Eastern Mediterranean Health Journal [2016; Vol.22, Issue 1]

Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 22 / No. 1 January/Janvier 1 ددع / نوشرعلاو نياثلا دلجلما نياثلا نوناك/رياني2016 Contents V o lu m e 2 2 N u m b er 1 Jan u ary 2 0 1 6 In order to protect people participating in health research and ensure their human rights are respected, ethical principles have been developed for the conduct of research involving humans, such as informed consent, confidentiality and protection of privacy. WHO provides leadership and guidance on ethics issues related to human health, including health research. Editorial Ethics and health in WHO Regional Office for the Eastern Mediterranean .............................................................. 3 Research articles Improved water and child health in Egypt: impact of interrupted water supply and storage of household water on the prevalence of diarrhoea 5 ............................................................................................... 5 Relative inequalities in geographic distribution of health care resources in Kermanshah province, Islamic Republic of Iran .............................................................................................................................................. 20 Meals served to hypertensive and cardiac inpatients in Jordan: comparison with WHO and NIH dietary guidelines ............................................................................................................................................... 28 Prevalence of oro-dental anomalies among schoolchildren in Sana’a city, Yemen ............................................... 34 Prévalence et facteurs associés au tabagisme parmi les étudiants de la ville de Sousse (Tunisie) .........................40 Paediatric continuing medical education needs and preferences of UNRWA physicians in Jordan .................... 48 Report Compiling comprehensive national health statistics in a fragmented health information system: lessons learned from Lebanon ....................................................................................................................................53 Case report Multidrug-resistant disseminated tuberculosis in a 9-month-old infant ................................................................. 59 Invited commentary Ethics in health practice and research: an EMR perspective .................................................................................... 62 WHO events addressing public health priorities Work of the research ethics review committee in the Eastern Mediterranean Region .......................................... 64 Health and the sustainable development agenda: enhancing the role of civil society organizations .................. 67 Strengthening the role of public health associations in the Region ........................................................................ 70 EMHJ Guidelines on Ethical Conduct and Publication of Health Research ................................................................... 72 Guidelines for authors ....................................................................................................................................................... 77 Cover 22-01.indd 1-3 4/13/2016 8:09:07 AM EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico‑sanitaire, aux ONG, Centres collabora‑ teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2016 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. 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 Cover photograph ©World Health Organization تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا .هجراخو ميلقلإا فى ةحصلاب ينمتهلما طسوتلما قشرل ةيحصلا ةلجلما Correspondence Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int 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 . 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 . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen Subscriptions and Permissions Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: emrgoksp@who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: emrgoegp@who.int. Cover 22-01.indd 4-6 4/13/2016 8:09:07 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 22 No. 1 1 ددع نوشرعلا و نياثلا دلجلما• 2016 • Editorial Ethics and health in WHO Regional Office for the Eastern Mediterranean Ala Alwan.............................................................................................................................................................................................................................................................................................................3 Research articles Improved water and child health in Egypt: impact of interrupted water supply and storage of household water on the prevalence of diarrhoea 5 R. Roushdy and M. Sieverding ......................................................................................................................................................................................................................................................................5 Relative inequalities in geographic distribution of health care resources in Kermanshah province, Islamic Republic of Iran S.Rezaei, A.K. Karyani, R . Fallah and B.K. Matin .............................................................................................................................................................................................................................20 Meals served to hypertensive and cardiac inpatients in Jordan: comparison with WHO and NIH dietary guidelines H.A. Bawadi, A.D. Banks, R .F. Tayyem and C. ElKhoury ..............................................................................................................................................................................................................28 Prevalence of oro-dental anomalies among schoolchildren in Sana’a city, Yemen M. Basalamah and K. Baroudi ..................................................................................................................................................................................................................................................................34 Prévalence et facteurs associés au tabagisme parmi les étudiants de la ville de Sousse (Tunisie) C. Zedini, A. Ben Cheikh, M. Mallouli, M. Limam, J. Sahli, M. El Ghardallou, A. Mtiraoui et T. Ajmi ...........................................................................................................................40 Paediatric continuing medical education needs and preferences of UNRWA physicians in Jordan A. Nasir, A. Khader, L. Nasir, I. Abuzayed and A. Seita ....................................................................................................................................................................................................................48 Report Compiling comprehensive national health statistics in a fragmented health information system: lessons learned from Lebanon M.K. Asmar, J.S. Yeretzian and A. Rady .................................................................................................................................................................................................................................................53 Case report Multidrug-resistant disseminated tuberculosis in a 9-month-old infant G. Sensoy A. Karli, A.Birinci, P.A. Uras, M.C. Bilgici and F. Karagoz ..........................................................................................................................................................................................59 Invited commentary Ethics in health practice and research: an EMR perspective Mohamed Salah Ben Ammar, Ahmed Mandil and Samar El-Feky..............................................................................................................................................................................................62 WHO events addressing public health priorities Work of the research ethics review committee in the Eastern Mediterranean Region ...........................................................................................................................64 Health and the sustainable development agenda: enhancing the role of civil society organizations ..........................................................................................67 Strengthening the role of public health associations in the Region......................................................................................................................................................................70 EMHJ Guidelines on Ethical Conduct and Publication of Health Research ............................................................................................................................................72 Guidelines for authors...................................................................................................................................................................................................................................................................................77 Ala Alwan, Editor-in-chief Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Zuhair Hallaj Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editors Fiona Curlet, Guy Penet (French) Freelance: Alison Bichard, Marie-France Roux Graphics Suhaib Al Asbahi, Diana Tawadros Administration Nadia Abu-Saleh, Yasmeen Sedky, Iman Fawzy طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 3 1Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. Editorial Ethics and health in WHO Regional Office for the Eastern Mediterranean Ala Alwan 1 The constitution of WHO states that, “The enjoyment of the highest attain- able standard of health is one of the fundamental rights of every human being”. Ethics therefore underpin the work of WHO. Governments too have an ethical responsibility to protect and promote the health their peoples at the public health level through the provision of appropriate and adequate health and social services, as do health care professionals working at the indi- vidual and community level in primary health centres and hospitals in both the public and private sector. Health research involving humans is essential to the advancement of health but to safeguard the partici- pants, ethical principles have been laid down for its conduct, such as informed consent, confidentiality and protec- tion of privacy and ethical clearance of research by a qualified and authorized ethics committee. The scope of ethics within health, health care delivery and health ad- vancement is diverse and varying. Developments and advancements in medicine and medical practice as well as the emergence of new diseases and re-emergence of old ones can raise important questions that require ethi- cal consideration. The HIV/AIDS epi- demic brought up issues of equitable access to HIV services and treatment, as well as testing and counselling. Out- breaks and emergencies have raised issues such as prioritization of access to health care resources when demand is increased and shortages may occur, responsibilities of healthcare workers in light of the risks to their own health and safety, and the balance between reducing disease spread by isolation and travel restrictions and protecting the individual right to free movement. During the recent Ebola outbreak in West Africa, several other ethical issues have been raised concerning the use of unregistered interventions, the equitable distribution of such in- terventions and data collection while providing optimal care with a scarcity of resources. Public health surveillance has raised concerns of informed con- sent and the provision of standards of care, while human organ and tissue transplantation requires consideration of issues like sources and allocation of organs. Within its ethics mandate, WHO is required to provide leadership and guidance to Member States on a wide range of public health ethics issues and support them in handling bioethics issues arising in their own countries. WHO articulates ethical and evidence-based policy options, promotes ethics-based approaches to health protection and promotion, and supports capacity-building to address ethical issues in public health nation- ally, regionally and globally. A vital aspect of health research, and an ethical obligation for research- ers, is the reporting of research findings in order to provide data and evidence for knowledge translation which may advance health and inform and guide policy-makers. The Eastern Mediterra- nean Health Journal (EMHJ) has been contributing to the dissemination of health research for 21 years and has endeavoured to maintain high ethical standards for the research articles it publishes, following established inter- national ethical standards and guide- lines on the conduct and publication of health research. However, it is ap- parent that those submitting papers to EMHJ are not always aware of their ethical obligations. Therefore, in order to articulate EMHJ’s position on the conduct and reporting of research, and with the support and guidance of the Editorial Board, EMHJ has de- veloped the Guidelines on the Ethical Conduct and Publication of Health Research. These aim to provide health researchers with information on the ethical standards they are expected to conform to in their papers submitted for consideration for publication. The WHO Regional Office for Eastern Mediterranean is committed to enhancing bioethics capability in countries of the Region. In that regard and to inform readers of this work, we are pleased to publish in this issue of EMHJ three pieces related to ethics and health in the Region: a report on the work of the Eastern Mediterranean Re- search Ethics Review Committee; an overview of ethics in health practice and research in the Region; and the EMHJ Guidelines on the Ethical Conduct and Publication of Health Research. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 4 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 5 1Population Council, Egypt Country Office, Cairo, Egypt. 2Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America (Correspondence to M. Sieverding: sieverdingm@globalhealth.ucsf.edu). Received: 24/05/15; accepted: 18/10/15 Improved water and child health in Egypt: impact of interrupted water supply and storage of household water on the prevalence of diarrhoea R. Roushdy 1 and M. Sieverding 2 ABSTRACT Egypt is approaching universal access to improved water supply, but the variable quality of improved water may have a measureable health impact. We investigated the impact of different measures of improved water access on the prevalence of diarrhoea among children aged under 5 years. Using data from the 2008 Egypt Demographic and Health Survey and propensity score matching techniques we compared children in households with improved water supplies, with/without interruptions to supplies and with/without in-home storage of water. Access to improved water that was not subject to cuts resulted in a significant 2.6 percentage point reduction in the prevalence of diarrhoea (4.7% reduction in rural areas), and access to improved water that was not stored prior to use resulted in a 3.5% reduction. Further research is needed to better understand the nature and causes of piped water interruptions in Egypt, in order to address potential infrastructure challenges that are leading to poorer health outcomes. لاهسلإا راشتنا لىع لزانلما في هايلما نيزتخو هايلما تادادمإ عاطقنا يرثأت :صرم في لافطلأا ةحصو ةن َّسحلما هايلما جندرفيس ايام ،يدشر ةينار رـثأ هـل نوـكي دـق ةنـ َّسحلما هاـيلما ةدوـج في تواـفتلا نـكلو ،عـيمجلل ةنـ َّسمح هاـيم تادادـمإ ىـع لوـصلحا ةـحاتإ نـم رـم برـقت :ةـصلالخا مـهرماعأ لـقت نـيذلا لاـفطلأا نـب لاهـسلإا راـشتنا ىـع ةنـ َّسمح هاـيم ىـع لوـصلحا رـبادت فـلتمخ رـثأ انيصقتـسا دـقلو .سوـملم يـحص اـّنراق ،ةزرـحلما لـيلما تاـجرد نـب ةـقباطلما تاـينقتو 2008 ماـعل رـلم يـحصلاو نياكـسلا حـسلما نـم تاـنايب مادختـسابو .تاونـس 5 نـع ىـع لوـصلحا نأ اـندجوف .لزـنلما في هاـيلما نـيزتخو ،تادادـملإا في تاـعاطقنا ةـيلماتحا بـسحب ةنـسمح هاـيم تادادـمإ اـيهدل سرأ في لاـفطأ نـب ةـيفيرلا قـطانلما في ضاـفخنلاا ةبـسن( 2.6 هردـق لاهـسلإا راـشتنا في ظوـحلم ضاـفخنا نـع رفـسأ دـق تاـعاطقنا لىإ ضرـعتت لا ةنـسمح هاـيم ثوـحبلا نـم دـيزم ءارـجإ لىإ ةـجاح كاـنه . 3.5% ةبـسنب ضاـفخنا لىإ ىدأ مادختـسلاا لـبق ن َّزـتخ لا ةنـسمح هاـيم ىـع لوـصلحا نأو ،) 4.7 لىإ يدؤـت يـتلا ةـلمتحلما ةـيتحتلا ةـينبلا تاـيدحتل يدـصتلا ةـيغب ،رـم في لزاـنلما هاـيم عاـطقنا بابـسأو ةـعيبطل لـضفأ مـهف لىإ لوـصولل .أوـسأ ةـيحص جـئاتن Eau améliorée et santé de l’enfant en Égypte : impact de l’interruption de l’approvisionnement en eau et de la conservation de l’eau à usage domestique sur la prévalence de la diarrhée RÉSUMÉ L’Égypte se rapproche de l’accès universel à l’approvisionnement en eau améliorée, cependant la qualité variable de l’eau améliorée peut avoir un impact sanitaire mesurable. Nous avons examiné l’impact de différentes mesures d’accès à l’eau améliorée sur la prévalence de la diarrhée chez des enfants de moins de cinq ans. A l’aide de données issues de l’Enquête démographie et sanitaire en Égypte de 2008, et de la méthode d'appariement par scores de propension, nous avons comparé des enfants vivant dans des foyers dotés d’un approvisionnement en eau améliorée, avec ou sans interruption d’approvisionnement et avec ou sans stockage de l’eau à domicile. L’accès à une eau améliorée qui n’avait pas fait l'objet de coupures entraînait une réduction importante de 2,6 points de pourcentage de la prévalence de la diarrhée (4,7 % de réduction dans les zones rurales), tandis que l’accès à une eau améliorée qui n’avait pas été stockée avant utilisation correspondait à une réduction de 3,5 points de pourcentage. Davantage de recherches sont nécessaires pour mieux comprendre la nature et les causes des coupures d’eau courante en Égypte, afin de lutter contre les problèmes d’infrastructure potentiels qui entraînent une dégradation des résultats sanitaires. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 6 Introduction The Mil lennium Development Goal (MDG) of reducing by half the world’s population that lives without sustainable access to safe drinking water has been met (1). However, as acknowledged by the WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation (2), the current defi- nition of improved water and means of measuring access are imperfect proxies for sustainable access, and leave many factors unexplored, such as water quality, continuity of supply and maintenance of facilities (3–5). As more countries, and regions within countries, approach universal access to improved water supply it is therefore increasingly important to re-evaluate what sustainable access to this basic service means. This is- sue has been part of the impetus for maintaining a dedicated water goal among the post-2015 Sustainable Development Goals (SDGs). Egypt is one of the middle- income countries that has met the MDG water target, and in which cov- erage of an improved water supply according to the current JMP defini- tion is nearly universal, at 99%, with 96% of households having water that is piped onto the premises (1). How- ever, the quality of delivery continues to serve as a barrier to sustainable access at the sub-national level (6,7). This makes Egypt an ideal context in which to examine the effect of access to improved water—using alternative definitions to those of the JMP—on child health. A major motivation for the provi- sion of improved water supply is the high disease burden associated with the consumption of contaminated water, much of which is attributable to diarrheal disease (8,9). In Egypt, the limited literature on the topic has suggested that contamination of drinking water is a concern due to the poor quality of the pipes that connect households to water treat- ment facilities (6,7). Leaking pipes allow contaminated groundwater to enter the drinking supply, as evi- denced by higher bacterial counts at the point of water usage than at treatment sites (7). This problem may be exacerbated by breaks in wa- ter pumping, as more groundwater enters the pipe system when it is not pressurized (5 ,7). Public officials have also blamed several diarrhoeal outbreaks in recent years on water that was contaminated due to poor pipe quality (10,11). These argu- ments emphasize the need for a more nuanced examination of the quality of improved services. A large number of studies have investigated the impact of water sup- ply on child health worldwide. Sys- tematic reviews and meta-analyses (3,12–14), as well as cross-national studies (15), have found that im- provements in water quality and in- creased water supply are effective in reducing morbidity due to diarrhoea. Individual and multi-country studies, however, have highlighted important differences in quality among types of water supply that are classified as improved (4,16). In Egypt, to the best of our knowledge, the limited re- search on the impact of water supply on child health has found that access to better quality water is associated with reductions in child mortality (17,18). Findings regarding the as- sociation with child diarrhoea have been more mixed (19,20). The re- sults are also sensitive to the method of estimation (18,20), suggesting that the statistical approach adopted in the study, as well as the definition used for improved water supply, may affect measures of the impact of im- proved water supply on child health. A problem that arises when at- tempting to quantify the effect of interventions aiming to improve water supply is that if we observe a household with improved drinking water, we will not be able to simulta- neously observe the same household without access to improved services. This issue, which can be thought of as a missing data problem, biases the results of simple choice regressions and hazard models, since unobserved characteristics of households may be important determinants both of the household water source and the inci- dence of childhood diarrhoea (18). Propensity score matching (PSM) methods have been widely used in the impact evaluation literature on access to water supply and sanitation to correct for this self-selection or simultaneity problem (21–24). PSM matches subjects in the intervention (treated) group with subjects in the control (untreated) group based on the likelihood of being in treatment status as a function of observed char- acteristics (25,26). Throughout the paper we use the term “treated” to refer to the intervention group with higher-quality water supply, by vari- ous definitions, and not treated in the sense of water treatment practices. PSM techniques therefore have the advantage over regression and haz- ard models of allowing the analyst to isolate a control group that best approximates the characteristics of the intervention group in order to es- timate treatment effects, even when using observational data (26,27). Matching techniques, however, do not control for selection based on un- observed characteristics. To reduce the possibility of selection bias when using matching methods, research- ers often control for a wide range of locality and household character- istics that might be correlated with the treatment and the outcome vari- ables (26). Following this literature, we use PSM methods to estimate the impact of improved water service quality on the prevalence of diar- rhoea among children aged under 5 years in Egypt. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 7 Methods Study design and data source Our analysis used data from the 2008 Egypt Demographic and Health Survey (EDHS), which successfully interviewed 18 968 households con- taining 10 581 children younger than 5 years old. The outcome of interest was diarrhoea prevalence, as meas- ured by whether a child was reported by the mother to have experienced diarrhoea during the 2-week period preceding the survey. The primary analytical unit for this analysis was the 9992 children for whom data were available on diarrhoea occurrence in the past 2 weeks. Definitions of improved water Based on the WHO/UNICEF JMP definition for “improved” water (1), the 2008 EDHS defines improved sources of drinking water as water obtained from a piped source within the dwelling, a public tap, a tubewell, borehole or a protected well or spring (28). This definition will henceforth be referred to as the JMP definition. Access to improved water services according to the JMP definition is nearly universal in Egypt, at 98% of households in 2008. The JMP defini- tion for improved water supply does not account for the quality of service delivery, yet a significant percentage of households in the EDHS experi- enced problems with service quality. According to the EDHS data, 29% of households with improved water sup- ply experienced a cut in water avail- ability during the 2 weeks prior to the survey, and 17% of households stored their water (authors’ calculations). We exploited these indicators of service delivery from the EDHS to create 2 alternative indicators for water quality among households that had an improved water supply according to the JMP definition. A household was defined as having: (1) “improved–uninterrupted” water supply if it had access to an improved source of drinking water with no interruption in water supply in the past 2 weeks, and (2) “improved–un- stored” drinking water if it had access to an improved source of drinking water and did not store that water before use. Due to the small number of children living in households with an unimproved water supply accord- ing to the JMP definition (Table 1), these children were dropped from the analysis. The definitions of improved–un- interrupted and improved–unstored water were not mutually exclusive; 55% of children had access to both types of water supply. We therefore also tested the impact of having both improved–uninterrupted and im- proved–unstored water by comparing children with improved–uninterrupt- ed–unstored water with children in all other households with improved water; and with children in house- holds with improved–interrupted– stored water. Finally, we tested the net effect of having uninterrupted water, controlling for storage practices, by comparing children in households with improved–uninterrupted–un- stored water with children with im- proved–interrupted–unstored water. Table 1 Prevalence of diarrhoea in the 2 weeks prior to the survey, by different definitions of improved water supply Definition No. of children Prevalence of diarrhoea (%) d P-value JMP definition a Improved 9731 8.4 NS Unimproved 261 6.9 Total 9992 8.4 Improved–uninterrupted definition b Improved–uninterrupted 5738 7.0 < 0.001 Improved-interrupted 3993 10.6 Improved–unstored definition c Improved–unstored 7909 7.8 < 0.001e Uninterrupted 5395 7.5 Interrupted 2514 10.8 Improved–stored 1822 11.2 Uninterrupted 343 10.8 Interrupted 1479 12.4 aWater obtained from a piped source within the dwelling, a public tap, a tubewell, borehole or a protected well or spring; bImproved water supply with no interruption in water supply in the past 2 weeks; cImproved water supply and household does not store water before use. dCalculations use Egypt Demographic and Health Survey sample weights. eP-value for improved–unstored versus improved–stored. JMP = WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation; NS = not significant. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 8 Estimation techniques Our primary estimation technique was one-to-one propensity score matching, in which each treated case was matched to the control case that had the closest propensity score (27). Throughout the paper, we defined treatment status as having access to improved water supply in the household of residence, but we used varying definitions of “improved”, as explained above. For all analyses, we estimated the average treatment effect on the treated, which estimates the effect of the intervention—in our case access to improved water—on treated (intervention) units only (26). Stand- ard errors of the estimates of average treatment effect on the treated were adjusted to account for the fact that the propensity score was estimated using a logistic regression model prior to the match, rather than known a priori (27). To reduce the possibility of selec- tion bias when using matching meth- ods, we used a range of child, parental and household characteristics that might be correlated with both treat- ment status and the outcome variable to predict the propensity score (26). The likelihood of children being in treatment status, i.e. to be living in a household with improved water sup- ply, was estimated using a core set of variables that consisted of wealth quintile (ordinal variable), region of residence, mother’s and father’s education in years, mother’s age in years, child’s age in months, dummy variables for dwelling type (apart- ment, house or other) and whether the household had livestock. These variables were selected based on their theoretical importance in predicting child diarrhoea or their identification in previous studies as risk factors for diarrhoea infection in Egypt (29). Additional covariates were needed to achieve balance in some of the PSM matching analyses. These primarily consisted of dummy variables for dif- ferent combinations of region and wealth, as urban residence and higher wealth quintile were the variables on which selection into treatment status consistently occurred. All PSM analy- ses were run without replacement with a caliper of 0.03 (27) and standard errors were calculated using robust Abadie–Imbens standard errors (30). To check the robustness of our results, for each analysis we compared the results produced by PSM with those produced by simple logistic regression and coarsened exact match- ing (CEM). CEM matches each treated case to all of the control cases with the same values on a range of coarsened covariates, approximating exact matching (31). For example, age in years is coarsened into age groups, and CEM then matches onto those groups. Compared with PSM, CEM tends to produce fewer matches but may improve balance (23). For con- sistency, we used the same set of co- variates across all 3 methods—PSM, CEM and logistic regression—for each analysis. Rural–urban differences Based on the 2008 EDHS, 51.7% of households, containing 63.4% of the children aged under 5 years, resided in rural areas in Egypt, making this an important subpopulation for child health outcomes. Household-level connections to water systems are dif- ficult to establish and maintain where populations are dispersed, and the rural water infrastructure in particular suffers from maintenance challenges in many low- and middle-income countries (8). In Egypt, many of the community-specific problems with pipe maintenance have been found in rural areas (6,7). We therefore hypoth- esized that the impact of having im- proved–uninterrupted water on child diarrhoea would be larger in rural ar- eas, because poorer pipe maintenance in these areas may lead to greater risk of water contamination during breaks in pumping. To test this hypothesis, we conducted a separate analysis for the improved–uninterrupted treatment definition by residence. Results Effect of improved– uninterrupted and improved– unstored water access Table 1 shows that 8.4% of children younger than 5 years of age were re- ported by their mothers to have expe- rienced diarrhoea during the 2-week period preceding the survey. There was no significant difference in the percentage of children who experi- enced diarrhoea between those living in households with unimproved and improved water supply according to the JMP definition (P = 0.20). I n c o n t r a s t , u n d e r b o t h t h e improved–uninterrupted and im- proved–unstored definitions of water supply, children residing in households with poorer quality water supply (improved-interrupted or improved- stored, respectively) were significantly more likely to have suffered from diar- rhoea (P < 0.001). Due to the small number of children living in house- holds with an unimproved water sup- ply according to the JMP definition (Table 1), adequate balance on key covariates could not be achieved and the PSM results were unreliable. We therefore present the multivariate re- sults for the other definitions only. PSM matching results for the improved–uninterrupted definition are shown in the first panel of Table 2, comparing children in households with improved water supplies that were uninterrupted (intervention) with those for whom water supplies was interrupted (control). PSM resulted in improved covariate balance across the treatment and control groups on nearly all covariates (Table 3). The results in- dicate that having access to improved water supplies that were uninterrupted resulted in a 2.6 percentage point de- cline (95% CI: –0.9% to –4.3%) in طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 9 the prevalence of diarrhoea in children under 5 years (Table 2), somewhat smaller than the estimate produced by the unmatched logit (the full logit models for all analyses are presented in Appendix 1, which is available in the on line version on the EMHJ website). As expected, CEM resulted in a substan- tially smaller analytic sample, as there were more unmatched (off common support) cases that were deleted from the sample than with PSM. The CEM analysis produced only a 1.9 percentage point reduction in diarrhoea prevalence (95% CI: –0.7% to –2.9%), but the Table 2 Estimates of the impact of different definitions of improved water supply on the prevalence of diarrhoea in children under 5 years old: comparison of propensity score matching (PSM), coarsened exact matching (CEM) and logistic regression analysis Definition/analysis method No. of treated No. of controls Estimate (% point change)a SE of % point change 95% CI of % point change P-value Main definitions Improved–uninterrupted definition: Improved–uninterrupted vs improved–interrupted PSM 5634 3877 –0.026 0.009 –0.043 to –0.009 < 0.01 CEM 3356 2501 –0.019 0.006 –0.029 to –0.007 < 0.001 Logistic regression 5738 3993 –0.031 0.005 –0.042 to–0.021 < 0.001 Improved–unstored definition: Improved–unstored vs improved–stored PSM 7764 1779 –0.035 0.012 –0.059 to–0.012 < 0.01 CEM 3289 1259 –0.027 0.007 –0.040 to–0.013 < 0.001 Logistic regression 7909 1822 –0.030 0.006 –0.044 to–0.016 < 0.001 Combined effects analysis Combined effects analysis 1: Improved–uninterrupted–unstored vs all other improved PSM 5302 4195 –0.027 0.009 –0.043 to–0.010 < 0.01 CEM 3232 2654 –0.020 0.006 –0.030 to–0.008 < 0.001 Logistic regression 5395 4336 –0.032 0.005 –0.042 to–0.022 < 0.001 Combined effects analysis 2: Improved–uninterrupted–unstored vs improved–interrupted–stored PSM 5302 1409 –0.050 0.015 –0.079 to–0.022 < 0.001 CEM 1996 868 –0.030 0.008 –0.045 to–0.015 < 0.001 Logistic regression 5395 1479 –0.047 0.006 –0.064 to–0.029 < 0.001 Combined effects analysis 3: Improved–uninterrupted–unstored vs improved–interrupted–unstored PSM 5302 2443 –0.028 0.009 –0.046 to–0.010 < 0.01 CEM 2721 1574 –0.013 0.006 –0.025 to–0.001 < 0.05 Logistic regression 5395 2514 –0.028 0.005 –0.040 to–0.015 < 0.001 Rural-urban analysis Improved–uninterrupted vs improved–interrupted: children residing in rural households only PSM 3372 2684 –0.047 0.010 –0.068 to–0.027 < 0.001 CEM 2130 1818 –0.025 0.009 –0.043 to–0.007 < 0.01 Logistic regression 3442 2748 –0.036 0.006 –0.049 to–0.023 < 0.001 Improved–uninterrupted vs improved–interrupted: children residing in urban households only PSM 2260 1186 –0.017 0.014 –0.045 to 0.011 CEM 1286 730 –0.008 0.011 –0.030 to 0.013 Logistic regression 2296 1245 –0.022 0.009 –0.041 to–0.004 < 0.05 aEstimates for the CEM and logit models are marginal effects SE = standard error; CI = confidence interval. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 10 result was still significant (P < 0.001). Access to improved water supplies that were unstored resulted in a 3.5 percent- age point reduction (95% CI: –1.2% to –5.9%) in the prevalence of diarrhoea under PSM matching (Table 2; balance statistics in Table 4). The CEM and logit results again showed somewhat smaller percentage point reductions. Combined effects analysis Turning to the analyses of the combined effects of these 2 types of higher-quality improved water, the second panel of Table 2 compares children in households with the “best” improved water (i.e. uninterrupted and unstored) against children with all other forms of improved water, as well as against children with the “worst” improved water (i.e. interrupted and stored). For the first analysis, we obtained estimates of similar magni- tude as the improved–uninterrupted definition, with a 2.7 percentage point reduction (95% CI: –1.0% to –4.3%) in diarrhoea prevalence under PSM (balance statistics in Table 5). However, in the second analysis, we obtained an estimate of a 5.0 percent- age point reduction (95% CI: –2.2% to –7.9%) in diarrhoea prevalence. The CEM and logit estimates were also larger than in the earlier analy- ses. However, the balance statistics on several covariates was not optimal under this specification, likely due to the relatively small number of children in the control group (Table 6). To control for potential effects of improper storage practices, we then investigated the net effect of having an uninterrupted water source among households that did not store water (Table 2). Among children with im- proved–unstored water, the net effect of having an uninterrupted water supply was a 2.8 percentage point re- duction (95% CI: –1.0% to –4.6%) in diarrhoea prevalence compared with those with interrupted supplies (balance statistics in Table 7). The estimate under CEM, however, was smaller, indicating a 1.3 percentage point reduction (95% CI: –0.1% to –2.5%) (P < 0.05). Rural–urban differences Having an interrupted water supply was more common in rural areas than in urban ones; 46% of rural children compared with 32% of urban children lived in a household where the water had been cut off at least once in the past 2 weeks. The third panel of Table 2 shows that, as expected, rural areas accounted for a greater part of the ef- fect seen with the improved–uninter- rupted definition. Access to this type of water resulted in a 4.7 percentage point reduction (95% CI: –2.7% to –6.8%) in diarrhoea prevalence among children in rural areas under the PSM specification (balance statistics in Table 8) compared with only a 1.7 percentage point reduction for those in urban areas. This result was again ro- bust to CEM, although with a smaller estimated reduction of 2.5 percentage points (95% CI: –0.7% to –4.3%). The estimate under the logistic regression model showed a 3.6 percentage point reduction. Among children in urban areas, the estimates for the impact of improved–uninterrupted water, while negative, were not significant under either PSM or CEM (balance statistics in Table 9). Discussion The results of this study support the growing body of evidence that there is a high degree of variability in the qual- ity of improved water, including piped water, in low- and middle-income countries (4,16), and that these varia- tions have measurable health impacts (5,16). We found that having access to an improved water supply that was not subject to cut-offs reduced the prevalence of diarrhoea in children under age 5 years in Egypt, as did access to improved water that was not stored prior to use. These results were robust both to the matching method used, and to different forms of overlap between improved–uninterrupted and improved–unstored water. These overall results were driven by treat- ment effects in rural areas, where access to an improved water supply that was uninterrupted led to substantial reduc- tions in the prevalence of diarrhoea in under-5s. In contrast, no treatment effects were found in urban areas. This confirms our hypothesis that the effects of an improved–uninterrupted water supply would be greater in rural areas, where access to this type of water is also less common. Although we are not able to assess the quality of water at the source, these findings are consistent with arguments that the poor quality of pipes, potentially in combination with pauses in water pumping, is leading to water contamination. We also found that treatment ef- fects for children with the highest quality water as compared to those with the lowest quality were particu- larly large, suggesting that there is a compounding effect between poor quality water delivery and improper water storage practices. This agrees with previous studies that have found that improper water storage practices are a source of contamination even for water that may be clean at the source, and can lead to negative health im- pacts (32,33). However, given that a substantial percentage of households in Egypt do experience water cuts with some regularity, and there is an associa- tion between cuts and water storage, it is unrealistic to propose that in-home water storage be abandoned. Thus, in the absence of more continuous water supplies, interventions to pro- mote proper water storage and water treatment practices would be expected to have a positive impact on child health (5). Water purification at home is currently very uncommon in Egypt, making this an area with substantial طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 11 Ta bl e 3 Ba la nc e st at is ti cs fo r t he e ffe ct o f t he im pr ov ed –u ni nt er ru pt ed d efi ni ti on o f i m pr ov ed w at er s up pl ie s on th e pr ev al en ce o f d ia rr ho ea in c hi ld re n, u si ng p ro pe ns ity s co re m at ch in g (P SM ) a na ly si s Va ri ab le U nm at ch ed s am pl e PS M m at ch ed s am pl e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e R eg io n U rb an L ow er E gy pt 0 .0 91 0 .0 76 5. 4 2. 62 0 .0 0 9 0 .0 92 0 .0 92 0 .2 0 .1 0 .9 22 Ru ra l L ow er E gy pt 0 .2 91 0 .2 59 7.3 3. 55 < 0 .0 0 1 0 .2 91 0 .2 97 –1 .3 –0 .6 8 0 .4 95 U rb an U pp er E gy pt 0 .13 3 0 .10 5 8. 6 4. 14 < 0 .0 0 1 0 .13 3 0 .13 8 –1 .5 –0 .7 7 0 .4 41 Ru ra l U pp er E gy pt 0 .3 0 3 0 .4 0 0 –2 0 .4 –9 .9 6 < 0 .0 0 1 0 .3 0 2 0 .2 99 0 .5 0 .2 7 0 .7 89 Fr on tie r g ov er no ra te s 0 .0 22 0 .0 89 –2 9. 7 –1 5. 26 < 0 .0 0 1 0 .0 21 0 .0 21 0 .1 0 .0 7 0 .9 47 W ea lt h qu in ti le W ea lth q ui nt ile 2 0 .19 1 0 .2 0 9 –4 .7 –2 .2 7 0 .0 23 0 .19 1 0 .19 0 0 .2 0 .12 0 .9 0 5 W ea lth q ui nt ile 3 0 .19 8 0 .19 6 0 .5 0 .2 4 0 .8 0 8 0 .19 9 0 .19 9 –0 .1 –0 .0 5 0 .9 62 W ea lth q ui nt ile 4 0 .2 27 0 .16 2 16 .3 7.7 6 < 0 .0 0 1 0 .2 26 0 .2 46 –4 .9 –2 .4 0 .0 17 W ea lth q ui nt ile 5 0 .2 35 0 .16 0 18 .8 8. 93 < 0 .0 0 1 0 .2 35 0 .2 27 1.9 0 .9 6 0 .3 36 D w el lin g ty pe H ou se 0 .4 15 0 .5 24 –2 2. 0 –1 0 .7 0 < 0 .0 0 1 0 .4 12 0 .3 95 3. 4 1.8 4 0 .0 65 A pa rt m en t 0 .5 66 0 .4 58 21 .7 10 .5 5 < 0 .0 0 1 0 .5 69 0 .5 85 –3 .1 –1 .6 6 0 .0 97 Pa re nt s’ e du ca ti on Fa th er ’s ed uc at io n 9. 29 5 8. 20 1 20 .4 9. 93 < 0 .0 0 1 9. 30 7 9. 37 2 –1 .2 –0 .6 6 0 .5 10 M ot he r’s e du ca tio n 8. 18 2 6. 50 7 30 .0 14 .6 2 < 0 .0 0 1 8. 19 9 8. 27 2 –1 .3 –0 .7 1 0 .4 78 A ge M ot he r’s a ge (y ea rs ) 28 .4 91 28 .4 72 0 .3 0 .16 0 .8 72 28 .4 94 28 .3 72 2. 1 1.1 2 0 .2 61 C hi ld ’s ag e (m on th s) 28 .2 12 28 .11 6 0 .6 0 .2 7 0 .7 88 28 .2 0 5 27 .7 29 2. 7 1.4 8 0 .14 0 Li ve st oc k Ye s 0 .2 42 0 .3 95 –3 3. 4 –1 6. 43 < 0 .0 0 1 0 .2 41 0 .2 44 –0 .6 –0 .3 3 0 .7 42 C om bi ne d ca te go ri es U pp er E gy pt ru ra l p oo r 0 .19 8 0 .2 80 –1 9. 2 –9 .4 2 < 0 .0 0 1 0 .2 0 2 0 .18 7 3. 6 2. 0 2 0 .0 43 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 12 Ta bl e 4 Ba la nc e st at is ti cs fo r t he e ffe ct o f t he im pr ov ed –u ns to re d de fin it io n of im pr ov ed w at er s up pl ie s on th e pr ev al en ce o f d ia rr ho ea in c hi ld re n, u si ng p ro pe ns ity s co re m at ch in g (P SM ) a na ly si s Va ri ab le U nm at ch ed s am pl e PS M m at ch ed s am pl e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e R eg io n U rb an L ow er E gy pt 0 .0 95 0 .0 42 21 .2 7.3 8 < 0 .0 0 1 0 .0 94 0 .10 5 1.3 –2 .3 1 0 .0 21 Ru ra l L ow er E gy pt 0 .2 88 0 .2 35 12 .0 4. 54 < 0 .0 0 1 0 .2 87 0 .2 83 1.0 0 .6 2 0 .5 33 U rb an U pp er E gy pt 0 .12 8 0 .0 91 12 .0 4. 43 < 0 .0 0 1 0 .12 8 0 .12 4 1.4 0 .8 5 0 .3 97 Ru ra l U pp er E gy pt 0 .3 25 0 .4 17 –1 9. 0 –7 .4 5 < 0 .0 0 1 0 .3 26 0 .3 22 0 .8 0 .4 8 0 .6 31 Fr on tie r g ov er no ra te s 0 .0 30 0 .13 2 –3 8. 0 –1 8. 48 < 0 .0 0 1 0 .0 30 0 .0 30 0 .0 0 .0 0 1.0 0 0 W ea lt h qu in ti le W ea lth q ui nt ile 2 0 .19 4 0 .2 18 –6 .0 –2 .3 0 0 .0 21 0 .19 5 0 .18 9 1.3 0 .8 6 0 .3 92 W ea lth q ui nt ile 3 0 .2 0 1 0 .18 2 5. 0 1.8 9 0 .0 58 0 .2 0 2 0 .2 0 3 –0 .4 –0 .2 4 0 .8 10 W ea lth q ui nt ile 4 0 .2 0 9 0 .16 0 12 .7 4. 69 < 0 .0 0 1 0 .2 0 9 0 .2 0 0 2. 3 1.3 5 0 .17 6 W ea lth q ui nt ile 5 0 .2 17 0 .14 8 18 .0 6. 56 < 0 .0 0 1 0 .2 16 0 .2 23 –1 .8 –1 .0 3 0 .3 0 4 D w el lin g ty pe H ou se 0 .4 39 0 .5 52 –2 2. 8 –8 .7 9 < 0 .0 0 1 0 .4 38 0 .4 40 –0 .5 –0 .2 9 0 .7 71 A pa rt m en t 0 .5 42 0 .4 33 21 .9 8. 43 < 0 .0 0 1 0 .5 44 0 .5 39 1.0 0 .6 0 0 .5 51 Ed uc at io n Fa th er ’s ed uc at io n 9. 0 34 8. 0 35 18 .5 7.1 8 < 0 .0 0 1 9. 0 22 8. 97 7 0 .8 0 .5 3 0 .5 98 M ot he r’s e du ca tio n 7.7 72 6. 28 9 26 .6 10 .2 1 < 0 .0 0 1 7.7 61 7.8 44 –1 .5 –0 .9 3 0 .3 55 A ge M ot he r’s a ge (y ea rs ) 28 .5 0 9 28 .3 71 2. 3 0 .9 0 0 .3 69 28 .4 99 28 .5 91 –1 .5 –0 .9 6 0 .3 36 C hi ld ’s ag e (m on th s) 28 .15 2 28 .2 62 –0 .6 –0 .2 4 0 .8 0 7 28 .15 7 27 .6 56 2. 9 1.7 9 0 .0 74 Li ve st oc k Ye s 0 .2 78 0 .4 21 –3 0 .4 –1 2. 0 9 < 0 .0 0 1 0 .2 78 0 .2 79 –0 .3 –0 .2 0 0 .8 44 C om bi ne d ca te go ri es U pp er E gy pt ru ra l p oo r 0 .2 16 0 .3 0 0 –1 9. 3 –7 .7 1 < 0 .0 0 1 0 .2 20 0 .2 19 0 .4 0 .2 3 0 .8 16 Lo w er E gy pt ru ra l p oo r 0 .0 88 0 .11 2 –7 .8 –3 .12 0 .0 0 2 0 .0 90 0 .0 99 –3 .1 –1 .9 8 0 .0 48 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 13 Ta bl e 5 Ba la nc e st at is ti cs fo r t he e ffe ct o f t he im pr ov ed –u ni nt er ru pt ed –u ns to re d ve rs us a ll ot he r d efi ni ti on s of im pr ov ed w at er s up pl ie s on th e pr ev al en ce o f d ia rr ho ea in c hi ld re n, us in g pr op en si ty s co re m at ch in g (P SM ) a na ly si s Va ri ab le U nm at ch ed s am pl e PS M m at ch ed s am pl e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e R eg io n U rb an L ow er E gy pt 0 .0 94 0 .0 73 7.4 3. 63 < 0 .0 0 1 0 .0 95 0 .0 95 0 .1 0 .0 3 0 .9 74 Ru ra l L ow er E gy pt 0 .2 93 0 .2 59 7.8 3. 80 < 0 .0 0 1 0 .2 93 0 .2 89 0 .7 0 .3 6 0 .7 16 U rb an U pp er E gy pt 0 .13 3 0 .10 8 7.7 3. 76 < 0 .0 0 1 0 .13 3 0 .13 9 –1 .8 –0 .8 8 0 .3 80 Ru ra l U pp er E gy pt 0 .2 93 0 .4 0 4 –2 3. 4 –1 1.5 3 < 0 .0 0 1 0 .2 93 0 .2 91 0 .3 0 .15 0 .8 81 Fr on tie r g ov er no ra te s 0 .0 21 0 .0 85 –2 8. 9 –1 4. 63 < 0 .0 0 1 0 .0 20 0 .0 21 –0 .3 –0 .2 1 0 .8 36 W ea lt h qu in ti le W ea lth q ui nt ile 2 0 .19 0 0 .2 0 8 –4 .5 –2 .2 0 0 .0 28 0 .19 1 0 .18 3 2. 0 1.0 7 0 .2 84 W ea lth q ui nt ile 3 0 .19 7 0 .19 8 –0 .3 –0 .14 0 .8 88 0 .19 7 0 .19 7 0 .1 0 .0 7 0 .9 42 W ea lth q ui nt ile 4 0 .2 28 0 .16 6 15 .6 7.5 4 < 0 .0 0 1 0 .2 28 0 .2 46 –4 .6 –2 .19 0 .0 28 W ea lth q ui nt ile 5 0 .2 41 0 .15 8 20 .9 10 .0 7 < 0 .0 0 1 0 .2 41 0 .2 36 1.3 0 .6 2 0 .5 38 D w el lin g ty pe H ou se 0 .4 0 7 0 .5 25 –2 3. 7 –1 1.6 4 < 0 .0 0 1 0 .4 0 5 0 .4 0 5 0 .1 0 .0 4 0 .9 68 A pa rt m en t 0 .5 74 0 .4 58 23 .3 11 .4 4 < 0 .0 0 1 0 .5 76 0 .5 77 –0 .3 –0 .16 0 .8 75 Pa re nt s’ e du ca ti on Fa th er ’s ed uc at io n 9. 34 7 8. 22 4 21 .0 10 .3 0 < 0 .0 0 1 9. 35 3 9. 27 2 1.5 0 .7 9 0 .4 31 M ot he r’s e du ca tio n 8. 25 4 6. 55 0 30 .6 15 .0 4 < 0 .0 0 1 8. 27 2 8. 25 5 0 .3 0 .16 0 .8 76 A ge M ot he r’s a ge (y ea rs ) 28 .4 94 28 .4 70 0 .4 0 .2 0 0 .8 38 28 .5 0 0 28 .5 94 –1 .6 –0 .8 2 0 .4 13 C hi ld ’s ag e (m on th s) 28 .2 0 2 28 .13 7 0 .4 0 .18 0 .8 54 28 .19 8 27 .9 75 1.3 0 .6 7 0 .5 0 6 Li ve st oc k Ye s 0 .2 28 0 .4 0 1 –3 8. 0 –1 8. 79 < 0 .0 0 1 0 .2 28 0 .2 30 –0 .6 –0 .3 2 0 .7 46 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 14 Ta bl e 6 Ba la nc e st at is ti cs fo r t he e ffe ct o f t he im pr ov ed –u ni nt er ru pt ed –u ns to re d ve rs us im pr ov ed –i nt er ru pt ed –s to re d de fin it io ns o f i m pr ov ed w at er s up pl ie s on th e pr ev al en ce o f di ar rh oe a in c hi ld re n, u si ng p ro pe ns ity s co re m at ch in g (P SM ) a na ly si s Va ri ab le U nm at ch ed s am pl e PS M m at ch ed s am pl e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e R eg io n U rb an L ow er E gy pt 0 .0 94 0 .0 41 21 .2 6. 57 < 0 .0 0 1 0 .0 92 0 .0 83 3. 6 1.6 2 0 .10 5 Ru ra l L ow er E gy pt 0 .2 93 0 .2 29 14 .6 4. 87 < 0 .0 0 1 0 .2 90 0 .2 82 1.8 0 .9 1 0 .3 64 U rb an U pp er E gy pt 0 .13 3 0 .0 80 17 .0 5. 47 < 0 .0 0 1 0 .13 5 0 .14 8 –4 .4 –1 .9 9 0 .0 47 Ru ra l U pp er E gy pt 0 .2 93 0 .4 0 8 –2 4. 3 –8 .4 7 < 0 .0 0 1 0 .2 96 0 .3 0 0 –0 .9 –0 .4 9 0 .6 23 Fr on tie r g ov er no ra te s 0 .0 21 0 .15 5 –4 8. 7 –2 1.7 3 < 0 .0 0 1 0 .0 20 0 .0 20 0 .0 0 .0 0 1.0 0 0 W ea lt h qu in ti le W ea lth q ui nt ile 2 0 .19 0 0 .2 23 –8 .1 –2 .7 7 0 .0 0 6 0 .19 3 0 .17 6 4. 1 2. 19 0 .0 29 W ea lth q ui nt ile 3 0 .19 7 0 .17 3 6. 3 2. 0 9 0 .0 37 0 .19 9 0 .2 0 4 –1 .4 –0 .7 1 0 .4 80 W ea lth q ui nt ile 4 0 .2 28 0 .14 9 20 .1 6. 51 < 0 .0 0 1 0 .2 21 0 .2 54 –8 .7 –4 .0 6 < 0 .0 0 1 W ea lth q ui nt ile 5 0 .2 41 0 .15 1 22 .7 7.3 2 < 0 .0 0 1 0 .2 43 0 .2 15 7.1 3. 44 0 .0 0 1 D w el lin g ty pe H ou se 0 .4 0 7 0 .5 56 –3 0 .1 –1 0 .2 9 < 0 .0 0 1 0 .4 0 5 0 .3 98 1.4 0 .7 4 0 .4 61 A pa rt m en t 0 .5 74 0 .4 29 29 .2 9. 95 < 0 .0 0 1 0 .5 77 0 .5 86 –1 .7 –0 .8 9 0 .3 73 Pa re nt s’ e du ca ti on Fa th er ’s ed uc at io n 9. 34 7 7.9 29 26 .2 9. 0 7 < 0 .0 0 1 9. 29 4 9. 33 2 –0 .7 –0 .3 7 0 .7 0 9 M ot he r’s e du ca tio n 8. 25 4 6. 11 4 38 .8 13 .2 7 < 0 .0 0 1 8. 20 6 8. 16 2 0 .8 0 .4 1 0 .6 81 A ge M ot he r’s a ge (y ea rs ) 28 .4 94 28 .3 54 2. 4 0 .8 2 0 .4 14 28 .4 61 28 .3 90 1.2 0 .6 2 0 .5 36 C hi ld ’s ag e (m on th s) 28 .2 0 2 28 .2 35 –0 .2 –0 .0 7 0 .9 47 28 .17 9 27 .8 47 1.9 0 .9 8 0 .3 25 Li ve st oc k Ye s 0 .2 28 0 .4 12 –4 0 .2 –1 4. 39 < 0 .0 0 1 0 .2 30 0 .2 24 1.3 0 .7 5 0 .4 56 C om bi ne d ca te go ri es Lo w er E gy pt ru ra l p oo r 0 .0 82 0 .11 7 –1 1.6 –4 .15 < 0 .0 0 1 0 .0 84 0 .0 83 0 .4 0 .2 5 0 .8 0 5 Ru ra l p oo r 0 .2 75 0 .4 53 –3 7.6 –1 3. 25 < 0 .0 0 1 0 .2 83 0 .2 73 2. 1 1.1 1 0 .2 66 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 15 Ta bl e 7 Ba la nc e st at is ti cs fo r t he e ffe ct o f i m pr ov ed –u ni nt er ru pt ed –u ns to re d ve rs us im pr ov ed –i nt er ru pt ed –u ns to re d de fin it io ns o f i m pr ov ed w at er s up pl ie s on th e pr ev al en ce o f di ar rh oe a in c hi ld re n, u si ng p ro pe ns ity s co re m at ch in g (P SM ) a na ly si s Va ri ab le U nm at ch ed s am pl e PS M m at ch ed s am pl e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e R eg io n U rb an L ow er E gy pt 0 .0 94 0 .0 97 –0 .8 –0 .3 5 0 .7 25 0 .0 95 0 .0 88 2. 4 1.2 8 0 .2 0 1 Ru ra l L ow er E gy pt 0 .2 93 0 .2 76 3. 9 1.6 1 0 .10 8 0 .2 93 0 .3 0 4 –2 .4 –1 .2 3 0 .2 18 U rb an U pp er E gy pt 0 .13 3 0 .12 0 3. 9 1.6 1 0 .10 8 0 .13 3 0 .14 0 –1 .9 –0 .9 3 0 .3 51 Ru ra l U pp er E gy pt 0 .2 93 0 .3 95 –2 1.5 –9 .0 2 < 0 .0 0 1 0 .2 93 0 .2 90 0 .6 0 .3 4 0 .7 32 Fr on tie r g ov er no ra te s 0 .0 21 0 .0 50 –1 5. 9 –7 .14 < 0 .0 0 1 0 .0 20 0 .0 17 1.6 1.1 5 0 .2 49 W ea lt h qu in ti le W ea lth q ui nt ile 2 0 .19 0 0 .2 0 1 –2 .8 –1 .16 0 .2 48 0 .19 1 0 .2 0 3 –2 .9 –1 .5 1 0 .13 0 W ea lth q ui nt ile 3 0 .19 7 0 .2 10 –3 .3 –1 .3 6 0 .17 5 0 .19 7 0 .2 0 1 –1 .0 –0 .5 1 0 .6 10 W ea lth q ui nt ile 4 0 .2 28 0 .17 0 14 .5 5. 85 < 0 .0 0 1 0 .2 28 0 .2 28 –0 .2 –0 .12 0 .9 0 8 W ea lth q ui nt ile 5 0 .2 41 0 .16 5 18 .9 7.5 7 < 0 .0 0 1 0 .2 41 0 .2 31 2. 6 1.2 6 0 .2 0 8 D w el lin g ty pe H ou se 0 .4 0 7 0 .5 0 5 –1 9. 8 –8 .2 1 < 0 .0 0 1 0 .4 0 5 0 .4 0 7 –0 .3 –0 .16 0 .8 74 A pa rt m en t 0 .5 74 0 .4 76 19 .7 8. 18 < 0 .0 0 1 0 .5 76 0 .5 77 –0 .3 –0 .16 0 .8 75 Pa re nt s’ e du ca ti on Fa th er ’s ed uc at io n 9. 34 7 8. 36 2 18 .4 7.6 8 < 0 .0 0 1 9. 35 3 9. 31 2 0 .8 0 .4 0 0 .6 89 M ot he r’s e du ca tio n 8. 25 4 6. 73 9 27 .1 11 .3 0 < 0 .0 0 1 8. 27 2 8. 30 3 –0 .6 –0 .2 9 0 .7 70 A ge M ot he r’s a ge (y ea rs ) 28 .4 94 28 .5 41 –0 .8 –0 .3 3 0 .7 42 28 .5 0 0 28 .4 66 0 .6 0 .2 9 0 .7 69 C hi ld ’s ag e (m on th s) 28 .2 0 2 28 .0 46 0 .9 0 .3 7 0 .7 10 28 .19 8 27 .9 89 1.2 0 .6 2 0 .5 33 Li ve st oc k Ye s 0 .2 28 0 .3 86 –3 4. 8 –1 4. 84 < 0 .0 0 1 0 .2 28 0 .2 37 –2 .1 –1 .15 0 .2 50 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 16 Ta bl e 8 Ba la nc e st at is ti cs fo r t he e ffe ct o f t he im pr ov ed –u ni nt er ru pt ed d efi ni ti on o f i m pr ov ed w at er s up pl ie s on th e pr ev al en ce o f d ia rr ho ea in c hi ld re n, u si ng p ro pe ns ity s co re m at ch in g (P SM ) a na ly si s: c hi ld re n in ru ra l h ou se ho ld s on ly Va ri ab le U nm at ch ed s am pl e PS M m at ch ed s am pl e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e R eg io n Ru ra l L ow er E gy pt 0 .4 86 0 .3 76 22 .3 8. 71 < 0 .0 0 1 0 .4 85 0 .4 89 –0 .8 –0 .3 2 0 .7 51 Ru ra l U pp er E gy pt 0 .5 0 5 0 .5 81 –1 5. 3 –5 .9 9 < 0 .0 0 1 0 .5 0 6 0 .5 0 2 0 .8 0 .3 2 0 .7 51 Fr on tie r g ov er no ra te s 0 .0 10 0 .0 43 –2 1.1 –8 .5 6 < 0 .0 0 1 0 .0 10 0 .0 10 0 .0 0 .0 0 1.0 0 0 W ea lt h qu in ti le W ea lth q ui nt ile 2 0 .2 58 0 .2 53 1.2 0 .4 8 0 .6 31 0 .2 60 0 .2 60 –0 .1 –0 .0 3 0 .9 78 W ea lth q ui nt ile 3 0 .2 28 0 .2 15 3. 2 1.2 2 0 .2 22 0 .2 28 0 .19 7 7.4 3. 0 7 0 .0 0 2 W ea lth q ui nt ile 4 0 .19 6 0 .12 6 19 .3 7.3 9 < 0 .0 0 1 0 .19 4 0 .2 12 –4 .9 –1 .8 2 0 .0 69 W ea lth q ui nt ile 5 0 .0 96 0 .0 57 14 .9 5. 70 < 0 .0 0 1 0 .0 97 0 .10 1 –1 .8 –0 .6 5 0 .5 14 D w el lin g ty pe H ou se 0 .5 80 0 .6 44 –1 3. 2 –5 .15 < 0 .0 0 1 0 .5 76 0 .5 63 2. 5 1.0 1 0 .3 13 A pa rt m en t 0 .4 0 0 0 .3 35 13 .6 5. 29 < 0 .0 0 1 0 .4 0 5 0 .4 18 –2 .8 –1 .14 0 .2 54 Pa re nt s’ e du ca ti on Fa th er ’s ed uc at io n 8. 45 6 7.4 17 19 .4 7.6 0 < 0 .0 0 1 8. 46 5 8. 44 3 0 .4 0 .16 0 .8 69 M ot he r’s e du ca tio n 6. 97 4 5. 33 6 30 .2 11 .8 1 < 0 .0 0 1 6. 96 7 6. 90 8 1.1 0 .4 4 0 .6 60 A ge M ot he r’s a ge (y ea rs ) 27 .8 92 28 .19 7 –5 .1 –2 .0 0 0 .0 46 27 .8 77 27 .8 31 0 .8 0 .3 2 0 .7 49 C hi ld ’s ag e (m on th s) 28 .2 75 28 .5 83 –1 .8 –0 .7 0 0 .4 86 28 .2 43 27 .7 54 2. 8 1.1 5 0 .2 50 Li ve st oc k Ye s 0 .3 63 0 .5 19 –3 1.9 –1 2. 49 < 0 .0 0 1 0 .3 63 0 .3 59 0 .8 0 .3 3 0 .7 41 C om bi ne d ca te go ri es Lo w er E gy pt ru ra l p oo r 0 .13 8 0 .15 6 –5 .2 –2 .0 3 0 .0 42 0 .14 0 0 .14 9 –2 .5 –1 .0 4 0 .2 99 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 17 Ta bl e 9 Ba la nc e st at is ti cs fo r t he e ffe ct o f t he im pr ov ed –u ni nt er ru pt ed d efi ni ti on o f i m pr ov ed w at er s up pl ie s on th e pr ev al en ce o f d ia rr ho ea in c hi ld re n, u si ng p ro pe ns ity s co re m at ch in g (P SM ) a na ly si s: c hi ld re n in u rb an h ou se ho ld s on ly Va ri ab le U nm at ch ed s am pl e PS M m at ch ed s am pl e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e M ea n tr ea te d M ea n co nt ro l % b ia s t- va lu e P– va lu e R eg io n U rb an g ov er no ra te s 0 .4 0 1 0 .2 30 37 .3 10 .3 7 < 0 .0 0 1 0 .4 0 0 0 .3 72 6. 1 1.9 3 0 .0 54 U rb an L ow er E gy pt 0 .2 28 0 .2 44 –3 .8 –1 .0 8 0 .2 79 0 .2 30 0 .2 39 –2 .1 –0 .7 0 0 .4 83 U rb an U pp er E gy pt 0 .3 32 0 .3 37 –1 .0 –0 .2 8 0 .7 80 0 .3 32 0 .3 51 –4 .0 –1 .3 5 0 .17 8 W ea lt h qu in ti le W ea lth q ui nt ile 2 0 .0 90 0 .11 3 –7 .7 –2 .2 0 0 .0 28 0 .0 90 0 .0 85 1.9 0 .6 8 0 .4 94 W ea lth q ui nt ile 3 0 .15 5 0 .15 6 –0 .4 –0 .11 0 .9 16 0 .15 5 0 .16 5 –2 .8 –0 .9 3 0 .3 51 W ea lth q ui nt ile 4 0 .2 72 0 .2 43 6. 5 1.8 3 0 .0 67 0 .2 71 0 .2 79 –1 .8 –0 .6 0 0 .5 49 W ea lth q ui nt ile 5 0 .4 41 0 .3 89 10 .5 2. 94 0 .0 0 3 0 .4 40 0 .4 32 1.6 0 .5 4 0 .5 89 D w el lin g ty pe H ou se 0 .16 8 0 .2 59 –2 2. 5 –6 .5 6 < 0 .0 0 1 0 .16 7 0 .16 4 0 .8 0 .2 8 0 .7 79 A pa rt m en t 0 .8 15 0 .7 31 20 .3 5. 88 < 0 .0 0 1 0 .8 17 0 .8 14 0 .6 0 .2 3 0 .8 18 Pa re nt s’ e du ca ti on Fa th er ’s ed uc at io n 10 .5 53 9. 92 8 12 .3 3. 52 < 0 .0 0 1 10 .5 38 10 .3 65 3. 4 1.1 7 0 .2 42 M ot he r’s e du ca tio n 9. 99 8 9. 0 87 17 .5 5. 0 1 < 0 .0 0 1 10 .0 0 4 10 .0 50 –0 .9 –0 .3 1 0 .7 55 A ge M ot he r’s a ge (y ea rs ) 29 .3 91 29 .0 78 5. 4 1.5 4 0 .12 3 29 .3 92 29 .3 42 0 .9 0 .2 9 0 .7 70 C hi ld ’s ag e (m on th s) 28 .11 8 27 .0 86 6. 0 1.7 0 0 .0 88 28 .11 6 28 .11 4 0 .0 0 .0 0 0 .9 97 potential for impact while longer-term investments in the continuity of water delivery are undertaken. On the other hand, our findings suggest that supply interruptions are driving the health impacts seen from the variations in water quality in this study. In other words, the direct health benefits of a continuous water sup- ply may be greater than the benefits achieved by reducing the likelihood that households will store their water. On a broader level, these findings also point to the importance of considering multiple dimensions of water quality in definitions of safe and sustainable wa- ter access. Although universal access to safe drinking water has been proposed as one of the SDG goals, the indicators to measure progress against this goal are still under discussion. Proposals include indicators for “safely managed” water, mentioning factors such as suf- ficient water supply and specific forms of contamination. The results of this study argue for including and ensur- ing the means to adequately measure a target indicator that captures suffi- ciency and consistency of water supply in particular. A main limitation of this study was the lack of more detailed measures of the quality of water service delivery in the EDHS. Unfortunately, an analysis of the frequency, duration and causes of piped water interruptions in Egypt was not possible using the EDHS data, nor, to our knowledge, are such in- dicators available in alternative data sources. We were also unable to com- pare water quality at the source with water quality at point-of-use among households with piped water, which is needed in order to develop recom- mendations for investments in the wa- ter delivery system in Egypt. Although hygiene practices and access to sanita- tion facilities may also affect diarrhoea prevalence among children, we were not able to address these factors in this analysis. Access to improved sanitation according to the JMP definition is also EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 18 near universal in Egypt, and we were unable to identify a robust alternative definition of sanitation access using the measures available in the EDHS. The EDHS also does not contain measures for hygiene practices such as hand-washing. Another limitation of this study is that it was based on observational data; there may therefore be unobserved fac- tors related to both water supply and child diarrhoea for which matching methods do not control. However, the fact that robustness checks using CEM showed highly consistent results with PSM suggests that, within the limita- tions of matching methods generally, our results are robust to the matching specification used. Our findings therefore call for fur- ther investigation of the dimensions of improved water quality in rural and urban areas. 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Received: 08/09/14; accepted: 08/11/15 Relative inequalities in geographic distribution of health care resources in Kermanshah province, Islamic Republic of Iran S.Rezaei,1 A.K. Karyani,2 R. Fallah 3 and B.K. Matin 1 ABSTRACT This study aimed to evaluate inequalities in the geographical distribution of human and physical resources in the health sector of Kermanshah province, Islamic Republic of Iran. In a retrospective, cross-sectional study, data from the Statistical Centre of Iran were used to calculate inequality measures (Gini coefficient and index of dissimilarity) over the years 2005–11. The highest Gini coefficient for human resources was observed for pharmacists in 2005 (0.75) and the lowest for paramedics in 2010 and 2011 (0.10). The highest indices of dissimilarity were also for pharmacists in 2005 (29%) and paramedics in 2011 (3%). For physical resources, the highest and lowest Gini coefficients were for rehabilitation centres in 2010 (0.59) and health houses in 2011 (0.12) respectively. Generally, inequalities in the distribution of health care resources were lower at the end of the study period, although there was potential for more equitable distribution of pharmacists, specialists, health houses and beds. ةيملاسلإا ناريإ ةيروهمجب هاشنمرك ةظفامح في ةيحصلا ةياعرلا دراولم فيارغلجا عيزوتلا في ةيبسنلا ةاواسلما مدع نتم يمرك دازبه ،حَّلاف ةيضار ،نيايرك يمظاك ليع ،يئاضر راتس ةـظفامح في يـحصلا عاـطقلا في ةـيدالماو ةـيشربلا دراوـملل فيارـغلجا عـيزوتلا في مـئاقلا تواـفتلا مـييقت لىإ ةـساردلا هذـه تـفده دـقل :ةـصلالخا سـيياقم باـسلح نارـيإ في ءاـصحلإا زـكرم نـم تاـنايب تمدختـسا ةـيعطقم ةيداعتـسا ةـسارد يـفف .ةيملاـسلإا نارـيإ ةـيروهمجب هاـشنمرك ةلدايصلل ةبـسنلاب ةـيشربلا دراوـملل ينيج لـماعُم ىـعأ نأ ظـحولف .2011-2005 تاونـسلا ىدـم ىـع )نـيابتلا بـسنَمو يـنيج لـماعُم( تواـفتلا ماـع في كـلذك ةـلدايصلل نـيابتلل بـسانَم ىـعأ تـناكو .)0.10( 2011 و 2010 يـماع في ناك نفعـسملل لـماعُم ىـندأو )0.75( 2005 ماـع في ناك )0.59( 2010 ماـع في لـيهأتلا زـكارلم يـنيج لـماعُم ىـندأو ىـعأ ناك ةـيدالما دراوـملل ةبـسنلابو .)3%( 2011 ماـع في نفعـسمللو )29%( 2005 ةـيانه في لـقأ ةـيحصلا ةـياعرلا دراوـم عـيزوت في تواـفتلا نأ ظـحول دـقلف ،ةـماع ةـفصبو .لياوـتلا ىـع )0.12( 2011 ماـع في ةـحصلا نكاـسلمو .ًاـفاصنإ رـثكأ ةـقيرطب ة َّسرلأاو ةـحصلا نكاـسمو نـيصاصتخلااو ةـلدايصلا عـيزوتل ةـيناكمإ كاـنه تـناك هـنأ نـم مـغرلا ىـع ،ةـساردلا ةرـف Inégalités relatives dans la répartition géographique des ressources en soins de santé dans la province de Kermânchâh (République islamique d’Iran) RÉSUMÉ La présente étude visait à évaluer les inégalités dans la répartition géographique des ressources humaines et physiques du secteur de la santé de la province de Kermânchâh (République islamique d’Iran). Dans une étude rétrospective transversale, des données du centre iranien des statistiques ont été exploitées pour calculer des mesures d’inégalité (le coefficient de Gini et l’indice de dissimilitude) entre 2005 et 2011. Le coefficient de Gini le plus élevé pour les ressources humaines a été observé chez les pharmaciens en 2005 (0,75) et le plus faible chez les personnels paramédicaux en 2010 et 2011 (0,10). Les indices de dissimilitude les plus élevés concernaient aussi les pharmaciens en 2005 (29 %) et les personnels paramédicaux en 2011 (3 %). Pour les ressources physiques, les coefficients de Gini les plus élevés et les plus faibles concernaient les centres de réadaptation en 2010 (0,59) et les maisons de santé en 2011 (0,12), respectivement. De manière générale, les inégalités dans la répartition des ressources en soins de santé étaient plus faibles à la fin de la période de l’étude, même s’il existait un potentiel pour une répartition plus équitable des pharmaciens, des spécialistes, des maisons de santé et des lits. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 21 Introduction Unequal geographical distribution of health care resources has been a persistent policy concern throughout the world (1–6). It is not only a chal- lenge to policy-makers, researchers and planners in the health sector but is also a major barrier to the successful performance of health systems (1,7,8). While there is a positive relationship between the geographical availability of health care resources and the health status of populations, increasing health care resources alone does not nec- essarily lead to improved health out- comes. People regardless of their race, sex and geographical region should be guaranteed fair access to health care services (9,10). Previous studies have mainly focused either on inequality in the distribution of health workers or of health care resources (8,11–16). However, sound decisions are de- pendent on timely and accurate infor- mation concerning the distribution all needed health care resources. In the Islamic Republic of Iran, stud- ies conducted over the country as a whole and in Kermanshah province in particular have reported a high rate of unemployment, low income among a significant proportion of the population and low access to health care resources. These conditions may contribute to inequality in the distribution of health care resources (17–20). Little evidence is available concern- ing inequality in health care resource distribution in Kermanshah province. Therefore, the aim of this study was to determine whether there were inequal- ities in the human and physical health care resources distributed across the province during the period 2005 to 2011 and whether was there a time trend in resource distribution. The findings are expected to contribute to evidence-based resource allocation in the province. Methods Context and geographical units of analysis Kermanshah province in the west of the Islamic Republic of Iran consists of 14 counties and is bordered by Hamadan, Kurdistan, Lorestan and Ilam provinces in the east, north, south and south of the country respectively and by Iraq in the west. The total population of the province in the year 2014 was estimated to be around 2 million. Study design and population We used a case-study design to describe the distribution of human and physical resources in the province. The data were obtained from the Statistical Centre of Iran (17). The data from each county was summed to represent the resource distribution in the province, and the unit of analysis was the entire province. In addition, the data on distribution of human resources (the number of spe- cialists, general medical practitioners, pharmacists, dentists and paramedics per 1 000 000 population) and physical resources (the number of health houses, beds, pharmacy, radiology centres, re- habilitation centres and laboratory fa- cilities per 1 000 000 population) over the years 2005 to 2011 were used to calculate inequality measures for the province. Inequality measures and data analysis There are many indicators to measure inequality in the geographic distribu- tion in health variables, such as the Lorenz curve, Gini coefficient, decile ratio, index of dissimilarity, Atkinson in- dex and Robin Hood index (4,21). We used the Gini coefficient and the index of dissimilarity which are both com- monly used in analysing inequality in the distribution of health care resources (10,22,23). The values of the Gini coefficient vary from 0 (perfect equality) to 1 (perfect inequality). This index can be derived from the Lorenz curve (Figure 1) using the following formula: Where A = area between the Lorenz curve and the 45° line, whole area under the 45° line. In the Lorenz curve, the cumulative percentage of the health care resource variables on the y-axis and the cumula- tive percentage of population on the x-axis are shown. The current study used Brown’s formula to calculate the Gini coefficient as follows (24): Where: Yi = cumulative percentage of health variable in the ith county, Xi = cu- mulative percentage of the population (ranked by variables) in the ith county, K = total number of counties. The index of dissimilarity indicates the percentage of all health variables that are redistributed across counties to achieve a situation of perfect equality. The value of the index varies between 0 (perfect equality) and 100 (perfect inequality) and is calculated using the following formula (25): Where: Xip = i th county’s population share, Xih = i th county’s health variable share, n = total number of counties. The time trend in inequality of health care resources was examined by estimating 11 regression models, one for each resource. The dependent variable was the Gini coefficient for the resource and the independent variable was the year as follows: Y= β0+ βix + εi Where Y = Gini coefficient for ith health variable; x = year. The robust standard error was applied for possible heteroscedastic- ity over time inferences. Also, the β Gini coefficient = A/A + B Gini coefficient = 1 – Σ (Yi+1 +Yi)(Xi+1 – Xi) Index of dissimilarity = 1 Σ│xip – xih│2 n i=1 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 22 coefficient was used to capture the direction and magnitude of the trend in the Gini for each health variable (3). Negative β implies that the Gini coefficient declined over time and the distribution of health variable became more equal. The data analysis was carried out using Stata, version 12, and DASP, version 2.3, and the findings were considered statistically significant at P-value < 0.05. Results This study assessed 14 counties in Ker- manshah province for inequalities in the distribution of human and physical resources in the health sector. Human and physical health resources per 1 000 000 population In general there was an increase in the allocated human and physical resources between 2005 and 2011. For example, the number of general practitioners increased from 195 per 1 000 000 population to 229 per 1 000 000 be- tween 2005 and 2011, while hospital beds increased from 1141 to 1575 per 1 000 000 population over the same period (Table 1). Gini coefficient and index of dissimilarity for distribution of human and physical health care resources Table 2 shows the Gini coefficients and indices of dissimilarity for the distribu- tion of human health care resources in Kermanshah province over the years 2005–2011. These demonstrate the presence of inequalities in the health human resources. The highest Gini coef- ficient was observed for pharmacists in 2005 (0.75) and the lowest was for paramedics in 2010 and 2011 (0.10). Similarly, analysis by index of dissimi- larity showed that in 2005 the highest and lowest index of dissimilarity were for pharmacists (29%) and for general practitioners (12%) respectively, while in 2011 the height and lowest index of dissimilarity were for dentists (19%) and for paramedics (3%) respectively. Generally, a reduction in the in- equalities was observed between the baseline and the end of the study. For instance, the Gini coefficient for all types of specialists reduced from 0.39 in 2005 to 0.26 in 2011. Similarly, the Gini coefficient for dentists fell from 0.39 in 2005 to 0.23 in 2010 and 0.32 in 2011. Table 3 shows the Gini coefficients and indices of dissimilarity for physical health care resources. The highest Gini coefficient was for rehabilitation centres in 2010 (0.59) and the lowest was for health houses in 2011 (0.12). Similarly, the highest index of dissimilarity was for rehabilitation centres in 2010 (36%) and the lowest was for laboratories in 2007 (5%). Time trends in Gini coefficient for distribution of human and physical health care resources The time trends in human and physical resources based on Gini coefficients in Kermanshah province over the years 2005–2011 are presented in Figures 2 and 3 respectively. Although irregularities were seen, between 2006 and 2011 the inequal- ity for the distribution of pharmacists showed a decreasing trend, whereas the inequality for general practitioners was almost constant at a Gini coefficient of about 0.2 and in paramedics it was almost constant at a Gini coefficient of about 0.1. Among the physical resources, the distribution of health houses, pharma- cies and rehabilitation centres remained almost constant between 2006 and 2011 at different levels of Gini coefficient. Regression analysis Regression analysis indicated that among the human resources there was a statistically significant reduction in inequality in the distribution of pharma- cists (P = 0.02) (Table 4). Among the physical resources, there was a statisti- cally significant reduction in inequality in the distribution of health houses (P = 0.01) and of pharmacies (P = 0.004). However, the reduction in inequality for rehabilitation centres was borderline in significance (P = 0.06). Discussion One of the main objectives of health pol- icy-makers is ensuring fair and equitable distribution of health services. Accord- ing to the Iranian statistical yearbook, Figure 1 Lorenz curve for derivation of the Gini coefficient 100 90 80 70 60 50 40 30 20 10 0 C um ul at iv e % o f s tu di ed h ea lt h Cumulative % of population 0 10 20 30 40 50 60 70 80 90 100 A B طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 23 the number of general practitioners, pharmacies, health houses and beds were 14 901, 8484, 17 649 and 103 365 per 1 00 000 population respectively in Islamic Republic of Iran in 2011, of which Kermanshah province had 2.9% of the general practitioners, 2.3% of pharmacies, 3.7% of health houses and 2.9% of beds. According to the 2011 census, 2.5% of the country’s population were in Kermanshah province in 2011. In 2011 on average, there were 233 specialists per 1 000 000 population in the whole country compared with 219 per 1 000 000 in Kermanshah province. The number of pharmacies in 2011 was 120 per 1 000 000 population in the whole country and 101.3 per 1 000 000 in Kermanshah. This study has shown inequalities in the distribution of human and physical resources in the province. For human resources the Gini coefficients for spe- cialists, general practitioners, dentists, pharmacists and paramedics were found to closely relate to the reports of other previous studies (22,26,27). However, the Gini coefficient for dentists in this study in 2011 was higher than that was reported from Japan (0.255) (28) and lower than the report from previous study across all provinces in Islamic Republic of Iran (0.39) (26). This dif- ference may be due to the inclusion of only one province in our study while the others represented entire nations. Also, the previous Iranian study included all dentists practising in the public and private sectors and this will add to the dif- ference in Gini coefficient between the current study and the previous one. The Gini coefficient for general practitioners in our study (0.18) is somewhat higher than the Gini coefficient of 0.14 for the distribution of physicians reported from a study in Turkey. The Gini coefficient reported from Turkey represented all physicians, including specialists, Table 2 Gini coefficient and index of dissimilarity for inequality in the distribution of human resources in Kermanshah province over the years 2005–2011 Year Specialists General practitioners Dentists Pharmacists Paramedics Gini (SE) ID % Gini (SE) ID % Gini (SE) ID % Gini (SE) ID %) Gini (SE) ID % 2005 0.39 (0.09) 17 0.22 (0.02) 12 0.39 (0.09) 21 0.75 (0.07) 29 0.30 (0.07) 12 2006 0.38 (0.10) 6 0.17 (0.07) 5 0.24 (0.05) 20 0.73 (0.11) 11 0.12 (0.03) 3 2007 0.34 (0.10) 6 0.16 (0.03) 5 0.23 (0.04) 8 0.62 (0.12) 10 0.12 (0.02) 4 2008 0.40 (0.09) 16 0.17 (0.02) 10 0.21 (0.03) 14 0.68 (0.10) 27 0.11 (0.02) 4 2009 0.31 (0.10) 6 0.16 (0.03) 12 0.24 (0.06) 18 0.56 (0.10) 21 0.11 (0.03) 4 2010 0.40 (0.10) 16 0.17 (0.03) 13 0.23 (0.05) 19 0.63 (0.11) 25 0.10 (0.02) 4 2011 0.26 (0.06) 12 0.18 (0.03) 14 0.32 (0.07) 19 0.40 (0.09) 17 0.10 (0.02) 3 Gini = Gini coefficient; ID = index of dissimilarity; SE = standard error. Table 1 Allocated human and physical health care resources per 1 000 000 population in Kermanshah province over the years 2005–2011 Health resource No. per 1 000 000 population 2005 2006 2007 2008 2009 2010 2011 Human resources Specialists 127 117 134 144 143 154 219 General practitioners 195 176 193 213 221 231 229 Pharmacists 13 10 14 14 15 19 21 Dentists 29 33 34 39 41 47 43 Paramedics 1093 2858 3083 3122 3205 3343 3373 Physical resources Health houses 352 353 353 353 351 347 340 Hospital beds 1141 1279 1302 1566 1574 1582 1575 Laboratories 58 51 61 61 65 66 65 Rehabilitation centres 26 29 29 30 31 32 32 Radiology centres 27 23 29 30 30 36 31 Pharmacies 89 94 101 102 97 99 101 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 24 however, and this implies lower inequal- ity than in our study (27). In this study, the distribution of resources was also analysed using the index of dissimilarity. For human re- sources the index of dissimilarity for dentists was 19%, which implies that 19% of the currently available dentists in the province could be redistributed from the over-served counties to the relatively under-served areas across the province to reach an equitable distribution. The index of dissimilarity for dentists in the current study is lower than that reported for dentists (30.5%) in the previous Iranian study (26). As mentioned above, that study considered all dentists, both private and public, and this could be a likely reason for this difference. In our study time-trend analysis showed inequalities in the distribution of all human and physical resources de- creased from baseline in the year 2005 to 2011. Although the findings showed a reduction in the inequality in the dis- tribution of health resources, regression analysis showed that the reductions were statistically significant only phar- macists, health houses and pharmacies. The reasons could be related to the emphasis given to the development of primary health care in areas where the public have unmet health care services (29). Although inequalities still exist, the improvement in the distribution of the health care resources over the 7-year pe- riod of our study may imply that Iranian health sector policy-makers have paid attention to improving the allocation of resources across the country. Besides, the increase in the number of specialists, general medical practitioners and phar- macists between the years 2005 and 2011 may indicate that the government Table 3 Gini coefficient and index of dissimilarity for inequality in the distribution of physical resources in Kermanshah province over the years 2005–2011 Year Health houses Hospital beds Pharmacies Laboratories Rehabilitation centres Radiology centres Gini (SE) ID % Gini (SE) ID % Gini (SE) ID % Gini (SE) ID % Gini (SE) ID % Gini (SE) ID % 2005 0.19 (0.04) 29 0.47 (0.09) 28 0.28 (0.07) 15 0.29 (0.07) 12 0.43 (0.09) 28 0.47 (0.09) 22 2006 0.15 (0.03) 13 0.45 (0.09) 10 0.21 (0.05) 5 0.22 (0.05) 6 0.51 (0.08) 10 0.35 (0.08) 9 2007 0.15 (0.03) 13 0.45 (0.09) 10 0.17 (0.03) 6 0.20 (0.03) 5 0.54 (0.10) 9 0.22 (0.03) 8 2008 0.14 (0.03) 30 0.46 (0.10) 24 0.18 (0.03) 7 0.21 (0.05) 13 0.48 (0.10) 29 0.20 (0.03) 16 2009 0.13 (0.02) 30 0.46 (0.09) 23 0.18 (0.06) 10 0.18 (0.04) 6 0.52 (0.11) 30 0.47 (0.09) 25 2010 0.13 (0.04) 31 0.44 (0.10) 24 0.21 (0.05) 12 0.18 (0.05) 8 0.59 (0.12) 36 0.22 (0.04) 19 2011 0.12 (0.01) 30 0.40 (0.10) 24 0.19 (0.04) 11 0.18 (0.04) 8 0.44 (0.09) 18 0.23 (0.04) 27 Gini = Gini coefficient; ID = index of dissimilarity; SE = standard error 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 2005 2006 2007 2008 2009 2010 2011 x x x x x x x x x x x x x x Specialist Dentist Paramedical General practitioner Pharmacist x x Figure 2 Trends in the Gini coefficient for the distribution of human resources in Kermanshah province, 2005–2011 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 25 has paid more attention to the produc- tion of these human resources. The increase in the percentage of these dis- tributed resources was higher than the population growth, which showed only a 4% increase between the beginning and end of the study period. A gov- ernment regulation which allows new graduate general practitioners, dentists, pharmacists and other health profes- sionals to work in remote areas seems to have contributed to the reduction in inequality in the distribution of human resources for health. A previous study also reported that improvement in roads and trans- portation systems and incentives and promotion opportunities to health workers has contributed to reducing inequalities in the distribution of re- sources for health (22). Other reasons could have due to improvement in the equity of distribution of health care resources. However, this study focused only on the distribution of public health resources across the province. The private sector is usually known to practise in areas where it can gener- ate profit from the delivery of services. It has been reported that in Islamic Republic of Iran about 80% of dentists are working in the private sector in urban areas (30). This study focused on analysis of inequality in the distribution of human and physical resources. The fact that the data were credible and representa- tive of the province helps us to con- fidently characterize the magnitude of inequality in the distribution of human and physical resources in Kermanshah and to suggest possible solutions. However, this analysis did not include the opinion of the people in the province concerning the dis- tribution of the resources analysed. Hence, obtaining additional informa- tion from the direct beneficiaries of Table 4 Regression analysis of time trends of inequality in the distribution of human and physical health resources in Kermanshah province over the years 2005–2011 Health resource β-coefficient t-statistic P-value (robust SE) Human resources Specialists –0.013 –1.45 0.2 General practitioners –0.004 –0.89 0.4 Pharmacists –0.04 –3.36 0.02 Paramedics –0.02 –1.69 0.15 Dentists –0.007 –0.047 0.6 Physical resources Health houses –0.009 –3.56 0.01 Hospital beds +0.006 0.43 0.68 Pharmacies – 0.015 –2.85 0.004 Laboratories – 0.009 –1.29 0.25 Rehabilitation centres – 0.007 –2.33 0.06 Radiology centres –0.02 –1.81 0.13 SE = standard error. 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 2005 2006 2007 2008 2009 2010 2011 Health house Pharmacy Rehabilitation centres Hospital bed Laboratory Radiology centres x x x x x x x x x x x x x x x x Figure 3 Trends in the Gini coefficient for the distribution of physical resources in Kermanshah province, 2005–2011 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 26 the services and health care managers in the area could consolidate the find- ings. 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Hosseinpoor AR, Itani L, Petersen PE. Socio-economic inequal- ity in oral healthcare coverage: results from the World Health Survey. J Dent Res. 2012 Mar;91(3):275–81. PMID:22205634 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 28 1Department of Health Sciences, University of Qatar, Doha, Qatar (Correspondence to H.A. Bawadi: hbawadi@qu.edu.qa). 2Jordan University of Science and Technology, Department of Nutrition and Food Technology, Amman, Jordan. 3Department of Adult Health Nursing, University of San Francisco, San Francisco, California, United States of America. 4Department of Clinical Nutrition and Dietetics, The Hashemite University, Zarqa, Jordan. Received: 17/03/15; accepted: 07/10/15 Meals served to hypertensive and cardiac inpatients in Jordan: comparison with WHO and NIH dietary guidelines H.A. Bawadi,1,2 A.D. Banks,3 R.F. Tayyem 4 and C. ElKhoury 1 ABSTRACT This study aimed to evaluate the compliance of daily meals served to hypertensive and cardiac inpatients in Jordan according to WHO guidelines and the Therapeutic Lifestyle Changes (TLC) and Dietary Approach to Stop Hypertension (DASH) diets plans. Weekly cycle menus from the food service department of major hospitals in Jordan (n = 16) were analysed using ESHA Food Processor software to obtain data about macro- and micronutrient contents and food groups represented. The results showed inappropriate amounts of several nutrients in the menus provided, along with a general noncompliance with the DASH, TLC and WHO guidelines. Meals had higher than recommended sodium content coupled with low potassium content. Fatty acid profiles were often outside the recommended ranges. Meals provided to cardiac inpatients in Jordan need to be revised to meet the guidelines specified for the health conditions of these patients. ةيئاذغلا ةيداشرلإا لئلادلا عم ةنراقم :ندرلأا في بلقلا ضىرمو مدلا طغض عافترا ضىرلم تايفشتسلما في مدقت يتلا تابجولا ةينطولا ةيحصلا دهاعلماو ةيلماعلا ةحصلا ةمظنلم تيزوك يرولخا هيقف ،مِّيت ماير ،سكناب لايجنأ ،يداوب ةبه في نــ مونلما بــ لقلا ضىرــ مو مدــ لا طــ غض عاــ فترا ضىرــ لم مدــ قت يــ تلا ةــ يمويلا تاــ بجولا في مازــ تللاا مــ ييقت لىإ ةــ ساردلا هذــ ه تــ فده دــ قل :ةــ صلالخا جـهنلا فيو ةاـيلحا طـمنل ةـيجلاعلا تارـيغتلا في ةدراوـلا يـئاذغلا ماـظنلا طـطخبو ةـيلماعلا ةـحصلا ةـمظنلم ةيداـشرلإا لـئلادلاب ةـيندرلأا تايفـشتسلما ماـعطلا تاـمدخ ماـسقأ نـم تذـخأ يـتلا ةيعوبـسلأا ةـيرودلا ماـعطلا مـئاوقل لـيلتح يرـجأ دـقلو .مدـلا طـغض عاـفترا فـقو لىإ فداـلها يـئاذغلا تاـيذغلما نـم اـهاوتمح نـع تاـنايب ىـع لوـصحلل ESHA اـشيإ ماـعطلا جـلاعم جـمانرب مادختـساب كـلذو ،)16 = ع( ندرلأا في ىرـكلا تايفـشتسلما في مـئاوقلا في ةدراوـلا تاـيذغلما نـم دـيدعلا تاـيمك نأ جـئاتنلا ترـهظأف .اـهيف ةـلَّثملما ةـيذغلأا تاـعوممج نـعو رادـقلما ةدـيهز تاـيذغلماو رادـقلما ةرـبك مدـلا طـغض عاـفترا فـقو لىإ فداـلها يـئاذغلا جـهنلا في ةدراوـلا يـئاذغلا ماـظنلا طـطخب – ًاـمومع – مازـتللاا مدـع بـناج لىإ ،ةـمئلام تـسيل ةـمدقلما لىإ ،هـب صىوـلما نـم ىـعأ موـيدوصلا نـم تاـبجولا ىوـتمح ناكـف .ةـيلماعلا ةـحصلا ةـمظنلم ةيداـشرلإا لـئلادلابو ةاـيلحا طـمنل ةـيجلاعلا تارـيغتلا فيو ضىرلم مدـقت يـتلا تاـبجولاف .اـبه صىوـلما تلااـجلما جراـخ - بـلاغلا في - ةـينهدلا ضاـحملأا ةـيمك تـناكو .مويـساتوبلا نـم اـهاوتمح ضاـفخنا بـناج .ضىرـلما ءلاؤـله ةـيحصلا فورـظلا بـسانتل ًاـصيصخ تـعضو يـتلا ةيداـشرلإا لـئلادلا يـبلت يـك ةـعجارم لىإ ةـجاحب ندرلأا تايفـشتسم في بـلقلا Repas servis aux patients hospitalisés atteints d’hypertension et de cardiopathie en Jordanie : comparaison avec les recommendations alimentaires de l’Organisation mondiale de la santé et de l’Institut national de santé RÉSUMÉ La présente étude visait à évaluer dans quelle mesure les repas quotidiens servis aux patients hospitalisés atteints d’hypertension ou de cardiopathie en Jordanie respectaient les recommendations de l'Organisation mondiale de la Santé (OMS) et les régimes alimentaires Therapeutic Lifestyle Changes (TLC) et Dietary Approach to Stop Hypertension (DASH). Les cycles hebdomadaires de menus du service de restauration des grands hôpitaux en Jordanie (n = 16) ont été analysés à l’aide du logiciel ESHA Food Processor pour obtenir des données sur la composition en macronutriments et en micronutriments ainsi que sur les groupes d’aliments représentés. Les résultats ont révélé des quantités inadaptées de plusieurs nutriments dans les menus servis, ainsi qu’un non-respect général des recommandations DASH, TLC et de l’OMS. Les repas avaient une composition en sodium trop élevée et un taux de potassium trop faible par rapport aux recommandations. Les profils des acides gras étaient souvent hors des plages recommandées. Les repas fournis aux patients hospitalisés atteints de cardiopathie en Jordanie doivent être revus pour répondre aux recommandations visant leurs pathologies. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 29 Introduction Cardiovascular disease (CVD) is the number one cause of death worldwide (1). The World Health Organization (WHO) estimated that deaths from cardiovascular diseases and diabetes contribute to about 53% of all mor- talities in Jordan (2). Hypertension is a major risk factor for CVD, affecting approximately 1 billion people globally and claiming the lives of more than 9 million annually (2). Hypertension is defined as a systolic blood pressure ≥ 140 mmHg and/or a diastolic blood pressure ≥ 90 mmHg (3). In Jordan, hypertension affects about 32% of the adult population over age 25 years (4). Of those affected, only 56% are aware they have hypertension, 63% are being treated and only 39% are adequately controlled (4). Diet is a major modifiable risk factor that underlies many chronic diseases (5). Two dietary strategies recommend- ed by the United States National Insti- tutes of Health—Therapeutic Lifestyle Changes (TLC) for lowering choles- terol and Dietary Approaches to Stop Hypertension (DASH) (6,7)—have been shown to reduce the risks of car- diovascular disease, high blood pres- sure and other related conditions. The World Health Organization (WHO) and the Food and Agriculture Organi- zation have also set out guidelines in the Population nutrient intake goals for preventing diet-related chronic diseases (8). Patients suffering from CVD and/ or hypertension may experience long durations of hospital stay, with an av- erage of 4.6 days for heart disease in general and 6.1 days for cerebrovas- cular disease (9). Nutritional status in most cases worsens during hospital stays, which further increases the risk of disease complications (10). Therefore hospital meals must be planned care- fully, not only to meet the nutritional needs of patients but also to improve their future health status (10). Previ- ous studies have found diets offered to hospitalized patients to be inadequate in macronutrient and micronutrients (11,12). For example, in Jordan, Hou- rani et al. looked at the adequacy of meals offered to patients with diabetes and found them to be lower in total carbohydrates and fibre, and higher in cholesterol and total fats, as compared with the guidelines set by the American Diabetes Association (12). The aim of the current study was to investigate and evaluate the compliance of daily meals served to inpatients suf- fering from hypertension and/or CVD in comparison with the DASH and TLC diet guidelines (13–15) and the diet and nutrition recommendations of WHO (8). The rationale for carrying out this study lies in the importance of evaluating meals provided for inpa- tients suffering from hypertension and/ or CVD against specified guidelines in order to improve patients’ health and prognoses and reduce hospital stays, to promote models of ideal meals to be prepared after hospital discharge and to identify areas for improvements in hospital meals. Meals served to hyper- tensive and cardiac patients have not previously been evaluated in Jordan. The results of this study will therefore be useful for hospital administrators and health authorities wishing to improve patients’ dietary intakes during their hospital stay. Methods This research was conducted in June 2012 and the study protocol was ap- proved by the institutional review board at Jordan University of Science and Technology. Sampling Food service departments in major hospitals in Jordan were approached and asked to participate in the study. Out of 35 hospitals approached, only 16 hospitals agreed to participate. Hospital size varied from small to large, with the number of beds ranging from less than 100 to more than 300 beds. Data collection Food service departments were asked to provide their weekly menu served for hypertensive and cardiac patients; these are regularly referred to as “low salt” menus. All types of meals (break- fast, lunch, dinner) and snacks were included and all daily possible combina- tions were considered for analysis and evaluation. The nutrient content of each food item was analysed using the Food Pro- cessor software, version 10.6.3 (ESHA Research; http://www.esha.com/ products/food-processor/). Cultural items that were not available in the ESHA database were added manu- ally using available cultural-specific food composition tables and tools (15–18). The criteria for evaluation of the diets included data about food groups, total energy, macronutrients, saturated fat, dietary cholesterol, simple and refined sugars, and mineral content. Intakes/day for each nutrient and each food group were obtained by cal- culating the average of 7 days intakes (from the weekly menus). The degree to which average daily menus content of the hospitals met the relevant nutri- tion recommendation for patients with hypertension and CVD was evaluated against WHO, DASH and TLC guide- lines (8,13,14), which were considered as the gold standards for comparisons of nutrient requirements in a cardiovas- cular context. Statistical analysis The data were analysed using SPSS software, version 17.0. Descriptive analy- sis was performed to obtain frequencies, means and standard deviations (SD). Student t-test was performed to analyse the differences between the nutrient and food group contents of the hospital meals and the gold standard guidelines. A P-value < 0.05 was considered the cut- off level for statistical significance. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 30 Results Nutrient contributions to total energy according to WHO guidelines Table 1 shows the average daily nutri- ent and macronutrient contribution to total energy content in meals served in the 16 Jordanian hospitals and com- pares these with the recommended nutrient contents of the different guide- lines for preventing diet-related chronic diseases. The mean protein content of hos- pital meals (19.0%) was significantly higher than the WHO guidelines (10–15%), the mean sodium content (2831 mg) was significantly higher than recommended (< 2000 mg) and the potassium content (2411 mg) was significantly lower than the guideline (3150 mg) (all P ≤ 0.5) (Table 1). No significant differences between the actual meal contents and the WHO guidelines were observed for calorie content, carbohydrates, total fats, saturated fats, cholesterol and trans- unsaturated fatty acids (trans fats) (Table 1). Table 2 shows the number and percentage of hospitals whose meals complied with the nutrient recom- mendations of the 3 guidelines. This analysis confirmed that none of the hospitals met the protein guidelines of WHO, and only 37.5% met the sodi- um and potassium recommendations. Nutrient contributions to total energy according to the DASH diet Compared with the DASH diet, it was found that on average the hospital meals provided significantly higher amounts of saturated fats (12.1% versus 6%), dietary cholesterol (343 mg versus < 200 mg) and sodium (2831 mg versus 2300 mg) and lower amounts of dietary fibre (25.5 g versus 30 g), calcium (899 mg versus 1250 mg) and potassium (2411 mg versus 4700 mg) than those recommended (P ≤ 0.5) (Table 1). Nearly 44% of the hospitals met the sodium content guidelines of the DASH diet, 25.0% met the calcium guidelines, 18.8% met the fibre guide- lines, 6.3% met guidelines on saturated fats and dietary cholesterol and 0% met the potassium recommendations (Table 2). The average content of the meals were also analysed by food groups and compared with the TLC and DASH diets (Table 3). WHO recommenda- tions were not defined for food groups in a similar way as our reported data and hence comparison was not applicable. It was found that daily meals offered in hospitals provided significantly fewer servings of vegetables (3.26), fruits (1.09) and milk (1.29) as compared with the DASH recommendations (4–5, 4–5 and 2–3 respectively) (P ≤ 0.5). Table 1 Average daily nutrient and macronutrient contribution to total energy content of meals served to hypertensive and cardiac patients in a sample of Jordanian hospitals (n = 16): comparison with recommendations of various guidelines for preventing diet-related chronic diseases Nutrient (units) Recommended nutrient content according to: Actual daily nutrient content of meals in hospitals DASH TLC WHO Mean (SD) Calories (kcal) 2000 2000 Not specified 2062 (529) Protein (%) 18 ≈ 15 10–15 19.0 (2.0)b,c Carbohydrates (%) 55 50–60 55–75 53.3 (5.3) Sugar (%) Not specified Not specified 10 14.3 (22.8) Fat (%) 27 25–35 15–30 27.7 (4.7) Monounsaturated fatty acids (%) Not specified Up to 20 By difference 10.6 (2.1) Polyunsaturated fatty acids (%) Not specified Up to 10 6–10 5.00 (0.79) Saturated fatty acids (%) 6 < 7 < 10 12.1 (2.12)a,b Trans fats (%) Minimum Minimum < 1 0.19 (0.16) Fibre (g) 30 20–30 From food 25.5 (7.2)a Soluble fibre (g) Not specified 10–25 Not specified 1.21 (0.85)b Cholesterol (mg) < 200 150 < 300 343 (118)a,b Calcium (mg) 1250 Not specified Not specified 899 (263)a Potassium (mg) 4700 Not specified 3150 2411 (472)a,c Sodium (mg) 2300 Not specified < 2000 2831 (942)a,c aP ≤ 0.05 versus DASH (1-sample t-test); bP ≤ 0.05 versus TLC (1-sample t-test); cP ≤ 0.05 versus WHO (1-sample t-test). TLC = Therapeutic Lifestyle Changes diet plan; DASH = Dietary Approaches to Stop Hypertension diet plan; WHO = World Health Organization population nutrient intake goals for preventing diet-related chronic diseases (8). SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 31 Nutrient contributions to total energy according to the TLC diet Compared with the TLC diet, the hos- pital meals on average had a significantly higher than recommended content of protein (19.0% versus ≈ 15%), satu- rated fatty acids (12.1% versus < 7%) and dietary cholesterol (343 mg versus 150 mg). The soluble fibre content was much lower than recommended by the TLC diet (1.21 g versus 10–25 g) (P ≤ 0.5) (Table 1). Only one-quarter (25.0%) of the hospitals studied met the dietary cholesterol recommendations; 18.8% met the saturated fatty acids recom- mendations and 0% met the soluble fibre and protein recommendations (Table 2). With regard to food groups, our study showed that the daily servings of vegetables (3.26), fruit (1.09) and milk (1.29) were significantly lower than those recommended by TLC (5, 4 and 2–3 respectively), whereas meat content was higher (6.17 versus < 5 servings) (P ≤ 0.5) (Table 3). Discussion The dietary factors that are most strongly implicated in hypertension include weight management and adequate dietary sodium and potas- sium intakes (7). To a lesser extent other factors also influence blood pressure and these include intake of saturated fats, trans fats, calcium and magnesium (7). Our study analysed the content of the primary dietary factors for cardiac patients, i.e. sodium and potassium, but also looked at all other factors associated with elevated blood pressure as presented by the DASH diet. Table 2 Percentage of Jordanian hospitals (n = 16) whose daily meals served to hypertensive and cardiac patients were compliant with the nutrient content recommendations of various guidelines for preventing diet-related chronic diseases Nutrient Hospitals compliant with recommended nutrient content according to: DASH TLC WHO No. % No. % No. % Calories 6 37.5 6 37.5 – – Protein 4 25.0 0 0.0 0 0.0 Carbohydrates 5 31.3 7 43.8 7 43.8 Sugar – – – 1 6.3 Fat 4 25.0 11 68.8 18.8 93.8 Monounsaturated fatty acid – – 16 100.0 – – Polyunsaturated fatty acids – – 16 100.0 9 56.3 Saturated fatty acids 1 6.3 3 18.8 13 81.2 Trans fats – – – – 16 100.0 Fibre 3 18.8 12 75.0 – – Soluble fibre – – 0 0.0 – – Cholesterol 1 6.3 4 25.0 8 50.5 Calcium 4 25.0 – – – – Potassium 0 0.0 – – 6 37.5 Sodium 7 43.8 – – 6 37.5 DASH = Dietary Approaches to Stop Hypertension diet plan; TLC = Therapeutic Lifestyle Changes diet plan; WHO = World Health Organization population nutrient intake goals for preventing diet-related chronic diseases (8). A dash (–) indicates data not applicable, i.e. no guideline specified. Table 3 Food groups content of daily meals served to hypertensive and cardiac patients in Jordanian hospitals (n = 16): comparison with recommendations of various guidelines for preventing diet-related chronic diseases Food group Recommended content according to: Actual daily food group content of meals in hospitals (servings) DASH (servings) TLC (servings) Grains and cereals 6–8 7 8.52 Vegetables 4–5 5 3.26a,b Fruit 4–5 4 1.09a,b Milk 2–3 2–3 1.29a,b Meat < 6 < 5 6.17b aP ≤ 0.05 versus DASH (1-sample t-test); bP ≤ 0.05 versus TLC (1-sample t-test). DASH = Dietary Approaches to Stop Hypertension diet plan; TLC = Therapeutic Lifestyle Changes diet plan; World Health Organization recommendations do not define food groups in a similar way as our reported data, hence comparisons were not applicable. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 32 Our study showed that the sodium content of meals served to hypertensive and cardiac patients in our sample of Jordanian hospitals was high compared with the recommended level and the potassium level was low. Previous research has shown that sodium and potassium levels are of utmost impor- tance for maintaining healthy blood pressure (19,20). Appel et al. suggested that increased potassium intakes have a stronger role in lowering blood pressure when combined with a high sodium diet; therefore increasing potassium, by increasing servings of fruits and vegeta- bles, could consist of the first realistically achievable step toward meeting at least part of the guidelines (21). Monitoring the types and amounts of dietary fat consumed by patients suffering from hypertension is a fun- damental goal towards reducing the mortality and morbidity associated with hypertension (22). Saturated and trans fatty acids are the principal di- etary determinants of plasma low-den- sity-lipoprotein (LDL) cholesterol. Decreasing the level of LDL choles- terol may be achieved by an increase in the intake of energy derived from monounsaturated fatty acids and poly- unsaturated fatty acids, which are rec- ommended to be up to 20% and 10% respectively. We found a meal content of monounsaturated fatty acids near 10% in our sampled hospitals and of polyunsaturated fatty acids about 5%. The amounts presented in Jordanian hospital menus were extremely low and combined with a high content of saturated fats (about 12% versus < 7% recommended menu content). A dietary cholesterol intake of < 200 mg daily is also recommended by the DASH guidelines and this too was violated by the actual average meal content of dietary cholesterol in our study hospitals of 343 mg per day. Other dietary components includ- ing fibre and calcium have been shown to have an impact on the management of elevated blood pressure. It has been reported that an average increase of about 14 g of fibre per day may decrease systolic blood pressure and diastolic blood pressure by 1.6 and 2.0 mmHg respectively. Again, the menus analysed by our study contained insufficient amounts of fibre in comparison with the recommendations set by DASH. As for calcium, we also found inadequate intakes (about 900 mg compared with 1250 mg set by DASH), and although the evidence is inconclusive with regard to the role of calcium in the manage- ment of hypertension, it is essential to note that calcium metabolism is influ- enced by elevations in serum sodium and may play a role in the blood pres- sure response to salt in the diet (23). Our results showed that there was no emphasis on fruit in the hospital menus and, whereas vegetables seemed to be offered more frequently, insuffi- cient fruit servings were provided. A previous study showed that high con- sumption of fruits and vegetables was associated with a significantly lower risk for hypertension (24). Hospitals should have an obliga- tion to cater therapeutic meals that are planned to achieve targets set by guidelines as a tool to help control blood pressure. Some governmental institutions across the world have set clear guidelines for hospital meals and menus. For instance the Scottish government has established nutrient specifications for hospital meals, recom- mending a sodium intake below 2400 mg per day (25). Similarly, New York City Food Standards have explicitly requested that hospital menus achieve the nutrition goals set by the Dietary guidelines for Americans 2010, specifying a sodium content of 2300 mg for those aged less than 51 years and 1500 mg of sodium for those 51 years or older and/ or suffering from hypertension (26). WHO also recommends that sodium consumption is kept below 2000 mg/ day (8). Clearly, the hospitals assessed in this study failed to meet the recommendations and furthermore they failed to do so in the so-called “low salt” diet, raising greater concerns about the sodium content of the “regular” diet menus. Similar to our findings, a Brazilian study by Moreira et al. reported inad- equate content of iron, zinc, copper, manganese and selenium in hospital meals (11). Additionally Hourani et al. looked at the adequacy of meals offered to patients with diabetes in Jordanian hospitals and found them to be lower in total carbohydrates and fibre, and higher in cholesterol and total fats, as compared with the guidelines set by the American Diabe- tes Association (12). Hospital meals offered to patients with chronic dis- eases should be considered as excel- lent educational tools to help patients implement lifestyle changes after dis- charge. Therefore the adequacy of the meals offered in the hospital may also influence the knowledge and eating habits of the patients after leaving the hospital, as well as that of their family members. The results of this study may be lim- ited due to the use of the ESHA Food Processor software as a tool to assess the nutrient content of the meals. Some researchers have questioned the valid- ity of Food Processor in estimating the mineral content of foods. Sullivan et al. compared the phosphorus content of poultry in comparison to the content listed by Food Processor and found a sig- nificantly higher content in the analysed samples (27). Future studies should consider analysing the content of hos- pital meals. In conclusion, our findings showed that Jordanian hospitals failed to meet some of the dietary recommenda- tions set by WHO and the National Institutes of Health in their DASH and TLC guidelines. The findings of this study imply that the low-salt diet offered by this group of hospitals is providing an adversely high level of sodium and a deficient potassium طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 33 References 1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2224–60. PMID:23245609 2. Causes of death 2008: data sources and methods. Geneva: World Health Organization; 2011 (http://www.who.int/health- info/global_burden_disease/cod_2008_sources_methods.pdf, accessed 21 October 2015). 3. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al.; Joint National Committee on Prevention, Detec- tion, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evalua- tion, and Treatment of High Blood Pressure. Hypertension. 2003 Dec;42(6):1206–52. PMID:14656957 4. Jaddou HY, Bateiha AM, Ajlouni KM. Prevalence, awareness and management of hypertension in a recently urbanised commu- nity, eastern Jordan. J Hum Hypertens. 2000 Aug;14(8):497–501. PMID:10962517 5. Preventing chronic diseases: a vital investment. WHO global report. Geneva: World Health Organization; 2005 (http://www. who.int/chp/chronic_disease_report/contents/en/, accessed 21 October 2015). 6. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd- Jones DM, et al. Effectiveness-based guidelines for the prel- vention of cardiovascular disease in women–2011 update: a guideline from the american heart association. Circulation. 2011 Mar 22;123(11):1243–62. PMID:21325087 7. Appel LJ; American Society of Hypertension Writing Group. ASH position paper: dietary approaches to lower blood pressure. J Am Soc Hypertens. 2009 Sep-Oct;3(5):321–31. PMID:20409975 8. Population nutrient intake goals for preventing diet-related chronic diseases. Diet, nutrition and the prevention of chronic disease: report of a Joint WHO/FAO Expert Consultation. Ge- neva: World Health Organization; 2003 (WHO Technical Report Series 916) 9. National hospital discharge survey 2010. Hyattsville (MD): Center for Disease Control, Ambulatory and Hospital Care Statistics Branch; 2010 (ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/ Dataset_Documentation/NHDS/NHDS_2010_Documentation. pdf, accessed 21 October 2015). 10. Thibault R, Chikhi M, Clerc A, Darmon P, Chopard P, Genton L, et al. Assessment of food intake in hospitalised patients: a 10-year comparative study of a prospective hospital survey. Clin Nutr. 2011 Jun;30(3):289–96. PMID:21067850 11. Al Hourani HM, Atoum M, Alboqai O, Ismail C. Evaluation of dia- betic diets in Jordanian hospitals. Diabetol Croat. 2007;38(1):7– 12. 12. Moreira DC, de Sá JS, Cerqueira IB, Oliveira AP, Morgano MA, Quintaes KD. Evaluation of iron, zinc, copper, manganese and selenium in oral hospital diets. Clin Nutr. 2014 Oct;33(5):808–14. PMID:24238849 13. Your guide to lowering your blood pressure. Bethesda (MD): US Department of Health and Human Service; National Institutes of Health; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program; 2003 (http://www. nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf, accessed 21 October 2015). 14. Your guide to lowering your cholesterol with TLC. Bethesda (MD): US Department of Health and Human Service; National In- stitutes of Health; National Heart, Lung, and Blood Institute; 2005 (http://www.nhlbi.nih.gov/files/docs/public/heart/chol_tlc. pdf, accessed 21 October 2015). 15. Pellet PL, Shadarevian S. Food composition tables for use in the Middle East. Beirut: American University of Beirut; 1970. 16. Musiager AO. Food composition tables for Arab Gulf countries. Manama, Bahrain: Arab Center for Nutrition; 2006. 17. Food composition tables for Egypt. Cairo: National Nutrition Institute; 2006. 18. Bawadi HA, Al-Sahawneh SA. Developing a meal-planning ex- change list for traditional dishes in jordan. J Am Diet Assoc. 2008 May;108(5):840–6. PMID:18442508 19. The American Heart Association's diet and lifestyle recommen- dations. Dallas (TX): American Heart Association; 2014 (http:// www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/ HealthyEating/The-American-Heart-Associations-Diet-and-Life- style-Recommendations_UCM_305855_Article.jsp, accessed 21 October 2015). 20. Maillot M, Monsivais P, Drewnowski A. Food pattern modeling shows that the 2010 Dietary Guidelines for sodium and potassi- um cannot be met simultaneously. Nutr Res. 2013 Mar;33(3):188– 94. PMID:23507224 21. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al.; DASH Collaborative Research Group. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997 Apr 17;336(16):1117–24. PMID:9099655 22. Parker B, Noakes M, Luscombe N, Clifton P. Effect of a high- protein, high-monounsaturated fat weight loss diet on glycemic control and lipid levels in type 2 diabetes. Diabetes Care. 2002 Mar;25(3):425–30. PMID:11874925 23. Chen Y, Strasser S, Cao Y, Wang KS, Zheng S. Calcium intake and hypertension among obese adults in United States: as- sociations and implications explored. J Hum Hypertens. 2015 Sep;29(9):541–7. PMID:25589211 24. Utsugi MT, Ohkubo T, Kikuya M, Kurimoto A, Sato RI, Suzuki K, et al. Fruit and vegetable consumption and the risk of hypertension determined by self measurement of blood pressure at home: the Ohasama study. Hypertens Res. 2008 Jul;31(7):1435–43. PMID:18957815 25. Food in hospitals: national catering and nutrition specification for food and fluid provision in hospitals in Scotland [Internet]. Edinburgh: The Scottish Government; 2008 (http://www.scot- land.gov.uk/Publications/2008/06/24145312/0 accessed 21 October 2015). 26. Patient meals [Internet]. New York: New York City Food Stand- ards; 2014 (http://www.nyc.gov/html/doh/downloads/pdf/ cardio/patient-meals-standards.pdf, accessed 21 October 2015. 27. Sullivan CM, Leon JB, Sehgal AR. Phosphorus-containing food additives and the accuracy of nutrient databases: implications for renal patients. J Ren Nutr. 2007 Sep;17(5):350–4. PMID:17720105 content. An intensive re-evaluation of meals offered to hypertensive and cardiac inpatients in Jordanian hospitals is recommended. An easy start would be increasing servings of fruits and veg- etables and considering greater provi- sion of culturally acceptable vegetarian meals. Funding: This project was funded by deanship of research at Jordan Univer- sity of Science and Technology. Competing interests: None declared. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 34 1Department of Preventive Dental Sciences, Al-Farabi College, Riyadh, Saudi Arabia (Correspondence to K. Baroudi: d_kusai@yahoo.co.uk). Received: 14/07/14; accepted: 21/10/15 Prevalence of oro-dental anomalies among schoolchildren in Sana’a city, Yemen M. Basalamah 1 and K. Baroudi 1 ABSTRACT Practitioners and policy-makers need information about the relative frequency of dental anomalies among children in their region. This study investigated the prevalence of different oral anomalies among schoolchildren in Sana’a city, Yemen. A sample of 1000 private and public schoolchildren aged 4–12 years were examined by the same examiner using disposable tongue blades. The total prevalence of oral anomalies was 15.1%, most commonly in boys (male:female ratio 3.2:1) aged 7–12 years. The most prevalent dental anomaly related to hard tissues was tooth hypoplasia (2.8%), followed by hypocalcification (2.6%), then microdontia (0.5%), macrodontia (0.4%), hypodontia (0.4%), supernumerary teeth (0.3%), tooth transposition (0.3%), dental fusion (0.2%) and gemination (0.2%). The most prevalent soft tissues anomaly was fissured tongue (4.0%), followed by ankyloglossia (1.8%), geographic tongue (0.9%), macroglossia (0.4%) and hairy tongue (0.3%). Appropriate measures need to be taken early to mitigate the negative impact and later costs of treatment of anomalies. نميلاب ءاعنص ةنيدم في سرادلما لافطأ ينب ةينسلا-ةيومفلا ةيقلِلخا بويعلا راشتنا يدوراب صيق ،ةملاساب دممح .مـهتقطنم في لاـفطلأا نـب ةـيقلِلخا بوـيعلل يبـسنلا ثودـلحا نـع تاـمولعم لىإ تاـسايسلا وـعضاوو نوـسرمالما ءاـبطلأا جاـتيح :ةـصلالخا تـصِحُفف .نـميلاب ءاـعنص ةـنيدم في سرادـلما ذـيملات نـب ةـيومفلا ةـيقلِلخا بوـيعلا فـلتمخ راـشتنا ىدـم ةـساردلا هذـه تصقتـسا دـقلو ضـفاوخ مادختـساب صـحافلا سـفن لـبق نـم ةنـس 12 و 4 نـب مـهرماعأ حوارـت ةـصالخاو ةـماعلا سرادـلما ذـيملات نـم ًاـفلأ تـمض ةـنيع ثاـنلإا:روكذلا ةبـسن( روـكذلا ىدـل ًاعويـش رـثكأ تـناكو ،15.1% ةـيومفلا ةـيقلِلخا بوـيعلل ليكـلا راـشتنلاا ناكـف .لماعتـسلاا ةدـيحو ناـسل صـقن :لـثم ًاراـشتنا رـثكلأا ةـبلصلا ةجـسنلأاب ةـطبترلما ةينـسلا ةـيقلِلخا بوـيعلا تـناكو .ةنـس 12 و 7 نـب مـهرماعأ حوارـت نـيذلا )1:3.2 ،)0.4%( نانـسلأا صـقنو ،)0.4%( نانـسلأا ةـماخضف ،)0.5%( نانـسلأا رـغص مـث ،)2.6%( سـلكتلا صـقن هـيلي ،)2.8%( نانـسلأا جـسنت ةجـسنلأا في ةـيقلِلخا بوـيعلا تـناكو .)0.2%( فـعاضتلاف )0.2%( نانـسلأا ماـحتلاف ،)0.3%( نانـسلأا ةـلقانمو ،)0.3%( ةدـئازلا نانـسلأاف ،)0.4%( ناـسللا ةـماخضف ،)0.9%( فيارـغلجا ناـسللاف ،)1.8%( ناـسللا قاـصتلا هـيلي ،)4%( ققـشلما ناـسللا :لـثم ًاراـشتنا رـثكلأا ةوـخرلا فـيلاكت فـيفتخو ةـ يقلِلخا بوـ يعلا هذـ له ةيبلـ سلا راـ ثلآا فـيطلتل رـ كبم تـ قو في ةبـ سانلما رـ بادتلا ذاـ تخا بـ يج .)0.3%( رعـشلأا ناـسللاف .ًاـقحلا اـهتلجاعم Prévalence des anomalies bucco-dentaires chez des écoliers de la ville de Sanaa (Yémen) RÉSUMÉ Les praticiens et les décideurs politiques ont besoin d’informations sur la fréquence relative des anomalies dentaires chez les enfants de leur région. La présente étude a évalué la prévalence de différentes anomalies bucco-dentaires chez des écoliers de la ville de Sanaa (Yémen). Dans un échantillon, 1000 enfants âgés de quatre à douze ans fréquentant des écoles publiques et privées ont été examinés par le même praticien à l’aide d’abaisse-langue à usage unique. La prévalence totale des anomalies bucco-dentaires était de 15,1 %, le plus souvent chez les garçons (rapport garçon : fille 3,2 : 1) âgés de sept à douze ans. L’anomalie dentaire la plus répandue liée aux tissus durs était l’hypoplasie dentaire (2,8 %), suivie de l’hypocalcification (2,6 %), puis de la microdontie (0,5 %), la macrodontie (0,4 %), l’hypodontie (0,4 %), les dents surnuméraires (0,3 %), la transposition dentaire (0,3 %), la fusion dentaire (0,2 %) et la gémination dentaire (0,2 %). Les anomalies des tissus mous les plus prévalentes étaient une langue fissurée (4,0 %), suivies d'une ankyloglossie (1,8 %), d'une langue géographique (0,9 %), d'une macroglossie (0,4 %) et d'une langue pileuse (0,3 %). Il est nécessaire de prendre des mesures précoces appropriées pour limiter l’impact négatif puis le coût ultérieur du traitement de ces anomalies. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 35 Introduction Dental anomalies are abnormalities of form, function or position of the teeth, bones and tissues of the jaw and mouth. They may affect both primary and permanent dentition, jaw articula- tion and the emotional development of a child (1). Dental anomalies not only cause aesthetic problems but also can lead to dental problems such as functional disorders, dental caries, pulp disease, malocclusions and in particular masticatory problems for infants and children. If untreated, these may per- sist throughout life leading to physical growth disorder (1). There are more than 500 anoma- lies caused by simple genetic factors and perhaps an equal number of others derived from multifactorial causes or chromosome aberrations where there are orofacial alterations (2). Dental anomalies can be evidence of systemic disease and may have more than one cause (3). After evaluating the patient’s symptoms, pain, health risks, family history, aesthetic considerations, treat- ment costs, and insurance coverage, the dentist needs to decide whether to treat or simply monitor the condition. Treatment is intended to eliminate or diminish the defect, manage pain, and alleviate the patient’s concerns. In most cases, surgery can correct the deform- ity, and psychological services are often included as part of the treatment along with speech and hearing services (1). Although many orofacial anomalies are currently managed, rather than treated, the rapid advances of science, such as the ability to identify mutated genes, promise future cures and treatment mo- dalities that will eliminate or reduce the number of defects currently seen (4). Many epidemiological surveys have been conducted in different parts of the world to determine the prevalence of various types of dental anomalies. For example, Cho et al. and Ezoddini et al. found a high prevalence of super- numerary premolars and dilacerations in Chinese and Iranian children (5,6). These earlier results have shown that there are regional and ethno-racial variations in the prevalence of dental and soft tissue anomalies. It is therefore important for practitioners to know the relative frequency of anomalies among children in their region in order to coun- sel patients who seek treatment (1). Furthermore, since dental anomalies such as missing teeth, supernumerary teeth and gemination problems are important etiological factors of maloc- clusion, it is essential to detect these anomalies in the primary and mixed dentition stages, as they can give rise later to serious complications includ- ing malocclusion. The aims of study therefore were to investigate the preva- lence of different oral anomalies among schoolchildren in Sana’a city, Yemen, and to determine the age and sex distri- bution of these anomalies. Methods Study design and setting This cross-sectional study was carried out in 2010 in different areas of Sana’a city. Before conducting the survey, information about the study was sent and written approval was obtained for the conduct of the study from the dean of medical science at the University of Science and Technology, Sana’a, the general manager of education and cul- ture of each district in Sana’a city and the managers of schools in each district in Sana’a city. The parents of school- children were also given information and asked to give permission for their children to participate in the research. Sampling This study was conducted on 1000 stu- dents (500 boys and 500 girls) out of the total school enrolment in Sana’a city of 122 500. As socioeconomic level was a factor in this study, it was conducted on children from both private and pub- lic schools, selected randomly from 6 different areas of Sana’a city according to a recent geographical map of the city. Using cluster sampling techniques 500 children (aged 4–6 years) were selected from 4 private preschools and 500 children (aged 7–8 years) from 5 public primary schools, out of 833 schools from the 6 districts of education in the city. Students who were aged 4–12 years and showed good coopera- tion during examination were recruited for the study. Data collection Before the examinations started, the examiner gave information to the stu- dents about the teeth and oral cavity and normal structure. Mouth examina- tions were carried out throughout the study by a single examiner (the principal investigator) wearing gloves and gauze mask. Each child was examined under natural light with a disposable plane mouth mirror, with a tongue blade to retract the cheek. The sole objective was to detect dental anomalies related to soft and hard tissues. A data collection chart was designed for recording the necessary information for each child, including personal data such as name, age, sex and birth date. The diagnosis of oral anomalies was made according to the clinical criteria described by Shafer et al. in 2000 (7). Statistical analysis Data analysis was carried out using the chi-squared test. Statistical analyses were considered significant at P < 0.05. Results We found dental anomalies in 151 of the 1000 children examined, giving an overall prevalence of oral anomalies of 15.1% (23.0% in boys and 7.2% in girls) (Table 1). The prevalence of oral anomalies was significantly higher among boys (115/500 cases 23.0%) than girls (36/500 cases; 7.2%) (male to female ratio 3.2:1) (P < 0.05). EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 36 Hard tissue anomalies The most prevalent anomaly related to dental hard tissues was tooth hy- poplasia in (28 cases; 2.8%), followed by hypocalcification (26 cases; 2.6%), then microdontia (5 cases; 0.5%), mac- rodontia (4 cases; 0.4%), hypodontia (4 cases; 0.4%), supernumerary teeth (3 cases; 0.3%), tooth transposition (3 cases; 0.3%), dental fusion (2 cases; 0.2%) and gemination (2 cases; 0.2%). (Figure 1). The cases of dental fusion and tooth gemination were found only in boys (Figure 1). Microdontia was detected in 3 boys and 2 girls; this anomaly affected only the anterior region. More boys than girls had macrodontia (3 boys and 1 girl). Dental hypoplasia, occurring mostly in the upper jaw, affected 20 teeth in boys and 8 teeth in girls. Tooth hypocalcification was observed in 22 boys and 4 girls; all cases were seen in the upper jaw only. Dental transposition oc- curred in 1 boy and 2 girls. Tooth trans- position usually involved the maxillary canine–lateral incisor. Hypodontia was seen in 2 boys and 2 girls; the maxillary lateral incisors were the most frequently absent teeth in both sexes. There were no congenitally missing primary teeth. Oligodontia (congenital absence of 6 or more teeth) was seen in only 1 case. Supernumerary primary teeth were also found only in boys and occurred mostly in the anterior region as mesiodens. Soft tissue anomalies Fissured tongue was the most prevalent anomaly of oral soft tissues (40 cases; 4.0%), followed by ankyloglossia (18 cases; 1.8%), geographic tongue (9 cases; 0.9%), macroglossia (4 cases; 0.4%) and hairy tongue (3 cases; 0.3%) (Figure 2). More of the cases of ankyloglossia were found in boys (13 cases) than girls (5 cases) (Figure 2). The same was true for geographic tongue (7 boys and 2 girls) and fissured tongue (30 boys and 10 girls). Hairy tongue and macroglos- sia occurred only in boys. Discussion Study of the most common dental anomalies is important for accurate and effective treatment planning. These anomalies cause a variety of clinical problems and therefore early diag- nosis should be made to avoid future problems and to plan comprehensive management. There was a gender difference in the prevalence of all anomalies in the present study, with a higher prevalence in boys: 23.0% of boys and 7.2% of girls. The reason for this difference might be related to ethnic and racial factors. Dental anomalies are caused by inher- ited genetic defects. Environmental and pathological factors may also be the cause (8). In relation to Yemen’s children several environmental factors such as chronic dry mouth, vitamin deficiency and oral use of certain drugs may be responsible for some of the anomalies (9). Our finding was in agree- ment with Aljawfi’s report of tongue anomalies among Yemeni children in 2013 (9). It also agrees with a study Table 1 Prevalence of dental anomalies in the sample of schoolchildren in Sana’a, Yemen Anomaly Boys (n = 500) Girls (n = 500) Total (n = 1000) No. % No. % No. % Hard tissue anomalies Enamel hypoplasia 20 4.0 8 1.6 28 2.8 Hypocalcification 22 4.4 4 0.8 26 2.6 Microdontia 3 0.6 2 0.4 5 0.5 Macrodontia 3 0.6 1 0.2 4 0.4 Hypodontia 2 0.4 2 0.4 4 0.4 Supernumerary teeth 3 0.6 0 0.0 3 0.3 Dental transposition 1 0.2 2 0.4 3 0.3 Dental fusion 2 0.4 0 0.0 2 0.2 Gemination 2 0.4 0 0.0 2 0.2 Soft tissue anomalies Fissure tongue 30 6.0 10 2.0 40 4.0 Ankyloglossia 13 2.6 5 1.0 18 1.8 Geographic tongue 7 1.4 2 0.4 9 0.9 Macroglossia 4 0.8 0 0.0 4 0.4 Hairy tongue 3 0.6 0 0.0 3 0.3 Total 115 23.0 36 7.2 151 15.1 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 37 of dental anomalies in neighbouring Saudi Arabia (1) and elsewhere in the world, from New Zealand (10). The results disagree, however, with a study in Australia, which reported that dental anomalies occurred more frequently in girls than boys. This lack of agreement can be attributed to their small sample size and the much higher ratio of girls to boys (65:46) in their study sample (11). The prevalence of dental fusion of this study was 0.2%. This is in agreement with findings from the New Zealand study (0.4%) (10) but is much lower than in studies from Saudi Arabia or in Brazil, which found the prevalence of dental fusion to be 1.3% and 3.7% re- spectively (1, 12). This might be attrib- uted to the large numbers of examiners (5 trained examiners) in those studies as against the use of a sole examiner in our study. Dental fusion in the present study was found in boys only, whereas the study in New Zealand found fu- sion in 4 boys and 2 girls (10). This can be attributed to genetic predisposition and racial differences, which have also been reported as contributing factors, or it may be due to trauma during crown formation of 2 adjacent teeth before calcification (10). The prevalence of dental gemina- tion in our study sample was 0.2%, which is similar to the findings of stud- ies in New Zealand (0.4%) (10) and Sweden (0.3%) (13). Our finding of dental gemination only in boys might be explained by the greater involvement of Yemeni boys in sports-related activi- ties compared with girls, thus exposing them to higher risk of accidents and orofacial trauma. Supernumerary teeth were ob- served in 0.3% of our subjects. This figure is close to the findings of another study in Yemen by Balkees and Garib (0.2%) (14), and also to data from the United Kingdom (0.8%) (15) and a study of 1260 Brazilian children (0.3%) (12), but significantly less than what was found in Sweden (1.9%) (13) and a smaller study of 172 Brazilian children (2.3%) (2). Supernumerary teeth occur frequently in the permanent dentition, more so in the anterior region as mesi- odens than in other parts of the arches (13). This can be related to hypergen- esis of the epithelial cord and hereditary and developmental defects such as cleft lip and palate. It may also be an autoso- mal dominant trait, with splitting of the permanent tooth germ. The present results found hypodon- tia in 0.4% of the study sample, which is similar to results from Brazil (0.6%) (12), but is considerably lower than findings from Sweden (7.4%) (13). The difference may be due to the size of the Swedish study sample. Hypodontia can be caused by mechanical trauma to the jaw during tooth formation, or due to infection (16). The prevalence of tooth transposi- tion in the present study (0.3%) fell within the range reported in a study car- ried out in India (0.4%) (17). The pre- sent study showed a higher incidence of tooth transposition among girls, in agreement with an earlier report from Israel (18). One study reported that transpositions were more commonly observed in males (17) while the study in Israel reported the opposite (18). We found that transpositions were more common in the maxilla than in the mandible. We also found that most transpositions occurred in the maxil- lary canine–lateral incisor. This can be related to hereditary or genetic factors or to migration during tooth formation. Trauma to deciduous teeth has also been suggested as a causative factor. The prevalence of microdontia in the present study was 0.5%, which falls within the prevalence range reported by studies in Brazil (0.3%) (12) and Japan (0.7%) (19). Microdontia were seen only in the anterior region of both max- illary and mandibular arches, as found in the Brazilian study (12). This may be due to hereditary factors. Similarly, the prevalence of macrodontia in our study was 0.4%. This is in agreement with the finding of 0.2% from Sweden (13). Macrodontia of a single tooth is rare (20). Boys Girls 25 20 15 10 5 0 En am el hy po pla sia Hy po ca lci fic ati on M icr od on tia M ac ro do nt ia Hy po do nt ia Su pe rn um era ry tee th De nta l tr an sp os itio n De nta l fu sio n Ge mi na tio n 20 22 8 4 3 2 3 1 2 2 3 2 1 2 2 000 N o. Figure 1 Prevalence (number of cases) of hard tissue anomalies among the sample of boys (n = 500) and girls (n = 500) in Sana’a, Yemen EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 38 Enamel hypoplasia was the most prevalent dental anomaly in this study at 2.8%, which is higher than the figure of 1.5% reported in Japanese children (2), but lower than 3.5% found among Bra- zilians (21). Enamel hypoplasia can be attributed to local infections or systemic disturbances during childhood illnesses. Of our 28 cases, there were 2 children with enamel hypoplasia in the lower arch. The other cases had hypoplasia that affected the upper anterior teeth. These findings were in agreement with those of authors in South Africa (22) and Islamic Republic of Iran (23), who found hypoplasia more commonly in the upper arch than in the lower. This can be attributed to mechanical trauma or hereditary factors, as suggested in a study of Mexican children (24). The prevalence of hypocalcifica- tion in our study population was 2.6%, much lower than 23.96% found among Iranian children (23) and the range of 10–19% mentioned by Kellerhoff and Lussi in their review article (25). The prevalence of ankyloglossia in this study was 1.8%. This figure is relatively low compared with reports from other populations in the world. For example, in a study of 1540 Iranian 7–17-year-old children the prevalence of ankyloglossia was 5% (3). The present survey showed that 0.9% of children had geographic tongue. The reported frequency of geographic tongue in children varies widely in the literature. Our finding is lower than the figures of 2.5% among institutional- ized orphans in Yemen (26) and 6.8% in Jordanian dental outpatients (27). However, a study of 2–17-year-old American children reported a similar figure of 1.05% (28). The prevalence of fissured tongue in this study was 4.0%. The rate differs from the reports from Jordan (11.4%) (27) and the Islamic Republic of Iran (11.8%) (3). The difference may be due to congenital anomalies or envi- ronmental factors such as chronic dry mouth or chronic trauma and vitamin deficiency. Hairy tongue was observed in 0.3% of our subjects, compared with 0.8% reported by Aljawfi in Sana’a, Yemen in 2013 (9) and 0.8% among Iranian children (3). However, it is less than the rate of 3.4% among Jordanian children (27). The difference in prevalence can be attributed to several predisposing factors such as oral use of certain drugs, chronic dry mouth or chronic trauma and vitamin deficiency. The present survey showed that 0.4% of boys had macroglossia, com- pared with none of the girls, perhaps due to overdevelopment of the musculature. There were some limitations to the study. We only sampled children in schools, so children who were not attending school (probably the poor- est children) were not included. Also, we only sampled children in Sana’a so the results cannot be generalized to all Yemeni children. Large-scale population-based studies would be required to further refine our under- standing of the genetics and hereditary of these anomalies. Nevertheless, the study has provided baseline data on the prevalence of oro-dental anomalies in schoolchildren in Sana’a. It is vital that assessment be carried out periodically to identify these anomalies early in life so that appropriate measures are taken early to mitigate their negative impact and costs of treatment in adult life. Boys Girls 35 30 25 20 15 10 5 0 Fissure tongue Ankyloglossia Geographic tongue Hairy tongueMacroglossia 30 13 10 5 7 2 4 0 3 0 N o. Figure 2 Prevalence (number of cases) of soft tissue anomalies among the sample of boys (n = 500) and girls (n = 500) in Sana’a, Yemen طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 39 References 1. Osuji O, Hardie J. Dental anomalies in a population of Saudi Arabian children in Tabuk. Saudi Dent J. 2002;14(1):11–4. 2. Miziara R, Mendes-Junior C, Wiezel C, Simoes A, Scuoteguaz- za J. Azoubel, R. A Statistical Study of the Association of Seven Dental Anomalies in the Brazilian Population. International Journal of Morphology. 2008;26(2):403–6. 3. Khozeimeh F, Rasti G. The prevalence of tongue abnormali- ties among the school children in Borazjan, Iran. Dent Res J. 2006;3(1):1–2. 4. Tai C-CE, Sutherland IS, McFadden L. Prospective analysis of secondary alveolar bone grafting using computed to- mography. J Oral Maxillofac Surg. 2000 Nov;58(11):1241–9. PMID:11078135 5. Cho SY, Ki Y, Chu V, Chan J. 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Aust Dent J. 1998 Dec;43(6):395–8. PMID:9973708 12. Kramer PF, Feldens CA, Ferreira SH, Spiguel MH, Feldens EG. Dental anomalies and associated factors in 2- to 5-year-old Brazilian children. Int J Paediatr Dent. 2008 Nov;18(6):434–40. PMID:18435724 13. Bäckman B, Wahlin YB. Variations in number and morphology of permanent teeth in 7-year-old Swedish children. Int J Paedi- atr Dent. 2001 Jan;11(1):11–7. PMID:11309867 14. Balkees T. Garib. The prevalence of oral developmental disturbances and dental alignment anomalies in females of secondary schools in Thamar city (14-21 years). J Bagh College Dentistry. 2006;18(2):35–9. 15. Brook AH. A unifying aetiological explanation for anomalies of human tooth number and size. Arch Oral Biol. 1984;29(5):373– 8. PMID:6611147 16. Rasmussen P. Severe hypodontia: diversities in manifestations. J Clin Pediatr Dent. 1999 Spring;23(3):179–88. PMID:10686864 17. Chattopadhyay A, Srinivas K. Transposition of teeth and genet- ic etiology. Angle Orthod. 1996;66(2):147–52. PMID:8712493 18. Shapira Y, Kuftinec MM. Maxillary tooth transpositions: characteristic features and accompanying dental anomalies. Am J Orthod Dentofacial Orthop. 2001 Feb;119(2):127–34. PMID:11174558 19. Fujita Y, Hidaka A, Nishida I, Morikawa K, Hashiguchi D, Maki K. Developmental anomalies of permanent lateral incisors in young patients. J Clin Pediatr Dent. 2009 Spring;33(3):211–5. PMID:19476093 20. Dugmore CR. Bilateral macrodontia of mandibular second premolars: a case report. Int J Paediatr Dent. 2001 Jan;11(1):69– 73. PMID:11309876 21. Yonezu T, Hayashi Y, Sasaki J, Machida Y. Prevalence of congenital dental anomalies of the deciduous dentition in Japanese children. Bull Tokyo Dent Coll. 1997 Feb;38(1):27–32. PMID:9566151 22. Hargreaves JA, Cleaton-Jones PE, Roberts GJ, Williams SD. Hy- pocalcification and hypoplasia in primary teeth of pre-school children from different ethnic groups in South Africa. Adv Dent Res. 1989 Sep;3(2):110–3. PMID:2640421 23. Asl Aminabadi N, Ghertasi Oskouei S, Pouralibaba F, Jamali Z, Pakdel F. Enamel defects of human primary dentition as virtual memory of early developmental events. J Dent Res Dent Clin Dent Prospects. 2009 Fall;3(4):110–6. PMID:23230497 24. Goodman AH, Allen LH, Hernandez GP, Amador A, Arriola LV, Chávez A, et al. Prevalence and age at development of enamel hypoplasias in Mexican children. Am J Phys Anthropol. 1987 Jan;72(1):7–19. PMID:3826330 25. Kellerhoff NM, Lussi A. [“Molar-incisor hypomineraliza- tion”]. Schweiz Monatsschr Zahnmed. 2004;114(3):243–53. PMID:15106501 26. Al-Maweri SA, Al-Soneidar WA, Halboub ES. Oral lesions and dental status among institutionalized orphans in Yemen: a matched case-control study. Contemp Clin Dent. 2014 Jan;5(1):81–4. PMID:24808701 27. Darwazeh AM, Pillai K. Prevalence of tongue lesions in 1013 Jordanian dental outpatients. Community Dent Oral Epide- miol. 1993 Oct;21(5):323–4. PMID:8222611 28. Shulman JD. Prevalence of oral mucosal lesions in children and youths in the USA. Int J Paediatr Dent. 2005 Mar;15(2):89– 97. PMID:15790365 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 40 1Faculte de Medecine Ibn El Jazzar de Sousse, Sousse, Tunisie (Correspondance à adresser à C. Zedini : chekib.zedini@gmail.com). Reçu : 12/11/14; accepté : 12/05/15 Prévalence et facteurs associés au tabagisme parmi les étudiants de la ville de Sousse (Tunisie) C. Zedini,1 A. Ben Cheikh,1 M. Mallouli,1 M. Limam,1 J. Sahli,1 M. El Ghardallou,1 A. Mtiraoui 1 et T. Ajmi 1 RÉSUMÉ Dans le cadre de la lutte contre le tabac auprès des jeunes, une étude descriptive transversale a été menée en 2013 afin d'estimer la prévalence du tabagisme et d'identifier les facteurs qui lui sont associés parmi les étudiants de la ville de Sousse. Un questionnaire a été administré auprès d'un échantillon représentatif de 556 étudiants inscrits dans cinq établissements universitaires à Sousse tirés au hasard. L'âge des répondants variait entre 17 et 35 ans. La prévalence de la consommation de tabac durant les 12 derniers mois était de 22,1 % et la consommation durant les trois derniers mois était de 65,3 %. L'âge moyen de début de consommation tabagique était de 17 ans. La prévalence tabagique augmente significativement avec le sexe masculin (p<0,001) et l'âge supérieur à 25 ans (p =0,002). Les étudiants de deux institutions universitaires consommaient plus de tabac que leurs collègues des autres facultés (p=0,027). La forte prévalence du tabagisme chez les étudiants fait de la prévention une mesure indispensable qui passe essentiellement par le renforcement de l'estime de soi et l'évaluation des programmes d'intervention mis en oeuvre avant la consommation de la première cigarette. Prevalence of and factors associated with smoking among students in Sousse, Tunisia ABSTRACT Within the framework of the fight against tobacco among young people, we conducted a descriptive cross-sectional study in 2013 to estimate the prevalence of smoking and to identify associated factors among students in Sousse. A questionnaire was administered to a representative sample of 556 students in 5 academic institutions in Sousse randomly drawn. The age of the participants was between 17 and 35 years. The prevalence of tobacco consumption in the past 12 months was 22.1% and consumption during the past 3 months was 65.3%. The average age of starting smoking was 17 years. Smoking prevalence was significantly higher for males (P < 0.001) and those aged over 25 years (P = 0.002). Students from 2 of the institutions were using more tobacco than their colleagues in the other institutions (P = 0.027). The high prevalence of smoking found among the students means that prevention measures are essential; this requires increasing self-esteem and evaluating intervention programmes implemented before smoking the first cigarette. كلذب ةطبترلما ُلماوعلاو سنوتب ةسوس ةنيدم في بلاطلا ينب ينخدتلا ُراشتنا يمجعلا ايرث ،يوارطلما ليع ،وُّلدرغلا ميرم ،ليحاسلا ناهيج ،ماملإا لانم ،ليوللما لانم ،خيشلا نب ءماسأ ،ينيديزلا بيكش نـب نـخدتلا راـشتنا لدـعم رـيدقتل 2013 ماـع في ةـيعطقم ةـيفصو ةـسارد اـنيرجأ بابـشلا نـب غـبتلا كلاهتـسا ةـحفاكم راـطإ في :ةـصلالخا ةـيميداكأ تاـسسؤم 5 في ًاـبلاط 556 نـم ةـن َّوكم ةـلِّثمم ةـنيعل نايبتـسا مادختـسا مـتف .كـلذب ةـطبترلما لـماوعلا دـيدتحو ةـسوس في بلاـطلا ةقباـسلا 12 ــلا رهـشلأا في غـبتلا كلاهتـسا راـشتنا ناكـف .ًاـماع 35 و 17 نـب نكراـشلما رماـعأ تـناكو .ةيئاوـشع ةـقيرطب اورـتخا ةـسوس في نـخدتلا راـشتنا ناكو .ًاـماع 17 نـخدتلا في ءدـبلا رـمع طـسوتم ناكو .65.3% ةـيضالما رهـشأ 3 ــلا للاـخ كلاهتـسلاا ناكو ،22.1% ثـحبلل نتـسسؤم ذيملات ىدـل غـبتلا كلاهتـسا ناكو .)P = 0.002( ًاـماع 25 ــلا مـهرماعأ تزواـتج نـَم ىدـلو )P < 0.001( روـكذلا ىدـل رـثكب ىـعأ رـبادت ذاـتخا نأ يـنعي بلاـطلا ىدـل دـجُو يذـلا نـخدتلا راـشتنا لدـعم عاـفترا نإ .)P = 0.027( ىرـخلأا تاـسسؤلما في مـنهارقأ نـم ىـعأ .لىولأا ةراجيـسلا نـخدت لـبق ذـ َّفنت يـتلا لـخدتلا جـمارب مـييقتو ،تاذـلا مارـحا ةـيمنت بـلطتي اذـهو .يروضر رـمأ ةـيئاقو طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 41 Introduction L ' a c c r o i s s e m e n t d e s c o n d u i t e s addictives constitue aujourd'hui un problème majeur de santé, notamment chez les étudiants (1,2). En effet, la transition que représente le passage du lycée à l’université est à l’origine de nombreux changements, et de l’apparition ou parfois l’aggravation des consommations de substances psychoactives (3). Parmi ces substances, on note le tabac qui représente un des produits addictifs les plus consommés chez les étudiants (3,4). Dans ce sens, de nombreuses études épidémiologiques ont permis de mesurer l’ampleur du tabagisme chez les jeunes générations (4). Selon l’Organisation mondiale de la Santé, 1,1 milliard sont fumeurs, soit le tiers de la population mondiale âgée de 15 ans et plus (5). En France, et d’après les données de l’Observatoire français des drogues et des toxicomanies (OFDT), 36,2 % des étudiants français s’avèrent être des fumeurs réguliers (2). C’est la prévalence tabagique la plus importante de toutes les tranches d’âge de la vie (2). Ainsi, le tabac tue chaque année plus de cinq millions de personnes et constitue un facteur de risque majeur pour de nombreuses pathologies (6). Son usage quotidien dès le jeune âge constitue la première cause de mortalité prématurée (7). Dans les pays en développement, l e n o m b r e d e j e u n e s a d u l t e s commençant à fumer s’est multiplié et la consommation de tabac par habitant a augmenté (8). Malgré une discrète tendance à la baisse constatée depuis une trentaine d’années, la situation ne semble pas être meilleure en Tunisie (9). En effet, on peut retenir que chez les célibataires de 18 à 29 ans, 30 % consomment du tabac (10). Au vu de la prévalence élevée du tabagisme, en particulier chez les jeunes, qui fument autant que la population générale (9), les mesures de lutte antitabac menées depuis quelques années doivent s’intensifier contre ce fléau (11). Auparavant, nous avons jugé utile d’estimer la prévalence de la consommation de nicotine durant les 12 derniers mois et d’explorer les facteurs qui y sont associés auprès des étudiants de cinq facultés de la région de Sousse en vue d’orienter notre intervention. Méthodologie Type d’étude et population étudiée Il s ’agit d’une étude descriptive transversale menée durant l’année universitaire 2012-2013 auprès d’un échantillon d’étudiants inscrits dans cinq établissements universitaires du gouvernorat de Sousse : • Institut Supérieur des Sciences Appliquées et de Technologie de Sousse (ISSAT) • Faculté de Médecine de Sousse (FMS) • Faculté de Droit de Sousse (FDS) • Institut Supérieur de Finances et de Fiscalité de Sousse (ISFFS) • Institut Supérieur de Musique de Sousse (ISMS). Dans le présent travail, n’ont été inclus que les étudiants présents les jours de passage dans l’établissement et ayant accepté de participer à notre étude. Échantillonnage U n e l i s t e d e s é t a b l i s s e m e n t s universitaires du gouvernorat de Sousse a été retirée auprès du rectorat. Ces derniers ont été regroupés par spécial i té ( l ittérature , économie, s c i e n c e s m é d i c a l e s , s c i e n c e s technologiques, sciences des arts), puis un établissement par spécialité a été tiré au sort. Nous avons procédé à plusieurs visites dans les établissements afin de remettre le questionnaire. Au sein de chaque établissement, nous nous sommes déplacés dans les différentes salles de cours, de travaux dirigés, les bibliothèques et les amphithéâtres et nous avons demandé aux étudiants de remplir le questionnaire de façon anonyme et confidentielle en leur expliquant le cadre de cette étude. Les questionnaires étaient récupérés sur le champ. Notre étude a concerné au total 574 étudiants quelle que soit l’année d’étude, en instance de thèse de doctorat ou inscrits dans un master de recherche. Collecte des données L’enquête a été entamée après avoir eu une autorisation du président de l’université de Sousse. L'étude a été effectuée à l'aide d'un auto- questionnaire, administré par un seul enquêteur préalablement formé. Les données portaient sur les éléments suivants : • c a r a c t é r i s t i q u e s s o c i o - d é m o g r a p h i q u e s : s e x e , â g e , établissement universitaire, niveau d’étude, redoublement, origine g é o g r a p h i q u e , n i v e a u s o c i o - économique, mode de vie, état civil de l’étudiant, état civil des parents. • L e n i v e a u s o c i o - é c o n o m i q u e e s t é v a l u é s e l o n l a c a t é g o r i e socio-professionnelle du père. L a c l a s s i fi c a t i o n a d o p t é e e s t inspirée de la classification du ministère de l’Éducation nationale, de l’Enseignement supérieur et de la Recherche (France) des professions et catégories socio- professionnelles (12): – Favorisée A : chefs d’entreprise de dix salariés ou plus, cadres et professions intellectuelles s u p é r i e u r e s , i n s t i t u t e u r s , professeurs des écoles. – F a v o r i s é e B : p r o f e s s i o n s intermédiaires. – Moyenne : agriculteurs exploitants, artisans et commerçants, employés. – Défavorisée : ouvriers, retraités, inactifs (chômeurs n’ayant jamais EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 42 travaillé, personnes sans activité professionnelle). • Les catégories « favorisée A » et « favorisée B » ont été regroupées en une seule catégorie « favorisée ». • C o n s o m m a t i o n t a b a g i q u e : consommation moyenne durant les 12 derniers mois (c’est la variable d’intérêt de la présente étude), consommation actuelle (ceux qui ont fumé tous les jours ou presque durant les trente derniers jours), âge de début de la consommation, fréquence de consommation de tabac et présence d’une éventuelle dépendance. • Concernant la fréquence de la c o n s o m m a t i o n t a b a g i q u e , l a classification de l’Institut de la statistique du Québec (13) qui classe les fumeurs en quatre catégories a été adoptée : – les fumeurs quotidiens sont des étudiants qui ont fumé au moins 100 cigarettes au cours de leur vie et qui ont fumé des cigarettes tous les jours au cours des trente jours précédant l’enquête ; – les fumeurs occasionnels sont des étudiants qui ont fumé au moins 100 cigarettes au cours de leur vie et qui ont fumé moins que tous les jours au cours des trente jours précédant l’enquête ; – les fumeurs débutants sont des étudiants qui ont fumé entre 1 et 99 cigarettes au cours de leur vie et qui ont fumé au cours des trente jours précédant l’enquête ; – les anciens fumeurs sont des é t u d i a n t s q u i o n t f u m é 100 cigarettes au cours de leur vie mais qui n’ont pas fumé au cours des trente jours précédant l’enquête. • Par ailleurs, le risque de dépendance nicotinique a été déterminé par le test de Fagerström abrégé (14). Ce test est composé de deux questions ; chacune est côtée de zéro à trois points. Un score de dépendance sera calculé par la suite et on obtient trois catégories de dépendance : – absence de dépendance à la nicotine si le score est inférieur ou égal à un ; – dépendance modérée à la nicotine si le score est supérieur ou égal à deux et inférieur ou égal à trois ; – forte dépendance à la nicotine si le score est supérieur ou égal à quatre et inférieur ou égal à six. Afin d’étudier les facteurs associés à l’usage de tabac, nous nous sommes basés sur les facteurs ayant prouvé leur lien avec le tabagisme dans certains articles, à savoir, sexe, famille monoparentale ou séparée versus parents en couple, conditions économiques, milieu de vie, tabagisme dans la famille (parents fumeurs) et redoublement ou échec scolaire (8,15-17). Analyse des données L'analyse statistique a été effectuée en utilisant le logiciel SPSS 18.0. Afin d'étudier la part de certains facteurs associés au tabagisme, le test du χ2 a été utilisé lorsque les conditions de validité le permettaient pour les variables qualitatives. Le seuil de significativité (p) était fixé à 0,05. Résultats Caractéristiques de la population étudiée Parmi les 574 étudiants recrutés dans cette étude, 556 ont répondu convenablement au questionnaire qui leur a été distribué (soit un taux de 96,9%) avec un sex ratio de 0,93. L’âge moyen des participants était de 21,8 ans (écart type [ET] 2,2) (n = 556). La répartition des étudiants selon le sexe, l’âge moyen et l’établissement universitaire est résumée dans le tableau 1. P l u s d e l a m o i t i é d e s étudiants (55,2 % ; n = 307) était inscrite en première et deuxième année, 30,8% des étudiants (n = 171) étaient inscrits en troisième et quatrième année et 14 % (n = 78) avaient un niveau d’études supérieur à cinq ans. Seulement 9,6 % (n = 53) étaient des redoublants. Concernant l’origine géographique et le niveau socio-économique, plus des trois quarts des étudiants vivaient en milieu urbain (78,5 % ; n = 434) et 40,2% (n = 202) appartenaient à la classe économique favorisée. La majorité des participants étaient célibataires (75,6 % ; n = 418) et Tableau 1 Répartition des étudiants selon le sexe, l’âge moyen et l’établissement universitaire Etablissement universitaire Total Féminins Masculins Age moyen (ET) (ans)Nbre % Nbre % Nbre % FMS 121 21,8 73 60,3 48 39,7 22,3 (2,2) FDS 143 25,7 96 67,1 47 32,9 22,87 (2,6) ISFS 58 10,4 39 67,2 19 32,8 20,64 (1,4) ISSAT 209 37,6 73 34,1 136 65,1 21,15 (1,5) IMS 25 4,5 7 28 18 72 22 (2,5) Total 556 100 288 51,8 268 48,2 21,8 (2,2) FMS : Faculté de Médecine de Sousse ; FDS : Faculté de Droit de Sousse ; ISFFS : Institut Supérieur de Finances et de Fiscalité de Sousse ; ISSAT : Institut Supérieur des Sciences Appliquées et de Technologie de Sousse ; ISMS : Institut Supérieur de Musique de Sousse. ET = écart type. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 43 vivaient avec les deux parents (73,6 % ; n = 408) (Tableau 2). Concernant l’état civil des parents des participants, 96,1 % (n = 514) des pères et 94,1 % (n = 513) des mères étaient mariés. Consommation tabagique Prévalence de la consommation tabagique L a p r é v a l e n c e g l o b a l e d e c o n s o m m a t i o n d e c i g a r e tt e s pendant les 12 derniers mois était de 22,1 %, intervalle de confiance à 95% (IC95 %) :18,9-25,7 (n = 123). La prévalence tabagique chez les étudiants de sexe masculin durant les 12 derniers mois était de 41 % (n = 110) et celle chez le sexe féminin était de 4,5 % (n = 13) (Tableau 2). Par ailleurs, la consommation actuelle (lors des 30 derniers jours) est de 13,8 % (n = 77) par rapport à la totalité de notre échantillon. Cette consommation représente 65,3 % (IC95 % : 55,9-73,7) parmi les fumeurs durant les 12 derniers mois (77/118). L’âge moyen de début du tabagisme était de 17,2 (ET 2,9) ans. Fréquence de la consommation tabagique Parmi les fumeurs , un étudiant sur deux (48,6 % ; n = 53) avait une consommation quotidienne. Environ un étudiant sur cinq (18,3 % ; n = 20) avait une consommation occasion-nelle ; 26,6 % (n = 29) étaient des fumeurs débutants et 6,4 % (n = 7) étaient des anciens fumeurs. La fréquence de la consommation tabagique ne différait pas significativement en fonction du sexe. Dépendance à la nicotine (n = 104) La prévalence de la dépendance tabagique était forte chez 33,9 % (n = 39) des cas et faible chez 14,8 % (n = 17) des étudiants dépendants. Cinquante- neuf (51,3 %) étaient non dépendants au tabac. Facteurs associés au tabagisme La prévalence du tabagisme augmente s i g n i fi c a t i v e m e n t a v e c l e s e x e masculin (p < 10 -3) et l ’âge des étudiants supérieur à 25 ans (p = 0 , 0 0 2 ) ( T a b l e a u 2 ) . S e l o n l e s é t a b l i s s e m e n t s u n i v e r s i t a i r e s , l a p r é v a l e n c e t a b a g i q u e é t a i t significativement différente (p = 0,027), en faveur de l’Institut Supérieur de Musique (40 % ; n = 10) (Tableau 2). Discussion Le tabagisme constitue un problème de santé publique (18). Les adolescents et les jeunes sont la principale cible : de ce fait, des actions de prévention s’avèrent nécessaires pour préserver la santé des jeunes et éviter les maladies liées au tabagisme. Afin d’avoir une idée sur le tabagisme en milieu universitaire et de planifier une éventuelle intervention de prévention, nous avons mené une étude chez les étudiants au niveau de cinq établissements universitaires. Par ailleurs, pour des raisons d’accessibilité aux étudiants de différents niveaux d’études au sein des établissements universitaires, nous avons opté pour un échantillonnage de convenance. La prévalence de la consommation t a b a g i q u e t r o u v é e d a n s n o t r e é t u d e ( 2 2 , 1 % ) é t a i t n e tt e m e n t inférieure à celle de la population générale tunisienne qui a été estimée en 2008 par l'Association tunisienne de Lutte contre le cancer (ATCC) à 36 % (9) . Les études faites en 2004 (Harrabi et al.) et 2011 (Khefacha et al .) à Sousse ont montré des prévalences respectives chez les étudiants de 19 % et de 32,6 % (19,20). D’autres études à l’échelle nationale ont trouvé des résultats différents. Ainsi, l’étude conduite par Soltani et al. en 1997 à Monastir [18] révélait une prévalence du tabagisme chez les étudiants de 33 % contre 10 % pour l’étude de Fakhfakh et al. faite en 2003 à Tunis (11). À l’échelle internationale, Chakroun et al., Fernandez et al., Kracmarova et al. et De Andrade et al. ont rapporté des prévalences respectives de 35,4 %, 29,3 %, 28,0 % et 27,8 % (4 ,21 - 23) (Tableau 3). Cette différence de résultats pouvait être expliquée par le fait que nous comparons des groupes d’étudiants de structures différentes en utilisant des instruments de mesure différents et un mode d’échantillonnage différent. Ainsi, d’après ces études et bien d’autres menées dans le monde, la consommation tabagique chez les étudiants reste élevée malgré les campagnes antitabac qui ont été mises en place. Ceci nous amène à réfléchir sur les stratégies adoptées actuellement et leur efficacité. L’analyse selon le sexe montre que la prévalence tabagique augmente avec le sexe masculin. La même constatation a été faite dans les autres études tunisiennes (9,11) et étrangères, notamment musulmanes et arabes (9 ,24). En effet, l’étude menée en Arabie saoudite auprès de 400 étudiants en 2014 a montré que la prévalence chez les étudiants était de 27,6 % contre 2,4 % chez les étudiantes (6). Cette différence entre les deux sexes envers le tabac peut être expliquée par des considérations d’ordre socio-culturel et religieux. En fait, les sociétés arabes considèrent le tabagisme féminin comme un tabou dévalorisant l’image de la fille, mais cette image est en train de changer ces dernières années en faveur du modèle occidental (25). Par ailleurs, cet écart se réduit dans les pays occidentaux où les femmes fument autant que les hommes. En effet, les femmes sont des victimes soumises à l’image séduisante, libérée et dynamique véhiculée par les campagnes publicitaires et les magazines de mode (26). Cette image pourrait expliquer la forte prévalence du tabagisme féminin où la cigarette fait partie des attributs symboliques de l’émancipation, de la féminité et du plaisir (26). L’âge moyen d’initiation au tabac est de 17,25 ans (ET 2,9) dans notre travail. Il est légèrement en dessous de EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 44 l ’âge de début retrouvé dans de nombreuses études tunisiennes (19- 20 ans) (8 ,9). En Europe, l’étude m u l t i c e n t r i q u e m e n é e a u p r è s d e 2 2 4 9 é t u d i a n t s e n 2 0 0 9 a m o n t r é q u e l ’ â g e m o y e n d e début de la consommation de tabac était entre 11 et 15 ans (7). Au niveau de cette dernière étude, le tabagisme a débuté à l’adolescence, avant l’entrée dans la vie universitaire. Ceci semble lié à un malaise personnel et psychologique, en principe transitoire (27). Il ressort ainsi que les programmes de prévention se basant, entre autres, sur l’éducation sanitaire doivent avoir comme cible principale les jeunes adolescents (11). Dans notre étude, la prévalence tabagique était plus élevée dans l a t r a n c h e d ’ â g e d e p l u s d e 25 ans (43,8 %). Par contre, en France, Tableau 2 Répartition de la prévalence du tabagisme pendant les 12 derniers mois selon les caractéristiques socio- démographiques et académiques des étudiants Caractéristique Fumeurs Non-fumeurs Total p Nbre % Nbre % No. Genre < 0,001 Masculin 110 41,0 158 59,0 268 Féminin 13 4,5 275 95,5 288 Tranche d’âge (ans) 0,002 17-25 108 20,7 414 79,3 522 > 25 14 43,8 18 56,3 32 Niveau socio-économique 0,922 Favorisé 43 21,3 159 78,7 202 Moyen 31 20,4 121 79,6 152 Défavorisé 33 22,3 115 77,7 148 Origine 0,236 Rurale 31 26,1 88 73,9 119 Urbaine 91 21,0 343 79,0 434 Etat civil - Célibataire 98 23,4 320 76,6 418 Marié 4 19,0 17 81,0 21 Divorcé 0 0 1 100,0 1 En couple 21 18,6 92 81,4 113 Mode de vie 0,775 Avec les parents* 101 22,4 349 77,6 450 Hors foyer parental 30 21,2 82 78,8 104 Redoublement 0,063 Nouveau 22 21,0 396 79,0 501 Redoublant 17 32,1 36 67,9 53 Niveau d’étude 0,975 1ère et 2ème année 69 22,5 238 77,5 307 3ème et 4ème année 37 21,6 134 78,4 171 5ème année et plus 17 21,8 61 78,2 78 Etablissement universitaire 0,027 FMS 24 19,8 97 80,2 121 FDS 22 15,4 121 84,6 143 ISSAT 55 26,3 154 73,7 209 ISFS 12 20,7 46 79,3 58 ISMS 10 40,0 15 60,0 25 aAvec les parents : soit avec les deux parents, soit avec l’un des deux parents, ou avec un membre de la famille. Tous les totaux ne sont pas égaux à 556 en raison des valeurs manquantes. FMS : Faculté de Médecine de Sousse ; FDS : Faculté de Droit de Sousse ; ISSAT : Institut Supérieur des Sciences Appliquées et de Technologie de Sousse ; ISFFS : Institut Supérieur de Finances et de Fiscalité de Sousse ; SIMS : Institut Supérieur de Musique de Sousse. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 45 d’après les données de l’Observatoire f r a n ç a i s d e s d r o g u e s e t d e s toxicomanies (OFDT), la tranche d’âge 18-25 ans est celle où la fréquence du tabagisme est maximale (36,2 %) (2). Cette fréquence diminue régulièrement dans les tranches d’âge supérieures (2). La différence de prévalence de cette tranche d’âge pourrait être expliquée par l’initiation tardive au tabac et l’indépendance financière des jeunes qui se concrétise à un âge tardif. S e l o n l ’ é t a b l i s s e m e n t d’enseignement supérieur, la Faculté de Médecine de Sousse se classe en quatrième position avec 19,8%. Dans le même sens, Moaouad et al. dans une étude comparative chez une population d’étudiants libanais a trouvé que la prévalence de la dépendance à la nicotine était significativement inférieure chez les étudiants en médecine par rapport à leurs homologues d’autres facultés (28). Certainement, le tabagisme constitue un problème sérieux pour tout étudiant quelle que soit sa discipline a c a d é m i q u e , m a i s c e tt e g r a v i t é nous semble prendre davantage d’importance lorsqu’il s’agit d’un futur médecin vu l’image négative qu’il va véhiculer, non seulement à ses pat ients , mais à toute la population en général (importance du rôle modèle) (29). Par ailleurs, plusieurs études ont montré un taux plus élevé d’abus de substances psychoactives (tabac, alcool, marijuana) chez les médecins comparés à la même tranche d’âge de la population générale en rapport avec le stress de la profession médicale (29,30). D a n s n o t r e é t u d e , 1 8 , 3 % des étudiants consommaient du t a b a c d e f a ç o n o c c a s i o n n e l l e . C e m o d e d e c o n s o m m a t i o n tabagique (occasionnelle), selon p l u s i e u r s é t u d e s , s e r e n c o n t r e plus fréquemment chez les jeunes adultes (31 ,32) qui chercheraient à partager cette consommation dans un cadre festif ou de convivialité (33). Ainsi , les fumeurs occasionnels utilisent le tabac comme un signe d’engagement social, mais aussi pour atténuer les émotions négatives (33). En outre, ces derniers ne se considèrent pas comme de vrais fumeurs et sont plus confiants quant à leur capacité d’arrêter de fumer (34), ce qui a comme conséquence une faible demande d’aide pour le sevrage tabagique et de faibles tentatives d’arrêt. Donc les a c t i o n s d e p r é v e n t i o n d o i v e n t e s s e n t i e l l e m e n t t o u c h e r c e tt e catégorie de fumeurs. En effet, bien q u e c e s f u m e u r s c o n s o m m e n t moins de cigarettes et aient moins de dépendance nicotinique (35), plusieurs études ont montré la progression de ces consommateurs vers des habitudes tabagiques plus enracinées en développant une dépendance nicotinique à long terme (31). Ce type de consommation tabagique doit être pris en considération dans les programmes de lutte antitabac afin d’inciter ces consommateurs au sevrage et de prévenir l’escalade. Conclusion Ainsi, au regard des résultats de cette étude, la prévention du tabagisme dans nos milieux universitaires est jugée prioritaire à plusieurs titres vu la forte prévalence de la consommation de c e tt e s u b s t a n c e p a r m i l e s étudiants (22,1 %), la lourde morbidité Tableau 3 Prévalence du tabagisme chez les étudiants dans le monde Auteurs Population Effectifs Année Pays Prévalence fumeurs (%) Soltani MS et al (14) Faculté de Médecine (Monastir) 501 2000 Tunisie 33,0 Harrabi I et al (15) Faculté de médecine (Sousse) 230 2004 Tunisie 19,2 Fakhfakh R et al (11) Ecole supérieure des sciences et des techniques de la santé (Tunis) 1288 2010 Tunisie 10,0 Khefacha AS et al (16) Institut Supérieur des sciences infirmières (Sousse) 150 2011 Tunisie 32,6 Maatouk F et al (9) Faculté de Médecine dentaire (Monastir) 1123 2013 Tunisie 14,2 Manoudi F et al (20) Université Caddi Ayyad de Marrakech 418 2010 Maroc 24,6 Chakroun N et al (4) Université de bordeaux II 1517 2005 France 35,4 Fernandez GD (19) Ecole des sciences de la santé (University of Léon) 265 2006 Espagne 29,3 De Andrade AG et al. (21) Vingt-sept Facultés au Brésil 12 721 2009 Brésil 27,8 Kracmarova L et al (18) Université centrale d’Italie 345 2011 Italie 28,0 Jradi H et al (32) Trois Facultés de médecine (King Saud Bin Abdul-Aziz University, King Abdul-Aziz University and Jazan University) 212 2014 Arabie saoudite 19,4 Présente étude Cinq établissements universitaires (Sousse) 556 2014 Sousse 22,1 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 46 et la mortalité qui y sont liées et son potentiel introductif, selon la théorie de l’escalade, vers d’autres produits comme le cannabis et l’alcool. Les stratégies de lutte contre le tabac ont consisté presque exclusivement jusqu’ici en une information sur les risques liés à l’usage du tabac. La majorité des actions de prévention étaient ponctuelles à l’occasion de la célébration de journées nationales, maghrébines et mondiales, dont certaines sont spécifiques au milieu universitaire. Dans ce cadre, nous prévoyons d’instaurer un programme d e p r é v e n t i o n t a b a g i q u e e n collaboration avec le service de médecine universitaire de la Direction régionale de santé de base de Sousse. Ce programme a pour objecti f non seulement d ’amél iorer les connaissances des étudiants sur les méfaits du tabac sur leur santé mais aussi, et surtout, de mettre en exergue la manipulation qu’exerce l’industrie du tabac, de favoriser l’estime de soi des étudiants, de créer des activités physiques (tournois sportifs) et intellectuelles (clubs de jeu d’échecs) en milieu universitaire. Ces actions s’étendront de façon régulière sur une période minimale de six mois, sinon plus, afin de provoquer une prise de conscience et engendrer un changement d’attitudes sur une période de 12 à 18 mois (36). Par ailleurs, en Tunisie, bien qu’on dispose depuis plus d’une dizaine d’années de mesures législatives relatives à l’interdiction de fumer dans les lieux publics, l’application de cette loi reste toutefois à vérifier ; son application en milieu universitaire afin de bénéficier d’une université sans tabac fait partie de notre mission. Remerciements Nous tenons à remercier tout le personnel administratif des différents établissements universitaires et du Rectorat de Sousse qui nous ont facilité la collecte des données. Conflit d’intérêt : aucun. Références 1. Décamps G, Idier L, Battaglia N. Personnalité et profils addictifs : étude des consommations de substances et des pratiques comportementales addictives en population étudiante. J Ther Comport Cogn. 2013;23(2):73–80. 10.1016/j. jtcc.2013.04.001 2. Dupuy G, Vorspan F, Lépine J-P. Épidémiologie des usages de substances addictives : résultats d’études réalisées en France et perspectives internationales. 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PMID:12794659 30. Da Silveira DX, Rosa-Oliveira L, Di Pietro M, Niel M, Doering- Silveira E, Jorge MR. Evolutional pattern of drug use by medical students. Addict Behav. 2008 Mar;33(3):490–5. 10.1016/j. addbeh.2007.10.005 PMID:18068309 31. White HR, Bray BC, Fleming CB, Catalano RF. Transitions into and out of light and intermittent smoking during emerging adulthood. Nicotine Tob Res. 2009 Feb;11(2):211–9. 10.1093/ ntr/ntn017 PMID:19246434 32. Lenk KM, Chen V, Bernat DH, Forster JL, Rode PA. Characterizing and comparing young adult intermittent and daily smokers. Subst Use Misuse. 2009;44(14):2128–40. 10.3109/10826080902864571 PMID:20001699 33. Waters K, Harris K, Hall S, Nazir N, Waigandt A. Characteristics of social smoking among college students. J Am Coll Health. 2006 Nov-Dec;55(3):133–9. PMID:17175899 34. Sutfin EL, Reboussin BA, McCoy TP, Wolfson M. Are college student smokers really a homogeneous group? a latent class analysis of college student smokers. Nicotine Tob Res. 2009 Apr;11(4):444–54. 10.1093/ntr/ntp006 PMID:19264866 35. Moran S, Wechsler H, Rigotti NA. Social smoking among US college students. Pediatrics. 2004 Oct;114(4):1028–34. 10.1542/ peds.2003-0558-L PMID:15466101 36. Smoking: preventing uptake in children and young people NICE guidelines [PH14]. London: National Institute for Health and Care Excellence; 2008 (https://www.nice.org.uk/ guidance/ph14, consulté le 26 octobre 2015). EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 48 1Section of General Paediatrics, Department of Paediatrics, University of Nebraska Medical Center, Omaha, Nebraska, United States of America (Correspondence to A. Nasir: anasir@unmc.edu). 2Department of Health, UNRWA Headquarters, Amman, Jordan. 3Department of Family Medicine, Creighton University School of Medicine, Omaha, Nebraska, United States of America. 4Department of Health, UNRWA Jordan Field Office, Amman, Jordan. Received: 29/09/14; accepted: 29/10/15 Paediatric continuing medical education needs and preferences of UNRWA physicians in Jordan A. Nasir,1 A. Khader,2 L. Nasir, 3 I. Abuzayed 4 and A. Seita 2 ABSTRACT Most physicians who work in the United Nations Relief and Works Agency (UNRWA) infant and child health programme in Jordan are general practitioners with no postgraduate training in paediatrics. Furthermore, in resource-poor or remote settings, the ability to deliver live continuing medical education (CME) is often limited. A questionnaire exploring the resources available for accessing CME, preferences for types of CME, current sources of CME and topics of interest in the field of paediatric care was sent to all 92 physicians practising in UNRWA clinics in Jordan. Of the 89 respondents 80% had attended live medical lectures for CME and 70% CME meetings. Despite most physicians having access to the Internet only 52.8% were interested in Internet-based courses for accessing CME. There was a statistically significant relationship between year of graduation from medical school and preference for Internet-based CME. Implications for CME participation and paediatric CME topics are discussed. لافطلأا بط لامج في رمتسلما يبطلا ميلعتلا صوصخب هنولضفي امو ندرلأا في اورنولأا ءابطأ تاجايتحا اتيس ورهيكأ ،دياز وبآ يويتشا ،صران ثيل ،ضرخ ليع ،صران قلحا دبع ىورأ )اورنولأا( نـئجلالا ليغـشتو ثوـغل ةدـحتلما مـملأا ةـلاكول عـباتلا لاـفطلأاو عـضرلا ةـحص جـمانرب في نوـلمعي نـيذلا ءاـبطلأا مـظعم نإ :ةـصلالخا رمتـ سم يـ بط مـ يلعت مـ يدقت ىـ ع ةردـ قلا نإـ ف كـ لذ ىـ ع ةولاـ عو .لاـ فطلأا بـ ط ىـ ع جرـ ختلا دـ عب اوـ ب َّردي لم نوـ ماع نوـ سرامم مـ ه ندرلأا في لـمعلا نوـسرماي نـيذلا 92 ــلا ءاـبطلأا عـيملج لـسرُأ دـقف .ةدودـمح نوـكت اـم ًاـبلاغ - ةـيئانلا قـطانلما في وأ دراوـلما ةحيحـش نـكاملأا في - شراـبم طماـنأ نـم هـنولضفي اـم فاـشكتساو ،رمتـسلما يـبطلا مـيلعتلل ةـيلالحا رداـصلماو ةـحاتلما دراوـلما ءاصقتـسلا نايبتـسا ندرلأا في اورـنولأا تاداـيع في اوضرـح مـنهأ 89 ــلا نـبيجلما نـم 80% رـكذف .لاـفطلأل ةـيبطلا ةـياعرلا لاـمج في مماـتهلاا تاذ تاـعوضولما ىـع فوـقولاو ،رمتـسلما يـبطلا مـيلعتلا مـظعم نأ نـم مـغرلا ىـعو .رمتـسلما يـبطلا مـيلعتلل تاـعماتجا اوضرـح مـنهأ 70% رـكذ ماـك ،رمتـسلما يـبطلا مـيلعتلل ةشراـبم ةـيبط تاضراـمح يـبطلا مـيلعتلا ىـع لوـصحلل تـنرنلإا ةكبـش تارودـب ًماـتهم ناك طـقف مـهنم 52.8% نإـف تـنرنلإا لىإ لوـصولا ةـيناكمإ مـيهدل رـفاوتت ءاـبطلأا ةكبـش قـيرط نـع رمتـسلما يـبطلا مـيلعتلا لـيضفت نـبو بـطلا ةـيلك نـم جرـختلا ةنـس نـب ةـيئاصحإ ةـللاد تاذ ةـقلاع كاـنه تـناكو .رمتـسلما .ةـشقانلما دـيق يـه لاـفطلأا بـط لاـمج في رمتـسلما يـبطلا مـيلعتلا عـيضاومو رمتـسلما يـبطلا مـيلعتلا في ةكراـشلما ىـع ةـبترلما راـثلآا نإ .تـنرنلإا Besoins et préférences en matière de formation médicale continue en pédiatrie des médecins exerçant en Jordanie de l’Office de secours et de travaux des Nations Unies pour les réfugiés de Palestine dans le Proche-Orient RÉSUMÉ La plupart des médecins qui travaillent pour le programme de santé du nourisson et de l’enfant en Jordanie à l’Office de secours et de travaux des Nations Unis pour les réfugiés de Palestine dans le Proche-Orient (UNRWA) sont des médecins généralistes sans spécialisation en pédiatrie. Par ailleurs, dans un contexte de ressources limitées ou dans des zones isolées, la capacité à dispenser une formation médicale continue (FMC) est souvent limitée. Un questionnaire étudiant les ressources disponibles qui permettent d’accéder à la formation médicale continue, les types de formation préférés, les sources actuelles de formation médicale continue et les sujets d’intérêt dans le domaine des soins pédiatriques a été envoyé à l’ensemble des 92 médecins exerçant dans des cliniques de l’UNRWA en Jordanie. Sur un total de 89 répondants, 80 % avaient assisté en personne à des conférences médicales dans le cadre de la formation médicale continue et 70 % à des réunions de formation médicale continue. Si la plupart des médecins avaient accès à l'Internet, seuls 52,8 % étaient intéressés par des cours en ligne permettant d’accéder à la formation médicale continue. Il existait une relation statistiquement significative entre l’année de fin d’études en faculté de médecine et la préférence pour une formation médicale continue sur l'Internet. Les implications pour une participation à la formation médicale continue et les sujets de formation médicale continue en pédiatrie sont en cours de discussion. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 49 Introduction Continuing medical education (CME) allows physicians to keep up with advances in medical knowledge that affect patient care. Evidence indicates that CME can be effective in improving knowledge, attitudes, skills and behav- iours (1). While Internet-based learning has been found to be associated with large positive effects on knowledge compared with no intervention, a meta-analysis of 81 trials has suggested that CME interventions that result in measureable improvements in patient outcomes are those that provide a combination of didactic and interactive elements (2). The health programme of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) delivers primary health care services to over 3 million Palestinian refugees in the Gaza Strip, the West Bank, Jordan, Syrian Arab Re- public and Lebanon (3). Through their infant and child health programme, UNRWA provides care for children across all phases of the life cycle, with specific interventions that meet the health needs of newborns, infants and school-age children. Both preventive and curative care is provided, with a special emphasis on prevention. In Jordan, UNRWA clinics are located in both refugee camps and in the commu- nity, at various locations throughout the country (Table 1). Physicians working in resource- limited countries or remote areas often have limited access to CME venues. This has an impact on their ability to access advances in medical knowledge and skills. Internet-based CME ac- tivities offer a potential solution to this problem (4). Particularly in resource- poor or remote settings, the ability to deliver live CME is often limited. This makes Internet-based delivery of courses and information a potentially attractive method by which information and education might be disseminated. Most physicians who work in the UNRWA infant and child health pro- gramme are general practitioners with no postgraduate training in paediatrics. CME on paediatric topics has been identified by both physicians and the UNRWA leadership as being very im- portant in maintaining and improving the quality and efficiency of health care in the UNRWA clinics in Jordan. Since little is known about the CME needs of UNRWA physicians, we wanted to ex- plore their current practices and format preferences for CME, with an emphasis on paediatric topics. Methods A questionnaire was developed for this survey by a team comprised of a board-certified academic paediatrician, a board-certified academic family physi- cian and physician leaders in the UN- RWA health department headquarters in Amman, Jordan. The questionnaire was also reviewed by the Center for Continuing Education at the University of Nebraska medical centre in Omaha, United States of America. It explored preferences, practices and access to CME as well as content needs in paedi- atrics. The questionnaire was reviewed and approved by the ethics committee at the UNRWA headquarters. The paper questionnaire was sent in February 2014 to the UNRWA physi- cians who staff the 23 primary health care centres in the 6 regions in Jordan. The questions explored the following themes: the preferred format for CME; current sources of CME; resources available to allow participation in online and other types of CME; and preferred paediatric topics for CME. Counts and percentages were used to describe all variables. Fisher exact test was used to determine associations between questions. A P-value < 0.05 was considered statistically significant. Results Of the 92 physicians, 89 completed and returned the questionnaire (96% response rate); 72 (80.9%) respondents were male and 15 (16.8%) were female (2 did not report their sex). The major- ity of physicians in the sample (50.6%) reported having graduated from medi- cal school before 1996. Preferred method of CME In the question about preferred meth- ods of CME 69.7% of the respondents were very interested in medical confer- ences as a method for obtaining CME. The next most preferred methods Table 1 Locations of United Nations Relief and Works Agency for Palestine Refugees in the Near East primary care clinics in Jordan Clinics within refugee camps Clinics outside refugee camps Amman new camp Tybeh Irbid Aqaba Jerash Waggas Husn North Shoneh Talbieh Mashare Suf Kraymeh Baqaa Amman town health centre South Baqaa Zarqa town Jabal Hussain Amir Hasan Quarter Zarqa camp Awajan Marka Nuzha Msheirfeh EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 50 were brief courses (65.2%) and lo- cal lectures and case presentations (58.4%). Although just over half of respondents (52.8%) were interested in Internet modules, other modes of electronic delivery were less preferred (webinars 18.0%, Internet databases 38.2%). None of the physicians re- ported an interest in accessing medical journals online or medical websites (Table 2). Current CME participation When asked about their current partici- pation in CME 85.4% of physicians said they participated in medical lectures and 70.8% participated in brief courses. Participation in Internet-based CME was significantly lower, with 49.4% ac- cessing CME through medical websites and only 31.5% using taking Internet- based courses and modules. One-fifth of respondents (20.2%) reported accessing medical databases such as PubMed. Only 5.6% participated in webinars (Table 3). Access to CME Although all UNRWA clinics in Jordan have an Internet connection, only 79.9% of the physicians surveyed reported that they had reliable access to the Internet, 37.0% reported having access to medi- cal databases and 35.9% had access to online medical journals. Paediatric topic preferences Physicians indicated that the paediatric topics they were most interested in were respiratory infections (76.4%), followed by asthma (71.9%), exami- nation of the newborn (70.8%), fever in infants (70.8%), immunization updates (70.8%) and gastrointestinal infections (69.7%). Subjects that were of least interest included oral health (31.5%), injury prevention (42.7%) and behavioural problems (48.3%) (Table 4). Preferences by year of graduation Further analysis of the data revealed that there was greater preference for online CME among those physicians who had graduated more recently from medical school: 91.3% among those who gradu- ated between 2005 and 2012 versus 88.9% among those graduating before 1996 (P = 0.03) (Table 5). Table 2 Preferred methods of accessing continuing medical education (CME) among physicians at United Nations Relief and Works Agency clinics in Jordan (n = 89) Method of accessing CME Very interested Somewhat/not interested No. % No. % Medical conferences 62 69.7 27 30.3 Brief courses 58 65.2 31 34.8 Local lectures and case presentation 52 58.4 37 41.6 Internet-based courses and modules 47 52.8 42 47.2 Medical databases 34 38.2 55 61.8 Webinars 16 18.0 73 82.0 Medical journals 0 0.0 89 100.0 Websites 0 0.0 89 100.0 Other 10 11.2 79 88.8 Table 3 Current types of continuing medical education (CME) participation among physicians at United Nations Relief and Works Agency clinics in Jordan (n = 89) Type of CME Participated Did not participate No. % No. % Local lectures 76 85.4 13 14.6 Brief courses 63 70.8 26 29.2 Medical websites 44 49.4 45 50.6 Medical conferences 33 37.1 56 62.9 Internet based courses and modules 28 31.5 60 67.4 Medical journals 27 30.3 62 69.7 Medical databases 18 20.2 71 79.8 Webinars 5 5.6 84 94.4 Other 5 5.6 84 94.4 No participation 88 98.9 1 1.1 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 51 Discussion Our data indicated that while most UNRWA physicians practising in Jordan reported that they had reliable access to the Internet, only 31.5% of the physician sample participated in Internet-based courses and modules, and similar numbers reported ac- cessing online medical journals. The respondents reported a strong prefer- ence for live interactive courses and lectures when participating in CME. Although all UNRWA clinics in Jordan are connected to the Internet, 20.2% of the physicians reported that they did not have a reliable access to the Inter- net. This may be due to local issues or difficulties on the part of the physicians trying to access this resource. In addition, the number of years since medical school graduation was significantly associated with lower in- terest in Internet-based CME delivery. Data from other regions regarding the relationship between physician age and Internet use for CME are scarce and conflicting (5–7). It is possible that among older physicians, less familiarity with computers and the Internet is a barrier to participation. Other possi- bilities might be that older physicians place a greater value on other aspects of group CME. These include the oppor- tunity for a respite from practice or to experience personal interactions with teachers, colleagues and other profes- sionals (8). Older physicians may also have a different understanding of the role played by the social environment in consolidating new knowledge (9). Research indicates that even in coun- tries where Internet access is nearly universal, the traditional live CME format continues to be preferred by many physicians, although it is unclear whether physician’s age is a factor in this preference (10,11). Paediatric topics reported to be of greatest interest included commonly seen paediatric conditions such as im- munizations and asthma. Oral health, injury prevention and behavioural problems were of less interest. Previous Table 4 Paediatric continuing medical education topics of interest among physicians at United Nations Relief and Works Agency clinics in Jordan (n = 89) Topic Very interested Somewhat/not interested No. % No. % Respiratory infections 68 76.4 21 23.6 Asthma 64 71.9 25 28.1 Newborn examination 63 70.8 26 29.2 Fever in small infant 63 70.8 26 29.2 Immunization update 63 70.8 26 29.2 Gastrointestinal infections 62 69.7 27 30.3 Failure to thrive 56 62.9 33 37.1 Micronutrient deficiencies 55 61.8 34 38.2 Physician professional development 55 61.8 34 38.2 Urinary tract infection 53 59.6 36 40.4 Late preterm infants 46 51.7 43 48.3 Behavioural and emotional problems 43 48.3 46 51.7 Injury prevention 38 42.7 51 57.3 Oral health 28 31.5 61 68.5 Other 5 5.6 84 94.4 Table 5 Preference for Internet-based continuing medical education (CME) as a function of year of medical school graduation among physicians at United Nations Relief and Works Agency clinics in Jordan Graduation year Interest in Internet-based CME P-value Somewhat/not interested Very interested No. % No. % 2005–2012 2 8.7 21 91.3 0.0316 1997–2004 3 15.0 17 85.0 1996 and before 5 11.1 40 88.9 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 52 References 1. Marinopoulos SS, Dorman T, Ratanawongsa N, Wilson LM, Ashar BH, Magaziner JL, et al. Effectiveness of continuing medi- cal education. Rockville (MD): US Department of Health and Human Services, Agency for Healthcare Research and Qual- ity; 2007 (AHRQ Evidence Report/Technology Assessment, Number 149). 2. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O’Brien MA, Wolf F, et al. Continuing education meetings and work- shops: effects on professional practice and health care out- comes. Cochrane Database Syst Rev. 2009; (2):CD003030. PMID:19370580 3. Bocco R. UNRWA and the Palestinian refugees: a history within history. Refug Surv Q. 2009;28(2-3):229–52. 4. Canchihuaman FA, Garcia PJ, Gloyd SS, Holmes KK. An inter- active internet-based continuing education course on sexually transmitted diseases for physicians and midwives in Peru. PLoS One. 2011;6(5):e19318. PMID:21573054 5. Schoen MJ, Tipton EF, Houston TK, Funkhouser E, Levine DA, Estrada CA, et al. Characteristics that predict physician partici- pation in a Web-based CME activity: the MI-Plus study. J Con- tin Educ Health Prof. 2009 Fall;29(4):246–53. PMID:19998447 6. Casebeer L, Engler S, Bennett N, Irvine M, Sulkes D, DesLauri- ers M, et al. A controlled trial of the effectiveness of internet CME. BMC Med. 2008 Dec 4;6:37. PMID:19055789 7. Alghamdi KM. Professional use of the internet among Saudi Arabian dermatologists: a cross-sectional survey. BMC Derma- tol. 2009;9:10. PMID:19835598 8. Wolf FM, Gruppen LD, van Voorhees C, Stross JK. Dimensions of motivation for continuing medical education of primary care physicians. Eval Health Prof. 1986 Sep 1;9(3):305–16. 9. Sandars J, Kokotailo P, Singh G. The importance of social and collaborative learning for online CME (OCME): direc- tions for future development and research. Med Teach. 2012 Aug;34(8):649–52. PMID:22830322 10. Stancic N, Mullen PD, Prokhorov AV, Frankowski RF, McAlis- ter AL. Continuing medical education: what delivery format do physicians prefer? J Contin Educ Health Prof. 2003 Sum- mer;23(3):162–7. PMID:14528787 11. Vollmar HC, Rieger MA, Butzlaff ME, Ostermann T. Gen- eral Practitioners’ preferences and use of educational media: a German perspective. BMC Health Serv Res. 2009;9(1):31. PMID:19220905 12. Barss P, Grivna M, Al-Maskari F, Kershaw G. Strengthening public health medicine training for medical students: devel- opment and evaluation of a lifestyle curriculum. Med Teach. 2008;30(9-10):e196–218. PMID:19117217 13. Kronfol NM. Access and barriers to health care delivery in Arab countries: a review. East Mediterr Health J. 2012 Dec;18(12):1239–46. PMID:23301399 research has suggested that physicians practising in the region may not have received much training in some of these topics (12). Additionally, they may consider some of these conditions to be outside of their sphere of responsi- bility (13). Therefore, CME on these important topics would be expected to improve the scope and quality of health care provided in these UNRWA primary care clinics. Although the response rate to our survey was high, the questions on the survey did not explore preferences and barriers to physician CME preferences in depth. Further work should focus on detailing these barriers and assessing the effectiveness of different types of CME delivery on patient outcomes in the UNRWA setting. A cost-effective health care system depends on a well-trained medical workforce. Continuing medical educa- tion is also an important means of co- ordinating and standardizing practices among a group of physicians across a medical system. These findings high- light the importance of understanding which specific types of CME activities are the most compelling to the target audience, and which are most likely to lead to measureable positive changes in clinical practice. Aligning modali- ties and subjects to take advantage of preferences, needs and resources avail- able will allow the health organization to maximize cost–effectiveness of the CME provided, while allowing patients to benefit fully from new advances in medical care. Funding: None. Competing interests: None declared. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 53 1Institute of Health Management and Social Protection, Saint-Joseph University of Beirut, Beirut, Lebanon (Correspondence to M.K. Asmar: michele.asmar@usj.edu.lb). 2National Professional Officer, World Health Organization Lebanon Country Office, Beirut, Lebanon. Received: 07/04/15; accepted: 16/11/15 Report Compiling comprehensive national health statistics in a fragmented health information system: lessons learned from Lebanon M.K. Asmar,1 J.S. Yeretzian 1 and A. Rady 2 ABSTRACT In view of the rapid health transition faced by the country and a highly dominant private sector, the issue of obtaining reliable health statistics is becoming a priority for Lebanon. This paper reviews the process of compiling and disseminating national health statistics from the multitude of public, private and nongovernmental partners in the country. The lessons learned from preparing two editions of the National health statistics report in Lebanon allow identification of some challenges and strengths of the current health information system in Lebanon. The experience emphasizes the need for a close partnership with all stakeholders, an efficient management system, adequate human resources and predefined systems and procedures. The process would benefit from having an interactive website for exchange of data and information among stakeholders and the public. The existence of clear guidelines with consistent definitions and standardized forms would also facilitate the collection and analysis of data. نانبل نم ةدافتسم سورد :أزمج ةيحص تامولعم ماظن في ةلماش ةينطو ةيحص تايئاصحإ عيمتج ضيار راسيلأ ،نايستيري نافطسا اناموج ،رمسأ ليمرق ليشيم ةـيحص تاءاـصحإ ىـع لوـصلحا حـبصأ ةـنميلها ديدـش صاـخ عاـطق دوـجولو دلاـبلا هـهجاوت يـتلا عـيسرلا يـحصلا لوـحتلل ًارـظن :ةـصلالخا نـم دـيدعلا نـم ةـينطولا ةـيحصلا تاـيئاصحلإا شرـنو عـيمتج ةـيلمع ثـحبلا اذـه ضرعتـسيو .ناـنبلل ةبـسنلاب ةـيولوأ تاذ ةلأـسم ةـقوثوم ةـيحصلا تاـيئاصحلإا رـيرقت" نـم نـتعبط دادـعإ نـم ةدافتـسلما سوردـلا نإ .دلاـبلا في يـموكلحا رـغو صاـلخاو ماـعلا عاـطقلا في ءاكشرـلا .ناــ نبل في نــ هارلا ةــ يحصلا تاــ مولعلما ماــ ظن اــ ههجاوي يــ تلا تاــ يدحتلا ضــ عب كــ لذكو ةوــ قلا طاــ قن ىــ ع فرــ عتلا حــ يتت "ناــ نبل في ةــ ينطولا مـظنو ،ةـيفاك ةـيشرب دراوـمو ،ءفـك ةرادإ ماـظن دوـجو لىإو ،ةـينعلما فارـطلأا عـيجم نـب ةـقيثو ةـكاشر ةـماقإ لىإ ةـجالحا دـكؤت ةـبرجتلا هذـهف فارـطلأا نـب تاـمولعلماو تاـنايبلا لداـبتل ليـعافت نيورـكلإ عـقوم دوـجو نـم ديفتـست نأ ةـيلمعلا هذـه نأـش نـمو .ًاقبـسم ةددـمح تاءارـجإو .اـهليلتحو تاـنايبلا عـجم لهـسي نأ هنأـش نـم ةدـحوم جذماـنو ةددـمح تاـفيرعت تاذ ةـحضاو ةيداـشرإ لـئلاد دوـجو نأ ماـك .روـهملجاو ةـينعلما Compilation de statistiques sanitaires nationales et exhaustives dans un système d’information sanitaire fragmenté : les enseignements tirés de l’expérience du Liban RÉSUMÉ Face à la transition sanitaire rapide dans le pays et à un secteur privé fortement dominant, l’obtention de statistiques de santé fiables devient une priorité au Liban. Le présent article analyse le processus de compilation et de diffusion des statistiques de santé nationales fournies par une multitude de partenaires publics, privés et non gouvernementaux dans le pays. Les enseignements tirés de la préparation de deux éditions du rapport sur les statistiques sanitaires nationales au Liban ont permis d’identifier certaines forces et faiblesses du système d’information sanitaire actuel dans le pays. L’expérience souligne la nécessité d’un partenariat étroit entre les parties prenantes, d’un système de gestion efficace, de ressources humaines adéquates ainsi que de systèmes et de procédures prédéfinis. La création d’un site Internet interactif pour l’échange de données et d’informations entre les parties prenantes et le public constituerait un avantage pour le processus. En outre, l’existence de recommandations claires, de définitions cohérentes et de formulaires normalisés faciliterait également le recueil et l’analyse des données. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 54 Introduction Statistics are essential in any process of evidence-based and informed policies and decisions (1). It is often mentioned that Lebanon lacks the accurate and rel- evant health statistics that are necessary for strategic decision-making. However, significant efforts to improve the health information system have been made by the Lebanese Ministry of Public Health (MoPH) over the past few years (2,3). These include periodic birth statistics reports, annual health bulletins on selected indicators as well as reports on services and vertical programmes delivered through the primary health care network supported by the MoPH. In addition, a geographical informa- tion system for health was introduced, but updated erratically, and several departments were computerized to al- low easier access to health data such as billing, drug dispensing and other data. Moreover, an effort to unify databases between different public funders, such as the National Social Security Fund and the MoPH, was also achieved to ensure transparency and accuracy of informa- tion (2,4). In an attempt to improve re- porting on communicable diseases and hospital-based mortality and morbidity, the Epidemiological Surveillance Unit at the MoPH has greatly expanded its sources of data by including hospitals, primary health care centres and public schools. However, compliance with reporting requirements is suboptimal. Health statistics in Lebanon are also generated from other sources. The Cen- tral Administration of Statistics which is mandated to produce national data and statistics including those related to health suffers from both a heavy bu- reaucracy and understaffing and under- funding, which limit its capacity to fulfil its mission. In addition, there is an abundance of small-scale health studies, generally limited to specific population groups and geographical areas. These studies are usually not reproducible, not representative and often incomplete, thus limiting the generalization of the results. Moreover, a significant number of indicators and variables are estimates or extrapolations. In general, health information from both the public and private sectors is fragmented and dif- ficult to access. In the health care field, valid and reliable information contributes to im- proving the quality of any intervention in the health sector, whether at the level of policy, planning, service delivery or impact assessment. Given the multitude of public, private and nongovernmental partners in health, the issue of obtaining reliable health statistics is becoming a priority for Lebanon, especially in view of the rapid health transition faced by the country and the highly dominant private health care sector. The deficiencies in the health in- formation systems, as described above, highlighted the importance of having an exhaustive national health statis- tics document that could be used as a reference by all concerned actors. This led to the publication of the first edition of the National health statistics report in Lebanon in 2004, which was subsequently updated and enriched in 2012. Each of these editions was a 3-year endeavour, published by the Institute of Health Management and Social Protection at the Saint-Joseph University of Beirut (IGSPS-USJ) in collaboration with the Italian Develop- ment Cooperation and the MoPH for the first edition (5) and the MoPH and the Lebanon country office of the World Health Organization (WHO) for the second edition (6). This article describes the experience of compiling and disseminating health information from multiple sources and draws on lessons learned through the challenges encountered and the op- portunities observed. It is too early to make a formal evaluation of the process, which should be done by evaluators external to the process, and so the main intent behind this article is to summa- rize and share the experience. Method for compiling health information data The first edition of the National health statistics report in Lebanon was a non- exhaustive compilation of existing health data. No similar project had been previously undertaken in the country. The objective was to provide a document that could on the one hand support decision-makers and planners and on the other hand offer the public reliable information and an overview of the Lebanese health sector. The report presented the available health data, the main health problems of the population and identified the public and private sources of health statistics in the coun- try. The ultimate goal of this first edition was to be a first step towards the devel- opment of a health information system. Two main reasons justified the pub- lishing of a second edition. First, there was the positive feedback received from several users of the first edition, men- tioning the importance and helpful- ness of such a report in their daily work. Second, was the interest shown by the MoPH and the WHO to produce an updated edition to enhance the quality and comprehensiveness of the previous report. The second edition of the report presented the range and types of data available as well as their evolution and trends over time. It was structured in such a way as to provide information on all the components of a health system. It described the health situation of the country in relation to the Millennium Development Goals and facilitated comparisons at both the national and international levels. Moreover, this edi- tion highlighted the existing gaps in the Lebanese health information system and emphasized the main issues to be developed. A team consisting of a physician, a health administration professional (pro- ject manager), a representative from the طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 55 MoPH and two management trainees was responsible for the first edition. The first step was the elaboration of a list of private and public institu- tions in the health sector. Contacts with various institutions, either by phone or through direct visits, were made by the IGSPS-USJ team, under the auspices of the MoPH. Health statistics pertaining to resources, services and results were requested as well as annual activity re- ports. Statistics were selected, taking into account mainly the relevance of the data, their nature, reliability, completeness and periodicity. The data were collected using a standard format that defined the origin, context, objectives, data col- lection method, periodicity of the data and field of interest. Tables were then developed and descriptive comments written. Information was collected from 22 private and public sources, including ministries, professional orders and syn- dicates, universities, nongovernmental organizations and international organi- zations. Before publication, two audits were done, one by the team, to check com- pliancy of the data in terms of content, analysis and relevance. In its final form, the document included 22 chapters covering the 22 sources of health data identified. For the second edition, the team responsible for the report included the same project manager, a biostatistician, two Master’s students in management, reviewers and a secretary. The develop- ment of the second edition began by building on the experience from the first report and analysing the recommenda- tions and suggestions received from the stakeholders and users of the first edition. A formal proposal with a new presentation scheme was elaborated and submitted to the IGSPS-USJ re- search committee and WHO Lebanon country office for funding. After updating the list of people and institutions to approach, data were col- lected from over 100 private and public sources, including ministries, universi- ties, nongovernmental organizations and international organizations, and from publications, including surveys, reports, statistical bulletins and utiliza- tion reports. Formal letters were sent to intro- duce the project and request access to data and information related to health. Follow-up was done through various means such as phone calls, emails and faxes. This phase was the longest and most time-consuming. The gathering of information was done simultane- ously for all data pertaining to one topic. A data retrieval form was developed and sent to key individuals within the chosen organizations. These forms were then collected, and data from differ- ent sources was compiled and unified whenever possible. Table 1 Methods and structure of the first and second edition of the National health statistics report in Lebanon First edition Second edition Methods • Developing a list of institutions/sources of health statistics • Establishing contacts with institutions/ sources • Collecting existing data on health • Selecting the data • Presentation of data by institution • Elaborating the tables • Writing the comments • Validation of final documents • Updating the list of institutions/sources of health statistics • Establishing contacts with institutions/ sources • Collecting existing data on health • Selecting the data • Standardization of data and definitions • Presentation of data by topics • Elaborating the tables • Writing the comments • Scientific and technical validation of final documents Number of chapters 22 5 Scope of chapters Compilation of information Compilation of data and integration of information Duration of data collection 2 years 2 years Duration of drafting/ editing 1 year 1 year Nature of chapters Descriptive Descriptive and analytical Team • Physician • Health administration professional • Ministry of Public Health representative • Two management trainees • Project manager • Biostatistician • Two data collection agents, reviewers • Secretary Data sources 22 private and governmental sources More than 100 private and governmental sources Funding Italian Development Cooperation Saint-Joseph University of Beirut World Health Organization EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 56 Primary data for each chapter were compiled in tables and graphs in order to facilitate understanding and utiliza- tion. Secondary data that seemed use- ful were added in the text. The main concern was to ensure the validity, reliability and compatibility of the data, while minimizing the risk of misinter- pretation. Graphs were used to identify possible trends over time. The editing consisted of describing each theme first within its general con- text and then more specifically within the Lebanese one. This was followed by an interpretation of all the tables and graphs. A technical and scientific review by WHO was obtained for all the tables and graphs, as well as the chapter content. Approval of the MoPH was also received for the overall document. The second edition document con- sisted of five main sections: • Chapter 1 focused on the description of the method used. • Chapter 2 presented Lebanon in terms of geographical location and sociodemographic structure and de- scribed the evolution of its health sys- tem, the Millennium Development Goals for Lebanon as well as the pub- lic health regulations for Lebanon. • Chapter 3, which was the core com- ponent of the document, focused on health population indicators, such as mortality, morbidity, risk behaviours, health status of different subgroups of the population and indicators of the health system dealing with infra- structure, human resources, national health programmes, funding and pharmaceuticals. • Chapter 4 discussed three determi- nants of health: poverty, employment and environment. • Chapter 5 gave a brief overview of the national and international partners working in the health sector. Table 1 compares and contrasts the two editions. Lessons learned These experiences have emphasized the strengths and weaknesses of the current Lebanese health statistics system. The national health statistics reports confirm that health statistics in Lebanon exist, that they are exhaus- tive for certain topics, that they are generated by researchers and com- petent authorities and that they are available through several sources. The findings based on both reports are summarized in the SWOT (strengths, weaknesses, opportunities and threats) analysis in Figure 1. A rapid assessment of the state of health statistics in Lebanon shows that even though health statistics exist at the national level they are still limited, incomplete, scattered and difficult to access. In fact, sometimes they are even contradictory and therefore hinder a comprehensive and in-depth view of the Lebanese health sector. Work in this sector, though abundant, is still difficult and riddled with red tape. Government organizations, nongov- ernmental organizations and private researchers are not always eager to share their data and benefit from each other’s experiences. Perhaps one of the hardest tasks in this compilation was obtaining the data itself and then finding it in a usable or compatible form. Very often, and especially with public institutions, the whole process had to be done several times, either because the person initially contacted was no longer in his/her position or STRENGTHS WEAKNESSES • Availability of data • Abundance of data in certain fields • Presence of qualified human resources • Limited national data • Incomplete data • Contradictory data • Scattered data • Absence of common denominators • Difficulty of access • Lack of dissemination OPPORTUNITIES THREATS • Awareness of the importance of health statistics • Existence of a will for improvement • High demand for quality data • Concern for transparency • Lack of funds • Turnover of human resources • Limited coordination and cooperation • Absence of a solid national information system Figure 1 SWOT (strengths, weaknesses, opportunities and threats) analysis of health data in Lebanon طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 57 because the administrative procedure was interrupted and had to be restarted from the beginning. In addition, most of the data were received in a raw for- mat and varied in their presentation, definitions and/or categories. It was very clear that there was no collabora- tion among data generators to unify definitions and baseline figures. In fact, for the most part, there was a lack of common denominators resulting in non-standardized definitions and operationalization of indicators. Con- sequently, a meticulous validation task was necessary in order to standardize the data and to allow for its exploita- tion and comparison. Moreover, it was noted that little effort had been put into the standardi- zation and computerization of health information generated by multiple sources. The Internet, although widely used for advertising and social media in Lebanon, has not been exploited to facilitate data retrieval and sharing of health information. As it is, the data obtained could not be manipulated to get more information than that for which it was intended. There was also a problem in terms of the timeliness of the data available. If health information is to be useful, it requires regular updat- ing, maintenance and tracking. Nevertheless, the relevant stake- holders appeared to be aware of the importance of statistics and the neces- sity of ensuring the transparency of the results. This was revealed through the growing demand for reliable and valid data in the Lebanese context characterized by limited and restricted funds as well as a poorly coordinated information system. Even though chal- lenging and time-consuming, this task was made easier by the following two factors which counter-balanced the difficulties encountered and ensured the success of the endeavour: the sup- port of the MoPH and of the WHO throughout the process, which was a guarantee of the credibility and qual- ity of the work; and the collaboration among MoPH, WHO and IGSPS-USJ, which greatly facilitated stakeholders’ compliance. In addition, the will of all the contributors to share the informa- tion greatly enriched the final product. Finally, the availability of funding made the compiling and publication of the report a reality. Both the reports have provided national benchmarks for the health of the population and have contributed to the dissemination of the available data. Moreover, they have also served to identify the existing gaps and areas to be strengthened. The reports highlight several tracks that could be exploited to develop a national health information system as well as potential obstacles that should be minimized to ensure success. The experiences with each report have emphasized the need for a close partnership with all stakeholders, an ef- ficient management system, adequate human resources and predefined systems and procedures. The process would benefit from having an interac- tive website with the dual purpose of exchanging data and information through an intranet system and of disseminating information to and receiving feedback from the public. The existence of clear guidelines with consistent definitions and standard- ized forms would also facilitate the collection and analysis of data. The following recommendations can be drawn from these experiences: • generation of data on a national level, especially in areas where information is scarce or unavailable, such as topics related to mental health, marginalized populations, risk factors and human resources; • creation of an official body to stand- ardize and validate data generated by different sources; • strengthening of the existing health statistics system as a basis for a future national health information system; and • development of adequate mecha- nisms to disseminate the information and render it accessible to all users and stakeholders. Conclusion The National health statistics report in Lebanon is an important step forward towards increasing multisectorial and multidisciplinary collaboration and coordination among the various parties involved in the health sector. It is also a means to ensure transpar- ency, greater reliability and sound decision-making. Such a publication demonstrates that, contrary to com- mon belief, relevant health statistics are available in Lebanon. However, merely compiling these statistics is no longer sufficient; it is time to utilize them within a broader health strategy. This can only occur if there is a formal involvement and a continuous input to process by all stakeholders in the health sector. Above all, there should be a commitment by all partners to sustain and improve this effort. While the dream of collecting in one volume the majority of health informa- tion available in Lebanon has now been realized, the process should not stop here. Our aim over the coming years is to enrich this tool with additional valuable and accurate health informa- tion and to offer a more holistic over- view of the health sector in Lebanon. In fact, the experience of publishing these two editions of health statistics should be considered in the short term as the basis for the institutionalization of the national health information system, which would also pave the road in the long term for a more ambitious project the establishment of a national health observatory whose role would be not only to collect information but also to undertake research within the complex health context of this country. Funding: None. Competing interests: None declared. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 58 References 1. Chan M, Kazatchkine M, Lob-Levyt J, Obaid T, Schweizer J, Sidibe M, et al. Meeting the demand for results and ac- countability: a call for action on health data from eight glob- al health agencies. PLoS Med. 2010 Jan 26;7(1):e1000223. PMID:20126260 2. Country cooperation strategy for WHO and Lebanon 2010– 2015. Cairo: World Health Organization, Regional Office for the Eastern Mediterranean; 2010 (EM/ARD/035/E/12.10) (http://applications.emro.who.int/docs/CCS_Leba- non_2010_EN_14483.pdf, accessed 27 November 2015). 3. Lebanon health profile. Country cooperation strategy at a glance [Internet]. Geneva: World Health Organization; 2010 (http://www.who.int/countryfocus/cooperation_strategy/ ccsbrief_lbn_en.pdf?ua=1, accessed 4 December 2015). 4. Ammar W. Health beyond politics. Cairo: World Health Or- ganization, Regional Office for the Eastern Mediterranean; 2009. 5. National health statistics report in Lebanon: 2004 edition. Beirut: Institute of Health Management and Social Protection at Saint-Joseph University; 2004 (http://www.igsps.usj.edu. lb/docs/recherche/recueil2004.pdf, accessed 27 November 2015). 6. National health statistics report in Lebanon: 2012 edition. Beirut: Institute of Health Management and Social Protection at Saint-Joseph University; 2012 (http://www.igsps.usj.edu. lb/docs/recherche/recueil12en.pdf, accessed 27 November 2015). طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 59 Introduction Multidrug-resistant tuberculosis (MDR) is an emerging problem in the world. It is a disease caused by strains of Mycobacterium tuberculosis that are resistant to at least isoniazid and rifampicin, the 2 most powerful first- line anti-tuberculosis drugs (1–3). The World Health Organization (WHO) in 2013 reported that an estimated 12 mil- lion people worldwide had tuberculosis, with about 630 000 (5.3%) of these people having MDR tuberculosis (1). MDR tuberculosis can affect people from all age groups. Children usually ac- quire primary drug-resistant tuberculo- sis from adults with MDR tuberculosis. However, because of the paucibacillary nature of childhood tuberculosis, a mi- crobiological diagnosis is made in only 20–40% of cases. Drug susceptibility testing is only possible following bac- teriological confirmation. Therefore, MDR tuberculosis in children is often undetected. Moreover, little is known about the clinical profile, treatment and prognosis of MDR tuberculosis in chil- dren (2,4–7). Here we report the clini- cal picture and treatment of an infant with disseminated MDR tuberculosis. Case report A 9-month-old girl was admitted to our department of paediatric infectious diseases in Samsun, Turkey with com- plaints of swelling on the right side of her neck and a draining lesion on her right forearm over the previous 2 months. Swelling on the left side of her neck in the previous month was also observed. The patient had not recovered despite previous antibiotic therapies. She also had poor appetite and failure to gain weight. When the patient’s history was further probed, the parents revealed that the child’s uncle had become ill during his military service and stayed at their home during his medical examination period. The uncle had been diagnosed with tuberculosis 5 months previously. There were no other cases of tuberculo- sis in the family. During physical examination, the child was in a generally good condition with a weight of 8.8 kg and height of 70 cm. Multiple firm lymphadenopathies (the largest 2 cm × 2 cm) in the right cervical region and a fluctuated, hyper- aemic lymph node (2 cm × 1.5 cm) in the left cervical region were observed. A draining lesion on her right forearm was also found. Pulmonary auscultation was normal. She had been vaccinated with bacillus Calmette–Guérin when she was 2 months old. Tuberculin skin test, which was done after she was admit- ted to our hospital, was positive, with an induration of 23 mm. HIV assay was negative. The left cervical node was drained and cultured. Direct mi- croscopy of the lymph node exudate showed acid-fast bacilli. Nucleic acid amplification polymerase chain reac- tion assays of the early morning gastric aspirate and lymph node exudate were positive for M. tuberculosis. Chest X- ray showed mediastinal lymphadenitis and consolidation on the right lung. Thorax computerized tomography re- vealed multiple lymph nodes located in the right paratracheal region, and consolidation on the middle lobe of the right lung. X-ray assay of the right arm showed an osteolytic lesion in the distal end of the right ulna, with soft tissue heterogeneity extending to the skin surrounding the bone (Figure 1). Cranial magnetic resonance imaging assay was performed to evaluate the disseminated tuberculosis. It showed multiple ring-enhancing lesions in the cerebral and cerebellar hemispheres. Moreover, cutaneous biopsy, which was performed on the right forearm, revealed granulomas with epithelioid histiocytes and Langerhans-type giant cells. On the 7th day of hospitalization, combined anti-tuberculosis therapy with isoniazid (10 mg/kg/day), ri- fampicin (15 mg/kg/day), pyrazina- mide (30 mg/kg/day) and ethambutol (20 mg/kg/day) was started, pending culture and drug susceptibility testing. Drug susceptibility testing of the uncle revealed MDR tuberculosis (isoniazid, rifampicin, ethambutol and streptomycin resistant). On the 20th day of admission, therefore, rifampicin and ethambutol treatments of the girl were stopped, and anti-tuberculosis treatment was readjusted to high doses of isoniazid (15 mg/kg once daily), pyrazinamide (30 mg/kg/day), Case report Multidrug-resistant disseminated tuberculosis in a 9-month-old infant G. Sensoy 1 A. Karli,1 A.Birinci,2 P.A. Uras,3 M.C. Bilgici 4 and F. Karagoz 5 1Department of Paediatric Infectious Diseases; 2Department of Medical Microbiology; 3Department of Paediatrics; 4Department of Radiology; 5Department of Pathology, Ondokuz Mayis University, Faculty of Medicine, Samsun, Turkey (Correspondence to A. Karli: drarzukarli@yahoo.com). Received: 26/04/15; accepted: 08/11/15 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 60 amikacin (15 mg/kg/day), levofloxacin (10 mg/kg twice daily), linezolid (10 mg/kg twice daily), cycloserine (15 mg/kg once daily) and clofazimine (5 mg/kg once daily) (8). M. tuberculosis was isolated from the early morning gastric aspirate samples and lymph node exudate on the 24th day of admission. The patient’s drug susceptibility testing revealed MDR tuberculosis, similar to her uncle’s test. In Turkey, tuberculosis is a notifi- able disease, so we declared the patient to the public health authorities in the city of Samsun. A charitable founda- tion (Dispensary of the War against Tuberculosis) provided the drugs for the patient. During hospitalization, the patient recovered and gained weight. The lesion on her right forearm began to heal, and she was discharged at the end of the 2nd month. After discharge, directly observed therapy could not be given to the patient, but the family was very coop- erative. The mother gave the drugs to the child regularly and the patient was followed up in our outpatient clinic at 1-month periods. Unfortunately, we could not monitor the serum levels of the drugs. Hearing tests were done regu- larly. At the end of the 3rd month of therapy, amikacin was given every other day and was stopped at the end of the 4th month. Linezolid therapy was also stopped in the 3rd month of therapy because of bone marrow sup- pression. Pyrazinamide was given for 9 months. The other drugs were given for 18 months. No drug side-effects were observed, except for red-brown skin coloration due to clofazimine. A follow-up cranial magnetic reso- nance image scan was conducted in the 3rd month of therapy, and revealed that the nodular lesions in the brain had disappeared. Moreover, osteomyelitis on the ulna recovered. At the end of the therapy, the patient was in excellent health, with a weight of 13 kg and a height of 86 cm. Discussion Young children usually contract tuber- culosis through the transmission of tu- berculous bacilli from a close contact in the family. In the absence of preventive therapy, infected infants younger than 12 months have up to 50% of lifetime risk of progression to disease follow- ing infection. Young children also have an increased risk of developing severe forms of the disease, such as miliary tuberculosis and tuberculosis meningi- tis (9,10). In our patient, an uncle was the source case, and we diagnosed dis- seminated tuberculosis in the patient, probably due to her immature immune system. The transmission of MDR ba- cilli from a close contact is one of the main causes of MDR tuberculosis in children. Seddon et al. reported that the most frequent sites of extrapulmonary tuberculosis in children with MDR tuberculosis were peripheral lymph node tuberculosis (42.1%), bone, joint or spinal tuberculosis (23.7%), and ab- dominal tuberculosis (21.1%) (4). They also found that HIV infection, malnutri- tion and extrapulmonary involvement were independent risk factors for death. Our patient also had lymph node, bone, cutaneous and central nervous system tuberculosis, aside from pulmonary tuberculosis. Fortunately, she recovered completely with the therapy, despite the extrapulmonary involvement. MDR tuberculosis therapy should contain at least 4, preferably 5, drugs to which the organism is susceptible. Treatment recommendations for children with MDR tuberculosis are based on clinical experience in adults, and second-line drugs are generally well-tolerated by children (7). We gave our patient a high dose of isoniazid and pyrazinamide (first-line agents), ami- kacin (injectable agent), levofloxacin (a floroquinolone), cycloserine (oral bacteriostatic second-line agent), and clofazimine and linezolid (agents with unclear efficacy), according to WHO recommendations (8). Her clinical condition was very good in the follow- up visits. We did not detect hearing loss due to amikacin therapy or side-effects due to levofloxacin therapy. However, we had to stop linezolid therapy be- cause of myelosuppression in the 3rd month of treatment. The other side- effect we observed was red-brown hyperpigmentation of the skin caused by clofazimine, but we could have com- pleted the therapy without any major complications. The patient recovered completely despite the disseminated disease. The optimal duration of treatment for children with MDR tuberculosis is uncertain. Therapy of at least 18 months is recommended for adults. This dura- tion may be too long for children with paucibacillary disease, but we gave an 18-month therapy considering the dis- seminated nature of the patient’s disease. There is a high prevalence of tu- berculosis in children who live with drug-resistant tuberculosis patients, regardless of the age of the child. There- fore, it is very important that all child Figure 1 Chest X-ray from a case of disseminated multidrug-resistant tuberculosis in a 9-month-old infant, demonstrating an osteolytic lesion in the distal end of the right ulna with soft tissue heterogeneity extending to the skin surrounding the bone طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 61 References 1. Global tuberculosis report 2013. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstre am/10665/91355/1/9789241564656_eng.pdf, accessed 16 November 2015). 2. Zignol M, Sismanidis C, Falzon D, Glaziou P, Dara M, Floyd K. Multidrug-resistant tuberculosis in children: evidence from global surveillance. Eur Respir J. 2013 Sep;42(3):701–7. PMID:23222872 3. Ettehad D, Schaaf HS, Seddon JA, Cooke GS, Ford N. Treat- ment outcomes for children with multidrug-resistant tubercu- losis: a systematic review and meta-analysis. Lancet Infect Dis. 2012 Jun;12(6):449–56. PMID:22373593 4. Seddon JA, Hesseling AC, Willemse M, Donald PR, Schaaf HS. Culture-confirmed multidrug-resistant tuberculosis in children: clinical features, treatment, and outcome. Clin Infect Dis. 2012 Jan 15;54(2):157–66. PMID:22052896 5. Schaaf HS, Garcia-Prats AJ, Hesseling AC, Seddon JA. Manag- ing multidrug-resistant tuberculosis in children: review of re- cent developments. Curr Opin Infect Dis. 2014 Jun;27(3):211–9. PMID:24751893 6. Jenkins HE, Tolman AW, Yuen CM, Parr JB, Keshavjee S, Pérez- Vélez CM, et al. Incidence of multidrug-resistant tuberculosis disease in children: systematic review and global estimates. Lancet. 2014 May 3;383(9928):1572–9. PMID:24671080 7. Feja K, McNelley E, Tran CS, Burzynski J, Saiman L. Manage- ment of pediatric multidrug-resistant tuberculosis and latent tuberculosis infections in New York City from 1995 to 2003. Pediatr Infect Dis J. 2008 Oct;27(10):907–12. PMID:18756183 8. Seddon JA, Hesseling AC, Marais BJ, McIlleron H, Peloquin CA, Donald PR, et al. Paediatric use of second-line anti-tuberculo- sis agents: a review. Tuberculosis (Edinb). 2012 Jan;92(1):9–17. PMID:22118883 9. Seddon JA, Hesseling AC, Godfrey-Faussett P, Fielding K, Schaaf HS. Risk factors for infection and disease in child con- tacts of multidrug-resistant tuberculosis: a cross-sectional study. BMC Infect Dis. 2013;13:392. PMID:23977834 10. Seddon JA, Hesseling AC, Finlayson H, Fielding K, Cox H, Hughes J, et al. Preventive therapy for child contacts of mul- tidrug-resistant tuberculosis: a prospective cohort study. Clin Infect Dis. 2013 Dec;57(12):1676–84. PMID:24065321 11. Amanullah F, Ashfaq M, Khowaja S, Parekh A, Salahuddin N, Lotia-Farrukh I, et al. High tuberculosis prevalence in children exposed at home to drug-resistant tuberculosis. Int J Tuberc Lung Dis. 2014 May;18(5):520–7. PMID:24903786 12. Becerra MC, Franke MF, Appleton SC, Joseph JK, Bayona J, Atwood SS, et al. Tuberculosis in children exposed at home to multidrug-resistant tuberculosis. Pediatr Infect Dis J. 2013 Feb;32(2):115–9. PMID:22926210 13. Turkova A, Welch SB, Paton JY, Riordan A, Williams B, Patel SV, et al. Management of paediatric tuberculosis in leading UK centres: unveiling consensus and discrepancies. Int J Tuberc Lung Dis. 2014 Sep;18(9):1047–56. PMID:25189551 14. Schaaf HS, Marais BJ. Management of multidrug-resistant tuberculosis in children: a survival guide for paediatricians. Paediatr Respir Rev. 2011 Mar;12(1):31–8. PMID:21172673 15. Seddon JA, Godfrey-Faussett P, Hesseling AC, Gie RP, Beyers N, Schaaf HS. Management of children exposed to multidrug- resistant Mycobacterium tuberculosis. Lancet Infect Dis. 2012 Jun;12(6):469–79. PMID:22373591 contacts of all drug-resistant patients are screened promptly for tubercu- losis (11,12). Preventive therapy for the contacts of MDR tuberculosis patients remains controversial, and no consensus has been reached on what regimen(s) should be used (13). However, it is generally agreed that preventive therapy is necessary for high-risk contacts, such as young children and immunocompromised individuals (14,15). This case serves as a reminder that child contacts of infectious MDR tuber- culosis source cases should be closely followed up for a minimum of 2 years, and appropriate treatment should be started as soon as tuberculosis is di- agnosed. Effective and safe preventive therapy regimens for drug-resistant tuberculosis are urgently needed. Funding: None. Competing interests: None declared. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 62 1Former Minister of Health, Tunisia, and Former Vice-President, International Bioethics Committee. 2Coordinator, Research, Development and Innovation, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. 3Technical Officer, Research Policy and Development, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. Invited commentary Ethics in health practice and research: an EMR perspective Mohamed Salah Ben Ammar,1 Ahmed Mandil 2 and Samar El-Feky 3 Background Ethics has been an integral part of medi- cine at least as far back as the time of Hippocrates. While the terms bioethics and medi- cal ethics are often used interchange- ably, traditionally medical ethics is mainly patient-oriented and focuses on health care services while bioeth- ics is predominantly society-oriented and centres on maximizing total human well-being. Medical ethics and law are closely related and regulations gener- ally exist in countries which govern how physicians should handle ethical issues in patient care and research (1). Con- versely, bioethics usually concerns ethi- cal questions related to health research and the application of biotechnology in medicine and biology (2). Research ethics as a particular area of concern evolved from the growing con- duct and formalization of research and the need to address ethical issues arising from such research on human subjects (3). The key ethical principles of health research include honesty, objectivity, integrity, carefulness, openness, respect for intellectual property, confidential- ity, responsible publication, responsible mentoring, respect for colleagues, so- cial responsibility, non-discrimination, competence, legality, animal care and human subjects’ protection (4). In this regard, the World Medial Association has developed internation- ally recognized global policies on key ethical issues related to medical practice and research, including the Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and the International Code of Medical Ethics and Human Rights. Other documents guiding ethical stand- ards have been developed by organiza- tions including WHO, the Council for International Organizations of Medical Sciences (CIOMS), UNESCO, the Committee on Publication Ethics, the International Committee of Medical Journal Editors, and the World As- sociation of Medical Editors. In fact, such ethical standards promote other important moral and social values such as social responsibility, human rights, patient welfare and safety, and compli- ance with the law (5,6). Regionally, the Eastern Mediter- ranean Health Journal (EMHJ), the flagship journal of the WHO Regional Office for the Eastern Mediterranean, has recently formulated ethical guide- lines for scientific research and pub- lication, based on these international guidelines, to ensure that articles sub- mitted for publication in the Journal conform to these standards (7). Developing bioethics in the EMR Ethics is an important aspect of the work of WHO and the Organization provides guidance and resources for Member States on a range of bioeth- ics issues, supports training on public health and research ethics, and hosts the secretariat of WHO’s Research Ethics Review Committee. In the WHO Eastern Mediterra- nean Region (EMR), in order to plan for the most doable and needed inter- ventions to scale up bioethics in coun- tries of the Region, the WHO Regional Office conducted a bioethics survey in 2015 to map the current situation in Member States and to identify areas of progress and improvement in bioethics for each country. The mapping survey aimed to analyse the situation in the Region in order to better assist Member States through prioritizing the needs and identifying the most appropriate approaches in view of the strengths and constraints identified. The results of the survey revealed a scarcity of structured curricula or train- ing programmes on bioethics in most health sciences’ colleges across the Re- gion (the Islamic Republic of Iran being among the few examples where it exists). Only a few countries in the Region offer formal training facilities for bioethics education. Furthermore, the laws, poli- cies and rules related to bioethics are not always well understood by health profes- sionals and the community. The results underscored the need to determine some key actions for fur- ther improvement of bioethics in the Region, including enhancing the role of civil society, as a key stakeholder, es- tablishing laws according to local needs and context, and developing/fostering a core bioethics curriculum within the health sciences’ curricula of academic institutions in the Region. The 2013 World Health Report, Research for universal health cover- age (8), emphasized the role of WHO in advancing research that addresses طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 63 the dominant health needs of Mem- ber States, supporting national health research systems, setting norms and standards for the proper conduct of research, and accelerating translation of research findings into health policy and practice. To ensure the scientific rigour and ethical conduct of health research recommended for WHO funding, an essential requirement of the research is its compliance with recognized ethical standards. There- fore, the Eastern Mediterranean Ethics Review Committee was established in 2007. It was reformulated in 2014 to include external (from Egypt, Islamic Republic of Iran, Lebanon, Morocco, Tunisia, UNESCO) and in-house (WHO) members and was renamed the “Eastern Mediterranean Research Ethics Review Committee”. Its primary function is to “review the protocols of all health research projects involving human subjects submitted to WHO for funding in the Region” in order to safeguard the dignity, integrity, human rights, safety and well-being of all the human participants. The Review Com- mittee can also has verify that ongoing studies comply with WHO policies and regulations for the conduct of health research in the Region. In view of the recent reformulation of the Committee, the Regional Office convened a meeting of the Committee in September 2015. The objectives were to: review the work of the Committee since October 2014 when its functions were updated; ensure compatibility of the work with international guidelines for review of health research on human subjects; update the current review pro- cess for health research supported by WHO; and address new health research challenges in the Region, including health policy and systems research (9). To enhance ethics in medical practice and health research in EMR, attention was given to ensuring compatibility of the Committee’s work with interna- tional guidelines for health research (in- cluding CIOMS, WHO and UNESCO guides). Additionally, the ethical review process was updated through critical review of current checklists for evaluat- ing submitted research proposals and sections on “conflict of interest” and “informed consent process for vulner- able groups”, (including minors, preg- nant women, emergencies, and mentally challenged persons) were added. Moreover, the Committee recom- mended: developing national laws and regulations which govern bioethics and related research; developing/ac- crediting national bioethics commit- tees which could oversee the work of institutional committees; establishing ethical review committees according to need (e.g. for research on human sub- jects, on animals); establishing national registries for clinical trials and research; regulating pharmaceutical companies’ contributions to clinical studies; and ensuring a rigorous ethical review pro- cess on different levels (institutional, national, regional). For its part, the Regional Office aims to use the expertise of global WHO col- laborating centres for bioethics-related matters, establish a regional WHO col- laborating centre network on bioethics, and support capacity-building activi- ties in bioethics and ethical conduct of health research. Furthermore, WHO is encouraging research on public health priorities in the Region, especially on crises and emergencies, in order to gen- erate much-needed, ethically sound, health-related data and evidence to sup- port health policy-making. The effort to develop bioethics has been undertaken to serve all, within and beyond the Region, in particular to ensure that the voice of the voiceless is heard and taken into account globally. References 1. Medical ethics manual, 3rd edition. World Medical Asso- ciation; 2015 [Online]. (http://www.wma.net/en/30publicati ons/30ethicsmanual/pdf/ethics_manual_en.pdf, accessed 12 February 2016) 2. Teaching bioethics. Report from a seminar organized by the Nordic Committee on Bioethics. Copenhagen: Nordic Council of Ministers; 2002 (http://ncbio.org/nordisk/arkiv/2002-2. pdf, accessed 12 February 2016). 3. European Commission. European textbook on ethics in re- search. Luxembourg: Publications Office of the European Union; 2010 (https://ec.europa.eu/research/science-society/ document_library/pdf_06/textbook-on-ethics-report_en.pdf, accessed 12 February 2016). 4. Resnik D. What is ethics in research & why is it Important? [Online]. National Institute of Environmental Health Scienc- es; 2013 (http://courses.washington.edu/bethics/Home- page/What%20is%20Ethics%20in%20Research%20%26%20 Why%20is%20it%20Important_.pdf, accessed 12 February 2016). 5. Elsayed D, Ahmed R. Medical ethics: What is it? Why is it im- portant? Sudanese Journal of Public Health. 2009; 4(2) (http:// www.sjph.net.sd/files/vol4i2/SJPH-vol4i2-p284-287.pdf, ac- cessed 12 February 2016) 6. The ethics of research related to healthcare in developing countries. London: Nuffield Council on Bioethics; 2014 (http:// nuffieldbioethics.org/wp-content/uploads/2014/07/Ethics- of-research-related-to-healthcare-in-developing-countries-I. pdf, accessed 12 February 2016). 7. EMHJ Guideline on Ethical Conduct and Publication of Health Research; 2016 [Online] (http://www.emro.who.int/emh- journal/authors/emhj-guidelines-on-ethical-conduct-and- publication-of-health-research.html, accessed 12 February 2016). 8. World health report: research for universal health coverage. Geneva: World Health Organization; 2013 (http://apps.who. int/iris/bitstream/10665/85761/2/9789240690837_eng.pdf, accessed 12 February 2016). 9. Research ethics in the Eastern Mediterranean Region. Eastern Mediterranean Health Journal. 2015; 21(9):702- 3 (http://applications.emro.who.int/emhj/v21/09/ EMHJ_2015_21_9_702_703.pdf?ua=1, accessed 12 February 2016). EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 64 WHO events addressing public health priorities Background The World Health Organization (WHO) is mandated by its constitution1 (1) to support and promote health research The World Health Report: research for universal health coverage (2013) (2) emphasized WHO’s role in advancing research that addresses the dominant health needs of its Member States, supporting national health re- search systems, setting norms and standards for the proper conduct of research and accelerating translation of research findings into health policy and practice in order to acceler- ate progress towards universal health coverage (UHC). In addition, in the WHO Regional Office for the Eastern Mediterranean (WHO/EMRO), the strategic document, Shaping the future of health in the WHO Eastern Mediterranean Region: reinforcing the role of WHO (2012) (3), outlined the following five strategic health priorities for the Region: health system strengthen- ing; emergency preparedness and response; maternal, reproductive and child health and nutrition; noncom- municable diseases, in addition to the unfinished agenda of communicable diseases. A key element within all the priority areas is building national capacities in research for health (4). To help realize WHO’s role in health research and tar- get the Eastern Mediterranean Region’s priorities, under the department of Information, Evidence & Research, the WHO/EMRO has the Research, Development & Inno- vation group and a Research Policy & Development unit, which (among other functions) serves as the Secretariat 1 The Constitution was adopted by the International Health Conference held in New York from 19 June to 22 July 1946, signed on 22 July 1946 by the representatives of 61 States (Off. Rec. Wld Hlth Org., 100 ,2), and entered into force on 7 April 1948. Amendments adopted by the Twenty-sixth, Twenty- ninth, Thirty-ninth and Fifty-first World Health Assemblies (resolutions WHA26.37, WHA29.38, WHA39.6 and WHA51.23) came into force on 3 February 20 ,1977 January 11 ,1984 July 1994 and 15 September 2005 respectively. of the Eastern Mediterranean Research Ethics Review Committee. Moreover, the unit coordinates three types of health research grants, namely Research in Priority Areas of Public Health grants which addresses the five strategic health priorities of the Region; the Improved Programme Implementation through Embedded Research grants offered in collaboration with the Alliance for Health Policy & Systems Research (WHO/HQ), and the Tropi- cal Disease Research – Small Grants Scheme, offered in collaboration with the WHO/UNDP/World Bank Special Programme for Research and Training in Tropi- cal Diseases (WHO/HQ). In this respect, it is worth referring to the current cooperation of WHO/EMRO with different stakeholders, including UN agencies such as UNESCO’s Regional Office in Cairo, in the field of bioethics applications with special emphasis on ethical conduct of health research. A recent WHO/EMRO survey for situation analysis of bioethics in the Region (Bioethics in the EMR: a situa- tion analysis, unpublished report, 2015) showed that most Member States have either national bioethics committees or institutional review boards, which safeguard ethical conduct of health research and protect the dignity, human rights, and well-being of its human participants. However, they still need technical support to develop the capacities needed to maintain such bodies. In addition, a recent review of research published in our flagship Journal, the Eastern Mediterranean Health Journal (EMHJ), for the period 1995–2014 (5), showed almost equal distribution of health research published on all the regional strategic health priorities, except emergency preparedness and response. With the Region suffering from crises/emer- gencies in more than half of its Member States, this is an area which urgently needs evidence generated from sound health research. Eastern Mediterranean Research Ethics Review Committee In order to ensure scientific rigour and ethical conduct of health research recommended for funding under Committee members: Gamal Aboul-Serour (co-chair, Egypt), Jamela Al-Raiby (WHO/EMRO), Thalia Arawi (Lebanon), Hoda Atta (WHO/ EMRO), Mohamed Ben Ammar (Tunisia), Nouzha Guessous (Morocco), Orio Ikebe (UNESCO), Bagher Larijani (co-chair, Islamic Republic of Iran), Ahmed Mandil (secretariat, WHO/EMRO), Awad Mataria (WHO/EMRO), Arash Rashidian (WHO/EMRO), Slim Slama (WHO/EMRO). Work of the research ethics review committee in the Eastern Mediterranean Region طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو نياثلا دلجلما لولأا ددعلا 65 the above-mentioned grants, the Regional Director re- formulated the Eastern Mediterranean Research Ethics Review Committee to include external (from Egypt, Islamic Republic of Iran, Lebanon, Morocco, Tunisia, UNESCO) as well as in-house members with an essential function to “review the protocols of all health research projects involving human subjects submitted to WHO for funding in the Region”. Such review aims to protect the dignity, integrity, human rights, safety and well-being of all the people participating in such research. The Com- mittee also has the authority to verify that ongoing studies comply with the Organization’s policies and regulations for conduct of health research in the Region. During the review process of the health research proto- cols, the Committee is expected to ensure compliance with the International Ethical Guidelines for Biomedical Research Involving Human Subjects (6), as well as other international guidelines which govern ethical conduct of health research (7–10), including equitable selection of subjects, appropri- ate safeguards to protect the rights and welfare of research participants, especially vulnerable groups, full informed consent process and protection/maintenance of privacy of individuals and confidentiality of the data collected. Meth- odologically, the review should ensure that the health re- search topic will add to scientific knowledge and is relevant to institutional and community interests, and that the research design is appropriate and study instruments are acceptable. For interventional studies, the review has to safeguard that clinical research facilities at the study site are appropriate, that all researchers involved have appropriate qualifications, train- ing and experience, and that potential benefits to be gained from the research outweigh any expected risks. Moreover, operational health research must provide evidence which supports sound health policy and decision-making in the Region (knowledge translation). First meeting of the re-formed Committee In light if the re-formulation of the Eastern Mediterranean Research Ethics Review Committee the Regional Office recently convened a meeting of the Committee during the period 6–7 September, 2015. The objectives of the meeting were to: review the Committee’s work in light its updated functions; ensure compatibility of the Com- mittee’s work with international guidelines for review of health research on human subjects; update the current review process for health research supported by WHO; and address new health research challenges in the East- ern Mediterranean Region, including health policy and systems research. Following the 2-day deliberations, the meeting provided a set of recommendations for ensuring compatibility of the Committee’s work with international guidelines for health research (7–10), updating the ethical review process (with special focus on its checklists) and providing special advice for current challenges in health policy and systems research. Recommendations The Committee ma de the following recommendations: encourage/soli cit research on public health priorities in the Region, especially on crises and emergencies; develop/ enforce national laws and regulations which govern bioeth- ics and related research; emphasize vigilance by editors of scientific journals to avoid fraud and falsification of health research subm itted for consideration for publication; develop/support/accredit national bioethics committees which could oversee the work of institutional committees, including ins titutional review boards; establish different ethical revie w committees according to need (e.g. for research on h uman subjects; on animals, etc.); promote rigorous ethical review process on different levels (institu- tional/nation al/regional); use the expertise of the global WHO-Collabora ting Centres on bioethics and regional technical col laborating centres; establish a regional col- laborating centre on bioethics; support capacity-building activities in bioethics/ethical conduct of health research; supporting in stitutional clearance (in the absence of na- tional cleara nce); establish national registries for clinical trials and re search; regulate pharmaceutical companies/ clinical studies. The Committee also advised that proposals on health policy and systems research should be reviewed using an expeditious process/applicable questions in checklists. In addition, i t recommended that some members of review committees (especially at a national/institutional level) should have training in health policy and systems research and that different stakeholders should be involved with the review process (as applicable). The Committee carefully reviewed the currently used checklists for review of submitted research proposals rec- ommended for WHO funding. It recommended modifi- cation/addition of some questions and added a section on conflict of interest as well as special sections for “informed consent process for vulnerable groups”, including minors, pregnant women, emergencies, and mentally challenged people. These are to be drafted in the near future. In the closing session, the Regional Director strongly supported the role and functions of the Committee in eval- uating the ethical conduct of WHO-funded health research carried out in the Region and emphasized the importance of collaboration with UN organizations working in the field of bioethics, especially UNESCO (with special focus on supporting national bioethics committees and inclusion of bioethics in curricula of health sciences’ colleges). EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 66 References 1. Constitution of The World Health Organization, Basic Doc- uments, Forty-fifth edition, Supplement. Geneva: World Health Organization; 2006. 2. World Health Report: research for universal health cover- age. Geneva: World Health Organization; 2013. 3. Shaping the future of health in the WHO Eastern Mediter- ranean Region: reinforcing the role of WHO. Cairo: World Health Organization Regional Office for the Eastern Medi- terranean; 2012. 4. Technical paper: Strategic directions for scaling up research for health in the Eastern Mediterranean Region. Fifty-eighth Session Regional Committee for the Eastern Mediterra- nean. Cairo: World Health Organization, 2011Eastern Medi- terranean Health Journal: 1995-2014 Review. Presentation at the Expanded EMHJ Board Meeting, WHO Regional Office for the Eastern Mediterranean, Cairo, 6–7 June, 2015. 5. International ethical guidelines for biomedical research in- volving human subjects. Geneva: Council for International Organizations of Medical Sciences (CIOMS); 1992. 6. International ethical guidelines for epidemiological studies. Geneva: Council for International Organizations of Medical Sciences (CIOMS); 2009. 7. Standards and operational guidance for ethical review of health-related research with human participants. Geneva: World Health Organization; 2011. 8. Universal declaration on bioethics and human rights. Paris: UNESCO; 2005. 9. Bioethics committees at work: procedures and policies (Guide 2). Paris: UNESCO; 2005. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو نياثلا دلجلما لولأا ددعلا 67 From MDGs to SDGs September 2015 was the target date set for achieve- ment of the Millennium Development Goals (MDGs) and the United Nations (UN) has been working on a post-2015 development agenda. The process of shaping the agenda of the Sustainable Development Goals (SDGs) that are replacing the MDGs has been led by Member States with the involvement of a broad par- ticipation of groups and civil society organizations. Since 2014, a number of civil society organizations worldwide have been closely involved through consultations and publications of position papers on governance, health, gender, equity and children, among other issues. There are 17 SDGs and 169 targets that build on the work done on the MDGs. Goal 3 (“Ensure healthy lives and promote well-being for all at all ages”) addresses health specifically, and covers four of the main regional health priorities: universal health coverage, maternal and child health, communicable diseases (HIV/AIDS, malaria, tuberculosis) and noncommunicable diseases prevention and control. The other goals refer to the social determinants of health. The SDG agenda poses several challenges and govern- ments will be unable to make progress alone. Other stake- holders, including civil society, will have an important role to play. The SDGs contain cross-cutting issues beyond health, providing an opportunity for cross-sectoral col- laboration and the development of multisectoral partner- ships with key stakeholders. Mainstreaming health in the SDGs will require the involvement of civil society organizations to ensure that upstream determinants of ill-health are not ignored. The MDGs created opportunities for the involve- ment and engagement of civil society organizations to ensure that community priority needs were considered in health and political agendas. It is important that the SDGs build on the work of civil society organizations and make use of existing platforms and networks. Since civil society participated in the development of SDGs at a global level, it is important that civil society organiza- tions play an active role in implementation at country level. In this context, the League of Arab States has been holding a series of consultations in preparation for the launch of the “Arab decade for civil society organiza- tions 2015–2025”. The Decade provides a platform for strengthening and mobilizing civil society organizations in the Arab region to become effective partners in achiev- ing the SDGs. WHO is cooperating with this initiative by helping to identify the specific role that civil society organizations can play in achieving SDG 3 (the health goal). As part of this, and in an effort to strengthen the en- gagement of civil society organizations in the Eastern Mediterranean Region in advancing the health and SDG agenda, the League of Arab States and the WHO Regional Office for the Eastern Mediterranean held a joint regional consultation on 23 and 24 August in Cairo, Egypt, bring- ing together representatives of the main civil society organizations in the Region dealing with health and its determinants. The main objectives of the consultation were to: • understand the current domain of activities of civil society organizations and the available capacities; • identify gaps and challenges in the current civil society organization work in the Region; • discuss how to overcome these challenges; and • deliberate on the main role of civil society organizations in the SDGs and in addressing the five regional health priorities. The consultation was attended by 20 representatives of civil society organizations from Egypt, Jordan, Kuwait, Morocco, Oman, Palestine, Saudi Arabia and Tunisia, in addition to regional civil groups and networks, including the Arab Scout Regional Office. The role of civil society organizations Civil society organizations have a key role to play in progress on the health-related SDG agenda, including in health literacy, advocacy, social mobilization and service provision, especially in countries in crisis and emergency situations. In the Region, civil society organizations vary in number according to country, but are increasing in Health and the sustainable development agenda: enhancing the role of civil society organizations This report is an abridged version of the report on the the Joint WHO and League of Arab States regional consultation to enhance the role of civil society organizations in the health and sustainable development agenda in the Eastern Mediterranean Region held in Cairo in Cairo on 23–24 August 2015. The complete report is available at: http://applications.emro.who.int/docs/IC_Meet_Rep_2015_EN_16665. pdf?ua=1 EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 68 number and influence. They play a crucial role in address- ing population health problems, providing institutional vehicles to address community needs and expectations, and complementing government action in implementing programmes not considered to be a priority or targeting marginalized population groups. Civil society organiza- tions also provide frontline services in countries with acute crises where governments are weakened or partially- absent (several countries in the Region). They facilitate community interaction with services such as those for hygiene, water and sanitation, support access to vaccines and promote health through information dissemination, such as in Ebola virus disease outbreaks and natural disasters, and for smoking prevention and promotion of healthy diet and physical activity. They also influence policy development, for instance through the Framework Convention on Tobacco Control and in HIV/AIDS, and contribute in resource mobilization, including for polio eradication and girls’ education. Impediments and challenges The role of civil society organizations and the importance of partnership with civil society are not well recognized by governments in the Region. There is a lack of legal frameworks for the establishment of civil societies and networks. As a consequence, inadequate trust exists be- tween governments and civil society, and coordination is difficult. Moreover, little use is made by government of the results of the research conducted by civil society organizations. Additionally, there is a weak culture of volunteering in the Region and poor understanding of its importance in development. Furthermore, cultural and social norms exist that prevent specific groups from participating in civil society. Specific challenges related to civil society organiza- tions include weak strategic planning, inadequate staff capacity, and weak governance and management, with often limited transparency in funding. There is an absence of tools to support inclusion of all members to ensure democratic processes and weak team work towards common goals. Working conditions do not attract high calibre and skilful staff, and there is a lack of plans for capacity-building of staff. The focus of work is often on activities rather than programmes and is frequently donor- rather than need-driven. There is weak utilization of information technology for database building and weak self-assessment at the institutional and performance levels, with no or limited tools being used. In general, there is a lack of mechanisms for collaboration between civil society organizations. Next steps The consultation concluded by offering recommendations for the League of Arab States and WHO and highlighting the next steps needed to move forward on enhancing the role of civil society organizations in the health and sustain- able development agenda (Box 1). To the League of Arab States 1. Finalize the criteria governing the relationship between civil society organizations and organs of the League of Arab States with a view to fostering close cooperation between civil society and the League. 2. Organize regular forums, workshops and training courses for civil society organizations in Arab states to raise awareness of the SDGs and promote civil society partici- pation in them. To WHO 1. Support the development of criteria for assessment of civil society organizations, particularly for those that are health-related. 2. Establish a network of civil society organizations working in the field of health in the region. 3. Map health-related civil society organizations and create an online database. 4. Raise the awareness of health-related civil society organi- zations on the SDGs and develop discussion on them through regular forums to address problems. 5. Support capacity-building of civil society organizations through organizing training-of-trainers courses to ensure sustainability. 6. Build capacities in health priorities, proposal writing, project planning and implementation, and promotional campaigns. 7. Support the establishment of liaison offices at ministries of health to act as an interface with civil society organiza- tions. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو نياثلا دلجلما لولأا ددعلا 69 Box 1 Next steps 1. Disseminate recommendations to all countries to inform them about the SDGs and the necessity to en- gage civil society organizations. 2. Establish a regional civil society organization database (by December 2015). WHO should seek names of civil society organizations from consultation participants and the Gulf Cooperation council, and partici- pants should review the list. 3. Develop an information sheet on civil society organizations (by 1 October 2015). 4. Make the database available online (by December 2015). 5. Conduct training on needs assessment through a rapid survey. 6. Develop training programmes, for instance on health-related topics, including the regional health priorities and the SDGs (by January 2016), and on management, strategic planning, advocacy, fund raising, pro- posal writing, monitoring and evaluation, and reporting (by September 2016). 7. Develop a standard training curriculum in the Arabic language. 8. Establish a regional roster of experts via email (by November 2015). 9. Develop a capacity self-assessment checklist for civil society organizations. 10. Conduct advocacy for involvement of civil society organizations in the SDGs through a regional forum. 11. Develop infographics on the SDGs for decision-makers. 12. Request ministries of health to establish a liaison office as an interface with other EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 70 The need for strengthening the role of public health associations The Eastern Mediterranean Region faces myriad public health challenges. It hosts the highest burden of refugees, mi- grant workers and displaced populations and political unrest and conflict are ongoing in several countries. Demographic and epidemiological shifts have resulted in an increased incidence of noncommunicable diseases in many countries, while communicable diseases remain as serious problems in others. This is all in addition to emerging health threats such as novel coronavirus, Ebola virus and antimicrobial drug resistance. In this regard, the WHO Regional Office for the Eastern Mediterranean has identified five main priorities for the work of WHO in the Region during 2012–2016: • strengthening health systems and the pursuit of universal health coverage; • intensifying action to prevent communicable diseases, in- cluding poliomyelitis eradication; • scaling up actions to promote health, including maternal and child health; • preventing and controlling noncommunicable diseases; • providing special support to countries experiencing hu- manitarian crises. Putting the priorities into context, WHO has been constantly updating its way of work to support member countries. However, WHO cannot deliver alone: its influ- ence will remain incomplete without the engagement, cooperation and political will of the countries themselves. While WHO’s principal partner is the Ministry of Health, responding to the ongoing challenges means that both WHO and the countries need to change their procedures. In this regard, WHO intends to extend partnership also to academic institutions and public health institutes and asso- ciations in order to address the regional priorities effectively and sustainably. To facilitate this, the WHO Regional Office for the East- ern Mediterranean organized a regional meeting of national public health associations and institutions in Cairo on 29–30 June 2015. Participants included representatives from public health associations and institutes from 18 countries in the Region. The meeting aimed to discuss ways of promoting public health in the Region through exchange of global and regional experiences and challenges, ways to strengthen network- ing and collaboration with associations and institutes, why public health associations and institutes have been unable to influence public health response in the Region so far. The objectives were to identify the barriers to the functionality of public health associations and institutes, develop recommen- dations to strengthen their roles in the national public health response in the Region, and explore options for support from WHO. Barriers to the effective contribution of public health associations There is a lack of clearly defined, standardized roles for public health associations and existing local partnerships are fragile. This absence impedes collaboration and prevents academic institutes and other bodies effectively contributing in public health response. The discussions focused on three topics important for the Region: • the priority actions to promote public health, • how national public health associations can be strength- ened, • what needs to be done for networking among public health associations and institutions. There was strong consensus that the regional role of national and local public health institutes and associations has been limited and not well defined till now. Possible underlying causes of weak performance include the multi- disciplinary nature of public health, which necessitates the engagement of non-health stakeholders; this is currently absent in the public health response. Related to this is the gap between the public health, clinical and non-health sectors, i.e. the lack of involvement of public health profes- sionals. In addition, public health education is limited in the curricula of primary and secondary schools. There is also a shortage of multidisciplinary undergraduate and postgraduate public health courses to train health and non-health professionals on taking action in unstable political and emergency settings. Uneven political com- mitment and lack of “know-how”; overdependence on a single institution (mainly the Ministry of Health) that Strengthening the role of public health associations in the Region This report is an abridged version of the report on the Meeting of the National Public Health Associations and Institutions in the Eastern Mediterranean Region held in Cairo in Cairo on 29–30 June 2015. The complete report is available at: http://applications.emro.who.int/docs/ IC_Meet_Rep_2015_EN_16666.pdf?ua=1 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو نياثلا دلجلما لولأا ددعلا 71 is not equipped to deliver all tasks and initiatives and to coordinate with other sectors; and limited public health human and financial resources also impede the inclusion and effective functioning of public health institutes and as- sociations Supporting measures Among the steps identified towards strengthening public health in the Region were: • standardizing and harmonizing public health education across the Region, taking into account regional diversity and priorities; • strengthening intersectoral partnership and collaboration between public institutes and associations with clearly iden- tified roles, mandates and responsibilities; • bringing priority stakeholders from outside the health sec- tor into discussions (e.g. ministries of interior, finance and social affairs); • promoting a sense of ownership of health in the general population “public health is for the public”; • integrating public health leadership into formal public health education and capacity-building efforts; • integrating regional essential public health functions into public health education, including leadership, research and monitoring and evaluation of the national public health response process; • strengthening multidisciplinary public health capacities to deliver both regional and national priorities. Actions needed For WHO • Engage national public health associations and institu- tions in the work of WHO through relevant meetings and workshops, and improve regular communication and dissemination of guidelines, approaches and actions developed. • Review and strengthen public health curricula. • Dedicate more scholarships to public health. Map public health associations and institutions and apply essential pub- lic health functions. • Establish a regional and international roster and network of public health experts, associations and institutions. EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 72 EMHJ Guidelines on Ethical Conduct and Publication of Health Research Published on the following pages are the EMHJ Guidelines on Ethical Conduct and Publication of Health Research. They are also available on the EMHJ webpage. These Guidelines set out key issues related to research and publication ethics and EMHJ’s expectations of papers submitted for possible publication. They are intended as a reference for both authors and reviewers. Background to the development of the Guidelines Adherence to ethical standards for the conduct and reporting of research is not only a moral imperative but it also results in better and more meaningful research. As with all research journals, EMHJ has encountered cases of suspected infringement of ethical research conduct and publication, including lack of ethical clearance and/or informed consent of participants when needed and instances of plagiarism and duplicate publication. Our experience in addressing such incidents suggested that in some cases the au- thors were genuinely unaware of or unfamiliar with key ethical aspects of research conduct and publication, for example what constitutes plagiarism, why duplicate publication is unacceptable. While we provide brief information in the EMHJ authors’ guidelines and links to relevant sites and publications, we have had no explicit or detailed guidelines on research and publication ethics and EMHJ’s position on these issues and response to cases of suspected ethical misconduct. It was considered that such guidelines were needed to make EMHJ’s position known and transparent and to provide authors with clear and easily accessible information on the important ethical issues to help ensure that their papers were ethically compliant. Therefore review and endorsement of draft guidelines on ethical conduct and publication of health research was included in the agenda of the Expanded EMHJ Editorial Meeting in June 2015. In preparation for the meeting, and based on key resources and documents from leading institutions and associations for research and publication ethics, guidelines were drafted and revised inhouse in April and May 2015. These were shared with the Editorial Board members and other invited participants of the Expanded Board meeting before the meeting and their comments invited. All participants provided their observations and these were compiled for review at the meeting. In follow-up and in line with the discussions and observations made at the meeting, the guidelines were further revised and finalized. EMHJ would like to thank all the Board Members and participants of the Expanded EMHJ Editorial Meeting for their valuable contribution to the preparation of these Guidelines. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 73 EMHJ Guidelines on Ethical Conduct and Publication of Health Research EMHJ endeavours to maintain the highest ethical standards for the articles it publishes. In order to do so, the Journal follows established international standards and guidelines on the conduct and publication of health research including: World Medical Association’s Declaration of Helsinki; the Council for International Organizations of Medical Sciences (CIOMS); the Committee on Publication Ethics (COPE); the International Committee of Medical Journal Editors (ICMJE); and the World Association of Medical Editors (WAME). These guidelines explain the EMHJ’s position on specific ethical aspects of the conduct and reporting of research. They provide authors with guidance on the ethical standards they are expected to conform to in their papers submitted for consideration for publication, and outline EMHJ’s procedures if standards are breached. Authors’ responsibilities Papers submitted for consideration for publication to the EMHJ should comply with the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly work in Medical Journals of the ICMJE. Ethical approval EMHJ expects authors to adhere to the Ethical Principles for Medical Research Involving Human Subjects laid down in the World Medical Association’s Declaration of Helsinki and CIOMS. For research involving humans, every research article sub- mitted to EMHJ must include a declaration that before carrying out its field work, the study had obtained ethical clearance from a recognized body in the country, for example from institutional review boards or research ethics committees. Ethical clearance from non-national bodies might be acceptable if there is a valid justification (e.g. lack of any national or local ethics committee). EMHJ may require to see the relevant documentation of ethical approval. Research involving animals will also be expected to follow the related standards of ethical research. If ethical clearance was not considered to be required, a statement to that effect must be provided indicating the reasons it was not required. In any case, the authors are expected to follow all requirements of ethical conduct of research, reporting of the findings and preparation of the manuscript. Informed consent EMHJ requires, where appropriate, a statement from the authors that all persons who participated in research had given their voluntary, informed written consent. Verbal consent might be acceptable, however, if there is a reasonable justification or where sanctioned by the body providing the ethical approval. Where participants were unable to give such consent, surrogate consent might be acceptable (e.g. from a parent), however surrogate consent always requires ethical approval. Authors may be asked to provide copies of detailed informed consent form, including explanatory information provided to participants. Participant confidentiality and respect Manuscripts should be prepared to preserve participants’ confidentiality. Authors are expected to obtain an individual’s explicit consent for the use of any personal or medical information that may make the participant identifiable. Authors are expected to ensure the dignity and respect of the participants and their communities in the manuscript. Competing interests EMHJ requires authors to provide details of any competing interests. A competing interest may occur when the author(s) personal, family or institutional interests (e.g. sources of funds, earnings, relationships, etc.) might be affected by the research, its findings or publication of the manuscript. EMHJ will not reject a paper solely on the basis of a declared competing interest but will take this into consideration when assessing a paper and, if considered relevant, it may be included in the published paper. Funding EMHJ requires authors to state all sources of funding for the study. Clinical trials registration EMHJ requires registration of clinical trials in a public trials registry before undertaking the trial as a condition of consideration for publication (more information can be obtained by visiting the web link: http://www.who.int/ictrp/trial_reg/en/). EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 74 Authorship EMHJ follows the ICMJE Recommendations on authorship credits, which aim to ensure that all and only those who have made material contribution to the research are named as authors. These require that all four of the following criteria be met to be considered an author: • substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND • drafting the work or revising it critically for important intellectual content; AND • final approval of the version to be published; AND • agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Every person who meets all four criteria should be identified as an author. Those who meet some but not all of these criteria should be included in an acknowledgement. It should be noted that data collection, laboratory testing, data management, acquisition of funds, provision of support for the study, etc. do not qualify (on their own) for being included in the list of authorship. Previous publication EMHJ expects papers submitted to be original and not published, accepted for publication or currently under consideration for publication elsewhere. EMHJ requires authors to affirm this and disclose any papers that overlap with the submitted paper. This applies to paper(s) published in other languages, although translation may occasionally be considered with the agreement of the other journal. Oral presentation of study findings at a conference or publication of an abstract only in conference proceed- ings does not normally prohibit submission of the full paper to the EMHJ. Such abstracts should not exceed 500 words. Scientific misconduct EMHJ takes any allegation or evidence of scientific misconduct seriously. Examples of scientific misconduct include: Violation of ethical research standards: failing to adhere to standards for research involving humans and animals. Fabrication and falsification of data and abuse of accepted research practices: making up data, deliberately suppressing and/or altering data, and manipulating experiments/analysis to obtain desired results. Plagiarism: using the published language, ideas of others without appropriate acknowledgment of their source and representing them as one’s own. When referring to the published ideas/opinions of others full referencing is expected. Brief quoted state- ments could be acceptable, if good justification is provided and they are placed within inverted commas. Duplicate publication: this refers to publication of a paper by at least some of the same authors that overlaps substantially with another one already published, without clear reference to the previous publication. Duplicate publication is considered unethi- cal in particular for original research because it can lead to double-counting of data and inappropriate weighting of the results of a single study. Improprieties of authorship: this refers to improperly assigning authorship credit either by inclusion (“guest” authorship) or exclusion (“ghost” authorship). Any misconduct in the conduct of research, and preparation or submission of the manuscript is considered unacceptable for publication in the EMHJ. EMHJ’s response to possible scientific misconduct EMHJ takes seriously any suspected misconduct in research, publication or professional behaviour. EMHJ will investigate, in confidence, any cause of concern on a case-by-case basis and seek resolution. EMHJ will follow the guidelines and recommendations of recognized bodies including COPE, the ICMJE, and the World Association of Medical Editors (WAME). EMHJ may seek advice from internal or external sources of advice if needed. In most cases, EMHJ will endeavour to resolve the issue in the first instance by discussion with the author(s). However if concerns remain, the case may be reported to the appropriate authorities, including supervisors/employers, and relevant professional body(ies). Submitted papers found to be in breach of publication ethics will be rejected. Even if an article would be rejected for other scientific reasons, if it is considered unethical, EMHJ may nonetheless take further action. In the case of an already published طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و نياثلا دلجلما لولأا ددعلا 75 paper, unethical behaviour may result in retraction of the paper. Authors found to have infringed ethical standards will be kept on record and may be banned from publishing in EMHJ in the future. EMHJ responsibilities EMHJ upholds the authors’ right to fair, objective and ethical handling of their papers. EMHJ follows the WAME recom- mendations on best practices for Peer Review Selection. EMHJ operates a double blind peer review system and endeavours to ensure that neither the authors nor the reviewers are aware of the each other’s identities. Editors and reviewers are required to declare any conflicts of interests and to maintain the confidentiality of the manuscript under review. Reviewers may not refer the manuscript to a colleague without the permission of the Editor nor make use of any part of it before publication. Authors may appeal decisions on their papers if they believe there is good case for making an appeal. Appeals will be carefully considered. Key resources 1. World Medical Association’s Declaration of Helsinki (http://www.wma.net/en/30publications/10policies/b3/) 2. Council for International Organizations of Medical Sciences (http://www.cioms.ch/) 3. International Ethical Guidelines for Biomedical Research Involving Human Subjects (http://www.cioms.ch/publica- tions/layout_guide2002.pdf ) 4. International Guidelines for Ethical Review of Epidemiological Studies (http://www.ufrgs.br/bioetica/cioms2008.pdf ) 5. Committee on Publication Ethics (http://publicationethics.org/) 6. International Committee of Medical Journal Editors (http://www.icmje.org/) 7. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly work in Medical Journals of the International Committee of Medical Journal Editors (http://www.icmje.org/icmje-recommendations.pdf ) 8. World Association of Medical Editors. Recommendations on Publication Ethics Policies for Medical Journals (http:// www.wame.org/about/recommendations-on-publication-ethics-policie) Additional publications and resources WHO 1. Ethical issues in patient safety research: interpreting existing guidance (2013) (http://apps.who.int/iris/bitstre am/10665/85371/1/9789241505475_eng.pdf ) 2. Standards and operational guidance for ethics review of health-related research with human participants (2011) (http:// apps.who.int/iris/bitstream/10665/44783/1/9789241502948_eng.pdf ?ua=1&ua=1) 3. Quality practices in basic biomedical research (QPBR) training manual (2010) (http:// apps.who.int/iris/bitstream/10665/44293/1/9789241599207_eng.pdf ?ua=1 and http://apps.who.int/iris/bitstre am/10665/44293/2/9789241599214_eng.pdf ) 4. Casebook on ethical issues in international health research (2009) (http://apps.who.int/iris/bitstream/10665/ 44118/4/9789241547727_eng.pdf ?ua=1 and http://apps.who.int/iris/bitstream/10665/44118/17/ 9789290219576_ara.pdf ) 5. Research ethics committees: basic concepts for capacity-building (2009) (http://apps.who.int/iris/bitstre am/10665/44108/1/9789241598002_eng.pdf ?ua=1) 6. Marshall PA. Ethical challenges in study design and informed consent for health research in resource-poor settings. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases http://apps. who.int/iris/bitstream/10665/43622/1/9789241563383_eng.pdf ?ua=1) 7. WHO ethical and safety recommendations for researching, documenting and monitoring sexual violence in emergencies (2007) (http://apps.who.int/iris/bitstream/10665/43709/1/9789241595681_eng.pdf and http://apps.who.int/iris/ bitstream/10665/43709/2/9789241595681_ara.pdf ) EMHJ  •  Vol. 22  No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 76 8. Scientific working group on life science research and global health security: report of the first meeting, Geneva, Switzer- land, 16-18 October 2006 (2007) (http://apps.who.int/iris/bitstream/10665/80111/1/WHO_CDS_EPR_2007.4_ eng.pdf ) 9. Handbook: quality practices in basic biomedical research 2006 (http://apps.who.int/iris/bitstream/10665/ 43512/1/9241594454_eng.pdf ) 10. A practical guide for health researchers (2004) (http://applications.emro.who.int/dsaf/dsa237.pdf ) 11. Manual for editors of health science journals (2009) (http://applications.emro.who.int/dsaf/dsa1034.pdf ) 12. Regulation of privacy and data protection in the use of electronic health information. An international perspective and reference source on regulation and legal issues related to person-identifiable health databases. Pan American Health Or- ganization (2001). Further WHO publications related to the ethics of specific issues can be found at: http://www.who.int/ethics/publications/ year/en/ Other 1. Council of Science Editors. White Paper on Publication Ethics (http://www.councilscienceeditors.org/resource-library/ editorial-policies/white-paper-on-publication-ethics/) 2. The Office of Research Integrity (http://ori.hhs.gov/about-ori) 3. National Institutes of Health. Office of Clinical Research and Bioethics Policy (http://osp.od.nih.gov/office-clinical-re- search-and-bioethics-policy) 4. Ethics and Research Guidance. Medical Research Council, UK (http://www.mrc.ac.uk/research/research-policy-ethics/) 5. Equator Network (Enhancing the QUAlity and Transparency Of health Research). Research ethics, publication ethics and good practice guidelines (http://www.equator-network.org/library/research-ethics-publication-ethics-and-good- practice-guidelines/#etguid) 6. Miguel Roig. Avoiding plagiarism, self-plagiarism, and other questionable writing practices: A guide to ethical writing (2006) (http://www.cse.msu.edu/~alexliu/plagiarism.pdf ) 7. Danis M, Largent E, Grady C, Wendler D, Chandros Hull S, Shah S, et al. Research ethics consultation: a casebook. OUP; 2012. طسوتلما قشرل ةيحصلا ةلجلما نوشرعلاو نياثلا دلجلما لولأا ددعلا 77 1. Papers submitted for publication to the Eastern Mediterranean Health Journal (EMHJ) must not have been published, accepted for publication or currently be under consideration for publication elsewhere. The World Health Organization (WHO) Regional Office for the Eastern Mediterranean reserves all rights of reproduction and republication of material that appears in the EMHJ. 2. Papers submitted for publication to the EMHJ should conform with the Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals (http://www.icmje.org/icmje-recommendations.pdf ) of the International Committee of Medical Journal Editors (ICMJE). 3. Ethical considerations: Where applicable, a statement must be included indicating approval for the study was granted by the ethics committee/institutional review board of the relevant institution. Authors should verify where appropriate that all persons on whom research has been carried out have given their voluntary, informed, written consent, and where participants (living or dead) were unable to give such consent, that surrogate consent was obtained. Authors may be asked to supply such consent forms. In cases where participants cannot read and write, oral consent is acceptable. Conflicts of interest: Authors will be asked to provide details of any competing interests and funding. Please see the ICMJE Recommendations. 4. Reporting guidelines: EMHJ encourages and recommends authors to adhere to the best research protocols available and follow established reporting guidelines. Reporting guidelines are available at the EQUATOR Network (http://www. equator-network.org/). The key guidelines for research in the field of public health are: CONSORT (guidelines for reporting randomized trials); STROBE (guidelines for reporting observational studies); PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses); STARD (Standards for Reporting of Diagnostic Accuracy); COREQ (Consolidated criteria for reporting qualitative research); CARE (guideline for clinical case report) as well as the COCHRANE handbook (for systematic reviews of interventions). Links to these sites and other useful resources are available under “Useful resources for authors and reviewers” (http://www.emro.who.int/emh-journal/links/). 5. Following WHO and ICMJE recommendations, EMHJ requires registration of clinical trials in a public trials registry as a condition of consideration for publication. Authors are recommended to register in one of the clinical trials registries certified by WHO and ICMJE which are available at the International Clinical Trials Registry Platform (http://www.who.int/ictrp/en/). 6. Submission: Original papers written in Arabic, English or French may be submitted for consideration through our online submission system. Instructions on submitting a manuscript through the online system and access to the system can be found on our website at: http://www.emro.who.int/emh-journal/ authors/ and by clicking on Editorial Manager. 7. Abstracts of papers accepted for publication will be translated into all three languages. To ensure the correct spelling of authors’ names to accompany the Arabic abstract, authors writing in English or French but whose mother tongue is written using Arabic characters should provide their full names in Arabic script along with transliterations in English or French. 8. Manuscripts should be prepared in word processed format (preferably Microsoft Word) double-spaced, single column, preferably using Times New Roman script, font size 12. 9. All papers considered for publication will be peer reviewed. The Editorial Board reserves the right to accept or reject any paper based on the reviewers’ comments, scientific rigor and suitability for the journal. Papers are accepted on the understanding that they are subject to statistical and editorial revision as deemed necessary, including abridgement of the text and omission of tabular or graphic material. 10. Topics: The subject of the paper should pertain to public health or a related biomedical or technical subject within the field of interest of the WHO, and should have particular relevance to the Eastern Mediterranean Region. 11. The title of the paper should be as concise as possible, preferably not more than 15 words. All authors should have made material contribution to the design, analysis or writing of the study and have approved the final version submitted. No change in authorship will be permitted after the paper has been accepted for publication and any change before this must be agreed by all authors listed. Authors may be asked to verify their contribution. Names of other contributors may be included in the acknowledgements. Please see the ICMJE Recommendations for authorship and contributorship. 12. Research articles: Papers reporting original research findings should follow the IMRAD format: Introduction; Methods; Results; Analysis; and Discussion. The text of Research articles and Reports should not exceed 3000 words (excluding the accompanying abstract, references, tables and figures). An abstract of not more than 200 words should be supplied, clearly and briefly stating the context, objectives, methodology, results and conclusions. The maximum number of references permitted is 35. The number of tables and figures should not exceed 5. 13. Review articles: (i.e. critical assessments of research on topics of relevance to public health in the Region). These should contain sections dealing with objectives, sources, methods of selection, compilation and interpretation of data and conclusions. The text should not exceed 3000 words (excluding the accompanying abstract, references, tables and figures), and should be accompanied by an abstract of not more than 200 words. The number of tables and figures should not exceed 5. 14. Reports: (i.e. papers reporting on projects of public health relevance to the Eastern Mediterranean Region). Manuscript specifications (length, references, tables/figures) are the same as a research article. 15. Short communications: Articles which do not constitute a complete research study but are of particular relevance or importance to public health issues in the Region may be considered for publication. The text should not exceed 1500 words (excluding Guidelines for authors EMHJ  •  Vol. 22     No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 78 the accompanying abstract, references, tables and figures), and should be accompanied by an abstract of not more than 150 words. The number of tables and figures should not exceed 3. 16. Case reports: Only reports of cases of an unusual nature are considered for publication. Text should include an Introduction, the Report of the case(s) and a Discussion. The text should not exceed 1500 words and the number of references kept to a minimum. No abstract is required. 17. Letters to the Editor: Letters commenting on published articles are welcome. Letters will be sent to the authors of the original article for their comments, and these will be published along with the letter. The text of letters should be kept as short as possible. 18. References: In-text citations of published works should be limited to essential up-to-date references. These should be numbered separately as they occur in the text with sequential Arabic numerals in parentheses, e.g. (1,5–8). These references should appear in a numbered list on a separate page after the Discussion. They should contain the following elements as appropriate: name(s) and initial(s) of author(s); title of paper or book in its original language plus translation; for research articles, abbreviated name of journal plus volume number and page range; for books and other texts, place of publication (city and country) and name of publisher (commercial or institutional); and date of publication; for texts published exclusively on the Internet, exact URL of the page cited and date when last accessed. For texts with up to 6 authors, all authors must be named. For texts with more than 6 authors, the first 6 authors should be named followed by “et al”. The following are examples of the Journal’s preferred style: Book: Al Hamza B, Smith A. The fifth sign of identity. Cairo: American University Press; 1990. Journal article: Rehmani R, Elzubair AG, Al Maani M, Chaudary IY, Al Qarni A, Khasshogi T et al. Population-based health survey in eastern region of Saudi Arabia. East Mediterr Health J. 2013; 19(5):417– 25. Document: Al-Itneen M, ed. The principles of uncertainty. Geneva: World Health Organization; 1985 (WHO/DOC/537). Thesis Smith S. Use of healthcare services by the elderly with the introduction of technical innovations. London: Drake University; 2013. Web text: Child growth standards. Geneva: World Health Organization; 2006 (http://www.who.int/childgrowth/en/, accessed 8 October 2008). 19. Figures and tables with appropriate captions should each be on a separate page and numbered sequentially with Arabic numerals. Each figure and table must be referred to in the text. Where appropriate, sources should be given. If any figures, tables or other materials have been copied from other sources, authors have the sole responsibility for securing the necessary permission. In order to avoid layout problems in final production, tables and figures should be limited as far as possible. Figures must be supplied in a format which can be edited, preferably Microsoft Excel format, and figures derived from data must be accompanied by those data, e.g. Excel data sheet, to enable redrawing if necessary. Photographs and illustrations should also be sent as separate files. The preferred format is JPG or TIFF; resolution should be minimum 300 dpi. 20. Submissions that do not comply with these guidelines will be returned to the author for correction before being considered for publication. المجلة الصحية لشرق المتوسط المجلد الثاني والعشرون العدد الأول 97 دلائل إرشادية للمؤلفين ينبغي لورقات البحث المقدَّ مة للنشر في المجلة الصحية لشرق المتوسط ألا . 1 تكون قد نشرت أو ُقبِلت للنشر أو تكون محًلا للنظر في نشرها في مكان آخر. ويحتفظ المكتب الإقليمي لمنظمة الصحة العالمية لشرق المتوسط بجميع حقوق إعادة إنتاج المواد التي ُتنشر في المجلة الصحية لشرق المتوسط أو إعادة نشرها. ينبغي لورقات البحث المقدَّ مة للنشر في المجلة الصحية لشرق المتوسط أن . 2 تلبِّي التوصيات حول السلوكيات والإبلاغ والتحرير والنشر للأعمال العلمية في المجلات الطبية التي أصدرتها اللجنة الدولية لمحرري المجلات الطبية. اعتبارات الُبعد الأخلاقي: بحسب الاقتضاء يجب إرفاق الورقة المقدَّ مة للنشر . 3 في المجلة الصحية لشرق المتوسط بما يفيد الموافقة عى الدراسة من جانب لجنة الأخلاقيات/مجلس المراجعة المؤسسية في المؤسسة ذات الصلة بالبحث، كما يجب عى المؤلفن التأكد، حيثما كان ذلك مناسبًا، من أن جميع الأشخاص الذين شملهم البحث قد قدموا موافقة كتابية طوعية مستنرة، وعندما يتعذر ذلك عى المشاركن في البحث (سواًء الأحياء منهم أو الأموات)، يجب عى المؤلفن الحصول عى موافقة بديلة. وقد ُيطلب من المؤلفن تقديم نماذج هذه الموافقات. كما يمكن قبول الموافقة الشفهية في حالة عدم معرفة المشاركن القراءة والكتابة. تضارب المصالح: سيطلب من المؤلفن تقديم معلومات تفصيلية حول أي تضارب في المصالح وحول التمويل. ُيْرَجى الاطلاع عى توصيات حول السلوكيات والإبلاغ والتحرير والنشر للأعمال العلمية في المجلات الطبية. دلائل إرشادية حول إعداد التقارير: تشجع المجلة الصحية لشرق المتوسط . 4 المؤلفن وتوصيهم بالالتزام بأفضل بروتوكولات البحوث المتاحة، واتباع الدلائل الإرشادية المعتمدة في إعداد التقارير، ويمكن الاطلاع عى الدلائل الإرشادية حول كتابة التقارير عى شبكة .www//:ptth( ROTAUQE gro.krowten-rotaqw(. وتتمثَّل الدلائل الإرشادية الرئيسية للبحوث في ميدان الصحة العمومية فيما يلي: المعاير المجّمعة لكتابة التقارير حول الدراسات )TROSNOC( وهي الدلائل الإرشادية لإعداد التقارير حول الدراسات المعّشاة، وEBORTS وهي الدلائل الإرشادية حول كتابة التقارير للدراسات الملاحظة، والمكونات المفضلة في كتابة تقارير المراجعات المنهجية والتحليل البعدي AMSIRP ومعاير إعداد التقارير حول الدقة التشخيصية DRATS، والمعاير المجّمعة لكتابة التقارير حول البحوث النوعية QEROC، وكتيب كوكرين ENARHCOC (للمراجعات المنهجية للتدخلات). والروابط إلى تلك المواقع وغرها من المصادر المفيدة متاحة عى الرابط "المصادر المفيدة للمؤلفن والمراجعن"( /tni.ohw.orme.www sknil/lanruoj-hme/. وفقًا لتوصيات منظمة الصحة العالمية وتوصيات اللجنة الدولية لمحرري . 5 المجلات الطبية، فإن المجلة الصحية لشرق المتوسط تطلب تسجيل الدراسات السريرية (الإكلينيكية) في سجل للدراسات العامة كشرٍط للنظر في نشرها، وُيوَص المؤلفون بالتسجيل في أحد سجلات الدراسات السريرية المشهود لها من ِقَبل منظمة الصحة العالمية واللجنة الدولية لمحرري المجلات الطبية، وتتوافر هذه السجلات عى البوابة الدولية لسجل الدراسات السريرية ra/prtci/tni.ohw.www//:ptth/. تقديم ورقات البحث: يمكن تقديم الورقات البحثية الأصلية المكتوبة باللغة . 6 العربية أو الإنكليزية أو الفرنسية للنظر فيها وذلك من خلال نظام التقديم عر الإنرنت الخاص بالمجلة الصحية لشرق المتوسط. ويمكن الاطلاع عى التعليمات حول تقديم مخطوطة الورقة عر نظام التقديم عى الإنرنت والدخول عى ذلك النظام عى موقع المجلة الصحية لشرق المتوسط عى الإنرنت، وهو srohtua/lanruoj-hme/tni.ohw.orme.www/ ثم الضغط عى أيقونة مدير التحرير. سوف ُترجم ملخصات ورقات البحث التي ُقبِلت للنشر إلى اللغات سوف . 7 ُترجم ملخصات ورقات البحث التي ُقبِلت للنشر إلى اللغات الثلاث، ومن أجل ضمان الكتابة الصحيحة لأسماء المؤلفن في سياق الملخص بالعربية، فإن عى المؤلفن الذين كتبوا بحوثهم بالإنكليزية أو الفرنسية ولكن لغتهم الأم تكتب بالحروف العربية أن يكتبوا أسماءهم بالحروف العربية مع مقابلاتها باللغة الإنكليزية أو بالفرنسية. يجب إعداد المخطوطة باستخدام برامج معالجة الكلمات (ويفضل برنامج . 8 ورد - ميكروسوفت) وأن تكتب بفواصل مضاعفة بن الأسطر وفي عمود واحد ويفضل استخدام الخط namoR weN semiT وأن يكون حجم الخط 21. تخضع جميع الورقات التي تقدم للنشر لمراجعة الزملاء، وتحتفظ هيئة التحرير . 9 بحق قبول أو رفض أي ورقة استنادًا إلى الملاحظات التي يبديها المراجعون، وإلى السلامة العلمية، وإلى ملاءمة الورقة للمجلة. ومن المتفق عليه أن قبول الورقات يستند إلى مراجعتها إحصائيًا وتحريريًا وفق ما تقتضيه الحاجة، ويتضمن ذلك اختصار النص وحذف بعض الجداول أو الرسوم البيانية. المواضيع يجب أن يكون موضوع الورقة له صلة بالصحة العمومية أو بأي . 01 مادة تقنية أو طبية حيوية في مجال يحظى باهتمام منظمة الصحة العالمية وله أهمية خاصة لإقليم شرق المتوسط. ينبغي لعنوان الورقة أن يكون مخترًا عى قدر المستطاع، ويفضل ألا يزيد . 11 عى 51 كلمة. وينبغي لجميع المؤلفن أن يكونوا قد أسهموا مساهمة مادية في تصميم الدراسة أو تحليلها أو كتابتها، وأن يكونوا قد وافقوا عى النسخة النهائية المقدمة. ولن يسمح بأي تغير في ما يتعلق بتأليف الورقة بعد قبولها للنشر، كما يجب أن يحظى كل تغير عى موافقة مسبقة من جميع المؤلفن المذكورة أسماؤهم. وقد يطلب من المؤلفن إثبات إسهاماتهم، كما يمكن إدراج أسماء مساهمن آخرين في عبارات الشكر، وُيْرَجى النظر في توصيات حول السلوكيات والإبلاغ والتحرير والنشر للأعمال العلمية في المجلات الطبية حول التأليف والإسهام. مقالات البحوث: يجب أن تتقيد الورقات التي تتضمن الإبلاغ عن نتائج . 21 أصلية للبحوث بالنموذج الخاص بالمقدمة والطرق والنتائج والتحليل والمناقشة DORMI. ويجب ألا تتجاوز مقالات البحث والتقارير 0003 كلمة (دون أن يتضمن ذلك ما يرافقها من الملخص والمراجع والجداول والأشكال). ويجب ألا يتجاوز الملخص 002 كلمة، وأن يوضح بإيجاز السياق والأهداف والطريقة والنتائج والاستنتاجات. أما العدد الأقصى المسموح به للمصادر والمراجع فهو 53 مصدرًا ومرجعًا، كما يجب ألا يتجاوز عدد الجداول والأشكال 5 جداول وأشكال. مقالات المراجعة: وهي تقييمات دقيقة للبحوث حول المواضيع ذات . 31 الصلة بالصحة العمومية في الإقليم. وينبغي لهذه المقالات أن تضم فقرات تتعلق بالأهداف والمصادر وطرق اختيار البيانات وتجميعها وتفسرها والاستنتاجات. وينبغي للنص ألا يزيد عن 0003 كلمة (ولا يتضمن ذلك ما يرافقه من ملخص ومراجع وجداول وأشكال)، كما يجب أن يرفق بملخص لا يتجاوز 002 كلمة، وألا يتجاوز عدد الجداول والأشكال 5. التقارير: وهي تقارير أعدت حول مشاريع ذات صلة بالصحة العمومية في . 41 إقليم شرق المتوسط، وتتطابق مواصفات المخطوطات (من حيث الطول والمراجع والجداول والأشكال) مع ما هو مطلوب بالنسبة لمقالات البحث. مراسلات قصرة: يمكن النظر في نشر مقالات لا تضم دراسة بحثية كاملة، . 51 ولكنها ذات صلة أو أهمية خاصة فيما يتعلق بقضايا الصحة العمومية في الإقليم. وينبغي للنص ألا يتجاوز 0051 كلمة (ولا يتضمن ذلك ما يرافقه من ملخص ومراجع وجداول وأشكال)، كما يجب أن يرفق بملخص لا يزيد عن 051 كلمة، أما عدد الجداول والأشكال فيجب ألا يزيد عن 3 جداول وأشكال. تقارير حالات: لا ينظر للنشر إلا في تقارير حالات ذات طبيعة غر معتادة. . 61 وينبغي أن يتضمن النص مقدمة وتقريرًا عن الحالة أو الحالات ومناقشة. وينبغي ألا يزيد النص عى 0051 كلمة، وأن يكون عدد المراجع في حده الأدنى، ولا ُيشرط كتابة ملخص. رسالة إلى المحرر: إن الرسائل التي تتضمن تعليقًا عى المقالات المنشورة هي . 71 موضع ترحيب، وترسل هذه الرسائل إلى مؤلفي المقالة الأصلية للتعليق عليها، ثم تنشر تلك التعليقات مع الرسائل. ويجب الإيجاز قدر الإمكان. المراجع: يجب أن يقتر الاقتباس من الأعمال المنشورة عى المراجع الأساسية . 81 والمحدَّ ثة. ويجب ترقيم هذه المنشورات عى نحو ٍمنفصل وفق ظهورها في lanruoJ htlaeH naenarretideM nretsaE 6102  •  1 .oN     22 .loV  •  JHME elatneiro eénarretidéM al ed étnaS ed euveR aL 08 النص مع استخدام أرقام عربية متتابعة، مثل (8–51). ويجب عرض هذه المراجع في شكل قائمة مرقمة عى صفحة منفصلة بعد قسم المناقشة، وينبغي للمراجع أن تتضمن العناصر التالية، وفق المقتضى: اسم المؤلف ولقبه وعنوان الورقة أو الكتاب باللغة الأصلية مع ترجمته؛ وينبغي لمقالات البحث أن تتضمن الاسم المختر للمجلة مع رقم المجلد وحدود الصفحات. وينبغي للكتب وغرها من النصوص أن تتضمن مكان النشر (المدينة ثم البلد)، واسم الناشر (تجاري أم مؤسسة)، وتاريخ النشر. وينبغي للنصوص التي اقتر نشرها عى الإنرنت أن تتضمن العنوان الإلكروني للصفحة المقتبسة وتاريخ الدخول عليها آخر مرة. وينبغي للنصوص التي لا يزيد عدد المؤلفن لها عن 6 مؤلفن أن يذكر أسماء جميع المؤلفن، أما النصوص التي يزيد عدد المؤلفن لها عى 6 مؤلفن، فُتذكر أسماء المؤلفن الستة الأوائل متبوعة بكلمة "وزملاؤهم". وفي ما يلي أمثلة عى النمط التي يفضل اتباعه في المجلة الصحة لشرق المتوسط: كتاب: الحمزة؛ سميت العلامة الخامسة للهوية، القاهرة، مطبعة الجامعة الأمريكية، 0991. مقالة في مجلة: رحماتي، الزبر، المعاني، شودري، القرين، خشوقي وزملاؤهم. مسح صحي يرتكز عى السكان في المنطقة الشرقية للمملكة العربية السعودية؛ المجلة الصحية لشرق المتوسط، 3102; 91 )5(: 52-714. وثيقة العطن م، إد. مبادئ الارتياب. جنيف، منظمة الصحة العالمية، 5891 (م ص ع/د/735). رسالة علمية: سميث: انتفاع المسنن بخدمات الرعاية الصحية مع إدخال مبتكرات تقنية، لندن، جامعة دريك، 3102. نص منشور على الانترنت: معاير نمو الأطفال، جنيف، منظمة الصحة العالمية: ne/htworgdlihc/tni.ohw.www//:ptth تم الدخول عليه في 8 تشرين الأول/أكتوبر 8002. الأشكال والجداول المشفوعة بشروحات ملائمة، ينبغي لكل منها أن يكون . 91 في صفحة مستقلة، وأن ُتعطى أرقامًا متتالية بأعداد عربية. ويجب الإشارة في النص لكل شكل ولكل جدول. ويجب توضيح المراجع حيثما كان ملائًما. وإذا ما نسخ المؤلفون أي شكل أو جدول أو مادة أخرى من مراجع أخرى، فإنهم يتحملون وحدهم المسؤولية عن تأمن الإذن اللازم للقيام بذلك. وبغية تفادي مشكلات التنسيق في مرحلة الإخراج النهائي، يجب الاقتصار عى أقل عدد ممكن من الجداول ومن الأشكال. ويجب تقديم الأشكال في صيغة قابلة للتعديل، ويفضل إكسل - ميكروسوفت، كما أن الأشكال المستخلصة من البيانات يجب أن ُترفق بها تلك البيانات، مثًلا صفحة إكسل للبيانات، حتى يصبح بالإمكان إعادة إنتاجها عند الضرورة. كما يجب إرسال الصور الفوتوغرافية والرسومات التوضيحية في ملفات منفصلة، ويفضل أن تكون في شكل ملفات GPJ أو FFIT، كما يجب أن يكون الوضوح بدرجة لا تقل عن 003 نقطة لكل بوصة. سُتعاد الورقات البحثية المقدمة التي لا تلتزم بالدلائل الإرشادية المذكورة إلى . 02 المؤلفن من أجل تصحيحها قبل النظر في نشرها. طسوتلما قشرل ةيحصلا ةلجلما نوشرعلاو نياثلا دلجلما لولأا ددعلا 81 Directives à l’intention des auteurs 1. 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Considérations éthiques : Le cas échéant, une déclaration devra être incluse, indiquant que le Comité d’éthique ou le Comité d’examen institutionnel de l’organisme concerné a donné son accord à l’étude. Les auteurs doivent vérifier, le cas échéant, que toutes les personnes sur lesquelles la recherche porte ont donné leur consentement volontaire et informé par écrit et que si certains participants (en vie ou décédés) n’ont pas pu le donner, un consentement de substitution a été obtenu. Il peut être demandé aux auteurs de fournir ce type de formulaire de consentement. Lorsque les participants ne savent ni lire ni écrire, un consentement oral est acceptable. Conflits d’intérêts : Il sera demandé aux auteurs de préciser tout conflit d’intérêts et financement. Veuillez vous reporter aux recommandations de l’ICMJE. 4. Directives de présentation : La Revue de Santé de la Méditerranée orientale encourage les auteurs à respecter les meilleurs protocoles de recherche disponibles et leur recommande de suivre les directives de présentation établies. Les directives de présentation sont disponibles sur le site Web du réseau EQUATOR (http://www.equator-network.org/). Les principales directives pour la recherche en santé publique sont les suivantes : directives CONSORT (essais randomisés) ; directives STROBE (études observationnelles) ; directives PRISMA (revues systématiques et méta-analyses) ; directives STARD (normes de présentation de rapports concernant l’exactitude de diagnostic) ; critères COREQ (recherche qualitative) ; directives CARE (publication de cas cliniques) et le manuel COCHRANE (pour les revues systématiques des interventions). Les liens vers ces sites Web et d’autres ressources utiles sont disponibles sous la rubrique « Ressources à l’intention des auteurs et des réviseurs » à l’adresse suivante : http://www.emro.who.int/fr/emh-journal/links/. 5. Suite aux recommandations de l’OMS et de l’ICMJE, La Revue de Santé de la Méditerranée orientale impose comme condition de publication que les essais cliniques soient enregistrés auprès du registre public des essais cliniques. Il est recommandé aux auteurs d’enregistrer leurs essais dans un des registres des essais cliniques certifiés par l’OMS et l’ICMJE disponibles dans la base de données du Système d’enregistrement international des essais cliniques (http://www.who.int/ictrp/fr/). 6. Soumission : Les articles originaux rédigés en anglais, arabe ou en français peuvent être soumis pour examen en utilisant notre système en ligne. Les instructions relatives à la soumission d’un manuscrit en utilisant le système en ligne sont disponibles en anglais sur notre site Web accessibles à l’adresse suivante : http://www.emro.who.int/emh-journal/authors/, et en cliquant sur « Editorial Manager ». 7. Les résumés des articles acceptés pour publication seront traduits dans les trois langues. Pour assurer que les noms des auteurs soient correctement écrits dans les résumés en arabe, les auteurs rédigeant en anglais ou en français mais dont la langue maternelle s’écrit en caractères arabes doivent fournir leur nom complet en écriture arabe avec une translittération de leur nom en anglais ou en français. 8. Les manuscrits doivent être préparés en format traitement de texte (Microsoft Word, de préférence), avec double interlignage, mise en page d’une seule colonne, police Times New Roman, taille de caractère 12. 9. Tous les articles dont la publication est envisagée seront revus par des pairs. Le Comité de rédaction se réserve le droit d’accepter ou de refuser tout article, sur la base des commentaires des réviseurs, de la rigueur scientifique et de la pertinence de l’article pour La Revue. Les articles sont acceptés sous réserve de la révision statistique et rédactionnelle dont ils feront l’objet, comme jugé nécessaire, ce qui peut amener à abréger le texte et à supprimer certaines données présentées sous forme de tableaux ou de graphiques. 10. Sujets : Le sujet de l’article doit concerner la santé publique ou un autre sujet biomédical ou technique connexe faisant partie du champ d’intérêt de l’OMS, et se rapporter plus particulièrement à la Région de la Méditerranée orientale ou revêtir une importance particulière pour celle-ci. 11. Le titre de l’article doit être aussi concis que possible, et de préférence ne pas dépasser 15 mots. Tous les auteurs devraient avoir apporté une contribution importante à la conception, à l’analyse ou à la rédaction de l’étude et avoir approuvé la version finale soumise. Aucun changement dans les noms des auteurs ne sera autorisé après l’acceptation de l’article pour publication ; avant cette acceptation, tout changement doit être accepté par l’ensemble des auteurs figurant dans la liste. Une vérification de leur contribution peut être demandée aux auteurs. Les noms d’autres contributeurs peuvent être inclus dans les remerciements. À ce sujet, veuillez vous reporter aux ICMJE recommendations for authorship and contributorship [Recommandations de l’ICMJE relatives à la qualité d’auteur et de contributeur]. 12. Articles de recherche : Les articles présentant des résultats de recherche originale devront suivre le format IMRAD : introduction, méthodes, résultats, analyse et discussion. Le texte des articles et des rapports de recherche ne doit pas excéder 3 000 mots (résumé, références, tableaux et figures exclus). Un résumé de 200 mots maximum sera fourni et mentionnera clairement et brièvement le contexte, les objectifs, la méthodologie, les résultats et les conclusions. Le nombre maximal de références autorisées est de 35. Il ne faut pas inclure plus de cinq tableaux ou figures. EMHJ  •  Vol. 22     No. 1  •  2016 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 82 13. Articles d’analyse : il s’agit d’évaluations critiques d’études de recherche sur des sujets pertinents concernant la santé publique dans la Région. Ils doivent être composés de paragraphes traitant des objectifs, des sources, des méthodes de sélection, de la compilation et de l’interprétation des données et des conclusions. Le texte ne doit pas excéder 3 000 mots (résumé, références, tableaux et figures exclus) et doit être accompagné d’un résumé de 200 mots au maximum. Le nombre maximal de tableaux et de figures autorisé est de 5. 14. Rapports : il s’agit d’articles présentant des projets pertinents de santé publique dans la Région de la Méditerranée orientale. Le format des manuscrits (longueur, références, tableaux et figures) est le même que pour les articles de recherche. 15. Communications brèves : Les articles ne constituant pas une étude de recherche complète, mais présentant un intérêt ou revêtant une importance particulière pour les questions de santé publique dans la Région peuvent être examinés pour publication. Le texte ne doit pas excéder 1 500 mots (résumé, références, tableaux et figures exclus) et doit être accompagné d’un résumé de 150 mots au maximum. Le nombre maximal de tableaux et de figures est de 3. 16. Études de cas : Seules les études de cas inhabituels seront examinées pour publication. Le texte doit comprendre une introduction, un exposé du/des cas et une discussion. Il ne doit pas excéder 1 500 mots et le nombre de références doit être minimal. Il n’est pas nécessaire de fournir un résumé. 17. Lettres à la rédaction : Les lettres commentant des articles publiés sont les bienvenues. Elles seront envoyées aux auteurs de l’article afin qu’ils fournissent leurs commentaires, qui seront publiés aux côtés de la lettre. Le texte des lettres doit être aussi court que possible. 18. Références : Les citations dans le texte de travaux publiés doivent être limitées aux références essentielles récentes. Elles doivent être numérotées séparément à l’aide de chiffres arabes indiqués entre crochets, par exemple (1,5–8). Les références doivent figurer sous forme de liste numérotée sur une page séparée après la partie « Discussion ». Elles doivent contenir les éléments suivants, selon le cas : nom(s) et initiales du ou des auteurs ; titre de l’article ou de l’ouvrage dans sa langue originale ainsi que sa traduction ; pour les articles de recherche, le nom abrégé de la revue ainsi que le numéro du volume et les pages concernées ; pour les ouvrages et autres textes, le lieu de publication (ville et pays) et le nom de la maison d’édition (commerciale ou institutionnelle) ; la date de publication ; pour les textes publiées exclusivement sur Internet, l’URL exact de la page citée et la date du dernier accès. Lorsque les textes comptent moins de six auteurs, tous les auteurs doivent être nommés. Lorsque les textes comptent plus de six auteurs, seul les noms des six premiers auteurs sont mentionnés, suivis de « et al. ». Exemples du style préféré de La Revue : Livre : Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990. Article de revue : Rehmani R, Elzubair AG, Al Maani M, Chaudary IY, Al Qarni A, Khasshogi T et al. Population-based health survey in eastern region of Saudi Arabia. East Mediterr Health J. 2013; 19(5):417– 25. Document : Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization, 1985 (WHO/DOC/537). Thèse : Smith S. Use of healthcare services by the elderly with the introduction of technical innovations. London: Drake University; 2013. Texte Web : Child growth standards. Geneva, World Health Organization, 2006 (http: //www. who. int/childgrowth/en/, consulté le 8 octobre 2008). 19. Les figures et les tableaux accompagnés des légendes appropriées doivent être placés chacun sur une feuille séparée, numérotés en chiffres arabes selon leur ordre. Chaque figure et chaque tableau doivent être référencés dans le texte, et le cas échéant, les sources doivent être indiquées. Si des figures, tableaux ou d’autres matériels ont été copiés d’autres sources, les auteurs portent l’entière responsabilité d’obtenir les autorisations nécessaires. Afin d’éviter les problèmes de mise en page lors de la production finale, le nombre de tableaux et de figures doit être aussi limité que possible. Les figures doivent être fournies dans un format permettant les modifications, de préférence Microsoft Excel, et celles qui sont établies à partir de données doivent être accompagnées de ces données, sur une fiche technique Excel par exemple, pour permettre une recomposition, le cas échéant. Les photographies et illustrations doivent être envoyées dans des fichiers séparés. Les formats préférés sont JPG et TIFF, et la résolution des images doit être de 300 dpi au minimum. 20. Les manuscrits ne respectant pas ces directives seront renvoyés à leur auteur pour correction avant d’être examinés en vue de la publication. EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico‑sanitaire, aux ONG, Centres collabora‑ teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2016 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. 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 Cover photograph ©World Health Organization تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا .هجراخو ميلقلإا فى ةحصلاب ينمتهلما طسوتلما قشرل ةيحصلا ةلجلما Correspondence Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int 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 . 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 . 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 . 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Cover 22-01.indd 4-6 4/13/2016 8:09:07 AM Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 22 / No. 1 January/Janvier 1 ددع / نوشرعلاو نياثلا دلجلما نياثلا نوناك/رياني2016 Contents V o lu m e 2 2 N u m b er 1 Jan u ary 2 0 1 6 In order to protect people participating in health research and ensure their human rights are respected, ethical principles have been developed for the conduct of research involving humans, such as informed consent, confidentiality and protection of privacy. WHO provides leadership and guidance on ethics issues related to human health, including health research. Editorial Ethics and health in WHO Regional Office for the Eastern Mediterranean .............................................................. 3 Research articles Improved water and child health in Egypt: impact of interrupted water supply and storage of household water on the prevalence of diarrhoea 5 ............................................................................................... 5 Relative inequalities in geographic distribution of health care resources in Kermanshah province, Islamic Republic of Iran .............................................................................................................................................. 20 Meals served to hypertensive and cardiac inpatients in Jordan: comparison with WHO and NIH dietary guidelines ............................................................................................................................................... 28 Prevalence of oro-dental anomalies among schoolchildren in Sana’a city, Yemen ............................................... 34 Prévalence et facteurs associés au tabagisme parmi les étudiants de la ville de Sousse (Tunisie) .........................40 Paediatric continuing medical education needs and preferences of UNRWA physicians in Jordan .................... 48 Report Compiling comprehensive national health statistics in a fragmented health information system: lessons learned from Lebanon ....................................................................................................................................53 Case report Multidrug-resistant disseminated tuberculosis in a 9-month-old infant ................................................................. 59 Invited commentary Ethics in health practice and research: an EMR perspective .................................................................................... 62 WHO events addressing public health priorities Work of the research ethics review committee in the Eastern Mediterranean Region .......................................... 64 Health and the sustainable development agenda: enhancing the role of civil society organizations .................. 67 Strengthening the role of public health associations in the Region ........................................................................ 70 EMHJ Guidelines on Ethical Conduct and Publication of Health Research ................................................................... 72 Guidelines for authors ....................................................................................................................................................... 77 Cover 22-01.indd 1-3 4/13/2016 8:09:07 AM