Eastern Mediterranean Health Journal [2013; Vol.19, Issue 4]

Contents Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 19 / No. 4 April / Avril 2013 4 ددع / شرع عساتلا دلجلما ليربأ / ناسين V olum e 19 N um ber 4 A pril 2013 World Health Day, 7 April, 2013 Hypertension is a serious health problem both Regionally and globally but it is preventable and treatable. World Health Day 2013 aims to: raise awareness of hypertension and promote behavioural change with respect to its primary prevention, improve the chances of early detection and promote effective management for patients with hypertension. Editorial Universal health coverage ........................................................................................................................................ 305 Research articles Factors affecting the prevalence of chronic diseases in Palestinian people: an analysis of data from the Palestinian Central Bureau of Statistics .................................................................................................... 307 WHO MPOWER tobacco control scores in the Eastern Mediterranean countries based on the 2011 report ........................................................................................................................................................... 314 Geographic epidemiology in a small area: cancer incidence in Baakline, Lebanon, 2000–2008 ...................... 320 Antenatal depression and its predictors in Lahore, Pakistan ...................................................................................327 Physical abuse in basic-education schools in Aden governorate, Yemen: a cross-sectional study ...................... 333 Do personal beliefs and peers affect the practice of alcohol consumption in university students in Lebanon? ................................................................................................................................................ 340 Factors influencing women’s willingness to volunteer in the healthcare system: evidence from the Islamic Republic of Iran ......................................................................................................................................348 Characterization of wound infections among patients injured during the 2011 Libyan conflict ...........................356 Relation between some haematological abnormalities, degree of immunosuppression and viral load in treatment-naïve HIV-infected patients .................................................................................................362 Study of methacholine positivity in patients with chronic cough at Masih Daneshvari hospital, Tehran, 2007–08....................................................................................................................................................... 369 Renal patients’ views on generic prescribing and substitution: example from the United Arab Emirates ...........373 Review Demographics and the social reckoning in the Arab region...................................................................................382 Report Consensus recommendation for meningococcal disease prevention for Hajj and Umra pilgrimage/travel medicine ........................................................................................................................... 389 Case report A case of vocal tic: an unusual presentation of neurobrucellosis ..........................................................................393 Cover 19-4.indd 1 4/30/2013 10:22:42 AM Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico‑sanitaire, aux ONG, Centres collabora‑ teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ 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) and the ExtraMed‑Full text on CD‑ROM, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2013 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. ISSN 1020‑3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نادوسلا بونج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . South Sudan Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Soudan du Sud . Tunisie . Yémen Cover 19-4.indd 2 4/30/2013 10:22:43 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 19 No. 4 4 ددع شرع عساتلا دلجلما•  2013  • Editorial Universal health coverage Marie-Paule Kieny and David B. Evans ...............................................................................................................................................................................................................................................305 Research articles Factors affecting the prevalence of chronic diseases in Palestinian people: an analysis of data from the Palestinian Central Bureau of Statistics H.F. Abukhdeir, L.S. Caplan, L. Reese and E. Alema-Mensah ......................................................................................................................................................................................................................................307 WHO MPOWER tobacco control scores in the Eastern Mediterranean countries based on the 2011 report Gh. Heydari, F. Talischi, H. Algouhmani, H.A. Lando and A. Ebn Ahmady ..........................................................................................................................................................................314 Geographic epidemiology in a small area: cancer incidence in Baakline, Lebanon, 2000–2008 S.M. Adib, N. Tabbal, R . Hamadeh and W. Ammar .......................................................................................................................................................................................................................320 Antenatal depression and its predictors in Lahore, Pakistan A. Humayun, I.I. Haider, N. Imran, H. Iqbal and N. Humayun .................................................................................................................................................................................................327 Physical abuse in basic-education schools in Aden governorate, Yemen: a cross-sectional study A.S. Ba-Saddik and A.S. Hattab ............................................................................................................................................................................................................................................................333 Do personal beliefs and peers affect the practice of alcohol consumption in university students in Lebanon? J. Salamé, B. Barbour and P. Salameh ...................................................................................................................................................................................................................................................340 Factors influencing women’s willingness to volunteer in the healthcare system: evidence from the Islamic Republic of Iran A. Alami, S. Nedjat, R . Majdzadeh, A.R . Foroushani, S.J. Hoseini and H. Malekafzali .....................................................................................................................................................348 Characterization of wound infections among patients injured during the 2011 Libyan conflict A.A. Dau, S. Tloba and M.A. Daw ......................................................................................................................................................................................................................................................356 Relation between some haematological abnormalities, degree of immunosuppression and viral load in treatment-naïve HIV-infected patients B.A. Denue, W. Gashau, H.S. Bello, I.M. Kida, B. Bakki and B. Ajayi ......................................................................................................................................................................................362 Study of methacholine positivity in patients with chronic cough at Masih Daneshvari hospital, Tehran, 2007–08 A. Cheraghvandi, L. Fadaizadeh, S.A. Taheri and M.R. Masjedi ...............................................................................................................................................................................................369 Renal patients’ views on generic prescribing and substitution: example from the United Arab Emirates M.N. Al Ameri, W. Mohamed, E. Makramalla, B. Shalhoub, A. Tucker and A. Johnston............................................................................................................................................................................ 373 Review Demographics and the social reckoning in the Arab region N.M. Kronfol.................................................................................................................................................................................................................................................................................................382 Report Consensus recommendation for meningococcal disease prevention for Hajj and Umra pilgrimage/travel medicine A. Shibl, H. Tufenkeji, M. Khalil, Z. Memish and the Meningococcal Leadership Forum (MLF) Expert Group ......................................................................................................389 Case report A case of vocal tic: an unusual presentation of neurobrucellosis G.I. Bayhan, G. Tanır, U. Ertan and S. Bodur ....................................................................................................................................................................................................................................393 Book 19-4.indb 305 5/12/2013 2:19:24 PM Dr Ala Alwan, Editor-in-chief Editorial Board Professor Zulfiqar Bhutta Professor Mahmoud Fahmy Fathalla Professor Rita Giacaman Dr Ziad Memish Dr Sameen Siddiqi Professor Huda Zurayk International Advisory Panel Dr Mansour M. Al-Nozha Professor Fereidoun Azizi Professor Rafik Boukhris Professor Majid Ezzati Dr Zuhair Hallaj Professor Hans V. Hogerzeil Professor Alan Lopez Professor El-Sheikh Mahgoub Professor Ahmed Mandil Dr Hooman Momen Dr Sania Nishtar Dr Hikmat Shaarbaf Editors Fiona Curlet, Guy Penet Eva Abdin, Alison Bichard, Marie-France Roux Graphics Suhaib Al Asbahi, Hany Mahrous, Diana Tawadros Administration Nadia Abu-Saleh, Yasmine El Sakhawy, Yasmeen Sedky Book 19-4.indb 304 5/12/2013 2:19:25 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 305 Editorial Universal health coverage Marie-Paule Kieny 1 and David B. Evans 2 1Assistant Director-General, Health Systems and Innovation, World Health Organization, Geneva, Switzerland. 2Director, Health Systems Financing, World Health Organization, Geneva, Switzerland. Universal health coverage (UHC), sometimes called universal coverage, is the aspiration that all people obtain the health services they need without suffering financial hardship paying for them. This requires coverage with a range of promotive, preventive, cura- tive, rehabilitative and palliative services, and in particular coverage with services linked to the current health-related Mil- lennium Development Goals (MDGs) and to noncommunicable diseases and injuries. UHC is increasingly seen by countries at all income levels as an important goal for their health system development, as reflected in resolu- tions of governing bodies of the World Health Organization (WHO) (e.g. WHA 58.33 of 2005 and 64.9 of 2011;  EM/RC59/R.3 of  2012)  and  in five  recent global ministerial-level meet- ings, including a joint WHO/World Bank meeting between ministries of health and finance in Geneva in Febru- ary 2013. But UHC is also broader than health. By improving people’s health, it enables adults to work and earn an income and children obtain an educa- tion – allowing many to escape from  poverty. By protecting people from financial hardship as a result of paying for health services, it prevents oth- ers from being pushed into poverty [1]. Recognizing this, the Member States of the United Nations adopt- ed  a  resolution  in December  2012  (A/67/L.3) emphasizing  that UHC  was important to overall human development and suggesting that it should be  included  in  the post-2015  development agenda. Moving closer to UHC contrib- utes to “the enjoyment of the highest attainable standard of health” which, as stated in the WHO constitution, is “one of the fundamental rights of every human being without distinc- tion of race, religion, political belief, economic or social condition” [2]. It is  consistent with the concept of “health for all” and the Alma Ata Declaration of 1978 [3]. In addition, within the concept of UHC it is recognized that achieve- ment of the highest attainable level of health is not possible without health financing systems that guarantee financial risk protection and health systems that function appropriately. Only then can people access the health services they need secure in the knowledge that they will not suffer financial hardship as a result of paying for them. Many factors help countries move closer to UHC and help protect the gains they have already made in cover- age with needed services and financial risk protection. Social determinants –  the conditions under which people  are born, grow up, live, work and age (e.g. levels and inequalities in income, wealth, education and power structures in society) – are important [4]. For ex- ample, education helps people not only protect their own health, but to access health services when they need them. Within health systems, the World Health Report of 2010 (Health systems financing: the path to universal coverage) focused largely on health financing and more  than 80 countries have since  re- quested WHO for technical support to help modify their health financing systems to: raise sufficient funds for health;  reduce  financial  barriers  and  spread risks across the population through prepayment and pooling; and  use the available funds efficiently and equitably [5]. Other parts of the health system are also critical. Service delivery at the primary care level is crucial, ensuring access to integrated health services across all priority health problems. This requires motivated and respon- sive health workers located close to the population they service [6,7] and  adequate supplies of good quality es- sential medicines and technologies for  diagnosis  and  treatment  [8].  A  well-functioning referral system al- lowing integrated management and care supports this, as does sufficient funding for prevention and health promotion services. Systems for gen- erating evidence through research and for collating and analysing the data necessary for informed decision- making and for governing all parts of the health system complete the picture. It can be technically and politi- cally difficult to adapt all the various components of the health system at the same time while also engaging in intersectoral actions targeting the social determinants of health. Countries must themselves lead in this process, but some will also require support from the global community. Book 19-4.indb 305 5/12/2013 2:19:25 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 306 The steps that countries can take, with support from WHO where de- sired, are: • Undertake a situation analysis of UHC and identify the main obstacles and opportunities within the health system for moving closer to UHC; • Engage in inclusive policy dialogue with all stakeholders to assess policy options for moving closer to UHC or maintaining existing gains; • Develop and implement holistic strategies and plans for health sys- tems strengthening to move closer to UHC;  • Engage in intersectoral action de- signed to encourage health-in-all policies for UHC, focusing on the areas that are likely to have the biggest impact first; • Monitor, evaluate and adapt plans and strategies as necessary. People cannot enjoy the greatest attainable level of health, or live long, dignified, healthy, and productive lives without being able to use the health 1. Evans DB, Marten R, Etienne C. Universal health coverage is a development issue. Lancet, 2012, 380(9845):864–865. 2. Constitution of the World Health Organization. Geneva, World Health Organization, 1948. 3. World Health Organization and United Nations Children’s Fund. Declaration of Alma Ata. In: Primary health care. Re- port of the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978. Geneva, World Health Organization, 1978. 4. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health: final report of the Commission on Social Determinants of Health. Geneva, World Health Organi- zation, 2008. 5. The world health report 2010. Health systems financing: the path to universal coverage. Geneva, World Health Organiza- tion, 2010. 6. Kuehn BM. Global shortage of health workers, brain drain stress developing countries. Journal of the American Medical Association, 2007, 298(16):1853–1855. 7. Henderson LN, Tulloch J. Incentives for retaining and moti- vating health workers in Pacific and Asian countries. Human Resources for Health, 2008, 15:6. 8. Millenium Development Goal 8. Delivering on the global partnership for achieving the Millenium Development Goals. MDG Gap Task Force Report 2008. New York, United Nations, 2008:35–43. References services they need. They cannot use these services if financial barriers threat- en them with financial ruin each time they seek care. People want the assur- ance that good quality health services are available and affordable, the aspira- tion of UHC. Moving closer to UHC is not a dream. Momentum is building and increasingly countries at all income levels are developing strategies and policies to move forward and make progress towards UHC. Book 19-4.indb 306 5/12/2013 2:19:25 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 307 Factors affecting the prevalence of chronic diseases in Palestinian people: an analysis of data from the Palestinian Central Bureau of Statistics H.F. Abukhdeir, 1 L.S. Caplan, 1 L. Reese 1 and E. Alema-Mensah 1 ABSTRACT This study determined whether there are significant differences in the prevalence of diabetes, hypertension, cardiovascular disease (CVD) and cancer among Palestinians with respect to different demographic variables using secondary data from the Palestinian Central Bureau of Statistics. Living in the Gaza Strip was a protective factor, with this group being 21% less likely to have diabetes, 35% less likely to have hypertension, and 48% less likely to have CVD than those living in the West Bank. No significant difference was found for cancer. Being a refugee was a significant risk factor for diabetes and CVD while being married/engaged or divorced/ separated/widowed was a risk factor for diabetes and hypertension. Gender was a risk factor for hypertension with females being 60% more likely to have hypertension than males. Living in a rural setting was protective against hypertension. As expected, age was a risk factor for diabetes, hypertension and CVD; the magnitude of this increased risk was alarming, 36 to 434 times greater in those aged 40–65 years compared with those aged 0–19 years. 1Morehouse School of Medicine, Atlanta, Georgia, United States of America (Correspondence to H.F. Abukhdeir: heshamabukhdeir@gmail.com). Received: 19/06/11; accepted: 11/02/11 ءاصحلإل ينيطسلفلا يزكرلما بتكلما نم ةدمتسلما تانايبلل ليلتح :ينينيطسلفلا ينب ةنمزلما ضارملأا راشتنا لدعم لىع رثؤت يتلا لماوعلا اسنم مايلأ تسنريإ ،سير يورل ،نلاباك لي ،يرضخ وبأ يمهف ماشه ضرلماو ،مدلا طغض عافتراو ،يركسلا راشتنا لدعم في ًايئاصحإ ابه ُّدَتْعُي تافلاتخا ة َّمث ناك اذإ ام لىع ف ُّرعتلا لىإ ةساردلا هذه فدته :ةـصلالخا يزكرلما بتكلما نم ةدمتسلما ةيوناثلا تانايبلا مادختساب كلذو ،ةفلتخلما ةيفارغوميدلا تايرغتلماب اهتقلاعو ،ينينيطسلفلا ينب ،ناطسرلاو ،يئاعولا يبلقلا نع عاطقلا في شيعت يتلا ةعومجلما ةباصإ تلاماتحا لقت ْذإ ،ةياقولا نمضي لماع وه ةزغ عاطق في شيعلا نأ ينثحابلل َّينبت دقو .ءاصحلإل ينيطسلفلا نوثحابلا ديج لمو .%48 رادقمب ةيعولأاو بلقلا ضارمأبو ،%35 رادقمب مدلا طغض عافترابو ،%21 رادقمب يركسلاب ةيبرغلا ةفضلا في شيعي نم ةباصإ .يئاعولا يبلقلا ضرلماو يركسلل ةبسنلاب هب ّدتعُي راطتخا لماع لثمي ناك ًائجلا ءرلما نوك نأ ظِحوُلو .ناطسرلاب قلعتي ام في ًايئاصحإ هب ُّدَتْعُي ًافلاتخا نم ردنلجا ناكو .مدلا طغض عافتراو ،يركسلاب ةباصلإل ًايئاصحإ ابه ُّدَتْعُي يتلا راطتخلاا لماوع نم تناك لمترلاو قلاطلاو ةبوطلخاو جاوزلا نأ ماك عقاولما في شيعلا نإ مث .مدلا طغض عافتراب ةباصلإل روكذلا نم %60 رادقمب رثكأ تاض َّرعم ثانلإا نإ ْذإ ،مدلا طغض عافتراب ةباصلإل راطتخلاا لماوع نأ لاإ ،ةيعولأاو بلقلا ضارمأو مدلا طغض عافتراو يركسلا راطتخا لماوع دحأ رمعلا نإف ،عقوتلما وه ماكو ،مدلا طغض عافترا نم ًايئاقو ًلاماع ناك ةيفيرلا .ًاماع 19-0 رمع في مه نمب ًةنراقم هيلع وه ام فعض 434 - 36 لىإ ًاماع 65-40 رمع في مه نم ىدل لصو ذإ ؛ريذحتلل ًايرثم ناك راطتخلاا لدعم في دايدزلاا Facteurs affectant la prévalence des maladies chroniques dans la population palestinienne : analyse des données du Bureau central palestinien des statistiques RÉSUMÉ La présente étude a déterminé l'existence ou l'absence de différences significatives dans la prévalence du diabète, de l'hypertension, des maladies cardio-vasculaires et du cancer chez les Palestiniens par rapport à différentes variables démographiques, à l'aide de données secondaires du Bureau central palestinien des statistiques. Vivre dans la Bande de Gaza était un facteur de protection, car ce groupe avait 21 % moins de risque d'avoir un diabète, 35 % moins de risque de souffrir d'hypertension et 48 % moins de risque d'être atteint d'une maladie cardio-vasculaire que la population cisjordanienne. Aucune différence significative n'a été observée pour le cancer. Être un réfugié représentait un facteur de risque pour le diabète et les maladies cardio-vasculaires, alors que le fait d'être marié/fiancé ou divorcé/ séparé/veuf était un facteur de risque pour le diabète et l'hypertension. Être une femme était un facteur de risque pour l'hypertension, celles-ci étant 60 % plus susceptibles d'en souffrir que les hommes. Vivre en milieu rural était un facteur de protection contre l'hypertension. Comme on pouvait s'y attendre, l'âge était un facteur de risque pour le diabète, l'hypertension et les maladies cardio-vasculaires ; l'ampleur de ce risque était alarmante : les Palestiniens âgés de 40 à 65 ans présentaient un risque 36 à 434 fois plus élevé que ceux âgés de 0 à 19 ans pour ces trois problèmes de santé. Book 19-4.indb 307 5/12/2013 2:19:25 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 308 Introduction There  are  currently  3  separate  com- munities of Palestinians: those living in the West Bank, those living in the Gaza Strip, and those living in Israel. Palestin- ians living in Israel are under Israeli rule, while those living in the West Bank and Gaza Strip are under Fatah and Hamas rule respectively. Fatah and Hamas have separate health care systems to pro- vide medical care to their citizens. The disease epidemiology of Palestinians is undergoing rapid change as noncom- municable diseases such as diabetes, hypertension, cardiovascular disease (CVD) and cancer are replacing com- municable diseases as the main causes of morbidity and mortality [1]. Due to the unavailability of data on Palestinians living in Israel, this study compared Palestinians living in the West Bank and the Gaza Strip. These 2  groups are in fact 1 population separat- ed by geographic and political bounda- ries. The differences between them with respect to overall quality of health have never been examined extensively. This study compared the effect of a number of factors, including location, on the prevalence of chronic diseases in Palestinians living in the Gaza Strip and the West Bank using data from the Palestinian Central Bureau of Statistics. Methods This study used existing data sets to describe the current health status of the Palestinian people across 2 distinct en- vironmental contexts. Secondary data from the Palestinian Central Bureau of Statistics [2] were obtained. The data had been collected using cross-sectional surveys to gather general health in- formation on the populations of the Palestinian territories. The surveys con- tained questions asking respondents whether they had been diagnosed with certain diseases, including diabetes, hypertension, CVD, and cancer. The survey questionnaire was designed to be answered by a head of household, who provided information for all other family members. In the absence of the head of household, the person with the highest authority in the household was interviewed. The target population of the Pales- tinian Central Bureau of Statistics survey was all Palestinian households within the West Bank and the Gaza Strip. The sampling  frame was 260 enumerated  areas constructed from the Population, Housing, and Establishment Census 1997 [3]. These enumerated areas were  geographic regions similar in size, each containing  an  average of  150 house- holds. The enumerated areas were divided into smaller units called cells containing an average of 25 households,  with 1 cell per enumerated area being surveyed. For the part of Jerusalem that was  annexed by  Israel  after  the 1967  war, 30 households were selected from  each enumerated area. Interviews were carried out by mobile teams between 20  May 2004 and 7 July 2004.  The number of households in the sample was  6574:  4456  in  the West  Bank and 2118  in  the Gaza Strip. The  response  rates  for  the 2  regions were  84.1% and 96.9% respectively [2]. Statistical analysis The dependent variables in this study were presence or absence of diabetes, hypertension, CVD and cancer. The independent variables included region, sex, returnee status, refugee status, school attendance status, educational attainment, labour force status, smoking status, number of cigarettes smoked daily, marital status, locality type, age grouping, and type of health insurance. Region defined where the respond- ent lived and was categorized into the West Bank and the Gaza Strip. Returnee status defined those surveyed as being a returnee or a non-returnee. A returnee is someone who returned to Palestine after moving to another country during times of war. Educational attainment was a measure of the level of education attained by the respondent. Locality type (domicile) was categorized as ur- ban, rural, and refugee camp. Age was categorized  into young people (0–19  years),  young  adults  (20–39  years),  older adults (40–64 years) and seniors  (65+ years).  Frequency distributions were run on each of these variables to ensure they were representative of the popula- tion. Bivariate analyses were performed comparing each of the independent variables with each of the dependent variables, and chi-squared analysis was used to determine any statistically sig- nificant associations. The results were used to guide the selection of independent variables to be included in the logistic regression models, which were constructed to determine the effects of each of the in- dependent variables on the prevalence of diabetes, hypertension, CVD and cancer, controlling for all the other vari- ables in the models. All analyses were conducted using SPSS, version 17.0. P < 0.05 was consid- ered statistically significant. Results The prevalence of diabetes, hyperten- sion, CVD and cancer are shown in Figure 1. People living in the Gaza Strip were less likely to have diabetes, hyper- tension and CVD than those living in the West Bank. Table 1 shows the results of the bivariate analyses performed for dia- betes, hypertension, CVD and cancer. Females were more than twice as likely to have hypertension as males and were also more likely to have diabetes. Those who had never attended school were about 3  to 4  times more  likely  to have  diabetes, hypertension and CVD and twice as likely to have cancer as those who attended school and either dropped out or graduated. Those who were illiterate were 4 or more times Book 19-4.indb 308 5/12/2013 2:19:25 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 309 than males. Non-refugees were  33%  less likely to have diabetes and 46% less  likely to have CVD than refugees. Full time  students were 90%  less  likely  to  have hypertension and 80%  less  likely  to have CVD than unemployed people. People involved full-time in household chores were  about 25%  less  likely  to  have diabetes and hypertension and 37%  less  likely  to have CVD. People  living in the Gaza strip were about 21%  less  likely  to  have  diabetes,  35%  less  likely  to have hypertension,  and 48%  less likely to have CVD than people living in the West Bank. Being married/engaged was shown to be a significant risk factor for diabetes and hypertension, with the odds of each of  these diseases being  about 2.9  and  2.6 times as high, respectively compared  with single people. The odds of having diabetes and hypertension were over 3.5 times as high in divorced/widowed/ separated as in single people, and this was statistically significant (P < 0.0001).  Those living in a rural setting were 23%  less  likely  to have hypertension.  The odds of diabetes, hypertension and CVD tended to increase with increasing age. Having Ministry of Health insur- ance was a significant risk factor for diabetes and CVD and having Israeli health insurance was a significant risk factor for diabetes and hypertension, while having Social Welfare Health in- surance was a significant risk factor for diabetes, hypertension, and CVD. Discussion This study was unique in that it focused on comparing the Palestinians living in the West Bank and the Gaza Strip as 2  different entities, as opposed to lumping all the Palestinians together. Husseini et al.’s study on cardiovascular diseases, diabetes mellitus, and cancer did give some prevalence statistics comparing the Gaza Strip and the West Bank, but they were limited to people over 40 years  who were registered refugees [1]. Given the fact that each region is controlled by a different political party and that the effects of this extend all the way to the health systems, it seems more appropri- ate to consider the 2 groups separately.  Our results showed significant dif- ferences in the prevalence of cancer, hypertension, CVD and diabetes be- tween Palestinians living in the Gaza Strip and those in the West Bank, with those living in the Gaza Strip having a lower prevalence of all 4 diseases. Fur- ther studies are required to understand these findings because data from the Food and Agriculture Organization of the United Nations (2003)  state  that  the Gaza Strip has a higher rate of food insecurity, is poorer, and has an overall lower socioeconomic status [4]. Being a refugee tended to be a risk factor, as would be expected. Refugees often live with poor housing conditions, which are not favourable to long term healthy outcomes [5]. Smoking is a proven risk factor for diabetes, CVD, and cancer and is associ- ated with hypertension, so its protective effect against hypertension in this study is surprising [4]. Smoking in this culture has many different uses. For many peo- ple, it is way to feel accepted, or to show off, or is a response to peer pressure more likely to have diabetes, hyperten- sion, CVD and cancer than those with higher levels of educational attainment. Those who were unemployed were at least 3  times more  likely  to have all 4  diseases compared to employed people. Ex-smokers were about 4 times more likely to have diabetes, 3 times as likely  to have hypertension, 7 times as likely to  have CVD, and 7 times as likely to have  cancer as those who had never smoked. Prevalence of all 4 diseases increased in those who smoked at least 40 cigarettes  a day. Those who were divorced/wid- owed/separated were many times more likely to have diabetes, hypertension or CVD than those in the other marital status categories and 50  times as  likely  to have cancer as single people. Seniors were about twice as likely to have diabe- tes, hypertension, and cancer and about 3.5 times more likely to have CVD than  older adults, who were in turn much more likely to have these diseases than those under 40 years old.  Table  2  shows  the  results  of  the  multivariate modelling using logistic regression. None of the variables for cancer were statistically significant, thus, only the results for diabetes, hyperten- sion and CVD are shown. Females were 60% more  likely  to have hypertension  2.8 3.9 1.6 0.1 1.9 2.4 0.9 0.1 0 0.5 1 1.5 2 2.5 3 3.5 4 Diabetes Hypertension CVD Cancer Pr ev al en ce (% ) Disease Figure 1 Disease Prevalence in the West Bank and the Gaza Strip, 2004 West Bank Gaza Strip Diabetes Hypertension CVD Cancer West Bank Gaza Strip Disease Pr ev al en ce (% ) 4 3.5 3 2.5 2 1.5 1 0.5 0 Figure 1 Disease prevalence in the West Bank and the Gaza Strip, 2004 (CVD = cardiovascular disease) Book 19-4.indb 309 5/12/2013 2:19:26 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 310 Table 1 Bivariate analyses of diabetes, cardiovascular disease (CVD), and cancer according to selected variables Factor Diabetes Hypertension CVD Cancer No. % No. % No. % No. % Region West Bank 570 2.8 802 3.9 337 1.6 21 0.1 Gaza Strip 247 1.9 306 2.4 112 0.9 13 0.1 P-value 0.0001 0.0001 0.0001 0.981 Sex Male 374 2.2 367 2.2 214 1.3 19 0.1 Female 443 2.7 741 4.5 235 1.4 15 0.1 P-value 0.005 0.0001 0.205 0.54 Returnee status Returnee 16 3.4 20 4.2 7 1.5 3 0.6 Non-returnee 801 2.4 1088 3.3 442 1.3 31 0.1 P-value 0.201 0.289 0.821 0.013 Refugee status Refugee 365 2.6 471 3.3 208 1.4 19 0.1 Non-refugee 452 2.4 637 3.4 241 1.3 15 0.1 P-value 0.318 0.754 0.148 0.128 School attendance status Currently attending school 10 0.1 7 0.1 12 0.1 3 0.01 Attended school and dropped out 292 4.4 379 5.7 148 2.2 10 0.2 Attended school and graduated 247 3.7 311 4.6 113 1.7 11 0.2 Never attended school 263 11.1 409 17.3 165 7.0 9 0.4 P-value 0.0001 0.0001 0.0100 0.0001 Educational attainment Illiterate 268 16.9 418 26.3 165 10.4 7 0.4 Can read or write 140 4.0 179 5.1 77 2.2 5 0.1 Elementarya 161 2.7 211 3.6 85 1.4 4 0.1 Preparatoryb 106 1.7 128 2.0 48 0.8 6 0.1 Secondary 61 1.7 84 2.3 27 0.7 2 0.1 Intermediate associated level diplomac 39 4.1 46 4.9 14 1.5 3 0.3 Bachelor degree 34 2.5 39 2.9 14 1.0 2 0.1 P-value 0.0001 0.0001 0.0001 0.008 Work statusd Employed 151 2.9 164 3.1 57 1.1 7 0.1 Unemployed 371 9.3 480 12.0 252 6.3 15 0.4 Full-time student 4 0.01 1 0.01 4 0.01 1 0.01 Involved full time in household chores 283 4.9 460 7.9 117 2.0 6 0.1 P-value 0.0001 0.0001 0.0001 0.0001 Smoking statusd Mostly cigarettes 130 3.5 119 3.2 70 1.9 9 0.2 Mostly pipe/hookah 17 5.4 28 8.9 9 2.9 1 0.3 Ex-smoker 74 12.1 76 12.4 67 10.9 4 0.7 Never smoked 588 3.2 882 4.7 284 1.5 15 0.1 P-value 0.0001 0.0001 0.0001 0.0001 Book 19-4.indb 310 5/12/2013 2:19:26 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 311 [6].  It  is  also used  as  an  escape  from  everyday life, a stress reliever. This may explain its surprisingly protective effect on hypertension, as those who smoke may use it as psychological escape from their troubles [6]. Few people see it as a  risk factor owing to the number of older people who smoke. They do not real- ize that these long-time smokers have health problems. Being an ex-smoker was associated with a higher prevalence for CVD. Ex- smokers may have had additional stress as a result of their quitting, and they may have begun eating as an outlet for their addiction. Being an ex-smoker was associated with a higher prevalence for CVD. Smoking cessation has been linked to an increase in obesity and diabetes, both of which are risk factors for CVD [7]. These findings could be  the focus of a new study in the region dealing with the perceptions of smoking and its repercussions. Being married has been shown to be a protective factor for cancer and CVD [8]. Considering  that hyperten- sion and diabetes are predisposing factors to CVD and some types of cancer, presumably, marriage would Table 1 Bivariate analyses of diabetes, cardiovascular disease (CVD), and cancer according to selected variables (concluded) Factor Diabetes Hypertension CVD Cancer No. % No. % No. % No. % No. cigarettes/day (n = 130 ≤ 10 25 3.0 23 2.8 14 1.7 2 0.2 11–20 54 2.8 43 2.3 25 1.3 4 0.2 21–40 41 4.8 44 5.2 25 2.9 3 0.4 40+ 10 6.3 9 5.7 6 3.8 0 0 P-value 0.01 0.001 0.008 0.824 Marital statuse Single 20 0.2 34 0.4 25 0.3 2 0.01 Engaged/married 624 5.5 784 7.0 299 2.7 22 0.2 Divorced/ widowed/separated 163 17.7 287 31.2 106 11.5 5 0.5 P-value 0.0001 0.0001 0.0001 0.0001 Locality type Urban 472 2.6 654 3.5 243 1.3 22 0.1 Rural 210 2.3 291 3.2 140 1.5 3 0.01 Camp 135 2.4 163 2.9 66 1.2 9 0.2 P-value 0.351 0.035 0.182 0.034 Age group (years) Young people (0–19) 12 0.1 5 0.01 23 0.1 6 0.01 Young adults (20–39) 47 0.5 77 0.8 31 0.3 3 0.01 Older adults(40–64) 510 11.4 633 14.1 204 4.5 16 0.4 Senior (65+) 248 20.9 393 33.1 191 16.1 9 0.8 P-value 0.0001 0.0001 0.0001 0.0001 Type of health insurance Ministry of Health 322 2.9 402 3.7 184 1.7 12 0.1 Military 25 1.8 26 1.9 8 0.6 2 0.1 UNRWA 211 2.1 273 2.7 121 1.2 9 0.1 Social welfare/elderly 52 6.2 89 10.6 35 4.2 3 0.4 Israeli 72 3.7 97 5.0 24 1.2 4 0.2 Private/from abroad 14 2.4 15 2.6 8 1.4 1 0.2 None 120 1.6 204 2.7 67 0.9 3 0.01 P-value 0.0001 0.0001 0.0001 0.086 aIncludes kindergarten through 5th grade; children under 5 years old not included. bIncludes 6th through 8th grade. cA 2-year degree awarded after secondary school. dIncludes only those aged ≥ 10 years. eIncludes only those aged ≥ 12 years.. Book 19-4.indb 311 5/12/2013 2:19:27 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 312 have similar protective effects against them. We found that people who were married/engaged were almost 3  times  as likely and that people who were separated, divorced, or widowed were almost 4 times as likely to have diabetes and hypertension as single individuals The impact of marriage, divorce, and the lifestyles associated with them on chronic diseases is an area of study that requires more investigation and is out of scope for this paper. Table 2 Logistic regression predictor model for region, refugee status, mid age groupings Factor Diabetes Hypertension CVD Adjusted for all variables OR (95% CI) Adjusted for all variables OR (95% CI) Adjusted for all variables OR (95% CI) Region West Bank 1.000 1.000 1.000 Gaza Strip 0.785 (0.658–0.936)** 0.646 (0.548–0.762)**** 0.522 (0.411–0.662)**** Sex Male 1.000 1.000 1.000 Female – 1.585 (0.269–1.980)**** – Refugee status Refugee 1.000 1.000 1.000 Non-refugee 0.658 (0.552–0.784)**** – 0.539 (0.428–0.677)**** Work status Unemployed 1.000 1.000 1.000 Employed 0.519 (0.418–0.646)**** 0.548 (0.443–0.678)**** 0.339 (0.247–0.465)**** Full-time student – 0.100 (0.014–0.733)* 0.207 (0.074–0.583)** Involved full time in household chores 0.782 (0.651–0.938)** 0.751 (0.606–0.930)** 0.630 (0.491–0810)**** Smoking status Never smoked 1.000 1.000 1.000 Mostly cigarettes – 0.538 (0.428–0.676)**** – Mostly pipe/hookah – 1.571 (1.001–2.466)* – Ex-smoker – 2.603 (1.920–3.529)**** Marital status Single 1.000 1.000 1.000 Married/engaged 2.918 (1.825–4.666)**** 2.634 (1.800–3.854)**** – Divorced/widowed/ separated 3.631 (2.195–6.008)**** 3.735 (2.492–5.597)**** – Locality type Urban 1.000 1.000 1.000 Rural – 0.777 (0.657–0.920)** – Age group (years) Young people (0–19) 1.000 1.000 1.000 Young adult (20–39) 4.783 (2.269–10.083)**** 14.511 (5.522–38.132)**** 3.186 (1.810–5.608)**** Older adult (40–64) 89.878 (43.338–186.397)**** 209.604 (80.631–544.878)**** 35.655 (22.254–57.126)**** Senior (65+) 138.141 (65.978–289.231)**** 433.597 (166.186–1131.302)**** 95.047 (59.819–151,021)**** Type of health insurance None 1.000 1.000 1.000 Ministry of Health 1.563 (1.302–1.877)**** – 1.607 (1.277–2022)**** Social Welfare 1.708 (1.225–2.381)** 2.049 (1.546–2.716)**** 1.958 (1.316–2.913)*** Israeli 1.819 (1.362–2.428)**** 1.406 (1.087–1.818)** – *P < 0.05; **P < 0.01; ***P < 0.001; ****P < 0.000l. – = not statistically significant. CVD = cardiovascular disease; OR = odds ratio; CI = confidence interval. Book 19-4.indb 312 5/12/2013 2:19:27 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 313 We found that living in a rural envi- ronment was protective against hyper- tension. Living in a rural environment allows for an easier ability to grow food and cost of living is lower [9]. Meat is not the primary source of protein as it is expensive. These slightly better living conditions could be the reason for the protective effect. Having any type of health insurance was associated with a higher prevalence of all diseases. However, it does not seem plausible that a person without health insurance would pay out of pocket on a consistent enough basis to be diagnosed with a chronic disease. Even if this were the case, it is a very difficult assumption to make for every person without health insurance, which would be necessary for this result to be accurate. The latter would also have to be true: those with insurance have to be getting consistent enough care to be diagnosed with a chronic disease. A questionnaire accompanied by medical tests would clear up many of these ques- tions and should be the goal for future studies.” As would be expected, older peo- ple had higher disease prevalence than younger people for all 3 diseases. How- ever, the degree to which being older was a risk factor was quite alarming, with  those aged 40–65 years and over  being anywhere  from 36  to 434  times  as  likely as people aged 0–19 years  to  have diabetes, hypertension, or CVD. This, coupled with the fact that qual- ity of health care has been decreasing since 2000 is very frightening for this age  group [10].  A major strength of this study was that it compared Palestinians living in the Gaza Strip and the West Bank and identified the possible presence of health disparities between them. A limitation of the study was that it was limited to prev- alence, as opposed to incidence data, which limited the ability to assess the risk of disease associated with potential risk factors. Another limitation was that disease data were obtained through self- reporting of medical diagnoses, which could have introduced reporting errors that might have biased the data. Despite the limitations, this study had a number of interesting results and can form the basis for future studies. In addition, it would be useful to include Palestinians living in Israel proper. Acknowledgement This study was part of the Master of Public Health thesis of H.F. Abukhdeir, “Palestinian public health: the effects of regional location on the prevalence of diabetes, hypertension, cardiovascular disease, and cancer”, Master of Public Health Program, Morehouse School of Medicine. References 1. Husseini A et al.Cardiovascular diseases, diabetes mellitus, and cancer in the occupied Palestinian territory. Lancet, 2009, 373:1041–1049. 2. Demographic and health survey, 2004: main findings. Ramallah, Palestine, Palestinian Central Bureau of Statistics, 2005. 3. Population, housing and establishment census 1997: marital characteristics in the Palestinian Territory. Ramallah, Palestine, Palestinian Central Bureau of Statistics, 2000. 4. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. 5. Al-Khatib I A, Tabakhna H. Housing conditions and health in Jalazone Refugee Camp in Palestine. Eastern Mediterranean Health Journal, 2006, 12(1–2):144–152. 6. Smoking and Associated Factors, in the Occupied Palestinian Territory. Birzeit, Palestine, Birzeit University, Institute of Com- munity & Public Health, 2010. 7. Chiolero A et al. Consequences of smoking for body weight, body fat distribution, and insulin resistance. American Journal of Clinical Nutrition, 2008, 87:801–9. 8. Jaffe D et al. The protective effect of marriage on mortality in a dynamic society. Annals of epidiomiology, 2007, 17(7):540–547. 9. Report of the food security assessment West Bank and Gaza Strip. Rome, Food and Agriculture Organization of the United Na- tions & World Food Programme, 2003. 10. Mataria A et al. The health-care system: an assessment and reform agenda. Lancet, 2009, 373(9670):1207–1217. Book 19-4.indb 313 5/12/2013 2:19:27 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 314 WHO MPOWER tobacco control scores in the Eastern Mediterranean countries based on the 2011 report Gh. Heydari,1,2 F. Talischi,2 H. Algouhmani,3 H.A. Lando 4 and A. Ebn Ahmady 5 ABSTRACT The aim of this cross-sectional study was to quantify the implementation of MPOWER tobacco control policies among Eastern Mediterranean Region countries. Information was obtained from the 2011 WHO MPOWER report. A checklist was designed and its scoring was agreed by Iranian and international tobacco control specialists. Seven questions were scored from 0–4 and 3 from 0–3. The 22 countries were ranked by their total score on a scale of 0 to 37. The highest scores were achieved by the Islamic Republic of Iran, Egypt and Jordan 29, 28 and 26 respectively. Twelve of the countries (55%) scored more than half of the possible score (19). The lowest and highest scores for all countries summed were on sections related to banning smoking in public places (18) and tobacco advertising bans (66) respectively. Compliance with smoke-free policies was especially low. MPOWER programmes are accepted in the Region but there is considerable room for improvement. Input from countries based on their successes and challenges is needed to strengthen the programmes. 1Tobacco Prevention and Control Research Center; 2National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran . 3Framework Convention Alliance (FCA), Tehran, Islamic Republic of Iran. 4Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, United States of America. 5Community Oral Health Department, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to A. Ebn Ahmady: a.ebnahmady@sbmu.ac.ir; aebnahmady@yahoo.com). Received: 21/11/11; accepted: 21/02/12 لىع طسوتلما قشر ميلقإ نادلب في غبتلا ةحفاكم في MPOWER ةيسادسلا ةيلماعلا ةحصلا ةمظنم ةسايس اتهزرحأ يتلا تاجردلا 2011 ريرقت ساسأ يدحمأ نبا وزرآ ،ودنل .آ يره ،نياهمولجا نياه ،يجسيلت ةزويرف ،يرديح اضرملاغ لصح دقو .طسوتلما قشر ميلقإ نادلب في ةيسادسلا غبتلا ةحفاكم تاسايس ذيفنت ةجرد لىع فرعتلا ةضرعتسلما ةساردلا هذه نم فدلها ناك :ةـصلالخا ةقفاوم لىع اهُزارحأ تزاح ةيد ُّقفت ةمئاق اوممصف ،2011 ماع MPOWER ةتسلا تاسايسلا لوح ةيلماعلا ةحصلا ةمظنم ريرقت نم تامولعلما لىع نوثحابلا .0-3 نم اهُزارحأ حواترت ةلئسأ ةثلاثو ،0-4 نم اهُزارحأ حواترت ةلئسأ ةعبس لىع ةمئاقلا تلمتشاو .غبتلا ةحفاكم في ينيلودلاو ينيناريلإا ينيصاصتخلاا دق ةيملاسلإا ناريإ ةيروهجم نأ َّينبتو ،0-37 نم حواتري لامج نمض اتهزرحأ يتلا ةيلاجملإا )تاجرد( زارحلأل ًاقفو ًادلب 22 اهددعو نادلبلا عيزوت متو ضفخأ نأو ،)19( ةنكملما زارحلأا فصن نم رثكأ تزرحأ )%55( ًادلب شرع ينثا نأو .)26( ندرلأاو )28( صرم بناج لىإ )29( زارحلأا لىعأ تققح نأو ،)66( غبتلا نع نلاعلإا رظح تلاامج في اهلاعأ نأو ،)18( ةماعلا نكاملأا في غبتلا رظحب قلعتت يتلا تلااجلما في تناك نادلبلا عيجم في زارحلأا ،ميلقلإا في لوبقلاب MPOWER ةيسادسلا تاسايسلا جمارب ىظتحو .لاجملإا هجو لىع ةضفخنم تناك ةصاخ غبتلا نم ر ُّرحتلا تاسايسل لاثتملاا زارحأ .جمابرلا كلت زيزعت لجأ نم ،نادلبلا هذه في تايدحتلاو تاحاجنلا ساسأ لىع ،نادلبلا لَبِق نم ماهسلإاو ينسحتلا نم ديزلما قيقتح بولطلما نأ لاإ Scores MPOWER OMS pour la lutte antitabac dans les pays de la Méditerranée orientale issus du rapport 2011 RÉSUMÉ La présente étude transversale visait à évaluer la mise en œuvre des politiques de lutte antitabac MPOWER dans les pays de la Région de la Méditerranée orientale. Les informations ont été obtenues à partir du rapport MPOWER de 2011 de l'Organisation mondiale de la Santé. Une liste de vérification a été élaborée et sa notation a été décidée en accord avec des spécialistes de la lutte antitabac internationaux et iraniens. Sept questions ont été notées sur une échelle allant de 0 à 4 et trois questions sur une échelle de 0 à 3. Les 22 pays ont été classés en fonction de leur score total sur une échelle allant de 0 à 37. Les scores les plus élevés ont été obtenus par la République islamique d'Iran (29), l'Égypte (28) et la Jordanie (26). Douze pays (55 %) ont obtenu des scores supérieurs à la moitié du score maximal (19). Les scores les plus faibles et les plus élevés cumulés pour l'ensemble des pays concernaient l'interdiction de fumer dans les lieux publics (18) et l'interdiction de la publicité en faveur du tabac (66). Le respect des politiques d'interdiction du tabagisme était particulièrement faible. Le programme MPOWER est accepté dans la Région mais beaucoup d'améliorations peuvent encore être apportées. Il est souhaitable que les pays mettent en commun leurs succès et leurs difficultés en la matière pour renforcer les programmes. Book 19-4.indb 314 5/12/2013 2:19:27 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 315 Introduction There is ample and indisputable evi- dence of the dangers of tobacco smok- ing  [1–10]. Tobacco use  kills  half  of  those who smoke [2] and  it decreases  life expectancy on average by 15 years  [2–4]. Worldwide  5 million  people  currently die from tobacco every year [1]. Without effective tobacco control measures, it is estimated that by the year 2030  the annual  global death  toll will  reach 8 million  [1,5].  In  the  absence  of effective tobacco control measures, consumption is likely to increase in many countries [11]. Indeed, develop- ing countries are facing an increased prevalence of tobacco consumption, but unlike developed countries have not yet faced the full burden of result- ing  illness and morbidity [5,7].  In our  Region, according to the latest data, smoking prevalence is still increasing or has plateaued [8].  To counter the global tobacco epidemic, the World Health Organi- zation (WHO) developed the WHO Framework Convention on Tobacco Control (WHO FCTC) to provide new legal dimensions for international health cooperation. As of 12 February  2012 the treaty has been ratified by 174  parties who wish to decrease the sup- ply  and  demand  of  tobacco  [12].  In  this regard, WHO introduced a pack- age of measures under the acronym of MPOWER with the aim of reducing tobacco consumption and prevalence [13]. This package focuses on 6 proven  policies for tobacco control to reduce consumption which include: monitor- ing tobacco use and prevention poli- cies, protecting people from tobacco smoke, offering help to quit tobacco use, warning about the dangers of tobacco, enforcing bans on tobacco advertising, promotion and sponsorship, and raising taxes on tobacco. Several scoring systems have been developed in different countries to evaluate anti-tobacco activities and their implementation. Gilpin and colleagues developed an index for the United States (US) state tobacco control outcomes based on cigarette prices and workplace and home smoking bans [14]. Chriqui and  colleagues  [15]  applied  a  rating  system to state indoor air laws in the US, and the American Lung Associa- tion measures tobacco control activities at the state level based on spending, smoke-free air laws, cigarette excise tax and youth access laws [16]. Jossens and  Raw developed a tobacco control scale according to a World Bank list of effec- tive tobacco control interventions and applied  it  to  30  European  countries  [17]. Their initial results showed coun- tries ranked by their score and discussed the merits and limitations of the scale. No such study has been done in the Eastern Mediterranean Region. Thus the aim of our study was to compare MPOWER Programnes among the countries of the WHO Eastern Medi- terranean Region to highlight what has been achieved and what still needs to be addressed by the countries to strength- en these programmes. Methods This was a cross-sectional study with collection of information from the WHO programme of tobacco preven- tion in the EMR countries found on pages  1–140,  9–128,  7–116,  3–102  from the MPOWER 2011 report [18]. A checklist of indicators was initially designed by Iranian and international tobacco control specialists and its cut- offs were set according to the scoring key sections of the MPOWER 2011 re- port. In order to score the checklist and create the scale, we convened a panel of experts [including 3 tobacco control  experts, 1 public health specialists and 1 epidemiologist from the Tobacco Pre- vention and Control Research Center, National Research Institute of Tuber- culosis and Lung Disease (NRITLD), Tehran] to determine the allocation of points  to  the  scale. Thus, 7 questions  were scored from 0–4 and 3 from 0–3,  giving a maximum possible score of 37. Five raters (medical doctors from the Tobacco Prevention and Control Re- search Center, NRITLD) were selected by the principle investigators. They went through a lengthy training process conducted by 1 experienced tobacco control expert (Head, Tobacco Pre- vention and Control Research Center) and 1 experienced rater (medical doc- tor from the Tobacco Prevention and Control Research Center). The train- ing involved reading about the tobacco control policies that were the focus of the study and the scoring section of the MPOWER 2011 report. After the train- ing and considered ready by the project coordinator, the raters carried out the subject review and their first scoring report was observed by the experienced rater. The reports were observed again by the project coordinator, who selected 2 final raters and determined when they  were ready to work alone. In order to achieve and maintain cal- ibration between the 2 raters, the project  coordinator gave them with 1 subject to report independently. Statistical analysis of the reliability of their ratings was used to maintain acceptable levels of reliabil- ity for the study. A correlation coefficient of 0.80 was calculated between these 2  raters. Data entry was done indepen- dently by the first selected rater and was checked  by  the  second. At  least  2  of  these reports were selected randomly and observed in order to monitor their rating against those made by the original coordinator, the tobacco control expert and the experienced rater. The scores were summed and the rankings were computed. The checklist, with its scoring and scale, is shown in Table 1. Results We uncovered large differences in scores across EMR countries. The results are shown in Table 2. Countries are ranked  Book 19-4.indb 315 5/12/2013 2:19:27 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 316 Table 1 WHO MPOWER score on tobacco control in Eastern Mediterranean countries based on WHO 2011 report Indicator Point scoring Adult daily smoking prevalence (4) Estimates not available 0 ≥ 30% or more 1 20%–29% 2 15%–19% 3 < 15% 4 Monitoring: prevalence data (3) No known data or no recent data or data that is neither recent nor representative 0 Recent and representative data for either adults or youth 1 Recent and representative data for both adults and youth 2 Recent, representative and periodic data for both adults and youth 3 Smoke-free policies (4) Data not reported 0 Up to 2 public places completely smoke-free 1 3-5 public places completely smoke-free 2 6–7 public places completely smoke-free 3 All public places completely smoke-free 4 Cessation programmes (4) Data not reported 0 None 1 NRT and/or some cessation services (neither cost-covered) 2 NRT and/or some cessation services (at least 1 cost-covered) 3 National quit line, and both NRT and some cessation services cost-covered 4 Health warning on cigarette packages (4) Data not reported 0 No warnings or small warnings 1 Medium-sized warnings missing some appropriate characteristics 2 Medium-sized warnings with all appropriate characteristics 3 Large warnings with all appropriate characteristics 4 Anti-tobacco mass media campaigns (4) Data not reported 0 No campaign conducted between January 2009 and August 2010 1 Campaign conducted with 1–4 appropriate characteristics 2 Campaign conducted with 5–6 appropriate characteristics 3 Campaign conducted with all appropriate characteristics 4 Advertising bans (4) Data not reported 0 Complete absence of ban in print media 1 Ban on national television, radio and print media only 2 Ban on national and some international television, radio and print media 3 Ban on all forms of direct and indirect advertising 4 Taxation (4) Data not reported 0 ≤ 25% of retail price is tax 1 26%–50% of retail price is tax 2 51%–75% of retail price is tax 3 75% of retail price is tax 4 Compliance with bans on advertising (3) Complete compliance (8/10 to 10/10) 3 Moderate compliance (3/10 to 7/10) 2 Minimal compliance (0/10 to 2/10) 1 Not reported 0 Compliance with smoke-free policy (3) Complete compliance (8/10 to 10/10) 3 Moderate compliance (3/10 to 7/10) 2 Minimal compliance (0/10 to 2/10) 1 Not reported 0 Total score 37 Book 19-4.indb 316 5/12/2013 2:19:27 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 317 Ta bl e 2 Ea st er n M ed ite rr an ea n Re gi on c ou nt ri es ra nk ed b y to ta l W H O M PO W ER s co re o n to ba cc o co nt ro l i n 20 11 C ou nt ry Sm ok in g pr ev al en ce M on ito ri ng Sm ok e- fr ee po lic ie s Sm ok e- fr ee p ol ic y co m pl ia nc e C es sa ti on pr og ra m m es H ea lt h w ar ni ng o n ci ga re tt e pa ck ag es M as s m ed ia ca m pa ig ns A dv er ti si ng ba ns A dv er ti si ng b an co m pl ia nc e Ta xa ti on To ta l N o. (% ) Ira n (IR ) 4 3 4 2 4 4 0 4 3 1 29 (7 8) Eg yp t 3 2 3 1 3 4 4 3 2 3 28 (7 5) Jo rd an 2 3 2 2 3 2 3 4 2 3 26 (7 0 ) U A E 4 1 2 2 4 1 2 4 2 2 24 (6 4) Ba hr ai n 3 1 1 0 4 1 3 3 3 2 21 (5 6) Ku w ai t 3 2 1 0 3 1 3 4 2 2 21 (5 6) Li by a 2 2 4 2 2 1 1 3 3 1 21 (5 6) Pa ki st an 3 0 4 1 2 3 1 1 2 3 20 (5 4) G az a & W es t B an k 0 0 3 3 2 1 1 3 3 4 20 (5 4) D jib ou ti 0 3 3 0 2 4 1 4 0 2 19 (5 1) Sa ud i A ra bi a 4 2 1 0 4 1 2 3 0 2 19 (5 1) Su da n 4 1 1 0 1 1 2 4 2 3 19 (5 1) M or oc co 3 3 2 0 2 1 4 3 0 0 18 (4 8) Sy ria n A ra b Re pu bl ic 0 1 3 2 3 1 0 4 2 2 18 (4 8) Le ba no n 1 3 2 1 2 1 4 1 0 2 17 (4 5) Q at ar 0 2 1 0 3 1 1 4 3 2 17 (4 5) Tu ni si a 1 2 1 0 2 1 2 3 2 3 17 (4 5) Ye m en 2 1 1 0 1 2 2 3 2 3 17 (4 5) Ira q 3 1 1 0 2 1 1 3 2 1 15 (4 0 ) O m an 4 2 1 0 2 1 1 1 0 2 14 (3 7) A fg ha ni st an 0 0 2 0 2 1 0 3 0 1 9 (2 4) So m al ia 0 0 1 2 1 1 0 1 0 1 7 (1 8) To ta l 44 35 44 18 54 35 38 66 34 43 IR = Is la m ic R ep ub lic ; U AE = U ni te d Ar ab E m ira te s. Book 19-4.indb 317 5/12/2013 2:19:28 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 318 by total score, and the score obtained for each indictor for each activity. The highest total scores were achieved by the Islamic Republic of Iran, Egypt and Jordan (29, 28, 26 respectively). Twelve  countries  (55%) achieved more  than  half of the maximum score (19). Despite its overall high score, the Islamic Repub- lic of Iran did not score well on mass media campaigns and tobacco taxation. The Syrian Arab Republic, Afghanistan and Somali scored the lowest on mass media campaigns with no campaigns conducted between January 2009 and  August  2010, while Morocco,  Egypt  and Lebanon scored highest. More than 50% of the countries (12) did not report  on compliance on  smoke-free policy;  whereas Gaza reported complete com- pliance with  smoke-free policy. All 22  countries reported having at least mini- mal restrictions on advertising. There was a considerable range of scores on most questions. The indictor with the lowest combined score for all countries was compliance with smoke-free policy (18) while the indicator with the high- est combined score for all countries was tobacco advertising bans (66). Only 12  countries  scored above 50%,  and  the  countries could be roughly divided into 3 groups: those with ≥ 70 (3 countries),  those with 37–64 (16 countries)  and  those with ≤ 24 (3 countries). Discussion This paper reports on the differences in  implementing of 6  tobacco control  policies in EMR countries based on the MPOWER 2011  report.  It  is  the first  study from MPOWER in the Region so there are no published comparison data for the Region. However, Heydari and colleagues [19] examined tobacco con- trol scales in 2009 that showed a general  view for tobacco control programme in countries which had the same finding. It is noted that many countries scored the same and there was little difference in scores for several countries. For example, Bahrain, Kuwait and Lebanon scored 21, Pakistan and Gaza 20 and Djibouti,  Serbia and Sudan scored 19. In the studies of Gilpin and col- leagues [14] and Chriqui and colleagues [15]  their  scoring  systems  compared  tobacco control policies within the same legal system, so measurement of enforcement and comparisons were easier. In a study by Joossens and Raw [17], which used a different but similar  methodology to our study, it was shown that only 50% of European  countries  scored more than 50%, which is similar  to what we found for the EMR coun- tries (55% or 12 countries scored higher  than 50%). Yet,  in  the previous  study,  only 14% or 3 countries achieved  this  score [19]. It can be concluded that these countries (Islamic Republic of Iran, Jordan and Egypt) are more active in tobacco control programmes, but that there is still room for improvement. The results of this study show that the Islamic Republic of Iran, despite ranking first, had low scores on mass media campaigning and taxation. This information can be helpful for health officials who might want to strengthen the tobacco control programmes in illustrating the measures that could be 1. Mathers CD, Loncar D. Projections of global mortality and bur- den of disease from 2002 to 2030. PLoS Medicine, 2006, 3:e442. 2. Peto R et al. Mortality from smoking worldwide. British Medical Bulletin, 1996, 52:12–21. 3. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, GA, US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center targeted. Similar suggestions for im- provement can be made in other coun- tries based on the results of this study. Egypt, Jordan, Pakistan, Sudan and Yemen scored well in taxation and in- creased cigarette prices. West Bank and the Gaza scored the highest in these policies. Our study found that many coun- tries either have not banned smoking in public places or are weak in this regard (12 countries scored 0 and 3 countries  scored 1 out of a total of 3). The average  country score for this indicator was 18,  which was the lowest for the categories assessed. On the other hand, bans on to- bacco advertisements had a combined score of 66 and was  the most popular  legal effort undertaken. The current data were gathered from the 2011 MPOWER report. We  acknowledge that the developed scale depends critically on these data and this is the first time such a scale has been applied to EMR countries. As these data were collected from the WHO report and were clear and easy to understand, we see no serious limitation to the ap- plicability of this scale. In conclusion, tobacco control measures according to MPOWER are generally well accepted, permit comparisons across EMR countries and provide preliminary results using a systematic scoring system. The current findings indicate that although progress has been made, there is significant room for improvement and regional countries should take steps to build on their suc- cesses and should continue to work on strengthening their weak points. References for Chronic Disease Prevention and Health, Promotion, Office on Smoking and Health, 2004. 4. Peto R et al. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet, 1992, 339:1268–1278. 5. Murray CJL, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet, 1997, 349:1498–1504. Book 19-4.indb 318 5/12/2013 2:19:28 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 319 6. Levine R, Kinder M. Millions saved: proven success in global health. Washington DC, Routledge, 2006. 7. Peto R, Lopez AD. Future worldwide health effects of current smoking patterns. In: Koop CE, Pearson CE, Schwarz MR, eds. Critical issues in global health. San Francisco, Wiley (Jossey- Bass), 2001:154–161. 8. Erikson M, Mackay J, Ross H. The tobacco atlas, 4th ed. Atlanta, American Cancer Society and New York, World Lung Founda- tion, 2012. 9. Benowitz NL. Pharmacology of nicotine: addiction and thera- peutics. Annual Review of Pharmacology and Toxicology, 1996, 36:597–613. 10. Battling big tobacco: Mike Wallace talks to the highest-rank- ing tobacco whistleblower. CBS News, 2005 (www.cbsnews. com/2100-500164-162-666867.html, accessed 5 December 2007 ). 11. Hendricks PS et al. The early time course of smoking withdraw- al effects. Psychopharmacology, 2006, 187:385–396. 12. Guindon GE, Boisclair D. Past, current and future trends in to- bacco use. Washington DC, World Bank, 2003 13. WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. Geneva, World Health Organization, 2008. 14. Gilpin EA et al. Index for US state tobacco control initial out- comes. American Journal of Epidemiology, 2000, 152(8):727– 738. 15. Chriqui JF et al. Application of a rating system to state clean indoor air laws (USA). Tobacco Control, 2002, 11(1):26–34. 16. State of tobacco control, 2004 report. New York, Washington DC, American Lung Association, 2005. 17. Joossens L, Raw M. The Tobacco Control Scale: a new scale to measure country activity. Tobacco Control, 2006, 15:247–253. 18. WHO report on the Global Tobacco Epidemic, 2011: warning about the dangers of tobacco. Geneva, World Health Organiza- tion, 2011. 19. Heydari G et al. Comparison of tobacco control policies in the Eastern Mediterranean Countries based on tobacco con- trol scale scores. Eastern Mediterranean Health Journal, 2012, 18:804–810. Note from the Tobacco Free Initiative programme This article is based on the information in the WHO report on the global tobacco epidemic, 2011, which is also founded on legislations issued in 2010. Since then, many legislations have been adopted at the national level, which makes the profile  of tobacco control measures different from that reflected in the article. However, the article may serve well as a baseline for data of 2011. In addition, due to new evidence on second-hand smoke mortality, the total global deaths attributed to  tobacco use are now reaching 6 million, which is significantly different from the number included in the article which is  based on old estimates. Book 19-4.indb 319 5/12/2013 2:19:28 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 320 Geographic epidemiology in a small area: cancer incidence in Baakline, Lebanon, 2000–2008 S.M. Adib,1 N. Tabbal,2 R. Hamadeh 3 and W. Ammar 4 ABSTRACT Aggregate data of the National Cancer Registry in Lebanon cannot discriminate cancer incidence in small areas. Trained community members surveyed the permanent population of the Baakline municipality using the verbal autopsy approach. We surveyed 1042 households with at least 1 member living permanently in Baakline during 2000– 2008. Data covered 4330 persons yielding 34 143 years of observation and 56 new cases of cancer were reported. Median age at diagnosis varied significantly between men (77 years) and women (56 years). The most common types were lung cancer (20%) followed by colorectal (12.5%) and breast (9%). Estimated crude cancer incidence rate was 164 cases/100 000 persons/year, significantly higher in men (194) than women (130), and much lower overall than the national figure (218). The permanent Baakline population is older than that of Lebanon itself, yet the cancer incidence rate is markedly lower than the national figure. This finding pleads for serious efforts to preserve the low environmental contamination and the healthy lifestyles in food and tobacco abstinence that have protected the population so far. 1Department of Epidemiology and Public Health, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon (Correspondence to S.M. Adib: salimadib@hotmail.com). 2INSERM U897, ISPED, Université Victor Segalen, Bordeaux, France. 3Primary Healthcare Department; 4Ministry of Public Health, Beirut, Lebanon. Received: 29/08/11; accepted: 12/12/11 2008-2000 :نانبل ،ينلقعب في ناطسرلا ثودح لدعم :ةيرغص ةقطنم في ةيفارغلجا تايئابولا رماع ديلو ،ةداحم ةدنار ،لابط ليبن ،بيدأ ميلس ىرجأ دقو .ةيرغصلا قطانلما في ناطسرلا ثودح تلادعم زييتم نانبل في ناطسرلل ينطولا لجسلا اهمّدقي يتلا ةمكاترلما تانايبلا حيتت لا :ةـصلالخا ناك يتلا لزانلما نم 1042 حسلما لمشو .يظفللا حيشرتلا بولسأ مادختساب ينلقعب ةيدلب في ينمئادلا ناكسلل تاحوسم عمتجلما في نوبردم ءاضعأ نم ةنس 34143 لداعي ماب ًاصخش 4330 تانايبلا تَّطغ دقف اذكهو ،2008-2000 ةترفلا في مئاد لكشب ينلقعب في شيعي لقلأا لىع ناكسلا دحأ اهيف 77( لاجرلا ينب ًايئاصحإ هب ُّدَتْعُي ًاتوافت توافتي غلابلإا تقو رمعلا يطسو ناكو ،ةديدج ةيناطسر ةلاح 56 نع غلبأ ةظحلالما ةترف للاخو .ةظحلالما .)%9( يدثلا ناطسرو )%12.5( ميقتسلماو نولوقلا ناطسر هولتي ،)%20( ةئرلا ناطسر ًاعويش ناطسرلا طمانأ رثكأ ناكو .)ًاماع 56( ءاسنلاو )ًاماع وه امم )194( لاجرلا ىدل ًايئاصحإ هب ُّدَتْعُي رادقمب لىعأ وهو ؛ماع/صخش فلأ ةئم لكل ةلاح 164 ناطسرلا ثودلح يريدقتلا مالخا لدعلما ناكو نأ لاإ ،ينينانبللا لممج رماعأ نم ًارمع لوطأ ينلقعب في نومئادلا ناكسلا ناكو .)218( ينطولا مقرلا لممج نم يرثكب لقأو ،)130( ءاسنلا ىدل هيلع لىإو ،ضفخنلما يئيبلا ثولتلا لىع لصاوتلما ظاَفِلحا ةيهمأ لىإ رظنلا جئاتنلا هذه تفلتو .ينطولا مقرلا نم حضاو لكشب لقأ ناطسرلا ثودح لدعم .نلآا ىتح ناطسرلا نم ناكسلا ةياقو في ينخدتلا نع عانتملااو ،ءاذغلا في ةيحصلا ةايلحا طمانأ ةيهمأ Épidémiologie géographique dans une petite zone : incidence du cancer à Baakline (Liban) entre 2000 et 2008 RÉSUMÉ Les données globales du registre national du cancer au Liban ne permettent pas de distinguer l'incidence du cancer dans des petites zones. Des membres de la communauté formés ont interrogé la population permanente de la municipalité de Baakline à l'aide de la méthode de l'autopsie verbale. Nous avons enquêté auprès de 1042 ménages au sein desquels au moins un membre a habité de manière permanente à Baakline entre 2000 et 2008. Les données concernaient 4 330 personnes, pouvant représenter 34 143 années d'observation. Pendant les neuf années de la période d'observation, 56 nouveaux cas de cancer ont été rapportés. L'âge médian au moment du diagnostic variait significativement entre hommes (77 ans) et femmes (56 ans). Les types de cancer les plus courants étaient le cancer du poumon (20 %), le cancer colorectal (12,5 %) et le cancer du sein (9 %). Le taux brut estimé de l'incidence du cancer était de 164 cas/100 000 personnes/an ; il était nettement plus élevé chez les hommes (194) que chez les femmes (130), et globalement bien plus faible que le taux national (218). La population permanente de Baakline est plus âgée que celle du Liban, cependant l'incidence du cancer est très inférieure au chiffre national. Ce résultat appelle d'importants efforts pour préserver le faible degré de contamination de l'environnement et les modes de vie sains, notamment pour ce qui est de l'alimentation et de l'abstinence tabagique, qui ont protégé la population jusqu'à aujourd'hui. Book 19-4.indb 320 5/12/2013 2:19:28 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 321 Introduction Systematic epidemiological data concerning cancer in Lebanon have become available on a regular basis only recently through the National Cancer Registry [1]. Most recently the inci- dence of cancer was estimated at about 180 cases per 100 000 population per  year  (2008),  for  a  total  annual  case- load  approximating  8000  new  cases  (unpublished data, Ministry of Health, 2008). Because of  the  relatively  small  number of new cases occurring annu- ally in Lebanon, aggregate data of the National Cancer Registry cannot dis- criminate cancer incidence accurately even at the mohafazat (governorate) level. In particular, the way data are collected cannot respond to the needs of the population in specific areas of Lebanon to know more about trends in cancer incidence particular to their area. Traditions in Lebanon still require that a deceased person should be buried in his/her original city, regardless of the place where death occurred. A person whose roots are in Baakline is highly likely to be buried there, even if the death occurred elsewhere in Lebanon or even abroad. When the body of a person who died abroad is not repatriated, the passing will be marked by the extended family in some form of social ceremony. As cancer incidence increases in Leba- non and worldwide, grieving ceremo- nies for persons dying from cancer will also increase. In a small community such as Baakline, this increase in cancer- associated deaths can become rapidly perceptible, notwithstanding the place of residence of the deceased person at time of diagnosis. In addition, a diagno- sis of cancer is more frequent than in the past, and the stigma against disclosing it is eroding. All these factors may give the impression that cancer is becom- ing a much more serious problem than elsewhere. This impression can only be validated using quantitative methods, such as the measure of the actual cancer incidence in Baakline. The Lebanese population is re- corded in vital statistics not by place of residence but rather by place of family origin. A person recorded in Baakline may have been born outside the city, lived all their life elsewhere, and never even seen it in their entire lifetime. In reality, even among those born in Baak- line, internal migration or expatriation will result in a large proportion, if not the majority, living most of their lives outside the city. Therefore, records in Baakline (and any other small town or village in rural Lebanon) will forever suggest a larger demographic dimen- sion than in reality. When a person dies, they will be ultimately recorded as dead in Baakline, regardless of the place men- tioned on the death certificate. These factors make it difficult to decide on the denominators to be used for the estima- tion of cancer incidence in a specific area, and on which cases should actually be included in the numerator. Hence, measuring local cancer dynamics can best be done when the confines of a stable, clearly defined population are defined first. Other arguments plead in favour of a down-up approach from popula- tion to disease. Cancer is associated with endogamy, cultural lifestyle norms (food, drinks, tobacco use, etc.) and common environmental exposures [2]. Changes in those variables, which  happen when people leave their origi- nal community, will lead to changes in cancer risks. Consequently, cancer incidence in Baakline or elsewhere can be assessed in a valid way only among those living there long enough to be ex- posed to a potential risk on a long-term basis, and to allow for that exposure to progress to pathology. In 2009, a  request was filed by  the  population of Baakline and surrounding areas, in the mountain caza (district) of Chouf (Central Lebanon) with the local Member of Parliament to provide evidence for or against a perceived in- crease in cancer incidence. This study responds to that community request. Baakline is a mid-sized, semi-rural, mountain town (altitude 900 m) 45 km  south-east of Beirut.  It has about 2800  households with a relatively affluent population  of  about  17 000,  but  the  proportion of those who are actual year- long permanent residents is unknown. The objectives of the field investiga- tion reported here were: to establish a yearly denominator of permanent residents of the Baakline area for 2000– 2008; to count all cases of death in each  of those years, for all reasons, for all cancers,  and  for  each  type of  cancer;  to compute age-adjusted mortality and cancer-specific mortality rates in the Baakline area, and to compare those with national figures. Methods We carried out a door-to-door sur- vey using the verbal autopsy method to measure the cancer incidence in Baakline between 2000 and 2008. All  households with permanent residents existing within the confines of the mu- nicipality of Baakline were assessed. For the purposes of this survey, a permanent resident of Baakline was defined as a person who had no other permanent residence outside those confines before 2009.  The project was presented to the population in a town meeting and vetted by the “neighbourhood com- mittees” representing families in each sector of Baakline. A data checklist was established to be completed in face-to-face interviews. This included household variables, information on cancer cases, and some selected en- vironmental factors whose potential association was deemed of interest to the community. We trained 25 women  from the neighbourhood committee (a women's association) on the inter- view checklist during 2 special sessions.  This prepared then in a standardized way to deal with all possible situations that might arise when conducting the Book 19-4.indb 321 5/12/2013 2:19:28 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 322 cancer incidence rate was calculated us- ing a denominator of person-years, and presented as incidence rate per 100 000  persons per year. Demographic, clinical and environ- mental characteristics of cancer cases/ households identified in the survey were presented as mean with standard deviation (SD) and median or frequen- cies and percentages, depending on the variable involved. Differences were tested using adequate procedures and significance was established at P ≤ 0.05.  Results Description of the participating population The surveyors  identified 1042 house- holds with at least 1 member living permanently in Baakline during the period of  the  survey (October 2009– March 2010). This  represents  about  1/3 of all households in Baakline. A few  households refused initially to allow the survey team access, however, informal contacts and further clarification of the aims of the research resulted in a rever- sal of the refusal. The family size per household was on  average 4.8  (SD 1.8; median  5) persons. Only 5.5% of households  included only 1 person and about 3%  included ≥ 8 members (Figure 1).  The total number of individuals who were permanent residents at any time between 2000 and 2008 was 4330  persons. We  found 47.8% were ≥ 40,  (mean 39.8, SD 22.7) years. Compared  to the general Lebanese population, the population surveyed in Baakline was older (median 29.8 years nationally  versus 38.0 in Baakline) (Table 1) [2]. It  included a lower proportion of women (46.4%) compared  to national figures  (49.7%) [3]. There were no meaningful  differences in mean age between men and women. The survey population contributed a total 34 143 person-years of observation. There were a number of reasons why a full 9-year observation period could not be obtained for 672 individu- als; these included: travelling away from  Lebanon  (40%), moving  away  from  Baakline (36%), death (23%) or birth  (1%).  The crude death rate from all causes was 4.6 per 1000 per  year;  the  crude  birth  rate was 0.2 per  1000 per  year.  Details on the age-sex distribution of the survey population compared to the general Lebanese population at mid-interval (CAS 2004) are shown in  Table 1. Cancer experience in Baakline During the 9-year observation period, 56 new cases of cancer were  reported;  62.5% were in men (versus 50% nation- ally)  [1].  In 5  cases,  the  respondents  were unable to clearly state the cancer sites, and another member of the family more acquainted with the details of that case was consulted. The mean age at diagnosis was 66.6  (SD 18.8; median  71.5) years. The median age at diagnosis  varied  significantly between men (77  years)  and women (56 years)  (P  < 0  .01). The most common sites were lung  (20%) followed by colorectum (12.5%)  and breast (9%). Case-fatality was 57%,  greater  in men  (63%)  than  in women  interviews. Following training, the sur- veyors started canvassing their respec- tive neighbourhoods door-to-door to further explain the aim of the survey to the community and to obtain volun- tary participation. In each household, 1 respondent was requested to provide accurate information on permanent household members who were still alive and also those who had died between 2000 and 2008. The entire encounter  did not last more than 20 minutes.  When reluctance to share informa- tion was perceived in a household, a fe- male committee member from another neighbourhood was brought into the process, and this simple step most often resulted in agreement to participate. The process was confidential but not anonymous. Activities were super- vised by a senior staff member located at the Municipality, who was in charge of trouble-shooting and had easy access to the research team in Beirut. Names and telephone numbers were obtained for validity and accuracy checks, which were conducted by the supervisor on questionnaires with missing, unclear or inadequate responses. The age-sex composition of the per- manent population, alive and dead be- tween 2000 and 2008 was analysed. The  0 50 100 150 200 250 300 1 2 3 4 5 6 7 8 9 10 12 Persons/family N o. Figure 1 Distribution of family size in the permanent population (n = 4337) of Baakline, Lebanon, 2000–2008 Book 19-4.indb 322 5/12/2013 2:19:29 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 323 (52%)  (Table  2). The  cancer-specific  death rate was 1.3 per 1000 per year (n= 46). Figure 2 presents the relative distri- bution of cancer diagnosis by year which shows random patterns with no clear trends over time, suggesting an average of 6–7 new cases to be expected per year,  in the absence of major shifts in the com- position and exposures of the population. Based on figures observed, a crude cancer incidence rate of 164 new cases  per  100,000  persons  per  year  could  be estimated  for  the  total population;  significantly higher in men (194) than women (130). Overall cancer incidence  unadjusted for age was lower in Baak- line compared to the national figure (218 cases per 1000 in 2004). Adjusting  for age would have brought the Baakline figures even lower, since its population was older than the national mean age, and was therefore judged to be of no added value to the study. The crude can- cer incidence rate was higher than the national figure for men but for women it was lower (Table 3).  Environmental factors Tables 4 and 5 provide details on several  environmental factors such as sources of water used in the household and the indoor environment. Microwaves which may be sources of potentially dangerous radiations were present in 45% of households. Most households  were free of any indoor smoke, either from cigarettes or narghileh (shisha). In Table 1 Age and sex distribution of the permanent population of Baakline, Lebanon, 2000–2008 Age (years) Males Females Total No. % No. % No. % 0–14 318 13.7 284 14.1 602 13.9 15–34 689 29.7 665 33.1 1354 31.3 35–64 915 39.4 747 37.2 1662 38.4 > 65 399 17.2 313 15.6 712 16.4 Total 2321 100.0 2009 100.0 4330 100.0 Mean (SD) 40.5 (22.7) 39.0 (22.5) 39.8 (22.7) Mediana 39.0 36.0 38.0 aIn comparison, median age in Lebanon is: males 28.7 years, females 31.0 years, total 29.8 years [3]. SD = standard deviation. Table 2 Demographic and prognostic characteristics of cancer cases in Baakline 2000–2008 (n = 56) Variable No. % Sex Male 35 62.5 Female 21 37.5 Age (years) 0–14 0 0.0 15–34 5 8.9 34–64 17 30.4 >64 34 60.7 Location of cancer Lung 11 19.6 Colon 7 12.5 Breast 5 8.9 Blood (leukaemia) 4 7.1 Liver 4 7.1 Stomach 4 7.1 Uterus 4 7.1 Kidney 3 5.4 Blood (lymphoma) 3 5.4 Prostate 2 3.6 Larynx 2 3.6 Bone 2 3.6 Bladder 1 1.8 Eye 1 1.8 Soft tissue 1 1.8 Prognosis by 2009 Death from cancer 32 57.1 Death from other cause 1 1.8 Alive 23 41.1 Mean age at diagnosis Mean (SD) median Men 70.6 (17.7) 77.0 Women 57.1 (17.9) 56.0 All 66.6 (18.8) 71.5 SD=Standard deviation. Book 19-4.indb 323 5/12/2013 2:19:29 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 324 almost all those which had smokers, the number rarely surpassed 1 per house- hold. Few households were in direct proximity to agricultural land using pesticides (7.4%) or to electromagnetic  fields generated by high-voltage electric power  lines  (2.7%).  Comparison  of  households with and without cancers did not show any significant differences for any of these selected environmental factors. Discussion From the outset, the characteristics of the permanent population of Baak- line which would be included in this door-to-door survey were particular. Compared to the Lebanese popula- tion,  it was  significantly  older  (2011  estimates) [3]. The proportion of those  aged 60 and more was 22%, compared  to 10%  in  the overall population  [4].  This clearly reflects the depletion of the rural population through migration, which leaves older persons behind. Another finding emerged also from the survey: the proportion of elderly men was unexpectedly higher than that of elderly women. This unusual situation very likely reflects the social reluctance of children to leave an elderly mother, more than an elderly father, alone in the mountains as they move away, and the higher probability that elderly men more than elderly women would resist moving away, even when left alone in the house. In the permanent population of Baakline, the incidence of cancer, un- adjusted for age, was lower than the national rate (Table 3) [1] (adjustment  was deemed irrelevant to the purpose of this study, since the population of Baakline is older than the population of Lebanon as a whole, and adjustment would therefore have increased the gap in rates). The difference was most marked in women, where incidence in Baakline was almost half the national rate. Another epidemiological differ- ence was for age at diagnosis, favouring Baakline’s men (median age 77 years)  compared to men in Lebanon as a whole (median age 63 years) [3]. There  were no differences in this regard in women (median age 56 years).  The favourable findings for cancer in Baakline may be largely attributable to the healthy environment, as indicated some selected variables measured in this survey. Arguably, factors directly associated with lifestyle would also con- tribute to this finding. Those factors were not included in this survey because they cannot be validly measured for several persons over a 9-year period us- ing 1 interview with 1 proxy respondent. Although no other studies have been done in this area and no data are availa- ble, empirical observation and informal exchanges with community members largely suggest that lifestyles remain for the most part traditional and healthy. The protective effects of the mountain environment and/or lifestyle are further confirmed in the interpretation of epi- demiological differences. When the risk factors are intrinsic, cancer occurs at the same age as in the rest of the population. The most common cancer in women, breast cancer, is caused by reproductive factors, and therefore occurs at the same age everywhere. Patterns of reproduc- tive life are believed to remain tradi- tional in Baakline (early age at marriage, larger families, longer breast-feeding periods, etc.) and may lead to a lower incidence of risk factors, and therefore lower incidence rates. These patterns will change inevitably with younger women, and therefore cancer in women may increase in the coming years, thus indicating the importance of awareness regarding early breast cancer detection as years pass by. 0 2 4 6 8 10 12 14 16 2000 2001 2003 2004 2005 2006 2007 2008 % Year of diagnosis Figure 2 Relative frequency of incident cancer cases in Baakline, Lebanon, 2000–2008 (n = 56) Table 3 Unadjusted cancer incidence rates (per 100 000 population) in the Baakline population (2000–2008) and in the Lebanese population Sex Baakline Lebanona Male 194 157 Female 130 224 All 164 218 aNational Cancer Registry, 2004 [1]. Book 19-4.indb 324 5/12/2013 2:19:29 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 325 Men also display a significant resist- ance to cancer, which occurs in Baakline almost 15  years  later  than  elsewhere  in most cases. For men in general, the most common cancers were of the lung and colon, both widely associ- ated with lifestyle, e.g. smoking and a diet low in fibre and rich in animal fats  [2]. The behavioural  risk  factors  we assessed are probably less promi- nent in Baakline, which may explain the delay in cancer incidence compared to elsewhere. However, the frequent finding of behaviourally-associated can- cers among older men suggests that they may be a special risk group in the population, whose social environment should be investigated and improved, if possible. There are very few studies specifically assessing differences in cancer incidence in mountainous and non-mountainous Table 5 Sources of environmental pollution of households (n = 1042) of the permanent population of Baakline, Lebanon, 2000–2008 Source No. % Indoor environment Microwave ownership 469 45.1 No cigarette smokers in the house 605 58.5 No narghileh users in the house 819 79.1 Outdoor environment Proximity of agricultural land 76 7.4 Proximity of high-voltage power lines 18 2.7 areas. A study from Kyrgyzstan found a lower incidence of oesophageal, pulmo- nary and breast cancers in ethnic groups historically living in mountainous areas [5]. The difference was attributed to the  adaptation of those groups to moun- tain hypoxia, which may “function like a brake for the development of cancer tumours”. However, this study did not consider an alternative/contributing attribution to lifestyles between the tra- ditional ethic groups in the mountains (mostly Kyrgyzs) compared to “new- comers” (Kazakhs and Russians). A certain level of interaction seems to exist between environmental and lifestyles factors associated with health outcomes. There are numerous ways through which the environment can interact with other factors to create situ- ations with varying effects on health. A cohort study in Japan found that vegeta- ble dishes high in salt specific to moun- tain areas may cause a more severe form of  stomach cancer  [6].  In China,  the  northern mountains are areas of “unde- veloped living conditions” with higher prevalence of H. pylori infection, leading to increased rates of upper gastro-intes- tinal cancer with rising altitudes [7].  Conclusions This is the first assessment of cancer epidemiology ever conducted in a geo- graphically/demographically specific area in Lebanon. Although the Baakline population is older than that of Lebanon as a whole, the cancer incidence rate is remarkably lower than the national figure. Further research may look at specific protective factors which make this population less vulnerable to cancer even as it grows older. Our findings are an indication that serious efforts should be made to main- tain the low contamination of the town’s Table 4 Water sources for households (n = 1042) of the permanent population of Baakline, Lebanon, 2000–2008 Water source Never Sometimes Always No. % No. % No. % Drinking water Private well 606 89.4 5 0.7 67 9.9 Sterilized bottles 318 37.8 207 24.6 317 37.6 Tanker 588 87.4 68 10.1 17 2.5 Tap water 200 22.3 49 5.5 649 72.3 Spring 440 59.1 89 11.9 216 29.0 Rainwater reservoir 645 96.0 6 0.9 21 3.1 Cooking water Private well 594 89.3 18 2.7 53 8.0 Sterilized bottles 540 79.5 71 10.4 69 10.1 Tanker 562 86.1 75 11.5 16 2.4 Tap water 83 8.9 29 3.1 823 88.0 Spring 504 67.2 53 7.1 193 25.7 Rainwater reservoir 627 95.7 7 1.1 21 3.2 Service water Private well 593 85.2 22 3.2 81 11.6 Sterilized bottles 628 94.3 13 2.0 25 3.8 Tanker 566 77.7 16 2.2 146 20.1 Tap water 59 6.5 17 1.9 829 91.6 Spring 565 77.5 16 2.2 148 20.3 Rainwater reservoir 619 94.5 8 1.2 28 4.3 Book 19-4.indb 325 5/12/2013 2:19:30 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 326 environment, and the healthy lifestyles which have served the population so well up till this survey. The decreas- ing fraction of Lebanese who maintain their permanent residence in tradition- al pristine mountainous areas such as Baakline should be encouraged by the evidence we present to know that they are less prone to cancer than the rest of the population. Acknowledgements Activities were hosted at the Baakline Municipality and the National Library of Baakline, our thanks to the Director and staff. Thanks also go to Dr Zaher Abu Shakra, qada physician, to Dr Fares Namour, head of the Health Committee at the Baakline Municipality, to Ms Raghi- da Timani, who coordinated the ladies of the Baakline neighbourhood committees in data collection, and to all the ladies in Baakline who devoted time and effort to data collection. Special thanks to Mr Moufid Seaid, who entered the data. Funding: This project was made pos- sible through a generous donation from H.E. Marwan Hamadeh, Member of Parliament. Competing interests: None declared. References 1. Cancer in Lebanon 2003–2004. Beirut, National Cancer Regis- try, Ministry of Public Health, 2008. 2. National Cancer Institute. Risk factors and possible causes, 2013. Site www.cancer.gov/cancertopics/factsheet/Risk 3. Factbook 2011: Lebanon. Central Intelligence Agency (CIA), 2011 (https://www.cia.gov/library/publications/the-world- factbook/geos/le.html, accessed 25 January 2013). 4. Yaacoub N, Badre L. Statistics in focus, 2011. Issue 1: The labour market in Lebanon. Beirut, Central Agency for Statistics (in col- laboration with the Ministry of Social Affairs), 2005 (http:// www.cas.gov.lb/images/PDFs/SIF/CAS_Labour_Market_In_ Lebanon_SIF1.pdf, accessed 12 February 2013). 5. Igisinov S et al. Epidemiology of esophagus, lung and breast cancer in mountainous regions of Kyrgyz Republic. Asian Pa- cific Journal of Cancer Prevention, 2002, 3(1):73–76. 6. Kurosawa M et al. Highly salted food and mountain herbs elevate the risk for stomach cancer death in a rural area of Japan. Journal of Gastroenterology and Hepatology, 2006, 21(11):1681–1686. 7. Wen D et al. Helicobacter pylori infection may be implicated in the topography and geographical variation of upper gastro- intestinal cancers in the Taihang Mountain high-risk areas in northern China. Helicobacter, 2010, 15(5):416–421. Book 19-4.indb 326 5/12/2013 2:19:30 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 327 Antenatal depression and its predictors in Lahore, Pakistan A. Humayun,1 I.I. Haider,2 N. Imran,3 H. Iqbal 4 and N. Humayun 5 ABSTRACT Mental health is an important but neglected component of reproductive health. This study aimed to determine the prevalence and risk factors for antenatal depression among women attending for antenatal care at an urban tertiary care hospital in Lahore, Pakistan. In a cross-sectional study, structured questionnaires were filled and screening for depression was done using the Edinburgh postnatal depression scale (EPDS). Out of 506 antenatal attendees 126 (24.9%) had no depression (EPDS scores < 10), 53 (10.5%) scored 10–12 and 327 (64.6%) had EPDS scores > 12. Depression scores (≥ 10) were more common in mothers aged < 20 years (93.7%) than those aged > 35 years (55.0%). Fear of childbirth and separation from husband were identified as significant risk factors for development of antenatal depression, while family history of psychiatric illness was significant protective factor. Domestic violence, drug abuse, lack of support, previous miscarriage and personal history of previous psychiatric illness were not found to be significant risk factors. 1Department of Community Medicine, Federal Postgraduate Medical Institute and Shaikh Khalifa Bin Zayed Al-Nahyan Medical College, Lahore, Pakistan (Correspondence to A. Humayun: drayeshah@gmail.com). 2Department of Psychiatry and Behavioural Sciences; 4Department of Community Health Sciences, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, Pakistan. 3Department of Psychiatry, King Edward Medical University, Lahore, Pakistan. 5Department of Community Medicine, Akhtar Saeed Medical and Dental College, Lahore, Pakistan. Received: 18/12/11; accepted: 06/03/12 ناتسكاب ،روهلا في هُِئباونو ةدلاولل قباسلا بائتكلاا نوياهم ديهان ،لابقإ اْيرَُحم ،نارمع شيزان ،رديح زاجعإ نارمع ،نوياهم ةشئاع لماوعو راشتنا تلادعم لىع فرعتلا لىإ ةساردلا هذه ْتَفَدَه دقو .لمهم هنكلو ةيباجنلإا ةحصلا صرانع نم ماه صرنع ةيسفنلا ةحصلا نإ :ةـصلالخا .ناتسكاب ،روهلا في ةيثلاثلا ةيَضَحـلا ةياعرلا تايفشتسم ىدحإ في ةدلاولا ةقباسلا ةياعرلا نعجاري تيلالا لماولحا ىدل ةدلاولل قباسلا بائتكلاا راطتخا في كراشو .ةدلاولل لياتلا بائتكلال هبرندأ سايق ملس لىإ ًادانتسا بائتكلاا يرتح َّمَث نمو اهُتَئِْلَتم تََّتم ةق ََّسنُم ةرماتسا لىإ تدنتسا ،ةضرعتسم ةسارد يهو حواترت زارحأ )%10.5( نهنم 53 ىدلو ،)10 نم لقأ سايقلا ملس في ّنتهاجرد( بائتكا )%24.9( نهنم 126 ىدل نكي لمو ،اتهدلاو لبق ةأرمإ 506 ةساردلا تيلالا تاهملأا ىدل ًاعويش رثكأ )10 لىع ديزت وأ يواست يتلا( بائتكلاا زارحأ تناك دقو .12 لىع ديزت زارحأ )%64.6( نهنم 327 ىدلو ،12و 10 ينب لاصفنلااو ةدلاولا نم فولخا نأ لىع نوثحابلا فرعتو .)%55.0( ًاماع 35 لىع نهرماعأ ديزت تياوللا ىدل هيلع يه امم )%93.7( ًاماع 20 نع نهرماعأ لقت نوثحابلا دجو ماك ،ماه يئاقو لماع يه سيفن ضرمب ةيلئاع ةصق نأ ينح في ،ةدلاولا لبق بائتكلاا ثودلح ةيهمأ راطتخلاا لماوع رثكأ اهم جوزلا نع .ةمهم راطتخا لماوع ُّدَعُت لا قباس سيفن ضرلم ةيصخشلا قباوسلاو ،ضاهجلإا قباوسو ،معدلا نادقفو ،تاردخلما ةرقاعمو ليزـنلما فنعلا نم ًلاك نأ Dépression prénatale et facteurs prédictifs à Lahore (Pakistan) RÉSUMÉ La santé mentale est une composante importante et pourtant négligée de la santé génésique. La présente étude visait à déterminer la prévalence et les facteurs de risque de la dépression prénatale chez les femmes consultant un service de soins prénatals à l'hôpital de soins de santé tertiaires de la ville de Lahore (Pakistan). Dans une étude transversale, des questionnaires structurés ont été complétés puis analysés à l'aide de l'Edinburgh postnatal depression scale (échelle de dépression post-natale d'Édimbourg) à la recherche d'indications de dépression. Sur les 506 patientes en période prénatale, 126 (24,9 %) ne souffraient pas de dépression (scores < 10), 53 (10,5 %) ont obtenu des résultats entre 10 et 12 et 327 (64,6 %) ont eu des résultats supérieurs à 12 sur l'échelle de dépression post-natale d'Édimbourg. Les scores de dépression (≥ 10) étaient plus fréquents chez les femmes âgées de moins de 20 ans (93,7 %) que chez celles de plus de 35 ans (55,0 %). La peur de l'accouchement et une séparation conjugale ont été identifiées comme des facteurs de risque significatifs pour le développement de la dépression prénatale, alors que les antécédents familiaux de maladie psychiatrique étaient des facteurs de risque protecteurs importants. La violence domestique, la toxicomanie, l'absence de soutien et des antécédents de fausses-couches et de maladie psychiatrique chez la patiente n'ont pas été identifiés comme des facteurs de risque importants. Book 19-4.indb 327 5/12/2013 2:19:30 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 328 Introduction Mental health is an important but neglected component of reproductive health. About 10%–15% of women in  industrialized countries and between 20%–40% of women  in developing  countries experience depression during pregnancy or after childbirth. The effects of depression, anxiety and demoralization are amplified in the context of social adversity and poverty [1]. Symptoms of antenatal depres- sion include sadness during most of the day, hopelessness, lack of inter- est and fatigue, trouble sleeping and eating along with extreme irritability and inability to feel happiness or en- joy. Moreover, inability to feel happy about the pregnancy adds to the con- fusion and guilt in the affected women. Antenatal depression can have clinical implications such as increased uterine irritability, pregnancy-induced hyper- tension, pre-eclampsia, postpartum bleeding, decreased uterine artery blood flow and preterm delivery. Common consequences also include emotional and behavioural problems and cognitive delay in children of de- pressed mothers [2]. Widely ranging rates of depres- sion during pregnancy have been found: for example from 27% to 62%  [3–5]. A comparison between Paki- stani and Canadian women showed a higher proportion of Pakistani women (48.4%) with  antenatal  depression  than aboriginal  (31.2%) and Cauca- sian  (8.6%) Canadian women  [6].  Risks for depression or anxiety during pregnancy are similar to the risk factors for any other depressive episode. They include personal or family history of depression, relationship difficulties, stressful life events, history of abuse, lack of social support and family vio- lence [2,7]. Previous pregnancy  loss,  problems with pregnancy, unplanned pregnancy and fear of childbirth have also been identified as risk factors for antenatal depression [8]. A study  by two of the authors of the current paper to determine the frequency of probable antenatal depression in pregnant women in Pakistan in the 3rd  trimester  and  to  assess  the  risk  factors showed a prevalence of 42.7%  and identified a number of effects on obstetric and neonatal outcomes [9]. Another study from Pakistan reported the prevalence of anxiety and/or de- pression among pregnant women was only 18%. Husband unemployment,  lower household wealth, having 10 or  more years of formal education and an unwanted pregnancy along with physical/sexual and verbal abuse were associated with depression and/ or anxiety [10]. The current study aimed to identify the frequency of antenatal depression among women attending for antenatal care at a tertiary care hospital in Lahore and to identify the potential risk factors for antenatal depression. Methods Sample The sample size was calculated using an expected prevalence of antenatal depression  as  10.7%  [11]. The  study  population was antenatal attendees in their 3rd trimester. All pregnant women  in  their 3rd  trimester consecutively at- tending the antenatal clinics at a tertiary care hospital in Lahore over the period May  to  July 2007 were  recruited (n = 506); women in the 1st and 2nd trimes- ters were excluded. Ethical approval for the study was obtained from the ethical review com- mittee of the FMS Center for Health Research, Lahore. The study was con- ducted in compliance with the ethical principles for medical research involv- ing human subjects of the Helsinki Declaration [12]. Patient names were  not recorded to assure confidentiality. Verbal consent was obtained from all subjects and documented in the pres- ence of a witness. Data collection All women completed the Edinburgh Postnatal Depression Scale (EPDS) [13] and a structured questionnaire that  was filled through personal interviews by psychiatry postgraduate students. To identify all those with minor or major depression we used the cut off of EPDS score > 10, but to obtain the frequency  of major depression in antenatal period we also analysed patients having EPDS score >12. The questionnaire  included  information about demographic and other potential risk factors for antenatal depression. These variables included history of previous miscarriages, un- planned pregnancy, fear of childbirth, lack of support, separation from hus- band, domestic violence, drug abuse, family and personal history of psychiat- ric disorder as nominal variables. Analysis The data were entered and analysed using SPSS, version 16.. For the statisti- cal analysis, the chi-squared test was applied and the statistical association of different factors with the presence of depression in antenatal attendees was determined. Results The mean  age  the  women  was  26.5  [standard deviation  (SD) 4.2]  years,  with a  range of 18–40 years. The great  majority (93.7%) were in the age group  20–30 years. The women  included  in  the study had gestation between 26  to  36 weeks. Out of  these 506 antenatal attend- ees,  126  (24.9%)  screened  negative  for depression (EPDS score < 10), 53  (10.5%)  screened positive  for depres- sion  at EPDS  scores between 10–12  and 327 (64.6%)  screened positive at  the EPDS cut-off > 12. i.e. a total of 380  (75.1%) screened positive at the EPDS  cut-off ≥ 10. In  younger  mothers  aged  <  20  years, depression  (EPDS  score ≥ 10)  Book 19-4.indb 328 5/12/2013 2:19:30 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 329 development of antenatal depression, whereas family history of psychiatric illness was a significant protective factor, Among women who feared childbirth 77.8% had depression scores compared  with 69.8% among  those who did not  fear childbirth (P = 0.046) and 86.5% of  women who were separated from their husbands had depression scores versus 73.8% who were  not  separated  (P = 0.044). In contrast, among women who  had a family history of psychiatric illness only 58.3% had depression scores com- pared with 76.9% of women with no  family history (P = 0.005). Domestic violence, drug abuse, lack of support, previous miscarriage and history of previous psychiatric illness were not found to be significant risk factors for antenatal depression in our study. Although more women with a history of domestic violence had depres- sion scores (94.1% versus 74.4%),  the  numbers of women reporting domestic was much more common (8/9, 93.7%)  than among older mothers aged > 35  years  (11/20, 55.0%). The prevalence  of depression scores among the women according to the risk factors measured are shown in Table 1 for depression scores 10–12 and ≥ 12. Table  2  shows  the  prevalence  of  depression comparing cut-off scores < 10 with ≥ 10. The  fear of  childbirth  and separation from husband were identified as significant risk factors for Table 1 Risk factors for antenatal depression among the study sample of pregnant women in their 3rd trimester Variable Total Screened negative Screened positive (n = 506) EPDS score < 10 EPDS score 10–12 EPDS score > 12 (n = 126) (n = 53) (n = 327) No. No. % No. % No. % Age (years) < 20 9 1 11.1 0 0.0 8 88.9 20–35 477 116 24.3 49 10.3 312 65.4 > 35 20 9 45.0 4 20.0 7 35.0 Pregnancy Unplanned 233 58 24.9 27 11.6 148 63.5 Planned 276 68 24.6 26 9.4 179 64.9 Fear of childbirth Yes 334 74 22.2 40 12.0 220 65.9 No 172 52 30.2 13 7.6 107 62.2 Miscarriage or intrauterine death Yes 180 39 21.7 22 12.2 119 66.1 No 326 87 26.7 31 9.5 208 63.8 Lack of support Yes 93 22 23.7 9 9.7 62 66.7 No 413 104 25.2 44 10.7 265 64.2 Separation from husband Yes 52 7 13.5 10 19.2 35 67.3 No 454 120 26.4 43 9.5 292 64.3 Domestic violence Yes 17 1 5.9 4 23.5 12 70.6 No 492 125 25.4 49 10.0 315 64.0 Drug abuse Yes 26 4 15.4 3 11.5 19 73.1 No 480 122 25.4 50 10.4 308 64.2 Previous psychiatric illness Yes 34 6 17.6 3 8.8 25 73.5 No 472 120 25.4 50 10.6 302 64.0 Family history of psychiatric illness Yes 48 20 41.7 3 6.3 25 52.1 No 458 106 23.1 50 10.9 302 65.9 Book 19-4.indb 329 5/12/2013 2:19:31 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 330 violence (physical or verbal or both type of violence) were very small and this did not reach statistical significance (P = 0.085). More women with a personal  history of psychiatric illness had depres- sion  than those without (82.4% versus  74.6%), so too did those with a history  of drug abuse compared with those who did not (84.6% versus 74.6%) but these  were also not significant (P = 0.41 and P = 0.249 respectively). Discussion A high prevalence of antenatal depres- sion has previously been found in women in Rawalpindi, Pakistan [14]. In the current study in Lahore, the frequency  of  3rd  trimester  antenatal  attendees who screened positive for antenatal depression above the EPDS cut-off score of 10 was 75.1% and above  the cut-off score of 12 was 64.6%, which  is high compared with other studies in Pakistan and elsewhere [11,15–18].  In  a study by Gorman et al. from 10 sites in  8 countries  the overall antenatal point  prevalence rate for caseness was 11.8%,  the rate for depression was 6.9%, the rate  for major depression was 3.5% and the  rate for EPDS score 13+ was 8.7% [18].  A  recent meta-analysis  of  21  studies  concluded that the mean prevalence of depression across the antenatal period was 10.7%, ranging from 7.4% in the 1st  trimester to a high of 12.8% in the 2nd  trimester [11]. An interesting finding in our study was the higher rate of depression in younger  mothers  aged  <  20  years  than older mothers, which might be explained by the younger women’s lack of experience, immaturity and emo- tional  instability  [19,20].  In a  study  in  the United States (US) young maternal age was associated with greater risk of antenatal and postpartum depressive symptoms, which were attributed to financial hardship, unwanted pregnancy and lack of a partner [21]. Similar find- ings were reported in other studies from the United Kingdom and US [22,23].  The mean age of our women was 26.5  years, which is identical to a hospital- based study of postnatal depression in Pakistan that showed the average age Table 2 Statistical analysis of risk factors for antenatal depression among the study sample of pregnant women in their 3rd trimester Risk factor Total Screened negative Screened positive P-value EPDS score < 10 EPDS score ≥ 10 (n = 126) (n = 380) No. No. % No. % Fear of childbirth Yes 334 74 22.2 260 77.8 0.046 No 172 52 30.2 120 69.8 Miscarriage or intrauterine death Yes 180 39 21.7 141 78.3 0.21 No 326 87 26.7 239 73.3 Lack of support Yes 93 22 23.7 71 76.3 0.75 No 413 104 25.2 309 74.8 Separation from husband Yes 52 7 13.5 45 86.5 0.044 No 454 119 26.2 335 73.8 Domestic violence Yes 17 1 5.9 16 94.1 0.085 No 489 125 25.6 364 74.4 Drug abuse Yes 26 4 15.4 22 84.6 0.25 No 480 122 25.4 358 74.6 Previous psychiatric illness Yes 34 6 17.6 28 82.4 0.41 No 472 120 25.4 352 74.6 Family history of psychiatric illness Yes 48 20 41.7 28 58.3 0.005 No 458 106 23.1 352 76.9 Book 19-4.indb 330 5/12/2013 2:19:31 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 331 of women was 26 years. Women with  depression were mostly in their 2nd or  3rd confinements (38%) [24]. Factors found to be statistically associated with a higher risk of depres- sion in our study were fear of childbirth and separation from the husband, while family history of psychiatric ill- ness was protective factor for depres- sion. A fear of childbirth in our culture might be related to the process of de- livery, the sex of the baby or poor faith in the care provider. These possibilities needs to be explored in further studies as fears related to childbirth need to be determined in the context of Pakistan. Domestic violence, previous miscar- riage and personal history of previous psychiatric illness were not found to be risk factors for antenatal depression in our study. Our findings contrast with a study reporting that the strong- est factors associated with depression/ anxiety were physical/sexual and ver- bal  abuse  [10]. They also contradict  a previous study in Pakistan which found that 72% of women who were  physically abused during pregnancy were anxious/depressed [25].  In  the  US study, the strongest risk factor for antenatal depressive symptoms was a history of depression (OR = 4.07),  and the strongest risk for postpartum depressive symptoms was depressive symptoms during pregnancy (OR = 6.78) or a history of depression before  pregnancy (OR = 3.82) [19]. Another  study from Pakistan showed a high frequency of antenatal depression (42.7%) and reported the risk  factors  to be problems in the marriage, prob- lems with parents/in-laws, history of domestic violence, past history of psy- chiatric problems and history of post- natal depression. Among the obstetric risk factors, history of previous miscar- riages, stillbirth and complications in previous pregnancies reached statisti- cal significance. Moreover, women with antenatal depression faced more obstetric complications and their babies had significantly lower birth weights and lower mean Apgar scores [9]. The study was conducted in a tertiary care setup, which mainly caters upper lower and lower middle socio- economic class of patients. The finding that the association of family history of psychiatric illness was protective, rather than a risk, for antenatal depression suggests a context- specific situation as the females here had specific cultural, social and economic conditions. A meta-analysis by O’Hara and Swain using 77 studies, showed no  association of family history of depres- sion with postpartum depression [26].  One limitation of this study was lack of follow-up of these women into the natal and postnatal period in order to determine neonatal outcomes and possible development of postnatal de- pression. This was due to financial and logistic constraints of the research. This is, however, an areas for future research. Antenatal depression itself is a predictor of postnatal depression. Findings from a study in Egypt revealed that the preva- lence of antepartum depression was 25.3% and that antepartum depression  was significantly linked to postpartum depression and negative attitudes to breastfeeding  [27].  In  a  study  in  the  United Arab Emirates in which women were followed from the second trimes- ter of pregnancy until 4 months post- partum, depression in the 2nd and 3rd  trimesters was found to be significantly associated with postnatal depression [28], while a study in the Islamic Repub- lic of Iran showed that antenatal state and trait anxiety at 28 and 38 weeks of  gestation were independent risk factors associated with postnatal depression [29]. In the present study, despite the high rate of depression, none of the women had been screened for depres- sion and other psychiatric illnesses during routine antenatal checkups. Therefore none of them were receiv- ing any treatment, which means that these females were at risk of developing postnatal depression. To address the growing epidemic of antenatal depres- sion  in Pakistan  [6], we need  to  look  into its epidemiological basis in our sociocultural context and then plan preventive and control measures. Conclusions Depression was highly prevalent in hospital antenatal attendees in an urban area of Pakistan. Many of the predictors, such fear of childbirth and separation from husband, are modifiable through awareness and counselling. Mental health should be made an integral part of reproductive health services in Pakistan and there is a need to conduct antenatal screening of women for depression and other psychiatric illness, through close collaboration of psychiatry services with the preventive obstetric services. References 1. Mental health aspects of women’s reproductive health, a global review of literature. Geneva, World Health Organization/ United Nations Population Fund, 2009. 2. Bonari L et al. Perinatal risks of untreated depression during pregnancy. Canadian Journal of Psychiatry, 2004, 49:726–735. 3. Dalton K. Prospective studies into puerperal depression. Brit- ish Journal of Psychology, 1971, 118:689–692. 4. Rona RJ et al. Anxiety and depression in mothers related to severe malformation of the heart of the child and foetus. Acta Paediatrica, 1998, 87:201–205. 5. Bowen A, Muhajarine N. Prevalence of antenatal depres- sion in women enrolled in an outreach program in Canada. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 2006, 35:491–498. Book 19-4.indb 331 5/12/2013 2:19:31 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 332 6. Shah SM et al. Prevalence of antenatal depression: comparison between Pakistani and Canadian women. Journal of the Paki- stan Medical Association, 2011, 61:242–246. 7. Bacchus L, Mezey G, Bewley S. Domestic violence: prevalence in pregnant women and associations with physical and psycho- logical health. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 2004, 113:6–11. 8. Leigh B, Milgrom J. Risk factors for antenatal depression, post- natal depression and parenting stress. BMC Psychiatry, 2008, 8:24. 9. Imran N, Haider II. Screening of antenatal depression in Pa- kistan: risk factors and effects on obstetric and neonatal out- comes. Asia-Pacific Psychiatry, 2010, 2:26–32. 10. Karmaliani R et al. Prevalence of anxiety, depression and asso- ciated factors among pregnant women of Hyderabad, Pakistan. International Journal of Social Psychiatry, 2009, 55:414–424. 11. Dennis CL, Ross LE, Grigoriadis S. Psychosocial and psycholog- ical interventions for treating antenatal depression. Cochrane Database of Systematic Reviews, 2007, 3:CD006309. 12. Declaration of Helsinki: ethical principles of research involving human subjects. World Medical Association [online] (http:// www.wma.net/en/30publications/10policies/b3/, accessed 17Januray 2013). 13. Edinburgh Postnatal Depression Scale (http://www.fresno. ucsf.edu/pediatrics/downloads/edinburghscale.pdf, ac- cessed 26 February 2013). 14. Rahman A et al. Association between antenatal depression and low birthweight in a developing country. Acta Psychiatrica Scandinavica, 2007, 115:481–486. 15. Niaz S, Izhar N, Bhatti MR. Anxiety and depression in pregnant women presenting in the OPD of a teaching hospital. Pakistan Journal of Medical Sciences, 2004, 20:117–119. 16. Blazer DG et al. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. American Journal of Psychiatry, 1994, 151:979–986. 17. Edwards B et al. Antenatal psychosocial risk factors and depres- sion among women living in socioeconomically disadvantaged suburbs in Adelaide, South Australia. Australian and New Zea- land Journal of Psychiatry, 2008, 42:45–50. 18. Gorman LL et al.TCS-PND Group. Adaptation of the structured clinical interview for DSM-IV disorders for assessing depres- sion in women during pregnancy and post-partum across countries and cultures. British Journal of Psychiatry, 2004, 46:s17–s23. 19. Aleem S. Emotional stability among college youth. Journal of the Indian Academy of Applied Psychology, 2005, 31(1–2):100–102. 20. Rich-Edwards JW et al. Sociodemographic predictors of ante- natal and postpartum depressive symptoms among women in a medical group practice. Journal of Epidemiology and Commu- nity Health, 2006, 60(3):221–227. 21. Rich-Edwards JW et al. Sociodemographic predictors of ante- natal and postpartum depressive symptoms among women in a medical group practice. Journal of Epidemiology and Commu- nity Health, 2006, 60:221–227. 22. Maskey S. Teenage pregnancy: doubts, uncertainties and psy- chiatric disturbance. Journal of the Royal Society of Medicine, 1991, 84:723–725. 23. Kessler RC et al. Social consequences of psychiatric disorders, II: Teenage parenthood. American Journal of Psychology, 1997, 154:1405–1411. 24. Hamirani MM et al. Frequency of prenatal depression in sec- ond and third trimesters of pregnancy in Karachi: a hospital based study. Journal of Liaquat University of Medical and Health Sciences, 2006, Sept.–Dec.:106–109. 25. Fikree FF, Bhatti LI. Domestic violence and health of Pakistani women. International Journal of Gynecology and Obstetrics, 1999, 65:195–201. 26. O’Hara MW, Swain AM. Rates and risk of postnatal depres- sion—a meta-analysis. International Review of Psychiatry, 1996, 8:37–54. 27. Abou Nazel MW, Nosseir SA. Antepartum and postpartum den- pression and infant feeding pattern: a prospective study. Jour- nal of the Egyptian Public Health Association, 1994, 69:397–424. 28. Hamdan A, Tamim H. Psychosocial risk and protective factors for postpartum depression in the United Arab Emirates. Ar- chives of Women's Mental Health, 2011, 14:125–133. 29. Alipour Z, Lamyian M, Hajizadeh E. Anxiety and fear of child- birth as predictors of postnatal depression in nulliparous women. Women and Birth, 25(3):e37–43. Book 19-4.indb 332 5/12/2013 2:19:31 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 333 Physical abuse in basic-education schools in Aden governorate, Yemen: a cross-sectional study A.S. Ba-Saddik 1 and A.S. Hattab 2 ABSTRACT Physical abuse in school has lifelong consequences affecting child health and educational achievements. A study was designed to assess the prevalence of physical abuse experienced by pupils in basic- education schools in Aden, Yemen, and to examine the risk factors associated with it. A cross-sectional study covering 1066 pupils in 7th–9th grades from 8 schools in different districts of Aden governorate were randomly selected. Answering an anonymous self-administered questionnaire, 55.7% of pupils reported physical abuse at least once in their school lifetime (73.2% of males versus 26.6% of females). Teachers were the main perpetrators (45.4%). A statistically significant association was found between physical abuse and sex, age group, family type and father’s education. Significant predictors of physical abuse on multivariate regression were male sex (OR = 7.89) and extended family type (OR = 1.36). Physical abuse in basic-education schools requires serious consideration by educational authorities, families and the community at large. 1Department of Behavioural Sciences; 2Department of Social Medicine and Public Health, Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen (Correspondence to A.S. Ba-Saddik: abasaddik@gmail.com). Received: 01/03/12; accepted: 13/03/12 ةضرعتسم ةسارد :نميلاب ،ندع ةظفامح في سياسلأا ميلعتلا سرادم في يدسلجا ءاذيلإا باّطح ديعس للها دبع ،قيدصاب لماس قيّدص لامآ هذه ناثحابلا مّمص دقو .يميلعتلا مهئادأ لىع رثؤتو متهايح ىدم لافطلأا ةحص بيصت بقاوع لىإ سرادلما في يدسلجا ءاذيلإا يدؤي :ةـصلالخا راطتخلاا لماوع ةساردلو ،نميلاب ،ندع ةظفامح في سياسلأا ميلعتلا سرادم في ذيملاتلل يدسلجا ءاذيلإا راشتنا لدعم مييقت لجأ نم ةساردلا قطانلما لىع ةعزوم سرادم نيماث في عساتلا ىتحو عباسلا فوفصلا نم ًايئاوشع اويرتخا ًاذيملت 1066 تلمش ةضرعتسم ةسارد يهو ؛هل ةقفارلما مهضرعت نع اوغلبأ دق ذيملاتلا نم 55.7% نأ ةساردلا نم حضتا دقو .ءماسلأا نم لفغم ،ًايتاذ ذ َّفني نايبتسا لماكتساب كلذو ،ندع ةظفامح في ةفلتخلما ىذلأل ينفترقلما رثكأ مه نوسردلما ناكو )ثانلإا ىدل %26.6و روكذلا ىدل %73.2( متهايح تاترف نم ةترف في لقلأا لىع ةدحاو ةرلم يدسلجا ءاذيلإل مُّلعتو ،ةسرلأا طمنو ،ةيرمعلا ةعومجلماو ،سنلجا نم ٍّلك ينبو يدسلجا ءاذيلإا ينب ًايئاصحإ هب دتعي ًاطبارت نوثحابلا دجوو .)%45.4( يدسلجا طمنو ،)7.89 = ةيحجرلأا لدعم( ةروكذلا سنج وه تايرغتلما ددعتلما ف ُّوحتلا قفو يدسلجا ءاذيلإاب ًايئاصحإ ابه َّدتعُي يتلا تائبنلما تناكو .بلأا تاطلسلا لبق نم ًايدج ًامماتها بلطتي سياسلأا ميلعتلا سرادم في يدسلجا ءاذيلإا نأ نوثحابلا ىريو .)1.36 = ةيحجرلأا لدعم( ةعسولما ةسرلأا .هسرأب عمتجلماو تلائاعلاو ةيميلعتلا Violence physique dans des écoles primaires du Gouvernorat d'Aden (Yémen) : étude transversale RÉSUMÉ La violence physique dans les écoles a des répercussions tout au long de la vie, affectant la santé de l'enfant et ses performances scolaires. Une étude a été conçue pour évaluer la prévalence de la violence physique vécue par des élèves dans des écoles primaires d'Aden (Yémen) et pour examiner les facteurs de risque associés. Dans une étude transversale, 1 066 élèves en classes de septième, huitième et neuvième ont été sélectionnés aléatoirement dans huit écoles de différents districts du Gouvernorat d'Aden. D'après les réponses au questionnaire auto-administré et anonyme, 55,7 % des élèves ont déclaré avoir souffert de violence physique au moins une fois dans leur vie scolaire (73,2 % de garçons contre 26,6 % de filles). Les enseignants étaient les principaux auteurs de violence (45,4 %). Une coorélation statistique significative a été constatée entre la violence physique et le sexe, la tranche d'âge, le type de famille et le niveau d'études du père. Être de sexe masculin (OR = 7,89), et appartenir à une famille élargie (OR = 1,36) comptaient parmi les facteurs prédictifs importants pour la violence physique à l'analyse de régression multivariée. La violence physique dans les écoles primaires requiert toute l'attention des autorités responsables de l'enseignement, des familles et de la communauté dans son ensemble. Book 19-4.indb 333 5/12/2013 2:19:31 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 334 Introduction Schools play an important role in chil- dren’s lives [1]. Nevertheless, the school is one setting where abuse of children can occur. A United Nation’s study on violence against children revealed a high incidence of violence committed by teachers and school staff as well as by other  students  [2].  Both  physical  and psychological forms of abuse in school are reported, usually both to- gether. Several studies have consistently shown that physically abused children have poorer school performance and lower educational achievement than non-abused  pupils  [3–5].  Physical  abuse also has long-lasting effects on mental health, social isolation, criminal behaviour, drug and alcohol misuse, risky sexual behaviour and even obesity, which persist into adulthood [6–9]. Globally, less than 20 of the world’s  190-plus countries have as yet prohibit- ed all forms of corporal punishment, and so only 52 million children out of  the  world’s 2 195 million  live  in countries  where the law gives them equal protec- tion  from being assaulted.  In about 90  countries out of 197 worldwide,  cor- poral punishment is still authorized in schools and other institutions, including at  least 7 states  in the Middle East and  North Africa [10]. A survey carried out in a wide range of developing countries found that between 20% and 65% of  school-age  children reported having been verbally or physically bullied in school in the pre- vious 30 days  [11]. Several  family and  community-based studies into child abuse conducted in the Middle East reported that teachers were among the perpetrators of physical abuse [12–17].  In Palestine, a study revealed that 32.3%  of the participants had been subjected to physical abuse by their teachers [14]. In Egypt, a survey reported that a sub- stantial proportion of boys (80.0%) and  girls  (61.5%)  incurred  physical  pun- ishment by a teacher during the scho- lastic  year  [17].  In Bahrain,  corporal  punishment was experienced by 23%  of girls at a  school [15].  In  the  Islamic  Republic of Iran, in Kurdistan province, a study found that 43.3% of the students  had been subjected to physical abuse at school [16]. There is a general scarcity of data on child abuse in school settings in de- veloping  countries.  In Yemen, only 2  community-based studies were found, both reporting extremely high rates of physical punishment experienced by pupils at school (81.7% and 90% respec- tively) [18,19]. The current study is the  first school-based study among pupils to be conducted in Yemen and aimed to assess the prevalence of physical abuse in basic-education schools in Aden. It is expected that it will increase the awareness of the educational authori- ties, families and the community at large about the magnitude of this problem and the importance of developing ap- propriate approaches for its control and management. Methods Study design and setting A cross-sectional survey was conducted in 4 randomly selected districts in Aden governorate. The study target was pupils in grades 7, 8 and 9 of basic-education  schools during  the  school year 2009– 10. Children in the ages 12–17 years are  usually able to perceive what is and is not abuse within the school context, and are capable of answering a question- naire and providing reliable information [17,20]. Study population and sample size The sample size was calculated using the assumed proportion of 0.5 in order  to obtain the maximum possible sample size,  with  a  level  of  confidence  95%,  and 0.03, as maximum allowable error.  Accordingly, the calculated sample size was  1066  pupils,  which was  propor- tionally distributed according to the sex  ratio  in  schools  (667 males  and  399  females). A multi-stage  stratified  random sampling was performed. In the first stage, 4 districts were randomly selected. In the second stage, 2 schools  from each district also were randomly selected. In third stage, systematic ran- dom sampling was applied to select the number of pupils assigned in each grade in the selected schools. Data collection Instrument An anonymous, self-administrated questionnaire adapted from the Ara- bic version of the International Child Abuse  Screening  Tool–Children’s  Institutional Version (ICAST-C) [20]  was used for data collection. The first part of the instrument covered ques- tions about pupil’s variables (sex, age, school grade, residence), in addition to parents’ sociodemographic variables (family type, parents’ education and parents’ marital status). The second part asked about different items of abuse acts. To examine the validity and reliabil- ity of the questionnaire we conducted a pilot  study  that covered 60 pupils (30  males and 30  females)  from 2 schools  not included in the main study, to en- sure that the questionnaire items were clear, understandable and culturally acceptable. The validity of the question- naire was tested using the content valid- ity method, where the questionnaire was  reviewed and  judged by 3 experts  in child abuse from Yemeni universities, to assess each item’s readability, clarity and comprehensiveness and to find out if it was socially acceptable. Accordingly, some items were rephrased, and some others were dropped. The reliability of internal consistency for the question- naire items was tested by entering data from the pilot study and the Cronbach alpha coefficient that was found to be 0.78. In the final modified version of the questionnaire the pupils were asked: “Have you ever been exposed to any of Book 19-4.indb 334 5/12/2013 2:19:32 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 335 its objectives. It also stated that the data confidentiality would be assured, partic- ipation in the study was voluntary and those who refused participation would not lose any rights or privileges. Parents were asked to put their signature if they agree to have their child participate in the  survey. About 15% of  the parents  initially selected did not agree for their children to participate in the survey, and other pupils were substituted to achieve the target sample size. Finally, parental consent was obtained for each pupil who participated in the study. The pupils’ informed assent was taken orally, detailed explanation of the objectives and the importance of the research were provided, and they were assured that all information obtained would be handled confidentially. Pupils were informed that they had the right to decline answering any question and to withdraw from the study at any time. All pupils whose parents gave consent to their participation agreed to participate in the study. Data analysis SPSS,  version  16 was  used  for  data  analysis. Quantitative variables were normally distributed after testing for normality  using  the  Kolmogorov– Smirnov test. Percentages were cal- culated as summary measure for the qualitative variables. Arithmetic mean and standard deviation (SD) was used to express the quantitative variables. The association between child’s char- acteristics and physical abuse were tested using the chi-squared test. The statistical significant level was set at P-value < 0.05. The multivariate analysis was done by the binary logistic regressions to identify risk factors associated with the outcome (dependent variable), i.e. physical abuse. For the dependent outcome, no abuse was coded “0” and  abuse was coded “1”. The results were discussed in terms of the adjusted odds ratio  (OR)  alongside  its  95%  confi- dence interval (CI). Results Sociodemographic characteristics of the study sample Table 1 shows the socioeconomic char- acteristics of the study sample. Male pu- pils constituted the highest proportion (62.6%). The mean age was 14.0 (SD  1.1) years. Most of  the pupils (70.1%)  lived in nuclear families. More than 50%  of mothers were illiterate or could just read and write. Prevalence of physical abuse A  total  of  594 out of  1066 pupils  re- ported experiencing one or more physi- cal abuse acts during their school life, a prevalence of 55.7%. Teachers were  by far the most common perpetrators (45.4% of  cases)  compared with  ad- ministrative staff (6.0%), while 4.3% of  children reported being abused by both teachers and administrative staff. As summarized in Table 2 the most  common physical abuse act reported by pupils was standing in a way that hurts (40.0%), twisting ear (34.4%) and  standing outside  in  the  sun  (33.9%).  The lowest physical abuse acts expe- rienced by the pupils were choking (4.1%), punching (4.7%) and slapping  on the face (8.3%). There were statistically significant dif- ferences by sex. Males were more likely than females to experience all kinds of abuse and this difference was significant for all except 1 type of abuse (Table 2). Association analysis As demonstrated in Table 1, the inde- pendent variables that showed a sig- nificant association with physical abuse were pupils’ sex, age group, father’s edu- cation and family type. Pupils were more likely to experience violence if they were male, of an older age, had an illiterate father and lived in an extended family. Table 3 displays  the variables with  significant univariate associations en- tered into the multivariate logistic re- gression. The only significant predictors these acts at school?”: slapped on your face, beaten on your head, beaten on your shoulder, twisting ear, throwing an object at you, punching, kicking, pinching, hands crushing, standing in a way that hurts, standing outside in the sun, taking food away from you, pull- ing hair, finger crushing, choking. We explained the questionnaire in detail to the pupils, and asked them to answer yes or no to each item. Those who responded affirmatively were asked how many times they had experienced the abuse act during their school life and who was the perpetrator (teachers or school administrative staff). The rate of physical abuse was calculated by recoding the acts into dichotomous categories (0 = never and 1 = once or  more). A 4-point scale was used to score how often they had experienced each  abuse  act  (0  =  none;  1  =  1–2  times; 2 = 3–4  times; 3 = ≥ 5  times)  [21]. Operational definition Physical abuse in this study referred to pupils’ reports of any act that occurred to them by teachers or other school administrators (school principal, vice principal or other workers) that could potentially victimize them while in school  [22]. Physically  abused pupils  were defined as those who answered positively to one or more of the physical abuse acts. Ethical considerations The research protocol was approved by the research committee for post- graduate studies in the Faculty of Medicine and Health Sciences. Sev- eral levels of permission were granted before the study could proceed, including official approval from the authority of Aden Education Office and then permission was sought from the districts directors of education, followed by the permission of school principals. A written informed consent was sent to the pupils’ parents describing the nature of the study, its importance and Book 19-4.indb 335 5/12/2013 2:19:32 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 336 for physical abuse remaining in the model  were  male  sex  (OR  =  7.89;  95% CI: 5.84–10.6)  (P  < 0.001)  and  extended family type (OR = 1.36; 95%  CI: 1.00–1.84) (P < 0.05). Discussion The present study is the first of its kind in Aden governorate to address physical abuse in schools. Covering a representative sample of public basic- education school pupils it aimed to study the prevalence of physical abuse at school and its associated factors. The study findings revealed that more than a half of pupils (55.7%) had expe- rienced at least 1 abuse act by teachers in their school life. This finding is lower than what was reported from India and Egypt  (65% and 72.8%  respectively)  [17,23]. The  lower  rate  in our  study  could be explained by the fact that this study covered pupils in basic-ed- ucation schools in Aden governorate, while in India, the study was a national study and that in Egypt included both basic- and secondary-school pupils. Physical punishment as a form of discipline for school pupils is still socially acceptable in many communi- ties. Teachers, who may themselves have suffered similar acts as children, might believe that it is normal to use physical force to make pupils better disciplined  [24,25]. This  applies  to  many countries in the region, includ- ing  Yemen  [17,26].  Other  studies  reported that teachers perceived cor- poral punishment of pupils as a form of social control [24]. However,  such  interpretations require further inves- tigation. Abuse by teachers was experi- enced by 45.4% of  children, which  is  very close to what was reported from India  (44.8%)  [23],  a  little  higher  than what was found in the Islamic Republic  of  Iran  (43.3%)  [16]  and  much higher than that reported from Lebanon (24.7%) [11]. On  the other  hand, higher rates of physical abuse by teachers were reported by studies from Korea, China  and Egypt  (62%,  51.1% and 72.8% respectively) [17,27].  The difference in the rates reported in these studies and our findings could be explained by differences in study design and time frame. The current study revealed that male pupils were more frequently physically abused than females (73.2% and 26.8%  respectively). This finding is consistent with other  studies  [11,17,21,23]. This  difference also could be interpreted as an expression of cultural values and norms dominant in traditional socie- ties, where touching the female body is  considered  impermissible  [17]. On  the other hand, male pupils are likely to be more engaged in and more per- missive to school violence behaviour than females [12]. We believe that both  explanations are valid. Table 1 Prevalence of physical abuse experienced by basic-education pupils, by personal and family demographic characteristics Variable Total Experienced physical abuse P-value No. No. % Total 1066 594 55.7 Pupil’s sex Male 667 488 73.2 < 0.001 Female 399 106 26.8 Pupil’s age group (years) 12–13 363 176 48.5 0.00214–15 618 364 58.9 16–17 85 54 63.5 School grade 7 322 173 53.7 0. 4108 366 214 58.5 9 378 207 54.8 Mother’s education Illiterate 264 152 57.6 0.288 Read/write 324 192 59.3 Basic 177 97 54.8 Secondary 162 82 50.6 University 139 71 51.1 Father’s education Illiterate 74 46 62.2 0.029 Read/write 281 163 58.0 Basic 103 63 61.2 Secondary 202 93 46.0 University 406 229 56.4 Family type Nuclear 747 393 52.6 0.002 Extended 319 201 63.0 Parents’ marital status Married 952 527 55.4 0.169 Separated 21 13 61.9 Divorced 33 24 72.7 Widowed 60 30 50.0 Book 19-4.indb 336 5/12/2013 2:19:32 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 337 Pupils in older age groups re- ported higher rates of physical abuse than  younger  age  groups  (63.5%  of  16–17-year-olds  versus  58.9%  of  14–15-year-olds  and  48.5%  of  12–13-year-olds).  This  finding  is  consistent with a  study  in  India  [23].  Others explained this difference by the longer lifespan of older children who could have more courage to dis- close  their experiences [12]. Although  there was no significant association between school grade and the preva- lence of physical abuse, pupils in higher grades were more frequently abused. A number  of  studies  [17,21,28],  re- ported similar findings. It seems that the relationship between physical abuse Table 2 Distribution of pupils’ reported experience of physical abuse, by sex Types of physical abuse Males (n = 667) Females (n = 399) Total (n = 1066) P-value No. % No. % No. % Standing in a hurtful way 296 44.4 130 32.6 426 40.0 0.011 Twisting ear 316 47.4 51 12.8 367 34.4 < 0.001 Standing in the sun 244 36.6 117 29.3 361 33.9 0.086 Beating shoulder 268 40.2 81 20.3 349 32.7 < 0.001 Beating head 260 39.0 35 8.8 295 27.7 < 0.001 Pinching 157 23.5 32 8.0 189 17.7 < 0.001 Crushing fingers 154 23.0 15 3.8 169 15.9 < 0.001 Throwing with objects 128 19.2 39 9.8 167 15.7 < 0.001 Pulling hair 150 22.5 14 3.5 164 15.4 < 0.001 Crushing hands 151 22.6 12 3.0 163 15.3 < 0.001 Taking food away 101 15.1 29 7.3 130 12.2 0.002 Slapping face 80 12.0 9 2.3 89 8.3 < 0.001 Kicking 67 10.0 1 0.3 68 6.4 < 0.001 Punching 50 7.5 0 0.0 50 4.7 < 0.001 Choking 40 6.0 4 1.0 44 4.1 < 0.001 Table 3 Logistic regression analysis of personal and family demographic characteristics associated with physical abuse Variable Univariate analysis Multivariate analysis OR 95% CI OR 95% CI Pupil’s sex Female 1.00 Ref. 1.00 Male 7.54 5.69–9.98*** 7.89 5.84–10.6*** Pupil’s age group (years) 12–13 1.00 Ref. 1.00 14–15 1.52 1.17–1.98** 1.14 0.84–1.54 16–17 1.85 1.14–3.01* 0.88 0.51–1.52 Family type Nuclear 1.00 Ref. 1.00 Extended 1.53 1.17–2.01** 1.36 1.00–1.84* Father’s education Illiterate 1.00 Ref. 1.00 Read/write 1.27 0.76–2.11 0.88 0.49–1.56 Basic 1.07 0.79–1.45 1.27 0.64–2.52 Secondary 1.22 0.78–1.89 0.76 0.41–1.39 University 0.66 0.47–0.93* 1.40 0.80–2.47 *P < 0.05; **P < 0.01; ***P < 0.001. OR = odds ratio; CI = confidence interval. Ref. = reference category. Book 19-4.indb 337 5/12/2013 2:19:32 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 338 References 1. Cohen J. Social, emotional, ethical, and academic education: Creating a climate for learning, participation in democracy, and well-being. Harvard Educational Review, 2006, 76:201– 237. 2. Pinheiro PS. World report on violence against children. Geneva, United Nations Children’s Fund, 2006. 3. Boden JM, Horwood LJ, Fergusson DM. Exposure to child - hood sexual and physical abuse and subsequent educa- tional achievement outcomes. Child Abuse and Neglect, 2007, 31:1101–1114. 4. Lansford JE et al. A 12-year prospective study of the long-term effects of early child physical maltreatment on psychological, behavioral, and academic problems in adolescence. Archives of Pediatrics and Adolescent Medicine, 2002, 156:824–830. 5. Potter DJ. 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Corporal punishment and psychological mal- treatment among school girls in Bahrain. Bahrain Medical Bul- letin, 1997, 19:70–73. 16. Sheikhattari P et al. Child maltreatment among school children in the Kurdistan Province, Iran. Child Abuse and Neglect, 2006, 30:231–245. 17. Youssef RM, Attia MS, Kamel MI. Children experiencing violence. II: Prevalence and determinants of corporal punish- ment in schools. Child Abuse and Neglect, 1998, 22:975–985. 18. Al Dhubhani N. Violence against children in selected areas of Yemen. Sana’a, Graphics International Press. 2004. 19. Habasch R. Physical and humiliating punishment of children in Yemen. Stockholm, Save the Children Sweden, 2005. 20. Child Abuse Screening Tool-Children’s Institutional Version (ICAST-CT). International Society for Prevention of Child Abuse and Neglect [website] (www.ispcan.org/, accessed 3 January 2013). 21. Chen JK, Wei HS. Student victimization by teachers in Taiwan: prevalence and associations. Child Abuse and Neglect, 2011, 35:382–390. 22. Zolotor AJ et al. ISPCAN Child Abuse Screening Tool Children’s Version (ICAST-C): Instrument development and multi-na- tional pilot testing. Child Abuse and Neglect, 2009, 33:833–841. 23. Kacker L, Varadan S, Kumar P. Study on child abuse: India 2007 New Delhi, Ministry of Women and Child Development, Government of India, 2007. 24. Toward a child-friendly education environment: a baseline study on violence against children in public schools. A baseline study on violence against children in public schools. Makati City, Philip- pines, Plan Philippines, 2009. and school grade were not studied suf- ficiently, and further investigation is required to better understanding this problem. Our study showed that pupils living in extended families experienced more physical abuse in school than those in nuclear families. This could be inter- preted according to the social learning theory, whereby children in extended families live in more crowded homes, therefore witnessing more family vio- lence, and may also remain outdoors longer hours, observing and imitating aggressive behaviours which affects their relationship with schoolteachers and make them more exposed to physi- cal abuse [29]. The study findings revealed an inverse association between father’s educational level and the prevalence of physical abuse. Fathers with lower education levels may be unable to avail themselves of the resources needed for coping with family problems and to avoid abusive  relationships;  therefore,  they resort to violent behaviour to deal with family problems [30]. This morbid  environment can negatively affect the children’s behaviour and makes them more vulnerable to different types of abuse and violence. Conclusion Physical abuse is a major public health and educational problem in basic school education, particularly among male pu- pils. Children of extended families were more victimized. Teachers stood out as the main perpetrators. Further studies are required to investigate indepth the risk factors associated with this prob- lem, particularly the school and family environment. The educational authori- ties should take the appropriate meas- ures to promote school safety and to adopt policy that enforces non-violent disciplinary approaches. Book 19-4.indb 338 5/12/2013 2:19:33 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 339 25. Vlasis-Cicvaric I et al. Children’s reflections on corporal pun- ishment. Public Health, 2007, 121:220–222. 26. Haj-Yahia MM, Ben-Arieh A. The incidence of Arab adoles- cents’ exposure to violence in their families of origin and its sociodemographic correlates. Child Abuse and Neglect, 2000, 24:1299–1315. 27. Kim DH et al. Children’s experience of violence in China and Korea: a transcultural study. Child Abuse and Neglect, 2000, 24:1163–1173. 28. Tang CSK. Corporal punishment and physical maltreatment against children: a community study on Chinese parents in Hong Kong. Child Abuse and Neglect, 2006, 30:893–907. 29. Newberger EH. Child abuse. In: Wallace RB, Doebbeling BN, eds. Public health and preventive medicine. Norwalk, Connecti- cut, Appleton and Lange, 1998. 30. Cox CE, Kotch JB, Everson MD. A longitudinal study of modifyA- ing influences in the relationship between domestic violence and child maltreatment. Journal of Family Violence, 2003, 18:5–17. Preventing child maltreatment: a guide to taking action and generating evidence Preventing child maltreatment: a guide to taking action and generating evidence is a joint publication of the World Health Organization (WHO) and the International Society for Prevention of Child Abuse and Neglect (ISPCAN). It aims to assist governments, NGOs and international agencies to undertake scientifically informed programmes to prevent child maltreatment. The ultimate objective is a world in which all countries routinely implement child maltreatment prevention programmes based on sound epidemiological data and on local experimental studies of what is effective in prevention. This publication is available at: http://whqlibdoc.who.int/publications/2006/9241594365_eng.pdf Book 19-4.indb 339 5/12/2013 2:19:33 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 340 Do personal beliefs and peers affect the practice of alcohol consumption in university students in Lebanon? J. Salamé,1 B. Barbour 2 and P. Salameh 3,4 ABSTRACT Alcohol consumption is frequent among university students in Lebanon as elsewhere in the world. A cross- sectional study was conducted in Lebanon’s public and private universities between October 2009 and September 2010 using a standardized questionnaire to assess personal beliefs about alcohol consumption, peers’ behaviours and opinions and history of and current drinking practices. Of 1235 students, 199 (16.1%) had an AUDIT score ≥ 8. Older age, male sex, Christian religion, attending a private university, studying a non-health specialty and residing in Beirut or Mount Lebanon were associated with a higher risk of harmful drinking. Beliefs concerning alcohol consumption and peers’ opinions and behaviours were factors significantly associated with harmful drinking, especially: ignoring the dangers of alcohol consumption; higher frequency of consumption with friends; and a higher proportion of friends who drank regularly. University students’ alcohol drinking behaviour was mostly influenced by peers’ behaviour, and a peer education programme is recommended to decrease the risk of harmful drinking. 1Faculty of Medicine; 2Faculty of Public Health; 3Faculty of Pharmacy; 4Faculty of Public Health, Lebanese University, Beirut, Lebanon (Correspondence to P. Salameh: psalameh@ul.edu.l; pascalesalameh1@hotmail.com). Received: 21/02/12; accepted: 19/03/12 ؟نانبل في ينيعمالجا بلاطلا ىدل لوحكلا يطاعت تاسرامم لىع ءلامزلا تادقتعمو ةيصخشلا تادقتعلما رثؤت له ةملاس لاكساب ،روبرب تيدانيرب ،ةملاس فيزوج ةصالخا تاعمالجا في ةضرعتسم ةسارد نوثحابلا ىرجأ دقو .لماعلا ءاحنأ رئاس في ماك ،نانبل في ينيعمالجا بلاطلا ينب لوحكلا يطاعت عيشي :ةـصلالخا يطاعت لوح ةيصخشلا تادقتعلما مييقت لجأ نم انَّنقم ًانايبتسا ينمدختسم ،2010 برمتبس/لوليأو 2009 ربوتكأ/لولأا نيشرت ينب ةترفلا في ةماعلاو )%16.1( مهنم 199 ىدل ناك ،ًابلاط 1235 ةساردلا تلمش دقو .ليالحا اهعضوو ،بشرلا تاسرامم قباوسو ،مهئارآو ءلامزلا تايكولسو ،لوحكلا ٍلك عم بشرلا ةلكشم راطتخا دُيازت قفارت دقو .AUDIT لوحكلا ءاستحا نع ةجمانلا تابارطضلاا لىع فرعتلا رابتخا في 8 لىع ديزت وأ يواست ةجرد امأ .نانبل لبج وأ تويرب في َىنك ُّسلاو ،يحص يرغ صاصتخا ةساردو ،ةصاخ ةعماج لىإ باستنلااو ،ةيحيسلما ةنايدلاو ،ةروكذلاو ،رمعلاب م ُّدقتلا نم تناكف ،بشرلا ةلكشم عم ًايئاصحإ ابه دتعي ةجردب تقفارت لماوع تناك يتلا متهايكولسو ءلامزلا تادقتعمو لوحكلا يطاعتب ةقلعتلما تادقتعلما ينثحابلل ينبتو .ماظتناب لوحكلا نوبشري نيذلا ءاقدصلأا ةبسن عافتراو ،ءاقدصلأا عم لوحكلا يطاعت لدعم عافتراو ،لوحكلا يطاعت رطاخمب لهلجا .لوحكلا بشر ةلكشم راطتخا صاقنلإ ءلامزلل فيقثت جمانبرب اْوَصوأو ،ءلامزلا تايكولسب رثأتي ةعمالجا بلاط ىدل لوحكلا يطاعت كولس نأ Les croyances personnelles et celles des pairs influent-elles sur la consommation d'alcool des étudiants au Liban ? RÉSUMÉ La consommation d'alcool est fréquente chez les étudiants au Liban comme ailleurs. Une étude transversale a été menée dans des universités publiques et privées du Liban, entre octobre 2009 et septembre 2010, à l'aide d'un questionnaire normalisé visant à évaluer les croyances personnelles en matière de consommation d'alcool, le comportement des pairs et leurs opinions ainsi que les pratiques passées et présentes de consommation d'alcool. Sur un total de 1 235 étudiants, 199 (16,1 %) ont obtenu un score AUDIT supérieur ou égal à 8. Être plus âgé, de sexe masculin, ou chrétien, fréquenter une université privée, étudier un autre domaine que la santé, vivre à Beyrouth ou dans la région du Mont-Liban étaient des facteurs associés à un risque accru de consommation nocive d’alcool. Les croyances concernant la consommation d'alcool et l'opinion et le comportement des pairs étaient des facteurs significativement associés à une consommation nocive d’alcool, en particulier le fait d'ignorer les dangers de la consommation d'alcool, d'en consommer fréquemment avec des amis et d'avoir une proportion élevée d'amis qui en consomment régulièrement. Le comportement des étudiants concernant la consommation d'alcool était principalement influencé par celui des pairs. Un programme d'éducation par les pairs est recommandé pour diminuer le risque de consommation nocive d’alcool. Book 19-4.indb 340 5/12/2013 2:19:33 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 341 Introduction Alcohol consumption is common among university students all over the  world  [1,2]  and  is  associated  with  social  [3]  and health problems  [4] in this population subgroup. For example, alcohol consumption may lead to low academic achievement [5],  psychological disturbances  [6],  social and relational problems [3],  il- licit drug abuse [7] and physical health  problems [4]. In Eastern Mediterranean coun- tries, very few data have been gathered concerning alcohol consumption in general, or by university students in particular  [8].  In  Lebanon,  a  study  published in 2000 on a limited sample  from 2 private universities showed that  49% of  students had ever  consumed  alcohol, 2.4% were alcohol dependent  and  2.1% were  alcohol  abusers  [9].  However, underreporting of this habit is likely for religious and social reasons (since alcohol drinking is prohibited in Islam). Therefore, while talking about alcohol consumption is a taboo in our conservative society [10], we sus- pect that harmful alcohol drinking is increasingly common in this young population. The objectives of this study were to confirm the validity of the AUDIT score in the Lebanese context before using it to assess harmful drinking in Lebanese students, and to evaluate whether personal beliefs about alcohol consumption and peers’ drinking af- fected alcohol consumption practice and harmful drinking of university students. Methods Study design We conducted a cross-sectional study in Lebanon’s public and private uni- versities,  between October 2009  and  September 2010. Population and sampling procedure A cluster proportionate sampling method was used to select students within campuses. From the list of uni- versities provided by the Ministry of Higher Education, we selected univer- sities with the highest proportion of students  in Lebanon (1% of  students  and more). In the public university (Lebanese University; 43.3% of  total  university students in Lebanon), we sampled all faculties: the faculties of Arts, Law and Political Sciences, Public Health, Medical Sciences, Engineer- ing, Economics, Information and Documentation, Social Sciences, Lit- erature and Humanities and Sciences. The private universities selected were Kaslik Holy Spirit University  (4.1%),  Saint  Joseph University  (5.6%), No- tre Dame University  (2.9%),  Beirut  Arab University  (10.6%), Balamand  University  (1.9%),  Sagesse Univer- sity  (1.0%), American University  of  Lebanon (1.0%), Lebanese American  University (2.9%), American Univer- sity of Science and Technology (3%),  Lebanese Germany University  (1%)  and Lebanese International University (4.6%). The American University of  Beirut (4.2%) refused to participate to  the study. In participating universities, we approached all students regardless of their field of specialization. Data collection Campus administrators were con- tacted and permission was given for enquirers to distribute a proportion- ate cluster sampling of questionnaires according to the number of students in every university. However, within every campus, an accidental sample of students was selected, because ad- ministrators did not allow us to have lists of students and interview students accordingly. A self-administered, anonymous questionnaire in Arabic language was prepared by the investigators and distributed to university students dur- ing breaks. Students gave their oral consent to participate to the study, after it had been explained to them that it was a “study done by university researchers that had extreme importance for their health” and ensuring anonymity (no names were required). To ensure maxi- mum objectivity in students’ answers, enquirers were instructed not to give any additional clarification for ques- tions that were not understood. The questionnaire was pilot-tested on 30  university students to correct or clarify questions when necessary. Sample size calculation Sample size calculation was performed using the following assumptions: a prev- alence of harmful alcohol consumption of 9% [11], and worst acceptable values  of  (6.5%–11.5%)  (a  bracket  of  5%  around 9%). The minimal  acceptable  sample  size was  calculated  to be 503  individuals;  taking  into account cluster  sampling, the number was doubled to 1006. Afterwards, we  added  an  addi- tional number of questionnaires (33%)  to allow for non-response. Thus, a total of 1500 questionnaires were distributed  to students from all universities. Study tool A standardized questionnaire, including closed and open-ended questions, was used. Questions about personal beliefs concerning alcohol consumption and peers’ behaviours and opinions were asked. For example, we asked whether students believed that alcohol drinking was dangerous for health, if alcohol was dangerous when consumed frequently and massively, if alcohol was danger- ous for pregnant women and if driving after a drink was dangerous. We also asked about the attitudes of their friends towards alcohol consumption and personal attitudes towards drinking, heavy drinking and causes of alcohol consumption or non-consumption. To study practices, we evaluated details of alcohol consumption, age of first and Book 19-4.indb 341 5/12/2013 2:19:33 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 342 the Promax rotation to show the most appropriate pattern and structure ma- trix. We also calculated the Cronbach alpha factor for reliability analysis. We also weighted the result to adjust for the distribution of students between public and private universities according to the list provided by the Ministry of Education. Harmful alcohol drinking according to the AUDIT score was considered as a dependent variable. The independent variables were as fol- lows: age, type of university, religion, sex, age of initiation of alcohol consump- tion, age of first alcohol consumption and region of residence. In addition, personal and peers’ beliefs and attitudes about alcohol were used as independ- ent variables. Missing values, which accounted for < 5% of answers, were not replaced,  and variables were analysed as available. The chi-squared test was used for com- parison between categorical variables. The Student t-test was used to compare means of continuous variables. Varia- bles showing association in the bivariate analysis at the P < 0.2 level were entered  in the multivariate logistic regression models. In the logistic regression a non- significant Hosmer and Lemeshow test should be obtained (P-value > 0.05) to  have an adequacy model. Results Out of 1500 distributed questionnaires,  1263 individuals (84.2%) returned their  questionnaires. After weighting indi- viduals according to the distribution of public and private universities, the number became 1266 individuals (due  to numbers rounding). Out of these, 1235 (97.6%) had no missing  values  and were thus used for the majority of analyses. AUDIT score validity Table 1 shows the structure of the AUDIT score when applied to the university students in Lebanon with no missing values, after ensuring sampling adequacy with Kaiser–Meyer–Olkin  measure of 0.872, and a Bartlett  test of  sphericity with  a  chi-square  of  4052  and a P-value < 0.001. When using  a  principal component analysis and a pro- max rotation, the AUDIT score items loaded on 2 factors (with eigenvalues >  1) that explained 53.7% of the total vari- ance: the factor represented problems with drinking last year, while the second of regular consumption, place of first alcohol consumption, frequency of high consumption, maximal number of drinks on one occasion, proportion of friends who frequently drink alcohol and frequency of alcohol consumption with friends. To assess harmful alcohol con- sumption, we used the AUDIT score recommended by the World Health Organization [12,13]. The score ques- tions were translated into Arabic by an independent translator and back-trans- lated into English by the researchers to resolve any translation discrepancy. A cut-off value of 8 was considered predic- tive of harmful drinking [12–14]. Statistical analysis Data was entered, managed and analysed by SPSS,  version 13.0. Before  proceeding with the analysis, we first validated the AUDIT score in the context where it was used: we first per- formed an exploratory factor analysis using the principal component analysis technique, and extracted the factors with an eigenvalue that was higher than 1, after ensuring sampling adequacy by Kaiser–Meyer–Olkin measure and  Bartlett test of sphericity. Since the ex- tracted factors were correlated, we used Table 1 Construct structure of the AUDIT score for problem drinking among university students in Lebanon Items Factor 1 loading Factor 2 loading Communality Frequency of feeling a morning urge to drink in previous 12 months 0.753 – 0.433 Unable to stop drinking in previous 12 months 0.681 – 0.554 Unable to remember what happened after drinking in previous 12 months 0.677 – 0.591 Frequency of guilt after drinking in previous 12 months 0.641 – 0.443 Any person who was hurt in consequence of your alcohol consumption in previous 12 months 0.633 – 0.316 Unable to perform usual activities because of alcohol consumption in previous 12 months 0.549 – 0.481 Did anybody suggest to you that you should decrease your alcohol consumption? 0.451 – 0.371 Frequency of consumption of 6 drinks and more on one occasion – 0.913 0.790 Mean number of drinks on one occasion – 0.903 0.759 Usual frequency of alcohol consumption – 0.813 0.631 Total AUDIT score correlation 0.842* 0.862* 0.552** *P < 0.001 for Pearson coefficients correlation with AUDIT score; **P < 0.001 for Pearson coefficients correlation between factor 1 and factor 2. The reliability of the total AUDIT score and of both factors was 0.815 for the total, 0.734 for factor 1 and 0.803 for factor 2. Book 19-4.indb 342 5/12/2013 2:19:33 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 343 mostly represented the frequency and heaviness of alcohol consumption. The reliability of the total AUDIT score and of both  factors was high: 0.815  for  the  total,  0.734  for  factor 1  and 0.803  for  factor 2. Sample characteristics Out of 1235  individuals, 199 (16.1%;  95% CI: 14.0%–18.2%) had an AUDIT  score of ≥ 8  and were  considered  to  have harmful drinking.  In Table 2, we  present the characteristics of the sam- ple, divided into AUDIT scores ≤ 7 (n = 1036; 83.9%) and ≥ 8 (n = 199; 16.1%).  There were significant differences concerning alcohol consumption with respect to all the sociodemographic characteristics evaluated: higher age, male sex, Christian religion, attending a private university, studying a non- health specialty and dwelling in Beirut or the Mount Lebanon region were associated with a higher probability of harmful alcohol drinking (P < 0.05 for  all) (Table 2). Personal beliefs and practice concerning alcohol consumption Believing that alcohol was not danger- ous  for health (crude OR = 6.67) and  thinking that it was acceptable to get drunk  sometimes  (OR =  5.39),  par- ticularly if good grades were achieved at university (OR = 8.21),  significantly  increased the risk of harmful drinking (P < 0.001) (Table 3). Moreover, knowing  that frequent and massive consump- tion of alcohol was dangerous (OR = 1.42) and  that  alcohol was dangerous  for pregnant women (OR = 1.94) sig- nificantly affected the risk of harmful drinking. However, believing that it was dangerous to drink and drive did not have a significant association with harmful drinking (Table 3). The mean  age at first consumption was lower in individuals with harmful drinking [13.6  (SD 3.2) versus 15.2 (SD 2.6) years]  (P  < 0.001)  and  their mean maximal  number of drinks on one occasion was higher  [11.0 (SD 6.9) versus 5.3 (SD  6.8)] (P < 0.001). Peers behaviours and opinion and association with harmful drinking Table 4 shows that peers’ opinion about drinking and behaviours strongly affect- ed the students’ risk of harmful drinking. Risk factors for harmful drinking were: friends’ agreeing with alcohol consump- tion (crude OR = 6.22), higher propor- tion of friends who drank regularly (OR = 17.3) and higher frequency of drinking  alcohol with  friends (OR = 80.1). Like- wise, having had their first drink with friends (OR = 3.27), at a relative’s house  (OR  =  1.81)  significantly  increased  the risk of harmful drinking versus first drinking alcohol in a public place. Table 2 Sociodemographic characteristics of university students in Lebanon by AUDIT scores for problem drinking Characteristic AUDIT score < 8 (n = 1036) AUDIT score ≥ 8 (n = 199) P-value OR (95% CI) No. % No. % Age group (years) 0.009 17–19 351 88.0 48 12.0 Ref. 20–21 500 83.2 101 16.8 1.48 (1.00–2.17) 22+ 184 79.0 49 21.0 1.95 (1.23–3.08) Sex < 0.001 Male 297 68.1 139 31.9 5.75 (4.13–8.00) Female 737 92.5 60 7.5 Ref. Religion < 0.001 Christian 821 82.1 179 17.9 2.41 (1.47–3.95) Muslim 210 91.7 19 8.3 Ref. Type of university Public university 484 90.1 53 9.9 < 0.001 Ref. Private university 552 79.1 146 20.9 2.41 (1.72–3.38) Specialty Non-health specialty 709 79.7 179 20.3 0.010 4.24 (2.62–6.85) Health specialty 333 94.3 20 5.7 Ref. Region of residence 0.003 Beirut 136 79.5 35 20.5 2.66 (1.26–5.69) Mount Lebanon 770 83.5 152 16.5 2.04 (1.07–3.98) Other region 124 91.2 12 8.8 Ref. Ref. = reference category; OR = odds ratio; CI = confidence interval. Book 19-4.indb 343 5/12/2013 2:19:34 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 344 Table 3 Beliefs concerning alcohol consumption and their association with problem drinking among university students in Lebanon Characteristic AUDIT score < 8 (n = 1036) AUDIT score ≥ 8 (n = 199) P-value OR (95%CI) No. % No. % Alcohol is always dangerous for health < 0.001 No 832 81.3 192 18.8 6.67 (2.91–15.2) Yes 173 96.6 6 3.4 Ref. Frequent and massive consumption of alcohol is dangerous 0.052 No 202 79.5 52 20.5 1.42 (1.00–2.01) Yes 803 84.6 146 15.4 Ref. Alcohol is dangerous for pregnant women < 0.001 No 527 79.6 135 20.4 1.94 (1.41–2.69) Yes 478 88.4 63 11.6 Ref. In general, alcohol is dangerous for health < 0.001 Yes 985 85.7 164 14.3 Ref. No 20 37.0 34 63.0 10.2 (5.74–18.2) It is dangerous to drink and drive < 0.001 Totally disagree 33 73.3 12 26.7 2.98 (1.41–6.23) Disagree 21 53.8 18 46.2 7.03 (3.45–14.3) Agree 139 68.1 65 31.9 3.83 (2.63–5.58) Totally agree 820 89.1 100 10.9 Ref. It is never good to drink alcohol < 0.001 Totally disagree 191 71.8 75 28.2 8.03 (3.76–17.7) Disagree 423 81.7 95 18.3 2.24 (1.00–5.17) Agree 215 93.1 16 6.9 1.52 (0.62–3.83) Totally agree 184 95.3 9 4.7 Ref. It is OK to get drunk sometimes < 0.001 Totally disagree 283 93.1 21 6.9 Ref. Disagree 288 85.7 48 14.3 2.25 (1.27–3.99) Agree 305 80.5 74 19.5 3.27 (1.91–5.64) Totally agree 125 71.4 50 28.6 5.39 (3.01–9.72) It is OK to get drunk sometimes if we have good academic results < 0.001 Totally disagree 495 92.2 42 7.8 Ref. Disagree 324 83.1 66 16.9 2.40 (1.56–3.70) Agree 131 73.6 47 26.4 4.23 (2.61–6.86) Totally agree 56 58.9 39 41.1 8.21 (4.75–14.2) Mean (SD) Mean (SD) Age of first consumption of alcohol (years) 15.2 (2.6) 13.6 (3.2) < 0.001 NA Maximal drinks on 1 occasion (no.) 5.3 (6.8) 11.0 (6.9) < 0.001 NA SD = standard deviation; Ref. = reference category; OR = odds ratio; CI = confidence interval; NA = not applicable. Book 19-4.indb 344 5/12/2013 2:19:34 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 345 Multivariate analysis A stepwise descendent logistic regres- sion  was  conducted  (Table  5),  and  the following factors had an effect on harmful drinking: male sex (adjusted OR = 2.36), believing that frequent and  massive consumption of alcohol was dangerous (OR = 2.94), believing  that  youngsters agreed with drinking (OR =  1.43;  trend  towards  significance),  higher frequency of consuming alco- hol  with  friends  (OR  =  1.71)  and  a  higher proportion of friends who drank alcohol  regularly  (OR = 1.38). Other  included variables in the model were removed by the procedure because of non-significant associations. Discussion We found that the AUDIT score had excellent construct validity and reliabil- ity in this sample of Lebanese students. Equivalent results were found by other researchers [15]. An important percent- age  of  students  (16.1%) were  found  to have harmful alcohol consumption (AUDIT  score ≥ 8). This proportion  is higher than that recently reported by Karam et al. in a rapid situation as- sessment for alcohol dependence in Lebanon (9%) [11]. This may be due  to the fact that harmful alcohol drink- ing includes the concepts of both alco- hol dependence and binge drinking. However, our results were similar to those found by the same authors in the 1990s on a sample taken from 2 private  universities [16], where non-Christians  and women were less likely to consume alcohol than Christians and men. Prohi- bition of alcohol consumption by Islam explains the higher number of students with harmful drinking in the Christian category than the Muslim one (OR = 3.17). Our results are comparable to those of a study of college students in the United States of America, many European countries and the Far East (Hong Kong), except for the sex ratio of consumers who had harmful drinking Table 4 Peer opinions and behaviours and their association with problem alcohol drinking among university students in Lebanon Characteristic AUDIT score < 8 (n = 1036) AUDIT score ≥ 8 (n = 199) P -value OR (95% CI) No. % No. % Friends generally agree with alcohol consumption < 0.001 Yes, they do 569 78.7 154 21.3 6.22 (2.60–15.9) They do not care 277 87.9 38 12.1 3.16 (1.24–8.52) They disagree 138 95.8 6 4.2 Ref. Frequency of consumption with friends < 0.001 Almost every time 68 41.5 96 58.5 80.1 (27.1–266) Almost half of the times 112 70.4 47 29.6 23.8 (7.96–79.9) Less than half of the times 91 91.0 9 9.0 5.61 (1.53–22.3) Occasionally 476 91.7 43 8.3 5.13 (1.74–17.0) Never 227 98.3 4 1.7 Ref. Proportion of friends who drink regularly < 0.001 Almost all 134 60.1 89 39.9 17.3 (7.79–39.8) More than half of them 162 74.7 55 25.3 8.83 (3.92–20.7) Less than half of them 155 89.6 18 10.4 3.02 (1.20–7.79) A few of them only 317 93.0 24 7.0 1.97 (0.82–4.86) None of them 208 96.3 8 3.7 Ref. Place of first consumption of alcohol < 0.001 At home 319 79.8 81 20.3 1.36 (0.92–2.02) At a relative’s house 71 74.7 24 25.3 1.81 (1.01–3.23) At a friend’s house 59 62.1 36 37.9 3.27 (1.92–5.59) At school 4 80.0 1 20.0 1.34 (0.68–1.64) In a public place 295 84.3 55 15.7 Ref. Ref. = reference category; OR = odds ratio; CI = confidence interval. Book 19-4.indb 345 5/12/2013 2:19:34 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 346 patterns. In Western societies as many females as males consumed alcohol [1], whereas in Lebanon more males than females were found to be at risk. The explanation for this discrepancy could be the fact in our more conservative so- ciety [10] fewer females than males are  used to drinking on a regular basis. This difference between men and women was demonstrated in a recent world- wide cross-national  comparison  [17].  However, Karam et al. found that alco- hol consumption among women was increasing and that once they became an ever-alcohol consumer, religion did not  affect  alcohol  dependence  [16].  Belief in God and religious practice per se seemed a protective factor against alcohol use disorders in Lebanese stu- dents [18]. Higher age (20–22 years) was ac- companied by a higher rate of harmful alcohol drinking than the lower age category  (17–19 years). This  is prob- ably due to greater independence from society’s rules in advanced college years than when freshly graduated from high school. It could also reflect the time period to acquire the habit of drinking alcohol during the years of university education. As for the type of university, the annual costs of private universities are many-fold higher than the public Lebanese University. The majority of private university students belong to a higher socioeconomic status, which is reflected in a way of living full of social gatherings between relatives and friends with many occasions for drinking alco- hol. Thus, the rate of harmful alcohol consumption was higher in private universities. Concerning the region of residence, students living in Beirut and Mount Lebanon were more likely to have an AUDIT score ≥ 8 and  this  is probably due to their higher socio- economic status as well as the greater number of restaurants, pubs and clubs offering alcohol in those regions. How- ever, all of these factors (age, region, age and religious beliefs) could not on their own explain the difference between students’ harmful drinking;  they were  actually confounded by other factors of knowledge and peers’ influence in the multivariate analysis. An interesting finding was that per- sonal beliefs about alcohol drinking had a significant but limited effect on the risk of harmful drinking; all beliefs  that  showed a significant effect on bivari- ate analysis seemed to be confounded by peers’ opinion about alcohol, peers’ drinking habits and knowledge about alcohol effects. Although both knowl- edge about alcohol effects and the influence of peers are important, the former seemed to have a limited effect on harmful drinking in our study. As students of health specialties would be expected to be aware of the dangers of alcohol, it is not surprising that the results showed that they were less prone to harmful alcohol drinking. This result was also apparent in the multivariate analysis. In fact, the regression analy- sis of factors associated with harmful drinking eliminated many factors within the personal beliefs category from the model, which means that personal beliefs had a limited effect on the risk of harmful drinking. Nevertheless, believ- ing that frequent and massive consump- tion of alcohol was dangerous remained a significant risk factor with an adjusted OR of 2.94. As for peers’ opinion and behav- iours, they seem to be the major driving force  for  harmful  drinking  of  youth;  many factors showed significant asso- ciations with harmful alcohol drink- ing, such as believing that their friends agreed with drinking, higher frequency of alcohol consumption with friends and higher number of friends who drink on a regular basis. Those factors had the highest explanatory ratio of the depend- ent variable variance;  they contributed  to a higher alcohol level among con- sumers, thus leading to possible danger- ous social and health outcomes. This concept has been demonstrated by oth- ers, such as Song et al. [19], Trucco et al. [20], and van der Zwaluw et al. [21].  Our study highlights the need for the introduction of peer education about alcohol consumption and its dangers in  all Lebanese universities;  a  similar  activity was initiated among Lebanese/ Armenian people to prevent substance abuse [22]. We suggest it could be gen- eralized to other young Lebanese as well. We are aware of the limitations of this study: a selection bias is possible since the sample was not randomly cho- sen and an information bias is possible, particularly given the delicate nature of the subject. Moreover, to keep the questionnaire simple we did not define Table 5 Multivariate analysis of factors associated with problem drinking among university students in Lebanon Factor ORa 95% CI P-valuea Male sex 2.36 1.52–3.66 < 0.001 Believing that frequent and massive consumption of alcohol is dangerous 2.94 1.59–5.44 < 0.001 Believing that friends agree with drinking 1.43 0.95–2.15 0.083 Higher frequency of alcohol consumption with friends 1.71 1.43–2.06 < 0.001 Higher number of friends who drink regularly 1.38 1.15–1.66 < 0.001 aHosmer–Lemeshow P-value = 0.076; Nagelkerke R2 = 0.298. Factors removed from the model because of non-significant association were: age, religion, region of residence, type of university, health specialty, believing that alcohol is dangerous for health and for pregnant women, age at first consumption, place of first consumption, believing that it is acceptable to get drunk from time to time and believing that it is dangerous to drink and drive. ORa = adjusted odds ratio; CI = confidence interval. Book 19-4.indb 346 5/12/2013 2:19:34 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 347 References 1. Tse EC. A comparative analysis of alcohol consumption pattern among global university students. Paper presented at the 2011 Annual Conference of the International Council on Hotel, Restaurant, and Institutional Education. Denver, Colorado, 27–30 July 2011 (http://scholarworks.umass.edu/refereed/ ICHRIE_2011/Saturday/10, accessed 28 January 2013). 2. Karam E, Kypri K, Salamoun M. Alcohol use among college students: an international perspective. Current Opinion in Psy- chiatry, 2007, 20:213–221. 3. Wechsler H et al. College alcohol use: a full or empty glass? Journal of American College Health, 1999, 47:247–252. 4. Hingson R et al. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18-24: changes from 1998 to 2001. Annual Review of Public Health, 2005, 26:259–279. 5. Singleton RA Jr, Wolfson AR. Alcohol consumption, sleep, and academic performance among college students. Journal of Studies on Alcohol and Drugs, 2009, 70:355–363. 6. Courtois R et al. Liens entre stresseurs, sante psychique et premieres consommations de tabac et d'alcool a la pre- adolescence. [Links between stress factors, mental health and initial consumption of tobacco and alcohol during pre- adolescence]. L'Encéphale, 2007, 33:300–309. 7. Gossop M, Marsden J, Stewart D. Dual dependence: assess- ment of dependence upon alcohol and illicit drugs, and the relationship of alcohol dependence among drug misusers to patterns of drinking, illicit drug use and health problems. Ad- diction, 2002, 97:169–178. 8. Chafetz ME. Consumption of Alcohol in the Far and Middle East. New England Journal of Medicine, 1964, 271:297–301. 9. Karam E et al. Use and abuse of licit and illicit substances: prevalence and risk factors among students in Lebanon. Euro- pean Addiction Research, 2000, 6:189–197. 10. Tohmé-Tabet A. Women, intangible heritage and development in Arab States. Paris, United Nations Educational, Scientific and Cultural Organization, 2001. (http://www.unesco.org/cul- ture/ich/doc/src/00161-EN.pdf, accessed 28 January 2013). 11. Karam EG et al. A rapid situation assessment (RSA) study of alcohol and drug use in Lebanon. Le Journal Medical Libanais, 2010, 58:76–85. 12. Babor TF et al. AUDIT. The alcohol use disorders identification test: guidelines for use in primary health care. Geneva, World Health Organization, 1992 . 13. Babor TF, Higgins-Biddle JC. Brief intervention for hazardous and harmful drinking: a manual for use in primary care. Geneva, World Health Organization, 2001. 14. Chen CH, Chen WJ, Cheng ATA. New approach to the valid- ity of the alcohol use disorders identification test: stratum- specific likelihood ratios analysis. Alcoholism, Clinical and Experimental Research, 2005, 29:602–608. 15. Selin KH. Test–retest reliability of the alcohol use disorder identification test in a general population sample. Alcoholism, Clinical and Experimental Research, 2003, 27:1428–1435. 16. Karam EG et al. Alcohol use among university students in Leba- non: prevalence, trends and covariates. The IDRAC University Substance Use Monitoring Study (1991 and 1999). Drug and Alcohol Dependence, 2004, 76:273–286. 17. Wells JE et al. Cross-national comparisons of sex differences in opportunities to use alcohol or drugs, and the transitions to use. Substance Use & Misuse, 2011, 46:1169–1178. 18. Ghandour LA, Karam EG, Maalouf WE. Lifetime alcohol use, abuse and dependence among university students in Leba- non: exploring the role of religiosity in different religious faiths. Addiction (Abingdon, England), 2009, 104:940–948. 19. Song EY et al. Everyone says it's ok: adolescents' perceptions of peer, parent, and community alcohol norms, alcohol con- sumption, and alcohol-related consequences. Substance Use and Misuse, 2012, 47:86–98. 20. Trucco EM, Colder CR, Wieczorek WF. Vulnerability to peer influence: a moderated mediation study of early adolescent alcohol use initiation. Addictive Behaviors, 2011, 36:729–736. 21. Van der Zwaluw CS, Larsen H, Engels RC. Best friends and alco- hol use in adolescence: the role of the dopamine D4 receptor gene. Addiction Biology, 2011, 17(6):1036–1045. 22. Arevian M. Training trainees, young activists, to conduct awareness campaigns about prevention of substance abuse among Lebanese/Armenian young people. Journal of Interpro- fessional Care, 2010, 24:173–182. the terms “frequent” and “massive” con- sumption in the questions, as our objec- tive was simply to gain an idea about personal beliefs rather than make a for- mal evaluation. Thus, our results could be overestimating or underestimating the prevalence of alcohol consumption or harmful drinking and its associated factors;  however,  these  biases would  be non-differential and the associations found would only be directed towards the null. Additional studies would be necessary to further refine these results in the Lebanese youth population. In conclusion, harmful alco- hol drinking was common among university students in Lebanon and was mainly affected by peers’ opinions and behaviours. Interventions are needed to help reduce this significant rate of regular alcohol consuming among stu- dents in our country and the danger of massive consumption, especially during gatherings of friends. Book 19-4.indb 347 5/12/2013 2:19:34 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 348 Factors influencing women’s willingness to volunteer in the healthcare system: evidence from the Islamic Republic of Iran A. Alami,1,2 S. Nedjat,2,3 R. Majdzadeh,2,3 A. Rahimi Foroushani,2 S.J. Hoseini 4 and H. Malekafzali 2 ABSTRACT This case–control study evaluated the factors influencing volunteering in the Islamic Republic of Iran’s Women’s Health Volunteer (WHV) programme, which is implemented in 150 centres in Khorasan-e-Razavi Province. We recruited 145 cases (volunteers) and 146 controls (non-volunteers) from the centres. Data were collected by questionnaire. Sociodemographic variables included were: length of residence in neighbourhood, number of siblings, husband’s age and education and job, family size, quality of life, self-rated health status, neighbourhood intimacy, child under 2 years, house ownership, wealth index. Social network variables included were: ego network size, type of acquaintance, intimacy with others, relationship communication, relationship duration, emotional support, advisory support, monetary support, physical support, time support. There were significant associations (P < 0.05) between women's propensity to volunteer and family size, presence of a child under 2 years in the family, neighbourhood intimacy, social network composition, and emotional and advisory support. 1School of Public Health, Social Development and Health Promotion Research Centre, Gonabad University of Medical Sciences, Gonabad, Khorasan Razavi, Islamic Republic of Iran. 2Department of Epidemiology and Biostatistics, School of Public Health; 3Knowledge Utilization Research Centre, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to S. Nedjat: nejatsan@tums.ac.ir). 4Health Centre of Khorasan-e-Razavi Province, Mashad University of Medical Sciences, Mashad, Islamic Republic of Iran. Received: 28/08/11; accepted: 2/12/11 ةيملاسلإا ناريإ ةيروهجم نم تانِّيب :يحصلا ماظنلا في عوطتلل ءاسنلا ةبغر لىع رثؤت يتلا لماوعلا یلضفا کلم ينسح ،ينيسح داوج ديس ،نياشورف يميحر سابع ،هدازدمج اضر ،تاجن زانرحس ،یلماع یلع ،ةيملاسلإا ناريإ ةيروهجم في يئاسنلا يحصلا عوطتلا جمانرب في ءاسنلا عوطت لىع رثؤت يتلا لماوعلل ًماييقت دهاوشلاو تلااحلل ةساردلا هذه مدقت :ةـصلالخا نوثحابلا عجمو .زكارلما كلت نم )ةدهاش 146و ةعوطتم 145( ةأرمإ 291 ةساردلا تلمش دقو .يوضر ي – ناسارخ ةيلاو في ًازكرم 150 في ذ َّفني جمانرب وهو ليم ينب ) ( ًايئاصحإ هب ُّدَتْعُي ًاطبارت اودجوو ؛ددعتلماو تايرغتلما ديحولا يتسيجوللا ف ُّوحتلا ليلحتب نوثحابلا ماقو .نايبتسا مادختساب تانايبلا معدلاو ،ةيعماتجلاا ةكبشلا نيوكتو ،نايرلجا عم ةقيثولا ةقلاعلاو ،ةسرلأا في رمعلا نم ينتنسلا نود لفط دوجوو ،ةسرلأا مجح ينبو عوطتلل ءاسنلا ضعب ءاشنلإ نكميو .كلذ زيزعت اندرأ اذإ عمتجلما دارفأ ينب عوطتلاب ةبغرلاب ةلصلا تاذ ةيتحتلا ىنبلا سيسأت نم ّدُبلاو .ةروشلماب معدلاو ،يفطاعلا .ةيكراشتلا جمابرلا هذه لىإ مماضنلاا في ةبغرلا ةدايز في مهاست نأ ،"راَوِلجا لزانم" ليبق نم ةبسانلما نكاملأا Facteurs influençant l'intention des femmes à devenir volontaires dans le système de soins de santé : données provenant de la République islamique d'Iran RÉSUMÉ La présente étude cas-témoin a évalué les facteurs influençant le volontariat dans le programme Femmes volontaires de la santé en République islamique d'Iran, mis en œuvre dans 150 centres de la province du Khorassan- Razavi. Nous avons recruté 145 cas (participation volontaire) et 146 témoins (participation sollicitée) dans ces centres. Des données ont été recueillies par questionnaire. Les variables sociodémographiques prises en compte étaient les suivantes : la durée de résidence dans le voisinage, le nombre de frères et sœurs, l'âge du mari, son niveau d'études et son emploi, la taille de la famille, la qualité de vie, l'état de santé auto-évalué, le degré de connaissance du voisinage, la présence ou non d'un enfant de moins de deux ans dans la famille, le fait d'être propriétaire de son logement et l'indice de richesse. Les variables des réseaux sociaux prises en compte étaient les suivantes : la taille du réseau égocentré, le type de connaissance, le degré d'intimité avec les autres, la communication relationnelle, la durée des relations, le soutien psychologique, l'appui consultatif, le soutien financier, le soutien physique et le soutien à la personne. Des corrélations significatives (P < 0,05) ont été trouvées entre la propension des femmes à devenir volontaires et la taille de la famille, la présence ou non d'un enfant de moins de deux ans, le degré de connaissance du voisinage, la composition du réseau social, et le soutien psychologique et consultatif. Book 19-4.indb 348 5/12/2013 2:19:35 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 349 Introduction Participation and volunteering Since the World Health Organization’s “Health for All” Strategy was devised in  1979,  participation has  been  con- sidered a subject central to health. The important role of participation in health promotion strategies was re-empha- sized in the “Ottawa Charter for Health Promotion”  in 1986 [1]. Participation  may be defined as “a process by which people are enabled to become actively and genuinely involved in defining the issues of concern to them, in making decisions about factors that affect their lives, in formulating and implementing policies, in planning, developing and delivering services and in taking action to achieve change” [2].  Volunteering would also be one of the important components of social capital at  the  level of community [3].  Jenner [4] defines a volunteer as “a person who, out of free will and with- out wages, works for a not-for-profit organization which is formally organ- ized and has as its purpose service to someone or something other than its membership”. The Women’s Health Volunteer programme Although most volunteers give their efforts to non-profit organizations, a noticeable proportion of all volunteer activity is directed to the public sector [5]. The Women’s Health Volunteer  (WHV) programme, as government- based voluntary action, is a national plan which was launched in some urban parts of the Islamic Republic of Iran in 1990–1991. This  community-based  health programme has gradually been expanded to all the urban parts of the  country  [6]. The WHVs (rabetin- e-behdashti in Farsi) are women who voluntarily participate in community health-based programmes. There is evi- dence that WHV activities could have positive effects on community health [6,7].  Therefore,  we  selected  this  programme to study, as a successful programme in the context of people’s engagement with community health- based programmes. Influencing factors on individuals’ willingness to volunteer There are various factors, such as per- sonal, family, and local characteristics, that could influence individuals’ willing- ness to volunteer. Recently, researchers have paid particular attention to the influence of social network character- istics on personal decisions. Indeed, it is believed that social networks are central to various social processes af- fecting health-related behaviours [8]. A  social network is a set of actors who may have relationships with one another [9]. Tindall and Wellman also define social network as “the study of social structure and its effects” [10].  Social network characteristics may be stratified  in 3 dimensions. The first  dimension is structural characteris- tics (size, density and network com- position). The second is interaction characteristics (relation type, contact frequency, relation permanency, and in- timacy with network members which is evaluated by closeness sensation of sub- ject with network members). The third dimension is functional characteristics (various types of support consisting of emotional, advisory, monetary, physical, and time support) [11,12].  Individuals  can obtain different types of support from their network members. Relatives, friends, and neighbours as well as col- leagues can be important resources to offer help and support. It is believed that diverse connections could create various types of social support for each person. It is also supposed that the more diverse connections in one’s personal social network, the better one’s access to a widespread range of different types of support [12]. In the Islamic Republic of Iran, although a number of studies have been carried out concerning the sociodemographic factors of WHVs as well as the influence of their activities on community health [7,13], less attention  has been paid to the effect of contextual factors on volunteering. The impact of sociodemographic and social network characteristics on individuals’ decisions to volunteer would still be a fruitful field for exploration. This study was conducted to assess the relationship between so- ciodemographic and social network characteristics, and women’s willing- ness to participate with Iran's WHV programme. Methods Sampling and study population We conducted this case–control study  in 2010  in Korasan-e-Razavi Province,  one of the largest and most populous provinces in the country. It has roughly 5.5 million inhabitants (about 7% of the  Iranian population). To select the sam- ples, we restricted the selection process by some potential confounding vari- ables: age, education level, marital status and job. Our research population was married women who were housewives, aged 15–49 years, with an education of  between 6 and 12 years, living in urban  parts of the province. To calculate the required sample size, we first conducted a pilot study on 20  individuals  from the population.  From this we identified the potential problems of the data collection phase and to determine P1 and P2. We then used the equation below to estimate the sample size for each group: n = [2(Z1 – α/2 + Z1 – β) 2 P(1 – P)]/(P1 – P2) Where P = (P1  + P2)/2 and con- sidering Z 1 – α/2 = 1.96 and Z1 – β = 0.84  (i.e. a power of 0.80), we calculated dif- ferent sample sizes  ranging  from 62  to  96  samples  in  each group. As we  ap- plied a 2-stage cluster sampling method  to select the samples, we considered Book 19-4.indb 349 5/12/2013 2:19:35 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 350 intra-class correlation coefficient of 0.82  (0.74–1.00).  The first section of the questionnaire covered sociodemographic characteris- tics including length of residence in her neighbourhood, the age and education level of the respondent and her hus- band, husband’s job, and family size. We also collected data on other factors in- cluding presence of a child under 2years  old in the family, and home ownership. To evaluate the family wealth index, we used a list of assets such as vacuum cleaner, washing machine, dishwasher, telephone line, motor car, computer, refrigerator, colour television, and CD or DVD player. We then measured family wealth index via principle com- ponent analysis. In the final part of this section, we used a 5-point Likert-range  question to assess quality of life and self- rated health status as well as a 7-point  Likert-range question to evaluate neigh- bourhood intimacy as perceived by the respondent. The second section of the question- naire was allocated to individual social network factors comprising the struc- tural, interactional and functional char- acteristics. The structural factors were size, density and network composition. Interactional characteristics consisted of relation type, contact frequency, rela- tion permanency, and intimacy with network members. In this study, 5 types  of support—emotional, advisory, mon- etary, physical, and time support—were considered social network functional characteristics. Data analysis We entered the data into Stata, ver- sion  10. We  evaluated  differences  between case and control groups via the Mann–Whitney U-test,  χ2 and Fisher exact test. Using univariate and multiple logistic regression with odds ratio (OR), P-value  and 95%  confidence interval. We assessed the association between volunteer- ing and sociodemographic as well as social network characteristics. All independent variables were entered separately in the univariate logistic regression model. Then, as Jewell in- dicated, those variables with P < 0.2  were selected for entering in multiple logistic regression [14]. In the final model, variables with P < 0.05 were  reported as statistically significant. Ethical considerations The researchers obtained the approval of the institutional review board of Tehran University of Medical Sci- ences. Before conducting the research, the research team obtained the au- thority of managers in regard to the research project. Agreement of all participants to participate the research was obtained before the interviews. As the interviews were prolonged (roughly 1 hour), respondents were offered rest breaks. The respondents were informed of their rights to cease their participation at any time during the interview. Results For the data analysis, we used 291 (out  of  300)  completed  questionnaires  (cases = 145, controls = 146), a refusal  rate of 3%. The mean  age  in  the  case  group was 28.84 (SD 8.26) years  and  the duration of  education was  10.06  (SD 2.08) years;  in  the control group  the  corresponding values were 29.59  (SD  6.9)  years  and  9.91  (SD  2.07)  years, respectively. Table 1 shows the respondents’ sociodemographic characteristics and their associations with participation in the WHV programme. Some soci- odemographic factors, including the presence of a child under 2 years (P = 0.020), quality of  life (P = 0.018) and  neighbourhood intimacy (P = 0.002),  had P < 0.05 in univariate logistic regres- sion. Table 2  shows  the  social network  characteristics and their associations with volunteering. Social network the design effect  equal  to 1.5. So, our  sample size was estimated at 145 sam- ples in each of the case and the control groups. To control potential problems during data gathering, the researchers increased the sample size to 150 partici- pants for each group. There are nearly 175 urban health  centres in Khorasan-e-Razavi prov- ince. The WHV programme is actively implemented among 150 centres. To  select the participants, we randomly selected 50 of these centres as clusters  and administered questionnaires to 3 women as cases  in each cluster. All  the respondents were women who had recently volunteered for partici- pation in the WHV programme in the selected centres during the research period, 1 May 2010  to 1 September  2010.  In the Islamic Republic of Iran near- ly all family members, including women, are registered in family health dossiers which are kept in the urban health cen- tres. After data gathering for the cases, we randomly selected 3 controls in each  of the centres among women who did not participate in the WHV programme and had not previously had any coop- eration with similar programmes. The questionnaires then were administered via face-to-face interview. There were 50  interviewers  in our  study. To assure quality and eliminate potential interviewer bias, a 1-day workshop was held for the interviewers. Additionally, an interview guide was made to use in the process of interview- ing. The researchers also used a coding system for the questionnaires to control potential bias in both data entry and analysis and to ensure anonymity for the participants. Data collection tool We used a 2-section questionnaire  to  collect data. Internal consistency was assessed using Cronbach’s alpha (0.73  in the social network characteristics do- main). Reliability of the questionnaire was assessed via test–retest with a mean  Book 19-4.indb 350 5/12/2013 2:19:35 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 351 density (P = 0.012) and heterogeneity  (P < 0.001), women’s  intimacy with  their network members (P < 0.001)  and emotional (P  <  0.001)  as well  as advisory (P < 0.001)  support ob- tained from network members also had P < 0.05  in  the univariate model.  We therefore entered these variables, together with those which had P < 0.20 (i.e. wealth index and family size),  in the multiple logistic regression analysis. The results of the multiple logistic regression analysis are shown in Table 3. There were significant associations  between volunteering and some so- ciodemographic factors including presence of a child under 2 years [ad- justed OR (AOR) = 0.46], family size  (AOR = 0.76)  and neighbourhood  intimacy  (AOR  =  1.31)  and  some  social network characteristics includ- ing type of acquaintance (which im- plies social network heterogeneity) (AOR = 0.60) and emotional support  obtained. We compared no support (level 1) with a little support (level 2)  conditions (AOR = 1.80), no support  with enough support (level 3) condi- tions  (AOR  =  1.82)  for  emotional  support obtained, as well as advisory support obtained in comparison with no support to a little support condi- tions (AOR = 1.48) and no support  to enough support conditions (AOR = 2.13). Table 1 Binary logistic regression analysis of sociodemographic characteristics in association with participation in the Women’s Health Volunteer programme Variable Case (n = 145) Control (n = 146) Crude OR P-value 95% CI Mean (SD) Mean (SD) Length of residence in neighbourhood (months) 99.57 (92.61) 86.10 (93.52) 1.00 0.342 0.99–1.00 No. of siblings 5.02 (2.34) 4.92 (2.06) 1.07 0.277 0.95–1.20 Husband's age (years) 33.54 (8.74) 34.17 (7.73) 0.99 0.870 0.97–1.03 Husband's education (years) 9.76 (3.02) 9.31 (3.58) 1.02 0.767 0.94–1.11 Family size 3.37* (1.20) 3.62* (1.13) 0.83a 0.100 0.66–1.04 Quality of life 3.88* (0.67) 3.66* (0.69) 1.60a 0.018 1.09–2.37 Self-rated health status 3.91 (0.64) 3.84 (0.70) 1.17 0.389 0.82–1.68 Neighbourhood intimacy 4.30* (1.34) 3.68* (1.39) 1.40a 0.002 1.14–1.72 No. % No. % Husband's job Governmental 22 16 23 16 1.00 0.902 0.50–2.20 Free market 84 61 92 63 1.05 0.779 0.27–5.63 Retired 4 34 5 3 1.24 0.655 0.18–2.96 Private office 6 6 4 0.73 0.663 0.48–3.21 Worker 20 14 18 12 1.24 0.840 0.16–9.90 Unemployed 2 2 2 2 1.24 Child under 2 years Yes 20 14 47 32 1.00a 0.020 0.21–0.88 No 125 86* 99 68* 0.43a House ownership Owner 63 44 55 38 1.00 0.689 0.50–1.58 Tenant 57 39 72 ( 49 0.89 0.492 0.60–2.87 Other 25 17 19 13 1.31 Wealth index 1 (poorest) 34 23 27 19 1.00 0.509 0.29–1.85 2 30 21 27 19 0.73 a 0.844 0.45–1.91 3 28 19 27 19 0.93 a 0.089 0.20–1.12 4 27 19 30 21 0.47 a 0.181 0.29–1.27 5 (richest) 26 18 31 22 0.60 a *P < 0.05 (Mann–Whitney U-test, χ2 test, Fisher’s exact test). aVariables with P < 0.2 and considered for multiple logistic regression. OR = odds ratio; CI = confidence interval. Book 19-4.indb 351 5/12/2013 2:19:35 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 352 Table 2 Binary logistic regression of social network characteristics of Women's Health Volunteer programme volunteers and controls Variable Volunteers (n = 145) Controls (n = 146) Crude OR P-value 95% CI Social network domain: structural Ego network size [mean (SD)] 12.79(7.43) 12.99 (5.62) 1.02 0.294 0.99–1.05 Density [mean (SD)] 0.64 (0.18) 0.70 (0.18) 0.13a 0.012 0.03–0.64 Type of acquaintance [No. (%)] Non-relative 457 (27) 264(15) 1.00 Relative 1257 (73)* 1499 (85) * 0.48a < 0.001 0.38–0.62 Social network domain: interactional Intimacy with others [mean (SD)] 3.99*(1.21) 3.70*(1.34) 1.19a < 0.001 1.06–1.34 No. of contacts [No. (%)] > once a week 898 (53) 921 (53) 1.00 once a week 342 (20)* 372 (21)* 0.94 0.646 0.73–1.21 once in 2 weeks 157 (9)* 87 (11)* 0.86 0.487 0.57–1.31 < once in 2 weeks 306 (18)* 273 (15)* 1.15 0.414 0.82–1.61 Relationship [No. (%)] Visual 1246(75) 1374 (79) 1.00 By telephone 396 (24)* 365 (21)* 1.20 0.244 0.89–1.62 By mail 7 (0)* 4 (0)* 1.93 0.424 0.39–9.67 Other 10 (1)* 6(0)* 1.84 0.345 0.52–6.49 Relationship duration (months) [mean (SD)] 203.94 (143.49) 196.87 (134.52) 1.00 0.505 0.99–1.00 Social network domain: functional Emotional support [No. (%)] None 170 (10) 401 (23) 1.00 A little 631 (37)* 680 (38)* 2.19a < 0.001 1.58–3.03 Enough 913 (53)* 680 (39)* 3.17a < 0.001 2.20–4-56 Advisory support [No. (%)] None 294 (17) 562 (32) 1.00 A little 656 (38)* 678 (39)* 1.85a < 0.001 1.45–2.36 Enough 762 (45)* 518 (29)* 2.81a < 0.001 2.09–3.78 Monetary support [No. (%)] None 931 (54) 962 (55) 1.00 A little 399 (23) 359 (20) 1.15 0.409 0.83–1.60 Enough 379 (22) 431 (25) 0.91 0.550 0.66–1.24 Physical support [No. (%)] None 583 (34) 639 (37) 1.00 A little 614 (36) 606 (35) 1.11 0.504 0.81–1.52 Enough 493 (30) 496 (28) 1.09 0.599 0.79–1.51 Time support [No. (%)] None 542 (32) 614 (35) 1.00 A little 644 (38) 638 (36) 1.14 0.344 0.87–1.51 Enough 515 (30) 496 (29) 1.18 0.316 0.86–1.62 *P < 0.05 ((Mann–Whitney U test, χ2 test, Fisher’s exact test). aP < 0.2 and considered for multiple logistic regression, OR = odds ratio; CI = confidence interval. SD = standard deviation. Book 19-4.indb 352 5/12/2013 2:19:36 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 353 Discussion To the best of our knowledge, this is the first study conducted in Iran that deals with the association between sociode- mographic and social network factors and willingness to participate in a volun- tary programme. By recognizing these potential associations, a new view could be created to improve such programmes. Multiple logistic regression analysis indicated that neighbourhood intimacy and the emotional and advisory sup- port obtained from network members may have a direct association with willingness to volunteer in the WHV programme, while presence of a child under 2 years  in  the  family,  family size  and network homogeneity may have an inverse association. We found no significant associations between certain sociodemographic variables and social network characteristics and participa- tion in the WHV programme. Arguments and counterarguments Family size was an influencing variable on volunteering. The smaller the family size, the more likely respondents were to participate in the WHV programme. As these women may have more time to participate in social activities, this would be logical. Nesbit also suggested that middle-aged women with larger family size have less time to engage in voluntary activities [15].  There was a significant association between presence in the family of a child under 2 years and volunteering. This  is  similar to the findings of Gomez and Gunderson who reported an associa- tion between the existence of a depend- ent child in the family and volunteering [16]. There was also a significant associ- ation between neighbourhood intimacy and volunteering in our research. Poley and Stephenson indicated strategies which develop common interests in their neighbourhood could have posi- tive effects on neighbourhood mem- bers’ civic engagement [17].  We found the number of non-rela- tive members (friends and neighbours) in the social networks of volunteers was statistically significantly greater than in the social networks of the control group. In fact, the social networks in the volunteers were more heterogeneous than those of the controls. Diversity in Table 3 Multiple logistic regression of sociodemographic and social network characteristics associated with participation in the Women's Health Volunteer programme Variable Adjusted OR P-value 95% CI Family size 0.76 0.027 0.60–0.97 Quality of life 1.41 0.108 0.93–2.14 Neighbourhood intimacy 1.31 0.018 1.05–1.64 Density 0.17 0.075 0.026–1.19 Child under 2 years No 1.00 Yes 0.46 0.037 0.22–0.96 Wealth index quintile 1 (poorest) 1.00 2 0.66 0.382 0.26–1.68 3 0.94 0.884 0.41–2.15 4 0.44 0.123 0.16–1.25 5 (richest) 0.79 0.588 0.34–1.84 Type of acquaintance Non-relative 1.00 Relative 0.60 < 0.001 0.47–0.77 Intimacy with others 1.01 0.875 0.90–1.13 Emotional support None 1.00 A little 1.80 < 0.001 1.31–2.46 Enough 1.82 0.003 1.22–2.72 Advisory support None 1.00 A little 1.48 0.007 1.11–1.96 Enough 2.13 < 0.001 1.52–2.99 OR = odds ratio; CI = confidence interval. Book 19-4.indb 353 5/12/2013 2:19:36 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 354 their personal social network may imply that an individual is more communica- tive, and this may be a predictor of will- ingness to volunteer. Our finding was similar to those of Wilson and Musick, which showed a direct association be- tween number of friends and voluntary activity [18].  Our results showed a significant as- sociation between the emotional and advisory support, as personal social network resources, and willingness to volunteer in the WHV programme. It was comparable with the results of the study of Tong, Hung and Yeun in Ma- cao, which was conducted to recognize the determinants and effects of social network characteristics on pro-social behaviours such as volunteering and helping others [19]. They emphasized those individuals who have resourceful social networks have more willingness to participate in such pro-social activities. In contrast, in our study, there was no significant association between social network size and willingness to volunteer. In the study carried out by Tong, Hung and Yeun, social network size may have had a direct association with personal willingness to help others and volunteering. As their study could not investigate temporality between exposure (social network size) and out- come (volunteering), the network size may itself be influenced by volunteering. As we used incident cases, there was no similar problem in our study. There was no significant association between wealth status of the partici- pants and volunteering in our study. In contrast, Goss implied that wealthy people are more willing to donate their time in voluntary efforts [20].  Although several studies have re- ported an association between home ownership and volunteering [21,22] we  did not find such an association. Insuf- ficient sample size may be a cause of the failure to find this association in our study. Neither did we find a significant association between social network density and volunteering, which was comparable to the results of Rotolo [23], but contrary to those of Kane [24].  Study limitations Case–control  studies  are  known  to  have more of a tendency to confound- ing, information bias and selection bias than other types of study. To control the problem, we restricted the selection of subjects on some variables such as age (15–49 years), duration of  education  (6–12 years), marital  status (married)  and job (housewife). We also conduct- ed some activities to improve quality assurance, such as holding a workshop for interviewers and preparing an in- terview guide. To avoid the effect of volunteering on the factors under study, especially social network characteristics, all the selected cases were new volun- teers (incident cases). We would particularly refer  to 2  is- sues. Although many studies have dem- onstrated a potential relation between education  level and volunteering [25],  we could not investigate the association between the variables. This was because of the restriction on this factor in the selection process. Similarly, associations between volunteering and the respond- ents' age, marital status, and job could not be evaluated in this study. Besides, a woman who is willing to participate in the WHV programme must obtain writ- ten agreement from her husband. This behaviour may be a proxy for a more democratic family. So it seems women living in such families may have more chance to participate in social activities such as the WHV programme. There- fore, our results might be influenced by this discrepancy between the volunteer group and the control group. Of course, this association should be investigated through a separate study. Policy implications As mentioned, there has been no pre- vious research to identify the charac- teristic factors of women who have a propensity to participate in the Iranian WHV programme, as a voluntary plan. Our findings can be used by policy- makers who work on community-based voluntary programmes, especially in the Islamic Republic of Iran and other countries with similar cultures. Ac- cording to our findings in regard to the relationship between volunteering and family size as well as the presence of a child under  2  years  in  the  family, we  suggest that managers should probably target their attempts at women who have small families, with no dependent children so that they may be able to select appropriate individuals for their voluntary programmes. We found that the greater the inti- macy in the neighbourhood, the greater the chance of a woman being willing to volunteer. To promote a volunteer- ing culture in the community, places such as “neighbourhood houses” (c.f. community centres) or “neighbour- hood councils” could be established. Through such places, neighbours could design and generally run public activi- ties, including educational and health/ exercise activities. The likelihood of more-communicative persons, i.e. those with a propensity for volunteering, at- tending such places would be quite high. So, we suggest establishing places such a “neighbourhood house”, because of these multi-dimensional effects. In conclusion, family size, neigh- bourhood intimacy, individual social network heterogeneity and received emotional and advisory supports from network members may be important determinants of participation in com- munity-based voluntary programmes such as the WHV programme. Acknowledgement This paper is based on the first author's PhD dissertation, supervised by the sec- ond author and submitted to the Epide- miology and Biostatistics Department, Tehran University of Medical Sciences, 2010 and granted by the University. Book 19-4.indb 354 5/12/2013 2:19:36 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 355 References 1. Baum FE, Ziersch AM. Social Capital. Journal of Epidemiology and Community Health, 2003, 57:320–323. 2. Community participation in local health and sustainable devel- opment: approaches and techniques. Geneva, World Health Organization, 2002 (European Sustainable Development and Health Series 4) (https://www.utexas.edu/nursing/norr/ docs/commparticipation.pdf, accessed 15 February 2013). 3. Cox E. Building social capital. Health Promotion Matters, 1997, 4:1–4. 4. Jenner JR. Participation, leadership, and the role of volunteer- ism among selected women volunteers. Journal of Voluntary Action Research, 1982, 11(4):27–38. 5. Brudney JL, Kellough JE. Volunteers in state government: involvement, management, and benefits. Nonprofit and Volun- tary Sector Quarterly, 2000, 29(1):111–130. 6. Vahidnia F. Case study: fertility decline in Iran. Population and Environment, 2007, 28(4–5):259–266. 7. Ramazani AA, Miri MR, Shayegan F. [Effect of health education on health coordinating volunteers of Birjand health center to promote healthy life styles in the community]. Journal of Birjand University of Medical Sciences, 2008, 14(4):9–15 [in Farsi]. 8. Marsden PV. Network methods in social epidemiology. In: Oakes JM, Kaufman JS, eds. Methods in social epidemiology. San Francisco, Jossey-Bass, 2006:267–286. 9. Hannemann RA, Riddle M. Introduction to social network meth- ods. Riverside, California, University of California, Riverside, 2005 (ch 2) (http://faculty.ucr.edu/~hanneman/nettext/, ac- cessed 15 February 2013). 10. Tindall D, Wellman B. Canada as social structure: social net- work analysis and Canadian sociology. Canadian Journal of Sociology, 2001, 26(2):265–308. 11. Israel BA, Antonucci TC. Social network characteristics and psychological well-being: A replication and extension. Health Education Quarterly, 1987, 14(4):461–481. 12. Bastani S, Salehi M. [Network social capital and gender: Inves- tigation of structural, interactional and functional character- istics of social network of men and women in Tehran]. Social Science Letter, 2007, 30:63–93 [in Farsi]. 13. Ganji F et al. [Evaluation of the impact of participatory inter- vention in the reduction of unnecessary caesarian (deliveries) in Shahrekord, Iran]. Shahrekord University of Medical Sciences Journal, 2006, 8(1(29)):14–18 [in Farsi]. 14. Jewell NP. Statistics for epidemiology. California, Chapman & Hall/CRC, 2004. 15. Nesbit B. A comparison of volunteering data in the panel study of income dynamics and the current population survey. Nonprofit and Voluntary Sector Quarterly, 2010, 39(4):753–761. 16. Gomez R, Gunderson M. Volunteer activity and the demands of work and family. Industrial Relations/Relations Industrielles, 2003, 58(4):573–589. 17. Poley L, Stephenson M. Community, trust and the habits of democracy: an investigation into social capital and civic engage- ment in U.S. cohousing neighborhoods (paper presented at the Annual Meeting of the American Political Science Associa- tion, Chicago, 30 August–2 September 2007). 2007 (http:// citation.allacademic.com//meta/p_mla_apa_research_cita- tion/2/0/9/9/8/pages209987/p209987-1.php, accessed 15 February 2013). 18. Wilson J, Musick MA. Social resources and volunteering. Social Science Quarterly, 1998, 79:799–814. 19. Tong KK, Hung EPW, Yeun SM. The quality of social networks: Its determinants and impacts on helping and volunteering in Macao. Social Indicators Research, 2011, 102(2):351–361. 20. Goss KA. Volunteering and the long civic generation. Nonprofit and Voluntary Sector Quarterly, 1999, 28(4):378–415. 21. Rohe W, McCarthy G, Van Zandt S. The social benefits and costs of homeownership: a critical assessment of the research. Washington DC, Harvard University, Joint Center for Hous- ing Studies, 2001 (Low Income Home Ownership Working Paper Series LIHO-01.12) (http://www.jchs.harvard.edu/ sites/jchs.harvard.edu/files/liho01-12.pdf, accessed 15 Feb- ruary 2013). 22. Volunteering in America 2010: national, state, and city informa- tion. Washington DC, Corporation for National and Commu- nity Service, Office of Research and Policy Development, 2010 (http://www.theartofcivicengagement.org/files/IssueBrief- FINALJune15.pdf, accessed 15 February 2013). 23. Rotolo T. Town heterogeneity and affiliation: a multilevel analysis of voluntary association membership. Sociological Perspectives, 2000, 43(2):271–289. 24. Kane DA. Network approach to the puzzle of women’s cultural participation. Poetics, 2004, 32:105–127. 25. Erlinghagen M, Karsten H. The participation of older Europeans in volunteer work. Ageing and Society, 2006, 26(4):567–584. Book 19-4.indb 355 5/12/2013 2:19:36 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 356 Characterization of wound infections among patients injured during the 2011 Libyan conflict A.A. Dau,1 S. Tloba 2 and M.A. Daw 2 ABSTRACT Few studies have analysed the bacterial pathogenesis of infections associated with war-wound in the Eastern Mediterranean region. We analysed surgical wound infections of 1200 patients injured during the Libyan conflict in 2011 and admitted to the emergency services at Tripoli medical centre. Culture swabs or surgical wound debridement samples were collected and cultures were identified and tested for antimicrobial resistance. Of the 1200 patients studied, 498 (42%) were infected with at least 1 pathogen and 57 with > 2 pathogens. The most common species were Acinetobacter spp. (isolated from 144 patients), coagulase-negative staphylococci (122), Escherichia coli (107), Pseudomonas aeruginosa (92) and Klebsiella spp. (86). A high level of resistance to the antibiotics tested was found, especially among Acinetobacter spp. Multi-drug-resistant Gram- negative bacilli were an important complicating factor in wound infections associated with war injuries among injured patients in Libya. Effective policies are needed to control and treat such infections particularly in trauma and emergency services. 1Department of Surgery; 2Department of Medical Microbiology, Faculty of Medicine, Tripoli, Libya (Correspondence to M.A. Daw: mohamedadaw@gmail.com; mohameddaw@gmail.com). Received: 01/03/12; accepted: 06/03/12 2011 ماع ايبيل في عاصرلا للاخ تاباصلإا يوذ ىدل حورلجا ىودع صئاصخ وض دممح ،ةبولط داعس ،وض ةينغا ةساردلا هذه فيو .طسوتلما قشر ميلقإ في برلحا حورج في ىودعلل ةببسلما لماوعلا لىع ف ُّرعتلل ًلايلتح ترجأ يتلا تاساردلا يه ٌةليلق :ةـصلالخا يبطلا زكرلما في ةيفاعسلإا تامدلخا في اوِلبُق نمم ،2011 ماع ايبيل في ىرج يذلا عاصرلا في باصم 1200 حورج في ىواَدَعلا فلتمخ نوثحابلا لَّلح .تابوركملل ةداضلما ةيودلأل اهتمواقمو ،ةببسلما تابوركلما لىع فرعتلل اهوعرزو حورلجا ةجسنأ نم تانيع وأ تاحسم اوعمجف ؛سلبارط في ْينَلماع نم رثكأب ىودع ميهدل مهنم 57 ناكو ،دحاو ضّرُمم لماع ىودعب ينباصم )%42( 498 ناك ةساردلا مهيلع تيرجُأ نيذلا ضىرلما ينب نمو ،)ًاضيرم 122( تلاوغاوكلا ةيبلسلا تايدوقنعلاو ،)ًاضيرم 144 نم تدرفتسا دقف( دكاو َّرلا عاونأ يه ًاعويش ةضرْمُمـلا عاونلأا رثكأ تناكو .ْينَضرمم ةمواقلما نم ًاعفترم ىوتسم نوثحابلا دجوو .)ًاضيرم 86( تلايسبكلا عاونأو )ًاضيرم 92( ةيراجنزلا ةفئازلاو ،)ضىرم 107( ةينولوقلا ةيكيشرلإاو حورلجا ىودعل ةمالها تافعاضلما نم ةددعتم ةيودلأ ةمواقلما مارغلا ةيبلسلا تايصعلا تناك دقو .دكاَو َّرلا عاونأ ىدل ماَّيسلاو ،ةيويلحا تاداضملل .تافاعسلإاو تاباصلإا تامدخ في ماَّيسلاو ،ىواَدَعلا هذه ةلجاعمو ةحفاكلم ةلا َّعف تاسايس لىإ ةجالحا ستمو .ايبيل في بورلحا تاباصلإ ةيلاتلا Caractérisation des infections de plaies chez les patients blessés pendant le conflit libyen en 2011 RÉSUMÉ Peu d'études ont analysé la pathogénèse bactérienne des infections associées aux plaies de guerre dans la Région de la Méditerranée orientale. Nous avons analysé les infections des plaies après un acte chirurgical chez 1200 patients blessés pendant le conflit libyen en 2011 et admis au service des urgences du centre médical de Tripoli. Des prélèvements par écouvillon ou des échantillons du parage des plaies ont été recueillis puis mis en culture pour identification et analyse à la recherche de résistances aux antimicrobiens. Sur l'ensemble des patients dont les plaies ont été étudiées, 498 étaient porteurs d'une infection (42 %) par au moins un agent pathogène, et 57 par plus de deux agents pathogènes. Les espèces les plus courantes étaient Acintobacter spp. (isolée chez 144 patients), les staphylocoques à coagulase négative (122), Escherichia coli (107), Pseudomonas areuginosa (92) et Klebsiella spp. (86). Un haut niveau de résistance aux antibiotiques testés a été observé, en particulier pour Acinetobacter spp. Les bacilles à Gram-négatif multirésistants représentaient un facteur de complication important pour les infections de plaies associées à des blessures de guerre chez des patients blessés en Libye. Des politiques efficaces sont requises pour lutter contre de telles infections et les traiter, notamment dans les services de traumatologie et des urgences. Book 19-4.indb 356 5/12/2013 2:19:36 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 357 Introduction Wound infections during wars cause se- rious morbidity and mortality and have to be treated with great care, particularly by clinical surgeons, who are often the first to treat such cases. The bacterial fea- tures of these infections are well-known and the evolution of such infections and the causative pathogens has attracted much attention [1]. Wounding patterns during wars depend on the intensity of fighting and include gunshot bullet wounds, ulceration of vital structures, cavitations and devitalization of tissues and limb amputations. Management of such injuries is no longer the exclusive preserve of military surgeons. Initial measures for treating war injury are similar to those for any severe injury [2]. Despite the clinical complications associated with war-wound infections few studies have analysed their bacterial pathogenesis in the Eastern Mediter- ranean region, an area that hosts many conflicts [3]. In this study we aimed to  analyse the bacterial patterns of war- trauma-associated infections in patients wounded in the conflicts in Libya in 2011, define the factors associated with  such infections and determine the anti- microbial resistance patterns of aerobic multi-drug resistant Gram-negative bacilli. Methods Sample A total of 1200  injured male patients  were admitted to the emergency de- partments in Tripoli medical centre, Tripoli, Libya, in the 9-month period from March  to October 2011. Their  ages  ranged  between  20–55  years.  They were brought from different re- gions of Libya including the Novosa mountains  (157  patients), Tripoli/ Zawiya  (398 patients), Bani Walid/ Sirte  (302 patients), Zlitan/Misrata  (236 patients) and other places (107  patients) (Table 1). Data collection Data collected from each casualty included the mechanism of injury, its anatomical location, previous medical care and antibiotics used. Clinical speci- mens, which included culture swabs and samples from any existing wound debridements, were collected from the admitted patients. Bacterial culture techniques The specimens were plated onto Co- lumbia blood agar plates, chocolate agar, MacConkey agar plates and into thioglycolate broth. Blood agar and MacConkey agar plates were incubated at 35  °C  in ambient air and chocolate  agar was incubated in presence of 5% CO 2   at  35  °C. The  thioglycolate  broth was Gram-stained as it became turbid. Negative culture plates were left for 5 days, after which negative bacterial  cultures were discarded. Each bacterial isolate was biochemically identified using the Analytical Profile  Index 20 Entero- bacteriaceae (bioMérieux) for lactose- fermenting Gram-negative bacilli. Others were identified according the standard microbiological methods established [4]. Antimicrobial susceptibility testing Antimicrobial susceptibility testing was determined using the Kirby–Bauer disk  diffusion test using National Commit- tee for Clinical Laboratory Standards criteria for each bacterial species [5]. The  following antibiotic disks were used for penicillins (ampicillin, amoxicillin, ticar- cillin and imipenem), cephalosporins (cefazolin, cefotaxime and ceftazidime), Table 1 Clinical and microbiological characteristics of patients with war-trauma injuries during the 2011 conflict in Libya Variable No. of patients % (n = 1200) Anatomical location of wound Chest and back 379 32 Abdomen 239 20 Head and neck 202 17 Extremity (upper or lower) 189 16 Loss of limb 93 8 More than 2 locations 98 8 Mechanism of injury of wound Gunshot 343 29 Shrapnel 283 24 Blunt instrument 197 16 Blast 171 14 Burn 89 7 Other 117 10 Outcome of wound treatment Died in hospital 310 26 Discharged alive 890 74 Bacteriological culture from wound Positive 498 42 Negative 702 58 No. of organisms isolated from positive wound cultures (n = 498) 1 293 59 2 148 30 > 2 57 11 Book 19-4.indb 357 5/12/2013 2:19:37 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 358 and were classified as uninfected. Both infected and non-infected patients had an average age of about 30 years, ranging  from 20–55 years, with no  significant  difference in age between the infected and uninfected patients. The injured patients were brought from different geographical zones across Libya. Table 2  shows  the dis- tribution of wound-infected and uninfected patients according to the battlefield area and type of battle. The greatest number of infected patients were brought from the Tripoli/Zawiya zone (177 patients),  followed by Bani  Walid/Sirte (105 patients) and Zlitan/ Misrata (102 patients). Patients bought  from Tripoli/Zawiya had the high- est  rate of  infection  (44%)  and Bani  Walid/Sirte  the  lowest  (35%). The  Novosa mountains area had the highest rate of deaths (39%). Patients injured in  ground battles (i.e. those were brought from the rebel fighting areas) had a higher  rate  of  infection  (43%)  than  those wounded by airstrikes (i.e. those brought from army compounds where there was no fighting on the ground) (36%) (Table 2).  Organisms cultured and susceptibility patterns Of the 498 patients with positive bacte- rial  cultures,  293  (59%) had  a  single  organism  isolated,  148  (30%) had  2  organisms and 57 (11%) had more than  2 pathogens. The most common organism cultured from wounded patients was Gram-negative bacilli, which included Acinetobacter spp. in 144 patients, Escheri- chia coli from 107 patients, Pseudomonas spp. from 92 patients, Klebsiella spp. from 86 patients, while other Gram-negative  species were cultured from 157 patients.  Gram-positive cocci were cultured from 178 patients, mainly  coagulase- negative staphylococci isolated from 122 patients, while other Gram-positive  bacteria were cultured from 56 patients. The antimicrobial susceptibility pat- terns of these organisms are shown in Table 3. Acinetobacter spp. were the most resistant pathogen. Other isolated Gram-negative bacteria showed great resistance  to  3rd-generation  cepha- losporins and aminoglycosides, apart from amikacin. However, P. aeruginosa was quite susceptible to commonly used antipseudomonal therapy particu- larly carbapenems. Coagulase-negative staphylococci were found to be sensi- tive to all the antibiotics tested particu- larly gentamicin and vancomycin. Discussion Wound infections associated with war injuries have changed over the last aminoglycosides (gentamicin and ami- kacin) and miscellaneous (ciprofloxa- cin and tetracycline) and vancomycin (only for Gram-positive cocci). Results Clinical and demographic profile of wounded patients The wound  injuries of  1200 patients  who were brought from different area of Libya were classified as combat-related according to internationally recognized criteria [2].  The mechanisms of wound inju- ries were as follows: gunshot wounds (29%),  shrapnel wounds (24%), blunt  instrument  wounds  (16%),  blast  wounds (14%) and burns (7%) (Table  1). The main anatomical sites of the wounds from which swabs for culture were taken were: chest and back (32%),  abdomen (20%), head and neck (17%)  and extremities  (16%);  in 98 patients  swabs were taken from more than 2 lo- cations (Table 1). A total of 310 (26%)  of these patients admitted with wound infections died in hospital. Wound infections Positive bacteriological cultures were obtained from the wounds of 498 (42%)  patients. The  remaining 702 patients  (59%) had negative bacterial  cultures  Table 2 Characteristics of patients with infections associated with war-trauma injuries during the 2011 conflict in Libya Variable Infected (n = 498) Uninfected (n = 702) Died (n = 310) Total (n = 1200) No. % No. % No. % No. Battlefield area Tripoli/Zawiya 177 44 221 56 93 23 398 Novosa mountains 68 43 89 57 61 39 157 Bani Walid/Sirte 105 35 197 65 79 26 302 Zlitan/Misrata 102 43 134 57 72 31 236 Other places 46 43 61 57 17 16 107 Type of battle Ground battles 391 43 508 57 127 14 899 Airforce strikes 107 36 194 64 183 61 301 n = number of patients. Book 19-4.indb 358 5/12/2013 2:19:37 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 359 century, not only in the pattern of the causative organisms and the antimi- crobials used to tackle such serious infection but also in the physician’s approach to handling them. Formerly the bacteriological characterization of war-associated infections was based on the colour of the discharge and the smell of the wound which was associ- ated with anaerobic bacteria particularly Clostridium spp. [6]. Such infection was  associated with a high rate of morbid- ity and mortality among the infected individuals. This has changed with the introduction of antibiotics and mod- ern surgical management of wounds. This has resulted in the diminution of Gram-positive bacteria and emergence of more resistant ones particularly the aerobic and facultative anaerobic Gram-negative bacilli [3,7,8]. Our study  in Libya showed that the infection rate among patients with war-associated infection was  42% with  no  variation  according to the different regions where the injured patients came from. The infections were mainly caused by multi- drug-resistant (MDR) Gram-negative bacilli. Gunshot wounds result in gross tissue destruction that is an excellent medium for infection. In this study di- rect gunshot, blast, blunt instrument and shrapnel wounds were the most common injuries. Such results are in agreement with other data collected from war conflicts in Vietnam, Somalia and Iraq [9,10]. MDR Gram-negative bacilli are known to be a major cause of nosoco- mial infection particularly in wound infections [3,10]. This  is more obvious  in war situations. However, MDR P. aeruginosa, extended-spectrum beta- lactamase-producing Klebsiella and Acinetobacter spp. were isolated exten- sively from wound infections during the Iraqi war [4,9]. In the present study, MDR Gram-negative bacilli were the major bacteria associated with wound infections in injured patients in Libya. MDR Acinetobacter spp. isolates were the most common pathogen, account- ing for 144 of the isolates cultured, followed by E. coli, P. aeruginosa and Klebsiella spp. The incidence of MDR Gram-negative bacilli and their rate of antibiotic resistance were higher in this study compared with similar studies carried in different geographical regions [6,8,11]. This,  however, may  suggest  different ecosystems and bacteria in- volved in these infections. Gram-positive bacteria have been known to be involved in wound injury and many studies have reported this [12]. In our study 122 coagulase-nega- tive staphylococci isolates and another 56 miscellaneous Gram-positive bac- teria were cultured from the wounded patients and sometimes were found to be co-pathogens with MDR Gram-neg- ative bacilli. All of them were sensitive to all the antimicrobials tested except oxa- cillin and ampicillin. This may indicate Table 3 Antimicrobial susceptibility profile of pathogens isolated from wounds associated with war-trauma injuries in the 2011 conflict in Libya Antimicrobials tested Escherichia coli (n = 107) Klebsiella spp. (n = 86) Acinetobacter spp. (n = 144) Pseudomonas spp. (n = 92) Coagulase- negative staphylococci (n = 122) No. % No. % No. % No. % No. % Penicillins Ampicillin 25 23 10 12 4 3 – – 0 0 Oxacillin – – – – – – – – 20 16 Ticarcillin 0 0 0 0 0 0 74 80 – – Imipenem 107 100 86 100 144 100 90 98 – – Cephalosporins Cefazolin 45 42 20 23 0 0 0 0 – – Cefotaxime 27 25 21 24 9 6 0 0 – – Ceftazidime 75 70 73 85 0 0 85 92 – – Aminoglycosides Gentamicin 47 44 51 59 46 32 47 51 70 57 Amikacin 107 100 63 73 20 14 82 89 – – Miscellaneous Ciprofloxacin 90 84 80 93 101 70 87 95 50 41 Tetracycline – – – – – – – – 115 94 Vancomycin – – – – – – – – 120 98 Other Gram-negative bacilli (n = 157 isolates); other Gram-positive bacteria (n = 56). n = number of isolates tested; zero (0) indicates no bacteria cultures; dash (–) indicates not applicable. Book 19-4.indb 359 5/12/2013 2:19:37 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 360 References 1. Eardley WG et al. Infection in conflict wounded. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 2011, 366:204–218. 2. Hospenthal DR et al. Guidelines for the prevention of infec- tions associated with combat-related injuries: 2011 update: en- dorsed by the Infectious Diseases Society of America and the Surgical Infection Society. Journal of Trauma, 2011, 71(Suppl. 2):S210–S234. 3. Daw MA, Dau AA, Elasifer H, Tloba S. Emergence of multi- resistant Acinetobacter baumannii among Libyan military personnel during recent Libyan conflict. In: Proceedings of the 22nd European Congress of Clinical Microbiology and Infectious Diseases, London, 31 March to 3 April, 2012. 4. Performance standards for antimicrobial disk susceptibility tests: approved standard, 7th ed. Wayne, Pennsylvania, National Committee for Clinical Laboratory Standards, 2000. 5. Bauer AW et al. Antibiotic susceptibility testing by a standard- ized single disk method. American Journal of Clinical Pathology, 1966, 45:493–496. 6. Manring MM et al. Treatment of war wounds: a historical review. Clinical Orthopaedics and Related Research, 2009, 467:2168–2191. 7. Martin GJ et al.; Prevention of Combat-Related Infections Guidelines Panel. Prevention of infections associated with combat-related thoracic and abdominal cavity injuries. Jour- nal of Trauma, 2011, 71(2 Suppl. 2):S270–281. 8. Scott PT et al. Acinetobacter baumanii infections among pa- tients at military facilities treating injured U.S. service mem- bers, 2002–2004. Morbidity and Mortality Weekly Report, 2004, 53:1063–1066. 9. Centers for Disease Control and Prevention. Acinetobacter baumannii infections among patients at military medical facilities treating injured U.S. service members, 2002–2004. Morbidity and Mortality Weekly Review, 2004, 53:1063–1066. 10. Mabry RL et al. United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. Journal of Trauma, 2000, 49:515–528. 11. Klein RS, Berger SA, Yekutiel P. Wound infection during the Yom Kippur War: observations concerning antibiotic prophy- laxis and therapy. Annals of Surgery, 1975, 182:15–21. 12. Ellis MW et al. Natural history of community-acquired methi- cillin-resistant Staphylococcus aureus colonization and infec- tion in soldiers. Clinical Infectious Diseases, 2004, 39:971–979. 13. Lolans K et al. Prevention and management of infections as- sociated with combat-related head and neck injuries. Journal of Trauma, 2008, 64:S265–S276. 14. Heath CH et al. A review of the Royal Perth Hospital Bali ex- perience: an infection control perspective. Australian Infection Control, 2003, 8:43–54. 15. Maegele M et al. The long-distance tertiary air transfer and care of tsunami victims: injury pattern and microbiological and psy- chological aspects. Critical Care Medicine, 2005, 33:1136–1140. they were skin-commensal pathogens which are considered to be of low viru- lence and pathogenicity [13]. The patients in this study were of- ten wounded far from hospital and evacuated under escalating conflict conditions with contaminated wounds and diminished vascular function. Patients with soft tissue injuries and blast, gunshot and burn injuries had open wounds that could easily have been contaminated with soil, dust and contact with the hands of the people who evacuated them. The bacteria may have colonized wounds at the time of injury or as a result of personnel contact during evacuation or inside the hospital. Similar results were reported from other investigators for victims of the tsunami in Bali as well as victims of the Bosnian and  Iraqi  conflicts  [14,15]. This  indi- cates that the source of acquisition of these organisms may be environmental from the battleground or endogenously from the patient him/herself. The use of antimicrobials in the treatment of surgical wound infections is still disputed. Antibiotics may affect the wound flora and thus enhance the more resistant bacteria. Furthermore, it is not clear which is the most ap- propriate antimicrobial to use in these circumstances: a narrow-spectrum one that covers a specific type of bacteria or a broad-spectrum one [16]. However,  in  certain conditions, such as unconscious or shocked patients and abdominal surgery, antibiotics have to be used. The antimicrobial resistance patterns in this study can be used to guide their empirical use in cases of pyrexia, shock or intensive soft tissue injury. The pathogenicity of the bacteria plays an important role in wound in- fection, which might be related to the virulence factors of the pathogens them- selves or existence of co-pathogens [17].  In  this  study 59% of  the patients  had a  single pathogen, 30% showed 2  different isolates and 11% showed 3 or  more isolates. This may suggest the role of co-pathogens in the development of necrotizing war trauma-related infec- tion, particularly in Acinetobacter spp., which has been indicated by other stud- ies  [3,18]. Further  studies are needed  to determine the virulence factors and mechanism of resistance of such patho- gens. Our study focused on Gram-nega- tive bacilli as most of the patients studied had required immediate evacuation and undergone immediate surgical debride- ment. This was likely to have minimized the role of anaerobic infection in these patients. Furthermore, anaerobic bac- teria are uncommonly recognized as a cause of wound war infections except in the Korean war [11]. This highlights the importance of the present study, which is one of the few studies in Arab countries that have documented the patterns of war-wound infections and characterized the causative agents of these injuries. Furthermore, the detec- tion of highly resistant bacteria, such as Acinetobacter spp., P. aeruginosa, Klebsiella spp. and E. coli, mandates a change in the management of surgical wounds and infection control measures, as well as specific guidelines for the use of an- timicrobials in all hospital settings and emergency trauma services in Libya [3,19,20]. Book 19-4.indb 360 5/12/2013 2:19:37 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 361 16. Hayda R, Harris RM, Bass CD. Blast injury research: modeling injury effects of landmines, bullets, and bombs. Clinical Ortho- paedics and Related Research, 2004, 422:97–108. 17. Sebeny PJ et al. Acinetobacter baumannii skin and soft-tissue in- fection associated with war trauma. Clinical Infectious Diseases, 2011, 47(4):444–449. 18. Moultrie D, Hawker J, Cole S. Factors associated with multid- rug-resistant Acinetobacter transmission: an integrative review of the literature. AORN Journal, 2011, 94(1):27–36. 19. Daw MA, Drah AM. Antibiotic resistance: prospects for the new millennium. Journal of Chemotherapy (Florence, Italy), 2001, 13:587–594. 20. Hospenthal DR et al.; Prevention of Combat-Related Infections Guidelines Panel. Infection prevention and control in de- ployed military medical treatment facilities. Journal of Trauma, 2011, 71(Suppl. 2):S290–S298. Prevention and management of wound infection Open injuries have a potential for serious bacterial wound infections, including gas gangrene and tetanus, and these in turn may lead to long term disabilities, chronic wound or bone infection, and death. Wound infection is particularly of concern when injured patients present late for definitive care, or in disasters where large numbers of injured survivors exceed available trauma care capacity. Appropriate management of injuries is important to reduce the likelihood of wound infections. The document Prevention and management of wound infection provides core principles and protocols for appropriate prevention and management of infected wounds. This document is available at: http://www.who.int/hac/techguidance/tools/guidelines_prevention_and_ management_wound_infection.pdf  Book 19-4.indb 361 5/12/2013 2:19:37 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 362 Relation between some haematological abnormalities, degree of immunosuppression and viral load in treatment-naïve HIV-infected patients B.A. Denue,1 W. Gashau,1 H.S. Bello,2 I.M. Kida,1 B. Bakki 1 and B. Ajayi 3 ABSTRACT This cross-sectional study at a teaching hospital in north-eastern Nigeria estimated the prevalence of anaemia, leukopenia and thrombocytopenia in treatment-naïve HIV-infected patients (177 males and 316 females), and the associations with virological and immunological markers. The overall prevalences of anaemia, leukopenia and thrombocytopenia were 49.5%, 5.5% and 4.5% respectively. The prevalence of anaemia was significantly higher in males than females (61.6% versus 42.7%), while the rates of leukopenia (5.1% versus 5.7%) and thrombocytopenia (5.7% versus 3.8%) were similar. Almost two-thirds of the HIV treatment-naïve studied patients, 293/493 (59.4%), had cytopenia and would require antiretroviral drugs. AIDS was diagnosed by clinical or immunological criteria in 70% of patients. The degree of cytopenia was directly related to the degree of immunosuppression and clinical AIDS status. No relationship was observed between cytopenia and viral load. 1Department of Medicine; 3Department of Immunology, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria (Correspondence to A Ballah: d_akawu@yahoo.co.uk). 2Department of Microbiology, University of Maiduguri, Maiduguri, Borno State, Nigeria. Received: 21/11/11; accepted: 11/03/12 زديلإا ىودعب ينباصلما ضىرلما ةلجاعم في ةيسويرفلا ةلوملحاو يعانلما تبكلا ةجردو ،ةيجولوتمايلها تاذوذشلا ضعب ينب ةقلاعلا لبق نم ةلجاعلما يقلت مله قبسي لم نّمـم ياجأ يديجاباب ،يككب ركب ،ادك ىسوم ميهربإ ،وليب .س .ـه ،وشاغ نيازداو ،ىونيد وواكأ لالب تاحيفصلاو ضيبلا تايركلا ةَّلِقو ،مدلا رقف راشتنا لدعم ريدقتل ،اييرجين َّليماش يميلعت ىفشتسم في ةضرعتسلما ةساردلا هذه تيرجأ دق :ةـصلالخا عم طبارـتلا عاونأ ريدقتو ،زديلإا سويرفل ةداضم ةقباس ةلجاعم اوقلتي لم ن َّمـم زديلإا ىودعب ينباصلما ثانلإا نم 316و روكذلا نم 177 ىدل دقو .%5.5 ضيبلا تايركلا ةلقو ،%4.5% تاحيفصلا صقنو ،%49.5 مدلا رقف راشتنلا لياجملإا لدعلما نأ حضتاو .ةيسويرفلاو ةيعانلما تماساولا داكتف ضيبلا تايركلا ةّلق تلادعم امأ ،)%42.7( ثانلإا ىدل امم )%61.6( روكذلا ىدل ًايئاصحإ هب ُّدتعُي رادقمب لىعأ مدلا رقف راشتنا لدعم ناك .ثانلإا دنع %3.8و روكذلا دنع %5.7 وهف ،تاحيفصلا صقنل ةبسنلاب كلذكو ،ثانلإا دنع %5.7و روكذلا دنع %5.1 يهف ينسنلجا ينب ةلثماتم نوكت نوبلطتي اوناكو ،ايلالخا في صقن )%59.4( 493 لصأ نم ًاضيرم 293 مهددعو ،لبق نم ةلجاعلما اوقلتي لم نيذلا ضىرلما يثلث نم برقي ام ىدل ناكو ايلالخا صقن ةجرد تناكو .ضىرلما نم %70 ىدل ةيعانلماو ةيريسرلا يرياعلما برع زديلإا صيخشت مت دقو .ةيرقهقلا تاسويرفلل ةداضلما ةلجاعلما .ةيسويرفلا ةلوُمُلحا ينبو ايلالخا صقن ينب ةقلاع يأ دهاشت لمو .زديلإل يريسرلا عضولاو يعانلما تبكلا ةجرد عم ًاشرابم ًاطبارـت طباترت Relation entre des anomalies hématologiques, le degré d'immunosuppression et la charge virale chez des patients infectés par le VIH et n'ayant jamais reçu de traitement RÉSUMÉ La présente étude transversale menée dans un hôpital universitaire au nord-est du Nigeria a estimé la prévalence de l'anémie, de la leucopénie et de la thrombocytopénie chez des patients infectés par le VIH et n'ayant jamais été traités (177 hommes et 316 femmes), et les associations aux marqueurs virologiques et immunologiques. Les prévalences globales pour l'anémie, la leucopénie et la thrombocytopénie étaient de 49,5 %, 5,5 % et 4,5 %, respectivement. La prévalence de l'anémie était significativement plus élevée chez les hommes que chez les femmes (61,6 % par rapport à 42,7 %), tandis que les taux de leucopénie (5,1 % par rapport 5,7 %) et de thrombocytopénie (5,7 % par rapport à 3,8 %) étaient similaires. Près des deux-tiers des patients de l'étude infectés par le VIH et n'ayant jamais été traités 293/493 (59,4 %) avaient une cytopénie et auraient besoin de médicaments antirétroviraux. Le diagnostic du sida a été posé à partir de critères cliniques ou immunologiques chez 70 % des patients. Le degré de cytopénie était directement lié au degré d'immunosuppression et au stade clinique du sida. Aucun lien n'a été observé entre la cytopénie et la charge virale. Book 19-4.indb 362 5/12/2013 2:19:38 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 363 Introduction H a e m a t o l o g i c a l a b n o r m a l i t i e s (anaemia, leukopenia and thrombo- cytopenia) are common manifesta- tions of advanced HIV-1 infection that could potentially limit the use of some components of antiretroviral therapy  (ART)  regimens  [1,2]. The  prevalence of anaemia in patients with HIV infection varies widely by sex and race/ethnicity, with rates ranging from 30%  in  asymptomatic HIV  to  as high as 63%–95%  in persons with  AIDS, depending on the study setting [3–7].  Anaemia  is  more  common  than leukopenia and thrombocytope- nia  in patients with AIDS [5–8]. The  prevalence of leukopenia also varies widely in patients with HIV; reported  prevalence  ranges  from  10%–50%  [7,8]. Various studies have suggested  that the progression of HIV, as meas- ured by deceasing CD4+ cell  counts  and increasing HIV-RNA levels, is significantly associated with develop- ing neutropenia [6,8,9]. Thrombocytopenia is a possible complication of HIV infection. Its pathogenesis has not yet been estab- lished. Possible mechanisms that have been reported are an increased plate- let destruction, either caused by the non-specific deposition of circulating immune complexes on platelets or by the presence of specific antiplatelet antibodies, as well as direct infection of megakaryocytes by HIV with a result- ing decrease in platelet production [10]. In all cases, a specific diagnosis of the cause, severity and mechanism of cytopenia should be sought, because a specific intervention other than the use of antiretroviral drugs may be in- dicated for its correction. The use of antiretroviral drugs could positively or negatively affect these parameters, depending on the choice of combina- tion used. Although many drugs used for the treatment of HIV-related dis- orders are myelosuppressive, severe cytopenia is most often related to the use of zidovudine [11]. Hence the need to review these parameters in a group of treatment-naïve HIV in- fected patients at our centre. The pre- sent study estimated the prevalence of anaemia, leukopenia and throm- bocytopenia at the initiation of ART, and investigated associations between each of pretreatment anaemia, leu- kopenia and thrombocytopenia and baseline covariates of sex, CD4 counts and HIV-RNA viral load and clinical AIDS status at a teaching hospital in north-eastern Nigeria. The find- ings could inform policy and practice regarding safe provision of ART to patients who are found to have cyto- penia or immunosuppression during recruitment. Methods Study area and design This prospective, observational cohort study was carried out in the department of medicine at University of Maiduguri teaching hospital, Borno State from March  2008  to April  2009. This  is  a  500-bed hospital designated as a centre  of excellence for infectious diseases and provides primary, secondary and ter- tiary services for the north-eastern part of Nigeria. It also caters for neighbour- ing countries such as Cameroon, the Niger and Chad. Permission for the study was ob- tained from the University of Maidu- guri teaching hospital ethics committee. Written informed consent (signed or thumbprint) was obtained from pa- tients. Sample The inclusion criteria for patients were: HIV seropositive status confirmed by Western  blot  test;  and  provision  of  informed (written) consent. The exclu- sion criteria were: age < 18 years; severe  renal  or hepatic  failure;  prior history  of highly active antiretroviral therapy (HAART) usage; bleeding disorder; or  inability to give consent or non-consent. All consenting participants were recruit- ed consecutively into the study. A  total of 493 patients with HIV  serological reactivity determined by enzyme immunoassay and confirmed by Western blot analysis were re- cruited into the study. They included patients with AIDS, diagnosed by im- munological or clinical criteria based on the Centers for Disease Control 1993  revised  classification  for HIV  infection [12]. Using a structured, pre- evaluated questionnaire, information was obtained on patients’ demographic characteristics, clinical manifestations, medication used, blood transfusion history and sexual and drug use behav- iour. Haematological parameters and viral load are free-of-charge, routine prerequisite and pretreatment evalu- ations done, among other ancillary investigations, for all registered HIV patients at our centre. Haemoglobin (Hb) and platelets count were analysed using a haematol- ogy analyser (Sysmex® Corporation). Samples for total lymphocytes count and CD4+ T-cell count was collected  between 09.00–10.00 hours  and as- sayed  within  6  hours  of  collection  of whole blood using a standardized flow cytometric machine (Cyflow®, Cytec). Plasma HIV-RNA levels was measured using freshly frozen speci- men separated within 6 hours of phle- botomy utilizing the Amplicor HIV-1 monitor  test,  version 1.5  (Roche®),  with a minimum cut-off value of 200  copies/mL. Statistical analysis SPSS,  version  15  statistical  software  was used for analysis. The results are presented as mean and standard devia- tion (SD). Unpaired t-test was used to compare the means of all continuous variables. Categorical data were ana- lysed using Fisher exact test. A P-value of < 0.05 was considered to be statistically  significant. Book 19-4.indb 363 5/12/2013 2:19:38 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 364 factor in majority of our study cohort as participants denied other risky sexual behaviour that could put them at risk of contracting HIV infection. The overall prevalence of anaemia, leukopenia and thrombocytopenia among the studied subjects, defined as Hb < 10 g/dL, WBC < 4 ×103/L and platelets < 100 ×103/L, was 49.5%,  5.5% and 4.5%  respectively  (Table  2). Anaemia was present in 109/177  males (61.6%) and 135/316 females  (42.7%)  (P  =  0.001).  Nine males  (5.1%) and 18  females  (5.7%) (P = 0.78) had leukopenia, while 10 males  (5.7%) and 12  females  (3.8%) (P = 0.33) were thrombocytopenic. Seven  (1.4%) patients  had both  anaemia  and  leukopenia, 4 (0.8%) had anae- mia and thrombocytopenia and none of the participants had leukopenia and thrombocytopenia or pancytopenia. Association of AIDS status with haematological parameters Patients’ AIDS status was associ- ated with presence of anaemia (P < 0.001) but not with  leukopenia  and  thrombocytopenia  (Table  2). The  prevalences of anaemia, leukopenia and  thrombocytopenia were 54.8%,  6.1% and 5.2% in AIDS patients versus  37.2%, 4.1% and 2.7% respectively  in  patients without the features of AIDS at evaluation. The mean Hb level of all patients was 10.0 (SD 2.5) g/dL, mean WBC  was 5.9 (SD 3.0) ×103/L and platelet count was 291 (SD 133) ×103/L (Ta- ble 3). The mean CD4 count of the studied sample was  232  (SD  205)  cells/µL,  ranging  from 5  to 1840 cells/µL. The  mean CD4 counts for females were significantly higher than for males: 254  Results Background characteristics A  total  of  493  patients  were  con- secutively  recruited, consisting of 316  (64.1%)  females  and  177  (35.9%)  males. The overall mean age of the patients  was  34.8  (SD  8.6)  years,  range 15–67 years. Male patients were  significantly older than their female counterparts: mean age 36.6 (SD 5.2)  years (range 18–67 years) versus 32.7  (SD 8.3)  years  (range 15–60) years  respectively (P < 0.001). Around 40%  of the study population had no formal education. The sociodemographic and clinical characteristics of males and females are shown in Table 1. A  total  of  345  patients  (70.0%)  were diagnosed with AIDS by either clinical or immunological criteria. The majority were married;  heterosexual  transmission was the presumed risk Table 1 Sociodemographic and clinical characteristics of the study group of treatment-naïve HIV-infected patients Variable Total (n = 493) Males (n = 177) Females (n = 316) P-value No. % No. % No. % Marital status Married 289 58.6 109 61.6 180 57.0 0.368 Single 164 33.3 51 28.8 113 35.8 0.138 Divorced 27 5.5 8 4.5 19 6.0 0.620 Separated 13 2.6 9 5.1 4 1.2 0.021 Literacy level No formal education 198 40.2 32 18.1 166 52.5 < 0.001 Quranic education 35 7.1 26 14.7 9 2.9 < 0.001 Primary education 116 23.5 47 26.6 69 21.8 0.274 Secondary education 78 15.8 48 27.0 30 9.5 < 0.001 Tertiary education 66 13.4 24 13.6 42 13.3 1.000 AIDS status Yes 345 70.0 116 65.5 229 72.5 0.127 No 148 30.0 61 34.5 87 27.5 0.127 Probable route of AIDS transmission Heterosexual 461 93.5 157 88.7 304 96.2 0.002 Blood transfusion 0 0.0 0 0.0 0 0.0 – MSM 0 0.0 0 0.0 0 0.0 – IV drug use 0 0.0 0 0.0 0 0.0 – Unknown 32 6.5 20 11.3 12 3.8 0.002 MSM = men who have sex with men; IV = intravenous. Book 19-4.indb 364 5/12/2013 2:19:38 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 365 (SD  223)  cells/µL  versus  194  (SD  162)  cells/µL  (P  =  0.002). Only  42  (8.5%) of  the participants had a CD4  count of ≥ 500 cells/µL;  the majority  (55.4%) had a CD4 count < 200 cells/ µL (Figure 1). No  sex difference was  observed with regard to presence of im- munological AIDS status (< 200 cells/ µL) (P = 0.512). Table 2 Distribution of cytopenia in the study group of treatment-naïve HIV-infected patients with and without AIDS Variable Total (n = 493) AIDS (n = 313) No AIDS (n = 180) P-value No. % No. % No. % Whole sample Males 177 35.9 116 33.6 61 41.2 0.131 Females 316 64.1 229 66.4 87 58.8 0.131 Anaemia Males 109 61.6 74 63.8 35 57.4 0.503 Females 135 42.7 115 50.2 20 23.0 0.000 Total 244 49.5 189 54.8 55 37.2 0.000 Leukopenia Males 9 5.1 7 6.0 2 3.3 0.676 Females 18 5.7 14 6.1 4 4.6 0.808 Total 27 5.5 21 6.1 6 4.1 0.498 Thrombocytopenia Males 10 5.7 7 6.0 3 4.9 1.000 Females 12 3.8 11 4.8 1 1.2 0.244 Total 22 4.5 18 5.2 4 2.7 0.319 Anaemia + leukopenia Males 3 1.7 3 2.6 0 0.0 0.510 Females 4 1.3 2 0.9 2 2.3 0.699 Total 7 1.4 5 1.5 2 1.4 1.000 Anaemia + thrombocytopenia Males 1 0.6 1 0.9 0 0.0 1.000 Females 3 1.0 2 0.9 1 1.2 0.969 Total 4 0.8 3 0.9 1 0.7 1.000 Leukopenia + thrombocytopenia Total 0 0.0 0 0.0 0 0.0 – Pancytopenia Total 0 0.0 0 0.0 0 0.0 – Table 3 Distribution of the study group of treatment-naïve HIV-infected patients by age and haematological status Variable Total (n = 493) Males (n = 177) Females (n = 316) Mean (SD) Min.–Max. Mean (SD) Min.–Max. Mean (SD) Min.–Max. Age (years) 34.8 (8.6) 15–67 36.6 (5.2) 23–67 32.7 (8.3) 15–59 Hb (g/dL) 10.0 (2.5) 3.9–35.3 10.3 (2.6) 3.9–16.1 9.9 (2.5) 4.5–35.3 WBC (×1 03/L) 5.9 (3.0) 1–27 6.0 (3.2) 2–21 5.8 (2.8) 1–27 Platelets (× 103/L) 291 (133) 10–1 008 264 (128) 10–837 306 (134) 47–1 008 CD4 (cells/µL) 232 (205) 5–1 840 194 (162) 5–909 254 (223) 13–1 840 Viral load (copies/mL) 324 873 (879 555) 200–8 480 982 441 222 (1 086 013) 200–7 601 010 259 657 (1 086 013) 200–8 480 982 Hb = haemoglobin; WBC = white blood cell count; CD4 = cluster of differentiation-4 cells; SD = standard deviation; Min. = minimum; Max. = maximum. Book 19-4.indb 365 5/12/2013 2:19:39 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 366 Among participants with CD4 count  <  200  cells/µL,  anaemia  was  observed  in  63.5%;  the  correspond- ing prevalences were 36.3%, 33.9% and  19.0% respectively in cohorts within the  CD4 count ranges 200–349, 350–499  and ≥ 500 cells/µL (P < 0.001). As pre- sented  in Figure 2,  an  inverse associa- tion was found between risk of anaemia, leukopenia and thrombocytopenia and CD4 count, as the prevalence of cytope- nia declined in patients with increased CD4 count (P  < 0.001). HIV-1  viral  load, however, was not associated with the risk of cytopenia (Figure 3). Discussion This  study  showed  that 49.5% of  the  sample population had anaemia, which is  higher  than  the  18.9%  prevalence  reported in Uganda [13] but lower than  80% obtained by Erhabor et al.  in Port  Harcourt, Nigeria, among untreated HIV patients [14]. This study is in agreement with previous studies by Ak- insegun et al. [15], Zon and Groopman  [7], Spivak et al. [16] and a multicentre  AIDS cohort study showing that anae- mia was directly related to the degree of immunosupression [16]. A  leukopenia  prevalence  of  5.5%  was reported in this study compared with the 10% reported by Erhabor et al.  [14]. It was also confirmed in this study that a high prevalence of leukopenia was associated with profound immuno- deficiency, as was reported by Zon and Groopman [7], Spivak et  al.  [16] and  the multicentre AIDS control cohort study [17]. A thrombocytopenia preva- lence of 4.5% was shown  in  this  study,  lower than 10% reported by Erhabor et  al.  [14] and 16.1% by Akinsegun et al.  [15]. The degree of  thrombocytopenia  was also directly related to the degree of immunosupression, in agreement with Jost et al. [10] and the multicentre  study [17]. A decrease  in serum eryth- ropoietin levels [16], auto-antibodies to  erythropoietin or marrow suppression by opportunistic infections, tumours or  various  medications  [16,18–20]  may also contribute to the anaemia commonly observed in HIV-infected persons. This study revealed that over half (55.4%)  of  newly  registered HIV  pa- tients will require antiretroviral drugs almost immediately because their CD4 count of < 200 cells/µL at enrolment will  qualify them automatically for HAART, irrespective of symptoms, according to World Health Organization (WHO) cri- teria for initiating antiretroviral therapy. This study reported a mean CD4 count of 254 cells/µL for females and  General Males Females < 200 200–349 350–499 ≥ 500 60 50 40 30 20 10 0 Pr op ro rt io n of p ar ti ci pa nt s CD4+ cell count levels (cells/µL) Figure 1 Distribution of CD4+ cell counts in the study group of treatment-naïve HIV-infected patients. Total n = 493; males n = 177; females n = 316 < 200 200–349 350–499 ≥ 500 70 60 50 40 30 20 10 0 % c yt op en ia CD+4 count level (cells/µL) Anaemia Leukopenia Thrombocytopenia Figure 2 Relationship between CD4+ counts and cytopenia in the study group of treatment-naïve HIV-infected patients. Total n = 493; males n = 177; females n = 316 Book 19-4.indb 366 5/12/2013 2:19:39 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 367 Anaemia Leukopenia Thrombocytopenia ≤ 200 200–4 999 70 60 50 40 30 20 10 0 % c yt op en ia Viral load levels (copies/mL) 5 000–9 999 10 000–49 999 50 000–99 999 ≥ 100 000 Figure 3 Relationship between viral load and cytopenia in the study group of treatment-naïve HIV-infected patients. Total n = 493; males n = 177; females n = 316 this was significantly higher than the mean of 194 cells/µL for males, similar  to  the  study of Akinsegun et al.  [15],  but contrary to the study of Omoti et al. that reported a slightly higher CD4 count  for males of 195 cells/µL  versus 180 cells/µL  for  females  [21].  Oladepo et al. established a reference value for CD4 in healthy Nigerian adults of 365–1571 cells/µL, with  a  mean CD4 count of 847 cells/µL [22],  and this was similar to the mean value of 828  cells/µL  reported by Aina  et  al.  in an earlier  study  in Nigeria [23].  Females were found to have signifi- cantly higher absolute CD4 counts in this study. This observation of higher CD4 count in females has also been reported in several other countries among Nigerians [24], Ugandans [25]  and Ethiopians  [26]. A  sex hormone  effect is one possible explanation for the reported difference in CD4 counts between the sexes [26]. Patients with features of AIDS (WHO clinical stage IV) or severe immunosuppression (CD4 count < 200 cells/µL) had  lower haemoglobin,  leucocyte and platelet levels. However, unlike other  reports  [27–29], no  rela- tionship was observed between plasma HIV-RNA levels and cytopenia in this study. The hypothesis that HIV-1 infec- tion of marrow stromal cells results in anaemia and other cytopenias was not supported by our study. Conclusion Almost two-thirds of HIV treatment- naïve patients at our centre had cyto- penia and would require antiretroviral drugs, and the degree of cytopenia was directly related to the degree of immu- nosupression. In this study, unlike some reports, no relationship was observed between cytopenia and viral load. In view of this high prevalence of cyto- penia, it is necessary to investigate its causes in these patients, and adminis- ter specific interventions. References 1. Levine A et al. 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Zon LI, Arkin C, Groopman JE. Haematologic manifestations of the human immune deficiency virus (HIV). British Journal of Haematology, 1987, 66:251–256. 8. Calenda V, Chermann JC. The effects of HIV on hematopoiesis. European Journal of Haematology, 1992, 48:181–186. 9. Zon LI, Groopman JE. Hematologic manifestations of the hu- man immunodeficiency virus (HIV). Seminars in Hematology, 1988, 25:208–218. 10. Jost J et al. HIV-assoziierte Thrombozytopenie. [HIV-associat- ed thrombocytopenia.] Schweizerische Medizinische Wochen- schrift, 1988, 118:206–212. 11. RD. Keruly JC, Chaisson RE. Anemia and survival in HIV infec- tion. Journal of Acquired Immune Deficiency Syndromes and Hu- man Retrovirology, 1998, 19:29–33. 12. Centers for Disease Control and Prevention. 1993 revised clas- sification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. Journal of the American Medical Association, 1993, 269:729–730. 13. Mugisha JO et al. Anaemia in rural Uganda HIV cohort, prevalence at enrolment, incidence, diagnosis and associ- ated factors. Tropical Medicine and International Health, 2008, 13:788–794. 14. Erhabor O et al. Some haematological parameters in human immunodeficiency virus (HIV) infected Africans: the Nigerian perspective. Nigerian Journal of Medicine, 2005, 14:33–38. 15. Akinsegun A et al. Hematologic abnormalities in treatment- naïve HIV patients. Infectious Diseases: Research and Treatment, 2010, 3:45–49. Book 19-4.indb 367 5/12/2013 2:19:40 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 368 16. Spivak JL et al. Serum immunoreactive erythropoietin in HIV- infected patients. Journal of the American Medical Association, 1989, 261:3104–3107. 17. Kaslow RA, Phair JP, Friedman HB. Infection with the human immunodeficiency virus: Clinical manifestations and their relationship to immune deficiency. A report from the Multi- center AIDS Cohort Study. Annals of Internal Medicine, 1987, 107:474–480. 18. Frickhofen N et al. Persistent B19 parvovirus infection in pa- tients infected with human immunodeficiency virus type 1: a treatable cause of anaemia in AIDS. Annals of Internal Medicine, 1990, 113:926–933. 19. Creagh-Kirk T et al. Survival experience among patients with AIDS receiving zidovudine-follow-up of patients in a compas- sionate plea program. Journal of the American Medical Associa- tion, 1988, 260:3009–3019. 20. Seneviratne LC et al. Clinical, immunologic, and pathologic correlates of bone marrow involvement in 291 patients with AIDS related lymphoma. Blood, 2001, 98:2358–2263. 21. Omoti CE, Udezi WA, Ediose RE. Haematological aspects of antiretroviral naïve HIV patients in a Nigerian tertiary hospital: laboratory and clinical consideration. International Journal of Biological and Chemical Sciences, 2007, 1:176–180. 22. Oladepo DK et al. Establishment of reference values of CD4 and CD8 lymphocyte subsets in healthy Nigerian adults. Clini- cal and Vaccine Immunology, 2009, 16:1374–1377. 23. Aina O et al. Reference values of CD4 T-lymphocytes in human immunodeficiency virus-negative adult Nigerians. Clinical and Diagnostic Laboratory Immunology, 2005, 12:525–530. 24. Njoku MO et al. CD4+ T-lymphocyte counts in patients with human immunodeficiency virus type 1 (HIV-1) and healthy population in Jos, Nigeria. Postgraduate Medical Journal, 2003, 10:135–139. 25. Tugume SB et al. Haematological reference ranges among healthy Ugandans. Clinical and Diagnostic Laboratory Immunol- ogy, 1995, 2:233–235. 26. Prins MJ et al. Do gender differences in CD4 counts matter? AIDS, 1999, 13:2361–2364. 27. Moses AU et al. Human immunodeficiency virus infection of bone marrow endothelium reduces induction of stromal he- matopoietic growth factors. Blood, 1996, 87:919–925. 28. Bahner I et al. Infection of human marrow stroma by HIV-1 is both required and sufficient for HIV-1 induced haematopoietic suppression in vitro: demonstration by gene modification of primary human stroma. Blood, 1997, 90:1787–1798. 29. Scadden DT et al. Human immunodeficiency virus infection of human bone marrow stromal fibroblasts. Blood, 1990, 76:317–322. Book 19-4.indb 368 5/12/2013 2:19:40 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 369 Study of methacholine positivity in patients with chronic cough at Masih Daneshvari hospital, Tehran, 2007–2008 A. Cheraghvandi,1 L. Fadaizadeh,2 S.A. Taheri 3 and M.R. Masjedi 4 ABSTRACT While airways reactivity is among the characteristics of asthma, it is not considered a sufficient condition diagnostically and the methacholine challenge is a non-specific diagnostic aid in cases of chronic cough and reactive airways disease. The aim of this cross-sectional study was to determine the metacholine response positivity and diagnosis of asthma in patients with chronic cough presenting to a hospital in Tehran during 2007 and 2008. Of 101 patients with chronic cough (with no history of sinusitis, recent pulmonary infection, bronchitis, gasteroesophageal reflux or underlying pulmonary conditions), 51.5% showed reactive airways disease to the methacholine test, 40.6% were unreactive and 7.9% were indeterminate. A positive methacholine challenge test was positively correlated with new wheezing. Although the methacholine challenge test is not a primary test for evaluating chronic cough, if no other reason for chronic cough is found, it may be a guiding test for asthma. 1Lung Transplantation Research Centre; 2Telemedicine Research Centre; 3Clinical Tuberculosis and Epidemiology Research Centre; 4Chronic Respiratory Diseases Research Centre, National Research Institute of Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to A. Cheraghvandi: cheraghvandiali@yahoo.com). Received: 21/12/11; accepted: 21/02/12 2008-2007 ،نارهط ،يراوشناد حيسم ىفشتسم في نمزم لاعسب ينباصلما ضىرلما ىدل ينلوكاثيلما لعافت ةيبايجإ لوح ةسارد يدجسم .ر.م ،يرهاط .أ .س ،هدازيئادف .ل ،يدنوغارج .ع يدحتلا نأ ماك ،ةيفاك ةلاح ةيصيخشتلا ةيحانلا نم برتعت لا انهإف ،وبرلا صئاصخ ىدحإ يه ةيئاولها لُبُسلا ةّيلعافت نأ نم مغرلا لىع :ةـصلالخا ةيبايجإ لىع فرعتلا لىإ ةضرعتسلما ةساردلا هذه فدتهو .ةيئاولها لبسلا ةيلعافت نمزلما لاعسلا تلاالح ةيعون يرغ ةيصيخشت ةادأ برتعي ينلوكاثيلماب تلمشو .2008-2007 ْينَماعلا للاخ نارهط تايفشتسم دحأ نوعجاري نيذلا نمزلما لاعسلا ضىرم ىدل وبرلا صيخشتو ،ينلوكاثيملل لعافتلا ةيأ وأ ،ةيمضلها تازرفلما عوجر وأ ،تابصق باهتلا وأ ،ةثيدح ةيوئر ىودع وأ ،بويلجا باهتلا قباوس نود( نمزلما لاعسلاب ًاضيرم 101 ةساردلا يرغ اوناك مهنم %49.6 نأو ،ينلوكاثيلماب رابتخلال ةيئاولها لُبُسلا لعافت ميهدل ةساردلا مهتلمش نمم %51.5 نأ حضتا دقو .)ةنطبتسم ةيوئر تلااح لا ينلوكاثيلماب يدحتلا رابتخا نأ مغرو .زيزلأا عم ًايبايجإ ًاطُبارت ينلوكاثيلماب يدحتلا رابتخا طبارت دقو .ةددمح يرغ مهنم %7.9 لعافت نأو ،ينلعافتم .نمزلما لاعسلل رخآ ببس حوضو مدع دنع وبرلا في ًايداشترسا ًارابتخا نوكي دقف ،نمزلما لاعسلا مييقت في ًايلوأ ًارابتخا ُّدَعُي Étude de la positivité à la méthacholine chez des patients souffrant de toux chronique à l'hôpital Masih Daneshvari de Téhéran entre 2007 et 2008 RÉSUMÉ Si la réactivité des voies aériennes compte parmi les caractéristiques de l'asthme, elle n'est pas considérée comme suffisante pour poser un diagnostic ; la provocation à la méthacholine est une aide non spécifique pour le diagnostic dans les cas de toux chronique et d'hyperréactivité des voies aériennes. La présente étude transversale visait à déterminer la positivité à la méthacholine et le diagnostic d'asthme des patients souffrant de toux chronique ayant consulté dans un hôpital de Téhéran entre 2007 et 2008. Sur un total de 101 patients atteints de toux chronique (sans antécédents de sinusite, d'infection pulmonaire récente, de bronchite, de reflux gastro-oesophagien ni d'affections pulmonaires sous-jacentes), 51,5 % ont présenté une hyperréactivité des voies aériennes au test de provocation à la méthacholine, 40,6 % n'ont pas eu de réaction et 7,9 % ont eu des résultats non concluants. Un résultat positif au test de provocation à la méthacholine était positivement corrélé à la survenue d'un sifflement. Le test de provocation à la méthacholine ne représente pas le test principal permettant d'évaluer une toux chronique mais peut toutefois être utile pour établir le diagnostic d'asthme si aucune autre cause n'est identifiée pour la toux chronique. Book 19-4.indb 369 5/12/2013 2:19:40 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 370 Introduction One of the characteristics of most asth- matic patients is cough and increased airways responsiveness on exposure to selected allergens. Yes, while airways reactivity is among the characteristics of asthma, it is not considered a sufficient condition diagnostically. It is also not clear which comes first, control of bron- chial diameter or hyper-reactivity [1]. The methacholine challenge test is a non-specific diagnostic aid in cases of chronic cough and reactive airways dis- ease. In a report by Wongtim et al. the methacholine test was shown to have an important role in reaching a diagnosis in patients with chronic cough and its positive predictive value for asthma was 60%–82% [2].  In another  large  study  in  Australia with 876 participants, 81% had  hyper-responsiveness to inhaled hista- mine while only 6% were diagnosed with  asthma based on reactivity of the airways [3].  In a  similar  study of airways  reactiv- ity linked to various occupations it was demonstrated that hyper-reactivity was much more common than what could be medically  termed asthma [4,5].  It  seems  therefore that airways hyper-reactivity is only one part of asthma and can also be a cause of chronic cough. As a result, it is prudent to look for other reasons for airways reactivity and not attribute it only to asthma. Specific and non-specific tests can be helpful in this endeavour. Studies concerning cough and asthma are few and we planned this study to determine the prevalence of asthma among patients with symptoms of cough who had an extensive work-up for this condition. Patients in whom a definite diagnosis using clinical symptoms or spirometry results could not be reached were invited to participate in the methacholine challenge test. Methods Sample This was a cross-sectional study of pa- tients with chronic cough during the years 2007 and 2008. All patients over  the 2-year period who presented with  chronic cough and who met the inclu- sion criteria were included in the study. The inclusion criteria were chronic cough of more  than 3 weeks duration,  cough without a known cause, age above 10 years and normal radiography  of the chest, sinuses and spirometry. Exclusion criteria were all patients with asthma, pulmonary infections, gastro- esophageal reflux, foreign body aspira- tion, recent upper respiratory infections (within 8 weeks),  chronic bronchitis,  sinusitis or other pulmonary conditions or symptoms consistent with airways disease such as wheezing. Data collection Patients were advised not to take methacholine, theophylline, antihista- mines, β 2 -agonists, sympathomimetics or anticholinergic medications  for 48  hours before the test. The methacholine test was performed according to the fol- lowing pulmonary laboratory protocol. A spirometry test was performed and if the patient’s forced expiratory volume in 1 sec (FEV1) was above 70% of expected, saline nebulizer treat- ment was given  for 2 minutes. After 3  minutes rest the patient underwent a spirometry test. If FEV1 did not drop by 20%,  treatment with methacholine  was started. The first concentration of the methacholine nebulizer was 0.03  mg/mL  for 2 minutes,  after which 3  minutes of rest was given and spirom- etry was performed again. If there was no drop  in FEV1 below 20%,  testing  was continued with double doses of methacholine until one of these oc- curred:  a  drop  in  FEV1  20%  below  the  first  FEV1  or  a  dose  of  16 mg/ mL methacholine was reached. If a pa- tient developed coughing, shortness of breath or wheezing, the test was ended and considered positive. A drop  in FEV1 of 20% was  con- sidered positive for airways hyper- reactivity, 16% was considered negative  and between 16%–20% was considered  indeterminate and the test was repeated after 2 weeks. Data analysis Information from the patient’s his- tory, physical examination and the methacholine test results were analysed statistically using the chi-squared test. Statistical analysis was done using SPSS, version 9. Results A total of 101 participants met the inclu- sion criteria (51 men and 50 women),  with a mean age of 38.8 [standard de- viation (SD) 15.4] years,  range 14–74  years. All patients had a history of cough of more  than 3 weeks. Other  clinical  symptoms, summarized in Figure 1, showed  that  61.4% had  shortness  of  breath, 52.5% had paroxysmal noctur- nal dyspnoea  and 48.5% had  sputum  production. Of  the  total patients 9.9%  were smokers but none reported being substance abusers. At study entry none of them had other pulmonary diseases, sinusitis, recent cold (past 8 weeks) and  wheezing on auscultation. In their past medical history 32 individuals (31.7%)  reporting having had sinusitis, 9.9% ec- zema and 4.0% acute bronchitis. The final results of the methacholine challenge  test  showed 52  cases were  positive (51.5%), 8 were indeterminate  (7.9%) and 41 were negative (40.6%).  The rate of airways reactivity was higher among women (58.0%) compared with  men (45.1%) but  this was not  statisti- cally significant (Table 1). The mean methacholine concentration in the nebulizer that gave positive test results was 7.8  (SD 6.9) mg/mL,  range 0.06  to 16 mg/mL. Of  the  individuals with  a  positive  test,  42/52  (80.8%) had  a  20% decrease  in FEV1, 9 (17.3%) had  wheezing and 1 (1.9%) developed se- vere coughing and the test was discon- tinued. Patients with positive tests were prescribed bronchodilators. Of  the 8  Book 19-4.indb 370 5/12/2013 2:19:40 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 371 Discussion In  this  study  101  participants  with  chronic cough underwent the metha- choline challenge test. The results showed  that 52 (51.5%) of  them had  airways hyper-reactivity to the test, which is comparable to the results from  similar  studies  [6–9].  Patients  with chronic cough may show hyper- reactivity significant enough to undergo more complete evaluation. The aver- age dose of methacholine that led to positive test was 7.8 (SD 6.9) mg/mL,  which is similar to these other studies. A positive methacholine test at doses < 8 mg/mL (proactive concentration)  may therefore be a good marker for diagnosis of asthma [1]. The rate of airways reactivity was higher  in  women  than men  (58.0%  versus 45.1%) but  this was not  statis- tically significant. While a similar re- sult has been found in some studies [10–13], other  studies do not  support  this finding [14,15].  In this study, only a positive methacholine challenge test had a positive correlation with wheezing, which could be sign of airways hyper- reactivity that is not seen with other symptoms. Individuals with sinusitis, eczema and acute bronchitis did not show a positive methacholine chal- lenge test and a history of such con- ditions may not influence airways hyper-reactivity. During the methacholine chal- lenge test, the average drop in FEV1 for positive tests for these patients was 21.4 (SD 8.6) L and the  increase after  bronchodilator administration was 15.7 (SD 9.5) L, which can be a sign of  bronchial asthma [1]. A 16% improve- ment in FEV1 using a bronchodilator is an indicator of effective therapeutic response. In conclusion, even though the methacholine challenge test is not a pri- mary test for evaluating chronic cough it may be a guiding test for asthma, if no other reason for chronic cough is found. Acknowledgements The authors would like to thank all col- leagues at Masih Daneshvari Hospital who helped with the preparation of this manuscript. Competing interests: None declared. patients who had indeterminate test results, none returned for retesting and a definite diagnosis was not possible. The mean fall in FEV1 on challenge was 21.4 (SD 8.7) L, for FVC was 14.7  (SD 9.4) L and for peak expiratory flow (PEF) was 19.8 (SD 6.1) L/min. On  receiving a bronchodilator, the mean increase  in FEV1 was 15.7 (SD 9.5) L,  FVC 8.7 (SD 5.9) L and PEF was 6.1  (SD 18.6) L/min. The chi-squared test showed that only a positive methacholine challenge test had a positive correlation with the presence of wheezing (P < 0.001) but  not with any other symptoms (includ- ing bronchitis, eczema and sinusitis) [data not shown]. Only 10  individuals  were smokers and therefore no statisti- cal conclusions could be reached about the influence of smoking. Table 1 Distribution of patients with chronic cough based on response to the methacholine challenge test, Masih Daneshvari hospital, 2007–2008 Sex Response Positive Negative Indeterminate Total No. % No. % No. % Male 23 45.1 25 49.0 3 5.9 51 Female 29 58.0 16 32.0 5 10.0 50 Total 52 51.5 41 40.6 8 7.9 101 52.0 48.0 18.0 24.0 40.0 50.0 0 10 20 30 40 50 60 Post-nasal drip Sputum production Sneezing Nasal congestion Wheezing Chest pressure % of respondents Figure 1 Clinical symptoms of 101 patients with chronic cough, Masih Daneshvari hospital, 2007–2008 Book 19-4.indb 371 5/12/2013 2:19:41 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 372 References 1. Fraser M, Colman P, editors. Diagnosis of diseases of the chest, 4th ed. Philadelphia, Pennsylvania, WB Saunders, 1999:380– 382;420–423. 2. Wongtim S et al. The role of the methacholine inhalation chal- lenge in adult patients presenting with chronic cough. Asian Pacific Journal of Allergy and Immunology, 1997, 15:9–14. 3. Woolcock AJ et al. Prevalence of bronchial hyperresponsive- ness and asthma in a rural adult population. Thorax, 1987, 42:361–368. 4. Weiss ST et al. Airways responsiveness in a population sample of adults and children. American Review of Respiratory Disease, 1984, 129:898–902. 5. Mortagy AK, Howell JBL, Waters WE. Respiratory symptoms and bronchial reactivity: identification of a syndrome and its relation to asthma. British Medical Journal, 1986, 293:525–529. 6. Irwin RS et al. Interpretation of positive results of a methacho- line inhalation challenge and 1 week of inhaled bronchodilator use in diagnosing and treating cough-variant asthma. Archives of Internal Medicine, 1997, 157:1981–1987. 7. Koh YY, Chae SA, Min KU. Cough variant asthma is associated with a higher wheezing threshold than classic asthma. Clinical and Experimental Allergy, 1993, 23:696–701. 8. Corrao WM. Methacholine challenge in the evaluation of chronic cough. Allergy Proceedings, 1989, 10:313–315. 9. Irwin RS, Curley FJ, French CL. Chronic cough. The spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy. American Review of Respiratory Disease, 1990, 141:640–647. 10. Wassmer G et al. The association between baseline lung func- tion and bronchial responsiveness to methacholine. European Journal of Medical Research, 1997, 2:47–54. 11. Abramson M et al. Risk factors for asthma among young adults in Melbourne. Australia Respirology, 1996, 1(4):291–297. 12. Kanner RE et al. Gender difference in airway hyperresponsive- ness in smokers with mild COPD. The Lung Health Study. American Journal of Respiratory and Critical Care Medicine, 1994, 150:956–961. 13. Larsson L, Boëthius G, Uddenfeldt M. Differences in utilisation of asthma drugs between two neighbouring Swedish prov- inces: relation to prevalence of obstructive airway disease. Thorax, 1994, 49:41–49. 14. Hedman J, Poussa T, Nieminen MM. A rapid dosimetric meth- acholine challenge in asthma diagnostics: a clinical study of 230 patients with dyspnoea, wheezing or a cough of unknown cause. Respiratory Medicine, 1998, 92:32–39. 15. Martin RJ et al.; Asthma Clinical Research Network (ACRN). Methacholine challenge testing: safety of low starting FEV1. Chest, 1997, 112:53–56. Book 19-4.indb 372 5/12/2013 2:19:41 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 373 Renal patients’ views on generic prescribing and substitution: example from the United Arab Emirates M.N. Al Ameri,1,2 W. Mohamed,2 E. Makramalla,2 B. Shalhoub,3 A. Tucker 1 and A. Johnston 1 ABSTRACT This survey examined current patient awareness and understanding of generic substitution. We surveyed 188 renal patients using 36 multiple-choice questions in 2 hospitals in the United Arab Emirates. We found that 70% of patients were aware of the availability of generic medicines, 60% understood the terms “generic” and “branded” in relation to medicines and 64% were conscious of generic substitution practice. However, 32% did not know if they were taking generics and 31% felt that generics were not equivalent or only sometimes equivalent to branded medicines. Nearly half (47%) the patients stated they would refuse generic substitution of ciclosporin when it became available if this was just to save the health authority money. In our opinion, random generic substitution should not be implemented because there is still uncertainty and lack of knowledge among patients. 1Department of Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom (Correspondence to: M.N. Al Ameri: m.al-ameri@qmul.ac.uk). 2Global Medical Solutions, Abu Dhabi, United Arab Emirates. 3Abu Dhabi Health Authority, Abu Dhabi, United Arab Emirates. Received: 07/08/11; accepted: 02/11/11 ةدحتلما ةيبرعلا تاراملإا نم ٌلاثم :اهلئادبو ةلثمالما ةيودلأا فصو لوح لىكلا ضىرم رظن تاهجو نوتسنوج لوثآ ،ركات رثرآ ،بوهلش ماسب ،للها مركم دماع ،دممح ءلاو ،يرماعلا صران كرابم ًاضيرم 188 ءارآ نوثحابلا حسم دقف .ةلثمالما ةيودلأا لئادبل مهمهف ىدمو ضىرلما ىدل ًايلاح رفاوتلما يعولا ىدم حسلما اذه سردي :ةـصلالخا ةيودلأا رفاوتب ملع لىع ضىرلما نم %70 نأ نوثحابلا دجوو .ةدحتلما ةيبرعلا تاراملإا في ينيفشتسم في تارايتخلاا ددعتم ًلااؤس 36 مادختساب في ةحاتلما ةلثمالما ةيودلأا لئادب لىع علاطا لىع مهنم %64 نأو ،ةيودلأل ةبسنلاب "يراتج مسا"و "لثامم" ينحلطصلما نومهفي مهنم %60 نأو ،ةلثمالما ةيودلأا ًايئزج ئفاكت وأ ئفاكت لا ةلثمالما ةيودلأا نأب نورعشي مهنم 31% نأو ،ةلثامم ةيودأ نولوانتي اوناك نإ نوفرعي لا مهنم %32 نأ لاإ .ةسرمالما يرفوت دصقب - رفاوتي امدنع – نيروبسولكيسلل لثمالما ليدبلا ذخأ نوضفيرس هنأ )%47( ضىرلما فصن نم برقي ام حصرو "يراجتلا مسلاا تاذ" تامولعلما دقف عم كوكشلا ضعب دوجول ،هذيفنت متي لا نأ يغبني ةلثمالما ةيودلأل يئاوشعلا للاحلإا نإف ينثحابلا يأر فيو .طقف تاطلسلا لاومأ .ضىرلما ىدل الهوح ةيفاكلا Points de vue des patients atteints d'une maladie rénale sur la prescription des génériques et leur utilisation en substitution : exemple des Émirats arabes unis RÉSUMÉ La présente étude a examiné les connaissances et la compréhension actuelles des patients en matière de substitution par des génériques. Nous avons enquêté auprès de 188 patients atteints d'une maladie rénale à l'aide de 36 questions à choix multiples dans deux hôpitaux des Émirats arabes unis. Nous avons trouvé que 70 % des patients connaissaient la disponibilité des médicaments génériques, 60 % comprenaient les termes « génériques » et « de marque » pour les médicaments et 64 % étaient conscients de la pratique de substitution par des génériques. Toutefois, 32 % des patients ignoraient s'ils prenaient des génériques et 31 % avaient le sentiment que les génériques n'étaient pas équivalents ou n'étaient que parfois équivalents aux médicaments de marque. Près de la moitié (47 %) des patients ont précisé qu'ils refuseraient une substitution par un générique de la ciclosporine quand ce dernier deviendra disponible, s'il s'agissait uniquement de permettre aux autorités de santé de faire des économies. À notre avis, la substitution par des génériques ne doit pas être mise en œuvre de manière aléatoire en raison de l'incertitude et des faibles connaissances des patients. Book 19-4.indb 373 5/12/2013 2:19:41 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 374 Introduction In  the  last 2 decades healthcare  costs  have been climbing globally. For exam- ple, spending on drugs in the United Kingdom  represents over 10% of the total health service budget, and has in- creased steadily over recent decades [1]. In the United Arab Emirates (UAE), the consumption of medicine reached 4 billion UAE dirhams in 2010 [2]. In the  next 2 decades, healthcare expenditure  is predicted to rise from US$ 14 billion in 2008 to US$ 60 billion  in  the coun- tries of  the Gulf  [2]. As a  result, many  countries may be encouraged to reduce their healthcare expenditures. Prescrib- ing generic equivalents of branded drugs could markedly lower medication costs. This strategy has proven to be effective since it is often easier to intervene on expenditure on medicines because of their identified cost [3,4].  About  85%  of  the UAE  pharma- ceutical market consists of branded products, therefore, in the UAE medi- cines are mostly prescribed and dis- pensed in their branded form. Most of the pharmacies in the government hospitals promote branded medicines, resulting in a huge burden for the cost of treatment. Physicians also prescribe medicines by their trade names. De- spite the availability of generics for some out-of-patent brands, physician still pre- scribe the branded form. For instance, the branded prescribing of Augmentin, Glucophage, Voltaren and Zocor is still growing despite the availability of a cer- tain amount of generic competition [5].  In  the 3  years  since 2009, private  health insurance has grown dramatical- ly in the UAE. This, as a result, improved the regulators’ ability to coordinate healthcare development in a direction that is beneficial to both the consumer and the pharmaceutical industry. In addition to prohibiting direct- to-consumer marketing, a new rule requires physicians to prescribe using chemical names and choosing from a list of medicines (the hospital for- mulary) to overcome the influence of pharmaceutical companies [5].  Generic substitution has raised concerns about whether it serves the interests of patients or the target of re- ducing healthcare costs. Indeed some authors are now questioning the qual- ity of  some cheaper drugs [6–8]. Cost  could be a very important factor in drug substitution and prescribability—the physician’s first consideration for pre- scribing between a branded drug and its generic counterpart for a new patient [9]. However, drug substitution can be considered more critical than drug pre- scribability for patients who have been on branded medicine for a long time. Therefore, there are some safety and ethical issues around switching patients from a branded to a generic drug [8,10].  This issue of drug substitution can easily mislead patients and doctors by sup- porting misconceptions about generic drugs and  substitution  [11,12]. Some  healthcare providers have been promot- ing generic substitution in an attempt to contain costs  [13,14] although  it may  be difficult to determine the extent of any long term savings. Drug substitu- tion may involve spending or costs addi- tional to the simple product acquisition costs. Health service providers and payers are also promoting generic substitu- tion and are not prepared to consider that there may be a problem in that pa- tient outcomes could be detrimentally affected, reducing potential savings from these substitutions and laying the providers open to legal redress from patients adversely affected by the substi- tution policies [15–17].  Generic substitution could reduce the United Kingdom (UK) National Health Service brand medicine bill by £80 million,  based  on  a  peak  yearly  spend of £8 billion [14]. Generics ac- count  for 83% of  general practitioner  prescribing in the United Kingdom [18].  Likewise, in Germany, health insurance could  save €1.5 billion  if prescriptions  were fully generically dispensed [19]. In the United States of America (USA) generic drugs accounted  for 47% of all  prescriptions dispensed in 1999, 61% in  2006 and 69% in 2008 [20]. Approving  generic drugs in the USA has resulted in average  savings of 77% of  the product  cost within 1 year [21].  It is well known that patient compli- ance can be attained when substitution is promoted after providing informa- tion, knowledge and education. The objective of this survey was, therefore, to evaluate current awareness, knowl- edge and understanding about generic substitution among renal patients’ in the UAE and how the medical profes- sionals are dealing with this issue, which directly involve patients. Methods We carried out this multicentre sur- vey in the nephrology departments of  2  tertiary hospitals  in  the United  Arab Emirates (UAE), the “UAE Gen- eral Hospital” and the “UAE University Hospital” (the names of the hospitals were kept anonymous to comply with their rules). This survey was approved by the administration of the UAE General Hospital and by Al Ain Medi- cal District Human Research Ethics Committee - Protocol No. 10/64. The  questionnaire had been piloted and validated previously in the Royal Lon- don Hospital in the United Kingdom for a survey carried out in that hospital [22]. The questionnaire was available  in both English and Arabic to cover all patients. The aim and the protocol of the survey was explained and discussed with the medical professionals involved in the study in both hospitals. Renal patients  over  18  years,  able  to  read  and write English and/or Arabic, and willing to fill in the questionnaire were targeted. This group of patients were specified in this survey because any small changes in the medicinal effect Book 19-4.indb 374 5/12/2013 2:19:41 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 375 The majority [80% (95% CI: 74–86)]  of the participants were on kidney di- alysis at the time of the survey. A total of 95 participants were classified as highly  educated (graduated from college, university or postgraduate), and 66 par- ticipants were classed as less-educated (graduated from secondary school, vo- cational training or sixth form) (Table 1). Many  patients  [70%,  (95%  CI:  64–77)]  stated  that  they were  aware  of the availability of different forms of  the  same medicine    and 60% (95%  CI: 53–67) said  that  they understood  the terms “generic” and “branded” in relation  to medicines(Table 2). Only  33% (95% CI: 26–40) of patients  felt  that generics are always equivalent to branded medicines. Many  patients  [85%  (95%  CI:  78–90)] were  unaware  or  uncertain  about the availability of the generic form of ciclosporin in the global market and 47% (95% CI: 40–55) stated that they  would refuse generic substitution of ciclosporin if it become available in local hospitals (Table 2). The effect of education on pa- tients’ acceptance of generic medi- cines and substitution was marked in  this  survey.  A  total  of  93  highly  educated patients (graduated from college, university or postgraduate) responded to a question evaluating their awareness of generic substitution practice, and 84% of these were aware  of the practice, while from the 64 less  educated (graduated from secondary school, vocational training or sixth can negatively impact on their clinical outcome. This survey was related to all medications, not immunosuppressant agents alone. According to the study protocol, a minimum of  100 patients were  re- quired to be surveyed in each hospital. However, nurses and pharmacists in the participating hospitals were only able to  recruit  a  total of 188 patients: 101  patients treated at the UAE General Hospital and 87 patients  treated at  the  UAE University Hospitals. It was diffi- cult to enrol a higher number of patients during the regular clinic hours because of time constraints. The questionnaire (developed by the principal researcher) used as a tool to obtain the required information had 36 multiple-choice,  closed questions.  Patients booked in for clinic visit were recruited by clinical pharmacists and nursing staff as patients over a period of 1 year (1 July 2010–1 January 2011  in the UAE General Hospital and 1 February 2011–1 July 2011 in the UAE  University Hospital). After reviewing the information sheet which contained a brief introduction in English or Arabic about generic medicines and substitu- tion, patients consented by agreeing to fill in the questionnaire. A researcher was available to clarify any unclear points. The data from the questionnaire were analysed using Microsoft Excel 2007 and Minitab 16 statistical soft- ware. Results are reported as percent- age plus 95% confidence interval (CI).  Missing values are not included in the calculations of percentages;  the  total  number of respondents for each ques- tion is given in parentheses after each question. Results A  total  of  122  (65%)  male  and  66  (35%) female patients with average age  49  (range  18–86; median  50)  years  were included in this study (Table 1). Table 1 Demographic characteristics of the renal patients surveyed (n = 188) in two tertiary hospitals in the United Arab Emirates Characteristic No. % (95% CI) Sex Male 122 65 (58–72) Female 66 35 (28–42) Age distribution (years) ≤ 39 41 22 (16–29) 40–49 48 26 (20–33) 50–59 59 32 (25–39) 60+ 38 20 (15–27) No. of medications taken daily 1–3 62 34 (27–41) 4–6 82 44 (37–52) 7–9 18 10 (6–15) > 9 22 12 (8–18) Time of organ transplanta < 1 year ago 8 4 (2–8) ≥ 1 year ago 29 16 (11–22) Only dialysis 149 80 (74–86) Education level Secondary school 46 29 (22–36) Vocational training 20 12 (8–19) Sixth form 0 0 (0–2) College 29 18 (12–25) University 53 33 (26–41) Postgraduate 13 8 (4–13) Some data are missing for most questions. CI = confidence interval. Book 19-4.indb 375 5/12/2013 2:19:41 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 376 form) patients who responded to the same question, only 45% were aware  of the practice. Furthermore, from the 95 highly educated renal patients  who responded  to  the question, 39%  said that they would accept generic substitution of the drug, while from the 62  less educated patients who re- sponded to the same question, only 18% confirmed that they would accept  the substitution (Table 3). Patients were asked to rate their satisfaction with generic drugs. From a  total of 36 highly  educated patients  who answered this question, almost half [47% (95% CI: 30–65)] stated that  they were very satisfied, while from a total of 26  less-educated patients who  answered  the  same  question,  only  6  [23% (95% CI: 9–44)]  said  that  they  were very satisfied. Table 2 Renal patients’ (n = 188) general knowledge of generic medicines and substitution Question Response No. % (95% CI) Were you aware that there are different forms of the same medicine available, produced by different manufacturers? (nr = 185) Yes 130 70 (63–77) No 32 17 (12–24) Uncertain 23 13 (8–18) Do you understand the terms “generic” and “branded” in relation to medicines? (nr = 185) Yes 111 60 (53–67) No 61 33 (26–40) Uncertain 13 7 (4–12) Are you aware of the generic substitution practice? (nr = 185) Yes 119 64 (57–71) No 18 10 (6–15) Uncertain 48 26 (20–33) Are you currently taking any generic prescription medications? (nr = 183) Yes 52 29 (22–36) No 72 39 (32–47) Uncertain 59 32 (26–40) Were you aware that a generic form of ciclosporin is available in most of the hospitals abroad? (nr = 138) Yes 21 15 (10–22) No 110 80 (72–86) Uncertain 7 5 (2–10) Would you agree to switch your current branded ciclosporin to a generic form to save the local health authority money? (nr = 178) Agree 51 29 (22–36) Disagree 84 47 (40–55) Uncertain 43 24 (18–31) Do you think that generic medicines are equivalent and have the same quality as the branded medicines? (nr = 182) Yes, always 59 33 (26–40) No, never 53 29 (23–36) Yes, sometimes 4 2 (0–6) Uncertain 66 36 (29–44) nr = total number of patients responding to the question. CI = confidence interval. Table 3 Relationship between education level and renal patients’ awareness of and attitude to generic substitution Question Choice Highly educated patientsa (n = 93) Less-educated patientsb (n = 64) No. % 95% CI No. % 95% CI Are you aware of the practice of generic substitution? Yes 78 84 75–91 29 45 33–58 No 5 5 2–12 7 11 5–21 Not sure 10 11 5–19 28 44 31–57 Would you agree to switch your current branded ciclosporin?c Yes 36 39 30–65 11 18 9–44 No 32 35 29–50 37 60 46–72 Uncertain 24 26 17–36 14 23 13–35 aGraduated from college, university or postgraduate. bGraduated from secondary school, vocational training or sixth form. cn = 92 for educated patients and 62 for less-educated patients. CI = confidence interval. Book 19-4.indb 376 5/12/2013 2:19:41 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 377 Attitudes towards generic medicines and substitution Most of  the patients  [66% (95% CI:  53–77)] who had ever received generic  medicines were dissatisfied or uncertain about their satisfaction concerning the generic alternative (Table 4). Only 33% (95% CI: 26–41)  felt  that being  prescribed generic medicines would not affect their adherence to the medication regime. Severity of disease also influenced patients’ acceptance of generic substitu- tion:  92 of  the 183 participants who  responded to this question stated that they would accept generic substitution if they had mild disease compared to only 43/181  [24% (95% CI: 18–31)  who would still do so if they had a chronic disease. Influence of professionals on patients’ acceptance of generic medicines and substitution We found that 17% (95% CI: 11–22)  of  175  respondents  stated  that  their  doctor had changed their medicine to a generic  form (Table 5). The major- ity  of  these  patients  [87%  (95% CI:  79–93)], however,  said  that  they were  either not monitored or were uncertain about being monitored after switching their medicine to generic. Moreover, 54% (95% CI:    44–64) declared  that  no background information regarding generics and substitution was provided. According  to 26% (95% CI:  20–34)  of patients, pharmacist was the main source of information regarding generic substitution. Of  theses, 74% (95% CI:  64–84)  admitted  that most  informa- tion was given verbally. The reasons for switching their medicines were not dis- cussed at all with 33% (95% CI: 24–43).  The vast majority of our participants (88%; 95% CI: 83–92) wished  to be  always notified when their medicines were  switched  (Table 5). More  than  half  (59%; 95% CI: 51–66), believed  that they should be consulted by hos- pital specialists or by both the general Table 4 Renal patients’ (n = 188) attitudes towards generic medicine and substitution Question Response No. % 95% CI Which of the following do you think may be the potential reason for switching your medicine to the generic form? (nr =153) Save the Ministry of Health money 56 37 29–45 Generics are more effective 8 5 2–10 Generics have the same effectiveness and less costs 43 28 21–36 The branded medicine was not available 45 29 22–37 Other 1 1 0–4 Do you think that receiving a generic medicine might affect how regularly you take your medicines? (nr =174) Yes 48 28 21–35 No 58 33 26–41 Uncertain 68 39 32–47 How satisfied are you with the generic alternative that you are taking?a (nr = 70) Very satisfied 24 34 23–47 Dissatisfied 20 29 18–41 Neither satisfied nor dissatisfied 26 37 26–50 Have you experienced any differences in terms of effectiveness or side-effects between branded and generic medicines?a (nr = 72) Yes 32 44 33–57 No 31 43 31–55 Uncertain 9 13 6–22 Do you think adapting to these differences was a concern? (nr = 52b) Yes 24 46 32–61 No 10 19 10–33 Uncertain 18 35 22–49 What differences between the branded and generic medicines have you experienced or heard of? (nr = 107) Packaging 26 24 17–34 Shape, colour or taste 22 20 13–29 Brand was more effective 31 29 21–39 Generic was more effective 3 3 0–8 Brand had more side-effects 2 2 0–7 Generic had more side-effects 22 21 13–29 Other 1 1 0–5 nr = total number of patients responding to the question. aNumber of patients on generic medicines = 81. bOut of the 72 who experienced differences. CI = confidence interval. Book 19-4.indb 377 5/12/2013 2:19:42 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 378 Table 5 Evaluation by renal patients (n = 188) of the role of healthcare professionals in their acceptance of generic substitution Question Response No. % (95% CI) In general, how far do you feel your doctor involves you in decisions regarding your medications? (nr = 175) A lot 82 47 (39–54) A bit 71 41 (33–48) Not at all 18 10 (6–16) Uncertain 4 2 (0–6) Has your doctor ever told you to make sure that you always receive the same brand of any medicine? (nr = 175) Yes 29 17 (11–23) No 142 81 (75–87) Uncertain 4 2 (0–6) Would you agree to switch your medicine to a generic alternative if your doctor felt that the 2 medicines were interchangeable? (nr = 104) Agree 74 71 (61–80) Disagree 17 16 (10–25) Uncertain 13 13 (7–20) How much would you favour or oppose a requirement that patients always be notified if their medicine is changed to a generic form? (nr = 178) Favour 156 88 (82–92) Oppose 12 7 (4–11) Neither favour nor oppose 10 5 (3–10) Do you think that you should be consulted about being given generic medicines? (nr= 188) Yes, by general practitioner 26 14 (9–20) Yes, by hospital specialist 56 30 (23–37) Agreement of both general practitioner and hospital specialist 54 29 (23–36) Do not think that this is necessary 52 27 (21–34) Has your doctor ever changed your medicine to a generic form? (nr= 175) Yes 29 17 (11–22) No 142 81 (75–87) Uncertain 4 2 (0–6) Did your doctor monitor the effect of your medicine after switching you to a generic medicine? (nr = 106) Yes 14 13 (7–21) No 50 47 (37–57) Uncertain 42 40 (30–50) Did anyone provide you with background information about your generic medicine? (nr = 105) Yes 40 38 (29–48) No 57 54 (44–64) Uncertain 8 8 (3–14) Who provided you with background information? (nr = 168) Specialist 38 23 (17–30) Hospital doctor 39 23 (17–30) General practitioner 39 23 (17–30) Pharmacist 44 26 (20–34) Nurse 6 4 (1–8) Other 2 1 (0–4) Did you consider the information provided about your generic medicine sufficient? (nr = 63) Yes 30 48 (35–61) No 12 19 (10–31) Uncertain 21 33 (22–46) Did anyone discuss the reasons for switching your medicine to the generic form? (nr = 100) Yes 65 65 (55–74) No 33 33 (24–43) Uncertain 2 2 (0–7) Who discussed the reasons for switching your medicine to the generic form? Choose all applicable (nr = 194) Specialist 51 27 (20–33) Hospital doctor 45 23 (17–30) General practitioner 41 21 (16–28) Pharmacist 9 25 (19–32) Nurse 8 4 (2–8) Other 0 0 (0–2) nr = total number of patients responding to the question. CI = confidence interval. Book 19-4.indb 378 5/12/2013 2:19:42 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 379 Table 6 The influence of healthcare professionals on renal patients’ (n = 188) acceptance of generic substitution Question Response Yes No Uncertain No. % (95% CI) No. % (95% CI) No. % (95% CI) With which healthcare professional would you be likely to accept generic substitution? Hospital consultant/doctor (nr = 179) 124 69 (62–76) 46 26 (19–33) 9 5 (2–9) General practitioner (nr = 168) 61 36 (29–44) 94 56 (48–64) 13 8 (4–13) Pharmacist (nr = 164) 56 34 (27–42) 97 59 (51–67) 11 7 (3–12) Nurse (nr = 156) 25 16 (11–23) 123 79 (72–85) 8 5 (2–10) nr = total number of patients responding to the question. CI = confidence interval. practitioner and the hospital specialist before having their medicine switched. Nevertheless,  69% (95% CI: 63–76)  of respondents stated that they would be more likely to accept generic sub- stitution if it was initiated by a hospital consultant/hospital doctor (Table 6). Discussion Many of our participants were familiar with the availability of different for- mulations of the same medicine and understood the term generic versus branded medications. In addition, many patients were able to define the generic substitution practice. However, many did not know whether if their medicine was substituted to a generic or if they were currently on generic medicines. Several were not convinced about generic medicines and substitution. These attitudes were mainly found in patients with less education, those not involved in their healthcare decisions and those who believed that substitu- tion was mostly performed because of a shortage in the healthcare budget or in the availability of the branded medicine. These attitudes might also be related to the belief that the cheaper medicine must be inferior to the more expensive branded medicines [23].  It is clear in this study that there are factors affecting patients’ decisions concerning their health. Those include education level, knowledge and the severity of disease. Highly educated pa- tients were more knowledgeable about the practice of substitution and were therefore more accepting of generic substitution of ciclosporin than those with a lower level of education. How- ever, there were still some highly edu- cated patients who were unsure about the efficiency of generic medicine and substitution. These patients were not as- sured by their healthcare professionals about the safety and the effectiveness of the drug substitution. Undoubtedly, the effort and time spent by healthcare professionals in monitoring patients after switching their medicine is very important to assure adherence. Most of the renal pa- tients in this survey favoured always be- ing notified when their medicines are switched;  this might positively  affect  their acceptance of drug substitution. Many others would agree to accept ge- neric substitution if they were informed clearly. This is supported by the results of a similar study on renal patients in the UK [22]. This indicates a need for  educating patients and for clarifying the reasons for generic substitution and the roles of healthcare professionals in successfully introducing this practice. Patients also reported that most information was given to them orally by pharmacists. It has been recommended that patients should be given informa- tion in written form to allow reviewing and remembering the complex medical information  whenever  needed  [24].  However, a survey evaluating the level of interaction between physicians and community pharmacists in the UAE showed that 60% of physicians rarely or  never discussed patients’ drug therapy with pharmacists [25].  The guidelines for approving bio- equivalency of generic medicines in the UAE are mostly based on the guidelines of the World Health Organization, the European Medicines Agency, the Food and Drug Administration in the USA, and the International Confer- ence on Harmonization. For example, to approve interchangeability between 2 medicines,  they  should be demon- strated as therapeutically equivalent to one another through bioequivalence studies, comparative clinical trials and/ or in vitro dissolution tests [26].  Our findings are comparable with those in the other studies. Although there are few published articles evaluat- ing patients’ views on generic substi- tution in the UAE, some have shown that drug substitution can be problem- atic  [23,27]. Small differences  in  some  particular drugs during manufacturing could theoretically result in significant adverse effects or loss of efficacy [7,28].  A large number of studies have been conducted to evaluate the potential effect of generic substitution on the clinical outcome. Some of these have concluded that generic substitution had unexpected and negative effects [29,30].  A number of studies have shown dif- ferences in the pharmacokinetic profile Book 19-4.indb 379 5/12/2013 2:19:42 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 380 References 1. Bloor K, Maynard A, Freemantle N. Lessons from interna- tional experience in controlling pharmaceutical expenditure. III: Regulating industry. BMJ (Clinical Research Ed.), 1996. 313(7048):33–35. 2. [The medicinal consumption in the UAE has reached four bil- lion Dirhams in 2010.] Alittihad (online newspaper), March 5th, 2011 [in Arabic]. 3. Andersson K et al.What are the obstacles to generic substitu- tion? An assessment of the behaviour of prescribers, patients and pharmacies during the first year of generic substitution in Sweden. Pharmacoepidemiology and Drug Safety, 2005, 14(5):341–348. 4. Tilson L, Bennett K, Barry M. The potential impact of imple- menting a system of generic substitution on the community drug schemes in Ireland. European Journal of Health Econom- ics, 2005, 6(3):267–273. 5. A b u D h a b i m o v e s t o w a r d s g e n e r i c p r e s c r i b - i n g . D a t a m o n i t o r , 2 0 A p r i l 2 0 0 9 ( h t t p : / / w w w . datamonitor.com/store/News/abu_dhabi_moves_towards_ generic_prescribing?productid=0F02EAF3-3EAB-4C7C-87F6- 8530E731DA65, accessed 14 Jan 2013). 6. Himmel W et al. What do primary care patients think about generic drugs? International Journal of Clinical Pharmacology and Therapeutics, 2005, 43(10):472–479. 7. Garattini S, Bertelé V. Non-inferiority trials are unethical because they disregard patients’ interests. Lancet, 2007, 370(9602):1875–1877. 8. Duerden MG, Hughes DA. Generic and therapeutic substitu- tions in the UK: are they a good thing? British Journal of Clinical Pharmacology, 2010, 70(3):335–341. 9. Chow S-C. Individual bioequivalence—a review of the FDA Draft Guidance. Drug Information Journal, 1999, 33:435–444. 10. AlAmeri M, Epstein M, Johnston A. Generic and therapeutic substitutions: are they always ethical in their own terms? Phar- macy World & Science, 2010, 32(6):691–695. 11. Christians U, Klawitter J, Clavijo CF. Bioequivalence testing of immunosuppressants: concepts and misconceptions. Kidney International, 2010, 77(115 Suppl.):S1–S7. 12. Generic substitution terminated for oral medicines containing cyclosporine or tacrolimus. Sundhedsstyrelsen, July 13th 2011, Danish Health and Medicines Authority (http://laegemid- delstyrelsen.dk/en/topics/authorisation-and-supervision/ licensing-of-medicines/news/generic-substitution-terminat- ed-for-oral--tacrolimus, accessed 21 January 2013). 13. Prescriptions dispensed in the community: statistics for 1996 to 2006. London, NHS National Statistics, The NHS Informa- tion Centre (Health Care) (Bulletin: IC 2007 11. 11). 14. Dombrowski C. UK drug pricing scheme to allow generic sub- stitution, promote innovation. EuroPharma Today, November 24, 2008 (http://www.europharmatoday.com/2008/11/uk- drug-pricing-scheme-to-allow-generic-substitution-promote- innovation.html, accessed 21 january 2013). 15. Helderman JH et al. Healthcare costs in renal transplant recipi- ents using branded versus generic ciclosporin. Applied Health Economics and Health Policy, 2010, 8(1):61–68. 16. Kingma I et al. Economic analysis of Neoral in de novo renal transplant patients in Canada. Clinical Transplantation, 1997, 11(1):42–48. 17. Cox DC et al. Guidelines for dissolution testing. Pharmaceuti- cal Technology, 1978, 2(4):40–53. 18. Kamerow D. The pros and cons of generic drugs. BMJ, 2011, 343:d4584. 19. Bioequivalence and labelling of medicinal products with regard to generic substitution. Sundhedsstyrelsen, July of branded and generic drugs that might affect clinical outcomes [31–34]. Some  have also indicated that healthcare costs were higher for patients receiving gener- ic versus branded medicine. One study revealed that total healthcare costs were significantly higher for patients receiv- ing generic ciclosporin A compared to the branded  form [15]. Another  study  reported that patients treated with the branded ciclosporin A had lower overall healthcare costs [16].  This study had a number of limi- tations. Attitudes toward generic sub- stitution were mainly assessed from the patients’ viewpoint and not that of healthcare professionals. The survey was  completed  in only 2 hospitals  in  the United Arab Emirates, the results cannot, therefore, be generalised to the whole country or region. There were missing responses to many of the questions asked and this will have an effect on the results; there- fore, these results have to be considered with caution. Conclusion Many patients were sceptical of accept- ing generic medicines and substitu- tions. Some considered cheaper drugs as being less effective and associated with increased adverse events. This can negatively affect patients’ adherence to a medication regime. In addition, the regulations surrounding generic bio- equivalence and substitution should be strengthened to maintain high quality of care. We believe that random generic substitution should not be implemented because there is uncertainty and lack of knowledge on the patients’ side. Proper patient education and monitoring and involving patients in decision regarding their health may improve transparency around the practice of generic substitu- tion, enhance patients’ assurance and promote efficient prescribing. Acknowledgements The authors are grateful to all the pharmacists and renal dialysis staff in both the UAE General Hospital and the UAE University Hospital for recruit- ing patients to participate in this study. We are also thankful to all participating patients and to the government of the United Arab Emirates for supporting and encouraging independent research. Funding: This survey was funded by the William Harvey Research Institute at Queen Mary University of London. M. Al Ameri was supported by the Gov- ernment of the United Arab Emirates, Abu Dhabi. Competing interests: None declared. Book 19-4.indb 380 5/12/2013 2:19:42 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 381 13th 2011, Danish Health and Medicines Authority (http:// www.dkma.dk/en/topics/authorisation-and-supervision/ licensing-of-medicines/marketing-authorisation/application- for-marketing-authorisation/bioequivalence-and-labelling- of-medicine--bstitution, accessed 21 january 2013). 20. Frank RG. The ongoing regulation of generic drugs. New Eng- land Journal of Medicine, 2007, 357(20):1993–1996. 21. Kozlowski S et al. Developing the nation’s biosimilars pro- gram. New England Journal of Medicine, 2011, 365(5):385–388. 22. Al Ameri MN et al. A survey to determine the views of renal transplant patients on generic substitution in the UK. Trans- plant International, 2011, 24(8):770–779. 23. Meredith P. Bioequivalence and other unresolved issues in generic drug substitution. Clinical Therapeutics, 2003, 25(11):2875–2890. 24. Weinman J. Providing written information for patients: psy- chological considerations. Journal of the Royal Society of Medicine, 1990, 83:303–305. 25. AbduelkaremAR, SharifSI. Current levels of interaction be- tween the physician and pharmacist: a comparative study in Libya and UAE. Jordan Journal of Pharmaceutical Sciences, 2008, 1(2):142–151. 26. UAE Guidelines of Bioequivalence Testing for Generic Phar- maceutical Products 2001. Dubai, United Arab Emirates, Ministry of Health, 2011 (http://www.cpd-pharma.ae/index. php?option=com_phocadownload&view=category&id=2&Ite mid=78&limitstart=20, accessed 21 January 2013). 27. Simoens S. Generic and therapeutic substitution: ethics meets health economics. International Journal of Clinical Pharmacol- ogy, Therapy and Toxicology, 2011, 33(3):469–470. 28. Masri M. The generics in transplantation and the rules on their use. Experimental and Clinical Transplantation, 2003, 1(1):65–68. 29. Berg MJ et al. Generic substitution in the treatment of epilepsy: case evidence of breakthrough seizures. Neurology, 2008, 71(7):525–530. 30. Richton-Hewett S, Foster E, Apstein CS. Medical and eco- nomic consequences of a blinded oral anticoagulant brand change at a municipal hospital. Archives of Internal Medicine, 1988, 148(4):806–808. 31. Kovarik JM et al. Differentiation of innovator versus generic cyclosporine via a drug interaction on sirolimus. European Journal of Clinical Pharmacology, 2006, 62(5):361–366. 32. Qazi YA et al. The clinical impact of 1:1 conversion from Neoral to a generic cyclosporine (Gengraf) in renal transplant recipi- ents with stable graft function. Clinical Transplantation, 2006, 20(3):313–317. 33. Taber DJ et al. Does bioequivalence between modified cyclo- sporine formulations translate into equal outcomes? Trans- plantation, 2005, 80(11):1633–1635. 34. Approved drug products with therapeutic equivalence evalu- ations (Orange book). Silver Springs, Maryland, US Food and Drug Administration, 2009. Book 19-4.indb 381 5/12/2013 2:19:42 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 382 Review Demographics and the social reckoning in the Arab region N.M. Kronfol 1 ABSTRACT Demographic transitions in the Arab countries, due to declining birth rates and mortality rates since the 1980s, are reflected in a low proportion of children, a relatively stable proportion of elderly and a high proportion of people of working age. This “youth bulge” of young, active, working-age individuals in the current population may open a demographic window for countries to benefit from increased savings and investment. This paper reviews the demographic situation in the Arab region and the impact of education, employment, migration, health status and participation in society on the further development of the region, including the impact of these factors on ageing and gender issues. The intent is to draw attention to the importance of these demographic changes and highlight the need for action to maximize the potential benefit to the population in this region. 1Lebanese Health Care Management Association, Beirut, Lebanon (Correspondence to N.M. Kronfol: dino@cyberia.net.lb). Received: 03/11/12; accepted: 11/03/12 ةيبرعلا نادلبلا في ةيعماتجلاا تارابتعلااو ةيفارغوميدلا تماسلا لفنرق ليبن ةبسنلا ضافخناب ّلىجتت ،تانينماثلا ذنم تايفولاو تادلاولا تلادعم صقانت ببسبو ،ةيبرعلا نادلبلا في ةيفارغوميدلا تلاوحتلا نإ :ةـصلالخا صاخشلأل "بيابشلا مخضتلا" اذه حتفي دقو ؛لمعلا نس في مه نلم ةعفترم ةيوئم ةبسنو ،خويشلا في ًايبسن ةرقتسم ةيوئم ةبسنبو ،لافطلأل ةيوئلما هذه ضرعتستو .رماثتسلااو يرفوتلا غلابم دايدزا نم ةدافتسلاا لجأ نم نادلبلل ةيفارغوميد ةذفان ينيلالحا ناكسلا ينب لمعلا نس في ينلاّعفلا نايتفلا في ريوطتلا نم ديزلما في يعمتجلما لمعلا في ماهسلإاو ةيحصلا ةلالحاو ةرجلهاو فيظوتلاو ميلعتلا يرثأتو ةيبرعلا ةقطنلما في فيارغوميدلا عضولا ةقرولا ،ةيفارغوميدلا تايرغتلا هذه ةيهمأ لىإ هابتنلاا بلج وه ةساردلا هذه نم دصقلاو .ردنلجاو ةخوخيشلا اياضق لىع لماوعلا هذه رثأ كلذ في ماب ،ميلقلإا .ميلقلإا ناكسل ةبسنلاب دح صىقأ لىإ ةلمتحلما دئاوفلا ةدايز لجأ نم لمعلا لىإ ةجالحا حيضوتو Démographie et reconnaissance sociale dans la Région arabe RÉSUMÉ Les transitions démographiques dans les pays arabes, en raison de la baisse des taux de natalité et de mortalité depuis les années 1980, se traduisent par une proportion plus faible d'enfants, une proportion relativement stable de la population âgée et une proportion élevée de personnes en âge de travailler. Cet excédent démographique de personnes jeunes, actives, en âge de travailler dans la population actuelle pourrait permettre aux pays de profiter d'une hausse de l'épargne et de l'investissement. Le présent article examine la situation démographique dans la Région arabe et l'impact du niveau d'études, de l'emploi, de la migration, de l'état de santé et de la participation dans la société sur le développement à venir de la Région, notamment l'impact de ces facteurs sur le vieillissement de la population et les questions liées aux spécificités homme- femme. L'objectif est d'attirer l'attention sur l'importance de ces changements démographiques et de souligner la nécessité d'intervenir afin de maximiser les bénéfices potentiels pour la population dans cette Région. Book 19-4.indb 382 5/12/2013 2:19:43 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 383 Introduction Understanding the effect of population change on economic growth and devel- opment is taking on added importance in the Arab region. Demographic transi- tion produces a “boom” generation that may provide an opportunity to unleash an economic growth spurt [1]. Because birth rates in Arab countries remained high until the 1980s and then declined  sharply, the proportion of young, active, working-age individuals in the current population is exceptionally large. Young people entering the labour market to- day do not have to mortgage the future benefits of their work to support either numerous children (as happened in the recent past) or the elderly (as will occur in the near future). The United Nations Population Division has defined the demographic dividend as the period when the proportion of children aged < 15 year falls below 30% and the propor- tion of old people 65+ years is still below  15% [2]. This  situation,  favourable  to  savings and investment, can theoreti- cally yield a dividend, a “demographic gift”, for the entire population. To seize this opportunity, critical policy areas need to be addressed. Policy-makers must plan for the future health care and pension income needs of this baby- boom generation when it ages. This is a review of the demographic situation in the Arab region and the impact of education, employment, mi- gration, health status and participation in society on the further development of the region, including the impact of these factors on ageing and gender issues. This review draws on published reports and studies by individual researchers and those in international organizations. No new data or findings are presented. The intent is to draw attention to the impor- tance of these demographic changes and highlight the need for action to maximize the potential benefit to the population in this region. Demography The population of the Arab countries has increased between 1980 and 2010,  rising  from 170 million  (3.8% of  the  total world population) to roughly 366  million in 2010 (about 6% of the world  population) [2]. The rate of expansion  has been most dramatic in the Gulf Cooperation Council (GCC) states, where the number of residents has increased nearly 7-fold since 1960 [3]  due to the region’s unique migration patterns and high fertility rates [4]. The annual population growth in the Middle East and North Africa reached a peak of 3%  in around 1980  (2%  in  the world) but  is predicted  to  decline to 2.0% (1.2% in the world [5])  between  2000  and  2020.  In  spite  of  this reduction, the population of the Arab countries is expected to continue to grow for several more decades. The Arab countries are therefore experienc- ing an unprecedented “youth bulge” with over 30% of the population now in  the age group 15–29 years, representing  over 100 million people [6]. Most Arab  countries have also experienced large growths in their urban populations (Table 1), as people from rural areas gravitated towards urban employment. Definition of youth The United Nations defines youth as the  age  range 15–24  years,  although  others have defined this differently, in- cluding a range as wide as 10–35 years  [7]. Youth  is  a  very  important phase  in the human life cycle. Economically, youth are in transition from economic dependency to economic productiv- ity. In terms of family formation, youth are often at the stage of identifying a partner for marriage, childbearing and establishment of an autonomous family. Mostly, youth is the stage of personality formation and self-realization. Despite major improvements in health and education over recent decades, and despite a wealth of oil re- sources, the “[Middle East and North Africa’s] political, social, and economic systems have not evolved in a way that effectively meets the changing needs of its rapidly growing young population, especially employment” [6]. The extent  to which this large group of young peo- ple will become productive members of their societies depends on how well governments and civil societies invest in the social, economic and political institutions that meet the current needs of young people. Political participa- tion and civic engagement are other Table 1 Distribution of university graduates in different regions of the world by field of study Field of study Middle East graduatesa Asian graduatesb Latin American graduatesc Education and Humanities 37 20 9 Social Sciences 31 34 39 Medicine 6 6 11 Scientific, Technical and Engineering 18 31 24 Other 8 10 9 aRepresented by Algeria, Egypt, Islamic Republic of Iran, Jordan, Morocco, Oman, Saudi Arabia, Palestine; bRepresented by China, Indonesia, Korea, Malaysia, The Philippines, Thailand; cRepresented by Argentina, Bolivia, Brazil, Chile, Columbia, Mexico, Peru. Source: World Bank [14]. Book 19-4.indb 383 5/12/2013 2:19:43 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 384 • Jordan, Syrian Arab Republic, Egypt will reach replacement level between 2030–2040. • Comoros, Djibouti, Sudan, Somalia, Iraq, Oman, Palestine, Mauritania, Yemen will reach replacement level after 2040. However,  until  at  least  2030,  the  generation reaching working age will be much larger than that reaching retire- ment age. Therefore, the size of the total working-age population will continue to rise steeply during the next 2 decades. Ageing and the older population Along with the demographic changes noted above, the Arab region will wit- ness the gradual (and fast) increase of its older population (aged 65+ years).  Whereas the proportion of older people is  still  in  the  range of 1%–4%  in most  countries of the region, Lebanon and Tunisia already report that the old con- stitute more than 7% of their respective  population  [9,10]. Therefore  govern- ments ought to plan for the needs of the older population, including better access to health care, social protection and pension plans especially for older women. Legislation for pension reforms have already been enacted in several Arab states. Much of the care required by the elderly in the Arab region is cur- rently provided by family caregivers. However, this is likely to change as due to social trends and population migra- tion an increasing share of older people are likely to be living apart from their families. Providing social and health care for the elderly will be a major chal- lenge in the region in years to come. Education Education is a fundamental human right. Over  the  last  2  decades,  Arab  countries have achieved remarkable progress in educational indicators. The average rate of inclusion in primary education has increased to 80.6%, while  the proportion of literate young people between 15–24 years of age has reached  83.4%. Moreover,  the gender parity  in- dex  for  literacy became 0.92  in 2005.  The region’s investment in female edu- cation in the past few decades has been impressive and most countries have nearly closed the gender gap on youth literacy [11]. However, despite this progress, the goal of universal education has not been achieved [12], nor has the  standard of achievement been uniform across subregions and countries in the Arab region. Participation in secondary and university education still needs to be improved  in  the Arab countries  [13].  Higher education tends to focus on academic disciplines that are often in- compatible with the needs of the labour market. The percentage of students enrolled in scientific disciplines such as natural sciences does not exceed 30% of  overall university enrolment  [6]. Arab  youth may find themselves having to re- consider their acquired skills, and make efforts to acquire new skills, especially in information and communications technology. Moreover, the region is still unable to bridge the educational gaps between rich and poor and between urban and rural areas, especially for women. Poverty, early marriage, lack of female teachers and girls’ schools and general security conditions and civic strife are the major impediments. Education in the Arab region suffers quantitative and qualitative deficiencies. The sector suffers from deficiencies in the curriculum and educational infra- structure, especially in public schools. Despite the increase in private universi- ties over the last decade, there are indi- cations that educational opportunities (when available), are often of low qual- ity due to overcrowding of classrooms, poor infrastructure, lack of teaching materials and a shortage of teachers and well-trained staff [14]. Access to uni- versity is highly dependent on passing important means of providing the youth populations in the region with the tools they need to build successful futures. Civil society organizations can play an important role in this domain. Fertility Although the mortality rate in the countries of the Arab region began to decline in the late 19th and early 20th  centuries,  the decline  in  fertil- ity (births per woman) did not start until the 1970s. On average, fertility in  the Arab countries has declined from 7 children per woman around 1960  to  3.6  in  2000  [8]. Coupled with  a  significant decline in child mortality, this led to an increase in the proportion of children under 15 years,  and  then  to an increase in the proportion of young people aged 15–24 years. The  youth bulge is more pronounced in countries where the onset of fertility decline occurred later and the decline was steeper. During  the 1980s, policy-makers  attempted to curb runaway popula- tion growth by encouraging birth con- trol and promoting family planning programmes which were effective in stabilizing, and even decreasing, the fertility rate. This decline in fertility is attributable to a variety of correlated factors including better levels of edu- cation, particularly among women, women’s relatively higher participation in the labour force, later marriages and increased contraceptive prevalence rates  [2]. The decline  in  fertility  rates  in the Arab countries is predicted to continue in the coming decades, yet with variable speed from one country to another: • Tunisia, Lebanon, Bahrain, Algeria, United Arab Emirates, Kuwait have reached or will reach replacement level (i.e. total fertility rate of 2.1 chil- dren/woman) before 2020. • Libya, Qatar, Morocco will reach re- placement level between 2020–2030. Book 19-4.indb 384 5/12/2013 2:19:43 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 385 national tests which are designed pri- marily to measure the acquisition of facts and knowledge through rote learn- ing rather than critical and independent thinking. Women continue to enrol in fields that are traditionally considered to be appropriate for women, such as education, humanities and the arts. Work and employment Employment is an important phase in the life cycle of youth, enabling them to achieve economic independence and the transition from dependence on family to self-reliance. Providing decent work opportunities for young people requires coherent social, economic and population policies. Tapping the full potential of youth is one of the most critical economic development chal- lenges facing the Middle East in the 21st century. The  time  spent between  the end of education and obtaining their first job is often measured in years rather than months. A large major- ity of youth continue to live with their parents until well  into  their  20s. The  combination of demographic pressures and social norms has creates what has been dubbed “waithood”—the long phase in which a large proportion of Middle Eastern youth spend waiting for employment and marriage [15]. Although unemployment rates vary from one country to another, on aver- age more than 25% of youth in the Arab  region are unemployed, the highest rate in the world. Youth unemployment in 2006 was  reported  to be 6.3%  in  the  United Arab Emirates,  15.7%  in Mo- rocco, 17.0% in Qatar, 18.7% in Yemen,  19.7%  in Oman,  21.3%  in  Lebanon,  25.8%  in Egypt  and 38.9%  in  Jordan  [16]. This is likely to worsen; according  to a World Bank report, the labour force of the Middle East and North Africa is expected  to  increase by 40% between  2000  and  2010,  and  by  nearly  80%  between 2000 and 2020  [17]. Youth  unemployment rates are especially high in countries that suffer from occupation and conflict; in Iraq the unemployment  rate among young people was estimated at 27% in 2004 and 17.5% in 2006; and  in Palestine at approximately 29.8%  in  2006 and 28% in 2008 [17,18]. Arab women still face barriers to em- ployment. While women’s participation in the labour force in the region reached 32% in 2006,  it  remained the  lowest  in  the world (the world average was 58%);  men’s labour force participation, on the other hand, is comparable to other regions of the world. There are great variations within the region in terms of women’s participation in the economy and the extent to which it has changed and the recent drop in birth rates and the expanded education opportunities for women [19] mean that women are becoming more likely to delay marriage and join the workforce instead. It is also worth noting that the actual rates may also be substantially higher as many women work in the informal sector. Care work is neither valued as a contribution to development, nor distributed equally, and limits the opportunities available to women to pursue education and engage in income-generating employment. Women in Arab countries work predominantly in the public sector (mostly in the education and health sectors); 49% of women’s employment  is  in  services,  compared with 39%  in  agriculture  and 12%  in  industry  [20].  There are several reasons for the failure of private firms in the Arab region to employ young women, including la- bour markets highly segregated along gender  lines;  employers  unwilling  to  assume the added cost of maternity leave and child care; women’s  limited  geographic mobility;  and  the  lack of  labour-intensive, export-oriented in- dustries that might otherwise employ women [21]. Nevertheless, the propor- tion of women who are wage and sala- ried workers has increased substantially [20]. This  increased  female economic  activity is due mainly to higher levels of education and a rise in the average age for marriage. More women  in  the 30+  years age group remain in the labour market, even after they are married and have children. This trend suggests that one income no longer suffices for the changing needs of the family and that attitudes toward women’s work outside the home are slowly changing. Promoting women’s entrepreneur- ship is an effective way to address female unemployment and to help enhance women’s economic empowerment. A re- cent study showed that women account for only 13% of company owners in the  Middle East region, compared with 24%  in Europe [19]. Women-owned firms are more likely to hire women. An issue that also deserves more attention is dis- couragement; when a person feels that a  job search is a futile effort. It is very likely that discouragement among women is higher than among men. Unemployment in Arab countries is concentrated among secondary-school and university graduates, rather than primary-school graduates and the illiter- ate (World Bank) [22]. This  situation  is caused by the gap between labour market requirements and educational outputs. University students are the fastest-growing group among new entrants to the labour market and the group most dependent on government employment, which is not growing fast besought or may even be shrinking [23]. Even for the most educated work- ers, a World Bank analysis suggests that the private sector in the Middle East and North Africa rewards education less than the public sector [17]. Added to the existing problems of youth unemployment, the workforce is expanding at  a  rate more  than 3% per  year, which means that the region will re- quire the creation of 100 million jobs in  the next 20 years. The Arab region needs  6%–7% sustained economic growth  in  order to keep up with its growing popu- lation. In a recent report, the director general of the Arab Labour Organiza- tion noted that Arab countries will need to  spend US$ 85 billion over  the next  Book 19-4.indb 385 5/12/2013 2:19:43 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 386 10 years in order to create new jobs and  address an unemployment crisis [24]. Governments in the region have not focused their education policies on how to ensure that the region’s young people have the right skills for the jobs being created. There is even less focus on how to encourage the private sector to play a role in addressing the region’s pressing employment needs. Surveys of private employers in the region report that only one-third of new graduate employees are ready for the workplace when hired (Table 2) [25]. Despite these challenges,  the United Nations Development Pro- gramme concludes that education has boosted human capital in the region [26]. The oil-rich,  labour-receiving Gulf  countries are faced with the additional challenge of addressing the employment balance between their national and non- national work force. A rapidly growing number of young nationals are entering the labour force at a time when their gov- ernments are no longer able to guarantee lifetime employment in the public sector, on which citizens have customarily re- lied. Nearly all of the Gulf states are now instituting policies that push the private sector to hire more nationals. The social and political turmoil in the region has given renewed urgency to the need to counter chronic joblessness, particularly  among young people  [27].  In its report, Unlocking the employment po- tential in the Middle East and North Africa: toward a new social contract, the World Bank argues that countries of the region must adopt new development policies that realign their economies [17]. Migration Statistics on international migra- tion in the Arab region remain scarce. Political instability and armed conflict, along with unemployment and under- employment, have been major push factors behind population movements within and from the region. All Arab countries, except for the GCC countries and Libya, have become both origin and destination countries for migrants. In certain member countries, refugees still form a large proportion of the migrants [28]. Morocco and Egypt have become  unwilling recipients of migrants from elsewhere, even while their own nation- als form a major part of the migrant workforce elsewhere [29]. After  slowing down  in  the 1990s,  emigration from Arab countries re- gained momentum in the early part of  this decade  [6,30]. The 20 million  migrants from Arab countries represent about 5% of  the  region’s  total  popu- lation  [6,30]. The  region  is  home  to  several economies that benefit from or even depend on remittances from abroad, such as Egypt, Jordan, Lebanon, Morocco and Tunisia, as well as coun- tries that are among the largest sources of remittances worldwide, such as Saudi Arabia, the United Arab Emirates, Qatar and Kuwait [31]. Remittances from mi- grant workers to Middle East and North African  countries  reached US$  28.5  billion in 2007 according to the World  Bank  [32]  and  form one of  the  least  volatile sources of foreign exchange earnings for developing countries [33]. Health The health of youth in the Arab re- gion has improved over past decades. Overall death rates have dropped in all Arab countries and are expected to decline more in the next 2 decades [34].  However, youth lifestyles, such as not exercising regularly, fastfood diets and smoking, are exposing them to numer- ous health hazards. There is an increase in the reported incidence of HIV/AIDS [35],  although official  figures may be  underestimates. On the other hand, progress has been made in reproductive health, with the rates of unwanted child- birth and maternal mortality declining among young women, and the number of young people having comprehensive, accurate knowledge of how to avoid sexually transmitted diseases increasing considerably [35]. Fertility rates among  adolescent women (ages 15–19 years)  in  the  region have decreased [15] and  the contraceptive prevalence rate (per- centage of women  ages  15–49  years  using contraceptives) has increased in all Arab countries [19]. There are still many problems to be tackled in women’s health. Women with lower education levels are still marry- ing young and having high numbers of Table 2 Survey of employers in the Arab region: responses to question about whether graduates hired in the last 5 years have appropriate skills Country % of HR managers agreeing University graduates, hard skills University graduates, soft skills Vocational graduates, hard skills Vocational graduates, soft skills Egypt 29 26 16 12 Jordan 22 25 10 16 Morocco 33 28 36 25 Saudi Arabia 51 45 41 38 Yemen 29 26 23 19 Source [25]. Book 19-4.indb 386 5/12/2013 2:19:43 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 387 children, thus reinforcing the cycle of poverty [36]. There are wide urban–ru- ral gaps in women’s access to health ser- vices [36]. Female circumcision remains  high in countries where it is traditionally practised (Djibouti, Sudan, Egypt, and in Yemen), even when the practice is illegal [37]. Violence against women, including  honour killings persists  [38], Honour  killings have not been considered homi- cide and therefore not punished as such. There is also a high prevalence of domes- tic violence and sexual harassment in the Arab region [39]. Participation in public life It is self-evident that youth who have the opportunity to participate in the life of their communities have a better chance of successful transition to adult- hood, as such activities promote social integration. Nevertheless, there are still obstacles to full participation of youth in society especially in the Arab region. A United Nations report showed that Arab youth are not being represented in Arab legislatures or parliaments [40].  Moreover, Arab parliaments do not have separate committees for youth issues;  instead,  these  are  dealt  with  by committees concerned with sport, culture or family affairs. Older people control the process and mechanisms of youth participation in those societies. Young people are averse to political participation as they lack confidence in its procedures and the outcomes [7]. On the other hand, the region has wit- nessed some encouraging developments in the area of women’s public participa- tion and representation, even though the regional average is still the lowest in the world [19]. Some countries have been able to increase female representation in parliament, mainly through the use of quotas and appointments. Women candidates are generally more successful in local and municipal elections. The feminization of poverty in the Arab region is reflected in the increasing number of poor households headed by women and a lack of adequate social wel- fare systems [19]. Gender inequality con- tributes to making women vulnerable to poverty. Women also face discrimination in property and inheritance rights [19]. Conclusion Arab countries have diverse economies and their populations are at different stages of the transition from high to low fertility. Thus, their governments may choose different approaches to improve educational and job opportunities for youth. However, none can succeed in strengthening human capacity among youth without fundamental reforms and a greater engagement of civil society. The labour market prospects of the region largely depend on how success- fully its governments can develop new social  contracts  for  the 21st  century.  The extent to which this large group of young people will become healthy and productive members of their societies depends on how well governments and civil societies invest in social, economic, and political institutions that meet the current needs of young people. The recent social and political turmoil in the Arab countries has given renewed urgency to the need to counter chronic joblessness, particularly among young people. Governments can implement a number of immediate measures to step up job creation and enhance the employability of their young popula- tions [27]. Policy should aim at relaxing  rigid labour market regulations and at providing effective social protection. Nations undergoing the demographic transition have an opportunity to capi- talize on the demographic dividend offered by the maturing of boom-era populations. Given the right kind of policy environment, this demographic dividend can help to produce a sus- tained period of economic growth [1]. I will end this review by quoting this declaration by Her Majesty Queen Ra- nia Al Abdullah of Jordan [41]: I was once told that the only way to predict the future is to have power to shape the future. Well, here in the Arab world, we have the power. The power is our youth. We have been blessed with the biggest youth population in the world; 60% of our region is under the age of thirty. If we could channel their energy… if we could harness their po- tential… we could change the fortunes of our region. With almost one quarter of our young people unemployed and losing hope every day, creating oppor- tunity has never been so urgent. But right now, we are letting them down. We are letting them down in ill- equipped classrooms with untrained teachers; we are letting them down with outmoded curriculums already obsolete in the modern marketplace; we are let- ting them down when they seek our advice and practical measures; and we are letting them down when we fail to expose them, at an early age, to the entrepreneurial spirit and potential of the private sector. From government to education providers to employers to civil society and to youth themselves, shaping our future is everyone’s responsibility. If we can provide quality education that leads to lasting employment, we will have done our part in shaping the future of the Arab world. No one said it would be easy, but it is a regional imperative. References 1. Bloom DE, Canning D, Sevilla J. The demographic dividend: a new perspective on the economic consequences of popula- tion change. Santa Monica, California, RAND Corporation, 2003. 2. World population prospects: the 2008 revision. New York, United Nations Population Division, 2008. 3. Goals and targets for monitoring the progress of youth in the global economy, Report of the Secretary General, addendum. Book 19-4.indb 387 5/12/2013 2:19:44 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 388 New York, United Nations, General Assembly, Econom- ic and Social Council, 2007 (A/62/61/Add.1-E/2007/7/ Add.1). 4. Khalifa AM. Youth bulge and the demographic window of op- portunity in the Arab world. Paper presented at the United Na- tions Economic and Social Commission for Western Asia Expert Group Meeting on Moving the Development Agenda Forward: opportunities and potential gains, Beirut, 5–6 November 2009. Beirut, ESCWA, 2009. 5. Roudi F. Population trends and challenges in the Middle East and North Africa. Washington DC, Population Reference Bureau, 2001. 6. Assaad R, Roudi-Fahimi F. Youth in the Middle East and North Africa: demographic opportunity or challenge? Washington DC, Population Reference Bureau, 2007. 7. Youth in the ESCWA region: situation analysis and implications for development policies. Beirut, United Nations Economic and Social Commission for Western Asia, 2010 (ESCWA Population and Development Report 4th issue). 8. World population to 2300. New York, United Nations Depart- ment of Economic and Social Affairs, Population Division (ST/ ESA/SER.A/236), 2004. 9. Ben Brahim A. [Transition des structures par âge et vieillissement en Tunisie. Seminaires du CICRED]. Paris Cedex, Committee for International Cooperation in National Research in Demogra- phy, 2005. 10. Sibai A, Kronfol N. CSA country profile. Older population in Leba- non: facts and prospects. Beirut, Center for Studies on Aging/ United Nations Population Fund, 2011. 11. Gender and education for all. The leap to equality. Paris, United Nations Educational, Scientific and Cultural Organization Edu- cation, 2003/4. 12. Doing business 2008. Washington DC, World Bank, 2007. 13. Najib K. Development of Arab education systems to empower youth: challenges and future prospects. Series of Population and Development Studies. Cairo, Secretariat-General of the League of Arab States, Department of Population and Migration Poli- cies, 2005 [in Arabic]. 14. Education statistics (edstats). World Bank [online database] (http://web.worldbank.org/WBsite/External/Topics/Extedu- cation/Extdatastatistics/Extedstats/0,menuPK:3232818~pag ePK:64168427~piPK:64168435~theSitePK:3232764,00.html, accessed 10 February 2013). 15. Salehi-Isfahani D, Dhillon N. Stalled youth transitions in the Mid- dle East: a framework for policy reform. Washington DC, Wolfen- sohn Center for Development/ Dubai School of Government, 2008 (Middle East Youth Initiative Working Paper No. 8). 16. Chaaban J. Job creation in the Arab economies: navigating through difficult waters. Arab Human Development Report Re- search Paper Series. New York, United Nations Development Programme, 2010. 17. Unlocking the employment potential in the Middle East and North Africa. Washington DC, World Bank, 2007. 18. Report on the impact of conflict and political crisis on the socioeco- nomic conditions of countries in Western Asia. Beirut, United Na- tions Economic and Social Commission for Western Asia, 2007. 19. The status and progress of women in the Middle East and North Africa. Washington DC, World Bank, 2007. 20. Global employment trends for women. Geneva, International Labour Organization, 2007. 21. The road not travelled: education reform in the Middle East and North Africa. Washington DC, World Bank, 2008. 22. World development report 2006: equity and development. Washington DC, World Bank, 2006. 23. Assaad R. Unemployment and youth insertion in the labor market in Egypt. Cairo, Egyptian Center for Economic Studies, 2007 (ECES Working Paper No. 118). 24. ةيبرعلا ةلاطبلا ةمزأ ةهجاولم رلاود رايلم 85 يرفوتب بلاطم. [Demands for provision of $ 85 billion to address the Arab unemployment crisis.] AlJa- zeera [online] (http://www.al-jazirah.com/20110521/ec2d. htm, accessed 10 February 2013). 25. Education for employment: realizing Arab youth potential. Wash- ington DC, World Bank International Finance Corporation and the Islamic Development Bank, 2011. 26. Arab human development report 2003: building a knowledge society. New York, United Nations Development Programme, 2003. 27. Masood A. Creating jobs in the Middle East and North Africa. A commentary by Masood Ahmed, Director, Middle East and Cen- tral Asia Department, International Monetary Fund. Published in Asharq Al Awsat, 20 May 2011. Interntatonal Monetary Fund [online] (http://www.imf.org/external/np/vc/2011/052011. htm, accessed 10 February 2013). 28. The state of the world’s refugees. Geneva, United Nations High Commission for Refugees, 2006. 29. Fargues P. Emerging demographic patterns across the Mediterra- nean and their implications for migration through 2030. Wash- ington D, Migration Policy Institute, 2008. 30. Fargues P. International migration in the Arab region: trends and policies. Paper presented at the United Nations Expert Group Meeting on International Migration and Development in the Arab Region, Beirut, May 2006. 31. Ghobril N. The global crisis and expatriates remittances to Lebanon. Chapter 31. In: Sirkeci I, Cohen JH, Ratha D, eds. Migration and remittances during the global financial crisis and beyond. Washington DC, World Bank, 2012. 32. Sirkeci I, Cohen JH, Ratha D, eds. Migration and remittances during the global financial crisis and beyond. Washington DC, World Bank, 2012. 33. Ratha D. Workers’ remittances: an important and stable source of external finance. Washington DC, World Bank, 2003. 34. Sibai A, Kronfol N. Situation analysis of population ageing in the Arab countries: the way forward towards implementation of MI- PAA. Beirut, United Nations Economic and Social Commission for Western Asia, 2008. 35. Youth in the ESCWA region: situation analysis and implications for development policies. Beirut, United Nations Economic and Social Commission for Western Asia, 2009 (Population and Development Report No. 4). 36. World DataBank. World Bank [online database] (http://data- bank.worldbank.org/data/home.aspx, accessed 10 February 2013). 37. Maternal mortality in 2005. Estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organization/United Nations Children’s Fund/ United Na- tions Population Fund/ World Bank, 2007. 38. Marriage in the Arab world. Washington DC, Population Refer- ence Bureau, 2005. 39. Gender and development in the Middle East and North Af- rica: women in the public sphere. Washington DC, World Bank, 2004. 40. Arab youth strategizing for the MDGs. New York, United Na- tions Development Programme/United Nations Department of Economic and Social Affairs, 2006. 41. Al Abdullah R. Reflections by the Chairperson. In: Education for employment: realizing Arab youth potential. Washington DC, World Bank International Finance Corporation and the Islamic Development Bank, 2011. Book 19-4.indb 388 5/12/2013 2:19:44 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 389 Report Consensus recommendation for meningococcal disease prevention for Hajj and Umra pilgrimage/ travel medicine A. Shibl,1,2 H. Tufenkeji,3 M. Khalil,4 Z. Memish 2,4 and the Meningococcal Leadership Forum (MLF) Expert Group ABSTRACT The Islamic Hajj to Makkah (Mecca) has been associated with outbreaks of invasive meningococcal disease and the global spread of Neisseria meningitidis serogroup W-135. For Hajj pilgrims the quadrivalent vaccination against serogroups A, C, W-135 and Y is a mandatory requirement. Novel conjugate vaccines may provide benefits for the community by reduction of carriage. With the introduction of the new generation of quadrivalent meningococcal conjugate vaccines (Menveo, Menactra, and others pending license) and their recent implementation in Saudi Arabia, experts from 11 countries in the Middle East region met at a Meningococcal Leadership Forum (MLF), in Dubai in May 2010 to exchange opinions on meningococcal disease and prevention strategies. These experts discussed the importance of introducing conjugate vaccines for pilgrims and travellers, and elaborated a consensus recommendation to support healthcare professionals and decision-makers. 1Department of Microbiology, King Saud University, Riyadh, Saudi Arabia (Correspondence to A.M. Shibl: amshibl@ksu.edu.sa; amshibl1@yahoo.com). 2College of Medicine, Alfaisal University,Riyadh,Saudi Arabia. 3King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia. 4Ministry of Health, Riyadh, Saudi Arabia. Received: 08/09/11; accepted: 01/11/11 رفسلا بط فيو ةرمعلاو جلحا في ةيئاحسلا تاروكلما ضرم نم ةياقولا لوح ءارلآا قفاوتب تردص تايصوت ةيئاحسلا تاروكملل يدايقلا برنلما ءابرخ ةعوممج ،شميم ديز ،ليلخ دممح ،يجكفنت مثيه ،لبش فطاع نم W-135 ةيعرفلا ةعومجملل يلماع راشتنابو ةيوزغلا ةيئاحسلا تاروكلما ضرم نم تايشافب ةمركلما ةكم لىإ ينملسلما جح قَفَاَرَت :ةـصلالخا ةديدلجا ةنراقتلما تاحاقللا مدقت دقو .جاّجحلل ًايمازلإ Y و W-135و C و A ةيعرفلا تاعومجملل داضلما حاقللاب ميعطتلا دعُيو .ةيئاحسلا تاَّيسرينلا ةيئاحسلا تاروكملل ةداضلما ؤفاكتلا ةيعابرلا ةنراقتلما تاحاقللا نم ديدلجا ليلجا لاخدإ عمو .تابوركلما لَْحم صاقنإب عمتجملل دئاوفلا ضعب قشر ميلقإ نم ًادلب 11 نم ءابرلخا عمتجا ،ةيدوعسلا ةيبرعلا ةكلملما في بيرق تقو ذنم اهقيبطت عمو )صيخترلل ةحشرلما اهيرغو ،اتركانيم ،ويفنم( تايجيتاترساو ةيوئرلا تاروكلما ضرم لوح رظنلا تاهجو لدابتل ،2010 ويام/رايأ في بيد في ةيئاحسلا تاروكلما لامج في يدايق برنم في طسوتلما قفاوتب تيظح تايصوت اوعضوو ،نيرفاسلماو جاجحلل ةيئاحسلا تاروكملل ةداضلما ةنترقتلما تاحاقللا لاخدإ ةيهمأ ءابرلخا شقان دقو .هنم ةياقولا .اهيف رارقلا يذختمو ةيحصلا ةياعرلا في ينلماعلا ينينهلما معد لجأ نم ءارلآا Recommandations consensuelles sur la prévention de la méningococcie pendant les pèlerinages (Hadj et Omra) et sur la médecine des voyages Le pèlerinage islamique (Hadj) à La Mecque a été associé à des flambées de méningococcies invasives et à la propagation mondiale de Neisseria meningitidis du sérogroupe W135. Pour les pèlerins du Hadj, le vaccin quadrivalent contre les sérogroupes A, C, W135 et Y est obligatoire. De nouveaux vaccins conjugués peuvent être bénéfiques pour la communauté en réduisant le nombre de porteurs. Avec l'introduction d'une nouvelle génération de vaccins antiméningococciques conjugués quadrivalents (Menveo, Menactra et autres licences en attente) et leur récente mise en œuvre en Arabie saoudite, des experts de 11 pays de la Région du Moyen- Orient se sont réunis au Meningococcal Leadership Forum, à Dubaï, en mai 2010 pour échanger sur la maladie méningococcique et les stratégies de prévention. Ces experts ont discuté de l'importance d'introduire des vaccins conjugués pour les pèlerins et les voyageurs, et ont rédigé des recommandations consensuelles pour appuyer les professionnels de santé et les décisionnaires. Book 19-4.indb 389 5/12/2013 2:19:44 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 390 Introduction World-wide, most cases of meningo- coccal  disease  are  caused by 5 of  12  known  serogroups  (A,  B, C, W-135,  Y) of Neisseria meningitidis. Asympto- matic carriage is common in the general population and can be as high as 35 %  [1]; during the  Hajj , however, this can  reach 86% [2]. There are several risk fac- tors associated with bacterial carriage: crowded conditions (e.g. military bar- racks, dormitories, pubs, events), travel to endemic areas and personal behav- iours (e.g. kissing, coughing, smoking) all increase exposure to the bacteria [1]. Even with appropriate treatment, the case fatality rate is high: 10%–30 %  depending on manifestation, age and serogroup [3,4]. Up to 20% of survivors  suffer from permanent severe sequalae such as hearing loss, skin necrosis, sei- zures or limb amputation [3]. All 5 major  serogroups of N. men- ingitidis exist everywhere at the same time, but relative proportions can vary greatly from country to country and can change unpredictably [5]. In Saudi  Arabia, serogroup W-135 gained domi- nance within only 2 years [6], followed  by other countries, e.g. Turkey, South Africa, Nigeria, Argentina, also observ- ing much higher proportions of W-135  [7].  Travel is one of the major drivers influencing changing epidemiology. International travel can promote and accelerate the spread of different sero- groups throughout the world, especially after mass gatherings such as the Hajj. In 2000 and 2001, serogroup W-135 was  transferred from Hajj to other countries [6]. A comparison of the 2 outbreaks in  Saudi Arabia  in 2000 and 2001 shows  the spread of disease outside the holy cities and an increase in cases in children < 5 years [8],  indicating that  the use of  polysaccharide vaccines after the first outbreak did not significantly reduce carriage or prevent transmission and infection in the unvaccinated. Plain meningococcal polysaccha- ride vaccines are now considered to be outdated because of a number of important limitations [9]: they are not immunogenic  in young children (< 2  years);  they do not  elicit  an  immune  memory and provide only limited du- ration of protection  (~3  years);  they  have no significant impact on carriage and  transmission; and  they cannot be  boosted—on the contrary, repeated polysaccharide vaccinations result in a reduced immune response (hypo- responsiveness). This has been dem- onstrated  for serogroups C and W135  in African toddlers after PS vaccine compared to naive children [10]. In May 2010, experts from 11 coun- tries in the Middle East region met at a Meningococcal Leadership Forum (MLF) in Dubai to exchange opinions on meningococcal disease and pre- vention strategies. They discussed the importance of introducing conjugate vaccines for pilgrims and travellers, and elaborated a consensus recommenda- tion to support healthcare professionals and decision-makers. A full background and description of transmission, burden of disease and changing pathogenicity as well as a com- parison of polysaccharide and conjugate vaccines can be found in the consen- sus recommendations for prevention of meningococcal disease in children and adolescents that emanated from the Forum [11]. The current report presents the consensus-recommendation for meningococcal quadrivalent (ACWY) conjugate vaccination of pilgrims/ travellers. This manuscript covers parts and extracts of the previously published paediatric consensus paper [11]. Consensus- recommendations Meningitis and travel Neisseria meningitidis is the only bac- terium that can generate widespread outbreaks and epidemics of meningitis [12]. Owing to the high morbidity and  mortality and the changing epidemiol- ogy, vaccination as broad as possible is recommended for prevention of meningococcal infections in travel- lers, particularly in pilgrims. While the incidence of infection in travellers to developing countries  is  about 0.5 per  100 000,  it can be much higher in Hajj  pilgrims (640 per 100 000) and  their  contacts  (up  to 28 per 100 000)  and  peaks during meningitis belt epidemics (up to 800 per 100 000) [13].  Current travel guidelines for preven- tion of meningococcal disease vary from country to country and according to the World Health Organization it is (only) generally recommended that vaccination should be considered for travellers to countries where outbreaks of menin- gococcal disease are known to occur [14]. However, for Hajj pilgrims and for travel to the extended African meningitis belt, quadrivalent vaccination is a manda- tory requirement, and for travel to the extended African meningitis belt, a clear indication for meningococcal vaccina- tion exists. Quadrivalent conjugate vaco- cines offer a broad serogroup protection and an assurance to prevent carriage. This would protect travellers as well as their contacts and could also be an important contribution to reduce the use of chemo- prophylaxis, especially in those regions. Meningococcal outbreaks related to Hajj pilgrimage With globalization, pilgrim burden at the Hajj is set to rise as more people perform the pilgrimage each year. Cur- rently,  almost 3 million Muslims  stay  around the Holy Mosque in Makkah (Mecca) for at least 4–7 days [15]. The  heavily overcrowded conditions during Hajj dramatically increase the transmis- sion and carriage of airborne infectious agents because of prolonged stay (some people come for Umra and Ramadan and stay until Hajj, perhaps 2–3 months  altogether), semi-permanent tents/ shared facilities, humidity and heat, and exhaustion from performing the Hajj Book 19-4.indb 390 5/12/2013 2:19:44 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 391 For the future, conjugate meningo- coccal ACWY vaccine should replace the polysaccharide vaccines that de- crease immune response with repeated doses. This hyporesponsiveness is an important issue, especially for those who often perform Hajj/Umra and get  vaccinated every 1–3 years.  Saudi  Arabia decided to convert to ACWY conjugate  vaccines  by  2010,  starting  with the following target populations: all national pilgrims, all people working in the Hajj areas and all residents of Makkah and Madinah. Consensual recommendation for ACWY conjugate vaccination The experts of the Middle East region agreed on the concept of using conju- gate vaccines, replacing polysaccharide vaccines. The overall consensus was that conjugate vaccines are the best choice for prevention of meningococ- cal disease, in particular because of the added value for the community: The potential of stopping transmission by prevention/clearance of carriage offers the possibility to protect the contacts of vaccinees and prevents dissemina- tion of the bacteria to other countries. In many countries the experience is made that meningococcal infections still occur (especially at the contacts around Hajjis) despite high coverage of polysaccharide vaccination among pilgrims. Therefore the impact of conju- gate vaccines on carriage is of major in- terest – from epidemiologic, economic  and also from public health perspective, as each single case of meningococcal disease, no matter if imported or indig- enous, requires a public health response (i.e. identification of close contacts for prophylaxis). It is assumed, that this class-effect of conjugate vaccines also applies to quadrivalent meningococcal conjugate vaccines, although confirm- ing data of course are not yet available for the new vaccines. Due to the fact that Hajj pilgrims often are of older age, it is reassuring that conjugate ACWY vaccines  in  the age group of 56  to 65  years of age resulted in higher percent- age of seroresponders for all serogroups, compared to polysaccharide vaccine [19]. Another important benefit is the chance of getting the "overuse" of anti- biotics under control: If the use of con- jugate vaccines becomes widespread, there will be no more or at least much less need for chemoprophylaxis. A re- maining concern in this context is, that also the conjugate ACWY vaccines do not cover all serogroups (B, X). People who should be vaccinated with ACWY conjugate vaccination These include: • all Hajj and Umra pilgrims (especial- ly when Umra is performed in peak times such as Ramadan); • travellers to the extended African meningitis belt; • travellers to countries where out- breaks are known to occur or with epidemic risk; • military and national guard;  • health-care workers in countries with a high burden of disease (especially those working in intensive care units, laboratories, paediatric ward); • health-care workers, policemen and other personnel in the Makkah and Madinah area as well as in airports and seaports that receive pilgrims; • participants of exchange programmes (pupils, students, au-pairs, expatriate workers) before long-term stays in countries with recommended menin- gococcal immunization, if required by host institution; • high-risk groups (e.g. the elderly; im- munodeficient patients). Recommended implementation strategy In general, conjugate vaccine should replace plain polysaccharide vaccines. Start with high-risk groups (primar- ily pilgrims) and continue going down. rites (a large number of Muslims are elderly with poor health status). The first large Hajj-associated meningococcal outbreak  (1841 cases;  serogroup A) occurred in 1987 and led  to mandatory bivalent (AC polysaccha- ride) vaccination [16].  It was not until  Hajj 2000 that a second, smaller, outbreak  of meningococcal disease occurred with 253 cases  in Saudi Arabia  (more  than  one-third  serogroup W-135;  less  than  a quarter serogroup A) with sustained community  transmission  [16]. Shortly  after  this more  than 400 W-135 cases  were reported among returned pilgrims and  their  contacts  from 16  countries  world-wide  [16,17]. All  global  isolates  associated with this outbreak were of the single clone ET-37 (the most com- mon clone causing epidemics), and the source of the strain was related to strains isolated in Mali, Algeria and Gambia in the 1990s  [18].  In 2001,  an additional  outbreak  (> 50%  of  cases  were  con- firmed W-135) could not be prevented,  mainly because not enough quadriva- lent vaccine could be made available for the Ministry of Health to make it a Hajj requirement. Again, W-135 spread  globally through international pilgrims, and in Saudi Arabia a large number of cases occurred among contacts of Hajjis. By May 2001 quadrivalent vaccination  became a mandatory visa requirement for all pilgrims from any country. All national pilgrims as well as all residents of Makkah and Madinah (Medina) were vaccinated. Oral decolonization with ciprofloxacin prior to departure from the Hajj premises was strongly recom- mended to Saudi pilgrims and a national vaccination campaign for children was implemented  [15]. Since  the 2006/07  Hajj season, the prevention policy still recommends quadrivalent vaccine (not further specifying which technology) to all pilgrims and residents of the holy cities, and chemoprophylaxis (1 tablet of  500 mg  ciprofloxacin)  for  arriving  pilgrims from the African meningitis belt, but no longer for pilgrims leaving the Hajj premises. Book 19-4.indb 391 5/12/2013 2:19:44 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 392 Owing to the fact that plain polysaccha- ride vaccines induce hyporesponsive- ness, consideration should be given to ensuring that anyone being vaccinated for the first time (i.e. polysaccharide- naive persons) gets a conjugate vaccine. For the transition period, when both types of vaccines are still available and polysaccharide vaccines will be used in parallel, one could consider to give it preferentially to older populations who will go to Hajj only once in lifetime and who do not travel frequently. For pilgrims at least it should be ensured that everyone coming for Hajj or Umra is vaccinated against ACWY meningococci, prioritizing conju- gate vaccines as early as available. At present the use of ACWY conjugate vaccines is limited to the registered age-ranges [2+ years or 11+ years  for  Menveo (depending on the country), 9 months–55 years for Menactra]. For certain countries the costs of conjugate vaccines may be a problem at introduction, but these will be recovered within a few years through the potential for prolonged protection and herd im- munity (which has to be demonstrated by clinical studies). Costs really need to be considered in relation to benefits;  after some years, and with widespread use, conjugate vaccines may even be cost–effective.  There are many questions to be an- swered in the coming years, nevertheless the concept of conjugate vaccines offers convincing and significant progress in preventing meningococcal disease, treat- ment for which is always is a race against time and immediate appropriate medi- cal care may not be available everywhere. Acknowledgements The authors would like to thank the following experts of Novartis Vac- cines for scientific contribution to the conference: Wolfgang Bender, MD, Michael Bröker, PhD, Brian Cooper, MD, Claudius Malerczyk, MD, Joshi Venugopal, MD. Additionally, the au- thors thank Irene Pemp of IP-Pharma agency for medical writing support with the preparation of this manu- script. F u n d i n g : Th e M e n i n g o c o c c a l Leadership Forum was organized and financially supported by Novartis Vac- cines. An unrestricted grant for this manuscript was provided by Novartis Vaccines. Opinions expressed are those of the authors. None of the authors have received any honorarium. References 1. Brigham KS, Sandora TJ. Neisseria meningitidis: epidemiology, treatment and prevention in adolescents. Current Opinion in Pediatrics, 2009, 21(4):437–443. 2. Al-GahtaniYM et al. Epidemiological investigation of an out- break of meningococcal meningitis in Makkah (Mecca), Saudi Arabia, 1992.Epidemiology and Infection, 1995, 115(3):399–409. 3. Bilukha OO, Rosenstein N; National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC). Prevention and control of meningococcal disease. Recom- mendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Recommendations and Reports, 2005, 54RR-7:1–21. 4. Trotter CL, Ramsay ME. Vaccination against meningococcal disease in Europe: review and recommendations for the use of conjugate vaccines. FEMS Microbiology Reviews, 2007, 31:101–107. 5. Khatami A, Pollard AJ. The epidemiology of meningococcal disease and the impact of vaccines. Expert Review of Vaccines, 2010, 9(3):285–298. 6. Khalil MK, Borrow R. Serogroup B meningococcal disease dur- ing Hajj: preparing for the worst scenario. Travel Medicine and Infectious Disease, 2009, 7(4):231–234 7. Von GottbergA et al.; Group for Enteric, Respiratory and Me- ningeal Disease Surveillance in South Africa. Emergence of endemic serogroup W135 meningococcal disease associated with a high mortality rate in South Africa. Clinical Infectious Diseases, 2008, 46(3):377–386. 8. Infectious diseases report. Riyadh, Ministry of Health, 2008. 9. Harrison LH. Prospects for vaccine prevention of meningococ- cal infection. Clinical Microbiology Reviews, 2006, 19(1):142–164. 10. Findlow H et al. Meningococcal group C and w135 immuno- logical hyporesponsiveness in african toddlers. Clinical and Vaccine Immunology, 2011, 18 (9):1492–1496. 11. Shibl A et al.; The Meningococcal Leadership Forum Expert Group. Consensus recommendation for meningococcal disease prevention in children and adolescents in the Mid- dle East region. Journal of Epidemiology& Global Health, 2012, 2(1):23–30. 12. Girard MP et al .A review of vaccine research and develop- ment: meningococcal disease. Vaccine, 2006, 24(22):4692– 4700. 13. Wilder-Smith A. Meningococcal vaccines: a neglected topic in travel medicine? Expert Review of Vaccines, 2009, 8(10):1343– 1350. 14. International travel and health 2010. Geneva, World Health Organization, 2010, Chapter 6:117–119 (http://www.who.int/ ith/en/, accessed 24 June, 2010). 15. Memish ZA, Venkatesh S, Ahmed QA. Travel epidemiology: the Saudi perspective. International Journal of Antimicrobial Agents, 2003, 21(2):96–101. 16. Lingappa JR et al. Serogroup W-135 meningococcal disease during the Hajj, 2000. Emerging Infectious Diseases, 2003, 9(6):665–671. 17. Hahné SJ et al. W135 meningococcal disease in England and Wales associated with Hajj 2000 and 2001. Lancet, 2002, 359(9306):582–583. 18. Mayer LW et al. Outbreak of W135 meningococcal disease in 2000: not emergence of a new W135 strain but clonal expan- sion within the electophoretic type-37 complex. Journal of Infectious Diseases, 2002, 185(11):1596–1605. 19. Stamboulian D et al. Safety and immunogenicity of an inves- tigational quadrivalent meningococcal CRM(197) conjugate vaccine, MenACWY-CRM, compared with licensed vaccines in adults in Latin America. International Journal of Infectious Diseases, 2010, 14(10):e868–e875. Book 19-4.indb 392 5/12/2013 2:19:45 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 393 Case report A case of vocal tic: an unusual presentation of neurobrucellosis G.I. Bayhan,1 G. Tanır,1 U. Ertan 2 and S. Bodur 3 1Department of Paediatric Infectious Diseases; 2Department of Paediatrics; 3Department of Child and Adolescent Psychiatry, Dr Sami Ulus Maternity and Children’s Health and Diseases Training and Research Centre, Ankara, Turkey (Correspondence to G.I. Bayhan: gibayhan@gmail.com). Received: 08/09/11; accepted: 12/12/11 Introduction Brucellosis is the most widespread zoon- osis in the world. The disease is endemic in countries bordering the Mediterra- nean [1–3].  It  is a multisystem disease  that may present with a broad spectrum of clinical manifestations and compli- cations. Neurologic manifestations of brucellosis are rare, occurring in 3%–5%  of patients with systemic brucellosis [4]. Nervous system manifestations are very heterogeneous, and include clinical syndromes like meningitis, encephalitis, myelitis, radiculitis and the involvement of cranial or peripheral nerves [2,5].  In this report we describe a case which presented with unexplained chronic cough, refusal to eat and consti- pation. The observation of “dry cough with a bark-like vocalizations” and psy- chiatric consultation established the diagnosis of tic disorder. After the diag- nosis and treatment of neurobrucellosis as an underlying condition, vocal tic of the patient completely resolved. Case report A 11-year-old boy presented with a 3-month history of cough, nervousness,  generalized arthralgia and headache. He had lost his appetite and been refusing any food intake for 1 month. He had been suffering from constipation and he had defecated only 1 time since the pre- vious month. He had lost an estimated 4 kg weight. On admission, physical examina- tion of the patient was completely nor- mal, including neurological signs. Dry cough with bark-like vocalizations was observed during hospitalization. These vocalizations were unrelenting and were precipitated by the presence of people in his room. It was also observed that the patient could not eat anything, for this reason a feeding tube was employed. Initial laboratory studies showed a white blood cell  count of 3600/mm3 with  44%  neutrophils,  46%  lympho- cytes; haemoglobin 15.2 g/dL; haema- tocrit  43.6%  and  platelets  261 000/ mm3. The erythrocyte sedimentation rate was 4 mm/h and C-reactive protein 1.89 mg/L (normal < 2.9 mg/L). Bio- chemical investigations were normal except for a high total protein level of (8.5 g/dL (normal  range 6–8 g/dL),  albumin 4.6 g/dL normal range 3.1–4.8  g/dL). Investigations were performed to explore the chronic cough, anorexia, vomiting and constipation. Chest X- ray was normal. Tuberculin skin test was negative. Mycoplasma pneumoniae IgM and IgG were negative by enzyme immunoassay. Vocal cord laryngos- copy was performed under general anaesthesia and revealed no oedema, swelling or inflammation of the vocal cords. Airway anatomy and vocal cord motion was normal. Ultrasonographic examination of the abdomen showed a mesenteric lymphadenopathy with nonpathological dimension. The child was given a barium swallow examination for refusal to eat and vom- iting. The findings were suggestive of partial web in the duodenum. For this reason gastrointestinal endoscopy was performed. There were no stricture, oesophagitis, gastro-oesophageal reflux and gastric ulcer. Colonoscopy was per- formed to rule out organic reasons of constipation. There were no stenoses, ulcerations, intestinal obstruction, ma- lignancies, inflammatory bowel disease, or diverticular disease. After these extensive investigations, a psychiatric consultation was done. Psychiatric evaluation revealed good general appearance and motor activity, stable affect and complete orientation. The patient was communicative but his speech had been frequently interrupted by a vocal tic. Thought content of the patient was generally about his cough. He was evaluated as having vocal tic disorder. Treatment with risperidone and fluoxetine was initiated. The presence of psychiatric findings which were unresponsive to 2-week an- ti-depressive treatment, the high serum protein level, and leukopenia suggested that the patient might have an organic disease with neuropsychiatric symp- toms. The history of the patient was re-evaluated and revealed the consump- tion of unpasteurized cheese. Rose ben- gal test, brucella tube agglutination and brucella Coombs’ test were all negative. Enzyme immunoassay was positive for Brucella IgM and IgG. The child was di- agnosed as having brucellosis and it was thought that the psychiatric findings Book 19-4.indb 393 5/12/2013 2:19:45 PM EMHJ  •  Vol. 19  No. 4  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 394 involvement, epilepsy, brain abscess, subarachnoid haemorrhage [4,6,14]. In  our patient, who had completely nor- mal neurological examination findings, meningoencephalitis, subarachnoid haemorrhage and brain parenchymal lesion were excluded by CSF and MRI investigations. Although headache, mental inattention, and depression are common complaints in patients with neurobrucellosis, presentation with isolated psychiatric symptoms is rare [15–17]. Our  patient  had  psychiat- ric symptoms include refusal eating, chronic irritating cough with barking and nervousness. These findings were attributed to vocal tic, which caused so- cial difficulties for the patient, especially in school, along with nervousness and depressive signs. We think that the patient’s tic severely affected his social and daily functioning;  for  this  reason medical  treatment was commenced. Transient tics  usually  begin  between  3  and  10  years of age and wax and wane over a period of 4 weeks to 1 year. The Diag- nostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria state that  they must persist  for  less  than 6  months  [18]. Although  the  patient’s  age and the duration of the tic were consistent with transient tic, in the end, the diagnosis of brucellosis discarded a diagnosis of transient tic. The etiology of tics in general remains unclear. The reported psychiatric mani- festations in neurobrucellosis in adult patients are depression, amnesia, psy- chosis, nervousness, irritability, agita- tion, nightmares, impaired cognitive function, loss of perception, amnesia, personality disorder, various degrees of behavioural abnormalities and euphoria [2,6,15–17,19].  In a  study of 27 adult  patients with brucellosis (14 with mani- fest neurological manifestation and 13  without apparent neurological mani- festation), it was demonstrated that the patients with brucellosis (neurobrucel- losis and patients without neurological manifestations) had highly significant impairment in some cognitive func- tion measures and had higher scores on depressive symptoms compared with  controls  [15].  In  another  study,  changes in mental and emotional status of the neurobrucellosis patients were investigated in adults. All of the neuro- brucellosis cases were diagnosed with mild depression [16]. Depression was  not detected in the brucellosis patients without neurological involvement. The mean Hamilton Depression Rating Scale test score among neurobrucello- sis patients improved significantly with anti-brucella treatment without anti- depressive and antipsychotic treatment while in the brucellosis patients without neurological involvement no significant improvements were observed with anti- brucella  treatment  [16]. A prospective  analysis of 73 patients with brucellosis  identified 13 (17.8%) neurobrucellosis  cases, 10 with chronic and 3 with acute  meningitis. Two patients with chronic meningitis presented only psychiatric disorders and headache [19]. Diagnosis of brucellosis is based upon serological tests and cultures. Blood culture is the gold standard in the diagnosis of brucellosis. Blood cultures are positive  in 15%–90% of patients  with brucellosis. In the absence of posi- tive culture, the diagnosis can be made using serological testing with a variety of agglutination tests such as the rose bengal test, serum agglutination test, etc. The sensitivity of the serological tests ranges from 65% to 95%, but their  specificity is low because of the high prevalence of antibodies in the healthy population. The lack of seropositiv- ity in patients with brucellosis may be attributed to the performance of tests early in the course of infection, de- creased serum agglutination test titre in subacute or chronic cases, or the pres- ence of blocking antibodies [1,20,21].  Enzyme-linked immunosorbent as- say (EIA) is more sensitive than other serological tests, especially when the detection of specific IgM antibodies is complemented with the detection of of the patient might be attributed to brucellosis. To investigate the neurobrucellosis lumbar puncture was performed. The cerebrospinal fluid (CSF) did not con- tain white blood cells, protein level was 23 mg/L (normal range 15–45 mg/dL)  and glucose  level was 66 mg/L (nor- mal 40–70 mg/dL). Bacterial cultures  of the CSF were negative. Magnetic resonance imaging of the brain revealed normal findings. Brainstem auditory evoked potential (BAEP) investigation of the patient was normal. For visual evoked potential (VEP), P100  latency  was prolonged bilaterally. Treatment with antibrucella drugs (oral  rifampicin  20 mg/kg  per  day,  doxycycline 200 mg/day and  intrave- nous gentamicin 7.5 mg/kg per day)  was administered at the 14th day of hospitalization. The patient’s condition gradually improved and the psychiatric symptoms resolved completely after 13  days of the antibrucella treatment so ris- peridone and fluoxetine were stopped. The patient was discharged from hospital 4 weeks later and antibrucella therapy was completed to 6 months. He  was symptom free and had gained 1 kg at the 6-month follow-up.  Discussion Brucellosis is a multisystem disease that may present with various clinical manifestations and complications. Neurobrucellosis is one of the com- plications and is rare in children, be- ing  reported  in  only  0%  to  3.8%  of  children  with  brucellosis  [1,6–12].  Paediatric neurobrucellosis studies are, however, scarce in the English scientific literature  [12,13]. Meningoencepha- litis is the most common neurologic manifestation. Other reported clinical presentations of neurobrucellosis are meningovascular involvement, par- enchymatous dysfunction, peripheral neuropathy/radiculopathy, sensorial and motor abnormalities, cranial nerve Book 19-4.indb 394 5/12/2013 2:19:45 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما عبارلا ددعلا 395 specific  IgG antibodies  [20,22]. The  specificity of EIA, however, seems to be lower than that of the agglutination tests. Serological testing with agglutina- tion tests and EIA has been applied in the diagnosis of central nervous system brucellosis with varying success, and further research is aimed to improve the diagnosis of this condition [20]. In  our patient, the lack of objective clini- cal findings and paucity of laboratory References 1. Tanir G, Tufekci SB, Tuygun N. Presentation, complications, and treatment outcome of brucellosis in Turkish children, Pediatrics International, 2009, 51:114–119. 2. Gul HC et al. Management of neurobrucellosis:an assessment of 11 cases. Internal Medicine (Tokyo, Japan), 2008, 47:995–1001. 3. Buzgan T et al. Clinical manifestations and complications in 1028 cases of brucellosis: a retrospective evaluation and review of the literature. International Journal of Infectious Dis- eases, 2010, 14:469–478. 4. Yetkin MA et al. Evaluation of the clinical presentations in neurobrucellosis. International Journal of Infectious Diseases, 2006, 10:446–452. 5. Bucher A, Gaustad P, Pape E. Chronic neurobrucellosis due to Brucella melitensis. Scandinavian Journal of Infectious Diseases, 1990, 22:223–226. 6. Al Shaalan M et al. Brucellosis in children: clinical observations in 115 cases. International Journal of Infectious Diseases, 2002, 6:182-186. 7. Tsolia M et al. Clinical features, complications and treatment outcome of childhood brucellosis in central Greece. Journal of Infection, 2002, 44(4):257–262. 8. Mantur BG et al. Childhood brucellosis—a microbiological, epidemiological and clinical study. Journal of Tropical Pediat- rics, 2004, 50(3):153–157. 9. Caksen H et al. Childhood brucellosis is still a severe prob- lem in the eastern region of Turkey. Tropical Doctor, 2002, 32(2):91–92. 10. Gür A et al. Complications of brucellosis in different age groups: a study of 283 cases in southeastern Anatolia of Tur- key. Yonsei Medical Journal, 2003, 44(1):33–44. 11. Giannakopoulos I et al. Presentation of childhood brucellosis in Western Greece. Japanese Journal of Infectious Diseases, 2006, 59(3):160–163. 12. Lubani MM et al. Neurobrucellosis in children. Pediatric Infec- tious Disease Journal, 1989, 8(2):79–82. 13. Al-Eissa YA. Clinical and therapeutic features of childhood neurobrucellosis. Scandinavian Journal of Infectious Diseases, 1995, 27(4):339–343. 14. Bilen S et al. Four different clinical manifestations of neurobru- cellosis (case reports). European Journal of Internal Medicine, 2008, 19:75–77. 15. Ghaydaa A et al. Neuropsychiatric evaluation of patients with brucellosis. Journal of Neurovirology, 2010, 16:48–55. 16. Eren S et al. Cognitive and emotional changes in neurobrucel- losis. Journal of Infection, 2006, 53:184–189. 17. Gul HC, Erdem H, Bek S. Overview of neurobrucellosis: a pooled analysis of 187 cases. International Journal of Infectious Diseases, 2009, 13(6):339–343. 18. Diagnostic and statistical manual of mental disorders, 4th ed (text revision) (DSM-IV-TR). Arlington, Virginia, American Psy- chiatric Association, 2000. 19. Bodur H et al. Neurobrucellosis in an endemic area of bru- cellosis. Scandinavian Journal of Infectious Diseases, 2003, 35:94–97. 20. Franco MP et al. Human brucellosis. Lancet Infectious Diseases, 2007, 7:775–786. 21. Alişkan H. Kültür ve serolojik yöntemlerin insan brusellozu tanisindaki değeri [The value of culture and serological meth- ods in the diagnosis of human brucellosis]. Mikrobiyoloji Bulteni, 2008, 42(1):185–195. 22. Al Dahouk S et al. Laboratory-based diagnosis of brucellosis—a review of the literature. Part II: serological tests for brucellosis. Clinical Laboratory, 2003. 49(11-12):577–589. abnormalities initially suggested the diagnosis of depression, and treatment with anti-psychotic drugs was initiated. The final diagnosis of neurobrucellosis was by positive testing for brucella IgM, the history of raw milk ingestion and the rapid response to a specific treat- ment protocol. We conclude that tic disorder during untreated neurobrucellosis in children is possible, and treatment of brucellosis may be associated with dramatic recovery of tic and co- morbid conditions. Presentation with only psychiatric manifestations is ex- tremely rare, especially in children, and clinicians should keep in mind that neurobrucellosis should be sus- pected in patients who experience unexplainable/unusual psychiatric problems, especially in areas endemic for brucellosis. 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ISSN 1020‑3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نادوسلا بونج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . South Sudan Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Soudan du Sud . Tunisie . Yémen Cover 19-4.indd 2 4/30/2013 10:22:43 AM Contents Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 19 / No. 4 April / Avril 2013 4 ددع / شرع عساتلا دلجلما ليربأ / ناسين V olum e 19 N um ber 4 A pril 2013 World Health Day, 7 April, 2013 Hypertension is a serious health problem both Regionally and globally but it is preventable and treatable. World Health Day 2013 aims to: raise awareness of hypertension and promote behavioural change with respect to its primary prevention, improve the chances of early detection and promote effective management for patients with hypertension. Editorial Universal health coverage ........................................................................................................................................ 305 Research articles Factors affecting the prevalence of chronic diseases in Palestinian people: an analysis of data from the Palestinian Central Bureau of Statistics .................................................................................................... 307 WHO MPOWER tobacco control scores in the Eastern Mediterranean countries based on the 2011 report ........................................................................................................................................................... 314 Geographic epidemiology in a small area: cancer incidence in Baakline, Lebanon, 2000–2008 ...................... 320 Antenatal depression and its predictors in Lahore, Pakistan ...................................................................................327 Physical abuse in basic-education schools in Aden governorate, Yemen: a cross-sectional study ...................... 333 Do personal beliefs and peers affect the practice of alcohol consumption in university students in Lebanon? ................................................................................................................................................ 340 Factors influencing women’s willingness to volunteer in the healthcare system: evidence from the Islamic Republic of Iran ......................................................................................................................................348 Characterization of wound infections among patients injured during the 2011 Libyan conflict ...........................356 Relation between some haematological abnormalities, degree of immunosuppression and viral load in treatment-naïve HIV-infected patients .................................................................................................362 Study of methacholine positivity in patients with chronic cough at Masih Daneshvari hospital, Tehran, 2007–08....................................................................................................................................................... 369 Renal patients’ views on generic prescribing and substitution: example from the United Arab Emirates ...........373 Review Demographics and the social reckoning in the Arab region...................................................................................382 Report Consensus recommendation for meningococcal disease prevention for Hajj and Umra pilgrimage/travel medicine ........................................................................................................................... 389 Case report A case of vocal tic: an unusual presentation of neurobrucellosis ..........................................................................393 Cover 19-4.indd 1 4/30/2013 10:22:42 AM