Eastern Mediterranean Health Journal [2010; Vol.16, Issue 7]

طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ةيبيللا ةيبرعلا ةييرهمالجا . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةينميلا ةيروهملجا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما 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 Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libyan Arab Jamahiriya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Republic of 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 . Jamahiriya arabe libyenne . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar République arabe syrienne . Somalie . Soudan . Tunisie . République du Yémen 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: sabrib@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. 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EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed-Full text on CD-ROM, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2010 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. 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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 Cover 6.indd 2 5/24/2010 11:46:47 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 16 No. 7 7 ددع شرع سداسلا دلجلما•  2010  • Letter from the Editor ..............................................................................................................................................................................................................................................................................................................................709 Research articles International Study of Asthma and Allergies in Childhood: phase 3 in the Syrian Arab Republic Y. Mohammad, K. Tabbah, S. Mohammad, F. Yassine, T. Clayton and M. Hassan .....................................................................................................................................................................................710 Household characteristics and allergen and endotoxin levels in Aleppo, Syrian Arab Republic W. Al Ali, A. Custovic, A. Simpson, A. Khoury and A. Woodcock .............................................................................................................................................................................................................................717 Screening for diabetes in Kuwait and evaluation of risk scores M.M. Al Khalaf, M.M. Eid, H.A. Najjar, K.M. Alhajry, S.A. Doi and L. Thalib ..........................................................................................................................................................................................725 Glycaemic control and its associated factors in type 2 diabetic patients in Amman, Jordan M. Adham, E. Sivarajan Froelicher, A. Batieha and K. Ajlouni ....................................................................................................................................................................................................................................732 Type A behaviour pattern: is it a risk factor for hypertension? J.N. Al-Asadi ..................................................................................................................................................................................................................................................................................................................................................740 Prévalence du surpoids et de l’obésité chez les enfants scolarisés à Tébessa (Algérie) entre 1998 et 2005 S. Taleb, H. Oulamara et A.N. Agli ................................................................................................................................................................................................................................................................................................746 Domestic abuse before, during and after pregnancy in Jahrom, Islamic Republic of Iran E. Mohammadhosseini, L. Sahraean and T. Bahrami .......................................................................................................................................................................................................................................................752 Determinants of maternal adaptation to mentally disabled children in El Minia, Egypt H.I. Awadalla, E.G. Kamel, E.M. Mahfouz, A.A. Mohamed and A.M. El-Sherbeeny ................................................................................................................................................................................759 Effect of group reminiscence therapy on depression in older adults attending a day centre in Shiraz, southern Islamic Republic of Iran F. Sharif, A.Mansouri, I. Jahanbin and N. Zare .....................................................................................................................................................................................................................................................................765 Proposal for a modernized Iranian notifiable infectious diseases surveillance system: comparison with USA and Australia F.E.F. Azar, N. Masoori, Z. Meidani and L. Paul .................................................................................................................................................................................................................................................................771 L’infection à Helicobacter pylori chez 755 patients présentant des symptômes digestifs : Institut Pasteur du Maroc, 1998-2007 H. Amrani Hassani Joutei, A. Hilali, T. Fechtali, N. Rhallabi et H.Benomar .......................................................................................................................................................................................................778 Prevalence and antibiotic resistance of Pseudomonas aeruginosa isolated from swimming pools in northern Greece I. Tirodimos, M. Arvanitidou, T. Dardavessis, A. Bisiklis and S. Alexiou-Daniil .....................................................................................................................................................................................783 Analysis of prescriptions dispensed at community pharmacies in Nablus, Palestine A.F. Sawalha, W.M. Sweileh, S.H. Zyoud, S.W. Al-Jabi, F.F. Bni Shamseh and A.A. Odah ......................................................................................................................................................................788 Evaluation of the level of micronutrients in fortified foods in Alexandria, Egypt S. Mohamed, M. El-Tawila, H. Ismail and N.F. Gomaa ...................................................................................................................................................................................................................................................793 Dental visit patterns and periodontal treatment needs among Saudi students J.M.A. Farsi ...................................................................................................................................................................................................................................................................................................................................801 Letter to the Editor .......................................................................................................................................................................................................................................................................................807 المجلة الصحية لشرق المتوسط المجلد السادس عشر العدد السابع 907 رسالة من المحرر rotidE eht morf retteL  ,)sDCN( sesaesid elbacinummocnon dna cinorhc ot detaler erew htaed fo sesuac gnidael 01 eht fo 5 ,yrutnec ts12 eht fo tesno eht tA shtaed ,yllabolg taht stsacerof )OHW( noitazinagrO htlaeH dlroW eTh .seirujni dna ecneloiv ,htlaeh latnem ,seicneicfied lanoitirtun  )%72( noiger nacirfA eht ni detcejorp sesaercni tsetaerg eht htiw ,edaced tnerruc eht revo %71 yb esaercni ot ylekil era sDCN morf .)%52( naenarretideM nretsaE eht yb dewollof ksir elbatneverp erahs dna sDCN tnenimorp tsom eht era setebaid dna esaesid yrotaripser cinorhc ,recnac ,esaesid ralucsavoidraC .lohocla fo esu lufmrah eht dna ytivitcani lacisyhp ,teid yhtlaehnu ,esu occabot ,elpmaxe rof ,selytsefil ot detaler srotcaf  dna noitneverP eht rof ygetartS labolG eht rof nalP noitcA eht gnisrodne noituloser a dessap ylbmessA htlaeH dlroW eht ,8002 nI  ,3102 dna 8002 neewteb detnemelpmi eb ot snoitca ,sevitcejbo tuo stes nalP noitcA eTh .sesaesiD elbacinummocnoN fo lortnoC  dna -wol no sucof ralucitrap a htiw ,slevel labolg dna lanoiger ,lanoitan ta OHW fo krow eht ediug ot srotacidni ecnamrofrep dna .snoitalupop elbarenluv dna seirtnuoc emocni-elddim  .nalP noitcA DCN eht  ni  defiitnedi  sa )tenDCN( krowteN esaesiD elbacinummoCnoN labolG eht  dehcnual OHW ,9002 nI hcraeser ,aimedaca ,snoitazinagro latnemnrevogretni ,seicnega NU fo desirpmoc tnemegnarra evitaroballoc yratnulov a si tenDCN tabmoc ot stroffe detnemgarf yltnerruc etinu ot smia tenDCN .ytinummoc ssenisub eht dna snoitazinagro latnemnrevognon ,sertnec ,lortnoc occabot htiw rehtegot seitinummoc esaesid yrotaripser dna setebaid ,esaesid ralucsavoidrac ,recnac eht gnignirb yb sDCN  sa hcus ,srekam-ycilop gnicaf segnellahc yek eht fo emos elkcat ot stpmetta krowten eTh .setacovda ytivitca lacisyhp dna steid yhtlaeh evitca yllacimonoce eht gnoma sessol cimonoce dna htlaeh eziminim ot woh ,ytrevop dna sDCN neewteb sknil eht sserdda ot woh .sDCN htiw elpoep fo srebmun gniworg morf gnitluser smetsys htlaeh no serusserp eht rof eraperp ot woh dna ,noitalupop dna weiver ot sredlohekats yek rehtegot thguorb hcihw tenDCN fo muroF labolG tsrfi eht denevnoc OHW ,raey siht yraurbeF nI ro detneverp eb nac sDCN eht fo ynaM .sDCN yb desop nedrub tnempoleved dna htlaeh labolg eht elkcat ot stroffe ecnavda  ,noitneverp yramirp ot detaler esoht ylralucitrap ,snoitnevretni hcus ni gnitsevnI .snoitnevretni desab-ecnedive ,elbadroffa yb detaert fo noitazilibom fo gninnigeb eht stneserper muroF labolG eTh .smret cimonoce dna htlaeh ni nruter tsehgih eht edivorp nac -elddim dna -wol  ni  sDCN fo lortnoc dna noitneverp eht  etomorp ot  semmargorp gnidliub-yticapac fo troppus ni  sredlohekats .seirtnuoc emocni مع بزوغ فجر القرن الحادي والعشرين، كان نصف الأسباب الرئيسية للوفاة تتعلق بالأمراض المزمنة والأمراض غير السارية، والأعواز التغذوية، والصحة النفسية، والعنف والإصابات. تتنبأ منظمة الصحة العالمية باحتمال زيادة الوفيات الناجمة عن الأمراض غير السارية على الصعيد العالمي، بنسبة تبلغ 71% على النسبة المسجَّ لة خلال الِعقد الحالي، مع توقُّ ع حدوث أكبر الزيادات في الإقليم الأفريقي (72%) يتبعه في ذلك إقليم شرق المتوسط (52%). وتتمثَّل أبرز الأمراض غير السارية في الأمراض القلبية الوعائية، والسرطان، والأمراض التنفسية المزمنة، وداء السكَّ ري، كما أنها تتشارك في عوامل الخطر الممكن توقِّ يها والمتعلِّ قة بأنماط الحياة، ومن هذه العوامل على سبيل المثال تعاطي التبغ، والُنُظم الغذائية غير الصحية، وانعدام النشاط البدني، والاستخدام الضار للكحوليات. وفي عام 8002، اعتمدت جمعية الصحة العالمية قرارًا صادقت به على خطة العمل المعنية بالاستـراتيجية العالمية للوقاية من الأمراض غير السارية ومكافحتها. وقد أوضحت هذه الخطة مجموعة من الأهداف والأعمال التي يتعينَّ تنفيذها بين عاَمْي 8002 و3102، علاوة على اشتمالها على مؤشرِّ ات الأداء التي توجِّ ه عمل المنظمة على المستويات الوطنية والإقليمية والعالمية، مع التـركيز بصورة خاصة على البلدان المنخفضة والمتوسطة الدخل والمجموعات السكانية المستضعفة. وفي عام 9002، أنشأت منظمة الصحة العالمية الشبكة العالمية للأمراض غير السارية (tenDCN)، وفقًا للخطة العملية للأمراض غير السارية. وهي شبكة تعاونية طوعية َتُضّم وكالات الأمم المتحدة، والمنظمات الحكومية الدولية، والجامعات، ومراكز البحوث، والمنظمات غير الحكومية، ورجال الأعمال. وتهدف الشبكة إلى توحيد الجهود المتناثرة لمكافحة الأمراض غير السارية من خلال َضّم المجتمعات التي تكافح مرض السرطان، والأمراض القلبية الوعائية، وداء السكَّ ري، والأمراض التنفسية إلى الجهات المناصرة لمكافحة التدخين، والتي تدعو إلى اتِّباع الُنُظم الغذائية السليمة لممارسة الأنشطة البدنية. كما يحاول القائمون على الشبكة التصدِّ ي لبعض التحدِّ يات الأساسية التي تواجه راسمي السياسات، مثل التعاطي مع الصلات التي تربط الأمراض غير السارية بالفقر، وكيفية تقليص الخسائر الصحية والاقتصادية بين السكان النشطين اقتصاديًا، وكيفية الاستعداد للضغوط المتوقعة على الُنُظم الصحية بسبب الأعداد المتنامية من المصابين بالأمراض غير السارية. وفي شهر شباط/فبراير من هذا العام، َعَقَدت منظمة الصحة العامية المنتدى العالمي الأول لشبكة الأمراض غير السارية، الذي َضمَّ الأطراف المعنية الرئيسية؛ من أجل استعراض ودفع الجهود المبذولة للتعامل مع العبء العالمي الذي تفرضه الأمراض غير السارية على الصحة والتنمية. والجدير بالذكر، أن العديد من الأمراض غير السارية يمكن توقِّ يها أو معالجتها من خلال تدخلات زهيدة التكلفة وُمْسَنَدة بالبيِّنات. ويمكن أن يوفِّ ر الاستثمار في مثل هذه التدخلات، ولاسيَّما تلك التي تتعلَّ ق بالوقاية الأولية، أعلى العوائد في ما يخص الصحة والاقتصاد. وُيَعدُّ المنتدى العالمي بمثابة الخطوة الأولى نحو استنهاض وحشد الأطراف المعنية الرئيسية لدعم برامج بناء القدرات التي تستهدف تعزيز الوقاية من الأمراض غير السارية ومكافحتها في البلدان المنخفضة والمتوسطة الدخل. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 710 International Study of Asthma and Allergies in Childhood: phase 3 in the Syrian Arab Republic Y. Mohammad,1 K. Tabbah,2 S. Mohammad,3 F. Yassine,1 T. Clayton 4 and M. Hassan 5 ABSTRACT The International Study of Asthma and Allergies in Childhood (ISAAC) uses standardized symptom- based questionnaires to describe the prevalence of symptoms of asthma, rhinoconjunctivitis and eczema in children worldwide. Three governorates in the Syrian Arab Republic (Aleppo, Lattakia and Tartous) participated in ISAAC phase 3 in 2001–03. Adolescents in the 13–14 year age group and parents of the 6–7-year-old children completed the questionnaire about asthma symptoms. The prevalence of current symptoms of asthma (wheezing in the last 12 months) in different centres ranged from 4.7% to 5.7% for 6–7-year-olds and 3.9% to 6.5% for 13–14-year-olds. In 13–14-year-olds the prevalence of severe speech-limiting wheeze was 2.0%–3.5%, of rhinoconjunctivitis was 8.6%–14.6% and of eczema was 3.3%–4.2%. 1Department of Internal Medicine; 5High Institute of Maritime Research, Tishreen University, Lattakia, Syrian Arab Republic (Correspondence to Y. Mohammad: mohamyou@scs-net.org). 2Department of Internal Medicine, Pulmonary Section, University of Aleppo, Aleppo, Syrian Arab Republic. 3Department of Paediatrics, Military Health Services, Lattakia, Syrian Arab Republic. 4Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand. Received: 02/10/08; accepted: 11/12/08 ةيروسلا ةيبرعلا ةيروهملجا في ةثلاثلا ةلحرلما :ةلوفطلا في ةَّيِجَرَلأاو وبرلا لوح ةيلود ةسارد نسح دنهم ،نوتيلاك دات ،ينساي ةمطاف ،دممح ةيرمس ،عابط نودلخ ،دممح سري وبرلا ضارعأ راشتنا ل َّدعم فصول ،ضارعلأا لىع زكتري ًايسايق ًانايبتسا ةلوفطلا في ةَّيِجَرَلأاو وبرلا لوح ةيلودلا ةساردلا مدختست :ةـصلالخا – 2001 ماوعلأا في ثلاثلا روطلا في ةيروس في ةساردلا هذه في ْتهماس دقو .لماعلا ءاجرأ فلتمخ في ،لافطلأا في مايزكلإاو ةمحتللماو فنلأا باهتلاو رماعأ في مه نمم لافطلأ ءابلآاو ،ًاماع 14و 13 ينب حواترت رماعأ في مه نمم نوقهارلما فىوتسا دقو ،سوطرطو ةيقذلالاو بلح يه تاظفامح ةثلاث 2003 في )ةيرخلأا ةشرع ينثلإا رهشلأا للاخ زيزأ( ليالحا وبرلا ضارعلأ راشتنلاا ل َّدعم حوارتو .وبرلا ضارعأ لوح ًانايبتسا ،تاونس 7و 6 ينب حواترت رماعأب ينقهارلما ىدل امأ ،ًاماع 14 – 13 رماعأب ينقهارلما ىدل %6.5 لىإ %3.9 نمو ،تاونس 7- 6 رمعب لافطلأا ىدل %5.7 لىإ %4.7 نم زكارلما فلتمخ ميهدل ةمحتللماو فنلأا باهتلا راشتنا ل َّدعم غلب مايف ،%3.5 - %2 ملاكلا ةيناكمإ نم ّديح يذلا ديدشلا زيزلأا راشتنا ل َّدعم غلب دقف ،ًاماع 14و 13 .%4.2 – %3.3 ميهدل مايزكلإا راشتنا ل َّدعم غلبو ،%14.6 - %8.6 Étude internationale de l’asthme et des allergies de l’enfant : phase 3 en République arabe syrienne RÉSUMÉ L’étude internationale de l’asthme et des allergies de l’enfant (ISAAC) utilise des questionnaires standardisés basés sur les symptômes de l’asthme, de la rhinoconjonctivite et de l’eczéma touchant les enfants dans le monde entier. Entre 2001 et 2003, trois gouvernorats de la République arabe syrienne (Alep, Lattaquié et Tartous) ont participé à la phase 3 de l’ISAAC. Les adolescents appartenant à la tranche d’âge 13-14 ans et les parents d’enfants âgés de 6 à 7 ans ont rempli le questionnaire concernant les symptômes de l’asthme. La prévalence des symptômes actifs de l’asthme (sifflement respiratoire au cours des 12 derniers mois) dans différents hôpitaux était comprise entre 4,7 % et 5,7 % pour les enfants âgés de 6 à 7 ans et entre 3,9 % et 6,5 % pour ceux âgés de 13 à 14 ans. Au sein du groupe des 13-14 ans, la prévalence du sifflement respiratoire sévère limitant la parole était comprise entre 2,0 % et 3,5 %, celle de la rhinoconjonctivite variait entre 8,6 % et 14,6 % et celle de l’eczéma oscillait entre 3,3 % et 4,2 %. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 711 Introduction There is a wide consensus that the preva- lence of asthma and allergies are on the  increase among children worldwide [1].  In some industrialized countries, asthma  and  allergies  have  reached  alarming  proportions, affecting up to one-third of  children within  the general population  [2]. While  the  prevalence  of  asthma  has been well-documented  in  the past  30 years,  variations  in  study methods  and  the  lack of uniform diagnostic cri- teria make direct comparison between  studies difficult.  In addition,  few of  the  studies of prevalence were completed  in developing countries. The  Interna- tional Study of Asthma and Allergies in  Childhood (ISAAC)  is a collaborative  project which has developed a  stand- ardized methodology  to describe  the  prevalence and severity of symptoms of  asthma, rhinoconjunctivitis and eczema  in children throughout the world [3,4].  The aim of  ISAAC  is  to  compare  the prevalence of allergic disorders be- tween populations in different countries  by using  standard validated questions,  thereby providing a  framework  for  re- search into possible modifiable lifestyle  and  environmental  factors  affecting  these disorders that may ultimately lead  to a  reduction  in  the personal burden  of allergic diseases [3,4]. Many centres  from developing  countries were  able  to participate  in ISAAC because of  the  simplicity of the questionnaires [4]. The  data  collected  by  ISAAC provides  a  unique  illustration of  the prevalence of  current symptoms of asthma, rhinocon- junctivitis and eczema  in children and  adolescents worldwide [5]. ISAAC Phase One (1992–97) pro- vided standardized data concerning the  prevalence of symptoms of asthma, rhi- noconjunctivitis and eczema  from 156  centres  in 56 countries.  ISAAC Phase  Three was  a  repeat  of  Phase One  to  investigate the trends in the prevalence  of  allergic  diseases  in  centres  which  participated  in  Phase  One  (ISAAC  Phase Two was a more intensive study  which examined objective markers of  asthma and allergies in children living in  specific centres [6]). New centres were  also accepted  in Phase Three  in order  to  extend  the database of  prevalence  around the world. The survey included  238 participating centres from 98 coun- tries including 3 centres from the Syrian  Arab Republic [7,8]. This paper reports  data on  the prevalence and burden of  asthma and other atopic diseases  from  the Syrian centres in order to provide a  basis for present and future national and  international comparisons. Methods Study areas The 3 centres in the Syrian Arab Repub- lic (Aleppo, Lattakia and Tartous) that  participated in ISAAC Phase Three were  chosen primarily because enthusiastic  researchers were present in each centre,  but also because  the centres provided  some  interesting contrasts: Aleppo has  a  very dry climate, while Lattakia  and  Tartous are both located in coastal areas  and Tartous experiences considerable  air pollution  from  industrial  activities  (e.g. oil refineries).  The  study  in  Aleppo was  carried  out in April 2001. The study in Lattakia  was carried out in February and March  2003  for  the 6–7-year-olds,  and  from  April 2001  to November 2002  for  the  13–14-year-olds. The study  in Tartous  was  carried out  from March 2001  to  November 2002 for the 6–7-year-olds,  and  from April 2001 to October 2002  for 13–14-year-olds. Sample For  ISAAC Phase Three  a  sample of  3000 13–14-year-olds was mandatory  for all  centres and a  second sample of  3000 6–7-year-olds was optional. The  ISAAC steering committee calculated  that a sample size of 3000 was necessary  to be  representative of children within  the general population and to provide suf- ficient power for the study [9]. The core  questionnaire was mandatory, while the  video questionnaire  (13–14-year-age  group  only)  and  the  environmental  questionnaire were  recommended but  optional due  to expected difficulties  in  some low-income countries [10]. In  Lattakia,  Tartous  and Aleppo,  schools  were  randomly  selected  to  ensure  that  the  sample of  schools was  representative  of  the wider  commu- nity. The number of  schools  surveyed  for  the 13–14 year  age group was 14  for Tartous, 13  for Lattakia and 11  for  Aleppo. For the 6–7 year age group 24  schools were surveyed  in Tartous and  16  in Lattakia  (Aleppo  included only  the 13–14-year-olds). All pupils  in  the  class and age range were approached. A  second visit was made to the schools if  necessary  to  recruit  students absent at  the initial visit. Ethical  approval  for  the  study was  given by the Ministry of Higher Educa- tion and the Ministry of Education. Questionnaires A questionnaire with separate modules  for  symptoms  of  asthma,  rhinocon- junctivitis and eczema was designed for  ISAAC Phase One  and Phase Three,  and administered  to pupils  aged 6–7  years  and 13–14 years  [9]. The ques- tionnaires were designed by the ISAAC  steering  committee  and  have  been  validated  for  specificity  and  sensitiv- ity  [9]. Phase Three also  including an  optional environmental questionnaire  which  examined  etiological  factors.  Students aged 13–14 years  responded  in  the classroom to a self-administered  8-page questionnaire (Arabic version)  after  a brief written  and verbal  expla- nation  from  the  research  staff  under  examination conditions. For  the 6–7  year age group, parents were met by the  research team and filled in the core and  environmental questionnaires but not  the video questionnaire. The main outcome measures in this  study, obtained  from responses  to  the  core questionnaires, were  the  current  prevalence  of  symptoms  of  asthma  EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 712 (wheezing in the last 12 months), rhi- noconjunctivitis  and eczema. Stand- ard  ISAAC  definitions  were  used:  asthma (wheezing or whistling  in  the  chest); current  rhinoconjunctivitis (a  problem with sneezing or a  runny or  blocked nose when you did not have a  cold or flu and accompanied by itchy,  watery eyes); and eczema (itchy rash  at  any  time affecting  folds of  the  el- bows, behind the knees, in front of the  ankles, under  the buttocks or around  the  neck,  ears  or  eyes). The degree  of  control  and  severity  of  wheeze  was also measured by  the core ques- tionnaire. Persistency of  symptoms  and uncontrolled  chronic disease  is  measured by sleep disturbance (been  woken by asthma symptoms in the last  12 months), while severe episodes are  indicated by attacks of speech-limiting  wheeze.  As  recommended  by  the  ISAAC  protocol,  the  core questionnaire was  followed by an optional video question- naire  for  the  13–14  year  age  group.  The  rationale  for  the video question- naire was  that by showing rather  than  describing  the signs and symptoms of  asthma to children, the video question- naire  would  provide more  accurate  recognition of  clinical  asthma  symp- toms  and  allow more  confidence  in  comparisons between populations with  different  cultures  and  languages. The  video  showed 5  sequences  related  to  asthma  symptoms and  severity. After  viewing  each  sequence,  participants  answered  specific  questions  about  moderate wheezing at  rest; wheezing  and shortness of breath after exercise;  nocturnal wheezing; nocturnal cough;  and severe wheezing and shortness of  breath at rest. The environmental  questionnaire  was  included  in all 3 Syrian centres. A  detailed analysis of the data will be pre- sented in a subsequent paper. Analysis Prevalence  values were  generated  at  the  ISAAC  international  data  centre  in Auckland, New Zealand,  and  ana- lysed using SAS,  version 9. Additional  analyses were completed  in  the Syrian  Arab Republic  to  examine  the  agree- ment between  the written  and  video  questionnaires. Results The  response  rate was  99.5%  for  the  6–7 year age group and 98.0%  for  the  13–14 year  age  group. Details of  the  demographic  characteristics  of  the  centres are presented  in Tables 1 and  2. The data from the 3 centres together  included more females than males, with  48.6% males for the 6–7 year age group  and 44.6% males for the 13–14 year age  group. There were  statistically  signifi- cant differences between the centres in  the age and sex distribution of respond- ents within each age group (Tables 1 and 2). Core written questionnaire The prevalence of  current  symptoms  of  asthma  (wheezing  in  the  last  12  months)  in  the  6–7  years  age  group  were  5.7%  and  4.7%  in Tartous  and  Lattakia respectively. For current symp- toms of  rhinoconjunctivitis  the figures  were  5.0%  and  2.4%  and  for  current  symptoms of  eczema 2.7%  and 3.9%  (Table 3). The prevalence of  current  symptoms of asthma (wheezing  in  the  last  12 months)  in  13–14-year-olds  were 3.9%, 6.5% and 5.1%  in Tartous,  Lattakia and Aleppo  respectively. The  corresponding  figures  for  rhinocon- junctivitis were 8.6%, 10.1% and 14.6%  and  for  eczema were 4.2%,  3.3% and  4.1% (Table 4). The prevalence of severe speech-limiting  wheeze  in  the  last 12 months  for  the  6–7-year-olds were 2.3% and 2.0% from  Tartous and Lattakia  respectively and  for  13–14-year-olds were 2.2%,  3.5%  and 2.0%  from Tartous, Lattakia  and  Aleppo respectively (Tables 3 and 4). The prevalence of sleep disturbance  for 6–7-year-olds was 5.3% and 2.9% for  Lattakia and Tartous  respectively and  for 13–14-year-olds was 4.5%, 3.2% and  2.6%  for Lattakia, Tartous and Aleppo  respectively (Tables 3 and 4). Video questionnaire In  the 13–14-year-olds  the prevalence  of symptoms of asthma, rhinoconjunc- tivitis and eczema were different based  on  the video questionnaire (Table 5)  than  the  written  core  questionnaire  Table 1 Demographic characteristics of the 6–7-year-old pupils Variable Tartous (n =2734) Lattakia (n = 2373) Total (n = 5107) No. % No. % No. % Age (years) a 6 1925 81.1 988 36.1 2913 57.0 7 448 18.9 1745 63.8 2193 42.9 8 – – 1 0.0 1 0.0 Sex a Male 1093 46.1 1390 50.8 2483 48.6 Female 1280 53.9 1344 49.2 2624 51.4 aChi-squared test for difference between centres, P < 0.001. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 713 (Table 4). However  the prevalence of  the main outcome measure—wheezing  in the last 12 months—from the video  questionnaire was similar to the written  questionnaire: 3.9%  for Tartous, 5.1%  for Lattakia and 6.2% for Aleppo. Agreement  between  the written  and video questionnaires in the 3 Syr- ian centres combined was assessed us- ing the kappa coefficient. This analysis  was based only on those pupils who re- sponded to both the video and written  questionnaires. The kappa values were:  for wheezing in the last 12 months κ =  0.22,  for ever wheezing κ = 00.20,  for  exercise wheeze κ = 0.05, for nocturnal  cough κ = 0.06 and for severe episodes  κ = 0.19. Once again, we found the best  agreement was for current wheeze. Comparisons between centres For  the 6–7 year age group there was  a general pattern  for Lattakia  to  show  a  lower prevalence of  symptoms  than  Tartous but  this was only  statistically  significant  for  ever  wheezing  [odds  ratio  0.62,  95%  confidence  interval:  0.45–0.86] (Table 3). For  the 13–14  year  age group written questionnaire  the pattern was reversed, with Lattakia  generally showing a higher prevalence  of  symptoms  than Tartous.  For  the  majority of  symptoms  the difference  was  statistically  significant (Table 4).  The prevalence values for Aleppo were  by and large intermediate between Tar- tous and Lattakia, with the exception of  night cough and rhinoconjunctivitis, for  which Aleppo showed a higher preva- lence than Tartous and Lattakia (Table  4). From the video questionnaire for the  13–14-year-age group Lattakia again  showed  generally  higher  symptom  prevalences than Tartous, although only  current wheeze  and  current  exercise  Table 2 Demographic characteristics of the 13–14-year-old pupils Variable Tartous (n = 2995) Lattakia (n = 3010) Aleppo (n = 3063) Total (n = 9068) No. % No. % No. % No. % Age (years) a 11 – – – – 152 5.0 152 1.7 12 1 0.0 – – 971 31.7 972 10.7 13 2201 73.5 2088 69.4 1347 44.0 5636 62.2 14 793 26.5 922 30.6 496 16.2 2211 24.4 15 – – – – 91 3.0 91 1.0 16 – – – – 4 0.1 4 0.0 Missing data – – – – 2 0.0 2 0.0 Sex a Male 1420 47.4 1075 35.7 1551 50.6 4046 44.6 Female 1575 52.6 1935 64.3 1512 49.4 5022 55.4 aChi-squared test for difference between centres, P < 0.001. Table 3 Prevalence of symptoms of asthma, rhinoconjunctivitis and eczema in the 6–7 year age group Variable Tartous (n = 2734)a Lattakia (n = 2373) Total (n = 5107) No. % No. % OR (95% CI)b No. % Wheezing ever 317 11.6 188 7.9 0.62 (0.45–0.85) 505 9.9 Wheezing in the last 12 months 156 5.7 111 4.7 0.76 (0.51–1.13) 267 5.2 Sleep disturbance 146 5.3 69 2.9 0.17 (0.11–0.27) 215 4.2 Severe wheeze in the last 12 months (speech-limiting) 64 2.3 47 2.0 0.88 (0.48–1.63) 111 2.2 Exercise wheeze in the last 12 months 113 4.1 62 2.6 0.58 (0.30–1.11) 175 3.4 Night cough in the last 12 months 453 16.6 362 15.3 0.89 (0.61–1.30) 815 16.0 Asthma ever 123 4.5 93 4.0 0.85 (0.55–1.31) 216 4.5 Rhinoconjunctivitis symptoms in the last 12 months 137 5.0 95 2.4 0.82 (0.55–1.23) 232 2.5 Eczema symptoms in the last 12 months 73 2.7 56 3.9 0.89 (0.54–1.46) 129 4.2 aReference category (Lattakia versus Tartous); bAdjusted for age and sex. OR = odds ratio; CI =confidence interval. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 714 wheeze  showed statistically  significant differences (Table 5).  However, in contrast to the written questionnaire, Aleppo in gen- eral showed higher prevalence values than Lattakia and Tartous (Table 5). Discussion Two  large  international  studies—ISAAC  in children and  the  European Community Respiratory Health Survey (ECRHS)  in adults—have studied  the prevalence of asthma and allergic  rhinoconjunctivitis worldwide  through  the use of  standardized  questionnaires. Based on  their  results,  there are approximately  300 million people with asthma worldwide, and asthma  is  the  25th ranked cause of a reduction in disability-adjusted life years  [1]. ISAAC provides a unique opportunity for developing coun- tries  to participate  in a multi-centre  international study and the  ISAAC survey  in  the Syrian Arab Republic has provided  the  first  ever  assessments of  the prevalence of  self-reported aller- gies  in  local  children using  standardized methods. Our  study  illustrates the burden of atopic diseases in Syrian schoolchildren.  Based on  the written questionnaire,  the prevalence of  current  symptoms of asthma defined as wheezing the last 12 months in  different centres ranged from 4.7%–5.7% for 6–7-year-olds and  3.9%–6.5% for 13–14-year-olds. These results form the basis for  local, regional and international comparisons. As  a  comparison,  the prevalence of  current  symptoms of  asthma among 13–14-year-olds in other countries of the Medi- terranean, Middle East  and North Africa who participated  in  ISAAC Phase Three was 14.6%  in Malta, 10.4%  in Morocco,  8.7%  in Algeria,  13.2%  in  Islamic Republic of  Iran,  11.7%  in  Pakistan and 7.6%  in Kuwait [11]. Prevalence rates around the  world  range  from 3.4%  in Albania  to 31.2%  in  the  Isle of Man  [11]. Analysis of  time  trends  for countries who participated  in  Phase One and Phase Three showed that, while the prevalence of  current symptoms of asthma appears to have reached a plateau  in industrialized countries, it is increasing in developing countries  [5,11]. As noted earlier,  there  are differences between  the Syrian  centres with respect to climate (dry in Aleppo, coastal in Tartous  and Lattakia) and exposure to air pollution (polluted in Tartous).  However there were no obvious associations between these fac- tors and the differences  in prevalence of symptoms. The lowest  prevalence values were generally  found  in Lattakia  for  the 6–7  year age group and in Tartous for the 13–14 year age group. The  planned analysis of  the environmental questionnaire data may  provide  further  insight  into  factors  that may be associated with  the differences  in prevalence of  symptoms between  the Syrian  centres. The Global  Initiative  for Asthma  (GINA) Global burden of asthma 2004 report notes  that  although written questions Ta bl e 4 Pr ev al en ce o f s ym pt om s of a st hm a, rh in oc on ju nc ti vi ti s an d ec ze m a in th e w ri tt en q ue st io nn ai re in th e 13 –1 4 ye ar a ge g ro up Va ri ab le Ta rt ou s (n = 2 99 5) a La tt ak ia (n = 3 0 10 ) A le pp o (n = 3 0 63 ) To ta l ( n = 90 68 ) N o. % N o. % O R (9 5% C I)b N o. % O R (9 5% C I)b N o. % W he ez in g ev er 23 0 7.7 35 2 11 .7 1.6 9 (1. 21 –2 .3 7) 26 9 8. 8 1.1 5 (0 .7 4– 1.7 7) 85 1 9. 4 W he ez in g in th e la st 12 m on th s 11 8 3. 9 19 5 6. 5 1.7 6 (1. 27 –2 .4 4) 15 7 5. 1 1.3 7 (0 .8 6– 2. 20 ) 47 0 5. 2 Sl ee p di st ur ba nc e 96 3. 2 13 5 4. 5 0 .4 6 (0 .3 5– 0 .6 2) 81 2. 6 0 .6 9 (0 .4 9– 0 .9 8) 39 4 4. 3 Se ve re w he ez e in th e la st 12 m on th s (s pe ec h lim iti ng ) 66 2. 2 10 5 3. 5 1.7 5 (1. 35 –2 .2 7) 62 2. 0 0 .9 0 (0 .5 4– 1.5 1) 23 3 2. 6 Ex er ci se w he ez e in th e la st 12 m on th s 36 4 12 .2 36 6 12 .2 1.0 5 (0 .7 4– 1.4 8) 39 1 12 .8 1.0 6 (0 .7 7– 1.4 6) 11 21 12 .4 N ig ht c ou gh in th e la st 12 m on th s 47 3 15 .8 62 6 20 .8 1.4 5 (1. 0 1– 2. 0 8) 84 8 27 .7 2. 0 8 (1. 41 –3 .0 7) 19 47 21 .5 A st hm a ev er 13 9 4. 6 18 3 6. 1 1.4 4 (1. 17 –1 .7 9) 14 1 4. 6 0 .9 1 ( 0 .7 4– 1.1 1) 46 3 5. 1 Rh in oc on ju nc tiv iti s s ym pt om s i n th e la st 12 m on th s 25 8 8. 6 30 3 10 .1 1.1 9 (0 .7 9– 1.7 7) 44 6 14 .6 1.8 7 (1. 22 –2 .8 8) 10 0 7 11 .1 Ec ze m a sy m pt om s i n th e la st 12 m on th s 12 5 4. 2 10 1 3. 3 0 .8 2 (0 .5 1– 1.3 2) 12 5 4. 1 0 .9 6 (0 .6 3– 1.4 7) 35 1 3. 9 a R ef er en ce ca te go ry (L at ta ki a an d Al ep po v er su s T ar to us ); b A dj us te d fo r a ge a nd se x. O R = od ds ra tio ; C I = co nfi de nc e in te rv al طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 715 about current wheeze are validated  for  a worldwide asthma prevalence survey,  the airway hyper-responsiveness chal- lenge  tests  in clinical practice are posi- tive in only 50% of individuals reporting  current wheeze  [1]. This  suggests  that  when wheezing  is  transient  and  very  mild  it  does not have  any  significant  impact on  the  individual  patient  and  does not require clinical care. According  to the GINA report an arbitrary figure of  50% of the prevalence of current wheez- ing  in children (self-reported wheezing  in  the  previous  12-month  period  in  13–14-year-old children) was used as  the prevalence of  clinical  asthma. Ac- cordingly  they  reported  that  the mean  prevalence of  clinical  asthma  for  the  Middle East was 5.8%, and for the Medi- terranean was 3.9%. However hyper- responsiveness  is  the most  common  test used  to confirm asthma diagnosis  in a clinical setting but not in the general  population. Hyper-responsiveness  is  not a good marker for asthma in popula- tions (as opposed to a clinical setting in  patients describing asthma symptoms)  and questionnaire-based prevalence  is  an appropriate methodology for epide- miological studies, which is the case for  ISAAC and the ECRHS [12,13]. The language used for the question- naire in our study was Arabic. Miller et  al.  studied  the  accuracy of  the Arabic  version  of  ISAAC  [14]. Their  study  compared physician diagnosis of asth- ma in children reporting current wheeze  in  the video or written questionnaires.  In this context the written questionnaire  showed good agreement with physician  diagnosis, except for the question about  exercise-induced asthma symptoms.  In  inner-city  schools  in  the United  States of America, a survey using a brief  questionnaire derived from the ISAAC  wheezing questionnaire  showed 60%  underdiagnosis of asthma. After valida- tion of the diagnosis by a physician the  authors concluded  that  school  screen- ing of asthma by questionnaire is a valid  tool even  in deprived populations and  regardless of the language [15]. Crane et  al.  published a paper on  behalf of  the  ISAAC Phase One study  group about  the degree of  agreement  between  the written  and  video ques- tionnaires,  focusing on current wheeze  and  comparing  the  results  between  regions,  language groups  and centres  [16]. They  concluded  that  the  video  questionnaire  gave  lower  prevalence  estimates, but the overall correlation be- tween the measures was good. The pro- portion of agreement was high (mean  0.89). The chance-corrected agreement  measured using  the kappa coefficient  varied between centres (0.45  to 0.10).  In our Syrian centres  the correspond- ing kappa value for current wheeze was  0.22. Crane  et  al.  concluded  that  the  ISAAC core written questionnaire  is  a valuable  tool  for comparison of data  between centres and for examining time  trends. These  results were used by  the  State of world allergy report 2008 [5]. Van Sickle noted that in developing  countries which have a high burden of  respiratory diseases other  than asthma,  the ISAAC video questionnaire may be  helpful  for  training practitioners  to  im- prove their diagnosis and management  of asthma [17]. A more challenging issue is that the  prevalence  of  severe  speech-limiting  wheeze ranged from 2.0%–2.3% for the  6–7-year-olds and 2.0%– 3.5% and  for  13–14-year-olds,  and  the prevalence  of  sleep disturbance once or more per  week ranged from 2.9% –5.3% in pupils  aged 6–7 years  and  from 2.6%–4.5%  of  pupils  aged  13–14  years  in  these  Syrian cities. This  is  alarming because  the  symptoms  experienced  by  these  children  indicate  that  their  asthma  is  not under control. Other countries of  the  region  have  a  similar  prevalence  of  severe  symptoms,  indicating poor  management of asthma [1]. The  prevalence  of  asthma  in  the  Eastern Mediterranean Region  is high  and deserves consideration as a public  health  priority,  in  concordance with  the WHO resolution  in  the year 2000  identifying chronic respiratory diseases Ta bl e 5 Pr ev al en ce o f s ym pt om s of a st hm a in th e vi de o qu es ti on na ir e in th e 13 –1 4 ye ar a ge g ro up Va ri ab le Ta rt ou s( n = 27 67 )a La tt ak ia (n = 2 91 3) A le pp o (n = 3 0 54 ) To ta l ( n = 87 34 ) N o. % N o. % O R (9 5% C I)b N o. % O R (9 5% C I)b N o. % W he ez in g ev er 15 9 5. 7 19 5 6. 7 1.2 5 (0 .9 4– 1.6 6) 29 1 9. 5 1.7 0 (1 .2 2– 2. 38 ) 64 5 7.4 W he ez in g in th e la st 12 m on th s 10 8 3. 9 14 9 5. 1 1.4 3 (1. 0 1– 2. 0 2) 18 8 6. 2 1.6 0 (1 .10 –2 .3 2) 44 5 5. 1 Se ve re w he ez e in th e la st 12 m on th s 74 2. 7 95 3. 3 1.2 9 (0 .8 4– 1.9 9) 11 5 3. 8 1.3 2 (0 .8 3– 2. 11 ) 28 4 3. 3 Ex er ci se w he ez e in th e la st 12 m on th s 17 0 6. 1 28 4 9. 7 1.7 9 (1. 26 –2 .5 5) 31 4 10 .3 1.7 1 ( 1.1 7– 2. 50 ) 76 8 8. 8 N ig ht c ou gh in th e la st 12 m on th s 17 9 6. 4 22 3 7.7 1.1 8 (0 .8 4– 1.6 6) 48 9 16 .0 2. 77 (2 .11 –3 .6 3) 89 1 10 .2 N ig ht w he ez e in th e la st m on th 63 1.7 87 2. 4 1.4 2 (0 .9 4– 2. 14 ) 11 2 1.7 1.5 3 (1. 0 6– 2. 23 ) 26 2 1.9 Se ve re w he ez e in th e la st m on th 56 2. 0 79 2. 7 1.4 0 (0 .8 6– 2. 27 ) 86 2. 8 1.3 4 (0 .7 3– 2. 46 ) 22 1 2. 5 a R ef er en ce ca te go ry (L at ta ki a an d Al ep po v er su s T ar to us ); b A dj us te d fo r a ge a nd se x. O R = od ds ra tio ; C I = co nfi de nc e in te rv al . EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 716 as  a  public  health priority  [18]. Con- sequently we conclude  that  large-scale  programmes  to  improve  diagnosis  in  a  cost-effective  manner  are  needed.  Regional  programmes  such  as GINA  [19],  and WHO programmes  such  as  the Global Alliance against Respiratory  Diseases and  the Practical Approach  to  Lung Health [18,20] could lead the way. Variations  in  asthma  prevalence  cannot be explained only by genetic fac- tors [1,21]. While the analysis of the glo- bal ISAAC Phase Three environmental  questionnaire data by  the  IIDC  is not  yet  complete,  other  studies  however  have shown a negative association with  increased numbers of  siblings  [21,22]  and positive associations with  less  tra- ditional  lifestyles and the consumption  of fast-foods [23]. Exposure to environ- mental  tobacco smoke  in  the home  is  another reported risk factor [24]. Lifestyle and environmental  factors  cannot be discounted as possible causes  of  the high prevalences  noted  in  the  present study [1,21]. Conclusions The  prevalence  of  current  asthma  in  selected  cities of  the Syrian Arab  Republic  ranged  from 4.7%  to 5.7%  for  6–7-year-olds  and 3.9%  to 6.5%  for  13–14-year-olds. These  results  form the basis for future local, national  and  international  comparisons  and  research  in order  to  explain  the  rea- sons  for  this  variability of prevalence  between countries. Masoli M et al. 1. Global burden of asthma 2004. Geneva, Global Initiative for Asthma, 2004 (http://www.ginasthma.com/re- portItem.asp?l1=2&l2=2&intId=94, accessed 22 March 2010). ISAAC Steering Committee. Worldwide variations in the preva-2. lence of asthma symptoms: the International Study of Asthma and Allergies in Childhood (ISAAC). European Respiratory Jour- nal, 1998, 12(2):315–335. Asher M et al. International study of asthma and allergies in 3. childhood (ISAAC): rationale and methods. European Respira- tory Journal, 1995, 8(3):483–491. International Study of Asthma and Allergies in Childhood manual4. , 2nd ed. Auckland, ISAAC Steering Committee, 1993 (http:// isaac.auckland.ac.nz/phases/phaseone/phaseonemanual. pdf, accessed 22 March 2010). Pawankar R et al. State of World Allergy Report 2008: allergy 5. and chronic respiratory diseases. World Allergy Organization Journal, 2008, 1(6):S4–17. Weiland SK, et al. Phase II of the International Study of Asthma 6. and Allergies in Childhood (ISAAC II): rationale and methods. European Respiratory Journal, 2004, 24(3):406–412. Mohammad Y et al. ISAAC phase III—Syrie [abstract]. 7. Revue des Maladies Respiratoires, 2006, 23:10S3. Tabbak K. Prevalence of asthma and allergies in children in 8. Aleppo. Research Journal of Aleppo University, Medical Series, 2006, 51:41–62. Ellwood P et al. 9. ISAAC phase three manual. Auckland, ISAAC International Data Centre, 2000. International Study of Asthma and Allergies in Childhood10. [web- site] (http://isaac.auckland.ac.nz, accessed 22 March 2010). Asher MI et al. Worldwide time trends in the prevalence of 11. symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC phases one and three repeat multicountry cross-sectional surveys. Lancet, 2006, 368:733–743. De Marco R et al. An undetected burden of asthma in Italy: the 12. relationship between clinical and epidemiological diagnosis of asthma. European Respiratory Journal, 1998, 11(3):599–605. References Pearce N, Beasley R, Pekkanen J. Role of bronchial respon-13. siveness testing in asthma prevalence surveys. Thorax, 2000, 55(5):352–354. Miller CJ et al. Accuracy of Arabic versions of three asthma 14. symptoms questionnaires against the clinical diagnosis of asthma. Journal of Asthma, 2007, 44(1):29–34. Galant SP et al. Predictive value of a cross-cultural asthma case-15. detection tool in an elementary school population. Pediatrics, 2004, 114(3):e307–e316. Crane J et al. Agreement between written and video questions 16. for comparing asthma symptoms in ISAAC. European Respira- tory Journal, 2003, 21(3):455–461. Van Sickle D. Perceptions of asthma among physicians: an 17. exploratory study with the ISAAC video. European Respiratory Journal, 2005, 26(5):829–834. Bousquet J et al. 18. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach. Geneva, World Health Organization, 2007. Global Initiative for Asthma19. [website] (http://www.ginasthma. com/index.asp, accessed 22 March 2010). Practical Approach to Lung Health. Manual on initiating PAL 20. implementation. Geneva, World Health Organization, 2008 (WHO/HTM/TB/2008.410, WHO/NMH/CHP/CPM/08.02). Pearce N, Douwes J. The global epidemiology of asthma in 21. children. International Journal of Tuberculosis and Lung Disease, 2006, 10(2):125–132. Al-Kubaisy W, Ali SH, Al-Thamiri D. Risk factors for asthma 22. among primary school children in Baghdad, Iraq. Saudi Medical Journal, 2005, 26(3):460–466. Wickens K et al. Fast foods—are they a risk factor for asthma? 23. Allergy, 2005, 60(12):1537–1541. Mitchell EA et al. The ecological relationship of tobacco smok-24. ing to the prevalence of symptoms of asthma and other atopic diseases in children: the International Study of Asthma and Allergies in Childhood (ISAAC). European Journal of Epidemiol- ogy, 2001, 17(7):667–673. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 717 Household characteristics and allergen and endotoxin levels in Aleppo, Syrian Arab Republic W. Al Ali,1,2 A. Custovic,1 A. Simpson,1 A. Khoury 2 and A. Woodcock 1 ABSTRACT Few data are available from Eastern Mediterranean countries about levels of domestic allergens and endotoxins. Dust samples were collected from mattresses and floors of 457 homes in the Syrian city of Aleppo and analysed for antigens and endotoxins. The most important predictors for detectable levels of house-dust mite allergen Der p 1 were Arabic-style houses (OR 3.21) and newer houses (OR 1.56). In homes without cats, rubber mattresses were associated with detectable cat allergen Fel d 1 in mattress dust (OR 1.6). Cockroach allergen Bla g 2 was significantly more likely to be detected in houses over 20 years old than newer houses. Endotoxin levels were significantly higher in wool/cotton mattresses and older houses. 1North West Lung Research Centre, Wythenshawe Hospital, Manchester, United Kingdom (Correspondence to W. Al Ali: walid1970uk@yahoo. co.uk). 2Allergy Clinic, University of Aleppo Hospital, Aleppo, Syrian Arab Republic. Received: 30/03/08; accepted: 28/07/08 ةيروسلا ةيبرعلا ةيروهملجا ،بلح في ةيلخادلا تانافيذلاو تاجِرْأَتْسُمـلا تايوتسمو نكاسلما صئاصخ كوكدوو ليشأ ،يروخ للها دبع ،نوسبميس لايجنأ ،كيفوتسوك ناندع ،ليعلا ديلو فيو .طسوتلما قشر نادلب في ةيلزنلما ةيلخادلا تانافيذلاو تاجِرْأَتْسُمـلا تايوتسم لوح ةرفاوتلما تايطعلما نم ليلقلا ىوس دجوي لا :ةـصلالخا تانافيذو تادضتسم نم اهيف ام اول َّلحو ،بلح ةيروسلا ةنيدلما في ًلازنم 457 تايضراو شُرُف نم رابغلا نم تانيع نوثحابلا عجم ،ةساردلا هذه ةيحجرلأا ل َّدعم( زارطلا ةيبرعلا لزانلما وه )Der p1( ليزنلما رابغلا ثع جِرْأَتْسُم نم اهفشك نكمي تايوتسم دوجوب تائبنلما مهأ ناك دقو .ةيلخاد ططقلا نم تاجِرْأَتْسُم عم تقفارت ةيطاطلما شُرُفلا نإف ،ططقلا نم ولتخ يتلا تويبلا فيو .)1.56 ةيحجرلأا ل َّدعم( ثدحلأا لزانلما مث )3.21 ًايئاصحإ هب ُّدَتْعُي ٍردقب ًلاماتحا رثكأ )Bla g2( يروصصرلا جِرْأَتْسُمـلا ناكو )1.6 ةيحجرأ ل َّدعمب( شرفلا رابغ في اهفشك نكمي تايوتسمب )Fel d1( ةعونصلما شُرُفلا في ًايئاصحإ هب ُّدَتْعُي ردقب لىعأ تناك دقف ةيلخادلا تانافيذلا تايوتسم امأ .ًاماع 20 نع اهرمع لقي يتلا نكاسلما في فشكي نلأ .ةميدقلا نكاسلما فيو ،نطقلاو فوصلا نم Caractéristiques des ménages et taux d’allergènes et d’endotoxines à Alep (République arabe syrienne) RÉSUMÉ Les données disponibles en matière de taux d’allergènes et d’endotoxines domestiques dans les pays de la Méditerranée orientale sont peu nombreuses. Des échantillons de poussières provenant de matelas et de sols ont été recueillis dans 457 foyers de la ville syrienne d’Alep et ont été analysés à la recherche d’antigènes et d’endotoxines. Les facteurs prédictifs les plus importants pour les taux détectables d’allergènes acariens de poussière domestique Der p 1 étaient les maisons de style arabe (odds ratio 3,21) et les maisons récentes (odds ratio 1,56). Dans les foyers ne possédant pas de chat, les matelas en mousse étaient associés à l’allergène de chat détectable Fel d 1 dans la poussière de matelas (odds ratio 1,6). L’allergène de blatte Bla g 2 était nettement plus susceptible d’être détecté dans les maisons de plus de 20 ans que dans les maisons plus récentes. Les taux d’endotoxines étaient beaucoup plus élevés dans les matelas en laine/coton et dans les vieilles maisons. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 718 Introduction Over the past 4 decades the prevalence  of asthma has increased worldwide, and  the debate about the causes of this have  focussed on  environmental  exposure  to pollutants and allergens  in modern  society  [1]. Many  studies  in different  settings have demonstrated a  relation- ship between household characteristics  and allergen  levels  in houses. Certain  common factors seem to  influence the  levels of house-dust mite allergens, such  as  relative humidity,  large numbers of  occupants, older homes and dampness  in the home, presence of carpets, older  carpets  and  older mattresses  [2–5].  However,  not  all  of  the  variation  in  house-dust mite  concentrations  can  be explained by housing characteristics  alone [6].  The  relationships between house- hold characteristics and allergen con- centrations  in  the United States were  investigated by Peterson et al. [7]. Lev- els  of  the American house-dust mite  allergen Der  f 1  in dust  increased with  increasing occupants  and  relative hu- midity,  and decreased with  forced-air  heating. European house-dust mite al- lergen Der p 1  levels were also higher  with high  relative humidity  and with  forced-air heating, but were also higher  in older homes and where dogs were  present. The relationship of other house- hold characteristics was inconclusive for  Der  f  1  and Der p 1  [7]. Household  endotoxin exposure is also a significant  risk  factor  for  increased prevalence of  asthma  [8]. However,  little  is  known  about  the  association between endo- toxin  levels and household characteris- tics. In a study in the United Kingdom,  the  indoor environment differed  little  between asthmatic and non-asthmatic  children, but  living-room carpet endo- toxin levels were higher in the homes of  asthmatics [9]. The  association  between  house- hold  characteristics  and  allergen  and  endotoxin  levels has only  rarely been  investigated in the Arab world [10]. The  present study therefore aimed to inves- tigate the association between different  household characteristics and allergen  and endotoxin levels in Syrian homes. Methods A  total  of  457 homes were  visited  in  the  northern  Syrian  city  of  Aleppo  between  July  2002  and  September  2003 to interview family members and  collect  samples  from households. The  participants were recruited as a part of a  larger case–control study to investigate  the risk factors for asthma in the Syrian  Arab Republic.  Participants To estimate  the  sample  size, we made  an assumption  that asthma prevalence  in Syrian adults was about 10%. With  a  logistic  regression analysis, a  study of  129 cases and 262 controls would have  > 95% power  to detect  an odds  ratio  (OR) of ≥ 2.8 at a  level of  significance  < 0.05. Phone  calls  and  invitation  letters  were used  to  contact 300  adults  aged  15 to 45 years who had been diagnosed  with  asthma. Of  the  total,  52 patients  were unwilling to participate and 85 were  excluded because they refused to sign the  consent form. Therefore 163 asthmatics  were  recruited  into  the  study: 91  from  the University of Aleppo hospital allergy  clinic, 26 from the chest outpatient clinic  at the University of Aleppo hospital and  46 from collaborating private respiratory  consultants in Aleppo. The inclusion cri- teria were all of the following: physician- diagnosed  asthma;  asthma  symptoms  (wheeze, cough or both) within the pre- vious 12 months; and use of anti-asthma  medication.  For  each  case,  2  age-matched  (to  within 2 years) and sex-matched con- trol  subjects without  respiratory symp- toms (confirmed by an interview) were  recruited within 3 weeks of enrolling a  case. All controls were recruited by ad- vertisements  from among  the medical  and nursing  students  from  the  faculty  of medicine and school of nursing and  from the orthopaedic clinic of the Uni- versity of Aleppo hospital. As a result of  contacting 1000  subjects we  received  620 responses, and after 148 refused to  participate, we were able to recruit 300  controls. Home visits The case and control participants were  pooled for this study. The homes of 457  of  the 463  recruited participants were  visited  (6  subjects  refused  the home  visit).  Each  home was  visited  by  the  investigator and a nurse to collect dust  samples and data about the household  environment. The data collected includ- ed: household size, presence of cigarette  smokers, presence of pets, type of house  (traditional Arabic courtyard design or  apartment/villa),  age of house  (built  before 1985 or  after 1985),  evidence  of dampness  (visible mould),  type of  heating  (stove,  radiators,  electricity),  type of cooking  fuel used, presence of  air-conditioning system, type of flooring  and presence of  carpets,  type of mat- tresses  (rubber or wool/cotton)  and  pillows  (synthetic fibre, wool/cotton  or  feather)  and age of mattresses  and  pillows.  Dust sample collection Dust samples were collected from mat- tresses  and  kitchen  floors. The  bed- room mattress was  inspected and any  sheet  covering  it was  removed before  vacuuming  the  selected  area  for  the  appropriate  time. Kitchen floors were  vacuumed  in  places where  dust  and  food remains were  found,  for example  above  the  fridge, near  the garbage bin,  above the shelves and behind the door.  A 1 m2 area was vacuumed for 2 minutes  using  a  special dust-collection nozzle  (ALK,  Denmark)  connected  to  the  inlet of  the  suction  tube of  a  vacuum  cleaner (Samsung 800 W, Japan), with  70 mm filter paper which retained 74%  of 0.3–0.5 µm particles and up to 100%  of  larger  particles.  Immediately  after  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 719 collection,  the filter papers were  trans- ferred into petri dishes and coded. Dust  samples for allergen assays were stored  at 4 °C until extraction. After each sam- ple collection the head of the nozzle was  cleaned using 70%  isopropyl  alcohol.  After  sampling,  each dust  sample was  coded showing  the study number,  the  place  sampled,  the date of  collection,  the subject surname and initials and the  presence of a cat or dog in the house.  Three dust  samples were collected  from each house: 2 samples  from mat- tresses and 1  sample  from the kitchen  floor. Of  the mattress  samples  1 was  kept  for endotoxin analysis  and 1 was  analysed  against  dust  mite  and  cat  allergen. Kitchen  floor  samples were  analysed for cockroach allergen only. A  total of 457 kitchen dust  samples, 443  mattress dust allergen samples, 435 mat- tress endotoxin samples were collected  (14 mattress samples and 22 endotoxin  samples were lost in transit).  Dust sample extraction and assay For allergen analysis a 100 mg aliquot  of house dust was extracted by rotation  with 2 mL borate-buffered  saline with  0.1% Tween-20 pH 8.0,  at  room tem- perature (20  °C)  for 2 h before being  centrifuged for 20 min at 1200 g at 4 °C.  The supernatant was  stored at −20  °C  until analysed for allergen concentration.  For kitchen floor samples, we sieved the  dust  and  then extracted  the dust with  the whole  filter  in  1%  bovine  serum  albumin with phosphate-buffered saline  solution with 0.05% Tween-20. Dust  samples were  assayed  for house-dust  mite, cat, dog and cockroach allergens  using  monoclonal  antibody-based  enzyme-linked  immunoassays, and the  results were expressed as detectable or  not detectable, with  the allergen con- centration when applicable. A value of  0.05 µg/g, was the lower limit of detec- tion of  the  assay  for house-dust mite  (Der p 1) allergen and 0.01 µg/g for cat  (Fel d 1), dog (Can f 1) and cockroach  (Bla g 2) allergens. For endotoxin analysis dust samples  were extracted with 5.0 mL of pyrogen- free water containing 0.05% Tween-20.  Endotoxin samples were measured us- ing a kinetic limulus amoebocyte lysate  assay, and the results were expressed as  endotoxin concentration (EU/mg).  Statistics The analysis was performed using  the  SPSS, version 11. The allergen  levels  in  dust  reservoirs were not  log-normally  distributed, so the results are presented  as  a percentage of  samples  above  the  limit  of  detection. Chi-squared  tests  were used  to analyse  individual house- hold  characteristics  associated  with  detectable  allergen  levels  in  homes.  Multiple  logistic  regression  analysis  was performed  to  identify household  characteristics that were independently  associated with detectable allergen  lev- els in homes, and odds ratios (OR) are  presented.  Endotoxin  data were  log- normally distributed and therefore were  log-transformed  before  the  analysis;  results are expressed as geometric mean  and 95% confidence interval (CI). Stu- dent t-tests and 1-way analysis of vari- ance  tests were performed to compare  groups. The  level of  significance was P < 0.05. Results Household characteristics Of the 463 homes, 86% were apartments  or flats, 13% were houses of  traditional  Arabic design and 1% were villas; 37% of  homes were < 20 years old, the majority  with 1 or 2 bedrooms (79%). Almost  one-quarter of households (23%) had  6+  occupants.  Almost  all  bedrooms  (99%) had marble or  concrete floors,  but 73% of  rooms contained a  rug  in  winter. Air-conditioning was used  in  summer  in  82%,  and  gas was  almost  exclusively  used  for  cooking  (98%).  Visible damp was  identified  in 37% of  homes. Mattresses were  rubber (60%)  or  cotton/wool  (40%). Pillows were  cotton/wool  (69%),  synthetic  (29%)  or feather (2%). House-dust mite allergen The house-dust mite allergen Der p 1  was detected  at  a  significantly higher  rate in Arabic-style houses than in apart- ments (P < 0.001) and  in newer-built  homes  compared  with  older  homes (P < 0.01) (Table 1). The Der p 1 detec- tion rate was higher  in new mattresses  than old mattresses (P < 0.05) but did  not differ by type of mattress or pillow.  Bedrooms which contained a rug had a  higher rate of detection of Der p 1 mite  allergens  in  the mattress  (P  <  0.01).  Homes with  gas fires  (P  < 0.01)  and  visible dampness (P < 0.01) were more  likely to have detectable levels of Der p  1 but presence of air-conditioning had  no  effect. Number of  occupants  also  had no significant effect on  the  rate of  detection of Der p 1. In  the multivariate analysis,  the  in- dependent associates of detectable Der  p 1  in  the mattresses were Arabic-style  house  (OR 3.21; 95% CI: 1.64–6.30,  P < 0.001) and newer house (OR 1.56,  95% CI: 1.07–2.27, P = 0.02). Cat allergen The cat  allergen Fel d 1 was  found at  significantly higher rates in older homes  (P  <  0.01), without  air-conditioning (P < 0.001) and with heating by radiators  or electricity (P < 0.001). Higher rates of  detectable  cat  allergen were  found  in  rubber mattresses (P < 0.05) and older  mattresses (P < 0.05) (Table 2).  In  the multivariate  logistic  regres- sion  analysis,  the  only  independent  predictor  of  the  presence  of  Fel  d  1  in mattresses was having  a  cat  in  the  home (OR 6.04, 95% CI: 1.98–18.49, P = 0.002). When restricted  to homes  without cats, the only independent pre- dictor was a  rubber mattress (OR 1.6,  95% CI: 1.04–2.32, P < 0.01). As expected, homes  that kept  cats  had  a  significantly  higher  detection  rates for the cat allergen Fel d 1 in mat- tress  dust  than  homes without  a  cat EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 720 (P < 0.001). However, Fel d 1 was highly  dispersible, as some homes without cats  contained high  levels of Fel d 1 pos- sibly by passive  exposure. For homes  with  a  cat  and detectable Fel d 1,  the  actual geometric mean Fel d 1 level was  0.14 µg/g  (95% CI: 0.05–0.42 µg/g)  (Figure 1).  In 4/22 homes with  cats  and 241/421 homes without cats  the  samples were below the detection limit. Only 1 home contained a dog and  therefore no data are presented for dog- mite allergen.  Cockroach Older homes had  significantly higher  detection rates of the cockroach allergen  Bla g 2 (P < 0.01) (Table 3). There was  no association between presence of the  cockroach allergen and  type of house,  heating,  air-conditioning,  household  size or the presence of damp.  Endotoxin From 430 detectable mattress samples  there were 2 samples above  the detec- tion  limit  (endotoxin  levels of > 1000  EU/mg  despite  2  dilutions). There  was  a  trend  towards  higher  levels  of  endotoxin  in Arabic-style houses  and  Table 1 Relationship between household characteristics and the rate of detectable levels of house-dust mite allergen Der p 1 in dust samples Household characteristic No. of samples Der P 1 allergen detected P-value No. % House type Arabic 60 21 35.0 < 0.001 Apartment 379 50 13.2 House age (years) < 10 52 15 28.8 0.006 10–20 114 20 17.5 > 20 277 36 13.0 Mattress type Wool/cotton 177 32 18.1 0.3 Rubber 264 38 14.4 Mattress age (years) < 1 74 16 21.6 0.05 1–3 130 23 17.7 3–5 42 8 19.0 > 5 197 24 12.2 Pillow type Wool/cotton 307 51 16.6 0.85 Synthetic fibre 125 19 15.2 Bedroom floor With rug 323 61 18.9 0.007 Without rug 120 10 8.3 Visible mould Yes 166 37 22.3 0.005 No 277 34 12.3 Air conditioning Yes 363 61 16.8 0.34 No 80 10 12.5 Heating Stove 277 55 19.9 0.01 Radiator 109 8 7.3 Electricity 56 8 14.3 Household size (no. of occupants) ≤ 6 378 59 15.6 0.5 > 6 65 12 18.5 P < 0.05 considered significant. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 721 older houses but  this was not  statisti- cally  significant. Endotoxin  levels were  significantly higher in wool/cotton mat- tresses (P < 0.001) and in new mattresses (P < 0.01), but not with visible mould,  type  of  pillows  or  type  of  heating (Table 4).  In  the multivariate  analysis,  inde- pendent predictors of high  endotoxin  levels  in mattresses were: wool/cotton  mattresses (GM 31.7%, 95% CI: 26.2%– 38.4%, P < 0.001) and older houses (GM  28.7%, 95% CI: 24.2%–34.0%, P = 0.03). Discussion This is the first large study to investigate  the relationship between housing char- acteristics and allergen and endotoxin  levels in a Middle Eastern country. Our  data  suggest  that Arabic-style houses  and newer houses were  the most  im- portant predictors  for detectable  levels  of house-dust mite allergen Der p 1. The  Arabic house  is unique  in both design  and structural materials. It usually has an  open-air courtyard and multiple families  in  the  same house. Arabic houses  are  built by using mud and wood, the floor  may be mud or hard cement or covered  by  tiles/marble and there  is no system  to  control  the  indoor  temperature  and humidity. Modern utilities are not  adapted for this type of house, and this  may contribute  to  a  suitable environ- ment  for house-dust mite growth [2].  Newer houses were also more likely to  have high detection rates of house-dust  mite allergens as they are more likely be  heated  in winter, which,  together with  Table 2 Relationship between household characteristics and the rate of detectable levels of cat allergen Fel d 1 in dust samples Household characteristic No. of samples Fel d 1 detected P-value No. % House type Arabic 60 29 48.3 0.5 Apartment 379 167 44.1 House age (years) < 10 52 16 30.8 0.0410–20 114 50 43.9 > 20 277 132 47.7 Mattress type Wool/cotton 177 69 39.0 0.03 Rubber 264 129 48.9 Mattress age (years) < 1 74 30 40.5 0.02 1–3 130 50 38.5 3–5 42 16 38.1 > 5 197 102 51.8 Pillow type Wool/cotton 307 127 41.4 0.1 Synthetic fibre 125 64 51.2 Bedroom floor With rug 323 142 44.0 0.6 Without rug 120 56 46.7 Air conditioning Yes 363 145 39.9 < 0.001 No 80 53 66.3 Heating Radiator 109 64 58.7 < 0.001Electricity 56 28 50.0 Stove 277 105 37.9 Cat ownership With cat 22 18 81.8 < 0.001 Without cat 421 180 42.8 P < 0.05 considered significant. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 722 reduced ventilation, may make them li- able to house-dust mite infestation. This  is consistent with modern houses and  modern energy systems, where reduced  ventilation  results  in higher humidity,  which makes them a more suitable en- vironment  for  the proliferation of dust  mites [2].  Figure 1 Distribution of mean levels of cat allergen Fel d 1 in dust samples from homes with and without a cat Pet ownership  is  rare  in  the Syrian  Arab Republic.  In our  study different  housing characteristics were  shown to  influence  the presence of  the cat aller- gen Fel d 1 in Syrian homes, such as the  presence of modern heating  systems  and the absence of air-conditioning. But  by far the most important factor was the  presence of  a  cat. When homes with- out cats were analysed  separately,  the  presence of  rubber mattresses was  the  only  independent  factor  to  influence  the detection of the Fel d 1 allergen. Our  data are consistent with  those of other  studies [7,11–13]. Older homes  (built before 1985)  were more  likely  to  have  detectable  cockroach  allergen,  possibly because  old houses tend have higher occupancy  rates  and  damaged  structures which  provide suitable habitats  for cockroach  infestation. High  endotoxin  levels  in  Syr- ian homes were associated with wool/ Table 3 Relationship between household characteristics and the rate of detectable levels of cockroach allergen Bla g 2 in dust samples Household characteristic No. of samples Bla g 2 allergen detected P-value No. % House type Arabic 61 17 27.9 0.7 Apartment 392 99 25.3 House age (years) < 10 54 7 13.0 0.00310–20 117 25 21.4 > 20 286 85 29.7 Visible mould Yes 170 48 28.2 0.3 No 287 69 24.0 Heating Stove 285 69 24.2 0.5Radiator 112 32 28.6 Electricity 59 16 27.1 Air conditioning Yes 374 96 25.7 0.5 No 83 21 25.3 Household size ≤ 6 389 101 26.0 0.7 > 6 68 16 23.5 P < 0.05 considered significant. With cats No cats Fe l d 1 µ g/ g 5.00 4.00 3.00 2.00 1.00 0.00 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 723 Table 4 Relationship between household characteristics and mean levels of endotoxin in dust samples Household characteristic No. of samples Endotoxin levels EU/mg P-value Geometric mean 95% CI House type Arabic 60 29.2 21.9–38.8 0.1a Apartment 366 23.7 21.6–25.9 House age (years) < 10 54 21.2 16.9–26.5 0.3b10–20 114 23.3 19.1–28.4 > 20 262 25.6 23.0–28.4 Mattress type Wool/cotton 174 32.9 28.4–38.2 < 0.001a Rubber 254 19.9 18.0–22.0 Mattress age (years) < 1 72 33.8 27.2–42.1 0.005b 1–3 126 23.9 20.1–28.7 3–5 45 25.7 19.0–34.6 > 5 187 21.4 19.1–24.2 Pillow type Wool/cotton 302 25.4 23.0–28.0 0.3a Synthetic fibre 120 23.0 20.0–26.0 Bedroom floor With rug 313 24.9 22.4–28.0 0.4a Without rug 117 22.9 19.5–27.0 Visible mould Yes 155 25.6 21.8–29.9 0.4a No 275 23.7 21.4–26.3 Heating Gas stove 271 25.0. 22.0–28.0 0.1bRadiator 104 21.2 18.0–25.0 Electricity 54 28.4 22.0–37.0 Air conditioning Yes 356 24.0 22.0–27.0 0.5a No 74 26.2 21.3–32.0 Household size ≤ 6 362 24.3 22.1–26.7 0.8a > 6 68 24.9 19.8–31.4 No. of bedrooms ≤ 2 337 24.6 22.4–27.1 0.6a > 2 93 23.4 19.0–28.7 No. of people sharing same bedroom 0 64 22.9 17.8–29.4 0.3b 1 150 23.3 20.1–27.0 2 108 23.3 19.5–27.8 > 2 108 28.1 23.7–33.2 Pet ownership With cat 18 19.0 12.3–29.5 0.2a Without cat 412 24.7 22.6–26.9 aStudent t-test; b1-way analysis of variance. EU = endotoxin unit; CI = confidence interval. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 724 cotton mattresses and older houses. Un- like a study in Germany [14] the present  data  suggest  that  endotoxin  levels  in- crease with  the decreasing age of mat- tresses. The reason  for  this  is not clear.  It may be that new mattresses with syn- thetic materials favour bacterial growth  or that porous fabrics allow higher rates  of sampling during vacuuming. We did  not  associate  endotoxin with  visible  dampness, in agreement with one previ- ous study [15] but in contrast with oth- ers [10,16,17]. Although homes with a  cat had slightly higher endotoxin levels  than those without a cat, the difference  was not statistically significant. This may  reflect  the  infrequent cat ownership  in  the Syrian Arab Republic and the even  lower ownership of dogs.  In  conclusion,  these data  indicate  that while indoor allergen levels are low  in Syrian households,  there are  impor- tant household characteristics that influ- ence both allergen and endotoxin levels.  Some of  these unique  features may be  amenable to change, while others are not  (house  type). More research  is needed  to  elucidate  the  contribution of  these  factors  to  the prevalence of  atopy and  asthma in the Syrian Arab Republic. Acknowledgements Many  thanks  to Mr Mark Craven, Dr  Gael Tavernier  and Mrs  Julie Morris  for their assistance, and for the Ministry  of Higher  Education  in  Syrian Arab  Republic for funding this study. Selgrade MK et al. Induction of asthma and the environment: 1. what we know and need to know. Environmental Health Perpec- tives, 2006, 114(4):615–619. Simpson A, Woodcock A, Custovic A. Housing characteristics 2. and mite allergen levels: to humidity and beyond. Clinical and Experimental Allergy, 2001, 31(6):803–805. Van Strien RT et al. Mite antigen in house dust: relationship 3. with different housing characteristics in the Netherlands. Clini- cal and Experimental Allergy, 1994, 24(9):843–853. Wickens K et al. Determinants of house dust mite allergen in 4. homes in Wellington, New Zealand. Clinical and Experimental Allergy, 1997, 27(9):1077–1085. Chan-Yeung M et al. House dust mite allergen levels in 5. two cities in Canada: effects of season, humidity, city and home characteristics. Clinical and Experimental Allergy, 1995, 25(3):240–246. Van Strien RT et al. The influence of air conditioning, humidity, 6. temperature and other household characteristics on mite aller- gen concentrations in the northeastern United States. Allergy, 2004, 59(6):645–652. Peterson EL, Ownby DR, Johnson CC. The relationship of 7. housing and household characteristics to the indoor concen- trations of Der f 1, Der p 1, and Fel d 1 measured in dust and air samples. Annals of Allergy, Asthma and Immunology, 2003, 90(5):564–571. Thorne PS et al. Endotoxin exposure is a risk factor for asthma: 8. the national survey of endotoxin in United States housing. References American Journal of Respiratory and Critical Care Medicine, 2005, 172(11):1371–1377. Tavernier G et al. IPEADAM study: indoor endotoxin expo-9. sure, family status, and some housing characteristics in English children. Journal of Allergy and Clinical Immunology, 2006, 117(3):656–662. El Sharif N et al. Concentrations of domestic mite and pet aller-10. gens and endotoxin in Palestine. Allergy, 2004, 59(6):623–631. Fahlbusch BL et al Allergens in house dust samples in Germany: 11. results of an East–West German comparison. Allergy, 1999, 54(11):1215–1222. Fahlbusch B et al. Predictors of cat allergen (Fel d 1) in house 12. dust of German homes with/without cats. Journal of Investiga- tional Allergology and Clinical Immunology, 2002, 12(1):12–20. Giovannangelo M et al. Childhood cat allergen exposure in 13. three European countries: the AIRALLERG study. Science of the Total Environment, 2006, 369(1–3):82–90. Gehring U et al. Levels and predictors of endotoxin in mattress 14. dust samples from East and West German homes. Indoor Air, 2004, 14(4):284–292. Gereda JE et al. Metropolitan home living conditions associ-15. ated with indoor endotoxin levels. Journal of Allergy and Clini- cal Immunology, 2001, 107(5):790–796. Bischof W et al. Predictors of high endotoxin concentrations in 16. the settled dust of German homes. Indoor Air, 2002, 12(1):2–9. Wickens KJ et al. Determinants of endotoxin levels in carpets in 17. New Zealand homes. Indoor Air, 2003, 13(2):128–135. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 725 Screening for diabetes in Kuwait and evaluation of risk scores M.M. Al Khalaf,1 M.M. Eid,1 H.A. Najjar,1 K.M. Alhajry,1 S.A. Doi 2 and L. Thalib 1 ABSTRACT This study aimed to develop a simple risk score to identify individuals at high risk for undiagnosed diabetes in the Kuwaiti adult population and to assess the performance of previously published diabetes risk scores. A cross-sectional survey with a sample of 562 Kuwaiti public sector employees was carried out in 2007. Data were collected through a self-administered questionnaire and a blood glucose test. The overall prevalence of diabetes using American Diabetes Association 2003 criteria was 21.4% (4.1% newly detected). The proposed score had 87% sensitivity and 64% specificity in predicting undetected diabetes using only 4 questions (age, waist circumference, use of blood pressure medication and diabetes in a sibling). Most previously published risk scores were not applicable to this population. 1Department of Community Medicine and Behavioural Sciences; 2Department of Medicine, Faculty of Medicine, University of Kuwait, Kuwait (Correspondence to L. Thalib: lthalib@hsc.edu.kw). Received: 03/08/08; accepted: 23/10/08 راطتخلاا زارحأ ميـيقتو تيوكلا في يركسلا نع ي ِّرحتلا بيلاث نماقل ،اود ليهس ،يرجلحا دلاخ ،راجن يدحم ،ديع دممح ،فللخا دممح ضرم نم ةص َّخشم يرغ تلاالح ةعفترم راطخلأ ينضرعلما صاخشلأا لىع فرعتلل راطتخلال ةطيسب زارحأ دادعلإ ةساردلا تفده :ةـصلالخا ةساردلا تلمشو .يركسلا لىع فرعتلل ًاقباس ت َ ِرشرُن يتلا زارحلأا ءادأ ميــيقتلو ،ينـيتيوكلا ينغلابلا نم ةيناكسلا تاعومجلما في يرّكسلا َفوتسي نايبتسا للاخ نم تايطعلما نوثحابلا عجم دقو .2007 ماع ْتَذ ِّفُنو ،ماعلا عاطقلا في ينـيتيوكلا ينفظولما نم 562 نم فلأتـت ةنيع ةيضرعلا %21.4 :2003 ماعل يركسلل ةيكيرملأا ةيعملجا يرـياعم مادختساب يركسلل لياجملإا راشتنلاا ل َّدعم غلب دقو ،مدلا زوكولغل تارابتخا ءارجإ عم ًايتاذ يرغ يركسلا تلااحب ؤبنتلا في %64 اهرادقم ةيعونو ،%87 اهرادقم ةيساسح ةحرـتقلما زارحلأل ناك دقو .)ًاثيدح ةفشتكلما تلاالحا نم% 4.1( ًاقباس ةروشنلما زارحلأا مظعم تناكو .)ءانبلأا في يركسلا دوجوو ،مدلا طغضل ءاود يطاعت ،صرلخا طيمح ،رمعلا( ةلئسأ 4 مادختساب ةفشتكلما .بولسلأا اذه لىع قبطنت لا راطتخلاا لىع فرعتلل Dépistage du diabète au Koweït et évaluation des scores de risque RÉSUMÉ Cette étude visait à mettre au point un score de risque simple destiné à identifier les individus à haut risque de diabète non diagnostiqué dans la population adulte koweïtienne et à évaluer la performance des scores de risque du diabète publiés auparavant. Une étude transversale sur un échantillon de 562 employés du secteur public koweïtien a été réalisée en 2007. Les données ont été recueillies au travers d’un auto-questionnaire et d’un test de glycémie. La prévalence globale du diabète selon les critères établis en 2003 par l’Association américaine du diabète était de 21,4 % (4,1 % de diabète nouvellement détecté). Le score proposé présentait 87 % de sensibilité et 64 % de spécificité dans la prédiction de diabète non détecté en se basant uniquement sur 4 questions (âge, tour de taille, prise de médicaments pour la pression artérielle et cas de diabète dans la fratrie). La plupart des scores de risque publiés antérieurement n’étaient pas applicables à cette population. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 726 Introduction The rapid  increase  in  the  incidence of  diabetes mellitus has led to heightened  public  concern  over  prevention  and  treatment [1]. Studies suggest that one- third of all people with diabetes may be  undiagnosed [2]; therefore early detec- tion of undiagnosed diabetes  and  the  identification of  those at high  risk are  crucial steps in reducing the associated  health  care burden  [3,4].  It  is  known  that  the  delay  from disease  onset  to  diagnosis may  sometimes  exceed 10  years [5] and that one or more vascular  complications  are  already present by  the time of diagnosis [6,7].  Identifying those at high risk allows  appropriate interventions to be initiated  so  that  the  transition to overt diabetes,  with  its  attendant  complications,  can  be prevented or delayed [8]. Question- naires based on multivariate  risk  factor  models have been used  in a number of  populations, with encouraging  results.  The aim of all  these  is  to  limit  the pro- portion of the population that needs to  undergo  laboratory-based diagnostic  glucose measurements. However, before  their widespread use  it  is necessary  to  validate the risk scores in different popu- lations because  a  single questionnaire  might not be universally applicable.  Arab  countries  are  undergoing  a  rapid epidemiological transition and are  reporting high  rates of  type 2 diabetes  in  the  population  [9–11]. Nonethe- less,  there  is  an  intense debate  about  how this should be managed and, while  much  research has  focussed on diag- nosed diabetics, little is known about the  prevalence and  risk  factors  associated  with  those  living with diabetes but un- diagnosed. None of these countries has  any  systematic  screening programme  for diabetes. In this context, we aimed to  explore  the prevalence of undiagnosed  diabetes and the factors associated with  it, so that a pen and paper risk score that  is non-invasive and simple to use could  be developed  for  the Kuwaiti popula- tion. We also aimed to assess locally the  performance of  previously published  diabetes risk scores. Methods Our findings were  based on  a  cross- sectional  survey  carried  out  during  March to April 2007.  Sample size determination The prevalence of  type 2 diabetes mel- litus  in  the Kuwaiti adult population  is  known to be about 15% [12]. Based on  findings that suggested that about one- third of diabetics are undetected [4], we  estimated  the prevalence of unknown  diabetes to be 5%. With a type 1 error of  5%, a power of 80% and an allowed error  of 3% in either direction, we required a  sample  size of at  least 413  to estimate  the prevalence of unknown diabetes  in  this population.  Study population We  used  sex-stratified  multi-stage  cluster  sampling among public  sector  employees in Kuwait. Of 9 government  ministries  5 were  randomly  selected.  Sampling  from each ministry was pro- portional  to  the  size of  each of  these  ministries. Each ministry building was  divided  into  7  clusters with one  and  half floors per  cluster. The number of  clusters  required was calculated based  on  the  sample  size  requirement  and  clusters  to be  included were  randomly  selected. All adult males and females in  the selected clusters were approached.  Stratification based on sex was possible as  males and females had separate working  areas. Pregnant women, who are prone  to develop gestational diabetes, were  excluded.  Of a total of 5430 employees in Ku- wait, we approached 578 and of  these  562 agreed  to participate  (a  response  rate of  98%). The  reasons  for  refusal  were  not  determined  but  unwilling- ness  to provide  a finger-prick  sample  may have been a reason for some of the  refusals.  The Ethics Committee of  the Fac- ulty of Medicine, University of Kuwait,  approved  this  study. We also obtained  written consent from each participant.  Data collection Data  were  collected  through  a  self- administered questionnaire and a blood  glucose test.  Detection of diabetes A  total of 97 participants  reported  that  they had been already diagnosed with  diabetes by  a physician. The diabetes  status of 2 participants was unknown.  This left 463 to be classified based on our  blood glucose measurements. We asked  the participants who agree to participate  and who  consented  to  fast  for more  than 8 hours  for  testing  the  following  day. Blood glucose was measured us- ing  the Accu-Check Go blood glucose  meter (Roche Diagnostics, Mannheim,  Germany). Diagnosis of diabetes was  based on  the American Diabetes As- sociation (ADA) 2003 criteria  [13].  If  fasting blood glucose was ≥ 7.0 mmol/L  or  random  glucose  ≥  11.1  mmol/L  participants  were  classified  as  newly  diagnosed diabetes. Those with  fasting  glucose levels between 5.6–6.9 mmol/L  were classified as having impaired fasting  glucose or pre-diabetic status. Screening tools Our  research  instrument consisted of  blood glucose measurements,  anthro- pometric  measures  (weight,  height,  waist  circumference) and a  specially- designed  self-administered question- naire. The questionnaire consisted of 24  items about physical activity, family his- tory of diabetes and food and drink con- sumption and dieting. To develop  the  questionnaire we performed a Medline search  in March 2007 using keywords  that  include diabetes. We  identified 8  tools  that were non-invasive  and had  clear criteria for screening that could be  applied to our study. The risk screening  tools were  from the  following popula- tions/sources: Thailand  [14], Oman  [15],  Rotterdam  (The Netherlands)  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 727 [16], Denmark [17], Cambridge (Eng- land)  [18],  the ADA (United States)  [19], Finland [20] and India [21]. We  pooled  the published  risk  factors  and  included  them  in  the questionnaire  to  which  the  required demographic vari- ables were added.  Statistical methods For the published risk scores, sensitivity  and  specificity were  computed using  the cut-offs proposed by  the original  publications. Then,  for  comparison,  specificity  was  calculated  using  an  adjusted cut-off  that  resulted  in 75%  to  85%  sensitivity  within  our  study  population.  The  survey  data  were  entered into a forward stepwise logistic  regression model  to  identify  the most  important  and  independent  predic- tors  for  undetected diabetes.  Points  were assigned  to each variable based  on  the magnitude  of  the  regression  coefficients. Each beta coefficient was  rounded  to  the nearest  integer. The  risk  score  for  an  individual  patient  was determined by  assigning points  for each  factor present and summing  these. A  receiver-operating character- istics (ROC) curve and the area under  the  curve were  used  to  evaluate  the  risk score developed and to determine  a cut-off  for our population based on  optimal sensitivity. Results A total of 562 participants were initially  recruited to the study, with a mean age  of 36.2 (standard deviation 8.9) years.  The crude prevalence of total diabetes in  the Kuwaiti adult population was 21.4%  (120/560). There were 97 participants  [17.3%; 95% confidence  interval (CI):  14.4%–20.7%] who  reported  a previ- ous diagnosis of diabetes and 23 (4.1%;  95% CI: 2.7%–6.1%) with undetected  diabetes.  Table 1 describes the study popula- tion  after  excluding  those  already di- agnosed with diabetes by a physician.  Table 1 Age, sex and anthropometric measurements of adult workers in Kuwait with different glycaemic states (n = 460) Variable Impaired fasting blood glucose (n = 57)a Newly detected diabetic (n = 23)a Normoglycaemic (n = 380)a Mean SD Mean SD Mean SD Age (years) 37.3 8.0 42.9 7.7 34.7 8.5 Height (cm) 165.0 11.0 166.4 8.1 165.4 9.7 Weight (kg) 85.0 26.0 90.0 12.7 77.2 18.1 BMI (kg/m2) 30.8 6.5 32.5 4.5 28.1 5.6 Waist circumference (cm) 98.3 16.0 108.1 12.2 94.8 15.3 No. % No. % No. % Age group (years) 20–29 12 8.1 2 1.3 135 90.6 30–39 23 13.3 4 2.3 146 84.4 ≥ 40 22 15.9 17 12.3 99 71.7 Sex Male 19 8.8 11 5.1 187 86.2 Female 38 15.6 12 4.9 193 79.5 BMI (kg/m2) Underweight (< 19) 0 0.0 0 0.0 6 100.0 Normal (19–25) 9 7.7 2 1.7 106 90.6 Overweight (> 25–30) 23 12.2 6 3.2 160 84.7 Obese (> 30–40) 21 16.6 13 10.2 93 73.2 Morbidly obese (> 40) 4 19.0 2 9.5 15 71.4 Waist circumference (cm) Males: < 102 5 4.3 2 1.7 110 94.0 ≥ 102 13 13.1 9 9.1 77 77.8 Females: < 88 18 17.0 1 0.9 87 82.1 ≥ 88 21 15.2 11 8.0 106 76.8 aAmerican Diabetes Association 2003 criteria [13]. BMI = body mass index. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 728 Those  whose  diabetes  status  was  unknown were divided  into 3 groups  based on  the  glucose  test:  newly de- tected diabetics (n = 23), those who had  impaired levels of glucose (n = 57) and  those without  any  rise  in  the glucose  levels  (n  =  380)  (normoglycaemic).  We compared these 3 groups  for  their  anthropometric measures  and  other  risk factors.  The  risk  factors  for  undetected  diabetes were evaluated using  forward  stepwise  modelling  (Tables  2  and  3). After multiple  logistic  regression,  age was  first  significant  independent  predictor  to be  included  in  the model significant independent predictor [odds  ratio (OR) 3.72, 95% CI: 1.05–13.2],  followed by waist  circumference (OR  6.89, 95% CI: 1.95–24.3), use of blood  pressure medication  (OR 2.66,  95%  CI: 1.00–7.05) and  family history of a  sibling with diabetes (OR 2.66, 95% CI:  1.08–6.54) (Table 3). A score for each  variable  in  the model was  calculated  by multiplying  the β-coefficient by 10  (Table 3). The ROC curve of the score  we developed had  an  area under  the  curve of 0.82 (Figure 1). We found that  the optimal cut-off (≥ 32 points) had an  acceptable  sensitivity of 87% and spe- cificity of 64% for predicting undetected  diabetes. A list of the risk factors investigated  in  this  study  and  those  used  in  the  other published risk scores  is given  for  comparison in Table 4 [14–21]. These  risk  scores were  tested on participants  in our study. All of  the  risk scores per- formed worse  than our  score  in  terms  of sensitivity and specificity at detecting  undiagnosed diabetes in our population  (Table 5). The worst performing scores  in terms of specificity (after adjustment)  were  the  Rotterdam, Thai  and ADA  scores. However, if the cut-offs were ad- justed appropriately,  the performance  of  the other  scores  improved  slightly.  The standardized cut-offs were gener- ally higher than those in the populations  for whom the risk scores were originally  developed,  except  for  the Rotterdam  and Danish scores, which needed to be  adjusted downwards. Discussion In this study the crude prevalence of to- tal diabetes in Kuwait was high (21.4%),  particularly given  the young age of  the  population  that  we  surveyed  (mean  age 36.2 years). It is possible that a high  prevalence of diabetes  is  common  to  the region, given the estimated 16% to  24% prevalence of  diabetes  reported  from neighbouring  countries  [10,22].  In contrast  to  these figures,  the crude  prevalence of total diabetes was 9.3% in  the United States of America popula- tion in 1999–2002 [23].  Previously  published  risk  scores  have several variables in common which  are (in order of importance): age, hyper- tension, obesity/waist circumference/ body mass  index,  family  history,  sex,  physical activity and smoking [14–21].  Although these risk factors are common  Table 2 Univariate regression analysis of risk factors for diabetes in a group of adult workers in Kuwait, using newly-detected diabetes as the dependent variable Variable OR (95% CI) P-value Sex Female Ref. Male 1.04 (0.45– 2.40) 0.93 Female with macrosomia 2.11 (0.59–7.52) 0.25 Age (years) 20–34 Ref. ≥ 35 6.82 (2.00–23.3) 0.002 BMI BMI per kg/m2 increment from 15 kg/m2 1.10 (1.04–1.16) 0.002 Waist circumference (cm) < 100 Ref. ≥ 100 10.8 (3.17–37.1) < 0.001 Exercise < 65 years and little or no exercise 1.90 (0.43–8.28) 0.40 Leisure time physical activity 1.16 (0.49–2.74) 0.74 Physical activity < 4 hours per week 1.18 (0.34–4.09) 0.79 Diet Consumption of vegetables, fruits or berries 1.05 (0.45–2.43) 0.91 Smoking status Non-smoker Ref. Previous smoker 3.09 (0.96–9.91) 0.05 Current smoker 0.66 (0.19–2.32) 0.52 Medical history Parent with diabetes 1.60 (0.65–3.97) 0.31 Sibling with diabetes 3.46 (1.48–8.07) 0.004 Both siblings and parent with diabetes 2.87 (1.20–6.86) 0.02 On steroids 2.50 (0.81–7.78) 0.11 Has hypertension 2.43 (0.86–6.85) 0.09 Previous diagnosis of hypertension 4.66 (1.87–11.6) < 0.001 Currently on hypertension treatment 3.92 (1.36–11.3) 0.01 Ref. = reference category; BMI = body mass index; OR = odds ratio; CI = confidence interval. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 729 across populations, their relative impor- tance varies from population to popula- tion. Obviously,  some  risk  factors  are  not applicable to all populations; e.g. use  of a bicycle (in a questionnaire from the  Netherlands) may not be a  risk  factor  in a  society  that does not use bicycles  as a common mode of  transport  [16].  The  inclusion of  specific medications  and smoking may also be problematic  because  the  rate of prescription drug  use and smoking show  large variations  in different  regions and over  time. Be- cause  their  relative  importance varies  from  population  to  population,  key  risk  factors  for  each population need  to be established.  In our population of  Kuwaiti  public  sector  employees  we  were  able  to define 4  risk  factors  that  were associated with diabetes  risk after  multiple  regression  analysis:  age ≥ 35  years, waist  circumference ≥ 100  cm,  use of blood pressure medication and  family history of diabetes in a sibling. It is  interesting to note that sex-specific waist  circumference was  not  an  independ- ently  associated  risk  factor  for  unde- tected diabetes  in our population and  only waist circumference ≥ 100 cm was  maintained in multivariate analysis. This  may be explained by excess weight being  equally prevalent in females and males. When we assessed other published  risk scores  incorporating these risk fac- tors, the cut-offs for Kuwait in most cases  needed to be moved upwards to retain  sensitivity. In other words, an individual  in  the Kuwaiti population would need  to score higher  in a given diabetes  risk  score  to  achieve  the  same probability  of having diabetes  as  an  individual  in  the population from which the diabetes  risk score was originally developed. This  is  a confirmation  that different cut-off  points are needed  in different popula- tions. However,  the  suggested cut-offs  needed to be moved downwards for the  Rotterdam and Danish scores. This may  be due  to  the  fact  that both  these  risk  scores  lacked waist circumference and  family history information, which are 2  risk  factors  that were  independent pre- dictors  in our population. The absence  of these 2 factors made those risk scores  less capable of detecting undiagnosed  diabetes in Kuwait.  One of the  limitations of this study  was  that our blood glucose  instrument  was not  the  recognized gold  standard  for determining plasma glucose  level.  The National Committee  for Clinical  Laboratory Standards guidelines  [24]  states  that  the difference between  the  meter  and  the  central  laboratory  in  95% of results should agree within 0.83  mmol/L at  glucose  concentrations <  4.2 mmol/L and within 20% at glucose  concentrations ≥ 4.2 mmol/L. Our me- ter  showed 95% of  the measurements  meeting the < 4.2 mmol/L requirement  and 91% meeting  the ≥ 4.2 mmol/L  requirement  [25].  It  therefore  came  Table 3 Multivariate regression analysis of risk factors for diabetes in a group of adult workers in Kuwait Variable Multiple logistic regression β-coefficient OR (95% CI) Risk score Intercept –5.018 – – Sibling with diabetes 0.979 2.66 (1.08–6.54) 10 Has hypertension previously 0.978 2.66 (1.00–7.05) 10 Age ≥ 35 years 1.315 3.72 (1.05–13.2) 13 Waist circumference ≥ 100 cm 1.930 6.89 (1.95–24.3) 19 A score for each variable in the model was calculated by multiplying the β-coefficient by 10. A score of ≥ 32 points indicated a high risk for having diabetes. OR = odds ratio; CI = confidence interval. Figure 1 Receiver operating characteristics (ROC) curve showing performance of the score in this study (area under curve = 0.82) 1- Specificity 1.0 0.8 0.6 0.4 0.2 0.0 0.0 0.2 0.4 0.6 0.8 1.0 Se ns iti vi ty EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 730 very close to the gold standard and was  deemed adequate  for  the purpose of  this  survey.  In our  study, plasma glu- cose  levels  for  the diagnosis of unde- tected diabetes were interpreted based  on  self-reported  fasting of > 8 hours.  Those who did not report fasting were  considered  to have a  random plasma  glucose measurement with  a  cut-off  Table 5 Performance of other noninvasive screening tools in detecting diabetes mellitus in the adult Kuwaiti population compared with the current study Risk score source/ population Original cut-off score OC previously published OC when original cut- off applied in this study Adjusted cut-off score OC when adjusted cut- off applied in this study Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity % % % % % % Thai ≥ 6 77 60 100 18 ≥ 11 83 54 Omani > 10 79 73 96 42 ≥ 13 70 64 American Diabetes Association ≥ 10 78 65 91 41 ≥ 12 78 56 Cambridge (pt A) ≥ 0.080 91 52 91 46 – – – Cambridge (pt E) > 0.199 77 72 87 72 ≥ 0.273 78 78 Indian ≥ 60 73 60 87 50 ≥ 70 74 65 Finnish ≥ 9 77 66 83 65 ≥ 9 83 70 Rotterdam > 6 78 55 43 79 ≥ 5 78 41 Danish ≥ 31 73 74 39 87 ≥ 21 78 62 Kuwaiti (present study) ≥ 32 87 64 – – – – – OC = operating characteristics. at 11.1 mmol/L  for diabetes, without  confirming this on a separate day. This  may have led to a slight underestimate  of the burden of undetected diabetes in  this community. Validation of  the  risk  score  in  the  same population and  the  use of a  larger sample size would have  further enhanced the generalizability of  our results. Conclusions We  found  the  crude  prevalence  of  total diabetes to be 21.4%, and almost  one-fifth of  the cases were previously  undiagnosed. We  provide  a  simple  screening tool that identifies individu- als who are at high risk of having diabe- tes  in the Kuwaiti population. It  relies  Table 4 Description of previously published diabetes risk questionnaires applied in this study Risk score source/ population Reference and year Variables American Diabetes Association [19] 1995 Age, sex, BMI, female with history of delivery of a macrosomal child, family history of diabetes in parent or sibling. Rotterdam, concise model [16] 1999 Age, sex, use of antihypertensives, presence of obesity. Cambridge [18] 2000 Age, sex, use of prescribed antihypertensives or steroids, diabetes family history, smoking status. Finnish [20] 2003 Age, BMI, waist circumference, use of antihypertensives, history of high blood glucose level, physical activity, consumption of vegetables, fruits or berries. Danish [17] 2004 Age, sex, BMI, known hypertension, physical activity at leisure time, history of diabetes in parent. Indian [21] 2005 Age, waist circumference, physical activity, family history of diabetes. Thai [14] 2006 Age, sex, BMI, waist circumference, hypertension, history of diabetes in parent or sibling. Omani [15] 2007 Age, waist circumference, BMI, family history of diabetes, current hypertension status. Kuwaiti Present study Age, waist circumference, use of blood pressure medication, family history of diabetes in a sibling. BMI = body mass index. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 731 Geiss LS et al. Changes in incidence of diabetes in U.S. adults, 1. 1997–2003. American Journal of Preventive Medicine, 2006, 30:371–377. Lamendola C. Early and more vigorous detection of diabetes. 2. Journal of Cardiovascular Nursing, 2003, 18:103–107. King H, Rewers M. Global estimates for prevalence of diabe-3. tes mellitus and impaired glucose tolerance in adults. WHO Ad Hoc Diabetes Reporting Group. Diabetes Care, 1993, 16:157–177. Harris MI, Eastman RC. Early detection of undiagnosed diabe-4. tes mellitus: a US perspective. Diabetes/Metabolism Research and Reviews, 2000, 16:230–236. Dallo FJ, Weller SC. Effectiveness of diabetes mellitus screening 5. recommendations. Proceedings of the National Academy of Sci- ences of the United States of America, 2003, 100:10574–10579. Spijkerman AM et al. Prevalence of macrovascular disease 6. amongst type 2 diabetic patients detected by targeted screen- ing and patients newly diagnosed in general practice: the Hoorn screening study. Journal of Internal Medicine, 2004, 256:429–436. Spijkerman AM et al. Microvascular complications at time of 7. diagnosis of type 2 diabetes are similar among diabetic patients detected by targeted screening and patients newly diagnosed in general practice: the Hoorn screening study. Diabetes Care, 2003, 26:2604–2608. Haffner S. Diabetes and the metabolic syndrome––when is 8. it best to intervene to prevent? Atherosclerosis. Supplements, 2006, 7:3–10. Abdella N et al. Known type 2 diabetes mellitus among the 9. Kuwaiti population. A prevalence study. Acta Diabetologica, 1996, 33:145–149. Al-Nozha MM et al. Diabetes mellitus in Saudi Arabia. 10. Saudi Medical Journal, 2004, 25:1603–1610. El Mugamer IT et al. Diabetes, obesity and hypertension in 11. urban and rural people of Bedouin origin in the United Arab Emirates. Journal of Tropical Medicine and Hygiene, 1995, 98:407–415. Abdella N et al. Non-insulin-dependent diabetes in Kuwait: 12. prevalence rates and associated risk factors. Diabetes Research and Clinical Practice, 1998, 42:187–196. References Report of the Expert Committee on the Diagnosis and Clas-13. sification of Diabetes Mellitus. Diabetes Care, 2003, 26(Suppl. 1):S5–20. Aekplakorn W et al. A risk score for predicting incident diabe-14. tes in the Thai population. Diabetes Care, 2006, 29:1872–1877. Al-Lawati JA, Tuomilehto J. Diabetes risk score in Oman: a 15. tool to identify prevalent type 2 diabetes among Arabs of the Middle East. Diabetes Research and Clinical Practice, 2007, 77(3):438–444. Baan CA et al. Performance of a predictive model to identify 16. undiagnosed diabetes in a health care setting. Diabetes Care, 1999, 22:213–219. Glümer C, Jørgensen T, Borch-Johnsen K. Targeted screening 17. for undiagnosed diabetes reduces the number of diagnostic tests. Inter99(8). Diabetic Medicine, 2004, 21:874–880. Griffin SJ et al. Diabetes risk score: towards earlier detection 18. of type 2 diabetes in general practice. Diabetes/Metabolism Research and Reviews, 2000, 16:164–171. Herman WH et al. A new and simple questionnaire to identify 19. people at increased risk for undiagnosed diabetes. Diabetes Care, 1995, 18:382–387. Lindström J, Tuomilehto J. The diabetes risk score: a practi-20. cal tool to predict type 2 diabetes risk. Diabetes Care, 2003, 26:725–731. Mohan V et al. A simplified Indian Diabetes Risk Score for 21. screening for undiagnosed diabetic subjects. Journal of the As- sociation of Physicians of India, 2005, 53:759–763. Al-Lawati JA et al. Increasing prevalence of diabetes mellitus in 22. Oman. Diabetic Medicine, 2002, 19:954–957. Cowie CC et al. Prevalence of diabetes and impaired fasting 23. glucose in adults in the U.S. population: National Health and Nutrition Examination Survey 1999–2002. Diabetes Care, 2006, 29:1263–1268. NCCLS document C30-A2: point-of-care blood-glucose testing 24. in acute and chronic care facilities, approved guidelines, 2nd ed. Wayne, Pennsylvania, National Committee for Clinical Labora- tory Standards, 2002. Hawkins RC. Evaluation of Roche Accu-Chek Go and Me-25. disense Optium blood glucose meters. Clinica Chimica Acta, 2005, 353:127–131. mainly on known  risk  factors  that  are  easy  to measure  and non-invasive.  It  is made up of only 4 questions  (age,  waist circumference, use of blood pres- sure medication and  family history of  diabetes in a sibling) but nevertheless it  had 87% sensitivity and 64% specificity.  Most of  the previously published  risk  scores were not applicable to our Kuwaiti  population; however their performance  improved if the suggested cut-off values  were adjusted appropriately. Acknowledgements The authors appreciate  the effort of  the  following organizations  for  their  support and funding: Roche Diagnos- tics and the Kuwait Diabetic Society. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 732 Glycaemic control and its associated factors in type 2 diabetic patients in Amman, Jordan M. Adham,1 E. Sivarajan Froelicher,1,2 A. Batieha 3 and K. Ajlouni 1 ABSTRACT A study of 1000 patients attending a diabetes referral centre in Amman, Jordan, identified factors associated with good glycaemic control, as measured by glycosylated haemoglobin (HbA1c) levels. Glycaemic control improved significantly between the first clinic visit and at 12-months follow-up. The proportion of patients with extreme HbA1c (≥ 10%) decreased from 15.3% to 6.0% after 12 months. The percentage of patients with optimal control (HbA1c < 7%) increased from 25.4% at the first visit to 27.5% at 12-month follow-up. Multivariate regression showed that low body mass index, shorter duration of diabetes and higher baseline HbA1c were related to reductions in HbA1c between the first and 12-month visits. 1National Centre for Diabetes, Endocrinology and Genetics, University of Jordan, Amman, Jordan (Correspondence to K. Ajlouni: ajlouni@ju.edu.jo). 2Univeristy of California San Francisco, San Francisco, California, United States of America. 3Jordan University of Science and Technology, Irbid, Jordan. Received: 01/07/08; accepted: 29/09/08 ندرلأا ،ن َّامع في نياثلا طمنلا نم ينيركسلا في هل ةقفارلما لماوعلاو مدلا زوكولغ طبض نيولجعلا دممح لماك ،ةحيطب دممح رونأ ،كيلورف ناجرافيس اكيرأ ،مهدلأا دممح يجان لانم طبضلل ةقفارلما لماوعلا لىع اوفرعتو ،ندرلأا ،ن َّامع في ينيركسلل ةلاحإ زكرم نوعجاري نمم ضيرم 1000 لىع ةسارد نوثحابلا ىرجأ :ةـصلالخا ةدايعلل لىولأا ةرايزلا ينب ًايئاصحإ هب ُّدَتْعُي ًان ُّستح مدلا ركس طبض نستح دقو .يزوكولغلا ينبولغوميلها تايوتسم سايقب كلذو ،مدلا زوكولغل ديلجا يزوكولغلا ينبولغوميلها نم )رثكأ وأ %10 لداعت( ىوصق ةدايز نم نوناعي نيذلا ضىرملل ةيوئلما ةبسنلا تضفخنا دقف .ةعباتلما نم ًارهش 12 دعبو )يزوكولغلا ينبولغوميلها نم %7 نم لقأ( ًايلاثم ًاطبض ميهدل نيذلا ضىرملل ةيوئلما ةبسنلا تدازو .ًارهش 12 دعب %6 لىإ لىولأا ةرايزلا في %15.3 نم صرقو ،مسلجا ةلتك بسنم ضافخنا نأ تايرغتلما ددعتلما رقهقتلا ليلتح حضوأ دقو .ةعباتلما نم ًارهش 12 دعب %27.5 لىإ لىولأا ةرايزلا في %25.4 نم دعبو لىولأا ةرايزلا ينب يزوكولغلا ينبولغوميلها ضافخناب طبترت يزوكولغلا ينبولغوميهلل عفترلما سياسلأا ىوتسلماو ،يركسلاب ةباصلإا ةرـتف .اهنم ًارهش 12 Contrôle de la glycémie et facteurs associés chez des patients souffrant de diabète de type 2 à Amman (Jordanie) RÉSUMÉ Une étude sur 1 000 patients consultant dans un centre d’orientation-recours spécialisé dans le traitement du diabète à Amman (Jordanie) a mis en évidence les facteurs associés à un bon contrôle de la glycémie, mesuré par les taux d’hémoglobine glycosylée (HbA1c). Le contrôle de la glycémie s’est amélioré de manière significative entre la première visite au centre et le suivi réalisé 12 mois plus tard. La proportion de patients présentant un taux de HbA1c extrêmement élevé (≥ 10 %) est passée de 15,3 % à 6,0 % à l’issue des 12 mois. Le pourcentage de patients présentant un contrôle optimal (HbA1c <7 %) est passé de 25,4 % lors de la première visite à 27,5 % lors de la consultation de suivi effectuée 12 mois plus tard. La régression multivariée a mis en évidence qu’un faible indice de masse corporelle, un diabète de plus courte durée et une ligne de base du taux de HbA1c plus élevée étaient associés à une baisse du taux de HbA1c entre la première consultation et celle réalisée 12 mois après. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 733 Introduction The  increasing  prevalence  of  type  2  diabetes mellitus  (DM) worldwide  is  reaching epidemic proportions and  is  becoming a major public health prob- lem [1]. DM  is  a chronic disease  that  needs  coordinated  efforts  between  the patient,  family  and medical  team.  Improving glycaemic control  is  a high  priority in decreasing the burden of DM  and delaying  its  complications  [2,3].  While  research has  identified patient  characteristics that influence glycaemic  control  in  type 1 DM,  little  is  known  about  the  factors  that  influence  glu- cose  control  in  type 2 DM [4];  such  information has the potential to reduce  the short- and long-term complications  associated with DM.  A  patient’s  glycosylated  haemo- globin (HbA1c) level is an indicator of  the status of glycaemic control over the  previous 3 months. A cut-off point of <  7% indicates optimal glycaemic control,  but may not be feasible to achieve for all  diabetics [5]. Nevertheless, the UK Pro- spective Diabetes Study  found  that  in  type 2 diabetics each percentage point  reduction  in HbA1c  was  associated  with a 35% reduction  in microvascular  complications  and a 7%  reduction  in  all-cause mortality [6].  The objectives of this study were to  investigate the extent of glycaemic con- trol, as measured by HbA1c, in patients  with type 2 DM attending the National  Centre  for Diabetes,  Endocrinology  and Genetics  in Amman (NCDEG),  Jordan;  to  assess  the  relationship be- tween various demographic and clinical  factors  and glycaemic  control;  and  to  assess  the  factors  related  to changes  in  HbA1c at 12-month follow-up. Methods This was a historical prospective study  design using a review of patients’ medi- cal  records  from an existing database,  supplemented by a structured interview  questionnaire designed for this study.  Setting NCDEG was established  in 1996 as a  part of the University of Jordan hospital  in Amman, Jordan. The centre provides  comprehensive diabetes care to patients  from all over the country by a team con- sisting of an endocrinologist, specialized  nurses, physicians and a dietician. An  established database of medical records  contains each patient’s clinical history.  In addition, there are several specialized  clinics related to complications of DM.  Sample All patients with  type 2 DM who had  made 2 or more visits  to  the centre 2  to  3 months  apart  between  July  and  December 2006, and for whom follow- up data were available over a 12-month  period, were eligible for the study.  The  required  sample  size was esti- mated assuming that the proportion of  diabetics with poor glycaemic control  was 50%,  the  level of  significance  (α)  equal to 0.05 and limits of error 5%. The  estimated sample size calculated for the  given  prevalence  at  95%  confidence  interval (CI) was 778. We deliberately  over-sampled (n  = 1000)  in order  to  account  for missing data  from medical  records.  Approval for the study was obtained  through  the  ethical  committee of  the  centre. Verbal  consent was obtained  from  each  subject  for  access  to  the  medical records and the interview. Measurement and data collection The  interview was  administered by  a  registered nurse and included informa- tion  on  sociodemographic  variables  (education, monthly family income and  marital  status)  and  also  asked  about  smoking and patients’ use of medica- tion. Educational status was classified by  the length of time in education: 0 years  (illiterate), 1–12 years (school) or ≥ 12  years of education (diploma, bachelors  and postgraduate education). Smoking  was categorized as nonsmoker (never  smoked) or smoker (regularly smoked  at least 1 cigarette daily). Data  obtained  from  the  patients’  records  included:  treatment  for diabe- tes, measurements of  blood pressure  (BP),  anthropometric measurements  for  body mass  index  (BMI),  fasting  blood sugar, HbA1c, lipid profile, kidney  function tests and eye and foot examina- tions obtained at each visit. Anthropometric  measurements  included weight (in light clothes to the  nearest 0.5 kg), height (without shoes to  the nearest 0.5 cm) and waist circumfer- ence (at  the narrowest point between  the umbilicus and the rib cage) and hip  circumference (at the widest part of the  body below the waist). BMI (weight in  kilograms/height  in metres  squared)  was  used  to  classify  patients  as  nor- mal weight (< 25 kg/m²), overweight  (25–29.9 kg/m²) or obese (BMI > 30  kg/m²).  Blood pressure was measured us- ing  a  standard  sphygmomanometer  (EN 1060, Riester). Hypertension was  defined as systolic BP ≥ 130 mmHg /or  diastolic BP ≥ 80 mmHg or regular use  of antihypertensive drugs).  Complications of DM such as retin- opathy, neuropathy and nephropathy  were  noted  from  the  records.  Oph- thalmic examination was done at each  visit by dilating the pupil of one eye with  mydriatic eye drops. Retinopathy was  classified as present or absent.  Laboratory measures and biochemical analysis The  primary  outcome measure  was  HbA1c (at baseline  and 12 months).  HbA1c represents an estimate of mean  glucose level over the last 120 days [7].  Current guidelines  for glycaemic con- trol recommend HbA1c values < 7% as  a treatment goal for most DM patients  [8]. HbA1c was  analysed  by  using  a  high-performance  liquid  chromatog- raphy method (Bio-Rad). Glycaemic  control was grouped  into 4 categories:  EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 734 good  (HBA1C  <  7%),  acceptable  (HbA1c  7%–7.9%),  poor  (HbA1c >  8%–9.9 %)  or  extremely  inadequate  (HbA1c ≥ 10 %).  Total  cholesterol,  triglycerides  (TG)  and  high-density  lipoprotein  (HDL)  and  low-density  lipoprotein  (LDL) cholesterol were analysed by an  enzymatic colorimetric method (Cobas  Integra).  Lipid  profile  cut-offs were:  high  total cholesterol (≥ 200 mg/dL);  high  serum TG (≥ 150 mg/dL);  low  HDL cholesterol (< 45 mg/dL); AND  high LDL cholesterol (≥ 100 mg/dL).  Albumin urea concentrations were  measured by urine dipstick (Klinitic). Statistical analysis Data were entered and analysed using  SPSS  software. Data was  screened  for  extreme outliers, logical inconsistencies  and errors. Means and standard devia- tion (SD) and frequencies described the  sample. Student paired  t-test was used  to  assess  the difference  in means be- tween the first clinic visit and 12-month  follow-up intervals. The chi-squared test  was used to assess statistical significance  for differences of categorical variables;  P  ≤  0.05 was  considered  statistically  significant. Multivariate  linear  regres- sion was used to assess the independent  effect  of  variables  related  to  change  in HbA1c  level between  the first  and  follow-up  visits  after  controlling  for  potential confounders.  Results Sociodemographic and clinical characteristics at the first visit Table 1  shows  the  sociodemographic  characteristics  of  the  sample of  1000  patients with  type 2 DM at baseline.  The mean age was 58.1 (SD 9.3) years,  with 48.3% of patients aged > 60 years;  50.5% of patients were female, 10% were  illiterate and 15% were current smokers.  The mean duration of DM was 9.4 (SD  7.2)  years. One-third of  patients had  retinopathy and  two-thirds had dysli- pidaemias (Table 2). More than half of  the patients were on oral hypoglycaemic  drugs and only 2.1% were managed by  diet alone. Obesity (BMI > 30 kg/m2)  was present  in 57.6% of patients  and  91.3% were overweight or obese. The overall mean HbA1c level at the  first visit  to  the clinic was 8.10%; only  24.1% of patients had HbA1c < 7% (Ta- ble 2), while 16.1% had extremely high  values (≥ 10%). The lipid profile at  the  first visit to the clinic showed that 22.8%  had high  total cholesterol, 43.6% high  TG, 57.4%  low HDL cholesterol  and  62.8% high LDL cholesterol. Micro- albuminurea was present  in 32.0% and  a large proportion (71.7%) were hyper- tensive (BP ≥ 130/80 mmHg).  Sex  differences  in  selected  socio- demographic  and clinical  characteris- tics are  shown  in Table 3. Males were  significantly  older  and  had  a  longer  duration of diabetes, longer duration of  education,  lower HDL cholesterol and  LDL cholesterol levels and lower mean  HbA1c at the first visit.  Glycaemic control at the first visit Mean HbA1c  levels  by patient’s  age,  sex  and  clinical  characteristic  at  the  first visit are  shown on Table 4. Males  had  significantly  lower mean HbA1c  levels  than  females (P = 0.02). HbA1c  levels  increased  with  a  longer  dura- tion of DM (P = 0.001). Age was not  related  to glycaemic  control. Patients  with BMI 25–29 kg/m2 had  the  low- est mean HbA1c  levels  and HbA1c  was  significantly different  comparing  patients with BMI < 25 and ≥ 30 kg/ m2. Hypercholesterolaemia,  elevated  LDL cholesterol  and  the presence of  microalbuminurea were found in those  with higher HbA1c  levels (all P-values  < 0.01). A higher HbA1c  level was sig- nificantly associated with  the presence  of  retinopathy  (P  <  0.001).  Patients  treated with insulin, or a combination of  insulin and hypoglycaemic agents, had  significantly higher HbA1c levels. Changes in glycaemic control at 12-month follow-up Mean HbA1c decreased significantly in  the subset of patients who had measure- ments at follow-up, from 8.1% (SD 1.8%,  range 4.7%–17.3%) at  the first visit  to  7.8% (SD 1.3%,  range 4.9%–13.6%) at  follow-up.  The distribution of HbA1c levels for  886 patients  for whom complete data  were available at the first and 12-month  follow up visits are  shown on Table 5.  Table 1 Sociodemographic characteristics of the study group of diabetic patients at the first clinic visit (n = 1000) Variable No. of patients % Sex Male 495 49.5 Female 505 50.5 Age (years) < 40 30 3.0 40–49 150 15.0 50–59 337 33.7 ≥ 60 483 48.3 Education (years) a 0 86 10.0 1–12 392 44.6 > 12 398 55.4 Current smoker 145 15.0 aData on education missing for 124 patients. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 735 The percentage of patients with opti- mal control  (HbA1c < 7%)  increased  from 25.4% at the first visit to 27.5% at  follow-up. The proportion with extreme  HbA1c  levels (≥ 10%) decreased  from  15.3%  to  6.0% between  the  first  and  12-month visit (P < 0.001). Multivariate  linear  regression  showed  that  the  initial HbA1c  level,  duration of DM, and BMI were all sig- nificantly  related  to change  in HbA1c  between  the first  and  follow-up visits  after controlling for potential confound- ers in the analysis (age, sex, retinopathy  and neuropathy were  found not  to be  confounders) (Table 6). Patients with  initially high HbA1c  level were more  likely to decrease their HbA1c level. The  regression coefficient (β = 0.7) showed  that  for each 1% higher  initial HbA1c,  there was  a 0.7% greater  reduction  in  the HbA1c at the last visit (P < 0.001).  The longer the duration of DM the less  likely  it was  that a patient would have  a  reduced HbA1c between  the 2 visits  (β  = –0.16, P  < 0.001).  Similarly,  the  higher  the BMI  the  lower  the  reduc- tion  in HbA1c  between  the  2  visits (β = –0.09, P < 0.001).  Discussion This  is  the only  study  from  Jordan  to  report on glycaemic control  in a  large  sample of patients  that  included  sub- jects who attended  this  referral  centre  from all parts of Jordan. NCDEG deliv- ers  fully  integrated  specialized health  care  for patients with DM, endocrine  and genetic diseases,  serving both  the  private  and  public  sector  in Amman  and elsewhere  in  the country. The rate  of optimal glycaemic control  (HbA1c  < 7%) among the study sample (27.5%  at 12 months) was comparable  to  that  reported  from many countries [9–11].  Extremely  inadequate control (HbA1c  ≥ 10%) was rare among the study group  (6.0% at 12 months). An HbA1c level of  < 7% as a proposed target for optimum  glycaemic control  in DM patients may  not be feasible or practical and has been  the  subject of considerable discussion  [11–13]. The  results of our  study are  consistent with those by Benoit et al. [2]  and Abdelazis et al. [12]. Factors  related  to better glycaemic  control included male sex, shorter dura- tion of DM and  lower  levels  of  total  cholesterol, LDL cholesterol  and TG.  A meta-analysis  found that only about  one-third of patients were controlled to  an HbA1c level of < 7% [12]. Achieving  or maintaining levels of < 7% is more dif- ficult in patients with a longer duration  Table 2 Clinical and laboratory characteristics of diabetic patients at the first clinic visit (n = 1000) Variable No. of patients % Mean value (SD) Duration of diabetes (years) 9.4 (7.2) < 5 303 30.3 5–9 279 27.9 10–19 284 28.4 ≥ 20 134 13.4 HbA1c level (%) 8.10 (1.80) < 7 241 24.1 7–7.9 301 30.1 8–9.9 296 29.6 ≥ 10 161 16.1 Total cholesterol (mg/dL) 173.7 (38.2) < 200 672 77.2 ≥ 200 198 22.8 Triglycerides (mg/dL) 158.3 (84.5) < 150 492 56.4 ≥ 150 381 43.6 HDL cholesterol (mg/dL) 44.3 (11.1) ≥ 45 360 42.6 < 45 486 57.4 LDL cholesterol (mg/dL) 113.1 (32.1) < 100 321 37.2 ≥ 100 542 62.8 Urine albumin present 314 32.0 Retinopathy present 326 33.4 Dyslipidaemia present 671 68.0 Hypertension presenta 717 71.7 BMI (kg/m2) 31.6 (5.4) < 25 86 8.7 25–29.9 335 33.7 30–34 329 33.1 ≥ 35 244 24.5 Type of treatment Oral hypoglycaemics 524 52.9 Insulin & oral hypoglycaemics 368 37.8 Insulin 77 7.8 Diet alone 21 2.1 aSystolic BP > 130 mmHg, diastolic BP > 80 mmHg. SD = standard deviation; HbA1c = glycosylated haemoglobin; HDL = high-density lipoprotein, LDL = low- density lipoprotein; BMI = body mass index. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 736 of DM. Rather than targeting an HbA1c  level of < 7%  for  all  diabetic patients,  individualization of the target levels has  been  suggested  [13]. However, while  the  risk  of  complications declines  as  HbA1c declines,  the  risk of  hypogly- caemia increases. The balance between  benefit and harm of intensive treatment  may be less favourable in children < 13  years or adults over 70 years, and in peo- ple with repeated severe hypoglycaemia,  or those who lack awareness of hypogly- caemia [14]. In patients with advanced  DM complications,  such as blindness,  end-stage  renal disease,  advanced au- tonomic neuropathy or cardiovascular  disease,  the benefit of more  intensive  treatment may be  limited by  comor- bidity  and  reduced  life  expectancy.  In  such patients,  less  stringent  goals  for  glycaemic control may be adopted [14].  A number of studies have demonstrated  that immediate feedback to the patient  about  their HbA1c,  intense education  and  ensuring  appropriate  changes  in  therapy  results  in  a  significant  short- term and  long-term  improvement of  glycaemic status and enhances DM care  [15–17]. This will  help  in  individual- izing  target HbA1c  levels according  to  patient’s preference, age, social, psycho- logical status and other risk factors.  Optimal  glycaemic  control  was  recorded  in  24.1% of  our  patients  at  their initial visit, a figure which increased  modestly to 27.5% at the last follow-up  visit. Such a  level of control  is consist- ent with the results of many studies. In  Saudi Arabia,  for example, only 27% of  the study group reached the target level  of  control,  and  the  author  explained  this as due  to poor eating habits, poor  compliance with medication  and  the  use of  inappropriate herbal medicines  [9].  In Kuwait, only 17.6% of patients  had achieved  the goal of HbA1c < 7%  [10].  In Finland, only 25% of  a  study  group had HbA1c < 7.3% [11]. How- ever, optimal  control was  reported  in  44%,  50%  and  58% of  patients  from  NHANES  III  [18],  the UK Prospec- tive Diabetes  Study  [6]  and  a  study  in  the Netherlands  [19]. The decline  in HbA1c  levels  in our  study between  the first and 1-year follow-up visits sug- gests  that patients may not have been  receiving optimum management before  visiting NCDEG, leaving room for fur- ther  improvement  in  control of  their  DM. It  is possible  that physicians who  treat patients  in  the  community have  more relaxed standards of control  that  permit higher  levels of glycaemia. Lack  of  resources,  including  lack of  facilities  for HbA1c measurement, unavailability  of medications and  lack of educational  efforts  regarding diet  and weight  are  alternative explanations.  Glycaemic control in our study was  related to a number of factors including  sex, duration of DM, BMI, dyslipidae- mia and treatment modality. Consistent  with our findings, women were found to  have worse glycaemic control than men  in Saudi Arabia; the author related this  to the social norms of women in some  conservative Arab communities which  limit  their  ability  to  take  up  exercise  or employment outside  the home [9].  Similar  findings were  reported  from  Finland  [11]. However,  a  study  from  the United States found that adult men  with insulin-dependent type 2 DM had  significantly poorer glycaemic control  than did women [4].  Our data showed that  longer dura- tion of DM was related to more difficulty  with maintenance of glycaemic control.  This finding  is consistent with 3 earlier  studies [6,11,20] but is contradicted by  another  report  [4]. The worsening of  glycaemic control over  time could be  explained by a  reduction  in pancreatic  beta cell  function and an  increased  fat  mass,  particularly  visceral  adiposity,  leading  to greater  insulin  resistance as- sociated with  the ageing process.  It  is  known that achieving and maintaining  HbA1c levels < 7% is difficult in patients  with a longer duration of DM even with  the addition of a third oral hypoglycae- mic  drug. Hypoglycaemia  remains  a  major  limiting  factor  in achieving  tight  glycaemic control with insulin.  In our study, 91.3% of patients were  overweight or obese. BMI appears  to  be  related  to  glycaemic  control. The  lack of a  relationship between age and  Table 3 Mean values of selected sociodemographic and clinical variables of male and female diabetic patients at the first clinic visit (n = 1000) Variable Males Females P-value No. of patients Mean value (SD) No. of patients Mean value (SD) Age (years) 494 58.8 (9.9) 506 57.3 (9.3) 0.01 Education (years) 405 13.7 (4.6) 402 8.7 (5.4) < 0.001 Duration of diabetes (years) 493 9.9 (7.4) 505 8.8 (7.0) 0.02 HbA1c (%) 491 8.07 (1.77) 505 8.30 (1.83) 0.04 LDL cholesterol level (mg/dL) 434 107.6 (30.6) 441 118.1 (33.2) < 0.001 HDL cholesterol level (mg/dL) 432 41.2 (10.0) 440 48.4 (19.1) < 0.001 Systolic BP (mmHg) 490 129.6 (21.1) 506 131.1 (60.7) 0.62 Diastolic BP (mmHg) 490 78.0 (11.1) 505 78.0 (10.7) 0.94 BMI (kg/m2) 493 31.5 (5.3) 502 31.7 (5.4) 0.46 SD = standard deviation; HbA1c = glycosylated haemoglobin; LDL = low-density lipoprotein; HDL = high-density lipoprotein; BP = blood pressure; BMI = body mass index. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 737 Table 4 Mean glycosylated haemoglobin (HbA1c) levels of diabetic patients at the first clinic visit by selected variables Variable No. of patientsa Mean HbA1c level% (SD) P-value Total 1000 8.10 (1.80) Sex Male 496 8.05 (1.76) 0.02 Female 504 8.31 (1.82) Age (years) < 40 30 8.40 (2.58) 0.29 40–49 150 8.10 (1.81) 50–59 337 8.30 (1.80) ≥ 60 82 8.10 (1.73) Duration of diabetes (years) < 5 303 7.74 (1.91) < 0.001 5–9 278 8.20 (1.68) 10–19 284 8.48 (1.72) ≥ 20 134 8.50 (1.74) Total cholesterol (mg/dL) < 200 671 7.97 (1.64) < 0.001 ≥ 200 198 8.78 (2.06) HDL cholesterol (mg/dL) > 45 360 8.13 (1.74) 0.95 ≤ 45 485 8.14 (1.79) LDL cholesterol (mg/dL) < 100 321 7.93 (1.63) 0.05 ≥ 100 541 8.28 (1.85) Triglycerides (mg/dL) < 150 492 7.99 (1.71) 0.02 ≥ 150 380 8.36 (1.85) Retinopathy Retinopathy 326 8.58 (1.79) < 0.001 No retinopathy 649 7.96 (1.76) Proteinurea Proteinurea 307 8.50 (1.90) < 0.001 No proteinurea 628 8.03 (1.73) Type of treatment Oral hypoglycaemics 524 7.87 (1.64) < 0.001 Insulin 77 8.47 (1.99) Insulin & oral hypoglycaemics 367 8.58 (1.86) Diet 21 7.27 (1.78) Blood pressure (mmHg) < 130/80 238 8.10 (1.94) ≥ 130/80 716 8.21 (1.73) 0.4 BMI (kg/m2) < 25 86 8.25 (2.23) 0.01 25–29 335 7.91 (1.70) 30–34 328 8.37 (1.71) ≥ 35 244 8.27 (1.82) aNot all proportions add up to 1000 due to some missing values. SD = standard deviation; HDL = high-density lipoprotein; LDL = low-density lipoprotein; BMI = body mass index. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 738 glycaemic control in our study is incon- sistent with  the findings of  a number  of  studies  [2,19] which  reported  that  younger age was associated with poorer  glycaemic control [19]. As in other stud- ies,  patients  treated with  insulin,  or  a  combination of insulin and hypoglycae- mic agents, were  found to have poorer  glycaemic control  [2,19,21]. This may  be related to the fact that patients treat- ed by  insulin or  combination  therapy  have more severe disease  that  requires  more  aggressive  treatment  to  control  their disease, while patients with milder  disease  are more  easily  controlled by  diet or oral hypoglycaemic agents.  Our study also concurs with others  that  showed a  significant positive  rela- tionship between HbA1c and elevated  total  and LDL cholesterol  [2,19,22].  In our  sample,  75.8% of patients had  uncontrolled  DM,  as  indicated  by  HbA1c ≥ 7%. Although high TG and  low HDL represent  the  typical pattern  of diabetic dyslipidaemia, such a pattern  was not evident  in our study, probably  because  the patients had been  treated  with  lipid-lowering drugs. Because of  the multiplicative  cardiovascular  risk  of hyperglycaemia and dyslipidaemia,  lipid  abnormalities  should be  treated  aggressively as part of a comprehensive  DM care programme.  Factors  related  to greater  improve- ment  in HbA1c  levels  at  follow-up  in  our study included higher initial HbA1c,  shorter duration of DM and lower BMI.  To our knowledge, this is the first study  in Jordan to report on changes in HbA1c  level during a follow-up period.  Limitations Several  limitations affect  the generaliz- ability of our  study findings  to all dia- betic patients in Jordan. This study used  convenience  sampling  and,  although  patients  receiving  care  in  NCDEG  came from all over Jordan, the sample of  patients may differ from diabetics in the  general  population  in  certain  aspects  such as  socioeconomic status,  severity  of  their disease  and health  awareness  and motivation.  It  is  reasonable  to as- sume  that  the  rate of optimal  control  in patients treated outside the centre is  lower.  Patients with only 1 prior  visit  to  the clinic were excluded and  therefore  patients  who  lived  outside  Amman  may have been  less  likely  to meet  the  inclusion  criteria  of  having  attended NCDEG more  than  twice,  creating  a  selection bias between residents of Am- man and those outside of Amman. Thus,  patients with poor metabolic control or  less  interest  in  their disease may have  been excluded.  The use of secondary data is associ- ated with  inherent  limitations because  study  variables  that  are  desirable  to  know may not be contained in the data.  Detailed data about some aspects of pa- tient management at baseline were not  available  in  this  study. Such data,  such  as changes in drug management, could  account  the  improvements  in HbA1c  levels. Such details would be useful  to  assess in future studies.  Certain important aspects were not  available to the us in this study, such as  physical activity  levels and compliance  of patients with the treatment protocol;  both are  likely  to  influence glycaemic  control. To clarify  these  limitations  a  prospective longitudinal study is needed  that includes all patients attending NC- DEG,  information  about  distance of  travel to the centre and other variables, a  longer follow-up period than the current  12 months  and more comprehensive  information on all relevant variables.  Nevertheless,  this  study had multi- ple strengths. The study objectives were  achieved at  in a short  time at  relatively  low cost and. Important research ques- tions were answered using the rich and  complete data  source of  the medical  records of NCDEG.  Conclusions The proportion of optimal  glycaemic  control  among  the  study population  at  12-month  follow  up  (27.7%) was  comparable to that reported from many  countries. Extremely  inadequate  con- trol (HbA1c ≥ 10%) was rare among the  sample. Factors related to better glycae- mic control at 12 months after the first  clinic  visit  included male  sex,  shorter  duration of diabetes  and  lower  levels  of  total  cholesterol, LDL cholesterol  and TG. Multivariate  linear  regression  analysis  showed  that  factors  related  to  greater changes in HbA1c level included  higher  initial HbA1c,  shorter duration  of DM and lower BMI.  Table 5 Glycosylated haemoglobin (HbA1c) levels of diabetic patients at the first clinic visit and 12-month follow-up (n = 886) HbA1c (%) Baseline 12-month follow-up P-value No. of patients % No. of patients % < 7 225 25.4 244 27.5 < 0.001 7–7.9 266 30.0 302 34.1 8–9.9 260 29.3 287 32.4 ≥ 10 135 15.2 53 6.0 Table 6 Multivariate linear regression analysis of factors related to changes in glycosylated haemoglobin (HbA1c) levels of diabetic patients between the first clinic visit and 12-month follow-up (n = 882) Variable β regression coefficient P-value HbA1c level 0.70 < 0.001 Duration of diabetes –0.16 < 0.001 BMI –0.09 < 0.001 BMI = body mass index. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 739 King H, Aubert R, Herman W. Global burden of diabetes, 1. 1995–2025: prevalence, numerical estimates, and projections. Diabetes Care, 1998, 21:1414–1431. Benoit S, Fleming R, Philis-Tsimikas A. Predictors of glycemic 2. control among patients with type 2 diabetes: longitudinal study. BMC Public Health, 2005, 5(1):36 (doi: 10.1186/1471-2458 -5-36). Sidorove J et al. Disease management for diabetes mellitus: 3. impact of HbA1c. American Journal of Managed Care, 2000, 6:1217–1226. Nichols G et al. Predictors of glycemic control in insulin-using 4. adult with type 2 diabetes. Diabetes Care, 2000, 23:273–277. Gavin LA et al. Troglitazone add-on therapy to a combination 5. of sulfonylureas plus metformin achieved and sustained effec- tive diabetes control. Endocrine practice, 2000, 6:305–310. UK Prospective Diabetes Study (UKPDS) Group. Intensive 6. blood-glucose control with sulphonylureas or insulin com- pared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet, 1998, 352:837–853. Goldstein DE et al. Tests of glycemia in diabetes. 7. Diabetes Care, 2005, 27:87–99. Aisha A, Alghamdi. Role of HbA1c in the management of diabe-8. tes mellitus. Saudi Medical Journal, 2004, 3:342–345. Akbar DH. Low rates of diabetic patients reaching good control 9. target. Eastern Mediterranean Health Journal, 2001, 7:671–678. Al-Sultan F, Al-Zanki N. Clinical epidemiology of type 2 diabetes 10. mellitus in Kuwait. Kuwait Medical Journal, 2005, 37:98–104. Valle T et al. Glycemic control in patients with diabetes in Fin-11. land. Diabetes Care, 1999, 22:575–579. Abdelazis B et al. Facteurs determinants du controle glycemi-12. que des patients diabetiques de type 2 suivis en premiere ligne References [Predictive factors of glycemic control in patients with type 2 diabetes mellitus in primary care]. Revue d’Épidemiologie et de Santé Publique, 2006, 54(5):443–52. American Diabetes Association. Standards of medical care for 13. patients with diabetes mellitus. Diabetes Care, 2003, 26(Suppl. 1):33–50. Diabetes Control and Complications Trial Research Group. 14. The absence of a glycemic threshold for the development of long term complications: the perspective of the Diabetes Con- trol and Complications Trial. Diabetes, 1996, 45:1289–1298. Petersen J et al. Effect of point-of-care on maintenance of 15. glycemic control as measured by HbA1c. Diabetes Care, 2007, 30:713–715. Cagliero E, Levina E, Nathan D. Immediate feedback of HbA1c 16. levels improves glycemic control in type 1 and insulin-treated type 2 diabetic patients. Diabetes Care, 1999, 22:1785–1789. Thaler L et al. Diabetes in urban African–Americans. XV11. 17. Availability of rapid HbA1c measurements enhances clinical decision-making. Diabetes care, 1999, 22:1415–21. Saadine J et al. Improvement in diabetes processes of care and 18. intermediate outcomes: United States, 1988–2002. Annals of Internal Medicine, 2006, 144:7465–7474. Goudswaard A et al. Patient characteristics do not predict poor 19. glycemic control in type 2 diabetes patients treated in primary care. European Journal of Epidemiology, 2004, 19:541–545. El-Kebbi I et al. Association of younger age with poor glycemic 20. control and obesity in urban African Americans with type 2 diabetes. Archives of Internal Medicine, 2003, 163:69–75. Spann SJ et al. Management of type 2 diabetes in the primary 21. care setting: a practice-based research network study. Annals of Family Medicine, 2006, 4:23–31. Habib SS, Aslam M. Risk factors, knowledge and health status in 22. diabetic patients. Saudi Medical Journal, 2003, 24:1219–1224. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 740 Type A behaviour pattern: is it a risk factor for hypertension? J.N. Al-Asadi 1 ABSTRACT Type A behaviour pattern has been found to be associated with coronary heart diseases, but its association with hypertension is inconsistent. To investigate the association between type A behaviour pattern and hypertension, 221 known hypertensive patients and a control group of 221 non-hypertensive patients in Basra, Iraq, were interviewed for type A behaviour using to a special questionnaire. Blood pressure, height and weight were measured. The proportion with type A behaviour was significantly higher in hypertensive than non-hypertensive patients (57.5% versus 24.9%) and a highly significant association was found between type A behaviour and hypertension (OR 4.08, 95% CI: 2.72–6.11). Type A behaviour pattern was shown to be an independent risk factor for the development of hypertension. 1Department of Community Medicine, College of Medicine, University of Basra, Basra, Iraq (Correspondence to J.N. Al-Asadi: jasim1951@yahoo. com). Received: 29/09/08; accepted: 04/01/09 ؟مدلا طغض عافترلا راطتخلاا لماوع دحأ وه له :أ كولسلا طمن يدسلأا ميعن مساج ةجرد ةساردل ،تباث يرغ مدلا طغض عافترا عم هقفارت نأ لىإ ،يجاتلا بلقلا ضرمب طبترم )أ( يكولسلا طمنلا نأ لىإ ثوحبلا يرشت :ةصلالخا عافتراب ينباصلما يرغ نم 221و مدلا طغض عافترا ضىرم نم 221 عم تلاباقم ثحابلا ىرجأ ،مدلا طغض عافتراو )أ( كولسلا طمن ينب طباترلا ةبسنلا نأ دجوو ،نزولاو لوطلاو مدلا طغض ساق ماك ،كلذب صاخ نايبتسا مادختساب )أ( كولسلا طمن نع اثحب ،قارعلاب ةصربلا في مدلا طغض نا دجوو ،)24.9% لباقم 57.5%( مدلا طغض عافتراب ينباصلما يرغب ةنراقم مدلا طغض عافتراب ينباصلما دنع رثكأ )أ( كولسلا مهيدل نلم ةيوئلما ،)6.11 و 2.72 ينب حواترت 95% ةقث ةلصافب 4.08 ةيحجرلأا لدعم( .مدلا طغض عافتراو )أ( طمنلا نم كولسلا ينب ايئاصحإ هب دتعي اطبارت كانه .مدلا طغض عافترا روهظل لقتسم راطتخا لماع وه )أ( كولسلا طمن نأ ثحابلل حضتاو Le schéma de comportement de type A est-il un facteur de risque d’hypertension ? RÉSUMÉ Il est apparu que le schéma de comportement de type A était associé aux coronaropathies, mais son association avec l’hypertension présente des contradictions. Afin d’étudier la relation entre le schéma de comportement de type A et l’hypertension, 221 patients hypertendus et un groupe témoin de 221 patients non hypertendus de Bassora (Iraq) ont été interrogés sur le comportement de type A au moyen d’un questionnaire spécial. Leur pression artérielle, leur taille et leur poids ont également été mesurés. Le pourcentage de patients présentant un comportement de type A était significativement plus élevé chez les hypertendus que chez les non hypertendus (57,5 % contre 24,9 %) et une association très importante a été observée entre le comportement de type A et l’hypertension (odds ratio 4,08, intervalle de confiance à 95 % : 2,72-6,11). Le schéma de comportement de type A est apparu comme un facteur de risque indépendant du développement de l’hypertension. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 741 Introduction Individuals with  “type A”  personality  tend  to be competitive  and ambitious  and respond to stress with hostility or ag- gression [1], showing more pronounced  haemodynamic  responsiveness when  there  is  a  threat of  failing  [2]. The ob- servation of  stress-related  sympathetic  nervous  system activity  and  increased  catecholamine secretion in people with  type A behaviour,  resulting  in a  rise  in  blood pressure and heart rate, prompted  the  suggestion of  an  association with  cardiovascular diseases [3]. Type A behaviour had been shown  to be associated with an  increased risk  of coronary heart disease (CHD) [4].  It has been  suggested  that  type A be- haviour  increases  exposure  to poten- tial  triggers  to coronary events,  rather  than materially affecting  the process of  atherosclerosis  [5]. Some  researchers  have  suggested  that  individuals with  type A behaviour may have greater car- diovascular  reactivity under conditions  of high job strain [6] or environmental  conditions  that  are  stressful  or  chal- lenging [3]. Conversely, data indicating  a  similar  association between  type A  behaviour and hypertension are incon- sistent [7,8]. Such inconsistency may be  due to the fact that hypertension status  was based on a single measurement [9].  The  results may  also have been  con- fused  by  the  use  of  antihypertensive  medication  such  as  beta-adrenergic  blocking drugs, which appear to reduce  the vigorous vocal style and hostility of  those with type A pattern [10,11].  Although many  studies  found  an  association between  type A behaviour  and cardiovascular diseases [4,12], oth- ers did not [13,14]. Uncertainty  in  the  definition of the global type A behaviour  pattern  itself may be an  important part  of  this problem [13]. Others have sug- gested that only certain components of  type A behaviour, such as hostility [15],  time urgency and impatience [16] (re- ferred  to as  “toxic” elements) are  likely  to be associated with the risk of CHD.  The aim of  this case–control  study  in  Iraq was  to  further  investigate  the  hypothesis  that  type A behaviour  is as- sociated with hypertension. Methods A case–control  study was undertaken  in Basra,  Iraq,  from April  to December  2007.  Sample Patients were  recruited  from Al-Sadr  teaching  hospital  and Al-Seef  public  medical clinic (a medical centre where  patients with chronic diseases are  reg- istered and drugs  for hypertension are  distributed). The sample represented all  eligible patients who attended either of  the 2 medical centres during  the study  period and were available at one of the  author’s visits to these centres (3 times/ week for 2 hours each visit). A total of 221  known hypertensive patients, currently  on  antihypertensive  treatment,  aged  26–74 years were chosen randomly. No  patients refused to participate. A further  221  non-hypertensive  patients  aged  26–74  years who  attended  the  same  medical centres for illnesses other than  hypertension were chosen as a control  group. All the subjects were residents of  Basra City centre.  Informed  consent  was  obtained  after  explaining  the  aim of  the  study.  Hypertensive patients were excluded  if  they  reported having suffered myocar- dial  infarction, congestive heart  failure,  stroke  or  angina  pectoris.  Pregnant  women and those on contraceptive pills  were  also  excluded. Control  patients  found  to have  systolic blood pressure  ≥ 140 mmHg and/or diastolic blood  pressure ≥ 90 mmHg at  examination,  i.e. identified as hypertensive for the first  time, were excluded.  Data collection Both groups were  interviewed accord- ing  to  a  special  questionnaire which  included sociodemographic data (age,  sex, marital  status, occupation,  level of  education),  in addition  to  information  about level of physical activity, smoking,  history of diabetes mellitus and the pres- ence of  family history of hypertension.  Family history was considered positive  if one or more first-degree relative had  hypertension.  The  physical  activity  of  subjects  was defined as active (regular exercise  ≥  2  hours/week),  irregular  (exercise  < 2 hours/week) or  inactive (no  type  of  exercise  practised). Non-smokers  were those who never smoked, current  smokers  those who smoked  regularly,  while ex-smokers were  those who had  stopped smoking more than 3 months  before  the  study.  Diabetes  mellitus  was based on self-reports of  a diagno- sis  of  diabetes  and  history  of  taking  anti-diabetes medication. Weight and  height were measured  and  the  body  mass index (BMI) was calculated using  the Quetlet index [17]. Non-obese was  defined as body mass index < 25 kg/m2,  overweight as BMI 25–29.9 kg/m2 and obese as BMI ≥ 30 kg/m2 [18].  Definition and measurement of blood pressure Hypertension was defined according to  the criteria of  the Joint National Com- mittee  7th  report,  i.e.  systolic  blood  pressure ≥ 140 mmHg and/or diastolic  blood pressure ≥ 90 mmHg [19] or cur- rent use of antihypertensive medication,  regardless of  the  recorded blood pres- sure measurement. A mercury  sphyg- momanometer with a suitable cuff size  was used  to measure blood pressure.  After 5 minutes rest, the right arm blood  pressure of a seated participant was as- sessed  twice, 5 minutes apart,  and  the  average was reported as the final blood  pressure measurement. Assessment of type A behaviour To  assess  type  A  behaviour  pattern,  both  the hypertensive and  the control  groups  were  interviewed  according  to  a  special  questionnaire which was  EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 742 modified by Al-Lami from that of Fried- man and Rosenman [20]. Re-phrasing  and  changes  in  wording  were made  to  questions  to make  them  easier  to  understand and resulted  in an 18-item  questionnaire based on a dichotomized  (Yes/No) response  format. The ques- tionnaire was  constructed  to create 2  nominal variables:  type A or non-type  A behaviour  [20]. The questionnaire  contained 6 criteria  for each of which  there were 3 questions. Questions 1–3  were  concerned  with  rapidity,  4–6  with impatience, 7–9 with competition  and ambition, 10–12 with expressive- ness,  13–15 with  aggressiveness  and  16–18 with need  to control. Having 2  positive answers out of 3 questions  for  each criterion  rendered  that  criterion  positive,  and having 5 criteria positive  out of 6 denoted that  the person has a  type A behaviour pattern; otherwise the  person was classified as having non-type  A behaviour.  The changes  to  the original ques- tionnaire were previously reviewed and  approved by 5 specialists  in the field of  psychiatry,  and  the questionnaire was  shown to be useful for assessing type A  behaviour  in  Iraqi people [21,22]. The  validity of the questionnaire was tested  with the Framingham type A behaviour  scale  [23]; overall  agreement  rate was  82%.  Before  starting  the  study,  the  test– retest reliability of the questionnaire was  tested  in a  sample of 50 people with a  6-week retest interval; it yielded a coeffi- cient of 0.79. The reliability of the ques- tionnaire was thus deemed adequate. Statistical analysis Statistical  analysis  was  done  using  SPSS software package, version 15. The  results were expressed as numbers and  percentages. The  comparison  of  the  frequencies of  the  studied parameters  between cases and controls was done  by  the  chi-squared  test  and  the  t-test was used  for  the differences between  means. Logistic regression analysis was  done  to estimate  the  independent  as- sociation of the studied risk factors with  hypertension. Frequencies, odds  ratios  (OR) and confidence intervals (CI) are  presented. A P-value < 0.05 was consid- ered statistically significant. Results As  shown  in  Table  1,  no  significant  differences were noted between cases  and controls  regarding any of  the de- mographic characteristics  studied: age,  sex, education, marital status or occupa- tion. The mean age [standard deviation  Table 1 General characteristics of patients with hypertension and the controls Variable Cases Controls P-value No. % No. % Age (years) 26–35 18 8.1 23 10.4 0.82 36–45 62 28.1 62 28.1 46–55 81 36.7 81 36.7 56–65 49 22.2 44 19.9 > 65 11 5.0 11 5.0 Sex Male 106 48.0 109 49.3 0.74 Female 115 52.0 112 50.7 Education Illiterate 59 26.7 51 23.1 0.89 Primary 38 17.2 39 17.6 Intermediate 22 10.0 26 11.8 Secondary 37 16.7 37 16.7 Basic university and more 65 29.4 68 30.8 Marital status Married 197 89.1 193 87.3 0.65 Unmarried 14 6.3 18 8.1 Widowed/divorced 10 4.5 10 4.5 Occupation Employed 70 31.7 79 35.7 0.40 Unemployed 151 68.3 142 64.3 Total 221 100.0 221 100.0 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 743 (SD)] of  the case group was 49.4 (SD  9.9) years while that of the controls was  48.3 (SD 10.2) years. Table 2 shows that the prevalence of  type A behaviour was significantly higher  among the hypertensive patients com- pared with the control group: 127/221  (57.5%) versus 55/221 (24.9%) (OR  4.08, 95% CI: 2.72–6.11, P < 0.001).  As shown in Table 3, the percentage  of  smokers  in  the hypertension group  (14.9%) was comparable to the control  group (13.6%), but  the percentage of  ex-smokers  among  the hypertensives  (11.3%) was  significantly higher  than  that  in  the non-hypertensives  (3.6%)  (P < 0.01) and the proportion of non- smokers  in  the  hypertension  group  (73.8%)  was  lower  than  that  in  the  non-hypertension group (82.8%). The  percentages of overweight  and obese  patients were significantly higher in the  hypertension group (43.4% and 37.1%  respectively) than  in the control group  (36.2% and 30.3%  respectively)  (P < 0.01). The other  studied  risk  factors  (i.e.  physical  inactivity,  diabetes mellitus  and  family  history  of  hypertension)  were more prevalent  in  the hyperten- sion group (79.6%, 26.2% and 64.3%  respectively)  in  comparison with  the  control group (65.2%, 14.9% and 48.9%  respectively) (P < 0.01). To examine the independent effect  of personality as a risk factor for hyper- tension,  a  logistic  regression  analysis  was performed (Table 4). The studied  variables were:  age,  sex, marital  status,  Table 2 Prevalence of type A behaviour pattern among patients with hypertension and the controls Risk factor Cases Controls OR (95% CI) No. % No. % Type A behaviour 127 57.5 55 24.9 Non-type A behaviour 94 42.5 166 75.1 Total 221 100.0 221 100.0 4.08 (2.72–6.11) χ2 = 48.4, df = 1, P < 0.001 OR = odds ratio; CI = confidence interval; df = degrees of freedom. Table 3 Prevalence of other risk factors among patients with hypertension and the controls Risk factor Cases Controls P-value OR (95% CI) No. % No. % Smoking Non-smokers 163 73.8 183 82.8 < 0.01 Ex-smokers 25 11.3 8 3.6 Smokers 33 14.9 30 13.6 1.23a (1.06–1.59) Body mass index (kg/m2) < 25 43 19.5 74 33.5 < 0.01 25–29.9 96 43.4 80 36.2 ≥ 30 82 37.1 67 30.3 2.10b (1.28–3.46) Physical activity level Active 21 9.5 36 16.3 < 0.01 Irregular 24 10.9 41 18.6 Inactive 176 79.6 144 65.2 2.10c (1.28–3.74) Diabetes mellitus Yes 58 26.2 33 14.9 < 0.01 No 163 73.8 188 85.1 2.03 (1.26–3.27) Family history of hypertension Yes 142 64.3 108 48.9 < 0.01 No 79 35.7 113 51.1 1.88 (1.29–2.75) Total 221 100.0 221 100.0 aSmokers versus non-smokers. bBody mass index ≥ 30 kg/m2 versus < 25 kg/m2. cInactive versus active. OR = odds ratio; CI = confidence interval. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 744 education, occupation,  smoking, BMI,  physical  activity,  family history of hy- pertension and diabetes mellitus,  and  personality  type. Personality, physical  activity,  family history,  diabetes mel- litus and BMI were  the only variables  which showed a significant association  with hypertension. Personality type was  the risk factor most strongly associated  with hypertension (OR 3.77, 95% CI:  2.48–5.73). Discussion It should be emphasized that in evaluat- ing  self-administered questionnaires,  type A individuals are often unaware of  many of  their behavioural patterns, or  will deny them. Furthermore, no single  type A  individual  should be expected  to exhibit all  the characteristics of type  A behaviour  [24]. To overcome such  limitations,  personal  interviews were  used  in  this  study,  since  it  has  been  found that personal interviews are more  accurate  than  self-reported question- naires [25]. The  results  of  our  study  show  that  the  type A behaviour pattern was  significantly more prevalent  in patients  with  hypertension  (57.5%)  than  in  non-hypertensive people (24.9%) (OR  4.08). This is in agreement with the find- ings of  Irvine et al.  [26] and Yan et al.  [27], although the prevalence of type A  behaviour among hypertensive patients  in the present study (57.5%) was lower  than that reported by Irvine et al. (78%)  [26]. This difference may be because the  people studied by Irvine et al. were un- treated hypertensive patients whereas  in the present study they were patients  on antihypertensive medication.  It has  been found that antihypertensive drugs  particularly beta-adrenergic blocking  drugs may affect  some characteristics  or modify  the expression of  type A be- haviour [10,11,13]. The difference may  also be attributed  to  sociocultural dif- ferences or  to psychosocial  variability,  since  it has been  found  that  there are  intra-individual,  inter-individual  and  inter-population  psychosocial  vari- ability [27]. It  is also believed that type  A behaviour  is  influenced by  cultural  values  in  some modern  societies  that  reward  those who  can  produce with  great amounts of  speed, efficiency and  aggressiveness [28].  Physical  inactivity,  obesity,  fam- ily history of hypertension and diabetes  mellitus  are well-known predictors of  hypertension [29–31], and all these fac- tors were  significantly more prevalent  in  the hypertension  than  the  control  group. However,  these  factors did not  eliminate the increased risk of hyperten- sion  that was  associated with  type A  behaviour (as shown by the logistic re- gression analysis). Smoking is also a risk  factor for hypertension but the percent- age of ex-smokers among the hyperten- sion group (11.3%) was  greater  than  that among  the control group (3.6%).  This might  be  because  patients with  hypertension  recognized  the harmful  effects of smoking or had been advised  by a physician to quit smoking. In  conclusion,  the  present  study  provides  some evidence of an associa- tion between type A behaviour and hy- pertension in the Iraqi population. Type  A behaviour can be viewed not as a fixed  personality trait but as the outcome of a  set of predispositions that interact with  specific situations that elicit certain be- haviour [32]. Singer et al. have pointed  out  that employees can  learn  to utilize  more relaxed working styles if demands  and deadlines  at work and  fear of  job  loss are diminished to a more acceptable  level [33]. Therefore, interventions such  as  counselling and behaviour  therapy  to  identify objectionable and maladap- tive behaviours and replace  them with  healthier types of behaviour, and health  education  to avoid stressful  situations,  may reduce the need for more harmful  antihypertensive medication. Table 4 Logistic regression analysis of risk factors for hypertension Risk factor β-coefficient P-value OR (95% CI) Personality type 1.326 < 0.001 3.77 (2.48–5.73) Physical activity level 0.431 0.005 1.54 (1.14–2.08) Family history of hypertension 0.539 0.011 1.71 (1.13–2.59) Diabetes mellitus 0.637 0.016 1.89 (1.13–3.17) Body mass index 0.045 0.039 1.05 (1.00–1.09) OR = odds ratio; CI = confidence interval. References Martin RA, Kupier NA, Westra HA. Cognitive and affective 1. components of the type A behavior pattern: preliminary evidence for a self-worth contingency model. Personality and Individual Differences, 1989, 10:771–778. Lucini D et al. Hemodynamic and autonomic adjustments 2. to real life stress conditions in humans. Hypertension, 2002, 39:184–188. Matthews KA, Jennings R. Cardiovascular responses of boys ex-3. hibiting the type A behavior pattern. Psychosomatic Medicine, 1984, 46(6):484–497. Yoshimasu K, and the Fukuoka Heart Study Group. 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Baghdad, Iraq, Department of Community Medicine, University of Baghdad, 1997. Al-Bayati SM. Type A personality in Iraqi patients with duode-21. nal ulcer. Saudi Medical Journal, 2003, 24(3):313–314. Al-Asadi JN, Habib OS, Al-Naama LM. Cardiovascular risk fac-22. tors among college students. Bahrain Medical Bulletin, 2006, 28(3):126–130. Haynes SG et al. The relationship of psychosocial factors to 23. coronary heart disease in the Framingham study, 1. Meth- ods and risk factors. American Journal of Epidemiology, 1978, 107:362–383. Rosch PJ. Stress and cardiovascular disease. 24. Comprehensive Therapy, 1983, 9(10):6–13. Herman S et al. Type As who think they are type Bs: discrepan-25. cies between self-ratings and interview ratings of the type A (coronary-prone) behaviour pattern. British Journal of Medical Psychology, 1986, 59:83–88. Irvine J et al. Prevalence of type A behavior in untreated hyper-26. tensive individuals. Hypertension, 1991, 18:72–78. Yan LL et al. Psychosocial factors and risk of hypertension: the 27. Coronary Artery Risk Development in Young Adults (CAR- DIA) Study. Journal of the American Medical Association, 2003, 290:2138–2148. Lachar BL. Coronary prone behavior. 28. Texas Heart Institute Jour- nal, 1993, 20:143–151. Niskanen L et al. Inflammation, abdominal obesity, and smok-29. ing as predictors of hypertension. Hypertension, 2004, 44:859– 865. Sharma AK, Bhardwaj S, Chaturvedi S. Predictors of hyperten-30. sion in an urban Indian population. Indian Heart Journal, 2006, 58:21–27. Chan GC. Type 2 diabetes mellitus with hypertension at pri-31. mary healthcare level in Malaysia: are they managed according to guidelines? Singapore Medical Journal, 2005, 46(3):127–131. Matthews KA, Haynes SG. Type A behavior pattern and coro-32. nary disease risk update and critical evaluation. American Jour- nal of Epidemiology, 1986, 123:923–960. Singer JA, Neale MS, Schwartz GE. Conflicting perspectives on 33. stress reduction in occupational setting: a system approach to their solutions. In: Cataldo MF, ed. Health and industry: a behavioral medicine perspective. New York, John Wiley, 1986:162–192. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 746 Prévalence du surpoids et de l’obésité chez les enfants scolarisés à Tébessa (Algérie) entre 1998 et 2005 S. Taleb,1,2 H. Oulamara 2 et A.N. Agli 2 RÉSUMÉ Nous avons étudié la prévalence du surpoids et de l’obésité chez les enfants âgés de 5 à 8 ans scolarisés à Tébessa (Algérie) entre 1998 et 2005. L’âge, le sexe, la taille et le poids ont été relevés pour l’ensemble des élèves fréquentant cinq écoles primaires (n = 3396). Pour la classification de l’obésité et du surpoids, nous avons utilisé les références de l’International Obesity Task Force (IOTF). La prévalence du surpoids et de l’obésité pour l’ensemble de l’échantillon est de 6,36 % : elle est passée de 7,44 % en 1998 à 5,81 % en 2005. Les garçons sont plus en surpoids que les filles (5,60 % contre 4,18 % ) (p = 0,057).Les filles sont plus obèses que les garçons (1,58 % contre 1,26 % ) (p = 0,430). 1Institut des sciences de la nature et de la vie, Département de Biologie, Centre universitaire Cheikh Laarbi Tebessi, Tébessa (Algérie) (Correspondance à adresser à S. Taleb : talebsalima@yahoo.fr). 2Laboratoire de Nutrition et de Technologies alimentaires (LNTA), INATAA, Université de Mentouri, Constantine (Algérie). Reçu : 22/09/07 ; accepté : 03/05/08 2005 – 1998 ،رئازلجا ،ةسبت في سرادلما لافطأ ينب ةنادبلاو نزولا طرف راشتنا ل َّدعم ليقع صرانلا دبع ،ةرماعلوأ ةايح ،بلاط ةميلس ةدلما في ،رئازلجا ،ةسبت في تاونس 8و 5 ينب مهرماعأ حوارـتـت نمم سرادلما لافطأ ينب ةنادبلاو نزولا طرف راشتنا ل َّدعم نوثحابلا سرد :ةـصلالخا ،سنلجاو ،لافطلأا رماعأ نوثحابلا لجسو ،ًلافط 3396 مهددعو ةيئادتبلاا سرادلما نم 5 في لافطلأا عيجم ةساردلا تلمشو .2005و 1998 ينب ةنادبلا راشتنا ل َّدعم نأ اودجوو .نزولا طرفو ةنادبلا فينصتل ةنادبلا لوح ليودلا لمعلا قيرف اهّرقأ يتلا فيراعتلا اومدختساو ،نزولاو ،لوطلاو ىدل امم 5.60 % دلاولأا ىدل لىعأ نزولا طرف راشتنا ل َّدعم نأو ،0.430 لماتحا ةوقبو )%1.26( دلاولأا ىدل هيلع وه امم لىعأ )%1.58( تانبلا ىدل .0.057 لماتحا ةوقب ،4.18 % تانبلا Prevalence of overweight and obesity in schoolchildren in Tebessa (Algeria) between 1998 and 2005 ABSTRACT We studied the prevalence of obesity and overweight in schoolchildren aged 5–8 years in Tebessa, Algeria between 1998 and 2005. All schoolchildren in 5 primary schools (n = 3396) were included. Age, sex, height and weight were recorded. For classification of obesity and overweight the International Obesity Task Force definitions was used. The prevalence of obesity and overweight for the total sample was 6.36% and fell from 7.44% in 1998 to 5.81% in 2005. The prevalence of obesity was higher in girls than boys (1.58% vs 1.26%) (P = 0.430) while the prevalence of overweight was higher in boys than girls (5.60% vs 4.18%) (P = 0.057). طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 747 Introduction Tout semble  indiquer aujourd’hui que  la prévalence du surpoids et de l’obésité  augmente partout dans  le monde à un  rythme alarmant. Les pays développés  comme les pays en développement sont  touchés. Ce problème semble progresser  rapidement  aussi  bien  chez  l’enfant  que  chez  l’adulte ;  ses  conséquences  réelles pour  la  santé  sont nombreuses  et  variées,  allant d’un  risque  accru de  décès prématuré  à plusieurs maladies  non mortelles mais débilitantes  ayant  des effets  indésirables  sur  la qualité de  vie. L’obésité est également un  facteur  de  risque  important  de  maladies  non  transmissibles,  tels  le  diabète  non  insulinodépendant  (DNID),  les  pathologies  cardio-vasculaires  et  certains  cancers,  et  est  associée dans  bon nombre  de  pays  industrialisés  à  divers problèmes psychosociaux [1]. L’obésité ne concerne plus les seuls  petits  américains  (aujourd’hui  30 %  des  jeunes sont en surpoids dont 17 %  d’obèses et parmi eux un tiers de super  obèses – une augmentation de 60 % en  10 ans) [2]. L ’obés i t é   s emble   ê t re   p lus  importante dans les pays industrialisés,  mais  elle  est  aussi  en  augmentation  préoccupante  dans  les   pays   en  développement. En Égypte,  en 2002,  une étude a montré que 3 % de filles et  1,7 % de garçons  étaient obèses  chez  les 2-6  ans,  6,5 % de filles  et 4,5 % de  garçons  l’étaient chez  les 6-11 ans [3].  En Tunisie,  en Zambie et  au Togo,  la  prévalence de  l’obésité chez  les enfants  d’âge  préscolaire (0-59 mois)  était  comprise entre 1 et 4 % [1]. En Algérie,  nous  ne  disposons  pas  de  données  actuelles  sur  l’ampleur  du problème.  Très peu d’études ont été  réalisées sur  l’obésité. L’objectif  de notre  étude  était  de  déterminer la prévalence du surpoids et  de l’obésité chez les enfants scolarisés à  Tébessa entre 1998 et 2005, en utilisant  les  références de  l’International Obesity Task Force (IOTF).  Méthodes L’é tude   a   por té   sur   3396  en- fants (1819 garçons  et  1577 filles)  âgés de 5 à 8 ans,  scolarisés dans cinq  écoles primaires à Tébessa. Les mesures  anthropométriques  concernant  le  poids et  la taille ont été relevées sur  les  carnets de santé des élèves. Ces mesures  étaient inscrites sur les carnets de santé  pendant  la  visite  médicale  annuelle  au  niveau  des  Unités  de  Dépistage  et  de Suivi  (UDS). Les données ont  été  collectées  entre  1998  et  2005.  L’indice de masse corporelle (IMC =  poids  [kg]/taille  [m]  au  carré)  a  été  retenu pour  estimer  la prévalence du  surpoids et de  l’obésité conformément  aux définitions  internationales [4]. Les  valeurs de référence ont été déterminées  à partir des observations recueillies dans  six pays. Le  logiciel StatView version 5  (Abacus  conceptsTM,  Berkeley, États- Unis d’Amérique) a été utilisé pour  le  traitement des données. Résultats Le  tableau  1  présente  les  mesures  anthropométriques  des  enfants  de  notre étude. On observe une différence  significative entre filles et garçons pour  les mesures moyennes du poids à 5 ans  (p = 0,023), à 6 ans (p < 0,0001) et à 7 ans  (p = 0,003).  Il y a aussi une différence  significative selon  le sexe pour  l’IMC à  5 ans (p = 0,033), a 6 ans (p < 0,0001)  et  à 7  ans  (p = 0,0018). Les mesures  moyennes du poids et de  la  taille  sont  supérieures à celles des enfants étudiés  en 1996-2004 [5]. Les valeurs de l’IMC  des enfants de  la ville de Tébessa  sont  proches des valeurs de l’IOTF.  La prévalence globale du  surpoids  incluant  l’obésité  chez  l’ensemble des  enfants est de 6,36 % et celle de l’obésité  est  de  1,41 %.  Les  garçons  sont  plus  en surpoids que  les filles (5,60 % chez  les  garçons  contre  4,18 %  chez  les  filles ;  p = 0,057). Les  filles  sont plus  obèses que les garçons (1,58 % chez les  filles  contre 1,26 % chez  les  garçons ; p = 0,43) (Figure1). La  prévalence  du  surpoids  et  de  l’obésité  atteint  son maximum à  l’âge  de 8 ans chez les filles (7,43 % ) et à l’âge  de 5 ans chez les garçons (10,86 %), La  différence  est  non  significative  entre  filles et garçons (Figure 2a). La prévalence maximale de l’obésité  se  situe  à  l’âge de 5  ans  chez  les filles  (2,70 % contre 1,26 % chez les garçons ;  p = 0,217)) et à  l’âge de 6 ans chez  les  garçons (1,73 % contre 1,46 % chez  les  filles ; p = 0,693) (Figure 2b). Tableau 1 Mesures anthropométriques par sexe et par âge [moyenne (écart type)] Âge (ans) Filles Garçons Poids (kg) Taille (m) IMC (kg/m2) Poids (kg) Taille (cm) IMC (kg/m2) 5 19,6 (3,1)a 1,16 (0,05) 14,5 (2,0) a 20,5 (2,9) 1,16 (0,05) 15,2 (1,7) 6 20,8 (3,4) a 1,18 (0,05) 14,7 (1,9) a 21,7 (3,4) 1,19 (0,05) 15,2 (2,0) 7 22,7 (4,0) a 1,23 (0,06) 14,8 (2,0) a 23,4 (3,6) 1,24 (0,06) 15,2 (2,0) 8 24,8 (6,7) 1,26 (0,06) 15,3 (3,1) 25,1 (4,2) 1,26 (0,06) 15,7 (1,9) a Différence significative entre filles et garçons. IMC = indice de masse corporelle. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 748 La prévalence du surpoids  incluant  l’obésité est maximale chez  les filles en  1999 (7,20 % ) contre 7,14 % chez  les  garçons ; p = 0,985). Chez  les garçons,  elle  atteint  son  maximum  en  2003  (12,12 % contre 5,63 % chez  les filles ; p = 0,035) (Figure 3a). La prévalence de  l’obésité a atteint  son maximum en 2003 pour  les deux  sexes ;  les filles  sont plus  touchées que  les  garçons  (3,125 %  contre 2,02 %   ; p = 0,507) (Figure 3b). Le surpoids est passé de 6,38 % en  1998  à  5,08 %  en  2005  (p  =  0,589).  Cette diminution de  la prévalence du  12 10 8 6 4 2 0 Pr év al en ce (% ) Filles Garçons Total 5 ans 6 ans 7 ans 8 ans Âge Figure 2a Prévalence du surpoids et de l'obésité par âge et par sexe entre 1998 et 2005 5 ans 6 ans 7 ans 8 ans Âge 3 2.5 2 1.5 1 0.5 0 Pr év al en ce (% ) Filles Garçons Total Figure 2b Prévalence de l'obésité par âge et par sexe entre 1998 et 2005 Filles Garçons Total Surpoids Obésité Surpoids + obésité 8 7 6 5 4 3 2 1 0 Pr év al en ce (% ) Figure 1 Prévalence globale de l'obésité et du surpoids (de 1998 à 2005) طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 749 différentes études  sur  la prévalence de  l’obésité. Les  valeurs de  l’IOTF  sont  établies  à  partir  d’une population de  référence obtenue  en  combinant des  données  représentatives sur  le poids et  la taille d’enfants issus de six pays [6].  Comparer la prévalence de l’obésité  dans  différents  pays  est  difficile.  Les  différences  dans  les  estimations  de  fréquences s’expliquent principalement  par  le  choix des  valeurs de  référence.  Elles  sont  établies  sur des niveaux de  percentiles différents, et les populations  de  référence  diffèrent  par  la  date  de  recueil des données,  le pays d’origine,  le schéma de l’étude et les méthodes de  lissage utilisées [6]. Pour comparer nos  résultats, nous  avons sélectionné dans  la  littérature  les  études utilisant  l’IMC comme  indice  anthropométrique  et  les  références  de  l’IOTF pour définir  le  surpoids  et  l’obésité. Aux États-Unis,  la  fréquence  du  surpoids  (obésité  incluse)  était,  chez les enfants de 6 à 8 ans, de 12,5 %  chez  les garçons et de 11,8 % chez  les  filles  dans  l’enquête National Health and Nutrition Examination Survey –  II  (NHANES-II)  (1976-1980),  et  de  18,3 % chez  les garçons et 22,7 % chez  les filles dans  l’enquête NHANES-III  (1988-1994)  [7].  Les  fréquences  de  surpoids  incluant  l’obésité  en France  en 2000 chez  les 7 ans était de 19,7 %  chez  les garçons et de 18,6 % chez  les  surpoids  et  de  l’obésité  est  peut-être  due  à un  faible pouvoir d’achat de  la  population (Figure 4).  Discussion Les mesures moyennes du poids et de la  taille des enfants dans notre population  sont légèrement supérieures à celles des  enfants étudiés entre 1996 et 2004 par  Oulamara au niveau d’une grande ville  de  l’Est algérien [5]. Dans notre étude,  la prévalence du surpoids incluant l’obé- sité entre 1998 et 2005 est de 6,36 %.  Cette prévalence a été calculée a partir  des nouvelles bornes internationales de  l’IOTF recommandées pour comparer  1998 14 12 10 8 6 4 2 0 Pr év al en ce (% ) Filles Garçons Total 1999 2000 2001 2002 2003 2004 2005 Année Figure 3a Évolution de la prévalence du surpoids incluant l’obésité par année et par sexe entre 1998 et 2005 (p = 0,035) Figure 3b Évolution de la prévalence de l’obésité par année et par sexe entre 1998 et 2005 1998 3.5 3 2.5 2 1.5 1 0.5 0 Pr év al en ce (% ) Filles Garçons Total 1999 2000 2001 2002 2003 2004 2005 Année EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 750 Obésité: prévention et prise en charge de l’épidémie mondiale1. . Rapport d’une Consultation de l’OMS. Genève, Organisation mondiale de la Santé, 2003 (Série de Rapports techniques, N° 894). Coudray B 2. et al. Prévenir l’obésité chez l’enfant. Alimentation et Précarité N° 5, avril 1999, édité par le Centre de Recherche et d’Information Nutritionnelles (CERIN) en partenariat avec le Comité Français d’Éducation pour la Santé (CFES). Marsaud O. L’Égypte des gros - L’obésité des Égyptiens. Dé-3. couverte - Afrique du Nord – Égypte - Santé, 2003. Afrik.com. (www.afrik.com/article6465.htm, consulté le 10 mai 2010). Cole TJ et al. Establishing a standard definition for child over-4. weigt and obesity worldwide: International Survey. British Medical Journal, 2000, 320:1–6. Références Oulamara H. 5. Obésité et surpoids des enfants scolarisés : préva- lence à Constantine 1996-2004 –facteurs de risque associés à Constantine et Jijel. [Thèse de Doctorat d’État]. Constantine, Université de Constantine, 2006. Castelbon K, Rolland-Cachera MF. Surpoids et obésité chez les 6. enfants de 7 à 9 ans, France 2000. Unité mixte de recherche Inserm U557/Inra U 1125, CNAM/ Institut de Veille sanitaire, 2004. Flegal KM et al. Prevalence of overweight in US children: 7. comparison of US growth charts from the Centers for Dis- ease Control and Prevention with other reference values for body mass index. American Journal of Clinical Nutrition, 2001, 73:1086–1093. filles  [8].  En Angleterre,  en  1994,  la  prévalence du surpoids chez les 7-8 ans  était de 12,5 % chez  les filles et de 9 %  chez  les  garçons  [9]. Au Canada,  en  1996, chez les enfants âgés de 7 à 13 ans,  la prévalence du surpoids était de 32,4 %  chez  les garçons et de 26,4 % chez  les  filles [10]. En Grèce, durant  la période  1997-1998,  la prévalence du  surpoids  chez  les 11,5 ans était de 18,6 chez  les  garçons et de 11,8 chez  les filles  [11].  En Algérie,  en 2003,  selon une étude  réalisée à Constantine, la prévalence du  surpoids incluant l’obésité chez les 7-13  ans était de 2 % [12].  Dans notre  étude, 5,60 % chez  les  garçons  et  4,18 %  chez  les  filles  sont  en  surpoids  avec  des  prévalences  maximales à 8 ans chez les filles et 5 ans  chez  les garçons. Ces prévalences sont  beaucoup  plus  faibles  que  celles  des  pays européens et des États-Unis. En Allemagne, en 1997, la prévalence  de l’obésité chez les 6 ans était de 2,9 %  chez  les  garçons  et  de 3,3 %  chez  les  filles [13]. En Espagne, en 1998-1999, la  prévalence de  l’obésité chez  les 6-7 ans  était de 8,5 % à Madrid [14]. Selon une  étude réalisée à Chypre en 1999-2000,  la  prévalence  de  l’obésité  chez  les  7  ans  était de 8,6 % chez  les  garçons  et  de 8 % chez  les filles  [15]. Dans notre  étude,  la prévalence de  l’obésité est de  1,41 % (1,58 % chez  les filles et 1,26 %  chez  les garçons) (p = 0,43). Ces  taux  sont plus  faibles que ceux observés en  Europe.  De 1998 à 2005,  la prévalence du  surpoids incluant l’obésité est passée de  7,44 % à 5,81 % (p = 0,372). L’obésité  est passée de 1,06 % en 1998 à 0,72 % en  2005. Le surpoids est passé de 6,38 % en  1998 à 5,08 % en 2005 (p = 0,589).  Sur  l’ensemble  de  l’échantillon,  aucun  lien  significatif  n’a  été observé  sauf pour l’année 2003 où la prévalence  du  surpoids  incluant  l’obésité  est  significativement plus  élevée  chez  les  garçons  que  chez  les  filles  (12,12 %  contre 5,63 % ) (p = 0,035). En revanche,  Figure 4 Comparaison de la prévalence du surpoids et de l’obésité entre 1998 et 2005 Surpoids Obésité Surpoids + obésité 8 7 6 5 4 3 2 1 0 Pr év al en ce (% ) 1998 2005 bien  que  la  différence  ne  soit  pas  significative,  les filles  sont plus obèses  que  les  garçons. Cette prédominance  féminine de l’obésité a été trouvée dans  d’autres études [16-18]. L’évolution des  fréquences du  surpoids et de  l’obésité  est  probablement  liée  au  mode  de  vie. Plusieurs  facteurs  sont  associés  à  cette maladie  comme  la  sédentarité,  les conditions socio-économiques et  la  corpulence des parents. Conclusion Cette  étude  est  la  première  ayant  estimé, sur un grand nombre d’enfants  scolarisés à Tébessa (Est de  l’Algérie),  la prévalence du surpoids et de l’obésité  chez  l’enfant.  Selon  les  références de  l’IOTF,  la prévalence du  surpoids est  de 6,36 % celle de l’obésité est de 1,4%.  Ces chiffres, comparés à d’autres études  réalisés à Constantine et dans d’autres  régions  de  l’Algérie  (8,9 %  surpoids  et  1,7 %  obésité)  [19], montrent  la  tendance  de  l’augmentation  de  la  prévalence de cette épidémie en Algérie.  Cette  augmentation  pourrait  poser  ultérieurement  un  grand  problème  de  santé  publique.  Il  est  nécessaire  d’entreprendre  une  surveil lance  épidémiologique précoce des enfants.  Un système tel un observatoire de l’état  nutritionnel des enfants est à mettre en  place.  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 751 Draft nutrition strategy and plan of action for countries of the Eastern Mediterranean Region, 2010–2019 In December 2009 in a timely response to the worsening food and nutrition situation regionally and globally, the World  Health Organization (WHO) launched a draft new nutrition strategy and plan of action for the Eastern Mediterranean  Region. The draft strategy document provides an analysis of the regional nutrition situation exploring the causes and conse- quences of nutrition problems. The overall goal of the proposed strategy is to improve the nutritional status of people  throughout the life-cycle by encouraging countries to reposition nutrition as central to their development agendas. The  WHO Regional Office, through this strategy, will work closely with Member States and provide technical support, in  coordination with other key partners and UN specialized agencies, to ensure that nutrition is ensured a prominent place  in national development plans and related programmes to achieve health and nutrition security for all. The Draft nutrition strategy and plan of action for countries of the Eastern Mediterranean Region, 2010–2019 can be  found at: http://www.emro.who.int/nutrition/pdf/nutrition_strategy_2010_2019.pdf Rolland-Cachera MF, Thibault H. Définition et évolution de 8. l’obésité infantile. Journal de Pédiatrie et de Puériculture, 2002, 15(8):448–53. Chinn S, Rona R. Prevalence and trends in overweight and 9. obesity in three cross sectional studies of British children, 1974–94. British Medical Journal, 2001, 322:24–26. Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends 10. in overweight and obesity in Canada, 1981–1996. Interna- tional Journal of Obesity and Related Metabolic Disorders, 2002, 26:538–543. Karayiannis D et al. Prevalence of overweight and obesity in 11. Greek school-aged children and adolescents. European Journal of Clinical Nutrition, 2003, 57:1189–1192. Oulamara H, Agli A, Benatallah L. Obésité et surpoids chez des 12. enfants scolarisés au niveau de la commune de Constantine : étude préliminaire. Santé Publique et Sciences Sociales, 2004, 11 & 12:169–178. Kalies H, Lenz J, von Kries R. Prevalence of overweight and 13. obesity and trends in body mass index in German preschool children, 1982–1997. International Journal of Obesity and Re- lated Metabolic Disorders, 2002, 26:1211–1217. Rodriguez-Artalejo F et al. Dietary patterns among children 14. aged 6–7 y in four Spanish cities with widely differing cardio- vascular mortality. European Journal of Clinical Nutrition, 2002, 56:141–148. Savva SC et al. Obesity in children and adolescents in Cyprus. 15. Prevalence and predisposing factors. International Journal of Obesity and Related Metabolic Disorders, 2002, 26:1036–1045. Aspray TJ et al. Rural and urban difference in diabetes preva-16. lence in Tanzania: the role of obesity, physical activity and ur- ban living. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2000, 94:637–644. Musaiger AO, Al-Awadi AA, Al-Mannai MA. Lifestyle and social 17. factors associated with obesity among Bahrain adult popula- tion. Ecology of Food and Nutrition, 2000, 39:121–133. Zagre NM, Nebie LVA, Niakara A. Obésité, facteurs sociaux et 18. style de vie en milieu urbain Ouest Africain : étude prospective en population. Médecine et Nutrition, 2001, 37(4):178–185. Oulamara H. 19. Prévalence de l’obésité et du surpoids chez des enfants scolarisés en Algérie en 2004 –2006. Communication affichée au 1er Congrès international de Nutrition de Tunisie 27/28 octobre 2006, Tunis. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 752 Domestic abuse before, during and after pregnancy in Jahrom, Islamic Republic of Iran E. Mohammadhosseini,1 L. Sahraean 2 and T. Bahrami 2 ABSTRACT We conducted a cross-sectional study among 300 women with a child aged 6 to 18 months, to determine the prevalence and determinants of domestic abuse against women in Jahrom; before, during and after pregnancy. The prevalence of abuse during pregnancy (42%) was lower than during the 1 year before pregnancy (51.7%) and after delivery (53.5%). The overall prevalence of emotional abuse, sexual abuse and physical abuse was 53.5%, 34.7% and 26.7% respectively. Abuse during any previous period was a strong risk factor for subsequent abuse. Other risk factors associated with abuse were: woman previously witnessing domestic violence, opium use by husband, woman’s education ≤ 12 years, age at marriage of woman < 18 years, husband’s education ≤ 12 years, woman’s economic dependency and living in an extended family. Routine screening of abuse in maternity clinics should be considered. 1Department of Psychiatry, Medical College; 2Mental Health Centre, Jahrom University of Medical Sciences, Jahrom, Islamic Republic of Iran (Correspondence to E. Mohammadhosseini: emh_56@yahoo.com). Received: 17/03/08; accepted: 20/07/08 ةيملاسلإا ناريإ ةيروهجم ،مورهج في لملحا دعبو ءانثأو لبق ليزنلما فينعتلا يماربه ةرهاط ،نايئارحص ندلا ،ينيسح دممح هلها راشتنا ل َّدعم لىع ف ُّرعتلا فدبه ؛ًارهش 18و 6 ينب هرمع حواتري ًلافط مهنم لك ىدل نمم ةأرما 300 تلمش ةيضرع ةسارد نوثحابلا ىرجأ :ةـصلالخا ل َّدعم نم لقأ وهو )%42( لملحا ءانثأ فينعتلا راشتنا ل َّدعم نأ اودجوو .لملحا دعبو ءانثأو لبق ،مورهج في هتاددمحو ءاسنلا دض ليزنلما فينعتلا %53.5 يفطاعلا فينعتلل لياجملإا ل َّدعلما نأو .)%53.5( لمحلل ةقحلالا ةنسلا في هراشتنا ل َّدعم نمو ،)%51.7( لمحلل ةقباسلا ةنسلا في هراشتنا لماوع امأ .قحلا فينعت ثودلح ةيوقلا راطتخلاا لماوع نم ةقباس ةترف يأ في فينعتلا ناك دقو .%26.7 يدسلجا فينعتللو %34 سينلجا فينعتللو جاوز نسو ،لقأ وأ ًاماع 12 ةأرلما ميلعت ةترفو ،نويفلأل جوزلا يطاعتو ،ًايلزنم ًافنع لبق نم تدهش ةأرما :يهف فينعتلل ةقفارلما ىرخلأا راطتخلاا نع ينيتورلا ي ِّرحتلل مماتهلاا ءلايإ يغبنيو .ةدتمم ةسرأ في شيعلاو ،ًايداصتقا ةأرلما لاكتاو ،لقأ وأ ًاماع 12 جوزلا ميلعت ةترفو ،ًاماع 18 نم لقأ ةأرلما .ةموملأا تادايع في فينعتلا Violence familiale avant, pendant et après la grossesse à Jahrom (République islamique d’Iran) RÉSUMÉ Nous avons réalisé une étude transversale auprès de 300 femmes ayant un enfant âgé de 6 à 18 mois, afin de d’identifier la prévalence et les déterminants de la violence familiale exercée avant, pendant et après la grossesse à l’encontre de femmes résidant à Jahrom (République islamique d’Iran). Au cours de la grossesse, la prévalence de la violence était plus faible (42 %) qu’au cours de l’année précédant la grossesse (51,7 %) et qu’après l’accouchement (53,5 %). La prévalence globale de la violence psychologique, sexuelle et physique s’élevait à 53,5 %, 34,7 % et 26,7 %, respectivement. La violence durant toute période antérieure constituait un facteur de risque élevé de violence future. D’autres facteurs de risque étaient associés à la violence : femme ayant déjà assisté à des scènes de violence familiale, mari consommant de l’opium, femme instruite jusqu’à l’âge de 12 ans au maximum, femme mariée avant 18 ans, mari instruit jusqu’à l’âge de 12 ans au maximum, dépendance économique de la femme et vie dans une famille élargie. Un dépistage systématique de la violence lors des consultations en maternité devrait être envisagé. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 753 Introduction According to world-wide studies, at least  1 in 5 women experiences a violent rela- tionship at some point in their lives [1]. The World Health Organization  (WHO) has defined domestic violence  as “the range of sexually, psychologically  and physically coercive acts used against  adult and adolescent women by current  or former male intimate partners” [2,3]. Domestic  violence  is  a  particular  problem  in obstetric care. Studies  sug- gest  that pregnancy can act as a  trigger  for domestic violence or exacerbate an  existing problem, although occasionally  it has been associated with a reduction  in violence [4]. Reported rates of physical, sexual or  emotional  violence during pregnancy  range  from 0.9% to 22% [5]. The risks  of  domestic  violence  are  particularly  acute  in pregnancy, where  the health  and  safety  of  2  potential  victims  are  placed  in  jeopardy. Domestic violence  is associated with increased rates of mis- carriage, premature birth [6],  low birth  weight,  chorioamnionitis,  fetal  injury  and fetal death [7–10]. Once the child  is born, battered women are more likely  to  report  child  abuse or  to  fear  it  [7].  Studies of abuse  in  the year preceding  pregnancy  reported a prevalence  rang- ing from 3.8% to 26% [11,12]. However,  women appear to be at even greater risk  of domestic violence in the postpartum  period compared with the time of preg- nancy [13,14]. According  to  some studies domes- tic violence  is a common public health  problem in the Islamic Republic of Iran  [15–19], but to our knowledge few stud- ies exist  that compared  the  rate of do- mestic violence  in pregnancy with  rate  of abuse before and after this period. Methods Study design This  was  a  descriptive,  analytical  cross-sectional  study conducted  from  November  2006  to  January  2007  in  Jahrom city in southern Islamic Repub- lic of Iran. Sample Married women who had a child aged  6  to  18 months were  the  subjects  of  this  study. Based on previous  studies  [15–19], the prevalence of wife abuse in  the Islamic Republic of Iran ranges from  37%  to 78%. Therefore  considering  a  lower approximate prevalence of 30%  (0.3),  the  estimated  sample  size was  224 [d = 0.06, 95% confidence interval  (CI)].  A  sample  of  300 women was  chosen  to  increase  the  statistical  reli- ability of the study. Immunization files  in public health  clinics  served  as  the  sampling  frame.  Public health clinics  in  the  Islamic Re- public of  Iran are governmental clinics  that provide some medical and primary  health  care  services  such  as  prenatal  care,  family  planning  and  childhood  immunization.  In  Jahrom,  childhood  immunization  is  exclusively  done  in  these clinics and all children are brought  there  for vaccination. Often, husbands  do not  accompany  their wives  to  the  vaccination clinics  and  in our  study  if  the husband was present,  the woman  was not enrolled. There are 9 public health clinics  in  Jahrom  city  and  each  of  them  has  a  number. We  started  screening  from  clinic number 1 and  subsequent days  screening was done in other clinics (one  clinic per day). Women were  selected  sequentially as an eligible woman (with  a  child  aged  6  to  18 months)  came  in  to  the  clinic  for  vaccination. After  9–11  days  (because  of  holidays  the  cycle duration might be more  than 9  days) we came back  to  the first  clinic  and continued this cyclical pattern until  300 women were entered  in  the study.  In each of  these clinics we  interviewed  about 33 (range: 31–35) women.  Data collection Data were obtained by  interview using  a pretested questionnaire in Farsi which  was derived from prior studies [4,15,20].  The questionnaire was administered by  one clinical psychologist  in  complete  privacy. Anonymity of  the  responses  was assured and verbal consent to par- ticipate was obtained. The  interviewer  was a main manager of mental health  programmes  in public health clinics  in  Jahrom and many of  the participants  were familiar with her. Thus we did not  face  any  refusals  to participate  in  the  study. The  interview  lasted  for an aver- age of 30 minutes. Questionnaire The questionnaire consisted of 2 parts.  The first part obtained  information re- garding some demographic characteris- tics and the second part assessed abuse,  including physical, emotional and sexual  abuse, during each of 3 periods: the 12  months before pregnancy, the period of  pregnancy and  the  time after delivery.  The  husbands  were  considered  per- petrators of abuse  in all questions. The  face  validity of  the questionnaire was  approved by 2 psychiatrists and a clini- cal psychologist and reliability analysis  showed satisfactory  results (Cronbach  alpha coefficient = 0.7). Physical abuse was graded on 4 lev- els from mild (I) to severe (IV): Abuse  involving beating or pushing • but without trauma or persistent pain  or  limited movement of  some parts  of the body. Beating with persistent pain or limited • movement of some parts of the body. B• eating  resulting  in  serious  contu- sions,  fractures  or  head  or  viscera  trauma. Physical  abuse with any  implement, • leading  to permanent  injury (for ex- ample blindness, lameness) To  assess  sexual  abuse,  women  were asked  if  they had been pressured  verbally  to  have  sexual  intercourse,  pressured with  threats  to have  sexual  intercourse or physically forced to have  sexual intercourse. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 754 To assess emotional abuse, women  were asked if they had been insulted or  made to feel bad, humiliated in front of  other people,  threatened with divorce  or abandonment or restricted access to  family and friends. Social support was assessed by ask- ing whether  the woman had any place  where she could go and stay, if the con- dition in the house became intolerable. An  economically  independent  woman  in  this  study was  considered  one who had a  job or  received finan- cial  support  from  another  sources  if  deprived by her husband. This study was supported by Jahrom  of Medical Sciences and approved by  the Ethics Committee of this university. Statistical analysis Data  analysis  was  carried  out  using  SPSS,  version  12.  Logistic  regression  models were applied to predict  the  fac- tors  that  affected  the  risk  of  violence  from husbands. Odds ratios (OR) and  95%  confidence  intervals  (CI)  were  calculated. P  <  0.05  was  considered  significant.  Results We  interviewed 300 married women  in  the age group 18  to 40 years with a  mean  age of  approximately  27  years  [standard  deviation  (SD)  4.24]. Of  these women, 53.3% had 1 child, 31.0%  had 2 children and 15.7% had 3 or more  children. The overall prevalence of any abuse  occurring  in  any period  (before, dur- ing or after pregnancy) was 64.7%. The  overall prevalence of emotional abuse,  sexual  abuse  and physical  abuse was  53.5%, 34.7% and 26.7%  respectively.  Abuse  during  pregnancy  was  lower  than  that during  the other 2 periods.  The prevalence of abuse before, during  and after pregnancy was 51.7%, 42.0%  and 53.3%  respectively.  In all periods,  emotional  abuse was  the most preva- lent  type of  abuse and physical  abuse  was the least prevalent (Table 1). Most  cases of physical abuse were not severe (Table 2). A significant association was  found  between abuse before pregnancy  and  abuse during pregnancy (OR = 27.31;  95% CI: 13.96–53.43). There was also  a significant association between abuse  before pregnancy and abuse after preg- nancy (OR = 10.31; 95% CI: 6.04%– 17.59%)  and  between  abuse  during  pregnancy and abuse  after pregnancy  (OR = 29.73%; 95% CI: 14.68–60.22). The prevalence of abuse with differ- ent variables is shown in Table 3. All  variables were  considered  for  the  logistic  regression model  to  as- sess  any  confounding  effects.  On  logistic  regression analysis  (Table 4),  the  strongest predictor of  all  types of  abuse was women witnessing violence  to  other  women  by  their  husbands (P < 0.0001).  In other words, women  Table 1 Prevalence of the 3 types of domestic abuse before, during and after pregnancy (n = 300) Period of abuse Emotional abuse Sexual abuse Physical abuse Any typea No. % No. % No. % No. % Before pregnancy 125 41.7 63 21 50 16.7 155 51.7 During pregnancy 99 33.0 52 17.3 30 10.0 126 42.0 After pregnancy 128 42.7 75 25 44 14.7 160 53.5 Overallb 160 53.5 104 34.7 80 26.7 194 64.7 Women may have had more than 1 type of abuse and in more than 1 period. aAny type of abuse, together. bIn all periods. Table 2 Severity of physical abuse experienced by the women (n = 300) Period of physical abuse Level I Level II Level III Level IV Any levela No. % No. % No. % No. % No. % Before pregnancy 47 15.7 15 5.0 15 5.0 2 0.7 50 16.7 During pregnancy 23 7.7 5 1.7 8 2.7 0 0.0 30 10.0 After pregnancy 37 12.3 15 5.0 15 5.0 2 0.7 44 14.7 Overallb 76 25.3 30 10.0 31 10.3 4 1.3 80 26.7 aAny level of physical abuse; bIn all periods. Women may have experienced more than 1 level of physical abuse and in more than 1 period. Level I) Abuse involving beating or pushing but without trauma or persistent pain or limited movement of some parts of the body; Level II) Beating with persistent pain or limited movement of some parts of the body; Level III) Beating resulting in serious contusions, fractures or head or viscera trauma; Level IV) Physical abuse with any implement, leading to permanent injury (for example blindness, lameness). طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 755 who,  as  children,  had witnessed  vio- lence to women in their family by their  husbands were more  likely  to be  the  victims of wife abuse. Overall incidence  of wife abuse was also greater when the  husband’s  education was  ≤  12  years (P = 0.002). Strong predictors of physi- cal  abuse were:  living  in  an  extended  family (P = 0.045), woman’s education  ≤ 12 years (P < 0.0001), woman’s eco- nomic dependency (P < 0.0001), hus- band’s education ≤ 12 years (P = 0.025),  woman previously witnessing domestic  violence (P = 0.001) and woman’s age  at marriage below 18 years (P = 0.007)  (Table  4). The  strongest  predictor  on  logistic  regression  for  sexual  abuse  was opium use by woman’s husband (P   =  0.01).  For  emotional  abuse  strong predictors of  abuse on  logistic  regression were: opium use by husband (P = 0.045) and husband’s education ≤  12 years (P = 0.01). Husband’s  smok- ing, woman’s age, parity and access  to  Table 3 Frequency of domestic violence according to women’s characteristics Characteristic Total (n = 300) Presence of domestic violence P-value No. No. % Woman’s years of education 0.08 0–12 237 159 67.1 > 12 63 35 55.5 Type of family 0.024 Nuclear family 246 153 62.2 Joint (extended) family 54 42 77.7 Witnessing abuse of another woman < 0.0001 Yes 163 123 75.5 No 137 71 51.8 Social support 0.40 Present 222 143 64.6 Absent 78 51 65.3 Woman’s economic status 0.39 Independent 153 97 63.4 Dependent 147 97 66 Woman’s age 0.13 < 20 19 15 78.9 ≥ 20 281 180 64 Woman’s age at marriage (years) 0.17 < 18 127 87 68.5 ≥ 18 173 108 62.4 Sex of child in index pregnancy 0.52 Female 148 95 64.2 Male 152 98 64.5 Parity 0.78 1 160 103 64.4 2 93 59 63.4 ≥ 3 47 32 68.1 Husband’s years of education < 0.0001 0–12 246 173 70.3 > 12 54 21 38.8 Husband a cigarette smoker 0.12 Yes 80 56 70 No 220 138 62.7 Husband an opium user 0.012 Yes 15 14 93.3 No 285 180 63.1 EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 756 social support were not associated with  any type of abuse. There was no associa- tion between the sex of the child in the  most recent pregnancy and incidence of  abuse during the postpartum period. In  the  perception  of  the women,  poor  relationship with  the husband’s  family,  discipline of  the  children  and  financial problems were  the most  fre- quent causes of abuse (Table 5). Discussion This is the first study in the Islamic Re- public of  Iran,  to our knowledge,  that  examines women’s  pregnancy  abuse  experiences  in comparison with abuse  before and after pregnancy. The prevalence of abuse occurring  in all periods, before, during and after  pregnancy was 64.7%, consistent with  some  studies  that  found  prevalence  of wife  abuse  in different parts of  the  country  ranging  from 36.8%  to 78.4%  [15–17,19]. This  rate of wife  abuse  is  considerably higher than the rates found  in some other countries such as  Japan  (14.3%) or Norway (26.8%)  [21,22],  but  it  is  similar  to  the rates reported  in  some neighbouring countries. For ex- ample, in a study from Turkey [2], 52%  of women experienced at  least 1  type  of violence and  in a  study of Pakistani  men [23], all the respondents admitted  to ever shouting or yelling at their wives,  32.8% admitted to ever having slapped  their wives and 77.1% admitted to ever  having engaged  in non-consensual  sex  with their wives. The prevalence of abuse during the  pregnancy period (42%) was  relatively  low compared with  the prevalence of  abuse  during  the  12 months  before  pregnancy (51.7%) and after pregnancy  (53.5%) so it seems that pregnancy was  a protective  factor  against wife  abuse.  The  results  from  a  number  of  other  studies  support  this finding  [4,15,18].  It may be related to a husband’s worry  about the health of the fetus. The rates of physical, emotional and  sexual  abuse  during  pregnancy were  respectively 10.0%, 33% and 17.3%. In a  study from Babol city (Islamic Republic  of Iran) the rates of physical, emotional  and sexual  intimate partner abuse dur- ing pregnancy were 9.1%,  30.8% and  19.2% respectively [24].  In a hospital- based  study conducted  in Tehran  the  prevalence  of  physical  abuse  during  pregnancy was 10.7%  [25]. The  rates  for physical  abuse  are  all  very  similar  to ours. Although the prevalence of abuse in  pregnancy was lower than the 2 another  periods (before and after pregnancy), it  is  still much higher  than  that  reported  from  some  other  countries:  4.3%  in  China, 28.4%  in  India and 23%  in Pa- kistan [4,20,26]. In another study from  Pakistan 44% of women reported abuse  during  index pregnancy; 43% of  these  experienced emotional abuse and 12.6%  reported  physical  abuse  [27]. These  variations  in  results may  reflect differ- ent definitions of abuse,  the  screening  method used or cultural differences. We  found  that  women  were  at  greater  risk of  domestic  abuse  in  the  postpartum period,  so more attention  should be paid  to high-risk women  in  this period. In  all  3  periods,  emotional  abuse  was  the most prevalent  type of  abuse,  followed by  sexual  abuse and physical  abuse. Consistent with  a  similar  study  in  China  [4], we  also  found  that  abuse  Table 4 Logistic regression analysis of predictors of domestic abuse Variable OR (95% CI) P-value Any type of abuse Witnessing violence to another woman 2.69 (1.56–4.64) < 0.0001 Husband’s education ≤ 12 years 3.22 (1.52–6.84) 0.002 Physical abuse Living in an extended family 2.32 (1.01–5.30) 0.045 Woman’s education class level 12 or lower 4.97 (2.03–12.14) < 0.0001 Woman’s age at marriage < 18 years 2.49 (1.28–4.83) 0.007 Woman’s economic dependency 3.98 (1.99–8.00) < 0.001 Husband’s education ≤ 12 years 3.43 (1.16–10.10 0.025 Witnessing violence to another woman 2.93 (1.51–5.67) 0.001 Sexual abuse Opium use by husband 3.81 (1.16–12.46) 0.01 Emotional abuse Opium use by husband 8.59 (1.04–69.8) 0.045 Husband’s education ≤ 12 years 2.66 (1.26–5.61) 0.01 OR = odds ratio; CI = confidence interval. Table 5 Reasons for domestic abuse as cited by the women Reason for abuse Frequency (%) (n = 300) Poor relationship with husband’s family 30.4 Discipline of the children 22.8 Financial problems 18.8 Visiting her parents or friends 8.8 Unsatisfactory cooking or housekeeping 3.5 Other 15.7 Total 100.0 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 757 before pregnancy was a strong risk fac- tor for abuse during pregnancy and after  pregnancy.  In general,  abuse during a  previous period was  a  strong  risk  fac- tor for subsequent abuse. According to  these results, women who were abused  before pregnancy should be considered  a high risk group for abuse during preg- nancy and in the postpartum period. Several  risk  factors were associated  with abuse. There was a strong positive  association between a woman witness- ing abuse and being a victim of abuse,  consistent with the findings of Su-Fang  et al. [4]. This lends support to the fact  that  domestic  violence  is  a  learned  behaviour and many of  these women  learned helplessness and acceptance of  violence many years before [4]. Living in an extended family increased  the  chance of physical  abuse.  It  seems  that family conflicts were more frequent  or greater  in  the  setting of an extended  family. Similar association between  this  factor and emotional abuse was found by  Su-fang and colleagues [4]. The risk of physical abuse was great- er when  the women’s  education was  ≤ 12 years.  In many previous  studies,  high education level was associated with  lower  levels  of  violence  [18,28–32],  although  in  a  study  from  India  [20]  high educational  level did not have  a  protective  role  against  wife  abuse.  Women with economic  independence  experienced physical  abuse  less  than  others. This demonstrates  the protec- tive effect of financial  independence of  women against violence, which concurs  with some previous studies [18,33,34],  although a number of other studies do  not support this finding [20,28,35]. Another predictor of a higher rate of  physical abuse was woman’s age at mar- riage > 18 years: when a girl marries  in  adolescence, she is at higher risk of abuse  by her husband and abuse probably con- tinues for the duration of the marriage. It  has been reported that wife abuse itself is  reinforcing; once a man has beaten his  wife, he is likely to do so again [36]. The  incidence  of  physical  and  emotional abuse were  increased when  the  husband’s  education  level was  ≤  12 years. Similar  results were  reported  by Khosla and colleagues [20] among  Indian women but other studies did not  find such association [16,35,37,38].  Positive  history  of  opium  use  in  women’s husbands was associated with  a higher  rate of  emotional  and  sexual  abuse. The  results  of  2  studies  con- ducted  in  the  Islamic Republic of  Iran  support this finding [15,16]. There was no relationship between  domestic  abuse  and  social  support,  which  is  surprising because social  sup- port  should  discourage  tolerance  of  abuse. It is possible that our assessment  of  social  support was  inadequate  and  we did not  consider  the  accessibility  of women to all types of social support  services. We predicted  that violence against  women who gave birth  to a  female  in- fant would  increase  in  the postpartum  period because in many countries such  as  the  Islamic Republic of  Iran parents  are sensitive to a child’s sex and there is  a preference for male infants. However,  the sex of child in the most recent preg- nancy had no effect on  the  incidence  of wife abuse  in  this period.  It may be  related  to  the promotion of  the socio- economic  status of women  in  recent  years. Women now can be  educated  and work  like a man and  this  fact may  reduce  the sensitivity of parents  to  the  sex of a child. It may also be that the sex  issue  is  influenced by  some other  fac- tors, such as parity and the sex of other  children  in  the  family,  and we did not  evaluate this. Our study has some  limitations.  It  was a retrospective study and the results  may be influenced by some recall bias.  The study  is  also  subject  to  selection  bias as women whose husbands came  with them were excluded and they may  be  significantly  different  from  those  whose husbands did not come in rela- tion  to abuse.  In addition, our defini- tion of wife abuse was limited to some  specific types of abuse and if we consid- ered more details and subtypes of abuse (e.g.  withdrawal  of money,  eviction  from the house), the actual prevalence  of  abuse may be higher  than our  re- sults indicate. Participants in this study  were selected  from specific group and  our  results  cannot be  generalized  to  all women of  Jahrom. A population- based  study  is  required  to  assess  the  frequency and risk factors of wife abuse  in this city. In conclusion, the prevalence of do- mestic abuse in this community sample  is very high and women are particularly  vulnerable during pregnancy  and  the  postpartum period. The actual preva- lence of abuse may be even higher than  our research has shown because of  the  shame traditionally associated with dis- closing domestic violence. Pregnant women are not  routinely  screened  for  the presence of domestic  violence in the Islamic Republic of Iran.  However, given the high level observed  in our study, routine screening of abuse  in maternity  clinics  is  advocated. All  health care providers,  especially mid- wives, general practitioners and obste- tricians, should be educated to identify  and detect domestic violence in order to  decrease the adverse impact of violence  on women and their babies. While there  are no formal provisions currently in the  system for dealing with spousal abuse,  other than counselling and advice,  it  is  hoped that identifying the problem and  drawing attention to its prevalence will  enhance  the awareness and sensitivity  of health care providers to this issue and  the need to address it. Acknowledgements We would  like  to  thank  the women  that participated  in  this  study  for  their  cooperation. We would also  like  to express our  appreciation to the staff of Jahrom pub- lic health clinics  for  their  assistance  in  this project. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 758 Violence against women1. . Geneva, World Health Organization, 2001 (WHO fact sheet, No. 239). Kocacik F, Dogan O. Domestic violence against women in 2. Sivas, Turkey: Survey study. Croatian Medical Journal, 2006, 47(5):742–749. Violence against women: a priority health issue3. . Geneva, World Health Organization, 1997 (WHO document WHO/FRH/ WHD/97.8#). Su–Fang G et al. Domestic abuse on women in China before, 4. during, and after pregnancy. Chinese Medical Journal, 2004, 117(3):331–336. Bacchus L et al. Domestic violence in pregnancy. 5. Fetal Maternal Medical Review, 2001, 12:249–271. Berenson AB et al. Perinatal morbidity associated with violence 6. experienced by pregnant women. 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Ethiopian Medical Journal, 1998, 36(2):83–92. Plichta SB, Duncan MM, Plichta L. Spouse abuse, patient–38. physician communication, and patient satisfaction. American Journal of Preventive Medicine, 1996, 12(5):297–303. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 759 Determinants of maternal adaptation to mentally disabled children in El Minia, Egypt H.I. Awadalla,1 E.G. Kamel,2 E.M. Mahfouz,2 A.A. Mohamed 3 and A.M. El-Sherbeeny 4 ABSTRACT This study was carried out in a governmental school for mentally disabled children in El Minia. We assessed maternal adaptation and the relationship between maternal sociodemographic factors and adaptation as well as examining maternal distress. All 100 mothers with children aged 6–18 years attending the school were recruited in the study. Three tools were used: demographic data sheet, adaptation scale to assess the nature of mothers’ interaction and patterns of psychosocial adaptation and depression scale to detect the presence of psychiatric disorders among the mothers. Only 35.0% of the mothers adapted positively to their child’s condition; 62.9% of those had female children. Negatively adapted mothers were slightly older than positively adapted mothers and had more children. Maternal education and occupation were significantly associated with psychosocial adaptation. Knowledge of mothers about their child’s condition significantly affected adaptation as well as the dependency of children in eating, drinking and sleeping. Two-thirds of mothers had high levels of psychopathology. 1Institute of Environmental Studies and Research, Ain Shams University, Cairo, Egypt (Correspondence to H.I. Awadalla: hala_awadalla@yahoo.com). 2Department of Public Health; 4Department of Neurology, Faculty of Medicine; 3Department of Community Health, Faculty of Nursing, El-Minia University, El Minia, Egypt. Received: 02/07/08; accepted: 21/09/08 صرم ،اينلما في ًايلقع ينفلختلما ملهافطأ عم تاهملأا فُّيَكَت تاد ِّد َ ُحم ينيبشر ورمع ،دممح فطاوع ،ظوفمح نمايإ ،لماك دماع ،للها ضوع ةلاه لماوعلاب نهتقلاعو ،تاهملأا فُّيكت اومَّيقف ،صرم ،اينلما في ًايلقع ينفلختلما لافطلأل ةيموكح ةسردم في ةساردلا هذه نوثحابلا ىرجأ :ةـصلالخا غلابلا تاهملأا عيجم ةساردلا هذه في نوثحابلا دشح دقو ،تاهملأا ىدل )بركلا( ةقئاضلا اوسرد ماك ،اهعم فيكتلاو ةيفارغوميدلاو ةيعماتجلاا تايطعلما ةفيحص :يه تاودأ ةثلاث نوثحابلا مادختساو ،ةسردلماب ينقحتللما ًاماع 18و 6 ينب مهرماعأ حواترت نيذلا نلهافطأو ةأرما ةئم نهددع دوجو فشكل ،بائتكلاا سايقو ،نيهدل يعماتجلاا سيفنلا فُّيكتلا طمانأو ،تاهملأا لعافت قرط ةعيبط مييقتل فُّيكتلا سايقو ،ةيفارغوميدلا نهنم 62.9 ىدل ناكو ،نلهافطأ ةلاح عم بيايجلإا فُّيكتلا نم َّن َّكََت تاهملأا نم طقف %35 نأ ينثحابلل ينبتو .تاهملأا ىدل ةيسفن تابارطضا لك طبتراو .لافطلأا نم بركأ ددع نيهدلو ،بيايجلإا فُّيكتلا تاوذ تاهملأا نم ليلقب ًارمع بركأ َّنكف يبلسلا فُّيكتلا تاوذ تاهملأا امأ .تلافط لىعو ،فُّيكتلا لىع ًايئاصحإ هب ُّدَتْعُي يرثأت نلهافطأ ةلاحب تاهملأا ةفرعلم ناكو .سيفنلا فُّيكتلاب ًايربك ًاطابترا ام ٍةنهم في ّنهلمعو تاهملأا ميلعت نم .ةيسفنلا تلالاتعلاا نم عفترم ىوتسم تاهملأا ْيَثلث ىدل ناك دقو .مونلاو باشرلاو ماعطلا لوانت في ّنهيلع ّنلهافطأ دماتعا Déterminants de l’adaptation maternelle aux enfants souffrant d’incapacité mentale à El Minia (Égypte) RÉSUMÉ Cette étude a été effectuée dans une école publique pour enfants souffrant d’incapacité mentale à El Minia. Nous avons évalué l’adaptation de la mère et la relation existant entre les facteurs sociodémographiques de la mère et son adaptation ; nous avons également analysé la détresse maternelle. La totalité des 100 mères ayant des enfants âgés de 6 à 18 ans scolarisés dans cette école a participé à l’étude. Trois outils ont été utilisés : une fiche technique démographique ; une échelle d’adaptation permettant d’évaluer la nature de l’interaction des mères et les modèles d’adaptation psychosociale ; et une échelle de dépression afin de détecter la présence de troubles psychiatriques chez les mères. Seules 35,0 % des mères se sont adaptées de manière positive à l’état de leur enfant; parmi elles, 62,9 % avaient des enfants de sexe féminin. Les mères présentant une adaptation négative étaient légèrement plus âgées que celles s’étant adaptées positivement, et avaient davantage d’enfants. L’instruction et la profession de la mère étaient associées de manière significative à l’adaptation psychosociale. Les connaissances des mères au sujet de l’état de leur enfant influaient considérablement sur leur adaptation ainsi que sur la dépendance de l’enfant pour manger, boire et dormir. Les deux tiers des femmes présentaient des niveaux élevés de psychopathologie. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 760 Introduction Mothers, who are the primary providers  of care for children with mental disabili- ties, face many challenges and stressors  that may lead to maternal distress if not  well  adjusted  and  adapted. For most  children with disabilities, their disability  is not a fixed condition, but is changeable  over  time and with circumstances and  offered care. A single disability could be  complicated by multiple disabilities  if  care, love and support are lacking [1]. Mothers  of  children with mental  disability may not only face greater chal- lenges owing to their child’s condition,  they may also be  less equipped  to deal  with those challenges. The strongest and  most consistent predictor of maternal  outcomes  is  the extent and severity of  the behavioural  symptoms of  the child  [2]. Children with mental disability and  their mothers are at  increased risks  for  psychosocial  problems  compared  to  their peers [3]. When a mother or primary caregiver  experiences depression or other stress- related mood problems and does not  manage her  stress appropriately when  she  is with her child,  the child  is more  likely to be directly affected [4]. In Egypt, medical and rehabilitation  care services are available and are pro- vided by governmental and nongovern- mental organizations. However, they do  not cover actual needs, particularly  in  rural areas and peri-urban areas. Teach- ers in some institutions for children with  intellectual  impairments were  trained  as part of  a project  to upgrade public  special education institutions [5] Adaptation  theory  acknowledges  that human beings  struggle  continu- ously to survive, adapt and change their  environment  as  well  as  to  deal  with  challenges  that can be present  in  these  environments  [6]. Mother  and  child  adaptation  is  mutually  interrelated.  Children  tend  to adapt most  success- fully to living with a chronic illness when  their mothers  and  family  functioning  remain  strong  [3,7]. Maternal  anxiety  is the main factor causing poor adapta- tion  in a child with mental  retardation  which makes the child liable to negative  outcomes [8]. Other challenges that can be stress- ful  to mothers  included  time spent  in  managing illness and in daily care giving  activities,  financial  difficulties  caused  by unexpected expenses and  increased  use of health services  to  treat and help  manage the condition, decreased family  socialization activities which alter family  life dramatically [9,10]. Identification of  the  stressors  that  lead to maladjustment of mothers with  mentally-disabled children and cause  maternal distress will help pave the way  towards  its elimination or appropriate  intervention by special  support groups  and programmes  to help mothers  to  care for their children. We  focused  on mothers  because  they still tend to have primary responsi- bility for child care and are most subject  to  the challenges associated with  their  child’s disability. We aimed  to  assess  maternal adaptation towards their child  with mental disabilities, describing  the  relationship between maternal  socio- demographic  factors and  their adapta- tion and determining  the presence of  maternal distress. Research hypothesis: mothers with  mentally  disabled  children  are  not  adapted  to  their  life and usually  suffer  from depression. Methods El Minia city  is  the capital of El Minia  governorate  in Upper Egypt  ,located  about 240 km south of Cairo. The city  has  only  1  governmental  school  for  mentally disabled  children, El-Fekrya  School. All mothers with children aged  6–18  years  old  attending  the  school  were invited to participate in the study.  The total was 111; 11 mothers refused  to  participate,  so  the  total  number  included  in  the  study was  100. This  study was carried out during the period  February–May 2008. Three  tools were used  for data col- lection: Demographic data sheet: a structured  questionnaire was designed by  the  re- searchers  to collect  information about  mothers’  age,  education  level, occupa- tion, number of  children,  social  status  and residence. It also included questions  about child’s age, sex, rank in the family,  degree of  child  independence  in daily  activities as well as mothers’ knowledge  about the illness. Adaptation scale: this was developed  and  applied  for  the Egyptian  culture  by Hewalla  [11].  It was used  to assess  the nature of mothers’  interaction and  patterns  of  psycho-social  adaptation  toward their mentally ill children. Items  were marked positive or negative;  the  following scores were used  for positive  items: 4 points for agree, 3 points for not  sure and 2 points for disagree. For nega- tive items: 2 points for agree, 3 points for  not sure and 4 points for disagree. Total  score ≥ 65 indicated a positive attitude,  while  score < 65  indicated  a negative  attitude toward adaptation [12]. Depression scale:  The  Structured  Clinical  Interview  for DSM-III-R was  used  to detect  the presence of psychi- atric disorders  in mothers of mentally  disabled children  in  the past year [13].  Mothers were  screened  for  the pres- ence  of  depressive  disorders,  panic  disorder, social phobia, specific phobia,  obsessive–compulsive  disorder  and  generalized anxiety disorder. They were  also  screened  to detect  subsyndromal  presentations of these disorders. A  pilot  study was  conducted  on  10% of  the studied participants (since  there  is only 1 school  for  the mentally  disabled in El Minia). Necessary modi- fications to the questionnaire were car- ried out on the basis of the pilot study.  Informed, written consent was  taken  from every mother participating  in the  study. Each mother was  individually  interviewed. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 761 The data were examined for signifi- cant associations using SPSS,  version  13. Quantitative data were presented  as mean and standard deviation (SD)  while qualitative data were presented  as  frequencies and percentages. The  chi-squared and Student  t-tests were  used  for  comparison  of  categorical  variables  and  continuous  variables  respectively. P < 0.05 was considered  to  indicate  a  statistically  significant  difference. Multiple linear regression was used  to predict  the presence or absence of  maternal adaptation based on a set of  predictor variables. The logistic regres- sion coefficients were used to estimate  t-value  for  each  of  the  independent  variables  in  the model. P  < 0.05 was  considered  to  indicate  a  statistically  significant difference. Results All  100  mothers  were  assessed  for  psychosocial  adaptation  toward  their  children’s disability. The mean age was  39.2 (SD 5.3) years (Table 1).  Almost  two-thirds  of  mothers  adapted negatively  to  their  children’s  disability  (Table 2). There was  a  sig- nificant  relationship between maternal  adaptation  and  sex  of  the  child:  just  over  three-quarters of mothers of male  children were negatively adapted. With  regard to birth order, 60% of single and  71.9%  of  the  second  or  higher  birth  orders had negatively adapted mothers,  however  if  the disabled child was  the  first  born,  just  over  half  the mothers  were negatively  adapted;  the  relation  between birth order and maternal adap- tation was not statistically significant. Maternal education and occupation  were  significantly  associated with psy- chosocial  adaptation (Table 1). More  than three-quarters of illiterate mothers  were negatively adapted (P < 0.05). The  majority of housewives  (72.6%) were  also negatively adapted (P < 0.05).  Knowledge of  the mothers  about  their  children’s  condition was  signifi- cantly associated with maternal adapta- tion. Few mothers  reported  that  they  had complete information or read about  their child’s condition (Table 3). In gen- eral, mothers who reported that they did  not know anything about the definition,  etiology, manifestation, management  and complications of the illness were for  the most part negatively adapted.  The relationships between maternal  adaptation and the child’s dependency  in  selected activities of daily  living are  Table 1 Relation between maternal adaptation and sociodemographic characteristics Sociodemographic characteristic Negative adaptation Positive adaptation No. % No. % Mother’s education Illiterate (n = 70) 55 78.6 15 21.4 Educated (n = 30) 10 33.3 20 66.7 χ2 = 16.9; P = 0.001 Mother’s occupation: Housewife (n = 73) 53 72.6 20 27.4 Employed (n = 27) 12 44.4 15 55.6 χ2 = 5.69; P = 0.02 Marital status Married (n = 91) 60 65.9 31 34.1 Divorced (n = 5) 3 60.0 2 40.0 Widowed (n = 4) 2 50.0 2 50.0 χ2 = 0.49; P =0.78 Residence Urban (n = 60) 40 66.7 20 33.3 Rural (n = 40) 25 62.5 15 37.5 χ2 = 0.18; P = 0.67 Total (n = 100) 65 65.0 35 35.0 Mean SD Mean SD Age of mother(years) 39.4 4.4 38.9 4.2 t = 0.11; P = 0.89 Number of children in the family 3.2 1.9 2.7 1.3 t = 1.55; P = 0.14 SD = standard deviation. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 762 shown in Table 4. By regression analy- sis, only dependency in eating, drinking  and sleeping were strong predictors of  maternal adaptation Mothers of mentally disabled chil- dren had high levels of psychopatholo- gy: 66% had either a syndromal disorder  (27%), a subsyndromal disorder (28%),  or  both  (11%). Generalized  anxiety  (32%) and dysthymic disorder (24%)  were  the most common disorders  fol- lowed by major depressive disorder and  depression  subsyndrome (both 18%)  (Table 5). Discussion Almost  two  thirds  of  mothers  with  mentally disabled children in this study  were negatively adapted  to  the condi- tion of  their  children. These findings  are  in accordance with  Johanson who  reported  that  mothers  were  usually  the primary caregivers of chronically  ill  children  [14]. They might  experience  greater demands upon  their personal  resources and consequently were more  distressed  and maladapted.  In  com- parison, Gosch reported that more than  half  the mothers of mentally disabled  children  showed negative  adaptation  to  their  children and  found difficulty  accepting them [15]. There was a  statistically  significant  relationship between maternal adapta- tion  and  sex of  the mentally disabled  children. This was  similar  to what was  found by Azar and Solomon [16], they  found that  the child’s  sex had an effect  on mother’s  feelings of  self-confidence  and  adaptation  in managing  the  case  and  that  the mother had more confi- dence when  the child was a girl. Simi- larly, Mott,  James and Sperhac  stated  that  the child’s  sex could  increase  the  risk of maladaptation and psychologi- cal burden  for mothers and  that  some  mothers may perceive that the disease is  more serious in boys than in girls [17]. It was clear  from the  results of  the  present study that there was a statistically  Table 2 Relation between maternal adaptation and child’s characteristics Child’s characteristic Negative adaptation Positive adaptation No. % No. % Sex Male (n = 55) 42 76.4 13 23.6 Female (n = 45) 23 51.1 22 48.9 χ2 = 6.9 P = 0.001 Age (years) 6–12 (n = 33) 18 45.5 15 45.5 > 12–18 (n = 67) 47 70.1 20 29.9 χ2 = 1.73 P = 0.18 Birth order Single (n = 5) 3 60.0 2 40.0 First (n = 31) 16 51.6 15 48.4 Second+ (n = 64) 46 71.9 18 28.1 χ2 = 3.83 P = 0.15 Total (n = 100) 65 65.0 35 35.0 Table 3 Relation between maternal adaptation and mother’ knowledge of her child’s condition Category/ knowledge level Negative adaptation (n = 65) Positive adaptation (n = 35) No. % No. % Definition Complete 3 4.6 5 14.3 Incomplete 12 18.5 18 51.4 Don’t know 50 76.9 12 34.3 χ2 = 17.6 P = 0.001 Etiology Complete 1 1.5 9 25.7 Incomplete 29 44.6 11 31.4 Don’t know 35 53.9 15 42.9 χ2 = 14.8 P = 0.001 Manifestations Complete 2 3.1 8 22.8 Incomplete 21 32.3 15 42.9 Don’t know 42 64.6 12 34.3 χ2 = 13.5 P = 0.001 Management Complete 1 1.5 3 8.6 Incomplete 9 13.8 10 28.6 Don’t know 55 84.7 22 62.8 χ2 = 6.8 P = 0.03 Complications Complete 2 3.1 10 28.6 Incomplete 6 9.2 3 28.6 Don’t know 57 87.7 22 62.8 χ2 = 14.1 P = 0.001 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 763 significant difference between maternal  adaptation and their employment status  and education: positive adaptation was  more common among working moth- ers and those who were educated. Edu- cated mothers can be more helpful  in  the adaptation process, Jeprrett showed  that the highly educated parents learned  to manage their child’s illness and move  from the early struggle with adaptation  to more competent care [18]. Working  mothers had more experience due  to  their presence  in  the community  and  greater experience, which helped  them  deal with  the problem. These findings  agreed with Fuller and Schaller [19] and  Refatt [20] who  reported a  significant  relationship between maternal adapta- tion and occupation. Working and/or  educated mothers know  that  they are  not alone having such a problem, and  this may be helpful  in  the  adaptation  process. These findings were also  sup- ported by Zin El-Dean [9], who noted  that educated and working mothers had  higher levels of adaptation than illiterate  and non-working mothers. There  were  significant  effects  of  maternal knowledge about  the child’s  condition on  their adaptation. A study  by Doornbos supported  this point; he  found  that  caregivers  of mentally  re- tarded children identified the beneficial  effect of  increasing  their knowledge  in  the adaptation process and that 88% of  mothers felt better about themselves by  learning  to manage  their child’s condi- tion [21]. Melnyk reported that the commonly  cited source of stress and maladaptation  for mothers was the difficult day-to-day  health care, which was time consuming  and described as the chronic burden of  care [22]. He added that mothers of the  mentally  ill  children often experienced  more strain related to time spent caring  for  the disabled child as well as higher  levels  of  psychological  distress  than  mothers of healthy children. We found  a statistically significant relationship be- tween maternal adaptation and children  dependency in activities such as eating,  drinking and sleeping. Abd El-Megeed  [23] found a statistically significant dif- ference between adaptation of mothers  having children with mental disabilities  and dependency of  these children on  their mothers  in  regard  to defecation,  urination and clothes care. In this study, we found that depres- sive disorders were  common among  the  reported  psychiatric  disorders.  These results are in agreement with the  findings of Singer  [24] who  reported  that  there was  an  increased psychiat- ric morbidity,  particularly depressive  disorders,  in  the mothers of mentally  disabled children. Table 4 Multiple linear regression analysis of child’s dependency related to maternal adaptation Dependency item Unstandardized y Standardized t P B SE Beta Constant 0.959 0.199 4.820 0.001 Eating –0.529 0.091 –0.881 5.800 0.001 Drinking 0.400 0.114 0.625 3.490 0.001 Sleeping 0.224 0.060 0.325 3.761 0.001 Defecation 0.187 0.132 0.303 1.410 0.161 Self cleaning after toilet 0.213 0.012 0.025 0.841 0.651 Bathing 0.007 0.079 0.114 1.010 0.317 Clothes care 0.005 0.093 0.086 0.584 0.560 Urination 0.005 0.123 0.085 0.457 0.649 Treatment 0.003 0.063 0.053 0.525 0.601 Going to school 0.003 0.079 0.044 –0.455 0.650 SE = standard error. Table 5 Frequency distribution of psychiatric disorders in mothers of children with mental disability (n = 100) Psychiatric disorder No. % Generalized anxiety 32 32 Dysthymia 24 24 Depression subsyndrome 18 18 Major depression 18 18 Generalized anxiety disorder 14 14 Panic disorder 12 12 Social phobia subsyndrome 8 8 Obsessive–compulsive subsyndrome 2 2 Social phobia 2 2 Specific phobia 2 2 Obsessive–compulsive disorder 0 0 More than one diagnosis was possible for each individual. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 764 Shaw P et al. 1. Barriers to inclusive child care: executive summary of research study findings and recommendations. Sacramento, California, Children and Families Commission, 2001. Witt WP, Rily AW, Jo Coiro M. Childhood functional status, 2. family stressors, and psychosocial adjustment among school- aged children with disabilities in the United States. Archives of Pediatrica and Adolescent Medicine, 2003, 157:68–95. Wallander J, Varni J. Effects of pediatric chronic physical 3. disorders on child and family adjustment. Journal of Children Psychology and Psychiatry, 1998, 1:29–46. Reyes RL. 4. Infant mental health: from parenting to policymaking in children’s mental health. Madison, Wisconsin, Wisconsin Coun- cil on Children and Families, Inc., 2002 (http://www.wccf. org/pdf/wiskids_mentalhealth.pdf, accessed 2 May 2010). Implementation of the United Nations standard rules on the equal-5. ization of opportunities for persons with disabilities, report on the inter-country meeting for the Eastern Mediterranean Region, Cairo (Egypt), 2–4 May, 2006. Cairo, World Health Organization Re- gional Office for the Eastern Mediterranean, 2007:27–40. Mohr K, Lafuze E, Brain D. Opening caregiver minds: National 6. Alliance for Mentally Ill’s provider education program. Archives of Psychiatric Nursing, 2000, 5:238–251. Allen P, Vessy J. 7. Primary care of the child with chronic condition, 4th ed. St Louis, Mosby, 2004:8–12. El-Nimr A. 8. Intelligence and psychosocial adjustment in children with chronic diseases [Masters thesis]. Cairo, Faculty of Medi- cine, Cairo University, 2001. Zin El-Dean M. 9. Children adaptation to chronic illness and related factors [Doctorate dissertation]. Menofya, Egypt, El-Menofya University Faculty of Nursing, 2000. Yantzi N et al. The impacts of distance to hospital on families 10. with children with chronic condition. Social Science & Medicine, 2001, 52(12):1777–1791. Hewalla A. 11. Family attitudes toward slow learner [Doctorate dis- sertation]. Cairo, Faculty of Education, Ain Shams University, 1994. Khalil AA et al. Maternal adaptation toward their children with 12. chronic conditions. Alexandria Scientific Nursing Journal, 2006, 5(2):83–98. References Spitzer RL, Davies M, Barkley RA. The DSM-III-R field trial of 13. disruptive behavior disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 1990, 29(5):690–697. Johanson S. 14. Health illness and families, 2nd ed. New York, Har- court Health Science, 2005:220–233. Gosch A. Maternal stresses among mothers of children with 15. Williwims-Beuren syndrome, Down’s syndrome, and mental retardation of non-syndromal etiology in comparison to moth- ers of non-disabled children. Zeitschrift für Kinder und Jugen- dpsychiatrie und Psychotherapie, 2001, 29(4):285–295. Azar R, Solomon R. Coping strategies of parents facing child 16. illness. Journal of Pediatric Nursing, 2001,16(6):418–428. Mott R, James R, Sperhac M. 17. Nursing care of children and families, 2nd edition, New York, Harcourt Health Science, 1999p:612–623. Jeprrett M. Parents of coming to know the care of chronically ill 18. child. Journal of Advanced Nursing, 1994,19(6):1050–1056. Fuller R, Schaller R. 19. Health assessments – a nursing approach, 2nd ed. London, Lippincott, 1999:503–510. Refatt H. 20. Adaptation of mothers having children with Down syn- drome [Masters thesis]. Cairo, Faculty of Nursing. Ain Shams University, 2002:102–114. Doornbos MM. The problems and coping methods of caregiv-21. ers of young adults with mental illness. Journal of Psychosocial Nursing, 1997, 35(9):22–26. Melnyk B. Intervention study involving parents of hospitalized 22. young children: an analysis of the past and future recommen- dations. Journal of Pediatric Nursing, 2000, 15(1):4–12. Abd El-Megeed A. 23. Stressors and coping patterns of mothers of mentally handicapped children [Masters thesis]. Alexandria, Faculty of Nursing, Alexandria University, 1999:1–15. Singer GH. Meta-analysis of comparative studies of depres-24. sion in mothers of children with and without developmental disabilities. American Journal of Mental Retardation, 2006, 111(3):155–169. To  sum  up,  the mothers  of  chil- dren with mental disabilities  adapted  negatively to their children’s condition.  Factors affecting  the adaptation of  the  mothers  were maternal  sociodemo- graphic characteristics,  sex of  the child,  the  mothers’  knowledge  about  the  condition and dependency of the child  in  some activities of daily  living. They  had  high  levels  of  psychopathology,  including a syndromal diagnosis, a sub- syndromal disorder, or both. Given  that  the  majority  of  the  mothers  displayed  a  high  burden  and poor adaption  to  their  situation,  there is a real need for better and more  specific support and interventions for  mothers caring  for mentally disabled  children  in  order  to  help  avoid  the  development of maternal psychiatric  disorders. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 765 Effect of group reminiscence therapy on depression in older adults attending a day centre in Shiraz, southern Islamic Republic of Iran F. Sharif,1 A.Mansouri,1 I. Jahanbin 2 and N. Zare 3 ABSTRACT The aim of this study was to examine the effectiveness of group reminiscence therapy on depression symptoms among elderly people attending a day centre in Shiraz, Islamic Republic of Iran. A sample of 49 people aged 60+ years participated in 6 group reminiscence sessions that were held twice weekly for a 3-week period and completed a Farsi version of the 15-item geriatric depression scale. Mean depression scores decreased significantly from 8.18 (SD 1.20) before the intervention to 6.73 (SD 1.20) immediately after it and 7.55 (SD 1.19) 1 month after the intervention. When analysed by demographic characteristics only marital status showed a statistically significant difference in depression scores comparing before and after the intervention. 1Department of Mental Health Nursing; 2Department of Public Health; 3Department of Statistics, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to F. Sharif: fsharif@sums.ac.ir). Received: 01/02/08; accepted: 10/06/08 بونج ،زايرش في ةيرانه ةيدايع نوعجاري نيذلا نسلا رابك ىدل بائتكلاا لىع تايركذلا قيرط نع ةيعمالجا ةلجاعلما يرثأت ةيملاسلإا ناريإ ةيروهجم ريز فجن ،ينب ناهج ناريا ،يروصنم يرمأ ،فيشر ةدنخرف ةدايع نوعجاري نيذلا يننسلما ىدل بائتكلاا ضارعأ لىع تايركذلا قيرط نع ةيعمالجا ةلجاعلما ةيلاعف ِّيصقت لىإ ةساردلا هذه تفده :ةـصلالخا دقعت تناك راكذتسا تاسلج 6 في اوهماسو ًاماع 60 لىع مهرماعأ ديزت ًاصخش 49 ةساردلا تلمشو ،ةيملاسلإا ناريإ ةيروهجم ،زايرش في ةيرانه ةيطسولا زارحلأا تصقن دقو .ًادنب 15 نم فلأتي يذلا يننسلما ىدل بائتكلاا سايقم نم ةيسرافلاب ةخسن ءافيتسا عم عيباسأ 3 ةدلمو ًايعوبسأ ينترم ،ةلجاعلما دعب ًةشرابم كلذو )1.20 يرايعم فارحناب( 6.73 لىإ لخدتلا لبق )1.20 يرايعم فارحناب( 8.18 نم ًايئاصحإ هب ُّدَتْعُي ٍردقب بائتكلال نأ اودجو ،ةيفارغوميدلا صئاصلخا قفو جئاتنلا نوثحابلا للح امدنعو .لخدتلا لىع رهش رورم دعب )1.19 يرايعم فارحناب( 7.55 لىإ تلصوو .هدعب امو لخدتلا لبق ام ينب ةنراقلماب بائتكلاا زارحأ في هب ُّدَتْعُي يئاصحإ فلاتخا تاذ اهدرفمب ةيجاوزلا ةلالحا Effet de la thérapie par la réminiscence en groupe chez des personnes âgées consultant dans un centre de jour à Shiraz (sud de la République islamique d’Iran) RÉSUMÉ L’objectif de cette étude était d’évaluer l’efficacité de la thérapie par la réminiscence en groupe chez des personnes âgées consultant dans un centre de jour de Shiraz (République islamique d’Iran). Un échantillon de 49 personnes âgées de 60 ans et plus a pris part à 6 séances de réminiscence en groupe. Ces séances, organisées deux fois par semaine sur une période de trois semaines, ont été complétées par une version en farsi de l’échelle de dépression gériatrique à 15 items. Les scores de dépression moyens ont diminué de manière significative, passant de 8,18 (écart type 1,20) avant l’intervention à 6,73 (écart type 1,20) immédiatement après, et à 7,55 (écart type 1,19) un mois après l’intervention. Lors de l’analyse en fonction des caractéristiques démographiques, seule la situation matrimoniale a révélé une différence statistiquement significative dans les scores de dépression avant et après l’intervention. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 766 Introduction The rising proportion of elderly people  in  the population  in both developed  and developing  countries  is  creating  new health care challenges  in  the 21st  century  [1–4]. Older age  is  inevitably  accompanied by an  increasing  risk of  physical  and psychological disorders.  Depression  is  the  most  common  psychiatric disorders  in older people  [5], with estimated  rates  ranging  from  10% to 65% [3]. One study  in  Isfahan,  Islamic Republic of Iran found that the  rate of depression among older adults  was 64.4% [6].  Depression and other mental health  disorders can have serious negative out- comes in old age. In addition to reduc- ing the general quality of life, depressive  symptoms  in older  adults  have  been  linked  to earlier mortality,  greater dis- ability,  higher health  care utilization,  longer  length of hospital  stay  [7],  in- creased risk of infections, falls and injury,  poorer nutrition [8] and increased risk of  suicide [9]. However, depression is one  of the most misdiagnosed, undiagnosed  and untreated  illnesses experienced by  the elderly [5].  As a strategy to avoid antidepressant  drugs  and  their  side-effects,  psycho- therapeutic  approaches  can  provide  significant  and  sustained  benefits  in  terms  of  improved  quality  of  life  for  elderly patients. One  type of psycho- therapy  that  has  been  researched  is  participation  in  reminiscence groups.  This  intervention  is  cost-effective  and  relatively free from harmful effects [10].  Reminiscence  is  an  activity  that  can  allow elderly people a sense of security  through rehearsal of comforting memo- ries, of belonging  through sharing, and  of  self-esteem through confirmation of  their uniqueness  [11]. Faced with  the  increasing numbers of elderly people in  the population, nurses need to be knowl- edgeable  about  reminiscence  therapy  and its relation to health promotion for  the elderly. The aim of  this  study was  to examine  the effectiveness of  group  reminiscence  therapy  on  depression  symptoms among community-resident  elderly people attending a day centre in  Shiraz, Islamic Republic of Iran. Methods Study design The study used  a quasi-experimental  design, with measurements of depres- sive  symptoms on  a  group of  elderly  people before,  immediately after and 1  month after  the  reminiscence  therapy  intervention. Study setting and sample The study was conducted from Septem- ber to December 2007 at the Jahandide- gan  centre,  a  day  centre  affiliated  to  Shiraz welfare organization. Established  in  1998,  the  centre  has  about  4500  registered members aged 55+ years of  age (about 3000 aged 60+ years). The  members participate voluntarily in vari- ous activities at the centre.  The participants for this study were  recruited  through flyers  and by word  of  mouth. The  selection  criteria  for  the study were  female and male adults  aged 60+ years, who were  living  in  the  community (i.e. outside a primary care  setting) and who were members of the  centre. The exclusion criteria were: hav- ing a personal crisis during the interven- tion (e.g.  loss of a  significant other) or  suffering severe physical or psychologi- cal disorder;  receiving  antidepressant  medication;  participating  in  other  activities during  the  intervention (e.g.  sports/physical activities, muscle relaxa- tion, yoga or counselling); unmarried;  not having orientation  to  time, place  or  person;  having major  depression  (GDS-15 score > 10). On the basis of  these criteria and taking account of the  ratio of males to females and the ratio of  participants  to non-participants  in  the  programmes,  300  active older  adults  were selected randomly to complete the  depression scale. Data collection The instrument used  in  the  study was  the 15-item geriatric depression  scale  (GDS-15), a shorter version of the 30- item GDS [12]. Malakouti  et  al. have  validated a Farsi version the GDS-15 on  a community sample [13]. Their results  showed that the GDS was an internally  consistent measure, with alpha, split-half  coefficients and test–retest reliability of  0.90, 0.89 and 0.58  respectively. They  concluded that  the Farsi version was a  valid and reliable screening  instrument  for major depression in older people in  the Islamic Republic of Iran [13]. After an explanation of  the aims of  the  study  by  the  researcher,  the  300  members completed  the GDS-15 and  50  participants with  all  the  required  criteria and GDS-15 score ≤ 10 out of  15 were  selected  as  the  study  sample  for  the  intervention. All participants  in  the  intervention completed  the GDS- 15 before  the start of  the  intervention,  immediately after  the  last  session and  1 month after  the  last  session of  remi- niscence  therapy.  Illiterate participants  completed the questionnaire with expla- nation and help from a co-researcher. To ensure confidentiality, no direct  or  indirect  identification of  the partici- pants was used. The participants and the  principal of  Jahandidegan centre gave  their verbal and written consent for par- ticipation in the study. Intervention The selected subjects were divided into  5 groups  for participation  in  the group  reminiscence sessions (6 sessions were  held twice weekly for 3-weeks). For this  study, 12 topics were used as a basis for  discussion (2  topics per  session) and  each person separately talked about his  or her reminiscences on that topic. The  topics used  in  this  study were:  young  adult  life prior to meeting their spouse,  first meeting with  spouse,  courtship  process, wedding day, setting up house,  housekeeping, married life prior to hav- ing children, having children, married  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 767 life after having children,  life after chil- dren  left home, having grandchildren,  life as a spousal caregiver and current life  situation. At the end of the session, the  researcher  summarized  the memories  of the members and the members were  notified  about  the  topics  for  the next  session. Data analysis SPSS, version 13 was used for data  analysis.  The  Mann–Whitney  test  and Kruskal–Wallis  test were used  for  evaluating the correlation between par- ticipants’ depression  scores  and  their  demographic characteristics. Wilcoxon  signed  ranks  test was used  to find out  the effect of group reminiscence on the  depression of  the  subjects before and  after the intervention. Results Out of  the final  sample of 50 people,  complete data were obtained on 9 men  and 40 women (1 woman was excluded  due  to  illness).  The  demographic  characteristics of  the participants  are  presented at Table 1.  Table 2  shows  the GDS-15 scores  of the whole group of older people be- fore and after  the group  reminiscence  intervention. The  mean  depression  score before  the  intervention was 8.18  [standard  deviation  (SD)  1.20]  and  this  decreased  significantly  immedi- ately  after  the end of  the  intervention  to 6.73  (SD 1.20)  (P  <  0.001). One  month after  the  intervention  the mean  depression score had increased to 7.55 (SD 1.19), although this was still signifi- cantly lower than before the intervention (P  <  0.001). Therefore,  the decrease  in  the overall mean depression  scores  comparing before and  immediately af- ter  the  intervention was 1.45, whereas  comparing scores before and 1 month  after  the  intervention  the decrease was  only 0.63.  Table  1  shows  the  decreases  in  GDS-15  scores  before  and  after  the  intervention  by  participants’  demo- graphic  characteristics  and history of  medical or mental  illness. When ana- lysed by Mann–Whitney and Kruskal– Wallis  tests, only marital  status had a  significant  effect  on  scores. Married  people showed a statistically significant  decrease in GDS-15 scores immediately  after group  reminiscence (P < 0.022)  and  1  month  after  the  intervention (P < 0.014) compared with before. Discussion As  the number of  elderly people con- tinues  to grow,  the need  for  studies  to  examine effective and accessible mental  health  treatments becomes ever more  pressing. The aim of  the present  study  was  to  examine  the  effectiveness  of  group reminiscence therapy on depres- sion  symptoms  among  community- resident  elderly  people  attending  a  day  centre.  Reminiscence  therapy  is  conceptualized  as  a  natural  process  that enables the elderly to organize and  evaluate their life experiences. It is one of  the most commonly used approaches  to group  therapy with  the elderly. The  discussion about past events, whether  joyful or painful, allows group members  to become acquainted with one another  at a deeper level, promotes the develop- ment of  group cohesion  and permits  supportive grieving and the affirmation  of accomplishments.  Reminiscence may be used as  the  central  focus of group therapy or as an  aspect of an  integrated approach [14].  The  literature  contains many  studies  which put  forth evidence of  the adap- tive  functions of  reminiscence  therapy.  The concept of ego integrity, defined in  Erickson’s  stage of  life model,  is often  used to promote quality of life in care of  the elderly  [15]. Butler  recognized  the  value of life review as the primary means  of  achieving  ego  integrity. Through  the process of  reminiscence  an  indi- vidual can make sense of his/her past,  enabling him/her to accept the past and  recognize  its  value  [16]. As Myerhoff  explains,  “the  integration with  earlier  stages of being confident provides  the  sense of  ‘continuity and completeness’  that may be considered as an essential  developmental  task  in old  age”  [17].  Sometimes, suggested Molinari and Re- ichlin, grappling with the past to accept  those  conflicts  and working  through  unresolved  issues  is  achieved  through  reminiscence [18].  In the present study the data analysis  revealed  a  statistically  significant  de- crease  in depression scores comparing  before,  immediately after and 1 month  after  the  intervention. The  findings  are  in accordance with  those of  Jones,  who showed  that group  reminiscence  therapy was an effective  treatment  for  reducing  depression  in  the  elderly  if  it  stimulates past memories  and con- versation among  the group members  [19].  Gatz  identified  a  number  of  mechanisms of change that improve the  mental health of the elderly: fostering a  sense of control, self-efficacy and hope;  establishing  relationships;  providing  or clarifying a sense of meaning for the  events of  life; promoting  educational  activities and development of skills; and  finding new ways of  coping  [20]. The  advantages of  group work with older  people  include  reducing  loneliness,  in- creasing social interactions and normal- izing the process of ageing [21].  We  used  12  topics  for managing  the group  reminiscence  sessions, with  2 topics per session. The use of themes  or  topics  in  reminiscence  groups  is  frequently mentioned  in  the  literature  and  is  recognized as an aid  to provide  a structure and format for groups [22].  However,  there  is  lack  of  agreement  about the most therapeutically effective  topics [23]. Group  reminiscence  therapy  also  provides  a warm and  empathic  envi- ronment  to help  the  subjects  feel  free  to  engage  in overt  reminiscence. The  advantage of group  reminiscence may  be  that  it  provides  the  subjects with  an opportunity  for self-expression. The  EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 768 subjects control the recall process and  therefore can downplay or emphasize  certain aspects of their lives as desired.  The  National  Institute  of  Nursing  Research  stated  that  cost-effective  non-pharmacological  methods  of  reducing  depression  in  elderly  peo- ple  are  required  and  that  even  small  improvements  should  be  viewed  as  worthwhile [24]. Health professionals,  especially  nurses,  can  learn  reminis- cence therapy as a useful strategy in the  care of the elderly. However, to ensure  that  reminiscence  therapy  is  effective  in various  settings  that  are  related  to  older  adults,  nurses  must  consider  the  specific  values  and  experiences  of older people  in  a  specific  cultural  group. Nurses are needed  to evaluate  and design  interventions  targeting  the  mental health needs of older  adults,  especially  those  residing  in  long-term  care  facilities. Consequently,  it  seems  plausible  that  strategies  for enriching  Table 1 Demographic characteristics and decreases in mean scores of older adults on the 15-item geriatric depression scale (GDS-15) before and after group reminiscence therapy (n = 49) Variable No. of subjects % Decrease in GDS-15 score Immediately after versus before intervention 1 month after versus before intervention Mean (SD) P-valuea Mean (SD) P-valuea Total 49 100.0 1.45 (0.02) 0.63 (0.01) Age (years) 0.922 0.381 60–64 24 49.0 1.45 (1.10) 0.50 (0.78) 65–69 18 36.7 1.38 (1.09) 0.66 (0.90) ≥ 70 7 14.3 1.57 (0.53) 1.00 (0.81) Sex 0.914 0.679 Female 40 81.6 1.45 (1.10) 0.60 (0.84) Male 9 18.4 1.44 (0.52) 0.77 (0.83) Marital status 0.022 0.014 Married 24 49.0 1.16 (0.76) 0.33 (0.76) Widowed or separated 25 51.0 1.72 (1.17) 0.92 (0.81) Educational level 0.922 0.178 Illiterate 9 18.4 1.33 (1.32) 0.55 (0.88) Primary school 22 44.9 1.45 (1.01) 0.68 (0.83) Secondary school 7 14.3 1.28 (1.11) 0.14 (0.37) Diploma and higher 11 22.4 1.63 (0.80) 0.90 (0.94) Employment status 0.352 0.636 Retired 11 22.4 1.72 (0.78) 0.72 (0.90) Employed or housewife 38 77.6 1.36 (1.07) 0.60 (0.82) Income per month (rials) 0.109 0.184 < 1 million 18 36.7 1.11 (1.13) 0.44 (0.85) 1–2 million 19 38.8 1.78 (1.03) 0.89 (0.80) ≥ 2 million 12 24.5 1.41 (0.66) 0.50 (0.79) Residential status 0.131 0.277 Lives alone 11 22.4 1.90 (0.94) 0.81 (0.75) Lives with family 38 77.6 1.31 (1.01) 0.57 (0.85) Medical illness 0.487 0.315 Yes 37 24.5 1.48 (1.09) 0.70 (0.87) No 12 75.5 1.33 (0.77) 0.41 (0.66) History of depression 0.794 0.283 Yes 18 36.7 1.44 (1.24) 0.77 (0.73) No 31 63.3 1.45 (0.88) 0.54 (0.88) aMann–Whitney and Kruskal–Wallis tests. SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 769 Problems of the elderly and the aged. Draft program and arrange-1. ments for the World Assembly on the Elderly: Report of the Secre- tary General. New York, United Nations, 1980. Tajvar M. Assessment of the conditions of health and treat-2. ment in Iran. In: Proceedings of the 22th National Congress of Gerontology and Geriatrics. Isfahan, Islamic Republic of Iran, 11–12 January 2005. Eliopoulos C. 3. Gerontological nursing, 6th ed. Philadelphia, Lip- pincott Williams and Wilkins, 2005. Prescription drugs and the elderly4. [online article]. www.the rubins.com (http://www.therubins.com/geninfo/eldpresc. htm, accessed 27 December 2009). Molony SL, Waszynski CM, Lyder CH. 5. Gerontological nursing: an advanced practice approach. Norwalk, Connecticut, Apple- ton and Lange, 1999:473. Eshaqi R, Shafie N. Depression among elderly in Esfahan at 6. 2005. In: Proceedings of the 22th National Congress of Geron- tology and Geriatrics. Isfahan, Islamic Republic of Iran, 11–12 January 2005. Mental health: a report of the Surgeon General7. , Rockville, Mary- land, National Institute of Mental Health, US Department of Health and Human Services, 1999. Haight B, Michel Y, Hendrix S. Life review: preventing despair 8. in newly relocated nursing home residents short and long-term effects. International Journal of Aging and Human Development, 1998, 47(2):119–142. Smeltzer SC, Bare BG. 9. Bruner and Suddarth’s textbook of medi- cal-surgical nursing, 10th ed. Philadelphia, Lippincott Williams and Wilkins, 2004:154. References Cully J, LaVoie D, Gfeller J. Reminiscence, personality and 10. psychological functioning in older adults. Gerontologist, 2001, 41:89–95. Hess P, Ebersole P. 11. Toward healthy aging: human needs and nursing response, 5th ed. St Louis, Missouri, Mosby, 1993:74. Yesavage JA, Brink TL. Development and validation of a geriat-12. ric depression scale: a preliminary report. Journal of Psychiatric Research, 1983, 17:37–49. Malakouti SK et al. Reliability, validity and factor structure of 13. the GDS-15 in Iranian elderly. International Journal of Geriatric Psychiatry, 2006, 21:588–593. Fielden MA. Reminiscence as a therapeutic intervention with 14. sheltered housing residents: a comparative study. British Jour- nal of Social Work, 1990, 20:21–44. Erikson EH. 15. Identity and the life cycle: psychological issues. New York, International University Press, 1959. Butler RN. 16. Why survive? Being old in America. New York, Harper and Row, 1975. Myerhoff B. 17. Remember lives: the work of ritual, storytelling, and growing older. Ann Arbor, Michigan, University of Michigan Press, 1995. Molinari V, Reichlin RE. Life review reminiscence in the elderly: 18. a review of the literature. International Journal of Aging and Hu- man Development, 1984, 20(2):81–92. Jones ED. Reminiscence therapy for older women with depres-19. sion: effects of nursing intervention classification in assisted- living long-term care. Journal of Gerontological Nursing, 2003, 29(7):26–33. the  lives of elderly people are crucial,  and that reminiscence offers a method  of promoting healthy ageing. Although a  follow-up was done 1  month  after  the  intervention  in  this  study,  caution  is  necessary when  in- terpreting  the  advantages  of  group  reminiscence because several previous  investigations have demonstrated  that  the  affective  improvements  resulting  from  reminiscence were more  short  term than  long  term [25]. Therefore  if  reminiscence  group  therapy  is  to  en- hance  the  lives of  the  impaired elderly  it should be a part of a continuous and  ongoing programme. There were some  limitations to the  current study. The study was conducted  in one geographic area of  the city and  the sample size was small. Therefore the  generalizability of  the  results  to other  elderly  populations  is  limited. There  was no control group and participation  in the pre-test may have an effect on the  post-test score of the case sample. Also,  subjects with depression  scores > 10  were excluded, and so  the effect of  the  therapy on  severe depression was not  studied. We  recommend  replicating  the study using different group settings,  with  a  larger  sample  size  and using  a  control group. We  conclude  that  group  reminis- cence  therapy  improves  the depression  scores of older people  attending  a day  centre. The findings of this study can pro- vide a basis for planning geriatric care in  the community and geriatric care centres.  Intervention strategies  focusing on pre- vention and improvement of depression  in older people need more exploration. Acknowledgement Research funding for this study was pro- vided by Shiraz University of Medical  Sciences Vice Chancellor for Research. Table 2 Comparison of mean scores on the 15-item geriatric depression scale (GDS-15) for the whole group of older adults before and after reminiscence therapy (n = 49) Variable Before intervention Immediately after intervention 1 month after intervention Mean (SD) GDS-15 score 8.18 (1.20) 6.73 (1.20) 7.55 (1.19) z-valuea – –5.626 –4.216 P-value – < 0.001 < 0.001 aWilcoxon signed ranks test. SD = standard deviation. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 770 Gatz M. Clinical psychology and aging. In: Storandt M, Vavden-20. Bos GR, eds. The adult year: continuity and change. Washington DC, American Psychological Association, 1989. Schwiebert VL, Myers JE. Counseling older adults. In: Ingresoll 21. ER, eds. The mental health desk reference. New York, John Wiley, 2001. Burnside I. Themes in reminiscence groups with older women. 22. International Journal of Aging and Human Development, 1993, 37:177–189. Rodriguez A. 23. A descriptive study of selected props used to elicit memories in elders [Master’s thesis]. Austin, Texas, School of Nursing, University of Texas at Austin, 1990. Managing the symptoms of cognitive impairment. 24. NIH guide, 1997, 26(10) (PA-97-050). Tadaka E, Kanagawa K. A randomized trial of a group care pro-25. gram for community-dwelling elderly people with dementia. Japan Journal of Nursing Science, 2004, 1:19–25. Ageing From 2000 until 2050, the world’s population aged 60 years and over will more than triple from 600 million to 2 billion.  Most of this increase is occurring in developing countries - where the number of older people will rise from 400 million  in 2000 to 1.7 billion by 2050.  This demographic change has several implications for public health. Good health is essential for older people to remain  independent and to play a part in family and community life. Life-long health promotion and disease prevention activi- ties can prevent or delay the onset of noncommunicable and chronic diseases, such as heart disease, stroke and cancer.  Information about the WHO programmes and activities in the area of ageing can be found at: http://www.who.int/ topics/ageing/en/ طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 771 Proposal for a modernized Iranian notifiable infectious diseases surveillance system: comparison with USA and Australia F.E.F. Azar,1 N. Masoori,2 Z. Meidani 3 and L. Paul 4 ABSTRACT This article reports on a comparative study of the national notifiable infectious diseases surveillance systems currently employed in the United States of America, Australia and the Islamic Republic of Iran, with the aim of developing a modified system specific to the needs of the Iranian health system. Features of the surveillance systems examined in each country included: official data gathering structures; types of data collected; case definition and classification criteria; data collection processes; data analysis methods; disease classification systems; data dissemination and distribution methods; data quality control; and confidentiality procedures and guidelines. After consolidating the data, a model for an Iranian notifiable infectious diseases surveillance system was developed and was tested by the Delphi method in 3 stages. 1School of Health; 3Department of Health Information Management, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to F.E.F. Azar: dr_febadi@yahoo.com). 2School of Allied Health Professions, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 4School of Public Health, La Trobe University, Melbourne, Australia. Received: 14/10/08; accepted: 25/12/08 ايلارـتسأو ةيكيرملأا ةدحتلما تايلاولا عم ًةنراقم ناريإ في غلابلإا ةبجاولا ةيدعلما ضارملأا د ُّصرـت ماظن لىع ةيصرع تماس ءافضلإ حاترقا لوب ياسدنيل ،نياديم ارهز ،يروسام رفولين ،رذآ درف يدابع دبرف ةدحتلما تايلاولا في ليالحا تقولا في مدختست يتلا ،غلابلإا ةبجاولا ةيدعلما ضارملأا د ُّصرـت مُظُنل ةنراقم ةسارد نع ًاريرقت لاقلما اذه مدقي :ةـصلالخا حملالما تن َّمضت دقو .نياريلإا يحصلا ماظنلا تاجايتحا ًاصيصخ يبلي ل َّدعم ماظن ريوطت فدبه ؛ةيملاسلإا ناريإ ةيروهجمو ،ايلارـتسأو ،ةيكيرملأا تلاالحا فيرعت يرـياعمو ،ةعومجلما تايطعلما طمانأو ؛ةيمسرلا تايطعلما عيمتج لكايه :ليي ام دلب لك في نوثحابلا اهسرد يتلا د ُّصرـتلا مظن في ،تايطعلما ةدوج ةبقارمو ،تايطعلما شرنو عيزوت قرطو ،ضارملأا فينصت مُظُنو ،تايطعلما ليلتح قرطو ،تايطعلما عيمتج تايلمعو ،اهفينصتو ،ناريإ في غلابلإا ةبجاولا ةيدعلما ضارملأا د ُّصرـت ماظنل ًاجذومن نوثحابلا دعأ ،تايطعلما ةسارد دعبو .ةيداشرلإا لئلادلاو ،ةَّي ِّرسلا تاءارجإو .لحارم 3 في يفلد ةقيرط عابتاب هوبرتخاو Proposition en vue de la modernisation du système iranien de surveillance des maladies infectieuses à déclaration obligatoire : comparaison avec les États-Unis et l’Australie RÉSUMÉ Cet article présente une étude comparative portant sur les systèmes nationaux de surveillance des maladies infectieuses à déclaration obligatoire actuellement en place aux États-Unis, en Australie et en République islamique d’Iran. Son objectif est de réformer le système pour l’adapter aux besoins du système de santé iranien. Les caractéristiques des systèmes de surveillance étudiés dans chaque pays comprenaient : les structures de collecte de données officielles, les types de données recueillies, la définition de cas et les critères de classification, les procédés de collecte des données, les méthodes d’analyse des données, les systèmes de classification des maladies, les méthodes de diffusion et de distribution des données, le contrôle de la qualité des données et les procédures et directives relatives à la confidentialité. Après regroupement des données, un modèle de système iranien de surveillance des maladies infectieuses à déclaration obligatoire a été mis au point et testé selon la méthode Delphi en 3 étapes. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 772 Introduction Despite expectations that  they would  eventually  be  eliminated  from  the  world,  a  number  of  infectious  dis- eases  still  remain  at  the  forefront of  global health  concerns. The  success  of  the  eradication  of  smallpox  [1]  has unfortunately not been  repeated  for other diseases.  Indeed,  infectious  diseases  increasingly  threaten public  health and contribute significantly  to  the escalating costs of health care  in  many countries, particularly develop- ing countries. New  infectious agents  are  continually  being  discovered,  while  infectious  diseases  that  have  previously been controlled re-emerge  in new  forms or become resistant  to  standard treatments.  In order  to con- tain such outbreaks an efficient health  surveillance system, with comprehen- sive, accurate and timely collection of  health data, is essential. Surveillance  data  can  be  used  to  inform  policy-making,  planning,  im- plementation,  resource allocation and  for  the prediction and early detection  of  epidemics at  local, national  and  in- ternational level [2]. In many countries  reporting of notifiable  infectious dis- eases  is mandatory, a process which  is  essential  to the efficacy of  their surveil- lance systems [3].  Health  surveillance  activities  in  any country are conducted within the  context of social  factors—such as age  distribution,  gender  issues,  lifestyle,  cultural  background  and  socioeco- nomic status—which may or may not  be  stable. Surveillance  systems  in de- veloping countries are  susceptible  to  shortcomings  [4]. While every coun- try needs  to develop  its own specific  surveillance system tailored to the pre- vailing  socioeconomic,  political  and  administrative  conditions, much can  be  learned  from a  study of  countries  that have well-established procedures  and extensive organizational structures  in place. Because the United States of  America  (USA)  and Australia  fulfil  these criteria, they were chosen for this  comparative  study of  the  Islamic Re- public of  Iran’s current system, which  although it has improved since 1990 is  nevertheless undergoing further mod- ernization [5,6]. Methods A cross-sectional comparative study of  the health  surveillance  systems  in  the  USA, Australia and Islamic Republic of  Iran was undertaken during 2004–05.  Data for the review were gathered from  a  variety of  sources,  including  library  resources, the Internet and consultation  with  Iranian, American and Australian  health professionals via  interviews and  email.  The following factors were reviewed  for each country and are presented  in  the Results. Official  data  gathering  structures: • the mechanisms by which data  are  gathered; the centres that collect and  consolidate data and the agencies that  are  responsible  for  reporting occur- rence of notifiable disease at national,  state or county and at local or district  levels. Types  of  data  collected  and  data • sources:  the  types of demographic,  laboratory and clinical data on notifi- able diseases that are reported to the  responsible  organizations;  sources  that contribute  to  the data-gathering  process. Case definition and classification cri-• teria:  the  uniform criteria  used  for  reporting notifiable infectious diseas- es; case classification guidelines (e.g.  “confirmed  case”,  “probable  case”,  “laboratory-confirmed case”,  “clini- cally  compatible  case”,  “supportive  laboratory  results”,  “epidemiologi- cally  linked case”);  case definitions  (“standard criteria for deciding wheth- er a person has a particular disease or  health-related condition, by  specify- ing clinical criteria and limitations on  time, place, and person”) [7].  Other factors that were examined as  part of the process were: data collection  processes (whether  the data collection  is passive or active;  time  frames  for  re- porting diseases;  how  information  is  transmitted  to  the national authority);  data analysis methods (health indicators  and computer  software used  for data  analysis); disease classification systems  used  for  international  comparisons;  data dissemination methods; data qual- ity control systems; and procedures and  guidelines for preserving confidentiality  of patient data. Using the comparative information  tabulated here, a model  for a notifiable  infectious diseases  surveillance system  tailored  to meet  the  unique  require- ments of  the  Iranian context was pro- posed. The  major  characteristics  of  the  Iranian  surveillance  system were  determined on the basis of the country’s  existing procedures, policies,  laws and  its prevailing  socioeconomic, political,  geographic location and administrative  context.  In  order  to  confirm  the  suit- ability  of  the  proposed model,  58  questionnaires were  distributed  to  infectious disease physicians, health  experts,  staff at Tehran and Shaheed  Beheshti Medical Universities,  the  Iranian Centre  for Disease Control  and Prevention and highly qualified  health information management pro- fessionals. Of  the 58 questionnaires  distributed, 49 were returned and the  respondents’  suggestions were  taken  into consideration.  The model was  then  tested by  the  Delphi method  [8]  (a  technique  for  achieving consensus among a panel of  experts)  in 3  stages by consulting ex- perts  from the Iranian Centre  for Dis- ease Control  and health  information  management professionals. The final  model was analysed and verified using  descriptive  statistics. SPSS was used  for data  entry  and descriptive  analy- sis  [9] of  the  frequency distributions  of  experts’  agreement  for  the Delphi  method. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 773 Results Both regional and government organizations in the USA  and Australia contribute to the formulation of procedures  in  the notifiable diseases  surveillance system, whereas  in  the Islamic Republic of Iran the focus is on the role of the  health information management professionals. Details of  the USA and Australian notifiable diseases  surveillance  systems and the current  Iranian system are presented  in  Tables 1–3, under  the  following  topics:  structure;  types  of  data  and  data  sources;  and  case  classification  and  definition. Structure of national notifiable diseases surveillance systems In the USA reporting of notifiable diseases is mandated only  at state  level (Table 1) and because each state determines  which diseases are notifiable within  its own  jurisdictions,  there  is  some  inconsistency between the states. Reporting  by states to the central agency, the US Centers for Disease  Control  and Prevention  (CDC) of  the Department of  Health  and Human Services  is  voluntary. However,  in  compliance with the World Health Organization (WHO)  international health  regulations,  all  states must  report  in- ternationally quarantinable diseases  (cholera, plague and  yellow fever). In Australia  the central agency  for collection of notifi- able disease data  is  the government National Notifiable  Diseases Surveillance System (NNDSS) of the Department  of Health and Ageing. Under this scheme, notifications are  made to the state or territory health authority under the pro- visions of the public health legislation within their jurisdic- tion. At state and local levels information is collected by the  state health departments (e.g.  in Victoria,  the Department  of Human Services). Notifiable diseases must be reported  in accordance with regulations.  In  the  Islamic Republic of  Iran,  the national  surveil- lance of  both  communicable  and noncommunicable  diseases  is  the  responsibility of  the  Iranian Centre  for  Disease Control and Prevention, which operates under  the auspices of the Ministry of Health and Medical Edu- cation. This central agency  is  responsible  for  legislation,  policy, norms and  standards  for  surveillance. Data are  collected from health houses, rural and urban health cen- tres, hospitals,  laboratories and the private health sector.  Different disease-specific programmes manage data  in  specific ways [10].  Types of data and data sources With a few variations, the 3 countries collect similar types of  data. The USA obtains data from a large number of sources.  In Australia, all health care practitioners who are qualified Ta bl e 1 St ru ct ur e of th e na ti on al n ot ifi ab le d is ea se s su rv ei lla nc e sy st em in s el ec te d co un tr ie s St ru ct ur e A us tr al ia U ni te d St at es o f A m er ic a Is la m ic R ep ub lic o f I ra n C ur re nt Pr op os ed D ec id in g or ga ni za tio ns a t na tio na l l ev el N at io na l N ot ifi ab le D is ea se s Su rv ei lla nc e Sy st em (D ep ar tm en t o f H ea lth a nd A ge in g) C en te rs fo r D is ea se C on tr ol a nd Pr ev en tio n (D ep ar tm en t o f H ea lth an d H um an S er vi ce s) Ira ni an C en tr e fo r D is ea se C on tr ol (M in is tr y of H ea lth a nd M ed ic al Ed uc at io n) Ira ni an C en tr e fo r D is ea se C on tr ol D ec id in g or ga ni za tio ns N at io na l H ea lth a nd M ed ic al Re se ar ch C ou nc il, in co lla bo ra tio n w ith te rr ito ria l a nd st at e he al th a ut ho rit ie s C ou nc il of S ta te a nd T er rit or ia l Ep id em io lo gi st s, in c ol la bo ra tio n w ith C en te rs fo r D is ea se C on tr ol an d Pr ev en tio n N at io na l C om m itt ee o f N at io na l N ot ifi ab le D is ea se s S ur ve ill an ce S ys te m re fo rm a ffi lia te d to Ir an ia n C en tr e fo r D is ea se C on tr ol H ea lth In fo rm at io n M an ag em en t D ep ut y H ea lth In fo rm at io n M an ag em en t A dv is or y C om m itt ee C on tr ib ut in g or ga ni za tio ns in da ta c ol le ct io n th ro ug ho ut th e co un tr y Pu bl ic h ea lth u ni ts Te rr ito ria l h ea lth a ut ho rit ie s St at e he al th a ut ho rit ie s D ep ar tm en t o f H ea lth a nd A ge in g Te rr ito ria l h ea lth d ep ar tm en ts St at e he al th d ep ar tm en ts C en te rs fo r D is ea se C on tr ol a nd Pr ev en tio n Pu bl ic h ea lth u ni t D is tr ic t h ea lth u ni t Te rr ito ria l h ea lth d ep ar tm en ts M ed ic al u ni ve rs iti es D ep ut y of H ea lth Ira ni an C en tr e fo r D is ea se C on tr ol Pu bl ic h ea lth u ni ts D is tr ic t h ea lth u ni ts Te rr ito ria l h ea lth d ep ar tm en ts M ed ic al u ni ve rs iti es D ep ut y of H ea lth Ira ni an C en tr e fo r D is ea se C on tr ol EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 774 Ta bl e 2 Ty pe o f d at a us ed in th e na ti on al n ot ifi ab le d is ea se s su rv ei lla nc e sy st em in s el ec te d co un tr ie s St ru ct ur e A us tr al ia U ni te d St at es o f A m er ic a Is la m ic R ep ub lic o f I ra n C ur re nt Pr op os ed Ty pe s o f d at a co lle ct ed D em og ra ph ic C lin ic al M ic ro bi ol og ic al Va cc in at io n hi st or y Ri sk fa ct or s D em og ra ph ic C lin ic al La bo ra to ry Fi na l d ia gn os is Ep id em io lo gi ca l D em og ra ph ic C lin ic al La bo ra to ry Ra di ol og ic al Ep id em io lo gi ca l D em og ra ph ic C lin ic al La bo ra to ry Fi na l d ia gn os is Ep id em io lo gi ca l Va cc in at io n hi st or y Ri sk fa ct or s D at a so ur ce s Ph ys ic ia n of fic es H os pi ta ls H ea lth c ar e pr ac tit io ne rs La bo ra to ry d ep ar tm en ts Sc ho ol s a nd c hi ld -c ar e fa ci lit ie s D ay -c ar e cl in ic s Ph ys ic ia n of fic es H os pi ta ls H ea lth m ai nt en an ce or ga ni za tio ns Bl oo d tr an sf us io n ce nt re s Bl oo d ba nk s H ea lth c ar e or ga ni za tio ns Ve te rin ar ia ns H ea lth c ar e pr ac tit io ne rs La bo ra to ry d ep ar tm en ts Sc ho ol s Pr is on s/ re fo rm sc ho ol s D en tis t o ffi ce s N ur si ng c ar e fa ci lit ie s M ed ic ol eg al Re gi st ra tio n of v ita l st at is tic s D ay -c ar e cl in ic s Pu bl ic h ea lth u ni ts D is tr ic t h ea lth u ni ts Te rr ito ria l h ea lth de pa rt m en ts M ed ic al u ni ve rs iti es D ep ut y of H ea lth Ph ys ic ia n of fic es La bo ra to ry o ffi ce s Pr iv at e an d pu bl ic ho sp ita ls Ph ys ic ia n of fic es H os pi ta ls Bl oo d tr an sf us io n ce nt re s Bl oo d ba nk s Ve te rin ar ia ns La bo ra to ry d ep ar tm en ts Sc ho ol s Pr is on s/ re fo rm sc ho ol s D en tis t o ffi ce s N ur si ng c ar e fa ci lit ie s M ed ic ol eg al Re gi st er o f v ita l s ta tis tic s D ay -c ar e cl in ic s Sc ho ol s a nd c hi ld -c ar e fa ci lit ie s M ili ta ry se rv ic es Pu bl ic h ea lth u ni ts D is tr ic t h ea lth u ni ts Te rr ito ria l h ea lth de pa rt m en ts طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 775 to  diagnose medical  conditions  are  issued with current  lists of notifiable  diseases  that  they are obliged by  law  to report to the appropriate authorities  (Table 2).  Case classification and definition Table  3  indicates  that  the USA  de- scribes more criteria for case classifica- tion  than Australia. Australia  and  the  USA both considered case definition  as variables. The USA and Australia use  the following common criteria for case  classification. Suspected: a case with clinically com-• patible  illness or meets  the  clinical  case  definition without  laboratory  testing, or a case with laboratory tests  suggestive of the disease without clin- ical information. Probable:  a  case  that  meets  the • clinical case definition without labo- ratory  confirmation  and  is  epide- miologically  linked  to  a  clinically  compatible case. Confirmed:  a  case  that meets  the • clinical  case definition or has  clini- cally compatible  illness;  is  indicated  by supportive laboratory results con- sistent with  the diagnosis;  is  either  laboratory-confirmed or  is epidemi- ologically linked to a confirmed case;  and supportive laboratory results (in  the USA). Proposed model for Iranian notifiable infectious diseases surveillance system After consolidation of the data collected  in this study and a detailed review of the  research and  reports on  information  management  for health units,  an out- line for a new Iranian notifiable diseases  surveillance system is proposed. For ease of comparison, details of  the proposed system are  listed  in  the  fourth columns of Tables 1–3. Figure  1  represents  the proposed organiza- tional  structure  for  the  Iranian notifi- able  infectious diseases  surveillance  system. Ta bl e 3 C as e cl as si fic at io n in th e na ti on al n ot ifi ab le d is ea se s su rv ei lla nc e sy st em in s el ec te d co un tr ie s St ru ct ur e A us tr al ia U ni te d St at es o f A m er ic a Is la m ic R ep ub lic o f I ra n C ur re nt Pr op os ed C rit er ia fo r p at ie nt cl as si fic at io n C on fir m ed c as e (r eq ui re s l ab or at or y de fin iti ve & c lin ic al e vi de nc e) Pr ob ab le c as e (r eq ui re s l ab or at or y su gg es tiv e ev id en ce ) Su sp ec te d ca se C on fir m ed c as e Pr ob ab le c as e La bo ra to ry -c on fir m ed c as e (c on fir m ed b y on e or m or e la bo ra to ry m et ho d ac co rd in g to e ac h no tifi ab le d is ea se ) C lin ic al ly c om pa tib le c as e (a c lin ic al sy nd ro m e ge ne ra lly c om pa tib le w ith th e di se as e) Su pp or tiv e la bo ra to ry re su lts (s pe ci fie d la bo ra to ry re su lts c on si st en t w ith th e di ag no si s b ut n ot m ee tin g th e cr ite ria fo r la bo ra to ry c on fir m at io n) Ep id em io lo gi ca lly li nk ed c as e (a c as e in w hi ch th e pa tie nt h as /h ad c on ta ct w ith o ne or m or e pe rs on s w ho h av e/ ha d th e di se as e an d tr an sm is si on o f t he a ge nt b y th e us ua l m od es o f t ra ns m is si on is p la us ib le ) Su sp ec te d ca se C on fir m ed c as e Pr ob ab le c as e Su sp ec te d ca se C on fir m ed c as e Pr ob ab le c as e Su sp ec te d ca se La bo ra to ry -c on fir m ed ca se C lin ic al ly c om pa tib le ca se Ep id em io lo gi ca lly lin ke d ca se D efi ni tio n of v ar ia bl es C as e de fin iti on s s in ce 19 94 C as e de fin iti on s s in ce 19 90 C as e de fin iti on s f or ad op tin g gu id el in es D ev el op in g ca se de fin iti on s f or a ll di se as e re po rt in g Re sp on si bl e or ga ni za tio n fo r d ev el op in g ca se de fin iti on N at io na l H ea lth a nd M ed ic al Re se ar ch C ou nc il C ou nc il of S ta te a nd T er rit or ia l Ep id em io lo gi st s, in c ol la bo ra tio n w ith C en te rs fo r D is ea se C on tr ol a nd P re ve nt io n N at io na l C om m itt ee fo r A do pt in g G ui de lin es H ea lth In fo rm at io n M an ag em en t A dv is or y C om m itt ee EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 776 Discussion In  all  3  countries  analysed, most no- tifiable diseases  are  reported  initially  to  the  local  county or  regional health  department,  from where  the data  are  transferred  to  the national  surveillance  institution  [3].  It  is  therefore  impor- tant  to  ensure  that  the data  collected  at  different  levels  are  consistent  and  comparable  and  that  the  interaction  between the departments is effective. Ef- fective  surveillance demands uniform- ity,  simplicity  and  standardization of  case definitions and classification. While case definitions are intended  to  establish uniformity  in disease  re- porting,  they  should  not  be  used  as  the sole criteria for establishing clinical  diagnoses; the use of additional clinical  factors  including epidemiological  and  laboratory data, may enable a physician  to diagnose a disease even though the  surveillance  case  definition may not  be available  [11,12]. Therefore,  in  the  proposed  revised  Iranian model,  the  criteria  “laboratory-confirmed  cases”  and  “epidemiologically  linked  cases”  have  been  added  to  the  established  items  for patient  classification  in  the  notifiable  infectious diseases  surveil- lance system. “Clinically  compatible  cases”  are  another set of criteria  in which clinical  symptoms are used to assign a case to a  specific disease. These clinical descrip- tions give a general outline of the disease  and do not necessarily  indicate all  the  features needed for clinical diagnosis of  the disease. This  survey  indicates  that  the de- scription of variables  in both  the USA  and  Australian  national  notifiable  diseases  surveillance systems are given  according  to  case definitions.  Iranian  health professionals  suggested  that  the  American disease classification system  would  be  appropriate  for  an  Iranian  notifiable  infectious diseases  surveil- lance system.  It  is desirable  that all  the different  agencies  and  stakeholders which are  involved  in  the registration,  reporting,  diagnosis,  treatment and publication  of data concerning nationally notifiable  diseases are involved in the surveillance  system. One of  the main  limitations  of  the US  surveillance  system  is  the  optional reporting of nationally notifi- able diseases to the CDC by individual  states.  A disease surveillance system is only  1 of the 5 interrelated subsystems of an  effective health  information manage- ment  system and  the knowledge  and  skills of  a health  information manage- ment professional  could be useful  in  supporting  its  different  components  (data collection,  transmission, process- ing and analysis) [13]. One outcome of  using the Delphi method to rationalize  the  information gathered  in  this  study  was the decision that it would be advis- able  to ensure  that  the  Iranian Office  of Health  Information Management,  along with  the Office of Communica- ble and Non-Communicable Diseases,  would be  responsible  for  formulating  related policies and procedures.  In  this  framework,  establishing  the  Health  Information Management  Advisory  Committee as a  sub-committee of  the  Deputy  of Health  is  recommended.  These modifications  are  required  to  enhance  the disease  control  systems.  WHO has concentrated  its  action on  the  establishment of national depart- ments  and agencies  in order  to  coor- dinate various activities of  surveillance  systems  and  well-organized  disease  control systems. A standard classification of diseases  is  a necessary  adjunct  to  an  accurate  notifiable  infectious diseases  surveil- lance  system  for  data  comparability  at  the national and  international  level.  Therefore  the use of  the  International classification of diseases  (ICD), or a vari- ation of  it,  is advisable and the Islamic  Republic of  Iran  is  currently working  on a modified version of the ICD [14].  Routine notifiable disease surveillance  often  suffers  from  incomplete  report- ing; hence not only case definition and  classification of diseases are  important  but the addition of other of data sources  (e.g.  coded  discharge  diagnoses  or  pharmacy dispensing data)  is  required  to improve the sensitivity of routine no- tifiable disease surveillance. Implemen- tation of these methods often depends  on  the existence of  tables  linking  the  laboratory or clinical codes  to  the no- tifiable conditions under  surveillance.  The  Systematized Nomenclature  of  Medicine  (SNOMED)  and Logical  Observation  Identifier  Names  and  Codes (LOINC) have been identified  as  important vocabulary  standards  for  creating  these  tables. They  should be  considered  for  further development  in  the Iranian context [15].  It is important that data be collected  and  processed  efficiently  in  order  to  meet time requirements for swift action  when a notifiable disease is detected in  the  community.  It  is  also  crucial  that  data are easily  interpreted and used  in  various ways without  compromising  patient  confidentiality. Computerized  surveillance  systems  in  conjunction  with  the common use of  the  Internet  and different methods of  information  distribution and dissemination are use- ful to ensure that relevant and updated  surveillance information is always avail- able at any time and place [16]. In this  regard, the proposed model involves the  use of a number of methods of distribu- tion of information (Internet, facsimile,  telephone,  email,  postal mail). An  in- creasing demand  for detailed data and  an ambition  to present care providers  with more  timely,  consolidated  infor- mation that can be a basis for preventive  and  therapeutic action are  the driving  forces behind the proposal to use mod- ern web  technology and geographical  information systems (GIS) software  in  the Iranian system.  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 777 Behebani AM. 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Morbidity and Mortality Weekly Report, 1997, 46(RR10):1–55. Lippeveld R, Sauerborn R, Bodart C, eds. 13. Design and imple- mentation of health information management systems. Geneva, World Health Organization, 2000. Safdari R, Meidani Z. Developing a model for an Iranian Classi-14. fication of Diseases (IRCD) compatible with other adaptations of the International Classification of Diseases. Health Informa- tion Management Journal, 2007, 36(1):36–41. Doyle TJ et al. PHSkb: a knowledgebase to support notifiable 15. disease surveillance. BMC Medical Informatics and Decision Making, 2005, 5:27 (doi: 10.1186/1472-6947-5-27). Rolfhamre P, Grabowska K, Ekdahl K. Implementing a public 16. web based GIS service for feedback of surveillance data on communicable diseases in Sweden. BMC Infectious Diseases, 2004, 4:17 (doi: 10.1186/1471-2334-4-17). Eastern Mediterranean Regional Health System Observatory The primary purpose of Eastern Mediterranean Regional Health System Observatory is to promote evidence-based  health policy-making by providing relevant and comparative information about health systems and reforms and to assist  policy-makers in development of health systems in their countries. The aim is to contribute to improvement of health  system performance and outcomes in countries of the Region.  The Observatory will also monitor and evaluate the attainment of critical outcomes and the efficiency of the health sys- tem in a way to allow comparison over time and across systems thus empowering policy-makers and build an evidence  base on the relationship between the design of the health system and its performance. Information about the Eastern Mediterranean Regional Health System Observatory can be found at: http://gis.emro. who.int/HealthSystemObservatory/Main/Forms/Main.aspx EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 778 L’infection à Helicobacter pylori chez 755 patients présentant des symptômes digestifs : Institut Pasteur du Maroc, 1998-2007 H.A.H. Joutei,1 A. Hilali,2 T. Fechtali,3 N. Rhallabi 1 et H.Benomar 4 RÉSUMÉ Nous avons évalué la prévalence de l’infection à Helicobacter pylori chez 755 patients présentant des symptômes digestifs, recensés au laboratoire de l’Institut Pasteur du Maroc de 1998 à 2007. Les facteurs épidémiologiques ainsi que les principales maladies gastriques liées à cette infection ont également été étudiés. Tous les patients avaient bénéficié d’une fibroscopie et le diagnostic a été fait par l’examen histologique. La prévalence de l’infection à H. pylori est de 69 %. Ce taux semble, après analyse statistique, lié significativement à l’âge. En effet, l’infection est plus importante dans la tranche d’âge 40-50 ans. En revanche, le sexe ne présente aucun effet sur la prévalence de l’infection qui est surtout associée aux gastrites chroniques (92 %). La région antrale est la plus colonisée par H. pylori (73 %), suivie du fundus (21 %) et du pylore (6 %). 1Laboratoire d’Environnement, Faculté des Sciences et Techniques, Université Hassan II, Mohammedia (Maroc) (Correspondance à adresser à H. ani Hassani Joutei : mhhanaa@hotmail.com). 2Département de Génétique médicale, Faculté de Médecine et Pharmacie, Université Hassan II, Casablanca (Maroc). 3Laboratoire de Physiologie et Pharmacologie, Faculté des Sciences et Techniques, Mohammedia (Maroc). 4Laboratoire d’Anatomo-cyto-pathologie, Institut Pasteur du Maroc, Casablanca (Maroc). Reçu : 08/04/09; accepté : 26/07/09 Helicobacter pylori infection in 755 patients with digestive complaints: Pasteur Institute, Morocco, 1998–2007 ABSTRACT We determined the prevalence of Helicobacter pylori infection in 755 patients with digestive complaints identified from laboratory records at the Pasteur Institute, Morocco from 1998 to 2007. Epidemiological factors and gastrointestinal conditions associated with this infection were also studied. All patients underwent endoscopy and diagnosis was by histology examination. The prevalence of H. pylori infection was 69%. The difference in prevalence between the age group 40–50 years and other age groups was statistically significant; gender had no significant association. H. pylori infection was found in 92% of chronic gastritis cases. The prevalence of H. pylori was significantly higher in the antrum (73%) than in the corpus (21%) and the pylorus (6%). 2007-1998 برغلما ،روتساب دهعم ؛ةيمضه ىوكشب ًاضيرم 755 ىدل ةيباوبلا ةيوللماب ىودعلا رمع نب ةميكح ،بيلاغ ةميعن ،لياتشف قيفوت ،ليلالها فيطللا دبع ،يطوج ينسح نيارمع ءانه في ةيبرتخلما تلاجسلا للاخ نم مهيلع اوفرعت ةيمضه ىوكشب ًاضيرم 755 ىدل ةيباوبلا ةيوللماب ىودعلا راشتنا ل َّدعم نوثحابلا سرد :ةـصلالخا ناكو .ىودعلا هذه عم ةقفارـتلما ةيمضلها تلاالحاو ةيجولويميديبلإا لماوعلا ًاضيأ نوثحابلا سرد ماك ،2007-1998 ةدلما في برغلما ،روتساب دهعم في قرفلا ناكو .%69 ةيباوبلا ةيوللماب ىودعلا راشتنا ل َّدعم ناكو .يجيسنلا صحفلاب صيخشتلا لىع اولصحو ليخاد يرظنتل اوعضخ دق ضىرلما عيجم .يئاصحإ دادتعا تاذ ةيهمأب ردنلجا قفارـتي لم مايف .ابه ُّدَتْعُي ةيئاصحإ ةيهمأ اذ ةيرمعلا تائفلا نم اهيرغو ًاماع 50-40 ةيرمعلا ةئفلا ينب راشتنلاا ل َّدعم اهولتي )%92( ةيباوبلا ةيوللماب ًارماعتسا رثكلأا يه ةدعلما داؤف ةيحان تناكو .نمزلما ةدعلما باهتلا تلااح نم %92 ىدل ةيباوبلا ةيوللما نوثحابلا دجوو .)%6( باوبلا مث )%73( ةدعلما عاق طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 779 Introduction Depuis  la  découverte  en  1982  par  Marshall  et  Warren  de  la  bactérie  H e l i c o b a c t e r p y l o r i   dans   l ’antre  gastrique,   les  nombreux  travaux  qui  lui ont  été  consacrés ont montré  son  rôle  étiopathogénique  dans  plusieurs  affections  gastriques  et  duodénales(gastrite, maladie ulcéreuse,  lymphomes, cancer gastrique) [1]. L ’ in f ec t ion   à   H . p y l o r i e s t probablement  l ’ infection  la  plus  fréquente à travers le monde et environ  40 %  de  la  population  mondiale  en  serai t  atteinte  [2]. De 20  à  90 % des  individus adultes sont  infectés selon  les  pays,  l’infection étant plus  fréquente en  milieu défavorisé, de bas niveau socio- économique [3]. Le mode de transmission de H. pylori est encore incertain. Étant donné que la  bactérie H. pylori  a été  isolée dans des  selles, ainsi que dans la salive et sur des  plaques dentaires,  ceci  laisse  supposer  qu’une  transmission  est  possible  par  voie oro-orale ou par voie féco-orale [4].  Notre objectif à  travers cette étude est  d’évaluer la prévalence de l’infection à H. pylori chez  les malades colligés sur une  période de 10 ans (du 1er  janvier 1998  au 31 décembre 2007) au Laboratoire  d’Anatomo-cyto-pathologie de l’Institut  Pasteur du Maroc et d’étudier  l’impact  des différents facteurs épidémiologiques  ainsi  que  les  principales  maladies  gastriques liées à cette infection. Méthodes Patients Il  s’agit d’une étude épidémiologique  intéressant 755 patients (334 hommes  et 421  femmes) dont  l’âge varie entre  3 et 89 ans avec une moyenne d’âge de  44,45 ans (ET 14,42).  Ils présentaient  tous des symptômes digestifs et avaient  bénéficié  d’une  fibroscopie  digestive  haute  entre  le  1er  janvier  1998  et  le  31  décembre 2007. La fiche d’enquête  du patient la plus complète mentionnait  le  nom,  l’âge,  le  sexe,  la  nature  du  prélèvement et le diagnostic clinique. Nature du prélèvement La fibroscopie  réalisée par  le médecin  traitant avait permis des prélèvements  biopsiques  souvent  au  niveau  des  régions antrales, parfois  au niveau de  la  région  antro-fundique  ou  antro- pylorique. Ces biopsies étaient souvent  fixées  à  l’aide de  formol  et  rarement  avec  le  liquide de Bouin. Ensuite, elles  étaient  acheminées  au  Laboratoire  d ’Anatomo-cyto-pathologie   de  l’Institut Pasteur du Maroc pour une  étude histologique. Méthode diagnostique L’examen  histologique  des  biopsies,  pièces  opératoires  et  prélèvements  t issulaires   post-mortem  permet  d ’ ob t en i r   une   bonne   qua l i t é  morphologique  et   a   également  l’avantage de permettre une conserva- tion quasi-illimitée des prélèvements  à  température  ambiante. Cet  examen  est  souvent  effectué,  en premier  lieu,  pour  rechercher  une  anomalie  de  la  muqueuse  gastrique,  notamment  une  inflammation  ou  un  processus  cancéreux.  Il est également utilisé pour  dépister H. pylori qui est souvent la cause  majeure de cette anomalie. La coloration hématoxyline-éosine,  qui  permet  de  déterminer  le  type  de  lésions  histologiques  causées  par  Tableau 1 Fréquence de la population infectée par Helicobacter pylori Population Nbre % Population infectée par H. pylori 521 69 Population non infectée par H. pylori 234 31 Total 755 100 H. pylori, a toujours été complétée par la  coloration de Giemsa lent qui donne un  meilleur contraste pour la bactérie. Analyse statistique La  saisie  et  l’analyse des données ont  été  réalisées  à  l’aide  du  logiciel  Epi  Info,  version  6.04  française,  et  les  comparaisons  entre  les  proportions  ont  été  effectuées  par  les  tests  de  χ2.  Les  différences  ont  été  considérées  significatives  si  la  valeur  de  p  est  inférieure à 0,05. Résultats Prévalence de l’infection à H. pylori dans la population étudiée Les  résultats de notre  travail montrent  une très grande fréquence de l’infection  à H. pylori dans la population concernée.  H. pylori  a  été mise  en évidence dans  69 % des  cas,  avec  un  âge moyen de  43,48 (ET 14,24) ans contre 46,53 (ET  14,85) ans pour  les  sujets non  infectés  par H. pylori (Tableau 1).  Effet du sexe sur la prévalence de l’infection Notre série démontre que  la positivité  à H. pylori est de 53 % chez les femmes  et de 47 % chez  les hommes (sex ratio de 1,12) présentant une différence non  significative (χ2 = 1,84 ; p = 0,18 > 0,05)  (Tableau 2). Tableau 2 Répartition des patients infectés par Helicobacter pylori selon le sexe Sexe Nbre % Masculin 245 47 Féminin 276 53 Total 521 100 EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 780 Effet de l’âge sur la prévalence de l’infection L’analyse  statistique de nos  résultats  a  permis de déterminer que seul  le  facteur  âge était associé de façon significative à la  prévalence de  l’infection à H. pylori  (χ2 = 38,22 ; p = 0,000003 < 0,05) (Tableau 3).  En  effet,  nous  avons  relevé  une  fréquence de 20 % des patients positifs  à H. pylori  dans  la  classe  d’âge de  30- 40 ans mais  la plus  forte prévalence est  notée  chez  les  sujets  appartenant  à  la  tranche d’âge 40-50 ans (35 %) avec une  moyenne d’âge de 43,48 ans (ET 14,24).  Effet du siège de prélèvement sur la prévalence de l’infection Concernant la répartition selon le siège  du prélèvement,  les  résultats obtenus  ont  démontré  que  la  localisation  préférentielle  de H. pylori  est  l’antre  gastrique. En effet, 73 % des lésions sont  attribuées à l’antre, 21 % sont observées  au niveau du fundus. Par contre, le pylore  reste  le  siège  le moins  infecté  (6 %) (Tableau 4). Types de pathologies gastriques associées à l’infection L’infection par H. pylori  est  devenue  le  facteur  étiologique  incontournable  de nombreuses pathologies gastriques.  Nous avons étudié, par conséquent,  sa  responsabilité dans le cadre de chacune  de  ces  affections.  L’analyse  de  nos  résultats  a  démontré  que  92 %  de  la  population  infectée par H. pylori  était  atteinte de gastrites chroniques souvent  atrophiques (Tableau 5). Concernant  l’ulcère gastrique,  sa  fréquence était de  5 % alors que  le cancer n’a été observé  que chez 3 % de cette population. Discussion L’infection  à H. pylori  est  universel- lement   répandue  mais   e l le   est  plus  élevée  dans  les  pays  en  voie  de  développement (78 % en Algérie, 71 %  au Maroc, 69 % en Côte d’Ivoire) [5].  La prévalence de cette  infection est de  69 % chez  la population étudiée. Cette  fréquence  se  situe dans  les  limites des  valeurs  rapportées par plusieurs études  africaines  qui  varient  de  56,4 %  à  91,3 % et  reste supérieure aux données  européennes  où  cette  fréquence  ne  dépasse pas 45 %  [6-8]. Il est à noter que  le personnel de santé qui travaille dans le  service de  gastro-entérologie  semble  exposé à un risque plus élevé à contracter  une infection par H. pylori [9], ce qui n’a  pas été confirmé dans notre étude. Elmanama et al. ont démontré que les  deux sexes sont indifféremment touchés  par  l’infection  due  à H. pylori   [10],  confirmant  les  résultats de notre  série.  Cependant,  d’autres  études ont noté  une prédominance masculine  [11,12]. Par  ailleurs,  si  on  compare  par  tranches d’âge, H. pylori  est  retrouvé  dans notre série à un taux de 35 % chez  les patients dont  l’âge se situe entre 40  et 50 ans,  avec une moyenne d’âge de  43,48 (ET 14,24) ans. Cette moyenne  est  inférieure  aux  chiffres  européens  qui sont autour de 60 ans [13,14] alors  que pour des  auteurs  ivoiriens  [6]  et  palestiniens  [10],  aucune  différence  s ign ificat ive   n ’a   é té   rapportée  concernant les tranches d’âge.  Ilboudo et al. avancent qu’en Afrique,  tout  individu pris à  l’âge adulte et quel  que soit  son niveau socio-économique  a vécu une enfance dans un environne- ment propice à  la contamination [15].  En  effet,  certains  travaux ont montré  que  la  contamination  se  fait  tôt dans  l’enfance, et avant 10 ans plus de 50 %  Tableau 3 Répartition des personnes infectées par Helicobacter pylori selon les classes d’âge Classes d’âge (ans) Nbre % < 20 31 6 20-30 63 12 30-40 104 20 40-50 183 35 50-60 68 13 60-70 57 11 70-80 10 2 > 80 5 1 Total 521 100 Tableau 4 Présence de Helicobacter pylori dans les différents sièges de prélèvement Siège de prélèvement Nbre % Antre 380 73 Fundus 110 21 Pylore 31 6 Total 521 100 Tableau 5 Les différentes pathologies associées à la présence de Helicobacter pylori dans l’estomac humain Type de pathologie causée Nbre % Ulcère 26 5 Cancer 16 3 Gastrite 479 92 Total 521 100 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 781 des enfants des pays en développement  seraient  déjà  contaminés  [16,17].  Comparativement à  notre  étude,  nous  avons  également  observé  des  taux d’infection par H. pylori chez des  enfants de moins de 13 ans mais  leur  faible effectif n’autorise pas à porter de  conclusion. Le siège de prolifération de H. pylori est  l’antre gastrique par excellence. En  effet,  l’antre est  colonisé par H. pylori chez  73 %  de  notre  population. Ces  résultats  sont  en accord avec ceux de  l’étude menée dans la région de Gharb- Chrarda-Beni Hssen qui attribue 70,9 %  des  lésions à ce  siège [18]. Par contre,  ces valeurs  restent  supérieures à celles  rapportées par Binan et al. et Seoane et  al. qui attribuent respectivement 40,0 %  et 48,1 % des lésions à H. pylori au siège  antral [19,20]. D’une  autre  part, H. pylori  est  à  l’origine  de  la  survenue  de  plusieurs  pathologies digestives dont  la gastrite  qui est  souvent asymptomatique. Des  auteurs  marocains  présument  que  H. pylori  est  effectivement  corrélée  le  plus  souvent à une gastrite chronique  atrophique  avec  une  prévalence  de  95,56 % [18]. Ces résultats concordent  avec ceux retrouvés dans notre étude.  Concernant  l’ulcère  gastrique qui  est  responsable d’un  taux de mortalité  de 2,5 %, son incidence annuelle est de  0,5/1000. Dans notre série, sa fréquence  dans  la population  infectée est de 5 %.  En outre, les preuves de l’implication de  H. pylori dans  l’ulcère gastrique  restent  moins documentées.  Il est à noter que  cette population  atteinte de  gastrites  et d’ulcères  constituerait un  terrain  à  risque pour la survenue d’un cancer.  Il  est  aujourd’hui  clairement  établi  que H. pylori  est  responsable du cancer  gastrique et qu’aucun cancer de ce  type  ne  se  développe  en  l’absence  de  cette  bactérie  [21].  Les  études menées  par  Haruma  ont  montré  une  prévalence  plus élevée d’infections à H. pylori dans les  populations  affectées  de  cancers  gastriques  que  dans  les  populations  témoins [22]. Ces résultats établissent un  lien de causalité qui a conduit un groupe  d’experts réuni par le Centre international  de Recherche sur  le Cancer à classer H. pylori  comme carcinogène certain  [23].  Néanmoins,  le  nombre  de  patients  susceptibles de développer un cancer est  minime comparativement à l’importance  de  la  population  infectée par H. pylori [22]. Ceci concorde avec les résultats de  notre  série où  seulement 3 % de notre  population avait développé un cancer. Conclusion H. pylori  a  été mise  en évidence  chez  69 % de  la  population  concernée ;  la  classe  d’âge  la  plus  infectée  pendant  ces dix années est celle comprise entre  40 et 50 ans avec un taux de 35 %. Elle  est  retrouvée autant chez  les hommes  que  chez  les  femmes,  les  taux  étant  respectivement  de  47 %  et  53 % ;  le  sexe ne présente donc aucun effet  sur  la prévalence de l’infection par H. pylori.  Notre  étude  a  démontré  également  que H. pylori  est  impliquée dans 92 %  des gastrites, 5 % des ulcères et 3 % des  cancers gastriques. Cet agent à l’origine  de ces différentes pathologies gastriques  a  comme  siège  préférentiel  l’antre  gastrique avec un taux de 73 %, suivi du  fundus (21 %), le pylore restant le siège  le moins infecté (6 %). Remerciements L’auteur  remercie  vivement  Mmes  Nadia Elgnaoui, Moutahir Saida, Ser- dani Marya  et Rifki Naima pour  leur  assistance  technique  ainsi  que Mme  Jihane Bouhala pour  son aide dans  la  recherche documentaire. Références Mignon M. Prix Nobel de Médecine 2005 : Barry J. Marshall 1. et J. Robin Warren. Helicobacter pylori couronné. Médecine Sciences, 2005, 21 (11):993–994. Thomson AB, Chiba N. From bench to bedside and back-2. report on the European Helicobacter pylori Study Group Xth International Workshop on Gastroduodenal Pathology and Helicobacter pylori . Canadian Journal of Gastroenterology, 1998, 12(6):437–446. Magalhaes DM, Luzza F. Epidemiology of. 3. Helicobacter pylori infection. Helicobacter, 2006, 11(Suppl 1):1–5. Everhart JE. Recent developments in the epidemiology of 4. Heli- cobacter pylori. Gastroenterology Clinics of North America, 2000, 29 (3):78–559. Faik M. Mise au point sur l’infestation gastrique par l’5. Hélicobacter pylori. 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H. pylori associated hypertrophic gastritis is explained by tobacco and alcohol use: an evidence for host-mediated inflammatory response to H. pylori gastritis. American Journal of Gastroenter- ology, 2000, 95:2452. Corallo J. 13. Helicobacter pylori. Acta Endoscopica, 1991, 21(1):112– 117. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 782 Glupczynski Y. Epidémiologie de l’infection à 14. Helicobacter pylori et méthodes diagnostiques. Annales Médicales de Nancy et de l’Est, 1994, 339(2):89–93. Ilboudo D 15. et al. Aspects épidémiologiques et cliniques de l’infection à Hélicobacter pylori en zone tropicale : à propos de 150 patients à l’hôpital national de Ouagadougou (Burkina Faso). Médecine d’Afrique Noire, 1997, 44 (1):24–28. De Giacomo C. Transmission de l’infection à 16. Helicobacter pylori chez l’enfant. La lettre de l’infectiologue, 1994, 4 (suppl), IX:8–9. Rafeey M, Nikvash S.17. Detection of Helicobacter pylori antigen in stool samples for diagnosis of infection in children. Eastern Mediterranean Health Journal, 2007, 13(5):1067–1071. Attaf N 18. et al. Profil épidémiologique de l’infection à Helico- bacter pylori dans la région du Gharb-Chrarda-Beni Hssen. Biologie & Santé, 2004, 4(1):25–34. Binan Y 19. et al. Cancer gastrique et Helicobacter pylori : résultats d’un centre d’endoscopie à Abidjan. Revue Internationale des Sciences Médicales, 2006, 8(1):23–27. Seoane A et al. 20. Helicobacter pylori and gastric cancer: relation- ship with histological subtype and tumor location. Gastroenter- ology and Hepatology, 2005, 28 (2):4–60. Delchier21. JC. Le lymphome gastrique du MALT, une infection maligne potentiellement curable par l‘éradication de Helico- bacter pylori. Gastroentérologie Clinique et Biologique, 2003, 27(3):453–458. Haruma K. Trend toward a reduced prevalence of 22. Helico- bacter pylori infection, chronic gastritis, and gastric cancer in Japan. Gastroenterology Clinics of North America, 2000, 29(3):31–623. Schistosomes, liver flukes and 23. Helicobacter pylori. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Lyon, 7-14 June 1994. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, 1994: 61:1–241. Helicobacter pylori The isolation of Helicobacter pylori from the human gastric mucosa in 1982 and the demonstration of its involvement  in gastritis, peptic ulcer disease and gastric adenocarcinomas have radically changed our perception of these diseases.  H. pylori has an estimated prevalence of about half the world’s population, possibly reaching up to 70% in developing  countries and 20%–30% in industrialized countries. Although infected individuals often have histological evidence of  gastritis, the vast majority of infections are asymptomatic. Infections seem to be more common with age but, in the trop- ics, they often occur before the age of 10 years, especially in high-density populations with low socioeconomic status.  Transmission is from person-to-person, presumably oral–oral and/or faecal–oral. In the absence of treatment, infection  is potentially lifelong. Treatment is based on the use of a proton-pump inhibitor and antibiotics (metronidazole and  clarithromycin).  Source: http://www.who.int/vaccine_research/documents/Helicobacter_pylori/en/index.html طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 783 Prevalence and antibiotic resistance of Pseudomonas aeruginosa isolated from swimming pools in northern Greece I. Tirodimos,1 M. Arvanitidou,1 T. Dardavessis,1 A. Bisiklis 2 and S. Alexiou-Daniil 2 ABSTRACT Pseudomonas aeruginosa is an important agent of opportunistic infection in aquatic environments. Our aim was to evaluate the occurrence and antimicrobial resistance of P. aeruginosa in the water of swimming pools in northern Greece. Water samples were obtained from hydrotherapy pools, jacuzzis/spas and swimming pools. A total of 16.6% (45/271) of the samples were positive for P. aeruginosa. Of the amenities examined, the most contaminated were hydrotherapy pools (25% of samples positive). A small percentage of isolates (20.0%) showed resistance to antibiotics. Compared with other studies, the prevalence of P. aeruginosa in swimming pools was relatively low, while the antibiotic resistance pattern of these community isolates was not high. 1Laboratory of Hygiene; 2Laboratory of Microbiology, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece (Correspondence to I. Tirodimos: iltirodimos@yahoo.gr). Received: 05/11/08; accepted: 27/11/08 ةيويلحا تاداضملل نانويلا لماش في ةحابسلا ضاوحأ نم ةَدَرفتسلما ةيراجنزلا ةفئازلا ةمواقم ل َّدعم ليـيناد وسكيلأ نيايلياتس ،سيلكيسيب سوردنسكلا ،سيسيفاد راد رودويث ،وديتينافرأ اينيتاملاام ،سوميدورـيت سايلإ هايم في ةيراجنزلا ةفئازلا عوقو ل َّدعم ميقت نوثحابلا فدهتساو .ةيئالما ةئيبلا في ةيزاهتنلاا ىودعلا لماوع نم ةَّيراجنزلا ةفئازلا دعت :ةـصلالخا ضاوحأو ،هايلماب ةلجاعلما ضاوحأ نم هايلما نم تانيع لىع نوثحابلا لصح دقف .ةيويلحا تاداضملل اهتمواقمو ،نانويلا لماش في ةحابسلا ضاوحأ ينب نمو ؛ةيراجنزلا ةفئازلل ةيبايجإ ةنيع )271 لصأ نم 45( %16.6 نأ اودجوو ،هيفترلاو جلاعلا في ةمدختسلما ضاوحلأا وأ يزوكالجاو ،ةحابسلا تادرفتسلما نم ةليئض ةيوئم ةبسن ترهظأو .)ةيبايجإ تانيعلا نم %25( ًاثولت رثكلأا يه هايلماب ةلجاعلما ضاوحأ تناك ،نوثحابلا اهصحف يتلا عقاولما نأ ينح في ،ىرخأ تاساردب ةنراقم ًايبسن ًاضفخنم ودبي ةيراجنزلا ةفئازلا راشتنا ل َّدعم هنأ لىإ ةساردلا يرشتو .ةيويلحا تاداضملل ةمواقم )%20( .ةعفترم نكت لم عمتجلما نم تادرفتسلما هذله ةيويلحا تاداضملل ةمواقلما طمانأ Prévalence et résistance antibiotique de Pseudomonas aeruginosa isolé dans des piscines du nord de la Grèce RÉSUMÉ Pseudomonas aeruginosa est un agent d’infection opportuniste fréquent, qui prolifère dans les environnements aquatiques. Notre objectif était d’évaluer la présence et la résistance de P. Aeruginosa aux antimicrobiens dans l’eau de piscines situées dans le nord de la Grèce. Des échantillons d’eau provenant de bassins d’hydrothérapie, de jacuzzis/spas et de piscines ont été prélevés. Au total, 16,6 % des échantillons(45/271) étaient positifs à P. Aeruginosa. Les bassins d’hydrothérapie étaient les plus contaminés des équipements analysés, (25 % des échantillons étaient positifs). Un faible pourcentage d’isolats (20,0 %) a révélé une résistance aux antibiotiques. En comparaison avec d’autres études, la prévalence de P. Aeruginosa dans les piscines était relativement faible, et le profil d’antibiorésistance de ces isolats communautaires était peu élevé. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 784 Introduction Pseudomonas aeruginosa  belongs  to  a  vast  genus  of  obligate  aerobic,  non- fermenting, saprophytic, Gram-negative  bacilli widespread in nature, particularly  in moist  environments  such as water,  sewage, soil, plants and animals [1]. The  organism is able to grow and multiply in  a variety of water sources including river  water, seawater, wastewater and bottled  mineral water [2,3]. P. aeruginosa  is  an  important agent  of opportunistic  infection  in patients,  particularly  in  those with  respiratory  complications and burns. According to  Craun et al., Pseudomonas  spp. was one  of the most frequently identified agents  associated with waterborne outbreaks  of  dermatitis  (rash  or  folliculitis),  as  well as conjunctivitis, otitis externa and  other  symptoms,  in  recreational water  in the United States of America (14%)  [4]. Pseudomonads  are well  adapted  to  survival  in whirlpools, hot  tubs and  indoor pools because of the warm water  temperatures. These waters  are  espe- cially prone  to  contamination during  periods of high use when it is difficult to  maintain adequate disinfection levels. Although  recreational  water  is  a  documented environmental  source of  P. aeruginosa, there are limited published  data about the prevalence of this organ- ism in swimming pools, saunas and hot  tubs  [5,6].  In  this  study, we aimed  to  identify the prevalence of P. aeruginosa in recreational water  facilities  in northern  Greece and to examine the correlation  of P. aeruginosa with standard faecal pol- lution  indicator bacteria. We also used  antibiograms  as  an  epidemiological  marker  for our P. aeruginosa  isolates  in  view of the fact that antibiotics are cheap  and easily available without prescription  to the Greek population, creating a risk  of antibiotic-resistant  strains emerging  [7].  Methods Sampling The Laboratory of Hygiene  is  the gov- ernment  reference centre  for assessing  the chemical and bacteriological quality  of potable and  recreational waters  for  the area of northern Greece (Macedo- nia  and Thrace).  In  the 1-year period  2005, 271  recreational water  samples  were sent from the local health authori- ties  and  other  public  services  to  our  laboratory. The samples were obtained  from 3  amenity  categories,  namely 4  hydrotherapy pools (n = 8 samples), 4  jacuzzis/spas (n = 49 samples) and 21  swimming  pools  (n  =  214  samples).  Samples were  taken  in  sterilized dark- coloured  1-litre  bottles  containing  chloride scavenger and were kept refrig- erated at a  temperature of 4 ºC before  microbiological analyses.  Microbiological analyses and antibiotic susceptibility testing Total  heterotrophic  bacteria  were  counted on plate count agar using 1 mL  infusion  technique after  incubation at  37 ºC  for 48 h. For  total coliforms,  the  100 mL membrane filtration technique  was used, with m-Endo medium at 3 ºC  for 24 h. For Escherichia coli, the 100 mL  membrane filtration technique was also  used, with  tryptone bile X-glucuronide  agar at 44.5 ºC for 24 h. P. aeruginosa was confirmed by  the  Vitek 2 automated microbiology system  (bioMérieux, Marcy  l’Etoile, France).  The minimum  inhibitory  concentra- tions (MIC) of antibiotics were deter- mined by broth microdilution assay on  the Vitek 2  system. MICs were  inter- preted  according  to  the 2004 criteria  of the National Committee on Clinical  Laboratory Standards (NCCLS) [8]. P. aeruginosa (ATCC 27853) was used as  the quality control strain. The antibiot- ics used were selected according to the  2004 NCCLS  guidelines:  amikacin,  aztreonam,  cefepime,  ceftazidime,  ciprofloxacin,  gentamicin,  imipenem,  meropenem, piperacillin,  ticarcillin +  clavulanic  acid  and  tobramycin. The  MICs of an isolate resistant to carbapen- ems (imipenem and meropenem) were  further  confirmed by  the  epsilometer  test (AB Biodisk, Solna, Sweden).  Statistical analysis Data analysis was performed using  the  statistical package SPSS  for Windows,  version 14.0. The chi-squared  test was  used at 5% significance level. Results Measurements  of  some  important  health-related microbiological param- eters and the prevalence of P. aeruginosa are given on Tables 1 and 2.  A  total of 271 water  samples  from  3  amenity  categories  (n  =  29)  were  obtained  (Table  1). Of  the  samples  examined  39/214  from  swimming  pools (18.2%), 4/49 from jacuzzis/spas  (8.2%)  and  2/8  from  hydrotherapy  pools (25%) were positive for P. aerugi- nosa (total 45/271, 16.6%). The highest  isolation  rate of P. aeruginosa  (25.0%)  was from hydrotherapy pools. However,  no  significant differences were  found  between different amenity categories in  the  rate of  isolation of pseudomonads  or the median number of colony-form- ing units of P. aeruginosa  per 100 mL (P > 0.05) (Tables 1 and 2). According  to  Greek  regulations,  the microbiological quality of  the wa- ter  samples  from  the different  amen- ity categories of  recreational water was  reasonably good, with the exception of  hydrotherapy pools (Table 1); 50% of  specimens  from hydrotherapy  pools  were not compliant with the Greek hy- giene  regulations. The median colony  count of faecal coliforms in this amenity  was also by far the largest at 30.5 per 100  mL (range 1–100) (Table 2). There was  therefore a significant difference among  the different  categories of  amenity  in  the  rate of compliance with  standards  (P < 0.05). طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 785 The rate of compliance of our sam- ples with the Greek chlorination stand- ard was 253/271 (93.4%) (Table 1).  No significant differences were  found  between different amenities in the chlo- rination compliance with  the standard  (P > 0.05).  A  total  of  45  isolates of P. aerugi- nosa were examined  for antibiotic  sus- ceptibility. The antimicrobial patterns  exhibited by  the  isolates are  shown  in  Table 3. There were 9  isolates (20.0%)  that showed resistance to aztreonam, 9  (20.0%) to  ticarcillin + clavulanic acid,  1  (2.2%)  to  imipenem and 1  (2.2%)  to  meropenem.  No  multi-resistant  strains were  found. The other antibiot- ics  showed  good  activity with  100%  susceptibility rates.  Discussion In  this  study we  found  that  the preva- lence of P. aeruginosa in swimming pools  and  recreational  waters  in  northern  Greece was 16.6%. So  far,  only  a  few  studies have examined  the prevalence  of P. aeruginosa  in  recreational waters.  Our results are close to these obtained  from a survey  in the Athens area (17%  prevalence) [9]. However, a study from  Ireland reported a very high prevalence  of P. aeruginosa  in  38% of  swimming  pools and 73% of jacuzzis and spas, while  another study from Switzerland showed  an overall  prevalence of  4%  [5,6]. As  Barben et al. suggested, the explanation  for the widely varying rates of P. aerugi- nosa  that have been  identified  in  these  studies  reflects different approaches  to  the maintenance of recreational waters  [6]. The level of free chlorine, the density  of use, poor operation, construction and  maintenance of  these pools  as well  as  the presence of  large plastic  inflatables  in the pool may affect the prevalence of  Pseudomonas spp. [10].  Waterborne outbreaks of conjuncti- vitis, otitis externa and dermatitis (rash or  folliculitis) caused by P. aeruginosa have  been reported [10,11]. Pseudomonads  are well adapted to survival in pools be- cause of  the warm water  temperatures,  something quite  common  in Greece.  Outbreaks of pseudomonas dermatitis  are preventable  if water  is maintained  at  a pH of 2.0–5.0 with  free  chlorine  levels in the range of 2.0–5.0 mg/L [12].  Close  attention  to bather overcrowd- ing,  as well  as  frequent monitoring of  disinfectant  levels and maintenance of  adequate  treatment  can help prevent  these outbreaks.  The rate of compliance of our sam- ples with the Greek chlorination stand- ard was 93.4%. One factor which should  be kept in mind is that most pathogens  of  concern  in  water  recreation  and  sports are more resistant than coliforms  to chlorine. For instance, Staphylococcus spp. and Pseudomonas  spp. were  found  to be many times more resistant to chlo- rine than coliforms [13].  It  is  therefore  not  surprising  to  recover Pseudomonas spp. in samples from swimming pools in  which no coliforms were found.  The  1973 Greek  hygiene  regula- tions [14] determining various  factors  to ensure good water quality  in  swim- ming pools of all  types are considered  obsolete.  Standards which  are more  complete and deal with modern proc- esses  such  as  ozonation  include  the  German  standard DIN 19643 Treat- ment and disinfection of swimming pool and bathing pool water  and DIN 19605  Filters for water treatment,  as well as  the  British Blue Book Treatment and quality of swimming pool water [15–17]. Thus, if  we use  the Greek  regulations, 31/271  samples (11.4%) were non-compliant  with sources. However,  if we use DIN  19605 which demands  absence of P. aeruginosa  in  the microbiological  pa- rameters, another 35 samples (12.9%, a  total of 24.4%) would be non-compliant  with standards (P = 0.02).  Half  of  the  samples  from  hydro- therapy pools were non-compliant with  Greek  hygiene  regulations  and were  also found with a high load of E. coli. Hy- drotherapy pools in Greece are popular  facilities used mainly by the elderly and Ta bl e 1 So m e im po rt an t m ic ro bi ol og ic al p ar am et er s an d pr ev al en ce o f P se ud om on as a er ug in os a in w at er s am pl es fr om re cr ea ti on al w at er fa ci lit ie s in n or th er n G re ec e W at er c at eg or y C om pl ia nt w it h ch lo ri na ti on s ta nd ar da To ta l h et er ot ro ph ic ba ct er ia (/ m L) To ta l c ol ifo rm s (/ 10 0 m L) Es ch er ic hi a co li (/ 10 0 m L) Ps eu do m on as ae ru gi no sa (/ 10 0 m L) C om pl ia nt w it h m ic ro bi ol og ic al st an da rd sa N o. % N o. % N o. % N o. % N o. % N o. % Sw im m in g po ol s ( n = 21 4) 20 4 95 .3 13 8 64 .5 15 7.0 5 2. 3 39 18 .2 19 4 90 .7 Ja cu zz is /s pa s ( n = 49 ) 47 95 .9 38 77 .6 7 14 .3 2 4. 1 4 8. 2 42 85 .7 H yd ro th er ap y po ol s ( n = 8) 2 25 .0 5 62 .5 5 62 .5 4 50 .0 2 25 .0 4 50 .0 To ta l ( n = 27 1) 25 3 93 .4 18 1 66 .8 27 10 .0 11 4. 1 45 16 .6 24 0 88 .6 a G re ek h yg ie ne re gu la tio ns (l im it va lu es ): ch lo rin at io n is 0 .4 –0 .8 p pm (> 0 .8 p pm is co ns id er ed a s h yp er ch lo rin at io n) ; t ot al h et er ot ro ph ic b ac te ria < 2 00 /m L, to ta l c ol ifo rm s < 5 /1 00 m L, E . c ol i 0 /1 00 m L. n = no . o f s am pl es a na ly se d. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 786 sick people. These people have  a  low  level of hygiene education and are very  prone  to  faecal accidents. When  these  characteristics are combined with over- crowding,  contamination  of  pools  is  very  likely. Training of hydrotherapy  pool  managers,  operators  and  staff  should  include  information about  the  transmission  of waterborne  illnesses  and the critical role of treatment, opera- tion/maintenance  and monitoring  in  preventing these illnesses.  P. aeruginosa  is  naturally  resistant  to many  antibiotics  because  of  their  relatively  impermeable  membrane,  constitutively expressed and  inducible  efflux  systems  and  a  chromosomally  encoded  inducible β-lactamase. These  antibiotics  include penicillin G,  ami- nopenicillins—even when combined  with β-lactamase inhibitors—and first-  and second-generation cephalosporins; P. aeruginosa  is  also naturally  resistant  to macrolides,  chloramphenicol,  co- trimoxazole,  rifampin, kanamycin and  first-generation fluoroquinolones,  such  as norfloxacin  [18]. At  this  point we  must mention  that  the study of antibi- otic resistance in environmental strains  is not common and may produce poor  results  in relation to clinical  isolates.  In  principle,  all  hospital  and household  wastewater  should  be  treated  before  release into the environment. However,  sometimes  the  uncontrolled  dispos- ing of  antibiotics  and  chemicals  into  the environment may create a selective  pressure on  these drugs. Furthermore,  the members of  a particular  environ- mental  clonal  complex may  be  very  successful and widespread in natural as  well as in clinical environments, having  developed  the ability  to quickly adapt  to noxious substances (antimicrobials,  detergents,  pesticides,  heavy metals)  entering their environment [19].  The overall  incidence of  antibiotic  resistance of our  isolates was very  low  compared with clinical isolates [7], while  no multi-drug  resistant  strains  were  found. All of our  isolates (100%) were  susceptible  to  cefepime,  ceftazidime,  piperacillin (β-lactams), amikacin, gen- tamicin, tobramycin (aminoglycosides)  and ciprofloxacin (fluoroquinolones).  The high level of resistance to aztreonam  (20.0%) and ticarcillin + clavulanic acid  (20.0%) has been mentioned in studies  with nosocomial  isolates  [20]. As  for  ticarcillin + clavulanic  acid,  in Greece  there are no official data  regarding  the  resistant  strains of P. aeruginosa. How- ever,  according  to data obtained  from  the Vitek2 system in AHEPA Hospital  in Thessaloniki during  the year 2005,  41% of clinical  isolates of P. aeruginosa were resistant  to  these antibiotics. Fur- thermore, survey data showed emerging  Table 2 Colony-forming units of bacteria in water samples from recreational water facilities in northern Greece Water category Median no. of colonies (min–max)a Total heterotrophic bacteria Total coliforms Escherichia coli Pseudomonas aeruginosa Swimming pools (n = 214) 20 (2–3000) 4 (1–50) 2 (1–16) 14 (0–100) Jacuzzis/spas (n = 49) 20 (2–3000) 4 (2–40) 4 (1–7) 10 (1–80) Hydrotherapy pools (n = 8) 20 (10–48) 2 (1–120) 30.5 (1–100) 11.5 (3–20) Total (n = 271) 20 (2–3000) 4 (1–120) 2 (1–100) 12 (0–100) aMedian is shown due to the statistically abnormal distribution of the sample. n = no. of samples analysed. Table 3 Results of susceptibility testing of Pseudomonas aeruginosa (n = 45 isolates), and minimum inhibitory concentration (MIC) of each antibiotic used Antibiotic Sensitive Intermediate Resistant No. % MIC (μg/mL) No. % MIC (μg/mL) No. % MIC (μg/mL) Amikacin 45 100.0 ≤ 16 0 – 32 0 – ≥ 64 Aztreonam 36 80.0 ≤ 8 8 17.8 16 1 2.2 ≥ 32 Cefepime 45 100.0 ≤ 8 0 – 16 0 – ≥ 32 Ceftazidime 45 100.0 ≤ 8 0 – 16 0 – ≥ 32 Ciprofloxacin 45 100.0 ≤ 1 0 – 2 0 – ≥ 4 Gentamicin 45 100.0 ≤ 4 0 – 8 0 – ≥ 16 Imipenem 44 97.8 ≤ 4 0 – 8 1 2.2 ≥ 16 Meropenem 44 97.8 ≤ 4 0 – 8 1 2.2 ≥ 16 Piperacillin 45 100.0 ≤ 64 0 – – 0 – ≥ 128 Ticarcillin/clavulanic acid 36 80.0 ≤ 64/< 2 0 – – 9 20.0 ≥ 128/≥ 2 Tobramycin 45 100.0 ≤ 4 0 – 8 0 ≥ 16 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 787 resistance to carbapenems [21], as was  the case with 2 of our isolates.  In  conclusion,  our  findings  re- vealed the prevalence of P. aeruginosa in recreational waters  in northern Greece  was  relatively  low and was  compliant  with established  local microbiological  standards. The  exception was  a  high  level of contamination in hydrotherapy  pools which might be attributed to lack  of hygiene practice of  the bathers and  lack of training of technical personnel. Goldberg JB. Pseudomonas: global bacteria. 1. Trends in Microbi- ology, 2000, 8:55–57. Kimata N et al. 2. Pseudomonas aeruginosa isolated from ma- rine environments in Tokyo bay. Microbial Ecology, 2004, 47:41–47. Hunter PR. The microbiology of bottled natural mineral waters. 3. Journal of Applied Bacteriology, 1993, 74:345–52. Craun GF, Calderon RL, Craun MF. Outbreaks associated with 4. recreational water in the United States. International Journal of Environmental Health Research, 2005, 15:243–262. Moore JE et al. Incidence of 5. Pseudomonas aeruginosa in rec- reational and hydrotherapy pools. Communicable Disease and Public Health, 2002, 5:23–26. Barben J, Hafen G, Schmid J. 6. Pseudomonas aeruginosa in public swimming pools and bathroom water of patients with cystic fibrosis. Journal of Cystic Fibrosis, 2005, 4:227–231. Arvanitidou M et al. Occurrence and antimicrobial resistance 7. of Gram-negative bacteria isolated in haemodialysis water and dialysate of renal units: results of a Greek multicentre study. Journal of Applied Microbiology, 2003, 95:180–185. Performance standards for antimicrobial susceptibility testing, 8. 14th informational supplement M100–S14. Wayne, Pennsylva- nia, National Committee for Clinical Laboratory Standards, 2004. Rigas F, Mavridou A, Zacharopoulos A. Water quality of swim-9. ming pools in Athens area. International Journal of Environmen- tal Health Research, 1998, 8:253–260. Tate D, Mawer S. Newton A. Outbreak of 10. Pseudomonas aeru- ginosa folliculitis associated with a swimming pool inflatable. Epidemiology and Infection, 2003, 130:187–192. Hajjartabar M. Poor-quality water in swimming pools as-11. sociated with a substantial risk of otitis externa due to Pseu- References domonas aeruginosa. Water Science and Technology, 2004, 50:63–67. Levin WC, Stephenson WT, Craun GF.12. Waterborne disease outbreaks 1986–88. Morbidity and Mortality Weekly Report, 1990, 39(SS-1):1–9. Tosti E, Volterra L. Water hygiene of two swimming pools: 13. microbial indicators. Journal of Applied Microbiology, 1988, 65:87–91. Greek hygienic14. regulation. Instructions for the construction and operation of swimming pools (G1/442). Athens, Greece, Depart- ment of Health, 1973. Filters for water treatment. DIN 1960515. . Berlin, Germany, Deut- sches Institut für Normung, 1975. Treatment and disinfection of swimming pool and bathing pool 16. water. DIN 1964. Berlin, Germany, Deutsches Institut für Nor- mung, 1984. Price TJ, Smith JM. Swimming pool waters: the new Blue 17. Book appreciated and discussed. Environmental Health, 1985, 93(2):31–35. Hancock RE. Resistance mechanisms in 18. Pseudomonas aerugi- nosa and other nonfermentative gram-negative bacteria. Clini- cal Infectious Diseases, 1998, 27(Suppl. 1):S93–99. Pirnay JP et al. 19. Pseudomonas aeruginosa displays an epidem- ic population structure. Environmental Microbiology, 2002, 4:898–911. Van Eldere J. Multicentre surveillance of 20. Pseudomonas aerugi- nosa susceptibility patterns in nosocomial infections. Journal of Antimicrobial Chemotherapy, 2003, 51:347–352. Mavroidi A et al. Carbapenem-hydrolysing VIM-2 metallo-21. β- lactamase in Pseudomonas aeruginosa from Greece. Journal of Antimicrobial Chemotherapy, 2000, 46:1041–1042. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 788 Analysis of prescriptions dispensed at community pharmacies in Nablus, Palestine A.F. Sawalha,1,2 W.M. Sweileh,2 S.H. Zyoud,1 S.W. Al-Jabi,2 F.F. Bni Shamseh 1 and A.A. Odah 1 ABSTRACT We investigated the prescription quality and prescribing trends of private clinicians in Nablus governorate, Palestine. A total of 363 prescriptions were collected from a random sample of 36 community pharmacies over a study period of 288 working hours. Data regarding elements in the prescription and the types of drugs prescribed were analysed. Physician-related variables were mostly noted, however, patient’s address and weight were absent in all prescriptions and less than half included age and sex. Information regarding strength of the medications prescribed was missing in over 70% of prescriptions. Other drug-related variables like frequency and instruction of use were present in over 80% of prescriptions. Antimicrobial agents were the most commonly prescribed followed by NSAIDs/analgesics. Amoxicillin alone or in combination was the most commonly prescribed antimicrobial agents followed by cefuroxime. Prescription writing quality in Nablus is deficient in certain aspects and improvement is required. 1Poison Control and Drug Information Centre; 2College of Pharmacy, An-Najah National University, Nablus, Palestine (Correspondence to A.F. Sawalha: ansam@najah.edu). Received: 09/12/08; accepted: 18/01/09 ينطسلف ،سلبان في ةيعمتمج تايلديص نم ف َ ْرصُت يتلا تافصولا ليلتح ةدوع نحمرلا دبع ،هسمش ينب يداف ،بيالجا حماس ،دويز دئاس ،حليوص ديلو ،ةلحاوص ماسنأ نم ةفصو 363 اوعمجف ،ينطسلف ،سلبان ةظفامح في صالخا عاطقلا في ءابطلأا ىدل ةيودلأا فصو تاهاتجاو ةدوج نوثحابلا سرد :ةـصلالخا تان ِّوكمب ةلصلا تاذ تايطعلما نوثحابلا للحو .لمع ةعاس 288 تقرغتسا يتلا ةساردلا ةرـتف نمض ،ةيعمتمج ةيلديص 36 نم ةيئاوشع ةنيع عيجم في ْنينَبئاغ اناك ضيرلما نزوو ناونع نأ لاإ ،ءابطلأاب قلعتت تدهوش يتلا تاظحلالما رثكأ تناكو .ةفوصولما ةيودلأا طمانأو ،تافصولا %70 لىع ديزي ام في ةدوقفم ةفوصولما ةيودلأا ةوق لوح تامولعلما تناكو .تافصولا فصن نم لقأ في ضيرلما سنج وأ رمع َرِكُذ مايف ،تافصولا %80 لىع ديزي ام في ةدوجوم تناكف ،لماعتسلاا لوح تمايلعتلاو ،لماعتسلاا راركت لثم ةيودلأاب ةلصلا تاذ ىرخلأا تامولعلما امأ .تافصولا نم .تانكسلماو ةيديئورـتيسلا يرغ باهتللال ةداضلما ةيودلأا اهولتت ،ًاعويش ةفوصولما ةيودلأا رثكأ تابوركملل ةداضلما ةيودلأا تناكو .تافصولا نم في تافصولا ةباتك ةدوج نإ ،ميسكوروفيسلا اهولتي ةفوصولما تابوركملل ةداضلما ةيودلأا رثكأ وه ةفيلوت نمض وأ هدحول ينليسيسكوملأا ناكو .اهنيستح يغبنيو ،بناولجا ضعب في روصقلا نم نياعت - سلبان Analyse des prescriptions délivrées dans des pharmacies communautaires de Naplouse (Palestine) RÉSUMÉ Nous avons étudié la qualité et les tendances de prescription de cliniciens privés du gouvernorat de Naplouse (Palestine). Au total, 363 ordonnances ont été collectées auprès d’un échantillon aléatoire de 36 pharmacies communautaires, au cours d’une période d’étude de 288 heures ouvrables. L’analyse a porté sur les informations relatives aux éléments figurant sur l’ordonnance et sur les types de médicaments prescrits. Les données concernant le médecin étaient indiquées dans la plupart des cas, mais moins de la moitié des ordonnances comportaient l’âge et le sexe du patient et aucune d’entre elles ne précisait son adresse ni son poids. Les informations relatives au dosage des médicaments prescrits manquaient sur 70 % des ordonnances. D’autres variables, notamment la fréquence et le mode de prise, figuraient sur plus de 80 % des ordonnances. Les médicaments les plus souvent prescrits étaient les agents antimicrobiens, suivis des médicaments anti- inflammatoires non stéroïdiens/analgésiques. Parmi les agents antimicrobiens, l’amoxicilline seule ou en association était la plus fréquemment prescrite, suivie du céfuroxime. La qualité de rédaction des prescriptions délivrées à Naplouse est défaillante sur certains points et une amélioration est nécessaire. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 789 Introduction Once a patient with a clinical problem  has been evaluated and a diagnosis has  been  reached,  the practitioner usually  selects a drug  therapy  regimen  from a  variety of  therapeutic approaches. This  requires the writing of a prescription— usually  for medication.  Prescription  writing is not merely putting a few drug  names on a piece of paper, rather it is an  art which can be attained only after years  of  experience,  hard work  and  sound  knowledge of the basic subject.  Although different countries might  have  slightly different  formats,  all pre- scriptions need to include the following  basic elements: name, address, specialty  and signature of the prescriber as well as  the name, sex, and age of the patient and  the strength, quantity, dose,  frequency,  dosage form and instructions for use of  the medication  [1–4]. Adherence by  the physician  to good quality prescrib- ing will minimize errors and ultimately  improve patient care. Prescribing errors  can occur as a result of errors in decision- making or the prescription-writing proc- ess. Unfortunately, incorrect prescribing  habits are not uncommon [5,6].  The  purpose  of  this  study was  to  screen  drug  prescriptions  dispensed  at  community pharmacies  in  the Na- blus  area  in Palestine  for  the essential  elements of  prescriptions mentioned  above, and to investigate the prescribing  trends of drugs dispensed at community  pharmacies. The results of this study may  be used by health officials  to optimize  drug prescribing practices and  improve  the patient’s pharmaceutical care. Methods All 150 community pharmacies  in Na- blus governorate were  stratified  into 6  subdistricts. A  random sample of 5 or  more pharmacies was selected from each  sub-district,  according  to  the number  of  pharmacies  in  the  sub-district  and  according to the willingness of the com- munity pharmacist  to participate  in  the  study. There were no refusals  to partici- pate, so the response rate was 100% and  a total of 36 pharmacies were surveyed. We collected prescriptions written  by private specialists, general practition- ers  and physicians  at private medical  centres.  Prescriptions were  collected  from the selected community pharma- cies on  the  same day. Collection was  carried  out  by  36  senior  pharmacy  students. Each  student was  randomly  assigned  to  a  community  pharmacy  and was asked  to collect all dispensed  prescriptions on  the  study day.  Infor- mation  present  on  the  prescription  was  transferred  to a  special  for  further  analysis. The prescriptions were carefully  analysed for physician, patient and drug  indicators using a checklist for the items  listed above. Types of drugs prescribed  were  analysed  to determine  the most  commonly prescribed drug classes. All  data  in prescriptions were  entered  in  the form by the first 3 authors and were  checked by  the  rest of  the authors. All  data were entered and analysed using  SPSS, version 16.0. Data were recorded  using a 0 or 1 coding system. For each  variable, a score of 1 was entered when  the variable was present and compliant  with the standard.  Physicians in the area did not know  about the study but the university ethics  committee and pharmaceutical bodies  gave approval. Results A  total of 367 prescriptions were  col- lected  during  a  study  period  of  288  work hours (36 pharmacies × 8 hrs). All  were private prescriptions. Only brand  names were used on  the prescriptions.  The number of drugs prescribed ranged  between 1 and 6, and 91.8% of prescrip- tions  included 3 or  fewer drugs. A total  of 752 medications were present  in the  367 prescriptions, with an average of 2.0  per prescription (Figure 1).  Number of drugs per prescription N um be r o f p re sc ri pt io ns 160 140 120 100 80 60 40 20 0 1 2 3 4 5+ Figure 1 Number of drug items present in the prescriptions dispensed at the community pharmacies EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 790 The majority of  the prescriptions  contained  the date of  the prescription,  address,  specialty and signature of  the  prescriber  and  name  of  the  patient  (Table 1). None of  the prescriptions  included  the weight or  address of  the  patient.  Drug-related  variables  were  also  analysed (Table 2). Strength of medica- tion was indicated for all drugs in 27.8%  of the prescriptions and for some drugs  in 23.7%. However,  in  about half  the  prescriptions,  the  strength of medica- tion was missing for all drugs. The total  quantity of a drug to be dispensed was  not  indicated  for any drug  in  just over  25% of prescriptions. The  instructions  for  taking  the medication were  com- plete  in  only  82.3%  of  prescriptions  (Table 2).  A  total  of  172  prescriptions  con- taining antimicrobial  agents were dis- pensed during  the observation period,  accounting for 46.9% of all prescriptions  (Table 3); 26 (7.1%) included > 1 agent.  Amoxicillin  alone  or  in  combination  (39.0%) was  the most commonly pre- scribed antibiotic,  followed by cefuro- xime  (9.9%)  (Table  4). There  were  147  (40%)  prescriptions  containing  non-steroidal  anti-inflammatory drugs (NSAIDs) and/or analgesics. Of  these,  12 (8.2%)  included > 2 NSAIDs. The  most common drug prescribed  in  this  category was diclofenac  sodium. Vita- min preparations accounted  for 11.2%  of all drugs dispensed (see Table 3  for  details). It was noted that 9 (2.5%) prescrip- tions were  for dipyrone, which  is not  approved for use in many countries.  Discussion This was the first study to investigate the  quality of prescription writing and  the  prescribing trends in community phar- macies  in Palestine. The  study clearly  showed that there are some deficiencies  in  the quality of prescription writing.  None of  the prescriptions  contained  the address of the patients and less than  half  included  the patients’  age or  sex.  These  elements  should  be  included  according  to World Health Organiza- tion  [1]. Other  studies  carried out  in  other developing countries have shown  similar,  less  than optimal prescription  quality. A study of outpatient prescrip- tions kept by the pharmacy department  at Asir Central Hospital in Saudi Arabia  showed that prescriptions were deficient  [7]. Another  Saudi Arabian  study of  prescriptions from 22 general hospitals  showed  that documentation was not  generally complete [8]. A study  in Su- dan also  found that  the quality of drug  prescribing among hospital doctors had  serious deficiencies in comparison with  studies done elsewhere [9].  One of  the problems encountered  in the analysis of prescriptions was that  physicians paid  little  attention  to  the  strength of prescribed drugs and to the  total quantity of  each drug  to be dis- pensed. Such deficiencies might create  confusion for the dispensing pharmacist  and given  the poor pharmacist–physi- cian communication  the patient might  receive the wrong strength or sub opti- mum quantities of  the drug. Moreover,  Table 1 Analysis of prescriber and patient information present on prescriptions (n = 367) Information present No. % Physician-related Address 525 88.6 Specialization 316 86.1 Signature 315 85.8 Date 298 81.2 Drug numbering 203 55.3 License number 0 0.0 Patient-related Name 335 91.3 Age 128 34.9 Sex 93 25.3 Weight 0 0.0 Address 0 0.0 Table 2 Analysis of variables related to drug present on prescriptions (n = 367) Variable Included for all drugs in prescription Included for some drugs in prescription Not included for any drug in prescription No. % No. % No. % Frequency 343 93.5 12 3.2 12 3.3 Quantity per dose 330 89.9 15 4.1 22 6.0 Dosage form 325 88.6 21 5.7 21 5.7 Instructions for use 302 82.3 21 5.7 44 12.0 Total quantity to be dispensed 225 61.3 40 10.9 102 27.8 Strength 108 27.8 81 23.7 178 48.5 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 791 a number of  the prescriptions had  inad- equate  information on  instruction  for  use, which might  lead  to poor  compli- ance. Only brand names of  the medica- tions were used in the prescriptions. This  might  impose dispensing problems  for  the pharmacists since not all community  pharmacies can afford  to store  the wide  variety of brand names of the same drug.  The  lack of  generic prescribing  in  this  study is different from prescription prac- tices in some other developing countries:  Uzbekistan 38%, Cambodia 99.8% and  India 46% [10–12]. There are no regula- tions on generic prescribing in Palestine.  Therefore, generic prescribing should be  actively promoted  to  facilitate  rational  and cost-effective prescribing practices. As  is  typical  in  developing  coun- tries,  anti-infective  agents,  analgesics  and vitamin  supplements  constituted  a high proportion of drugs dispensed,  whilst medications  for  cardiovascular  diseases  and mental  health problems  were less frequently dispensed [12–14].  A probable  reason  for over-prescribing  of  antibiotics  is,  as  reported  in  other  countries,  the high prevalence of  infec- tion  [11,12,15–18]. Over-prescribing  was evident particularly for children and  in cases where the infection was of likely  viral origin. Newer generation antibiotic  (coamoxiclav, azithromycin, and cipro- floxacin) use was relatively high, adding  to costs and potentially affecting  resist- ance patterns [19,20]. Given the current  high levels of unemployment (26%) and  poverty  (67%)  in Palestine, medicine  costs present a significant financial bur- den to patients [21,22]. Unfortunately,  no data on microbial  resistance  for  the  most  commonly prescribed  antibiot- ics  studied are available  in Palestine  to  facilitate  developing  evidence-based  antibiotic prescription guidelines. Analgesics and NSAIDs were com- monly prescribed but  less  than  that  in  neighbouring countries  such as Saudi  Arabia (51%) and the Islamic Republic  of Iran (63%) [16,23]. Analgesics such  as dipyrone continue  to be marketed  and prescribed.  In many parts of  the  world, dipyrone is considered a danger- ous drug and is banned. Serious adverse  effects, often  leading  to  fatalities, were  observed and confirmed over 60 years  ago  [24,25]. The Palestinian Ministry  of Health needs  to  revise  the  registra- tion status of dipyrone for analgesic use  based on  current  data.  Furthermore,  prescribers need to be aware of the toxic  effects of dipyrone.  This  study  is  limited  in  that  only  community pharmacies  in Nablus dis- trict were  included. Another  limitation  is  that  the prescription collection was  made  on  only  1  working  day  rather  than over a  long period. Despite  these  limitations,  there was evidence of  sub- optimal prescribing practices with over- prescribing of  certain drug categories,  particularly new generation antibiotics.  Table 3 Prescribing trends of various drug classes dispensed at community pharmacies Drug class No % Antimicrobials 172 46.9 NSAIDs/analgesics 147 40.0 Dermatological preparations 48 13.1 Vitamins 41 11.2 Gastrointestinal medications 37 10.0 Antihistamines 37 10.0 Mental drugs 26 7.0 Ophthalmics 26 7.0 Cough syrups 26 7.0 Bronchodilators 26 7.0 Corticosteroids 18 5.0 Others 37 10.1 Each prescription might contain several different drug classes and therefore the sum of percentages exceeds 100%. NSAID = non-steroidal anti-inflammatory drug. Table 4 Review of prescriptions containing antimicrobial agents (n = 172) Drug class No. % Fluoroquinolones Ciprofloxacin 11 6.4 Ofloxacin 4 2.3 Macrolides Azithromycin 16 5.9 Clarithromycin 7 4.1 Erythromycin 4 2.3 Amoxicillin Amoxicillin + clavulanic acid 31 18.0 Amoxicillin 29 16.9 Amoxicillin + cloxacillin 7 4.1 Cephalosporins Cefuroxime 17 9.9 Metronidazole 10 5.8 Cefadoxil 8 4.7 Cephalexin 5 2.8 Sulfamethoxazole + trimethoprim 3 1.7 Other 20 11.6 EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 792 De Vries TP et al., eds. 1. Guide to good prescribing: a practical manual. Geneva, World Health Organization, 1995:51–55 (WHO/DAP/94.11). Lofholm PW, Katzung BG. Rational prescribing and prescrip-2. tion writing. In: Katzung BG, ed. Basic and clinical pharmacol- ogy, 8th ed. New York, McGraw-Hill, 2001:1104–1112. Prescription writing. In: 3. British national formulary, No. 41. London, British Medical Association & Royal Pharmaceutical Society of Great Britain, 2000:4–5. Safe writing. In: Lacy CF et al., eds. 4. Drug information handbook, 9th ed. Cleveland, Ohio, Lexi-Comp, 2001:12. Blatt A, Chamban R, Lemardeley P. Forme lègale et coût des 5. prescriptions à l’Hôpital Central de Yaoundé, Cameroun [Le- gal format and costs of prescriptions at the Central Hospital in Yaounde, Cameroon]. Médecine Tropicale, 1997, 57(1):37–40. François P et al. Evaluation of prescription-writing quality in 6. a French university hospital. Clinical Performance and Quality Health Care, 1997, 5(3):111–115. Irshaid YM et al. Compliance with good practice in prescrip-7. tion writing at outpatient clinics in Saudi Arabia. Eastern Medi- terranean Health Journal, 2005, 11(5–6):922–928. Bawazir S. Prescribing pattern of ambulatory care physicians in 8. Saudi Arabia. Annals of Saudi Medicine, 1993, 13(2):172–177. Yousif E et al. Deficiencies in medical prescriptions in a 9. Sudanese hospital. Eastern Mediterranean Health Journal, 2006,12(6):915–918. Pavin M et al. Prescribing practices of rural primary healthcare 10. physicians in Uzbekistan. Tropical Medicine & International Health, 2003, 8(2):182–190. Chareonkul C, Khun VL, Boonshuyar C. Rational drug use in 11. Cambodia: study of three pilot health centers in Kampong Thom Province. Southeast Asian Journal of Tropical Medicine & Public Health, 2002, 33(2):418–424. Hazra A, Tripathi SK, Alam MS. Prescribing and dispens-12. ing activities at the health facilities of a non-governmen- tal organisation. National Medical Journal of India, 2000, 13(4):177–182. The world drug situation13. . Geneva, World Health Organization, 2004. Karande S, Sankhe P, Kulkarni M. Patterns of prescription and 14. drug dispensing. Indian Journal of Pediatrics, 2005, 72(2):117– 121. Otoom S et al. Evaluation of drug use in Jordan using WHO 15. prescribing indicators. Eastern Mediterranean Health Journal. 2002, 8(4–5): 537–543. Moghadamnia AA, Mirbolooki MR, Aghili MB. General 16. practitioner prescribing patterns in Babol city, Islamic Re- public of Iran. Eastern Mediterranean Health Journal, 2002, 8(4–5): 550–555. Nsimba SE, Massele AY, Makonomalonja J. Assessing pre-17. scribing practices in church-owned primary healthcare (PHC) institution in Tanzania: a pilot study. Tropical Doctor, 2004, 34(4):236–238. McCaig LF, Besser R, Hughes M. Trends in antimicrobial pre-18. scribing rates for children and adolescents. Journal of the Ameri- can Medical Association, 2002, 287(23):3096–3102. Stimac D, Vukusic I, Culig F. Outpatient use of systemic antibi-19. otic in Croatia. Pharmacy World and Science, 2005, 27(3):230– 235. Priest P et al. Antibiotic prescribing and antibacterial resistance 20. in English general practice: cross sectional study. British Medi- cal Journal, 2001, 323(7320):1037–1041. Palestine in numbers, 200421. . Ramallah, Palestine, Palestinian Central Bureau of Statistics, 2005:17. Palestine human development report, 200422. . Birzeit Palestine, Development Studies Programme, Birzeit University, 2005:61. Irshaid Y et al. A pharmacoepidemiological study of prescrip-23. tion pattern in outpatient clinics in South-Western Saudi Ara- bia. Saudi Medical Journal, 2004, 25(12):1864–1870. Hugueley CM. Agranulocytosis induced by dipyrone, a hazard-24. ous antipyretic and analgesic. Journal of the American Medical Association, 1964, 189(12):938–941. Simpson RG. Aminopyrine and agranulocytosis. 25. British Medical Journal, 1963, 1(5334):877. References طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 793 Evaluation of the level of micronutrients in fortified foods in Alexandria, Egypt S. Mohamed,1 M. El-Tawila,1 H. Ismail 1 and N.F. Gomaa 1 ABSTRACT Food fortification is an effective, low-cost way to eliminate dietary micronutrient deficiencies in developing countries. This study in Egypt aimed to evaluate the levels of and variations in fortification with iron, iodine and vitamin A in food products from different manufacturers. Almost all iodized salt samples contained iodine concentrations within Egyptian standards. The iron content of iron-fortified biscuits supplied to schools and of vitamin-A-fortified margarine, infant formula milk powder and infant cereal food were highly variable and many samples were not within Egyptian standards. Monitoring of fortification levels of key products is required at the factory, retail and household levels. 1Department of Nutrition, High Institute of Public Health, University of Alexandria, Alexandria, Egypt (Correspondence to N.F. Gomaa: naglafgomaa@yahoo.com). Received: 09/01/08; accepted: 07/05/08 صرم ،ةيردنكسلإا في ،ةمعطلأا ءانغإ دعب رادقلما ةديهزلا تايذغلما ىوتسم مييقت ةعجم ءلاجن ،ليعماسإ ءانه ،ةليوطلا دوممح ،دممح ءمايش تفدهو .ةيمانلا نادلبلا في رادقلما ةديهزلا تايذغلما زوع تلااح نم صلختلل ةلاعفلاو فيلاكتلا ةديهزلا لئاسولا نم ماعطلا ءانغإ دعي :ةـصلالخا ةعانصل ةفلتمخ تاكشر نم ةدمتسلما ماعطلا تاجتنم في أ ينماتيفلاو دويلاو ديدلحاب ءانغلإا في تاتوافتلاو تايوتسلما مييقت لىإ صرم في ةساردلا هذه ىنغلما توكسبلا ىوتمح امأ .ةيصرلما سيياقلما دودح في دويلا تازيكرـت لىع يوتتح ًابيرقت نَدويلما حللما تانيع عيجم نأ نوثحابلا دجوو .ماعطلا تاجتنلما ءانغإ تايوتسم ةبقارم يروضرلا نمو .ةيصرلما سيياقلما نمض نكي ملف أ ينماتيفب ىنغلما نيرغرلما ىوتمحو ،سرادملل مدقي يذلاو ،ديدلحاب .ةسرلأا ىوتسمو ةئزجتلا ىوتسمو عنصلما ىوتسم لىع ةيسيئرلا Évaluation du taux de micronutriments dans des aliments enrichis à Alexandrie (Égypte) RÉSUMÉ L’enrichissement des aliments est un moyen efficace et peu coûteux d’éliminer les carences alimentaires en micronutriments dans les pays en développement. L’objectif de cette étude, réalisée en Égypte, était d’évaluer les taux et les variations d’enrichissement en fer, en iode et en vitamine A dans des produits alimentaires issus de différents fabricants. Quasiment tous les échantillons de sel iodé contenaient des concentrations en iode respectant les normes égyptiennes. La teneur en fer des biscuits enrichis en fer fournis aux écoles et la teneur en vitamine A de la margarine enrichie, du lait pour nourrissons et des produits céréaliers pour nourrissons variaient considérablement et de nombreux échantillons ne respectaient pas les normes égyptiennes. Un contrôle des taux d’enrichissement des produits essentiels est nécessaire au niveau de l’usine, du commerce de détail et du ménage. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 794 Introduction Food  fortification has been defined as  “the addition of one or more essential  nutrients  to  a  food, whether or not  it  is normally  contained  in  the  food,  for  the purpose of preventing or correcting  a  demonstrated deficiency of  one or  more  nutrients  in  the  population  or  specific population groups”  [1]. Food  fortification  is  recognized as being  the  most  inexpensive  and  effective  way  to  eliminate  dietary  micronutrient  deficiencies.  It  is  socially  acceptable,  does not change  the characteristics of  the  food,  requires no changes  in  food  habits, has  readily visible benefits  and  can legally be enforced for a nationwide  action [2].  Deficiencies of  iron,  iodine and vi- tamin A  are worldwide public health  problems. At  the World  Summit  for  Children in 1990 goals were set for the  year 2000 that included the virtual elimi- nation of vitamin A and iodine deficien- cies and the reduction of iron deficiency  in women by one-third [3].  Interventions  to combat micronu- trient deficiencies in Egypt are targeted  at different  sectors of  the population  [4]. To combat anaemia  in pregnancy,  iron supplements are given to pregnant  women via primary health care  facili- ties. Schoolchildren are provided with  biscuits fortified with iron and zinc. Nu- trition education programmes aimed at  increasing  the consumption of dietary  iron and enhancing  its  absorption are  carried out.  In  addition, programmes  for  the eradication of parasitic  infesta- tions,  and pilot  studies  for  a national  nutritional surveillance programme are  under way. A flour  fortification project  has  been  discussed,  including  the  fortification  level,  quality  control  and  method of  fortification [5]. Steps have  been taken to start universal  iodization  of salt. Food fortification with vitamin A  holds considerable potential as a tool to  alleviate vitamin A deficiency. This study in Alexandria city, Egypt,  aimed to evaluate the levels of and vari- ations  in  fortification of  selected prod- ucts: iron-fortified biscuits produced for  school children;  iodized  table salt  sold  in local markets; and vitamin-A-fortified  margarine,  infant  formula milk powder  and infant cereal products sold locally. Methods Food samples A  total of 99 biscuit  samples  fortified  with  iron were analysed as  follows: 54  packets  of  biscuits  collected  from  6  primary-school  children  feeding pro- grammes in Alexandria city (36 samples  produced during March  and 18 pro- duced during April);  and 45 packets  of  biscuits  collected  from 5 different  manufacturers  (18  samples produced  during March  and 27 produced dur- ing April).  Samples were  collected  in  different months in order to detect vari- ations in the iron fortification levels in different production months. A  total  of  50  samples  of  iodized  salt were  selected  randomly  from  the  local markets  of  Alexandria  city:  10  samples  from batches  of  salt  from 5  different manufacturers, both local and  imported. Samples of  food products  fortified  with  vitamin  A  were  collected  from  the  local markets  of Alexandria  city:  18 samples of margarine with different  production dates (6 from each of 3 dif- ferent manufacturers); 24  samples of  infant  formula milk  powder  (6  from  each of 4 different manufacturers); and  12 samples of infant cereal food (6 from  2 different manufacturers).  Methods of analysis The biscuits were analysed for iron using  atomic absorption spectrophotometry  by  standard methods  [6,7]. Egyptian  standards for iron concentrations of for- tified flour  range  from 37.5–62.5 ppm  [standard no. 12018/2003].  Iodized salt was analysed for iodine  using  the  titration method  [8]. The  Egyptian standards  for  the  iodine con- tent of  iodized  salt  range  from 30–70  ppm [standard No.2371-1/2005]. The  vitamin  A  concentration  of  samples of  fortified margarine,  infant  milk formula and baby cereal food was  determined  using  spectrophotomet- ric methods  [9,10]. Percentage  losses  of vitamin A were calculated  from the  vitamin A content mentioned on  the  product label. Statistical analysis Statistical analysis was carried out using  SPSS,  version 11. The  statistical  tests  used were as  follow: cross-tabulations  and percentages, arithmetic mean and  standard  deviation  (SD),  analysis  of  variance  (ANOVA)  and  t-test. The  levels of  iron,  iodine and vitamin A  in  samples  were  compared  statistically  across different batches and  suppliers  and with Egyptian national standards. Results Iron-fortified samples Of the 45  iron  fortified biscuit packets  collected during March and April,  24  (53.3%) had iron concentrations lower  than Egyptian standards (< 37.5 ppm),  21  (46.7%) were within  the  range of  standards (37.5–62.5 ppm) and none  were higher than the standards (> 62.5  ppm) (Table 1). Of  the  sample of 54  iron-fortified  biscuits  distributed  to  children in schools, 12 (22.2%) had an  iron  concentration  lower  than Egyp- tian standards, 27 (50.0%) were within  standards and 15 (27.8%) were higher  than standards.  The mean  iron  concentration  of  samples  ranged  from 9.24 (SD 0.76)  ppm (company K) to 58.35 (SD 5.15)  ppm  (company D). The mean  iron  levels were significantly  lower  than  the  midpoint of  the  standard  for  samples  from all the companies (P < 0.01) except  for company K (insignificantly  lower)  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 795 and company D (significantly higher)  in April (Table 2). There were substan- tial variations across samples at schools,  ranging  from  10.55  (SD  0.20)  ppm  (at school S)  to 83.62 (SD 25.7) ppm  (at  school R). The mean  iron  levels  in  samples at all schools were significantly  lower  that  the  standard  at  2  schools  (P < 0.01) and significantly higher at 3  schools (P < 0.01). There were  also  significant  varia- tions  in  mean  iron  concentrations  Table 1 Distribution of iron-fortified biscuit samples with iron levels lower than, within and higher than Egyptian standards collected from different companies and schools Source/collection month Iron concentration < 37.5 ppm 37.5–62.5 ppma > 62.5 ppm No. % No. % No. % Companies March (n = 18) 15 83.3 3 16.7 0 0.0 April (n = 27) 9 33.3 18 66.7 0 0.0 Total 24 53.3 21 46.7 0 0.0 School March (n = 36) 12 33.3 12 33.3 12 33.3 April (n = 18) 0 0.0 15 83.3 3 16.7 Total 12 22.2 27 50.0 15 27.8 aThis is the Egyptian standards range. Table 2 Mean iron concentration of iron-fortified biscuit samples collected from different companies and schools during March and April Source/collection month Iron concentration (ppm) F-valuea t-valueb Package 1 Package 2 Package 3 Total Mean (SD) Mean (SD) Mean (SD) Mean (SD) Companies March Company D (n = 9) 17.74 (6.32) 35.50 (1.37) 37.49 (7.74) 30.30 (10.90) 18.60** –5.79** Company K (n = 9) 9.24 (0.76) 30.03 (17.60) 29.78 (4.48) 22.14 (11.90) 32.53** –7.11** Total (n = 18) 13.49 (6.01) 32.77 (3.87) 33.64 (5.76) 26.22 (11.40) April Company S (n = 9) 32.81 (4.07) 22.97 (2.58) 18.22 (4.03) 24.66 (7.44) 12.64* –11.02** Company D (n = 9) 53.99 (6.22) 58.35 (5.15) 58.33 (6.87) 56.70 (2.51) 0.5 3.51** Company K (n = 9) 46.25 (7.02) 52.31 (6.25) 47.14 (3.67) 48.57 (3.28) 0.95 –0.74 Total (n = 27) 44.35 (10.72) 44.54 (18.93) 41.23 (16.66) 43.31 (1.93) – –3.969 Schools March School S (n = 9) 10.55 (0.20) 42.35 (4.93) 28.86 (5.80) 27.30 (16.00) 39.16** –4.76** School C (n = 9) 27.37 (1.58) 39.34 (7.36) 28.32 (3.880 31.67 (6.60) 5.56* –7.70** School R (n = 9) 57.52 (2.09) 69.66 (3.39) 83.62 (25.7) 70.27 (13.10) 2.28 3.53** School M (n = 9) 64.51 (2.53) 70.50 (9.88) 58.54 (7.71) 64.52 (5.98) 1.96 5.30** Total (n = 36) 39.99 (25.40) 55.46 (19.93) 48.44 (22.02) 48.44 (22.02) – – April School D (n = 9) 48.96 (4.22) 47.91 (0.59) 55.21 (8.53) 50.59 (3.95) 1.54 0.35 School R (n = 9) 70.23 (1.58) 64.58 (7.10) 66.10 (3.48) 66.96 (2.92) 1.19 6.76** Total (n = 18) 59.60 (15.04) 56.25 (11.78) 60.66 (7.70) 58.78 (11.58) – –1.59 aComparing iron concentration among the 3 biscuit packages. bComparing iron concentrations with midpoint of Egyptian standards (50 ppm, range 37.5–62.5 ppm). **P < 0.01 SD = standard deviation. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 796 across batches within  each company.  This  variation was  highly  significant  for  companies  D  and  K  in  March (P <  0.01)  and  company  S  in  April (P < 0.05). Variations  across batches  were statistically significant at  school S  (P < 0.01) and school C (P < 0.05). Iodine-fortified samples Table 3 showed that all salt samples that  were collected  from companies EL, C  and M had iodine concentration within  Egyptian standards (30–70 ppm) dur- ing the year 2004 and 2005, whereas 2  out of 10 salt samples (from companies  E  and S) had below-standard  iodine  concentrations. No samples were higher  than the standard (> 70 ppm).  The mean  iodine concentration of  samples was highest from company C, a  local company [57.54 (SD 4.90) ppm],  followed by company M (an imported  product)  [46.12 (SD 4.70) ppm] and  company EL (local)  [43.61 (SD 9.20  ppm]. The  lowest mean  iodine  con- centration was  from  company  S  salt  (imported)  [32.68  (SD  2.40)  ppm]  (Table 4). Only company C produced  salt with an iodine concentration signifi- cantly higher than the average Egyptian  standard 50 ppm (P < 0.01). The other  companies had  iodine concentrations  lower than the standard, significantly so  for companies E and S (P < 0.01). How- ever,  for  all  the companies  there were  no significant differences  in  the  iodine  levels  comparing  batches  produced  in 2004 and 2005,  suggesting  that  the  companies had uniform procedures for  adding potassium iodate to salt. Vitamin A- fortified samples Margarine  samples  produced  by  the  3  companies  studied  contained  low  concentrations of vitamin A and varied  greatly between  the different brands,  from a mean of 2.88 (SD 2.54) IU/10g  Table 3 Distribution of iodized salt samples with iodine levels lower than, within and higher than Egyptian standards collected from different companies by production year Company Iodine concentration Production date 2004 Production date 2005 Total < 30 ppm 30–70 ppma > 70 ppm < 30 ppm 30–70 ppma > 70 ppm < 30 ppm 30–70 ppma > 70 ppm No. No. No. No. No. No. No. No. No. Locally produced Company El (n = 10) 0 5 0 0 5 0 0 10 0 Company C (n = 10) 0 5 0 0 5 0 0 10 0 Company E (n = 10) 1 4 0 1 4 0 2 8 0 Total 1 14 0 1 14 0 2 28 0 Imported Company S (n = 10) 0 5 0 2 3 0 2 8 0 Company M (n = 10) 0 5 0 0 5 0 0 10 0 Total 0 10 0 2 8 0 2 18 0 aEgyptian standards range: 30–70 ppm. Table 4 Mean iodine concentration of iodized salt samples produced by different companies Company Iodine concentration (ppm) t1-value a t-valueb Production date 2004 Production date 2005 Total Mean (SD) Mean (SD) Mean (SD) Locally produced Company EL (n = 10) 47.98 (10.81) 39.22 (5.23) 43.61 (9.2) 1.63 –2.18 Company C (n = 10) 58.32 (5.18) 57.28 (4.88) 57.54 (4.90) 0.08 4.8** Company E (n = 10) 35.76 (3.64) 31.03 (8.45) 33.49 (6.60) 0.51 –7.86** Imported Company S (n = 10) 34.22 (1.64) 31.33 (2.38) 32.68 (2.40) 1.16 –22.35** Company M (n = 10) 48.61 (3.90) 43.62 (4.58) 46.12 (4.70) 1.12 1.59 aComparing iodine concentrations between samples produced during 2004 and 2005. bComparing iodine concentrations with midpoint of Egyptian standards (50 ppm, range 30–70 ppm). **P < 0.01. SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 797 for  company G  to 60.99  (SD 27.38)  IU/10g  for  company R. The highest  percentage  loss of  vitamin A  in mar- garine was  in  samples  from company  G  (99.5%)  followed  by  company  E  (68.2%) and the  lowest  in company R  (39.0%). These  levels were highly  sig- nificantly lower than the concentrations  mentioned on  the  label  for companies  G and E (P < 0.01) (Table 5).  Similarly,   infant  powder  milk  produced  by  4  different  companies  contained  vitamin A  concentrations  lower  than  the  concentration on  the  label, although this difference was only  significant  for  company L  (P  < 0.05)  (Table 5). Mean measured concentra- tions ranged from 486.96 (SD 173.97)  IU/10 g  for  company B1  to 1067.02  (SD 722.9)  IU/10 g  for company B2.  The highest  loss  of  vitamin A was  in  samples from company B1 (71.3%) and  the lowest from company B2 (40.7%).  In  the  case  of  infant  cereal  food  the mean measured concentrations of  vitamin A were  446.41  (SD 271.34)  IU/10 g  from company R and 341.70  (SD 88.90) IU/10 g from company C,  but considerably  less  than  the  labelled  concentration (2500 and 1032 IU/10  g respectively) (Table 5). The percent- age  loss of vitamin A was 82.1%  in  the  samples  from company R and 66.9%  from company C. This difference was  significant for company R (P < 0.01). Discussion Food  fortification, when  imposed on  existing  food patterns, does not neces- sitate  changes  in  the  customary  diet  of  the population and does not call  for  individual compliance.  It  can often be  dovetailed  into existing  food produc- tion and distribution systems. For these  reasons,  fortification  can  be  imple- mented and yield  results quickly  and  be sustained over a long period of time.  It  can  thus be  the most  cost-effective  means  of  overcoming  micronutri- ent malnutrition  [11].  In developing  countries, the focus of the international  community  has  been  on  the  3 most  prevalent deficiencies: vitamin A, iodine  and iron [12].  Iron-fortified biscuits The addition of iron to wheat flour is a  common practice  in many developed  countries [12]. In a national programme  for fortified complementary food it was  associated with  higher  haemoglobin  levels and lower prevalence of anaemia  in children [11]. Various  forms of  iron  are used  in  fortification [13], although  no  significant  difference  has  been  demonstrated between flour enriched  with  ferrous  sulfate  and  that  enriched  with elemental iron [12]. The Egyptian  standards  for  iron-fortified biscuits  set  a  level of  ferrous  sulfate  ranging  from  37.5–62.5 ppm to be added to fortified  flour.  In our  study,  among  the  iron-for- tified  biscuit  samples  collected  from  different manufacturers, 53.3% had iron  concentrations  lower  than  Egyptian  standards  (< 37.5 ppm). Of  the  iron- fortified biscuit  samples distributed  to  children  in  schools, 22.2% were  found  to have iron concentrations lower than  standards. A mean  iron concentration  as  low as 10.55 ppm was detected  in  biscuit  samples at 1 school, which was  highly significantly lower than the mid- point  of  the  Egyptian  standards  (50  ppm). Also a mean  iron concentration  as high as 83.62 ppm was detected  in  some biscuit samples of another school  Table 5 Percentage loss of vitamin A in samples of fortified margarine, infant powder milk and infant cereal food produced by different companies Product/ company Production dates (range) Storage time before analysis (range in months) Vitamin A concentration (IU/10 g) t-valuea Actual Product label % loss Mean (SD) Margarine Company R (n = 6) 11/2005–02/2006 3–18 60.99 (27.38) 100.0 39.1 –2.46 Company G (n = 6) 02/2005–07/2005 13–15 2.88 (2.54) 570.0 99.5 –129** Company E (n = 6) 09/2005–12/2005 5–8 9.55 (2.29) 30.0 68.2 –21.77** Infant formula milk Company B1 (n = 6) 12/2004–8/2005 9–17 486.96 (173.97) 1698.3 71.3 0.23 Company B2 (n = 6) 09/2004–3/2005 16–20 1067.02 (722.9) 1800.0 40.7 1.43 Company S (n = 6) 03/2005 17 687.94 (371.0) 1400.0 50.9 –2.71 Company L (n = 6) 03/2005–04/2005 11–17 914.27 (243.5) 1800.0 49.2 –6.29* Infant cereal food Company R (n = 6) 05/2005–10/2005 7–12 446.41 (271.34) 2500.0 82.1 –13.11** Company C (n = 6) 03/2005–10/2005 7–12 341.70 (88.90) 1032.3 66.9 0.62 aComparing vitamin A in samples with vitamin A concentration on label. *P < 0.05; **P < 0.01. SD = standard deviation. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 798 and  this was  significantly higher  than  the standards. Minerals  are  more  resistant  to  manufacturing processes than vitamins.  However,  they  do  undergo  changes  when  exposed  to  heat,  air  or  light.  Minerals  such  as  iron  are  affected by  moisture and may react with other food  components such as proteins and carbo- hydrate. Iron and other minerals may be  also lost through leaching into cooking  and processing water [13]. When added  to bakery flour,  levels higher  than 40  ppm or storage for more than 3 months  under high  temperature and humidity  have been found to cause rancidity and  taste deterioration [13]. Large variations in iron content be- tween different batches of biscuits were  also  found  in  our  study, which were  significant for 3 of the 4 companies and  at 2 of the 6 schools. This suggests that  the  amounts of  ferrous  sulfate  added  to flour were not  consistent  in  all  the  producing  companies.  Ensuring  the  adequacy and quality of  fortified  food  products from production to consump- tion is a critical component of any food  fortification programme;  it  should be  a primary concern of the food industry  to validate the consistency of the manu- facturing process to achieve a uniformly  fortified product  for distribution  that  has all  the  intended characteristics and  qualities. The availability of trained staff  to carry out  the procedures  is of great  importance  for  a  successful outcome  [14].  Iodized salts The most successful global fortification  experience is the fortification of salt with  iodine. A number of countries have suc- cessfully iodized their salt supplies, thus  reducing  the rates of goitre and cretin- ism, preventing mental retardation and  subclinical  iodine deficiency disorders,  and contributing to improving national  productivity [15]. Once established in a  country,  salt  iodization  is a permanent  and long-term solution to the problem  of iodine deficiency. Toxicity issues are  negligible and cost considerations fairly  small, amounting to only 1 to 3 US cents  per person per year [11]. Potassium  iodate  is  preferred  to  potassium iodide for salt iodization as it  is resistant to oxidation and does not re- quire the addition of stabilizers [14]. In  Egypt  salt  is  fortified by adding 30–70  ppm potassium  iodate.  In  the present  study salt samples from 3 of the 5 com- panies studied (2 local, 1 imported) had  iodine concentrations within Egyptian  standards  (30–70  ppm).  In  2  other  companies  (1  local, 1  imported)  salts  batches had iodine concentrations < 30  ppm. The mean  iodine concentration  was highest  in  a  local  company (57.5  ppm), and lowest in an imported brand  (32.7 ppm). Only 1  (local)  company  produced  salt with  an  average  iodine  concentration significantly higher  than  the standard, at 57.5 ppm.  The stability of iodine in salt depends  on the water content, acidity and purity  of the salt to which it is added. In order  to  reduce  iodine  losses during storage,  the  iodized salt must be as pure and as  dry as possible, and it must be appropri- ately packaged [16].  In our study no significant variations  were detected between different batches  of salt produced during 2004 and 2005,  suggesting  that all  the companies were  consistent in the amounts of potassium  iodate used for fortification of salt.  Although  considerable  progress  has been made in control programmes  of  salt  iodization  in  several  countries  including Egypt, producer compliance,  quality assurance, logistic problems and  supply bottlenecks  remain. The chal- lenge  is  to  systematically  identify  and  tackle  these constraints  through effec- tive advocacy,  social communications,  monitoring of salt  iodine  levels,  regula- tion and enforcement [11]. Vitamin A-fortified products Food fortification with vitamin A holds  considerable potential as a tool to allevi- ate vitamin A deficiency by bridging the  gap between dietary  intake of vitamin  A and requirements [14]. Pure vitamin  A and carotenoid  structures  are  fairly  stable when heated  to a modest  tem- perature  in an  inert atmosphere and in  the dark, but are unstable  in  the pres- ence of oxygen or air or when exposed  to ultraviolet light. The food fortification  industry has developed vitamin A and  carotenoid structures with addition of  antioxidants as stabilizing agents [17]. In the present study margarine sam- ples produced by  the 3 different com- panies contained low concentrations of  vitamin A,  significantly  lower  than  the  concentrations on the label in margarine  from 2 of  the 3 companies. The loss of  vitamin A ranged from 39.0% to 99.3%.  These percentages were extremely high  and  were  not  related  to  the  time  of  storage before  analysis.  For  example,  margarine  samples  from 1  company  stored  for 3 months at  room tempera- ture had a percentage loss of 32.4% and  69.1%, which was  higher  than  those  stored  for 18 months  (15.6%). These  results  contradict  data  showing  that  storage of vitamin-A-fortified margarine  for 6 months at 20–25 ºC results in only  minimal  losses  [18]. Losses occurring  during heating or overstorage would be  due  to oxidation of  the oily vitamins, a  process  that would cause  rancidity of  the fats at the same time [14].  Infant  powder milk  produced  by  the  4  different  companies  contained  vitamin A  concentrations  lower  than  the concentration on the label, although  the differences were not significant  for  any of  the  companies  except  for one.  Vitamin A concentrations ranged from  486.96  IU/10g  to  1067.02  IU/10g  across  products  from different  com- panies. Compared with  the  labelling,  vitamin A was found to be lost in infant  milk  powder  samples  at  percentages  ranging from 49.2%–11.3%. These per- centages were high but were parallel  to  the  time of  storage before analysis,  especially  for 1 company. This was not  the case, however, for samples from the  other 3 companies.  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 799 These results may be interpreted by  the  improper packaging and handling  of the products, which in Egypt may be  transported over  long distances under  hot  and humid conditions  leading  to  micronutrient  losses [19]. Micronutri- ent  losses  can be  reduced by  adding  appropriate plastic coating to packages.  Because of high costs  and  the  lack of  availability of packaging material  in de- veloping countries, packaging assumes  great importance and should be a major  factor to consider at the beginning of a  fortification programme [13].  Similarly, infant baby food produced  by both of the 2 companies investigated  had vitamin A concentrations  signifi- cantly  lower  than  the  label. Again  the  percentage  loss of  vitamin A  in baby  food samples was very high in both cas- es (82.1% and 66.9%) and did not seem  to be  related  to  the  length of  storage.  Studies showed that losses of vitamin A  from fortified cereals can be as high as  40% depending on ambient conditions  and storage times [20–22]. Other stud- ies mentioned  that between 30% and  50% of vitamin A  that  is  added  to  the  blended cereals  is  lost  in  shipping and  storage [23–25]. Packaging may again  have an effect. This can be overcome by  adding  the appropriate plastic coating  and/or an appropriate overage of  the  most  sensitive micronutrients,  such as  vitamin A. For  all  these  vitamin-A-fortified  products,  the  amount  of  vitamin  A  mentioned on the label may be not the  one  added  to  the products. Thus  an- other  interpretation of  the  results may  be inadequate fortification levels during  manufacture,  especially  in  the case of  powdered milk, where  the  fortification  can be been achieved  in different ways  (by the addition of dry vitamin prepara- tions to the milk powder or by vitamin  addition to the liquid milk just prior to  spray drying).  It  is  known  that  vitamin A breaks  down at  a predicted percentage  rang- ing  from 10%  to 15% after 6 months  of  storage  at  20  ºC  and 75%  relative  humidity [13]. Moreover, the choice of  the  food-processing operation greatly  affects  vitamin  losses;  roller  drying,  for  example,  causes  vitamin A  losses  of 26.2% (process  loss) and 39.2% (at  6 months  of  storage)  and  60.6%  (at  12 months of  storage).  Proper  food- processing operations should be used to  minimize  the deterioration of vitamins  caused by oxidation during drying. Nu- trients may be added after drying. This  process is relatively simple and efficient,  but  requires  extra mixing  equipment  which may not be available in develop- ing countries [18].  To compensate  for micronutrient  losses  an  appropriate  overage  of  the  most  sensitive micronutrients  can be  added  [12]. The overage will  vary  ac- cording  to  the  inherent  stability of  the  nutrients,  the conditions under which  the food is prepared and packaged, and  the  anticipated  shelf  life of  the prod- uct. Thus,  the more  labile or unstable  nutrients, such as vitamin A, generally re- quire high overages. An overage of 25%  is needed for milk-based fortified drink  powder with a  shelf  life of 12 months.  This means that if the declared amount  of  vitamin A  is,  for example, 20 mg/g  of product,  then  the  input  level or  the  amount of nutrient  in  the  formulation  should be 25 mg/g of product [13].  Food  fortification aims  to provide  meaningful levels of the nutrient, usually  30% to 50% of  the daily adult  require- ments, at normal levels of consumption  of the food. The levels also need to take  into  account  variations  in  food  con- sumption so  that  the safety of  those at  the higher and of  the scale and  impact  on  those at  the  lower end are ensured.  They  should  also  consider  prorated  intakes  by  young  children  to  ensure  efficacious and safe dosages [11].  Recommendations Based on  the  results  of  our  study we  recommend monitoring of  fortification  levels of key products at the factory, retail  and household  levels  to provide more  rapid  feedback about  the adequacy of  fortificant  levels.  It  is also  important  to  ensure that food is packaged and stored  appropriately as  these  influence micro- nutrient losses. An overage of fortificants  (especially of  the most sensitive micro- nutrients,  such  as  vitamin A) may be  required to compensate for losses during  processing, distribution and storage.  General principles for the addition of essential nutrients to foods 1. 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In: 22. Opportunities for micronutrient in- terventions. Arlington, Virginia, John Snow International, 1997. Atwood SJ et al. Stability of vitamin A in fortified vegetable 23. oil and corn soy blend used in child feeding programs in India. Journal of Food Composition and Analysis, 1995, 8:32–44. Fortification of wheat flour with vitamin A: an update. In: 24. Op- portunities for micronutrient interventions (OMNI). Washington DC, United States Agency for International Development, 1998. Final report of the Micronutrient Assessment Project25. . Washing- ton, DC, Sharing United States Technology to Aid in the Im- provement of Nutrition, 1999. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 801 Dental visit patterns and periodontal treatment needs among Saudi students J.M.A. Farsi1 ABSTRACT The aim of this study was to report on dental visit patterns and their association with periodontal health among young Saudi Arabian students. A representative sample of 3090 students was randomly selected. The students’ dental visit patterns were assessed with a questionnaire. Clinical examinations were carried out using the community periodontal index of treatment needs. Age, sex and education level were significantly associated with the periodontal health. The prevalence of periodontal disease was significantly lower among subjects who were taught the right way to brush their teeth by the dentist. The highest occurrence of healthy periodontium (23.9%) and the lowest need for complex treatment (0%) were found among students who had annual reminders for check-ups (only 2.8% of the students). 1Department of Oral Basic and Clinical Sciences, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia (Correspondence to J.M.A. Farsi: Jamila_Farsi @yahoo.com). Received: 20/11/08; accepted: 04/01/09 ينـِّيدوعسلا بلاطلا ىدل نانسلأا معاود ةلجاعلم تاجايتحلااو نانسلأا ءابطلأ تارايزلا طمانأ سيراف ليع دممح ةليجم ةكلملما في بابشلا بلاطلا ىدل نانسلأا معاود ةحصب اهطابتراو ،نانسلأا ءابطلأ تارايزلا طمانأ فيصوت لىإ ةساردلا هذه تفده :ةـصلالخا مادختساب نانسلأا ءابطلأ بلاطلا ةرايز طمانأ ةثحابلا تمَّيقو .ًابلاط 3090 مضت ًايئاوشع تيرتخا ةلِّثمم ةنّيع ةساردلا تلمش دقو .ةيدوعسلا ةيبرعلا نأ ةثحابلا تظحلاو .ةلجاعلما نم تاجايتحلاا لىع ف ُّرعتلل يعمتجلما نانسلأا معاود بَسْنَم مادختساب ةيريسرلا تاصوحفلا تَيرجأو .نايبتسا ُّدَتْعُي ةجردب لقأ نانسلأا معاود ضرم راشتنا ل َّدعم ناكو .نانسلأا معاود ةحصب ًايئاصحإ ابه ُّدَتْعُي ةجردب طبترت يميلعتلا ىوتسلماو سنلجاو رمعلا نانسلأا معاودل ل َّدعم لىعأ نأ ةثحابلا تدجو دقو .ةاشرفلا مادختسلا ةحيحصلا قرطلا مهميلعت لىع نانسلأا ءابطأ فشرأ نيذلا ينب ًايئاصحإ ابه مهو( ينيتور ينس صحف ءارجإب يونس يركذت ميهدل نيذلا بلاطلا ىدل تناك )%0( ةد َّقعلما ةلجاعملل جايتحا لقأو ،)%23.9( يه ةحصلاب ةعتمتلما .)بلاطلا نم طقف %2.8 Habitudes de consultation dentaire et besoins en traitements parodontaux chez des étudiants saoudiens RÉSUMÉ L’objectif de cette étude était de décrire les habitudes de jeunes étudiants saoudiens en matière de consultations dentaires et leur association avec la santé parodontale. Un échantillon représentatif de 3 090 étudiants a été sélectionné de manière aléatoire. Leurs habitudes de consultation dentaire ont été évaluées au moyen d’un questionnaire. Des examens cliniques ont été réalisés à l’aide de l’indice des besoins de la collectivité en matière de traitement des parodontopathies. L’âge, le sexe et le niveau d’instruction étaient associés de manière significative avec la santé parodontale. La prévalence des parodontopathies était sensiblement plus basse chez les sujets à qui leur dentiste avait appris à se brosser correctement les dents. La fréquence la plus élevée de ligaments alvéolo-dentaires sains (23,9 %) et le besoin de traitement complexe le plus faible (0 %) ont été relevés chez les étudiants qui recevaient des rappels annuels au sujet de leur bilan périodique (2,8 % des étudiants seulement). EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 802 Introduction Personal  oral  hygiene  routines  are  important  at  an  individual  level  to  maintain oral health. Equally important  are regular dental visits, as they provide  professional diagnostic and prophylac- tic services that are essential to prevent  periodontal disease [1,2]. The percent- age of individuals who report having vis- ited the dentist the preceding year varies  between  studies  in different countries  [1,3–5]. As  for gender,  literature  from  several  countries  reported differences  in oral health behaviour between males  and  females.  In  some  studies,  females  visited dentists  and used oral hygiene  tools more frequently than males [4–8],  whereas other studies did not find such  a gender difference [3,9]. Various stud- ies showed an association between the  utilization of dental  services  and oral  health [1,10,11]. This research is part of a larger study  of the epidemiology of periodontal dis- ease among  the young Saudi Arabian  population. The aims of this study were  to assess  the association between peri- odontal health  status  and dental  visit  patterns, and to identify the reasons for  visiting or not visiting the dentist among  students aged 11–24 years in Jeddah. Methods Study design and sample This was  a  cross-sectional  study con- ducted in Jeddah, the second largest city  in Saudi Arabia and  the  largest city  in  Western province. The  target popula- tion was middle-school,  high-school  and university  students,  aged  11–24  years old and resident in Jeddah city. Prior to the study, a pilot study was  carried out on a sample of 50 students to  determine  the sample size and  test  the  questionnaire. Sampling was performed  to  select  a  population  representative  of young adults  in the city and provide  sufficient power to detect differences in  periodontal disease where  it existed. A  sample size of 3100 Saudi Arabian stu- dents was selected based on the Leme- show formula [12]. A  complete  list  of middle  schools  and high schools was obtained from the  Ministry  of  Education.  Schools  were  stratified  according  to  sex  (male  and  female),  source of  funding (private and  public)  and  6  geographic  locations.  Schools were  then  selected  randomly  from each stratum by proportional allo- cation; 21 middle schools (15 public and  6 private) and 14 high schools (10 public  and 4 private) were included, out of a to- tal of 260 middle and 210 high schools.  Students  from 8 colleges (4  female and  4 male) were  selected,  also  using  the  proportional allocation technique. Questionnaire The questionnaire  used  in  the  study  included questions about demographic  factors,  dental  visits,  the  reasons  for  visiting or not visiting  the dentist  and  some signs of oral health conditions that  might be noticed by the subjects.  The response  rate was 97.5%, as  the  questionnaire was distributed  to 3200  subjects and returned by 3122. Question- naires were administered and collected in  class by one of the dentists. The anonym- ity of participants was emphasized. Clinical examination Examinations  were  conducted  in  classrooms  by  calibrated  dentists.  A  lightweight portable examination  light  was used, and subjects were positioned  so as to receive maximum illumination.  Plane  mouth  mirrors  and  standard  probes were used  to  conduct  the  ex- aminations. Teeth were examined using  the  community periodontal  index of  treatment needs (CPITN) procedure  of  the  World  Health  Organization  (WHO)  [13]. Teeth were  examined  in  the  following sequence: upper  right  sextant, upper  anterior  sextant, upper  left posterior sextant, lower left posterior  sextant, lower anterior sextant and lower  right posterior  sextant. For each of  the  6  sextants examined, a code  from 0  to  4 was given according  to  the  following  clinical criteria: (0) healthy gingiva; (1)  bleeding observed directly or by using  mouth mirror; (2) calculus  felt during  probing, but black  areas of  the probe  were visible (3.5–5.5 mm from ball tip);  (3) a pocket of 4 or 5 mm, the gingival  margin was situated on the black area of  the probe (3.5–5.5 mm form the probe  tip); and (4) a pocket of > 6 mm, black  area of  the probe not visible. Based on  the clinical findings,  each  subject was  categorized into 1 of 4 treatment groups  on  the basis of  the most  severe condi- tion  found. The 4  treatment categories  were as follows: no treatment (code 0);  improved oral hygiene  (code 1);  im- proved oral hygiene and scaling (codes  2 & 3); and improved oral hygiene and  complex treatment (code 4). Prior  to  the  study, 6 dentists were  trained  at King Abdulaziz University  dental  clinics,  and  the kappa  statistics  among  the examiners  for  the CPITN  were  calculated.  Examinations  for  CPITN  among  50  students  gave  an  inter-examiner kappa value of 0.65 and  an intra-examiner kappa value of 0.72.  A total of 3090 students were exam- ined according to the above methods. Statistical analysis Data were processed and analysed using  the statistical package SPSS, versions 13  and 16. Descriptive statistics,  including  frequency and percentages, were used.  Two-sided likelihood ratio chi-squared  tests  were  used  to  test  associations  between  the dependent  variable  and  the  independent variables. The  level of  significant was set at 0.05. Results Description of the study population The  study  sample  consisted  of  3090  students aged 11–24 years, 1281 aged  11–15, 1091 aged 16–19 years and 670  aged 20–24 years. Of these, 56.8% were  females and 43.2% were males. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 803 Periodontal status The association between CPITN and  students’  age,  education  level  and  sex  is  shown  in Table 1. Age,  sex and  education  level were  significantly  as- sociated with periodontal health status  (P  <  0.001). Approximately  20% of  the 11–15 year age group and 10% of  the 20–24 year age group had healthy  periodontium. Over  half  the males  (58.0%)  and  females  (53.9%)  had  calculus. The prevalence of periodontal dis- ease  increased significantly with age  in  both sexes (P < 0.001). Dental visits and CPITN Table 2 shows the relationship between  the periodontal health of students and  dental  visits. Of  the  students  22.6%  had never visited the dentist and 61.8%  of  them needed  scaling;  in  contrast,  among  the majority of  students who  had  ever  visited  the  dentist,  54.3%  needed  scaling.  Among  participants  who reported that they had not visited  the dentist within  the past year, 59.0%  needed scaling. The prevalence of periodontal dis- ease was significantly  lower among the  subjects who  reported  that  they had  been taught the right way to brush their  teeth by the dentist (18.0% had healthy  periodontium and 51.1% needed scal- ing), while  among  the  rest of  the  stu- dents, 14.5% had healthy periodontium  and 59.3% needed scaling.  Dental visits by students’ sex Significantly more  females  (61.2%)  had visited the dentist during the previ- ous year  than had males (55.9%).  In  addition, more females than males had  been  taught  the  right way  to  brush  their teeth by their dentist (P < 0.001)  (Table 3). Table 1 Students’ age, sex and education level by community periodontal index of treatment needs (CPITN) scores Demographic characteristic Total studentsa % of students P-valueb CPITN score No. % 0 1 2 3 Age (years) 11–15 1281 42.1 20.5 31.8 46.8 0.9 16–19 1091 35.9 14.2 23.6 60.6 1.6 < 0.001 20–24 670 22.0 10.3 16.9 65.7 7.2 Sex Male 1267 43.2 22.3 17.7 58.1 1.9 < 0.001 Female 1656 56.8 11.1 31.8 54.1 3.0 Education level Middle 1420 47.9 19.6 30.3 49.2 1.0 Secondary 871 29.4 14.9 23.5 60.7 0.8 < 0.001 University 671 22.7 10.3 17.9 63.9 7.9 aNumbers do not add up due to missing data. bChi-squared test. Table 2 Students’ visits to the dentist by community periodontal index of treatment needs (CPITN) scores Dental visit Total students % of students P-valuea CPITN score No. % 0 1 2 3 I have visited the dentist Yes 2337 77.4 16.5 26.7 54.3 2.6 0.005 No 684 22.6 14.6 21.3 61.8 2.2 I visited the dentist last year Yes 1768 58.9 15.8 27.7 53.8 2.7 0.007 No 1236 41.1 16.4 22.3 59.0 2.3 The dentist taught me the right way to brush teeth Yes 1182 39.0 18.0 29.1 51.1 1.6 < 0.001 No 1845 61.0 14.5 23.2 59.3 3.0 aChi-squared test. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 804 Reasons for dental visits and CPITN Pain and dental problems were the most  common reason to visit the dentist, fol- lowed  by  random  check-ups  (Table  4). The  subjects who were  reminded  of  the annual visit by  their dentist had  the highest occurrence of healthy peri- odontium (23.9%) and none needed  complex oral treatment (Table 4). Reasons for not visiting the dentist and CPITN As shown in Table 5, the most common  cause for not visiting the dentist was the  feeling of having no need  for  a dental  visit,  followed by  the  fear of  pain  and  not having the time to do so. There was  a  significant  relationship between  the  periodontal health of  students  and  the  reasons  they  stated  for not visiting  the  dentist. The  students who  stated  that  there was no need for dental visits had the  highest percentage of healthy periodon- tium (21.9%) and lowest percentage for  needing complex treatment (0.9%). Discussion This  is  the first study to explore the re- lationship between dental visit patterns  and periodontal health in a representa- tive sample of the young Saudi Arabian  population. The almost universal oc- currence of  dental  calculus  in  young  populations  suggests  inadequate oral  hygiene practices and other unhealthy  dental behaviours. In the present study,  the presence of calculus was  the most  common periodontal condition in both  sexes and all age groups. This was similar  to most studies in the regions and else- where  [14–16],  but  different  from  another  study  in Saudi Arabia  [17].  In  addition, calculus was present  in more  males  than  females,  in agreement with  studies from other countries [7,18,19]. In  this  study,  around 60% of  indi- viduals  had  visited  the dentist  in  the  previous year, 8.6% had received regular  check-ups and only 2.8% were remind- ed of annual check-ups by  the dentist.  In  contrast,  in  Sweden,  90%–95% of  all  individuals  visited  the dentist on a  regular basis every year or every other  year, and about 70%–80% of all adults  were enrolled  in a  recall  system on the  dentist’s initiative [19]. Also in the USA,  Dye and Selwitz  reported  that around  70% of  subjects had visited  the dentist  within the past 12 months [1]. A study  Table 3 Students’ visits to the dentist by sex Dental visit Sex P-valuea Male Female No. % No. % I have visited the dentist Yes 960 74.7 1333 79.9 < 0.001 No 326 25.3 335 20.1 I visited the dentist last year Yes 715 55.9 1014 61.2 0.002 No 565 44.1 644 38.8 The dentist taught me the right way to brush teeth Yes 466 36.6 669 40.1 < 0.001 No 808 63.4 998 59.9 aChi-squared test. Table 4 Reasons given by students for visiting the dentist last year by community periodontal index of treatment needs (CPITN) score Reason for dental visit Total students % of stuentsa CPITN score No. % 0 1 2 3 Pain and dental problems 1179 49.4 15.0 26.5 56.1 2.4 Random check-up 399 16.7 18.3 26.1 52.4 3.3 Regular check-up 205 8.6 22.0 33.2 43.9 1.0 Gingival problems 171 7.2 8.2 23.4 66.7 1.8 Dentist reminder of annual visit 67 2.8 23.9 37.3 38.8 0.0 2 reasons 315 13.2 13.0 27.6 56.2 3.2 3+ reasons 50 2.1 26.0 34.0 38.0 2.0 aP < 0.001. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 805 conducted in California found that 66%  reported visiting  the dentist  in  the pre- ceding year. About 41% said that getting  a  regular check-up was  their main  rea- son for the last dental care visit, and this  percentage was higher  in  females  than  males [5]. A study in Michigan found a  much higher percentage of regular visits,  where 75% of subjects  reported having  a dental  check-up at  least once a  year  [20]. On the other hand, in Uganda only  21%–37% of  the population has  ever  visited a dentist [21], and 44% received  dental care in the past 2 years [22]. Simi- lar to our results, other studies reported  that  females use dental  services more  regularly than males [4,6,23,24]. Others  found no difference in dental behaviour  between males and females [3,9].  In our study, the most common rea- son for visiting the dentist was pain and  dental problems (49.9%). The  regular  check-up  as  a  reason  for  visiting  the  dentist accounted for 8.6%, and reason  for visits due  to dentist  reminders  ac- counted  for only 2.8%. Almas et  al.  in  Saudi Arabia reported that 67% of males  and 59% of females visited dentists only  when in pain [25]. Similarly,  in Jordan,  male  students  visited  the dentist only  when  in pain  [4].  In  contrast,  in Fin- land,  the most common reason for the  most  recent dental  visit was a  routine  examination  [24]. As  for  reasons  for  not visiting the dentist, our study found  that  feeling  that  there was no need  for  a  dental  visit was  the most  common  reason, followed by the fear of pain.  Our  study  showed an  association  between  the utilization of dental  serv- ices and periodontal health, especially if  the dental visit was due to a reminder by  the dentist or the patient was given oral  hygiene instructions (i.e. taught how to  brush by  the dentist). The  study  also  showed a very low percentage of regular  annual visits  in  this group, which  indi- cates  a need  to emphasize  the  impor- tance of regular dental visits in addition  to a better recall system by dentists.  The CPITN was  endorsed  by  the  WHO for population-based  surveys  in  the 1980s. Although  it has  limitations,  CPITN reflects unmet treatment needs  and  can  give  a  fair  assessment  of  the  periodontal condition. It was used in this  study because it has proved to be a simple  and effective method for measuring and  monitoring  the  severity of periodontal  disease at the community level [26].  There  are  some  limitations  to our  study. First, we used self-reported data.  Such data may be less accurate than data  collected by observation or examination.  Measurement error due to misinterpreta- tion of questions and memory error may  occur [27]. To overcome this problem, a  pilot study was performed, and the ques- tions were worded as simply as possible.  As a cross-sectional  study design,  infer- ences cannot be drawn about the casual  relationship between  the risk  indicators  and periodontal disease. Nonetheless we  were able  to show a significant associa- tion between  the periodontal health of  students and  the  reasons  they gave  for  not visiting the dentist. Knowledge about the epidemiology  of periodontal disease  in Saudi Arabia  will help to establish baseline data about  dental health needs. The importance of  the utilization of dental services should  be emphasized  through various chan- nels, including schools, mass media and  the oral  health providers  themselves.  Schools provide a unique setting to de- velop awareness of  the  importance of  regular dental visits. To help individuals  and group advocates of health promo- tion in schools, the WHO has produced  a programme “Information services on  school health” [28]. The experiences of  systemic oral health care programmes in  some Middle Eastern countries should  also be considered [3,29]. Acknowledgements This study was financially supported by  King Abdulaziz University, Grant No.  015/415. The  author  acknowledges  Professor Mahassen Farghaly  and Dr  Ahmed Bahnasy  for  their contribution  to  the  study design and  sampling, Dr  Soleman Mirdad for the statistical analy- sis, and Dr Leena Merdad for reviewing  the manuscript. Table 5 Reasons given by students for not visiting the dentist last year by community periodontal index of treatment needs (CPITN) score Reason for not visiting the dentist Total students % of studentsa CPITN score No. % 0 1 2 3 No need for dental visits 647 28.7 21.9 23.6 53.5 0.9 Fear of pain 556 24.7 12.9 25.2 59.2 2.7 Do not have time 385 17.1 13.5 25.5 58.4 2.6 Difficulty making an appointment 121 5.4 13.2 21.5 63.6 1.7 Difficulty reaching the dental clinic 78 3.5 16.7 26.9 50.0 6.4 Expensive treatment fees 68 3.0 16.2 20.6 58.8 4.4 2 reasons 322 14.3 10.6 23.3 63.7 2.5 3+ reasons 75 3.3 13.3 20.0 62.7 4.0 aP < 0.001. EMHJ  •  Vol. 16  No. 7  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 806 Dye BA, Selwitz RH. The relationship between selected meas-1. ures of periodontal status and demographic and behavioural risk factors. Journal of Clinical Periodontology, 2005, 32(7):798– 808. Satcher D. 2. Oral health in America: a report of the Surgeon Gen- eral. Rockville, Maryland, National Institutes of Health, US Department of Health and Human Services, 2000. Rajab LD et al. Oral health behaviour of schoolchildren and 3. parents in Jordan. International Journal of Paediatric Dentistry, 2002, 12(3):168–176. Al-Omari QD, Hamasha AA. Gender-specific oral health at-4. titudes and behavior among dental students in Jordan. Journal of Contemporary Dental Practice, 2005, 6(1):107–114. Tomar SL, Azevedo AB, Lawson R. Adult dental visits in Cali-5. fornia: successes and challenges. Journal of Public Health Den- tistry, 1998, 58(4):275–280. Behbehani JM, Shah NM. 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The community peri-13. odontal index of treatment needs (CPITN) procedure for popu- lation groups and individuals. International Dental Journal, 1987, 37(4):222–233. Khader YS. Factors associated with periodontal diseases in 14. Jordan: principal component and factor analysis approach. Journal of Oral Science, 2006, 48(2):77–84. Farsi N et al. Periodontal health and its relationship with sali-15. vary factors among different age groups in a Saudi population. Oral Health and Preventive Dentistry, 2008, 6(2):147–154. Albandar JM. Epidemiology and risk factors of periodontal 16. diseases. Dental Clinics of North America, 2005, 49(3):517–532, v–vi. References Guile EE A, Al-Shammary, El-Backly M. Prevalence and severity 17. of periodontal diseases in Saudi Arabian schoolchildren aged 6, 9 and 12 years. Community Dental Health, 1990, 7(4):429– 432. Olsson B. Efficiency of traditional chewing sticks in oral hygiene 18. programs among Ethiopian schoolchildren. 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Oral health knowledge, attitude 23. and behaviour among Saudi school students in Jeddah city. Journal of Dentistry, 2004, 32(1):47–53. Murtomaa H, Metsaniitty M. Trends in toothbrushing and uti-24. lization of dental services in Finland. Community Dentistry and Oral Epidemiology, 1994, 22(4):231–234. Almas K et al. The knowledge and practices of oral hygiene 25. methods and attendance pattern among school teachers in Ri- yadh, Saudi Arabia. Saudi Medical Journal, 2003, 24(10):1087– 1091. Senna A et al. Socio-economic influence on caries experience 26. and CPITN values among a group of Italian call-up soldiers and cadets. Oral Health and Preventive Dentistry, 2005, 3(1):39–46. Schwarz N. Assessing frequency reports of mundane behav-27. iours: contribution of cognitive psychology to questionnaire constructions cited. In: Hendinck C, Clark MS, eds. Research methods in personality and social psychology. Beverly Hills, Cali- fornia, Sage Publications, 1990:98–119. Petersen PE. Challenges to improvement of oral health in the 28. 21st century: the approach of the WHO Global Oral Health Programme. International Dental Journal, 2004, 54(6 Suppl. 1):329–343. Vigild M et al. An oral health programme for schoolchildren 29. in Kuwait 1986–97. Community Dental Health, 1999, 16(2):102– 106. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما عباسلا ددعلا 807 Letter to the Editor Sir, In 2005–2007 we surveyed mental health services in Lebanon [1]. At the time, we found a paucity of com- munity-based mental health services, deficiencies in education programmes for professionals and the public, misal- location of health care finances, and lack of a clear governmental policy on delivery of mental health services and prevention of mental illness. Several barriers related to the government, pa- tients, and physicians were identified, and solutions to address them, and to move Lebanon forward in meeting World Health Organization (WHO) recommendations for action on mental health, were proposed. Four years have now passed since our survey. While we have not conducted further formal investigations as to the state of mental health care in Lebanon at this time, we would like to provide some updated points. From 2005–2008, the Lebanese population grew by approximately 400 000. In 2008, approximately LL 3.7 trillion (US$ 2.45 billion) were spent on health care [2] compared to 3.5 tril- lion in 2005 [1]. Total expenditure on health was 8.8% of the gross domestic product (GDP) [2]. This accounted for 11.7% of governmental expenditure that year. The majority of health care expenditure was from the private sec- tor rather than the government, with the former contributing 53.9% of total health expenditure and the latter 46.1% [2]. Out-of-pocket expenditures con- stituted 11.7% of total health expendi- ture. Therefore, as compared to 3 years earlier, total government expenditure on health care increased, but private sector expenditure was greater. Private household expenditure has apparently declined [2]. Regarding the availability and cost of medications, shortages in essential medications such as antipsychotics and mood stabilizers continue to oc- cur intermittently. The cost of some medications has significantly declined, particularly generic medications, whereas others have become more expensive. Previously reported costs were based on 2007 prices [1]. Up- dated costs of maintenance therapy for an episode of mania, depression or psychosis as of 2009 include: clo- mipramime LL 25 200 (US$ 16.8), lithium (Camcolit®) LL 252 000 (US$ 168.0) and generic lithium, LL 75 373 (US$ 50.25), chlorpromazine LL 53 579 (US$ 35.7), Prozac LL 232 062 (US$ 154.71), Depakote® LL 198 855 (US$ 132.5) and Risperdal® LL 804 000 (US$ 536.0). It is hoped that in the next decade, significant steps towards meeting WHO recommendations for action on mental health are taken in Lebanon as outlined [1]. Update on mental health care in Lebanon Lama M. Chahine Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States of America (chahinl@ccf.org) Zeina N. Chemali Director of Neuropsychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America Chahine LM, Chemali Z. Mental health care in Lebanon: 1. policy, plans, and programmes. Eastern Mediterranean Health Journal, 2009, 15(6):1596–1612. References National health accounts. Lebanon. World Health Organiza-2. tion [website] (http://www.emro.who.int/emrinfo/index. asp?Ctry=leb, Accessed 10 April 2010). طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ةيبيللا ةيبرعلا ةييرهمالجا . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةينميلا ةيروهملجا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما 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 Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libyan Arab Jamahiriya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Republic of 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 . Jamahiriya arabe libyenne . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar République arabe syrienne . Somalie . Soudan . Tunisie . République du Yémen 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: sabrib@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. 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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 Cover 6.indd 2 5/24/2010 11:46:47 AM