilled medical staff is difficult. Results of the study were published in the Lancet, Early Online Publication, 6 March 2012 (http://www.thelancet.com/ journals/lancet/article/PIIS0140-6736(12)60206-2/abstract). EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 426 Maternal mortality in Jordan: role of substandard care and delays A.M. Okour,1 Y. Khader,1 Z. Amarin,1 H. Jaddou 1 and M. Gharaibeh 2 ABSTRACT Understanding the factors that operate during pregnancy, delivery and postpartum is the key to success in the prevention of maternal mortality. This cross-sectional survey in Jordan for the years 2007–2008 aimed to identify the role of substandard care and delays in maternal deaths. All maternal deaths among women aged 15–49 years over this period (n = 76) were investigated retrospectively through file review and household interviews in all hospitals (n = 102) and forensic medicine departments in Jordan; elements of substandard care and delays at hospital, home and transport levels were evaluated. Substandard care accounted for 52.6% of deaths, delay in seeking care 55.3%, delay in transport 15.8% and delay in hospital care 17.1%. Women who did not recognize the danger signs of pregnancy (OR 6.32), refused medical advice to terminate the pregnancy (OR 1.78) or at a gestational age > 37 weeks (OR 1.85) were significantly more likely to delay seeking care, as were those with larger mean family size. 1Department of Public Health and Community Medicine, Faculty of Medicine; 2Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan (Correspondence to A.M. Okour: aokour@just.edu.jo). Received: 23/01/11; accepted: 09/03/11 ةياعرلا بلط في رخأتلاو ةياعرلا ىوتسم ني ِّدت رود :ندرلأا في تاهملأا تايفو هبيارغ ىهتنم ،عودج مشاه ،نيرماع يرهز ،ضرخ فسوي ،روكع ميكلحا دبع اذه فدهو .تاهملأا تايفو نم ةياقولا في حاجنلا ساسأ يه ةدلاولل ةيلاتلا ةترفلاو ةدلاولاو لملحا ءانثأ رثؤت يتلا لماوعلا مهف نإ :ةصلالخا ىرجأ دقو .تاهملأا تايفو لىع ةياعرلا بلط في ر ُّخأتلاو ةياعرلا ىوتسم ِّيندت يرثأت لىع فرعتلا وه 2008-2007 ْنيَماعلل ندرلأا في يعطقلما حسلما تلاباقلماو تافللما ةعجارم للاخ نم )76 ددعلا( ةترفلا هذه لاوط ةنس 49-15 رمع في ءاسنلا يب تاهملأا تايفو عيملج ًايداعتسا ًايصقت نوثحابلا ىوتسم لىع يرخأتلاو ،ةياعرلا ىوتسم ِّيندت صرانع مييقت ىرجو ؛ندرلأا في يعشرلا بطلا ماسقأ فيو )102 ددعلا( تايفشتسلما عيجم في سرلأا عم مهاس دق ةياعرلا بلط في رخأتلا نأو ،تايفولا نم %52.6 ثودح في مهاس دق ةياعرلا ىوتسم ِّيندت نأ حضتا .تلاصاولما فيو ،لزنلما فيو ،ىفشتسلما تاملاع نفرعي لم تيلالا ءاسنلا نأو .اهنم %17.1 في مهاس دق ىفشتسلما في ةياعرلا رخأت نأو ،اهنم %15.8 في مهاس دق لقنلا رخأت نأو ،اهنم %55.3 في نله ليملحا رمعلا ناك وأ ،)1.78 ةيحجرلأا ةبسن( نيهدل لملحا ءانهإب ةيبطلا ةروشلما سماتلا نضفر تيلالا وأ ،)6.32 ةيحجرلأا ةبسن( لملحا في رطلخا .ةياعرلا بلط في نرخأت تيلالا نه حجرلأا لىع نك ددعلا ةيربكلا َسرلأا في ءاسنلاو ،)1.85 ةيحجرلأا ةبسن( ًاعوبسأ 37 نم لقأ Mortalité maternelle en Jordanie : rôle de la qualité insuffisante des soins et des retards RÉSUMÉ La compréhension des facteurs entrant en jeu au cours de la grossesse, de l'accouchement et de la période du postpartum est la clé d'une prévention efficace de la mortalité maternelle. La présente enquête transversale menée en Jordanie entre 2007 et 2008 visait à identifier le rôle de la qualité insuffisante des soins et des retards dans les décès maternels. Tous les décès maternels survenus dans le groupe d'âge des 15-49 ans au cours de la période (n = 76) ont été étudiés rétrospectivement dans le cadre d'un examen des dossiers et d'un entretien avec les ménages dans tous les hôpitaux (n = 102) et les services de médecine légale en Jordanie ; les éléments concernant la qualité insuffisante des soins de et l'origine des retards, c'est-à-dire à l'hôpital, au domicile ou dans les transports, ont été évalués. Les soins de qualité insuffisante représentaient 52,6 % des décès ; les retards dans la recherche de soins comptaient pour 55,3 % ; les retards dus aux transports expliquaient 15,8 % des décès ; et les retards dans les soins hospitaliers participaient pour 17,1 %. Les femmes qui ne reconnaissaient pas les signes de danger pendant leur grossesse (O.R. 6,32), qui refusaient de consulter un médecin pour mettre un terme à leur grossesse (O.R. 1,78) ou qui étaient enceintes de plus de 37 semaines (O.R. 1,85) avaient davantage tendance, et ce de manière significative, à retarder la recherche de soins, tout comme les femmes appartenant à des familles plus nombreuses en moyenne. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 427 Introduction Maternal mortality data reflect the health care status of any given country in general and the efficiency of health care to wom- en in particular [1,2]. Understanding the specific details of responsible factors that operate during pregnancy, delivery and the postpartum are the key to success in the prevention of maternal mortality [3]. Inadequate quality of hospital care and delays at different levels have been linked by many studies to rising maternal mortality rates [4–6]. Delays have been described briefly in a previous national study on maternal mortality in Jordan in 1995, in which delayed obstetric care was present in 68% of cases, delays in seeking care in 62% and delays in transportation in 12% [7]. Other studies in the region have reported on some of the different aspects of delays [8–11]. In Jordan, recent national figures indicated that about 99% of women re- ceived some antenatal care during the first trimester of pregnancy from a medi- cal professional and that 74% had 7 or more antenatal care visits. However, only 50% were informed about the symptoms and signs of pregnancy complications during the visits and only 38% were in- formed about puerperal complications. Almost all of Jordan’s births occurred in health facilities, 75% of them were as- sisted by a doctor and 25% were assisted by a nurse or a midwife; 19% of births were delivered by caesarean section [12]. The data reported here were derived from the Jordan national maternal mor- tality study for 2007–08 [13]. The initial study described the methods, maternal mortality ratio and causes of death [13]. The present report describes an audit of the avoidable causes of maternal death, focusing on substandard care and delays. Methods Sample The original study methodology is described in detail elsewhere [13]. Briefly, the reproductive age mortality survey method was applied. The names of all women in the age range 15–49 years who had died in the period from January 2007 through December 2008 were reviewed. Women in this list were identified with contact information including address, telephone number, place of death and hospital(s). This led to identifying 76 maternal deaths out of a total of 1406 dead women. Data collection All hospitals (n = 102) and forensic medicine departments in Jordan were visited in addition to visits to the dead women’s households. A questionnaire was developed to collect data from hospitals. It included items about the personal identification of the deceased woman (name, age, address); date of admission, date and time of death; reproductive history of previous and last pregnancy; chief com- plains; narrative section about the se- quence of events from admission until death, provisional diagnosis, case man- agement, surgeries; cause of death and autopsy reports, where available. The main source of information was medi- cal files at hospitals and, if necessary, through interviews with attending phy- sicians, midwifes and nurses that dealt with the case. Medical staff were asked to give full details about the woman’s medical condition from admission to death. In most cases, information were collected through interviews with 2 or more doctors in the same or different hospitals (for those women who were referred from one hospital to another due to lack of expertise, equipment or intensive care units or beds, or for other reasons). Midwives and/or nurses were interviewed for all details around the death event. In addition, clue data on women’s lack of awareness of their ur- gent medical conditions were looked up in medical files (e.g. women delayed hospital visit for hours or days although having complains of shortness of breath, lower abdominal pain or bleeding). During home visits a structured questionnaire interview was conducted with the woman’s husband, mother or sister. The questionnaire included the following sections: sociodemographic information about the deceased and her family; narrative details of the circum- stances of death; last pregnancy history; reproductive history; chronic health problems and medications; utilization and satisfaction with the received health care. Variables for analysis included maternal age, education, gravidity, ges- tational age, health insurance, prenatal care, family size, family income, distance to nearest hospital, place of residence and awareness of pregnancy danger signs. Identifying women who were unaware of pregnancy danger signs was done using questions to the husband and or family members on whether the dead woman or her family were able to recognize pregnancy danger signs at the time before seeking hospital care (if ever). For the sake of this report, category adjustment for some variables was made (gestational age, family size, family income). Delay in emergency obstetric care was confirmed when a woman arrived alive at hospital, but initiation of medical care was delayed, which was confirmed by checking the medical files, reports by the medical staff or by the family. Substandard care was defined as inap- propriate case management which was recognized by reviewing medical files, interviewing doctors responsible for cases or heads of obstetric departments at each hospital. Deficiencies in facility preparedness reported in the notes or by medical staff or family, such as lack of equipment, specialists or intensive care facilities were considered as substandard care. In some instances hospital delay was counted twice, once as a delay per se, and again as substandard care. Delay in seeking care was identified by asking the family about the time between the onset of complains and the decision of the woman or her family to seek care. In many cases information about delay EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 428 in seeking care were extracted from the medical files. Delay in access to hospital was confirmed by asking the family if there were any transport problems in getting to the nearest hospital. Analysis Data on delays and substandard care were processed and analysed using SPSS software, version 15. Chi-squared and t-tests at 95% confidence were applied. Results There were 76 maternal deaths in the years 2007 and 2008 out of 397 588 live births for the same period. The median age of women was 31.0 years and they had a mean family size of 5.5 (SD 2.6). Around two-thirds of them had less than high school education and 60.8% had a monthly family income of < 250 Jordanian dinars (US$ 352). The main causes of death were haemorrhage and pulmonary embolism. Substandard hospital care Substandard care accounted for 40 (52.6%) of maternal deaths (Table 1). A total of 13 women (17.1%) out of 76 dying were the subject of hospital delays due to delayed initiation of care or sending the women home with re- assurance. Substandard management was evident in 16 women (21.1%) and included misdiagnosis and mishandling of postpartum haemorrhage and other obstetric complications. There were 11 maternal deaths (14.5%) in hospitals that were inadequately equipped for emergency obstetric care due to a lack of beds or intensive care, lack of experi- ence or lack of specialists. Access problems We identified 12 women (15.8%) who failed to get transportation in good time; in 6 cases the families reported this was due to financial difficulties, in 4 cases due to living in a remote area far away from regular transport and for 2 women whose symptoms worsened after midnight transport became avail- able only after 30 minutes (Table 1). Delay in seeking care There were 42 women (55.3%) who delayed seeking care for one or more reasons. These were mainly attributed to lack of knowledge about danger signs and refusal of care (Table 1). Table 2 shows the demographic and pregnancy characteristics of women who delayed versus those who did not. Women who did not recognize the danger signs of pregnancy (OR = 6.32, P < 0.001), those who refused medical advice to terminate the pregnancy (OR = 1.85, P = 0.008) and those who were at a gestational age > 37 weeks (OR = 1.78, P < 0.01) were significantly more likely to delay seeking care. In contrast, women with easy access to obstetric care, and those who resided within a ≤ 10-minute car journey to the nearest hospital were more likely to seek care (OR= 0.50, P = 0.006 and OR = 0.60, P = 0.035 respectively). Women who delayed seeking care had a significantly larger mean family size than those who did not delay seeking care: 5.6 (SD 2.9) versus 5.1 (SD 2.3) (P < 0.001). Discussion Compared with the results of a similar study in Jordan in 1995 [7], our results indicate a decrease in delays of obstetric care (17.1% versus 68% of deaths) and delays of seeking care (55.3% versus 62%); however, there was an increase Table 1 Details of substandard care and delays for maternal deaths in Jordan, 2007–2008 Variable No. of deaths % (n = 76) Reported aspects Substandard care Total 40 52.6 Case management 16 21.1 Misdiagnosis; mishandling of postpartum haemorrhage; mismanagement of other obstetric complications Hospital preparedness 11 14.5 Lack of beds or intensive care unit; lack of experience; lack of specialists Delay in hospital care 13 17.1 After reporting to hospital, women were reassured, sent home and came back dead; delayed initiation of care Delay in seeking care 42 55.3 Symptoms started 2 hours to 5 days before arrival to hospital; bleeding; headache; severe lower abdominal pain; shortness of breath; cyanosis; hyperemesis; semi-consciousness; dizziness; intrauterine fetal death or postmaturity; refused to go to hospital until collapsed; unsure about the need for hospital care; refused medical procedures and discharged against medical advice; rejected medical pregnancy termination Delay in transport 12 15.8 Unable to afford transport (6 women); dwelling in remote area and far away from regular transport (4 women); symptoms worsened after midnight and transport found after 30 minutes (2 women) طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 429 Table 2 Demographic, pregnancy and access variables of maternal deaths in women who delayed seeking care (n = 42) and those who did not (n = 34) Variable Delay in seeking carea OR (95% CI) P-valueb Yes No Woman’s age (years) NA 0.828 19–29 17 14 30–39 16 11 ≥ 40 9 9 Woman’s education NA 0.303 Illiterate 5 1 1–12 years 15 11 > 12 years 8 9 Residency 1.42 (0.96–2.09) 0.092 Urban 23 25 Rural 19 9 Family income (US$ monthly) 1.36 (0.78–2.38) 0.254 ≤ 352 19 12 ≥ 353 9 11 Gravidity 0.99 (0.63–1.56) 0.969 1–3 15 13 4–14 20 17 Pregnancy planned 0.79 (0.50–1.24) 0.360 Yes 23 17 No 8 3 Health insurance 1.10 (0.64–1.91) 0.722 Yes 27 22 No 8 8 Family size Mean (SD) 5.6 (2.9) 5.1 (2.3) < 0.001 Prenatal care in current pregnancy 0.65 (0.46–0.91) Yes 26 19 0.078 No 8 1 Distance to nearest hospital by car (min) 0.60 (0.37–0.98) 0.035 ≤ 10 12 15 > 10 17 6 Easy access to hospital 0.50 (0.37–0.67) 0.006 Yes 22 22 No 9 0 Gestational age (weeks) 1.78 (1.12–2.82) 0.008 2–37 27 12 38–43 14 22 Refused termination of pregnancy 1.85 (1.36–2.52) Yes 10 1 0.010 No 32 33 Unrecognized pregnancy danger symptoms 6.32 (3.02–13.2) Yes 36 1 < 0.001 No 6 33 aNumbers may not add to 76 due to missing data; bChi-squared test for binomial and t-test for means. OR = unadjusted odds ratio; CI = confidence interval.; NA = not applicable; SD = standard deviation. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 430 in the rate of transport delays (15.8% versus 12%). This change could not be verified since the data collection ap- proach and results of the 1995 study were not available for review. Our results indicate serious flaws in diagnosing specific conditions includ- ing uterine rupture and concealed post- partum haemorrhage, thrombosis and thromboembolism. The role of better quality in obstetric care has been ad- dressed by many studies on pregnancy complications [14–16]. Evidence- based practice has been acknowledged as a vital modality in enhancing ma- ternal health. Reductions in maternal deaths can only be attained by improv- ing the quality of maternal and obstetric care, in addition to coverage, and will require constant monitoring and as- sessment with dynamic use of data to guide decisions and actions [3]. In fact, increasing the level of attentiveness for emergencies and capacity to manage common obstetric complications, ac- cording to evidence-based practices, has led to increased availability, improved quality and greater use of services and consequently a decline in the case fa- tality rates of obstetric complications [3,17,18]. The present study indicates that delay in seeking care was a major factor contributing to maternal mortality in Jordan. Lack of awareness of danger signs in pregnancy was a crucial fac- tor. This finding is consistent with other studies about lack of awareness of pregnancy danger signs [19,20]. So- cioeconomic status, extended family size, health beliefs, access and level of trust in available local medical care may have affected the decision to seek care. Other studies had reported the notion that different cultures affect women’s care-seeking decisions, despite the exist- ence of similar danger signs [14,19–21]. In addition, religious beliefs may have affected the decision of those women who refused pregnancy termination. Furthermore, health education on the warning signs in early pregnancy and husband’s support have been shown to be factors of value in timely decision- making [2,15,16]. An association has been shown be- tween sociodemographic factors and delay in seeking care [1,2,6]. This study did not confirm that, but indicated a significant difference in relation to mean family size between women who delayed seeking care and those who did not. This may be related to inferior health outcomes in larger families with underprivileged life conditions [16]. Women who decide to seek obstetric care may be influenced by their experi- ence during antenatal care visits. This study failed to show a significant statisti- cal difference between having prenatal care and delay in seeking emergency obstetric care. However, previous stud- ies had emphasized the importance of skilled prenatal care in enhancing the utilization of obstetric services [14,15,19]. Easy access to hospitals is a critical issue for women seeking health care [19]. This study indicated that lack of easy access to a health facility, as one of the types of delay, was not related to in- come. In Jordan, the poverty line was es- timated at US$ 711 per capita annually, or US$ 353 per household monthly. In 2005, this comprised 14.7% of the total population of Jordan [22]. Around 60% of the women in this study were below the poverty line; nevertheless they man- aged to access their nearest hospital for routine and emergency obstetric care. Difficult access to emergency obstet- ric care due to lack of transport, paved roads or a nearby hospital have been found to play a major role [23]. Those findings are important in the search for interventions aimed at maternal mortal- ity reduction [18,19]. Our study emphasizes the role of vigilant health care and competent clinical practice in reducing maternal deaths. With the recent advent of mini- mally invasive treatments and drugs, physicians now have more options at their disposal to diagnose and manage thromboembolism or temporize bleed- ing. Evidence-based protocols of prac- tice should be promoted, in addition to emphasis on training, continuous medical education and professional development [3,17,18]. This study suffered a number of limi- tations. First the retrospective design of data collection from dead women’s families and medical staff may have introduced recall bias. To avoid this set- back, data collection was carried out in a precise manner for each item. If there were insufficient data, other visits to the sources were performed including all of Jordan’s hospitals and forensic depart- ments. In most cases interviews were made with more than one medical staff (doctor, head of department, midwife, nurse) and family member (husband, mother, sister). Careful reviews of data including interviews and files were con- ducted for each case by the study team, who comprised experts in obstetrics and gynaecology, maternal and child health, public health and biostatistics. In addition, other experts in pathology and obstetrics were consulted. Secondly, in many cases there were difficulties in data collection in hospitals due to lack of an adequate filing system. Thirdly, household visits were difficult due to lack of complete information on the patient’s address in medical files. Ad- dresses were identified by checking the civil registry and city records and calling relatives. Nevertheless, this is the first study in Jordan that has addressed the delays and substandard care of maternal deaths in a reliable manner, and its results should be considered in efforts towards pre- vention of maternal mortality in the country. Acknowledgements The authors wish to thank the Jorda- nian Ministry of Planning and Interna- tional Relations and Higher Population Council for sponsoring this study. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 431 References 1. McCaw-Binns A et al. Access to care and maternal mortality in Jamaican hospitals: 1993–1995. International Journal of Epide- miology, 2001, 30:796–801. 2. Baraté P, Temmerman M. Why do mothers die? The silent tragedy of maternal mortality. Current Women's Health Reports, 2009, 5:230–238. 3. Otchere SA, Kayo A. The challenges of improving emergency obstetric care in two rural districts in Mali. International Journal of Gynaecology and Obstetrics, 2007, 99:173–182. 4. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social Science & Medicine, 1994, 38:1091–1110. 5. Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Social Science & Medicine, 1998, 46:981–993. 6. Ramos S et al. Maternal Mortality in Argentina Study Group. A comprehensive assessment of maternal deaths in Argen- tina: translating multicentre collaborative research into action. Bulletin of the World Health Organization, 2007, 85:615–622. 7. Essential obstetric care clinical guidelines for physicians. Health systems strengthening, Amman, Ministry of Health Jordan, 2007. 8. Türkyilmaz AS et al. The Turkey national maternal mortality study. European Journal of Contraception & Reproductive Health Care, 2009, 14:75–82. 9. Bashour H et al. Maternal mortality in Syria: causes, contribut- ing factors and preventability. Tropical Medicine and Interna- tional Health, 2009, 14:1122–1127. 10. Gipson R et al. The trend of maternal mortality in Egypt from 1992–2000: an emphasis on regional differences. Maternal and Child Health Journal, 2005, 9:71–82. 11. Al Serouri AW et al. Reducing maternal mortality in Yemen: challenges and lessons learned from baseline assessment. International Journal of Gynaecology and Obstetrics, 2009, 105:86–91. 12. Jordan population and family health survey 2007. Calverton, Maryland, Department of Statistics, Ministry of Health, Jordan and Macro International, 2008. 13. Amarin Z et al. National maternal mortality ratio for Jordan, 2007–2008. International Journal of Gynaecology and Obstet- rics, 2010, 111:152–156. 14. Tann CJ et al. Use of antenatal services and delivery care in Entebbe, Uganda: a community survey. BMC Pregnancy and Childbirth, 2007, 7:23. 15. Gülmezoglu AM. Promoting standards for quality of maternal health care. British Medical Bulletin, 2003, 67:73–83. 16. Filippi V et al. Maternal health in poor countries: the broader context and a call for action. Lancet, 2006, 368:1535–1541. 17. Paxton A et al. The evidence for emergency obstetric care. International Journal of Gynaecology and Obstetrics, 2005, 88:181–193. 18. Kayongo M et al. Making EmOC a reality – CARE’s experiences in areas of high maternal mortality in Africa. International Jour- nal of Gynecology and Obstetrics, 2006, 92:308–319. 19. Fotso JC et al. What does access to maternal care mean among the urban poor? Factors associated with use of ap- propriate maternal health services in the slum settlements of Nairobi, Kenya. Maternal and Child Health Journal, 2009, 13:130–137. 20. Cham M, Sundby J, Vangen S. Maternal mortality in the rural Gambia: a qualitative study on access to emergency obstetric care. Reproductive Health. 2005, 2(1):3. 21. Portela A, Santarelli C. Empowerment of women, men, fami- lies and communities: true partners for improving maternal and newborn health. British Medical Bulletin, 2003, 67:59–72. 22. Appraisal of poverty indicators based on the household expendi- ture survey 2005. Amman, Jordanian Directorate of Economic Statistics, 2006. 23. Kongnyuy EJ, Leigh B, van den Broek N. Effect of audit and feedback on the availability, utilisation and quality of emer- gency obstetric care in three districts in Malawi. Women and Birth, 2008, 21:149–155. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 432 Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors F.H. Al Dallal 1 and I.N. Grant 2 ABSTRACT The prevalence of postnatal depression in Bahrain is unknown and screening for known risk factors does not take place. This study estimated the prevalence of postnatal depressive symptoms and the associated risk factors among a random sample of Bahraini women attending primary health care centres with their babies for the 8-week child check-up. The Arabic version of the Edinburgh Postnatal Depression Scale (EPDS) was used with a cut-off score of ≥ 12 for depression. The prevalence of postnatal depressive symptoms among 237 mothers was 37.1%. No significant relationships were identified between depression symptoms and any of demographic variables or pregnancy/birth characteristics studied. However, several psychosocial risk factors were significantly associated with postnatal depression and, after multiple regression analysis, a history of depressive symptoms and perceived lack of support from the husband remained significant factors. Further studies that include diagnostic assessments are needed to confirm these findings. 1Primary Health Care, Ministry of Health, Manama, Bahrain (Correspondence to F.H. Al Dallal: drfareeda@hotmail.co.uk). 2Department of Family Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain. Received: 02/08/10; accepted: 19/12/10 ةيعماتجلاا ةيسفنلا رطلخا لماوعو ضارعلأا راشتنا تلادعم :نيرحبلا في ءاسنلا ينب ةدلاولل لياتلا بائتكلاا تنارج لين ،ّللادلا ديحم ةديرف هذه حمطت .ةفورعلما رطلخا لماوع نع ي ِّرحتلا متي لمو ، ،نيرحبلا في ةدلاولل لياتلا بائتكلاا راشتنإ لدعم فرعت ةقباس ةسارد دجوت لا :ةصلالخا زكارلما لىع نددرت يئلالا ،نيرحبلا في ءاسنلا نم ةنيع في اله ةبحاصلما رطلخا لماوعو ،ةدلاولل لياتلا بائتكلاا ضارعأ راشتنا ل َّدعم ريدقت لىإ ةساردلا EPDS ةدلاولل لياتلا بائتكلال هبرندأ سايقم نم ةيبرعلا ةخسنلا تمدختسا دقو .نلهافطأ ميعطت و صحفل ةدلاولا نم نماثلا عوبسلأا في ةيحصلا ابه ُّدتعي تاطابترا فشتكت لمو .%37.1 تاهملأا نم 237 ينب ةدلاولل لياتلا بائتكلاا ضارعأ راشتنا لدعم غلبو .بائتكلال 12 ≥ هردق و لصاف دحب اطابترا تطبترا رطخلل لماوع ةدع نكل .اهتسارد ىرج يتلا ةدلاولا وأ لملحا تماس وأ ةيفارغوميدلا تايرغتلما نم يأ ينبو بائتكلاا ضارعأ ينب اهم جوزلا نم معدلا صقنب ساسحلإاو ،بائتكلاا ضارعأب ةباصلإا قباوس لظ ،فوحتلل تلايلتح ةدع دعبو ،ةدلاولل لياتلا بآتكلإا عم هب دتعي .جئاتنلا هذه نم د ُّكأتلل ةيصيخشت تماييقت نمضتت يتلا تاساردلا نم ديزلم ةجاح كانهو .نماّهلما نلاماعلا Dépression postnatale chez des femmes bahreïnies : prévalence des symptômes et des facteurs de risque psychosociaux RÉSUMÉ La prévalence de la dépression postnatale à Bahreïn n'est pas connue et aucun dépistage des facteurs de risque avérés n'est réalisé. La présente étude a estimé la prévalence des symptômes de dépression postnatale et des facteurs de risque associés dans un échantillon aléatoire de femmes bahreïnies consultant les centres de soins de santé primaires avec leur bébé pour la visite des huit semaines. La version en langue arabe de l'Edinburgh Postnatal Depression Scale (Échelle de dépression postnatale d'Édimbourg) a été utilisée avec une valeur seuil supérieure ou égale à 12 pour la dépression. La prévalence des symptômes de la dépression postnatale chez les 237 mères de l'étude était de 37,1 %. Aucune relation significative n'a été identifiée entre les symptômes de dépression et les variables démographiques ou les caractéristiques des grossesses ou des accouchements étudiés. Toutefois, plusieurs facteurs de risque psychosociaux étaient significativement associés à la dépression postnatale et, après l'analyse de régression multiple, des antécédents de symptômes dépressifs ainsi que le sentiment de recevoir un soutien insuffisant de la part du conjoint se sont révélé être des facteurs importants. Des études supplémentaires comprenant des évaluations diagnostiques sont requises pour confirmer ces résultats. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 433 Introduction Postnatal depression is an important health issue, with not only immediate health effects on the woman and her self- confidence as a mother, but also on her infant’s social, emotional, cognitive [1– 3] and even physical development [4,5]. Varying rates of postnatal depression and depressive symptoms have been reported within and across countries. The rate of postnatal depression ranges from 10% to 15% in developed coun- tries [6–8], but is higher in developing countries where rates ranging from 16% to 36% have been recorded [9–15]. Several risk factors have been found to be associated with postnatal depres- sion, including a mother’s history of major depressive disorder and a past history of postnatal depression [8,10], depression during pregnancy [11] and a family history of depression [16]. Other important factors in some low-income countries are family disruption and a lack of social support [9–14,17], poor economic status and dissatisfaction with having a female child [10,14,17]. Not breastfeeding, stressful life events, baby’s health problems and unintended pregnancy were also found to be as- sociated with postnatal depression [9–13,18]. Despite its high prevalence and importance, postnatal depression is commonly under-diagnosed by health professionals [19,20]. The prevalence of postnatal depres- sion in Bahrain is unknown and screen- ing for known risk factors does not take place, even though the primary health care service provides postnatal check- ups 6 weeks after delivery [21]. Despite the availability of the service, only 57% of Bahraini women comply with scheduled appointments [21]. On the other hand, women’s compliance with the 8-week child vaccination schedule is high (93.6%) [22]. The aim of this study was to provide data about the prevalence of postnatal depressive symptoms and associated risk factors among Bahraini women at 8 weeks postpartum. Methods This cross-sectional descriptive study was carried out on Arabic-speaking Bahraini women who were in the post- natal period, attending the 8-week child screening clinic at primary health care centres. Sample Using a confidence interval of 95% (a precision of 5%) and an estimated prevalence of 20% [11,12], the sample size was calculated to be 250. The study participants were drawn from all 5 governorates of Bahrain through 20 randomly chosen primary health care centres and 2 clinics. A proportional sample was calculated for each governorate, health centre and clinic using the list of birth no- tifications relevant to each selected health centre that were collected over a period of 1 month from 15 May 2008 to 15 June 2008. The names of participant mothers were chosen by simple random sampling from those lists. Data collection Data collection was completed during the months of July and August 2008. Three instruments were used in the col- lection of data: A birth notification form is issued for each newborn in Bahrain. A copy of this form is given to the parents and another one is sent to their correspond- ing health centre. It is mandatory to have the birth notification form in or- der to obtain a birth certificate for the newborn, and therefore all parents have to visit the health centre for registra- tion purposes, regardless of the place of antenatal care visits and the place of delivery (i.e. public or private hospital). Information collected from the birth notification form included mother’s age, number of live children, history of dead children in the family, and baby’s sex, type of delivery, single/multiple births and gestational age. The Arabic version of the Edinburgh Postnatal Depression Scale (EPDS) was used to screen for postnatal depres- sion symptoms. The EPDS is a 10-item self-report scale, specifically designed to screen for postnatal depression in community samples. The scale rates the intensity of depressive symptoms present within the previous 7 days [23]. Each item is scored on a 4-point scale (from 0 to 3 reflecting increased se- verity of symptoms). The minimum and maximum total scores are 0 and 30, respectively, in which 0 is least de- pressed and 30 is most depressed. The Arabic version of the EPDS has been demonstrated to be a reliable and valid screening tool [24]. Gubash et al. found that using a cut-off score of 12, the sensi- tivity and the specificity of the scale were 73% and 93% respectively. However, using a cut-off score of 10, the sensitivity of the scale rose to 91% without much decrease in its specificity (84%) [24]. In this study, a cut-off score of ≥ 12 was used so that comparisons could be made with other regional studies. A self-administered questionnaire reflecting important demographic, maternal, infant, and psychosocial risk factors for postnatal depression was appended to the EPDS [9–18]. A pilot study of recent mothers was conducted to assess the reliability of the Arabic EPDS and the self-administered questionnaire, and the validity was tested by seeking feedback from field experts, e.g. family physicians, midwives, community health nurses and special- ists in obstetrics and gynaecology and psychiatry. Appropriate modifications were made to the questionnaire. The internal consistency of the Arabic ver- sion of the EPDS was checked using the data from the pilot study. The calculated Cronbach alpha was 0.82, indicating a high inter-item consistency. The EPDS and self-administered questionnaires were distributed by the researcher and designated maternal and child health nurses in each selected health centre, and collected at the time of EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 434 the mother’s attendance. Non-attendee mothers were followed up after 1 week. Face-to-face interviews with mothers who were unable to read and write were carried out by the researcher. The research proposal was approved by the research and ethics committees of the Arabian Gulf University and the Ministry of Health. Informed consent was obtained from study participants. The instruments were coded to pro- tect confidentiality and data from birth notification forms was extracted by the researcher only. Arrangements were made for appropriate referral of women identified at risk for depression. Data analysis Data were coded, entered and analysed using SPSS, version 16.0. Descriptive statistics including mean and standard deviation (SD) were used to describe continuous variables, and frequencies were used to describe categorical vari- ables. Chi-squared test of independence was used to test the association between the dependant variable postnatal de- pressive symptoms and each of the sociodemographic, maternal, infant, social support and psychiatric health conditions. Fisher exact test was used for counts < 5. Odds ratios (OR) were calculated with the 95% confidence intervals (CI) to measure the risk of postnatal depressive symptoms in rela- tion to the studied risk factors. Multiple logistic regression was used to iden- tify the most important risk factors. The model was estimated using the back- ward conditional logistic regression. Adjusted OR were calculated for the significant predictors. P-values < 0.05 were considered statistically significant. Results A total of 237 Bahraini mothers took part in the study, representing a re- sponse rate of 94.8%. More than one- third (37.1%) of the women had EPDS score ≥ 12. Demographic factors In terms of demographic factors, no significant associations were found be- tween EPDS score ≥ 12 and mother’s age or age at marriage, educational level and occupation of mother and father, the marital status of the mother or the presence of another wife (Table 1). Pregnancy and birth factors Furthermore, no statistically significant relationships were found between post- natal depressive symptoms and: sex of the last born baby, type of delivery (vagi- nal or caesarean section), product of the delivery (single, twins or more), pre- maturity, health condition of the baby, birth order (firstborn or not), history of sibling death, history of separation from the newborn baby and breastfeeding or problems with breastfeeding (Table 2). No statistically significant relation- ship was apparent between EPDS score and planning of the last pregnancy, tim- ing of the last pregnancy and use of contraception (Table 3). History of depression and perceived support Table 4 shows the association between postnatal depressive symptoms and the mother’s satisfaction with support at home, previous history of depressive symptoms, depression during pregnan- cy and a previous history of depression diagnosed by a health professional ei- ther in herself or family member. Moth- ers who were less satisfied with the help provided at home were more likely to have depressive symptoms than those who were satisfied. Further, when moth- ers did not perceive their husbands as involved in the care of the newborn, there was a significant association with EPDS scores of ≥ 12 (P = 0.002). Mothers who reported a previous his- tory of depressive symptoms were 6 times more likely to have EPDS scores of ≥ 12 than those without such history (P < 0.001). Mothers who had been previously diagnosed by a health profes- sional as suffering from depression were 7 times more likely to have an EPDS score of ≥ 12 than those without this diagnosis (P = 0.006). A family history of depression was also found to be sig- nificantly associated with the presence of postnatal depressive symptoms and mothers who reported such a history were almost 3 times more likely to have postnatal depressive symptoms than those without (P = 0.038). In multiple logistic regression analy- sis a history of depressive symptoms (OR 8.13, 95% CI: 3.77–17.5) (P < 0.001) and not perceiving the husband as supportive (OR 2.41, 95% CI: 1.24– 4.69) (P = 0.01) were the only statisti- cally significant independent predictors of postnatal depression (Table 5). Discussion Comparisons with studies of postnatal depression in other Arab countries are difficult because of variability in the tools used (screening, standardized diagnostic tools), the point in time applied, different cut-off points of the same tool and cultural issues [5,8]. Notwithstanding these difficulties, the prevalence of depressive symptoms in this study was higher than in other regional studies, and leads to a con- cern that the prevalence of postnatal depression may be commensurately higher. In a study of 95 women in a hospital in Dubai, United Arab Emirates, using the Present State Examination (PSE) assessment, a prevalence of 15.8% for postnatal depression was reported [15]. In Morocco, the prevalence of postna- tal depression at 2 weeks post-delivery was 18.7%, using the Mini International Neuropsychiatric Interview (MINI), and 20.1%, using a cut-off score of 12 with the EPDS [13]. Chaaya et al. in Lebanon using an EPDS score of 12/13 at 4–5 months postpartum recorded a prevalence rate of 21% [11], although at 4 months depression may have resolved spontaneously. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 435 As for risk factors, the current study showed that a previous history of depressive symptoms reported by the mother was significantly associated with postnatal depression scores. This finding is in accordance with other stud- ies. Indeed, a history of depression or depressive symptoms and of depression during pregnancy are among the most important and significant predictors of postnatal depression [8,10,15,16,25,26]. Despite the fact that depression dur- ing pregnancy is a strong predictor of postnatal depression, the current study did not show any significant relation- ship between postnatal depression and depressive symptoms reported during pregnancy. This can be attributed first, to the small sample size of this study, and second, to the point in the postnatal period under evaluation, i.e. 8 weeks. O’Hara and Swain found in their meta- analysis that assessment at 1 or 2 weeks postnatal was strongly associated with pregnancy depression, while assess- ment at 9 weeks was only weakly associ- ated with depression [8]. Of course, it is possible that an in-pregnancy depres- sion had not resolved. In contrast with other studies [10,11,16,26], the logistic regression analysis in this study did not show a significant relationship between fam- ily history of depression and postnatal depressive symptoms, and this agrees with the meta-analysis of O’Hara and Swain [8]. The other risk factor identi- fied in this study, as in others, concerned support for the new mother at home. Lack of support was shown in this study to be strongly correlated with depres- sive symptoms, and has been linked consistently with postnatal depression [8,26]. Traditionally after the birth of a child in Bahrain, the mother moves to live with her own mother for 40 days before she returns back to her husband’s house. During this time, the new moth- er is relieved from her normal duties, which are taken over by female relatives. Table 1 Association between high score on the Arabic version of the Edinburgh Postnatal Depression Scale (EPDS) and the demographic characteristics of the newborn’s mother and father Variable Total no. EPDS ≥ 12 OR (95% CI) P-value No. % Mother’s age (years) 0.572 17–20 8 4 50.0 21–30 127 49 38.6 31–40 92 33 35.9 41–44 10 2 20.0 Mother’s education 0.264 Illiterate or read and write 11 6 54.5 Primary or intermediate 24 11 45.8 Secondary or diploma 114 36 31.6 University 88 35 39.8 Mother’s occupation 0.311 Housewife 145 49 33.8 Employed 74 30 40.5 Student 18 9 50.0 Age at marriage (years) 0.570 11–20 91 36 39.6 21–30 138 48 34.8 31–39 8 4 50.0 Father’s education 0.502 Illiterate or read and write 5 2 40.0 Primary or intermediate 54 20 37.0 Secondary or diploma 114 47 41.2 University 64 19 29.7 Father’s occupation 2.32 (0.51–10.6) 0.429a Working 230 84 36.5 Not working 7 4 57.1 Marital profile 0.38 (0.06–2.34) 0.362a One wife 230 84 36.5 More than one wife 5 3 60.0 The total of some variables vary due to missing values. aFisher exact test was used because some cells have expected count < 5. OR = odds ratio; CI = confidence interval. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 436 Table 2 Association between high score on the Arabic version of the Edinburgh Postnatal Depression Scale (EPDS) and characteristics of the last born baby Variable Total no. EPDS ≥ 12 OR (95% CI) P-value No. % Baby’s sex 0.94 (0.55–1.59) 0.808 Male 108 41 38.0 Female 129 47 36.4 Type of delivery 1.57 (0.85–2.90) 0.145 Vaginal 182 63 34.6 Caesarean 55 25 45.5 Product of delivery 3.50 (0.63–19.5) 0.198a Singleton 231 84 36.4 Twins or more 6 4 66.7 Gestational age 1.19 (0.46–2.65) 0.835 Term 214 79 36.9 Premature 23 9 39.1 Birth order 0.99 (0.57–1.71) 0.959 First child 83 31 37.4 Second or greater 154 57 37.0 Baby was sick Yes 7 4 57.1 0.43 (0.09–1.98) 0.429a No 230 84 36.5 Separated from baby Yes 36 18 50.0 0.54 (0.26–1.09) 0.084 No 198 69 34.8 History of a dead sibling in the family Yes 13 5 38.5 1.06 (0.34–3.35) 1.000a No 224 83 37.1 Breastfed Yes 230 85 37.0 1.08 (0.34–8.64) 0.674a No 6 3 50.0 Problems with breastfeeding Yes 83 37 44.6 0.62 (0.36–1.06) 0.081 No 154 51 33.1 aFisher exact test. OR = odds ratio; CI = confidence interval. Table 3 Association between high score on the Arabic version of the Edinburgh Postnatal Depression Scale (EPDS) and marital status of the mother and planning of the last pregnancy Variable Total no. EPDS ≥ 12 OR (95% CI) P-value No. % Marital status 1.70 (0.11–27.5) 1.000a Married 235 87 37.0 Divorced 2 1 50.0 Pregnancy was desired Yes 171 60 35.1 1.36 (0.76–2.44) 0.295 No 66 28 42.4 Timing of last pregnancy was suitable Yes 152 54 35.5 1.21 (0.70–2.09) 0.494 No 85 34 40.0 Got pregnant while using contraception Yes 45 15 33.3 1.24 (0.62–2.46) 0.542 No 191 73 38.2 aFisher exact test. OR = odds ratio; CI = confidence interval. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 437 This extended family system is a potent source of support in the Bahraini com- munity and it is a duty of its members to support each other as far as they are able. This traditional custom is becom- ing less common these days, however. A study in the UAE found that more than half of the new mothers returned to their homes and only about one- third went to their mother’s home [12]. Bahrain may be in a transitional stage, but this issue was not explored in this study. In the current research, the support offered by participants’ mothers and husbands, was examined. No significant association with EPDS score ≥ 12 was found when the participant’s mother was not identified as a provider of sup- port. On the other hand, when the hus- band was not identified as a support, this was found on logistic regression to be a risk factor. Whether this perception was a reflection of reality or a manifestation of depressive symptoms could not be determined in this study. Two further studies have examined the importance of social support, and in particular part- ner support, as risk factors for postnatal depression [27,28] and confirm this study’s finding. In conclusion, this study showed a high rate of depressive symptoms among Bahraini mothers at 8 weeks postpartum, with a previous history of depressive symptoms and the hus- band’s perceived lack of social support emerging as associated risk factors. As the prevalence of symptoms was high in comparison with other studies conduct- ed in the region, this study’s findings need to be corroborated by a similar study that is supplemented by the in- clusion of an appropriate diagnostic tool. If such research were to confirm a higher level of depression than might be expected, then the implications for the health care system are important. Con- siderable effort and resources would be needed to mount both prevention and treatment programmes. Table 4 Association between high score on the Arabic version of the Edinburgh Postnatal Depression Scale (EPDS) and support provided at home and history of depression among Bahraini women Variable Total no. EPDS score ≥ 12 OR (95% CI) P-value No. % Satisfied with help at home Yes 192 66 34.4 2.00 (1.03–3.90) 0.04 No 43 22 51.2 Help provided by husband Yes 130 37 28.5 2.33 (1.36–4.00) 0.002 No 106 51 48.1 Help provided by mother Yes 107 36 33.6 1.33 (0.78–2.27) 0.292 No 129 52 40.3 History of depressive symptoms Yes 64 44 68.8 6.45 (3.44–12.05) < 0.001 No 173 44 25.4 Previous diagnosis of depression Yes 10 8 80.0 7.35 (1.52–35.7) 0.006a No 227 80 35.2 Diagnosis of depression during pregnancy Yes 1 1 100.0 2.71 (2.30–3.21) 0.371a No 236 87 36.9 Family history of depression Yes 18 11 61.1 2.77 (1.03–7.46) 0.038 No 188 68 36.2 aFisher exact test. OR = odds ratio; CI = confidence interval. Table 5 Multiple logistic regression analysis of the risk factors for a high score on the Edinburgh Postnatal Depression Scale (≥ 12) Risk factor OR (95% CI) P-value Husband not perceived as supportive 2.41 (1.24–4.69) 0.01 History of depressive symptoms 8.13 (3.77–17.5) < 0.001 OR = odds ratio; CI = confidence interval. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 438 References 1. Moehler E et al. Maternal depressive symptoms in postnatal period are associated with long term impairment of mother– child bounding. Archive of Women’s Mental Health, 2006, 9 (5):273–278. 2. Murray L. The impact of postnatal depression on infant devel- opment. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 1992, 33:543–561. 3. Cogill SR et al. Impact of maternal postnatal depression on cognitive development of young children. British Medical Jour- nal, 1986, 292:1165–1167. 4. Patel V, Rodrigues M, De Souza N. Postnatal depression and infant growth and development in low income countries: a cohort study from Goa, India. Archives of Disease in Childhood, 2003, 88:34–37. 5. Rahman A et al. Impact of maternal depression on infant nu- tritional status and illness. A cohort study. Archives of General Psychiatry, 2004, 61:946–952. 6. Helbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symp- toms. Journal of Affective Disorders, 2006, 91:97–111. 7. Josefsson A et al. Prevalence of depressive symptoms in late pregnancy and postpartum. Acta Obstetricia et Gynecologica Scandinavica, 2001, 80:251–255. 8. O’Hara MW, Swain AM. Rates and risk of postpartum depres- sion: a meta-analysis. International Review of Psychiatry, 1996, 8:37–54. 9. Husain N et al. Prevalence and social correlates of postnatal depression in a low income country. Archives of Women’s Men- tal Health, 2006, 9:197–202. 10. Inandi T et al. Risk factors for depression in postnatal first year, in eastern Turkey. International Journal of Epidemiology, 2002, 31:1201–1207. 11. Chaaya M et al. Postpartum depression: prevalence and de- terminants in Lebanon. Archives of Women’s Mental Health, 2002, 5(2):65–72. 12. Green K, Broome H, Mirabella J. Postnatal depression among mothers in the United Arab Emirates: socio-cultural and physi- cal factors. Psychology Health and Medicine, 2006, 11:425–431. 13. Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in Moroccan sample. Archives of Women’s Mental Health, 2005, 8(1):37–43. 14. Patel V, Rodrigues M, De Souza N. Gender, poverty and post- natal depression: a study of mothers in Goa, India. American Journal of Psychiatry, 2002, 159:43–47. 15. Ghubash R, Abou-Saleh MT. Postpartum psychiatric illness in Arab culture: prevalence and psychosocial correlates. British Journal of Psychiatry, 1997, 171:65–68. 16. Steiner M. Postnatal depression: a few simple questions. Fam- ily Practice, 2002, 19:469–470. 17. Chandran M et al. Post-partum depression in a cohort of women from a rural area of Tamil Nadu, India. Incidence and risk factors. British Journal of Psychiatry, 2002, 181:499–504. 18. Iranfar S et al. Is unintended pregnancy a risk factor for depres- sion in Iranian women? Eastern Mediterranean Health Journal, 2005, 11:618–624. 19. Evins GG, Theofrastous JP, Galvin SL. Postpartum depres- sion: a comparison of screening and routine clinical evalu- ation. American Journal of Obstetrics and Gynecology, 2000, 182(5):1080–1082. 20. Seehusen DA et al. Are family physicians appropriately screen- ing for postpartum depression? Journal of the American Board of Family Practice, 2005, 18:104–112. 21. Al Kawari MA. A survey among Bahraini women on the utiliza- tion of postnatal check-ups: policy implications [Master’s thesis]. Manama, Bahrain, Department of Family Medicine, Arabian Gulf University, 2007:101. 22. Health statistics 2008. Health Information Directorate, Ministry of Health, Bahrain [online database] (http://www.moh.gov. bh/PDF/Publications/Statistics/HS2008/hs2008_e.htm, ac- cessed 1 March 2012). 23. Dennis CL. Detection, prevention and treatment of postpar- tum depression. In: Stewart DE et al., eds. Postpartum depres- sion: literature review of risk factors and interventions. Toronto, Faculty of Nursing, University of Toronto, University Health Network Women’s Health Program, 2003:73–196. 24. Ghubash R, Abu-Saleh MT, Daradkah TK. The validity of the Arabic Edinburgh postnatal depression scale. Social Psychiatry and Psychiatric Epidemiology, 1997, 32:474–476. 25. Dennis C-L, Ross LE. The clinical utility of maternal self-report personal and familial psychiatric history in identifying women at risk for postpartum depression. Acta Obstetricia et Gyneco- logica Scandinavica, 2006, 85:1179–1185. 26. Verkerk GJM et al. Prediction of depression in the postpartum period: a longitudinal follow-up study in high-risk and low-risk women. Journal of Affective Disorders, 2003, 77:159–166. 27. Dennis C-L, Janssen PA, Singer J. Identifying women at-risk for postpartum depression in the immediate postpartum period. Acta Psychiatrica Scandinavica, 2004, 110:338–346. 28. Dennis C-L, Ross L. Women’s perceptions of partner support and conflict in the development of postpartum depressive symptoms. Journal of Advanced Nursing, 2006, 56:588–599. Acknowledgements We would like to thank the women who participated in this study for their cooperation. We would also like to thank Mr Mohammed Obaidat, lecturer at the Arabian Gulf University, for his as- sistance in the statistical part of the study. This work was derived from a thesis submitted in partial fulfilment of the Mas- ter’s degree in Health Policy and Popula- tion Studies, Arabian Gulf University. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 439 Predictors of fetal demise after trauma in pregnant Saudi Arabian women A.S. Al Mulhim,1 M.H. Balaha 2 and F. Tudiver 3 ABSTRACT In Saudi Arabia, road traffic crashes are becoming a serious public health problem and there are no recent, large-scale, published reports discussing maternal and fetal injuries. We aimed to explore the predictors of fetal death/abortion after maternal trauma. A retrospective case–control study was performed exploring cases of maternal trauma. The study group included 118 women with pregnancy loss while 308 women without loss represented the control group. All data were compared using univariate analysis followed by multivariate regression analysis. Only 3 predictors were associated with significant effect on pregnancy loss after trauma (P < 0.05): second trimester of pregnancy (OR 2.77, 95% CI: 1.66–4.63, placental abruption (OR 3.69, 95% CI: 2.01–6.79) and severe injury score (OR 6.78, 95% CI: 4.04–11.37). 1Department of Surgery; 2Department of Obstetrics and Gynaecology, King Faisal University, Al Ahsa, Saudi Arabia. 3Department of Family Medicine, James H Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee, United States of America (Correspondence to F. Tudiver: tudiverf@etsu.edu). Received: 27/07/10; accepted: 31/10/10 حوضرلل ةيدوعسلا ةيبرعلا ةكلملما في لماولحا ءاسنلا ض ُّرعت دعب ةنجلأا توم نع تائبنم رفيدوت درف ،ةحلب نسح يدمج ،محللما حلاص نحمرلا دبع قاطنلا ةعساو ةثيدح ةروشنم ريراقت دجوت لاو ،ةيرطخ ةيمومع ةيحص ةلكشم ةيرورلما ثداولحا تحبصأ ،ةيبرعلا ةيدوعسلا ةكلملما في :ةصلالخا ةعوممج تلمتشاو .تاهملأا ينب حوضرلا تلااح نع فشكلل دهاوشلاو تلااحلل ةيداعتسا ةسارد تَيرجأ دقو .ةنجلأاو تاهملأا تاباصإ شقانت مادختساب تايطعلما عيجم ينب نوثحابلا نراقو .دهاوشلا ةعوممج نل َّكش اهلحم لوصمح دقفت لم ةأرما 308و ،اهلحم لوصمح تدقف ةأرما 118 لىع ةساردلا )P <0.05( حوضرلا دعب لملحا نادقف لىع يرثأتلاب هب ُّدَتْعُي ًاطابترا طقف تائبنم ةثلاث تطبتراو .تايرغتلما ددعتم فوتح ليلتح هلات يرغتلما ديحو ليلتح :%95 ةقثلا ةلصاف ،3.69 ةيحجرلأا ةبسن( ةميشلما لاصفناو ،)4.63-1.66 :%95 ةقثلا ةلصاف ،2.77 ةيحجرلأا ةبسن( لملحا نم نياثلا ثلثلا :يهو .)11.37-4.04 :%95 ةقثلا ةلصاف ،6.78 ةيحجرلأا ةبسن( ةميخو ةجرد نم انهأ لىع حوضرلا فينصتو ،)6.79-2.01 Facteurs prédictifs des décès fœtaux après un traumatisme chez des femmes saoudiennes enceintes RÉSUMÉ En Arabie saoudite, les accidents de la circulation deviennent un problème de santé publique majeur. Toutefois, aucun rapport de grande envergure n'a été récemment publié sur les traumatismes maternels et fœtaux. Nous avions pour objectif de rechercher les facteurs prédictifs des décès fœtaux ou des avortements après un traumatisme maternel. Une étude cas-témoin rétrospective a été menée pour rechercher des cas de traumatismes maternels. Le groupe de l'étude comprenait 118 femmes ayant eu une fausse couche alors que le groupe témoin était composé de 308 femmes dont le fœtus avait survécu. Toutes les données ont été comparées à l'aide d'une analyse univariée suivie d'une analyse de régression multivariée. Seuls trois facteurs prédictifs ont été associés à un effet important pour la fausse couche suite à un traumatisme (P < 0,05) : le deuxième trimestre de grossesse (O.R. 2,77 ; IC à 95 % : 1,66–4,63) ; un hématome rétroplacentaire (O.R. 3,69 ; IC à 95 % : 2,01–6,79) et le score de gravité du traumatisme (O.R. 6,78 ; IC à 95 % : 4,04–11,37). EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 440 Introduction In the past, most causes of maternal mortality and morbidity during preg- nancy were obstetric resulting from a lack of prenatal care and/or inadequate assistance during delivery. Nowadays the rate of maternal mortality is much lower; fetal demise has not, however, been significantly reduced because of a rise in non-obstetric causes, especially trauma [1]. Between 6% and 7% of pregnant women have some type of physical trauma [2]. Many studies have reported that the most common etiologies of trauma injuries in pregnancy include transportation crashes, falls, domestic abuse and assaults, puncture wounds and burn injuries [3,4]. Trauma in pregnancy is currently a leading cause of non-pregnancy-related maternal death, and maternal death remains the most common cause of fetal demise [5]. The effect of trauma on pregnancy depends on gestational age, intensity of maternal–fetal aggression (severity of both maternal and fetal injury) and type and severity of the injury [6]. In Saudi Arabia there is rapid mod- ernization, expansion and economic growth with massive new road construc- tion and increased numbers of high powered luxury vehicles. Road traffic crashes are becoming a serious public health problem [7]. In 2006, the Saudi Arabian Ministry of Health reported that accidents were the third most com- mon cause of death among all groups (18.3% of all deaths) [8]. According to the 2009 WHO health statistics report, the maternal mortality ratio in Saudi Arabia was 18 per 100 000, compara- ble to that of developed countries [9]. Moreover, the mortality rate due to injuries was reported as 76 per 100 000. In the eastern province of Saudi Arabia, Al Ahsa, it was reported that the average daily number of accidents was 14–18. The accident–injury rate and accident–death rate per 100 accidents was 26.2 and 2.6 respectively [10]. With such accident rates, the ability to predict adverse outcomes for both the mother and fetus is an important goal in pregnancies where there is trauma, particularly since the frequency and on- set of adverse outcomes are uncertain. We hypothesized that by identifying a group of injured pregnant women who were “at risk” for termination of their pregnancy, we could define a sub- population of women who should be targeted in future prevention efforts. To our knowledge, there has been no local or regional study published addressing this subject. The aims of this research were to identify the characteristics of pregnant women in Eastern Saudi Arabia who had been injured and who had pregnan- cy loss in the form of abortion or fetal demise and to determine the risk factors for pregnancy loss and compare these findings to those of injured pregnant women who did not have pregnancy loss. Methods This study was conducted in Al-Ahsa, Saudi Arabia. Al-Ahsa is the largest province in the Eastern Region, cover- ing an area of 2500 km2. It has a popula- tion of more than 900 000 people, who mainly inhabit Al-Ahsa's 4 major cities: Al-Hofuf, Al-Mobarraz, Al-Oyoun, and Al-Omran, plus 50 scattered vil- lages. Small desert collections of people, called hegars, are also present. Al Hofuf King Fahd Hospital is the central pool- ing hospital in Al Ahsa Province. This hospital is a referral centre providing secondary level of care to approximately 1.5 million people in Al Ahsa and the nearby regions. The data used in the current study were derived from Al Hofuf King Fahd Hospital database with the permission of the hospital authorities and maintain- ing file and patient confidentiality. The study protocol and the data collection forms were approved by the ethics com- mittees of King Faisal University, Al Ahsa, and Al Hofuf King Fahd Hospital. The design of this research was a retrospective, case–control study. The researchers searched through all the files in the period July 2006–August 2009, searching for cases on patients who had survived after being admitted with trauma during pregnancy. The fetal stage was defined as the period from the beginning of the ninth week after fertilization through to birth [11]. Trauma survivors were defined as all traumatized pregnant women admitted during the study period who had had fetal loss. Fetal loss was defined as either abortion (< 24 gestational weeks), fetal death at any gestational duration, or pre- term delivery of a non-viable fetus (< 28 gestational weeks) [12]. Controls were traumatized pregnant women admitted in the same time period, at the same stage of gestation (9–40 weeks) but who had not had pregnancy loss. Our sample included 459 survivors: these included 118 women who had pregnancy loss (cases) and 341 who did not have pregnancy loss (controls). All the files were cross-checked, either through the same file in Al Hofuf King Fahd Hospital or through files in the Maternity Department where data were missing or needed to be checked. All the files were also checked for all investiga- tions available and all recorded findings. During the search and data collection, 33 of the control group were excluded as their files contained conflicting or incomplete data. The final number of cases that were included in the control group was 308. Each file was reviewed regarding the admission data, history, examina- tion and investigations. The sociode- mographic characteristics included maternal age, residence (urban, rural, hegar or desert scattered) education, nationality and family income (< 3000, 3000–< 6000, ≥ 6000 Saudi riyals). Ob- stetric history data included gravidity, gestational age, diseases associated with طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 441 pregnancy (diabetes mellitus, sickle-cell disease, hypertension), and presenting with leucorrhoea, vaginal bleeding or abdominal pain. Each file was reviewed regarding the mode of injury, site of injury, cause of trauma (motor vehicle crash, physical domestic violence, or fall), and distance (km) from the site where the trauma occurred to hospital. The data retrieved included the injury severity score [13], vital signs, the presence of shock on admission (systolic blood pressure < 90 mmHg), length of stay in hospital, the number of days spent in the intensive care unit, whether or not a blood transfusion was given, details of the injury and surgical interventions. The injury severity score was used because it is an anatomic scor- ing system used for trauma patients and it works by assigning 6 body regions with scores, the highest 3 scores are then squared and summed to produce the in- jury severity score. Scores less than 9 are categorized as non-severe and scores 9 or greater as severe injuries [13]. One study found that an injury severity score ≥ 9 had 85.7% sensitivity and 70.9% specificity in predicting a nonviable pregnancy, which was the highest com- pared to other cut-off values [5]. The findings of the obstetric exami- nations, including fetal heart, uterine monitoring with cardiotocography, and ultrasonography, were assessed regarding the presence or absence of a retro-placental haematoma (placental abruption), fetal position, biophysical profile, and fetal weight. Mode of deliv- ery was also recorded. Neonatal data, including birth weight and respiratory problems, were also collected. Fetal/ neonatal/infant outcomes included: premature delivery (before 37 weeks), low birth weight (under 2500 g), respir- atory distress syndrome, and neonatal and infant death [11,12]. Data analysis Data were analysed using Epi-Info, ver- sion 3.5.1, and SPSS, version 16. De- scriptive statistics were used to present the findings in both the case and control groups. To determine which variables served as predictors of pregnancy loss, univariate analysis was employed with reporting of crude odds ratios and 95% confidence intervals. For continuous data, mean and standard deviation were used for expression; t-test was also employed for comparison when appropriate. P-value < 0.05 was consid- ered statistically significant. Multivariate logistic regression models were then constructed to adjust for and to con- trol for the influence of all predictors on pregnancy loss. All the significant predictors in the univariate analysis were included in 2 multivariate logistic regression models: model I for the soci- odemographic factors and model II for the obstetric and surgical factors. Results The final sample size in this study was 426 (92.8%) and these were evaluated according to their allocation in either the study (n = 118) or control (n = 308) groups. Car crashes represented 90% and 68% of trauma respectively in the study and control group with significant differences [odds ratio = 1.2 (1.05–1.37)]. In the study group (cases), abortion, intrauterine fetal death and non-viable birth occurred in 59 (50.0%), 34 (28.8%) and 25 (21.2%) cases, respectively. The clinical and ultrasonographic findings showed that placental abruption occurred in 58 cases (49.2%). While normal, continuing preg- nancy was reported in 59.7% of cases in the control group, continued pregnancy with some antenatal obstetric prob- lems was reported as preterm labour (14.6%), placental abruption (17.5%) and premature rupture of membranes (11.4%) (Table 1). Comorbidity was nearly the same in both groups: 20.4% in the study group and 19.2% in the control group. Combined diabetes and sickle-cell disease were found in 16.7% and 13.6% respectively, and combined hypertension, diabetes and sickle-cell disease were present in 2.8% and 3.6% respectively. Reassuring cardiotocogra- phy, normal vaginal delivery and normal neonatal outcomes were reported in 52.6%, 57.1% and 58.1% respectively (Table 1). Table 2 shows the results of univari- ate analysis of the sociodemographic, obstetric, and surgical risk factors for pregnancy loss. The following showed significantly higher odds of pregnancy loss (P < 0.05): older age (> 40 years), non-urban residence, employment out- side the home, family income > 6000 riyals, second trimester of pregnancy, vaginal bleeding at admission, placental abruption, car crash, abdomino-pelvic trauma, injury score ≥ 9, stay in hospital > 21 days and having an antenatal medi- cal disease. Women with secondary or post-secondary education, women in the first trimester of pregnancy, and women undergoing laparotomy were less likely to suffer from a pregnancy loss. Table 3 displays the results of the multivariate logistic regression models for pregnancy loss after inclusion of all the significant variables in the uni- variate analysis. In model I, none of the sociodemographic predictors were significant, so none of those risk factors were independent predictors of loss of pregnancy. In Model II only 3 variables were significant predictors for pregnancy loss (P < 0.05): second trimester of pregnan- cy, placental abruption and injury score ≥ 9. This confirmed that these putative risk factors were predictors of preg- nancy loss. Although vaginal bleeding and abdomino-pelvic trauma increased the risk for pregnancy loss, the associa- tions were not statistically significant as predictors in the regression model. The correlation between the different factors in the model showed that each of these 3 risk factors was significantly correlated to the others, and all were significantly EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 442 correlated with the abdomino-pelvic cause of trauma. Discussion To our knowledge, this is the largest reported study which used statistical regression analysis to document the prediction of pregnancy loss second- ary to trauma in the Eastern region of Saudi Arabia. We found that there were 3 important predictors of pregnancy loss after trauma: second trimester of pregnancy, placental abruption, and severe injury score. Trauma, whether major or minor, has been associated with an increased risk of spontaneous abortion; pre- mature labour; preterm, premature rupture of the membranes; uterine rupture; placental abruption; fetal distress; maternal death; and stillbirth [5,14]. It has been reported that motor ve- hicle crashes account for 66% of all trau- mas, and falls and assaults account for the remaining 33% [15]. In this study, car crashes were responsible for 76.3% and 67.8% of trauma respectively in the study and control groups. Despite this, in the multivariate analysis it was not a significant predictor for pregnancy loss after trauma. This may be because the increased number of car crashes did not necessarily result in greater severity of injuries. A number of studies have reported a variable incidence of physical violence during pregnancy; ranging from 8% to 20% [16,17]. In this study, it rep- resented nearly 15% in both the case and control groups. In contradiction to our findings, a study in Saudi Arabia reported physical violence in 21% of pregnancies. These cases were associ- ated with increased preterm labour, placental abruption, caesarean section and fetal distress [18]. In the univariate analysis, we found that pregnancy loss was significantly greater in older, non-urban, employed women and in women with family in- come > 6000 riyals. This appears to be a new finding as there are no published reports of this in the literature. We con- sidered higher family income could be a proxy for the presence of high powered, luxury cars, which may encourage fast driving [7]. Although we found that pregnancy loss was associated with increased se- verity of the trauma score, it was not associated with the presence of mater- nal shock at admission (see Table 2). This may be explained by the presence of other factors such as direct uterine trauma in cases of severe trauma. Severe fetal suffering may occur in the absence of clinical signs of shock because the physiological changes during pregnan- cy may mask the diagnosis. Moreover, a reduction of up to 20% in uterine blood Table 1 Obstetric outcomes in pregnant Saudi Arabian women after admission to hospital due to trauma Outcome No. % Women who had pregnancy loss (n = 118) Outcome Abortion 59 50.0 Intrauterine fetal death 34 28.8 Non-viable birth (< 28 weeks) 25 21.2 Course of condition a Abruptio placentae 58 49.2 Preterm rupture of membranes 14 11.9 Co-morbidity 7 5.9 No data found 46 38.9 Women who did not have pregnancy loss (n = 308) Course of pregnancy a Uncomplicated pregnancy 184 59.7 Abruptio placentae 54 17.5 Preterm labour 45 14.6 PROM 35 11.4 Co-morbidity 16 5.2 Delivery After trauma periodb 292 63.6 During the trauma periodb 16 3.5 Delivery mode Normal vaginal 176 57.1 Assisted 81 26.3 Caesarean 51 16.6 At birth cardiotocography Reassuring 162 52.6 Non reassuring 79 25.8 Ominous 67 21.8 Neonatal outcome Normal 179 58.1 Respiratory problems 85 27.6 Low birth weight 44 14.3 aThe sum of the percentage exceeds the total item percentage due to the co-morbid findings. bTrauma period is 1 month after the trauma. PROM = premature rupture of membranes. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 443 Table 2 Univariate analysis of the risk factors in the study group (having pregnancy loss) and control group (no pregnancy loss) Variable Control group (n = 308) Study group (n = 118) OR (95% CI) No. % No. % Maternal age groups (vs < 20) 20–40 234 76.0 32 27.1 0.86 (0.73–1.02) > 40 39 12.7 75 63.6 2.22 (1.64–3.01)* Residence (vs urban) Rural/hegar 220 71.4 99 83.9 1.19 (1.06–1.34)* Level of education Illiterate 54 17.5 15 12.7 Reference < Secondary 69 22.4 20 16.9 1.04 (0.46–2.38) Secondary or higher 185 60.1 83 70.3 1.62 (0.83–3.18) Occupation (vs housewife) Student 35 11.4 14 11.8 1.18(0.96–1.44) Employment outside the home 210 68.2 92 78.0 1.21(1.07–1.37)* Family income (Saudi riyals) < 3000 75 24.4 20 16.9 Reference 3000– < 6000 185 60.1 70 59.3 1.09 (0.96–1.24) ≥ 6000 48 15.6 28 23.7 1.25 (1.02–1.53)* Mean (SD) graviditya 4.3 (1.9) 4.08 (1.8) t = –0.86 (–0.22–0.57) Vaginal bleeding 64 20.8 42 35.6 1.26 (1.07–1.49)* Antenatal medical disease (≥ 1) 147 47.7 65 55.1 1.09 (0.96–1.22) Gestational age groups (weeks) ≤ 13 (first semester) 71 23.1 20 16.9 Reference 14–26 (second semester) 100 32.5 73 61.9 1.35 (1.14–1.6)* > 26 (third semester) 137 44.5 25 21.2 0.92 (0.81–1.05) Placental abruption 54 17.5 58 49.2 1.68 (1.37–2.05)* Premature rupture of membranes 35 11.4 14 11.8 1.01 (0.84–1.22) Mean (SD) distanceb,c (km) 23.7 (3.6) 22.9 (3.3) 2.28 (0.11–1.55)* Cause of trauma Falling 51 16.6 10 8.5 Reference Home violence 48 15.6 18 15.3 1.15 (0.96–1.38) Car crash 209 67.8 90 76.3 1.20 (1.05–1.37)* Site of trauma Head, spine, limbs 110 35.7 21 17.8 Reference Abdomen 104 33.8 58 49.2 2.92 (1.60–5.36)* Pelvis 94 30.5 39 33.1 2.17 (1.15–4.13)* Injury severity score ≥ 9 (vs < 9) 64 20.8 76 64.4 1.87 (1.55–2.25)* Shock at admission 42 13.6 11 9.3 0.90 (0.77–1.05) Surgical treatment Non-laparotomy 144 53.5 47 44.3 Reference Laparotomy 125 46.5 59 55.7 1.45 (0.90–2.23) Stay in hospital (days) < 7 54 17.5 12 10.2 Reference 7–21 215 69.8 84 71.2 1.76 (0.86–3.66) > 21 39 12.7 22 18.6 2.54 (1.05–6.23)* *Significant at P < 0.05. aRange: 1–8; bfrom trauma site to hospital; crange: 15–33 km. OR = odds ratio; CI = confidence interval; SD = standard deviation. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 444 flow can occur without changes in ma- ternal blood pressure. Maternal blood pressure and pulse rate in predicting fetal loss has been shown to be unreli- able [19]. Our findings indicated that placen- tal abruption was significantly more common in the study group than in the control group. Schiff and Holt reported that placental abruption complicates 1%–5% of minor and 20%–50% of ma- jor injuries, and causes most of the as- sociated fetal death [20]. A small Saudi Arabian study on motor vehicle crashes showed that they caused fetal loss of 13% with placental abruption present in 17% of all cases [21]. These results support our finding of the association between trauma-associated placental abruption and fetal loss, but reported frequencies were lower in that study. This difference may be due to different inclusion criteria and number of included cases. In our study, pregnancy loss was sig- nificantly greater in women in the second trimester of pregnancy compared to the first trimester. Some studies have report- ed that the second trimester represented the most vulnerable period for fetal trauma because the gravid uterus ascends out of the bony pelvis in the cephalad di- rection to reach the level of the umbilicus by 24 weeks; here the gravid uterus may sustain direct traumatic injury. In the third trimester, the fetus is well protected by the amniotic fluid [22,23]. A study in Saudi Arabia on motor vehicle crashes and pregnancy out- comes concluded that a high injury severity score was associated with a 17-fold increase in the rate of fetal loss. This conclusion was based on a small number of cases (45); it did not exclude the effect of maternal death and did not use suitable statistical analyses to deline- ate the association [21]. Other studies have covered a number of independent risk factors: collectively, the significant predictors in these studies were: increased injury severity score, increased face and ab- dominal injury severity, increased fluid Table 3 Multivariate logistic regression analysis for sociodemographic, obstetric and surgical predictors of pregnancy loss in 118 Saudi Arabian women who had pregnancy loss after trauma Model and variables β SE P-value OR (95% CI) Model I: sociodemographic predictors Age group: ≥ 40 years –0.106 0.377 0.780 0.90 (0.43–1.88) Residence: rural/hegar –0.398 0.242 0.099 0.67 (0.42–1.07) Occupation: employed –0.055 0.339 0.872 0.95 (0.49–1.80) Family income (Saudi riyals): ≥ 6000 0.091 0.225 0.687 0.89 (0.70–1.70) Constant –0.805 0.334 0.016 0.45 Predicted (%) 72.3 χ2 3.23 Model II: clinicosurgical predictors Gestational age: second trimester 1.018 0.262 < 0.001 2.77 (1.66–4.63) Vaginal bleeding: present 0.183 0.328 0.577 1.20 (0.63–2.28) Placental abruption: present 1.308 0.311 < 0.001 3.69 (2.01–6.79) Cause of trauma: car crash –0.125 0.356 0.726 0.88 (0.44–1.77) Site of trauma: abdomen/pelvis 0.109 0.276 0.693 1.12 (0.65–1.92) Injury severity: severe (score ≥ 9) 1.914 0.264 < 0.001 6.78 (4.04–11.34) Length of hospital stay: >21 days –0.582 0.355 0.101 0.56 (0.28–1.12) Constant –2.173 0.543 < 0.001 0.114 Predicted (%) 79.8 χ2 123.94 SE = standard error; OR = odds ratio; CI confidence interval. requirements, maternal acidosis, mater- nal hypoxia, maternal shock, placental abruption, and gestational age < 32 weeks [24,25]. These findings support our results. Study limitations This study had several limitations. First, the retrospective design did not allow the investigators to study patients in a prospective, uniform, standardized man- ner for each group of risk factors. Second, the study included only hospitalized patients and cannot be generalized to minor traumas not requiring hospi- talization. Third, the files did not contain complete obstetric data for some cases, making it difficult to fully comment on the neonatal outcome and the related risk factors. The typical management options and investigations for obstetric cases were not documented owing to either under-use or under-reporting, as management was done case by case based mainly on personal preference and not on a specific protocol. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 445 References 1. Corsi PR et al. Trauma in pregnant women: analysis of maternal and fetal mortality. Injury, 1999, 30:239–243. 2. Lavery IP, Staten-McCormick M. Management of moderate to severe trauma in pregnancy. Obstetric and Gynecology Clinics of North America, 1995, 22:69–90. 3. Shah AJ, Kilcline BA. Trauma in pregnancy. Emergency Medicine Clinics of North America, 2003, 21:615–629. 4. Connolly AM et al. Trauma and pregnancy. American Journal of Perinatology, 1997, 14:331–336. 5. Kissinger DP et al. Trauma in pregnancy: predicting pregnancy outcome. Archives of Surgery, 1991, 126:1079–1086. 6. Pearlman MD, Tintinalli JE, Lorenz RP. Blunt trauma during pregJ- nancy. New England Journal of Medicine, 1990, 323:1609–1613. 7. Al-Ghamdi AS. Road accidents in Saudi Arabia: a compari- son and analytical study. Proceedings of the 2nd International Conference on Urban Transport and the Environment for the 21st Century, Barcelona, Spain. Southampton, UK, Computational Mechanics Publications, 1996:231–253. 8. Saudi health indicators. Jeddah, Ministry of Health, Department of Statistics, 2008 (http://www.moh.gov.sa/en/Ministry/ Statistics/Indicator/Pages/Indicator-2012-01-10-0001.aspx, accessed 17 April 2012). 9. World health statistics. Geneva, World Health Organization, 2009 (http://www.who.int/whosis/whostat/EN_WHS09_ Full.pdf, accessed 2 April 2012.) 10. Qayed MH. Epidemiology of road traffic accidents in Al-Ahsa Governorate, Saudi Arabia. Eastern Mediterranean Health Jour- nal, 1998, 4:513–519. 11. Klossner NJ. Introductory maternity nursing. Philadelphia, Lip- pincott Williams and Wilkins, 2006:100. 12. Vavasseur C, Foran A, Murphy JF. Consensus statements on the borderlands of neonatal viability: from uncertainty to grey areas. Irish Medical Journal, 2007, 100 (8):561–564. 13. Baker SP. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. Journal of Trauma, 1974, 14:187–196. 14. Pearlman MD. Evaluation and treatment of the gravida and fetus following trauma during pregnancy. Obstetric and Gyne- cology Clinics of North America, 1991, 18:371–381. 15. Goodwin TM, Breen MT. Pregnancy outcome and fetoma- ternal hemorrhage after non catastrophic trauma. American Journal of Obstetrics and Gynecology, 1990, 162:665–671. 16. Poole GV et al. Trauma in pregnancy: the role of interpersonal violence. American Journal of Obstetrics and Gynecology, 1996, 174:1873–1877. 17. Parker B, McFarlane J, Soeken K. Abuse during pregnan- cy: effects on maternal complications and birth weight in adult and teenage women. Obstetrics and Gynecology, 1994, 84:323–328. 18. Chibber R et al. Prevalence and complications of physical violence during pregnancy. European Journal of Obstetrics, Gynecology & Reproductive Biology, 2002, 103:26–29. 19. Srinarmwong C. Trauma during pregnancy: a review of 38 cases. Thai Journal of Surgery, 2007, 28:138–142. 20. Schiff MA, Holt VL. The injury severity score in pregnant trauma patients: predicting placental abruption and fetal death. Jour- nal of Trauma, 2002, 53:946–949. 21. Wahabi HA, Saleh AT, Abdelrahman AA. Motor vehicle ac- cidents during pregnancy: a review of maternal and fetal outcomes in Saudi Arabian population. Saudi Medical Journal, 2007, 28:1456–1457. 22. Kuczkowski KM. Trauma during pregnancy: a situation preg- nant with danger. Acta Anasthesiologica Belgica, 2005, 56:19– 21. 23. Rudra A et al. Trauma in pregnancy. Indian Journal of Anaesthe- siology, 2007, 51:100–105. 24. Ikossi DG et al. Profile of mothers at risk: an analysis of in- jury and pregnancy loss in 1195 trauma patients. Journal of the American College of Surgeons, 2005, 200:49–56. 25. Hitosugi M et al. Traffic injuries of the pregnant women and fetal or neonatal outcomes. Forensic Science International, 2006, 25:51–54. Acknowledgements We would like to thank all the staff members in the filing department of Al Hofuf King Fahd Hospital, Al Ahsa, for their help and support. We extend our appreciation to them. This filing was a relatively powerful tool for our study. We would also like to thank Dr Abdulla Khaled Al Mukahwy, a demonstrator in the Obstetrics and Gynaecology Department, College of Medicine, Al Ahsa. He was a medical student during the data collection phase and he helped us in many ways. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 446 General practitioners’ awareness and management of common psychiatric disorders: a community-based survey from Karachi, Pakistan H.A. Naqvi,1 S. Sabzwari,2 S. Hussain,1 M. Islam 2 and M. Zaman 3 ABSTRACT This study assessed the knowledge and management of common psychiatric disorders by general practitioners (GPs) in Karachi, Pakistan. Structured interviews were carried out in 2009 with 360 GPs selected by cluster random sampling. Patients with psychiatric disorders were estimated to be up to 10% of the daily caseload according to 71.8% of doctors. Two-thirds of GPs were unaware of the ICD-10 diagnostic criteria for depression and anxiety disorders. Benzodiazepines were the most recognized category of medication (75.3%) and were the most commonly used medication for all mental health conditions. Fewer GPs were familiar with selective serotonin reuptake inhibitors (35.1%) or tricyclic antidepressants (20.2%). Lack of time and patients’ financial constraints were reported to be barriers to care. Most GPs (69.2%) had not received any recent medical education about mental health problems. Gaps in GPs’ knowledge about the management of mental disorders have implications for the rational use of psychotropic medications in primary care. 1Department of Psychiatry, Aga Khan University, Karachi, Pakistan (Correspondence to H.A. Naqvi: haider.naqvi@aku.edu). 2Department of Family Medicine; 3Section of Epidemiology and Statistics, Community Health Sciences, Aga Khan University Hospital, Karachi, Pakistan. Received: 10/03/10; accepted: 30/08/10 ناتسكاب في شيتاراك في يعمتمج حسم :ةعئاشلا ةيسفنلا تابارطضلال مهتلجاعمو ينّماعلا ينسرمالما يعو نامز دممح ،ملاسإ دممح ،ينسح داجس ،يراوزبس هيناس ،يوقن ليع رديح تلاباقم نوثحابلا ىرجأ دقو .ناتسكاب في شيتاراك في ةعئاشلا ةيسفنلا تابارطضلال مهتلجاعمو ينماعلا ينسرمالما فراعم ةساردلا هذه تَمَّيق :ةصلالخا لصي ةيسفن تابارطضاب ينباصلما ضىرلما ددع نأ نوثحابلا ر َّدقو .ةعومجملل يئاوشعلا نايتعلاا قفو مهوراتخا ًاماع ًاسرامم 360 عم 2009 ماع في ةيجهنم تابارطضلا صيخشتلا يرياعمب ةفرعم ينماعلا ءابطلأا يثلث ىدل نكي لمو .ءابطلأا نم %71.8 تاريدقتل ًاقفو كلذو ،تلاالحا نم يمويلا ءبعلا نم %10 لىإ رثكلأاو ينبيزايدوزنبلا يه اهيرغ نم رثكأ ةفورعلما ةيودلأا ةعوممج تناكو .ICD-10 ضارملأل ليودلا فينصتلل ةشراعلا ةعجارملل ًاقفو ،قلقلاو بائتكلاا وأ ،)%35.1( يننوتويرسلا طاقتللا ةيئاقتنلاا تاطبثلماب ةيارد لىع مومعلا ينسرمالما نم لقأ ةعوممج ناكو .)%75.3( ةيسفنلا ةحصلا تلااح عيملج ًلاماعتسا غلبأ يتلا تابقعلا نمض نم يه ضىرلما ىدل ةيلالما دويقلاو فياكلا تقولا دوجو مدع نأ نوثحابلا دجوو .)%20.2( تاقللحا ةيثلاثلا بائتكلاا تاداضم تاوجفلا نأو ،ةيسفنلا ةحصلا لكاشم لوح ثيدح يبط ميلعت يأ اوقلتي لم )%69.2( ينماعلا ينسرمالما بلغأ نأ نوثحابلا دجو ماك .ةياعرلا مامأ فقت انهأ .ةيلولأا ةياعرلا في ةيسفنلا ةيودلأل ديشرلا مادختسلاا لىع اهراثآ اله ةيسفنلا تابارطضلاا ةلجاعم لوح ينماعلا ينسرمالما فراعم في Sensibilisation des médecins généralistes aux troubles psychiatriques courants et prise en charge de ces troubles : une enquête communautaire à Karachi (Pakistan) RÉSUMÉ La présente étude a évalué les connaissances des médecins généralistes sur les troubles psychiatriques courants et la prise en charge de ces troubles par ces derniers à Karachi (Pakistan). Des entretiens structurés ont été menés en 2009 auprès de 360 médecins généralistes sélectionnés par échantillonnage aléatoire en grappes. Il a été estimé que les patients souffrant de troubles psychiatriques représentaient 10 % du nombre de cas à traiter par jour selon 71,8 % des médecins. Deux tiers des médecins généralistes ne connaissaient pas les critères diagnostiques de la CIM-10 pour les troubles dépressifs et anxieux. Les benzodiazépines représentaient la catégorie de médicaments la plus connue (75,3 %) et la plus fréquemment utilisée pour tous les troubles mentaux. Les médecins généralistes qui connaissaient bien les inhibiteurs sélectifs de la recapture de la sérotonine (35,1 %) ou les antidépresseurs tricycliques (20,2 %) étaient moins nombreux. Le manque de temps et les contraintes financières des patients étaient des obstacles aux soins. La majorité des médecins généralistes (69,2 %) n'avaient pas suivi de formation médicale récente sur les troubles de santé mentale. Les failles dans les connaissances des médecins généralistes concernant la prise en charge des troubles mentaux ont des conséquences sur l'utilisation rationnelle des médicaments psychotropes en soins de santé primaires. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 447 Introduction The World Health Organization (WHO) has proposed that mental health care should be integrated within general health services in a decentral- ized manner [1]. Goldberg has argued that closer collaboration between general practitioners (GPs) and psy- chiatric services can bring advantages to patients, to primary care staff and to mental health staff [2]. Certainly the supply of psychiatrists in developing South East Asian countries is much smaller than that in the developed world (typically below 0.4 per 100 000 versus 9–25 per 100 000), implying that primary care must be one of the main providers of mental health care for all forms of disorders. However, many developing countries are not only short of psychiatrists they are also short of physicians [3,4]. The situation is not so different in Pakistan where the primary health care system is weakly developed and poorly functioning [5]. Studies on the benefits of integra- tion of mental health services into pri- mary care centres in India and Pakistan are inconclusive [6]. Most psychiatric patients in Pakistan bypass primary care services and access services at second- ary and tertiary care centres directly, the primary reason being the question- able quality of services offered at these centres [7]. Additionally, in the absence of any kind of health insurance, most patients pay out of their own pocket [8]. In a study carried out at a tertiary care centre in Karachi, 68% of patients pre- sented to psychiatrists for the first time. In the care pathway to mental health specialists, only 18% of patients had past contact with a primary care physi- cian [9]. Although common mental disorders were diagnosed in one-third to a half of primary care attendees in In- dia, primary care staff were reported to recognize only 10% of these cases [10]. The expertise of primary care physicians in the recognition of men- tal disorders is an important factor in the effective management of patients in primary care [11]. There is ample evidence of the benefits of early recogni- tion and management of mental health problems from industrialized countries, where health systems are better devel- oped. However, this needs to be studied systematically in the context of Paki- stan, where the realities of health care delivery are quite different. In Pakistan almost 70% of health care services are provided by the private health care sec- tor, therefore it is important to explore the opinion of these GPs regarding common psychiatric disorders. The objectives of this study therefore were to assess the knowledge and awareness of primary care physicians in Karachi, Pakistan, regarding the recognition and management of common psychiatric disorders and to gather their opinions about the care and services for patients with common mental disorders. Methods We conducted this study in 2 stages over a course of 9 months from April to December 2009. In the first stage, we carried out a survey over 6 months, mapping the GPs in Karachi, the largest metropolitan city in Pakistan in order to create a representative sampling frame of GPs. The primary reason for con- ducting the mapping exercise was that the existing lists of GPs available from various professional bodies in Pakistan were inaccurate. In the second stage, through a systematic sampling strategy, we randomly selected GPs to answer the questionnaire. Sampling strategy Assuming 50% prevalence (in the ab- sence of any previous reference on GPs’ opinions in Pakistan), with 95% confi- dence level and ± 5% error the estimated sample size was 385 doctors. Using a reference database on the estimated population of practising physicians in the country [12] the sample size was adjusted to 352. The final sample size was increased to a round figure of 360 subjects. The subjects were selected using cluster random sampling. Karachi city is divided into administrative 18 towns. Among these towns there are 178 union councils. The population of each union councils varies from 40 000–75 000 individuals according to the most recent census in 1998. In order to represent each of the 18 towns, 1 union council was selected randomly by ballot from each town. This created a sampling frame of 18 union councils. A list of all GPs practising in each of the councils was prepared, with separate codes assigned to other (alternative) care providers, in order to distinguish them from registered medical practi- tioners. Preliminary information, such as contact address and telephone num- bers, nature and timing of practice were documented for these GPs, enabling us to construct a sampling frame of 1800 GPs. Then 20 GPs were enrolled from each union council, thereby generating a sample of 360 GPs. Data collection In the initial stage, we took permission from the city government officials and administrative officers in the charge of towns, after informing them of the study objectives. Two field surveyors carried out the first stage mapping of GPs. In the second stage, 2 research officers were recruited due to their past experience in data collection and each research officer approached the GPs for participation. The research officers were trained by the principal investigator (H.N.) in order to standardize the data collection proce- dure, enhance compliance and ensure the accuracy of information. A field co- ordinator supervised the overall project. He was instrumental in monitoring the initial survey of GPs in selected union councils, besides maintaining overall quality control through random checks. He also supervised the second stage data collection in the field. As part of the EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 448 study protocol, we made 3 visits to the GPs in case of non-response. First and second visits were made by the research officer, while the field coordinator made the third and the last visit, noting down the concerns and reasons for non- participation. Despite these measures we encountered a refusal rate of 5%. Questionnaire The study questionnaire was developed by a focus group of psychiatrists and family physicians from the departments of psychiatry and family medicine at Aga Khan University. The study ques- tionnaire was pre-tested and modified using 10% of the study sample size. It was administered to the identified GPs in the second stage of survey. The questionnaire included in- formation about GPs’ awareness of various psychiatric disorders in their routine practice. It also asked about the International Statistical Classification of Diseases and Related Health Prob- lems (ICD-10) diagnostic criteria [13], treatment and referral difficulties and barriers to care. Individual characteris- tics of the practice that may have had an influence on the services rendered were collected. Some background in- formation on the GPs was also included in the questionnaire. The section on medications assessed the GP's familiar- ity with a broad group of psychotropic medications. The choices included selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, sero- tonin and noradrenaline reuptake inhibitors (SNRIs), benzodiazepines, bupropion (wellbutrin®), buspirone, antipsychotics and mood stabilizers. Physicians were free to choose multiple responses, thereby generating response rates greater than 100%. The ethics review committee of Aga Khan University Hospital reviewed the study protocol and granted permission to conduct it. The study was conducted in compliance with the ethical principles for medical research involving human subjects of the Helsinki Declaration. Data analysis Data was initially entered in the Epi- Data, version 3.1 then transferred to SPSS, version 15.0 for further analysis. Percentages of responses were calcu- lated for relevant variables pertaining to knowledge and awareness. For cat- egorical variables the chi-squared test of association was calculated, while for continuous variables Student t-test was used. The significance level was P < 0.05. Results In this survey we interviewed 360 GPs: 314 males and 43 females. The mean age of physicians was 44 (SD 10.4) years. They had been in practice for an average of 15 (SD 9.5) years. Table 1 shows the general characteristics of the GPs stratified by public or private sector medical college attended. Type of clinics A majority of the GPs (342, 95.0%) worked in private clinics where patients paid a fee for their services, while 4.8% of GPs were providing free services at welfare clinics affiliated with a non- governmental organization or charity (Table 1). Frequency of psychiatric disorders in general practice The frequency of patients with mental disorders seen in their daily practice was reported to be up to 10% of their case- load by 71.8% of GPs and 11%–25% of their caseload by 10.3%. Surprisingly 12.9% of GPs denied seeing any psy- chiatric patients. When we inquired specifically about the frequency of pa- tients with depressive disorders, 72.2% reported that around 1–5 patients daily had a depressive disorder and 13.6% reporting seeing 6–10 patients daily with depression. Only 6.4% of GPs de- nied seeing any patient with depres- sion in their practice. This trend was somewhat similar for anxiety disorders: 70.6% participants reported seeing 1–5 patients, while 15.8% reported seeing 6–10 patients daily. Awareness of diagnostic criteria GPs’ knowledge about the ICD-10 diagnostic criteria for depressive disor- der, generalized anxiety disorder, panic disorder, bipolar affective disorder and somatization disorder was assessed. Around two-thirds of GPs reported a lack of awareness with the ICD-10 diagnostic criteria for all these disorders (Table 2). Awareness of the ICD-10 criteria for depression was significantly better for among the 289 GPs gradu- ating before 1999 (28.9%) compared with the 70 graduating in year 2000 or later (11.4%) (χ2 = 7.87, df = 2, P = 0.019). Psychotropic medications in general practice When asked about their knowledge of psychotropic medications 75.3% of GPs reported awareness of the benzo- diazepine group (Table 3). The next most familiar drug groups were antip- sychotics and mood stabilizers, cited by 50.6% and 43.5% of GPs respectively. Only 35.1% of GPs reported familiarity with SSRIs and only 20.2% with tricyclic antidepressants. Figure 1 illustrates the physicians’ choice of medications for various psy- chiatric disorders. Benzodiazepines were the first choice of medication for all conditions and 52.3% of GPs reported using them in the treatment of depression. The next most commonly choice for depression were SSRIs, antip- sychotics, mood stabilizers and tricyclic antidepressants, cited by 31.6%, 27.1% and 20.9% GPs, respectively. The cor- rectness of responses were compared with American Psychiatric Association guidelines. When we grouped the drugs into potentially correct (SSRIs, SNRIs, tricyclic antidepressants and bupro- pion) and incorrect (benzodiazepines, mood stabilizers, antipsychotics and buspirone) choices 42.2% of GPs chose طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 449 a suitable drug. GPs graduating before the year 2000 were significantly more likely to be correct than those graduat- ing after 2000 (45.2% versus 30.0%) (χ2 = 5.321, df = 2, P = 0.021) When asked about the choice of medication for bipolar disorder, ben- zodiazepines were cited by 30.1% phy- sicians and antipsychotics and mood stabilizers by only 23.0% and 11.4% physicians. However, 40% reported that they did not know which medication to prescribe in the treatment of bipolar affective disorder. When we grouped the responses into potentially correct (antipsychotics and mood stabilizers) and incorrect responses (other medica- tions), an overwhelming majority of GPs (71.7%) made a wrong choice of medication. For the treatment of generalized anxiety disorder benzodiazepines were again the most favoured drugs, chosen by 50.7% of GPs, and SSRIs was cho- sen by only 15.4% of GPs. However, there were more correct (63.3%) than incorrect (36.7%) choices when drug categories were grouped. This was not a surprise since GPs could select any of the 6 drug groups (SSRIs, tricyclic Table 1 Characteristics of general practitioners in Karachi stratified by type of medical college attended Variable Public sector medical college (n = 330)a Private sector medical college (n = 30)a Total (n = 360)a No. % No. % No. % Mean (SD) age in years 45 (10.5) 42 (11.2) 44 (10.4) Sex Male 284 87.4 27 90.0 311 87.9 Female 41 12.6 2 6.7 43 12.1 Year of graduation 1950–60 2 0.6 0 0.0 2 0.6 1961–70 8 2.5 2 6.7 10 2.8 1971–80 44 13.5 3 10.0 47 13.2 1981–90 119 36.5 6 20.0 125 35.1 1991–2000 104 31.9 10 33.3 114 32.0 After 2001 49 15.0 9 30.0 58 16.3 Nature of clinic/centre Private practice 316 95.8 26 86.7 342 95.0 Welfare service, affiliation with NGO 13 3.9 4 13.3 17 4.7 Other 1 0.3 0 0.0 1 0.3 Third party payment/panel patients Yes 49 15.0 4 13.3 53 14.8 No 278 85.0 26 86.7 304 85.2 Proportion of psychiatric patients seen in practice None 43 13.5 2 6.7 45 12.9 ≤ 10% 228 71.7 22 73.3 250 71.8 11%–25% 32 10.1 4 13.3 36 10.3 26%–50% 12 3.8 2 6.7 14 4.0 > 50% 3 0.9 0 0.0 3 0.9 No. of patients with diagnosis of depression seen daily 0 21 6.4 1 3.3 22 6.2 1–5 240 73.4 19 63.3 259 72.5 6–10 42 12.8 7 23.3 49 13.7 11–15 13 4.0 1 3.3 14 3.9 > 16 11 3.4 2 6.7 13 3.6 aData were missing in some categories. SD = standard deviation; NGO = nongovernmental organization. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 450 antidepressants, SNRIs, benzodiaz- epines, bupropion and buspirone) in order to score a correct answer. In the medication of choice for pan- ic disorder benzodiazepines were again cited by 37.3% physicians. Antipsychot- ics and mood stabilizers were cited by 30.8% and 18.8% of GPs, respectively, while only 8.5% cited SSRIs as the treat- ment of choice and 34.5% did not know which medication to prescribe for panic disorder. Overall, 60.6% gave an incor- rect response when the choices were di- chotomized into correct and incorrect. The last question on the choice of medication was about treatment of so- matization disorder. Although 47.9% GPs reported that they did not know which medication to prescribe, 34.3% chose benzodiazepines in this category too. Antipsychotics (18.7%), mood sta- bilizers (15.0%), buspirone (13.6%) and SSRIs (7.6%) were the other choices for treatment of somatization disorder. Other treatment modalities When asked if they used any other treat- ment modality besides medications 74.4% GPs reported that they employed counselling themselves, while 8.6% gave “general advice” regarding health. Two GPs reported that they used “spir- itual advice” as a treatment modality. The remaining physicians reported that they preferred to refer patients after the initial treatment. When asked whether they considered their treatment to be effective or not, 71.4% believed that their treatments were effective, while 8.3% re- ported it was not and 9.7% were not sure. Treatment difficulties and referrals When asked if they encountered diffi- culties in managing patients with mental disorder 86.7% agreed that they had difficulties. The type of difficulties GPs experiences were grouped into physi- cian- and patient-related factors. Lack of time and lack of interest were the main physician-related factors, mentioned by 84.6% and 26.0% physicians respec- tively (Figure 2 ). A minority (16.0%) re- ported that their own lack of knowledge about management of mental disorders was the main difficulty in providing care. Among patient-related factors, 58.0% of Table 2 Awareness about ICD-10 diagnostic criteria for selected psychiatric disorders among general practitioners in Karachi (n = 360) ICD-10 diagnostic criteria for: Aware Unaware Aware to some extent No. % No. % No. % Depression 85 23.6 229 63.6 46 12.8 Bipolar affective disorder 89 24.7 234 65.0 37 10.3 Generalized anxiety disorder 97 26.9 229 63.6 34 9.4 Panic disorder 98 27.2 228 63.3 34 9.4 Somatization disorder 76 21.1 246 68.3 37 10.3 ICD-10 = International Statistical Classification of Diseases and Related Health Problems, 10th revision [13]. 0 10 20 30 40 50 60 70 80 90 100 Depression Bipolar affective disorder Generalized anxiety disorder Panic disorder Somatization disorder % o f G Ps SSRI TCA SNRI Bupropion BDZ Buspirone Antipsychotic Mood stabilizer Figure 1 Drugs used by general practitioners (GPs) in Karachi (n = 360) for treatment of common psychiatric disorders (SSRI = selective serotonin reuptake inhibitors, TCA = tricyclic antidepressants, SNRI = serotonin and noradrenaline reuptake inhibitors, BDZ = benzodiazepines) طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 451 GPs reported that patients’ refusal for the treatment was the main issue. There were some interesting re- sponses when we asked about the type of patients that were generally referred to specialist services. The majority of GPs cited patients displaying violence towards others (83.8%), violence towards self (72.2%) and psychoses (70.4%). Sexual disorders were a low priority for referral, cited by only 23.4% physicians. When asked about the diffi- culties encountered in referring patients to specialized services, 90.3% of GPs reported patients’ financial constraints as the major impediment (Figure 3). Continuing medical education We asked if they felt that their knowl- edge and expertise was sufficient to treat their patients with mental disorders. A majority of GPs (74.7%) believed that they lacked information in this special- ized area, while 10.6% thought that had enough expertise in managing patients with mental disorders and 14.2% were unsure. When asked if they had attended any seminars, workshops or continuous education programmes about mental disorders during the last 3 years 69.2% Figure 2 Barriers to patients’ care according to general practitioners (GPs) in Karachi (n = 312) (physicians could choose more than 1 response) Figure 3 Barriers to patients’ referral to specialized services according to general practitioners (GPs) in Karachi (n = 340 ) (physicians could choose more than 1 response) 84.6 26.0 16.0 17.0 58.0 0 10 20 30 40 50 60 70 80 90 Lack of time Lack of interest in treating mental disorders Own lack of knowledge Patients' lack of awareness Patients refused treatment % of GPs 0 10 20 30 40 50 60 70 80 90 21.8 19.1 22.1 22.9 No information about mental health providers No information about psychiatrists Patients' f inancial problems Distance from mental health center Appointment-related issues with psychiatrists % of GPs 90.3 EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 452 reported that they had not, while 30.6% had had some form of continuing medi- cal education. Finally, we enquired if they would like to attend a course on management of mental disorders in general practice; 48.9% showed interest in attending such a course, while the rest felt no need for it. Discussion It is not realistic to refer all patients with psychiatric problems to specialist servic- es, nor is this desirable. Many patients with depression and anxiety, as well as other disorders, can be managed well by primary care physicians who are mo- tivated to provide care. This is the first study from Pakistan which examined the knowledge and awareness about common psychiatric disorders among GPs in the private health care sector, which provides almost 70% of health care services in the country. The key findings of our study are that GPs lacked knowledge of internationally recog- nized diagnostic categories for mental disorders and that their choice of drugs for these disorders was not based on standard treatment practice. Although GPs reported that they did not have enough time for the management of mental disorders, they also believed that patients were unable to afford to attend specialist psychiatric services. A great majority of our GPs had not attended any form of continuing medical educa- tion about mental disorders in general practice. Furthermore, psychiatry is not taught and examined as an essential undergraduate subject in most medical colleges in Pakistan. These gaps in GPs’ knowledge and education have implica- tions for the rational use of psychotropic medications in primary care and for the quality of care delivered in general. We identified substantial gaps in physicians’ knowledge and under- standing of mental disorders and their management in primary care. The fact that 63.6% of GPs were unaware of the ICD-10 diagnostic criteria for depres- sion and anxiety is concerning. In Pa- kistan, where prevalence estimates of depression and anxiety are reported to be around 30% to 50%, non-recognition of these problems can have serious con- sequences [14]. Even in situations when these conditions were recognized, the lack of adequate knowledge regarding management strategies is concerning. The fact that benzodiazepines were the most familiar drugs to three-quarters of surveyed GPs, and were prescribed for the treatment of depression by 52.3% of them, has serious public health implica- tions. The irrational use of psychotropic medication, however, is not limited to benzodiazepines alone. That 30.8% of GPs in our survey considered using an- tipsychotics for the treatment of panic attacks is also alarming, so too is the use of antipsychotics for the treatment de- pression by 27.1% of GPs. Somatization disorder was another category in which various psychotropic medications were prescribed incorrectly. A previous study from our centre showed that patients who were prescribed psychotropic medications knew less about the effects, side-effects and hazards of their use compared with those who were pre- scribed other medications [15]. Data from the National Ambula- tory Medical Care Survey in the United States also supports our observations [16]. In their reports, general and fam- ily practitioners wrote psychotropic drug prescriptions in 84 per 1000 patient visits, in contrast to psychiatrists who had a rate of 441 per 1000 visits. The allegations that primary care physicians prescribe psychotropic drugs inappropriately may be correct in part, but it is also likely that these physicians are treating very different patients than those seen by specialists. In a study from the United Kingdom, explor- ing the reasons behind psychotropic drug prescriptions, Hyde et al. concluded that GPs used symptom severity (as measured on the General Health Questionnaire) for deciding who received treatment for depression and anxiety [17]. This survey has a few limitations which should be kept in mind while interpreting the results of this study. This was an opin- ion survey, in which GPs were asked to give their views on the frequency of com- mon disorders in their own practice. Like all self-reported surveys, we have no way of knowing if their assessments were cor- rect. The primary reasons for conducting an opinion survey rather than an objective assessment was to build the trust and con- fidence of the GPs, thereby establishing a link with specialist services. In the initial stages of the survey, GPs expressed ap- prehension about the research study and the implications of the findings on their daily practice. However, they were reas- sured that the survey would not have any negative bearing on their practice, only that they would receive regular commu- nications on various continuous medical education programmes for primary care physicians. Finally, one possible reason for the under-recognition of antidepressants could be that we asked about the generic names of drug groups, rather than using the specific brand names. Further research is needed to explore the prevalence estimates of common psychiatric conditions from a repre- sentative sample base of general practice throughout Pakistan. The prescription of psychotropic medications, especially benzodiazepines, also needs to be stud- ied systematically. There is an urgent need to study the cost-effectiveness of managing mental disorders in primary care in countries such as Pakistan, which have a dearth of resources. Acknowledgements We like to acknowledge the contribution of Mr Sajid Reza Shah, field coordinator, whose untiring efforts and commitment to the field work, in very testing times, made this survey possible. We would also like to acknowledge the administra- tive support of Mr Dominic Dsouza, administrative officer, Department of Psychiatry, Aga Khan University. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 453 Mental health: strengthening our response More than 450 million people suffer from mental disorders. Many more have mental problems. WHO supports governments in the goal of strengthening and promoting mental health. WHO has evaluated evidence for promoting mental health and is working with governments to disseminate this information and to integrate the effective strategies into policies and plans. More specifically, WHO’s mental health Gap Action Programme (mhGAP) aims at scaling up services for mental, neurological and substance use disorders for countries especially with low- and middle-income. When adopted and implemented, tens of millions can be treated for depression, schizophrenia, and epilepsy, prevented from suicide and begin to lead normal lives – even where resources are scarce. Source: WHO Fact sheet, No. 220 September 2010 (http://www.who.int/mediacentre/factsheets/fs220/en/) References 1. World health report 2001. Mental health: new understanding, new hope. Geneva, World Health Organization, 2001. 2. Golderg D et al. The treatment of common mental disorders by a community team based in primary care: a cost effective- ness study. Psychological Medicine, 1996, 26:487–492. 3. Goldberg D. Psychiatry and primary care. World Psychiatry; Official Journal of the World Psychiatric Association, 2003, 2:153–157. 4. Patel V et al. Mental health services in primary care in ‘devel- oping’ countries. World Psychiatry; Official Journal of the World Psychiatric Association, 2003, 2:163–164. 5. Khattak FH. Health economics and planning in Pakistan. Islama- bad, Ad-Rays Publishers, 1996. 6. James S et al. Demand for, Access to and use of community mental health care: Lesson from a demonstration project from India and Pakistan. International Journal of Social Psychiatry, 2002, 48:163–176. 7. Chisolm D et al. Integration of mental health care in to primary care: demonstration cost-outcome study in India and Paki- stan. British Journal of Psychiatry, 2000, 176:581–588. 8. Statistical annex. In: World health report 2004. Changing his- tory. Geneva, World Health Organization, 2004. 9. Naqvi HA et al. Pathway to psychiatric care in Karachi. Journal of the College of Physicians and Surgeons of Pakistan, 2006, 16:438–439. 10. Patel V et al. Somatic and psychological models of common mental disorder in primary care in India. Psychological Medi- cine, 1998, 28:135–143. 11. Jencks SF. Recognition of mental distress and diagnosis of mental disorder in primary care. Journal of the American Medi- cal Association, 1985, 253:1903–1907. 12. Karachi city: physicians’ directory, 2005. Medi Publications [website] (http://www.urdf.net/paksehat/index.htm/, ac- cessed 21 March 2012). 13. International statistical classification of diseases and related health problems, 10th revision. Geneva, World Health Organi- zation, 1993. 14. Mirza I, Jenkins R. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic re- view. British Medical Journal, 2004, 328:794–797. 15. Ganatra HA et al. Educating and informing patients receiving psychopharmacological medications: are family physicians in Pakistan up to the task? PLoS ONE, 2009, 4:e4620. 16. Mechanic D. Treating mental illness: generalists versus spe- cialists. Health Affairs, 1990, 2:61–75. 17. Hyde J et al. Deciding who gets the treatment for depression and anxiety: a study of consecutive GP attendees. British Jour- nal of General Practice, 2005, 55:846–853. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 454 Smoking habits and attitudes among university students in Palestine: a cross-sectional study S.G. Musmar 1 ABSTRACT Information about the rate of smoking and factors associated with initiating and maintaining the behaviour is scarce in Palestine. The aim of this study was to explore the rate of and attitudes towards smoking among An-Najah National University students. During spring 2010, a questionnaire adopted from the Global Health Professionals Survey and the Global Youth Tobacco Survey was administered to 954 randomly selected full-time students. Overall 34.7% of the study sample were cigarette or waterpipe smokers, and this rate was higher among males than females (52.7% versus 16.5%). In logistic regression analysis, sex (male), type of college (humanities), older age and higher family income were predictors of current smoking status. Smokers had more negative attitudes to banning smoking in public areas on campus and to education about the harmful effects of smoking. Antismoking programmes with special attention to males and students in humanities are badly needed. 1Department of Medicine and Society Faculty of Medicine, An-Najah National University, Nablus, Palestine (Correspondence to S.G. Musmar: smusmar@najah.edu). Received: 31/08/10; accepted: 28/11/10 ةيعطقم ةسارد :ينطسلف في ةعمالجا ةبلط ينب ينخدتلا نم فقاولماو تاداعلا رماسم لازغ رمس لىإ ةساردلا هذه فدتهو ،ةردان ينطسلف في هيف رارمتسلااو ينخدتلا كولس ءدبب ةطبترلما لماوعلاو ينخدتلا ل َّدعم لوح تامولعلما نإ :ةصلالخا نم ًادمتسم ًانايبتسا ةثحابلا تدعأ ،2010 ماع نم عيبرلا مسوم للاخو .هنم مهفقاومو ةينطولا حاجنلا ةعماج ةبلط ينب ينخدتلا ل َّدعم فشك مهراتخا ةساردلل ينغرفتم ًابلاط 954 لىع هعزوو ،بابشلا ينب غبتلا كلاهتسلا يلماعلا حسلماو ينيحصلا ينلماعلا ينب غبتلا كلاهتسلا يلماعلا حسلما ءارجإبو .%16.5 ثانلإاب ةنراقم %52.7 روكذلا ينب لىعأ ل َّدعلما ناكو ،ةشيشلا وأ رئاجسلا نونخدي ةساردلا ةنيع نم %34.7 نأ حضتاف .ًايئاوشع ينخدتلا ةلاح نع تائبنلما يه ةسرلأا لخد عافتراو ،نسلا بركو ،)ةيناسنلإا مولعلا( ةيلكلا عونو ،)روكذلا( سنلجا ناك يتسجوللا فوحتلا ليلتح كانهو .ينخدتلل ةراضلا تايرثأتلاب فيقثتلا هاتجو ،ةعمالجا مرح فيو ةماعلا نكاملأا في ينخدتلا رظح هاتج ةيبلس فقاوم يننخدملل ناك .ةنهارلا .ةيناسنلإا مولعلا تايلك في ةبلطلاو روكذلا لىع زيكترلا عم ينخدتلا ةحفاكلم جمابرل ة َّحلم ةجاح Étude transversale sur le tabagisme et les attitudes des étudiants de niveau universitaire en Palestine RÉSUMÉ Les informations sur le pourcentage de fumeurs et sur les facteurs associés à l'initiation au tabagisme puis à son maintien sont rares en Palestine. La présente étude visait à connaître le taux de fumeurs chez des étudiants de l'Université nationale An-Najah et leur attitude vis-à-vis du tabagisme. Au cours du printemps 2010, un questionnaire issu de l'enquête mondiale sur les professionnels de santé et l'enquête mondiale sur le tabagisme chez les jeunes a été administré à 954 étudiants à temps plein sélectionnés aléatoirement. Au total, 34,7 % de l'échantillon de l'étude étaient des fumeurs de cigarettes ou de pipes à eau, et ce pourcentage était plus élevé chez les hommes que chez les femmes (52,7 % contre 16,5 %). Dans une analyse de régression logistique, le sexe (masculin), le type de faculté (lettres et sciences humaines), un âge plus élevé et un revenu familial supérieur étaient des facteurs prédictifs du statut de fumeur actif. Les fumeurs avaient des attitudes plus négatives au sujet de l'interdiction du tabac dans les zones publiques du campus et de l'éducation sur les effets nocifs du tabac. Des programmes antitabac portant une attention spéciale aux hommes et aux étudiants en lettres et sciences humaines sont sérieusement nécessaires. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 455 Introduction Tobacco use is the leading preventable cause of death worldwide [1]. Tobacco use continues to kill more than 5 mil- lion people worldwide each year, and this number is expected to grow [2]. According to the latest estimates more than 80% of the 8.3 million tobacco- attributable deaths in 2030 will occur in low to middle-income countries [1]. Although the most serious health outcomes associated with smoking typically emerge later in life, studies have shown that the earlier individuals begin to smoke, the higher their risk for cancer, heart disease, stroke, chronic obstruc- tive lung disease [3], nicotine addiction [4] and possibly their risk of developing anxiety disorders and depression [5,6]. According to the Palestinian Central Bureau of Statistics (PCBS), the youth proportion of Palestine is as high as 27% [7]. Although PCBS has also reported a high rate of smoking among youth (19.8%) [8], information on smoking and factors associated with initiating and maintaining such behaviour in this group in Palestine is very limited. The aim of this study therefore was to explore the rate of and attitudes to smoking behaviour among students at An-Najah University in Nablus. The results of such a study are expected to provide data to inform specific interventions tailored to this important and vulnerable group. Methods After obtaining approval from the in- stitutional review board of An-Najah National University, this cross-sectional study was carried out during the spring semester of the 2009–10 academic year. Sample The study cohort consisted of full-time students enrolled at An-Najah National University. Our objective was to recruit about 5% of all registered full-time stu- dents (n = 17 521) in the 16 faculties at the university. Taking into considera- tion the percentage of types of colleges and sex, 1000 students from all faculties were selected from the university regis- ter using stratified randomization and were invited to participate in the survey. Of the 1000 students approached, 960 students agreed to participate and filled the questionnaire; 6 questionnaires were discarded because they were in- correctly filled (overall response rate 95.4%). Data collection Anonymous self-administered ques- tionnaires were handed to students by research assistants during breaks be- tween lectures and were collected after 10–20 minutes. Students gave verbal consent after being assured that par- ticipation was voluntary, their identity was not recorded on the questionnaire, all data would be used for research pur- poses only and there was no penalty for non-participation. Questionnaire A 4-component (48-item) smoking- use questionnaire was used to collect information on select demographic variables, participants’ opinions about smoking behaviour, smoking habits of smokers and knowledge and attitude of all participants towards smoking. The questionnaire was developed in Arabic from relevant instruments used for the assessment of tobacco use, including the Global Health Professionals Survey and the Global Youth Tobacco Sur- vey [9,10]. The average time needed to complete the questionnaire was 10 minutes. The first 8 items (sociodemo- graphic profile) covered age, sex, marital status, residence, type of college, level of study, family income and smoking status (both cigarette and waterpipe). All participants answered 8 questions about their opinions of smoking habits, reasons for practising and not practising the habit, banning smoking at home and banning it in public areas. Smokers answered 8 questions about their smok- ing habits (their first smoking attempt, amount, type and duration of smoking, smoking expenses, smoking cessation attempts and their willingness to quit smoking). Overall knowledge and at- titude towards the effect of smoking on health were measured by 12 ques- tions about positive attitudes and 12 questions about negative attitudes. The negative attitude questions asked about knowledge of harmful irreversible ef- fects of smoking on general health, pregnancy, its relationship to cancer, heart disease, general lifespan and the effect of passive smoking. The positive attitude questions asked about beliefs and myths of the benefits of smoking and doubts about the evidence for its harmful effects. Each question was an- swered on a 5-point Likert scale. The average score out of 10 for all positive attitude questions and all negative was given for every participant (i.e. a raw score out of 60 which was transformed to out of 10). The Arabic version questionnaire items were evaluated by 4 faculty mem- bers in the field of health for accuracy, relevance, and appropriateness. The questionnaire was then pilot tested for wording and clarity on 30 university students who were not part of the sam- ple and it was modified accordingly. Cronbach alpha was used to measure the internal consistency of the question- naire, which was 0.79 for the opinion of all participants about smoking habits, 0.81 for smoking habits of smokers and 0.93 for knowledge and attitude. Definitions Smoking status was established in accordance with World Health Or- ganization criteria for cigarette smoking and the criteria set by Maziak et al. for waterpipe smoking [11,12]. Smokers were subjects who at the time of the survey smoked either regularly (≥ 1 cigarette/day or ≥ 1 waterpipe/week) or occasionally (< 1 cigarette a day or < 1 waterpipe/week). Nonsmoker EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 456 control students had never smoked at the time of the survey. According to PCBS data average family income in Palestine was about US$ 500 [13], therefore the family in- come item was divided into low (US$ < 300/month), average (US$ 300–600/ month) and high (US$ >600/month). Statistical analysis Data on all components of the ques- tionnaire were entered and analysed using Minitab, software version 14. Descriptive statistics were used to show the demographic profile of the study sample. Binary logistic regression analysis was used to examine the as- sociation between smoking and factors such as age, sex, study level, college and income. Correlations between smoking behaviour and attitudes and beliefs towards smoking were analysed using the chi-squared test; t-test and 1-way analysis of variance (ANOVA) were applied for the comparison of positive and negative attitudes. All results were considered statistically significant at P ≤ 0.05. Results Table 1 summarizes the overall de- mographic characteristics of the 954 students (480 male and 474 females) participating in the study. The mean age was 20.5 (standard deviation 1.1) years, with males and females almost equal ages. More students (57.1%) were enrolled in the arts and humanities colleges than in sciences (35.9%) or health care (7.0%). The great majority of students were single (92.7%) and living with their parents (73.5%), and about half the students’ families (51.9%) had average income. The total number of students who reported that they smoked was 331 (34.7%). The rate was higher among males than females (52.7% versus 16.5%), older than younger students (39.3% versus 28.9%) and among stu- dents living in dormitories compared with those living with their families (40.3% versus 32.7%). By college the highest rate was among students of the humanities and arts (41.1%) (Ta- ble 1). Table 2 details factors that were associated with being a smoker. Since smokers were coded as 1 and Table 1 Smoking status of the study sample of students by demographic characteristics Characteristic Total Smokers χ2-test P-value No. No. % Sex 138.3 < 0.01 Male 480 253 52.7 Female 474 78 16.5 Age (years) 10.3 < 0.01 18–20 425 123 28.9 > 20 529 208 39.3 College 27.4 < 0.01 Arts and humanities 545 224 41.1 Sciences 342 82 23.9 Health 67 25 37.3 Study level 0.039 NS Junior (years 1 or 2) 347 119 34.3 Senior (years 3+) 607 212 34.9 Martial status 0.501 NS Married 70 27 38.6 Single 884 304 34.4 Residence With family 701 229 32.7 4.8 < 0.05 Dormitory 253 102 40.3 Family income (per month) 3.29 NS Low (< US$ 300) 114 31 27.2 Average (US$ 300–600) 495 175 35.6 High (> US$ 600) 345 125 36.2 Total 954 331 34.7 NS = not significant. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 457 nonsmokers as 0, the odds ratio (OR) denotes the probability of being a smoker for each of the demographic variables included in the logistic regres- sion model (after being validated using different goodness-of-fit tests). The standard cut-off value of 0.5 was used for all variables. There was a strong statistically significant association of smoking with sex (male) and type of college (humanities) (P < 0.001). In- come (average and high income) and age (> 20 years) were also statistically significant predictors of smoking (P < 0.05). There was no significant as- sociation between risk of smoking and residence, marital status or study level (junior or senior). Table 3 summarizes the attitudes of smokers and nonsmokers towards smoking behaviour and the banning of smoking at home or in public places. Compared with nonsmokers more of the smokers had a positive attitude towards smoking (54.0% versus 5.4%) (P < 0.05) and its use for recreational purposes (45.0% versus 15.7%) (P < 0.05). The study showed that peer pressure and smoking as a way of “proving manhood” were seen by more nonsmokers as possible reasons for smoking. More of the smokers would allow smoking in their household than would the nonsmokers (34.4% versus 6.9%) (P < 0.05). More of the smokers would allow their children to smoke than would the nonsmokers (28.7% versus 4.0%) (P < 0.05). Finally, fewer smokers than nonsmokers agreed that smoking should be banned in public places (52.3% versus 85.4%) (P < 0.05). Table 4 shows a summary of stu- dents’ scores for knowledge about the effect of smoking on health. Most stu- dents had above-average knowledge about the negative effect of smoking on health, which was statistically significant in favour of nonsmokers compared with smokers and females compared with males. However, there was no significant differences according to the type of college. Viewing the effect of smoking on health positively was significantly more common for smok- ers than nonsmokers and males than females. The college of art students also scored higher than those in science and health in their view of the positive effect Table 2 Relationship between demographic factors and smoking among university students (n = 954) Factor β SE z-value P-value OR (95% CI) Age 0.47 0.22 2.18 0.029 1.62 (1.05–2.49) Sex –2.55 0.21 –11.85 < 0.001 0.08 (0.05–0.12) College –0.57 0.14 –3.95 < 0.001 0.56 (0.42–0.75) Study level –0.39 0.22 –1.73 0.084 0.68 (0.43–1.05) Residence 0.33 0.17 1.89 0.058 1.39 (0.99–1.96) Marital status 0.51 0.31 1.65 0.100 1.67 (0.91–3.10) Income 0.27 0.12 2.26 0.024 1.32 (1.04–1.68) β = estimated coefficient; SE = standard error; OR = odds ratio; CI = confidence interval. Table 3 Attitudes and beliefs concerning smoking among university students Item Total Smokers Nonsmokers χ2-test P-value No. % No. % No. % Do you agree with smoking behaviour?a 213 22.3 179 54.0 34 5.4 288.1 < 0.001 Why do students smoke?b 138.8 < 0.001 Recreation 247 25.9 149 45.0 98 15.7 Proving manhood 335 35.1 73 22.0 262 42.0 Peer pressure 140 14.6 14 4.2 126 20.2 Other reasons 232 24.3 95 28.7 137 22.0 Would you allow smoking in your household? a 157 16.4 114 34.4 43 6.9 113.2 < 0.001 Would you allow your children to smoke in the future? a 120 12.6 95 28.7 25 4.0 119.8 < 0.001 Do you agree with banning smoking in public areas? a 705 73.8 173 52.3 532 85.4 121.6 < 0.001 aAffirmative answer. bRespondents could select more than 1 reason. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 458 of smoking on health, although this did not reach statistical significance. In a sub-analysis of smoking behav- iour among the different colleges (Ta- ble 5), a higher percentage of smokers in the humanities college started smoking before age 15 years compared with the other 2 colleges (40.4% versus 23.1% and 20.0% respectively). The duration of smoking and the number of cigarettes smoked per day only become statisti- cally significantly different after the first year of smoking and when the number of cigarettes exceeded 3 per day. Finally, the desire to stop smoking, attempts to stop smoking and willingness to ac- cept help to stop smoking were similar between the 3 groups. Table 4 Overall scores on positive and negative knowledge and attitudes towards the effect of smoking on health Factor Negative attitudes Positive attitudes Mean (SD) score t or F-value P-value Mean (SD) score t or F-value P-value Smoking –12.57 < 0.001 5.65 < 0.001 Smokers 7.4 (1.6) 6.2 (1.8) Nonsmokers 7.9 (1.1) 4.7 (1.5) Sex 4.75 < 0.001 5.1 < 0.001 Male 7.6 (1.5) 5.6 (1.8) Female 7.9 (1.1) 4.9 (1.6) College 2.56 0.06 1.65 0.192 Arts and humanities 7.8 (1.4) 5.4 (1.9) Sciences 7.6 (1.3) 5.1 (1.6) Health care 7.7 (0.9) 5.0 (1.5) t is the value of Student t-test, and F is the value of 1-way ANOVA test. SD = standard deviation. Table 5 Smoking behaviour among smokers and its relation to type of college Item Arts and humanities (n = 225) Sciences (n =81) Health care (n = 25) Total (n =331) χ2-test P-value No. % No. % No. % No. % Age of first cigarette smoking? (years) 12.6 0.01 < 15 91 40.4 19 23.1 5 20.0 115 34.7 15–18 81 36.0 38 46.3 16 64 .0 135 40.8 > 18 53 23.6 24 29.2 4 16.0 81 24.5 How long you have been smoking? (years) 7.78 0.25 < 1 38 16.9 9 11.1 3 12.0 50 15.1 1–3 84 37.3 31 38.3 15 60.0 130 39.3 >3–5 56 24.9 19 23.5 3 12.0 78 23.5 > 5 47 20.9 22 27.1 4 16.0 73 22.1 How much do you smoke? 12.27 0.05 < 3 cigs/day 58 25.8 15 18.5 5 20.0 78 23.5 4–10 cigs/day 56 24.9 20 24.7 11 44.0 87 26.3 1 pack/day 72 32.0 34 42.0 9 36.0 115 34.7 > 1 pack/day 39 17.3 12 14.8 0 0.0 51 15.5 Do you think about quitting smoking? 139 62.0 50 61.7 13 52.0 202 61.0 1.04 0.59 Did you try to stop smoking? 116 52.0 46 57.0 14 56.0 176 53.0 1.05 0.59 Will you accept help to quit smoking? 152 68.0 50 61.7 16 64.0 218 66.0 0.703 0.71 طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 459 Discussion The response rate to the questionnaire (95.4%) indicated a high degree of will- ingness by the students to participate in the study. The age and sex distribution of the participants was also comparable to the general university population which has almost equal proportions of male and female students. Our results showed a high self- reported rate of smoking among uni- versity students; 34.7% of the overall study sample (52.7% among males and 16.4% among females). These figures are higher than the PCBS estimates of the proportion of smokers in the general Palestinian population which was 19.8% (37.0% among males and 2.2% among females) [8]. Compared with university students in Arab coun- tries, our Palestinian students had a higher rate compared with Jordanian (28.6%) [14] and Saudi (17.5%) stu- dents [15] but lower than Lebanese (40%) students [16]. Although many more males than females smoked, the percentage of female students smoking was much higher than the rate of smoking among women in the general population [8]. The rising rate of smoking among wom- en in Arab countries has been a focus for several studies, especially the increasing use of waterpipe smoking among young women. For example, an Egyptian study investigating behavioural and soci- odemographic factors associated with tobacco use among female university students in Cairo found an urgent need to correct a misperception that water- pipe smoking is safer and less harmful than cigarette smoking [17]. Waterpipe smoking is known to be popular in the Nablus area among both males and fe- males, which might explain the high rate of smoking among female university students at An-Najah University. The study showed that most smok- ers were over 20 years of age. A reason for that may be the family pressure against smoking during adolescence. Once students get older and acquire more freedom, family pressure lessens. This is consistent with the findings of Gfroerer et al., who showed that among a sample of college students in the Unit- ed States, those who lived with their par- ents were less likely to have smoked in the last month compared with students who did not [18]. However, there was no statistically significant association between students’ age or the years they spent in university and their tendency to smoke. This study found a significantly higher risk of smoking among students in the arts and humanities field com- pared with students enrolled in the sci- ences or in health care. The lower risk of smoking by health sciences students is probably due to the strong effect of edu- cation about the health risks of smoking. We have no explanation for the inter- mediate risk in students in the science schools. Similar findings were observed in a Saudi study in Abha that compared smoking between college of education and college of medicine students [15], and a Syrian study that found that the rate of smoking was lower among medi- cal students [19]. The negative effects of smoking seemed to be perceived by all students; however, more smokers and male stu- dents perceived positive effects com- pared with nonsmokers and females. This finding is consistent with a Jorda- nian study that looked at knowledge and attitude towards smoking among Jordan University of Science and Tech- nology students [14]. This reflects the tendency to defend one’s behaviour despite knowledge of its risk and might also reflect a greater tendency of women to care for their own health and that of others. “Recreation” was the main rea- son for smoking according to most of the current smokers, followed by “prov- ing manhood”. Nonsmokers, however, believed that their peers smoked mainly to prove their manhood and popular- ity. In other, similar studies “curiosity” was believed to be the main reason for smoking [15]. In this study, the attitudes of stu- dents towards smoking were different among smokers and nonsmokers. Smokers tended to be more tolerant of smoking and its role as a recreation activity. Moreover, smokers were more tolerant toward smoking at home and would be less likely to put pressure on their children not to smoke. Smokers also were less enthusiastic about ban- ning smoking in public places. Although this study had some im- portant findings regarding the factors affecting smoking in a young popula- tion, the findings cannot be generalized to all young people in Palestine since the study sample included only university students. Conclusion This study shows that the self-reported rate of smoking among students at An- Najah National University was higher than previous estimates for the rest of the Palestinian population. An ant- ismoking programme including health education and extensive counselling on the harmful effect of smoking is needed at this university for both male and fe- male students, with special attention to students in the humanities colleges. References 1. Mathers CD. Loncar D. Projection of global mortality and burden of disease from 2002 to 2030. PLoS Medicine, 2006, 3:e442. 2. WHO report on the global tobacco epidemic 2009. Implementing smoke-free environments. Geneva, World Health Organization, 2009. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 460 3. Davis JW et al. Passive smoking affects endothelium and plate- lets. Archives of Internal Medicine, 1989, 149:386–389. 4. Taioli E, Wynder EL. Effect of the age at which smoking begins on frequency of smoking in adulthood. New England Journal of Medicine, 1991, 325:968–969. 5. Goodman E, Capitman J. Depressive symptoms and cigarette smoking among teens. Pediatrics, 2000, 106:748–755. 6. Johnson JG et al. Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. Journal of the American Medical Association, 2000, 284:2348– 2351. 7. Youth in Palestinian territory: statistical indicators. On the occa- sion of the International Youth Day 12 August 2008. Palestinian Central Bureau of Statistics [online factsheet] (http://www. pcbs.gov.ps/Portals/_pcbs/PressRelease/shabab2008.pdf, accessed 15 March 2012). 8. On the eve of World Day to Stop Smoking, May 31, the PCBS issues a press release about the prevalence of smoking in the Palestinian Territory [press release]. Palestinian Central Bureau of Statistics, 31 May 2009 (http://www.pcbs.gov.ps/Portals/_pcbs/Press- Release/smoking%20English.pdf, accessed 29 February 2012). 9. The Global Youth Tobacco Survey (GYTS). World Health Or- ganization [website] (http://www.who.int/tobacco/surveil- lance/gyts/en/, accessed 15 March 2012). 10. The Global Health Professional Survey (GHPS). World Health Organization [website] (http://www.who.int/tobacco/sur- veillance/ghps/en/, accessed 15 March 2012). 11. Maziak W et al. Standardizing questionnaire items for the as- sessment of waterpipe tobacco use in epidemiological stud- ies. Public Health, 2005, 119:400–404. 12. Guidelines for controlling and monitoring the tobacco epidemic. Geneva, World Health Organization, 1998. 13. Press release on Labour Force Survey results (January–March, 2010) Round [press release]. Palestinian Central Bureau of Sta- tistics, 18 May 2009 (http://www.pic-palestine.ps/userfiles/ file/pdfs/labour_force_survey_en.pdf, accessed 29 February 2012). 14. Haddad LG, Malak MZ. Smoking habits and attitudes towards smoking among university students in Jordan. International Journal of Nursing Studies, 2002, 39:793–802. 15. Abolfotouh MA et al. Smoking habits of King Saud University students in Abha. Annals of Saudi Medicine, 1998, 18:212–216. 16. Hala Tamim et al. Tobacco use by university students in Leba- non. Addiction, 2003, 98:933–939. 17. Labib N et al. Comparison of cigarette and water pipe smok- ing among female university students in Egypt. Nicotine and Tobacco Research, 2007, 9:591–596. 18. Gfroerer JC, Greenblatt JC, Wright DA. Substance use in the US college-age population: differences according to educa- tional status and living arrangement. American Journal of Public Health, 1997, 87:62–65. 19. Almerie MQ et al. Cigarettes and waterpipe smoking among medical students in Syria: a cross-sectional study. International Journal of Tuberculosis and Lung Disease, 2008, 12:1085–1091. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 461 Low adherence of Kuwaiti adults to fruit and vegetable dietary guidelines S. Zaghloul,1 C. Waslien,2 M. Al Somaie 3 and P. Prakash 3 ABSTRACT The study aimed to assess the adherence of Kuwaiti adults to dietary guidelines for daily fruit and vegetable intake. Data were compiled from national cross-sectional studies from 2006 to 2008 including 9350 adults. Demographic data, frequency of fruit and vegetable consumption and anthropometric and lifestyle indicators were collected. Approximately 11% of people reported consuming 5 or more fruits and vegetables daily with a mean consumption of 3.04 times per day. Consumption increased with age and body mass index but decreased with smoking and non-exercising. Minimal change in compliance with 5-per-day fruit and vegetable consumption was observed between 2006 and 2008. However, the average daily consumption of total vegetables and green salads decreased and of total fruits, fruit juices and cooked and fried potatoes increased. The low frequency of fruit and vegetable consumption among Kuwaiti adults indicates the need to adopt more healthy eating patterns to control chronic diseases. 1Kuwait Institute for Scientific Research, Safat, Kuwait (Correspondence to S. Zaghloul: szaghloul@kisr.edu.kw). 2College of Women, University of Kuwait, Kuwait. 3Food and Nutrition Administration, Ministry of Health, Kuwait. Received: 28/04/10; accepted: 20/09/10 تاواضرلخاو ةهكافلاب ةينغلا ةيئاذغلا مظنلا لوح ةيداشرلإا لئلادلاب ينغلابلا ينيتيوكلا لاثتما ىوتسم نيدت شاكارب اناسرب ،يعيمصلا ىنم ،ينلساو لوراك ،لولغز رحس دقو .ًايموي تاواضرلخاو ةهكافلاب ةينغلا ةيئاذغلا مظنلا لوح ةيداشرلإا لئلادلاب ينغلابلا ينيتيوكلا لاثتما مييقت لىإ ةساردلا هذه تفده :ةصلالخا لوحو ،ةيفارغوميد تايطعم عجم دقو .ًاغلاب 9350 تلمشو ،2008 ىتح 2006 نم ةدلما في ةيضرع ةيعطقم ةينطو تاسارد نم تايطعلما تع ُمجم ةهكافلا نم صصح 5 ملهوانت نع سانلا نم %11 لياوح ركذ دقو .ةايلحا طمانلأو ةيشربلا تاسايقلل تاشرؤمو ،تاواضرلخاو ةهكافلا كلاهتسا راركت عمو ،ينخدتلا عم ضفخنا هنكلو ،مسلجا ةلتك شرؤم عمو رمعلا عم كلاهتسلاا داز .ًايموي تارم 3.04 كلاهتسلاا طسوتم غلبو ،ًايموي تاواضرلخاو نأ لاإ .2008و 2006 يماع ينب ًايموي تاواضرلخاو ةهكافلا نم صصح 5 لوانتب لاثتملاا في فيفط يرغت ظحولو .ةيضايرلا نيرماتلا ةسرامم مدع .ةيلقلماو ةخوبطلما سطاطبلاو ةهكافلا يرصعو ةهكافلا لوانت لممج داز مانيب ،لق دق ءاضرلخا ةطلسلاو تاواضرلخا لمجلم يمويلا كلاهتسلاا طسوتم .ةنمزلما ضارملأا ةحفاكلم ةيحص ةيئاذغ طمانأ يِّنبت لىإ ةجالحا لىإ ينغلابلا ينيتيوكلا ينب تاواضرلخاو ةهكافلا لوانت راركت ضافخنا يرشيو Faible application des directives diététiques concernant les fruits et les légumes par les adultes koweïtiens RÉSUMÉ La présente étude visait à évaluer l'application par les adultes koweïtiens des directives diététiques concernant la consommation journalière de fruits et de légumes. Les informations ont été compilées à partir d'études nationales transversales menées entre 2006 et 2008 portant sur 9350 adultes. Des données démographiques, la fréquence de consommation de fruits et de légumes, des indicateurs anthropométriques et les habitudes de vie ont été collectés. Environ 11 % des personnes de l'étude ont indiqué consommer au moins cinq fruits et légumes par jour. La consommation moyenne était de 3,04 fois par jour. La consommation augmentait avec l'âge et l'indice de masse corporelle mais diminuait chez les fumeurs et les personnes sans activité physique. Une faible évolution vers la consommation journalière de cinq fruits et légumes a été observée entre 2006 et 2008. Toutefois, la consommation quotidienne moyenne totale de légumes et de salades vertes a diminué, alors que celle de fruits, jus de fruits frais et pommes de terre cuisinées ou frites a augmenté. La faible fréquence de la consommation de fruits et de légumes chez les adultes koweïtiens démontre la nécessité d'adopter des modes alimentaires plus sains pour lutter contre les maladies chroniques. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 462 Introduction Fruit and vegetable consumption is an integral component of healthy eating behaviour [1]. High fruit and vegetable consumption is associated with low risk of diabetes, cancer, hypertension and cardiovascular diseases [2–5]. Data from the 2002–03 World Health Survey of adults aged 19–99 years in 52 low- to middle-income countries showed that 78.0% consumed less than the mini- mum recommended 5 daily servings of fruit and vegetables [6]. Similar results from high-income countries (United States, France and England) showed a low prevalence of adequate fruit and veg- etable intake [7–9]. The Healthy People 2010 guidelines established objectives to increase the percentage of people in the population who consume 3 por- tions of vegetables and 2 of fruit per day [1]. The World Health Organization (WHO), the United States National Cancer Institute and the Committee on Dietary Guidelines for Americans also recommended increasing the level of fruit and vegetable consumption to improve health [10–12]. In Kuwait about 75% of the adult population are either overweight or obese and suffer from one or more nutrition-related noncommunicable diseases such as diabetes, coronary heart diseases and hypertension [13,14]. A trend of increased overweight and obe- sity among adults aged 30–60 years was observed between 1996 and 2006, with a faster increase in the obesity rate, from 31% to 46% among men and 48% to 58% among women. In addition, 40%–46% of Kuwaiti adolescents aged 10–19 years are overweight or obese, the highest prevalence in the world [15]. The Food and Agriculture Or- ganization food balance sheets data for Kuwait revealed decreased per capita availability of cereals, pulses, fruits and sugar between 1969 and 1971, and 1992 and 1994 and increased per capita consumption of vegetables and fat and oils [16,17]. Meats, eggs, fish and milk were more available. The per capita veg- etables consumed increased from 107 to 147 kg/year while the per capita fruit consumed decreased from 128 to 120 kg/year [16]. In the absence of national food consumption data for individuals, de- terminants of the rapid growth in the prevalence of overweight, obesity and nutrition-related noncommunicable diseases and the level of compliance of Kuwaitis to a healthy dietary pattern are not clear. The current study assessed the adherence of Kuwaiti adults to in- ternational fruit and vegetable dietary guidelines using the Kuwait national surveillance system data. Methods The Administration of Food and Nutrition of the Ministry of Health in Kuwait established a national surveil- lance system in 1998 to monitor the health of adult Kuwaitis attending the Kuwait Medical Council and Public Authority for Social Security facilities. The system was designed to collect data on a broadly representative sample of the Kuwaiti population. Study population For this report a cross-sectional study design was applied. Adults who at- tended the health centres of the Kuwait Medical Council or Public Author- ity for Social Security over the period 2006 to 2008 were recruited for the study. Kuwait Medical Council is the only health facility in the country that provides mandatory checkups for potential employees. If problems are identified during screening, patients are referred to an appropriate health facil- ity for medical intervention. The Public Authority for Social Security provides pension benefits to retirees and health screening. This is the only facility of its type in Kuwait. Staff from the Administration of Food and Nutrition attended the 2 centres in order to invite randomly selected participants from the waiting rooms of the clinics to participate in the study. The refusal rate was 3%. Infor- mation on 9350 adults equally repre- sentative of years 2006 (n = 2953), 2007 (n = 3417) and 2008 (n = 3384) was analysed. The purpose of the surveil- lance was explained at both centres and informed consent was obtained from each subject. The Ministry of Health gave ethical approval for the study. Data collected The analysis for this report was based on data collected from surveillance ac- tivities in the years 2006–08. The data collected included: measurements of body weight and height to calculate body mass index (BMI); demographic and lifestyle data (age, sex, education level attained, employment status, smoking and physical activity level); and assessment of fruit and vegetable consumption. Employment status, cur- rent smoking and physical activity were binary variables (yes/no). The food frequency questionnaire was a 7-item questionnaire based on the Centers for Disease Control (CDC) Behav- ioral Risk Factor Surveillance System (BRFSS) [18] and included questions about how often fruit juices, fresh fruits, green salads, french fries, potatoes other than french fries, carrots and other vegetables were eaten. Total daily fruit consumption was calculated from the sum of the number of times fruit juice and fresh fruit were consumed, while total daily vegetable consumption was the sum of the number of times the 5 vegetables, including french fries, were eaten. Total daily fruit and total daily vegetable intakes were calculated. To calculate times of consumption per day, weekly frequencies were divided by 7, monthly frequencies by 30 and yearly frequencies by 365. Statistical analysis Data were analysed using SPSS, version 15. Pearson chi-squared and analysis of طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 463 variance (ANOVA) were used to detect differences in the frequency of fruit and vegetable intakes by sociodemographic variables, survey year, smoking, employ- ment status and exercise level. Arithme- tic means of frequency of daily fruit and vegetable consumption were calculated and differences by age and survey year were tested using ANOVA with post hoc least significant difference test (alpha). The percentage of participants comply- ing with the 2005 US dietary guidelines for fruit and vegetables consumption [10] was described. P < 0.05 was consid- ered statistically significant. Results Sample description The mean age of the participants was 38.9 (SD 12.2) years. Women repre- sented 52.4% of the sample of all survey years combined. Almost one-quarter of the sample reported attaining less than high school education while 30.8% had a bachelor degree or more. The pro- portion of participants employed was 61.6%. A total of 29.1% reported taking physical exercise and 27.2% reported that they were smokers. Frequency of fruit and vegetable intake Only 10.8% of the sample consumed ≥ 5 fruits and vegetables daily (Figure 1), 14.7% consumed ≥ 3 vegetables and 24.9% consumed ≥ 2 fruits per day. In addition, the percentage consuming ≥ 5 fruits and vegetables increased from 2006 to 2008 by almost 2%, and the consumption of ≥ 2 fruits per day sig- nificantly increased from 2006 to 2008 by 6.6% (P < 0.05). The percentage con- suming vegetables ≥ 3 times decreased almost 2% The characteristics of the partici- pants by frequency of fruit and vegetable consumption and changes in consump- tion between 2006 and 2008 are shown in Table 1. Men differed significantly from women in the amounts of fruit and vegetables consumed only in 2008. More men consumed ≤ 2 fruits and veg- etables per day while fewer consumed 3–4 fruits and vegetables daily. In con- trast, more women consumed ≥ 5 fruits and vegetables while fewer consumed 1–2 and 3–4 per day. There was a significant linear re- lationship between age category and adequacy of fruit and vegetable intake in each survey year. A higher percent- age of younger age groups fell in the lowest fruit and vegetable consumption categories (χ2 = 24.2, P = 0.06 in 2006; χ2 = 33.9, P = 0.05 in 2007; χ2 = 34.9, P = 0.003 in 2008). Participants 60 years and older, however, were more likely to be in the highest category of intake in each survey year. Education level was not significantly associated with frequency of fruit and vegetables consumption; however a slightly higher percentage of college graduates were in the highest 2 catego- ries for fruit and vegetable consumption in all 3 survey years. Surprisingly, unem- ployed participants were significantly more likely to meet the 5 per day of fruit and vegetable consumption (χ2 = 8.5 P = 0.04 in 2006; χ2 = 8.9 and P = 0.03 in 2008). Exercisers were also more likely to fall into the 2 highest fruit and vegetables in all 3 survey years (χ2 = 54.6, 22.1 24.5 28.7 24.9 15.0 16.6 13.2 14.7 9.4 12.0 11.5 10.8 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 2006 2007 2008 Total % o f r ep on de nt s ≥ 2 fruits ≥ 3 vegetables ≥ 5 fruits & vegetables Figure 1 Daily frequency of fruit and vegetable consumption among Kuwaiti adults, 2006–2008 (n = 9350) EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 464 Ta bl e 1 D ai ly fr eq ue nc y of fr ui t a nd v eg et ab le c on su m pt io n by K uw ai ti a du lts (n = 9 35 0 ) b y de m og ra ph ic a nd li fe st yl e ch ar ac te ri st ic s, 2 0 0 6– 20 0 8 Va ri ab le To ta l 20 0 6 20 0 7 20 0 8 < 1 ti m e 1– 2 ti m es 3– 4 ti m es ≥ 5 ti m es < 1 ti m e 1– 2 ti m es 3– 4 ti m es ≥ 5 ti m es < 1 ti m e 1– 2 ti m es 3– 4 ti m es ≥ 5 ti m es N o. N o. % % % % N o. % % % % N o. % % % % Se x a W om en 48 88 15 60 5. 0 46 .7 39 .0 9. 3 16 53 3. 7 45 .1 38 .6 12 .6 16 75 7.5 44 .1 36 .4 12 .1 M en 44 62 12 27 4. 6 48 .0 37 .4 10 .0 16 49 4. 1 48 .2 35 .8 11 .9 15 86 5. 7 49 .2 33 .8 11 .3 A ge (y ea rs ) b 18 –2 9 24 14 73 7 3. 7 49 .5 37 .3 9. 5 74 9 4. 3 47 .7 34 .7 13 .4 92 8 7.5 49 .2 32 .2 11 .0 30 –3 9 24 96 70 4 5. 7 48 .9 36 .5 8. 9 89 5 3. 7 50 .4 34 .2 11 .7 89 7 7.8 49 .3 32 .7 10 .3 40 –4 9 24 82 79 5 5. 8 48 .6 37 .0 8. 7 87 9 4. 6 48 .1 37 .0 10 .4 80 8 5. 4 44 .9 36 .1 13 .5 50 –5 9 14 0 6 41 0 3. 7 40 .2 44 .6 11 .5 54 1 2. 6 39 .9 44 .2 13 .3 45 5 5. 1 39 .6 42 .9 12 .5 > 60 55 2 14 1 4. 3 41 .1 41 .1 13 .5 23 8 4. 2 39 .1 41 .6 15 .1 17 3 4. 6 44 .5 38 .2 12 .7 Ed uc at io n Be lo w h ig h sc ho ol 22 79 65 3 4. 9 46 .2 38 .9 10 .0 86 5 5. 3 48 .0 35 .1 11 .6 76 1 5. 4 50 .3 33 .4 10 .9 H ig h sc ho ol 18 25 50 2 6. 4 49 .0 35 .9 8. 8 65 6 3. 7 46 .0 37 .5 12 .8 66 7 5. 8 46 .9 35 .1 12 .1 D ip lo m a 23 47 67 6 5. 0 48 .8 37 .9 8. 3 79 6 4. 1 48 .5 36 .6 10 .8 87 5 7.7 46 .9 35 .0 10 .5 A bo ve c ol le ge ed uc at io n 28 99 95 6 3. 8 46 .0 39 .4 10 .8 98 5 2. 6 44 .4 39 .4 13 .6 95 8 7.1 43 .1 36 .6 13 .2 Em pl oy m en tc N o 35 57 11 46 6. 0 46 .5 37 .0 10 .5 12 78 4. 4 46 .6 36 .1 12 .9 11 33 6. 9 43 .1 37 .2 12 .9 Ye s 56 93 15 41 4. 0 47 .8 39 .2 9. 0 20 24 3. 6 46 .6 37 .9 11 .8 21 28 6. 4 48 .4 34 .0 11 .1 Ex er ci se d N o 65 90 19 38 5. 6 50 .9 35 .4 8. 1 22 79 4. 2 50 .3 35 .0 10 .6 23 73 7.1 49 .4 33 .4 10 .1 Ye s 27 60 84 9 3. 1 39 .0 44 .9 13 .1 10 23 3. 3 38 .5 42 .2 15 .9 88 8 5. 3 39 .0 39 .6 16 .1 BM I ( kg /m 2 ) ≤ 25 20 30 60 3 4. 0 49 .1 38 .8 8. 1 67 7 4. 7 47 .8 35 .3 12 .1 75 0 6. 9 48 .4 34 .1 10 .7 25 –3 0 34 42 99 8 5. 1 47 .4 37 .3 10 .2 12 0 4 4. 1 46 .3 37 .1 12 .5 12 40 6. 5 45 .8 35 .2 12 .5 ≤ 30 38 69 11 84 5. 0 46 .3 38 .9 9. 9 14 17 3. 4 46 .4 38 .2 12 .1 12 68 6. 6 46 .3 35 .6 11 .5 Sm ok in ge N o 47 53 12 17 3. 6 48 .1 38 .8 9. 5 14 58 4. 3 47 .7 36 .8 11 .2 20 78 7.2 45 .0 35 .4 12 .4 Ye s 17 75 48 6 6. 8 48 .1 35 .0 10 .1 63 5 4. 6 48 .3 34 .6 12 .4 65 4 6. 3 48 .5 33 .9 11 .3 P < 0. 05 , c hi -s qu ar ed te st s: a B et w ee n m en a nd w om en (2 00 8) ; b Be tw ee n ag e gr ou ps (2 00 7 an d 20 08 ); c B et w ee n em pl oy ed a nd u ne m pl oy ed (2 00 6 an d 20 08 ); d B et w ee n ex er ci se rs a nd n on -e xe rc is er s ( 20 06 , 2 00 7 an d 20 08 ); e B et w ee n sm ok er s an d no n- sm ok er s ( 20 06 ). BM I = b od y m as s i nd ex . طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 465 P = 0.001 in 2006; χ2 = 48.8, P = 0.001 in 2007; χ2 = 45.5, P = 0.001 in 2008). Par- ticipants with BMI < 25 kg/m2 tended to be in the lowest 2 categories of fruit and vegetable consumption although this relationship was not statistically significant. Smokers were significantly differ- ent from non-smokers and were more likely to have lower intakes of fruit and vegetables (χ2 = 9.2, P = 0.03 in 2006); 55% of smokers compared to 52% of non-smokers consumed ≤ 2 fruit and vegetable in 2006. Changes in intake of fruits and vegetables over time Table 2 shows the average frequency of consumption of fruit and vegetable items between 2006 and 2008. The total fruit intake showed a significant increase mainly due to an increase in fruit juice intake. Total vegetable intake decreased significantly in spite of an increase in cooked and fried potato consumption (P < 0.05). There was a marked decline in consumption of green salads and other vegetables (P < 0.05). Furthermore significant sex differences were detected. The total fruit intake increased significantly among women but insignificantly among men (P < 0.05). Both fresh fruit and fruit juice intakes increased markedly among women while in men intake of fruit juice increased but intake of fresh fruits de- creased (P < 0.05). Discussion The recommended 5 per day fruit and vegetable consumption was practised by only 10.8% of Kuwaiti adults, with no differences between the sexes and little change between 2006 and 2008. The fre- quency of fruit and vegetable consump- tion was lower than the recommended WHO and US dietary guidelines [1,5] and was less than that of adults in the US, Britain and France [7–9]. In Kuwait, the percentage of adults who consumed fruit ≥ 2 times daily was 24.9% and vegetables ≥ 3 times daily was 14.7%, while in the US it was 33% and 27%, respectively [19]. Moreover, a regional comparison showed that 22.2% of Emirati men and 25.5% of Emirati women consumed ≥ 5 portions of fruits and vegetables per day, again far more than their Kuwaiti counterparts [6]. The current study showed that men did not differ from women in daily fruit and vegetable consumption. US reports showed more men (36.4%) than wom- en (28.7%) consumed fruit ≥ 2 times per day [20]. In addition to determining the ex- tent to which Kuwaiti adults adhere to dietary guidelines for fruit and vegeta- ble consumption, this study described those who did not comply with the guidelines. Unlike other studies from Europe and the US, there was no signifi- cant association between educational attainment and fruit and vegetable consumption and there was a negative association with being employed. Simi- lar to other countries, non-exercisers and smokers consumed fewer total fruit and vegetables and < 2 fruits and < 3 vegetables daily [6,7,9,20] and, as in the US, older adults consumed more fruit and vegetables. Kuwaiti adults consumed fruit and vegetables an average of 3.04 times per day compared with 3.24 times for Americans [7], 3.6 portions for French [9] and 2.8 portions for Brit- ish [21] adults for similar years. Fruit and vegetable consumption among American adults decreased over time, from 1994 through 2005, for all food items except for green salad [7]. It is Table 2 Mean frequency of daily fruit and vegetable consumption among Kuwaiti men and women, 2006–08 Type of fruit and vegetable Mean no. of times per day Both sexes Women Men 2006 2007 2008 2006 2007 2008 2006 2007 2008 Fruit Fruit juice 0.53b 0.57b 0.63a 0.52b 0.56b 0.65a 0.54b 0.57b 0.61a Fresh fruit 0.63 0.64 0.64 0.58a 0.62a,b 0.66b 0.68 0.66 0.63 Total fruit 1.15b 1.18b 1.25a 1.09b 1.16b 1.29a 1.21 1.21 1.22 Vegetables Green salad 0.74b 0.77b 0.69a 0.74b 0.80a 0.73b 0.73b 0.74b 0.65a Fried potatoes 0.22b 0.25b 0.33a 0.23b 0.25b 0.32a 0.20b 0.24b 0.33a Other potatoesc 0.28b 0.28b 0.33a 0.28b 0.27b 0.34a 0.28b 0.29b 0.33a Carrots 0.36 0.41 0.35 0.41b 0.44b 0.35a 0.29a 0.37b 0.35b Other 0.39b 0.40b 0.37a 0.37b 0.39b 0.33a 0.42 0.40 0.40 Total vegetables 1.90b 1.99b 1.78a 1.94b 2.05b 1.78a 1.85b 1.93a 1.79b Total fruit & vegetable 3.04b 3.18a 3.04b 3.03b 3.21a 3.07b 3.06 3.14 3.01 aP < 0.05; bP > 0.05 versus values marked with the same letter. cBaked, boiled or mashed. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 466 worth noting that within the 3 survey years of the current study, the total fruit and vegetable consumption did not change, but a major increase took place in fruit juice and cooked and fried potato intakes, accompanied by a marked reduction in consumption of green salads and other vegetables, indicating a distinct deviation from the recommendation to increase dark green and orange vegetables. As the current study did not differentiate between types of juice products— whether fresh fruit juice, packaged drinks or nectar—it is not possible to conclude whether the increase in fruit products actually helped to meet the 5-per-day recommendation or if it only reflects the expansion of the Kuwaiti market for sweetened bev- erages. As pointed out by Caswell, increased consumer understanding, knowledge and proper interpretation when selecting juice products in the market is required to satisfy fruit intake recommendations [22]. Another limitation of this study was that traditional Kuwaiti foods are com- posite dishes that include vegetables that may not be included in the estima- tion of vegetable consumption. This may explain the higher estimates of 6.1 servings per day reported previously for Kuwaitis using a 152-item food frequency questionnaire [23]. Further- more, participants were not asked about serving sizes or amounts consumed, which may have distorted the true frequency of intake. Dietary data from 1999–2000 in the National Health and Nutrition Examination Survey estimat- ed that 45.6% of adults aged 18 years and older had 5 or more serving of fruit and vegetables [24], while almost half that percentage (22.5%) was reported when analysing the 2003 CDC-BRFSS data [9]. Different dietary data instru- ments and food frequency estimates between these studies explain the large discrepancies. The strength of the current study was the large sample size and the standardized protocol for collection of data over time, which was able to reveal significant trends. Nevertheless, more research is needed to develop a reliable, valid instrument for accurate identification and estimation of fruit and vegetable consumption for the Gulf region. Additionally, determination of the population’s knowledge and aware- ness of dietary patterns that prevent and control chronic diseases is necessary to develop and implement comprehensive programmes aimed at increasing fruit and vegetable consumption. Assessment of Kuwaiti adults’ com- pliance with dietary guidelines for fruit and vegetable consumption warrants public health action to identify op- portunities for improvement through environmental, policy and system ap- proaches. The Kuwait surveillance sys- tem is an important tool for monitoring progress, revealing trends in consump- tion frequencies and evaluating the country’s efforts in promoting healthy lifestyles. References 1. Dietary guidelines for Americans, 6th ed. Washington DC, United States Department of Health and Human Services and Department of Agriculture, 2005. 2. Bes-Rastrollo M et al. Association of fiber intake and fruit/ vegetable consumption with weight gain in a Mediterranean population. Nutrition (Burbank, Los Angeles County, Calif.), 2006, 22:504–511. 3. He FJ, Nowson CA, MacGregor GA. Fruit and vegetable con- sumption and stroke: meta-analysis of cohort studies. Lancet, 2006, 367:320–326. 4. He FJ et al. Increased consumption of fruit and vegetables is related to a reduced risk of coronary heart disease: meta- analysis of cohort studies. Journal of Human Hypertension, 2007, 21:717–728. 5. Food, nutrition and the prevention of cancer: a global perspec- tive. Washington DC, World Cancer Research Fund/American Institute for Cancer Research, 1997. 6. Hall JN et al. Global variability in fruit and vegetable con- sumption. American Journal of Preventive Medicine, 2009, 36:402–409. 7. Blanck HM et al. Trends in fruit and vegetable consumption among U.S. men and women, 1994–2005. Preventing Chronic Disease, 2008, 5:A35–A44. 8. Blake M, Chaudhury M, Deverill C. Health survey for England 2003, volume 2: Risks factors for cardiovascular disease. In: Sproston K, Primatesta P, eds. Health survey for England 2003. Norwich, United Kingdom, Her Majesty’s Stationery Office, 2004. 9. Tamers SL et al. U.S. and France adult fruit and vegetable consumption patterns: an international comparison. European Journal of Clinical Nutrition, 2009, 63:11–17. 10. Healthy people 2010: understanding and improving health, 2nd ed. Washington DC, United States Department of Health and Human Services, 2000. 11. Global strategy on diet, physical activity and health. Geneva, World Health Organization, 2004 (WHA57.17). 12. Preventing chronic diseases: a vital investment. Geneva, World Health Organization, 2005. 13. Jackson RT et al. Prevalence of coronary risk factors in healthy adult Kuwaitis. International Journal of Food Sciences and Nutri- tion, 2001, 52:301–311. 14. Kuwait nutrition surveillance 2001–2004. In: Food and nutrition administration. Kuwait, Ministry of Health, 2004. 15. Ng SW. et al. The prevalence and trends of overweight, obesity and nutrition-related non-communicable diseases in the Gulf States. Obesity Review, 2010, 12:1–13. 16. Miladi S. Changes in food consumption patterns in the Arab countries. International Journal of Food Sciences and Nutrition, 1998, 49:S23–S30. 17. Al-Hooti SN et al. Food consumption pattern for the populat- tion of the State of Kuwait based on food balance sheets. Ecol- ogy of Food and Nutrition, 2002, 41:501–514. 18. BRFSS 2007. Behavioral Risk Factor Surveillance System Sur- vey Questionnaire. Atlanta, Georgia, Centers for Disease Control and Prevention, 2006 (http://www.cdc.gov/brfss/ طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 467 Promoting a healthy diet for the WHO Eastern Mediterranean Region Promoting a healthy diet for the WHO Eastern Mediterranean Region provides dietary advice to promote health and reduce the risk of major chronic diseases through diet and physical activity. This user-friendly guide presents a set of dietary recommendations that are compatible with the different cultures and eating patterns of consumers in the Region, based on the availability of local and affordable foods. This publication represents an essential tool in supporting national and regional strategies to improve nutrition outcomes and health in the Region. It is primarily intended for use by policy-makers, health care providers, nutritionists, nutrition educators and anyone involved in food distribution and food service. It can also be used by schools, homes, cafeterias and businesses to improve the food choices of a range of consumers. Further information about this and other EMRO publications is available at: http://www.emro.who.int/publications/ questionnaires/pdf-ques/2007brfss.pdf, accessed 18 March 2012). 19. State Indicator Report on fruits and vegetables, 2009. Atlanta, Georgia, Centers for Disease Control and Prevention, 2009. 20. Fruit and vegetable consumption among adults—United States 2005. Morbidity and Mortality Weekly Report, 2007, 16:213–217. 21. Hoare J et al. The National Diet and Nutrition Survey: adults aged 19–64 years. Volume 5, summary report. London, Her Majesty's Stationery Office, 2004. 22. Caswell H. The role of fruit juice in the diet: an overview. Nutri- tion Bulletin, 2009, 34:273–288. 23. Dehghan M et al. Development of a semi-quantitative food frequency questionnaire for use in United Arab Emirates and Kuwait based on local foods. Nutrition Journal, 2005, 4:18. 24. Guenther PM et al. Most Americans eat much less than recom- mended amounts of fruits and vegetables. Journal of the Ameri- can Dietetic Association, 2006, 106:1371–1379. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 468 Feasibility of a peer-led, school-based asthma education programme for adolescents in Jordan N.A. Al-Sheyab,1 R. Gallagher,2 J.K. Roydhouse,3 J. Crisp 2 and S. Shah 4 ABSTRACT The Adolescent Asthma Action programme (Triple A) has been used successfully to promote asthma knowledge, awareness and quality of life in adolescents with asthma in Australia. We describe the feasibility and acceptability of an adaptation of this English-language, peer-led, asthma education programme in a girls’ high school in Northern Jordan. The pilot was conducted by bilingual health workers. Feasibility, acceptability and adaptability were measured through participation rates, open-ended questionnaires completed by peer leaders, a focus group for junior students and reflective journal notes. The programme was well-received by staff and students, with high levels of participation. The peer-led approach was viewed positively. Students reported that they enjoyed the interactive learning activities and the opportunity to practise English. The students reported increased asthma knowledge and awareness, with students with asthma reporting receiving more support from peers. A peer-led asthma education programme is feasible and acceptable in the Jordanian school context. 1Faculty of Nursing, Midwifery, and Health, Jordan University of Science and Technology, Irbid, Jordan (Correspondence to N.A. Al-Sheyab: jood1965@yahoo.com). 2Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, New South Wales, Australia. 3Sydney Nursing School; 4Primary Health Care Education and Research Unit, Primary Care and Community Health, Sydney West Area Health Service, School of Public Health, University of Sydney, Sydney, New South Wales, Australia. Received: 13/10/10; accepted: 06/03/11 ندرلأا في ينقهارلما ءلامز هدوقي وبرلا نع ةسردلما لىع زكتري يفيقثت جمانرب قيبطت ىودج هاش اتيمس ،بسيرك يكاج ،سواهديور اكيساج ،رقلاق ينبور ،بايشلا ةيانه ةايلحا ةدوجو ،يعولاو ،فراعلما زيزعت في حاجنب )A A A ـب ًاراصتخا فورعلماو( ينقهارلما ينب وبرلاب صالخا لمعلا جمانرب مدختسي :ةصلالخا وبرلا لوح يفيقثتلا جمانبرلا اذله فُّيكتلاو لوبقلاو قيبطتلا ةيناكمإ فصوب نوثحابلا ماقو .ايلاترسأ في وبرلا نم نوناعي نيذلا ينقهارلما ىدل ينتغللاب نوثدحتي نويحص لماع يدايترلاا ثحبلا ىرجأو .ندرلأا ليماش في تايتفلل ةيوناث ةسردم في ءلامزلا هدوقيو ،ةيزيلكنلإا ةغللاب دعأ يذلا اهلمكتسا يتلاو تاباجلإا ةحوتفلما ةلئسلأاو ،ةكراشلما تلا َّدعم قيرط نع فييكتلا ةيناكمإو ،لوبقلاو ،ىودلجا سايق متو .ةيزيلكنلإاو ةيبرعلا ،ًانسح ًلاابقتسا جمانبرلا تابلاطلاو نولماعلا لبقتسا دقو .ةيمويلا تاظحلالما نمو ،تادجتسلما تابلاطلا نم ةيرؤب ةعوممجو ،تلايمزلا نم ةداقلا صَرُفو ةيلعافتلا ةيميلعتلا ةطشنلأاب نعتمتسا ننهأ تابلاطلا تغلبأو .تلايمزلا ةدايق بولسأ لىإ ًايبايجإ َرِظُنو .ةكراشلما نم ةيلاع تايوتسمبو نم معدلا نم ًاديزم نهي ِّقلت نع وبرلاب تاباصلما تابلاطلا تغلبأو ،وبرلاب مهيعوو مهفراعم ةدايز نع اوغلبأو .ةيزيلكنلإا ةغللا لىع نيرمتلا .ندرلأا في سرادلما قايس في لوبقمو ،ٍدمج ءلامزلا ةدايقب وبرلا لوح فيقثتلا جمانرب نأ لىإ ثحبلا صلخو .تلايمزلا Faisabilité d'un programme d'éducation sur l'asthme en milieu scolaire mené par des pairs auprès d'adolescentes en Jordanie RÉSUMÉ Le programme d'Action contre l'Asthme auprès des Adolescents (« Triple A ») a été mis en œuvre avec succès pour promouvoir les connaissances sur l'asthme et la qualité de vie auprès d'adolescents atteints d'asthme en Australie. Nous avons décrit la faisabilité et l'acceptabilité d'une adaptation de ce programme d'éducation sur cette maladie mené par des pairs en langue anglaise, auprès de filles d'un lycée du nord de la Jordanie. La partie pilote a été menée par des agents de santé bilingues. La faisabilité, l'acceptabilité et l'adaptabilité ont été mesurées au moyen des taux de participation, de questionnaires composés de questions ouvertes remplis par des camarades jouant un rôle d'animatrices, d'un groupe de discussion pour les élèves les plus jeunes et d'un cahier de notes de réflexion. Le programme a été bien accueilli par le personnel et les élèves, et les niveaux de participation étaient élevés. L'approche consistant à impliquer des pairs a été perçue positivement. Les élèves ont affirmé avoir aimé les activités d'apprentissage interactif et l'opportunité de parler l'anglais, et avoir accru leurs connaissances sur le sujet. Les élèves atteints d'asthme ont déclaré que leurs camarades les soutenaient davantage. Un programme d'éducation sur l'asthme mené par des pairs est réalisable et acceptable dans le contexte scolaire jordanien. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 469 Introduction Adolescence is a period of growth and development that promotes transition to adulthood but also increases vul- nerability and risks for health-related behaviours [1,2]. Peer-led, school- based programmes, which utilize peers to serve as positive role models to en- courage healthy behaviour, such as ap- propriate self-management of chronic diseases, have been used successfully in providing meaningful health education for adolescents [3]. Peer allies are usu- ally trained to implement interventions that lead to a change in peers’ self-man- agement behaviours, development of positive group norms, or improvement in adolescents’ ability to make healthy decisions [4,5]. The school setting is often used for adolescent health education pro- grammes, as it enables programmes to reach large numbers of adolescents in the community, is familiar to stu- dents and promotes the opportunity to reinforce student knowledge through continuous social contact [6–10]. Compared with adult-led programmes, peer-led programmes are at least as effective in improving knowledge [11] and more effective in changing health behaviours and attitudes and promoting self-management in adoles- cents [12]. Adolescents with asthma are often difficult to access and tend to have greater difficulties in appropriate management and treatment [13], and therefore school-based programmes may be particularly appropriate for this group. There is thus a need for such pro- grammes globally, and particularly in Jordan where asthma is relatively com- mon in adolescence and rates are com- parable to some developed countries [14,15]. The aim of this study was to assess the feasibility in the Jordanian context of a peer-led, school-based asth- ma education programme which has improved health-related outcomes and knowledge in Australian adolescents [16]. The Adolescent Asthma Action (Triple A) programme uses a 3-step cascade process from senior to junior students to deliver asthma education (Figure 1) and has well-developed re- sources, including standardized training manuals, educational videos, asthma- related models and devices and first aid kits (http://triplea.asthma.org.au). Trained health-workers provide the initial training of the peer leaders and facilitate the steps of the programme. The programme content covers management of asthma exacerba- tions, resisting pressure to smoke and asthma medication and triggers [17]. Programme delivery occurs through interactive teaching and learning ac- tivities, including role-play and group discussion, all of which are more effec- tive than traditional didactic education for adolescents [18]. Importantly, Triple A is grounded in universally ap- plicable theoretical concepts including peer leadership, self-efficacy [19] and empowerment [20,21], suggesting its potential for use in different cultural contexts. Methods Subjects A private school for girls (n = 240) in a large city in northern Jordan, which is the second largest in the district was se- lected. Using the Triple A peer-training cascade, junior students from years 7 and 8 and more senior students from years 10 and 11 attending regular school classes were invited to participate. Intervention Prior to the programme, the lead researcher, who is a nurse in Jordan, received training from the developer of the Triple A programme in Australia. She then trained 2 research assistants from Jordan to co-facilitate the peer leaders’ training workshop. As the Triple A programme is delivered in English, this modification to the original programme was important to provide Information session to year 11 students for recruitment of peer leaders Implementation Training workshop for peer leaders (3 × 90 mins) Peer-led asthma lessons to year 10 students (3 x 45 mins) Year 10 students presented 5 asthma performances (5 mins each) to the school community Evaluation Peer leaders’ training workshop (n = 10) Peer leaders’ asthma lessons by 10 years students (n = 24) Year 10 asthma performances by year 7 & 8 students (n = 31) Figure 1 Flow chart of implementation, students’ participation and evaluation of the Triple A programme EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 470 bilingual and bicultural health care pro- viders who were familiar with the beliefs and practices of Jordanian adolescents and their families. Two teachers who were nominated by the school princi- pal to act as liaisons were informed of the Triple A programme content and resources. The Triple A programme was then implemented in 3 steps as outlined in Figure 1. Volunteers recruited to serve as asthma peer leaders were trained (step 1) to deliver asthma lessons to younger peers in 3 sessions. These ses- sions, conducted in both Arabic and English, focused on asthma knowledge, empowerment and leadership and par- ticipants received a standardized man- ual. Following this training, the asthma peer leaders conducted 3 asthma les- sons for year 10 students (step 2). In steps 1 and 2, activities were introduced in English and then explained in Arabic to make sure that all health messages in all activities were understood by all students. Volunteers from year 10 developed key asthma and smoking messages to present to the school com- munity (step 3) using songs, drama, poems and short acts; these messages were delivered in a 30-minute school as- sembly. Student participation involved a total of 14 hours over a 6-day period to deliver the programme: 10 hours for asthma peer leaders, 3 hours for year 10 students, and 30 minutes for the whole school. Instruments Asthma peer leaders’ perceptions of the programme effectiveness and ac- ceptability were assessed by 3 open- ended questions in English developed for the original Triple A programme trial [16,22]. Students wrote their feedback in Arabic. Acceptability was also assessed by a focus group discus- sion conducted in Arabic with year 7 and 8 students, following the school assembly. Feasibility was assessed by the level of support, voluntary involvement and commitment of the teachers and students and recorded in field notes by the first author. Ethical approval for the study was obtained from the Ministry of Educa- tion in Jordan and the ethics commit- tee of the University of Technology, Sydney, Australia. As gaining parental consent is not a custom in Jordan, the consent form was signed by the students, a variation approved by both countries’ ethics committees. Data analysis Students’ responses to the evaluation questions and the researchers’ notes from the focus group were collated by the first and second authors and inde- pendently sorted into themes labelled using the students’ actual words. Results Staff and students enthusiastically par- ticipated in all steps of the programme. The school principal was supportive and committed to implementing the Triple A programme in her school, as were the 2 nominated teachers. The programme was widely accepted by the students with many volunteering to participate (Figure 1). Programme evaluation Evaluations were completed by the 10 asthma peer leaders (83%) follow- ing the training workshop and by 24 year-10 students (73%) following the lessons delivered by the asthma peer leaders. As the evaluation of both the workshop and lessons revealed very similar themes they have been com- bined to avoid repetition. The themes, outlined in Table 1, reflect improved awareness and knowledge of asthma and a positive reception to the peer- led approach among participating students. As shown in Table 2, year 7 and 8 students gained increased aware- ness of and positive attitudes and be- liefs towards asthma, as well as better understanding of the harmful effects of smoking. The researcher noted that the year 10 volunteers were confident and seemed to enjoy giving the perfor- mances, which were presented using poetry, drama, posters and songs. The information presented by the peer lead- ers in English was correct and Arabic words were appropriately substituted for English words when needed. Over- all, the positive effects of Triple A noted in these evaluations were consistent with the overall educational aims and objectives of Triple A as illustrated in Table 3. Discussion A modified peer education programme about asthma was well-received, feasible and acceptable to students and staff in a Jordanian high school. Participating students, including peer leaders, gained a better understanding of asthma and its related management and the negative effects of smoking and developed more acceptance and support for students with asthma. This is the first study to test an English language peer-led school- based education programme in an East- ern Mediterranean region setting, The positive results of this study suggests that the peer education programmes can be successfully adapted and imple- mented in different contexts and that the influence of peers is powerful and potentially universal. An unexpected benefit of the pro- gramme was students’ interest and increased confidence in using spoken English. This is promising for further dissemination of the programme in schools where the level of English may be lower and in other non-English speaking countries where English is a school subject. However, it is essential that bilingual local health workers are involved in the programme adaptation and implementation, and that partici- pants’ level of English is considered and modifications made as necessary. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 471 The positive reception for the peer-led approach is consistent with previous studies [22] and hypotheses about the importance of peer role modelling [23], and provides further support for the value of peer educa- tion programmes. The study findings also support the use of programme activities based on general theories and principles [19,20], and indicate that similar interventions should be theoretically based. In practical terms, the findings also point to the success of standardized training resources and training workshops, consistent with other research [24]. Having the programme conducted by bilingual health workers was also important [25–27], and the support and vol- untary participation of the school principal and teachers was critical for programme delivery. Gaining school support and commitment required the lead researcher to explain the pro- gramme and the need for it. A limitation of the study was that it was conducted in a single, private, girls’ school and so the findings may not be generalizable, particularly to schools where English is not studied Table 1 Common themes derived from participants in the asthma peer leader workshops and lessons provided by year 10 students Themes Student quotes Improved asthma-related knowledge and awareness “Now I know more about the different types of asthma medications and when to use them.” “Before the workshop, I thought that students with asthma shouldn’t be involved in sports, now I know that they can part as long as they know how to take precautions.” “I feel confident enough to help in case of asthma exacerbation if occurs in school…I know what I should do to save my friends with asthma.” Enjoying and valuing the learning activities “The video, especially the stuff about peer pressure and smoking, was a good activity and highlights the huge influence that students with asthma face in school.” “It’s like you feel very engaged especially when you get to do the activity yourself.” “I liked all the activities because they were simple and fun…different to what we normally do in class.” Appreciating the peer-led approach “I enjoyed being taught by my mates and other older students.” “The language that the students used during the classes was very simple and I liked the fact that they took over.” Peer leaders appreciated local bilingual trainers “The language was simple but having the educator explaining some of the scenes in Arabic definitely helped.” Opportunity to practise English “I chose to participate in this just to get a chance to practise speaking English in front of my friends.” “It was fun to listen to peer leaders use some English words.” Students with asthma felt more supported and confident regarding asthma “I feel happy that all my friends now know about the nature of the disease…. I don’t have to hide the symptoms anymore.” “If I have an attack from now on at school, I think I’m more confident to be able to control it before it gets any worse.” Table 2 Themes derived from focus group of year 7 and 8 students following year 10 students’ presentations Themes Quotes from participating students Improved awareness of asthma in students with asthma “Made me realize the burden that asthma symptoms can have if not correctly managed.” Increased awareness of the negative consequences of smoking “I never knew that if you’re not a smoker you can still be affected by cigarettes when someone else smokes…it must be hard for our classmates who have asthma.” Improved attitudes and beliefs about asthma “The skits taught me to support students with asthma…they’re still similar to anyone else in the school.” Liked the peer-led approach “I found it really interesting to see some year 10 students perform to us…it was fun and creative.” EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 472 extensively. Quantitative evaluation and longer-term assessment of the pro- gramme impact are essential, but were beyond the scope of the study. The lack of quantitative evaluation precludes a definitive assessment of the effect of the programme on adolescent knowledge and health outcomes, but the positive findings from the qualitative evaluation of feasibility and acceptability point to the suitability of undertaking a larger study with a quantitative evaluation component. Conclusion A peer-led asthma education programme developed in Australia was feasible and acceptable in the Jordanian cultural and linguistic context. These findings pro- vide a positive message about the use of peer education, as well as support for fur- ther testing of the Triple A programme in Jordan. A randomized controlled trial is being conducted to examine the effect of the adapted programme on specific outcomes, including asthma-related quality of life and knowledge, and the ability to resist smoking. Acknowledgements We would like to thank the participating students for their involvement and the school staff for their support. This work was supported by Jordan University of Science and Technology by a scholar- ship for the first author and provision of research assistant support. References 1. Steinberg L. Cognitive and affective development in adoles- cence. Trends in Cognitive Sciences, 2005, 9:69–74. 2. Paus T. Mapping brain maturation and cognitive develop- ment during adolescence. Trends in Cognitive Sciences, 2005, 9:60–68. 3. Green J. Peer education. Promotion & Education, 2001, 8:65–68. 4. Turner G. Peer support and young people’s health. Journal of Adolescence, 1999, 22:567–572. 5. Bament D. Peer education literature review. Adelaide, South Australian Community Health Research Unit, 2001. 6. Cohall AT et al. Overheard in the halls: what adolescents are saying, and what teachers are hearing, about health issues. Journal of School Health, 2007, 77:344–350. 7. Ennett ST, Bauman KE. Adolescent social networks: School, demographic, and longitudinal considerations. Journal of Ado- lescent Research, 1996, 11:194–215. Table 3 Fulfilment of programme aims, objectives and process outcomes according to student evaluations Triple A programme Peer leaders Year 10 students Year 7 & 8 students Aims Create a supportive school environment for asthma ü ü ü Decrease asthma emergencies at school NA NA NA Promote asthma awareness in the school community ü ü ü Prevent smoking ü ü ü Programme objectives Use asthma reliever medications when required NA NA NA Take preventive action to avoid exercise-induced asthma ü ü ü Recognize signs of worsening asthma ü ü ü Understand the need to see a doctor for their asthm ü ü ü Comply with the daily use of preventer medications NA NA NA Educational objectives Increase knowledge of asthma and its management ü ü ü Promote positive attitudes towards asthma ü ü ü Promote avoidance of smoking and passive smoking ü ü ü Identify the steps to take in an asthma emergency ü ü ü Process outcomes Promotes social responsibility and leadership ü ü NA Enhances collaborative group work skills ü ü NA Offers opportunities to participate in community action ü ü NA Builds friendships ü ü ü Adapted from Shah & Cantwell [17]. NA = not assessed. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 473 8. Ennett ST et al. School and neighborhood characteristics as- sociated with school rates of alcohol, cigarette, and marijuana use. Journal of Health and Social Behavior, 1997, 38:55–71. 9. McCann DC et al. A controlled trial of a school-based interven- tion to improve asthma management. European Respiratory Journal, 2006, 27:921–928. 10. Valeros L, Kieckhefer G, Patterson D. Traditional asthma education for adolescents. Journal of School Health, 2001, 71:117–119. 11. Cuijpers P. Effective ingredients of school-based drug preven- tion programs. A systematic review. Addictive Behaviors, 2002, 27:1009–1023. 12. Mellanby AR, Rees JB, Tripp JH. Peer-led and adult-led school health education: a critical review of available comparative research. Health Education Research, 2000, 15:533–545. 13. Sawyer SM, Shah S. Improving asthma outcomes in harder- to-reach populations: challenges for clinical and com- munity interventions. Paediatric Respiratory Reviews, 2004, 5:207–213. 14. Abu-Ekteish F, Otoom S, Shehabi I. Prevalence of asthma in Jordan: comparison between Bedouins and urban schoolchil- dren using the International Study of Asthma and Allergies in Childhood phase III protocol. Allergy and Asthma Proceedings, 2009, 30:181–185. 15. Al-Akour N, Khader YS. Quality of life in Jordanian children with asthma. International Journal of Nursing Practice, 2008, 14:418–426. 16. Shah S et al. Effect of peer led programme for asthma educar- tion in adolescents: cluster randomised controlled trial. British Medical Journal, 2001, 322:583–585. 17. Shah S, Cantwell G. Triple A program: educator’s manual. Canber- ra, Commonwealth Department of Health and Aged Care, 2000. 18. Ochieng BMN. Adolescent health promotion: the value of being a peer leader in a health education/promotion peer education programme. Health Education Journal, 2003, 62:61–72. 19. Bandura A. Recycling misconceptions of perceived self-effica- cy. Cognitive Therapy and Research, 1984, 8:231–255. 20. Freire P. Pedagogy of the oppressed. New York, Continuum Books, 1970. 21. Freire P, Reynolds R. Pedagogy of the city. New York, Con- tinuum Books, 1993. 22. Shah S, Mamoon HA, Gibson PG. Peer-led asthma educa- tion for adolescents: development and formative evaluation. Health Promotion Journal of Australia, 1998, 8:177–182. 23. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychological Review, 1977, 84:191–215. 24. Story M et al. Peer-led, school-based nutrition education for young adolescents: feasibility and process evaluation of the TEENS study. Journal of School Health, 2002, 72:121–127. 25. Bronheim S, Sockalingam S, National Center for Cultural Com- petence. A guide to choosing and adapting culturally and linguis- tically competent health promotion materials. Washington DC, National Center for Cultural Competence, 2003. 26. Simmons R et al. Health education and cultural diversity in the health care setting: tips for the practitioner. Health Promotion Practice, 2002, 3:8–11. 27. Boyer CB et al. Youth united through health education: com- munity-level, peer-led outreach to increase awareness and improve noninvasive sexually transmitted infection screening in urban African American youth. Journal of Adolescent Health, 2007, 40:499–505. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 474 Study of the relation between quality of inpatient care and early readmission for diabetic patients at a hospital in the Eastern province of Saudi Arabia S.A.Mokhtar,1 A.A. El.Mahalli,2,3 S. Al-Mulla 4 and R. Al-Hussaini 4 ABSTRACT Readmission of diabetic patients after discharge from hospital has potential value as a quality of care indicator. This retrospective cohort and case–control study aimed to determine the readmission rate for diabetic patients within 28 days after discharge and the association between quality of inpatient care and unplanned readmission. An audit of records was conducted in a hospital in the Eastern province of Saudi Arabia during 2000–2008. The rate of unplanned readmission of patients originally admitted with diabetes mellitus (n = 1125) was 5.2%. Comparison of data from readmitted patients (n = 62) and a sample of nonreadmitted patients (n = 62) showed that adherence by health care providers to American Diabetes Association guidelines for admission work-up (OR 0.91, 95% CI: 0.85–0.99) and readiness for discharge criteria (OR 0.89, 95% CI: 0.84–0.95) were significantly more likely to decrease the risk of readmission within 28 days. 1Department of Biostatistics, 2Department of Health Administration and Behavioural Sciences, High Institute of Public Health, University of Alexandria, Alexandria, Egypt (Correspondence to A.A. El.Mahalli: aelmahalli90@gmail.com). 3College of Applied Medical Science, University of Dammam, Dammam, Saudi Arabia. 4Health Information Management and Technology Programme, College of Applied Medical Sciences, King Faisal University, Dammam, Saudi Arabia. Received: 30/05/10; accepted: 30/08/10 ةقطنلما في تايفشتسلما دحأ في ًاركبم يركسلا ضىرم لاخدإ ةداعإو ينيلخادلا ضىرملل ةمدقلما ةياعرلا ةدوج ينب ةقلاعلا ةسارد ةيدوعسلا ةيبرعلا ةكلملما نم ةيقشرلا ينيسلحا انر ،لالما ىملس ،ليحلما ليع ةزع ،راتمخ دحمأ ةحيمس ةيداعتسلاا ةساردلا هذه فدتهو .ةياعرلا ةدوج لىع شرؤم هنأ لىع ةلمتمح ةميق هل ىفشتسلما نم مهجارخإ دعب يركسلا ضىرم لاخدإ ةداعإ :ةصلالخا ةدوج ينب ةقلاعلاو ،اهنم مهجورخ دعب ًاموي 28 للاخ يركسلا ضىرلم ىفشتسلما لىإ لاخدلإا ةداعإ ل َّدعم ديدتح لىإ دهاوشلاو تلااحللو بارتلأل في تايفشتسلما دحأ في تلاجسلل ًاقيقدت تاثحابلا ترجأ .كلذل قباس طيطتخ نود ىفشتسلما لىإ ملهاخدإ ةداعإو ينيلخادلا ضىرملل ةم َّدقلما ةياعرلا ،كلذل قباس طيطتخ نود ىفشتسلما لىإ ضىرلما لاخدإ ةداعإ ل َّدعم نأ ندجوف .2008-2000 ةترفلا للاخ ةيدوعسلا ةيبرعلا ةكلمملل ةيقشرلا ةقطنلما ةنِّيعو )62 ددعلا( ىفشتسلما ملهاخدإ ديعأ نيذلا ضىرلما تايطعم ةنراقم ترهظأو .)1125 ددعلا(%5.2 يركسلا ءاد جلاعل ىفشتسملل ملهاخدإ دعب لاخدإ في ةيكيرملأا يركسلا ةيعملج ةيداشرلإا لئلادلاب ةيحصلا ةياعرلا يم ِّدقم مازتلا نأ )62 ددعلا( ىفشتسلما لىإ ملهاخدإ داعي لم نيذلا ضىرلما نم ةقثلا ةلصاف ،0.89 ةيحجرلأا ةبسن( ىفشتسلما نم ضىرلما جارخلإ بهأتلا يرياعمو )0.99-0.85 :%95 ةقثلا ةلصاف ،0.91 ةيحجرلأا ةبسن( ضىرلما .ًاموي 28 للاخ ىرخأ ةرم ىفشتسلما لىإ ضىرلما لاخدإ ةداعإ رطامخ نم للقت نأ ًايئاصحإ هب ُّدَتْعُي وحن لىع اله ح َّجرلما نم ناك )0.95-0.84 :%95 Étude de la relation entre la qualité des soins en séjour hospitalier et une réadmission précoce des patients atteints de diabète dans un hôpital de la province est de l'Arabie saoudite RÉSUMÉ La réadmission de patients diabétiques après leur sortie de l'hôpital peut être une information utile en tant qu'indicateur de la qualité des soins. La présente étude cas-témoin, de cohorte et rétrospective visait à déterminer le taux de réadmission des patients diabétiques dans les 28 jours suivant leur sortie de l'hôpital et la relation entre la qualité des soins en séjour hospitalier et une réadmission non programmée. Un examen des dossiers a été réalisé dans un hôpital de la province est de l'Arabie saoudite entre 2000 et 2008. Le taux des réadmissions non programmées de patients initialement admis pour un diabète (n = 1125) était de 5,2 %. La comparaison des données concernant les patients réadmis (n = 62) et un échantillon de patients n'ayant pas été réadmis (n = 62) a mis en exergue que l'application par les prestataires de soins de santé des directives de l'American Diabetes Association [Association américaine contre le diabète] concernant l'admission des patients (O.R. 0,91 ; IC à 95 % : 0,85–0,99) et les critères de sortie (O.R. 0,89 ; IC à 95 % : 0,84–0,95) permettait de réduire significativement le risque de réadmission dans les 28 jours. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 475 Introduction Diabetes mellitus is fast emerging as one of the most serious health problems worldwide. In Saudi Ara- bia 4 million people are estimated to suffer from diabetes mellitus [1]. Good diabetes self-management is of critical importance in preventing seri- ous long-term complications [2]. Dia- betic patients may face problems in controlling or managing blood sugar levels. The most frequent problems are hyperglycaemia or hypoglycae- mia. When patients face any of these conditions, they should be admitted immediately to hospital to receive proper care [3]. At the hospital, dia- betic patients should receive multidis- ciplinary management in addition to regular follow up [4,5]. As diabetes is associated with many acute and chronic complications and comorbidities, diabetic patients are frequently readmitted to hospital [6,7]. Hospital readmission is a matter of concern due to its implications for the cost and utilization of hospital resourc- es in addition to the burden on the patients and their families. In general, hospitalization consumes about half of health care expenditure. Hospital readmissions have considerable po- tential as an indicator of the quality of care [7–9]. In the United States, almost 18% of Medicare hospital admissions result in readmissions within 30 days of discharge, resulting in $15 billion in annual expenditures [8]. About $12 billion of that is spent on potentially preventable readmissions. The Ameri- can Diabetes Association (ADA) has identified 3 major categories as stand- ards of the quality of inpatient diabetes care: admission workup, evaluation of treatment during hospitalization and discharge criteria (readiness for dis- charge) [10]. Several studies have documented the relationship between hospital re- admission and quality of care. Ashton et al. in the United States concluded that early readmission was signifi- cantly associated with the process of inpatient care and 55% of readmitted patients were more likely to have had a quality of care problem [7]. On the other hand, no studies have addressed the relationship between quality of diabetes care and early readmission in Saudi Arabia. Therefore the present study aimed to determine the 28-day readmission rate for diabetic patients at a hospital in the Eastern province of Saudi Arabia, to assess compliance of health care providers with the ADA guidelines and to identify factors pre- dicting readmission. Methods Study design and sample This was a retrospective cohort and case–control study. The target population was the medical records of diabetic patients admitted to a hospital in Al Khobar, Eastern prov- ince of Saudi Arabia between January 2000 and December 2008. This was a 340-bed teaching hospital affiliated to King Faisal University. Diabetic patients are referred to the hospital from a specific primary health care centre. Ethical considerations Formal approval from the Ministry of Health was taken before conducting the research. Confidentiality of the data collected from medical records was maintained. Cohort study To determine the 28-day readmis- sion rate we examined the electronic and paper-based medical records of diabetic patients who were readmitted to the internal medicine department within 28 days of index hospitalization for the same diagnosis (unplanned readmission). The index hospitaliza- tion was defined as the initial hospi- talization after which the patient was readmitted to the hospital within 28 days after discharge during the study period. Case–control study Sample To determine the sample size for the case–control study, it was assumed that the odds ratio (OR) of readmis- sion among diabetic patients exposed to substandard care was 2.24, and the fraction of early unplanned readmis- sions attributable to substandard of care was 14.9% [7]. With a relative precision of 50%, and 95% confidence level, the minimum required sample size was estimated as 62 cases and 62 controls [11]. The cases were all the diabetic patients (n = 62) readmitted within 28 days with the same diagnosis for unplanned reasons. The controls (n = 62) were selected using systemic random sampling after calculating the sampling interval from among the total number of diabetic patients not readmitted within 28 days after discharge. The exclusion criteria were: gestational diabetes, patients with planned readmission and patients readmitted due to reasons other than diabetes mellitus. Data collection Data were collected onto a proforma which was divided into 3 categories: demographic characteristics of the study sample (age, sex and marital status); hospital stay and disease his- tory (date of admission and discharge, length of stay, number of hospital admissions within 2 years previous to the index admission and patient read- mission within 28 days after discharge, comorbidities); and assessment of the degree of compliance of health care providers with ADA guidelines for inpatient diabetes care. Items from the ADA guidelines were grouped into 3 categories: ad- mission workup (history, physical ex- amination and initial investigations); EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 476 evaluation of treatment during stay; and readiness for discharge (discharge criteria). Each item in the ADA guide- lines was given a score of 1 if it was achieved and 0 if not. The total ad- herence score for each category was expressed as the average percentage of achieved items over the total number of items for that category: 12 for ad- mission workup, 12 for evaluation of treatment during hospital stay and 7 for discharge criteria. Statistical analysis Data entry and analysis were performed using SPSS, version 11.5 [12]. Patients’ demographic and clinical characteris- tics were examined in relation to the outcome (readmission). Statistical analysis was done using the Student t-test for continuous variables and the chi-squared test for qualitative variables. Means, standard deviations (SDs) and frequencies are presented. Multiple logistic regression analysis was used to estimate the unique effect of adherence scores on the probability of readmission after controlling for patients’ demo- graphic factors, hospital stay informa- tion and disease history. Odds ratios (ORs) and confidence intervals (CIs) are presented. The statistical significance was set at P < 0.05. Results Readmission rate According to the electronic medi- cal records of the diabetic patients discharged from the study hospital between January 2000 and December 2008, there were 62 patients readmit- ted within 28 days and 1125 patients not readmitted. The rate of unplanned readmission for diabetic patients was therefore 5.2% (95% CI: 1.1%–8.9%). Comparison of readmitted (cases) and non-readmitted patients (controls) The results showed that 84% of the 62 cases were readmitted once within 28 days, 11% were readmitted 2 times, 3% 3 times and 2% 4 times, with a mean number of readmissions of 1.2 (SD 0.6). In addition, 34% of the patients were readmitted 1 week after discharge, 19% within 2 weeks, 15% within 3 weeks and 32% within 4 weeks. The mean length of time be- tween discharge and readmission was 14.4 (SD 9.5) days. Table 1 shows that 66.1% of re- admitted patients had type 2 diabetes and 33.9% had type 1; 95.2% suffered from diseases other than diabetes. For controls, the corresponding figures were 60.3%, 39.7% and 75.8% respec- tively. Concerning hospital admission, 85.5% of patients did not have any admissions in the previous 2 years and 12.9% had 1 previous admission. The mean duration of stay of the index admission was 12.9 (SD 25.1) days. For controls, 62.9% had no previous admissions and 27.4% had 1 admis- sion. The mean duration of stay of the index admission was 13.0 (SD 17.9) days. No statistically significant differ- Table 1 Demographic data, clinical history and history of previous hospital admission for diabetes among cases (diabetic patients subsequently readmitted within 28 days) and controls (diabetic patients not readmitted) Variable Cases (n = 62) Controls (n = 62) Demographic variables Mean (SD) age (years) 42.8 (2.5) 41.7 (25.2) Male (% of patients) 55.6 51.6 Married (% of patients) 44.7 59.2 Clinical variables Type 2 diabetes (% of patients) 66.1 60.3 Presence of comorbidity (% of patients) 95.2* 75.8 Previous admissions No. of hospital admissions in previous 2 years (% of patients) 0 85.5 62.9 1 12.9 27.4 2 1.6 6.5 Mean (SD) no. of admissions in previous 2 years 0.16 (0.41) 0.53 (0.90) Mean (SD) length of stay for index admission (days) 12.9 (25.1) 13.0 (17.9) Discharged against medical advice (% of patients) Yes 6.5 4.8 No 93.5 95.2 *P < 0.05 versus controls. SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 477 ence was detected between cases and controls, except for the presence of comorbidity (P < 0.05). Figure 1 illustrates that health care providers were compliant with the to- tal list of admission workup guidelines for only 46.8% of the cases but 87.1% of controls. Concerning treatment dur- ing the hospital stay, providers were adherent for only 50.0% of the cases but 82.3% of controls. Regarding readi- ness of discharge, providers were con- forming to guidelines for only 46.8% of the cases and 95.2% of controls. A statistically significant difference was detected regarding level of compli- ance of health care providers to the guidelines when caring for cases and controls in the admission workup (χ2 = 22.8, P < 0.05), treatment during hospital stay (χ2 = 14.4, P < 0.05) and readiness of discharge (χ2 = 35.2, P < 0.05). Table 2 shows that adherence of health care providers with most as- pects of admission workup guidelines was lower for cases than for controls: diabetes history (74.2% and 98.4% respectively), comorbidity (75.8% and 95.2%), diabetes complications (82.3% and 93.5%), serum creatinine (59.7% and 69.4%), electrocardiogra- phy (EKG) (64.5% and 82.3%), uri- nalysis (74.2% and 100%), glycated haemoglobin (30.6% and 38.7%) and lipid profile (40.3% and 67.7%). For the control group health care provid- ers had significantly better adherence with history taking (Fisher exact test, P < 0.001), documentation of comor- bidity (Fisher exact test, P = 0.004), EKG analysis (χ2 = 4.9, P < 0.05), urine analysis (Fisher exact test, P < 0.001) and lipid profile (χ2 = 9.4, P < 0.05). Table 3 shows that the compli- ance of health care providers with hospital stay treatment guidelines was lower for cases than controls in almost all aspects. A significant better adherence of health care providers to ADA guidelines was found for the control group in the following aspects: reporting alert of any danger signs/ abnormal values to consultant physi- cian (χ2 = 6.9, P < 0.05), consultation with expert physician (χ2 =14.5, P < 0.05), continuous insulin IV infusion (χ2 =23.2, P < 0.05), comprehensive nutrition assessment (χ2 = 12.9, P < 0.05), nutrition reassessment (χ2 = 18.3, P < 0.05) and education plan (χ2 = 37.4, P < 0.05). Table 4 illustrates that the compli- ance of health care providers with all ADA guidelines of readiness for 46.8 46.8 87.1 82.3 95.2 0 10 20 30 40 50 60 70 80 90 100 Admission w ork-up Treatment during hospital stay Readiness of discharge % o f p at ie nt s 50.0 Readmitted within 28 days Not readmitted within 28 days Figure 1 Compliance of health care providers to American Diabetes Association guidelines for case (n = 62) and control (n = 62) diabetic patients Table 2 Adherence of health care providers to the admission workup guidelines of the American Diabetes Association for cases (diabetic patients subsequently readmitted within 28 days) and controls (diabetic patients not readmitted) Admission workup guidelines % adherence to guidelines Cases (n = 62) Controls (n = 62) Identification of diabetes 100.0 100.0 History of diabetes 74.2* 98.4 Documentation of symptoms 93.5 100.0 Documentation of comorbidity 75.8* 95.2 Documentation of complications 82.3 93.5 Documentation of physical examination 100.0 100.0 Serum creatinine analysis 59.7 69.4 EKG analysis 64.5* 82.3 Urinalysis 74.2* 100.0 Plasma glucose analysis 100.0 100.0 Glycated haemoglobin analysis 30.6 38.7 Lipid profile analysis 40.3* 67.7 *P < 0.05 versus controls. EKG = electrocardiography. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 478 discharge was lower among the cases than the controls and the difference in compliance in all these aspects was statistically significant (P < 0.05). Table 5 shows that the logistic regression model fit was satisfactory (χ2 = 78.2, P < 0.05). Factors in the model succeeded in explaining 76% of the variation in the probability of readmission. The model was able to predict the correct category for each case in 85% of occasions. Significant predictors were adherence of health care providers to admission workup Table 3 Adherence of health care providers to the treatment during hospital stay guidelines of the American Diabetes Association for cases (diabetic patients subsequently readmitted within 28 days) and controls (diabetic patients not readmitted) Treatment during stay guidelines % adherence to guidelines Cases (n = 62) Controls (n = 62) Glycated haemoglobin analysis 25.8 32.3 Bedside plasma glucose analysis 98.4 98.4 Blood glucose review 98.4 98.4 Reporting alert to consultant 22.9* 43.5 Reassessment of regimen 66.1 80.6 Consultation with expert physician 40.3* 74.2 Treatment for hypoglycaemia 80.0 100.0 Continuous insulin intrvenous infusion 32.7* 65.6 Nutrition plan 91.9 100.0 Comprehensive nutrition assessment 30.6* 62.9 Nutrition reassessment 12.9* 48.4 Education plan 19.4* 74.2 *P < 0.05 versus controls. and discharge criteria guidelines (OR 0.91, 95% CI: 0.85–0.99 and OR 0.89, 95% CI: 0.84–0.95 respectively). Discussion Diabetes is associated with many complications and comorbidities for which diabetic patients are frequently readmitted to hospital [6]. Complica- tions of diabetes include damage to the nerves, blood vessels, heart, eye and kidneys. Diabetic neuropathy affects about 50% of diabetic patients. About 10%–20% of people with diabetes die of kidney failure and 50% die of cardiovascular diseases [13]. The present study showed that 5.2% of discharged diabetic patients were readmitted to hospital within 28 days. Ashton et al. revealed that 10% of diabetic patients in Veterans Affairs hospitals in the United States were readmitted within 14 days [7] and Robbin et al. found that 20% of diabetic patients in Philadelphia hospitals were readmitted within 30 days [6]. A literature review revealed that readmitted patients were more likely to have had a quality of care problem [7]. The present study showed that completeness of admission workup guidelines may decrease the likelihood of readmission (OR = 0.91, 95% CI: 0.85–0.99). The significant differ- ences in admission criteria between cases and controls, however, were documentation of diabetic history and comorbidity, and performance of EKG, urinalysis, glycated haemoglo- bin and lipid profile tests. Moreover, adherence of health care providers to readiness for discharge criteria was more likely to reduce the probability of early readmission (OR 0.89, 95% CI: 0.84–0.95). All items of the discharge criteria including clinical stability, pa- tients’ education and follow-up plan in the outpatient clinic were statisti- cally significant. This was compatible Table 4 Adherence of health care providers to the readiness for discharge guidelines of the American Diabetes Association for cases (diabetic patients subsequently readmitted within 28 days) and controls (diabetic patients not readmitted) Readiness for discharge guidelines % adherence to guidelines Cases (n = 62) Controls (n = 62) Acceptable blood glucose control (3.3–13.9 mmol/L) 75.8* 98.4 No changes in insulin or sulfonylurea dose for at least 24 h before discharge 59.7* 85.5 Ensure that patient or family is able to do finger-stick glucose measurement 6.5* 27.4 Ensure that patient or family understands medication regimen and is able to administer insulin or oral sulfonylurea 16.1* 75.8 Patient or family has been instructed in and understands the dietary regimen 6.5* 66.1 Patient or family has been instructed in and understands foot care 6.5* 25.8 Appointment for follow-up in outpatient department 72.4* 95.2 *P < 0.05 versus controls. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 479 CI: 1.11–4.49) [7]. On the other hand, other studies did not detect any as- sociation between quality of inpatient care and readmission [14]. Conclusions Early readmission is common in pa- tients with diabetes mellitus. Quality of inpatient care exerts a substantial influ- ence on the risk of readmission. We therefore recommend that the study hospital should improve the quality of care delivered to diabetic patients espe- cially with respect to health education for nutrition, insulin and drug regimen, dietary regimen, symptoms of uncon- trolled diabetes and how to control complications. Special emphasis should be placed on attendance at outpatient clinics for follow up after discharge. Table 5 Logistic regression analysis of predictors of readmission to hospital within 28 days after discharge for patients admitted with diabetes Variable OR (95% CI) Age 1.02 (0.99–1.01) Sex (male) 1.23 (0.64–2.37) Marital status (not married) 7.14 (1.13–14.1)* Length of stay 0.97 (0.92–1.02) Previous admission within 2 years 1.03 (0.40–2.71) Type of diabetes (type 2) 0.96 (0.19–4.90) No. of comorbidities 12.8 (0.16–16.5) Type of discharge (against medical advice) 1.80 (0.10–4.12) Adherence of health care providers to: Admission workup guidelines 0.91 (0.85–0.99)* Treatment during hospital stay guidelines 0.99 (0.94–1.06) Discharge criteria guidelines 0.89 (0.84–0.95)* *P < 0.05. OR = odds ratio; CI = confidence interval. References 1. Elhazmi M et al. Diabetes mellitus as a health problem in Saudi Arabia. Eastern Mediterranean Health Journal, 1998, 4:58–67. 2. O’Reilly CA. Managing the care of patient with diabetes in the home care setting. Diabetes Spectrum, 2005, 18:162–166. 3. American Diabetes Association. American Diabetes Associa- tion Position Statement. Standards of Medical Care in Diabetes, 2008, 3:S12–S46. 4. Vrca-Botica M, Zelić I. Quality indicators for diabetes care in primary care. Diabetologia Croatica, 2007, 1:101–120. 5. Inpatient diabetes certification. The Joint Commission [web- site] (http://www.jointcommission.org/cetificationprogram/ Inpatient+Diabetes, accessed 19 January 2012). 6. Robbin JM, Webb DA. Diagnosis of diabetes and preventing re-hospitalization: the urban diabetes study. Medical Care, 2006, 44:292–296. 7. Ashton CM et al. The association between quality of inpatient care and early readmission. Annals of Internal Medicine, 1995, 122:415–421. 8. Report to the Congress. Medicare payment policy. Washington DC, Medicare Payment Advisory Committee. (http://med- pac.gov/documents/Mar10_EntireReport.pdf, accessed 21 March 2012). 9. Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care. Archives of Internal Medicine, 2000, 160:1074–1080. 10. Diabetes care. American Diabetes Association [website] (http:// care.diabetesjournals.org/content/35/Supplement_1/S11. full?sid=d003310c-2d9b-4be2-8254-04092f81060e, accessed 24 March 2012). 11. Lwanga SK. Lemeshows. Sample size determination in health studies: a practical manual. Geneva, World Health Organiza- tion, 1991. 12. Pallent J. SPSS survival manual, 2nd ed. Milton Keynes, UK, Open University Press, 2004. 13. Diabetes. World Health Organization [website] (http://www. who.int/mediacentre/factsheets/fs312/en/, accessed 21 March 2012). 14. Luthi JC et al. Is readmission to hospital an indicator of poor process of care for patient with heart failure? Quality and Safety in Health Care, 2004, 13:46–51. with the results of another study which showed that the release of patients with diabetes or heart failure before meeting readiness for discharge criteria was as- sociated with an increased probability of early readmission (OR 2.24, 95% EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 480 Relationship between consultation length and rational prescribing of drugs in Gorgan city, Islamic Republic of Iran V. Khori,1 S. Changizi,1 E. Biuckians,1 A. Keshtkar,2 A.M. Alizadeh,3 A.M. Mohaghgheghi3 and M.R Rabie 4 ABSTRACT Doctors with longer consultation times tend to diagnose illnesses more precisely, prescribe fewer drugs and present better health advice to their patients. The aim of this study was to measure the average consultation time of general practitioners in Gorgan, Islamic Republic of Iran and to investigate the factors affecting consultation length, especially in relation to rational prescribing of drugs. Data were collected on 620 patient consultations with 62 randomly selected general practitioners. Mean consultation length was 6.9 (SD 2.6) minutes. Patient factors that were significantly associated with a longer mean duration of consultation time were: higher number of health problems, older age and fewer items of previously used drugs. Physician factors that were significantly associated with a longer mean consultation time were: younger age, higher numbers of items prescribed and injectable drugs prescribed, frequency of interruptions and higher workload. 1Golestan Cardiovascular Research Centre; 2Department of Preventive and Social Medicine, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Islamic Republic of Iran (Correspondence to V. Khori: vaph99@yahoo.com). 3Cancer Research Centre, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Faculty of Mathematics, Shahrood University of Technology, Shahrood, Islamic Republic of Iran. Received: 01/02/10; accepted: 27/09/10 ةيملاسلإا ناريإ ةيروهجم في ناغروغ ةنيدم في ةيودلأل ديشرلا فصولاو ةراشتسلاا ةترف لوط ينب ةقلاعلا يعيبر اضر دممح ،يققمح ليع دممح ،هدازيلع دممح ليع ،راكتشك ليع سابع ،سنايكويب نيودإ ،يزيكنج مايش ،يروخ ديحو نوم ِّدقيو ،ًاددع لقأ ةيودأ نوفصيو ،تلااحلل قدأ صيخشت لىإ بلاغلا في ةيبطلا متهرواشم في لوطأ ًاتقو نوقرغتسي نيذلا ءابطلأا لصي :ةصلالخا ناريإ ةيروهجم في ناجرج ةنيدم في ينماعلا ينسرماملل ةراشتسلاا تقو طسوتم سايق لىإ ةساردلا هذه فدتهو .ضىرلما لىإ لضفأ ةيحص ةحيصن 620 لوح تايطعلما نوثحابلا عجم .ةيودلأل ديشرلا فصولاب ةقلاعلا تاذ ماَّيسلاو ،ةراشتسلاا ةترف لوط لىع رثؤت يتلا لماوعلا صيقتو ،ةيملاسلإا تاذ لماوعلا تناك .)2.6 يرايعلما فارحنلاا( ةقيقد 6.9 ةراشتسلاا ةترف طسوتم غلب .ًايئاوشع اويرتخا ًاماع ًاسرامم 62 ىدل ضىرملل ةيبط ةراشتسا قبس يتلا ةيودلأا فانصأ ةلق ،نسلا برك ،ةيحصلا لكاشلما ددع ةرثك :يه ةراشتسلاا ةترف لوط عم هب ُّدَتْعُي ًاطابترا تطبترا يتلاو ضىرلماب ةلصلا ةيودلأا فانصأ ددع ةرثك ،نسلا رغص :تناكف ةراشتسلاا ةترف لوط عم ابه ُّدَتْعُي يتلا ةلصلا تاذ ينماعلا ينسرمالماب ةصالخا لماوعلا امأ .اهمادختسا .لمعلا ءبع دايدزاو ،ةراشتسلاا عطق راركتو ،ًانقح ذخؤت يتلا ةيودلأا فصو ،ةفوصولما Relation entre la durée des consultations et la prescription rationnelle de médicaments dans la ville de Gorgan (République islamique d’Iran) RÉSUMÉ Les médecins dont les consultations sont plus longues posent souvent des diagnostics plus précis, prescrivent moins de médicaments et offrent de meilleurs conseils en matière de santé à leurs patients. La présente étude visait à mesurer la durée moyenne de consultation des médecins généralistes à Gorgan (République islamique d’Iran), à rechercher les facteurs qui l'influencent, et à étudier la relation avec la prescription rationnelle de médicaments. Les données ont été recueillies auprès de 62 médecins généralistes sélectionnés aléatoirement et à partir de 620 consultations de patients. La durée moyenne de la consultation était de 6,9 minutes (E.T. 2,6). Les facteurs relatifs aux patients et qui étaient fortement associés à une durée moyenne supérieure de la consultation étaient les suivants : de nombreuses comorbidités, un âge avancé et un petit nombre de médicaments déjà utilisés. Les facteurs relatifs aux médecins et qui étaient fortement associés à une durée moyenne supérieure de la consultation étaient les suivants : un âge plus jeune, la prescription de traitements injectables et d'un grand nombre de médicaments, des interruptions fréquentes et une charge de travail élevée. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 481 Introduction The effect of consultation time on care in general practice has been studied many times [1–13]. Doctors with longer consultation times tend to diagnose illnesses more precisely, prescribe fewer drugs and present better health advice to their patients [14–16]. Other studies have looked at correlations between aspects of the consultation process and the quantity and quality of prescribed drugs in each prescription [17–24]. In the Eastern Mediterranean region, short consultation times in general practice have been associated with a higher mean number of drugs prescribed [2,3]. Consultation time is affected by several factors including the physician, the pa- tient, the reason for the encounter, the doctor–patient relationship, structural factors, geographical area and the health care system [4]. In Gorgon province of the Islamic Republic of Iran, nearly 98% of patients are covered by government insurance, and due to the generic drug regulations in the country, there is no pressure from pharmaceutical companies to persuade physicians to buy brand-name products. Insurance companies pay for more than 65% of the drug cost of a prescription. There is therefore no direct relationship between the income of a physician and the number of items prescribed in a pre- scription. However, patients in Gorgan province have a tendency to receive more medicines at each visit than other provinces of the country [unpublished data]. The reasons for these differences may be due to sociocultural factors such as the multi-ethnic population liv- ing in Gorgan, the high proportion of uneducated and illiterate people, low incomes and use of self-medication. In view of the sociocultural and financial situation in Gorgan district, different results about factors affecting consulta- tion time could be expected. The aim of present study was to measure the average consultation time of general practitioners (GPs) in Gorgan, Islamic Republic of Iran and to investigate the factors affecting con- sultation length, especially in relation to rational prescribing of drugs. Methods We performed a cross-sectional study in Gorgan district, during spring and summer 2007. Sample According to a preliminary study on the consulting time of 30 physicians, using a mean consultation time of 8 (SD 2) min. with 95% confidence we estimated that at least 620 consultations were required to meet the objectives of the study. According to the available data on the prescribing rate of GPs in Gorgan (registered by the government insurance company in Gorgan), the average daily number of patient visits to physicians was 10. From 190 GPs that were classified alphabetically, 62 GPs were selected (46 men and 16 women) using systematic random sampling. The first 10 patients arriving at the physi- cian’s office were selected consecutively for analysis and checklists were filled out for all of them. Data collection Two medical staff members were se- lected and trained by an internist and a pharmacologist during a 1-week period (4 sessions). Observers were employed by Golestan University of Medical Sciences. All observations were made by the same 2 observers. Doctors and patients were blind to the aims of this study but all of them gave consent to participate. The study was approved by the institutional ethical committee of Golestan University of Medical Sci- ences. For the data collection one ob- server was located in the physician’s room and was responsible for record- ing data about GPs. The other observer was located in the waiting room to fill out the patient questionnaire after the consultation. Children under 12 years old who attended with a parent were included in our study and the parent was requested to complete the questionnaire. The entry and exit times of patients to and from the GP’s room was recorded using a stopwatch and was used to calculate the consultation time. All variables studied were based on previous studies [5,14,25] and on factors know to affect physicians’ pre- scribing pattern in Gorgan district (sex, age, practice location and mean rate of drug prescribing) (unpublished data). For GPs, we considered the following independent variables: age and sex of physician, practice location, knowledge about patient’s medical history, diagno- sis (somatic, psychological or require- ment for laboratory investigations), taking patient’s drug history, number of drug items prescribed, number of injectable drugs prescribed and number of patients in waiting room (workload). For patients, the independent variables were: age, sex, reason for encounter (for prescription or for laboratory test follow-up), degree of satisfaction with the consultation (not satisfied, some- what satisfied or completely satisfied), knowledge about use and precautions of drugs prescribed, tendency to ex- pect a drug prescription [19], number of previously used drugs, frequency of interruptions to the consultation and number of health problems presented. Satisfaction and tendency to expect a drug prescription were assessed using methods described in previous studies [5,24,26]. Data analysis Data entry and analysis was done using SPSS, version 15. Data were analysed using descriptive statistics [percent- age, mean and standard deviation (SD)], Mann–Whitney U-test and Kruskal–Wallis and linear regression. P < 0.05 was considered as statistically significant. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 482 Results Characteristics of patients and physicians A total of 620 patients were studied: 323 (52.1%) males and 297 (47.9%) females. Patients were aged between 0 and 80 years, although the majority were between the ages of 29 to 35 years old and the mean age was 39.4 (SD 18) years. There were 62 GPs (46 men and 16 women) between the ages of 31 and 63 years old with a mean age of 43.7 (SD 9.6) years old. Most of the GPs practised in urban areas (80.6%). Consultation time Patient factors The total mean consultation time was 6.9 (SD 2.6) min, while the mean num- ber of health problems presented were 1.8 (SD 0.8) and number of previously used drugs were 1.3 (SD 1.5). The mean consultation length for female patients was significantly longer than for male patients: 7.5 (SD 2.8) versus 6.3 (SD 2.2) min (P < 0.001) (Table 1). Patients with fewer health problems had shorter mean consultation times: 5.4 (SD 1.5) min for patients who only complained about 1 health problem compared with 11.2 (SD 2.0) min for patients with 4 complaints/health problems. Con- sultation time was shorter for patients who attended only for a prescription (5.8 versus 7.1 min) or only for labo- ratory tests follow-up (5.4 versus 7.0 min). Consultation time increased with a higher self-reported expectation of pa- tients for prescribed drugs (from 4.8 to 7.2 min). Consultation time for patients who did not have a complete knowl- edge about the use and precautions of their prescribed drugs was shorter (6.4 versus 7.1 min). There was a direct relationship between the degree of patients’ satis- faction and mean consultation time. Consultation length for patients completely satisfied with the consulta- tion was 7.0 min but only 4.8 min for those who reported not being satisfied (P < 0.001) (Table 1). Physician factors There was no significant difference between the mean consultation times of male and female GPs (6.9 versus 6.9 min). Mean consultation time for GPs practising in the city was shorter than those in villages (6.7 versus 7.5 min) (P < 0.001). Knowing the patient’s medical his- tory decreased the consultation time significantly from 5.3 to 7.5 min (P < 0.001). When GPs recognized a psy- chological problem, mean consultation time increased to 12.8 min compared Table 1 Relationship between patient variables and mean consultation time (n = 620) Variable No. of consultations % Consultation time (min.) P-value Mean (SD) Patient’s sex Male 323 52.1 6.3 (2.2) < 0.001 Female 297 47.9 7.5 (2.8) Reason for visit For prescription Yes 126 20.3 5.8 (2.5) < 0.001 No 494 79.7 7.1 (2.5) For laboratory test follow-up Yes 63 10.2 5.4 (2.1) < 0.001 No 557 89.8 7.0 (2.6) Expectation of drug prescription Not inclined 7 1.1 4.7 (0.8) Somewhat inclined 29 4.7 5.8 (2.2) < 0.001 Completely inclined 520 83.9 7.2 (2.5) Knowledge about use and precautions of prescribed drugs Somewhat 28 4.5 6.4 (2.7) > 0.09 Yes completely 528 85.2 7.1 (2.5) Degree of satisfaction with consultation Not satisfied 5 0.8 4.8 (0.9) Somewhat satisfied 27 4.4 5.1 (1.1) < 0.001 Completely satisfied 588 94.8 7.0 (2.6) SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 483 with only 6.5 min for a somatic problem (P < 0.001). Deciding to request labora- tory tests decreased the mean consulta- tion time to 5.5 min (P < 0.001). Taking the patient’s medical and drug history was associated with longer consultation times (7.1 versus 4.5 min) (P < 0.001) (Table 2). The mean number of drug items prescribed in each consultation was 3.2 (SD 0.7) (median 3) and of inject- able drugs was 0.2 (SD 0.4). The mean number patients in the waiting room (a measure of workload) was 4.4 (SD 1.8) and the mean number of interruptions to the consultation were 0.7 (SD 0.7). When doctors did not prescribe any drugs, the mean consultation time was shorter, at 5.2 (SD 2.3) min [median 5 min, 95% confidence interval: 4.6–5.8]. Factors affecting consultation time: linear regression analysis In multivariate linear regression analy- sis, patient factors that were was sig- nificantly associated with a longer mean duration of consultation time were: higher number of health problems, older age and fewer items of previously used drugs (Table 3). Physician factors that were significantly associated with a longer mean consultation time were: younger age, higher numbers of items prescribed and injectable drugs pre- scribed, frequency of interruptions and number of patients in the waiting room. Discussion Statement of principal findings Consultation times were low and prescribing quality was poor in Gor- gan, similar to data from many other countries in the Middle East and Asia [1–3,26]. For example, the mean con- sultation times in other Asian countries were 1.8 min in Pakistan, 6.6 min in Qa- tar and 2.3 min in Bangladesh. Among several determinant factors we showed that physician factors significantly af- fecting consultation length were physi- cian’s age, urban/rural location, taking patient’s medical/drug history and type of diagnosis. Significant patient factors were age, sex, tendency to expect a drug prescription and number of health problems. One limitation of our study is that we ignored some confounding factors related to physicians, such as income and employment, so we cannot easily generalize our findings to other physi- cians. In addition, the presence of an observer recording notes in the GP’s office during the consultation might have influenced the doctor’s behaviour and this could bias our study findings. The relationship between quality of consultations and average consultation time was not measured in this study, although patient satisfaction was as- sessed. On the other hand, determining the relationships between consultation time and factors related to drug pre- scriptions may be a strength of our study. We measured patient and physi- cian parameters directly and indirectly with observers in order to eliminate patient bias related to physicians. Comparison with other studies Consultation length The main finding of this study was the short mean consultation length (6.9 min.) for GPs in this location in the Table 2 Relationship between physician variables and mean consultation time (n = 620) Variable No. of consultations % Consultation time (min.) P-value Mean (SD) Physician’s sex Male 460 74.2 6.9 (2.5) > 0.5 Female 160 25.8 6.9 (2.6) Practice location Urban 500 80.6 6.7 (2.6) < 0.001 Rural 120 19.4 7.5 (2.0) Knew patient’s medical history Yes 173 27.9 5.3 (2.2) < 0.001 No 447 72.1 7.5 (2.4) Diagnosis Psychological 8 1.3 12.8 (3.2) Somatic 541 87.3 6.5 (2.0) < 0.001 Requirement for laboratory tests 36 5.8 5.5 (1.4) Took medical and drug history Yes 568 91.6 7.1 (2.5) < 0.001 No 52 8.4 4.5 (2.1) SD = standard deviation. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 484 Islamic Republic of Iran. Although con- sultation time in our study was shorter than in several other developed and developing countries [5,15,16,23,25], knowledge about the use and precau- tions of prescribed drugs and satisfac- tion of patients was comparable with some other countries [1–3,26]. Others have suggested that while consultation time is an important indicator of quality of care the impact of cultural and socio- psychological factors should not be underestimated in determining patient satisfaction and quality of health care services [13,27,28]. Physician factors that influenced con- sultation time When we analysed the characteristics of GPs, we found that consultation time for rural GPs was longer than those practising in urban areas. This is con- trary to the findings of Deveugele et al. [5], perhaps because the presence of more psychosocial problems (e.g. addiction), self-therapy and delay in submission, complicated patients with several diseases and lower workload (as measured in the waiting room) caused longer consultation times among rural patients our study. Deveugele et al. and Howie et al. showed that consultations for psycho- logical problems had a direct effect on consultation length [5,25]. Our study also showed that consultation time for patients diagnosed with psy- chological problems was considerably longer than for those with somatic (non- psychological) problems. The most prevalent psychological problems in the Gorgan region are opium addiction and depression [29]. When our GPs requested labora- tory tests, the average consultation time was lower. This is consistent with the findings of Hull and Hull [30] and Camasso and Camasso [31]. In rural areas, from an economic point of view, patients may prefer to use medication instead of travelling to the laboratory so the rate of prescribing laboratory tests is usually lower and consultation times are longer in rural regions than urban areas. There was a positive relationship between GPs recording a patient’s medical and drug history and longer consultation times in our study, a find- ing that is consistent with Deveugele et al.’s [5] and other studies [30,31]. Complaints about a new problem will force GPs to make more investigations and so lengthen the consultation time. Despite the absence of a comprehen- sive family practice health care system in Gorgan, the low cost of physicians’ fees and drugs may result in frequent visits of patients to the same physician. Doctors are usually therefore aware of their patients’ medical and drug history and this can explain the relatively short consultation times in Gorgan. We found that there was no sig- nificant difference between the consul- tation times of male and female GPs. Deveugele et al. also found that the sex of the doctor did not influence con- sultation time [5]. This is surprising as female patients in our study had longer mean consultation times than men and if women in Islamic Republic of Iran had a preference to be seen by a female physician we might have expected that the consultation time for female GPs would also be longer than for male GPs. We can explain this by the smaller num- ber of female physicians in the sample. Our finding that consultation length was longer for younger GPs agrees with Deveugele et al. [5] but contradicts a previous study showing that older phy- sicians had longer consultations [4]. More research would be needed into this aspect of consultation length. There was a direct correlation be- tween the number of items prescribed and consultation length. The prescribing rate and mean number of prescribed drugs was much higher in Gorgan com- pared with previous studies in other countries (Figure 1) [4,32–38]. In the United Kingdom, however, Howie et al. Table 3 Linear regression of consultation time with patient and physician variables (dependent variable) Variable B SE Beta t P-value Constant 3.00 0.45 6.72 < 0.001 Patient variables Age 0.03 0.00 0.24 8.15 < 0.001 No. of health problems 1.43 0.09 0.49 16.62 < 0.001 No. of previously used drugs –0.29 0.05 –0.17 –5.25 < 0.001 Physician variables Age –0.03 0.01 –0.12 –4.24 < 0.001 No. of drugs prescribed 0.49 0.10 0.15 4.90 < 0.001 No. of injectable drugs prescribed 0.03 0.15 0.05 2.03 0.043 No. of patients in waiting room –0.11 0.04 –0.08 –3.25 < 0.001 Frequency of interruptions to consultation 1.06 0.09 0.30 11.66 < 0.001 Model: F = 131.4, degree of freedom = 8, P < 0.001. Predictors: (constant), physician’s age, number of patients in waiting room, injectable drugs, frequency of interruptions, number of previously used drugs, number of health problems, patient’s age, number of prescribed drugs. B = raw score regression coefficient; SE = standard error of B; beta = standardized regression coefficient; t = t-value for B (B divided by SE). طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 485 found higher rates of prescribing by phy- sicians with shorter consultation times [32], and Hartzema and Christensen showed a direct relationship between prescribing volume and shortness of consultation time [39]. Among several factors that might explain this contro- versy are the lower cost of drugs in the Is- lamic Republic of Iran, the consequences of self-medication, more complicated cases and more interruptions by patients. Patient factors that influenced consultation time Consistent with the results of other studies, we showed that consultation length was correlated with patient’s sex, with women having longer consulta- tions [4,5,25]. The reason for the visit was also a factor, with consultations for prescriptions and laboratory test follow- ups being shorter and this also agrees with other research [4,5,25]. There was a direct relationship be- tween patients’ tendency to expect a drug prescription and consultation length. More patients in our study expected a prescription (84%) than in comparable studies in Europe; for example, according to Himmel et al. less than half of patients (46.5%) expected a drug prescription from their doctor [40]. This may put pres- sure on physicians to consult longer in order to improve patients’ drug informa- tion and increase their satisfaction. Such influences were not evident in Howie at al.’s study in the United Kingdom [25]. However, as mentioned by previ- ous researchers, accurate assessments of the relationship between patients and 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Inside of Iran (IR) Outside of Iran (IR) Go rga n Kh or as an Te hr an Fa rs Kh oz es tan Ke rm an sh ah Isf ah an Ira n ( IR) Be ng alo re dis tri ct Sa ud i A rab ia Gr ea t B rit ain Figure 1 Mean number of drugs prescribed in consultations in the Islamic Republic of Iran and other countries physicians is difficult and needs further investigation [19–21]. Our study showed that there was a direct and significant relationship be- tween patient satisfaction and consulta- tion time and this agrees with previous studies in other countries [14,27,31,33]. Despite this, we cannot ignore the pos- sible influence of cultural and socioeco- nomic factors on patient satisfaction in Gorgan. As stated before, the factors influencing patient satisfaction are com- plex and require further research [26,41]. More objective patient factors that affected consultation time were in agree- ment with the results of other studies [5,25]: age, number of health problems and number of previously used drugs. Among these, the number of health prob- lems had a greater impact on consultation time compared with these other studies. Unanswered questions and future research For comparative purposes, it is sug- gested that this survey be repeated in other provinces of the Islamic Republic of Iran and nationwide. Performing this study for different specialties of physician may also result in interesting findings. A study about the influence of waiting time on patient satisfaction may be useful. A more complete investiga- tion about relationships between drug interactions and adverse effects and consultation time may be needed. Acknowledgements The authors are deeply grateful to all the GPs who took part in this study and to Golestan University of Medical Sciences for organizational support. References 1. Voo YO. Consultation length and case mix in a general practice clinic. Singapore Medical Journal, 1999, 40:13–17. 2. Hafeez A et al. Prescription and dispensing practices in public sector health facilities in Pakistan. Journal of the Pakistan Medical Association, 2004, 54:187–191. 3. Bener A et al. Do minutes count for health care? Consultation length in a tertiary care teaching hospital and in general practice. Middle East Journal of Family Medicine, 2007, 5(1)3–8. 4. Petek Ster M et al. Factors related to consultation time: experience in Slovenia. Scandinavian Journal of Primary Health Care, 2008, 26:29–34. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 486 5. Deveugele M et al. Consultation length in general practice: cross sectional study in six European countries. British Medical Journal, 2002, 325:1–6. 6. Cape J. Consultation length, patient-estimated consultation length, and satisfaction with the consultation. British Journal of General Practice, 2002, 52:1004–1006. 7. Graffy J. Patient choice in a practice with men and women general practitioners. British Journal of General Practice, 1990, 40:13–15. 8. Ogden J et al. “I want more time with my doctor”: a quantita- tive study of time and the consultation. Family Practice, 2004, 21:479–483. 9. Andersson SO, Mattsson B. Features of good consultation in general practice: is time important? Scandinavian Journal of Primary Health Care, 1994, 12:227–232. 10. Dugdale DC, Epstein R, Pantilat SZ. Time and the patient- physician relationship. Journal of General Internal Medicine, 1999, 14:34–40. 11. Lussier MT, Richard C. Communication tips. Time flies: pa- tients' perceptions of consultation length and actual duration. Canadian Family Physician Medecin de Famille Canadien, 2007, 53:46–47. 12. Hutton C, Gunn J. Do longer consultations improve the management of psychological problems in general practice? A systematic literature review. BMC Health Services Research, 2007, 7:71. 13. Grol R et al. Patients' priorities with respect to general practice care: an international comparison. European Task Force on Patient Evaluations of General Practice (EUROPEP). Family Practice, 1999, 16:4–11. 14. Wilson A, Childs S. The relationship between consulta- tion length, process and outcomes in general practice: a systematic review. British Journal of General Practice, 2002, 52:1012–1020. 15. De Silva N. The consultation and doctor–patient communica- tion. Ceylon Medical Journal, 1999, 44:28–31. 16. Wilson A et al. Health promotion in the general practice con- sultation: a minute makes a difference. British Medical Journal, 1992, 304:227–230. 17. Stevenson FA et al. Doctor–patient communication about drugs: the evidence for shared decision making. Social Science and Medicine, 2000, 50:829–840. 18. Howie JG, Porter AM, Forbes JF. Quality and the use of time in general practice: widening the discussion. British Medical Journal, 1989, 298:1008–1010. 19. Stevenson FA et al. GPs' perceptions of patient influence on prescribing. Family Practice, 1999, 16:255–261. 20. Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations--a questionnaire study. British Medical Journal, 1997, 315:520–523. 21. Britten N, Ukoumunne O. The influence of patients' hopes of receiving a prescription on doctors' perceptions and the decision to prescribe: a questionnaire survey. British Medical Journal, 1997, 315:1506–1510. 22. Lundkvist J et al. The more time spent on listening, the less time spent on prescribing antibiotics in general practice. Family Practice, 2002, 19:638–640. 23. Britt H, Valenti L, Miller G. Time for care. Length of general practice consultations in Australia. Australian Family Physician, 2002, 31:876–880. 24. Little P et al. Importance of patient pressure and perceived pressure and perceived medical need for investigations, re- ferral, and prescribing in primary care: nested observational study. British Medical Journal, 2004, 328:444. 25. Howie JGR et al. Quality at general practice consultations: cross- sectional survey. British Medical Journal, 1999, 319:738–743. 26. Mendoza Aldana J, Piechulek H, Al-Sabir A. Client satisfaction and quality of health care in rural Bangladesh. Bulletin of the World Health Organization, 2001, 79:512–517. 27. Freeman GK et al. Evolving general practice consultation in Britain: issues of length and context. British Medical Journal, 2002, 324:880–882. 28. Campbell JL, Ramsay J, Green J. Age, gender, socioeconomic and ethnic differences in patients' assessments of primary health care. Quality in Health Care, 2001, 10:90–95. 29. Mohammadi MR et al. An epidemiological study of psychiatric disorders in Golestan province, 2001. Journal of Gorgan Uni- versity of Medical Sciences, 2004, 6(1):67–77. 30. Hull FM, Hull FS. Time and the general practitioner: the pa- tient’s view. Journal of the Royal College of General Practitioners, 1984, 34:71–75. 31. Camasso MJ, Camasso AE. Practitioner productivity and the product content of medical care in publicly supported health centres. Social Science & Medicine, 1994, 38:733–748. 32. Howie JG et al. Long to short consultation ratio: a proxy meas- ure of quality of care for general practice. British Journal of General Practice, 1991, 41:48–54. 33. Hughes D. Consultation length and outcome in two group general practices. Journal of the Royal College of General Practi- tioners, 1983, 33:143–147. 34. Cheraghali AM, Idries AM. Availability, affordability, and pre- scribing pattern of medicines in Sudan. Pharmacy World and Science, 2009, 31(2):209–215. 35. Safaeian L. et al. General physicians and prescribing pattern in Isfahan, Iran. Oman Medical Journal, 2011, 26(3):205–206. 36. Srishyla MV et al.. A comparative study of prescribing pattern at different levels of health care delivery system in Bangalore district. Indian Journal of Physiology and Pharmacology, 1995, 39(3):247–251. 37. Neyaz Y et al. [Medication prescribing pattern in primary care in Riyadh City, Saudi Arabia]. Eastern Mediterranean Health Journal, 2011, 17(2):149–155 [in Arabic]. 38. Damanhori AH et al. Diurnal variation of prescribing pattern of primary care doctors in Bahrain. Journal of Evaluation in Clinical Practice, 2007, 13(1):25–30. 39. Hartzema AG, Christensen DB. Non-medical factors associ- ated with the prescribing volume among family practitioners in an HMO. Medical Care, 1983, 21:990–1000. 40. Himmel W et al. Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scandinavian Journal of Primary Health Care, 1997, 15(3):118–122. 41. Mansour AA, Al-Osimy MH. A study of satisfaction among primary health care patients in Saudi Arabia. Journal of Com- munity Health, 1993, 18:163–173. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 487 Social and behavioural HIV/AIDS research in Jordan: a systematic review E. Alkhasawneh,1 L. Ismayilova,2 H. Olimat 3 and N. El-Bassel 2 ABSTRACT This systematic review evaluated the extent of HIV/AIDS research conducted in Jordan related to behavioural and/or social outcomes. MEDLINE, CINAHL, PsycINFO and OVID (1980–2009) were searched as well as the International AIDS Society abstract archives (2000–2009). Existing reviews and primary studies were cross-referenced for further citations, and unpublished literature and ongoing trials were searched by contacting experts and active researchers in the field. Google Scholar was used to search in peer-reviewed local or regional journals not included in the above-mentioned databases. Searches were also conducted of Arabic literature. Only 8 relevant studies were identified; all were descriptive cross-sectional studies, either quantitative or qualitative. Convenience samples were used in the majority of the studies, severely limiting the generalizability of the findings. The studies focused on HIV/AIDs knowledge and attitudes in the general population and among health professionals; at-risk populations were not assessed. ¹School of Nursing, Hashemite University, Zarqa, Jordan & Sultan Qaboos University, Muscat, Oman (Correspondence to E. Alkhasawneh: emanursing@yahoo.com). ²Social Intervention Group, School of Social Work, Columbia University, New York, New York, United States of America. ³School of Social Work, Jordan University, Amman, Jordan. Received: 09/06/10; accepted: 03/03/11 ةيجهنم ةعجارم :ندرلأا في هسويرفب ىودعلاو زديلإاب ةصالخا ةيكولسلاو ةيعماتجلاا ثوحبلا لسابلا هليبن ،تمايلغ دوحم ،افوليعماسإ لىيل ،ةنواصلخا ءاسرا ةيعماتجلااو ةيكولسلا جئاتنلاب ةقلعتلماو ندرلأا في تَيرجأ يتلا هسويرفب ىودعلاو زديلإا ثوحب رادقم ةيجهنلما ةعجارلما هذه تَمَّيق :ةصلالخا -1980( ةترفلا لوح OVIDو ،PsycINFOو ،CINAHLو ،MEDLINE في ةيثحبلا تانايبلا دعاوق في ًاثحب نوثحابلا ىرجأ .هسويرفب ىودعلاو زديلإل ةيلولأا تاساردلاو ةدوجولما تاعجارلما نع نوثحابلا صىقتساو .)2009-2000( ةيلودلا زديلإا ةيعجم تاصخلم فيشرأ في كلذكو ،)2009 ينثحابلاو ءابرلخا عم لاصتلااب ءارجلإا ديق يه يتلا تاساردلا نعو ،ةروشنلما يرغ تايبدلأا نعو ،تافطتقلما نم ديزلما نع اهعجارم في ثحبلاو ةعجارلم عضتخ يتلا ةم َّكَحُلما ةيميلقلإاو ةيلحلما تلاجلما نع ثحبلل Google Scholar يملعلا لغوغ ثحب كرمح مدخُتساو .ناديلما في ينلماعلا تناك اهعيجم ؛طقف تاسارد 8 لىع اورثعف ،ةيبرعلا تايبدلأا في ًاثحب نوثحابلا ىرجأ ماك .ةروكذلما ةيثحبلا تانايبلا دعاوق في جَردت لمو ءلامزلا في مئلام ٍوحن لىع اهرايتخا مت دق تانيعلا نأ نوثحابلا دجوو .ةيفيك تاسارد امإو ةيمك تاسارد امإ يهو ،ةيفصو ةيضرع ةيعطقم تاسارد زديلإا لوح ناكسلا ةماع تاهجوتو فراعم لىع تاساردلا تزّكرو .تاساردلا هذه جئاتن ميمعت ىدم نم ّديح دق كلذ نأ لاإ ،تاساردلا ةيبلاغ .رطخلل ينضرعلما ناكسلل ًماييقت نوثحابلا ريج لمو ؛ينيحصلا ينلماعلا ينبو ،هسويرفب ىودعلاو Revue systématique de la recherche sociocomportementale sur le VIH/sida en Jordanie RÉSUMÉ La présente revue systématique a permis d'évaluer l'ampleur de la recherche sur le VIH/sida menée en Jordanie en relation avec des critères sociaux et/ou comportementaux. Les bases de données MEDLINE, CINAHL, PsycINFO et OVID (1980–2009) ainsi que les archives de résumés 2000–2009 de l'International AIDS Society [Association internationale de lutte contre le sida] ont été consultées. Les revues existantes et les études primaires ont été croisées pour obtenir davantage de références, et la littérature non publiée ainsi que les essais en cours ont été étudiés en contactant des experts et des chercheurs en activité dans ce domaine. Google Scholar a été utilisé pour faire des recherches dans des revues régionales et locales pratiquant l'examen collégial qui ne faisaient pas partie des bases de données mentionnées ci-dessus. Des recherches ont également été menées dans la littérature en langue arabe. Seules huit études ont été identifiées ; toutes étaient des études transversales descriptives, soit quantitatives, soit qualitatives. Des échantillonnages de commodité ont été utilisés dans la majorité des études, limitant de manière importante la possibilité de généraliser les résultats. Les études étaient axées sur les connaissances et les attitudes du public et des professionnels de santé en matière de VIH/sida ; les populations à risque n'ont pas été évaluées. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 488 Introduction Available evidence suggests that HIV prevalence in Middle Eastern coun- tries is low, with an average of 0.2%. Although between 2001 and 2009 the epidemic was controlled in most re- gions of the world and prevalence rates in the Middle East and North Africa were still low, it has increased from 0.1% to 0.2%; the number of new infections doubled between 2001(36 000) and 2009 (75 000); the actual number of people living with HIV/AIDS also dou- bled from 180 000 in 2001 to 460 000 in 2009 [1].When comparing with international HIV data and other socio- economic indicators, it is suggested that current prevalence rates are likely to be underestimated, on average by 0.2% to 1% [2], and reliable data are still limited making it a challenge to estimate actual numbers [1]. By the end of 2009 there were only 850 officially registered HIV cases Jor- dan [3], which places the prevalence at < 0.2% [4]. Only 25% (n = 211) of the registered HIV/AIDS cases were Jordanians; the rest were immigrants. The age range for most of the people di- agnosed with HIV is between 20 and 49 years [5]. Currently, the male/female sex ratio is 4:1. Fear of stigma may re- duce testing and care-seeking behaviour and this, together with an inadequate surveillance system, suggests that the true number of people living with HIV exceeds the number of officially reg- istered cases [1,4,5]. Moreover, little is known about transmission patterns and structural forces that drive the HIV epidemic in Jordan. Most HIV cases in Jordan are attributed to sexual contact (60%), but it is not clear whether it is homosexual or heterosexual, followed by unknown causes (18.2%), blood transfusion (16.5%), injection drug use (3.3%), and mother-to-child transmis- sion (1.8%) [4]. Overall, HIV research in the Middle East is limited because of the low preva- lence of the disease, stigma about the topic and conservative cultural norms [6]. Taboos and strict values surround- ing sexuality outside and within mar- riage make it challenging to examine the sexual behaviour of Jordanian men and women [5–7]. Stigma and con- servative beliefs surrounding socially unacceptable behaviours—sex work, homosexuality and drug use—limit the number of research studies that examine HIV risk behaviours among high risk groups. Studies on HIV/AIDS in Jordan have been particularly absent compared to other Middle Eastern countries such as Egypt and Lebanon [7]. In the meantime, the incidence of HIV/AIDS is rising and without empirical data from epidemiological, socio-behavioural and intervention research, it is difficult to understand the dynamics of the virus’s spread and develop interventions that can prevent the currently low rate of HIV in Jordan from increasing [8–11]. Therefore, the objectives of this pa- per were to review available HIV stud- ies conducted in Jordan and to discuss implications for future research in the country. The paper aims to address the following research questions: 1. What is the state-of-the-science on HIV/AIDS research in Jordan? 2. What types of HIV/AIDS studies have been conducted in Jordan (pop- ulation-based, intervention, surveys, cross sectional studies)? 3. What are the gaps in HIV research in Jordan? Methods Literature search An electronic literature search of MEDLINE, CINAHL, PsycINFO and OVID from 1980 to 2009 was carried out by reviewers during the period September 2009 to January 2010. The International AIDS Society abstract archives from 2000 to 2009 were also searched. In addition, existing reviews and primary studies were cross- referenced for further citations and we searched for unpublished literature and ongoing trials by contacting experts and active researchers in the field. The search included key words specific to HIV/AIDS, study designs (e.g. de- scriptive, case–control, comparative), and sample characteristics (e.g. Mus- lim, Islam, Jordan, Jordanian, Arabs, Middle East). No language limitation was imposed. Two of the authors are bilingual so searches were conducted in Arabic literature as well. Using Google Scholar, we supplemented our database search with a search in peer reviewed publications published in other local or regional journals that are not included in the above-mentioned databases. Inclusion criteria We identified studies from peer-re- viewed journals that used experimental, cross-sectional or descriptive method- ologies. We included all studies that reported research on HIV/AIDS in Jor- dan, involved participants from Jordan, or were related to HIV/AIDS in Jordan. We included studies that measured any behavioural and/or social outcomes (e.g. unprotected sex, risky behaviours, knowledge of HIV, attitudes about HIV) as relevant markers of HIV risk. Since the target of the paper was to systematically review peer-reviewed, published literature, we did not include country reports or reports by interna- tional organizations. Studies that did not report a behavioural or social outcome were excluded; as a result, we excluded 2 studies because they primarily and solely focused on biological factors re- lated to HIV, 1 of the studies estimated the prevalence of the most important sexually transmitted infections (STIs) among a group of symptomatic and asymptomatic women in Jordan, but did examine any behavioural factors that might contribute to the occurrence of STIs [12]. The second study was a seroprevalence study conducted to طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 489 examine HIV infection in Jordan and did not examine behavioural or social factors in relation to HIV [13]. All the articles were initially screened by the authors to exclude studies that were not relevant. The authors met to agree on the initial screening criteria using a small subset of abstracts to ensure that they reached a high level of agreement; all studies that met the inclusion criteria were re- viewed by the researchers. The authors were able to identify authors, funding and other characteristics of studies un- der analysis. A complete review of each study was conducted by all the authors, who read each study and decided on its methodological relevance to this review. Data extraction The authors decided to include all the data available in the studies. Analysis and assessment of study quality We summarized the state of the sci- ence on research in the area of HIV/ AIDS in Jordan, with a secondary aim of assessing the quality of the existing studies. Since all studies were descrip- tive and cross-sectional, we provided a narrative summary and critical analysis. We assessed the following aspects of the study quality: (1) study design; (2) method of selecting participants for the study; (3) sampling; (4) data collection instruments and methods; and (5) data analytical procedures. Results We were only able to identify 8 stud- ies that were relevant to our research questions and were included in the review. Four studies were excluded since they only reviewed biological factors related to HIV. The studies were conducted between 1987 and 2005. A summary of articles is pro- vided in Table 1. Topics covered Seven of the reviewed articles examined HIV knowledge and attitudes of Jorda- nian citizens or health professionals and the readiness of the Jordanian health care system and personnel to address the emerging HIV cases/epidemic. Attitudes toward HIV: Four of the reviewed studies focused on data about attitudes towards people living with HIV and HIV preventive behaviours [14–17] Three of the reviewed studies reported that young people in Jordan, including nursing students, nurses and medical doctors, did not have positive attitudes to people with HIV [14,17]. Attitudes were relatively more favour- able among doctors than among nurses [17]. One study demonstrated that only 15% of dentists were willing to serve an HIV-positive patient [15]. The studies concluded that negative social attitudes towards HIV-positive individuals con- tributed to social discrimination and were especially detrimental when prac- tised by health professionals. Knowledge of HIV: In addition to attitudes, 3 studies collected informa- tion about the level of HIV prevention knowledge among the general popu- lation in Jordan, primarily youth, and among health professionals [14,17,18]. The studies showed that the level of knowledge was fairly low both for youth and medical students. Compared to the mid-1990s [14], the percentage of nurs- es and doctors who had heard of HIV/ AIDS rose to 76% by 2002, although HIV knowledge was often superficial and not accurate [17]. Lack of accurate HIV/AIDS knowledge and numerous misconceptions about HIV created a basis for negative and discriminatory attitudes towards people with HIV [17]. Preparedness of health care system: Health care professionals are not entirely responsible for the limited awareness of HIV. Two of the reviewed studies examined the preparedness of health care providers, 1 study reported that the 2 medical schools’ educational curriculum did not address the issue of HIV and students and practitioners had limited exposure to people with HIV/ AIDS [14]. Assessment of the health care system indicated that health care facilities also were not well-prepared to provide care for people with HIV [19,20]; the authors described the situ- ation as “a discrepancy between reality and rhetoric” when commenting on the lack of services and facilities despite numerous pledges and commitments at the official level. Methodological quality Study designs: All HIV/AIDS studies included in the review were descriptive cross-sectional studies; 6 were quantita- tive and 2 were ethnographic qualitative studies. Sampling: The studies had sufficient sample sizes. In 2 of the quantitative studies the sample size ranged from 126 to 1124 cases [13,18]. On average, the 2 qualitative studies [19,20] had smaller, but sufficient, sample sizes (n = 27) for conducting analysis for qualitative data. However, all 8 studies reviewed used available (or convenience) sampling techniques; in addition, none of the studies targeted high-risk populations such as men who have sex with men (MSM), sex workers and drug users. Data collection methods and measure- ment instruments: Both quantitative and qualitative methodologies were equally presented among the available HIV research in Jordan. In the 2 quantita- tive studies where instruments were modified from standardized scales, the psychometric properties were not tested and reported in the new popula- tion [16,18]. Only 1 study conducted biological testing of participants to determine their HIV status [13]. The remaining 4 studies relied on self-re- ported data collection methods. The assessment of the qualitative studies was more thoroughly developed and in- cluded detailed observational protocols for observers [19,20]. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 490 Ta bl e 1 Su m m ar y of th e st ud ie s in cl ud ed in th e re vi ew St ud y da te & ci ta ti on D es ig n Sa m pl in g m et ho d St ud y se tt in g, s am pl e si ze a nd c ha ra ct er is ti cs In st ru m en t D at a co lle ct io n pr oc ed ur es Fi nd in gs Im pl ic at io ns 20 0 2 [1 7] C ro ss -s ec tio na l/ ob se rv at io na l C on ve ni en ce Fo ur th -y ea r f em al e nu rs in g st ud en ts fr om Jo rd an (n = 6 3) a nd th e U SA (n = 6 3) . s el ec te d fro m th e U ni ve rs ity o f Jo rd an in A m m an a nd O ak la nd U ni ve rs ity in M ic hi ga n, U SA Q ue st io nn ai re a da pt ed fro m th e Kn ow le dg e, A tti tu de s, a nd B el ie fs (K A B) in st ru m en t d ev el op ed b y Ku lw ic ki a nd C as s ( 19 94 ), ba se d on th e C en te rs fo r D is ea se C on tr ol a nd Pr ev en tio n m od el s f or K A B su rv ey s Se lf- ad m in is te re d qu es tio nn ai re M or e A m er ic an st ud en ts sc or ed co rr ec tly o n kn ow le dg e of H IV / A ID S (7 3% ) t ha n Jo rd an ia n st ud en ts ’ ( 52 % ). A m er ic an st ud en ts h ad m or e po si tiv e at tit ud es to A ID S th an Jo rd an ia n st ud en ts . M or e A m er ic an st ud en ts (8 2. 5% ) a pp ro ve d of co nd om s f or p re ve nt in g th e sp re ad o f H IV th an Jo rd an ia n st ud en ts (3 0 .2 % ). A c al l f or a ct io n to or ga ni ze e du ca tio n an d pr ev en tio n pr og ra m m es di re ct ed a t J or da ni an st ud en ts o ve r a nd a bo ve w ha t i s c on ta in ed in th e cu rr ic ul um 20 0 0 [1 9] C ro ss -s ec tio na l C on ve ni en ce 10 13 u nd er gr ad ua te un iv er si ty st ud en ts a t th e sc ie nc e, m ed ic al an d hu m an iti es de pa rt m en ts o f t he U ni ve rs ity o f J or da n Q ue st io nn ai re a da pt ed fro m th e KA B in st ru m en t de ve lo pe d by K ul w ic ki an d C as s ( 19 94 ), ba se d on th e C en te rs fo r D is ea se C on tr ol m od el s f or K A B su rv ey s Se lf- ad m in is te re d qu es tio nn ai re Kn ow le dg e- de fic it an d m is co nc ep tio ns e xi st a m on g th e Jo rd an ia n un iv er si ty st ud en ts w ith re ga rd to H IV /A ID S tr an sm is si on . 5 4% k ne w v er y lit tle a bo ut A ID S an d 14 % h ad ne ve r h ea rd o f i t. N ee d to in tr od uc e a ta ilo r- m ad e co ur se o n H IV /A ID S fo r s tu de nt s a s pa rt o f t he ir cu rr ic ul um 20 0 5 [2 0 ] Et hn og ra ph ic qu al ita tiv e – 3 ru ra l a nd 3 u rb an P H C se tti ng s. 2 7 in te rv ie w s w ith 15 g en er al in fo rm an ts (r eg is te re d nu rs es a nd a id nu rs es ) a nd 12 o ut si de in fo rm an ts 45 m in –1 h se m i-s tr uc tu re d in te rv ie w s w ith k ey in fo rm an ts Pa rt ic ip an t ob se rv at io n, ke y in fo rm an t in te rv ie w s N ur se s’ H IV k no w le dg e an d sk ill ba se a re in ad eq ua te . H ea lth ca re fa ci lit ie s h av e m in im al hu m an a nd p hy si ca l r es ou rc es N ee d to d ev el op a co m pr eh en si ve sy st em o f PH C c en tr es a nd im pr ov e in fra st ru ct ur e of h ea lth fa ci lit ie s a nd to a dd re ss th e sh or ta ge o f n ur se s an d im pr ov e th ei r s ki lls . 20 0 5 [2 1] Et hn og ra ph ic qu al ita tiv e Pu rp os iv e 3 ru ra l a nd 3 u rb an P H C se tti ng s. 2 7 in te rv ie w s w ith 15 g en er al in fo rm an ts (r eg is te re d nu rs es , a id n ur se s) a nd 12 o ut si de in fo rm an ts . Bo dy la ng ua ge , fa ci al e xp re ss io n, co m m un ic at io n te ch ni qu es a nd h um an in te ra ct io ns w er e ob se rv ed an d re co rd ed , a llo w in g fo r e lu ci da tio n of th e cu ltu re o f n ur si ng p ra ct ic e w ith in th es e se tti ng s. To c on fir m a nd fu rt he r ex pl or e co nc ep tu al un de rs ta nd in gs , i nt er na l ke y in fo rm an ts (n ur se pa rt ic ip an ts ), to ok p ar t i n in -d ep th in te rv ie w s Pa rt ic ip an t ob se rv at io n, ke y in fo rm an t in te rv ie w s D is cr ep an cy b et w ee n he al th po lic ie s a nd h ea lth c ar e pr ac tic e in H IV c ar e. H IV /A ID S re sp on se w ea ke ne d by : p oo r re so ur ce s, li m ite d nu rs es ’ s ki lls , la ck o f a cc es s t o pr of es si on al de ve lo pm en t, la ck o f n ur si ng le ad er sh ip a nd ro le m od el s, cu ltu ra l b el ie fs a nd g eo gr ap hi c is ol at io n. T he se re du ce th e ca pa ci ty o f P H C n ur se s t o ra is e aw ar en es s a nd e ng ag e ac tiv el y in H IV /A ID S pr ev en tio n. M O H a nd se ni or n ur si ng ad m in is tr at io n sh ou ld su pp or t n ur si ng th ro ug h pr ac tic e de ve lo pm en t an d re cr ui tm en t in iti at iv es to m ai nt ai n a lo w H IV /A ID S in ci de nc e. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 491 Ta bl e 1 Su m m ar y of th e st ud ie s in cl ud ed in th e re vi ew (c on cl ud ed ) St ud y da te & ci ta ti on D es ig n Sa m pl in g m et ho d St ud y se tt in g, s am pl e si ze a nd c ha ra ct er is ti cs In st ru m en t D at a co lle ct io n pr oc ed ur es Fi nd in gs Im pl ic at io ns 20 0 5 [1 6] C ro ss -s ec tio na l Ra nd om se le ct io n 24 2 ge ne ra l d en ta l pr ac tit io ne rs O ne a ut ho r p re te nd in g to be H IV +v e ca lle d de nt is ts ac ro ss Jo rd an re qu es tin g de nt al c ar e. T o as se ss to le ra nc e am on g de nt is ts , th e “p at ie nt ” e xp la in ed h is w ill in gn es s t o pa y pr iv at el y fo r t he tr ea tm en t. Ph on e in te rv ie w O nl y 15 % o f t he d en ta l p ra ct ic es w er e w ill in g to p ro vi de d en ta l ca re . W ill in gn es s w as n ot in flu en ce d by fi na nc ia l f ac to rs or th e lo ca l H IV p re va le nc e. H IV +v e in di vi du al s w ill h av e di ffi cu lty o bt ai ni ng d en ta l c ar e in Jo rd an . N ee d to a dd re ss pr ej ud ic es a nd st er eo ty pe s a bo ut H IV +v e pe op le a nd re so lv e th e un w ill in gn es s of d en tis ts to tr ea t t he m . 19 96 [1 5] C ro ss -s ec tio na l U nk no w n 13 4 Jo rd an ia n & 9 0 C an ad ia n nu rs in g st ud en ts A q ue st io nn ai re e xp lo rin g at tit ud es a nd le ve ls o f kn ow le dg e ab ou t A ID S Se lf- ad m in is te re d qu es tio nn ai re Jo rd an ia n nu rs in g st ud en ts h ad lim ite d H IV /A ID S co nt en t i n th ei r c ur ric ul um , w ith ju st 4 % re po rt in g to h av e ca re d fo r so m eo ne w ith A ID S. K no w le dg e an d at tit ud es o f b ot h gr ou ps w er e un sa tis fa ct or y. Jo rd an ia n nu rs es ' l ac k of e xp os ur e to p er so ns w ith A ID S an d in fo rm at io n ab ou t A ID S m ay ac co un t f or th ei r l ow sc or es . N ee d fo r e du ca tio na l st ra te gi es to a dd re ss co gn iti ve a nd a ffe ct iv e do m ai ns o f l ea rn in g. Th e le ct ur e fo rm at a lo ne se em s t o be in ef fe ct iv e in m od ify in g at tit ud e. 19 87 [1 4] C ro ss -s ec tio na l ep id em io lo gi ca l st ud y U nk no w n 11 24 h ea lth y ru ra l an d ur ba n Jo rd an ia n re si de nt s, re si de nt s w ith h ep at iti s & th ei r co nt ac ts , a nd p at ie nt s w ith o th er d is ea se s Bi ol og ic al te st in g fo r H IV Sc re en in g fo r H IV an tib od ie s by e nz ym e im m un oa ss ay 2 he pa tit is p at ie nt s w er e po si tiv e fo r H IV . N ei th er h ad A ID S- lik e ill ne ss a nd b ot h pr ob ab ly a cq ui re d H IV in fe ct io n ab ro ad . Re pe at ed te st in g is re co m m en de d. 20 0 2 [1 8] C ro ss -s ec tio na l A va ila bi lit y sa m pl in g 26 7 nu rs es a nd 7 3 ph ys ic ia ns fr om 6 ho sp ita ls o f t he R oy al M ed ic al S er vi ce s a nd th e M in is tr y of H ea lth A ID S A tti tu de s S ca le tr an sl at ed in to A ra bi c Se lf- ad m in is te re d qu es tio nn ai re 76 % h ad k no w le dg e of A ID S, w ith a si gn ifi ca nt d iff er en ce be tw ee n nu rs es a nd p hy si ci an s: nu rs es h ad le ss k no w le dg e of H IV a nd a m or e ne ga tiv e at tit ud e co m pa re d w ith d oc to rs . Th er e w er e si gn ifi ca nt g en de r di ffe re nc es w ith re ga rd to pr ox im ity to p eo pl e w ith A ID S, vi ew o f A ID S as a m or al is su e, an d so ci al w el fa re re ga rd in g A ID S, b ut n o si gn ifi ca nt di ffe re nc e in a tti tu de s b as ed o n ye ar s o f e xp er ie nc e. Kn ow le dg e of H IV co nt rib ut es to m or e po si tiv e at tit ud es to w ar d H IV /A ID S pa tie nt s am on g he al th c ar e pr ov id er s c om pa re d to nu rs es . PH C = p rim ar y he al th ca re ; M O H = M in is tr y of H ea lth EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 492 Analytical approach: All the studies were limited to descriptive analyses of findings and relied solely on univariate analysis and reporting of frequency data by various groups. Researchers: Most of the studies included were conducted by medical doctors and all were from the health field. Only the Ministry of Health was involved in planning and implementing studies related to HIV/AIDS. Funding: Acknowledgement of funding was not mentioned in any of the 8 reviewed studies. Discussion The systematic review conducted for this paper clearly shows that behaviour- al research on HIV/AIDS in Jordan is limited, even compared to other Middle Eastern countries. Those studies that were identified assessed HIV/AIDS knowledge, beliefs and/or attitudes of the general population or the level of preparedness of health professionals to deal with HIV positive individuals. The studies were fairly simple in design: all were descriptive cross-sectional studies conducted by health care professionals and the majority recruited participants through convenience samples, which severely undermines the generaliz- ability of the findings. No studies using longitudinal, randomized or quasi-ex- perimental were identified, none tested and evaluated HIV/AIDS prevention and intervention approaches, and none examined AIDS knowledge among high-risk groups such as sex workers, MSM, injection drug users (IDUs) and migrant workers. Such reluctance to study these groups might be due to the strict Arabic social norms related to addressing sexual activity and sexual- ity, difficulty to reach such populations. Funding source was not mentioned in any of the studies. This point suggests a lack of funding for research studies in Jordan, especially studies that target HIV/AIDS; however, reports in the grey literature were funded by different national and international organiza- tions We acknowledge that this paper has some limitations. Our main goal was to systematically review the literature avail- able in peer-reviewed journals and thus we excluded data available in so-called grey literature. However, most HIV re- search in Jordan is conducted outside of academia at the level of the Ministry of Health or by nongovernmental in- ternational organizations; the results are rarely published in peer-reviewed journals and thus have never been validated or distributed to international reader. The strength of this review is its comprehensive search of published sources in regional, national and inter- national databases, both in English and Arabic. This is the first systematic review of HIV/AIDS research in Jordan and one of the very few in the Middle East and North Africa. While Jordan is considered to have a low prevalence of HIV, the incidence is increasing. Several factors have been reported to be associated with the low prevalence : 1) the norms and tradi- tions of a conservative society dictate social behaviour in the country [11]; 2) male circumcision is almost universal in Muslim communities [21]; and 3) alcohol intake is low [22]. However, while a conservative society may be seen to contribute to a low HIV preva- lence, it should be remembered that India, which is a conservative society with patriarchal relations between men and women, now has an HIV/AIDS prevalence of 0.36% with the threat of wider spread [23]. Patriarchal norms can create power imbalance in sexual relations, which can contribute to an increase in risky sexual behaviour [8] and gender inequalities in relationships put women at higher risk for HIV infec- tion [24–28]. Factors that may be driving the in- creasing incidence of HIV in Jordan include the stigma associated with HIV [1,11], gender inequalities [23,29], a demographically young population, increased unemployment rates [5], migration and the political instabil- ity of surrounding countries [5], and labour migration [23,29]. Economic hardship has meant that young Jorda- nians are delaying marriage, which has led to more sexual contacts outside of marriage. High unemployment has left young people free to spend their spare time in cafés and amusement centres or working as unskilled labourers, thus exposing them to potential pressure for risky sexual behaviour [4]. Political instability in the region and the influx of a large number of migrant workers to Jordan, the return of 300 000 Jordani- ans as a result of the Gulf War and the migration of hundreds of thousands of Iraqis to Jordan as a result of the 2003 War have created multiple challenges for the country. This influx has resulted in an increase in unemployment rates and placed a strain on the education system. Vulnerability to risks associated with instability and migration create an environment that puts local peo- ple at higher risk for HIV [30]. Large displaced and migrant populations, mobility of migrant workers from high endemic countries into Jordan, poverty and gender inequalities are often asso- ciated with increases in sex work and casual sex. Personal factors also increase the risks of the spread of HIV; although Jordanians know about and have ac- cess to condoms, they still do not use it as a protective measure. A recent unpublished study of workers in indus- trial zones and small business owners in Jordan revealed that most participants knew about AIDS, had heard about condoms and had easy access to them; however, a significant number of the study participants reported exchanging sex for money, contacting a commercial sex worker and rarely using condoms [8]. In addition, only 15% of MSM in Jordan reported using a condom during their most recent episode of intercourse with a male partner [31]. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 493 References 1. UNAIDS. Fact sheet. Middle East and North. Increasing HIV prevalence, new HIV infections and AIDS-related deaths Africa (http://www.unaids.org/documents/20101123_FS_ mena_em_en.pdf, accessed 23 February 2012). 2. Pierre-Louis M, Jenkins C, Robalino D. The threat of HIV/AIDS in the Middle East And North Africa region. Paper presented at the 14th International Conference on AIDS, Barcelona, Spain 7–12 July 2002. 3. AIDS statistics. Amman, Jordan, Ministry of Health, 2009. 4. USAID. Success stories: HIV/AIDS. AIDS hotline reaches youth in Jordan. (http://www.usaid.gov/our_work/global_health/ aids/News/successpdfs/jordanstory.pdf, accessed 23 Febru- ary 2012). 5. UNGASS Country Report: Hashemite Kingdom of Jordan 2006–2007 (http://data.unaids.org/pub/Report/2008/ jordan_2008_country_progress_report_en.pdf, accessed 23 February 2012). 6. Akala FA, Jenkins C. Preventing HIV/AIDS in the Middle East and North Africa: a window of opportunity to act. Washington DC, World Bank, 2005. 7. Abu-Raddad LJP et al. Analytic insights into the popula- tion level impact of imperfect prophylactic HIV vaccines. Journal of Acquired Immune Deficiency Syndromes, 2007, 45:454–467. 8. Knowledge, attitudes, and practices survey of workers in qualified industrial zones and small businesses in Jordan. Family Health In- ternational & USAID, 2008 (http://pdf.usaid.gov/pdf_docs/ PNADM793.pdf, accessed 23 February 2012). 9. Jenkins C. Vulnerability to HIV/AIDS in the Middle East and North Africa: a socio-epidemiology overview. Paper presented at the 15th International AIDS Conference, 11–16 July, 2004, Bangkok, Thailand (Satellite meeting of global researchers of HIV/AIDS in the Middle East and North Africa Region). 10. Jenkins C, Robalino D. HIV/AIDS in the Middle East and North Africa: the costs of inaction. Washington DC, World Bank, 2003. 11. Sufian S. HIV/AIDS in the Middle East and North Africa. Middle East Report (New York, NY), 2004, 233:6–9. 12. Mahafzah AM et al. Prevalence of sexually transmitted infec- tions among sexually active Jordanian females. Sexually Trans- mitted Diseases, 2008, 35:607–610. 13. Toukan AU, Schable CA. Human immunodeficiency virus (HIV) infection in Jordan: a seroprevalence study. [Case Re- ports]. International Journal of Epidemiology, 1987, 16:462–465. 14. Al-Ma'aitach R. Jordanian and Canadian nursing students' knowledge about AIDS. International Nursing Review, 1996, 43:89–92. 15. El-Maaytah M et al. Willingness of dentists in Jordan to treat HIV-infected patients. Oral Diseases, 2005, 11:318–322. 16. Petro-Nustas W, Kulwicki A, Zumout A. Students’ knowledge, attitudes, and beliefs about AIDS: a cross-cultural study. Jour- nal of Transcultural Nursing, 2002, 13:118. 17. Saleh F. Nurses’ and physicians’ attitudes towards AIDS in Jor- dan. Jordanian Royal Medical Services, 2002, 9:51–55. 18. Petro-Nustas W. University students' knowledge of AIDS. Inter- national Journal of Nursing Studies, 2000, 37:423–433. These circumstances might be af- fecting sexual practices among Jordan’s general population and various risk groups and may have an impact of the spread of HIV in the country. However, very little information is available on these factors. Prevention is the foremost viable strategy in countries with low preva- lence of HIV and in the last 2 years, the Jordanian government has increased the attention paid to preventing the HIV epidemic from gaining a foothold in the population. There have been ef- forts to encourage nongovernmental organizations to conduct HIV studies among high-risk groups. Family Health International, in collaboration with the USAID mission in Jordan, has con- ducted several knowledge, attitudes, and practices (KAP) studies with men and women working in industrial zones [8] with youth [4] and with sex work- ers [8]. However, findings from these studies are only available in annual re- ports and have never been published in peer-reviewed scientific journals; in ad- dition, the National Strategy on HIV/ AIDS indicated that there appears to be almost no information available on the vulnerable groups in Jordan. Even numbers for well-defined groups, such as the military and prisoners, are not readily available. The only figures relat- ing to vulnerable groups are those from law enforcement services on prison- ers. It was estimated that around 6% of prisoners were injecting drug users [32]. Thirty years after HIV was first de- scribed, only 8 peer-reviewed, published HIV/AIDS studies exist in Jordan and none focused on prevention or interven- tion [33]. There is an urgent need there- fore for more multidisciplinary research using diverse methodologies to be con- ducted in order to better understand the HIV/AIDS situation in Jordan so as to inform prevention and intervention policies. Such research should focus on the general population, such as children, families, as well as on high-risk groups, particularly migrant workers and their sex partners, sex workers and their cli- ents, and men having sex with men [6]. There is also a need for research that evaluates the factors contributing to HIV/AIDS in Jordan, such as gender inequalities, migration, poverty, stigma and risky sexual behaviours. In order to encourage such research, training of Jor- danian researchers on different types of HIV/AIDS research (epidemiological, population-based, prevention, interven- tion) is necessary. This training could take place in university research centres that focus on medicine and health. Such training would promote scientifically- based research on HIV, and would also assist the country in being better prepared to address HIV, especially among at-risk groups. At the same time, adequate funding for different types of HIV research is needed in Jordan. Without a funding commitment, HIV behavioural research in Jordan will con- tinue to lag far behind other countries in the region and the world, as identified by this review. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 494 19. Nawafleh H, Francis K, Chapman Y. The influence of HIV/ AIDS on the practice of primary care nurses in Jordan: Rheto- ric and reality. International Journal of Nursing Practice, 2005, 11:200–205. 20. Nawafleh H, Francis K, Chapman Y. Jordan’s vulnerability: A population at risk of HIV/AIDS. Contemporary Nurse, 2005, 19:197–210. 21. Male circumcision: global trends and determinants of preva- lence, safety and acceptibility. Geneva, World Health Organi- zation and Joint United Nations Programme on HIV/AIDS, 2007. 22. Public health problems of alcohol consumption in the Region. Technical paper presented at the Fifty-third Session of the Re- gional Committee for the Eastern Mediterranean, September 2006 (EM/RC53/4) (http://www.emro.who.int/rc53/media/ pdf/EMRC5304En.pdf, accessed 23 February 2012). 23. Preventing HIV/AIDS in the Middle East and North Africa. A win- dow of opportunity to act. Washington DC, World Bank, 2005. 24. El-Bassel N et al. Intimate partner violence prevalence and HIV risks among women receiving care in emergency departments: implications for IPV and HIV screening. Emergency Medicine Journal, 2007, 24:255–259. 25. Hoffman S et al. HIV risk behaviors and the context of sexual coercion in young adults' sexual interactions: results from a diary study in rural South Africa. Sexually Transmitted Diseases, 2006, 33:52–58. 26. Kim Jb et al. Exploring the role of economic empowerment in HIV prevention. AIDS (London, England), 2008, 22(Suppl. 4):S57–S71. 27. Kulwicki AD, Cass PS. An assessment of Arab American knowl- edge, attitudes, and beliefs about AIDS. Journal of Nursing Scholarship, 1994, 26(1):13–17. 28. Shawky S et al. HIV surveillance and epidemic profile in the Middle East and North Africa. Journal of Acquired Immune Defi- ciency Syndromes, 2009, 51(Suppl. 3):S83–S95. 29. UNICEF. Jordan. Statistics (http://www.unicef.org/infoby- country/jordan_statistics.html, accessed 23 February 2012). 30. Jordan Population and Family Health Survey 2007. Calverton, Maryland, USA: Department of Statistics [Jordan] and Macro International Inc., 2008 (http://www.measuredhs.com/pubs/ pdf/FR209/FR209.pdf, accessed 23 February 2012). 31. Country Progress Report. Hashemite Kingdom of Jordan. Report to the Secretary General Of the United Nations on the United Nations General Assembly Special Session On HIV/ AIDS January 2008–December 2009 (http://www.unaids. org/es/dataanalysis/monitoringcountryprogress/2010progr essreportssubmittedbycountries/file,33630,es.pdf, accessed 17 April 2012). 32. National AIDS Strategy. Amman, Jordan, Ministry of Health, 2005. 33. Abu-Raddad LJ et al. Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: time for strategic action. Wash- ington DC, World Bank, 2010. Situation of HIV testing and counselling policies and practices in the Eastern Mediterranean Region HIV testing and counselling constitute a major bottleneck in scaling up HIV prevention, treatment and care services in the WHO Eastern Mediterranean Region. The situation of HIV testing and counselling policies and practices in the Eastern Mediterranean Region (EMRO Technical Publications Series, No. 38) provides policy-makers with an up-to-date and comprehensive review of the situation in 2010 and argues powerfully for an effective public health approach to HIV testing and counselling. Further information about this and other EMRO publications is available at: http://www.emro.who.int/publications/ طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 495 Aspects actuels des infections nosocomiales au Centre Hospitalier Libanais de Beyrouth A. Al-Hajje,1 M. Ezedine,2 H. Hammoud,3 S. Awada,1 S. Rachidi,1 S. Zein 1 et P. Salameh 1 RÉSUMÉ Les infections nosocomiales constituent un problème majeur et tout hôpital doit connaître sa situation en matière d’infections nosocomiales. Cette étude rétrospective visait à identifier les infections nosocomiales bactériennes chez les patients admis au Centre Hospitalier Libanais de janvier 2006 à janvier 2008, déterminer les germes en cause, étudier la sensibilité de ces germes aux antibiotiques et évaluer le traitement adopté à l’hôpital. Au total, 96 patients développant une infection nosocomiale ont été recensés. Les infections nosocomiales les plus courantes étaient les infections urinaires (42 %), suivies par les infections pulmonaires (28 %). Les bacilles à Gram négatif étaient responsables dans 89 % des cas et les staphylocoques dans 7 %, Escherichia coli et Pseudomonas aeruginosa étant les plus fréquents (46 % et 26 % respectivement), avec une résistance majeure à divers antibiotiques ; 18 % des patients infectés étaient traités par imipénème, 7 % par vancomycine, 42 % par céphalosporines de 3e génération et 24 % par amikacine. La lutte contre les infections nosocomiales doit passer par des mesures d’hygiène dans l’hôpital et par une politique de prescription d’antibiotiques adaptée à l’évolution des résistances bactériennes. 1Département de Pharmacie clinique, Faculté de Pharmacie, Université Libanaise, Campus Hadath, Beyrouth (Liban) (Correspondance à adresser à P. Salameh : psalameh@ul.edu.lb). 2Laboratoire de Microbiologie, Faculté des Sciences, Université Libanaise, Campus Hadath, Beyrouth (Liban). 3Faculté de Pharmacie, Université Libanaise, Campus Hadath, Beyrouth (Liban). Reçu : 04/10/11 ; accepté : 20/12/11 تويرب ،نانبل في يزكرم ىفشتسم في تايفشتسلما ىودعل ةنهارلا ةلالحا ةملاس لاكساب ،نيز ملاس ،يديشر رمس ،ةضاوع ءانس ،دوّحم نسح ،نيدلا زع دممح ،جالحا لمأ لىإ ةيداعتسلاا ةساردلا هذه فدتهو .اهيف ىودعلا هذه ةلاح فرعت نأ تايفشتسلما لىع يغبني ذإ ،ةماه ةلكشم تايفشتسلما ىودع ُّدَعُت :ةصلالخا نوناك ىتح 2006 رياني/نياثلا نوناك نم ًاءدب نانبل في يزكرلما ىفشتسلما لىإ اولخدأ نيذلا ضىرلما ينب تايفشتسلما في ةييرتكبلا ىوادعلا لىع فرعتلا ةساردلا في جردأ دقو .ىفشتسلما في ةلجاعلما مييقتو ،ةيويلحا تاداضملل تابوركلما ةيساسحو ،ىودعلل ةببسلما تابوركلما ديدتحو ،2008 رياني/نياثلا ىودعلا اهيلت ،)%42( ًاعويش رثكلأا يه ليوبلا ليبسلا ىودع تناكو .تايفشتسلما ىودعب اوبيصأ نيذلا ًاضيرم 96 مهددع غلابلا ضىرلما عيجم ةيكيشرلإاو ،%7 نع ةلوؤسم ةيدوقنعلا تاروكلماو ،تايفشتسلما ىودع نم %89 نع ةلوؤسلما يه مارغلل ةيبلسلا ايتركبلا تناكو .)%28( ةيسفنتلا ضىرلما نم %18 جلوعو ،ةيويلحا تاداضلما نم ديدعل ةمواقم ايتركبلا تناكو .)بيتترلاب %26و %46( ًاعويش رثكلأا اهم ةيراجنزلا ةفئازلاو ةينولوقلا ةفاظن لىع ظافحلل يربادت ذاتخا لىإ ةجاح كانهو .ينساكيملأاب %24و ،نيروبسولافيسلا نم ثلاثلا ليلجاب %72و ،ينسيموكنافلاب %7و ،منبيميلإاب .ةيويلحا تاداضملل ايتركبلا فلتمخ ةمواقم نم ّدلحاو ،تايفشتسلما ىودع ةحفاكم لجأ نم ةيويلحا تاداضلما فصول تاسايس عضوو ،ىفشتسلما Current status of nosocomial infections in the Lebanese Hospital Center, Beirut ABSTRACT Nosocomial infections are a significant problem and hospitals need to be aware of their nosocomial infection status. This retrospective study aimed to identify nosocomial bacterial infections in patients admitted to the Lebanese Hospital Center from January 2006 to January 2008 and determine the causative micro-organisms, the antibiotic sensitivity of the micro-organisms and evaluate the hospital treatment. In total 96 patients with nosocomial infection were included. Urinary infections were the commonest nosocomial infections (42%) followed by pulmonary infections (28%). Gram-negative bacteria were responsible for 89% of nosocomial infections and staphylococci for 7%, with Esherichia coli and Pseudomonas aeruginosa being the most common (46% and 26% respectively) The organisms were resistant to multiples antibiotics and 18% of the patients were treated with imipenem, 7% with vancomycin, 42% with third-generation cephalosporins and 24% with amikacin. Hospital hygiene measures and antibiotic prescription policies are required to fight nosocomial infections and reduce antibiotic resistance among organisms. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 496 Introduction Les infections nosocomiales constituent un problème réel de santé publique du fait de leur fréquence croissante, de leur gravité compte tenu de la multirésistance des germes en cause et de leur coût socio-économique. Si le temps des grandes épidémies est passé, ces infections touchent toujours les malades hospitalisés dans une proportion souvent inquiétante. Selon les données de la littérature, 5 à 10 % des malades hospitalisés contractent une infection nosocomiale lors de leur séjour hospitalier [1]. Les infect ions nosocomiales sont définies comme des infections apparaissant au cours ou à la suite d'une hospitalisation et n’étant pas présentes, ni en incubation ni à l'admission à l'hôpital. Lorsque l’état infectieux à l'admission n'est pas connu, un délai d'au moins 48 heures après l'admission (ou un délai supérieur à la période d'incubation lorsque celle- ci est connue) est communément accepté pour distinguer une infection d'acquisition nosocomiale d'une infection communautaire [2,3]. Les infections nosocomiales peuvent concerner tous les types d’agents infectieux, mais elles sont le plus fréquemment bactériennes, et plus occasionnellement virales, fongiques ou parasitaires [2]. De nombreux facteurs contribuent à augmenter les risques d’acquérir ces infections, dont ceux liés au patient (âge avancé, immunodépression, diabète, obésité et dénutrition), ceux liés aux soins et aux interventions (sondage urinaire, gastrique ou trachéal, cathéter veineux, intervention chirurgicale, endoscopie) et ceux liés à l’agent infectieux (virulence et résistance aux antibiotiques) [4]. Notre étude, menée dans le Centre Hospitalier Libanais (CHL), comprend les objectifs suivants : identifier les infections nosocomiales bactériennes chez les patients hospitalisés, dégager les caractéristiques des patients présentant ces infections nosocomiales, déterminer les germes en cause, étudier la sensibilité de ces germes aux antibiotiques et évaluer le traitement adopté à l’hôpital. Méthodes N o u s a v o n s m e n é u n e é t u d e rétrospective sur une période de deux ans (janvier 2006-janvier 2008), incluant les patients hospitalisés dans les différents services du CHL et ayant présenté des infections nosocomiales bactériennes. Ont été exclus les patients développant une infection nosocomiale autre que bactérienne, les patients venant d’un autre hôpital, ceux présentant une infection à l’admission, ainsi que les services pédiatriques. La sélection des patients ayant développé des infections nosocomiales était réalisée par la revue des rapports d’infections nosocomiales détectées par le CLIN (Comité de lutte contre les infections nosocomiales). Celui-ci considère une infection comme nosocomiale si son délai d’apparition est d'au moins 48 heures après l'admission [2,3]. Le support d’évaluation était un questionnaire rempli à partir des dossiers des malades ayant présenté ces infections, et constitué de trois parties : • la partie « Caractéristiques des patients » comprenait l'âge, le sexe et les antécédents médicaux des patients ; • la partie « Culture bactérienne » d é c r i v a i t l e t y p e d ’ e x a m e n bactériologique réalisé, le germe responsable, l’antibiogramme, la sensibilité et la résistance du germe aux antibiotiques étudiés. Les différents examens bactériologiques étudiés étaient l ’hémoculture, l ’ e x a m e n c y t o b a c t é r i o l o g i q u e des urines (ECBU), les sécrétions pulmonaires par aspiration trachéale profonde et le pus. • La partie « Traitement antibiotique » évaluait le traitement antibiotique empirique, le traitement antibiotique après réalisation de l’antibiogramme a i n s i q u e l a c o n f o r m i t é d e l’antibiotique eu égard à la dose et à la durée du traitement par rapport aux recommandations du Collège des Universitaires des Maladies Infectieuses et Tropicales (CMIT, ex- APPIT – Association des professeurs de pathologies infectieuses et tropicales) et de la Commission des anti-infectieux de l 'Agence régionale de l’hospitalisation (ARH) de Bourgogne [5,6]. Le profil de l’antibiogramme a été pris en compte selon la méthode des disques et a été interprété selon les recommandations d e l a S o c i é t é F r a n ç a i s e d e Microbiologie (SFM) [7]. Analyse statistique Nous avons mené une étude descriptive des différentes variables des patients ayant développé des infect ions nosocomiales, des germes en cause et du traitement antibiotique. Les calculs statistiques ont été réalisés à l’aide du logiciel SPSS. Résultats Quatre-vingt-seize patients hospitalisés développant une infection nosocomiale ont été inclus dans notre étude. Il s’agissait de 50 hommes et 46 femmes. L’âge moyen de notre population était de 64 ans ; 69 % avaient un âge supérieur ou égal à 65 ans. Soixante-dix-huit pour cent (78 %) des patients avaient au moins deux antécédents médicaux ; parmi ces antécédents figuraient les maladies cardiaques (68 %) et le diabète (46 %). Les 96 patients de notre étude ne présentaient aucune infection à leur admission. La durée moyenne d’hospitalisation était de 10 jours. Le tableau 1 synthétise les différentes caractéristiques des patients ayant développé des infections nosocomiales. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 497 Soixante-douze pour cent (72 %) des patients porteurs d’infections nosocomiales étaient hospitalisés dans les services de soins intensifs, 19 % en médecine interne et 9 % en chirurgie. Les localisations étaient surtout urinaires (42 %) et pulmonaires (28 %). Suivaient les bactériémies (19 %) et les infections nosocomiales de plaie opératoire (8 %). D’autres localisations é t a i e n t r e t r o u v é e s , n o t a m m e n t cutanées (3 %). Pour les infections pulmonaires, la porte d’entrée ou le facteur d’exposition était la sonde naso-gastrique ou trachéo-bronchique, alors que pour les infections nosocomiales urinaires, c’était la sonde urinaire que portaient presque la totalité des patients. Les infections de plaie opératoire étaient superficielles. Quatre-vingt-neuf pour cent (89 %) des germes isolés étaient des bacilles à Gram négatif avec une prédominance d’Escherichia coli (46 %), suivi du germe Pseudomonas aeruginosa (26 %). Le tableau 2 présente les différentes bactéries isolées. Concernant les infections urinaires, les souches nosocomiales d’E. coli représentaient la proportion la plus élevée et pour les infections pulmonaires, les P. aeruginosa venaient au premier rang. Staphylococcus aureus était retrouvé dans des proportions non négligeables, avec un taux de 7 % de bactéries isolées. Ces germes partageaient presque la même fréquence entre les bactériémies et les infections nosocomiales de plaie opératoire (4 % et 3 %). En ce qui concerne la sensibilité aux antibiotiques des germes isolés, la totalité des souches d’E. coli étaient résistantes aux céphalosporines de deuxième génération et environ la moitié à l’association amoxicilline- acide clavulanique. Toutes les souches d ’ E . c o l i é t a i e n t s e n s i b l e s a u x c é p h a l o s p o r i n e s d e t r o i s i è m e génération et aux aminosides. Seule ment 20 % des souches de Klebsiella étaient résistantes aux céphalosporines de troisième génération. La totalité des souches de S. aureus étaient résistantes aux céphalosporines de deuxième génération et le caractère méticillino-résistant (méti-R) était trouvé dans 72 % des souches. Toutes les infections à S. aureus étaient traitées par vancomycine. Près de 65 % des patients infectés étaient traités par imipénème dès qu’une infection était détectée. Mais selon le résultat de l’antibiogramme, l’imipénème était administré chez 18 % des patients ayant développé des infections nosocomiales, les c é p h a l o s p o r i n e s d e t r o i s i è m e génération chez 42 %, l’amikacine chez 24 % et la vancomycine chez 7 % (Tableau 3). Discussion Les infections nosocomiales présentes dans nos structures de soins constituent un problème majeur de santé publique. Dans notre étude, les patients âgés de 65 ans et plus paraissaient plus exposés aux infections nosocomiales, confirmant le fait que l’âge avancé constitue un facteur de risque de développer une infection nosocomiale [1,4]. Ce n'est sans doute pas l'âge seulement, mais plutôt la pathologie sous-jacente fréquente chez les patients âgés qui affaiblit leurs défenses et les rend plus exposés aux risques infectieux [1]. Les pathologies responsables d’une sensibilité particulière à certaines infections (pathologie chronique, qu’elle soit cardio-vasculaire, rénale, respiratoire ou hépatique, dénutrition, diabète, etc.) paraissent comme des facteurs de risque propres aux malades et déterminent en grande partie la fréquence des infections nosocomiales [1]. Dans notre étude, 78 % des patients présentaient au moins deux antécédents médicaux. Tableau 1 Caractéristiques des patients ayant développé des infections nosocomiales Caractéristiques Nbre (n = 96) % Âge ≥ 65 ans 66 69 Sexe masculin 50 52 Antécédents de maladies cardiaques 65 68 Antécédents de diabète 44 46 Antécédents de chirurgie (de plus d’1 an) 30 31 Antécédents d’insuffisance rénale 22 23 Antécédents de maladies respiratoires 13 14 Antécédents d’insuffisance hépatique 8 8 Tableau 2 Distribution des infections nosocomiales par germes isolés Germes isolés Nbre (n = 96) % Escherichia coli 44 46 Pseudomonas aeruginosa 25 26 Klebsiella spp. 11 11 Staphylococcus aureus 7 7 Acinetobacter spp. 4 4 Proteus mirabilis 1 1 Autres 4 4 EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 498 La prévalence des infections nosocomiales pour un service donné varie selon la durée d’hospitalisation mais aussi selon les activités qui y sont menées : 72 % des patients porteurs d’infections nosocomiales étaient retrouvés dans les services de soins intensifs. Nos résultats sont comparables à d’autres enquêtes [1,8]. Les taux élevés observés dans les services de soins intensifs pourraient être en rapport avec la sévérité des pathologies sous-jacentes, le séjour relativement prolongé des patients et la fréquence des procédures invasives à visée diagnostique et/ou thérapeutique [9-11]. Les infections urinaires étaient prédominantes, ce qui est généralement le cas dans d’autres études [12-14] ; cela peut être expliqué par l’utilisation courante des bandelettes urinaires et la demande quasi systématique de l’ECBU dans certains pays, alors que dans notre étude c’est par la présence de sondes urinaires. Le sondage urinaire représente l’un des principaux gestes de soins à risque d’infection nosocomiale [10]. La pose de sonde urinaire constitue le facteur de risque majeur des infections urinaires et exige qu’elle soit un acte m é d i c a l [ 1 5 ] . L ’ é v a l u a t i o n d e s pratiques de sondage et la mise en place de mesures pour diminuer ce risque sont nécessaires [16]. Ces actions vont de la suppression des sondes inutiles à la limitation des sondes exploratrices et l’introduction du système de sonde clos [17]. Les infections pulmonaires étaient retrouvées fréquemment dans notre étude (28 %) du fait du risque infectieux élevé chez les patients en soins intensifs portant des sondes naso-gastriques ou trachéo-bronchiques. La ventilation artificielle constitue le principal facteur de risque dans la survenue des infections pulmonaires nosocomiales [9,18,19]. La prévention de ces infections repose avant tout sur la maîtrise des risques évitables et vise essentiellement la réanimation et les soins intensifs. Elle consiste souvent en une désinfection et une stérilisation soigneuse des appareils de ventilation, des aspirateurs et des nébuliseurs [18]. L’alimentation entérale a encore été identifiée comme facteur de risque significatif dans la littérature. Une étude mexicaine montre qu’elle expose les malades à un risque accru d’infection nosocomiale [9]. Les infections nosocomiales de plaie opératoire venaient en quatrième place (8 %). Le risque nosocomial lié à l’infection du site opératoire n’est pas toujours élevé [20]. Il est en rapport avec les caractéristiques préalables du patient, la durée et le type d’intervention [21]. Pour lutter contre ces infections, des mesures préventives spécifiques doivent s’appliquer en pré-opératoire, au bloc et durant la période post-opératoire [3]. Dans notre étude, les bacilles à Gram négatif étaient les germes les plus fréquemment retrouvés comme agents responsables des infections nosocomiales avec une prédominance d’E. coli , ce qui est retrouvé également dans la plupart des séries bibliographiques [12- 14]. Les souches nosocomiales de P. aeruginosa étaient rencontrées avec une fréquence importante dans notre étude et venaient au premier rang dans les infections pulmonaires. Ces germes sont prédominants dans les infections pulmonaires [3,6]. La totalité des souches d’E. coli étaient résistantes aux céphalosporines de deuxième génération et environ la moitié à l’association amoxicilline- acide clavulanique. La conduite thérapeutique devant une bactérie résistante est d’utiliser une association d’antibiotiques bactéricides à spectre étroit pour réduire la possibilité de sélection de mutants encore plus résistants [22]. S. aureus, retrouvé avec un taux de 7 %, était principalement rencontré dans les bactériémies et les infections de plaie opératoire. Ceci est dû à la multiplication des différents gestes invasifs [23]. Ces germes sont montrés insensibles aux céphalosporines de deuxième génération et à l’association amoxici l l ine-acide clavulanique, conformément aux données de la littérature indiquant que ces germes sont généralement insensibles aux β-lactamines [12]. Dans notre étude, tous les germes isolés de S. aureus étaient traités par vancomycine malgré la sensibilité de ce germe à la méticilline dans 28 % des cas. En ce qui concerne le germe P . a e r u g i n o s a , m i s à p a r t s a résistance naturelle vis-à-vis des c é p h a l o s p o r i n e s d e p r e m i è r e génération et de l’amoxicilline-acide clavulanique (Augmentin), ce bacille a une forte propension à produire de nouvelles souches résistantes aux antibiotiques sélectionnés en milieu hospitalier. Dans notre étude, 68 % des souches de P. aeruginosa étaient Tableau 3 Fréquence des antibiotiques utilisés après les résultats de l’antibiogramme Antibiotiques Nbre (n = 96) % Céphalosporines de troisième génération 40 42 Ceftazidine 18 19 Ceftriaxone 12 13 Cefotaxime 10 10 Amikacine 23 24 Imipénème 17 18 Lévofloxacine 9 9 Vancomycine 7 7 طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 499 résistantes à l ’ imipénème. Cette résistance peut être expliquée par la perte de la porine D2 qui entraîne une diminution spécifique de la perméabil i té pour l ’ imipénème. La résistance ne s’exprime à haut niveau que si la perte de D2 est accompagnée d’une hyperproduction de la céphalosporinase chromo- s o m i q u e [ 2 4 ] . L e s s o u c h e s d e P. aeruginosa peuvent avoir encore une tendance à acquérir des plasmides qui leur confèrent un haut degré de résistance par exemple à la gentamycine et à la tobramycine [25]. Dans notre étude, toutes les souches nosocomiales de P. aeruginosa étaient sensibles à l ’amikacine. L’imipénème était remplacé dans la majorité des cas par l’amikacine ou une céphalosporine de troisième génération en cas de résistance. Dans notre étude, les protocoles d ’ u t i l i s a t i o n d e s a n t i b i o t i q u e s reposaient sur une monothérapie : près de 65 % des patients infectés étaient traités par imipénème dès qu’une infection était détectée et avant le résultat de l’antibiogramme. La dose du traitement antibiotique était conforme aux référentiels dans 95 % des cas [5,6]. Selon le résultat de l’antibiogramme, l ’ imipénème était prescrit dans 18 % des infections nosocomiales, les céphalosporines de troisième génération dans 42 %, l’amikacine dans 24 % et la vancomycine dans 7 %. Le choix de l’antibiotique était conforme aux résultats de l’antibiogramme. La dose et la durée du traitement antibiotique étaient conformes aux référentiels dans 90 % des cas [5,6]. Face à ce problème réel, et dans le souci de dispenser des soins de qualité assurant aux patients à la fois l’efficacité thérapeutique et la sécurité, nous proposons quelques recommandations pratiques, notamment de renforcer les activités du CLIN pour l’investigation des infections nosocomiales. Cette unité sera chargée d’organiser la lutte contre les infections nosocomiales, de mettre en place des programmes de surveillance et de formation du personnel, voire de formation continue, aux pratiques de soins et d’hygiène, à la prescription des antibiotiques, et d’en établir des protocoles. Ces protocoles devront nous permettre d’améliorer le choix initial de l’antibiothérapie par la rédaction des recommandations en fonction des infections, de dresser une liste d’antibiotiques réservés à certaines indications et délivrés sur justification écrite. L’implication de tous les personnels travaillant au sein de l’établissement dans la lutte contre les infections n o s o c o m i a l e s e t l a r é a l i s a t i o n d’enquêtes en permanence portant sur l’incidence et la prévalence des infections nosocomiales ainsi que sur la prescription des antibiotiques doivent être menées dans chaque structure de santé sous l’égide du CLIN, qui est un instrument fondamental pour améliorer la qualité dans un hôpital. Conclusion Les infections nosocomiales constituent un indicateur de qualité des services et des établissements de santé dont dépend l'accréditation. Elles englobent deux grandes catégories de facteurs de risque. Les premiers sont intrinsèques aux malades et reflètent l’existence d’une immunodépression relative ou d’une pathologie responsable d’une sensibilité particulière à certaines infections. Les seconds sont des facteurs extrinsèques aux malades, directement ou indirectement liés aux interventions médicales et à l’environnement dans lequel celles-ci sont effectuées. Ces derniers peuvent être évités grâce à la surveillance et à la prévention. La lutte contre les infections nosocomiales doit passer par une coordination avec les différents services médicaux (soins intensifs, médecine, pharmacie, chirurgie, laboratoire, etc.) sous l’égide du CLIN. La réduction de l’incidence et de la prévalence de ces infections passe non seulement par des mesures d’hygiène générales et spécifiques (gestes invasifs) dans l’hôpital mais aussi par une politique de prescr ipt ion d’ant ibiot iq ue s adaptée aux différentes situations et surtout ajustée en permanence à l’évolution des résistances bactériennes. L’usage approprié des antibiotiques, les modalités thérapeutiques et l’expérience clinique de chaque service conditionnent l’évolution de l’écologie bactérienne hospitalière. Références 1. Brun-Buisson C, Girou E. Les infections nosocomiales : bilan et perspectives [Nosocomial infections: review and perspec- tives]. Médecine/sciences, 2000, 16(8-9):892–899. 2. Berche P, Gaillard JL, Simonet M, eds. Bactériologie - Bactéé- ries des infections humaines [Bacteriology - Bacteria of human infections]. Paris, Médecine Sciences Publications, Collection PCEM Flammarion, 1991: 64-71. 3. Beaucaire G. Infections nosocomiales. Épidémiologie, critères du diagnostic, prévention, principes de traitement [Noso- comial infections. Epidemiology, diagnostic criteria, preven- tion, principles of treatment]. La Revue du Praticien, 1997, 47(2):201–209. 4. Centre de Coordination de la Lutte contre les Infections No- socomiales de l'interrégion Nord (CCLIN Paris-Nord) (http:// www.cclinparisnord.org/Usagers/faq/FAQDream.htm, con- sulté le 11 mars 2012). 5. Portier H et al. Propositions thérapeutiques pour les princi- pales infections nosocomiales [Therapeutic proposals for the main nosocomial infections]. In : Portier H et al. Antibioguide 2005 [Antibioguide 2005]. Bourgogne, Animé par la Com- mission des Anti-Infectieux de l'ARH (Agence Régionale de l’Hospitalisation) de Bourgogne, 2005:40–48. 6. Collège des Universitaires de Maladies Infectieuses et Tropicales (CMIT). Le POPI. Maladies infectieuses. Guide de EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 500 traitement. Référence pour une bonne pratique médicale, 8e édition [The POPI. Infectious diseases. Treatment guide. Reference forgood medical practice, 8th ed.]. Montmorency, 2M2, 2003. 7. Comité de l’antibiogramme de la Société Française de Microbiologie. Recommandations 2008 (http://www.sfm- microbiologie.org/UserFiles/file/CASFM/casfm_2008.pdf, consulté le 25 mars 2012). 8. Fki H et al. Épidémiologie des infections nosocomiales dans les hôpitaux universitaires de Sfax : résultats de la première enquête nationale de prévalence de l’infection nosocomiale [Epidemiology of nosocomial infections in the university hospitals of Sfax: results of the first national point prevalence survey]. Revue Tunisienne d'Infectiologie, 2008, 2(1):22–31. 9. Sanchez-Velazquez LD, Ponce de Leon Rosales S, Sigfrido Rangel Frausto M. The burden of nosocomial infection in the intensive care unit: Effects on organ failure, mortality and costs. A nested case-control study. Archives of Medical Research, 2006, 37:370–375. 10. Maugat S et al. Ratio standardisé d’incidence : un indice de risque pour la surveillance des infections liées aux cathéters veineux centraux en réanimation adulte (réseau REACAT) dans l’inter-région nord [Standardized incidence ratio: a risk index for catheter-related infection surveillance in intensive care units (REACAT network) in Northern France]. Revue d'Épidémiologie et de Santé Publique, 2005, 53(S1):39–46. 11. Sligl W, Taylor G, Brindley PG. Five years of nosocomial Gram-negative bacteraemia in a general intensive care unit: Epidemiology, antimicrobial susceptibility patterns, and outcomes. International Journal of Infectious Diseases, 2006, 10:320–325. 12. Dia NM et al. Résultats de l’enquête de prévalence des infections nosocomiales au CHNU de Fann (Dakar, Sénégal) [Results of a study on the prevalence of nosocomial infections at the National University Hospital, Dakar, Senegal]. Médecine et maladies infectieuses, 2008, 38(5):270–274. 13. Metinbas S et al. Prevalence and characteristics of nosocomial infections in a Turkish University Hospital. American Journal of Infection Control, 2004, 22:404–413. 14. Rigaux-Barry F, Blech MF. Enquêtes de prévalence des infections nosocomiales - Les résultats régionaux de la Lorraine de 1997 à 2000 [Prevalence surveys of nosocomial infections: results for the Lorraine Region from 1997 to 2000]. Hygiènes, 2003, 11(4):348–353. 15. Bridger JC. A study of nurses’ views about the prevention of nosocomial urinary tract infections. Journal of Clinical Nursing, 1997, 6:379–387. 16. Agodi A et al. Active surveillance of nosocomial infections in urologic patients. European Urology, 2007, 51:247–254. 17. Christensen M, Jepsen OB. Reduced rates of hospital acquired UTI in medical patients. Prevalence surveys indicate effect of active infection control programmes. Journal of Hospital Infection, 2001, 47:36–40. 18. Halwani M et al. Cross-transmission of nosocomial pathogens in an adult intensive care unit: Incidence and risk factors. Journal of Hospital Infection, 2006, 63:1–8. 19. Lee SC et al. Risk factors of mortality for nosocomial pneumonia: Importance of initial antimicrobial therap. International Journal of Clinical Practice, 2005, 59:39–45. 20. Michalopoulos A et al. Frequency, characteristics, and predictors of microbiologically documented nosocomial infections after cardiac surgery. European Journal of Cardio- Thoracic Surgery, 2006, 29:456–460. 21. Baffoy N. Prévalence des infections nosocomiales chez les patients opérés [Prevalence of nosocomial infections in surgical patients]. Le Bulletin du CCLIN Paris-Nord, 2005, 1997, 7:6–8. 22. Materston R et al. Appropriate antimicrobial treatment in nosocomial infections: The clinical challenges. Journal of Hospital Infection, 2004, 56:142–149. 23. Besnier JM, Choutet P. Infections sur matériel étranger [Prosthetic device infections]. Médecine et Maladies Infectieuses, 1993, 23:765–767. 24. Vurma-Rapp U et al. Mechanism of imipenem resistance acquired by three pseudomonas aeruginosa strains during imipenem therapy. European Journal of Clinical Microbiology & Infectious Diseases, 1990, 9:580–587. 25. Nasnas R et al. Traitement des méningites à Pseudomonas et à Acinetobacter par l’amikacine par voie intrathécale [Treatment of Pseudomonas and Acinetobacter meningitis with intrathecal amikacin]. Médecine et maladies infectieuses, 1990, 20(11):573– 578. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 501 Evaluation of specific biochemical indicators of Helicobacter pylori-associated gastric cancer in Egypt M.M. Anwar,1 A.I. Youssef,2 M.I. Sheta,3 A. Zaki,4 N.R. Bernaba 2 and M.A. El-Toukhi 2 ABSTRACT The aim of the study was to assess the accuracy of some specific biochemical indicators in discriminating between Helicobacter pylori-associated gastritis and H. pylori-associated stomach cancer (serum gastrin level, serum soluble E-cadherin and tissue COX-2 activity, as well as serodiagnostic markers for H. pylori infection) in order to find a simple diagnostic test that can reasonably predict the development of gastric cancer. The study participants comprised 20 patients with gastric carcinoma, 20 patients with positive H. pylori- associated gastritis and 20 individuals as the control group. Standard procedures and quality control measures were followed. Using cut-off values and ROC analysis to assess the diagnostic abilities of the biochemical indicators, E-cadherin showed the highest sensitivity (100%). We suggest that close follow-up together with periodic endoscopic examination for all patients with persistent H. pylori infection and serum soluble E-cadherin level above 5 µg/mL is essential. 1Department of Experimental and Clinical Surgery; 2Department of Applied Medical Chemistry; 3Department of Pathology; 4Department of Medical Informatics and Medical Statistics, Medical Research Institute, University of Alexandria, Alexandria, Egypt (Correspondence to M.M. Anwar: medhatanwar@gmail.com). Received: 01/08/10; accepted: 22/11/10 صرم في ةيباوبلا ةيوللماب طبترلما ةَدعلما ناطسرل ةيويلحا ةيئايميكلا تاشرؤلما مييقت يخوطلا حاتفلا دبع تفيرم ،ابانرب تفأر ينفين ،يكز لداع ،اتش ميهاربإ لانم ،فسوي ميهاربإ نيامأ ،رونأ دممح تحدم ناطسرو ةيباوبلا ةيوللماب طبترلما ةدعلما باهتلا ينب زييمتلا في ةيعونلا ةيويلحا ةيئايميكلا تاشرؤلما ضعب ةقد مييقت لىإ ةساردلا هذه فدته :ةصلالخا كلذكو ،جسنلا في COX-2 ميزنإ طاشنو ،بئاذلا E-cadherin نم لصلما ىوتسمو ،لصلما في نيترساغلا ىوتسم( ةيباوبلا ةيوللماب طبترلما ةدعلما في كراشو .ةدعلما ناطسر ثودحب هب ؤبنتلا نكمي طيسب صييخشت رابتخا فاشتكا لجأ نم ،)ةيباوبلا ةيوللما ىودعل ةيلصلما ةيصيخشتلا ةمساولا نوثحابلا عبتا .دهاوشلا نم ةعومجمك ًاصخش 20و ،ةيباوبلا ةيوللماب طبترم ةدعم باهتلا ميهدل ًاضيرم 20و ،ةدعلما ةناطسر ميهدل ًاضيرم 20 ةساردلا E- رهظأ ،ةيويلحا ةيئايميكلا تاشرؤملل ةيصيخشتلا تاردقلا ميقتل ROC ليلتحو لصف ميق مادختسابو .ةدولجا ةبقارم يربادتو ةيرايعلما تاءارجلإا ينباصلما ضىرلما عيملج ليخادلا يرظنتلاب يرودلا صحفلا عم برق نم ةعباتلما يروضرلا نم نأ نوثحابلا حترقيو .)%100( ةيساسح لىعأ cadherin .ترليللما في مارغوركيم 5 نم لىعأ E-cadherin نم لصلما في بئاذلا ىوتسلما ناك اذإو ،ةيباوبلا ةيوللماب ةميدتسم ىودعب Évaluation des indicateurs biologiques spécifiques du cancer de l'estomac associé à Helicobacter pylori en Égypte RÉSUMÉ La présente étude visait à évaluer l'exactitude de certains indicateurs biologiques spécifiques (gastrinémie, concentration sérique de la E-cadhérine soluble, activité tissulaire de la cyclo-oxygénase 2, et marqueurs sérologiques d'une infection à Helicobacter pylori) permettant de différencier une gastrite associée à H. pylori d'un cancer de l'estomac associé à cette bactérie, afin de déterminer un test diagnostique simple capable de prédire raisonnablement l'apparition d'un cancer de l'estomac. L'étude portait sur 20 patients atteints d'un carcinome gastrique, 20 patients souffrant d'une gastrite à H. pylori et 20 personnes en tant que groupe témoin. Des procédures normalisées ont été suivies et des mesures de contrôle de la qualité ont été effectuées. Après l'utilisation de valeurs seuils et d'une analyse de la fonction d'efficacité du récepteur pour évaluer les qualités diagnostiques des indicateurs biologiques, la E-cadhérine a montré la sensibilité la plus élevée (100 %). Nous suggérons qu'un suivi attentif et un examen endoscopique régulier sont essentiels pour tous les patients atteints d'une infection à H. pylori persistante et présentant une concentration sérique de la E-cadhérine soluble supérieure à 5 µg/ml. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 502 Introduction Gastric cancer is the fourth commonest malignant disorder and the second com- monest cause of cancer-related death worldwide [1]. It represents 1.64% of all cancers in Egypt, according to the National Cancer Institute registry and the median age is 55 years with male predominance [2]. Several studies have linked Helicobacter pylori and gastric cancer. The etiopathogenetic cascade of the infection leads to various errors in the genome of dividing gastric epithelial cells, which leads to abnormal differen- tiation of cells [3]. In addition, chronic inflammation associated with the infec- tion leads to damage in proteins, the production of reactive oxygen species and deficient repair of replication errors of DNA. All increase the risk of gastric cancer [3,4]. Among the pathogenic virulence factors in H. pylori infection is CagA protein, which is produced by most strains into the gastric cells and phos- phorylated by the host kinases, resulting in morphological changes in the epi- thelial cells [5]. CagA positive H. pylori infection up-regulates the expression of the enzyme cyclo-oxygenase-2 (COX- 2), which converts arachidonic acid to prostaglandin E2 [6]. The angiogenic- enhancing role of COX-2 facilitates the process of invasion and metastasis through decreasing the expression of the adhesion molecule E-cadherin. E-cadherin is expressed by epithelial cells and is responsible for homotypic cell–cell adhesion. Degradation of tis- sue E-cadherin produces serum soluble E-cadherin, which is greatly elevated in inflammatory conditions by mediators, or in cancerous disease due to the over- expression of proteases [7]. As the initial stage of H. pylori infection is an acute gastritis, so the acid response of the stomach is affected, and gastrinaemia is induced; this is associated with the oc- currence of gastric adenocarcinoma [8]. Researchers have documented that H. pylori eradication therapy attenuates the endoscopic and histological lesions [9]. Besides, many studies have consist- ently reported that H. pylori eradication can lead to a regression of acute gastritis and intestinal metaplasia, and that such intervention could reduce the risk for adenocarcinoma of the distal stomach [10,11]. When clinically manifested, gastric cancer has an extremely poor progno- sis since the 5-year survival rate using currently available treatments, surgery and radio-chemotherapy, is less than 20% [12]. Therefore a potential benefit could be expected if we had a feasible diagnostic test for follow-up of patients with H. pylori gastritis and were able to predict the risk of development of stomach cancer. In this study, we aimed to assess the accuracy of specific biochemical indicators to discriminate between H. pylori-associated gastritis and H. pylori- associated stomach cancer. Methods Patients and samples Twenty consecutive adult patients at- tending the Endoscopy Unit, Depart- ment of Surgery, Medical Research Institute in the University of Alexandria during the period January 2008–June 2009 and proven by endoscopic, patho- logical and radiological examinations to have an operable stomach cancer were involved in the study. Sample size was restricted owing to limited time resources. None of the patients had received chemotherapy before surgi- cal operation. For each patient with stomach cancer, the next adult patient with endoscopic diagnosis of H. pylori- associated gastritis, free of any malignant changes, was recruited in the study. In addition, for each patient with stomach cancer, the next age-matched (within 5 years) individual presenting with epigastric pain which proved to have normal endoscopic findings and who was negative for H. pylori was included in the study as part of the control group. All individuals in the study sample were subjected to routine history and clinical examination, followed by an upper gastrointestinal endoscopic ex- amination using a long forward viewing instrument (Fuji, EG 250D video). The stomach was completely examined for the presence or absence of any gross pathological sign. All 60 contributors were subjected to multiple endoscopic gastric mucosal tissue biopsies. These were examined pathologically to confirm the presence or absence of gastritis and/or malignan- cy and for biochemical determination of tissue COX-2 activity using COX Activity Assay Kit (Cayman Chemical Company, Cat. No.760151). The COX activity assay utilizes the peroxidase component of cyclo-oxygenases. Per- oxidase activity was assayed colorimet- rically by monitoring the appearance of oxidized N,N,N',N'-tetramethyl-p- phenylenediamine at 590 nm [13]. The assay included COX-1 and COX-2 spe- cific inhibitors in order to distinguish between the 2 isozymes. Serological examination was car- ried out to estimate serum gastrin level and serum soluble E-cadherin level besides serodiagnostic markers for H. pylori infection, H. pylori antigen, H. pylori CagA antibody and H. pylori IgG antibody. Serum gastrin level was measured using Gastrin-17 ELISA kit (Biohit Plc, Cat. No.601035). The G-17 ELISA is based on a sandwich enzyme immu- noassay technique with a G-17 specific capture antibody adsorbed to a micro- well plate and a detection antibody la- belled with horseradish peroxidase [14]. Serum soluble E-cadherin was measured using the Human E-cadherin EIA kit (Takara Bio Inc., Code No. MK117). The human E-cadherin EIA kit is a solid phase EIA based on a sandwich method that utilizes 2 mouse monoclonal anti-human E-cadherin antibodies to detect soluble E-cadherin in a 2-step procedure [15]. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 503 H. pylori Ag ELISA (ABC Di- agnostics, New Damietta) was used to determine serum H. pylori antigen level; determination of serum H. py- lori CagA antibodies was done using ELISA H. pylori CagA IgG Quantita- tive (RightChoice Diagnostics, code REP1004), while H. pylori IgG anti- body was measured using H. pylori IgG Quantitative ELISA Kit (MP Biomedi- cals, LLC, Cat. No. 07BC1052). All steps were carried out according to the manufacturer’s instructions [16–18]. Quality control All the steps for the blood and tissue sampling were done under the authors’ supervision and followed standard pro- cedures. All tests were performed in duplicate. All individuals agreed to par- ticipate after the aims of the study were explained to them and gave informed consent. The study was approved by the institutional ethical committee of the Medical Research Institute, Alexandria University. Histopathological examination After the surgical management for pa- tients with stomach cancer was done, the gastric specimens were fixed into 10% formalin and routinely processed for pathological examination. Paraffin wax-embedded sections were cut into 3–5 µ thick serial sections and stained with haematoxylin and eosin. Gastric cancer was classified according to Lau- ren’s classification [19], which divides gastric adenocarcinoma into intestinal, diffuse and mixed types. Statistical analysis Data analysis was conducted using SPSS, version 17.0. Descriptive statistics were presented as mean [standard de- viation (SD)] for quantitative data and frequency for qualitative data. Analysis of variance (ANOVA) was used to test the significance of the mean differences in serum gastrin level, serum soluble E-cadherin, CagA antibody, and tissue COX-2 activity between the 3 different groups. Unpaired t-test with Bonferroni correction for multiple comparisons was used to test the significance of dif- ferences in mean H. pylori antigen, H. pylori IgG antibody and H. pylori CagA antibody. Due to the small sample size in the subgroups of stomach cancer patients, a non-parametric test (Mann– Whitney) was used. P-value < 0.05 was considered statistically significant. The ROC analysis was used to assess the diagnostic abilities of the biochemical indicators in the discrimi- nation between patients with H. pylori gastritis and those with stomach cancer. The cut-off point which optimizes the accuracy of the diagnostic test was de- fined as the point which maximizes the value of the Youden index (sensitivity + specificity – 1). Results Patients were divided into 3 groups, each with 20 patients, group I (con- trol group), group II (patients with H. pylori-associated gastritis), and group III (patients with stomach cancer). The distribution of sex and age of all the participants is shown in Table 1. Endoscopic, surgical and histopathological findings In group II patients, pathological ex- amination of the gastric tissue biopsies showed 5 cases with superficial gastritis, 4 cases with atrophic gastritis, 2 cases with gastroduodenitis, and 9 cases with benign gastric ulcer. In group III patients, all endoscopic malignant changes were localized in the antrum and prepyloric region except in 2 patients where cancer was localized in the body of the stomach as malignant ulcers and polypoidal mass. After con- firmation of the malignant nature of the disease by pathological examination of the endoscopic biopsies, 14/20 (70%) underwent subtotal gastrectomy and 6/20 (30%) underwent total gastrec- tomy. After surgery, the pathological findings were as follows: 10 cases (50%) were of intestinal type adenocarcinoma, 7 (35%) were diffuse type adenocarci- noma and 3 (15%) were of the mixed type. Table 2 shows the histopatho- logical type of operated gastric cancer patients. None of the gastric cancer patients included in this study was free from H. pylori infection. Biochemical indicators All the differences in mean serum gastrin level, tissue COX-2 activity, serum E-cadherin and CagA antibody between the study groups were highly significant (P < 0.01). Patients with stomach cancer had the highest in se- rum gastrin levels, tissue COX-2 activity and serum E-cadherin followed by the group with positive H. pylori-associated gastritis (Table 3). For CagA antibody, Table 1 Demographic characteristics of the participants Characteristic Group I (n = 20) Group II (n = 20) Group III (n = 20) No. % No. % No. % Sex Male 9 45 14 70 13 65 Female 11 55 6 30 7 35 Mean (SD) age (years) 48.5 (2.3) 49.3 (1.6) 46.9 (2.0) Group I = control group; group II = patients with Helicobacter pylori-associated gastritis; group III = patients with stomach cancer. The chi-squared test was used for difference in of distribution among the study groups and ANOVA for difference in mean age, P < 0.05. SD = standard deviation. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 504 the group with H. pylori gastritis showed the highest level. Considering the levels of the studied biochemical indicators in the 3 pathologic subtypes of gastric can- cer patients, serum gastrin and tissue COX-2 activity were significantly high- er in the intestinal subtype compared with the diffuse type (P < 0.05), while serum E-cadherin was significantly higher in the diffuse type (Table 4). Intermediate levels were seen in the mixed type. ROC analysis was adopted to identify the cut off points for serum gastrin level, tissue COX-2 activity, and serum E-cadherin, which maximizes the overall accuracy of these biochemi- cal indicators in the discrimination between individuals with H. pylori infection with or without stomach can- cer. The corresponding sensitivity and specificity of each cut-off point was rela- tively high, ranging from 80% to 100%. E-cadherin had the greatest sensitivity (100%) in detecting stomach cancer (Table 5). Serum levels of H. pylori antigen, CagA and IgG antibodies were signifi- cantly greater in groups II and III than group I (P < 0.05) (Table 6). Com- paring group II with group III, these parameters were significantly lower in group III (P < 0.05). Discussion In our study all patients with stomach cancer were positive for H. pylori. The significantly higher levels in H. pylori antigen and H. pylori IgG and CagA antibodies when comparing each of the infected groups with the control group explain the evidence that CagA positive strains of H. pylori are considered viru- lent and have a highly pathogenic effect on gastric mucosa and that they have been related to ulcers and greatly in- crease the risk of gastric cancer [20,21]. In our work, the levels of H. pylori CagA antibodies in the gastric cancer group were about 19% lower than those in Table 2 Histopathology and type of surgery for the 20 patients with stomach cancer Type of gastrectomy Histopathological adenocarcinoma type Intestinal (n = 10) Diffuse (n = 7) Mixed (n = 3) Total (n = 20) No. No. No. No. % Subtotal 9 2 3 14 70 Total 1 5 0 6 30 Table 3 Levels of serum gastrin, tissue COX-2 activity, serum E-cadherin, and CagA antibodies (Ab) in the 3 study groups Parameter Group Ia (n = 20) Group IIa (n = 20) Group IIIa (n = 20) P-valueb Mean (SD) Mean (SD) Mean (SD) Serum gastrin (pmol/L) 5.3 (1.4) 16.6 (3.8) 30.3 (5.9) < 0.01 COX-2 activity (U/mL) 414.9 (87.4) 632.8 (122.7) 1106.4 (298.5) < 0.01 Serum E-cadherin (µg/mL) 1.9 (0.3) 4.3 (0.7) 6.4 (1.2) < 0.01 Serum CagA-Ab (Uarb/mL) 2.2 (1.0) 64.4 (14.3) 52.4 (11.0) < 0.01 aAll between-group comparisons were statistically significant (P < 0.05). bANOVA test. Group I = control group; group II = patients with H. pylori-associated gastritis; group III = patients with stomach cancer. SD = standard deviation. Table 4 Mean levels of the studied parameters in different pathological types of gastric cancer Parameter Type of gastric cancer Diffuse (n = 7) Intestinal (n = 10) Mixed (n = 3) Mean (SD) Mean (SD) Mean (SD) Serum gastrin (pmol/L) 24.0 (1.3) 33.8 (1.2)* 33.7 (1.5) Tissue COX-2 activity (U/mL) 880 (87) 1297 (440)* 999 (271) Serum E-cadherin (µg/mL) 7.80 (0.30) 5.50 (0.11)* 6.45 (0.01) Mann–Whitney test was used for comparison between diffuse and intestinal type. No statistical tests were applied to the mixed type owing to the very small sample size. *Significant at P < 0.05. SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 505 the H. pylori-associated gastritis group, while, H. pylori IgG antibodies were about 26% lower. The significant differ- ence in these parameters was similar to the results obtained by Meimarakis et al., who found that there was a sponta- neous decline in H. pylori antibody as gastric carcinogenesis proceeds, and that CagA antibody persists longer in serum that H. pylori IgA antibody [22]. This also may be explained by the idea that in patients with severe atrophic gas- tritis, H. pylori infection may be difficult to demonstrate because the bacteria disappear spontaneously and even H. pylori antibody titres eventually decline to normal [23]. The availability of a simple diagnos- tic test which can reasonably predict the development of stomach cancer could be of high practical importance. The most impressive finding in this study was the striking differences in the levels of serum gastrin, COX-2 activity, serum soluble E-cadherin and CagA antibody in patients with H. pylori gastritis compared with healthy control individuals. A further striking increase in these biochemical param- eters is found in individuals with H. pylori-associated gastric cancer. The reasons for that need some explana- tion. Gastrin is involved in the tumor- ogenesis in the gastrointestinal tract [24], and plays a key role in the ini- tiation and the progression of cancer through the adenoma-carcinoma se- quence in the stomach [25]. Recent studies showed a significantly higher level in H. pylori-infected patients than the seronegative ones [26], which is secondary to H. pylori colonization of the gastric body and fundus, resulting in decreased acid secretion and thus low- ering the inhibitory feedback on gastrin release [27]. Also, H. pylori infection plays a significant role in the stimula- tion of G cells [28]. This explains the progressively significantly higher serum gastrin levels in groups II and III. The statistically significant eleva- tion of serum gastrin level in group III, especially in the intestinal and mixed forms, compared with patients in group II led us to believe like other researchers that gastrin could originate from extra G-cell sources, including cancer cells themselves [2]. Also, a strong positive correlation between serum gastrin and each of H. pylori IgG and CagA antibod- ies confirms that hypergastrinaemia and H. pylori expressing CagA might con- tribute to the transformation of normal epithelial cells into cancer cells in the H. pylori-infected stomach [2]. Väänänen et al. determined this blood test panel, together with the assay of H. pylori antibodies, as a good non-endoscopic diagnostic and screening tool for gastric cancer [29]. The roles of H. pylori infection and gastrin have been reported to stimulate and induce overexpression of COX-2 [30]; this explains the increase in tissue COX-2 activity in the cancer group be- ing H. pylori positive compared to group II. This increase may inhibit apoptosis and increase the invasiveness of malig- nant cells [31]. The highest activity for COX-2 was found in patients with the intestinal subtype of stomach cancer and this finding is in agreement with previous studies which revealed that COX-2 expression may be associated with the carcinogenesis of the intestinal type of gastric cancer and, speculatively, inhibition of COX-2 might have pre- ventative effects on the intestinal type of gastric cancer. Also, in tumours of mixed type, COX-2 is increased in the intestinal component compared to the diffuse one [32]. Conditions with rapid cell turnover or inflammation lead to an increase in serum level of E-cadherin [7]. Perturba- tion in the expression or function of the transmembrane glycoprotein leading to an increase in permeability mediated by the reduction in cell adhesion might allow H. pylori antigens to reach the gastric lamina propria with resultant Table 5 ROC curve analysis: cut-off points for serum E-cadherin level, COX-2 activity and serum gastrin level in individuals with Helicobacter pylori infection to discriminate between those with and without stomach cancer Parameter Cut-off Sensitivity (%) Specificity (%) E-cadherin (µg/mL) 5 100 80 COX-2 (U/mL) 755 85 90 Gastrin (pmol/L) 26 80 100 Table 6 Mean levels of Helicobacter pylori antigen, CagA and IgG antibodies (Ab) in the 3 groups of participants Parameter Group Ia (n = 20) Group IIa (n = 20) Group IIIa (n = 20) P-valueb Mean (SD) Mean (SD) Mean (SD) H. pylori antigen 0.20 (0.01) 1.10 (0.04) 0.71 (0.03) < 0.05 H. pylori CagA-Ab (Uarb/mL) 2.2 (0.2) 64.4 (3.2) 52.3 (2.4) < 0.05 H. pylori IgG-Ab (U/mL) 8.8 (0.5) 58.9 (1.97) 43.6 (1.4) < 0.05 aAll between-group comparisons were significant (P < 0.05) using Bonferroni correction. bANOVA test. Group I = control group; group II = patients with H. pylori-associated gastritis; group III = patients with stomach cancer. SD = standard deviation. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 506 tissue damage [33]. In our work, the significant elevation of serum soluble E-cadherin in the cancer group is in agreement with previous work which showed that serum E-cadherin is found in the circulation of normal individuals, but is particularly elevated in patients with gastric carcinoma [34]. Generally, tissue E-cadherin is strongly expressed in well differentiated cancers, but is absent, or markedly reduced in undif- ferentiated cancers [35], this decrease was mainly observed in diffuse type of gastric cancer and less in intestinal type [36]. These results are supported by our own since we found a significant elevation in serum soluble E-cadherin in the diffuse type of group III compared with the intestinal type (5.5 µg/mL). The elevated level could be an indica- tor for poor prognosis, metastases and decreased survival [7]. The ROC curve analysis demon- strated that tissue COX-2 activity, serum gastrin and serum soluble E-cadherin have a very important diagnostic possi- bility for discrimination between people with H. pylori-associated gastritis and those with H. pylori-associated stom- ach cancer. The high accuracy of these parameters in prediction of stomach cancer, as shown by a greater area under ROC curve, raises the possibility of their potential benefit as a follow-up test in individuals with H. pylori positive gas- tritis. As E-cadherin showed the highest sensitivity (100%) in discriminating between H. pylori gastritis and stom- ach cancer, we suggest close follow-up together with endoscopic examination for all patients with previous history of H. pylori-associated gastritis and serum E-cadherin levels above 5 µg/mL. Although our findings suggest a potential benefit for measuring E- cadherin in the serum of patients with gastritis, we would need to conduct a larger clinical trial that would extend to include early stomach cancer as well as advanced cancer together with proper staging of the disease in order to obtain a level of confidence that would lead to a change in current clinical practices and outcomes. With a larger trial, we would be able to make more definitive statements regarding the importance of these biochemi- cal parameters and the proper timing for measurement, especially in those patients positive for H. pylori. Further research is needed to help planning the follow-up strategy using these bio- chemical indicators. Acknowledgements The authors thank Professor El-Sayed Ibrahim Awad, Professor of Surgery, Medical Research Institute, Alexandria University, for his advice and valuable suggestion throughout the work. References 1. Kamangar F, Dores GM, Anderson WF. Patterns of cancer incidence, mortality, and prevalence across five continents: defining priorities to reduce cancer disparities in different geographic regions of the world. Journal of Clinical Oncology, 2006, 24(14):2137–2150. 2. El-Bolkainy N. Topographic pathology of cancer. Cairo, Egypt, Rhone Poulenc Rorer, 2005. 3. Vauhkonen M, Vauhkonen H, Sipponen P. Pathology and molecular biology of gastric cancer. Best Practice & Research Clinical Gastroenterology, 2006, 20(4):651–674. 4. Kim JJ et al. Helicobacter pylori impairs DNA mismatch repair in gastric epithelial cells. Gastroenterology 2002, 123(2):542– 553. 5. Huang JQ et al. Meta-analysis of the relationship between cagA seropositivity and gastric cancer. Gastroenterology, 2003, 125(6):1636–1644. 6. Guo XL et al. Association of cyclooxygenase-2 expression with Hp-cagA infection in gastric cancer. World Journal of Gastroen- terology, 2003, 9(2):246–249. 7. Chan AO et al. Soluble E-cadherin is a valid prognostic marker in gastric carcinoma. Gut, 2001, 48(6):808–811. 8. Konturek PC et al. Cancerogenesis in Helicobacter pylori infected stomach—role of growth factors, apoptosis and cyclooxygenases. Medical Science Monitor, 2001, 7(5):1092– 1107. 9. Ito M et al. Causal role of Helicobacter pylori infection and eradication therapy in gastric carcinogenesis. World Journal of Gastroenterology, 2006, 12:10–16. 10. Mera R et al. Long term follow up of patients treated for Helico- bacter pylori infection. Gut, 2005, 54:1536–1540. 11. Leung WK et al. Factors predicting progression of gastric intes- tinal metaplasia: results of a randomised trial on Helicobacter pylori eradication. Gut, 2004, 53:1244–1249. 12. Egan BJ, O’Morain CA. A historical perspective of Helicobacter gastroduodenitis and its complications. Best Practice & Re- search Clinical Gastroenterology, 2007, 21(2):335–346. 13. Kulmacz RJ, Lands WE. Requirements for hydroperoxide by the cyclooxygenase and peroxidase activities of prostaglandin H synthase. Prostaglandins, 1983, 25:531–540. 14. Goetze JP, Rehfeld JF. Impact of assay epitope specificity in gastrinoma diagnosis. Clinical Chemistry, 2003, 49(2):333–334. 15. Katayama M et al. Soluble E-cadherin fragments increased in circulation of cancer patients. British Journal of Cancer, 1994, 69(3):580–585. 16. Attallah AM et al. Use of a novel enzyme immunoassay based on detection of circulating antigen in serum for diagnosis of Helicobacter pylori infection. Clinical and Diagnostic Laboratory Immunology, 2004, 11(4):775–779. 17. Gerstenecker B et al. Serodiagnosis of Helicobacter pylori infections with an enzyme immunoassay using the chro- matographically purified 120 kilodalton protein. European Journal of Clinical Microbiology & Infectious Diseases, 1992, 11(7):595–601. 18. Perez-Perez GI et al. Seroprevalence of Helicobacter pylori infection in couples. Journal of Clinical Microbiology, 1991, 29(3):642–644. 19. Lauren P. The two histological main types of gastric carcinoma: diffuse and so-called intestinal-type carcinoma. An attempt at a histo-clinical classification. Acta Pathologica et Microbiologica Scandinavica, 1965, 64:31–49. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 507 20. Konturek SJ et al. Helicobacter pylori and CagA status, se- rum gastrin, interleukin-8 and gastric acid secretion in gas- tric cancer. Scandinavian Journal of Gastroenterology, 2002, 37(8):891–898. 21. Aviles-Jimenez F et al. Evolution of the Helicobacter pylori vacu- olating cytotoxin in a human stomach. Journal of Bacteriology, 2004, 186(15):5182–5185. 22. Meimarakis G et al. Helicobacter pylori as a prognostic indica- tor after curative resection of gastric carcinoma: a prospective study. Lancet Oncology, 2006, 7(3):211–222. 23. Kokkola A et al. Spontaneous disappearance of Helicobacter pylori antibodies in patients with advanced atrophic corpus gastritis. Acta Pathologica, Microbiologica. et Immunologica Scandinavica, 2003, 111(6):619–624. 24. Song DH et al. Gastrin-induced gastric adenocarcinoma growth is mediated through cyclin D1. American Journal of Physiology. Gastrointestinal & Liver Physiology, 2003, 285(1):G217–G222. 25. Smith AM, Watson SA. Gastrin and gastrin receptor activation: an early event in the adenoma-carcinoma sequence. Gut, 2000, 47(6):820–824. 26. Liu Y et al. Gastrin (G) cells and somatostatin (D) cells in patients with dyspeptic symptoms: Helicobacter pylori associ- ated and non-associated gastritis. Journal of Clinical Pathology, 2005, 58(9):927–931. 27. Ferrand A, Wang TC. Gastrin and cancer: a review. Cancer Let- ters, 2006, 238(1):15–29. 28. Maciorkowska E et al. Mucosal gastrin cells and serum gastrin levels in children with Helicobacter pylori infection. Advances in Medical Sciences, 2006, 51:137–141. 29. Väänänen H et al. Non-endoscopic diagnosis of atrophic gas- tritis with a blood test. Correlation between gastric histology and serum levels of gastrin-17 and pepsinogen I: a multicentre study. European Journal of Gastroenterology & Hepatology, 2003, 15(8):885–891. 30. Konturek PC et al. Helicobacter pylori, gastrin and cyclooxyge- nases in gastric cancer. Journal of Physiology & Pharmacology, 2000, 51:737–749. 31. Konturek PC et al. Influence of gastrin on the expression of cyclooxygenase-2, hepatocyte growth factor and apoptosis- related proteins in gastric epithelial cells. Journal of Physiology & Pharmacology, 2003, 54(1):17–32. 32. Yamagata R et al. Cyclooxygebase-2 expression is increased in early intestinal-type gastric cancer and gastric mucosa with intestinal metaplasia. European Journal of Gastroenterology & Hepatology, 2002, 14(4):359–363. 33. Chan AO et al. Promoter methylation of E-cadherin gene in gastric mucosa associated with Helicobacter pylori infection and in gastric cancer. Gut, 2003, 52(4):502–506. 34. Chan AO. E-cadherin in gastric cancer. World Journal of Gastro- enterology, 2006, 12(2):199–203. 35. Milne AN et al. Early-onset gastric cancers have a different mo- lecular expression profile than conventional gastric cancers. Modern Pathology, 2006, 19(4):564–572. 36. Wijnhoven BP, Dinjens WN, Pignatelli M. E-cadherin-catenin cell-cell adhesion complex and human cancer. British Journal of Surgery, 2000, 87(8):992–1005. Infectious agents and cancer Infectious agents are responsible for almost 22% of cancer deaths in the developing world and 6% in industrialized countries. Viral hepatitis B and C cause cancer of the liver; human papilloma virus infection causes cervical cancer; the bacterium Helicobacter pylori increases the risk of stomach cancer. In some countries the parasitic infection schistosomiasis increases the risk of bladder cancer and in other countries the liver fluke increases the risk of cholangiocarcinoma of the bile ducts. Preventive measures include vaccination and prevention of infection and infestation. Further information about WHO’s response to cancer can be found at: http://www.who.int/cancer/en/ طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 508 بط ةنهم مهرايتخا بابسأ لوح قشمد ةعماج في نانسلأا بط ةيلك في بلاطلا ءارآ نانسلأا حلشم دوممح رماع Dentistry students’ reasons for choosing dentistry as a career in Damascus University ABSTRACT This cross-sectional questionnaire survey assessed the motives for choosing dentistry as a profession among dentistry students at Damascus University, Syrian Arab Republic. A total of 408 undergraduate students (233 males and 175 females) aged 18–23 years were selected randomly from students in the second, third and fourth years of dentistry study. They completed a questionnaire that enquired about their reasons for studying dentistry as well as their sociodemographic characteristics. The number of admissions in females had increased over the 3 years. Most parents of the students were university-educated. The main motivation for choosing dentistry was as a means to achieve personal goals, including getting a good job abroad, having financial independence, and attaining a good reputation. There were significant differences between the sexes with regard to the reasons for choosing dentistry. .(mashlah@scs-net.org :نيورـتكللإا ديبرلا) ايروس ،قشمد ةعماج ،نانسلأا بط ةيلك ،مفلا بط مسق في دعاسم ذاتسأ 11/12/12 :لوبقلا ،11/11/30 :ملاتسلاا A.M. Mashlah, Oral Medicine Department, Faculty of Dental Medicine, Damascus University, Damascus,Syrian Arab Republic. ةيروهملجا في ،قشمد ةعماج في نانسلأا بط ةيلك ةبلط ينب ةنهمك نانسلأا بطل ةبلطلا رايتخا عفاود ضيرعلا يعطقلما نايبتسلاا اذه مّيق :ةصلالخا في ةعبارلاو ةثلاثلاو ةيناثلا ةنسلا ةبلط ينب نم ،ةنس 23-18 رمع في )ثانلإا نم 175 ،روكذلا نم 233( ًابلاط 408 ًايئاوشع يرتخا .ةيروسلا ةيبرعلا ةيعماتجلاا تماسلا نع راسفتسلاا كلذكو ،نانسلأا بط ةساردل مهتعفد يتلا بابسلأا نع سرفتسي ًانايبتسا ةبلطلا لمكأو .نانسلأا بط ةيلك اوناك ةبلطلا ءابآ مظعم نأو .ةيرخلأا ثلاثلا تاونسلا للاخ نانسلأا بط ةساردب تايتفلا قاحتلا ل َّدعم داز هنأ حضتا دقو .مله ةيفارغوميدلاو في لمع لىع لوصلحا كلذ في ماب ،ةيصخشلا متهاحومط قيقتح وه نانسلأا بط مهرايتخلا سييئرلا عفادلا ناكو .تاعمالجا نم ينجرختمو ينملعتم .نانسلأا بط ةسارد رايتخا بابسأ صيخ ام في ينسنلجا ينب ابه ُّدَتْعُي تافلاتخا كانه ناكو .ةنسلحا ةعمسلاو ،يدالما للاقتسلااو ،جرالخا Motifs du choix de l’odontologie par les étudiants de l’Université de Damas RÉSUMÉ La présente enquête transversale par questionnaire a évalué les motifs du choix de la profession de dentiste chez des étudiants en odontologie de l’Université de Damas (République arabe syrienne). Au total, 408 étudiants de premier cycle (233 hommes et 175 femmes) âgés de 18 à 23 ans ont été sélectionnés aléatoirement dans des promotions d’étudiants des deuxième, troisième et quatrième années de la Faculté dentaire. Ils ont rempli un questionnaire portant sur les motifs du choix de leurs études ainsi que sur leurs caractéristiques sociodémographiques. Le nombre d’admissions de femmes a augmenté au cours des trois dernières années. La majorité des parents des étudiants avaient reçu une formation universitaire. La réalisation d’objectifs personnels, tels qu’obtenir un bon poste à l’étranger, être financièrement indépendant et acquérir une bonne réputation, était la motivation principale du choix de la faculté dentaire. Les hommes et les femmes choisissaient la profession de dentiste pour des motifs très différents. lanruoJ htlaeH naenarretideM nretsaE 2102  •  5 .oN  81 .loV  •  JHME elatneiro eénarretidéM al ed étnaS ed euveR aL 905 المقدمة تبين الدراسات التي توضح كيفية اختيار الأفراد مهنتهم أن العديد من الأشخاص يجدون أنفسهم في اختصاصات ليس لديهم فكرة عن السبب الذي دفعهم إليها. البعض الآخر يتخذون قرارهم بما يتعلق بمهنتهم عبر اختيار المسار الأقل صعوبة مثل ابتاع مسار مهنة يختارها الآباء أو ابتاع نفس الخطى التي اتخذها أشقاؤهم [1–3]. يحتل أطباء الأسنان مكانة هامة في المجتمع كمقدمي رعاية صحية مجازين [1٫4] ، حيث يبدأ الاختلاط مع المجتمع الاحترافي منذ لحظة التقدم بطلب لكلية طب الأسنان وتستمر طوال فترة الدراسة [1٫5] ، وقد كشف استطلاع للرأي عن الدوافع لاختيار طب الأسنان كمهنة لدى طلاب طب الأسنان المستقبليين أنهم يتمتعون بعدد من السمات المميزة [1٫2٫6٫8]. إن الحاجة للوصول إلى مكانة وسمعة جيدة تبدو للعديد منهم مطلبًا مرغوبًا ينبغي تحقيقه ، وهذا يشير إلى أن امتلاك المال ممكن أن يكون واحد من أهم العوامل التي تقع ضمن الصورة الرفيعة المستوى والمحسوسة التي يوحي بها مجال طب الأسنان [1٫2]. إن اختيار المهنة هو قرار حرج ذو تأثير مباشر على نمط الحياة المستقبلية. ومن المهم أيضًا أن نفهم الأولويات والخلفية الاجتماعية السكانية لهؤلاء الطلاب الذين يختارون دراسة طب الأسنان، لأن العوامل الاقتصادية يمكن أن تؤثر على درجة التزام المرء باختصاصه. ومن المثير للاهتمام أيضًا المدى الذي تؤثر فيه التغييرات الاجتماعية الحضارية على اختيار طب الأسنان كمهنة. إن الدراسات التي بحثت في أسباب اختيار طب الأسنان أظهرت أن عدد الطالبات اللواتي يخترن دراسة طب الأسنان قد ازداد في العقد الماضي، وقد أظهرت التقارير أيضًا أن معظم الفتيات يخترن طب الأسنان لأنهن يعتقدن أنه سوف يكون بمقدورهن أن يحققوا التوازن بين حياتهن الشخصية والمهنية كطبيبات أسنان [9]. ومن الأسباب الأخرى لزيادة عدد الفتيات في دراسة طب الأسنان الفرصة للعمل مع الناس، والربح المادي، والسمعة، والتوقعات بين الفتيات بأنهن قادرات على خدمة المجتمع كطبيبات أسنان [1٫2٫6٫8]. وبشكل عام، فإن اختيار المهنية يتأثر بشكل أساسي بنصيحة الأهل والأقارب والأصدقاء والأستاذة والمستشارين. ويبدو أن الاختلافات تظهر بين بلد وآخر. ففي معظم البلدان المتطورة مثل فنلندا [4] والمملكة المتحدة [9]، فإن الحديث مع الأقارب والأصدقاء بمجال طب الأسنان كانت من العوامل الأكثر تأثيرًا، أما في معظم الدول النامية فإن النصيحة من الأساتذة والأهل كانت هي الأكثر ارتباطا [01–21]. كما كانت المكانة والأمان الاقتصادي من العوامل الأكثر ارتباطًا باختيار طب الأسنان كمهنة بين طلاب جنوب أفريقيا [2٫6]. تهدف الدراسة الحالية إلى تقييم الخلفية الاجتماعية والديموغرافية لطلاب طب الأسنان في جامعة دمشق خلال العام الدراسي 0102– 1102م، وكذلك تقييم الدوافع لاختيار طب الأسنان كمهنة. وتأمل أن تساعد النتائج التي توصلت إليها الدراسة في توجيه من سينتسب من الطلاب إلى كلية طب الأسنان مستقبًلا، وتخطيط برامج الدراسة في علوم طب الأسنان. مواد وطرائق البحث تم استخدام استبيان لاستطلاع الرأي، يمكن الإجابة عليه بشكل ذاتي في هذه الدراسة، وتم اختبار الاستبيان مسبقًا على عينة من طلاب طب الأسنان. وقد أجريت بعض التعديلات لإزالة الغموض في بعض مواد الاستبيان النهائي، كما تم إعلام الطلاب حول طبيعة الدراسة، وكذلك تم التأكيد على الخصوصية لدى المشاركين. يتألف الاستبيان من 91 بندًا مغلقًا، (الإجابة عليه محددة بنعم، أو لا، ربما، ...) يتضمن كل منها سؤالا ً حول أحد أسباب اختيار مهنة طب الأسنان لكل طالب وطالبة في عينة البحث. وقد تم اعتماد المقياس الخماسي (على طريقة ليكرت) المؤلف من خمس فئات متدرجة تصاعديًا وفقًا لدرجة الموافقة في استبيان البحث، إذ تم إعطاء كل فئة قيمة متزايدة تصاعديًا وفقًا لدرجة الموافقة كما في الجدول التالي: وقد تم تحديد القيمة المعيارية (3) في المقياس المستخدم في البحث الحالي لأنها تقابل الفئة الوسطى من المقياس الخماسي المستخدم (على طريقة ليكرت). النتائج تم جمع 804 استبيانًا من 332 طالبًا و571 طالبة ( 75 % ذكور و 24 % إناث) من طلاب كلية طب الأسنان في جامعة دمشق تراوحت أعمارهم بين 81و32 سنة، ومتوسط أعمارهم (9.91 ± 8.0 للذكور، و5.02 ± 0.1 للإناث)، وقد تم اختيارهم بشكل عشوائي من طلاب السنوات الثانية والثالثة والرابعة من المرحلة الجامعية الأولى، ويوضح الجدول رقم (2) توزع كامل العينة، حيث تمت الإجابة على هذا الاستبيان بالكامل وتم شملها بالتحليل النهائي، وكانت نسبة الاستجابة النهائية حوالي 55.98%. قمنا باستخدام كل من اختبار t- ستيودنت، sillaW–laksurK، و U yentihW–nnaM في الدراسة الإحصائية للبحث الحالي. لاحظت الدراسة بعد إجراء اختبار T ستيودنت للعينة الوحيدة tset-t elpmas eno لدراسة دلالة الفروق بين القيمة المعيارية 3 (وهي القيمة الموافقة لفئة الإجابة «ربما») وكل من القيم المتوسطة لأسباب اختيار مهنة طبيب الأسنان في عينة البحث (الجدول رقم 3) أن طلاب عينة البحث كانوا غير موافقين على كل من الأسباب المتضمنة في البنود (1 و3 و4 و7 و21 و31 و41 و61 و91) لاختيار مهنة طبيب الأسنان (50.0 > P)، بينما كانوا موافقين على كل من الأسباب المتضمنة في البنود الأخرى الباقية لاختيار مهنة طبيب الأسنان في عينة البحث، عدا البند رقم 6، حيث أن طلاب عينة البحث كانوا يرون أن انتظام ساعات العمل في مهنة الجدول 1 يبين فئات الإجابات عن البنود المتعلقة بدرجة الموافقة في استبيان عينة البحث والقيم الموافقة المعطاة لكل فئة القيمة المعطاةإجابة البنود المغلقة في الاستبيان 1لا، أبدًا 2لا 3ربما 4نعم 5نعم بالتأكيد المجلد الثامن عشرالمجلة الصحية لشرق المتوسط العدد الخامس 015 طب الأسنان (ربما) تكون أحد الأسباب التي أدت إلى اختيار مهنة طبيب الأسنان، وكانت قيمة الانحراف المعياري مرتفعة نسبيًا (62.1) ما يعني تفاوت الآراء حول البند المذكور لدى طلاب عينة البحث. وكذلك، بينت الدراسة بعد إجراء اختبار sillaW–laksurK لدراسة دلالة الفروق في تكرارات فئات درجة موافقة الطلاب على كل من بنود الاستبيان بين مجموعات السنة الدراسية الثلاثة المدروسة (الجدول رقم 4) أن درجة موافقة طلاب السنة الرابعة على مضمون كل من البنود (6 و7 و8 و9 و01 و51 و71) كانت أقل منها في كل من مجموعة طلاب السنة الثانية ومجموعة طلاب السنة الثالثة في عينة البحث (50.0 > P). أما بالنسبة لكل من باقي البنود المدروسة فلا تأثير للسنة الدراسة على درجة موافقة الطلاب على كل من البنود المعنية في عينة البحث (50.0 > P). وقد بين اختبار U yentihW–nnaM لدراسة دلالة الفروق في تكرارات فئات درجة موافقة الطلاب على كل من بنود الاستبيان بين مجموعة الطلاب الذكور ومجموعة الطالبات الإناث (الجدول رقم 5) وجود فروق ذات دلالة إحصائية في درجة موافقة الطلاب على كل من البنود (2 و4 و6 و9 و11 و31 و51 71 و81 ) بين مجموعة الطلاب الذكور ومجموعة الطالبات الإناث في عينة البحث (50.0 > P)، وكذلك لوحظ أن درجة موافقة مجموعة الطلاب الذكور على مضمون البند رقم 4 المتعلق بالمردود المادي الجيد لمهنة طب الأسنان كانت أعلى منها في مجموعة الإناث، وأن درجة موافقة الطالبات الإناث على كل من البنود (2 و6 و9 و11 و31 و51 71 و81) كانت أعلى منها في مجموعة الطلاب الذكور في عينة البحث. أما بالنسبة لكل من باقي البنود المدروسة فلا تأثير لجنس الطالب على درجة موافقة الطلاب على كل من البنود المذكورة في عينة البحث (50.0 > P). وبعد إجراء اختبار sillaW–laksurK لدراسة دلالة الفروق في تكرارات فئات درجة الجدول 2 يوضح توزع كامل عينة البحث المجموعالمستوى الثقافي للوالَدْيننوع المدرسة الثانويةالجنستوزع أفراد العينة مدرسةطالبةطالب حكومية مدرسة خارجمدرسة خاصة القطر ابتدائي أولا يوجد إعدادي جامعيثانوي 691341/30132/4482/732/21628521129401سنة ثانية 30146/2502/6281/021/50162766475سنة ثالثة 90197/9591/327/224/56102377327سنة رابعة 804682/41226/3935/977/2225401252571332عينة البحث كاملًة الجدول 3 يبين نتائج اختبار ستيودنت للعينة الوحيدة tset-t elpmas eno لدراسة دلالة الفروق بين القيمة المعيارية (3) وكل من القيم المتوسطة لأسباب اختيار مهنة طبيب الأسنان في عينة البحث وفقًا للسنة الدراسية. رقم البند القيمة المعيارية = 3البيان المتوسط الحسابي الانحراف المعياري قيمة مستوى الدلالةقيمة t المحسوبة eulav-P 1000.0 <115.52-10.127.1لأن أحد أفراد عائلتي أو أحد أصدقائي طبيب أسنان.1 1000.0 <279.321.122.3إن علاماتي العالية في الثانوية العامة شّجعتني لأختار مهنة طبيب الأسنان.2 1000.0 <566.9-81.134.2لقد اخترت مهنة طبيب الأسنان لأن أهلي كانوا يرغبون بذلك.3 1000.0 <571.6-21.166.2لأن المردود المادي لطبيب الأسنان أعلى من المردود المادي لباقي المهن.4 1000.0 <653.0191.116.3لأني أريد أن أعمل عمًلا مهنيًا خاصًا.5 609.0811.062.110.3الأخرى.لأن ساعات العمل في مهنة طب الأسنان منتظمة أكثر من غيرها من المهن الطبية 6 1000.0 <582.8-13.164.2لأن حلمي كان أن أصبح طبيب أسنان يومًا ما.7 1000.0 <801.2110.116.3لأني أستطيع ممارسة طب الأسنان بشكل مستقل وخاص بعد التخّرج مباشرًة.8 1000.0 <460.5189.037.3لأني أحّب التعامل مع الناس وخدمتهم.9 1000.0 <038.1150.116.3لأن مهنة طبيب الأسنان تعتمد على العلم.01 1000.0 <249.3288.040.4لأن مهنة طبيب الأسنان محترمة من الناحية الاجتماعية.11 1000.0 <063.9-52.124.2لقد تشكلت لدي الرغبة باختيار مهنة طبيب الأسنان في مرحلة الدراسة الثانوية.21 1000.0 <779.11-81.192.2لأن طبيب الأسنان لا يتعرض لحالات فيها حياٌة أو موٌت عادًة.31 1000.0 <758.04-57.084.1لأني عملت في مجال طب الأسنان سابقًا وأريد الآن أن أصبح طبيب أسنان.41 1000.0 <169.449.032.3لأن مهنة طبيب الأسنان من المهن المستقّرة نسبيًا.51 1000.0 <786.3-11.108.2لأني أستطيع العمل كطبيب أسنان دون الحاجة إلى التخصص باختصاص معّين.61 1000.0 <387.0140.155.3لأني أحب معالجة الناس وتحسين مظهرهم الجمالي.71 1000.0 <996.0249.089.3لأني أريد أن أعمل عمًلا خاصًا بي ذاتيًا.81 1000.0 <641.32-40.118.1لأن طبيب أسنان عائلتي نصحني أن أختار مهنة طبيب الأسنان.91 lanruoJ htlaeH naenarretideM nretsaE 2102  •  5 .oN  81 .loV  •  JHME elatneiro eénarretidéM al ed étnaS ed euveR aL 115 الجدول 4 يبين نتائج اختبار sillaW-laksurK لدراسة دلالة الفروق في تكرارات فئات درجة موافقة الطلاب على بنود الاستبيان بين مجموعات السنة الدراسية في عينة البحث. رقم البند قيمة كايمتوسط الرتبالوسيطالبيان مربع قيمة مستوى الدلالة سنة ثانية سنة ثالثة سنة رابعة سنة رابعةسنة ثالثةسنة ثانية 403.0383.266.21256.01237.591111لأن أحد أفراد عائلتي أو أحد أصدقائي طبيب أسنان.1 761.0385.330.88138.61251.602343إن علاماتي العالية في الثانوية العامة شّجعتني لأختار مهنة طبيب الأسنان.2 304.0718.140.49112.00275.112222لقد اخترت مهنة طبيب الأسنان لأن أهلي كانوا يرغبون بذلك.3 512.0570.369.71290.70265.491333لأن المردود المادي لطبيب الأسنان أعلى من المردود المادي لباقي المهن.4 443.0531.209.49116.79164.212444لأني أريد أن أعمل عمًلا مهنيًا خاصًا.5 لأن ساعات العمل في مهنة طب الأسنان منتظمة أكثر من غيرها من المهن 6 500.0646.0164.08183.39126.222333الطبية الأخرى. 500.0834.0182.19162.08145.122222لأن حلمي كان أن أصبح طبيب أسنان يومًا ما.7 540.0322.641.38122.89196.512444لأني أستطيع ممارسة طب الأسنان بشكل مستقل وخاص بعد التخّرج مباشرًة.8 600.0523.0171.57110.70233.712444لأني أحّب التعامل مع الناس وخدمتهم.9 100.0770.5177.96177.40228.022444لأن مهنة طبيب الأسنان تعتمد على العلم.01 014.0187.169.39167.31205.402444لأن مهنة طبيب الأسنان محترمة من الناحية الاجتماعية.11 429.0851.051.99162.20274.402222لقد تشكلت لدي الرغبة باختيار مهنة طبيب الأسنان في مرحلة الدراسة الثانوية.21 957.0355.078.20266.60209.691222لأن طبيب الأسنان لا يتعرض لحالات فيها حياٌة أو موٌت عادًة.31 018.0124.055.30289.69147.402111لأني عملت في مجال طب الأسنان سابقًا وأريد الآن أن أصبح طبيب أسنان.41 700.0458.934.08140.49189.912334لأن مهنة طبيب الأسنان من المهن المستقّرة نسبيًا.51 938.0053.044.69187.30290.402333لأني أستطيع العمل كطبيب أسنان دون الحاجة إلى التخصص باختصاص معّين.61 800.0247.987.77183.52291.602344لأني أحب معالجة الناس وتحسين مظهرهم الجمالي.71 531.0600.454.38180.90283.702444لأني أريد أن أعمل عمًلا خاصًا بي ذاتيًا.81 223.0762.245.29119.41284.302125.1لأن طبيب أسنان عائلتي نصحني أن أختار مهنة طبيب الأسنان.91 الجدول 5 يبين نتائج اختبار U yentihW–nnaM لدراسة دلالة الفروق في تكرارات فئات درجة موافقة الطلاب على بنود الاستبيان بين مجموعة الطلاب الذكور ومجموعة الطالبات الإناث في عينة البحث. رقم البند قيمة مستوى الدلالةقيمة Uمتوسط الرتبالوسيطالبيان طالبةطالبطالبةطالب eulav-P 102.00.3698163.69167.90211لأن أحد أفراد عائلتي أو أحد أصدقائي طبيب أسنان.1 200.00.7786165.32252.98143إن علاماتي العالية في الثانوية العامة شّجعتني لأختار مهنة طبيب الأسنان.2 334.05.9049119.89148.70222لقد اخترت مهنة طبيب الأسنان لأن أهلي كانوا يرغبون بذلك.3 200.05.0776188.38120.91223لأن المردود المادي لطبيب الأسنان أعلى من المردود المادي لباقي المهن.4 061.00.6178150.31271.79144لأني أريد أن أعمل عمًلا مهنيًا خاصًا.5 200.00.5476113.42286.88133لأن ساعات العمل في مهنة طب الأسنان منتظمة أكثر من غيرها من المهن الطبية الأخرى.6 206.05.9749104.60264.00222لأن حلمي كان أن أصبح طبيب أسنان يومًا ما.7 669.05.5099177.20203.20244لأني أستطيع ممارسة طب الأسنان بشكل مستقل وخاص بعد التخّرج مباشرًة.8 520.05.6577135.71278.29144لأني أحّب التعامل مع الناس وخدمتهم.9 826.00.8359160.60227.00244لأن مهنة طبيب الأسنان تعتمد على العلم.01 620.05.5987147.71246.39144لأن مهنة طبيب الأسنان محترمة من الناحية الاجتماعية.11 525.05.6729185.60254.99122لقد تشكلت لدي الرغبة باختيار مهنة طبيب الأسنان في مرحلة الدراسة الثانوية.21 500.00.8856121.91252.78122لأن طبيب الأسنان لا يتعرض لحالات فيها حياٌة أو موٌت عادًة.31 089.00.7599146.20293.20211لأني عملت في مجال طب الأسنان سابقًا وأريد الآن أن أصبح طبيب أسنان.41 300.00.2986174.12249.88143لأن مهنة طبيب الأسنان من المهن المستقّرة نسبيًا.51 180.00.9697132.31274.39133لأني أستطيع العمل كطبيب أسنان دون الحاجة إلى التخصص باختصاص معّين.61 000.00.3516107.62239.58143لأني أحب معالجة الناس وتحسين مظهرهم الجمالي.71 440.05.7867139.31229.19144لأني أريد أن أعمل عمًلا خاصًا بي ذاتيًا.81 547.00.3689105.10210.50221لأن طبيب أسنان عائلتي نصحني أن أختار مهنة طبيب الأسنان.91 المجلد الثامن عشرالمجلة الصحية لشرق المتوسط العدد الخامس 215 الجدول 6 يبين نتائج اختبار sillaW–laksurK لدراسة دلالة الفروق في تكرارات فئات درجة موافقة الطلاب على بنود الاستبيان بين مجموعات المدرسة الثانوية للطالب في عينة البحث. رقم البند قيمة كايمتوسط الرتبالوسيطالبيان مربع قيمة مستوى الدلالة eulav-P مدرسة حكومية مدرسة خاصة مدرسة خارج القطر مدرسة حكومية مدرسة خاصة مدرسة خارج القطر 211.0683.467.92208.70290.791211لأن أحد أفراد عائلتي أو أحد أصدقائي طبيب أسنان.1 100.0362.3132.25105.91203.802343إن علاماتي العالية في الثانوية العامة شّجعتني لأختار مهنة طبيب الأسنان.2 833.0961.291.69172.29184.012222لقد اخترت مهنة طبيب الأسنان لأن أهلي كانوا يرغبون بذلك.3 497.0264.016.20245.01216.102333لأن المردود المادي لطبيب الأسنان أعلى من المردود المادي لباقي المهن.4 994.0093.156.90235.31288.891444لأني أريد أن أعمل عمًلا مهنيًا خاصًا.5 6 لأن ساعات العمل في مهنة طب الأسنان منتظمة أكثر من غيرها من المهن 404.0518.181.78175.99123.902333الطبية الأخرى. 300.0194.1125.15257.88128.891322لأن حلمي كان أن أصبح طبيب أسنان يومًا ما.7 515.0523.191.91200.00221.002444لأني أستطيع ممارسة طب الأسنان بشكل مستقل وخاص بعد التخّرج مباشرًة.8 071.0245.341.71286.68175.702444لأني أحّب التعامل مع الناس وخدمتهم.9 978.0752.004.60224.89181.402444لأن مهنة طبيب الأسنان تعتمد على العلم.01 746.0078.035.19180.30209.602444لأن مهنة طبيب الأسنان محترمة من الناحية الاجتماعية.11 21 لقد تشكلت لدي الرغبة باختيار مهنة طبيب الأسنان في مرحلة الدراسة 900.0424.912.64289.98147.891222الثانوية. 964.0615.105.68138.90244.002222لأن طبيب الأسنان لا يتعرض لحالات فيها حياٌة أو موٌت عادًة.31 146.0888.017.31239.79170.202111لأني عملت في مجال طب الأسنان سابقًا وأريد الآن أن أصبح طبيب أسنان.41 000.0576.5129.12291.66132.412433لأن مهنة طبيب الأسنان من المهن المستقّرة نسبيًا.51 320.0055.797.99155.67198.212323لأني أستطيع العمل كطبيب أسنان دون الحاجة إلى التخصص باختصاص معّين.61 531.0999.376.78163.09162.212444لأني أحب معالجة الناس وتحسين مظهرهم الجمالي.71 109.0802.079.00266.50288.991444لأني أريد أن أعمل عمًلا خاصًا بي ذاتيًا.81 378.0172.097.79174.10225.5025.111لأن طبيب أسنان عائلتي نصحني أن أختار مهنة طبيب الأسنان.91 موافقة الطلاب على كل بند من بنود الاستبيان بين مجموعات المدرسة الثانوية الثلاث المدروسة (الجدول رقم 6) نستنتج أن درجة الموافقة على رقم 2 في مجموعة الطلاب خريجي المدارس الثانوية خارج القطر كانت أقل منها في كل من مجموعة الطلاب خريجي المدارس الثانوية الحكومية ومجموعة الطلاب خريجي المدارس الثانوية الخاصة، ونستنتج أن درجة الموافقة على كل من البند رقم 7 والبند رقم 21 في مجموعة الطلاب خريجي المدارس الثانوية خارج القطر كانت أعلى منها في كل من مجموعة الطلاب خريجي المدارس الثانوية الحكومية ومجموعة الطلاب خريجي المدارس الثانوية الخاصة، ونستنتج أن درجة الموافقة على كل من البند رقم 51 والبند رقم 61 في مجموعة الطلاب خريجي المدارس الخاصة كانت أقل منها في كل من مجموعة الطلاب خريجي المدارس الثانوية الحكومية ومجموعة الطلاب خريجي المدارس الثانوية خارج القطر في عينة البحث، أما بالنسبة لكل من باقي البنود المدروسة فُيلاحظ أنه لا تأثير للمدرسة الثانوية للطالب على درجة موافقة الطلاب على كل من البنود الواردة في عينة البحث (50.0 > P). وكذلك لوحظ أن درجة الموافقة على كل من البندين 1 و51 في مجموعة الطلاب ذوي الوالَدْين من المستوى الثقافي الجامعي كانت أعلى منها في كل من مجموعة الطلاب ذوي الوالَدْين من المستوى الثقافي إعدادي أو أقل ومجموعة الطلاب ذوي الآباء من المستوى الثقافي الثانوي بينما كانت درجة الموافقة على البند رقم 1 فقط في مجموعة الطلاب ذوي الأمهات من المستوى الثقافي الجامعي أعلى منها في كل من مجموعة الطلاب ذوي الأمهات من المستوى الثقافي الإعدادي أو أقل، ومجموعة الطلاب ذوي الأمهات من المستوى الثقافي الثانوي ، كما أن درجة الموافقة على البند رقم 9 في مجموعة الطلاب ذوي الآباء -وكذلك الحال بالنسبة لذوي الأمهات- من المستوى الثقافي الإعدادي أو أقل كانت أكبر منها في كل من مجموعة الطلاب ذوي الآباء، وكذلك الحال بالنسبة لذوي الأمهات، من المستوى الثقافي الثانوي، ومجموعة الطلاب ذوي الآباء، وكذلك الحال بالنسبة لذوي الأمهات، من المستوى الثقافي الجامعي في عينة البحث، أما بالنسبة لكل من باقي البنود المدروسة فلا تأثير للسنة الدراسة على درجة موافقة الطلاب على كل من البنود الواردة في عينة البحث (50.0 > P) (الجدولين 8٫7). المناقشة َقيَّمت الدراسة الحالية دوافع طلاب طب الأسنان في كلية طب الأسنان بجامعة دمشق، وهي جامعة حكومية، وذلك بالإضافة لأوضاعهم الاجتماعية والسكانية. إن اختيار مهنة هو القرار الحاسم الذي له تأثير واضح على نمط الحياة في المستقبل. لوحظ أن أغلب الطلاب اختاروا هذه المهنة بسبب العلامات العالية التي خولتهم دخول هذا الفرع الدراسي، ووجود فرص للحصول على الدخل الجيد لهذه المهنة، والعمل المهني الخاص الذي يمكن ممارسته بشكل مستقل، وكذلك حب مساعدة الناس، وهذا مشابه لماوجدته بعض الدراسات الأخرى lanruoJ htlaeH naenarretideM nretsaE 2102  •  5 .oN  81 .loV  •  JHME elatneiro eénarretidéM al ed étnaS ed euveR aL 315 الجدول 7 يبين نتائج اختبار sillaW–laksurK لدراسة دلالة الفروق في تكرارات فئات درجة موافقة الطلاب على بنود الاستبيان بين مجموعات المستوى الثقافي للأب في عينة البحث. رقم البند قيمة كاي متوسط الرتبالوسيطالبيان مربع قيمة مستوى الدلالة إعدادي أو أقل إعدادي أو جامعيثانوي أقل جامعيثانوي 500.0037.0148.41264.58186.171111لأن أحد أفراد عائلتي أو أحد أصدقائي طبيب أسنان.1 652.0227.299.89195.60252.522334إن علاماتي العالية في الثانوية العامة شّجعتني لأختار مهنة طبيب الأسنان.2 437.0816.091.10234.21218.802222لقد اخترت مهنة طبيب الأسنان لأن أهلي كانوا يرغبون بذلك.3 481.0983.396.01243.19123.581333لأن المردود المادي لطبيب الأسنان أعلى من المردود المادي لباقي المهن.4 783.0698.198.70266.30238.581444لأني أريد أن أعمل عمًلا مهنيًا خاصًا.5 6 لأن ساعات العمل في مهنة طب الأسنان منتظمة أكثر من غيرها من المهن 090.0528.475.50283.87113.322333الطبية الأخرى. 983.0688.120.80245.19116.091222لأن حلمي كان أن أصبح طبيب أسنان يومًا ما.7 746.0078.048.40227.30232.091444لأني أستطيع ممارسة طب الأسنان بشكل مستقل وخاص بعد التخّرج مباشرًة.8 800.0486.962.69131.79143.442444لأني أحّب التعامل مع الناس وخدمتهم.9 312.0190.342.99188.79199.522444لأن مهنة طبيب الأسنان تعتمد على العلم.01 322.0200.359.79160.71262.912444لأن مهنة طبيب الأسنان محترمة من الناحية الاجتماعية.11 356.0258.024.50291.19104.002222لقد تشكلت لدي الرغبة باختيار مهنة طبيب الأسنان في مرحلة الدراسة الثانوية.21 134.0486.165.40273.10279.381222لأن طبيب الأسنان لا يتعرض لحالات فيها حياٌة أو موٌت عادًة.31 333.0002.290.89100.81202.702111لأني عملت في مجال طب الأسنان سابقًا وأريد الآن أن أصبح طبيب أسنان.41 010.0441.959.21280.86171.291333لأن مهنة طبيب الأسنان من المهن المستقّرة نسبيًا.51 715.0023.112.89137.50281.612333لأني أستطيع العمل كطبيب أسنان دون الحاجة إلى التخصص باختصاص معّين.61 893.0548.126.20270.29182.912434لأني أحب معالجة الناس وتحسين مظهرهم الجمالي.71 421.0371.476.80250.28177.781444لأني أريد أن أعمل عمًلا خاصًا بي ذاتيًا.81 209.0702.040.20246.80221.50215.15.1لأن طبيب أسنان عائلتي نصحني أن أختار مهنة طبيب الأسنان.91 الجدول 8 يبين نتائج اختبار sillaW–laksurK لدراسة دلالة الفروق في تكرارات فئات درجة موافقة الطلاب على بنود الاستبيان بين مجموعات المستوى الثقافي للأم في عينة البحث. رقم البند قيمة كايمتوسط الرتبعدد الإجاباتالبيان مربع قيمة مستوى إعدادي الدلالة أو أقل إعداديجامعيثانوي أو أقل جامعيثانوي 110.0900.951.81206.59198.181111لأن أحد أفراد عائلتي أو أحد أصدقائي طبيب أسنان.1 994.0983.172.50278.29136.112333إن علاماتي العالية في الثانوية العامة شّجعتني لأختار مهنة طبيب الأسنان.2 484.0054.156.89152.40222.512222لقد اخترت مهنة طبيب الأسنان لأن أهلي كانوا يرغبون بذلك.3 877.0205.086.70292.10246.891333لأن المردود المادي لطبيب الأسنان أعلى من المردود المادي لباقي المهن.4 614.0557.173.50224.31203.291444لأني أريد أن أعمل عمًلا مهنيًا خاصًا.5 6 لأن ساعات العمل في مهنة طب الأسنان منتظمة أكثر من غيرها من المهن 512.0670.345.49166.41243.412333الطبية الأخرى. 079.0160.052.40292.20299.002222لأن حلمي كان أن أصبح طبيب أسنان يومًا ما.7 779.0740.024.10282.40261.302444لأني أستطيع ممارسة طب الأسنان بشكل مستقل وخاص بعد التخّرج مباشرًة.8 110.0470.917.88101.11245.722444لأني أحّب التعامل مع الناس وخدمتهم.9 314.0767.101.69136.90264.112444لأن مهنة طبيب الأسنان تعتمد على العلم.01 860.0963.505.29130.12285.212444لأن مهنة طبيب الأسنان محترمة من الناحية الاجتماعية.11 638.0953.012.50229.69188.102222لقد تشكلت لدي الرغبة باختيار مهنة طبيب الأسنان في مرحلة الدراسة الثانوية.21 391.0392.349.20210.41291.581222لأن طبيب الأسنان لا يتعرض لحالات فيها حياٌة أو موٌت عادًة.31 978.0752.021.00223.50259.402111لأني عملت في مجال طب الأسنان سابقًا وأريد الآن أن أصبح طبيب أسنان.41 934.0646.134.89197.51249.002333لأن مهنة طبيب الأسنان من المهن المستقّرة نسبيًا.51 823.0822.273.49126.60258.312333لأني أستطيع العمل كطبيب أسنان دون الحاجة إلى التخصص باختصاص معّين.61 880.0468.492.29137.01256.022444لأني أحب معالجة الناس وتحسين مظهرهم الجمالي.71 391.0192.333.01248.69152.781444لأني أريد أن أعمل عمًلا خاصًا بي ذاتيًا.81 928.0573.009.00211.90278.302121لأن طبيب أسنان عائلتي نصحني أن أختار مهنة طبيب الأسنان.91 المجلد الثامن عشرالمجلة الصحية لشرق المتوسط العدد الخامس 415 fo snoitavitom yduts dna scitsiretcarahC .E zrawhcS ,M dligiV .1 naeporuE .evitcepsrep lanidutignol a ni stneduts latned hsinaD .331–721:)3(5 ,1002 ,noitacudE latneD fo lanruoJ htuoS ni yrtsitned ot sedutitta ’stnedutS .EMU etkihC ,AA dnarB .2 fo noitaicossA latneD eht fo lanruoJ .sloohcs latned nacirfA .027–317:)21(25 ,7991 ,acirfA htuoS ta stneduts yrtsitned raey tsrfi fo elfiorp laicoS .D tlezteiG .3 ,7991 ,lanruoJ latneD nailartsuA .yendyS fo ytisrevinU eht .662–952:)4(24 :yrtsitned dna stsitneD .Y rednaxelA-dnahrellA ,H seduJ ,I ilE .4 ,snoitaleR namuH .noisseforp nesohc eht sdrawot sedutitta .739–929:14 ,9891 -rac a sa yrtsitned gnisoohc rof snosaeR .D letaP ,M.H deyiaS .5 tnI fo lanruoJ .aidnI ,stneduts latned raey tsrfi fo yduts a :reer .91–01:1 ,9002 ,htlaeH larO gnisoohc rof snosaeR .KE olugnA-odagleD ,LJ azacI ,E ébanreB .6 -tsrfi elamef dna elam gnivlovni yduts a :reerac a sa yrtsitned ,noitacudE latneD fo lanruoJ naeporuE .ureP ni stneduts raey .142–632:)4(01 ,6002 yevrus a—noisseforp eht fo erutuf ehT .la te JMF trawetS .7 ,4002 ,lanruoJ latneD hsitirB .stnacilppa loohcs latned fo .375–965:791 -oned gnisoohc rof snosaer dna snoitaripsa reeraC .KB alraG .8 latned ihdnaG ni stneduts latned fo yevrus a – reerac a sa yrtsit fo ecnessE dna slannA .rawsenabuhB ,latipsoh dna egelloc .011–801:)2(3 ,1102 ,yrtsitneD - revinu ni snoitairav redneg dna cinhtE .SM eprohtliG ,R ideB .9 .sloohcs latned dna lacidem modgniK detinU ot stnacilppa ytis .512–212:)4(981 ,0002 ,lanruoJ latneD hsitirB gnoma eciohc reerac gnicneuflni srotcaF .la te AE awbiznoguM .01 ,noitacudE latneD fo lanruoJ .ainaznaT ni stneduts loohcs hgih .924–324:)6(46 ,0002 drawot stneduts latned nainarI fo sedutittA .la te M dnavrahaB .11 latneD fo lanruoJ .yduts yrotarolpxe na :sreerac erutuf rieht .5941–9841:)11(57 ,1102 ,noitacudE -ntaudarg a fo snoitaripsni dna snoitaripsa ehT .la te UJ ireahO .21 nairegiN .nadabI ta stneduts latned dna lacidem fo ssalc gni .81–31:)1(3 ,6991 ,lanruoJ lacideM etaudargtsoP ,airegiN ni stsitned fo noitubirtsid redneG .OE ededobnugO .31 .81–51:)S7(86 ,4002 ,noitacudE latneD fo lanruoJ .0002 ot 1891 -ned gnisoohc rof snosaeR .N yaR ,A naginnaH ,J yessilaH .41 latned a gnidnetta stneduts latned fo yevrus a :reerac a sa yrtsit latneD fo lanruoJ naeporuE .9991–8991 gnirud dnalerI ni loohcs .18–77:)2(4 ,0002 ,noitacudE المراجع [1٫2٫3٫7٫31] وقد كان غالبية الطلاب في الدراسة الإيرلندية [41] منجذبين لدراسة طب الأسنان بسبب التفهم الايجابي لظروف العمل، والحوافز الإيثارية لمساعدة الناس، وتحسين مظهرهم، بينما بينت دراسات أخرى [5] أن الطلاب اختاروا طب الأسنان كبديل عن الطب البشري. كما كانت هناك اختلافات بين الجنسين فيما يتعلق بأسباب اختيار طب الأسنان، وكانت هناك زيادة ملحوظة في عدد القبول للذكور، وبهذا نختلف مع نتائج بعض الدراسات في الهند ونيجيريا [5٫31]. فكلا الجنسين في دراستنا أراد أن يعمل عمًلا مهنيًا خاصًا به، كما مال نحو العمل بيده، كما تأثر كل منهم بالأقارب أو الأهل، وتتفق هذه النتائج مع ما ذكر في بعض الأدبيات [5–7]، في حين ازداد طلب الإناث على طب الأسنان بسبب مجموع علامات الثانوية العامة، لأن هذه المهنة لائقة اجتماعيًا، وتسمح بساعات عمل أكثر مرونة، مما قد يجعلهن يستطعن تحقيق التوازن بين مهنتهن ومتطلبات حياتهن اليومية وهذه التقارير مشابهة للاستنتاجات التي ظهرت في دراسات أخرى [5٫31] حيث اختار المزيد من الإناث طب الأسنان بسبب ساعات العمل المحددة. كما اختلفت أسباب اختيار هذه المهنة بين الطلاب بحسب المدارس الثانوية التي تخرج منها الطلاب، حيث كان الميل لها أكبر لأسبابها الاجتماعية لدى المتخرجين من المدارس الثانوية الخاصة ومدارس خارج القطر، وربما يعود ذلك إلى طبيعة ظروف الحياة الاقتصادية والتي تكون أكثر جودة عادة لدى طلاب هؤلاء المدارس. كما لاحظت هذه الدراسة أن معظم الآباء كانوا مثقفين وحملة شهادات جامعية، وعملت الأمهات في مجالات تخصصية. إن الاستنتاجات التي وجدتها الدراسة الحالية عن ديموغرافية عائلات الطلاب كانت مختلفة عن تلك التي وجدتها في البلدان الغربية الصناعية. وعندما نقارن نتائج هذه الدراسة مع التقارير المنشورة في دراسات منشورة أخرى [2٫5٫6٫8] فإننا نجد نسبة أكبر من الطلاب في هذه الدراسة ينحدرون من عائلات تعمل في مهن اختصاصية، ووالَدْين مثقفين بشكل جيد. ويمكن تفسير ذلك بأن معظم الأهالي الناجحين في أعمالهم يلعبون دورًا رئيسيًا في عملية اتخاذ أبنائهم لقرار اختيار هذه المهنة. على كل حال، لم يكن هناك من ارتباط هام احصائيًا بين الحالة الثقافية للأم أو للأب أو لكليهما والمهنة التي يختارها الطالب بالمرتبة الأولى. وفي سياق السعي لإيصال خدمات صحية فموية فعالة لأقصى الحدود، فإنه من المهم أيضًا البحث في الممارسة العملية وتحديد احتياجات أطباء الأسنان. الخلاصة وأخيرًا، تبين من الدراسة أن الدوافع لاختيار طب الأسنان في هذه المجموعة من الطلاب متعلقة بصورة طب الأسنان كوسيلة لتحقيق الأهداف الشخصية، وهذا يتضمن فرص عمل جيدة، والمردود المادي الجيد، والعمل المستقل، والسمعة الحسنة. وندعو إلى إجراء دراسات أخرى لتقييم مدى تقبُّل الطلاب الذين لم يكن طب الأسنان رغبتهم الأولى لهذا الاختصاص، كما ننصح أن يتم تشجيع خريجي المدارس الثانوية لرؤية طب الأسنان كمهنة من المصدر الأساسي، إما عبر الممارسة العامة أو عبر أيام مخصصة لهذه الغاية في كليات طب الأسنان أو المشافي. ويجب أن يؤكد الموجهون على التفاصيل وتنوع أنماط العمل في طب الأسنان بالإضافة إلى عوامل أخرى مثل التحدي الثقافي والمهارة اليدوية المطلوبة التي يجب أن يتمتع بها طبيب الأسنان أكثر من اهتمامه بالمردود المالي. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 515 Review Appraisal of the research grant schemes of the World Health Organization Regional Office for the Eastern Mediterranean: the way forward O. Shideed 1 and N. Al-Gasseer 2 ABSTRACT One way that the World Health Organization Regional Office for the Eastern Mediterranean (EMRO) promotes the important area of health research is by providing research grants within the Region. A desk review of 2 of the EMRO-supported research grant schemes was done to assess: the selection process of the research proposals, the priority areas, country data and information on the principal investigator. The 2 schemes were: EMRO grant for Research in Priority Areas of Public Health, started in 2002, and the EMRO and Organization of Islamic Conference Standing Committee for Science and Technological Cooperation Grant for Research in Applied Biotechnology & Genomics in Health, started in 2004. The paper proposes the following recommendations to enhance benefit from the grant process: create a critical mass of researchers through joint collaboration in proposals and mentoring; instigate a more rigorous process to disseminate the call for proposals more widely and effectively; and include relevant stakeholders in the identification of priority areas for research and overall monitoring of the process. 1Research Policy and Cooperation Unit, World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt. Received: 05/01/12; accepted: 20/03/12 ماملأل قيرطلا :طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم يميلقلإا بتكلما نم ةم َّدقلما ةيثحبلا حنلما جمانرب مييقت يرصقلا ةميعن ،ديدش لاع ةيحصلا ثوحبلا زيزعتل طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم يميلقلإا بتكلما اهجهتني يتلا قرطلا دحأ وه ميلقلإا في ةيثحبلا َحنلما ميدقت :ةصلالخا تاحترقلما رايتخا ةيلمع :مييقتل يميلقلإا بتكلما اهمعد يتلا ةيثحبلا َحنلما نم ينمجانبرل ةيبتكم ةعجارم ناتثحابلا ترجأ دقو .ةمالها تلااجلما في بتكلما ةحنم :اهم ماهتعجارم تتم ناذللا نامجانبرلا ناكو .سييئرلا ثحابلا نع تامولعلماو ،ةيرطُقلا تايطعلماو ،ةيولولأا تاذ تلااجلماو ،ةيثحبلا ةحصلا ةمظنلم يميلقلإا بتكلما ينب ةكترشلما ةنجللا ةحنمو ،2002 ماع تأدب يتلاو ةيولولأا تاذ ةيمومعلا ةحصلا تلاامج في ثوحبلل يميلقلإا تايصوتلا لىإ ةيملعلا ةقرولا تضفأ دقو .2004 ماع تأدب يتلاو ،ينقتلاو يملعلا نواعتلاب ةينعلما يملاسلإا رتمؤلما ةمظنلم ةمئادلا ةنجللاو ،ةيلماعلا ةوعدلا شرن ةيلمع ليعفت ؛هيجوتلا فيو تاحترقلما في كترشلما نواعتلا قيرط نع ينثحابلا نم ةجرح ةلتك دايجإ :َحنلما نم دئاوفلا ميظعت لجأ نم ةيلاتلا .دصرلا ةيلمع لممجو ةيثحبلا ةيولولأا تاذ تلااجلما ديدتح في ةحلصلما تاذ ةينعلما تاهلجا جاردإو ؛رثكأ ةيلاعفو عسوأ قاطن لىع تاحترقلما ميدقتل Évaluation et orientations futures des programmes de subventions à la recherche du Bureau régional de l'Organisation mondiale de la Santé pour la Méditerranée orientale RÉSUMÉ Les subventions à la recherche dans la Région sont l'une des méthodes choisies par le Bureau régional de l'Organisation mondiale de la Santé (OMS) pour la Méditerranée orientale pour promouvoir le domaine essentiel de la recherche en santé. Une analyse documentaire des deux programmes de subventions à la recherche soutenus par le Bureau régional a été réalisée pour évaluer les points suivants : le processus de sélection des propositions de recherche, les domaines prioritaires, les données de pays et les informations concernant le chercheur principal. Les deux programmes étaient les suivants : subventions à la recherche dans les domaines prioritaires de la santé publique (lancé en 2002), et subventions conjointes destinées à soutenir la recherche en biotechnologie et génomique appliquées à la santé, accordées par le Bureau régional et le Comité permanent pour la coopération scientifique et technologique de l’Organisation de la Conférence islamique (qui existe depuis 2004). L'article énumère des recommandations susceptibles de renforcer les effets bénéfiques des programmes de subvention : former un nombre suffisant de chercheurs grâce à une collaboration sur les propositions et au tutorat ; instaurer un processus plus rigoureux pour diffuser les appels à propositions plus largement et plus efficacement ; et impliquer les parties intéressées dans l'identification des domaines prioritaires pour la recherche et le suivi global du processus. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 516 Introduction The research for health landscape has changed since the introduction of the term “10/90 gap” in 1990 [1]. Overall investments in research for health have increased. However, this is coupled with an epidemiological transition in many countries burdening them with increased chronic diseases while still struggling with infectious and commu- nicable diseases. Nevertheless, the term “10/90 gap” is still valid referring to the mismatch between the investments in research for health and the emerg- ing needs of the communities. This is further referred to in the WHO strategy on research for health, “Investments in health research are insufficient; further, they are not appropriately directed to- wards tackling priority health problems” [2]. The Eastern Mediterranean Region has witnessed an increase in invest- ments in research in general; invest- ment in the Islamic Republic of Iran rose from 0.59% of GDP in 2006 to 4% today and in Tunisia from 0.03% in 1996 to 1.25% in 2009, and Qatar aims to spend 2.8% of GDP on research by 2015 [3]. Nonetheless, the proportion of investment allocated to research for health is still less than desired. As part of the World Health Or- ganization’s (WHO) mandate as a knowledge-based organization, and in accordance with its constitution, one of its important functions is, “to promote and conduct research in the field of health” [4]. Additionally, in the Elev- enth General Programme of Work, one of WHO’s 6 core functions is, “Shaping the research agenda and stimulating the generation, translation and dissemina- tion of valuable knowledge” [5]. The WHO Regional Office for the Eastern Mediterranean (EMRO) has continuously promoted and high- lighted the importance of research for health in providing the evidence neces- sary to inform health policy, planning and practice. It is within this context that since the establishment of the Ad- visory Committee on Health Research (ACHR) in EMRO in 1976 (known then as the Regional Advisory Commit- tee on Biomedical Research), EMRO has supported a considerable number of research proposals received from researchers across the Region [6]. The priority areas for such research have focused on the emerging needs of the countries in the Region. The purpose of this paper is to provide an overview of the EMRO- supported research grants. The review was initiated as part of the process towards developing the strategic direc- tions for scaling up research for health in the Eastern Mediterranean Region, which were endorsed by the ministers of health during the 58th Session of the Regional Committee in October 2011 [7]. The initial results of the review were presented during the 25th Session of the Advisory Committee on Health Research (ACHR) in October 2010, for its deliberations and recommenda- tions [8]. Currently there are 3 research grant schemes through which EMRO awards funding to researchers from the Region: one is administered and managed by the Division of Communicable Diseases (DCD), and the other 2 are adminis- tered and managed by the Research Policy and Cooperation unit (RPC). EMRO grant for Tropical Disease Research, DCD, 1992– present The Tropical Disease Research (TDR) grants focus on tropical diseases rel- evant to the Region, namely malaria, schistosomiasis, tuberculosis, leishma- niasis and lymphatic filariasis. These areas were further expanded in 2002 to include other communicable diseases: HIV/AIDs and sexually-transmitted diseases, vaccine-preventable diseases, haemorrhagic fevers, brucellosis, men- ingitis and echinococcosis [9]. The objectives of the grant are to: strengthen operational research in tropical and other communicable diseases in the Re- gion; support research that contributes to the prevention and control of tropi- cal and other communicable diseases; and strengthen the research capacity of researchers in the Region. In response to the previous 16 calls for applications for the EMRO TDR grants from 1992 to 2008, 346 propos- als have been funded in the Region, out of a total of 2341 proposals submitted, a funding rate of 15% [9]. The researchers are granted 12 months to conduct their research projects or it may be consid- ered the first phase (12 months) of a 24-month project, with funding of up to US$ 20 000. EMRO grant for Research in Priority Areas of Public Health, RPC, 2002–present The main objective of the grant for Re- search in Priority Areas of Public Health (EMRPPH) is to enhance and pro- mote the sustainability and efficiency of health systems in the countries of the Region. The specific objectives are to: generate knowledge relevant to local priority problems and issues of public health importance with special emphasis on health systems research; help in capacity building for research through learning by doing and hands on training; strengthen the link between re- search and policy/decision making; and enhance the exchange of experiences between the countries in the region. The EMRPPH grant is open to all researchers in health from the Region, through a competitive selection pro- cess. The researchers are granted ap- proximately 9 months to conduct their research projects, with funding of up to US$ 10 000. The announcement process for the calls has been done by: email to all technical units in EMRO requesting them to share the call with interested researchers and scientists; email to WHO Representative Offices (WRO) in Member States requesting them to inform the Ministry of Health, طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 517 WHO Collaborating Centres, academ- ia, medical and public health research institutes, and other interested partners; email to all researchers who have submit- ted proposals to the previous calls; and announcement on the EMRO website. EMRO and COMSTECH Grant for Research in Applied Biotechnology & Genomics in Health, RPC, 2004–present The EMRO and Organization of Islamic Conference Standing Committee for Science and Technological Cooperation (COMSTECH) Grant for Research in Applied Biotechnology & Genomics in Health (RAB&GH) was initiated in response to Regional Committee resolution EM/RC51/R.11 which requested EMRO to, “facilitate and provide opportunities for exchange and sharing of knowledge and information on genomics technology” and, “foster partnerships among the main stakehold- ers and contribute to capacity-building and resource mobilization” [10]. The main objective of the grant is to focus on the application of biotech- nological and genomic techniques to strengthen health systems and improve health care. Additionally, one of the main purposes is to support regional collaboration for the conduct of applied research. The collaboration among re- searchers from different organizations/ institutions in the countries is expected to: synergize the process to overcome obstacles and manage the necessary interdependencies involved in research in genomics and biotechnology; make services more accessible and effective; increase the integration of research re- sults into other sectors (e.g. industry, government agencies or departments, community groups, universities) and offer opportunities to aid the dissemi- nation of results; diversify capability to accomplish tasks (e.g. provide op- portunities for trainees to spend time in different laboratories, exchange of data and experience between institutions and sectors); and foster ties between researchers in the academic, commu- nity, private and public sectors. The re- searchers are granted approximately 18 months to conduct their research pro- jects, with funding up to US$ 15 000. The main focus of this paper is a review of the latter 2 grant schemes, ad- ministered by the RPC unit in EMRO. Methods A desk review was conducted of the RPC unit’s grant database. Informa- tion for both schemes, EMRPPH and RAB&GH, was retrieved. The data col- lected included: title of the submitted proposal, country of submission, name of the principal investigator (PI), and the funds granted for the selected proposals. The priority area which the proposal ad- dressed for the EMRPPH grant was not mentioned in the database, therefore, as an alternative, 3 categories (health systems and services, health promotion and protection, and communicable diseases) were identified and the pro- posals were classified based on the title provided. For some cases, the title alone was not indicative of the priority area that the proposal addressed and was thus marked as “not specified”. With regard to the 2010–2011 rounds for both schemes, more infor- mation was retrieved from the applica- tion forms of the submitted proposals. In addition to the information men- tioned above, gender and discipline of the PI were obtained. Additionally, for the EMRPPH grant, the specific priority areas as stated by the PI were consid- ered and for the RAB&GH grant, the age of the PI was noted. Results EMRPPH 2002–2008 In response to the previous 6 calls for applications for the EMRPPH grant 2002–2008, 143 proposals were funded in the Region (Figure 1), out of 935 submitted proposals (a funding rate of 15.3%). It is also evident from Figure 1 that in some cases the same research- ers were funded in different years. As mentioned in the methods section, the priority area was not stated in the data available for 2002–2008, so the title of the proposal was used as a proxy for this. Throughout the years, the majority of the proposals addressed health protec- tion and promotion areas (noncom- municable diseases, mental health and substance abuse, nutrition, maternal and child health, environmental de- terminants of health, etc.) followed by health systems and services (Figure 2). Review process of EMRPPH 2002– 2008 submissions Internal review: All the proposals re- ceived are screened by the RPC unit and those qualifying for the grant (meeting the eligibility criteria set out in the guidelines and application form) are reviewed to assess relevance to the specified priority areas and are scored on an evaluation form. Final selection committee: The quali- fying proposals are sent to the final selection committee, an independent committee formed of experts from the Region. The proposals are reviewed to assess the overall merit of the proposed research, and the committee members provide their feedback regarding the proposals assigned to them. The final recommendations are set and accord- ingly the proposals to be funded are identified. The selected proposals are then reviewed to ensure ethical consid- erations have been taken into account in research involving human partici- pants. The ethical review is carried out by a separate committee, the EMRO Ethics Review Committee. EMRPPH 2010–2011 In response to the seventh call for research protocols for the EMRPPH grant for 2010–2011, 84 proposals were received from researchers in the Region (Figure 3). EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 518 Review process of EMRPPH 2010– 2011 submissions A different approach was followed in the review process of the applications sub- mitted for the 2010–2011 EMRPPH grant. Internal review: all the proposals re- ceived were screened and those qualify- ing for the grant were categorized and sent to the relevant technical unit within the various divisions of the Regional Office. Proposals were reviewed by the technical unit to assess relevance to the specified priority areas and overall merit of the study, scored on an evaluation form. Responses were received from the technical units and summarized and proposals which were recommended by the technical units were sent for ex- ternal review. External review : a number of prominent researchers and academi- cians from the Region were identified and an independent committee formed, with multidisciplinary mem- bership and gender balance. The review was done virtually (through Ira n ( IR) Pa kis tan Eg yp t Le ba no n Su da n M or oc co Ye me n Om an Jo rd an Sa ud i A rab ia Pa les tin e Tu nis ia So ma lia Sy ria n A rab Re pu bli c 223444 2 2 2 5 2 6 2 6 5 10 317 13 1027 12 Funded Same principal investigator Figure 1 Distribution of funded proposals (n = 143) by member country: EMRO grant for Research in Priority Areas of Public Health 2002–2008 Figure 2 Distribution of priority areas of proposals submitted (n = 935) by year: EMRO grant for Research in Priority Areas of Public Health 2002–2008 2002 2003 2004 2006 2007 2008 70 60 50 40 30 20 10 0 % Communicable diseases Health protection and promotion Health systems and services Not specified طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 519 emails and teleconference) in this round. The short-listed proposals were sent to the committee members for review; each proposal was sent to 2 re- viewers. The proposals were reviewed to assess the overall merit of the proposed research and the scientific soundness of the proposal. Once the final recom- mendations of the external reviewers were received, the proposals selected for funding were compiled. The ethical review process is similar to that men- tioned earlier. Descriptive characteristics of EMRPPH 2010–2011 submissions A total of 84 proposals were received from researchers from 17 Member States of the Region (Figure 3). There was a gender balance with regard to the PI: in 55% of the submissions the PI was male. Age data were available for 60% of the PIs; in some cases the date of birth was not stated so an approximate calculation was made based on the years of educa- tion stated. The average age of PIs was 45.5 years (range 29–60 years). The PIs came from a broad range of disciplines (data were available for 66% of the submitted proposals): 35% had a background in public health, 31% in medicine, 13% in nursing, 7% in biomedical sciences, 5% each in pharmacology and nutrition and 4% in dentistry. The distribution of the submitted proposals among the priority areas as- signed for the EMRPPH 2010–2011 grants, as mentioned by the PIs in the application were: • Climate change and environmental health (5 proposals) • Preparedness, risk reduction and re- sponse to emergencies and disasters: man-made and natural (1 proposal) • Knowledge generation leading to evidence-informed health policy (36 proposals) • Assessment of the burden of non- communicable diseases: cancer, diabetes, cardiovascular and renal dis- eases (23 proposals) • Development and sustainability of community ownership in socioeco- nomic and health-related interven- tions (1 proposal) The remaining 18 proposals sub- mitted were categorized as “unspeci- fied by PI”, i.e. those that did not have a specified priority area indicated on the application form, yet after review were found to address at least one of the priority areas. Priority area identification for the EMRPPH has used several methods over the years. In some instances priori- ties were set by: a task force assembled for this reason; contribution of techni- cal units in EMRO which identified priority areas relevant to their work; discussions during ACHR meetings; emerging global and regional priorities. RAB & GH 2004–2008 In response to the previous 3 calls for applications for the EMRO- COMSTECH Grant for RAB&GH 2004–2008, 48 proposals were funded in the Region, out of 212 submitted proposals (a funding rate of 23%). Review process of RAB&GH submis- sions Initial review: all the proposals received are initially screened by the RPC unit, and those qualifying for the grant (meeting the eligibility criteria set out in the guidelines and application form) are short-listed. External review: this is done by a se- lection committee identified jointly by WHO/EMRO and COSMTECH and comprising renowned health research- ers from the Region who are special- ists in the research areas specified in the RAB&GH grant. Each member of Figure 3 Distribution of submitted proposals (n = 84) by member country and sex of the principal investigator: EMRO grant for Research in Priority Areas of Public Health 2010–2011 Eg yp t Ira n ( IR) Pa les tin e Jo rd an Su da n Un ite d A rab Em ira tes Le ba no n Pa kis tan Ye me n M or oc co Sy ria n A rab Re pu bli c So ma lia Ba hr ain Dj ibo ut i Ira q Lib ya Tu nis ia 111112 1 232 2 3 13 2 2 4 5 2 5 2 6 4 7 5 8 8 Male Female N o. o f p ro po sa ls su bm itt ed EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 520 the committee is requested to critically examine the proposals pertaining to his/her area of specialization either as primary or secondary reviewer. A meet- ing of the selection committee is then held and the proposals are presented by the reviewers and discussed by the committee members. Each proposal is scored and the decision for funding is finalized. The members of the selection committee usually consider the merit of the research protocol, degree of collabo- ration and expected impact of the pro- posed research on national and regional health issues. The ethical review process is similar to that mentioned earlier. RAB&GH 2010–2011 In response to the fourth call for applica- tions for the EMRO-COMSTECH 2010–2011, 30 proposals were received from researchers from the Region. All the submitted proposals were of a col- laborative nature except for one, which was an individual submission. Descriptive characteristics of the RAB & GH 2010–2011 submissions The 30 proposals received were from researchers from 6 Member States (Figure 4). For 53% of the submis- sions the PI was a male. Age data were available for 60% of the PIs; in some cases the date of birth was not stated so an approximate calculation was made based on the years of education stated. The average age of the PIs was 51 years (range 31–73 years). The PIs of the submitted proposals came from a broad range of disciplines (the data were available for 90% of the PIs) with the majority from medical and clinical sciences backgrounds (78%). Medical and clinical sciences here refer to; bio- technology (n = 2), molecular biology (n = 6), microbiology (n = 4), organic chemistry (n = 1), biochemistry (n = 2), parasitology (n = 1) and genetics (n = 2). The other 2 disciplines were medicine and public health with 18.5% and 3.5% respectively. Discussion As part of its commitment to promot- ing research for health in the Region through providing both technical and financial support, EMRO has managed to reach a broad range of researchers in the Region. The research grants that EMRO provides to researchers have also contributed to capacity-strength- ening in terms of developing research- ers’ ability to conduct research from the design to dissemination phase. The submitted proposals varied by country, and in some instances were from the same researchers. This may indicate a number of issues: the dissemination of the call for proposals is limited and therefore reaching the same audiences; the amount of the grant fund is not at- tractive for researchers; the priorities are of interest to a specific group; the language of the grant (English) may pose a barrier; or this may be a reflection of research for health capacity in the country. Increased attention needs to be given to countries with no or few sub- missions to assess the reasons for low submissions and address impediments, if any. From the desk review, there was neither documented nor accessible information on the ability or success of EMRO in reaching researchers in coun- tries that have low or no submissions. Furthermore, the relationship between EMRO’s active work in capacity-build- ing in research methodology and the actual conducting of research is difficult to assess with the current degree (num- ber and quality) of submissions. Setting priorities for research for health is vital to ensure maximum ben- efit from funds allocated for research for health [11]. Priority setting is a complex process as there are many factors (e.g. availability of funds, feasibility, public health benefit, etc.) that contribute to it, and thus “one-size fits all” is not applica- ble in this case. There is a need to revisit the various processes EMRO has been following in setting research for health priorities and identify a more systematic Figure 4 Distribution of submitted proposals (n = 30) by member country and sex of the principal investigator: grant for Research in Applied Biotechnology & Genomics in Health 2010–2011 4 7 6 2 2 5 2 1 1 Female Male Pa kis tan Eg yp t M or oc co Ira n ( IR) Ba hr ain Pa les tin e N o. o f p ro po sa ls su bm itt ed طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 521 approach taking into consideration the checklist proposed by Viergever et al. where they identify 9 common themes of good practice for identifying research for health priorities [12]. Moreover, in both the global and regional research for health strategies, the 2010 WHO Strategy on research for health [2] and the 2011 stra- tegic directions for research for health in the Eastern Mediterranean Region [7] respectively, one of the goals is priorities. This goal refers to setting priorities for re- search for health that respond to national, regional and global needs. The following recommendations for the development of the EMRPPH pro- cess are proposed based on this review and in line with the deliberations of the ACHR members during the Commit- tee’s 25th session and research for health stakeholders during a consultative expert meeting in preparation of the strategic di- rections for scaling up research for health in the Eastern Mediterranean Region • Involve stakeholders in the grant pro- cess from the beginning (i.e. in selec- tion of priority areas, screening of the proposals, following the progress, etc.). • Provide grants with the aim of creat- ing a critical mass of researchers who can transfer the knowledge and skills of grant proposal writing for research for health, by strengthening research capacity through direct mentoring of researchers at the national level on writing research proposals. • Provide technical support for re- searchers, as needed, with the grant application, completion of the grant, and dissemination and utili- zation of the results. • Encourage experienced researchers to collaborate with newcomers in developing joint research propos- als. • Encourage and support researchers to disseminate their research results with concerned individuals and in- stitutions at the national level, and regional/global level as appropriate. The main focus of this paper has been on the process of identifying the priorities, announcing the call and selecting proposals for funding. It is strongly recommended that this work to be further strengthened by conduct- ing a standardized assessment of the quality of the research implemented, whether it achieved the specified objec- tives of the proposal, and the impact that this research has had, whether at national or regional levels. References 1. Health Research: essential link to equity in development. New York, The Commission on Health Research for Development, Oxford University Press, 1990. 2. World Health Organization’s role and responsibilities in health research. Geneva, World Health Organization, 2010 (WHA 63/22) (http://apps.who.int/gb/ebwha/pdf_files/WHA63/ A63_22-en.pdf, accessed 28 March 2012). 3. Knowledge, networks and nations: Global scientific collabora- tion in the 21st century. London, The Royal Society, 2011. 4. Constitution of the World Health Organization. In: Basic docu- ments, 45th ed. (Suppl.). Geneva, World Health Organization, 2006. 5. Engaging for health: Eleventh General Programme of Work 2006–2015: a global health agenda. Geneva, World Health Organization, 2006 (http://whqlibdoc.who.int/publica- tions/2006/GPW_eng.pdf, accessed 28 March 2012). 6. World Health Organization, Regional Office for the East- ern Mediterranean. Research Policy and Cooperation. Re- newed regional Strategy for Health Research for Development (http://www.emro.who.int/rpc/policy.htm, accessed 28 March 2012). 7. Fifty-eighth Session of the Regional Committee for the Eastern Mediterranean, September 2011. Technical paper. Strategic di- rections for scaling up research for health in the Eastern Medi- terranean Region (EM/RC58/6), 2011 (http://www.emro.who. int/rc58/PDF/EMRC58_06en.pdf, accessed 28 March 2012). 8. Twenty-fifth session of the Eastern Mediterranean Advisory Com- mittee on Health Research: report to the Regional Director. Cairo, World Health Organization, Regional Office for the Eastern Mediterranean, 2010. (http://www.emro.who.int/rpc/ACHR. htm, accessed 28 March 2012). 9. World Health Organization, Regional Office for the Eastern Mediterranean. Operational research in tropical and com- municable diseases: History and progress. Cairo [webpage] (http://www.emro.who.int/tdr/history.htm, accessed 28 March 2012). 10. Fifty-first Session of the Regional Committee for the Eastern Mediterranean Cairo, Egypt, 3–6 October 2004. Resolutions. Development and use of genomics and biotechnology for public health (Resolution EM/RC51/R.11) (www.emro.who. int/governance/PDF/RC51_Resolutions.pdf , accessed 28 March 2012). 11. Bamako call to action on research for health: Strengthen- ing research for health, development and equity. From the Global Ministerial Forum on Research for Health Bamako, Mali, November 17–19, 2008 (http://www.who.int/rpc/ news/BAMAKOCALLTOACTIONFinalNov24.pdf , accessed 28 March 2012). 12. Viergever R et al. A checklist for health research priority setting: nine common themes of good practice. Health Research Policy and Systems, 2010, 8:36. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 522 Short communication Crimean–Congo haemorrhagic fever outbreak investigation in the Western Region of Afghanistan in 2008 J. Mofleh 1 and A.Z. Ahmad 1 ABSTRACT Crimean–Congo haemorrhagic fever (CCHF) is a life-threatening viral haemorrhagic fever. This paper reports on the first multifocal outbreak recorded in the Afghanistan. The outbreak was detected in 2008 in the Western Region of the country and 30 cases (17 males and 13 females) were detected between 10 July and 22 October 2008. Standard case definitions based on World Health Organization sources were used. Most of the cases (27) occurred in Herat province; 25 were aged between 18–55, 1 was > 55 years and 4 were12–18 years (median age was 27 years). The case fatality rate was 33%; 41% among males and 23% among females (P = 0.29). Significantly more patients infected by contact with meat and body fluids died that those whose contact was through animal husbandry or ticks (P = 0.0048). Of the 30 cases, 33 close contacts were traced; 3 were positive for CCHF IgM with no symptomatic evidence of the disease. 1Disease Early Warning System, Afghan Public Health Institute, Ministry of Public Health, Kabul, Afghanistan (Correspondence to J. Mofleh: jmofleh@yahoo.com). Received: 25/08/10; accepted: 29/03/11 2008 ماع ،ناتسناغفأ نم ةيبرغلا ةقطنلما في ةيفزنلا وغنوكلا-مرقلا ىحم ةيشاف ِّيصقت دحمأ فيرظ نايبركأ ،حلفم داوج .ناتسناغفأ في رؤبلا ةددعتم ةيشاف لوأ نع ريرقت ةيملعلا ةقرولا هذه فيو .ةايحلل ةددهم ةيفزن ةيسويرف ىحم يه ةيفزنلا وغنوكلا-مرقلا ىحم :ةصلالخا ويلوي/زوتم 10 ينب ةترفلا في )ءاسنلا نم 13 ،روكذلا نم 17( ةلاح 30 تفشتكا امدنع ناتسناغفأ نم ةيبرغلا ةقطنلما في 2008 في ةيشافلا تفشتكا دقو في )ةلاح 27( تلاالحا رثكأ تعقو دقو .ةيلماعلا ةحصلا ةمظنم رداصم لىإ ًادانتسا ةلالحا فيرعت يرياعم تَمِدخُتساو .2008 ربوتكأ/لولأا نيشرت 22و طيسو( ةنس 18و 12 يَرمع ينب تلااح عبرأ تناكو ،ةنس 55 رمع نم بركأ ةدحاو ةلاح تناكو ،ةنس 55-18 رمع في ةلاح 25 تناكو ؛تاراه ةقطنم نيذلا ضىرلما ينب تعقو تايفولا رثكأ .)P= 0.29( ثانلإا ينب %23 و ،روكذلا ينب %41 تناك ذإ ؛%33 تلاالحا ةتامإ ل َّدعم غلبو .)ةنس 27 ناك رمعلا ىرج تلااح ثلاث ،ةلاح ينثلاثلا ينب نمو .)P=0.0048( دارقلل ةجيتن وأ رئاظلحا في سماتلل اوضرعت نيذلاب ًةنراقم ،مسلجا لئاوسو موحللا اوسملا .ضرلما ضارعأ لىع تانِّيب نودب )CCHF IgM( ةيفزنلا وغنوكلا – مرقلا ى َّملح مإ يعونلا يعانلما ينبولغلل ةيبايجإ تناك تلااح ثلاث ؛اهؤافتقا Investigation de la flambée de fièvre hémorragique de Crimée-Congo dans la région ouest de l'Afghanistan en 2008 RÉSUMÉ La fièvre hémorragique de Crimée–Congo est une fièvre hémorragique virale qui engage le pronostic vital. Le présent article traite de la première flambée à foyers multiples enregistrée en Afghanistan. La flambée a été détectée en 2008 dans la région ouest du pays et 30 cas (17 hommes et 13 femmes) ont été dépistés entre le 10 juillet et le 22 octobre 2008. Les définitions normalisées des cas établies par l'Organisation mondiale de la Santé ont été utilisées. La plupart des cas (27) étaient situés dans la province d'Herât ; 25 patients étaient âgés de 18 à 55 ans, un patient avait plus de 55 ans et 4 patients avaient entre 12 et 18 ans (âge médian 27 ans). Le taux de létalité était de 33 % : 41 % chez les hommes et 23 % chez les femmes (P = 0,29). La mortalité des patients infectés par contact avec de la viande ou des fluides corporels était nettement plus élevée que celle des patients ayant contracté la maladie par des animaux d'élevage ou des tiques (P = 0,0048). À partir des 30 cas, 33 contacts rapprochés ont été suivis ; les analyses de trois d'entre eux étaient positives pour les IgM spécifiques de la fièvre hémorragique de Crimée-Congo malgré l'absence de symptômes de la maladie. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 523 Introduction Crimean–Congo haemorrhagic fever (CCHF) is a severe vector-borne viral haemorrhagic fever. The causative agent belongs to the genus Nairovirus in the Bunyaviridae family. Infection is transmitted to humans by Hyalomma ticks or by direct contact with the blood or tissues of infected humans or viraemic livestock [1]. It is primarily a zoonosis which sporadically causes cases and outbreaks of CCHF in humans. CCHF infects a wide range of domestic and wild animals. A se- roprevalence rates of 13%–36% have been reported in animals [2,3].The geographical distribution of the virus, like that of its tick vector, is widespread; Africa, Asia, the Middle East and East- ern Europe [4,5]. CCHF is mainly found in rural areas and transmission is associated with poverty and poor medical facilities [6]. The disease has a sudden onset of fever, malaise, weakness, irritability and headache, and severe limb and loin pain. Patients have marked anorexia. Vomit- ing, abdominal pain and diarrhoea oc- casionally occur. Face and chest flushes and conjunctival injection are reported at the early stages of the disease de- velopment. Haemorrhagic symptoms include enanthem of soft palate, uvula and pharynx, and a fine petechial rash spreading over the chest, abdomen and rest of the body; sometimes large purpuric areas are reported. In serious and fatal cases, bleeding from the gums, nose, lungs, uterus and intestine are re- ported; these manifestations are often associated with severe liver damage. Haematuria and albuminuria are com- mon but usually not severe [5]. Blood oozing is not uncommon [6]. Fever is constantly elevated from 5 to 12 days or may be biphasic [5]. Other findings are leukopenia with marked lymphopenia. Thrombocytopenia is common. The case fatality rate is reported to be about 30% [4] but ranges of 2%–70% have been reported [6–8]. Most of the fatalities occur 5–14 days after onset of the disease [5]. The disease has the potential for nosocomial spread [5]; hospital trans- mission of disease is well documented in the Islamic Republic of Iran [6]. Early diagnosis of CCHF is impor- tant for case management and protec- tion of medical staff. Convalescence is prolonged [1,2]. Supportive therapy is the corner- stone of treatment [4] as no specific treatment is available. A systematic re- view and meta-analysis found that stud- ies conducted on CCHF and the use of ribavirin were heavily confounded, and the one trial carried out had limited power [9]. However intravenous ribavi- rin and convalescent plasma with a high neutralizing antibody titre are reported to be a useful treatment [5]. Oral ribavi- rin therapy has also been reported to be effective [10]. Afghanistan is located in the activity range of the Hyalomma tick and experi- ences the disease regularly. However, in 2008 the first multifocal outbreak was recorded in the country. The outbreak was detected in the Western Region of Afghanistan following trade of 8000 sheep and goats from the northern region of the country. The Western Region consists of 4 provinces of Herat, Badghis, Ghor and Farah (Figure 1). The total population of the western region is 3 155 600. Herat is the largest province in this region with a popula- tion of 1 642 700. As this is the first multifocal out- break detected in the Western Region of the country, it is very important to detect all cases and discover why the outbreak happened. Herat province is the second largest province in Af- ghanistan and borders 2 countries, the Islamic Republic of Iran in the west and Turkmenistan in the north, and other provinces of the country that lead to the main cities in the south of the country; it also acts as a meat supplier to the aforementioned areas. In particular, illegal trade of sheep and goats between Afghanistan, Islamic Republic of Iran and Turkmenistan is a threat to all 3 countries. Therefore a thorough out- break investigation was necessary. The aim of this paper therefore is to report on the CCHF outbreak, the epidemi- ology of the disease and the control measures taken. Methods The first case of CCHF reported by the Disease Early Warning System (DEWS) was from Zindajan district of Herat on 10 July 2008. This case was found through passive surveillance. As a result, the system was sensitized and the case definition was sent to all health facilities so as to detect new cases of CCHF throughout the region. The rest of the cases were found through ac- tive case finding and surveillance in the affected districts. Demographic data and information on medical history, exposure history, treatment, contacts and travel history of all cases and con- tacts were collected. The team used the standard case definitions from World Health Organization sources [11,12]. Suspected case: Patient with sudden onset of illness with high-grade fever > 38.5 °C for more than 72 hours and less than 10 days, especially in CCHF- endemic areas and among those in contact with sheep or other livestock (shepherds, butchers and animal han- dlers). Probable case: This was defined as follows. • Suspected case with acute history of febrile illness ≤ 10 days AND • Thrombocytopenia < 50 000/mm3 with any 2 of the following: petechial or purpuric rash, epistaxis, haemate- mesis, haemoptysis, blood in stools, ecchymosis, gum bleeding, other haemorrhagic symptom AND • unknown predisposing host factors for haemorrhagic manifestations. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 524 Confirmed case: Probable case with positive diagnosis of CCHF in blood sample, performed in specially equipped high bio-safety laboratory, i.e. • Confirmation of the presence of IgG or IgM antibodies to the CCHF virus in serum by enzyme-linked immuno- sorbent assay (ELISA) • Detection of viral nucleic acid in spec- imen by polymerase chain reaction (PCR) • Isolation of the virus. Results During the period 10 July to 22 Oc- tober 2008, 30 cases of CCHF were found in 4 provinces of the Western Region of Afghanistan; 27 cases were detected in Herat province and 1 each in 3 other provinces of the region (Fig- ure 1). The first case of CCHF reported by Disease Early Warning System (DEWS) was from Zindajan district of Herat on 10 July 2008. Cases were found in Sar-e-Hadira area of Herat city and Aliabad village of Karoukh district. Later on cases were found in Gulran, Guzara, Injil, Kohsan, Rabat Sangi, Obeh, Shindand and Torgho- nidi districts of Herat, and Farah Rood district of Farah, Shahrak district of Ghor and Jawand district of Badghis province (Figure 1). Figure 2 show the epidemic curve indicating the peak around 20 August to 2 September. Based on epidemiological investigations, only 2 cases were sec- ondary cases (a nurse and a family con- tact); the rest (28 cases) were primary cases resulting from direct contact with animals or animal products. Median age of the cases was 27 years with a range of 12–70 years. The age category affected the most was the 18–55-year-olds, the productive age, and infection probably happened out- side of the home (Table 1). As regards sex, 43% of the cases were female. Most cases (93%) presented to the hospital with fever, 83% with headache, 77% with body pain and 70% with epistaxis. Treatment with ribavirin was started soon after diagnosis for 24 cases with a cure rate of 79% (P > 0.0088). All patients received supportive therapy (e.g. transfusion of fresh blood, symp- tomatic treatment and treatment with tranexamic acid). The rest of the pa- tients either did not come to the hos- pital or died before diagnosis. In all, 10 (33%) cases died due to complications of the disease; 2 of the deaths were not registered in the hospitals but, accord- ing to their relatives, they fitted the case definition and were also living in the area where CCHF was found. There- fore the team decided to include them in the list of deaths. A greater proportion of men died (41%) than women (23%) but the dif- ference was not statistically significant (P = 0.29). The death rate was higher in butchers and housewives compared with other occupations (Table 2). More patients infected by contact with meat and body fluids died that those whose contact was through animal husbandry or ticks (P = 0.0048) (Table 2). We also studied the association be- tween signs and symptoms of disease at the time of admission to the hospital and outcome of disease. Only epistaxis was significantly associated with a high- er frequency of death; 90% of cases who died in hospital had epistaxis at the time of admission (P = 0.021). Figure 1 Map of districts affected by Crimean–Congo haemorrhagic fever, Afghanistan 2008 Affected districts in Badghis province Affected districts in Herat province Affected districts in Farah province Affected districts in Ghor province Table 1 Number and frequency of cases of Crimean–Congo haemorrhagic fever in Western Region of Afghanistan by sex, 2008 Age group (years) Males Females Total No. % No. % No. % 12–18 2 6.7 2 6.7 4 13.3 18–55 14 46.7 11 36.7 25 83.3 > 55 1 3.3 0 0.0 1 3.3 Total 17 56.7 13 43.3 30 100 طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 525 All males who died were aged 18–55 years while there were deaths in females in all age categories. No children < 12 years presented with the disease. Of the 30 cases of CCHF, 33 close contacts were traced. All the contacts were examined and 3 were found positive for CCHF IgM but had no signs, symptoms or history of disease. All close contacts were family members, so all the positive contacts were family members. None of the contacts was treated and all of them survived. Measures implemented to control the outbreak An isolation ward was established 10 km from Herat city and full-time medi- cal teams were assigned to take care of the patients. Specimens were collected from all suspected cases and contacts and examined by the Central Public Health Laboratory for confirmation. Personal protective equipment, ribavirin and other medications and equipment for supportive therapy were provided to the clinicians. Universal and general infection prevention precau- tions were strengthened in the hospitals and health care facilities. The case defini- tion was circulated to all health facilities in the regions and staff orientation was conducted in the regional and provin- cial hospitals. Door-to-door health education campaigns and media campaigns were conducted in the affected villages, ar- eas and provinces to inform people of the risks and how they can protect themselves against the disease. The health education campaign was un- dertaken with the support of the Pro- vincial Health Director and Governor of Herat province. The same messages were broadcasted by television, radio and newspapers. Infection prevention/control ma- terials were distributed to the slaughter houses and illegal slaughter houses were all shut down by public health officials. Ruminants and their stables were de- contaminated in the affected villages and areas. Table 2 Socioeconomic data of cases who died from Crimean–Congo haemorrhagic fever in Western Region of Afghanistan by sex, 2008 (n = 10) Variable Males Females Total Mortality rate (%) Age group (years) 12–18 0 1 1 10 18–55 7 1 8 80 < 55 0 1 1 10 Occupation Butcher 2 0 2 20 Housewife 0 3 3 30 Farmer 1 0 1 10 Shopkeeper 1 0 1 10 Cook 1 0 1 10 Jobless 1 0 1 10 Daily wage worker 1 0 1 10 Type of contact Meat and body fluids 6 1 7 70 Animal husbandry 0 1 1 10 Tick bite 1 0 1 10 Unknown 0 1 1 10 July 1011 31 11 15 20 2 17 2923 15 1 222025 August September October 3 2 1 0 N o. 27 30 Figure 2 Epidemic curve of Crimean–Congo haemorrhagic fever outbreak in Western Region of Afghanistan,2008 EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 526 References 1. Wölfel R et al. Virus detection and monitoring of viral load in Crimean–Congo hemorrhagic fever virus patients. Emerging Infectious Diseases, 2007, 13(7):No.1097–1100. 2. Gonzalez JP et al. A fatal case of Crimean–Congo haemor- rhagic fever in Mauritania: virological and serological evidence suggesting epidemic transmission. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1990, 84(4):573–576. 3. Morrill JC et al. Serological evidence of Crimean–Congo haemorrhagic fever viral infection among camels imported into Egypt. Journal of Tropical Medicine and Hygiene, 1990, 93(3):201–204. 4. Crimean-Congo haemorrhagic fever. Geneva, World Health Organization, 2001 (WHO Fact sheet No. 208) (http://www. who.int/mediacentre/factsheets/fs208/en/index.html, ac- cessed 25 March 2010). 5. Heymann DL. Control of communicable diseases manual, 19th ed. Washington DC, American Public Health Association, 2008:59-61. 6. Boon NA, Colledge NR, eds. Davidson’s principle and practice of medicine, 20th ed. Oxford, Elsevier, 2006:310. 7. Kuljic-Kapulica N. [Emerging diseases. Crimean–Congo hem- orrhagic fever]. Medikinski Pregled, 2004, 57(9-10):453–456 [In Serbian]. 8. Ergonul O. Crimean–Congo haemorrhagic fever. Lancet Infec- tious Diseases, 2006, 6(4):203–214. 9. Soars-Weiser K et al. Ribavirin for Crimean–Congo hemor- rhagic fever: systematic review and meta-analysis. BMC Infec- tious Diseases, 2010, 10:207. 10. McPhee SJ, Papadakis MA. Current medical diagnosis and treat- ment, 48th ed. New York, McGraw–Hill, 2009: 1231–1232. 11. Mofleh MJA, ed. Disease early warning system guidelines. Kabul, Afghanistan, Ministry of Public Health, 2008. 12. Communicable disease profile. Afghanistan and neighbouring countries. January 2002. Geneva, World Health Organization, 2002 (WHO/CDS/2002.7) (http://www.who.int/disease- control_emergencies/toolkits/Afghanistan_profile.pdf, ac- cessed 17 April 2012). Discussion During the first time multi-focal out- break of CCHF in the Western Region of Afghanistan during July to October 2008, 30 cases were detected with a case fatality rates of 33%. The outbreak affected 11 districts of Herat province and the districts of Farah Rood, Shahrak and Jawand in the 3 provinces of Farah, Ghor and Badghis. The death rate was much higher in butchers and housewives. Butchers are routinely exposed to the blood and other body fluids of animals, which suggest exposure to higher doses of the virus. The high mortality in house- wives could be due to 2 reasons: the first is that if slaughtering takes place in the house, housewives cleaning the house will be exposed to the blood and fresh meat, which generally happens in Afghanistan; the second reason is that if women are sick, the decision to take them to the doctor or hospital is often delayed, unless the onset of the disease is very severe, which led to the late admission of the women cases to the hospital and thus a greater risk of death. All cases and deaths were aged 12–70 years, but no cases of CCHF were found in children under 12 years of age although children in rural Afghani- stan are the people who mainly who take care of animals in the pastures and fields; this may be due to cultural barri- ers and late presentation to hospital or it may be that children < 12 years have some protection against the disease. The collaborative action of different ministries, led by the Ministry of Public Health, resulted in quick control of the outbreak and the last case was reported on 22 October 2008. Furthermore early detection and diagnosis of the cases increased the chances of survival of the patients and protected health care workers from infections. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 527 Short communication Sanjad Sakati syndrome: a case series from Jordan J. Albaramki,1 K. Akl,1 A. Al- Muhtaseb,1 M. Al-Shboul,2 T. Mahmoud,2 M. El-Khateeb 2 and H. Hamamy 3 ABSTRACT Sanjad Sakati syndrome is a rare autosomal recessive disorder that has been described in Arabs. We report 8 patients from 7 Jordanian families, 6 of whom underwent genetic testing and were found to have a 12 bp (155-166 del) deletion within the tubulin-specific chaperone E (TBCE gene) in exon 3 at 1q42-43. All patients had severe growth retardation, distinct phenotypic features and hypoparathyroidism. Parental consanguinity was recorded in all families. This is the first genetically proven case series of Sanjad Sakati syndrome in Jordan. 1Department of Pediatrics, Jordan University Hospital, Amman, Jordan (Correspondence to J. Albaramki: jumanabaramki@hotmail.com). 2National Center for Diabetes Endocrinology & Genetics, Amman, Jordan. 3Department of Genetic Medicine and Development, Geneva University Hospital, Geneva, Switzerland. Received: 05/09/10; accepted: 06/03/11 ندرلأا نم تلااح ةلسلس :تياكاس داجناس ةمزلاتم يماحم نانح ،بيطلخا دممح ،دوممح اراتم ،لوبشلا دممح ،بستحلما ءايلع ،لقع لماك ،يكمابرلا ةناجم نم ضىرم 8 نع نوثحابلا غلبأ دقو .برعلا ينب هفصو قبس يحنتلما يدسلجا يغبصلاب طبترم ردان بارطضا يه تياكاس داجناس ةمزلاتم :ةصلالخا (TBCE) يإ ينلوبويتلا نع لوؤسلما يعونلا ينلجا نمض (del 155-166) عضولما في نبَخ دجوو ،تانيلجا رابتخا اهنم 6 ـل يرجأ ،ةيندرأ سرأ 7 ةرواجلما ددغلا في روصقو ،يرهاظلا طمنلا في ةزيمم حملام عم ،ومنلا في ديدش رخأت ضىرلما عيجم ىدل ناكو .1q42-43 عضولما في 3 نوسكيلإا في تياكاس داجناس ةمزلاتلم اتهابثإ مت يتلا ةيثارولا تلااحلل ةلسلس لوأ يه هذهو .سرلأا عيجم في نيوبلأا ينب ةبارق دوجو ل ِّجُسو .)تاقيردلا( ةيقردلل .ندرلأا في Le syndrome de Sanjad-Sakati : une série de cas en Jordanie RÉSUMÉ Le syndrome de Sanjad-Sakati est un trouble autosomique récessif rare qui a été décrit dans la population arabe. Nous avons étudié les dossiers de huit patients faisant partie de sept familles jordaniennes ; les analyses génétiques réalisées sur six d'entre eux ont révélé une délétion de 12 bp (155-166 del) dans l'exon 3 localisé en 1q42-43 dans le gène TBCE codant la protéine chaperon E spécifique de la tubuline. Tous les patients présentaient un grave retard de croissance, des caractéristiques phénotypiques singulières et une hypoparathyroïdie. Une consanguinité des parents a été observée dans toutes les familles. Il s'agit de la première série de cas du syndrome de Sanjad-Sakati confirmés génétiquement en Jordanie. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 528 Introduction Sanjad Sakati syndrome or hypopar- athyroidism-retardation-dysmorphism (HRD) is an autosomal recessive disorder that was first described in 1988 [1]. It is characterized by congenital hypoparathy- roidism, growth and mental retardation with distinct phenotypic features. It is linked to the TBCE gene on chromosome 1q42-43 which encodes for the tubulin- specific chaperone E protein [2–4]. Sanjad Sakati syndrome has been re- ported in areas of the Middle East and has a high prevalence among Arabs. Since it may be confused with other syndromes that can present with hypocalcaemia and dysmorphic features, genetic testing allows Sanjad Sakati to be excluded in any child presenting with hypocalcaemia and deep-set eyes. The availability of ge- netic testing enables accurate diagnosis of affected children, discovery of carriers and prospective counselling as well as prenatal diagnosis of Sanjad Sakati syn- drome in high-risk families. This case series reports 8 patients with Sanjad Sakati syndrome from 7 families in Jordan, 6 of whom had genet- ic testing. There have been no previous reports with genetic testing from Jordan. Case series Hospital records were reviewed for the period 2001–2009 only these 8 cases were found. Information was extracted from the medical records and personal interview. All the patients first presented during the neonatal period, at around 2–3 weeks of age, with hypocalcaemic seizures. Two of the patients were first seen in 2007, 2 in 2004 and 1 each in 2001, 2002, 2006, 2009. Their cur- rent mean age is 5 years (range 11 months–10 years). There were 3 fe- males and 5 males and 6 of them had low birth weight. All 8 patients had measurements taken of their calcium, phosphorus and parathyroid hormone (PTH) levels; 7 had brain imaging and skeletal survey, and 3 patients had an ophthalmologi- cal assessment. All of the patients were diagnosed biochemically to have hy- poparathyroidism by the low levels of PTH, hypocalcaemia and elevated phosphorus levels (Table 1). All of the patients were put on vitamin D and calcium supplements. One patient developed generalized non-uraemic calcification and another had mild bi- lateral medullary renal nephrocalcino- sis as a complication of the treatment. One patient had refractory hyper- phosphataemia. Three patients had recurrent hos- pital admissions for various infections, such as pneumonia and meningitis, and 2 patients died at home in 2009 from unknown causes. Phenotypic features All the patients had severe failure to thrive, microcephaly, delayed motor milestones, mental retardation and learning difficulties. All of them had teeth abnormalities such as delayed teething, dental caries or abnormal teeth. They had distinct dysmorphic features including deep-set eyes, mi- crognathia, depressed nasal bridge, microphthalmia, prominent forehead and small hands and feet (Figure 1, Ta- ble 2).One patient had large ears and a high-arched palate. Family history Parental consanguinity was reported in all 7 families. The parents of 3 cases were first cousins. Three patients had a positive family history of the same condition, 2 of them were siblings. One of the patients had a sibling who had been diagnosed prenatally by genetic testing at 11 weeks of pregnancy and the mother had undergone a selective abortion of the affected fetus. Imaging results Seven patients underwent brain imag- ing: 2 cases showed bilateral symmetri- cal calcifications in the basal ganglia, 1 had thinning of the corpus callosum and 1 patient had craniosynostosis; the rest had normal brain imaging. Skeletal survey was normal in all patients. Bone age was assessed for 2 patients and was delayed in both. Table 1 Characteristic of cases Case Sex Date first seen Calcium (mg/dL) Phosphorus (mg/dL) PTH Brain CT Consanguinity Genetic testing Died 1 Male Apr-2004 7.9 8.6 Low Not done Second degree Yes – 2 Male Nov-2001 6.3 10.0 Low Calcification, thin corpus callosum Second degree No – 3 Male Jun-2006 4.80 13.7 Low Normal Second degree No – 4. Male Oct-2007 7.79 8.44 Low Normal First degree Yes Yes 5 Male Aug-2007 8.69 8.58 Low Normal First degree Yes – 5 Female Aug-2002 6.32 9.68 Low Normal First degree Yes Yes 7 Female Aug-2009 4.95 11.95 Low Craniosynostosis Second degree Yes – 8 Female Feb-2004 7.90 7.3 Low Calcification Second degree Yes – PTH = parathyroid hormone; CT = computed tomography. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 529 Ophthalmological assessment Ophthalmological assessment was done for 3 patients and it showed abnormal retinal vessels dilatation and tortuos- ity in 1, bilateral dense central corneal opacity suggestive of congenital cataract in another who needed lensectomy, and papilloedema in the third patient. Genetic testing EDTA-blood samples were col - lected from each patient at the time of presentation, and DNA was extracted using the conventional phenol–chlo- roform proteinase K method [5]. The isolated DNA was dissolved in water and diluted to a concentration of 200 ng/μL. Polymerase chain reaction (PCR) was performed to identify 12 bp (155–166 del) deletion in exon 3 of the TBCE gene since this mutation has been commonly described in of San- jad Sakati syndrome in nearby Middle Eastern countries. Samples were am- plified in duplicate along with positive and negative controls. The sequence of forward and reverse PCR primer was designed by Primer 3 software. PCR reactions were carried out in 25 μL reac- tion mixture containing 10 mmol/L Tris hydrochloride pH 8.3, 50 mmol/L potassium chloride, 1.5 mmol/L mag- nesium chloride, 0.2 mmol/L dNTPs, 10 mmol/L primers and 1 U of hot star Taq polymerase (Qiagen, USA). The amplification conditions used were: 95 °C for 4 minutes, followed by 30 cy- cles at 94 °C for 45 seconds, annealing at 62 °C for 45 seconds and extension at 72 °C for 1 minute. PCR products were directly run over 3% (3:1) low electro- endosmosis (LE) and low molecular mass polypeptide (LMP) agarose gel (Promega, USA) for 120 minutes at 80 V in 1 × Tris boric EDTA buffer. The gel was then stained with ethidium bromide (Promega, USA), visualized by illumination with ultraviolet light, and documented by photography (Gel Doc, Bio-Rad, USA). The size of the product was about 138 bp for the nor- mal allele and 126 bp for the mutant allele (Figure 2). Six patients underwent genetic test- ing. All of them had 12 bp (155–166 del) deletion within the TBCE gene in exon 3. For prenatal diagnosis, around 30 mg of chorionic villi were obtained at 11 weeks of gestation using the transcervi- cal approach. Chorionic villi were rinsed in hypotonic solution (37% sodium chloride) and the whitish, branched tis- sue which represent the fetal tissue were used for DNA extraction by the phenol– chloroform–proteinase K method [5]. Prenatal diagnosis was carried out for 1 case for a consanguineous couple with 2 affected children (boy and girl). The fetal sample showed homozygous deletion of the 12 bp (155–166 del) within the TBCE gene in the fetus. Both parents were heterozygous for the dele- tion mutation. Discussion This is the first genetically proven case series of Sanjad Sakati syndrome from Jordan. A recent review from Kuwait revealed a high incidence of the condi- tion of 7–8 per 100 000 live births [3]. Sanjad Sakati syndrome is a rare autosomal recessive disorder and was first described in Arabs by Sanjad et al. in Saudi Arabia in 1988 [1] and in 1991 [6], followed by reports from other coun- tries [7–9]. In 1998, Parvari et al. used homozygosity and linkage disequilib- rium to map the gene on chromosome 1q42-43 [2] and in 2002 demonstrated that mutation of the TBCE gene caused Sanjad Sakati and autosomal recessive Kenny–Caffey syndrome [3]. Figure 1 One of our patients with low-set ears, deep-set eyes and micrognathia: permission was granted by the family to show the photograph Table 2 Clinical picture of Sanjad Sakati syndrome in 8 Jordanian patients Feature No. of patients IUGR 6 Short stature 8 Microcephaly 8 Deep-set eyes 8 Small hands and feet 8 Hypoparathyroidism 8 Mental retardation and learning difficulties 8 Affected sibling 3 Consanguinity 8 First cousin parents 3/7a Second cousin parents 4/7a Positive genetic testing 6 Normal skeletal survey 8 Brain calcification 2/7b Thin corpus callosum 1/7b aNo. of families assessd = 7. bOne patient did not have brain imaging. IUGR = intrauterine growth retardation. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 530 The TBCE gene encodes for a pro- tein that participates in beta tubulin folding. Homozygous deletion of 12 bp in exon 3 of the TBCE gene was con- firmed to be the cause of this syndrome (OMIM 241410) [4]. This mutation has been described in Arabs with Sanjad Sakati syndrome, but in 2006 Cour- ten et al. described a 4.5-year-old girl with the syndrome who did not have a mutation in the TBCE gene and found another possible gene locus [10]. The syndrome can be confused with autosomal recessive Kenny–Caffey syndrome, caused by mutation in the TBCE gene, that shares similar phe- notypic features but in addition has osteosclerosis, medullary stenosis of long bones, and normal intelligence. Sanjad Sakati syndrome is characterized by congenital hypoparathyroidism, pre- natal and postnatal growth retardation, developmental delay as well as mental retardation. The common dysmorphic features are microcephaly, prominent forehead, deep-set eyes, micrognathia, depressed nasal bridge, small hands and feet, dental anomalies and micro- phthalmia. Ophthalmic manifestations include errors of refraction, retinal Figure 2 Lanes 1, 2, 4: homozygous for 12 bp (155–166 del) deletion; Lane 3: heterozygous for 12 bp (155–166 del) deletion; Lanes 5: negative controls; Lane 6: blank and M: 50 bp DNA ladder vascular tortuosity, strabismus [11], and corneal opacities [12]. Thin corpus callosum has been described in patients with this syndrome [13]. Patients with Sanjad Sakati syndrome have increased susceptibility to recurrent infections but have normal immunological profile. Di George syndrome should also be con- sidered in patients with hypoparathy- roidism but these patients usually have cardiac defects and impaired immune functions and special facial features dif- ferent from those found in Sanjad Saka- ti syndrome. Genetic testing is used to differentiate between these syndromes. Our patients had a high rate of pa- rental consanguinity reaching 100%, much higher than the 12.5% reported in Kuwait indicating a high rate of het- erozygous carriers in Kuwait [7]. The treatment of patients with Sanjad Sakati syndrome is a challenge for most physicians especially in controlling their high phosphate levels, and the adverse effects of therapy include generalized cal- cifications, as seen in one of our patients. Nowadays, genetic testing for San- jad Sakati syndrome can confirm the diagnosis and provide the option of pre- natal testing in families with an affected child, or for parents with genetically proven carrier state. References 1. Sanjad S, Sakati N, Abu-Osba Y. Congenital hypoparathy- roidism with dysmorphic features: a new syndrome. Pediatric Research, 1988, 23:71A. 2. Parvari R et al. Homozygosity and linkage-disequilibrium mapping of the syndrome of congenital hypoparathyroidism, growth and mental retardation, and dysmorphism to a 1-cM interval on chromosome 1q42-43. American Journal of Human Genetics, 1998, 63:163–169. 3. Parvari R et al. Mutation of TBCE causes hypoparathyroidism- retardation-dysmorphism and autosomal recessive Kenny- Caffey syndrome. Nature Genetics, 2002, 32:448–452. 4. Kelly TE et al.Confirmation of the assignment of the Sanjad- Sakati (congenital hypoparathyroidism) syndrome (OMIM 241410) locus to chromosome lq42-43. Journal of Medical Genetics, 2000, 37 (1):63–64. 5. Sambrook J, Fritsch EF, Maniatis T. Molecular cloning: A labora- tory manual, 2nd edition. Cold Spring Harbor, New York, Cold Spring Harbor Laboratory Press, 1989. 6. Sanjad SA et al. A new syndrome of congenital hypoparathy- roidism, severe growth failure, and dysmorphic features. Ar- chives of Disease in Childhood, 1991, 66(11):193–196. 7. Naguib KK et al. Sanjad–Sakati syndrome/Kenny–Caffey syn- drome type 1: a study of 21 cases in Kuwait. Eastern Mediter- ranean Health Journal, 2009, 15(2):345–352. 8. Hershkovitz E et al.Hypoparathyroidism-retardation-Dysmor- phism (HRD) syndrome—a review. Journal of Pediatric Endocri- nology and Metabolism, 2004, 17 (12):1583–1590. 9. Hershkovitz E et al. The new syndrome of congenital hypopar- athyroidism associated with dysmorphism, growth retarda- tion, and developmental delay—a report of six patients. Isreal Journal of Medical Sciences, 1995, 31(5):326–327. 10. Courtens WF et al. Hypoparathyroidism-retardation-dys- morphism syndrome in a girl: A new variant not caused by a TBCE mutation--clinical report and review. American Journal of Medical Genetics, 2006, 140(6):611–617. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 531 Community genetics services. Report of a WHO Consultation on community genetics in low- and middle- income countries. Geneva, Switzerland, 13–14 September 2010 The above-mentioned document presents the findings and recommendations of WHO Consultation on community genetics in low- and middle-income countries. The objective of the Consultation was to develop an evidence-based report on community genetics services to provide guidance to low- and middle-income countries (LMIC) in accordance with the 2008–2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. The goal of community genetics in LMIC is to prevent congenital disorders and genetic diseases at population level and, at the same time, to provide genetics services (diagnosis and counselling) in the community for individuals and families. Congenital disorders (birth defects) constitute a major health problem worldwide especially in LMIC. Factors that may contribute to the high rates of congenital disorders in LMIC include the general low availability of public health measures directed at the care and prevention of these disorders, the high frequency of haemoglobinopathies in Africa, Middle-East and South-East Asia, the high consanguinity rates in the Eastern Mediterranean and South-East Asia regions that can increase the occurrence of recessively inherited diseases, advanced maternal age at conception in many low- and middle-income countries, which increases the predisposition to chromosomal trisomies such as Down syndrome, and large family size that may increase the number of affected children in families with autosomal recessive conditions. Prevention programmes have been successfully implemented in some LMIC, thus reducing the burden of congenital disorders or genetic diseases. Examples of countries adopting such programmes are, among others, Bahrain Cyprus and the Islamic Republic of Iran. Further information about this and other WHO publications on genetics is available at: http://www.who.int/ genomics/publications/en/index.html 11. Al Dhoyan N, Al Hemidan AI, Ozand PT. Ophthalmic manifesi- tations of Sanjad-Sakati syndrome. Ophthalmic Genetics, 2006, 27(3):83–87. 12. Khan AO, Al-Assiri A, Al-Mesfer S. Ophthalmic features of hypoparathyroidism-retardation-dysmorphism. Journal of the American Association for Pediatric Ophthalmology and Strabis- mus, 2007,11(3): 288–290. 13. Padidela RF et al. Mutation in the TBCE gene is associated with hypoparathyroidism-retardation-dysmorphism syndrome featuring pituitary hormone deficiencies and hypoplasia of the anterior pituitary and the corpus callosum. Journal of Clinical Endocrinology and Metabolism, 2009, 94 (8):2686–2691. EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 532 Brève communication Profil étiologique des pancytopénies chez l’adulte à Marrakech (Maroc) H. Nafil,1 I. Tazi,1 M. Sifsalam,1 M. Bouchtia 1 et L. Mahmal 1 RÉSUMÉ Cette étude rétrospective a évalué la fréquence des différentes causes de pancytopénie chez tous les patients adultes admis pour pancytopénie au service d’Hématologie du CHU Mohammed VI de Marrakech du 1er janvier 2008 au 31 décembre 2010. Au total, 118 cas de pancytopénie ont été colligés (moyenne de 39 cas par an). L’âge moyen des patients est de 52 ans (extrêmes 18-82 ans) et 52,5 % des patients sont de sexe masculin. Les signes cliniques sont dominés par la pâleur cutanéo-muqueuse (100 %), l’asthénie (100 %) et la fièvre (30,5 %). Le taux moyen d’hémoglobine est de 6,5 g/dL (extrêmes 2,9-9,2 g/dL), le taux moyen des globules blancs est de 2360/mm3 (extrêmes 840-3360/mm3) et celui des plaquettes de 66 000/mm3 (extrêmes 3000-123 000/mm3). Le myélogramme est réalisé chez 112 patients. Il objective une mégaloblastose médullaire dans 32,2 % des cas et une blastose médullaire dans 23,7 %. L’anémie par carence en vitamine B12 (32,2 %), les leucémies aiguës (23,7 %) et l’aplasie médullaire (15,2 %) sont les principales causes de pancytopénie. La fréquence des leucémies aiguës fait toute la gravité de la pancytopénie, imposant un diagnostic et un traitement urgent. 1Service d’Hématologie, CHU Mohammed VI, Université Cadi Ayyad, Marrakech (Maroc) (Correspondance à adresser à H. Nafil : solhatim@ hotmail.com). Reçu : 31/10/11 ; accepté : 12/12/11 برغلماب شكارم في ينغلابلا ىدل ةلماشلا تايركلا ةلق بابسأ مسترم لماهم ينسلح ،هيتشوب دممح ،ملاسلا فيس دممح ،يزاتلا سايلإ ،ليفن متاح لىإ ينمداقلاو ضرلماب ينباصلما ينغلابلا ضىرلما عيجم ىدل ةلماشلا تايركلا ةلقل ةفلتخلما بابسلأا راركت ةيداعتسلاا ةساردلا هذه تمَّيق :ةصلالخا تلمشو .2010 برمسيد/لولأا نوناك 31 ىتح 2008 رياني/نياثلا نوناك لوأ نم ًاءدب ،شكارم في ،سداسلا دممح كللما ىفشتسم في تايومدلا مسق % 52.5 ناكو )ةنس 82-18 ىدلما( ةنس 52 ضىرلما رمع يطسو غلبو .)ًايونس ةلاح 39 يطسولا ناكو( ةلماشلا تايركلا ةلق نم ةلاح 118 ةساردلا طسوتم غلبو .)%30.5( ىملحاو ،)%100( نهولاو ،)%100( بوحشلا يه ةيسيئرلا )ةيكينيلكلإا( ةيريسرلا ضارعلأا تناكو .روكذلا نم مهنم بعكم ترميلم لكل 2360 ءاضيبلا ةيومدلا ايلالخا ددع طسوتم غلبو ،)ترل سييد لكل مارغ 9.2-2.9 ىدلما( ترل سييد لكل مارغ 6.5 ينبولغوميلها دقو .)بعكم ترميلم لكل 123000-3000 ىدلما( بعكم ترميلم لكل 66000 تاحْيَف ُّصلا ددع غلبو ،)بعكم ترميلم لكل 3360-840 ىدلما( ةيسيئرلا بابسلأا ناكو .%23.7 في يقنلا تامورأو ،%32.2 في يقنلا في ةمخض تامورلأا ةرثك تدجوو ؛ًاضيرم 112 في مظعلا عاخنل طفش يرجأ ًارظنو .)%15.2( جسنلا مدعب مدلا رقفو ،)%23.7( دالحا مدلا ضاضيباو ،)%32.2( 12ب ينماتيف زوع ببسب مدلا رقف وه ةلماشلا تايركلا ةلق في .ينلجاع جلاعو صيخشت لىإ نوجاتيح ةلماشلا تايركلا ةلق مهيلع رهظي نيذلا ضىرلما نإف ،ةساردلا تلااح ينب دالحا مدلا ضاضيبا راشتنا لدعلم Etiological profile of pancytopenia in adults in Marrakesh, Morocco ABSTRACT This retrospective study evaluated the frequency of different causes of pancytopenia in all adult patients with pancytopenia presenting to the Department of Haematology of Mohamed VI Hospital, Marrakesh from 1 January 2008 to 31 December 2010. A total of 118 cases of pancytopenia were found (average of 39 cases per year). The mean age of patients was 52 years (range 18–82 years) and 52.5% were male. The main clinical signs were pallor (100%), asthenia (100%) and fever (30.5%). Mean haemoglobin was 6.5 g/dL (range 2.9–9.2 g/dL), mean white blood cell count was 2360/mm3 (range 840–3360/mm3) and platelet count 66 000/mm3 (range 3000–123 000/mm3). Bone marrow aspiration was performed in 112 patients; megaloblastosis was found in 32.2% and marrow blasts in 23.7%. Anaemia due to vitamin B12 deficiency (32.2%), acute leukaemia (23.7%) and aplastic anaemia (15.2%) were the main causes of pancytopenia. Given the incidence of acute leukemia among our cases, patients presenting with pancytopenia require urgent diagnosis and treatment. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 533 Introduction La pancytopénie se définit par l’association, à des degrés variables, d’une anémie, d’une neutropénie et d’une thrombopénie [1]. C’est une entité clinico-biologique fréquente en hématologie qui peut s’observer dans diverses situations [1]. Elle peut être d’origine centrale par trouble de la production médullaire (insuffisance médullaire qualitative ou quantitative) ou d’origine périphérique (destruction ou séquestration extra-médullaire d e s é l é m e n t s s a n g u i n s ) . D a n s d’autres cas, elle peut associer les deux mécanismes [1,2] . Devant une pancytopénie, les problèmes diagnostiques essentiels concernent l’évaluation de la gravité et la recherche de l’affection causale [3]. Au Maroc, la f réquence des pancytopénies est inconnue. L’objectif de notre étude est d’étudier le profil étiologique des pancytopénies dans la région de Marrakech. Méthodes Il s'agit d'une étude rétrospective réalisée du 1er janvier 2008 au 31 décembre 2010 au service d’Hématologie du Centre Hospitalier Universitaire (CHU) M o h a m m e d V I d e M a r r a k e c h . Sont inclus dans cette étude tous les patients adultes admis au service pour pancytopénie. La pancytopénie est définie par l’association des critères suivants : • un taux d’hémoglobine (Hb) < 12 g/ dL ; • un taux de globules blancs (GB) < 4000/mm 3 avec un taux de polynucléaires neutrophiles (PNN) < 1500/mm3 ; • un taux de plaquettes (Plq) < 150 000/mm3. Les patients pris en charge pour aplasie post-chimiothérapie et acutisa- tion d’hémopathies malignes connues ont été exclus de cette étude. Pour tous les patients ont été précisées leurs caractéristiques (âge, sexe, antécédents médicaux, signes cliniques) ainsi que les données de l’hémogramme avec frottis sanguin. En fonction de l’orientation clinique et de l’hémogramme, un bilan complé- mentaire était réalisé, comportant un myélogramme, un dosage de la vitamine B12 et de l’acide folique, une biopsie ostéo-médullaire, un immuno- phénotypage médullaire et une écho- graphie abdominale. Résultats Caractéristiques des patients Entre le 1 er janvier 2008 et le 31 décembre 2010 (3 ans), 118 cas de pancytopénie sont colligés, soit une moyenne de 39 cas par an. L’âge moyen des patients est de 52 ans (extrêmes 18-82 ans) ; 52,5 % des patients sont de sexe masculin et 47,5 % de sexe féminin (sex ratio hommes/femmes : 1,1). Les patients sont d’origine rurale dans 52 % des cas. Caractéristiques cliniques La durée moyenne d’évolution est de 3 mois (extrêmes 10 jours-36 mois). Les signes cliniques sont dominés par la pâleur cutanéo-muqueuse (100 %), l ’ a s t h é n i e ( 1 0 0 % ) e t l a fièvre (30,5 %) (Tableau 1). Caractéristiques biologiques Le taux moyen d’hémoglobine est de 6,5 g/dL (extrêmes 2,9-9,2 g/dL), le taux moyen des globules blancs est de 2360/mm3 (extrêmes 840-3360/ mm3) et celui des plaquettes de 66 000/ mm3 (3000-123 000/mm3). Sur les 118 patients, 40,5 % présentaient une anémie et 42,4 % une anémie avec macrocytose (Tableau 2). Le myélogramme est réalisé chez 112 patients (95 %). Il objective une mégaloblastose médullaire dans 32,2 % des cas, une blastose médullaire (≥ 20 %) dans 23,7 % des cas, une moelle pauvre dans 17,0 % des cas et des signes de dysplasie dans 10,2 % des cas. Le myélogramme est d’aspect normal dans 6,7 % des cas (Tableau 3). Le dosage de la vitamine B12 et de l’acide folique, réalisé en cas de mégaloblastose médullaire, a confirmé le déficit en vitamine B12. Le taux moyen de vitamine B12 est de 74 pg/ mL (extrêmes 20-99 pg/mL) [Valeur normale : 200-1100 pg/mL]. L a b i o p s i e o s t é o - médullaire (BOM), réalisée en cas de myélogramme pauvre ou non concluant, a objectivé une aplasie médullaire dans 18 cas (15,2 %), Tableau 1 Signes cliniques des patients Signes cliniques Nbre (%) Pâleur cutanéo-muqueuse 118 (100) Asthénie 118 (100) Fièvre 36 (30,5) Splénomégalie 22 (18,6) Syndrome hémorragique cutanéo-muqueux (purpura, ecchymose, gingivorragie, épistaxis) 22 (18,6) Amaigrissement 11 (9,3) Adénopathies 10 (8,5) Signes digestifs (glossite, troubles dyspeptiques, diarrhée) 10 (8,5) Signes neurologiques (paresthésies isolées, sclérose combinée de la moelle, neuropathie sensitive isolée) 8 (6,4) Ictère 4 (3,4) Hépatomégalie 4 (3,4) Douleur osseuse 2 (1,7) EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 534 une myélofibrose médullaire dans deux cas (1,7 %), une leucémie à tricholeucocytes dans deux cas (1,7 %), et des métastases médullaires de cancers non hématologiques dans deux cas (1,7 %). L ’ i m m u n o p h é n o t y p a g e médullaire, réalisé en cas de leucémie aiguë difficile à classer (LADAC) et de cellules lymphoïdes atypiques au myélogramme, a permis le diagnostic de leucémie aiguë lymphoblastique (LAL) chez quatre patients, de leucémie aiguë myéloblastique (LAM) chez deux patients et d’infiltration médullaire par un lymphome du manteau chez deux patients. L ’ é c h o g r a p h i e a b d o m i n a l e , réalisée en cas de splénomégalie o u h é p a t o m é g a l i e , a o b j e c t i v é u n e s p l é n o m é g a l i e i s o l é e d a n s six cas (5,1 %), une splénomégalie associée à une hépatomégalie dans quatre cas (3,4 %) et une splénomégalie associée à des signes d’hypertension portale (HTP) en rapport avec une cirrhose hépatique dans 12 cas (10,2 %). Étiologies Les causes sont dominées par l’anémie par carence en vitamine B12 (32,2 %), l e s l e u c é m i e s a i g u ë s ( 2 3 , 7 % ) et l ’aplasie médullaire (15,2 %) (Tableau 4). Discussion Il n’existe à ce jour qu’un nombre limité d’études évaluant le spectre étiologique de la pancytopénie [2,3]. Notre étude concerne 118 cas de pancytopénie, colligés sur une période de 3 ans. L’âge moyen des patients est de 52 ans a v e c u n e l é g è r e p r é d o m i n a n c e m a s c u l i n e ( s e x r a t i o h o m m e s / femmes : 1,1). Le motif le plus fréquent de consultation est représenté par la pâleur cutanéo-muqueuse (100 %) et l’asthénie (100 %). Des résultats identiques ont été rapportés dans d’autres études [3]. Les autres signes diffèrent selon les études, certainement en raison du large spectre étiologique de la pancytopénie [3]. Les causes de la pancytopénie varient en fonction de l’âge et de l’origine géographique des patients [2,3]. L’anémie par carence en vitamine B12 est la cause la plus fréquente de pancytopénie dans notre étude (32,2 % des cas). L a c a r e n c e e n v i t a m i n e B12 (cobalamine), particulièrement f r é q u e n t e d a n s l a p o p u l a t i o n â g é e ( 1 5 % ) , e s t c l a s s i q u e m e n t r e s p o n s a b l e d e s a n é m i e s mégaloblastiques. Elle est responsable d'un défaut de synthèse de l’ADN, lui-même responsable d'une diminution des mitoses, de la prolongation du cycle cellulaire et de la destruction intramédullaire des érythroblastes. Elle peut être grave si non diagnos- tiquée à cause des complications h é m a t o l o g i q u e s ( p a n c y t o p é n i e , p s e u d o - m i c r o a n g i o p a t h i e thrombotique) et neurologiques (sclérose combinée médullaire) [4]. I l s 'agit de la cause la plus fréquente de pancytopénie en Asie et en Afrique[5,6]. Sa fréquence varie de 38 à 74 % en Asie [3,5,7-9] et elle est de 49 % en Afrique [6]. Cette fréquence est probablement expliquée par le mode d’alimentation pauvre en nourriture carnée et en végétaux, Tableau 2 Valeurs hématologiques moyennes et fréquence des troubles diagnostiqués Paramètres hématologiques et troubles observés Valeurs Paramètres Valeurs (extrêmes) Taux moyen d’hémoglobine (g/dL) 6,5 (2,9-9,2) Taux moyen du VGM (fL) 97 (70-134) Taux moyen de globules blancs (/mm3) 2360 (840-3360) Taux moyen de plaquettes (/mm3) 66 000 (3000-123 000) Troubles Nbre de patientsa (%) Anémie < 6 g/dL 48 (40,5) Anémie et macrocytose (VGM > 98 μm3) 50 (42,4) Neutropénie < 500/mm3 18 (15,2) Thrombopénie (< 20 000/mm3) 22 (18,6) an = 118. VGM : volume globulaire moyen. Tableau 3 Caractéristiques du myélogramme Signes cliniques Nbre (%) Mégaloblastose médullaire 38 (32,2) Blastose médullaire (≥ 20 %) 28 (23,7) Leucémie aiguë myéloblastique (LAM) 16 (13,5) Leucémie aiguë lymphoblastique (LAL) 6 (5,1) Leucémie aiguë difficile à classer (LADAC) 6 (5,1) Moelle pauvre 20 (17,0) Signes de dysplasie 12 (10,2) Moelle d’aspect normal 4 (3,4) Plasmocytose médullaire 2 (1,7) Cellules lymphoïdes atypiques 2 (1,7) Amastigotes 2 (1,7) Myélogramme non concluant 4 (3,4) طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 535 sources principales de cobalamines [6]. L’anémie par carence en vitamine B12 est une cause rare de pancytopénie en France (7,5 %) [10]. Dans notre étude, la fréquence élevée de la carence en vitamine B12 parmi les causes de pancytopénie peut s’expliquer, en dehors d’une carence d’apport, par l’évolution insidieuse de la maladie : l’anémie est d’installation lente et souvent bien tolérée. Les patients consultent à un stade avéré de la carence, la pancytopénie est bien installée [4]. Dans notre étude, les hémopathies malignes représentent 47,5 % des causes de pancytopénie. La cause majeure est la leucémie aiguë (23,7 %), souvent myéloblastique (15,2 %). L e s l e u c é m i e s a i g u ë s ( L A ) aboutissent à l’accumulation, dans la moelle, le sang et éventuellement d'autres organes, de précurseurs des cellules sanguines de nature myéloïde ou lymphoïde bloqués à u n s t a d e p r é c o c e d e l e u r différenciation (blastes). En raison d u r e m p l a c e m e n t d e s c e l l u l e s hématopoïétiques normales par les cellules blastiques, les patients s e p r é s e n t e n t a v e c d e s s i g n e s d ' i n s u ffi s a n c e m é d u l l a i r e a u premier plan (anémie, hémorragie, i n f e c t i o n ) [ 1 1 ] . L e c o n t e x t e h é m a t o l o g i q u e é v i d e n t d o i t faire évoquer le diagnostic et un myélogramme doit être réalisé sans retard car l'évolution spontanée est rapidement fatale [11]. Dans l’étude de Imbert et al., les hémopathies malignes constituent 60 % des causes de pancytopénie [10]. La fréquence des leucémies aiguës parmi les causes de pancytopénie varie de 3,85 à 19,59 % selon les études [2,3] . La leucémie aiguë myéloblastique (LAM) est le type prédominant [2, 3]. La LAM est le type de leucémie aiguë le plus fréquent chez l’adulte [11]. N o s r é s u l t a t s , c o r r o b o r a n t les données de la littérature, sont probablement dus à un diagnostic b i o l o g i q u e b i e n é l a b o r é . L a caractérisation de la population b l a s t i q u e p a r l e s m a r q u e u r s immunologiques et cytogénétiques permet de surmener les difficultés du diagnostic et du classement des LA au myélogramme seul. L’aplasie médullaire (AM) est la troisième cause, la plus fréquente, de pancytopénie dans notre étude (15,2 %). C’est une maladie rare dont l’incidence est de 2 cas par million d’habitants par an en Europe et aux États-Unis [12]. Les critères diagnostiques associent une diminution stable de 2 ou 3 lignées sanguines et une moelle pauvre sur biopsie médullaire. L’AM peut être d’origine constitutionnelle, acquise ou souvent idiopathique [13]. Dans d’autres études, la fréquence de cette cause varie de 18,26 à 29,05 % en Asie [2, 3,14], et elle est de 10-25 % en Occident [15]. L’AM est parfois la cause la plus fréquente de pancytopénie dans certains pays : l’effet de l’exposition professionnelle chronique aux pesticides et insecticides est largement évoqué pour expliquer cette fréquence [16]. Bien que le Maroc soit un pays agricole, aucune exposition aux pesticides n’est observée chez nos patients. L’AM est considérée idiopathique dans tous les cas. Les étiologies de la pancytopénie sont nombreuses et variées . Le diagnostic des causes rares (leucémie à tricholeucocytes, myélofibrose médullaire) impose une confrontation clinico-biologique optimale. Conclusion La pancytopénie est un motif de consultation fréquent en hématologie. Les causes sont multiples, dominées dans notre contexte par l’anémie par carence en vitamine B12, affection engageant rarement le pronostic vital des patients. La fréquence des leucémies aiguës fait toute la gravité de la pancytopénie, imposant un diagnostic et un traitement urgent. Tableau 4 Causes des pancytopénies Causes Nbre (%) Anémie par carence en vitamine B12 38 (32,2) Leucémie aiguë 28 (23,7) Leucémie aiguë myéloblastique 18 (15,2) Leucémie aiguë lymphoblastique 10 (8,5) Aplasie médullaire 18 (15,2) Syndromes myélodysplasiques 12 (10,2) Cirrhose hépatique avec hypersplénisme 12 (10,2) Infiltration médullaire d’un lymphome du manteau 2 (1,7) Leucémie à tricholeucocytes 2 (1,7) Myélofibrose médullaire 2 (1,7) Métastases médullaires de cancers non hématologiques 2 (1,7) Leishmaniose viscérale 2 (1,7) EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 536 1. Williams DM. Pancytopenia, aplastic anemia and pure red cell aplasia. In: Greer JP et al., eds. Wintrobe’s clinical hematology, 10th ed. Baltimore, William and Willkins, 1993:1449–1484. 2. Jha A et al. Bone marrow examination in cases of pancytope- nia. Journal of the Nepal Medical Association, 2008, 47:12–17. 3. Gayathri BN, Rao KS. Pancytopenia: a clinic hematological study. Journal of Laboratory Physicans, 2011, 3:15–20. 4. Federici L et al. Manifestations hématologiques de la carence en vitamine B12 : données personnelles et revue de la littéra- ture [Update of clinical findings in cobalamin deficiency: per- sonal data and review of the literature]. La revue de médecine interne, 2007, 28(4):225–231. 5. Kumar R et al. Pancytopenia—a six year study. Journal of the As- sociation of Physicians of India, 2001, 49:1078–1081. 6. Lavigne C et al. Place des étiologies carentielles dans les pan- cytopénies à Djibouti. À propos de 81 patients consécutifs [Role of vitamin deficiency in pancytopenia in Djibouti. Find- ings in a series of 81 consecutive patients]. Médecine tropicale, 2005, 65(1):59–63. 7. Tilak V, Jain R. Pancytopenia—a clinico-hematological analysis of 77 cases. Indian Journal of Pathology & Microbiology, 1999, 42:399–404. 8. Khunger JM et al. Pancytopenia—a clinico haematological study of 200 cases. Indian Journal of Pathology & Microbiology, 2002, 45:375–379. 9. Ishtiaq O et al. Patterns of pancytopenia patients in a general medical ward and a proposed diagnostic approach. Journal of Ayub Medical College, Abbottabad, 2004, 16:8–13. 10. Imbert M et al. Adult patients presenting with cytopenia: a re- appraisal of underlying pathology and diagnostic procedures in 213 cases. Hematologic Pathology, 1989, 3:159–167. 11. Lowenberg B, Burnett AK, Downing JR. Acute myeloid leu- kaemia. New England Journal of Medicine, 1999, 34:1051–1062. 12. Incidence of aplastic anemia: the relevance of diagnostic crite- ria. By the International Agranulocytosis and Aplastic. Anemia Study. Blood, 1987, 70:1718–1721. 13. Brodsky RA, Jones RJ. Aplastic anaemia. Lancet, 2005, 365:1647–1656. 14. Santra G, Das BK. A cross-sectional study of the clinical profile and aetiological spectrum of pancytopenia in a tertiary care centre. Singapore Medical Journal, 2010, 51:806–812. 15. Young NS. Acquired aplastic anemia. Annals of Internal Medi- cine, 2002, 136:534–546. 16. Issaragrisil S et al. Aplastic anemia in rural Thailand: its asso- ciation with grain farming and pesticide exposure. American Journal of Public Health, 1997, 87:1551–1554. Références طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما سمالخا ددعلا 537 Case report Jessner lymphocytic infiltrate presenting on a cutaneous leishmaniasis scar: case report G. Sadeghian 1 and H. Ziaei 2 1Skin Disease and Leishmaniasis Research Centre; 2Medical School, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran (Correspondence to G. Sadeghian: Sadeghian@sdlrc.mui.ac.ir). Received: 18/10/09; accepted: 31/12/09 Introduction Jessner lymphocytic infiltration of the skin is an uncommon skin disorder characterized by benign accumulations of lymphocytes by a “coat-sleeve”-like perivascular infiltration in the skin [1]. These small lesions are solid, pink or red in colour and appear on the face, neck and back. The lesions may remain unchanged for several years and then spontaneously disappear, leaving no scars [2]. Prognosis is good because lymphocytic infiltration of the skin may resolve spontaneously and require no treatment. Treatments include cosmetic camouflage, photo- protection, excision of small lesions, topical steroids, hydroxy chloroquine, intralesional steroids, systemic steroids and cryotherapy [3]. We report here on a case of Jessner lymphocytic infiltration associated with an atrophic scar due to cutaneous leish- maniasis from 5 years before. Case report A 30-year-old man presented with asymptomatic erythematous nodules and plaques on the face where he had suffered cutaneous leishmaniasis (CL) 5 years before, which had improved leav- ing an atrophic scar (Figure 1A). The lesion had begun as 1 nodule but had gradually progressed to several nodules and plaques. The disease had lasted for 1 year and there was history of indolent courses of resolution and subsequent recurrence. Skin examination revealed multiple erythematic deeply infiltrated nodules and plaques with smooth and shiny surface with no evidence of scaling. At first, in view of the patient’s histo- ry, the lupoid form of CL was suggested, and the patient was treated with system- ic antileishmanial therapy (meglumine antimoniate, 20 mg/kg for 20 days). There was no sign of improvement and the lesions continued to progress. In paraclinical examination all rou- tine biochemical and haematological investigations, including urine analysis, complete blood count, erythrocyte sedi- mentation rate, antinuclear antibody test, anti-Ro and anti-La antibodies were normal. Direct smear for leishman bodies was negative. A biopsy sent for routine haematoxylin and eosin staining revealed a normal epidermis with well- demarcated dense perivascular infiltrate and periadnexal infiltrate in the dermis composed of mature lymphocytes (Fig- ure 2) and these lymphocytes showed immunoreactivity to CD4 antibodies with immunohistochemistry (IHC) staining (Figure 3). There was no sign of granuloma formation or histiocytes containing Leishman bodies or other signs of leishmaniasis. The diagnosis was changed to lym- phocytic infiltration of the skin and the patient was treated with triamcinolone ointment twice daily. The lesions disap- peared after 2 weeks (Figure 1B). The patient was followed up and fortunately there was no recurrence of the problem after 3 years of follow-up Discussion Jessner and Kanof first described as an uncommon skin condition in 1953 [4]. The condition, now known as Jessner Figure 1 Erythematous plaques and nodules on left check (A) before and (B) after treatment A B EMHJ  •  Vol. 18  No. 5  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 538 lymphocytic infiltration of the skin, is poorly understood and indeed the very existence of such a condition has been questioned. The literature suggests how- ever that certain patients monitored for as long as 30 years remain within the spectrum of Jessner lymphocytic infiltration with no progression [3]. The cause of Jessner lymphocytic infiltration is unknown. Over the years a number of etiologies have been proposed. Several studies have linked Borrelia spp. infection to lymphocytic infiltration of the skin, yet most recent studies have disputed this association [3,5]. There has been a report in the past of drug eruptions induced by angi- otensin-converting enzyme inhibitors that resemble lymphocytic infiltrate (of Jessner–Kanof) [6]. This condition was also reported after treatment with a hydroquinone containing bleaching cream [7]. Histologically, moderately dense superficial and deep perivascular lymphocytic infiltrate is observed in the dermis. In our case there was also infiltration in the dermis, the epidermis was normal and there was no evidence of discoid lupus erythematosus includ- ing atrophy, follicular plaguing or basal layer vacuolation. There was no sign of dermal oedema seen in polymor- phous light eruption and no germinal follicle formation as would be observed in lymphocytoma cutis or cutaneous follicular centre cell lymphoma. On the other hand, there was no evidence in this case of leishman bodies or granulomatous reactions, as seen in lupoid leishmaniasis. There are no other reports of Jessner lymphocytic infiltration following CL and this is the first time that this condi- tion was reported as presenting on the scar of parasitic diseases from CL. Due to the similarity to the lupoid type of CL the lesions were misdiagnosed at first, but biopsy and immunoreactiv- ity to CD4 antibodies (IHC staining) confirmed the diagnosis. Figure 2 Moderately dense lymphocytic infiltration is present around the dermis and pilosebaceous follicles (haematoxylin and eosin staining) at (A) low power and (B) high power A B Figure 3 Mature lymphocytes show immunoreactivity for CD4 antibody (immunohistochemistry staining) at (A) low power and (B) high power A B References 1. Dippel E et al. Familial lymphocytic infiltration of the skin: histochemical and molecular analysis in three brothers. Der- matology (Basel, Switzerland), 2002, 204:12–16. 2. Lymphocytic infiltrate of Jessner. WebMD [online factsheet] (http://www.webmd.com/skin-problems-and-treatments/ lymphocytic-infiltrate-of-jessner. accessed 22 May 2011). 3. Jessner lymphocytic infiltration of the skin. Medscape reference [online factsheet] (http://emedicine.com/derm/topic200. htm, accessed 22 May 2011). 4. Jessner M, Kanof NB. Lymphocytic infiltration of the skin. Ar- chives of Dermatology, 1953, 68:447–449. 5. Abele DC, Anders KH, Chandler FW. Benign lymphocytic infiltration (Jessner–Kanof): another manifestation of borre- liosis. Journal of the American Academy of Dermatology, 1989, 21:795–797. 6. Schepis C et al. ACE-inhibitor-induced drug eruption resem- bling lymphocytic infiltration (of Jessner–Kanof) and lupus erythematosus tumidus. Dermatology (Basel, Switzerland), 2004, 208:354–355. 7. Caroli UM et al. Lymphocytic infiltration of the skin Jessner– Kanof after treatment with a hydroquinone-containing bleach- ing cream. Archives of Dermatology, 2006, 142:1655–1656. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما عبارلا ددعلا 539 Translation Quality of life of Iranian β-thalassaemia major patients living on the southern coast of the Caspian Sea H. Khani,1 M.R. Majdi,2 E. Azad Marzabadi,3 A. Montazeri,4 A. Ghorbani 1 and M. Ramezani 5 ABSTRACT In the present study, the aim was to explore the quality of life of thalassaemia major (TM) patients according to age, sex, school performance, severity and complications of the disease. A cross-sectional descriptive study was conducted. Quality of life was evaluated by 4 questionnaires; demographic characteristics, the short form 36 health survey (SF-36), Persian version of symptoms checklist-90-revised (SCL-90-R) and life satisfaction index (LSI). 687 (41.08%) of the eligible patients with TM completed the questionnaires. With the SF-36 questionnaire, 329 (47.9%) participants had an excellent level of physical functioning. With the SCL-90-R questionnaire, 446 (64.9%) participants had a global severity index of > 0.7, considered psychiatric patients, 141 (20.5%) patients had GSI between 0.4 and 0.7, considered suspected psychiatric patients and 100 (14.6%) participants had GSI of < 0.4, considered non-psychiatric patients. The mean score of LSI questionnaire was 20.50 (SD 5.95), range 2–37. Beta- TM patients are at risk of psychiatric symptoms and need appropriate psychiatric counselling. 1Iranian Applied Research Center for Public Health and Sustainable Development (IRCPHD), North Khorasan University of Medical Sciences, Bojnurd, Islamic Republic of Iran (Corresponding author H. Khani: dr.h.khani@gmail.com). 2Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran. 3Behavioural Sciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Iranian Institute for Health Sciences Research, ACECR, Tehran, Islamic Republic of Iran. 5Iranian Institute for Young Thalassemia, Ghaemshahr, Islamic Republic of Iran. This paper was published in Farsi in the Journal of Behavioral Sciences, 2009, 2(4):325–332; the translation is published here with kind permission. نيوزق رحبل بيونلجا ئطاشلا في ىبركلا اتيب ايميسلاثلاب ضىرلما ينيناريلإا ىدل ةايلحا ةيعون نياضمر مثيم ،نيابرق ةنمآ ،ىرظتنم لىع ،يدابأ زرم دازآ رايدنفسا ،يدمج اضر دممح ،نياخ نسح ايميسلاثلا ضرلم تافعاضلما ةماخوو سيردلما ءادلأاو سنلجاو رمعلا بسحب ةايلحا ةيعونو ةعيبط فاشكتسا لىإ ةساردلا هذه ْتَفَدَه :ةصلالخا ةيفارغوميدلا صئاصلخا لوانتي ا ُهل َّوأ /ةعبرأ تانايبتسا مادختساب ةايلحا ةيعون مييقتل ةيفصو ةضرعتسم ةسارد ءارجإب نوثحابلا ماق دقو .ىبركلا نع َضرلا بَْسنَم عبارلاو ،ضارغلأل 90 ةيد ُّقفتلا ةمئاقلل ةث َّدحلما ةيسرافلا ةجارخلإا ثلاثلاو ،يحصلا حسلما نم صرتخلما 36 جذومنلل نياثلاو في امأ .نايبتسلاا اولمكتسا دق ةساردلاب ةكراشملل ينلهؤلما ىبركلا ايميسلاثلا ضرم عيجم نم )%41.08( 687 نأ نوثحابلا دجو دقو .ةشيعلما 446 نإف ضارعلأل ةيد ُّقفتلا ةمئاقلا في امأو .ةيندبلا فئاظولا ءادأ نم زاتمم ىوتسم ميهدل ناك )%47.9( ًاكراشم 329 نإف صرتخلما 36 جذومنلا بسنلما ميهدل ناك )%20.5( ًاكراشم 141و ،ينيسفن ضرم اوبرُهتعا دقو 0.7 نم رثكأ ضارعلأا ةماخول يلماعلا بسنلما ميهدل ناك )%64( ًاكراشم نم لقأ يلماعلا بسنلما ميهدل ناك )%14.6( ًاكراشم 100و ،نويسفن ضرم منهأب ينهَبَتشم اوبرُهتعاو 0.7و 0.4 ينب حواتري ضارعلأا ةماخول يلماعلا .37و 2 ينب حواتري لامج في 5.95 ± 20.50 ةشيعلما نع ضرلا بَْسنَم زارحأ ط ِّسوتم غلبو .ينيسفن ضرم اوسيل منهأ اوبرتعاو 0.4 Qualité de vie de patients iraniens atteints de β-thalassémie majeure vivant sur la côte sud de la mer Caspienne RÉSUMÉ La présente étude vise à examiner la qualité de vie de patients atteints de thalassémie majeure en fonction de l'âge, du sexe, des résultats scolaires, et de la gravité et des complications de la maladie. Une étude descriptive transversale a été menée. Dans cette étude, la qualité de vie a été évaluée au moyen de quatre outils : les caractéristiques démographiques, le questionnaire d'évaluation de la santé SF-36 en version abrégée, la version en persan de l'échelle de symptômes SCL-90-R et l'indice de satisfaction de vie. Parmi les patients éligibles souffrant de thalassémie majeure, 687 d'entre eux (41,08 %) ont rempli les questionnaires. Selon les résultats du questionnaire SF-36, 329 participants (47,9 %) avaient un excellent niveau de capacité physique fonctionnelle. En tout, 446 participants (64,9 %) ont obtenu un indice de sévérité global de plus de 0,7 (patients psychiatriques) au questionnaire SCL-90-R ; 141 participants (20,5 %) présentaient un indice de sévérité global allant de 0,4 à 0,7 (patients psychiatriques présumés) ; et 100 participants (14,6 %) avaient des résultats inférieurs à 0,4 (patients non psychiatriques). Le score moyen au questionnaire d'indice de satisfaction de vie était de 20,50 (± 5,95, extrêmes 2-37). Les patients souffrant de β-thalassémie majeure risquent de présenter des symptômes psychiatriques et ont donc besoin d'un accompagnement dans ce domaine. EMHJ  •  Vol. 18  No. 4  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 540 Introduction Beta-thalassaemia major (TM) is a chronic hereditary disease of the blood due to the defective synthesis of 1 or more globin polypeptide chains. This disease is characterized by lack of ap- propriate growth, overly large spleen and liver, and abnormality of the bones, particularly in the face and head, which can be observed in the physiognomy [1]. Although not curable, TM can be treated. However, these treatments are unpleasant, long and repetitive, and can affect a patient’s general health, mental health and life satisfaction. These treat- ments can also have an impact on the families of patients, especially on sib- lings [2–10]. Some investigations have found that 80% of people diagnosed with TM have at least 1 psychiatric disorder [2], the most frequent being disembodiment [3,4], anxiety [5,6], depression [7], somatoform disorders [8] and anger [9,10]. This disease can also have a deleterious impact on the social activities and education of pa- tients [11,12]. Some investigations have found that patients with TM are able to over- come their problems [13]. Differences, however, have been observed among countries or even among different districts of the same country [4]. The prevalence of TM in Mazandaran province of Iran has been estimated at 0.62 per thousand [14]. Many in- fants and teenagers in this province have TM, making it a major long- term problem for their families [15]. Due to recent advances in treatment, adolescents with TM can participate actively in social activities. Increasing public awareness of the incidence and treatment of TM can help ameliorate patient conditions and improve their quality of life. We assessed the quality of life among Iranian beta-thalassaemia major patients aged ≥ 15 years in Mazandaran province of the Islamic Republic of Iran. Methods Study design This was a cross-sectional, population- based study investigating the quality of life, mental health and life satisfaction among TM patients aged ≥15 years and treated between 1 March and 30 November, 2008 at any of the 16 special TM units in several hospitals of Mazandaran province, Iran, located on the southern coast of the Caspian Sea. The study protocol was approved by the ethnic review committees of 5 institutions, the Iranian Applied Re- search Center for Public Health and Sustainable Development (IRCPHD); North Khorasan University of Medical Sciences, Mashhad University of Medi- cal Sciences, Behavioural Sciences Re- search Center; Baqiyatallah University of Medical Sciences, Iranian Institute for Health Sciences Research, Iranian Institute for Young Thalassemia and all participants gave written informed consent. Participants and procedures We assessed TM patients who were dependent on blood transfusions, and who visited for monthly blood transfu- sions and clinical examinations. TM diagnosis was based on the results of electrophoresis of blood haemoglobin. All subjects were asked to complete a 6-page self-administered questionnaire; anyone who had difficulty reading the questionnaire was provided with assistance. Of the 1672 TM patients asked to complete the questionnaire, 687 (41.08%) did so. Measures The following instruments were used: Demographic researcher-made ques- tionnaire: In addition to information on subjects’ clinical and demographic characteristics, including age, sex, marital status, educational level, educa- tional status, disease complications, and treatment received, the questionnaire included questions on facial changes due to TM and on the deaths of near or distant relatives due to TM. Short Form 36 Health Survey Ques- tionnaire (SF-36): This questionnaire evaluated the general health of TM patients according to 8 categories: physical functioning, role-physical, bod- ily pain, general health, vitality, social functioning, role-emotional, and mental health. The Cronbach alpha the reliabil- ity of this questionnaire has been found to range from 0.77 to 0.90 in Iran and from 0.65 to 0.96 in other countries [16]. The total score of these 8 indices ranged between 0 and 100, with desig- nations of weak (≤ 20), bad (21–40), good (41–60), very good (61–80), and excellent (> 81) [16]. Symptoms checklist-90-revised (SCL- 90-R): This scale was used to estimate the type and intensity of psychologi- cal symptoms. The questionnaire includes 9 scopes (somatization, obsessive–compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychosis) and 3 indices [global severity index (GSI), with each question scored from 0 to 4; positive symptom total (PST) index, with a total score of 0 to 90; and positive symptoms distress in- dex (PSDI), with each question scored from 0 to 4] to indicate the sadness, depth and degree of mental problems. In Iran, the reliability of this question- naire has been reported to be from 0.80 for somatization to 0.90 for paranoid ideation and to range between 0.77 and 0.90 in other countries [17,18]. We scored participants with GSI > 0.7 as likely to require hospitalization, those with GSI between 0.4 and 0.7 as hav- ing a probable mental illness and those with GSI < 0.4 as probably safe and healthy. In addition, subjects with GSI scores higher than the mean score of the population were considered as likely to have mental problems, whereas those subjects with GSI lower than the mean score of the population were considered probably safe and healthy [19]. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما عبارلا ددعلا 541 Life Satisfaction Index (LSI): This questionnaire consisted of 20 questions on participants’ life satisfaction. Each question could be answered “agree” (2 points), “disagree” (0 points) or “I don’t know” (1 point). The scores of participants ranged from 0 to 40, with subjects categorized as unacceptable, poor, medium and acceptable [20]. Statistical analysis Descriptive statistics were used for all items. Statistical evaluations were performed using Q-Score and t-test, as assessed by the Statistical Package for the Social Sciences (SPSS 17.0). A P- value < 0.05 was considered statistically significant. Results Of the 1672 eligible patients with TM, 687 (41.08%) completed the question- naires. The mean age [standard deviation (SD)] of the participations was 21.93 (SD 5.90) years (range, 15–45 years). Of these individuals, 363 (52.8%) were female and 602 (87.6%) were unmar- ried. The subjects’ demographic charac- teristics are shown in Table 1. Of the 687 assessed TM patients, 284 (36.1%) were diagnosed before age 6 months, 167 (24.3%) from 6 months to 1 year, 182 (26.5%) between 2 and of 5 years and 90 (13.1%) after age 5 years. These patients received blood transfu- sions at a mean interval of 35.89 (SD 29.25) months (range, 2–144 months). Most patients (n = 620, 90.24%) visited the thalassaemia health units regularly for blood transfusions. On average, each patient was transfused with 528.77 (SD 158.28) mL of blood at each visit. We found that 656 patients (95.8%) were using Desferal transfusion medicine, with 650 (94.6%) applying it subcutane- ously along with the Desferal pump. Of the 687 TM patients we assessed, 437 (63.6%) had noticeable mild to severe changes in facial bones accompanied by some changes in figures and 477 (69.4%) patients showed mild to severe changes of complexion. Disease complications of thalassaemia are shown in Table 2. The mean scores on the 8 indexes of the SF-36 Test are shown in Table 3. Physical functioning index had the highest mean score [73.58 (SD 21.89)], while vitality had the lowest mean score [52.79 (SD 12.73)]. Scores between 80 and 100 for each of the 8 indexes were achieved by 329 patients (47.9%) for physical functioning, 224 (32.6%) for Role-physical, 206 (30%) for bodily pains, 83 (12.1%) for general health, 5 (7%) for vitality, 222 (32.3%) for social functioning, 201 (29.3%) for role-emo- tional, and 13 (1.9%) for mental health. Scores on the 9 scores and 3 indices of the SCL-90-R test were assessed, as shown in Table 4. GSI scores > 0.7% were observed in 449 (64.9%) subjects, indicating a need for treatment of mental illness. In addition, 141 (20.5%) subjects had GSI scores between 0.4% and 0.7%, suggesting that they may have a mental disease. However, 100 (14.6%) subjects had GSI scores < 0.4%, indicating that they were probably safe and healthy. The mean score of GSI of 405 patients (59%) was less than the GSI score of the population of this investigation; there- fore, they were considered probably safe and healthy. In contrast, the mean score GSI score of the remaining 282 patients (42%) was higher than the GSI score of the population, suggesting a need for mental health treatment. The mean (SD) scores of 9 scopes and 3 indexes Table 1 Demographic characteristics of the study sample (n = 687) Characteristic No. % Age (years) 15–25 537 78.2 25–35 127 18.5 35–45 23 3.3 Mean (SD) 21.93 (5.90) Range 15–45 Sex Male 324 47.2 Female 363 52.8 Marital status Single 602 87.6 Married 85 12.4 Education level Illiterate 28 4.1 Secondary 123 17.9 High school 314 45.7 Higher education 222 32.3 Educational status Normal 435 63.3 Retarded 252 36.7 Employment status Housewife 77 11.2 Student 243 35.4 University student 57 8.3 Employed 69 10.0 Jobless 241 35.1 SD = standard deviation. EMHJ  •  Vol. 18  No. 4  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 542 of SCL-90-R test in subgroups aged 15–25 and 25–45 years and in males and females are shown in Table 5. The TM patients in this study had a mean score of 20.5 (SD 5.95) (range, 2–37) on the life satisfaction question- naire. We found that 26 participants (3.8%) had scores corresponding to un- acceptable life satisfaction, 317 (46.1%) to poor life satisfaction, 314 (54.7%) to medium life satisfaction and 30 (4.4%) to acceptable life satisfaction. Discussion TM has become a major general health problem throughout the world, espe- cially in developing and poor countries [15]. TM is usually recognized in childhood, at which time patients begin treatment. Over their lives, however, patients and their families are at risk for social and behavioural disorders. Due to distress from both the illness itself and the need for iron chelation, thalassaemia subjects frequently display maladap- tive coping strategies and high levels of anxiety with psychosocial dysfunction [21,22]. The probability of behavioural abnormality in children with TM has been estimated to be 1.6-fold higher than that in healthy children [21]. Our findings support the results of other studies [2–14] on the qual- ity of life of TM patients and those with other chronic diseases, includ- ing Crohn disease, ulcerative colitis, cystic fibrosis, congenital heart disease, asthma, epilepsy, sweet diabetes and cancer [23––26]. These studies found that patients with these diseases show a significant decrease in life satisfaction and mental health or a significant in- crease in probable psychiatric disorders, including somatisation, interpersonal sensitivity, depression, anxiety and psy- chosis. Patients with different diseases, however, show differing intensity or type of psychiatric abnormalities. This may be due to differences in illness, the use of different research instruments, social class, ethnicity, the amount of support available to patients, previous treatments and self-coping strategies [27,28]. Table 2 Frequency of clinical disorders among participants (n = 687) Characteristic No. % Headache 127 18.5 Dyspnoea and chronic cough 68 9.9 Depression and anxiety 158 23 Hearing loss 50 7.3 Heart failure 45 6.6 Splenectomy 225 32.8 Lower back pain 212 30.9 Hyperthyroidism 7 1 Hepatitis 92 13.4 Visual loss 88 12.8 Cholecystectomy 56 8.2 Hypothyroidism 15 2.2 Hyperthyroidism 7 1 Osteoporosis 63 9.2 Bone fractures 84 12.2 Hypoparathyroidism 7 1 Allergy 63 9.2 Vertigo 127 18.5 Renal stones 25 3.6 Diabetes 50 7.3 Hypertension 9 1.3 Hyperlipidaemia 10 1.5 Table 3 Mean scores of participants on the 8 indices of the SF-36 test (n = 687) Indices of SF-36 Test Mean (SD) score Group A No. (%) Group B No. (%) Physical functioning 73.58 (22.81) 270 (39.3) 417 (60.7) Role-physical 59.06 (36.90) 331 (48.2) 356 (51.8) Bodily pain 64.45 (21.03) 353 (51.4) 334 (48.6) General health 57.88 (18.15) 368 (53.6) 319 (46.4) Vitality 52.79 (12.73) 349 (50.8) 338 (49.2) Social functioning 69.06 (21.41) 336 (48.9) 351 (51.1) Role-emotional 53.61 (37.78) 312 (45.4) 375 (54.6) Mental health 52.88 (13.94) 360 (52.4) 327 (47.6) Group A: participants in this group scored lower than the mean score of the sample for each index of SF-36. Group B: participants in this group have scored higher than the mean score of the sample for each index of SF-36. SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما عبارلا ددعلا 543 Our study findings indicate that TM patients in Mazandaran province lack pre-planned instructions on life skills and lack accessibility to psychi- atric consultations. These findings differ from those of a previous study [29], which found that most children become adjusted to their chronic disease and return to normal life. The marital status, level of education and educational status of TM patients were significantly lower than those of the general population, indicating that TM patients lack personality skills enabling them to adapt to their situation. The anxieties and behavioural abnormalities displayed by TM patients in previous decades were thought to be due to hav- ing to adapt to death, with adjustments associated with less depression. At pre- sent, however, due to the progress of medical remedial programmes, these patients encounter different aspects of life [30]. Moreover, inequalities between TM patients and their healthy peers, in aspects including emotional attitudes of adulthood, marriage circumstances and job opportunities, have decreased life satisfaction and increased psychiatric abnormalities in TM patients. Male and female patients have the same psychiatric abnormalities, in particular Table 4 Mean scores of participants on the scopes and indices of the SCL-90-R test (n = 687) Scopes and indices of SCL-90-R Test Total Patients Mean (SD) scores (n = 687) Group A Mean (SD) scores (n = 405) Group B Mean (SD) scores (n = 282) Somatization 0.97 (0.61) 0.64 (0.37) 1.43 (0.59) Obsessive–compulsive 0.96 (0.65) 0.59 (0.38) 1.48 (0.60) Interpersonal sensitivity 1.12 (0.72) 0.7 (0.41) 1.74 (0.64) Depression 1.13 (0.76) 0.66 (0.38) 1.8 (0.67) Anxiety 0.9 (0.66) 0.53 (0.35) 1.42 (0.64) Hostility 0.96 (0.74) 0.59 (0.45) 1.48 (0.76) Phobic anxiety 0.64 (0.58) 0.36 (0.32) 1.04 (0.63) Paranoid ideation 1.26 (0.78) 0.84 (0.51) 1.86 (0.71) Psychoticism 0.78 (0.61) 0.43 (0.33) 1.28 (0.57) Global severity index 0.97 (0.02) 0.6 (0.25) 1.51 (0.44) Positive symptom total 47.64 (0.73) 36.25 (14.37) 64 (12.18) Positive symptom distress index 1.77 (0.01) 1.52 (0.38) 2.12 (0.47) Group A: probable safe subjects having lower global severity index than the mean score of the sample in this research Group B: probable patient subjects having higher global severity index than the mean score of the sample in this research. SD = standard deviation. Table 5 Mean scores of participants on scopes and indices of the SCL-90-R test, by age and sex (n = 687) Scopes and indices of SCL- 90-R test Males (n = 324) Mean (SD) scores Females (n = 363) Mean (SD) scores P 15–25-year-olds (n = 537) Mean (SD) scores 25–45-year-olds (n = 150) Mean (SD) scores P Somatization 0.96 (0.6) 0.98 (0.62) 0.688 0.95 (0.62) 1.03 (0.58) 0.152 Obsessive- Compulsive 0.97 (0.65) 0.94 (0.66) 0.531 0.94 (0.66) 1 (0.61) 0.31 Interpersonal sensitivity 1.13 (0.72) 1.12 (0.72) 0.924 1.11 (0.74) 1.17 (0.67) 0.352 Depression 1.13 (0.76) 1.13 (0.76) 0.951 1.1 (0.77) 1.25 (0.74) 0.033 Anxiety 0.88 (0.64) 0.91 (0.67) 0.456 0.87 (0.65) 0.98 (0.67) 0.094 Hostility 0.98 (0.76) 0.94 (0.73) 0.486 0.93 (0.73) 1.04 (0.78) 0.126 Phobic anxiety 0.64 (0.56) 0.64 (0.59) 0.928 0.62 (0.56) 0.71 (0.62) 0.083 Paranoid ideation 1.22 (0.75) 1.3 (0.80) 0.193 1.24 (0.79) 1.34 (0.73) 0.142 Psychoticism 0.79 (0.62) 0.78 (0.60) 0.804 0.77 (0.62) 0.82 (0.58) 0.360 Global severity index 0.97 (0.55) 0.98 (0.62) 0.688 0.95 (0.62) 1.03 (0.58) 0.152 Positive symptom total 47.83 (18.43) 0.94 (0.66) 0.531 0.94 (0.66) 1 (0.61) 0.31 Positive symptom distress index 1.75 (0.51) 1.12 (0.72) 0.924 1.11 (0.74) 1.17 (0.67) 0.352 P < 0.05 was considered to be statistically significant. SD = standard deviation. EMHJ  •  Vol. 18  No. 4  •  2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 544 anxiety and behavioural abnormali- ties until adulthood; afterwards these abnormalities intensify more in females than in males [31]. Some studies have not found any gender-related differ- ences in the prevalence of behavioural abnormalities in children with chronic diseases [28]. In some diseases such as asthma and epilepsy, girls show higher rates of depression than boys [32], whereas in other diseases such as cancer, depression is seen more in boys [33]. We found, however, that the frequency of mental difficulties, as assessed by a GSI ≥ 0.7% mean score, was heightened in both genders, albeit equally. The latter may be due to the delay in sexual maturation in TM pa- tients [34]. References 1. Kasper DL et al. Harrison’s principles of internal medicine,16th ed. New York, McGraw–Hill, 2005 2. Aydin B et al. Psychosocial aspects and psychiatric disorders in children with thalassemia major. Acta Pediatrica Japanonica, 1997, 39:354–357. 3. Hoch C, Gobel U, Janssen G. Psychosocial support of patients with homozygous beta-thalassemia. Clinical Pediatrics, 2000, 212(4):216–219. 4. Tsiantis J et al. Psychosocial problems and adjustment of chil- dren with beta-thalassemia and their families. European Child & Adolescent Psychiatry, 1996, 5(4):193–203. 5. Z. Pourmovahed Kh. Dehghani M, Ardakani Y. [Evaluation of hopelessness and anxiety in young patients with thalassemia major]. Journal of Medical Research (JMR), 2003, 2(1):45–52. [In Farsi]. 6. Ghaffari Saravi V, Zarghami M, Ebrahimi E. [The prevalence of depression in Thalassemic patients in the city of Sari]. Iranian Journal of Psychiatry and Clinical Psychology (Andeesheh Va Raf- tar), 2004, 9(35):40–33 [In Persian]. 7. Khodaei Sh, Karbakhsh M, Asasi N. [Psychosocial status in Ira- nian adolescents with beta-thalassemia major]. Journal of the Tehran Faculty of Medicine, 2005, 63(1):23–18 [In Farsi]. 8. Monastero R et al. Cognitive deficits in beta-thalassemia ma- jor. Acta Neurologica Scandinavica, 2000, 102(3):162–168. 9. Noll RB et al. Social, emotional and behavioral functioning of children with cancer. Pediatrics, 1999, 103(1):71–78. 10. Lavigne JV, Ryan M. Psychological adjustment of siblings of children with chronic illnesses. Pediatrics, 1979, 63(4):616– 627. 11. Di Palma A et al. Psychosocial integration of adolescents and young adults with thalassemia major. Annals of the New York Academy of Sciences, 1998, 850:355–360. 12. Bush S, Mandel FS, Giardina PJ. Future orientation and life expectations of adolescents and young adults with thalas- semia major. Annals of the New York Academy of Sciences, 1998, 850:361–369. 13. Goldbeck L, Baving A, Kohne E. Psychosocial aspects of beta- thalassemia: distress, coping and adherence. Clinical Pediat- rics, 2000, 212(5):254–259. 14. Gharakhail A, Abedian M. Prevalence of beta thalassemia major in Mazandaran Province, Iran [Thesis]. Mazandaran, School of Medicine, Mazandaran University of Medical Sci- ences, 1997. 15. Olivieri NF. The beta-thalassemias. New England Journal of Medicine, 1999, 341:99–109. 16. Montazeri A et al. The Short Form Health Survey (SF-36): Trans- lation and validation study of the Iranian version. Quality of Life Research, 2005, 14(3):875–882. 17. Derogatis LR, Rickels K, Rock A. The SCL-90 and the MMPI: a step in the validation of a new self-report scale. British Journal of Psychiatry, 1976, 128:280–289. 18. Mirzai R. Standardizing and validating of SCL-90-R in Iran. Archives of Iranian Medicine, 2009, 1(12):5–14. 19. Bagheri Yazdi A, Bolhari J, Shah Mohammadi D. [An epide- miological study of psychological disorders in a rural area (Meibod, Yazd)]. Iranian Journal of Psychiatry and Clinical Psy- chology (Andeesheh Va Raftar), 1994, 1(1):41–32 [In Farsi]. 20. Neugarten BL, Butler N, Dawson I. Engagement levels on a unit for people with a physical disability. Clinical Rehabilitation, 1989, (3):299–304. 21. Jarman F, Oberklaid F. Children with chronic illness: Factors af- fecting psychosocial adjustment. Current Opinion in Pediatrics, 1990, 2(3):868–872. 22. Gortmaker SL et al. Chronic conditions, socioeconomic risk and behavior problems in children and adolescents. Journal of Pediatrics, 1990, 85(3):267–276. 23. Holden EW, Chmieiewski D, Nelson CC. Controlling for gen- eral and disease-specific effects in child and family adjustment to chronic childhood illness. Journal of Pediatric Psychology, 1997, 22:15–27. 24. Drotar D, Crawford P. Psychological adaptation of siblings of chronically ill children: Research and practice implica- The intensity of mental abnormali- ties in both genders and the similarity of mental and social anxiety factors in boys and girls suggest the necessity for these patients to have access to psychiatric consultants. The lack of significant differ- ences among age groups suggests that these patients have the same emotional and social needs, regardless of age [7]. The major limitation of this study was the relatively low participation rate, in that only 41% of the eligible patients participated. The uneven participation of the subjects may have been due to the severe mental and emotional disorders of TM patients at the time the survey was administered. We found that TM patients seen in special TM units in hospitals of Mazandaran province, on the southern coast of the Caspian Sea in Iran, are on the verge of suffering from different sorts of psychiatric abnormalities, indicat- ing a need to consult with proficient psychiatric consultants to be taught life skills and how to deal with the social and emotional disorders accompanying TM for improvement of their quality of life. Acknowledgements The authors thank the study sites and in- structors for their valuable contribution. The authors are thankful for contribu- tions of those who helped to carry this study especially the researchers who evaluated the questionnaires and those who carried out the interviews. طسوتلما قشرل ةيحصلا ةلجلماشرع نماثلا دلجلما عبارلا ددعلا 545 tion. Journal of Developmental and Behavioral Pediatrics, 1985, 6:355–362. 25. Canning EH, Canning RD, Boyce WE. Depressive symptom and adaptive style in children with cancer. Journal of the American Academy of Child and Adolescent Psychiatry, 1992, 31:1120–1124. 26. Kovacs M et al. Psychological functioning of children with insu- lin dependent diabetes mellitus: a longitudinal study. Journal of Pediatric Psychology, 1990, 15(5):619–632. 27. Burke P et al. Depression and anxiety in pediatric inflamma- tory bowel disease and cystic fibrosis. Journal of the American Academy of Child and Adolescent Psychiatry, 1989, 28:948–951. 28. Youssef NM. Scholl adjustment of children with congenital heart disease. Maternal–Child Nursing Journal, 1988, 17:217–302. 29. Eiser C. Psychological effects of chronic disease. Journal of Child Psychology and Psychiatry, and allied disciplines, 1990, 31:85–98. 30. Kaplan H, Sadock B. Synopsis of psychiatry, 9th ed. Baltimore, Williams & Wilkins, 2003. 31. Kashani J et al. Psychology in a community sample of children and adolescent: a development perspective. Journal of the American Academy of Child and Adolescent Psychiatry, 1989, 28:701–706. 32. Austin JK. Comparison of child adaptation to epilepsy and asthma. Journal of the American Academy of Child and Adolescent Psychiatry, 1989, 2:139–144. 33. Kashani J, Hakami N. Depression in children and adoles- cents with malignancy. Canadian Journal of Psychiatry, 1982, 27(6):474–477. 34. Melevendi C. Growth and sexual maturation in thalassemia major. Journal of Pediatrics, 1985, 106:150–155. Community genetics services. Report of a WHO Consultation on community genetics in low- and middle- income countries, Geneva, Switzerland, 13-14 September 2010 The objective of the above-mentioned Consultation was to develop an evidence-based report on community genetics services to provide guidance to low- and middle-income countries (LMIC) in accordance with the 2008–2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. The goal of community genetics in LMIC is to prevent congenital disorders and genetic diseases at the population level and, at the same time, to provide genetics services (diagnosis and counselling) in the community for individuals and families. The Consultation included a group of internationally-recognized specialists in the field of community genetics in LMIC. The group agreed that availability of community genetics services in LMIC is less than adequate. The report presents the deliberations of the group and its recommendations. 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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 ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نادوسلا بونج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما 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 . South Sudan 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 . Soudan du Sud . Tunisie . Yémen Cover 18-6.indd 2 6/19/2012 8:50:23 AM Contents V olum e 18 N um ber 5 M ay 2012 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 18 / No. 5 May / Mai 2012 5 ددع / شرع نماثلا دلجلما ويام / رايأ Tobacco control Tobacco use kills nearly 6 million people yearly, 600 000 of whom were exposed to second-hand smoke. Children are vulnerable both to the adverse effects of second-hand smoke and to enticement to smoke in the future. They need to be protected from both by ensuring smoke-free environments and educating them about smoking. World No Tobacco Day on 31 May 2012 focuses on the tactics of the tobacco industry to undermine tobacco control efforts, including the WHO Framework Convention on Tobacco Control. Letter from the Editor ....................................................................................................................................................... 409 Research articles Promoting public–private mix for TB-DOTS: a multi-country study from the WHO Eastern Mediterranean Region .......................................................................................................................410 Reproductive and non-reproductive health status of women aged 15 years and above in southern Jordan ...... 417 Maternal mortality in Jordan: role of substandard care and delays ....................................................................... 426 Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors .............432 Predictors of fetal demise after trauma in pregnant Saudi Arabian women ...........................................................439 General practitioners’ awareness and management of common psychiatric disorders: a community-based survey from Karachi, Pakistan ................................................................................................ 446 Smoking habits and attitudes among university students in Palestine: a cross-sectional study ............................454 Low adherence of Kuwaiti adults to fruit and vegetable dietary guidelines S. Zaghloul, C. Waslien, M. Al Somaie and P. Prakash ............................................................................................. 461 Feasibility of a peer-led, school-based asthma education programme for adolescents in Jordan...................... 468 Study of the relation between quality of inpatient care and early readmission for diabetic patients at a hospital in the Eastern province of Saudi Arabia ...............................................................................................474 Relationship between consultation length and rational prescribing of drugs in Gorgan city, Islamic Republic of Iran ............................................................................................................................................ 480 Social and behavioural HIV/AIDS research in Jordan: a systematic review .......................................................... 487 Aspects actuels des infections nosocomiales au Centre Hospitalier Libanais de Beyrouth .................................495 Evaluation of specific biochemical indicators of Helicobacter pylori-associated gastric cancer in Egypt ............ 501 نانسلأا بط ةنهم مهرايتخا بابسأ لوح قشمد ةعماج في نانسلأا بط ةيلك في بلاطلا ءارآ ............................................................................ 508 Review Appraisal of the research grant schemes of the World Health Organization Regional Office for the Eastern Mediterranean: the way forward ............................................................................................................515 Short communications Crimean–Congo haemorrhagic fever outbreak investigation in the Western Region of Afghanistan in 2008 ....522 Sanjad Sakati syndrome: a case series from Jordan .................................................................................................527 Profil étiologique des pancytopénies chez l’adulte à Marrakech (Maroc) .............................................................532 Case report Jessner lymphocytic infiltrate presenting on a cutaneous leishmaniasis scar: case report ...................................537 Translation Quality of life of Iranian β-thalassaemia major patients living on the southern coast of the Caspian Sea ...........539 Cover 18-5.indd 1 5/15/2012 9:06:51 AM