Eastern Mediterranean Health Journal [2011; Vol.17, Issue 4]

Contents V olum e 17 N um ber 4 A pril 2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 17 / No. 4 April / Avril 2011 4 ددع / شرع عباسلا دلجلما ليربأ / ناسين Letter from the Editor .............................................................................................................................................................. 265 Research articles Evaluation of two doses of triclabendazole in treatment of patients with combined schistosomiasis and fascioliasis ........................................................................................................................................................................ 266 Female spouses of injection drug users in Pakistan: a bridge population of the HIV epidemic? .......................... 271 Low rate of placental pathological examination in a tertiary care hospital in Sana’a, Yemen ................................ 277 Relationship between maternal characteristics and neonatal birth size in Egypt ................................................... 281 Relationship between birth weight and domestic maternal passive smoking exposure ....................................... 290 Knowledge and attitude about antismoking legislation in Morocco according to smoking status ...................... 297 Parental smoking and risk of childhood cancer: hospital-based case–control study in Shiraz ............................. 303 Smoking among Saudi university students: consumption patterns and risk factors ............................................... 309 High prevalence of vitamin D deficiency in the sunny Eastern region of Saudi Arabia: a hospital-based study .................................................................................................................................................... 317 ينطسلف – ةيربلاو للها مار ةظفامح ناكس ىدل جذومنك ةيئيبلا ةحصلا لامج في تاسرمالماو فقاولماو فراعلما مييقت ............................................... 323 Knowledge about standard precautions among university hospital nurses in the United Arab Emirates ............ 331 Validity and reliability of the Persian (Farsi) version of the Job Content Questionnaire: a study among hospital nurses ...................................................................................................................................... 335 Clinical guidelines Clinical management guidelines for pandemic (H1N1) 2009 virus infection in the Eastern Mediterranean Region: technical basis and overview ............................................................................ 342 Reviews Smoking and normative influence among Egyptian youth: a review of the literature ............................................ 349 Adherence to medication among chronic patients in Middle Eastern countries: review of studies ............................................................................................................................................................. 356 Tobacco harvest, Pakistan (photo copyright: WHO) Tobacco is the leading preventable cause of death and disability. However, it affects not only the smoker, but others subjected to 2nd hand smoke, including the unborn child. Low birth weight and low Apgar scores in neonates and SIDS are considered to be directly related to passive exposure of the mother to smoke. Cover 17-4.indd 1 4/19/2011 12:01:39 PM 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: khayat@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico‑sanitaire, aux ONG, Centres collabora‑ teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed‑Full text on CD‑ROM, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2011 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. ISSN 1020‑3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Cover 17-8.indd 2 8/8/2011 10:11:18 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 17 No. 4 4 ددع شرع عباسلا دلجلما•  2011  • Letter from the Editor ..............................................................................................................................................................................................................................................................................................................................265 Research articles Evaluation of two doses of triclabendazole in treatment of patients with combined schistosomiasis and fascioliasis M.M. Osman, A.Y. Shehab, A. Zaki and H.F. Farag ...........................................................................................................................................................................................................................................................266 Female spouses of injection drug users in Pakistan: a bridge population of the HIV epidemic? S. Ahmad, J. Mehmood, A.B. Awan, S.T. Zafar, K. Khoshnood and A.A. Khan ...............................................................................................................................................................................................271 Low rate of placental pathological examination in a tertiary care hospital in Sana’a, Yemen A.H. Al Harazi and K.A. Frass .........................................................................................................................................................................................................................................................................................................277 Relationship between maternal characteristics and neonatal birth size in Egypt N.E. Hassan, A.H. Shalaan and S.A. El-Masry .....................................................................................................................................................................................................................................................................281 Relationship between birth weight and domestic maternal passive smoking exposure M.A.A. Wadi and S.S. Al-Sharbatti ...............................................................................................................................................................................................................................................................................................290 Knowledge and attitude about antismoking legislation in Morocco according to smoking status N. Tachfouti, K. El Rhazi, M. Berraho, M.C. Benjelloun, K. Slama and C. Nejjari ........................................................................................................................................................................................297 Parental smoking and risk of childhood cancer: hospital-based case–control study in Shiraz M. Edraki and M. Rambod .................................................................................................................................................................................................................................................................................................................303 Smoking among Saudi university students: consumption patterns and risk factors A. Mandil, A. BinSaeed, R . Dabbagh, S.A. Shaikh, M. AlSaadi and M. Khan ................................................................................................................................................................................................309 High prevalence of vitamin D deficiency in the sunny Eastern region of Saudi Arabia: a hospital-based study M.Y. Elsammak, A.A. Al-Wossaibi, A. Al-Howeish and J. Alsaeed ..............................................................................................................................................................................................................................317 ينطسلف – ةيربلاو للها مار ةظفامح ناكس ىدل جذومنك ةيئيبلا ةحصلا لامج في تاسرمالماو فقاولماو فراعلما مييقت بيطلخا دحمأ ماصع ......................................................................................................................................................................................................................................................................................................................................323 Knowledge about standard precautions among university hospital nurses in the United Arab Emirates J. Sreedharan, J. Muttappillymyalil and M. Venkatramana ............................................................................................................................................................................................................................................331 Validity and reliability of the Persian (Farsi) version of the Job Content Questionnaire: a study among hospital nurses A. Choobineh, H. Ghaem and P. Ahmedinejad .......................................................................................................................................................................................................................................................................335 Clinical guidelines Clinical management guidelines for pandemic (H1N1) 2009 virus infection in the Eastern Mediterranean Region: technical basis and overview S. Al Hajjar, M.R. Malik, Z. Hallaj, H. El-Bushra, M. Opoka and A.R . Mafi ..................................................................................................................................................................................................342 Reviews Smoking and normative influence among Egyptian youth: a review of the literature C. Harbour .....................................................................................................................................................................................................................................................................................................................................................349 Adherence to medication among chronic patients in Middle Eastern countries: review of studies A. Al-Qasem, F. Smith and S. Clifford ..........................................................................................................................................................................................................................................................................................356 Book 17-4.indb 3 4/27/2011 11:00:28 AM M. Haytham Khayat MD, FRSH, Editor-in-chief Muhammad Afzal MSc, MPhil, PhD, Executive Editor Editorial Board Mohammad Abdur Rab MBBS, DTM&H, MPH&TM, PhD Naeema Al Gasseer MSc, PhD Mohamed M. Ali BSc, MSc, PhD, DTMH Abdulla S. Assaedi MBBS, MPH Mounir Farag MD, DGS, DEmS, DPH Abdul Ghaffar MD, MPH, MHA, PhD Malekafzali Hossein MK, MPH, PhD Jaouad Mahjour MD, MPH Mamunur Rahman Malik MBBS, Dip (Health Economics), MSc, MPhil Kassem Sara MD International Advisory Panel Dr S. Aboulazm. Professor of Orthodontics. Egypt Dr Abdul Rahman Al-Awadi BSc, MD, MPH, Honorary FRCM, Ireland Dr Law, Korea, Honorary FRCS & P, Glasgow, FRCP, Edinbugh. Kuwait Dr Fariba Al-Darazi RN, MSc, PhD. Bahrain Dr M. Al-Nozha, MD, FRCP, FACC, FESC. Professor of Medicine and Consultant Cardiologist. Saudi Arabia Dr Ala’din Alwan MD, FRCP, FFPHM. Iraq Dr F. Azizi. Professor of Internal Medicine and Endocrinology. Islamic Republic of Iran Dr K. Bagchi BSc, MD, PhD. India Professor K. Dawson BA, MD, PhD, FRCP, FRACP, FRCPCH, DObst, RCOG. New Zealand Professor Kaussay Dellagi MD. Tunisia Dr R. Dybkaer MD. Denmark Dr M. Aziz El-Matri. Professor of Medicine. Tunisia Professor F. El-Sabban BSc, MS, PhD. United States of America Dr A.H. El-Shaarawi MSc (Stat), PhD (Stat). Canada Professor N. Fikri-Benbrahim PhD (Pub health) (SocSci). Morocco Professor A.T. Florence BSc (Pharm), PhD, DSc, FRSC, FRPharmS, FRSE. United Kingdom Professor Cheherezade M.K. Ghazi BS (Nursing), MS (Nursing), DPH, MPA. Egypt Professor M.A. Ghoneim MD, MD (Hons). Egypt Dr J.A. Hashmi DTM&H, FRCP. Pakistan Professor J. Jervell MD, PhD. Norway Professor G.J. Johnson MA, MD, BChir, FRCS (C), FRCOphth, DCEH. United Kingdom Dr M. Kassas. Emeritus Professor of Plant Ecology. Egypt Professor M.M. Legnain MBBS, MRCOG, FRCOG. Libyan Arab Jamahiriya Professor El-Sheikh Mahgoub DipBact, PhD, MD, FRCPath. Sudan Professor A.M.A. Mandil MSc (Paediatr), MPH, DrPH. Egypt Professor A.B. Miller MB, FRCP. Canada Professor S.S. Najjar MD. Lebanon Dr Abubaker A. Qirbi BSc, MD (Edin), FRCPC (Can), FRCP FRCPath (UK). Republic of Yemen Professor O.S.E. Rasslan MD, PhD. Egypt Professor W.A. Reinké MBA, PhD. United States of America Professor I.A. Sallam, MD, Dip High Surgery Cairo, Honorary FRCS, PhD (Glasgow), LRCP, MRCS, FRCS (London), ECFMG. Egypt Dr C.Th.S. Sibinga FRCP (Edin), FRCPath. The Netherlands Mr Taoufik Zeribi Eng BSc, MSc. Tunisia Editors Fiona Curlet, Eva Abdin, Alison Bichard, Guy Penet Graphics Suhaib Al Asbahi, Hany Mahrous, Diana Tawadros Administration Nadia Abu-Saleh, Yasmine El Sakhawy Book 17-4.indb 4 4/27/2011 11:00:28 AM المجلة الصحية لشرق المتوسط المجلد السابع عشر العدد الرابع 562 رسالة من المحرر rotidE eht morf retteL gurD tabmoC“ ,emeht s’raey siTh .yaD htlaeH dlroW setarbelec )OHW( noitazinagrO htlaeH dlroW eht lirpA 7 no raey yrevE .noigeR ruo fo seirtnuoc eht ot ecnaveler ralucitrap fo si ,”worromot eruc on ,yadot noitca on :ecnatsiser laiborcimitnA .ecnatsiseR -depmi si ecnatsiser gurD .ecnatsiser laiborcimitna fo daerps eht tabmoc ot egakcap ycilop tniop-xis a ecudortni lliw OHW lirpA siTh noitalupop eht fo hcum netaerht taht sesaesid evarg owt ,airalam dna sisolucrebut sa snoitcefni hcus lortnoc ro etanimile ot stroffe gni sa hcus smsinagro htiw snoitcefni deriuqca-latipsoh ni nrecnoc gniworg a osla si tI .noigeR naenarretideM nretsaE OHW eht ni .taert ot elpmis dna suouconni ylriaf deredisnoc ylsuoiverp ,iloc aihcirehcsE dna suerua succocolyhpatS si emeht s’raey siTh .yaM 13 no detaromemmoc si hcihw ,yaD occaboT oN dlroW si radnelac OHW eht ni etad tnatropmi rehtonA lortnoc occabot tsomerof s’dlrow eht tneserp ta si hcihw ,)CTCF OHW( ”lortnoC occaboT no noitnevnoC krowemarF OHW eTh“  fo yrotsih eht ni seitaert decarbme ylediw tsom eht fo eno ydaerla si ti ,5002 ecnis ecrof ni neeb ylno sah ti hguoht nevE .tnemurtsni  dna ,htlaeh fo dradnats tsehgih eht ot elpoep lla fo thgir eht smrffiaer ytaert eTh .seirotangis 071 naht erom htiw ,snoitaN detinU eht .lortnoc occabot ni noitarepooc rof snoisnemid lagel sedivorp ylralucitrap ,spuorg niatrec gnoma gnisaercni si noigeR ruo ni gnikoms ,snoiger OHW rehto emos ni noitautis eht ot tsartnoc nI hcihw( gnikoms nemow ot sreirrab larutluc dna laicos ni enilced eht edulcni snosaer dednuoporP .nemow dna elpoep gnuoy gnoma ralucitrap eseht ot gnisitrevda fo gnitegrat eht dna )tsap eht ni tibah rieht gnilaecnoc yllautca nemow rof nosaer a neeb evah yam .yteicos fo spuorg eht sebircsed yduts iduaS A .htlaeh dna gnikoms fo stcepsa tnereffid no srepap evfi hsilbup ew ,JHME eht fo eussi s’htnom siht nI repap iqarI na ;recnac doohdlihc dna gnikoms latnerap setagitsevni zarihS morf yduts lortnoc–esac a ;stneduts gnoma srotcaf ksir egdelwonk sebircsed occoroM morf repap a ;rehtom eht ni gnikoms evissap dna thgiew htrib neewteb pihsnoitaler eht setagitsevni .tpygE ni elpoep gnuoy gnirevoc weiver erutaretil a osla si ereht dna ;noitalsigel gnikoms-itna fo تحتفل منظمة الصحة العالمية في السابع من نيسان/أبريل من كل عام بيوم الصحة العالمي، وقد ركَّ زت المنظمة في هذا العام على موضوع يهّم بلدان الإقليم كثيرًا، ألا وهو موضوع «مكافحة استعصاء الجراثيم على الأدوية»، واختارت شعارًا له عبارة: «معًا ن ُـ جابه استعصاء الجراثيم على الأدوية». وسوف تقدم المنظمة في شهر نيسان/أبريل من هذا العام حزمة سياسات قائمة على ستة محاور تهدف إلى مكافحة انتشار استعصاء المكروبات على المضادات المكروبية. فاستعصاء هذه الجراثيم على الأدوية ُتَعْرقل الجهود المبذولة في مجال استئصال أو مكافحة بعض أنواع العدوى مثل السل والملاريا، وهما المرضان الخطيران اللذان يهددان قطاعًا عريضًا من السكان في إقليم شرق المتوسط. كما أن الاستعصاء على الأدوية يعد كذلك مصدر قلق متزايدًا في حالات العدوى المكتسبة في المستشفيات بجراثيم من قبيل العنقودية الذهبية والإشريكية القولونية، وهي حالات كانت تعتبر في ما َمَض من حالات العدوى الحميدة والسهلة العلاج. وهنالك قريبًا موعٌد آخر لا يقل أهمية في نظر المنظمة؛ ألا وهو اليوم العالمي لمكافحة التدخين الذي يوافق الحادي والثلاثين من شهر أيار/مايو من كل عام، والذي يحمل هذا العام شعار «اتفاقية منظمة الصحة العالمية الإطارية بشأن مكافحة التبغ»؛ تلك الاتفاقية التي ُتَعدُّ حاليًا أهمَّ أداة لمكافحة التبغ على مستوى العالم. وعلى الرغم من دخولها حيز النفاذ في عام 5002 فقط، فإن هذه الاتفاقية ُتَعدُّ واحدة من أكثر المعاهدات التي حظيت بالقبول في تاريخ الأمم المتحدة حيث وقَّ ع عليها ما يزيد على 071 بلدًا. وتؤكد الاتفاقية على حق الجميع في الحصول على أعلى مستويات الصحة، كما توفر الأبعاد القانونية للتعاون في مجال مكافحة التبغ. وعلى النقيض من الوضع في بعض أقاليم المنظمة، يتزايد التدخين في إقليمنا بين أفراد فئات بعينها، ولاسّيما بين الشباب والسيدات. وقد تعزى الأسباب المفتـرضة في هذا الشأن إلى تضاؤل الوازع الاجتماعي والثقافي لدى المدخِّ نات (والذي ربما كان سببًا في إخفاء السيدات لهذه العادة في الماضي)، أِضْف إلى ذلك استهداف الحملات الإعلانية لهذه الفئات بعينها من بين فئات المجتمع. وفي عدد هذا الشهر من المجلة الصحية خمسة أبحاث حول الجوانب المختلفة للتدخين والصحة، من بينها دراسة سعودية تبحث في عوامل الاختطار بين الأطفال؛ ودراسة حالة ُمْنَشِهَدة ُأجرَيْت في مدينة شيراز تتحري العلاقة بين تدخين الآباء وبين السرطان عند الأطفال؛ وورقة بحثية عراقية تتحرى العلاقة بين أوزان المواليد وبين تعرُّ ض الأمهات للتدخين السلبي؛ وورقة بحثية من المغرب تعرض المعارف المتوافرة حول تشريعات مكافحة التدخين؛ كلُّ ذلك بالإضافة إلى مراجعة للبحوث المنشورة حول الشباب في مصر. MA 82:00:11 1102/72/4 562 bdni.4-71 kooB EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 266 Evaluation of two doses of triclabendazole in treatment of patients with combined schistosomiasis and fascioliasis M.M. Osman,1 A.Y. Shehab,1 A. Zaki 2 and H.F. Farag 1 AbstrAct to determine the safety and efficacy of 2 consecutive doses of triclabendazole (tcbZ) in the treatment of Schistosoma mansoni infection in human cases infected with both S. mansoni and Fasciola sp., we conducted a field survey involving 6314 individuals from 15 villages. the overall prevalence of schistosomiasis alone was 15.8%, of fascioliasis alone 2.2%, and of combined infection 0.7%. treatment with 2 doses of tcbZ was given to the 49 cases with combined infection. Eight weeks after treatment, the cure rate was 96% for fascioliasis and was 32.7% for schistosomiasis. All schistosomiasis cases cured had a low intensity infection. Liver function tests done before treatment and 8 weeks after substantiate the safety of 2 doses of tcbZ given to those with combined infection. Administration of tcbZ should precede praziquantel in treatment of combined infection, however tcbZ cannot be recommended for infection with S. mansoni alone. 1Department of Parasitology; 2Department of Medical Statistics, Medical Research Institute, Alexandria University, Alexandria, Egypt (Correspondence to H.F. Farag: hfarag@link.net). received: 08/04/09; accepted 16/09/09 تاقّروتلما ءادو تايسراهلبلا ءادب ةكرـتشم ىودعب ينباصلما ضىرلما ةلجاعم في لوزادنبلاكيترلا يتعرج مييقت جرف يمهف ىده ،يكز لداع،باهش فسوي لمأ ،نماثع ىفطصم تفرم نم لكب ةباصلما تلاالحا في ةينوسنلما ةيسراهلبلا ىودع ةلجاعم في لوزادنبلاكيترلا نم ينتيلاتتم ينتعرج ةعاجنو ةملاس ديدحتل :ةـصلالخا اهدحو ةيسراهلبلا راشتنا لدعم لياجمإ ناكو .ةيرق 15 نم ًاصخش 6314 لىع لمتشا ًايناديم ًاحسم نوثحابلا ىرجأ ،ةقّروتلماو ةينوسنلما ةيسراهلبلا ميهدل ًاضيرم 49 لىإ لوزادنبلاكيترلا نم ينتعرج نم نّوكم جلاع يطعُأ دقو .%0.7 ينتنثلااب ةكرـتشلما ىودعلاو ،%2.2 اهدحو ةقّروتلماو ،%15.8 ضىرلما عيجم ىدل ناكو .ةيسراهلبلا نم %32.7و ،تاقّروتلما نم %96 ءافشلا لدعم غلب ،جلاعلا نم عيباسأ ةينماث ضيم دعبو .ةكرـتشم ىودع ةملاس لىع عيباسأ ةينماثب جلاعلا دعبو جلاعلا لبق تيرجأ يتلا دبكلا فئاظو تارابتخا تدكأو .ةدشلا ةضفخنم ،اهنم اوفشو ةيسراهلبلاب ينباصلما ليتناوكيزابرلا ءاطعإ قبسي نأ بيج لوزادنبلاكيترلا ءاطعإ نأ عمو .ةكرـتشم ىودعب ينباصلما ضىرملل لوزادنبلاكيترلا نم ينتعرجب جلاعلا ءاطعإ .اهدحو ةينوسنالما ةيسراهلبلاب ىودعلا جلاعل هب ةيصوتلا نكمي لا لوزادنبلاكيترلا نأ لاإ ،ةكرـتشلما ىودعلا ةلجاعم في Évaluation d’un traitement à deux doses de triclabendazole pour des patients atteints d’une schistosomiase associée à une fasciolase résumé Afin de déterminer l’innocuité et l’efficacité de deux doses consécutives de triclabendazole dans le traitement de l’infestation par Schistosoma mansoni chez des patients atteints à la fois par S. mansoni et Fasciola sp., nous avons conduit une enquête de terrain impliquant 6314 individus provenant de 15 villages. La prévalence globale de la schistosomiase seule était de 15,8 %, celle de la fasciolase seule s’élevait à 2,2 %, et celle de l’infestation double à 0,7 %. un traitement par deux doses de triclabendazole a été administré aux 49 cas atteints de la double infestation. Huit semaines après le traitement, le taux de guérison était de 96 % pour la fasciolase et de 32,7 % pour la schistosomiase. tous les cas de schistosomiase guéris étaient des infestations de faible intensité. Les analyses de la fonction hépatique avant le traitement puis huit semaines après apportent la preuve de l’innocuité de deux doses de triclabendazole administrées aux patients atteints de l’infestation double. L’administration de triclabendazole doit précéder celle du praziquantel dans le traitement de l’infestation double, toutefois le triclabendazole ne peut être recommandé pour traiter une infestation unique par S. mansoni. Book 17-4.indb 266 4/27/2011 11:00:28 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 267 Introduction In Egypt, despite government efforts aimed at control, schistosomiasis re- mains an important public health prob- lem. It is still endemic in rural areas and transmission is still ongoing [1]. Human fascioliasis has emerged in Egypt over the past 3 decades and prevalence rates in rural areas range between 2% and 19% [2–5]. As a result,  schistosomiasis and fascioliasis co-exist in the same environment and they pre- vail in some villages [6,7]. A drug effec- tive against both parasites would be highly welcome. Praziquantel (PZQ) is still the ideal drug for control of schistosomiasis [8].  However, the extensive reliance on just 1 drug is of utmost concern due to the risk of possible development of drug- resistant parasites. In view of this con- cern, there is a great need for developing novel antischistosomal drugs. Triclabendazole (TCBZ; Egaten), an effective and safe drug for Fasciola in- fection, was evaluated experimentally on schistosomiasis. In vitro, adult Schistosoma mansoni worms exposed to the drug were reported to show rapid destruction of the tegument; the damage was found to be  irreversible and 100% of  the worms  were killed after 24 hours  [9].  Studies  performed on experimentally-infected mice revealed conflicting results; 2 have  reported 84% and 87% of worms killed 4  weeks after treatment [10,11], however,  a more recent study  found  low efficacy  (18%–36%) for TCBZ in vivo [12]. No studies with high power on the effect of TCBZ on Schistosoma infection in humans are available. Recently, Bar- duagni et al. evaluated the use of TCBZ for treatment of patients co-infected with Fasciola sp. and Schistosoma sp. using a single dose of 10 mg/kg body weight  [13]. They concluded that TCBZ was insufficiently effective on schistosomiasis.  Further studies with 2 consecutive doses  of TCBZ could be of value. Methods A field survey was carried out by the Parasitology Department of the Medical Research Institute in 15 villages near Al- exandria in Beheira governorate. These villages were known to be endemic for both Schistosoma sp. and Fasciola sp. A census of the inhabitants was performed and demographic data were collected and  recorded.  All  individuals  over  5  years of age (n = 6314) were asked  to  submit a stool sample; there were no refusals to comply. We prepared 3 Kato–Katz slides [14] of 41.7 mg each for each sample and eggs were counted by trained technicians. Each technician examined 1 set of slides. All positive cases with combined infection (n = 42) identified in the field  survey, together with 7 cases which were referred to the Parasitology Depart- ment within the study period, were en- rolled in the study. Interview and clinical examination were conducted. Partici- pants included in the study had no past history of jaundice or viral hepatitis or history of receiving schistosomicidal or fasciolicidal drugs within the preceding 6 months. Treatment and follow-up Prior to treatment, a blood sample was obtained and liver function tests were performed. TCBZ for human use (Egaten, Novartis Pharma AG, Basle, Switzerland) was used. Each tablet con- tained 250 mg TCBZ and each case re- ceived 2 doses on 2 successive days after  a fatty meal. Each dose was calculated at 10 mg/kg body weight. The maximum  dose was 2.5 tablets. For follow-up after treatment, all cases were asked to provide a stool sample  after  1,  2,  3,  and  8  weeks;  3  Kato–Katz slides were examined for each sample, and eggs were counted for positive cases. Cases were considered cured of ei- ther S. mansoni or Fasciola sp. infection at any examination when no eggs of the corresponding parasites were found in stools after examination of 3 Kato–Katz slides. Actual cure was considered when eggs were absent on the 8th week after  treatment. Blood samples were taken at the 8th  week and liver function tests repeated. Statistical analysis Data were processed using SPSS , version 11. Intensity of infection was expressed as geometric mean egg count (GMEC). Cure rates were calculated as the percentage of individuals becom- ing parasitologically negative. For cases remaining positive after treatment, per- centage changes in egg counts were calculated using the formula: % change = ((GMECb – GMECa)/ GMECb) × 100 where: b = before and a = after treatment The sign rank test was used to test the significance of changes in egg count, and the Cochrane test was used to assess changes in cure rates in the weeks of follow-up. Ethics The ethical aspects were respected throughout the study: informed con- sent was obtained from all participants and from parents of infected children. They were informed about the drug and the study protocol. Results The field survey covered a total of 6314  individuals from villages near Alex- andria. Prevalence of schistosomiasis single  infection was 15.8% (n = 996),  of  fascioliasis  single  infection was 2.2%  (n = 142),  and of  combined  infection  was 0.7% (n = 42). For the 49 cases with  combined infection (including the 7 referred ones)  age  ranged between 5  and 50 years; 27 (57%) of  these were  males. Book 17-4.indb 267 4/27/2011 11:00:29 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 268 Treatment of cases with combined infection Cure rates for Fasciola and Schistosoma infection in combined cases were as- sessed. The cure rate for Fasciola was 98.0% (only 1 positive case) in the 1st,  2nd  and  3rd week  and  decreased  to  95.9% in the 8th week (2 cases). Table 1 demonstrates the results for S. mansoni individually over time. Only 8  cases were negative on all examinations, 19 cases did not  show negative  results  in any examination, all other cases gave varying results. The cure rate was around 40% at weeks 1, 2 and 3 and fell to 32.7%  at week 8. Only cases with low intensity of infection [< 100 eggs per gram (epg)]  partially responded to TCBZ treatment (cure  rate  =  41.0% 8 weeks  after  tri- clabendazole treatment); not a single cure occurred in cases with moderate (100–400 epg) or heavy (> 400 epg)  Schistosoma infection. No significant changes in Schisto- soma egg counts were found in cases remaining positive after TCBZ treat- ment (Table 2). Liver function tests are presented in Table 3, showing no significant changes 8 weeks after treatment. No side effects  were reported. Thus TCBZ is consid- ered tolerable and safe in cases with combined infection. Discussion The  efficacy  and  safety  of  TCBZ  in  treatment of Schistosoma infection was not  sufficiently  studied  in human  schistosomal infections. The existence of a relatively large number of patients infected with both Schistosoma and Fas- ciola detected in the present field study made it feasible and ethically accepted to assess the schistosomicidal effect of TCBZ while treating Fasciola infections in these patients. As some workers recommended  the  use  of  2  doses  of  TCBZ (10 mg/kg each)  in  treatment  Table 1 Individual findings for Schistosoma mansoni infection in 49 combined cases 1–8 weeks after triclabendazole treatment Combined cases EPG Cure rate 1st week 2nd week 3rd week 8th week 1 24 – – – – 2 12 – – – – 3 96 – – – – 4 24 – – – – 5 12 – – – – 6 12 – – – – 7 12 – – – – 8 24 – – – – 9 252 + + + + 10 192 + + + + 11 12 + + + + 12 336 + + + + 13 336 + + + + 14 36 + + + + 15 36 + + + + 16 36 + + + + 17 12 + + + + 18 12 + + + + 19 48 + + + + 20 276 + + + + 21 240 + + + + 22 1440 + + + + 23 96 + + + + 24 96 + + + + 25 72 + + + + 26 36 + + + + 27 24 + + + + 28 24 + – – – 29 36 + – – – 30 12 + – – – 31 60 – – + – 32 528 – + + + 33 36 – + + + 34 84 – + – – 35 24 – + + + 36 12 – – + + 37 12 – – – + 38 204 – – – + 39 36 – – – + 40 36 – + – + 41 60 – – + – 42 12 + + + – 43 84 + + – – 44 156 + – + + 45 36 + + – + 46 12 + + – + 47 12 + – + + 48 36 + + – + 49 36 + – + + + = positive, eggs seen on stool examination; – = negative, no eggs seen on stool examination. EPG = eggs per gram. Book 17-4.indb 268 4/27/2011 11:00:29 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 269 of Fasciola infection [15] this treatment  schedule was followed to increase the possibility of detecting any potential schistosomicidal effect in cases with combined infection. In our study, according to the results of the 8th week, TCBZ cured more than  one-third of the patients with combined infection. It is important to note that cases cured from schistosomiasis were generally those with low egg counts (epg < 100). Some of  them ceased  to  pass ova starting 1 week after treatment, others became negative starting from the second week. Some cases gave vary- ing results in the different examinations, probably due to the low sensitivity of the Kato–Katz technique to detect light infection. In cases with moderate or heavy Schistosoma infection (epg > 100),  TCBZ failed to cure any case, or even to reduce the intensity of infection. This latter finding is difficult to interpret, but  it raises the possibility that TCBZ is not effective on immature worms, expected to be present more frequently in patients with higher intensity of infection. In  the 8th week,  the  reported cure  rates for fascioliasis and schistosomiasis were slightly lower than those in the first few weeks. This is possibly due to the recovery of a few worms that were affected but not killed by the drug and resumed oviposition. Considering cases that ceased pass- ing eggs throughout the follow-up pe- riod, the actual cure rate would amount to 16.3%. The variability in the effect of TCBZ on Schistosoma versus Fasciola, on high intensity versus low intensity infection, and in vitro versus in vivo Schistosoma infec- tion needs more research. Pharmaco- kinetics in the host might play a key role in the differing susceptibilities to TCBZ between Schistosoma and Fasciola; it might also explain the difference in the in vitro and in vivo activity of the drug on schistosomes. TCBZ was reported to be highly protein bound in animal species and, while Fasciola is known to be very susceptible to drugs that mainly bind to plasma proteins, schistosomes might be less affected by the protein- bound TCBZ [16].  To sum up, this study emphasizes the fact that TCBZ, given in 2 consecu- tive doses cannot be recommended for treatment of Schistosoma infection alone because its efficacy is so inferior to that  of PZQ. However, in areas where com- bined infection with both Schistosoma and Fasciola are prevalent, our findings indicate that the use of TCBZ followed by PZQ could be of value. Acknowledgements The authors acknowledge the TDR unit, World Health Organization, Regional Office  for  the Eastern Mediterranean,  for funding and supporting this work. (Project ID: A 30049). Thanks are due to staff members of TDR for their encouragement during the work. Special thanks are due to the late Professor Dr Laila Abou-Basha who spent a lot of effort in the initiation of this project. Table 2 Change in Schistosoma egg count in cases with combined infection remaining positive after triclabendazole treatment When examineda No. cases not curedb Geometric mean egg count (95% CI) % change P-value Before treatment After treatment 1 30 56.31 (35.97–89.68) 64.02 (39.36–104.4) +12.0 > 0.05 2 29 69.26 (42.88–111.87) 68.66 (42.14–111.87) –0.9 > 0.05 3 29 65.30 (39.95–106.76 74.43 (46.48–119.20) +12.3 > 0.05 8 33 60.34 (38.44–94.71) 58.48 (36.53–93.61) –3.1 > 0.05 aWeeks after treatment. bCases found positive differed from week to week. CI = confidence interval. Table 3 Liver function indicators before and 8 weeks after triclabendazole treatment in 49 cases with combined infection Parameter Before treatment After treatment t P-value AST (≥ 12 U/L) a 0.76 > 0.05 range 4–34 4–27 mean (sD) 12.55 (6.35) 12.0 (5.53) cases with high values 21 17 ALT (≥ 12 U/L) a 1.5 > 0.05 range 4–63 4–35 mean (sD) 12.3 (9.23) 10.8 (4.63) cases with high values 17 9 AKP (9–35 IU/L) a 0.65 > 0.05 range 7–557 7–289 mean (sD) 44.29 (83.94) 40.04 (49.30) cases with high values 13 13 aNormal range. SD = standard deviation. AST = aspartate aminotransferase; ALT = alanine aminotransferase; AKP = alkaline phosphatase. Book 17-4.indb 269 4/27/2011 11:00:29 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 270 References botros s et al. Efficacy of mirazid in comparison with praziqu-1. antel in Egyptian Schistosoma mansoni infected school chil- dren and households. American Journal of Tropical Medicine and Hygiene, 2005, 72(2):119–123. Control of foodborne trematode infections. Report of a WHO 2. Study Group. Geneva, World Health Organization, 1995 (tech- nical report series, No. 849). Esteban JG, bargues mD, mas-coma s. Geographical distribu-3. tion, diagnosis and treatment of human fascioliasis: a review. Research and Reviews in Parasitology, 1998, 58:13–42. curtale F et al. Human fascioliasis, an emerging public health 4. problem in the Nile Delta, Egypt. Research and Reviews in Para- sitology, 2000, 60:129–134. Haseeb AN et al. A review on fascioliasis in Egypt. 5. Journal of the Egyptian Society of Parasitology, 2002, 32:317–354. Esteban JG et al. Hyperendemic fascioliasis associated with 6. schistosomiasis in villages in the Nile Delta of Egypt. American Journal of Tropical Medicine and Hygiene, 2003, 69(4):429– 437. curtale F et al. Human fascioliasis infection: gender differ-7. ences within school-age children from endemic areas of the Nile Delta, Egypt. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2007, 101(2):155–160. Doenhof FmJ et al. resistance of 8. S. mansoni to praziquantel: is there a problem? Transactions of the Royal Society of Tropical Medicine and Hygiene, 2002, 96:465–469. El-sayad mH, Allam AF. Effect of triclabendazole on the 9. tegument of Schistosoma mansoni: a scanning electron mi- croscopic study. Journal of the Egyptian Society of Parasitology, 1997, 27:143–152. coles Gc. Anthelmintic activity of triclabendazole. 10. Journal of Helminthology, 1986, 60:210–212. Khalil ss. On the schistosomicidal effect of triclabendazole: an 11. experimental study. Journal of the Egyptian Society of Parasitol- ogy, 2000, 30:799–808. Keiser J et al. triclabendazole and its two main metabolities 12. lack activity against Schistosoma mansoni in the mouse model. American Journal of Tropical Medicine and Hygiene, 2006, 75(2):287–291. barduagni P et al. use of triclabendazole for treatment of pa-13. tients co-infected by Fasciola spp. and S. mansoni in behera Governorate, Egypt. Parasitology Research, 2008,102(4):631– 363. Katz N, chaves A, Pellegrino J. A simple device for quantita-14. tive stool thick smear technique in schistosomiasis mansoni. Revista do Instituto de Medicina Tropical de São Paulo, 1972, 14:397–400. El-morshedy H et al. triclabendazole in the treatment of hu-15. man fascioliasis: a community based study. Eastern Mediter- ranean Health Journal, 1999, 5(5):888–894. Keiser J et al. triclabendazole for the treatment of fascioliasis 16. and paragonimiasis. Expert Opinion on Investigational Drugs, 2005, 14:1513–1526. Global Health Observatory Map Gallery The WHO Global Health Observatory map gallery includes an extensive list of maps on major health topics and covers all countries of the world. Maps are classified by themes, e.g. cholera, neglected tropical diseases and violence and injuries, and can be further searched by keyword. Searches can be conducted from this page: http://gamapserver.who.int/mapLibrary/ Book 17-4.indb 270 4/27/2011 11:00:29 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 271 Female spouses of injection drug users in Pakistan: a bridge population of the HIV epidemic? S. Ahmad,1 J. Mehmood,2 A.B. Awan,3 S.T. Zafar,3 K. Khoshnood 4 and A.A. Khan 2,5 AbstrAct An estimated 21% of injection drug users (IDus) in Pakistan are HIV-positive and data suggest that the spouses of IDus may be a critical component of the HIV transmission chain. this study interviewed 101 spouses of male IDus about their sexual practices and drug use. We found that 43% had been sexually active with their partners in the past month but only 4% reported selling sex. Almost a quarter (23%) used drugs and 19% injected drugs, usually a combination of diazepam and pheniramine. Although sex work was infrequent among spouses of IDus, their risk of contracting HIV and transmitting it to others was high because they received injection drugs, sometimes along with their IDu husbands, from the same health centres that provided therapeutic injections to the rest of the community. IDu spouses may thus serve as a bridge group via therapeutic injections, rather than via sex work. 1Yale University School of Medicine, New Haven, Connecticut, United States of America. 2Research and Development Solutions, Islamabad, Pakistan (Correspondence to A.A. Khan: adnan@khans.org). 3Nai Zindagi Trust, Islamabad, Pakistan. 4Yale School of Public Health, New Haven, Connecticut, United States of America. 5Ministry of Health, Islamabad, Pakistan. received: 20/07/09; accepted: 13/10/09 ؟يشربلا يعانلما زوعلا سويرف ءابول نياكس سرج :ناتسكاب في ًانقح تارّدخلما يطاعتم تاجوز ناخ دحمأ ناندع ،دونشُخ هواق ،رَفَظ قراط دّيس ،ناوعأ شخب دحمأ ،دوممح ةَيرْيَوُج ،دحمأ ةَيَمُس نأ لىع تانايبلا لدتو ،%21 ناتسكاب في ًانقح تارّدخلما يطاعتم ينب يشربلا يعانلما زوعلا سويرفب ينباصملل ةيريدقتلا ةبسنلا غلبت :ةصلالخا ىطاعتي ةجوز 101 عم تلاباقم ةساردلا هذه في تَيرجأ دقو .سويرفلاب ىودعلا لاقتنا ةلسلس في ةماه ةقلح َنْف ِّلؤي ًانقح تارّدخلما يطاعتم تاجوز للاخ ّنهئاَنَرُق عم ًايسنج تاطيشن َّنك نهنم %43 نأ دجوو .تاردخملل َّنهيطاعتو ةيسنلجا نتهاسرامم ةفرعلم كلذو ،ًانقح تارّدخلما َّنهجاوزأ يهو ،ًانقح تارّدخلما ينطاعت %19و ،تارّدخلما ينطاعت )%23( نهنم عبرلا لياوح نإ مث .ءاغبلا نسرماي طقف نهنم %4 نأولو ،ةساردلل قباسلا رهشلا زوعلا سويرفب نهتباصإ رطخ نأ لاإ ،ًانقح تاردخلما يطاعتم تاجوز ينب ًافولأم نكي لم ءاغبلا نأ عمو .ينمايرنيفلاو مابيزايدلا نم طيلخ ةداعلا في نمو ،ًانقح تاردخملل نيرقاعلما نهجاوزأ عم ًانايحأو ،ًانقح تارّدخلما ينطاعتي ننهلأ ًارظن ًاعفترم ناك نيرخلآل ىودعلل نهلقنو يشربلا يعانلما ىودعلا لقنل ًاسرج َنْفِّلؤُي ًانقح تاردخملل نيرقاعلما تاجوز نأ نوثحابلا ىريو .عمتجلما رئاسل نقلحاب تاجلاعلا م ِّدقت يتلا ةيحصلا زكارلما سفن .ءاغبلاب نهلمع للاخ نم ىودعلل ّنهلقن نم رثكأ ،نقلحاب جلاعلا برع Épouses de consommateurs de drogues injectables au Pakistan : un maillon de la chaîne de transmission de l’épidémie du VIH dans la population ? résumé Il a été estimé que 21 % des consommateurs de drogues injectables au Pakistan étaient positifs au VIH et les données laissent à penser que les épouses de ces derniers pourraient être un maillon critique de la chaîne de transmission du VIH. Pour la présente étude, 101 épouses de consommateurs de drogues injectables ont été interrogées au sujet de leurs pratiques sexuelles et de leur consommation de drogues. Nous avons découvert que 43 % d’entre elles avaient eu une activité sexuelle avec leur partenaire au cours du mois précédent, mais que seulement 4 % déclaraient vendre des services sexuels. Près d’un quart de ces femmes (23 %) consommaient des drogues et 19 % des drogues injectables, le plus souvent une association de diazépam et de phéniramine. même si le commerce du sexe était peu fréquent chez les épouses de consommateurs de drogues injectables, le risque d’infection par le VIH et de transmission à des tiers était élevé car elles recevaient des drogues injectables, parfois avec leur époux consommateur de ces drogues, dans les mêmes centres de santé fournissant des injections de médicaments à l’ensemble de leur communauté. Les épouses de consommateurs de drogues injectables pourraient représenter un maillon de la chaîne de transmission du VIH par l’intermédiaire des injections de médicaments, et non par le commerce du sexe. Book 17-4.indb 271 4/27/2011 11:00:30 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 272 Introduction The human immunodeficiency virus (HIV) epidemic in Pakistan has be- come well established among injection drug users (IDUs) [1–3].  In 2008,  the  national AIDS control programme es- timated that  there were about 100 000  street-based IDUs in Pakistan, of whom nearly  21% had HIV  infection  [2,3].  More recently male and transgender sex workers have shown early evidence of epidemic transmission, particularly in cities where they have the most sexual contacts with  IDUs  [2,3]. At present,  there is little evidence of HIV transmis- sion to the general population, and it is unclear which subgroups will provide the bridge for transmission from IDUs to the population. About 95% of IDUs in Pakistan are  sexually active and 38% have a  regular  sexual partner [3]. A recent modelling study demonstrated that IDUs were more likely to transmit HIV to their spouses and regular sex partners than to sex workers in any city in Pakistan [4]. This is consistent with regional experi- ence. A 2000  study  showed  that 45%  of wives of HIV-positive IDUs from Manipur, India were also HIV infected [5]. However, it is unclear if’ the spouses and regular partners of IDUs are merely at risk of HIV infection or if they play a bridging role in the onward transmission of the infection to others. To date, few studies provide information about this vulnerable population, and none have examined the vulnerabilities or HIV transmission potential of the spouses of IDUs in Pakistan. We conducted this study in Faisal- abad and Lahore where the nongovern- mental organization Nai Zindagi (New Life) provides harm reduction services for IDUs. Lahore is the second most populous city in Pakistan, with over 3000 IDUs, an estimated 4% of whom  have HIV infection. Faisalabad is the third most populous city, with over 8000 IDUs, 13% of whom are estimated  to be HIV-positive [3]. The purpose of this study was to inquire about infec- tion risk, sexual habits and drug use by spouses and regular partners of male IDUs to understand whether these women have a role in the HIV transmis- sion chain from IDUs to the general population. Furthermore, we wished to ascertain what the mode of such trans- mission would be, if it were to occur. Our hypothesis, based on discussions with IDU harm reduction workers, was that transmission of HIV was most likely via commercial sex, which many of the IDUs’ spouses were believed to be engaging in. Methods Sample Nai Zindagi NGO has 4733 registered IDUs in Lahore and 4696 in Faisalabad,  compared with surveillance estimates of 3350  and of  8030  respectively. At  least 60% of all IDUs in these cities are  using these services—over-registration of IDUs in Lahore is high as names of IDUs are not removed once they move away, and turnover of IDUs is high—therefore the probability of se- lection bias based on service seeking was considered low. We used the NGO client records to identify married male IDUs from urban and peri-urban areas of Lahore and Faisalabad, Pakistan, and asked them to introduce us to their spouses or long-term sex partners. Each male IDU reported only 1 long-term partner and therefore only 1 subject was inter- viewed per  IDU client. A  total of 102  women were recruited consecutively by randomly selecting their husbands’ names from the NGO records. We interviewed 97 of  these  subjects  and  excluded  the 5 women who  reported  not living with their husbands currently or who had incomplete information. We also recruited 4 female sex work- ers who had been identified by local NGOs as having long-term IDU sexual partners, giving a  total of 101 subjects.  Interviewees were compensated for transportation when applicable but no other compensation was given. Data collection and analysis Interviews were conducted during June and July 2007. The study questionnaire  incorporated components from inter- nationally standardized instruments [6], including basic background and socioeconomic information, sexual history/risk  factors,  perceived  risk of  HIV and history of testing, plus separate modules for drug users and female sex workers. Both the basic background informa- tion and sexual history questionnaires were  taken  from  the  AIDS/CAPS/ WHO counselling  and efficacy  study  (counselling and testing baseline instru- ment) survey, which has been interna- tionally validated [6]. Basic background information collected included age, marital status, number of living children, current living situation (including de- tails about household utilities), number of years spouse has been using drugs, number of living inhabitants, job status and information. We assessed details of our subjects’ sexual and drug histories using a sepa- rate qualitative instrument that was de- rived from Canada Africa Partnership’s Client qualitative guide  [6].  It  included  details about the frequency of sexual encounters, condom use, relationships and drug use history, including ques- tions about length and frequency of drug use, moods and attitude toward drugs, experiences and details of the last encounter, HIV risk and history of testing, and questions about hygiene and the acquisition of drugs. The research team filled out the survey during the interview, which was also tape-recorded. Interviews were conducted in our drop-in facility in La- hore or at subjects’ homes. We ensured privacy by allowing only the subject and research team into the interview room. A consent form was read and ex- plained to the interview subjects, which Book 17-4.indb 272 4/27/2011 11:00:30 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 273 explained that any identifying informa- tion about them would be destroyed and that the recordings we made would not have their name, husband’s name, or other identifying information within it. The subjects, if literate, were allowed to read the consent form and sign it. Il- literate subjects were asked to repeat the information given and thumb-print the consent form. All procedures including recruitment and consent were approved by human investigation committees from both Yale University and Nai Zindagi’s Institutional Review Board in Pakistan. The interviews took 15–35  minutes each. We analysed the data using descrip- tive statistics and univariate analysis with SPSS, version 13. Results The women interviewed had a mean age of 35 years and nearly all were currently  married. Most (62%) were employed,  a quarter provided the sole income for their households and only 29% received  any income support from their spouse (Table 1). Sexual behaviour with spouses Our subjects reported infrequent sex with their spouses, with a mean of 1.01  sex acts per month (median: 0,  range:  0–15) and 57% reported having no sex  with their spouse in the past month. Only  17% of women  reported  using  a condom during the last sex act with their spouse. Four reported anal sex of these, 1 used a condom. Five knew that their husbands had had sex with some- one else in the past 6 months. One-third  (33%) felt it would be easy or very easy  to ask their spouses to use a condom. Sex work Four women (4%) from the main (con- secutive recruitment) sample reported selling sex to supplement their income. We interviewed an additional 4 women who had been identified by the NGO as both a sex worker and spouse of a drug user. Only 1 of  the 8  sex workers had  used condoms regularly with clients; 4 claimed that condoms gave them infec- tions and so did not use them. These women charged about US$ 2 per  sex  act. Most of them (7/8) used drugs. Sex and protection knowledge Almost half  (48%) of  the women had  never heard of the term “HIV”. Of these, 22%  felt  they were highly unlikely  to  be HIV  infected and only 7%  felt  they  were highly likely to acquire HIV. Only 9 (9%) women had  ever been  tested  for HIV; all the tests had been negative. Only 13% had ever discussed HIV risk  with their IDU husbands and over half did not feel that they could have this discussion (Table 2). Drug use Drugs were used by 22 (23%) women,  including 18 (19%) who injected (Table  3). Most of the injection users (17/18)  went to a local doctor/quack to receive  injections of a pharmaceutical cocktail (diazepam and pheniramine); only 1 injected herself. The women receiving injections  received  an  average  of  20  (5–60) monthly and 13/17 had started  injecting following their husbands. Only 2/17  ensured  that  the  syringes  they  used were new; all others reported that the injection was prepared behind a curtain or door and they were not sure if it was prepared with sterile techniques Table 1 Sociodemographic characteristics of the study participants (n = 97) Variable Value Age [mean & range, years] 35 (18–66) Marital status (%) married 94 Divorced 1 Widowed 0 separated 1 Not married 1 Spouse [mean & range, years] cohabitation with current spouse/sexual partner 11 (0.2–42) spouse’s use of drugs 7 (0.6–30) Household [mean & range] No. of living children 4 (0–12) No. of cohabitants in house 7.5 (0–35) Income (%) receive regular financial support from spouse/partner 29 sole provider of household income 25 Employment (%) Employed 62 Feel that current job is stable 43 Payment for medical expenses (%) Out-of-pocket 79 utilized free/clinical services 15 Other 4 Risk behaviour (%) use drugs 23 Inject drugs 19 sell sex 4 Book 17-4.indb 273 4/27/2011 11:00:30 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 274 or with a new syringe. Besides diazepam, a few smoked or inhaled heroin (n = 2)  and marijuana (n = 3). Finally, all but 1 female sex worker interviewed admitted to using drugs. Most of the women had been taking drugs for more than 1 year. Some had not realized that their husbands were IDUs until they themselves started to go to the doctor each evening and saw their husbands waiting in line for the injection. One woman said, “Once I started going regularly, it suddenly oc- curred to me why my husband would disappear each evening. It made a lot more sense.” Most of the women were aware that they were IDUs. Many had started drugs to control actual physical pain but were now in severe pain without drugs. They accepted the idea of having drugs every other day or every week in order to feel productive or well and felt that they could not function or do much without drugs. They had the “routine built into their lives to go to the doctor”. One woman said, “Sometimes when I am feeling ill, I go to the doctor twice a week. After my injection, I go to sleep, then wake up and feel fresh. I am able to wash my children’s clothes, make food, and do my work. The injection makes it easier.” Another woman who injected daily claimed, “On the days I don’t have the injection, I have no peace. I work all day, not only my own work but also my mother-in-law’s too. I get very tired and need it (drugs). I take it right before bed and go to sleep. Without it, I am also unable to pray. At least when I take it, the next morning, I am able to pray and begin my work.” Reasons for beginning drug use were varied. “We work outside on the farm and go through a lot of pain at the end of the day”, one woman said. Her husband had aches and pains through- out his body and decided to go more frequently to get injections. She said that soon after her husband began injecting, her body began to ache as well and she decided that she would start injecting. Regardless of the original rea- son they began injecting, all the women felt that they must continue injecting since they could not live comfortably without it. Discussion We found that IDUs’ spouses in this study were at moderate risk of ac- quiring HIV from their husbands via infrequent but unprotected sexual intercourse. While the overall numbers of sexual encounters were few, the low rate of condom use and HIV protection knowledge are concerning, given that an estimated 21% (range: 0%–52%) of  all IDUs in Pakistan are HIV infected [1–3]. However, it is useful to know that many women (33%) perceived  it easy  to ask their partners to use condoms. Many of these women (and some of their IDU husbands) received frequent injections from community providers who may use the same equipment to inject others in the community. This may be an important route for transmis- sion of HIV from IDUs to their wives to the general public. Finally, a minor- ity of these women also sold sex. Both community-based injections and sex work expand their HIV risk networks to include IDUs, clients of sex workers and community members. This is the first such study among IDUs’ sexual partners in Pakistan and among the first in the region. Prior to this study, anecdotal reports had suggested that sex work among IDUs’ spouses was common, raising concern that IDUs’ spouses may be an important bridging group [7] in Pa- kistan. Very  few of  the women (4%)  reported that they sold sex. However those that did charged some of the low- est rates nationwide (Rs 100 versus the  national median  of Rs  200)  [8]  and  virtually never used condoms. It is dif- ficult to draw more inferences due to the small number of female sex workers in our sample. Almost a quarter of our subjects used drugs and 19%  injected. Of  these,  the  majority went to local doctors or quacks for injections (usually of a cocktail of phenirimine and diazepam). Diazepam is readily available in Pakistani pharma- cies, who sometimes sell it without a Table 2 Human immunodeficiency virus (HIV) risk perception and testing among the spouses of male injection drug users Variable Subjects (n = 97) (%) Does not know about HIV 48 Perception of HIV risk Highly unlikely 22 unlikely 10 moderate 4 Likely 9 Highly likely 7 Previously tested for HIV 9 Discussed risk with spouse 13 Difficulty in asking spouse to use condom Very easy 18 Easy 16 Difficult 11 Very difficult 5 Does not use and would not ask 52 Table 3 Types of drugs used by the spouses of male injection drug users Drug No. % of all subjects (n = 97) % of those using drugs (n = 22) Diazepam and pheniramine 18 18 78 Heroin 3 2 9 marijuana 3 3 13 total 22 23 100 Book 17-4.indb 274 4/27/2011 11:00:30 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 275 prescription. Many of our IDU clients describe that diazepam produces a dif- ferent kind of a “high” from opioids and crave it for itself. Although the injections may have started for medical indications (albeit incorrect ones), these women eventu- ally became addicted and went for injec- tions regularly. In addition, 7/8 women  who sold sex also used drugs, increasing their exposure. Almost none of our subjects were sure if the injections they received were sterile or not. Since medical practice is unregulated, many unqualified people set up practices in Pakistani communities and over time become indistinguishable to their clients from qualified physicians. These and many medical doctors prescribe/give  injec- tions extensively for a variety of medical ailments [9] and it has been shown that  local residents from periurban com- munities may receive between 8 and 14  therapeutic injections annually [10,11].  Frequent injections by our subjects and their husbands and the high fre- quency of therapeutic injections in some Pakistani communities suggest that the potential for HIV or HCV transmission from IDUs to their wives and onto other members of the same communities. This route of bridging of HIV transmission has been observed elsewhere  [12–14].  Since HIV  [15– 18]  (and hepatitis C  [19])  transmits  more  efficiently  through  injections  than via sex and because therapeutic injections are so common in Pakistan [8–11,20–22],  the  overall  exposure  of communities to these viruses may be far greater from unsafe therapeutic injections than from commercial or non-commercial sex. There are several limitations to our study. Some of the women were identi- fied as sex workers by the Nai Zindagi team, but did not discuss their sex work during the interview and therefore were not included among sex workers for our study. Strong cultural taboos and fear of discrimination or persecution inhibit discussion of the sex trade and non-marital sex in Pakistani society. This may have resulted in fewer women discussing their sex trade, particularly since they were accessed via the NGO that provides harm reduction services to their husbands. The same may apply to drug histories. We suspected that many women felt uncomfortable dis- cussing their sexual and drug histories during the interview, despite extensive explanation and attempts at establishing rapport, leading to under-reporting of sexual contacts and drug use among our subjects. Conducting additional inter- views over time with the same subjects could help to establish trust and obtain more accurate information. In addition, our study recruited a small number of subjects  from 2 cities. The sample size  may not have been sufficient  to assess  aspects of drug use and the sex trade suf- ficiently, and local cultural diversity may mean that similar studies will have to be repeated in other cities to understand these nuances and intercity variations. Finally, as the NGO identified subjects who utilized their harm reduction serv- ices, the results from this research may not be generalizable to other IDUs. Our findings suggest the need for interventions that reduce the reliance of IDUs’ spouses on community injectors and for services that provide psychologi- cal support and enhance IDUs’ skills or provide opportunities to enable them to deal with the economic hardship imposed on them by their husbands’ drug use. A wider issue is that better injection practices need to be promoted in Pakistan, which has possibly the high- est frequency of therapeutic injections in the world. Further research should study aspects of syringe and sexual net- works of spouses of IDUs in order to understand their role in transmission of HIV in Pakistan. References HIV-AIDS surveillance project of Pakistan (HASP): pilot round1. . Islamabad, Pakistab, National AIDs control programme of Pakistan, 2005. HIV-AIDS surveillance project of Pakistan (HASP): round 12. . Islam- abad, Pakistan, National AIDs control programme of Pakistan, National AIDs control Programme of Pakistan, 2006. HIV-AIDS surveillance project of Pakistan (HASP): round 23. . Islam- abad, Pakistan, National AIDs control programme of Pakistan, National AIDs control Programme of Pakistan, 2008. HIV risk in spouses of IDUs and sex workers in Pakistan4. . Present- ed at the 17th meeting of the International society for sexually transmitted Diseases research (IsstDr), seattle, Washington, 30 July–1 August 2007. Panda s et al. transmission of HIV from injecting drug users 5. to their wives in India. International Journal of STD and AIDS, 2000, 11:468–473. coates tJ, the Voluntary HIV-1 counseling and testing Efficacy 6. study Group. Efficacy of voluntary HIV-1 counselling and test- ing in individuals and couples in Kenya, tanzania, and trini- dad: a randomised trial. the Voluntary HIV-1 counseling and testing Efficacy study Group. Lancet, 2000, 356:103–112. Aral sO. behavioral aspects of sexually transmitted diseases: 7. core groups and bridge populations. Sexually Transmitted Dis- eases, 2000, 27:327–328. National AIDS control programme8. . Family Health Internation- al/Pakistan medical and research council/National study of sexual and reproductive tract Infections, 2004. Janjua NZ, Akhtar s, Hutin YJ. Injection use in two districts of 9. Pakistan: implications for disease prevention. International Journal for Quality in Health Care, 2005, 17:401–408. Pasha O et al. Household members of hepatitis c virus-10. infected people in Hafizabad, Pakistan: infection by injections from health care providers. Epidemiology and Infection, 1999, 123:515–518. Khan AJ et al. unsafe injections and the transmission of hepati-11. tis b and c in a periurban community in Pakistan. Bulletin of the World Health Organization, 2000, 78:956–963. Book 17-4.indb 275 4/27/2011 11:00:30 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 276 brewer DD et al. Investigating iatrogenic HIV transmission in 12. ugandan children. Journal of Acquired Immune Deficiency Syn- dromes, 2007, 45:253–254. brody s et al. Evidence of iatrogenic HIV transmission in chil-13. dren in south Africa. BJOG, 2003, 110:450–452. correa m, Gisselquist D. routes of HIV transmission in India: 14. assessing the reliability of information from AIDs case surveil- lance. International Journal of STD and AIDS, 2006, 17:731–735. Hudgens mG et al. Estimating the transmission probability of 15. human immunodeficiency virus in injecting drug users in thai- land. Applied Statistics, 2001, 50:1–14. Hudgens mG et al. subtype-specific transmission probabilities 16. for human immunodeficiency virus type 1 among injecting drug users in bangkok, thailand. American Journal of Epidemiology, 2002, 155:159–168. Kaplan EH, Heimer r. A model-based estimate of HIV infectiv-17. ity via needle sharing. Journal of Acquired Immune Deficiency Syndromes, 1992, 5:1116–1118. Gray rH et al., rakai Project team. Probability of HIV-1 trans-18. mission per coital act in monogamous, heterosexual, HIV-1-dis- cordant couples in rakai, uganda. Lancet, 2001, 357:1149–1153. mcmahon Jm, Pouget Er, tortu s. Individual and couple-level 19. risk factors for hepatitis c infection among heterosexual drug users: a multilevel dyadic analysis. Journal of Infectious Dis- eases, 2007, 195:1572–1581. Luby s. Injection safety. 20. Emerging Infectious Diseases, 2001, 7(suppl.):535. raglow GJ, Luby sP, Nabi N. therapeutic injections in Pakistan: 21. from the patients’ perspective. Tropical Medicine & Interna- tional Health, 2001, 6:69–75. Luby s et al. Long-term improvement in unsafe injection prac-22. tices following community intervention. International Journal of Infectious Diseases, 2005, 9:52–59. HIV surveillance in the Middle East and North Africa: a handbook for surveillance planners and implementers This handbook is aimed at surveillance officers and programme managers. It is designed to assist them in the planning  and implementation of key components of a surveillance system for HIV infection and AIDS in a region where low- level and concentrated HIV epidemicscurrently predominate. It focuses primarily on the components of surveillance systems that track HIV prevalence and related risk behaviour among most-at-risk populations over time. The full text of this handbook is available at http://www.emro.who.int/publications/Book_Details.asp?ID=1099  Book 17-4.indb 276 4/27/2011 11:00:31 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 277 Low rate of placental pathological examination in a tertiary care hospital in Sana’a, Yemen A.H. Al Harazi 1 and K.A. Frass 2 AbstrAct the aim of this study was to evaluate the rate of submission of placentas for pathological examination and compare the observed and expected numbers of placentas submitted. records were reviewed for all deliveries occurring at a tertiary care hospital in sana’a, Yemen, during 2007. Data from pathology department records were compared with data on pathology request forms. the observed and expected numbers of placentas examined were compared. Of 11 472 placentas delivered, 1501 were expected to be pathologically examined, based on college of American Pathologists indications. Only 73 of these (4.9%) had actually been examined. the examination rates for conditions associated with the possible recurrence risks in the subsequent pregnancies were low, below 20%. Only 42% of the pathology request forms gave detailed clinical histories and 0% gave information about Apgar scores. Placental pathological examination was under-utilized in this hospital. 1Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Dhamar, Dhamar, Yemen (Correspondence to A.H. Al Harazi: yem008@yahoo.com). 2Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Sana’a, Sana’a, Yemen. received: 02/07/09; accepted: 05/10/09 نميلا في ءاعنص ةنيدم في ةيثلاثلا ةياعرلل ىفشتسم في ةميشملل يجولوثابلا صحفلا لّدعم ضافخنا صارف للها دبع ةمئاق ،يزارلحا نسح نحمرلا دبع تعجور دقو .ةعقوتلماو ةصوحفلما مئاَشَمـلا دادعأ ينب ةنراقلماو ًايجولوثاب ةميشلما صحف تابلط لّدعم مييقت لىإ ةساردلا هذه فدته :ةصلالخا مسق نم اهيلع لصحتلما تايطعلما تنروقو .2007 ماع للاخ ،نميلاب ءاعنص ةنيدم في ةيثلاثلا ةياعرلل ىفشتسم في تَّتم يتلا تادلاولا عيجم تلاجس نم هنأ ينبتو .مئاشملل ةعقوتلما دادعلأا عم ةصوحفلما دادعلأا تنروق ماك .يجولوثابلا صحفلا بلط جذومن لىع ةنّودلما تانايبلا عم ايجولوثابلا نكلو .ينيكيرملأا ينيجولوثابلا صياصتخا ةيلك يرياعم لىع ءانب ،ًايجولوثاب اهصحف عقوتُي ةميشم 1501 كانه تناك ،اهملاتسا ّمت ةميشم 11472 ينب تادلاولا في رطاخلما راركت لماتحاب ةطباترلما تلاالحا في ةميشلما صحف تلاّدعم تناكو .)%4.9( طقف ّنهنيب نم ةميشم 73 لعفلاب ْتَصِحُف ينح في اهنم ٌّيأ نكي لمو ،ل َّصَفم يريسر خيراتب ًةبوحصم يجولوثابلا صحفلا ءارجإ تابلط نم طقف %42 نم رثكأ نكي لمو .)%20 نم لقأ( ةضفخنم ةيلاتلا .ىفشتسلما اذه في ىوتسلما نود تناك ةميشملل يجولوثابلا صحفلا نم ةدافتسلاا نأ لصالحاو .)%0( راغبأ زَرَح نع تامولعم يأب ًابوحصم Faible taux d’examen pathologique du placenta dans un hôpital de soins de santé tertiaires à Sanaa (Yémen) résumé La présente étude a évalué le nombre de placentas soumis à un examen pathologique et l’a comparé avec le nombre de placentas qui auraient dû être soumis à cet examen. Les dossiers de tous les accouchements pris en charge en 2007 dans un hôpital de soins de santé tertiaires de sanaa (Yémen) ont été étudiés. Les données des dossiers du service de pathologie ont été comparées avec celles des formulaires de demande d’examen pathologique. Le nombre de placentas examinés et le nombre de placentas attendus ont été comparés. sur 11 472 placentas, 1501 auraient dû être soumis à un examen pathologique, selon les recommandations du College of American Pathologists. Dans les faits, seuls 73 d’entre eux (4,9 %) avaient été examinés. Les taux de recherche de pathologies associées à des risques de récurrence au cours des grossesses ultérieures étaient faibles, inférieurs à 20 %. seuls 42 % des formulaires de demande d’examen pathologique donnaient des précisions sur les antécédents cliniques et aucun formulaire (0 %) ne fournissait d’information sur le score d’Apgar. L’examen pathologique du placenta était sous-utilisé dans cet hôpital. Book 17-4.indb 277 4/27/2011 11:00:31 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 278 Introduction Pathological examination of the pla- centa has the potential to clarify the pathophysiology of an adverse preg- nancy outcome, to help improve the management of the mother’s subse- quent pregnancies and to assist in the medicolegal assessment of an adverse outcome [1]. It also helps to understand any antenatal and intrapartum events that contribute to long-term neurode- velopment morbidities [2]. In 1991  the College of American  Pathologists (CAP) reported a list of maternal, fetal and neonatal and pla- cental conditions for which gross and microscopic placental examination was recommended [3]. However, most hos- pitals do not follow these recommenda- tions. Instead, the delivering physician is usually responsible for determining when pathological interpretation of the placenta is indicated [4]. The preva- lence of such examination is frequently low in most hospitals. A survey of practices showed that most pathology departments  (71%) examined 25% or  fewer of the placentas delivered at their institutions [5]. Badawi et al. in Australia found that placentas were examined in only 11.2% of cases and 0.7% of controls  fulfilling the (maternal or fetal) criteria for placental examination [6]. The aim of this study in Yemen was to evaluate the rate of submission of placentas for pathological examination in a tertiary care hospital in Sana’a and compare the observed numbers sent for examination with the expected numbers according to CAP indications. Methods Al-Thawra general hospital in Sana’a, Yemen, is a tertiary care level hospital. Submission of placentas for pathology depends totally on the decision of the delivering physician. There are no hos- pital guidelines regarding pathological examination of the placenta, and the pathology of the placenta is often not part of the teaching programme given for the staff at the hospital. Data for this study were obtained from the hospital pathology department records, which contained details of all placentas submitted from the delivery room from 1 January to 31 Decem- ber 2007. These  included the mother’s  name, date of submission, indications for examination and a summary of the results. The data were collected and compared with the information pre- sented on the pathology request forms. The request forms were assessed for 4 points: indications for placental exami- nation, gestational age, clinical history of the mother and Apgar scores. The hospital outcome records were reviewed  for  all  11 472  deliveries  at  the hospital during the study period. We categorized the indications for pla- cental  examination  into 12 categories  according to CAP guidelines (7 for rec- ommended maternal indications; 2 for  other maternal indications; and 3 for recommended fetal and neonatal indi- cations). All deliveries matching these conditions were taken as the expected number of placentas. Placentas actually sent for pathology were classified in the same way for examination to give the observed number. The demographic data of each woman whose placenta was examined were obtained. Data were computed and analysed using the Medcalc statistical programme. The data were expressed as mean and standard deviation (SD). Percentages were used when appropriate. The ob- served and expected percentages of placentas examined pathologically were compared. The difference between the 2 population values was considered sig- nificant at P < 0.05. Results During  the  year  2007,  there  were  11 472 placentas delivered at Al-Thawra  general hospital for neonates between 28 and 42 weeks of gestation. Of these,  records  showed  that  1501  placentas  met the CAP criteria for pathological examination. Only 73 of these placentas (4.9%) had actually been examined. The  difference between the expected and observed rate of placental examination was statistically significant (P = 0.003).  The demographic data of the women who had and had not had their placen- tas examined are summarized in Table 1 according to the 12 CAP indications. Evaluation of the information given in the pathology request forms revealed that 96% stated  the  indications  for pa- thology,  42% gave  a  detailed  clinical  history of the mothers and 0% gave in- formation about the Apgar score. Table 2 shows the examination rates for each  indication. The placental examination rates for cases of premature labour, still- birth and those with more than 2 previ- ous miscarriages were 16.8%, 13.6% and  7.8% respectively. Discussion Only 73 out of 1501 placentas (4.9%)  fulfilling the CAP criteria for pathology examination were actually examined in the hospital. Spencer and Khong found that one-third of placentas that should have been examined were examined [1]. However, our finding was consider- ably lower than this figure. In our hospital, the indications for placental examination are dependent on the decision of the delivering physician. For this reason, we were unable to de- termine if such indications were valued and followed by all clinicians. There are instances when one clinician decides to examine the placenta under a particular indication whereas another would not [3]. Thus, we diagnosed the cases us- ing CAP guidelines. We noted that the examination rates for some conditions associated with the possible risk of recur- rence in subsequent pregnancies were very  low, below 20%. For example,  the  placental examination rates for cases of Book 17-4.indb 278 4/27/2011 11:00:31 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 279 premature labour, stillbirth and those with more than 2 previous miscarriages  were  16.8%,  13.6%  and  7.8%  respec- tively. The low submission rate of placental examination in this hospital indicates that the practice was not considered useful by most physicians. It is likely that the lack of clear and teachable guidelines might negatively affect the appreciation of the clinical value of such practice. There is a general lack of inter- departmental communication between obstetricians and pathologists. Lack of communication between obstetricians and pathologists indicate a failure to use the information provided for each case studied. The absence of standard criteria and terms for each placental lesion used by the pathologists, combined with a lack of awareness of the need for exami- nation may contribute to discouraging obstetricians from submitting placental tissues. Most pathology reports in this hospital use histological terms that are often unfamiliar to obstetricians and not linked clinically to the underlying disease. Sun et al. stated that placental and perinatal pathology is rarely part of the residency training programme in either pathology or obstetrics, resulting in a lack of mutual vocabulary and poor communication between pathologists and obstetricians [2,7]. As the indica- tions for microscopic placental exami- nation listed by CAP guidelines are not always used in most hospitals [1,2], each institution should have its own explicit practice guidelines based on the best available evidence and com- municated to the staff. Emphasis on increasing the experience and improv- ing the diagnostic ability of the hospi- tal pathologist could help encourage obstetricians to submit placentas for examination, particularly for high-risk cases. Redline et al. emphasized that it is important for each lesion to be defined by unambiguous histological terms and subclassified according to severity, du- ration, extent and type of involvement [8]. Also enhancement of the patholo- gist’s feedback could help avoid errors, and improve the pathologist’s ability to diagnose the underlying lesions. Despite using checklist pathology request forms, there were inadequate clinical histories in 58% of cases. Failure  to provide adequate information useful for understanding the current and previ- ous pregnancy scenarios could affect the interpretation of placental examination findings and therefore hamper meaning- ful results. In our study the Apgar score Table 1 Placenta examination status according to the characteristics of mothers and pregnancy outcome Variable Placenta examined (n = 73) Placenta not examined (n = 1428) P-value Mean (SD) Mean (SD) Maternal age (years) 27.2 (6.1) 27.5 (4.7) 0.5649 Gravidity (No.) 1.35 (0.56) 1.50 (0.56) 0.7853 Gestational age (weeks) 35.7 (3.9) 36.8 (7.1) 0.1893 No. % No. % Outcome Alive 39 53.4 889 62.3 stillborn 34 46.6 539 37.7 Mode of delivery Vaginal 64 87.7 1255 87.9 caesarean 9 12.3 173 12.1 SD = standard deviation. Table 2 Observed and expected numbers of placentas sent for pathological examination according to College of American Pathologists indications Indication No. examined/no. indicated Examination rate (%) Premature delivery ≤ 34 weeks gestation 26/155 16.8 stillbirth or perinatal death 11/81 13.6 severe oligohydramnios 7/70 10.0 unexplained or recurrent pregnancy complication 8/102 7.8 Gestational age 42+ weeks 5/101 5.0 severe hypertensive disorder 2/460 0.4 Placental abruption 1/89 1.1 unexplained 3rd trimester bleeding 1/146 0.7 severe unexplained polyhydramnios 3/90 3.3 major congenital anomaly 5/77 6.5 thick or viscid meconium 3/113 2.7 Hydrops fetalis 1/17 5.9 total 73/1501 4.9 Book 17-4.indb 279 4/27/2011 11:00:31 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 280 was not recorded at all. Placental exami- nation can help determine whether the cause of death (when acute) is related to underlying pathological processes or caused by fetal distress unrecognized by the physician. Conclusion A very small proportion of placen- tas that met the CAP indications for pathological examination were actually examined in this hospital. Agreed and expl ic i t hospital guidelines detailing when to submit placentas to the pathology department for examination are needed. These are particularly important with regard to high-risk cases. References spencer mK, Khong tY. conformity to guidelines for patho-1. logic examination of the placenta. Archives of Pathology and Laboratory Medicine, 2003, 121:205–207. sun cJ et al. Discrepancy in pathologic diagnosis of placental 2. lesions. Archives of Pathology and Laboratory Medicine, 2002, 126:709–709. curtin Wm et al. Pathologic examination of the placenta 3. and observed practice. Obstetrics and Gynecology, 2007, 109:35–41. Joseph FY. Examination of placenta. 4. American Family Physician, 1998, 57(5):1045–1054. Gersell DJ, American society of clinical Pathologists. AscP 5. survey on placental examination. American Journal of Clinical Pathology, 1998, 109:127–143. badawi N et al. Why is the placenta being ignored? 6. Australian and New Zealand Journal of Obstetrics and Gynaecology, 2000, 40:343–346. salafia cm, Vintzileos Am. Why all placentas should be exam-7. ined by a pathologist in 1990. American Journal of Obstetrics and Gynecology, 1990, 163:1282–1293. redline rW et al. Placental diagnostic criteria and clinical 8. correlation—a workshop report. Placenta, 2005, 26(suppl. A):s114–117. Gender, women and primary health care renewal: a discussion paper This discussion paper brings together evidence and experience from around the world focusing on making health systems more gender responsive. The paper uses a framework that combines WHO’s six building blocks for health systems and the primary health care reforms propounded in the World Health Report 2008 on primary health  care. Furthermore, the paper provides examples of what has worked and how, and ends with an agenda for action to strengthen the work of policy-makers, their advisers and development partners as well as practitioners as they seek to integrate gender equality perspectives into health systems strengthening, including primary health care reforms. This paper can be accessed at: http://www.who.int/gender/documents/women_and_girls/9789241564038/en/ index.html Book 17-4.indb 280 4/27/2011 11:00:31 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 281 Relationship between maternal characteristics and neonatal birth size in Egypt N.E. Hassan,1 A.H. Shalaan 1 and S.A. El-Masry 1 AbstrAct this study in Egypt investigated the influence of selected maternal factors on neonatal birth size. Data were collected after delivery from 782 apparently healthy pregnant women and their neonates. A questionnaire on personal, medical, socioeconomic status, smoking habits and exposure to smoking was completed. maternal weight and height, food frequency intake during pregnancy and haemoglobin levels were recorded for 594, 234 and 246 of the mothers respectively. Neonatal birth weight, length and head circumferences were measured. A significant positive correlation between maternal anthropometric variables with neonatal birth dimensions was observed and the effect was more evident in girls than boys for bmI and head circumference. statistically significant negative correlations were found between maternal haemoglobin levels and birth size. birth size was strongly correlated with maternal consumption of micronutrient-rich food at all stages of gestation. Passive smoking significantly affected birth weight and bmI of girls more than boys. 1Department of Biological Anthropology, National Research Centre, Cairo, Egypt (Correspondence to S.A. El-Masry: masrysa@yahoo.com). received: 21/07/09; accepted: 16/09/09 صرم في ديلولا مجح ينبو ةيموملأا صئاصلخا ينب ةقلاعلا يصرلما فوؤرلا دبع رحس ،نلاعش دماح فشرأ ،نسح سيرلما ة ِّيرن ًايرهاظ نعتمتي ًامأ 782 نم ةدلاولا دعب تانايبلا تعجمو .ديلولا مجح لىع ةنَّيعم ةمومأ لماوع يرثأت ءاصقتساب ةّيصرلما ةساردلا هذه تماق :ةصلالخا .ينخدتلل ضّرعتلاو ،ينخدتلا تاداعو ،ةيداصتقلااو ةيعماتجلااو ،ةيبطلاو ،ةيصخشلا ةلالحا لوح نايبتسا لِمكُتساو .ننهادلو نمو ،ةحصلاب ،ديلولا ُنزو َسيِقو .لياَوَّتلا لىع ًاّمأ 246 ،234 ،594 في ينبولغوميلها ىوتسمو ،لملحا ءانثأ ماعطلا لوانت تا َّرَمو ،تاهملأا لوطو نزو ل ِّجُس دقو في ًاحوضو رثكأ رثلأا ناكو ،ديلولا تاسايق ينبو تاهملأل ةيترموبورثنلأا تا ِّيرغتلما ينب هب ُّدَتْعُي بيايجإ طُبارت ظحول دقو .هسأر طيمحو ،هلوطو تايوتسم ينب يبلسلا طباترلا تلااح نم ًايئاصحإ ابه ُّدتعُي ةبسن تدهوش ينح في .سأرلا طيمحو مسلجا ةلتك بَسْنَم ثيح نم روكذلا نم ثانلإا عيجم في رادقلما ةديهزلا تايذغلماب ةَّينغلا ةيذغلأل تاهملأا لوانت عم ًايوق ًاطُبارت ديلولا مجح َطَبارتو .ديلولا مجح ينبو تاهملأا في ينبولغوميلها .روكذلاو ثانلإا في مسلجا ةلتك بَسْنَمو ديلولا نزو لىع هب ُّدَتْعُي ٌيرثأت يسرقلا ينخدتلل ناك دقو .لملحا لحارم Corrélations entre les caractéristiques maternelles et les mensurations du nouveau-né en Égypte résumé La présente étude a analysé l’influence de certains facteurs maternels sur les mensurations du nouveau-né en égypte. Les données ont été recueillies après l’accouchement auprès de 782 femmes qui étaient apparemment en bonne santé pendant leur grossesse, et auprès de leur nouveau-né. un questionnaire a été administré afin d’évaluer leur situation personnelle et socioéconomique, leur état de santé, leurs habitudes en matière de tabagisme et l’exposition à la cigarette. Le poids et la taille des mères, la fréquence de leurs apports alimentaires pendant leur grossesse et leur taux d’hémoglobine ont été enregistrés pour 594, 234 et 246 d’entre elles, respectivement. Le poids, la taille et le périmètre crânien du nouveau-né ont été mesurés à la naissance. une corrélation positive significative a été établie entre les variables anthropométriques maternelles et les mensurations du nouveau-né à la naissance. celle-ci était plus élevée chez les nouveau-nés de sexe féminin pour l’indice de masse corporelle et le périmètre crânien. Les taux maternels d’hémoglobine et les mensurations du nouveau-né étaient liés par des corrélations négatives statistiquement significatives. Les mensurations du nouveau-né étaient étroitement corrélées à la consommation maternelle d’aliments riches en micronutriments à toutes les étapes de la gestation. Le tabagisme passif influait significativement sur le poids de naissance et l’indice de masse corporelle des nouveau-nés, et l’effet était plus marqué chez les filles que chez les garçons. Book 17-4.indb 281 4/27/2011 11:00:32 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 282 Introduction Intrauterine growth is now considered an important determinant of both short and long-term outcomes for an individ- ual [1]. Remarkable diversity of size and health of offspring are observed after normal pregnancies. When pregnancies are complicated by extrinsic variables such as parental factors [2], inappropri- ate maternal nutrition [3], maternal anaemia [4] or smoking [5], the birth weight and health of the neonate are substantially affected. Maternal anthropometry is a poten- tially valuable tool in the evaluation of pregnancy status and prediction of birth weight [6]. In recent years infant birth weight has been increasing in many countries, representing an obstetric haz- ard and a potential public health prob- lem since high birth weight involves a risk of obesity later in life [7]. In con- trast, a low pre-pregnancy body mass index (BMI) is one of strongest predic- tors of adverse pregnancy outcomes such as preterm birth and fetal growth retardation. A low BMI interacts with other risk factors such as smoking and stress to increase risk of these outcomes, whereas zinc supplementation and low- dose aspirin increase birth weight in thin but not normal size women. The asso- ciation between maternal thinness and adverse pregnancy outcomes may be mediated more by a low plasma volume than by decreased protein or energy status. Maternal micronutrient status may partially mediate plasma volume expansion in pregnancy, therefore im- proving maternal micronutrient status may reduce adverse outcomes through this mechanism [8]. Policy-makers and health care pro- viders need evidence about the state of maternal and child health, especially of neonates, in order to plan counselling and behavioural interventions for preg- nant women. The aim of the current study in Egypt was to investigate the influence of selected maternal factors— nutritional status, haemoglobin levels, socioeconomic class and exposure to passive smoking during pregnancy— on birth size. Methods Sample This was a cross-sectional study of normal newborn babies delivered at El-Galaa hospital for gynaecology and obstetrics in Cairo and their mothers. Permission to perform the study was granted by the Ministry of Health and Population and local ethical approval was received from El Galaa hospital. The mothers were informed about the purpose of the study and their verbal informal consent was obtained. This hospital is the largest referral hospital for gynaecology and obstetric cases in Egypt and receives women of different socioeconomic status from all governo- rates of Egypt. All neonates delivered on 3 days per week during the study period (from January  to  June 2008) were  selected.  The total sample was 782 newborn ba- bies of both  sexes (404 boys and 378  girls) and their mothers. The selected babies were singletons, full term, of ges- tational age range between 37 and 41 weeks (expressed as completed weeks since the first day of the last menstrual period), documented by ultrasound. None had detectable congenital anom- alies, genetic malformations or evident intrauterine infections. The mothers, aged between 20  and 35  years, were  free from any apparent pathological conditions or risk factors which might impair fetal intrauterine growth, such as diabetes, hypertension or renal disease. The mean age of the mothers was 26.3  years, and 34.5% were primiparous. All  had had a normal vaginal delivery. Maternal data collection A simple questionnaire was distributed to the mothers to collect information on: demographic data; obstetric history of the present pregnancy and previous pregnancies; self-reported smoking habit and exposure to passive smok- ing; and nutritional history during the present pregnancy. Trained researchers helped the mothers to complete the questionnaire. Smoking exposure Mothers were asked to provide data about active and passive smoking be- fore and during the pregnancy: her own smoking habit (how many cigarettes smoked per day); smoking habit of the baby’s father (how many cigarettes smoked per day); and her exposure to environmental tobacco smoke at home or at work (how many smokers who smoked more than a packet a day were present at her usual place of work/ home). On the basis of the question- naire, the mothers were divided into 2 groups:  controls  (non-smokers  and  non-exposed); and smoke-exposed (smokers and passive smokers). In fact none of the women were smokers so the smoke-exposed comprised only moth- ers with exposure to environmental tobacco smoke at work or at home. The controls included 241 women and their  infants  (118 males  and 123  females)  and the passive smoke-exposed group included 541 women and  their  infants  (286 males and 255 females). Socioeconomic status Mother’s SES was classified using a composite score based on parental education, paternal occupation crowd- ing score, water supply, housing, light supply and sewage disposal. A score of 16 was used as the cut-off point between  high and low SES (8–15 = low SES and  16–22 = high SES). All  the mothers  were housewives. Dietary intake Maternal dietary intake was assessed retrospectively using a food frequency questionnaire (FFQ) to obtain the frequency of  consumption of 12  food  categories  (beverages,  rice/macaroni,  legumes, vegetables, green leafy veg- etables,  fruits, meat/fish/liver/chicken,  eggs,  milk/milk  products,  bakery  Book 17-4.indb 282 4/27/2011 11:00:32 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 283 products,  sweets/molasses/halawa etc.) on a 3-point scale (once a week or less,  twice a week and alternate days/ every day). This dietary questionnaire was  completed by 234 mothers who  agreed to participate in this part of the study (of whom 116 delivered boys and  118 delivered girls). The food frequency  questionnaire was filled in after the birth: mothers were asked to remember what  they ate during  the 1st, 2nd and  3rd trimesters of pregnancy. Anthropometric measurements The following measurements were taken  for 594 mothers who agreed  to  participate in the assessment of mater- nal anthropometric status and health status  (of whom 310 delivered  boys  and 284 delivered girls): body weight to  the nearest 0.1 kg with minimal clothes  using a standardized Seca beam bal- ance; and body height to the nearest 0.1 cm using a Holtain portable anthro- pometer. Maternal haemoglobin Maternal blood haemoglobin level was evaluated  for 246 of  the mothers who  agreed to the laboratory tests for haemo- globin (of whom 156 delivered boys and  108 delivered girls). Maternal  venous  blood was taken during the first stage of labour before the administration of any venous fluids during labour; a 5 mL  sample was drawn into EDTA for com- plete blood count [haemoglobin (Hb) level, red cell count, haematocrit value and blood indices]. Maternal blood Hb value was determined by the standard cyanmethaemoglobin technique. Neonatal data collection The neonates were matched to the predetermined inclusion criteria using information from a simple question- naire to mothers about her obstetric history of previous pregnancies and the present pregnancy. Anthropometric measurements Each neonate was examined clini- cally to exclude those having any anomaly that might affect their growth. Anthropometric measures were ob- tained  for  all  782  selected  neonates  and 594 mothers [9]. The infants were measured after 6 hours to allow for birth  oedema to subside and not more than 24  hours after delivery. All measurements were made by  the  same 2  researchers.  The  neonates  wore  no/or  minimal  clothes (for which no correction was made). The following measurements were made: body weight to the nearest 10 g using a Zalamp scale;  recumbent  length (crown–heel length) to the nearest  0.1  cm  using  a  Harpenden  infantometer; and head circumference (at the level of the occiput, parietal prominence and supra-orbital ridge) to the nearest 0.1 cm using a flexible non- stretchable plastic tape. Each measure was recorded as the mean of 3 consecu- tive readings. Statistical analysis Body mass  index (BMI)  in kg/m2 was calculated for each mother and neonate. Mean and standard deviation of the anthropometric measurements were calculated separately for boys, girls and the sexes combined, and for mothers. Pearson correlation test was used for the anthropometric measurements of the neonates’ weight, length, head circum- ference and BMI and their mother’s weight, height, BMI and Hb level. The correlations were repeated with boys, girls and the combined sample. Maternal dietary intake was clas- sified into macronutrients (proteins, carbohydrates, and fat) and micronutri- ent-rich foods (milk and milk products, fruits and green leafy vegetables). Intake of specific foods based on the FFQ and socioeconomic scores were analysed as grouped variables. These groupings reflected as closely as possible the fre- quency of consumption per week. All analyses were adjusted for the neonate’s sex and maternal parity. Analysis of vari- ance test was done to examine the rela- tionship between frequency of intake of different food categories and the neona- tal anthropometric measurements. Mean and standard deviation (SD) of the studied anthropometric param- eters were calculated separately for the controls and the study group, and com- pared using the Student t-test. Data were analysed using SPSS, ver- sion 9.05. Results Anthropometric characteristics Anthropometric measurements were recorded  for  594 mothers  and  their  neonates (310 boys and 284 girls). For  various reasons, 1 or more measure- ments were missing for some of the babies and mothers. The anthropometric measurements of the mothers and their neonates are presented in Table 1. The boys had slightly higher mean values for birth weight, length and head circumference than the girls, but the differences were not significant. There were also non- significant differences regarding the anthropometric measurements of the mothers who delivered boys and those who delivered girls. Correlation between maternal and neonatal anthropometric measurements Correlation tests between maternal and neonatal anthropometric measure- ments revealed that for both sexes com- bined, maternal weight as well as height had a significant positive correlation with neonatal birth weight, length, BMI and head circumference, while maternal BMI showed a significant positive corre- lation only with birth weight, length and BMI. Similar results were found when analysing the data for girls separately. For boys, all maternal anthropometric measurements showed significant posi- tive correlations only with birth weight and length (Table 2). To control for the influence of ma- ternal height, the results of partial cor- relation tests between maternal weight and neonatal birth weight were: for boys Book 17-4.indb 283 4/27/2011 11:00:32 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 284 r = 0.138, P = 0.020,  for girls r = 0.178,  P < 0.001 and  for  the  sexes combined  r = 0.160, P < 0.001. The results of  the  correlation tests before and after con- trolling for maternal height were not significantly different. Correlation between maternal Hb & neonatal anthropometric measurements The correlation tests showed that overall maternal Hb level had a negative correlation with all neonatal anthropometric measurements, which was significant for neonatal weight, length and head circumference (Table 2). The same findings were  re- corded for each sex separately (data not shown). Maternal nutrient intake and social class This dietary questionnaire was com- pleted by 234 mothers (of whom 116  delivered boys and 118 delivered girls). Over the 3 trimesters there were no significant differences between mothers of high and low SES classes as regards the frequency of maternal intake of the micronutrients studied (milk and milk products, fruits or green leafy vegetables) for both sexes, and of the macronutrients (proteins, carbohydrates and fat) for the female neonates (data not shown). However, for male neonates, there was a signifi- cant difference between mothers’ SES as regards the frequency of maternal intake of protein and carbohydrate in the 1st trimester and of protein in the 2nd (P < 0.001). Table 1 Anthropometric parameters for neonates and their mothers Variable Neonatal parameters Maternal parameters No. of neonates Mean (SD) No. of mothers Mean (SD) Boys Weight (kg) 308 3.38 (0.5) 310 71.4 (12.1) Length (cm) 309 49.8 (2.2) 285 157.5 6.2) bmI (kg/m2) 307 13.6 (1.5) 285 28.8 (4.6) Hc (cm) 310 34.8 (1.4) n/a n/a Girls Weight (kg) 284 3.32 (0.52) 284 71.6 (13.3) Length (cm) 284 48.9 (2.3) 255 157.7 5.8) bmI (kg/m2) 284 13.8 (1.6) 255 28.8 (5.1) Hc (cm) 284 34.2 (1.4) n/a n/a Both sexes Weight (kg) 592 3.35 (0.49) 594 71.5 12.7) Length (cm) 593 49.4 (2.3) 540 157.6 (6.0) bmI (kg/m2) 591 13.7 (1.6) 540 28.8 (4.8) Hc (cm) 594 34.5 (1.4) n/a n/a BMI = body mass index; HC = head circumference; SD = standard deviation; n/a = not applicable. Table 2 Correlation between maternal and neonatal anthropometric measurements for boys and girls and correlation between neonatal anthropometric measurements and maternal haemoglobin (Hb) level in both sexes combined Neonatal parameter Maternal parameter Weight Height BMI Hb level r P-value r P-value r P-value r P-value Boys Weight 0.19 < 0.001 0.12 0.037 0.13 0.026 – – Length 0.20 < 0.001 0.15 0.011 0.14 0.022 – – bmI 0.07 0.194 0.05 0.371 0.05 0.430 – – Hc 0.07 0.196 0.10 0.095 0.03 0.630 – – Girls Weight 0.24 < 0.001 0.18 0.003 0.37 0.006 – – Length 0.18 0.003 0.15 0.018 0.13 0.045 – – bmI 0.18 0.003 0.13 0.032 0.13 0.046 – – Hc 0.15 0.012 0.15 0.020 0.10 0.102 – – Both sexes Weight 0.22 < 0.001 0.15 < 0.001 0.15 < 0.001 –0.11 0.03 Length 0.18 < 0.001 0.14 < 0.001 0.13 0.003 –0.13 0.03 bmI 0.13 0.002 0.09 0.029 0.09 0.041 –0.00 0.45 Hc 0.11 0.009 0.11 0.008 0.07 0.133 –0.14 0.02 BMI = body mass index; HC = head circumference. Book 17-4.indb 284 4/27/2011 11:00:32 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 285 Effect of maternal nutrient intake on neonatal anthropometric measurements The effect of the frequency of maternal intake of nutrients (once a week, twice a week or on alternate days) during the 3 trimesters of pregnancy, on the physical growth of neonates was studied. For boys, the frequency of maternal intake of macronutrients (carbohydrates, fat and protein) had a non-significant influence on neonatal anthropometric measurements during the 3 trimesters (data not shown). For girls, frequent intake of carbohydrates by mothers showed a non-significant effect on neo- natal anthropometric measurements during the 3 trimesters. The frequency of maternal intake of fats had a significant effect on weight and BMI during the 3rd trimester. The frequency of maternal intake of protein during the 2nd trimes- ter had a significant effect on length and head circumference and during the 3rd trimester on weight (P < 0.05). A significant relationship with birth size was found for frequency of ma- ternal consumption of micronutrient- rich foods (milk and milk products, fruits and green leafy vegetables) especially  during  the  2nd  trimester  (Tables 3–5).  For boys, maternal intake of milk and milk products during  the 2nd  tri- mester had a significant relationship with birth weight and BMI (Table 3). Consumption of these during the 3rd trimester had a significant influence on boys’ birth weight  (Table 5). Fre- quent intake of fruits and green leafy vegetables  from the 2nd  trimester had  a significant effect on boys’ birth weight, length, head circumference and BMI at birth. Frequency of intake of fruits and green leafy vegetables during the 3rd trimester showed a significant effect on boys’ birth weight. For girls, the frequency of maternal consumption of milk and milk products during the 2nd trimester had a significant  relationship with birth weight and BMI but not length (Table 4). Frequent in- take of  fruits during  the 2nd  trimester  had a significant effect on girls’ weight, length and BMI. Frequent intake of fruits during the 3rd trimester had a significant effect on girls’ birth weight and BMI (Table 5). Maternal intake of  green  leafy vegetables during  the 2nd  trimester had a significant effect on girls’ birth weight and BMI and during the 3rd trimester had a significant effect on BMI. Data for head circumference for girls showed no significant influences on neonatal anthropometric measure- ments (data not shown). Effect of passive smoking on neonatal anthropometric measurements Comparison of the neonatal anthropo- metric parameters of the control group, whose mothers were not exposed, and the group whose mothers were exposed to environmental tobacco smoke are presented  in Table 6. For both  sexes  Table 3 Relationship between maternal intake of food rich in micronutrients during the second trimester and newborn anthropometric measurements for boys Food group/maternal frequency of intake No. of neonates Neonatal parameters: boys Weight (kg) Length (cm) HC (cm) BMI (kg/m2) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Milk & milk products Once a week 6 3.23 (0.43) 49.8 (1.8) 34.3 (1.0) 13.0 (0.8) twice a week 48 3.11 (0.45) 49.2 (2.6) 34.0 (1.6) 12.8 (1.5) Alternate/every day 62 3.45 (0.43) 50.4 (2.0) 34.6 (1.3) 13.6 (1.3) F-value 6.79 2.68 1.75 4.34 P-value 0.002 0.073 0.179 0.015 Fruits Once a week 14 2.83 (0.34) 48.4 (2.6) 33.1 (0.9) 12.1 (1.2) twice a week 34 3.17 (0.49) 49.1 (2.4) 33.9 (1.5) 13.1 (1.5) Alternate/every day 68 3.45 (0.43) 50.4 (2.0) 34.6 (1.3) 13.5 (1.3) F-value 13.37 7.49 8.32 6.74 P-value < 0.001 < 0.001 < 0.001 0.002 Green leafy vegetables Once a week 2 3.33 (0.11) 50.5 (0.7) 33.7 (0.5) 13.0 (0.1) twice a week 33 3.02 (0.43) 48.9 (2.5) 33.7 (1.3) 12.6 (1.2) Alternate/every day 81 3.40 (0.47) 50.2 (2.2) 34.5 (1.4) 13.5 (1.4) F-value 8.11 3.85 3.53 4.87 P-value < 0.001 0.024 0.033 0.009 BMI = body mass index; HC = head circumference; SD = standard deviation. Book 17-4.indb 285 4/27/2011 11:00:33 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 286 combined and for girls separately, the control group had higher values than the smoke-exposed group but the differ- ences were significant only for weight and BMI. For boys, no significant differ- ences were observed for any anthropo- metric parameters. Discussion There is a considerable amount of evi- dence from humans and other animals, including the results of embryo transfer studies, that size at birth is primarily determined by the mother, whose influ- ence acts more through the intrauterine environment than through the genes transmitted to her baby [10,11]. Transplacental exchange provides all the metabolic demands of fetal growth and uterine and umbilical blood flow rates are in turn dependent to a large degree on the vascularization of the placenta. Therefore, factors that influence placental vascular develop- ment are likely to impact on fetal growth and development, and thus on neonatal morbidity and mortality [12]. In a study on nutrient intake in rats during preg- nancy on placental growth and vascular development, both nutrient restrictions and over-nourishment during preg- nancy suppressed placental cell prolif- eration and vascularity [12]. Further studies in this area will lead to improved methods of managing nutritionally- compromised pregnancies. Maternal passive smoking has also been shown to affect the fetal environ- ment, causing fetal growth disturbance [13] and abnormal morphological changes in the internal tissue of new- borns [14]. Non-smoking pregnant women exposed to environmental smoke have been found to have detect- able elevated levels of nicotine and coti- nine in their serum, urine and umbilical cord blood [15–17] and hair [18]. Al- though these levels were not as high as those of active smokers, there is evi- dence that exposure to passive smoking Table 4 Relationship between maternal intake of food rich in micronutrients during the second trimester and newborn anthropometric measurements for girls Food group/ maternal frequency of intake No. of neonates Neonatal parameters: girls Weight (kg) Length (cm) BMI (kg/m2) Mean (SD) Mean (SD) Mean (SD) Milk & milk products Once a week 13 2.92 (0.71) 48.3 (3.2) 12.4 (2.1) twice a week 45 3.12 (0.41) 48.6 (2.4) 13.2 (1.1) Alternate/every day 61 3.27 (0.38) 49.2 (1.9) 13.5 (1.4) F-value 4.21 1.53 3.80 P-value 0.017 0.221 0.025 Fruit Once a week 25 2.82 (0.39) 47.8 (2.2) 12.3 (1.3) twice a week 38 3.18 (0.45) 48.9 (2.3) 13.3 (1.3) Alternate/every day 56 3.33 (0.37) 49.3 (2.1) 13.8 (1.4) F-value 14.07 3.73 10.37 P-value < 0.001 0.027 < 0.001 Green leafy vegetables Once a week 4 2.74 (0.91) 48.8 (3.0) 11.3 (3.2) twice a week 34 3.08 (0.39) 48.5 (1.8) 13.1 (1.2) Alternate/every day 81 3.24 (0.43) 49.0 (2.4) 13.5 (1.4) F-value 3.63 0.59 5.09 P-value 0.029 0.555 0.008 BMI = body mass index; SD = standard deviation. Table 5 Relationship between maternal intake of food rich in micronutrients during the third trimester and birth weight and BMI for both sexes Food group/ maternal frequency of intake No. of neonates Neonatal parameters Boys Girls Both Weight (kg) Weight (kg) BMI (kg/m2) Mean (SD) Mean (SD) Mean (SD) Milk & milk products Once a week 42 2.97 (0.37) 3.03 (0.30) 13.0 (1.1) twice a week 48 3.47 (0.47) 3.31 (0.52) 13.6 (1.7) Alternate/every day 26 3.47 (0.41) 3.33 (0.54) 13.4 (1.7) F-value 3.38 1.43 0.75 P-value < 0.001 0.099 0.822 Fruits Once a week 38 3.12 (0.34) 3.02 (0.26) 12.9 (1.2) twice a week 26 3.29 (0.52) 3.15 (0.53) 13.1 (1.5) Alternate/every day 51 3.46 (0.50) 3.64 (0.42) 14.5 (1.4) F-value 1.72 3.66 3.00 P-value 0.026 < 0.001 0.004 Green leafy vegetables Once a week 20 3.05 (0.39) 3.13 (0.52) 13.2 (1.7) twice a week 48 3.24 (0.48) 3.19 (0.38) 13.3 (1.3) Alternate/every day 48 3.44 (0.48) 3.21 (0.49) 13.3 (1.3) F-value 2.55 1.06 1.98 P-value < 0.001 0.409 0.045 BMI = body mass index; SD = standard deviation. Book 17-4.indb 286 4/27/2011 11:00:33 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 287 can produce nicotine uptake sufficient  to affect birth outcome through mecha- nisms similar to those affecting smokers. Passive smoking causes placental va- soconstriction, resulting in diminished utero–placental blood flow which con- tributes to the lower birth weight associ- ated with passive smoking. Also, fetal growth is known to be retarded by the direct toxic effects of nicotine, carbon monoxide and other substances gener- ated by burning cigarettes [19–21]. Our findings highlighted the inter- relations between the body physique of the mother, her nutritional status, hae- moglobin levels, socioeconomic class and her exposure to passive smoking during pregnancy versus intrauterine growth and birth size of her neonate. Significant positive correlations be- tween maternal anthropometric param- eters and neonatal birth dimensions were observed. These effects were more evident in girls than boys as regards BMI and head circumference. Our results are in agreement with many other studies which indicated that neonatal growth, as reflected by birth weight, length and head circumference, are mostly influenced by maternal size [22,23]. A study in Bangladesh found that the best predictor of birth weight as a con- tinuous variable was maternal weight at registration and that a combination of initial weight and height of the mother was not as good a predictor of low birth weight as weight alone [24]. A study in Canada concluded that slower fetal growth due to maternal short stature or low prepregnancy BMI was physi- ological and not associated with a risk of perinatal death [25]. In Croatia, mater- nal pregestational weight, weight at de- livery, gestational weight gain and body height correlated significantly with neo- natal birth weight and birth length [26].  However, Gonzalez-Cossio et  al.  [27]  and Haschke and Van’t Hof [28] found  that maternal predictors for neonatal birth weight were different from those for neonatal birth length. A study in the Netherlands showed that there were ethnic differences in fe- tal growth, which to a large extent could be attributed to differences in maternal weight, height, age and parity. For some ethnic groups, however, additional fac- tors are involved, as differences remain significant after correction for fetal and maternal characteristics [29]. Statistically significant negative cor- relations were found between maternal haemoglobin levels and birth size. These findings agree with results reported on neonates from different ethnic commu- nities of African, European and Ameri- can neonates [30–32]. The  increase  in  plasma volume appears necessary for normal fetal growth and development. It has been reported that this physi- ological change results in low haema- tocrit values during pregnancy [33]. It is likely that poor outcomes associated with a high haematocrit are related to a failure of expansion of plasma volume which is necessary for promotion of the uteroplacental circulation which in turn promotes the nourishment and growth of the fetus. In ours study among the macronutrients, only fat and pro- tein intake showed an association with girls’ birth size during the 3rd trimester. The frequency of maternal intake of macronutrients was unrelated to any of the studied anthropometric indices for boys. Agarwal et al. indicated that increased caloric intake during preg- nancy was significantly associated with increased birth weight [34]. On the other hand, in a study in Spain, caloric intake did not show a direct effect on intrauterine  growth  retardation  [35].  However, other studies found that bal- anced protein–energy supplements dur- ing pregnancy can reduce the incidence of small-for-gestational-age infants by almost one-third [36,37]]. Birth size was strongly correlated with maternal micronutrient-rich food intake at all stages of gestation. The present data suggest that improved maternal intake of milk and green leafy vegetables at all stages of gestation and fruits from the second trimester until late gestation could lead to improved fetal growth. In a Danish study, milk intake Table 6 Comparison of neonatal anthropometric measurements by maternal passive smoking exposure Neonatal parameter Controls (boys n = 118; girls n = 123) Passive smoke- exposed (boys n = 286; girls n= 255) P-value Mean (SD) Mean (SD) Boys Weight (kg) 3.39 (0.42) 3.38 (0.37) Ns Length (cm) 49.9 (2.1) 49.8 (2.0) Ns bmI (kg/m2) 13.6 (1.4) 13.6 (1.4) Ns Hc (cm) 34.7 (1.3) 34.8 (1.4) Ns Girls Weight (kg) 3.41 (0.53) 3.30 (0.49) < 0.01 Length (cm) 49.1 (1.9) 48.9 (2.0) Ns bmI (kg/m2) 14.1 (1.8) 13.7 (1.5) < 0.01 Hc (cm) 34.4 (1.5) 34.1 (1.3) Ns Both sexes Weight (kg) 3.40 (0.48) 3.34 (0.43) < 0.05 Length (cm) 49.5 (2.0) 49.4 (2.1) Ns bmI (kg/m2) 13.9 (1.6) 13.6 (1.5) < 0.05 Hc (cm) 34.5 (1.4) 34.5 (1.4) Ns SD = standard deviation; BMI = body mass index; HC = head circumference; NS = not significant. Book 17-4.indb 287 4/27/2011 11:00:33 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 288 in pregnancy was associated with higher birth weight for gestational age, lower risk of small-for-gestational-age babies, and higher risk of large-for-gestational- age babies. Birth weight was related to intake of protein, but not of fat derived from milk [38]. Rao et al. in India found  that birth size was affected by milk and its products at week 18 of gestation and  by high intake of fruits and green leafy vegetables  at week  28  [39]. Godfrey  et al. concluded that low maternal in- takes of dairy and meat protein in late pregnancy were associated with lower placental growth and birth weight [40].  Maternal energy requirements are not a great influence on small-for-gestation- age babies but maternal consumption of micronutrients is believed to have an effect [41]. In south-east Nepal multiple micronutrients increased birth weight and head and chest circumferences but not body length [42]. Passive smoking of mothers in our study significantly affected the birth weight and BMI of girls more than boys. No explanation could be found in the literature for this sex difference. Jad- sri and Jadsri in Thailand observed no association between maternal passive smoking, low birth weight and sex of newborn infants [43]. In Nagoya, Japan, a prospective study on maternal active and passive smoking and fetal growth reported an adverse effect of maternal active smoking on fetal growth in the Japanese pregnant population, but with a small influence of maternal passive smoking [44]. In the Czech Republic, passive smoking exposure increased the risk of low birth weight [45]. Nafstad et  al. also concluded that women exposed to passive smoking were more likely to deliver small-for-gestational-age infants [18]. On the other hand, Chen, Peder- son and Lefcoe found a non-significant birth weight difference between new- born infants of mothers exposed and not exposed to passive smoking [46]. Read and Stanley stated that paternal smoking was an independent risk fac- tor for recurrent small-for-gestational- age term births among non-smoking mothers [47]. Luciano et al. noted that exposure of the fetus to passive smoking involved a reduction of most anthropo- metric measurements and body fat, not only birth weight [48]. This agrees to a  certain extent with the current results in female neonates. 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European Journal of Obstetrics, Gynecology, and Reproductive Biology, 1998, 81:101–109. Kalinka J et al. Influence of environmental smoke exposure 21. during pregnancy on umbilical blood flow velocity. Ginekolo- gia Polska, 2000, 71:653–657. Parsons tJ, Power c, manor O. Fetal and early life growth and 22. body mass index from birth to early adulthood in 1958 british cohort: longitudinal study. BMJ (Clinical Research Ed.), 2001, 323:1331–1335. schmidt mK et al. Nutritional status and linear growth of Indo-23. nesian infants in west java are determined more by prenatal environment than by postnatal factors. Journal of Nutrition, 2002, 132:2202–2207. Nahar s, mascie-taylor cG, begum HA. maternal anthropom-24. etry as a predictor of birth weight. Public Health Nutrition, 2007, 10(9):965–970. Zhang X et al. Are babies born to short, primiparous, or thin 25. mothers “normally” or “abnormally” small? Journal of Pediatri- cs, 2007, 150(6):603–607. miletić t et al. Effect of parental anthropometric parameters on 26. neonatal birth weight and birth length. Collegium Antropologi- cum, 2007, 31(4):993–997. González-cossío t et al. Length and weight at birth: the role of 27. maternal nutrition. Salud Pública de México, 1998, 40:119–126. Haschke F. Van’t Hof mA. Euro-growth references for length, 28. weight, and body circumferences, Euro-Growth study Group. Journal of Pediatric Gastroenterology and Nutrition, 2000, 31(suppl. 1):s14–38. Drooger Jc et al. Ethnic differences in prenatal growth and the 29. association with maternal and fetal characteristics. Ultrasound in Obstetrics and Gynecology, 2005, 26(2):115–122. steer P. the effect of maternal anaemia and iron deficiency on 30. the ratio of fetal weight to placental weight. British Journal of Obstetrics and Gynaecology, 1992, 99:271–272. Khalid mE, Ali mE, Ali KZ. Full-term birth weight and placental 31. morphology at high and low attitude. International Journal of Gynaecology and Obstetrics, 1996, 57:259–265. thame m et al. relationship between maternal nutritional sta-32. tus and infant’s weight and body proportions at birth. European Journal of Clinical Nutrition, 1997, 51:134–138. Lu Zm, Goldenberg rL, clever ZP. the relation between 33. maternal hematocrit and pregnancy outcome. Obstetrics and Gynecology, 1991, 77(2):190–194. Agarwal KN et al. Impact of the integrated child development 34. services (IcDs) on maternal nutrition and birth weight in rural Varanasi. Indian Pediatrics, 2000, 37:1321–1327. martins Eb, Núñez urquiza rm. consumo calorico, estado nu-35. tricional materno, y retraso del crecimiento intrauterine [En- ergy intake, maternal nutritional status and intrauterine growth retardation]. Cadernos de Saude Publica, 2003, 19:279–285. rush D. maternal nutrition and perinatal survival. 36. Nutrition Reviews, 2001, 59:315–326. Kramer ms. Effects of energy and protein intakes on pregnancy 37. outcome: an overview of the research evidence from control- led clinical trials. American Journal of Clinical Nutrition, 1993, 58:627–635. Olsen sF et al. NutrIX consortium. milk consumption during 38. pregnancy is associated with increased infant size at birth: pro- spective cohort study. American Journal of Clinical Nutrition. 2007, 86(4):1104–1110. rao s et al. Intake of micronutrient-rich foods in rural Indian 39. mothers is associated with the size of their babies at birth: Pune maternal Nutrition study. Journal of Nutrition, 2001, 131:1217–1224. Godfrey K et al. maternal nutrition in early and late pregnancy 40. in relation to placental and fetal growth. British Medical Jour- nal, 1996, 312:410–414. coutts A. Nutrition and the life cycle. 1: maternal nutrition and 41. pregnancy. British Journal of Nursing, 2000, 9:1133–1138. christian P et al. Effects of alternative maternal micronutrient 42. supplements on low birth weight in rural Nepal: double blind randomised community trial. British Medical Journal, 2003, 326:571–586. Jadsri s, Jadsri c. Parental smoking habits and infant birth 43. weight. Asia-Pacific Journal of Public Health, 1995, 8:134–137. matsubara F et al. maternal active and passive smoking and 44. fetal growth: A prospective study in Nagoya, Japan. Journal of Epidemiology, 2000, 10:335–343. Dejmek J et al. the exposure of nonsmoking and smoking 45. mothers to environmental tobacco smoke during different gestational phases and fetal growth. Environmental Health Per- spectives, 2002, 110:601–606. chen Y, Pederson LL, Lefcoe Nm. Passive smoking and low 46. birthweight. Lancet, 1989, 334:54–55. read AW, stanley FJ. A comparison of recurrent and isolated 47. small-for-gestational-age term births. Paediatric and Perinatal Epidemiology, 1991, 5:138–156. Luciano A et al. the influence of maternal passive and light 48. active smoking on intrauterine growth and body composition of the newborn. European Journal of Clinical Nutrition, 1998, 52:760–763. Book 17-4.indb 289 4/27/2011 11:00:34 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 290 Relationship between birth weight and domestic maternal passive smoking exposure M.A.A. Wadi 1 and S.S. Al-Sharbatti 2 AbstrAct this study aimed to assess the relationship between birth weight and maternal exposure to passive smoking during pregnancy, and to investigate some other determinants of birth weight. A retrospective cohort study in baghdad, Iraq was conducted during February to August 2004 on a random sample of 300 non-smoker housewife mothers, interviewed 24 hours after delivery: 150 were not exposed to passive smoking at home and 150 were exposed. the mean birth weight of exposed newborns was significantly lower than non-exposed newborns. In exposed newborns, a significant inverse relationship was noticed between birth weight and the number of cigarettes smoked by household members (r = –0.27). multiple regression analysis showed that after controlling for all the variables studied, birth weight had a significant inverse correlation with the maternal exposure to passive smoking and a positive correlation with adequate antenatal care. 1Ministry of Health, Baghdad, Iraq. 2Department of Community Medicine, College of Medicine, Gulf Medical University, Ajman, United Arab Emirates (Correspondence to S.S. Al-Sharbatti: shatha_alsharbatti@yahoo.com). received: 02/07/09; accepted: 05/10/09 نيرخلآا يننخدلما ناخدل ًايسرق تاهملأا ض ُّرعتب دولولما نزو ةقلاع يتبشرلا ىذش ،يداو اهم نزول ىرخلأا تاد ِّدحلما ضعب ءاصقتسا عم ،)يبلسلا( يسرقلا ينخدتلل هتدلاو ض ُّرعتب دولولما نزو ةقلاع مييقتل ةساردلا هذه ْتَيرجُأ :ةصلالخا ةنّوكم ةيئاوشع ةنيع لىع 2004 سطسغأ/بآو ريابرف/طابش يرهش ينب مايف قارعلاب دادغب ةنيدم في ةيداعتسلاا ةساردلا هذه ْتَيرجُأ دقو .دولولما ناخدل ًايسرق نضّرعتي لم ًامأ نوسخمو ةئم :ةدلاولا دعب ةعاس نيشرعو عبرأ نوضغ في ّنهتلباقم ْتََّتمو ،تانخدلما يرغ تويبلا تابر نم ةئمثلاث نم ديلاومب ًةنراقم ابه ُّدَتْعُي ةجردب لقأ ينخدتلل متهاهّمأ تضّرعت نيذلا ديلاولما نزو طسوتم ناك دقو .هل َنْض َّرَعَت ًاّمأ نوسخمو ةئمو لزنلما في يننخدلما .) r = -0.27 طابترلاا لماعم( ةسرلأا دارفأ اهنخدي يتلا رئاجسلا ددعو ديلولا نزو ينب ابه ُّدَتْعُي ةيسكع ةقلاع تظحول دقو .ينخدتلل تاضّرعتلما يرغ ُّدَتْعُي ةجردب ًايسكع ًاطبارت ًاطباترم ناك دولولما نزو نأ – دهاوشلا تاّيرغتم لىع ةسوردلما تاّيرغتلما عيجم طبض دعب - ددعتلما ّفي ُّوَحَّتلا ليلحتلا رهظأو .لملحا لبق ةمئلام ةياعر دوجولو يسرقلا ينخدتلل تاهملأا ض ُّرعت عم ابه Association entre le poids de naissance du nouveau-né et l’exposition au tabagisme passif de la mère à son domicile résumé La présente étude a évalué l’association entre le poids de naissance du nouveau-né et l’exposition au tabagisme passif de la mère pendant la grossesse, et a recherché d’autres déterminants du poids de naissance. une étude de cohorte rétrospective a été conduite à bagdad, en Iraq, entre février et août 2004 sur un échantillon sélectionné au hasard de 300 mères au foyer non fumeuses, interrogées 24 heures après l’accouchement : 150 mères n’avaient pas été exposées au tabagisme passif à leur domicile, contrairement aux 150 autres femmes. Le poids de naissance moyen des nouveau-nés exposés était significativement inférieur à celui des nouveau-nés non exposés. chez les nouveau-nés exposés, une relation inverse significative a été observée entre le poids de naissance et le nombre de cigarettes fumées par les membres du ménage (r = –0,27). L’analyse de régression multiple a indiqué qu’après le contrôle de toutes les variables étudiées, le poids de naissance était inversement et fortement corrélé au tabagisme passif, mais positivement et fortement corrélé au recours à des soins prénatals appropriés. Book 17-4.indb 290 4/27/2011 11:00:34 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 291 Introduction Although tobacco smoke has long been linked to various diseases among smokers, it was not until 1964 that this  association was publicly established by the landmark report of the US Surgeon General [1]. Twenty years later, atten- tion turned to the possible effect of tobacco smoke on non-smokers [2]. Passive smoking is involuntary or forced smoking when non-smokers inhale en- vironmental tobacco smoke [3–5]. Maternal exposure to tobacco smoke has been associated with in- creased levels of nicotine and cotinine in the serum or urine of the mother and the neonate and in the amniotic fluid [6]. These substances constitute a hazard to the fetus as they cross the placental barrier and may act to inhibit fetal growth [6–8]. Maternal passive and light active smoking has been as- sociated with significant reductions in birth weight, crown–heel length, up- per- and lower-arm length and head circumference of neonates [9]. The relation between maternal smoking and fetal development is thought to arise from a direct toxic effect of smoke or from an indirect effect mediated by a reduction in maternal weight gain. The relation between birth weight and pas- sive smoking via the father and/or other  household members  is more difficult  to explain; one theory is that smoke inhaled passively has the same effect on the fetus as maternal smoking [10]. No previous studies on this subject have been conducted in Baghdad, Iraq. Hence, the aim of the current study was to assess the relationship between birth weight and home exposure to passive smoking during pregnancy, and to as- certain the influence of selected factors on neonatal birth weight. Methods A retrospective cohort study was con- ducted during February–August 2004. Sample The study included a convenience sample of 300 non-smoker housewife  mothers who delivered in the labour ward of Al-Yarmok hospital, Baghdad. Only women who were housewives were selected in order to overcome the confounding effect of possible exposure at the work place. The women were interviewed within 24 hours  after delivery. A  sys- tematic random sampling method was used to select the women. None of the women invited refused to participate in the study. The study included 2 groups  of  150 women:  the  first  group were  non-smoker mothers who were not exposed to passive smoking at home during pregnancy; the second group were non-smoker mothers who had a history of smoke exposure. Mothers’ home exposure to pas- sive smoking was defined as 5 or more  cigarettes smoked per day by others in the mother’s presence [11]. Women who were healthy (no history of acute or chronic diseases), had accurate in- formation about their last menstrual period, age and prepregnancy weight, had a singleton pregnancy and gave birth to a full-term baby with no obvious congenital anomalies were included in this study. Data collection Direct interview of the participants was done by the research team using a specially designed questionnaire which included the following information: mother’s age and residence, parents’ level of education (primary school or less; intermediate or secondary school; college or higher education), number of household members and number of rooms (used for calculation of crowd- ing index). Parents’ education and crowding index were used as indicators for socioeconomic status. Informa- tion about the current pregnancy was collected (gestation; last menstrual period) and expected date of delivery was determined depending on infor- mation concerning the last menstrual period. Adequacy of antenatal care was evaluated depending on the number of visits to a primary health care centre (adequate = 5 or more visits during the  whole pregnancy [12]). Data about the smoking habit of the child’s father and the smoking habit of all household members in the presence of the preg- nant woman were collected. The birth weight of the baby and the mother’s weight before delivery were measured and weight gain during preg- nancy was calculated by subtraction of the prepregnancy weight from the predelivery weight. Mother’s height was also measured and recorded. The study was approved by the Scientific Council of Community and Family Medicine. The study was dis- cussed with the participants and verbal consent was taken from them before enrolment in the study. Statistical analysis The data analysis was carried out using SPSS, version 13. The statistical significance of the difference between the mean and standard deviation (SD) values was assessed using the independ- ent sample t-test, and the significance of the association between the frequencies of other variables was assessed using the chi-squared test. Multiple regression analysis was used to control for inter- relations between potential predictors of birth weight. P < 0.05 was used as the cut-off level  for statistical significance. Results A  total of 300 women were  included  in  this  study: 150 women not exposed  to passive  smoking at home and 150  women exposed to passive smoking. The number of low birth weight ba- bies  (<  2500  g)  in  the  exposed  and  non-exposed groups were 17 (11.3%)  and  6  (4.0%)  respectively. The odds  Book 17-4.indb 291 4/27/2011 11:00:34 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 292 ratio was 3.07 (95% confidence interval:  1.17–8.01),  i.e.  exposed women had a  3.07 higher  risk of having  a  low birth  weight baby (P < 0.05). The mean birth weight of the passive smoke-exposed babies was significantly lower [3183 (SD 550) g] than that of the  non-exposed babies [3381 (SD 531) g]  (t = 3.786, P < 0.001) (Table 1). In the exposed neonates, a signifi- cant inverse relationship was noticed between birth weight and the number of cigarettes smoked by household mem- bers (r = –0.27, P = 0.002) (Figure 1). The proportion of males and females in the non-exposed babies was 54% and  46% respectively, while  for  the exposed  group  it was 35% and 65% respectively  (z =3.37, P  <  0.05). The mean  birth  weights were lower in the exposed male and female subgroups compared with their counterparts in the non-exposed groups; the differences were significant for both males and females (Table 1). Most of  the 300 women  studied,  86%, resided in urban areas. In these ar- eas the proportion of women exposed to passive smoking was higher than those who were  not  exposed  (52%  versus  48%);  for women with  rural  residence  the  reverse  was  found  (38%  versus  62%). No  significant  association was  found between residence and exposure to passive smoking (χ2 = 2.77, P = 0.1).  No significant differences were noticed between the mean birth weights of the exposed and non-exposed babies from the  rural  residence  group  (Table  2).  However, the mean birth weight of the exposed babies in the urban residence group was significantly lower than their counterparts in the non-exposed group. Table 1 Distribution of neonatal birth weight by sex and maternal passive smoking exposure Sex/exposure No. of neonates Mean (SD) birth weight (g) t-value P-value Males Non-exposed 81 3325 (509) 2.570 < 0.001 Exposed 53 3061 (573) Females Non-exposed 69 3319 (602) 2.192 0.03 Exposed 97 3112 (552) Both sexes Non-exposed 150 3381 (531) 3.786 < 0.001 Exposed 150 3183 (550) SD = standard deviation. Figure 1 Relationship between birth weight and number of cigarettes smoked by household members (r = –0.27; P = 0.002) of Book 17-4.indb 292 4/27/2011 11:00:34 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 293 Analysis of birth weight according to parents’ education level (Table 3) showed that the mean birth weights were lower in the exposed group for all education levels of mothers and fathers. The differences between the mean birth weights of the exposed and non-exposed groups were significant in neonates whose parents had lower levels of education. Concerning  history  of  iron/folic  acid supplement intake during preg- nancy, the frequency of women who had such a history in the non-exposed and  exposed groups were 49.3% and  50.7% respectively (P > 0.05). The mean  birth weight values were significantly lower among the smoke exposed ver- sus non-exposed babies, regardless of whether the mothers had or had not received  iron/folic  acid  supplements  during their pregnancies (Table 4). Multiple regression analysis To control for interrelations between different variables, a multiple regression analysis was done with birth weight as the dependent variable and selected independent variables (Table 5). After  controlling for all the variables studied, only passive smoking exposure and utilization of primary health care serv- ices (adequate antenatal care) had a statistically significant correlation with birth weight (P  < 0.001 and P  = 0.03  respectively). Discussion The negative effects of passive smok- ing on the health of the fetus or child continue to receive little attention in the Eastern Mediterranean Region, despite the large volume of research in this area. Passive smoking during pregnancy has been associated with a reduction in head circumference at birth, a higher inci- dence of sudden infant death syndrome, decreased lung function and increased risk of severe infections, including res- piratory syncytial virus bronchiolitis; there is also a relationship between pas- sive smoking and behavioural disorders, including attention deficit/hyperactivity  disorder [13]. A significant relationship has been documented between active smoking during pregnancy and fetal growth re- tardation [14]. Increased interest has also been focused on the effect of pas- sive smoking on birth weight [15]. The  present study was conducted to assess the relationship between birth weight and domestic exposure to passive smok- ing during pregnancy. Selection of the 300 women for the study was based on  the history of home exposure to passive smoking during pregnancy. None of the women in the sample worked outside the home and the esti- mation of smoke exposure in the cur- rent study was done by a questionnaire that involved the number of cigarettes Table 2 Distribution of neonatal birth weight by residence and maternal passive smoking exposure Residence/ exposure No. of neonates Mean (SD) birth weight (g) t-value P-value Urban Non-exposed 124 3364 (570) 4.186 < 0.001 Exposed 134 3073 (545) Rural Non-exposed 26 3228 (520) 0.293 0.771 Exposed 16 3281 (648) SD = standard deviation. Table 3 Distribution of neonatal birth weight by parents' education level and maternal passive smoking exposure Education level/ exposure No. of neonates Mean (SD) birth weight (g) t-value P-value Fathers Primary school or lower Non-exposed 124 3349 (565) 3.440 < 0.001 Exposed 119 3103 (551) Secondary school Non-exposed 19 3298 (507) 1.253 0.22 Exposed 24 3077 (624) College or higher Non-exposed 7 3289 (728) 0.784 0.448 Exposed 7 3021 (532) Mothers Primary school or lower Non-exposed 111 3319 (552) 2.922 0.004 Exposed 99 3091 (579) Secondary school Non-exposed 23 3513 (557) 2.984 0.004 Exposed 36 3111 (469) College or higher Non-exposed 16 3239 (601) 0.667 0.510 Exposed 15 3087 (652) SD = standard deviation. Book 17-4.indb 293 4/27/2011 11:00:35 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 294 smoked by household members and took into account several potential confounders. Other studies depend on measurement of urine cotinine level to evaluate the risk of exposure to pas- sive smoking [16]. However, a study by the Centers for Disease Control and Prevention found that urine cotinine concentration did not explain more variability in birth weight than did self- reported number of cigarettes smoked per day [17]. Ourt data showed that exposure to passive smoking during pregnancy was associated with a significantly lower mean birth weight in neonates of exposed mothers than those of non- exposed mothers. This observation con- firms other reports that passive smoking during pregnancy can adversely affect fetal growth [11,18]. In the present study the group of newborn infants exposed to passive smoking had a mean birth weight 198.4 g lower than non-exposed infants.  This is consistent with another study which showed that the birth weight of babies of passive smoking-exposed mothers was 189 g  lower  than  that of  babies of the non-exposed mothers [19]. Similarly, a study in Denmark showed that maternal exposure to passive smoking was associated with a reduction  in birth weight of 120 g per  pack of cigarettes smoked per day by the father. This relationship remained statistically significant after controlling for mother’s age, parity, alcohol and tobacco consumption, illness during pregnancy and sex of the baby [20]. We found that exposure to passive smoking during pregnancy increased the risk of having a low-birth-weight infant  (< 2500 g) 3-fold. This finding  is consistent with the study in Den- mark, in which exposure to passive smoking during pregnancy significantly increased the risk of having a low birth weight infant (relative risk 2.17, 95% CI:  1.05–4.50) [20]. We found a significant inverse re- lationship between birth weight and number of  cigarettes  smoked/day by  household members. This finding is consistent with that obtained in an in- tervention controlled study in the Czech Republic, where a strong dose–effect relationship was observed between amount of mothers’ exposure to passive smoking and birth weight [19]. Simi- larly, the study conducted in Denmark showed a direct relationship between birth weight and average tobacco load when all variables had been controlled in the regression model [20]. The higher frequency exposure to passive smoking in mothers who were urban residents and the significant re- duction in the mean birth weight among these mothers noted in our study sug- gests that the effect of passive smoking on birth weight is more pronounced in urban residents. Consumption of tobacco was less common in rural areas compared with urban areas in a study of smoking and lung cancer in England [10]. Similarly, a prospective cohort study carried out in the United States of America showed that urban popula- tions were more likely to be exposed to passive smoking [21]. The present study showed that the mean birth weight of exposed neonates was lower than that in the non-exposed group, irrespective of their parents’ Table 5 Multiple regression model with neonatal birth weight as the dependent variable and selected independent variables Independent variable β P-value maternal passive smoking exposure during pregnancy –2-81.7 0.001 residence (urban versus rural) –119.7 0.305 sex of newborn (male versus female) –55.5 0.465 maternal iron/folic acid supplementation (user versus non-user) 8.3 0.907 Antenatal care (adequate versus inadequate) 152.4 0.035 maternal weight gain during pregnancy 12.1 0.559 Education level of mother (≤ primary school versus ≥ college) 67.9 0.69 Education level of father (≤ primary school versus ≥ college) 41.3 0.778 Parity (primiparous versus multiparous parity 3+) 33.2 0.757 R2 = 0.19. Table 4 Distribution of neonatal birth weight by history of maternal iron/folic acid supplementation and maternal passive smoking exposure Iron/folic acid supplement/ exposure No. of neonates Mean (SD) birth weight (g) t-value P-value (2-tailed) Supplements Non-exposed 68 3378 (566) 3.035 0.003 Exposed 70 3094 (534) No supplements Non-exposed 82 3309 (561) 2.365 0.019 Exposed 80 3097 (583) SD = standard deviation. Book 17-4.indb 294 4/27/2011 11:00:35 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 295 education levels. The differences be- tween mean values were significant in babies whose parental levels of educa- tion were lower. This suggests that the effect of exposure to passive smoking was less pronounced among neonates whose parents’ education levels were higher, a finding which could be attrib- uted to a lower intensity of exposure. In another study done in Poland, the prevalence of smoking was found to be higher among less educated men [22]. Also, a finding of the American Cancer Society study confirmed that passive smoking exposure was greater among households with lower levels of education [23]. In our study, we noted a significant- ly lower birth weight in the exposed babies, irrespective of maternal intake of  iron/folic  acid  supplements during  pregnancy. However, in the unexposed babies, the mean birth weight of those whose mothers  took  iron/folic  acid  supplements was slightly higher than that of their counterparts whose moth- ers did not receive supplements during pregnancy. This is in agreement with the findings of a prospective cohort study in India to evaluate the effect of iron therapy in reducing maternal anaemia and to evaluate the associa- tion of maternal haemoglobin and fetal growth. The reasearchers concluded that iron supplementation was an effec- tive mode of treating anaemia among pregnant women, and was inversely associated with fetal growth [24]. Another study in the United Kingdom to evaluate the influence of erythrocyte folate status on birth weight showed that maternal folate intake was a significant predicator of infant birth weight [25]. The multiple regression analysis in this study using birth weight as the dependent variable showed that after the controlling for all variables studied, only passive smoking and antenatal care were associated with birth weight. Passive smoking exposure of mothers during pregnancy was significantly asso- ciated with a lower mean birth weight in the exposed group compared with the non-exposed group, and adequate an- tenatal care for mothers was associated with a significantly higher mean birth weight compared with mothers receiv- ing no antenatal care. Similarly, multiple regression analysis in the Danish study found that paternal smoking remained a significant influence on birth weight after controlling for mother’s age, parity, alcohol and tobacco consumption dur- ing pregnancy, illness during pregnancy, social class and sex of the baby [20]. References Smoking and health: report of the advisory committee to the Sur-1. geon General of the Public Health Service. Washington Dc, us Department of Health Education and Welfare, 1964. Adams JD, O’mara-Adams KJ, Hoffmann D. toxic and carcino-2. genic agents in undiluted mainstream smoke and sidestream smoke of different types of cigarettes. Carcinogenesis, 1987, 8:729–731. Jamie H. 3. Islamic ruling on smoking. cairo, World Health Or- ganization, 1996 (http://www.emro.who.int/publications/ healthedreligion/smoking/Ft_HamidJamie.htm, accessed 23 January 2011). cook DG et al. Passive exposure to tobacco smoke in children 4. aged 5–7 years: individual, family, and community factors. Brit- ish Medical Journal, 1994, 308:384–389. Guerin mr, Jenkins rA, tomkins bA. 5. The chemistry of environ- mental tobacco smoke: composition and measurement. chelsea, michigan, Lewis Publishers, 1992. Luck W et al. Extent of nicotine and cotinine transfer to the hu-6. man fetus, placenta and amniotic fluid of smoking mothers. De- velopmental Pharmacology and Therapeutics, 1985, 8:384–395. mochizuki m, maruo t, masuko K. mechanism of foetal 7. growth retardation caused by smoking during pregnancy. Acta Physiologica Hungarica, 1985, 65:295–304. mochizuki m et al. Effects of smoking on fetoplacental-mater-8. nal system during pregnancy. American Journal of Obstetrics and Gynecology, 1984, 149:413–420. Luciano A et al. the influence of maternal passive and light 9. active smoking on intrauterine growth and body composition of the newborn. European Journal of Clinical Nutrition, 1998, 52:760–763. rubin DH et al. Effect of passive smoking on birth weight. 10. Lan- cet, 1986, 2:415–417. Dejmek J et al. the exposure of nonsmoking and smoking 11. mothers to environmental tobacco smoke during different gestational phases and fetal growth. Environmental Health Per- spectives, 2002, 110:601–606. Gann P, Nghiem L, Warner s. Pregnancy characteristics and 12. outcomes of cambodian refugees. American Journal of Public Health, 1989, 79:1251–1257. Hofhuis W, merkus PJ, de Jongste Jc. Nadelige effecten van 13. passief roken op het (ongeboren) kind [Negative effect of pas- sive smoking on the (unborn) child]. Nederlands Tijdschrift voor Geneeskunde, 2002, 146(8):356–359. matsubara F et al. maternal active and passive smoking and 14. fetal growth: a prospective study in Nagoya, Japan. Journal of Epidemiology, 2000, 10:335–343. Nelson E, Jodscheit K, Guo Y. maternal passive smoking dur-15. ing pregnancy and fetal developmental toxicity. Part 1: gross morphological effects. Human and Experimental Toxicology, 1999, 18:252–256. England LJ et al. measures of maternal tobacco exposure and 16. infant birth weight at term. American Journal of Epidemiology, 2001, 153:954–960. Eskenazi b, Prehn AW, christianson rE. Passive and active 17. maternal smoking as measured by serum cotinine: the ef- fect on birthweight. American Journal of Public Health, 1995, 85:395–398. England LJ et al. measures of maternal tobacco exposure and 18. infant birth weight at term. American Journal of Epidemiology, 2001, 153:954–960. Windham Gc et al. Prenatal active or passive tobacco smoke 19. exposure and the risk of preterm delivery or low birth weight. Epidemiology (Cambridge, Mass.), 2000, 11:427–433. Book 17-4.indb 295 4/27/2011 11:00:35 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 296 Hruba D, Kachlik P. Influence of maternal active and passive 20. smoking during pregnancy on birth weight in newborns. Cen- tral European Journal of Public Health, 2000, 8:249–252. Perea FP et al. A summary of recent findings on birth outcomes 21. and developmental effects of prenatal Ets, PAH, and pesticide exposure. Neurotoxicology, 2005, 26:573–587. Hennekens cH, buring JE. 22. Epidemiology in medicine, 1st ed. boston, massachusetts, Little, brown, 1987. De Ferranti D, chen J. 23. Curbing the epidemic: governments and the economics of tobacco control, 1st ed. Washington Dc, World bank, 1999. steenland K et al. Environmental tobacco smoke and coronary 24. heart disease in the American cancer society cPs-II cohort. Circulation, 1996, 94:622–628. Gomber s et al. Impact of daily versus weekly hematinic sup-25. plementation on anemia in pregnant women. Indian Pediatrics, 2002, 39(4):339–346. Newborns: reducing mortality: Fact sheet N°333 http://www.who.int/mediacentre/factsheets/fs333/en/ Every year nearly 40% of all under-five child deaths are among babies in their first 28 days of life. • Three quarters of all neonatal deaths occur in the first week of life. • In developing countries nearly half of all mothers do not receive skilled care during and immediately after birth. • Up to two thirds of neonatal deaths can be prevented if effective health measures are provided during the first week. • The vast majority of neonatal deaths take place in developing countries where access to health care is low. Most of these babies die at home, without skilled care that could greatly increase their chances for survival. WHO and its partners agree that a core principle underlying maternal, neonatal and child health efforts is lifelong access to health care: a continuum of care for the mother starting from long before pregnancy (during childhood and adolescence) through pregnancy and childbirth. The continuum begins again with adequate care for the new life. As appropriate, care can be delivered in the home and community, as well as health clinics and hospitals. Book 17-4.indb 296 4/27/2011 11:00:35 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 297 Knowledge and attitude about antismoking legislation in Morocco according to smoking status N. Tachfouti,1 K. El Rhazi,1 M. Berraho,1 M.C. Benjelloun,2 K. Slama 3 and C. Nejjari 1 AbstrAct Despite tobacco control legislation enacted in morocco in 1996, the moroccan population appears to have little interest in or awareness of tobacco control measures. this household survey aimed to assess knowledge and attitudes about tobacco legislation among moroccans, according to their smoking status. A cross- sectional study was conducted on a random sample of 9195 moroccans. Only 33.3% knew about the antismoking legislation: 38.7% of smokers versus 32.3% of non-smokers. Among the 3050 people who knew about the law, 60.1% knew about the ban on smoking in public areas and 22.4% knew there was an obligatory health warning on tobacco packaging. the attitude questions showed that 27.2% agreed that the price of tobacco products should increase sharply and 45.0% that antismoking legislation should prohibit tobacco sales to children. these data demonstrate low levels of information among moroccans concerning current tobacco control legislation. 1Laboratory of Epidemiology, Clinical Research and Community Health, Faculty of Medicine, Fez, Morocco (Correspondence to N. Tachfouti: tachfoutinabil@yahoo.fr). 2Department of Pneumology, Hassan II University Hospital Center, Fez, Morocco. 3International Union against Tuberculosis and Lung Disease (IUATLD), Paris, France. received: 21/07/09; accepted: 16/09/09 ينيخدتلا عْضَولا بسح برغلما في ينخدتلا ةحفاكم تاعيشرت لوح فقاولماو فراعلما يراجنلا بيكش ،ةملاس نيراك ،نولجنب بيكش دممح ،وحرب دممح ،يزاغلا ةميرك ،تيوفشات ليبن ةحفاكم يربادتب يعو وأ مماتها ّيأ اودبُي لم برغلما لياهأ نإف ،1996 ماع في تَّنُس دق برغلما في غبتلا ةحفاكم تاعيشرت نأ نم مغرلا لىع :ةـصلالخا ةسارد تَيرجأ دقو .ينيخدتلا مهعضو بسحب ،ةبراغلما ينب غبتلا تاعيشرت لوح فقاولماو فراعلما مييقت لىإ ليزنلما حسلما اذه فديهو .غبتلا %32.3% لباقم يننخدلما نم %38.7 مهنم :غبتلا ةحفاكم تاعيشرت نع ةفرعم مهنم طقف %33.3 ىدل ناك .ًايبرغم 9195 ّمضت ةيئاوشع ةنيعل ةضرعتسم ،ةماعلا نكاملأا في ينخدتلل ًارظح كانه نأ نوفرعي مهنم %60.1 ناك ،نوناقلاب ةفرعم ميهدل تناك نيذلا ًاصخش 3050 ـلا ينب نمو .يننخدلما يرغ نم رعس ةدايز ةروضر لىع اوقفاو %27.2 نأ فقاولماب ةصالخا ةلئسلأا ترهظأو .غبتلا تاوبع لىع ةيرابجإ ةيحص ريذتح تاملاع دوجوب نوفرعي %22.4و تايوتسم ّندت تايطعلما هذه ترهظأ دقو .لافطلأل غبتلا َعيب تاعيشرتلا كلت رظتح نأ ةروضر لىع %45.0 قفاو ينح في ،ةيربك ةدايز غبتلا تاجتنم .غبتلا ةحفاكم تاعيشرت صيخ ام في ةبراغلما ينب ةفرعلما Connaissances et attitudes concernant la législation antitabac au Maroc en fonction du statut tabagique résumé En dépit de la législation antitabac votée en 1996 au maroc, la population marocaine semble peu intéressée par les mesures de lutte antitabac ou faiblement sensibilisée en la matière. La présente enquête auprès des ménages visait à évaluer les connaissances et les attitudes concernant la législation antitabac dans la population marocaine, en fonction du statut tabagique. une étude transversale a été conduite sur un échantillon sélectionné aléatoirement de 9195 marocains. seuls 33,3 % avaient connaissance de la législation antitabac : 38,7 % étaient fumeurs et 32,3 % étaient non-fumeurs. Parmi les 3050 personnes interrogées qui avaient connaissance de la législation, 60,1 % savaient qu’il était interdit de fumer dans les lieux publics et 22,4 % avaient vu la mise en garde sanitaire obligatoire figurant sur les paquets de tabac. Les questions concernant l’attitude ont révélé que 27,2 % des répondants étaient en faveur d’une forte hausse du prix des produits de tabac et que 45,0 % souhaitaient que la vente de tabac aux enfants soit interdite par la législation. ces données soulignent le faible niveau d’information des marocains au sujet de la législation antitabac en vigueur dans leur pays. Book 17-4.indb 297 4/27/2011 11:00:35 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 298 Introduction Two decades ago, cigarette smoking in Africa was referred to as ‘the com- ing epidemic” [1]. This prediction has been confirmed, as many countries on the continent are now in the middle of the epidemic; the available information shows that the prevalence of smoking in African countries  ranges  from 17%  to 32%  [2–5]. The adoption  and  en- forcement of legislative tobacco control measures [6,7] are particularly needed  in many African countries. There is a view that Africa has been targeted by the tobacco industry because there is little control of tobacco advertising [8].  Furthermore, in most African countries where there is no control over cigarette manufacture, the tobacco companies manufacture low-quality cigarettes that would not be sold in Europe and North America [9]. In Morocco a tobacco control law was enacted  in 1996 [10];  it  included  bans on advertising, on sponsorship and on smoking in public transport and educational and health care facilities. The law requires that all packs of ciga- rettes display messages on both sides warning about the harmful effects of tobacco. Efforts to inform and educate the public about the health risks associ- ated with tobacco consumption were later initiated. However, the law has not been strictly enforced and has gener- ally not been respected by the general population. The law has therefore had little impact on tobacco use in a country where the average tobacco expenditure for households with a daily smoker is 30% of total income [11]. The most re- cent data shows that between 2000 and  2006,  smoking  increased  from 17.2%  to 18.5% among  adults  aged over 20  years [12,13], and from 13.9% to 15.5%  among youth aged 13–15 years. Moreo- ver, the overall prevalence of exposure to environmental tobacco smoke among school  students  increased  from 27.7%  to 30.0% [14,15]. In  July  2008,  the Moroccan  par- liament unanimously approved a new law which modified and reinforced the previous law. It prohibits smoking in certain enclosed public places, such as coffee shops and restaurants, and bans advertising or publicity for tobacco in specified places. The sale of cigarettes to minors is also prohibited and pun- ishable by a fine. Mandatory fines are imposed for non-compliance with the law. Half of the collected fines are to be paid to nongovernmental organizations (NGOs) working to educate people about the dangers of smoking. Despite the legislation, there re- mains a widespread view that the Mo- roccan population has little interest in, or awareness of, tobacco control. Data on the knowledge and attitudes of Mo- roccans about tobacco control policies and legislation are, however, not avail- able. This study examined the public’s knowledge of and attitudes to general and specific tobacco control policies in Morocco, with an emphasis on differ- ences according to smoking status. Methods Population A cross-sectional study of a representa- tive sample of the Moroccan popula- tion was conducted in 2006 (the Maroc  Tabagisme survey). A multi-stage, strati- fied probability sampling design of 7 administrative regions, representing 43.8%  of  the  total  population,  was  adopted using protocol recommenda- tions of the International Union against Tuberculosis and Lung Diseases (IUT- LD) and in line with the Moroccan population census of 2004 [16]. In each administrative region, a pre- fecture was randomly chosen according to the size of the population. The sample was selected in 2 stages: first, each pre- fecture was grouped  into 2  strata with  probability proportional to size within each primary sampling unit selected. The first stratum was the prefecture centre covering the urban area and the second stratum included the surround- ing villages. In each urban area 3 districts were defined as low, middle and high income using the Moroccan population census criteria of the socioeconomic levels of residential areas [16]. Residen- tial districts of each socioeconomic cat- egory were then selected according to the size of the population. A random sample of households was visited in each stratum. After giving informed consent to participate and reassurance of the confi- dentiality of their responses, individuals aged 15 years and above in the selected  household were invited, alternating be- tween males, females and children, to participate in the survey. The desired to- tal sample size was established as 9000  individuals, with an alpha error of 5%.  The sample was large enough to obtain sufficient numbers of smokers and non- smokers so as to study factors related to each of these groups. Data collection A questionnaire was developed based on a tobacco questionnaire devised by the IUTLD [17]. A French version of the questionnaire was then developed by the Department of Epidemiology and Public Health in Fez with IUTLD collaboration. The questionnaire was also translated into Moroccan Arabic dialect. The revised version was sub- jected to a pilot survey and the final form was adapted and refined on the basis of the results of the pilot study. The questionnaire was administered face-to-face to the head or any other competent adult member of the house- hold. The questions covered demo- graphic variables, smoking behaviour (how many cigarettes smoked in their lifetime, number of cigarettes smoked, whether a daily or occasional smoker) and exposure to passive smoking (by family members or work colleagues). Respondents were also asked about their knowledge of the existence of the law and about specific aspects of the Book 17-4.indb 298 4/27/2011 11:00:36 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 299 law. They were also asked whether or not they favoured each of the 5 tobacco  control legislative measures included in the World Health Organization Frame- work Convention on Tobacco Control [7]: smoking bans in public places, in- creasing cigarette taxes, tobacco adver- tising bans, health warnings on cigarette packs and banning sales to children. Respondents were classified as smokers or non-smokers. Smokers were those who had smoked at least 100  cigarettes in their lifetime and who still smoked daily or occasionally (current smokers) at the time of TB diagnosis or had recently stopped (for less than 3 months). Non-smokers were those who had never smoked or had smoked fewer  than 100 cigarettes prior  to  the  date of the interview or had smoked at least 100 cigarettes in their lifetime, but  had quit for more than 3 months. Analysis Statistical analyses were performed using Epi-Info  software,  version 3.3.2.  Chi-squared tests were conducted to examine differences in attitudes towards 5  legislative measures  included  in  the  WHO Framework Convention on To- bacco Control according to smoking status. Missing cases were not included in the analysis. Results Smoking status A total of 9195 subjects, i.e. 1 per house- hold, were included in the survey (Table 1); 51.7% of  respondents  (n  = 4753)  were men. The mean age was 31.1 (SD 13.7) years; 53.2% of  the  sample were  aged < 30  years,  37.3%  lived  in  rural  areas and 45.5% were either illiterate or  had a very low educational level. Table 1 shows that the prevalence of smoking according to sex and sociode- mographic characteristics. The overall prevalence of current smoking was reported to be 18.0% (95% CI: 17.2%– 18.8%): 31.5% (95% CI: 30.2%–32.9%)  in males and 3.3% (95% CI: 2.8%–3.8%)  in females. According to residential area, the prevalence of current smoking was 16.9% in rural and 18.6% in urban areas.  Among men, the highest proportion of smokers was among those aged 30–50  years (40.4%) and among the  illiterate  (39.0%). The prevalence of  smoking  was inversely associated with level of education in men but increased with educational level in women. Environmental tobacco smoke ex- posure at home was reported by 41.7%  of respondents, but the proportion who had passive smoke exposure at work- sites was much higher (62.4%). Knowledge about tobacco legislation Table  2  summarizes  respondents’  knowledge of the existence of the tobacco legislation according to their sociodemographic characteristics. Among  respondents,  3050  (33.5%)  overall knew of the existence of the law: 39.5% of men and 27.0% of women. The  proportion who knew about the law was higher among  smokers (38.7% versus  32.3%),  people  living  in  urban  areas  (35.8% versus 29.4%) and  those with  the highest educational level (rising from 17.1% among  illiterates  to 56.5%  of those with a university degree). Knowledge of tobacco control measures Knowledge of key tobacco control measures contained in the law was variable among respondents who knew that a law existed. Table 3 illustrates the knowledge about tobacco control measures according to sex and smok- ing status. Men were more informed Table 1 Prevalence of current smoking according to respondents’ sex and sociodemographic characteristics Variable Males Females Total Smokers P-value Total Smokers P-value No. % No. % Age (years) < 0.01 < 0.01 15–30 2519 27.0 2371 3.9 30–50 1602 40.4 1561 2.8 > 50 632 27.7 440 1.6 Residence Ns < 0.001 urban 2907 31.9 2741 4.6 rural 1816 30.9 1615 1.1 Educational level < 0.01 < 0.001 Illiterate 544 39.0 1072 1.5 basic/primary 1483 32.2 1080 1.8 secondary 1683 29.3 1419 4.2 university degree 996 29.8 765 6.0 Total 4753 31.5 4442 3.3 Book 17-4.indb 299 4/27/2011 11:00:36 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 300 than women on the contents of the law. Only  31.0%  of men  and  27.0%  of women knew about the ban on to- bacco advertising. More than half of the study population knew about the ban on smoking in public areas: 61.2%  of males  and 58.6% of  females. Only  11.1% of males  and 11.9% of  females  knew about the ban on selling tobacco to children. Among women, significantly more non-smokers than smokers knew about the ban on advertising, but in males there was no significant difference ac- cording to smoking status (Table 3). More non-smokers than smokers knew about the ban on smoking in public for both males (63.2% versus 56.7%) and  females (59.3% versus 45.3%). Attitudes to strategies for reducing smoking Table 4 shows the opinions of the respondents about how to reduce smoking: 34.8%  felt  that  there  should  be a complete ban on advertising, 34.8%  agreed that smoking should be restricted in  public  places  and  45.0%  said  that  cigarette sales to children aged younger than 16 years should be prohibited. There were significant differences for 2 of 5 suggested regulations accord- ing to smoking status. Smokers were less favourable to the idea of an increase in tobacco product prices (24.5% versus  27.8%) and about health warnings on  packets (19.0% versus 22.0%). Discussion This study reports knowledge and at- titudes toward tobacco control in a representative sample of the Moroc- can population. Some limitations of the study need to be discussed; first, participants were not of similar age to the national population and the survey included only adults aged 18 years and  over. Moreover, we used self-reported data on smoking, which may result in underreporting of smoking due to its negative sociocultural connotations, especially among the youngest ages and among females. However, this is the first study that provides information about the prevalence, knowledge and attitudes about smoking in Morocco, as the number of respondents in this study (n = 9195) was  large enough  to  Table 2 Knowledge about the existence of the tobacco control law according to respondents’ sociodemographic characteristics Variable Total Knew about law P-value No. % Sex < 0.01 male 4753 39.5 Female 4442 27.0 Residence < 0.01 urban 2907 35.8 rural 1816 29.4 Education level < 0.01 Illiterate 544 17.1 basic 1483 31.2 Primary 1683 23.7 secondary 996 35.6 University degree 56.5 Smoking status < 0.01 smoker 1631 38.7 Non smoker 7471 32.3 Ta bl e 3 K no w le dg e ab ou t t ob ac co c on tr ol m ea su re s ac co rd in g to re sp on de nt s’ s ex a nd s m ok in g st at us K no w le dg e ite m Bo th s ex es (n = 9 19 5) M al es Fe m al es A ll (n = 4 78 1) Sm ok er s (n = 1 50 6) N on -s m ok er s (n = 3 27 5) P- va lu e A ll (n = 4 41 4) Sm ok er s (n = 1 45 ) N on -s m ok er s (n = 4 26 9) P- va lu e % % % % % % % A dv er tis in g ba n 29 .0 31 .0 31 .9 30 .6 N s 27 .0 41 .5 26 .3 < 0 .0 1 ba n on sm ok in g in p ub lic p la ce s 60 .1 61 .2 56 .7 63 .2 < 0 .0 1 58 .6 45 .3 59 .3 < 0 .0 5 ba n on se lli ng to ba cc o to th os e un de r a ge 16 11 .4 11 .1 10 .7 11 .2 N s 11 .9 9. 4 12 .1 N s H ea lth w ar ni ng s o n ci ga re tte p ac ks 22 .4 24 .1 28 .9 21 .9 < 0 .0 1 19 .7 26 .4 19 .4 N s N S = no t s ig ni fic an t. Book 17-4.indb 300 4/27/2011 11:00:36 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 301 represent the national population, and to compare attitudes of self-reported smokers with those of non-smokers. These data show a weak level of knowledge about the law among the Moroccan population despite the first enactment of the law more than 10 years  ago. Only 33.5% of  the survey popula- tion knew about the law and, among them, no more than 11.0% knew of the  ban on selling tobacco to minors. The highest level of knowledge was among those with a university degree. Small proportions of smokers and non-smokers indicated their support for tobacco control measures. Only about a third supported a ban on advertising. Similar results were found in Turkey (24.5%  supported  advertising  bans),  whereas greater support from the public has been reported in China and the United States [18,19]. Less  than 35% of  the  respondents  in Morocco favoured a ban on smok- ing in public places, a figure which is lower than among the general public in Taiwan  [20]. The more  favourable  support in Taiwan might be due to the extensive government efforts to combat tobacco use in Taiwan, which were sup- plemented by tobacco-counter adver- tising and mass media campaigns [21].  Actually, the overall low awareness of the law and relatively limited support for some measures of tobacco control among Moroccans indicate that public awareness campaigns and the general enforcement of existing laws are limited and ineffective. In  2004,  a  great  deal  of  publicity  was generated by the purchase of the Moroccan Tobacco Monopoly by Altadis, a multinational manufacturer and distributor of cigarettes. Positive promotional efforts by that company may have played a role in the relatively small proportions of the population supporting tobacco control measures. A less favourable attitude towards preventive legal measures, especially protection of children, was shown by smokers than by non-smokers. The results emphasize the need for better information on the different specific as- pects of the law and the need for better enforcement of the regulations. About 27.2% of  our  respondents were  sup- portive of increased taxes on cigarettes; some studies report that smokers are less likely to support a cigarette tax than non-smokers  [22]. This  is  true  in our  sample as well, but even non-smokers showed low support for such a measure. This again indicates a lack of efforts to inform the public and generate support for tobacco control measures including price policy. In the WHO Eastern Mediter- ranean Region each country displays varying strengths and weaknesses concerning tobacco control. In Egypt, cigarette consumption is the highest in the Middle East. Legislation restricts smoking in some public places, such as work and other enclosed areas, but taxes on cigarettes are  low [23].  Jordan has  prohibited tobacco sales to minors and became the first country in the region to place prominent health warnings on cigarette packets. Despite these efforts, a Jordanian Ministry of Health survey found that smoking increased from 27%  to 29% between 2005 and 2007 [23].  With Morocco now moving towards ratifying the WHO Framework Con- vention on Tobacco Control, which contains comprehensive anti-smoking policies  [24],  the  need  to  adapt  and  enforce effective legislation becomes crucial. To implement tobacco control strategies successfully and to improve their effectiveness, knowledge about the impact of tobacco legislation and other tobacco control activities should be monitored regularly in terms of preva- lence of use, public attitudes, socioeco- nomic patterns and health indicators. Acknowledgements We thank the Moroccan Health Min- istry for having authorized the survey and the International Union Against Tuberculosis and Lung Diseases for its support and help. We also thank Dr Jean-François Tessier for his contribution and assist- ance and we thank all the interviewers for their participation in gathering the information. Table 4 Attitudes towards tobacco control measures according to respondents’ smoking status among those who had heard about the law Attitude item All (n = 3050) Smokers (n =631) Non-smokers (n = 2399) P-value % % % cigarette packs should contain health warnings 19.5 19.0 22.0 < 0.05 smoking in public places should be prohibited 34.8 36.6 34.4 ≥ 0.05 Price of tobacco products should increase sharply 27.2 24.5 27.8 < 0.01 cigarette sales to children should be prohibited 45.0 45.9 44.9 ≥ 0.05 tobacco advertising should be completely banned 34.8 36.6 34.4 ≥ 0.05 Book 17-4.indb 301 4/27/2011 11:00:36 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 302 References taha A, ball K. smoking in Africa: the coming epidemic. 1. World Smoking & Health, 1982, 7:25–30. Koffi N et al. [smoking in the African setting (Abidjan, Ivory 2. coast): patient knowledge, attitude and behavior.] connais- sances, attitudes et comportements des patients vis-a-vis du tabagisme en milieu africain a Abidjan (cote d’Ivoire) Revue de Pneumologie Clinique, 2004, 60:217–222. mpabulungi L, muula As. tobacco use among high school 3. students in Kampala, uganda: questionnaire study. Croatian Medical Journal, 2004, 45:80–83. Kwamanga DH, Odhiambo JA, Amukoye EI. Prevalence and 4. risk factors of smoking among secondary school students in Nairobi. East African Medical Journal, 2003, 80:207–212. Youssef rm, Abou-Khatwa sA, Fouad Hm. Prevalence of 5. smoking and age of initiation in Alexandria, Egypt. Eastern Mediterranean Health Journal, 2002, 8:626–637. botelho A et al. 6. Environmental tobacco smoke risk perception and smoking behavior in Portugal. Lison, Portugal, ministry of science and technology, 2008. Report on the WHO framework convention on tobacco control7. . Geneva, World Health Organization, 2008. chapman s et al. All Africa conference on tobacco control. 8. British Medical Journal, 1994, 308:189–191. Awotedu AA, Higenbottam tW, Onadeko bO. tar, nicotine, 9. and carbon monoxide yields of some Nigerian cigarettes. Jour- nal of Epidemiology and Community Health, 1983, 37:218–220. [Dahir No. 1-91-112 of 26 June 1995 promulgating Law No. 15-91 10. prohibiting smoking and advertising or publicity for tobacco in certain places]. rabat, morrocco, General secretariat of the Government, Bulletin official, 1995, 4318:542 [in Arabic]. tachfouti N et al. socioeconomic status and tobacco expendi-11. tures among moroccans: results of the “maroc tabagisme” sur- vey. American Journal of Health Promotion, 2010, 24:334–339. tazi mA, Abid-Khalil s, chaouki N. Prevalence of the main car-12. diovascular risk factors in morocco: results of a national survey in 2000. Journal of Hypertension, 2003, 21:897–903. El rhazi K et al. Inequalities in smoking profiles in morocco: 13. the role of educational level. International Journal of Tubercu- losis and Lung Disease, 2008, 12:1327–1332. cherqaoui s, tazi mA, chaouki N. 14. Rapport de l’enquête épidé- miologique sur le tabagisme chez les jeunes scolarisés au Maroc. rabat, morocco, ministry of Health, 2002:10. Fact sheet: Eastern Mediterranean Region. Global Youth Tobacco 15. Survey (GYTS): Morocco. centers for Disease control and Pre- vention [website] (http://www.cdc.gov/tobacco/global/ gyts/factsheets/emr/2001/morocco_factsheet.htm, accessed 16 January 2011). Rapport national du recensement general de la population et de 16. l’habitat de 2004. rabat, Haut commissariat au Plan, 2001. Tobacco or health: a global status report17. . Geneva, World Health Organization, 1997. biener L, mccallum-Keeler G, Nyman AL. Adults’ response to 18. massachusetts anti-tobacco television advertisements: impact of viewer and advertisement characteristics. Tobacco Control, 2000, 9:401–407. Yang t et al. Attitudes and behavioral response toward key to-19. bacco control measures from the Fctc among chinese urban residents. BMC Public Health, 2007, 7:248. tsai YW et al. Public opinion regarding earmarked cigarette tax 20. in taiwan. BMC Public Health, 2003, 3:i42. Levy Dt et al. Increasing taxes to reduce smoking prevalence 21. and smoking attributable mortality in taiwan: results from a tobacco policy simulation model. Tobacco Control, 2005, 14(suppl. 1):i45–i50. schumann A et al. Attitudes towards smoking policies and 22. tobacco control measures in relation to smoking status and smoking behaviour. European Journal of Public Health, 2006, 16:513–519. Gavlak D. smoke alarm from Afghanistan to morocco. 23. Bulletin of the World Health Organization, 2008, 86:89–90. Gilmore Ab, collin J. the world’s first international tobacco 24. control treaty. BMJ (Clinical Research Ed.), 2002, 325:846–847. Book 17-4.indb 302 4/27/2011 11:00:37 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 303 Parental smoking and risk of childhood cancer: hospital-based case–control study in Shiraz M. Edraki 1 and M. Rambod 1 AbstrAct this case–control study in shiraz aimed to determine the relationship between parental smoking and childhood cancer. A questionnaire was completed by the mothers of 98 children newly diagnosed with cancer before the age of 14 years and 100 age- and sex-matched controls. maternal smoking (prior to and during pregnancy and after the birth), and the numbers of maternal cigarettes smoked were not associated with an increased risk of childhood cancer. However, maternal exposure to passive smoke during pregnancy increased the risk of cancer childhood (Or = 3.6, 95% cI: 1.3–5.0). Father’s smoking prior to (Or = 1.8, 95% cI: 1.4–6.0) and during pregnancy (Or = 3.0, 95% cI: 1.4–5.0) was significantly associated with an increased risk of cancer and this increased with heavy smoking. there were no relationship between an enhanced risk of childhood cancer and father’s smoking after the child’s birth. 1Department of Paediatric Nursing, Nursing and Midwifery, Shiraz University of Medical Science, Shiraz, Islamic Republic of Iran (Correspondence to M. Edraki: mitraedraki@yahoo.com). received: 07/07/09; accepted: 05/10/09 زايرش في ىفشتسلما لىع ةزكترلما دهاوشلاب ةد َّهَشُم تلااح ةسارد :ةلوفطلا ناطسر راطتخاو نيدلاولا ينخدت دُبمار ةموصعم ،يكاردإ ارـتيم دقو .ةلوفطلا ناطسر ينبو نيدلاولا ينخدت ينب ةقلاعلا ديدتح لىإ زايرش ةنيدم في تَيرجأ يتلا ةد َّهَشُمـلا تلااحلل ةساردلا هذه فدته :ةـصلالخا ينقفاوتلما دهاوشلا نم لفط ةئلمو ،ةشرع ةعبارلا نس مهغولب لبق ًاثيدح ناطسرلاب مهتباصإ صيخشت مت لافطلأ ًاّمأ ينعستو ٍنماثل نايبتسا ىرجُأ ةباصإ راطتخا ةدايزب تاهملأا اهنخدت يتلا رئاجسلا ددع لاو ،)ةدلاولا دعبو لملحا ءانثأو لبق( تاهملأا ينخدت طباتري لمو .سنلجاو رمعلا في مهعم Or = 3.6، 5.0 – 1.3:( ناطسرلاب نلهافطأ ةباصإ راطتخا نم داز دق لملحا ءانثأ يبلسلا ينخدتلل ّيسرقلا تاهملأا ضّرعت نأ لاإ ،ناطسرلاب نلهافطأ ًايئاصحإ هب ُّدَتْعُي ًاطُبارت .)Or = 3.0، 5.0 – 1.4: Ic%95( لملحا ءانثأو .)Or = 1.8، 6.0 – 1.4: Ic%95( لملحا لبق ءابلآا ينخدت طباَرَت ماك .)Ic%95 دعب ءابلآا ينخدت ينبو ةلوفطلا ناطسرب ةباصلإا راطتخا ةدايز ينب ةقلاع دهاشت لمو .ينخدتلا ةدش عم طباترلا دادزا دقو ،ناطسرلا راطتخا ةدايزب .لفطلا ةدلاو Tabagisme des parents et risque de cancer chez l’enfant : une étude cas-témoins en milieu hospitalier à Chiraz résumé La présente étude cas-témoins, conduite à chiraz, visait à déterminer la relation entre le tabagisme parental et le cancer chez l’enfant. un questionnaire a été rempli par les mères de 98 enfants chez lesquels un diagnostic de cancer avait été posé récemment et avant l’âge de 14 ans et par 100 témoins appariés selon l’âge et le sexe. Le tabagisme maternel (avant, pendant et après la grossesse), et le nombre de cigarettes fumées par la mère n’étaient pas associés à un risque accru de cancer chez l’enfant. toutefois, l’exposition de la mère au tabagisme passif pendant la grossesse augmentait le risque de cancer chez l’enfant (O.r. = 3,6 ; Ic à 95 % : 1,3-5,0). Le tabagisme paternel avant la grossesse de la mère (O.r. = 1,8 ; Ic à 95 % : 1,4-6,0) et pendant (O.r. = 3,0 ; Ic à 95 % : 1,4-5,0) était significativement associé à un risque accru de cancer, et ce risque était même supérieur en présence d’un tabagisme paternel important. Aucun lien n’a été retrouvé entre un risque accru de cancer chez l’enfant et le tabagisme paternel après la naissance. Book 17-4.indb 303 4/27/2011 11:00:37 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 304 Introduction The evidence for a link between parental smoking during pregnancy and child- hood cancer is controversial. Several types of childhood cancer have been re- searched in relation to parental smoking including kidney cancer, eye tumours, Ewing’s sarcoma, lung cancer and endo- crine tumours. However, the results are too varied to permit a conclusion [1]. Genetic changes that occur in certain childhood haematopoietic can- cers may originate in utero [2]. A case– control study reported a non-significant increasing trend for risk of childhood leukaemia associated with paternal pre- conception smoking and a significantly decreasing trend for maternal smoking during pregnancy [3]. In contrast, a large case–control study did not detect evidence of the relationship between childhood leukaemia and paternal or maternal smoking before or during preg- nancy [4]. Smoking also appears to lead to oxidative damage and aneuploidy of the sperm [5], supporting a finding that the rate of childhood cancer is higher in those whose fathers smoke more than 10 cigarettes per day [6]. Some studies [7,8] but not others [9,10] have shown a positive association between paternal smoking and brain tumours in children. A research study also indicated that regular exposure of the mother to the fa- ther’s cigarette smoke during pregnancy was associated with an increased risk of astroglial tumours in the children [11]. Preston-Martin also reported a positive association between brain tumours and the mother living with a smoker during pregnancy [12]. Although the data are inconclusive at present, smoking remains an expo- sure of interest because of its known carcinogenicity for numerous organs [13]. The present study in Shiraz, Is- lamic Republic of Iran, aimed to add to the evidence on this subject with an analysis of paternal and maternal smok- ing during pregnancy and after the birth with the risk of childhood cancer. Methods Data were obtained from a hospital- based case–control study conducted in Shiraz University of Medical Science (SUMS) between December 2007 and  November 2008. Sample Eligible cases were all the children newly diagnosed with any type of cancer before the age of 14 years, whom the interviewers were authorized to contact by the physician. The inclusion criteria were having literate parents, no previous diagnosis of cancer and being diagnosed for  at  least  30 days  (or  since date of  recurrence/relapse). The sample size of the study with a power of 80%, α = 5%, prevalence of  cancer  in  children = 12.9% and odds  ratios of 2.8 was  estimated  to be 120  persons in the case and control groups. A total of 220 childhood cancer patients  were newly diagnosed at the cancer centre of SUMS over the study period. Of these, 98 parents were eligible and  participated in the study. The control subjects comprised 120 children with- out any disease or other birth defects who were selected randomly from the students in schools and day care in the 4 districts of the Ministry of Education, matched for age and sex. From the control  group,  120  children/parents  met  the  inclusion  criteria  and 100 of  the parents consented to participate in the study and returned the question- naire to the researcher. Therefore the final sample included 198 children and  their parents. Data collection Medical interviewers conducted face- to-face interviews with the parents, us- ing a specially designed questionnaire based  on  previous  research  [14,18].  This included questions on the parents’ sociodemographic characteristics and the child’s age and sex. Maternal smok- ing history included smoking status (ever smoked or current smoker: yes or no), intensity of smoking (number of cigarettes smoked per day) and the timing of smoking (before the current pregnancy, during the pregnancy and after the birth). The history of paternal smoking included the same questions as for maternal smoking. The mothers were asked whether during pregnancy the atmosphere at home was smoky (maternal exposure to passive smoke during pregnancy). The study protocol was reviewed and approved by the ethics committee of the cancer research centre of SUMS. The parents were informed about the study, both verbally and in writing. Participation was voluntary and the parents could stop their involvement without giving any reason. The ques- tionnaires were coded in order to guar- antee anonymity. The internal consistency of the questionnaire was measured using Cronbach alpha  reliability (α = 0.84). Content validity for the questionnaire was also supported. Analysis Descriptive statistics were used to ex- amine the data. The non-parametric chi- squared test and 2 independent samples  t-test was used to assess the relationship between the variables. Statistical analy- sis was performed using unconditional logistic regression models including the stratification variables (age, sex and parental education) for measuring the risk of childhood cancer associated with parental smoking. Separate analyses and regressions were also used to estimate specific odds ratios (ORs) and their 95% con- fidence intervals (CIs) for cancer patients. SPSS,  version 10.0 was used  to create descriptive statistics, includ- ing frequency statistics and measures of central tendency, to describe the demographic characteristics of the sample and the major variables of the study. A P-value ≤ 0.05 was considered  statistically significant. Book 17-4.indb 304 4/27/2011 11:00:37 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 305 Results Socioeconomic data The distribution of cases and con- trols by socioeconomic variables is shown in Table 1. There were slightly more males (51.0%) than females with  childhood cancer (49.0%). However, a  significantly higher percentage of chil- dren in the control group were female (52.0% versus 48.0%; χ2 = 0.26, P > 0.05).  The age distribution peaked in the case and control groups at ages 6–10 years  (58.2% and 56.0%). The groups were  nearly  identical  in age: mean 8.9 (SD  4.4) years versus 8.9 (SD 4.4) years for  the case and control groups respectively (t = 0.18, P > 0.05). There were no statis- tically significant differences in the age and sex distributions between the case and control groups. The mothers of the control group were significantly younger than those of the cases: mean age 32.2 (SD 5.4) years  versus 35.3 (SD 6.9) years respectively  (t = 5.18, P ≤ 0.05). The father’s age were  also significantly different in the case and control groups: mean age 40.9 (SD  9.1) years  versus 38.8  (SD 6.9) years  respectively (t = 4.69, P ≤ 0.05). The case families were of significant- ly lower economic status than those of the controls (χ2 = 7.13, P ≤ 0.05). In ad- dition, the level of education of the case families was significantly lower than the control group (for mother’s education χ2 = 87.43, P < 0.001; for father’s educa- tion χ2 = 58.68, P < 0.001). Smoking exposure and risk of cancer Among the mothers of cases, 1 (1.0%)  reported  ever having  smoked  both prior to and during pregnancy, compared with 3 (3.0%) of the control  mothers. After the birth, the propor- tions of case and control mothers who had smoked were the same (1.0%). The  overall risk of cancer was not significant- ly associated with maternal smoking at any stage, prior to pregnancy (χ2 = 0.64,  P > 0.05) (OR = 0.33; 95% CI: 0.4–3.9),  during pregnancy (χ2 = 0.64, P > 0.05)  (OR = 0.33; 95% CI: 0.4–3.0) or after  the birth (χ2 = 0.11, P > 0.05) (OR = .02;  95%, CI: 0.6–2.5) (Table 2). The mothers in the case and con- trol groups did not vary by the number of cigarettes smoked daily (t  =  0.03,  P > 0.05). Only 1 of  the case mothers  and 3 of the control mothers reported having  smoked ≥ 5  cigarettes during  pregnancy. Thus there was no asso- ciation with the number of cigarettes smoked by mothers (OR = 0.03, 95%  CI: 0.3–2.5). In  the case group, 36.7% of  fathers  reported smoking prior to the mother’s pregnancy compared with 29.0% of the  control group fathers. Paternal smoking was associated with cancer prior to (χ2 = 3.25, P < 0.05) (OR = 1.8, 95% CI:  1.4–6.0) and during the mother’s preg- nancy (χ2 = 3.18, P < 0.05) (OR = 3.0,  95% CI: 1.4–5.0). In addition, there was  an association between number of ciga- rettes smoked by fathers and childhood cancer (t  =  2.58, P  <  0.05);  children  whose fathers smoked ≥ 11 cigarettes per day during the mother’s pregnancy had a > 2.7-fold higher  risk of  cancer  (OR = 2.7, 95% CI: 1.4–6.0). However,  the relationship between childhood cancer and paternal smoking after the birth was not  significant  (OR = 0.02,  95% CI: 0.3–5.9). The regression analysis also showed a 3.6-fold  increased  risk of  childhood  cancer for mothers who reported be- ing exposed to passive smoke during pregnancy (χ2 = 4.23, P < 0.05; OR = 3.6,  95% CI: 1.3–5.0). Discussion This study found no relationship between the risk of cancer childhood and maternal cigarette smoking at any stage—prior to pregnancy, during pregnancy or after the birth. There are currently no arguments in support of an influence of maternal smoking dur- ing pregnancy on the risk of childhood cancer [14], tumours of the brain or central nervous  system [15]  and  leu- kaemia [3,14], and the present results are consistent with this fact. In only a few studies was maternal smoking sig- nificantly associated with the risk of cancer  [7,8,16]. All  the  smoker moth- ers  in  the  study smoked only 5 or  less  cigarettes per day. The low number of cigarettes smoked per day by moth- ers may partially explain the lack of as- sociation between maternal smoking and the risk of childhood cancer in our study. Our findings agree with those of case–control studies conducted in Ger- many and the UK [3,17]. In addition, MacArthur et al. reported there was no relationship between childhood cancer and number of cigarettes smoked dur- ing pregnancy [18]. On the other hand, the data showed an association between childhood cancer and father’s smoking prior to and during pregnancy. There was also a 2.7-fold higher risk of cancer in children  whose fathers smoked more than 11 cigarettes per day compared with men who did not smoke. This was similar to the results of Memegaux et al. [14]. Fraga et al. reported that the level of  8-hydroxy-2′-deoxyguanosine,  a  product of oxidative DNA damage, was 50% higher  in  the  sperm of  smokers  compared with that of non-smokers [19]. Shi et al. demonstrated that, com- pared with non-smoking men, light and heavy smoking men were more likely to manufacture abnormal sperm with disomy of chromosome 15, which could  be linked to development of childhood cancer  [20]. These data are consistent  with a possible mechanism linking pa- ternal preconception smoking to an enhanced risk of childhood cancer [21].  In a number of studies, paternal smok- ing, especially in the prenatal period, has been shown to increase the risk of childhood  leukaemia  [6–8,21–23].  In another study the associations with father’s smoking in the absence of mother’s smoking were found for all cancers combined, as well as for acute Book 17-4.indb 305 4/27/2011 11:00:37 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 306 lymphocytic leukaemia, lymphomas and brain cancer [7]. The findings of the study indicated that there was no relationship between childhood cancer and paternal cigarette smoking after the birth. This result was similar  to that of other studies [14,22].  However, Lee et al. reported that post- natal paternal smoking might play a role in the development of childhood leukaemia and that paternal smoking at home, rather than paternal smoking itself, significantly increased the risk of childhood leukaemia [22].  In the current study mother’s expo- sure to smoke during pregnancy was as- sociated with a significant increase in the risk of childhood cancer (OR = 3.6, 95%  Table 1 Description of the case and control children and parents Variable Cases (n = 98) Controls (n = 100) Statistics No. % No. % Child’s age (years) < 2 3 3.1 3 3.0 2–5.9 13 13.3 14 14.0 6–9.9 58 58.2 56 56.0 10–14 24 24.5 27 27.0 t = 0.18 mean (sD) 8.87 (4.42) 8.93 (4.40) P > 0.05 Child’s sex Female 48 49.0 52 52.0 χ2 = 0.26 male 50 51.0 48 48.0 P > 0.05 Mother’s age (years) < 20 3 3.1 4 4.0 20–24.9 10 10.2 13 13.0 25–29.9 24 24.5 31 31.0 30–34.9 38 38.8 42 42.0 ≥ 35 23 23.5 10 10.0 t = 5.18 mean (sD) 35.25 (6.87) 32.24 (5.40) P ≤ 0.05 Father’s age (years) < 20 0 0.0 0 0.0 20–24.9 1 1.0 2 2.0 t = 4.69 25–29.9 26 26.5 29 29.0 P ≤ 0.05 30–34.9 29 29.6 32 32.0 ≥ 35 42 42.9 37 37.0 mean (sD) 40.92 (9.12) 38.81 (6.94) Mother’s education uneducated 37 37.8 2 2.0 1–8 grade 43 43.9 28 28.0 χ2 = 78.43 9–12 grade 14 14.3 31 31.0 P < 0.001 college degree 4 4.1 39 39.0 Father’s education uneducated 27 27.6 2 2.0 1–8 grade 40 40.8 26 26.0 χ2 = 58.68 9–12 grade 20 20.4 31 31.0 P < 0.001 college degree 11 11.2 42 42.0 Economic status Good 11 11.2 20 20.0 moderate 58 59.2 73 73.0 χ2 = 7.13 Poor 29 29.6 7 7.0 P < 0.05 SD = standard deviation. Book 17-4.indb 306 4/27/2011 11:00:38 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 307 CI: 1.3–5.0). Maternal exposure to pas- sive smoke during pregnancy has been associated with cancer in children [11]. However, other researchers indicated no association between cancers such as leukaemia and passive smoking at home [14]. Environmental exposure to cigarette smoking among children has been related to the level of biomarkers of genetic damage, such as an increased rate of sister chromatid exchange, a cytogenetic biomarker [24]. One limitation of the present study was the small number of cases with can- cer, which led to high statistical uncer- tainty in the estimated associations. There were also other important limitations in the study design. The chil- dren included in the study were aged from 0–14 years. Therefore, especially  for the older age groups of children with cancer, mothers and fathers were asked to remember specific details of smoking habits from a long time ago and this may have affected the accuracy of their recall. Furthermore, the lifetime duration of exposure to tobacco smoke was much longer for some children than others and this may also have affected their risk of developing cancer. Conclusion The results from the current study suggest that the paternal smoking and maternal exposure to passive smoke during pregnancy may be important in the development of childhood cancer. Currently, the public is becoming generally more aware of the detrimental impact of passive maternal smoking during pregnancy on the health of the fetus. Parents need more information on the adverse effects of environmen- tal tobacco smoke and the benefits of stopping smoking. The knowledge of a potentially harmful effect of paternal smoking exposure may give parents a strong incentive to quit smoking.Ta bl e 2 Sm ok in g ex po su re a nd ri sk o f c hi ld ho od c an ce r: lo gi st ic re gr es si on Va ri ab le M ot he rs Fa th er s C as es C on tr ol s O R (9 5% C I) P- va lu e C as es C on tr ol s O R (9 5% C I) P- va lu e (n = 9 8) (n = 1 0 0 ) (n = 9 8) (n = 1 0 0 ) % % % % Sm ok ed p ri or to p re gn an cy Ye s 1.0 3. 0 0 .3 3 (0 .4 –3 .9 ) 36 .7 29 .0 1.8 0 (1 .4 –6 .0 ) N o 99 .0 97 .0 1 ( re f) > 0 .0 5 62 .2 71 .0 1 ( re f) < 0 .0 5 Sm ok ed d ur in g pr eg na nc y Ye s 1.0 3. 0 0 .3 3 (0 .4 –3 .9 ) 36 .7 12 .0 3. 0 0 (1 .4 –5 .0 ) N o 99 .0 97 .0 1 ( re f) > 0 .0 5 62 .2 88 .0 1 ( re f) < 0 .0 5 Sm ok ed a ft er b ir th Ye s 1.0 1.0 1.0 2 (0 .6 –2 .5 ) 33 .6 36 .0 0 .0 2 (0 .3 –5 .9 ) N o 99 .0 9 9. 0 1 ( re f) > 0 .0 5 66 .3 54 .0 1 ( re f) > 0 .0 5 N um be r o f c ig ar et te s s m ok ed /d ay ≤ 5 10 0 .0 10 0 .0 1 ( re f) > 0 .0 5 5. 5 17 .8 1 ( re f) < 0 .0 5 6– 10 0 .0 0 .0 0 .0 2 (0 .3 –2 .9 ) 19 .4 53 .6 1.2 0 (1 .1– 3. 0 ) ≥ 11 0 .0 0 .0 0 .0 3 (0 .3 –2 .5 ) 75 .1 28 .6 2. 70 (1 .4 –6 .0 ) M ot he r’s e xp os ur e to p as si ve sm ok e du ri ng p re gn an cy Ye s 54 .1 30 .0 3. 6 (1. 3– 5. 0 ) – – – – – N o 45 .9 70 .0 1 r ef < 0 .0 5 – – – – – O R = od ds ra tio ; C I = co nfi de nc e in te rv al ; R ef = re fe re nc e ca te go ry . Book 17-4.indb 307 4/27/2011 11:00:38 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 308 References boffetta P, trédaniel J, Greco A. risk of childhood cancer and 1. adult lung cancer after childhood exposure to passive smoke: A meta-analysis. Environmental Health Perspectives, 2000, 108:73–82. Anderson Lm. Environmental genotoxicants/carcinogens and 2. childhood cancer: bridgeable gaps in scientific knowledge. Mutation Research, 2006, 608:136–156. Pang D, mcNally r, birch Jm. Parental smoking and childhood 3. cancer: results from the united Kingdom childhood cancer study. British Journal of Cancer, 2003, 88:373–381. brondum J et al. Parental cigarette smoking and the risk of 4. acute leukemia in children. Cancer, 1999, 85:1380–1388. shi Q et al. cigarette smoking and aneuploidy in human sperm. 5. Molecular Reproduction and Development, 2001, 59:417–421. chang Js et al. Parental smoking and the risk of childhood 6. leukemia. American Journal of Epidemiology, 2006, 163:1091– 1100. John Em, savitz DA, sandler DP. Prenatal exposure to parents’ 7. smoking and childhood cancer. American Journal of Epidemiol- ogy, 1991, 133:123–132. sorahan t et al. childhood cancer and parental use of to-8. bacco: deaths from 1971 to 1976. British Journal of Cancer, 1997, 76:1525–1531. Howe Gr et al. An exploratory case-control study of brain tu-9. mors in children. Cancer Research, 1989, 49:4349–4352. Kuijten rr et al. Gestational and familial risk factors for child-10. hood astrocytoma: results of a case-control study. Cancer Research, 1990, 50:2608–2612. Filippini G et al. relation of childhood brain tumors to expo-11. sure of parents and children to tobacco smoke: the sEArcH international case-control study. surveillance of Environmen- tal Aspects related to cancer in Human. International Journal of Cancer, 2002, 100:206–213. Preston-martin s et al. N-nitroso compounds and childhood 12. brain tumors: a case-control study. Cancer Research, 1982, 42:5240–5245. Tobacco smoking. Summary of data reported and evaluation.. 13. Tobacco Smoking, IARC. IARC Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Humans. Volume 38. Lyon, World Health Organization/International Agency for research on cancer, 1986. menegaux F et al. maternal coffee and alcohol consumption 14. during pregnancy, parental smoking and risk of childhood acute leukaemia. Cancer Detection and Prevention, 2005, 29:487–493. Polanska K et al. Environmental tobacco smoke exposure 15. and children’s health. Acta Paediatrica Supplement, 2006, 95:86–92. stjernfeldt m et al. maternal smoking during pregnancy and 16. risk of childhood cancer. Lancet, 1986, 1:1350–1352. schüz J et al. Association of childhood cancer with factors 17. related to pregnancy and birth. International Journal of Epide- miology, 1999, 28:631–639. macArthur Ac et al. risk of childhood leukemia associated 18. with parental smoking and alcohol consumption prior to con- ception and during pregnancy: the cross-canada childhood leukemia study. Cancer Causes and Control, 2008, 19:283–295. Fraga cG et al. smoking and low antioxidant levels increase 19. oxidative damage to sperm DNA. Mutation Research, 1996, 351:199–203. Greaves mF, Wiemels J. Origins of chromosome transloca-20. tions in childhood leukaemia. Nature Reviews. Cancer, 2003, 3:639–649. sorahan t et al. childhood cancer and parental use of to-21. bacco: findings from the inter-regional epidemiological study of childhood cancer (IrEscc). British Journal of Cancer, 2001, 84:141–146. Lee Km et al. Paternal smoking, genetic polymorphisms in 22. cYP1A1 and childhood leukemia risk. Leukemia Research, 2009, 33:250–258. Ji bt et al. Paternal cigarette smoking and the risk of childhood 23. cancer among offspring of nonsmoking mothers. Journal of the National Cancer Institute, 1997, 89:238–244. mollerup s et al. sex differences in risk of lung cancer: Expres-24. sion of genes in the PAH bioactivation pathway in relation to smoking and bulky DNA adducts. International Journal of Cancer, 2006, 119:741–744. Book 17-4.indb 308 4/27/2011 11:00:38 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 309 Smoking among Saudi university students: consumption patterns and risk factors A. Mandil,1 A. BinSaeed,1 R. Dabbagh,1 S.A. Shaikh,1 M. AlSaadi 2 and M. Khan 3 AbstrAct tobacco use is increasing among young people, especially in Gulf nations such as saudi Arabia. the objectives of this study were to estimate the prevalence and behavioural patterns of tobacco use among undergraduate students at King saud university, riyadh, saudi Arabia during the academic year 2008/09 and investigate factors that influenced their tobacco use. A cross-sectional study was done of a representative sample (n = 6793) of the undergraduate student population using a modified version of the global youth tobacco survey questionnaire. the prevalence of smoking was 14.5% among students, 22.2% and 2.2% among fathers and mothers and 43.1% and 14.8% for male and female siblings; 15.0% reported all or most of their friends smoked. the most important independent predictors of smoking were: friends’ smoking (some: Or = 6.7 and all: Or = 54.9), sister’s smoking (Or = 2.2), mother’s smoking (Or = 2.1), single status (Or = 1.7) and age (Or = 1.18). 1Department of Family and Community Medicine; 2Department of Paediatrics; 3Department of Epidemiology and Public Health, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Correspondence to A. Mandil: ahmed.mandil@yahoo.com). received: 19/06/10; accepted: 07/07/10 راطتخلاا لماوعو كلاهتسلاا طمانأ :ةيدوعسلا في ةعمالجا ةبلط ينب ينخدتلا ناخ شيواهم ،يدعاصلا ملسم ،خيش دحمأ فياش ،غابد ةديفر ،ديعس نب زيزعلا دبع ،ليدنم دحمأ هطمانأو غبتلا يطاعت راشتنا لدعم ريدقت لىإ ةساردلا هذه فدتهو .ةيدوعسلا لثم جيللخا لود في ماَّيسلاو ،بابشلا ينب غبتلا يطاعت ديازتي :ةـصلالخا يتلا لماوعلا ّصقتو ،2009-2008 سياردلا ماعلا للاخ ةيدوعسلا ةيبرعلا ةكلملماب ضايرلا ةنيدم في ،دوعس كللما ةعماج في ةبلطلا ينب ةيكولسلا يطاعتل يلماعلا نايبتسلاا نم لّدعم جذومن مادختساب ةبلطلا نم )6793 اهددع( ة ِّبرعم ةنّيع لىع ةضرعتسم ةسارد تَيرجأ دقو .غبتلا يطاعت لىع ر ّـِ ثؤت ؛تاوخلأاو ةوخلإا ينب 14.8%و 43.1%و ،تاهملأا ينب 2.2%و ،ءابلآا ينب 22.2%و ،ةبلطلا ينب 14.5% ينخدتلا راشتنا لدعم غلبو .بابشلا ينب غبتلا & 6.7( تاقيدصلا وأ ءاقدصلأا ينخدت :يه ينخدتلل ةلقتسلما تائبنُلما مهأ تناكو .نونخدي مهئاقدصأ عيجم وأ مظعم نأ ةبلطلا نم 15.0% ركذو .) = 1.18Or( رمعلاو ،) = 1.7Or( ةبوزُعلاو ،) = 2.1Or( تاهملأا ينخدت ،) = 2.2Or( تاوخلأا ينخدتو ،) = 57.9Or Tabagisme chez les étudiants saoudiens à l’université : modes de consommation et facteurs de risque résumé La consommation de tabac est en augmentation chez les jeunes, en particulier dans les pays du Golfe tels que l’Arabie saoudite. La présente étude visait à estimer la prévalence de la consommation de tabac chez les étudiants de premier cycle à l’université King saud à riyadh (Arabie saoudite) pendant l’année universitaire 2008-2009 et à évaluer leur comportement en la matière, mais aussi à rechercher les facteurs influençant cette consommation. une étude transversale a été conduite sur un échantillon représentatif (n = 6793) de la population des étudiants de premier cycle aux moyens du questionnaire de l’enquête mondiale sur le tabagisme chez les jeunes dans une version modifiée. La prévalence du tabagisme était de 14,5 % chez les étudiants, de 22,2 % chez les pères et de 2,2 % chez les mères, de 43,1 % chez les frères et de 14,8 % chez les sœurs. Les étudiants interrogés ont été 15,0 % à déclarer que tous leurs amis ou la plupart d’entre eux étaient fumeurs. Les facteurs prédictifs indépendants les plus importants pour la consommation de tabac étaient les suivants : le tabagisme des amis (O.r. = 6,7 [certains des amis] et O.r. = 54,9 [tous les amis]), d’une sœur (O.r. = 2,2), de la mère (O.r. = 2,1), le fait d’être célibataire (O.r. = 1,7) et l’âge (O.r. = 1,18). Book 17-4.indb 309 4/27/2011 11:00:38 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 310 Introduction Tobacco use is increasing among young people. For the period 1999–2008, the  World Health Organization (WHO)/ Centers for Disease Control global youth tobacco survey (GYTS) has shown that smoking starts as early as  13–15  years.  Estimates of  current  cigarette smoking at this age in Eastern Mediterranean Region (EMR) na- tions range from 2% among girls to 7%  among boys, but for waterpipe smok- ing the rates are higher for both sexes, ranging  from 9% among girls  to 14%  among boys. Moreover, susceptibility to initiate smoking was estimated to range between 14% (girls)  and 20% (boys)  in  the  same  age  group  [1].  In  2007,  the GYTS in Saudi Arabia estimated that 6.7% of 13–15-year-old  students  currently smoked cigarettes and an estimated 11.9% currently smoked wa- terpipes [2]. Studies on tobacco use and  its risk factors among secondary-school students in Gulf countries have been carried out in Bahrain [3], Saudi Arabia [4–7], Kuwait [8] and Yemen [9], and  can be compared with high-school stu- dents in the Syrian Arab Republic [10]  and Egypt [11]. In spite of the many studies carried out in the EMR on to- bacco consumption among secondary/ high-school students, only some have focused on university students, such as studies performed in Saudi Arabia [12], Jordan [13], Egypt [14], Lebanon  [15], Bahrain [16] and the United Arab  Emirates (UAE) [17]. A compendium of tobacco con- sumption surveys in Saudi Arabia dur- ing  the past decade (1999–2009) has  shown that the prevalence estimates of tobacco use among young adults of university age range  from 2.4%–37.0%.  Such studies have also demonstrated that smoking, particularly cigarettes and waterpipes, is a widespread problem, which is increasing in scale and over time [18]. Higher prevalence has been  associated with age, being male, single and highly educated. Desire, idleness, peer pressure and enjoyment were examined as predictors for smoking among youngsters in Saudi Arabia [4–7]. Although many studies have been conducted in Saudi Arabia regarding tobacco consumption among second- ary and university students (especially males), university-wide surveys are needed to highlight tobacco consump- tion patterns and different risk factors that may contribute to adoption of the habit among Saudi youngsters, comparing students of different sexes, majors and school years. Thus, the ob- jectives of this study were to estimate the prevalence and behavioural patterns of tobacco use among undergraduate students at King Saud University, Riy- adh, Saudi Arabia during the academic year 2008/09 and  investigate different  factors that contribute to tobacco use among the students. Methods Sample A cross-sectional approach was used for data collection, which took place during  the  academic  year  2008/09.  A representative sample of the total King Saud University undergraduate student population of 69 498  (males  and females) was selected, based on an estimated prevalence of tobacco use in  Saudi Arabia  of  24%–25%, which  is higher than the average mentioned above. The sample was stratified ac- cording to college, and then clusters of classes were taken from each stratum. The total target student population of 69 498 was stratified according  to col- lege and sex. Different colleges were further stratified into 3 groups accord- ing to type of studies: health-related colleges (including: medicine, dentistry, nursing, pharmacy and applied medical sciences); non-health related colleges (including science, computer science, arts, education, language and translation, administrative sciences); and Islamic studies. The initial sample of 7550 male  and  female  students  comprised 2500  students from health-related colleges (to ensure good representation of this group in the sample) and 5250 students  from non-health-related colleges. The inclusion criteria for the study sample were: full-time student status, enrolment in one of the university’s undergraduate programmes during the academic year 2008/09, studying at the  Riyadh campus, age range 17–25 years. Data collection The GYTS questionnaire [19] was used for data collection, modified to suit the King Saud University student popula- tion (rather than a school population), and 2 versions  for males/females were  used, with questions in Arabic language. The original Arabic GYTS version has been validated by WHO in different Arabic speaking countries, and a pilot study was  carried out on 50  students  to finetune the questions before actual data collection. The self-administered questionnaire covered demographic data (age, sex, college, marital status, employment); tobacco use patterns (type of smoking, frequency, age of initiation, duration), as well as possible risk factors which could encourage students to start smoking. A smoker was defined as someone who was currently using ≥ 1 tobacco prod- ucts (cigarettes, waterpipe, etc.). Cur- rent smoking included daily, non-daily and occasional smoking (according to WHO, prevalence of current tobacco use among adults aged > 15 years). The questionnaires were distributed and collected by 40 medical  students.  The anonymity of participants was emphasized and confidentiality strictly maintained on all collected question- naires. Permission of the dean of the college and the instructors of selected classes was obtained to collect data dur- ing classes. Approval of King Saud Uni- versity research ethics committee as well as administrative sections in different college departments was obtained. Book 17-4.indb 310 4/27/2011 11:00:39 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 311 Data analysis Data were reviewed on a daily basis for completeness and accuracy, then managed and analysed using SPSS, ver- sion 17.0. Data management  included  coding, cleaning, entry, analysis and presentation in tables. Descriptive sta- tistics [mean, standard deviation (SD) and proportion] were used to describe the study variables. The chi-squared test was used to test for associations and the chi-squared test for trend and Student t-test for independent samples were used for bivariate analyses. Crude odds ratios (OR), with 95% confidence  intervals, were calculated to measure the strength of association of each of the categorical variables with the nominal outcome variable (smoking status). The Breslow–Day test was used to test for the possible effect modification by some variables on the outcome variable. Stepwise multiple logistic regression was then used to arrive at the adjusted OR to identify the most important predictors for smoking among students in our sample. A P-value  <  0.05 was  considered statistically significant. Results Background data The response rate for distributed ques- tionnaires was about 90% (6793  from  the target of 7550 students), but not all  questions were attempted by all partici- pants. The mean age of the participants was 21 (SD 1.9) years. As seen in Table  1,  44.5% of  students were males  and  55.5% females. Most sampled students  were single (90.0%). As planned during  sampling, about one-third of the stu- dents were from health-related colleges (33.2%). More  students participated  from the first 4 years of  study (87.5%)  than from the final 2 years (5th and 6th)  (12.5%), who were predominantly from  health-related colleges. More mothers of students in our sample (12.8%) were  reported to “neither read nor write” than fathers (6.6%). Also, more mothers  (59.0%)  than  fathers  (46.2%)  had  received basic education, while more fathers (47.2%) than mothers (28.3%)  had received university education (in- cluding graduate studies) (Table 1). Prevalence of smoking The overall prevalence of smoking among students in our sample was 14.5% (Table 2);  among  fathers  and  mothers  prevalence  was  22.2%  and  2.2%  respectively  and 15.0%  reported  that most or all of their friends smoked. Table 3 shows the consumption pattern of smoking with respect to type of tobacco product. More male smokers reported consuming cigarettes (48.2%)  compared with waterpipe (36.4%) and  snuff (4.3%);  the distribution  among  female smokers was similar. On the Table 1 Sociodemographic characteristics of the sample of King Saud University students, 2009 Characteristic No. % Sex (n = 6686) male 2973 44.5 Female 3713 55.5 Marital status (n = 6674) single 6009 90.0 married 612 9.2 Divorced 46 0.7 Widowed 8 0.1 College (n = 6698) Health related 2222 33.2 Non-health related 4294 64.1 Islamic studies 182 2.7 Year of study (n = 6236) 1st 1266 20.3 2nd 1506 24.2 3rd 1405 22.5 4th 1280 20.5 5th 543 8.7 6th 236 3.8 Mother’s education status (n = 6583) Neither reads or writes 843 12.8 reads and writes 803 12.2 Elementary school 849 12.9 middle school 768 11.7 High school 1461 22.2 undergraduate 1625 24.7 Graduate 234 3.6 Father’s education status (n = 6624) Neither reads or writes 436 6.6 reads and writes 405 6.1 Elementary school 517 7.8 middle school 735 11.1 High school 1407 21.2 undergraduate 2132 32.2 Graduate 992 15.0 Book 17-4.indb 311 4/27/2011 11:00:39 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 312 other hand, an almost equal distribu- tion of smoking type was reported from health-related college students for ciga- rettes (45.5%) and waterpipe (45.2%).  This was very different from non-health related  students  (51.3%  and  31.2%  respectively). Greater cigarette than waterpipe consumption was observed across all years of study (Table 3). Bivariate analyses Table 4 shows the results of bivariate analyses when cross-tabulating smok- ing status (outcome variable) with independent potential risk factors: sex, marital status, type of studies, year of study, family member smoking status and peer (friend) smoking status. Sex was significantly associated with smok- ing  status,  as  there were 778 (32.7%)  male smokers compared with only 181  (5.9%)  females (OR = 7.8, P < 0.001).  Moreover, marital status (compar- ing single with married subjects) was significantly associated with smoking status (OR = 1.8, P < 0.001). Students  of Islamic studies were at lower risk of smoking than students studying in health-related  (OR = 2.1, P  = 0.018)  and non-health  related  (OR = 2.3, P = 0.004) departments.  In  addition,  a  highly statistically significant rising trend of smoking risk was observed from freshmen in their 1st year of study to  final  year  students  in  the 6th  year  (OR = 3.0, P < 0.001). Parent’s (both father’s and mother’s) education level was not significantly associated with the smoking status of study subjects. But father’s (OR = 1.8),  mother’s (OR = 2.8) and sister’s  (OR  = 6.1) smoking habits had a statistically  significant association with the smoking habit of the sample (P < 0.001). Surpris- ingly, our data did not show a statisti- cally significant association between the smoking status of study subjects and brother’s smoking status (OR = 0.9, P = 0.29). Also, a  increasing  trend  of risk of smoking among students was observed according to friends’ smoking status (peer pressure), which increased significantly from some friends (OR = 8.8)  to most  friends (OR = 44.0)  to  all  friends  (OR = 75.5)  (χ2 = 1451.9,  P <  0.001) (Table 4). Thus, peer pressure was used as the most important predictor for smok- ing among students in our sample for further analysis for potential effect modification by variables (sex, paternal Table 2 Smoking prevalence of the sample of King Saud University students, 2009 Characteristic Smoking status 95% CI No. % total (n = 6793) 986 14.5 13.7–15.3 Father (n = 6646) 1475 22.2 21.2–23.2 mother (n = 6534) 147 2.2 1.8–2.5 brother (n = 6793) 2929 43.1 39.4–46.8 sister (n = 6793) 1004 14.8 13.9–15.6 Friends (n = 6486) some 2081 32.1 28.5–35.7 most 831 12.8 12.0–13.6 All 142 2.2 1.8–2.5 CI = confidence interval. Table 3 Tobacco use pattern of the sample of King Saud University students, 2009 Variable Cigarettes Waterpipe Snuff Other Total No. % No. % No. % No. % No. total 547 48.2 413 36.4 50 4.4 117 10.3 1136 Sex male 475 51.1 344 37.0 40 4.3 61 6.6 929 Female 72 34.8 69 33.3 10 4.8 56 27.1 207 College Health-related 172 45.5 171 45.2 8 2.1 27 7.1 378 Non-health-related 383 51.3 233 31.2 41 5.5 90 12.0 747 Islamic studies 9 52.9 7 41.2 0 0 1 5.9 17 Year of study 1st 80 47.6 50 29.8 8 4.8 30 17.9 168 2nd 97 47.1 70 34.0 13 6.3 26 12.6 206 3rd 124 50.8 83 34.0 14 5.7 23 9.4 244 4th 95 43.6 93 42.7 6 2.8 24 11.0 218 5th 81 53.3 65 42.8 3 2.0 3 2.0 152 6th 32 45.1 31 43.7 1 1.4 7 9.9 71 Book 17-4.indb 312 4/27/2011 11:00:39 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 313 smoking status, brother’s smoking sta- tus and year of study) which have been shown to be effect modifiers (statisti- cally significant P-values) when strati- fied and when tested by Breslow–Day test as shown in Table 5. Independent risk factors of smoking (multivariate analysis) Table 6  shows  the  results of  stepwise  logistic regression including statistically significant variables from the bivariate analyses. The most important inde- pendent predictors of smoking among the students in our sample were: friends’ smoking  status  (OR =  6.7  for  some,  31.7  for most  and 54.9  for  all  friends,  P < 0.001); sister’s smoking (OR = 2.2,  P  <  0.001); mother’s  smoking  (OR  = 2.1, P  < 0.006); marital  status  (OR  = 1.7 for single, P = 0.014) and older age  (OR = 1.2; P < 0.001). Discussion The overall prevalence of smoking among  students of different  colleges/ sexes in our sample was estimated at 14.5%. A recent systematic review of 66  studies reflecting an international com- parison of tobacco smoking surveys conducted among medical students between  1976–2006  indicated  that  the overall prevalence ranged  from 3%  (in Australia)  to 44% (in Spain) [20].  Moreover, a recent compendium of tobacco consumption surveys in Saudi Arabia during  the past decade (1999– 2009) has  shown  that  the prevalence  of tobacco use among young adults of university age ranged from 2.4%–37.0%  [18].  Recent  estimates  of  tobacco  consumption among male medical stu- dents in Riyadh, Saudi Arabia reflected a decline from 33% in 1992 [21] to 13%  in 2006 [22]. This seems to agree with our estimate of 14.5% and that of a sur- vey carried out at University of Sharjah, United Arab  Emirates,  during  2005,  which estimated the overall prevalence of smoking among its students at 15.1%  Table 4 Risk factors for smoking in King Saud University students, 2009 Variable Smoking status OR 95% CI P-value Smoker Non- smoker Sex male 778 1603 7.8 6.5–9.2 < 0.001 Female 181 2891 Marital status single 897 3988 1.8 1.3–2.4 < 0.001 married 57 454 1.0 – Divorced/widowed 11 48 1.8 0.8–3.9 0.14 College Health-related 309 1482 2.1 1.2–3.9 0.018 Non-health-related 652 2856 2.3 1.3–4.4 0.004 Islamic studies 13 134 1.0 – Year of study 1st 145 905 1.0 – 2nd 178 1046 1.1 0.8–1.3 0.66 3rd 204 945 1.3 1.1–1.7 0.01 4th 186 877 1.3 1.0–1.7 0.02 5th 128 308 2.6 2.0–3.4 < 0.001 6th 57 118 3.0 2.1–4.4 < 0.001 Father’s education status Neither reads nor writes 70 287 1.2 0.9–1.7 0.27 reads and writes 63 262 1.2 0.8–1.7 0.33 Elementary school 79 321 1.2 0.9–1.7 0.25 middle school 106 486 1.1 0.8–1.5 0.56 High school 203 979 1.0 0.8–1.3 0.84 undergraduate 293 1463 1.0 0.8–1.2 0.98 Graduate 135 672 1.0 – Mother’s education status Neither reads nor writes 133 538 0.9 0.6–1.4 0.8 reads and writes 135 510 1.0 0.7–1.5 0.9 Elementary school 115 569 0.8 0.5–1.1 0.2 middle school 103 525 0.7 0.5–1.1 0.16 High school 199 1030 0.7 0.5–1.1 0.11 undergraduate 225 1107 0.8 0.5–1.1 0.18 Graduate 40 149 1.0 – Father smokes Yes 304 904 1.8 1.6–2.2 < 0.001 No 643 3529 Mother smokes Yes 45 78 2.8 1.9–4.1 < 0.01 No 897 4308 Brother smokes Yes 408 1986 0.9 0.8–1.04 0.17 No 578 2544 Sister smokes Yes 383 425 6.1 5.2–7.2 < 0.01 No 602 4106 Friends smoke None 86 2752 1.0 – some 259 1301 8.8 6.8–11.4 < 0.001 most 407 296 44.0 33.6–57.7 < 0.001 All 85 36 75.5 473.0 120.9 < 0.001 OR = odds ratio; CI = confidence interval. Book 17-4.indb 313 4/27/2011 11:00:40 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 314 [17]. Nevertheless, such estimates are still high among young educated adults who should be role models for their community, fighting tobacco use rather than using it. Although bivariate analysis showed that sex was significantly associated with smoking status among students in our survey, further analysis showed that, in fact, sex was an effect modifier, related to peer pressure and smoking status. Such an observation differs from recent articles which dealt with sex as an independent fisk factore for smoking, such as a recent international compari- son of smoking surveys among medical students [20], among Sharjah university  students [17], as well as among adult Saudi  nationals  [23].  However,  the  prevalence of smoking among female students may be an underestimate, as smoking is considered taboo in con- servative communities such as Saudi Arabia. Considering students of Islamic studies as baseline (assuming them to be more conservative owing to the na- ture of their studies), students in health and non-health related subjects were at higher estimated risk of smoking. Such a finding agrees with those reported from the student survey at University of Sharjah where smokers were pre- dominantly  (89%)  from non-health  related majors [17], and a recent study in Rawalpindi, Pakistan where smoking prevalence was estimated  to be 32.7%  among medical students compared with 41.0%  among non medical  stu- dents  [24]. This  reflects  the possible  effect of Islamic studies and health- related curricula on raising awareness of students, protecting them to a cer- tain extent from taking up the habit of smoking. In addition, we observed a highly statistically significant rising trend of smoking risk from 1st year students to 6th year students. A similar finding was  reported from a recent Turkish longi- tudinal study of tobacco consumption among medical students in which about one-third of original non-smokers in the 1st year had become smokers by the end of the 6th year of study [25]. An  Indian study reported a steady increase in smoking prevalence from 17% during  the 1st year to 43% in the 5th year [26].  At a time when we expect that more university education prevents students Table 5 Possible effect modification of the association between peer pressure and smoking status of the sample of King Saud University students, 2009 Student variable/peer pressure Smoking status OR 95% CI P-value (chi squared test) P-value (Breslow– Day test)Yes No Male some/most/all friends smoke 713 1209 6.6 4.4–9.9 < 0.001 0.009 No friends smoke 29 325 1.0 Female some/most/all friends smoke 118 414 12.7 8.9–18.1 < 0.001 No friends smoke 54 2407 1.0 Father smokes: yes some/most/all friends smoke 276 350 29.2 16.4–53.1 < 0.001 0.02 No friends smoke 14 519 1.0 Father smokes: no some/most/all 545 1246 14.2 10.9–18.7 < 0.001 No friends smoke 67 2181 1.0 Brother smokes: yes some/most/all friends smoke 342 937 7.9 5.7–11.2 < 0.001 None 45 983 1.0 < 0.001 Brother smokes: no some/most/all friends smoke 509 695 31.6 22.4–44.6 < 0.001 No friends smoke 41 1768 1.0 Year of study: 1st to 4th year some/most/all 595 1307 13.9 10.8–17.0 < 0.001 0.002 No friends smoke 77 2351 1.0 Year of study: 5th and 6th year some/most/all friends smoke 180 200 97.6 23.5–208.8 < 0.001 No friends smoke 2 217 1.0 OR = odds ratio; CI = confidence interval. Book 17-4.indb 314 4/27/2011 11:00:40 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 315 Table 6 Results of multiple logistic regression analysis of the sample of King Saud University students, 2009 Risk factor Adjusted OR 95% CI P-value Age (years) 1.2 1.1–1.2 < 0.001 marital status: single 1.7 1.1–2.5 0.014 mother smokes: yes 2.1 1.2–3.5 0.006 sister smokes: yes 2.2 1.8–2.8 < 0.001 Friends smoke All 54.9 32.5–92.5 < 0.001 most 31.7 23.5–42.8 < 0.001 some 6.7 5.1–8.8 < 0.001 OR = odds ratio; CI = confidence interval. from becoming smokers, it seems that stress and perceived relaxation and better mood, as usually reported by smokers, may be related to the observed increase in smoking prevalence during the final years of basic university educa- tion at King Saud University. Father’s, mother’s and sister’s smok- ing habits had a statistically significant effect on the smoking habits of their off- spring/siblings. Such findings confirm  similar results reported from the UAE indicating that having a smoking family member (father/mother/both) was an  important predictor of smoking among University of Sharjah students [17]. In Bahrain too there were reports that the smoking status of fathers and broth- ers were significantly different between smokers and non-smokers [3]. In India a study found tobacco use was more common among male medical students belonging to families where tobacco use was prevalent [27]. The strongest predictor of smoking among students in our study was peer pressure (having a smoking friend), with regression analysis showing a rising trend from OR = 6.7 for some friends smoking  to 54.9 for all friends as smokers. Such a  finding has been consistently reported from numerous studies carried out in different Gulf nations, such as Saudi Arabia [4–6,22,23], UAE [17], Bahrain  [3,16] and outside the Gulf, such as from  India  [27], Pakistan  [24] and Turkey  [25]. However,  it  should be noted that  sex, father’s smoking, brother’s smoking and year of study were shown to be effect modifiers (i.e. association of peer pres- sure with the smoking status of students in our sample). Qualitative methods could be used to further study the findings of this quantitative study, to give more in depth understanding of this social phenomenon among university stu- dents. Moreover, better estimates of smoking among young women should be sought in further research among this sub-group of the community. University students in Gulf Coop- eration Council nations, as in Saudi Arabia, are vulnerable to taking up the habit of smoking, especially waterpipe and cigarettes among males. The impor- tance of role-models (parents, siblings, peers, teachers, etc.) cannot be empha- sized enough. Anti-smoking campaigns are warranted during university educa- tion to follow similar activities during basic education. Banning smoking on university premises can also help re- strict students from smoking, as much as possible, in addition to providing on-campus special services which could assist smokers efficiently quit this addic- tive habit. Finally, sporting and exercise facilities should be availed to allow for dissipating energy of youngsters in this critical age. References Warren cW et al. 1. Global tobacco surveillance system. The GTSS atlas. Atlanta, Georgia, centers for Disease control and Pre- vention, 2009. Global youth tobacco survey (GYTS). Country factsheet of the 2. Kingdom of Saudi Arabia 2007. cairo, World Health Organiza- tion regional Office for the Eastern mediterranean, 2008. Al-Haddad N, Hamadeh rr. smoking among secondary 3. school boys in bahrain: prevalence and risk factors. Eastern Mediterranean Health Journal, 2003, 9:91–94. Felimban Fm. Jarallah Js. smoking habits of secondary school 4. boys in riyadh, saudi Arabia. Saudi Medical Journal, 1994, 15:438–492. Jarallah Js et al. Predictors of smoking among male junior 5. secondary school students in riyadh, saudi Arabia. Tobacco Control, 1996, 5:26–29. Al-Faris EA. smoking habits of secondary school boys in rural 6. riyadh. Public Health, 1995, 109:47–55. 7. Al-Yousef mA, Karim A. Prevalence of smoking among high 7. school students. Saudi Medical Journal, 2001, 22:872–874. moody Pm. Factors associated with the initiation of smoking by 8. Kuwaiti males. Journal of Substance Abuse, 1998, 10:375–384. bawazeer AA, Hattab As, morales E. First cigarette smoking 9. experience among secondary-school students in Aden, re- public of Yemen. Eastern Mediterranean Health Journal, 1999, 5:440–449. maziak W, mzayek F. characterization of the smoking habit 10. among high school students in syria. European Journal of Epi- demiology, 2000, 16:1169–1176. Gadalla s et al. Prevalence of smoking among rural secondary 11. school students in Qualyobia governorate. Journal of the Egyp- tian Society of Parasitology, 2003, 33 (suppl):1031–1050. mandil A et al. Knowledge, attitudes and smoking pattern 12. among nursing and laboratory technology students, Dam- mam, saudi Arabia. Journal of Family and Community Medicine, 1999, 6(2):51–58. Haddad LG, malak mZ. smoking habits and attitudes towards 13. smoking among university students in Jordan. International Journal of Nursing Studies, 2002, 39:793–802. Book 17-4.indb 315 4/27/2011 11:00:40 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 316 Nassar H. 14. The economics of tobacco in Egypt. A new analysis of demand. Health, nutrition and population discussion paper. Washington Dc, International bank for reconstruction and Development/World bank, 2003. tamim H et al. tobacco use by university students, Lebanon, 15. 2001. Public Health, 2003, 98:933–939. Hamadeh rr. smoking habits of medical students in bahrain. 16. Journal of Smoking-Related Diseases, 1994, 5:189–195. mandil A et al. characteristics and risk factors of tobacco con-17. sumption among university of sharjah students, 2005. Eastern Mediterranean Health Journal, 2007, 13:1449–1458. bassiony mm. smoking in saudi Arabia. 18. Saudi Medical Journal, 2009, 30:876–881. Smoking and tobacco use.19. GYTS core questionnaire. centers for Disease control and Prevention [online factsheet] (http:// www.cdc.gov/tobacco/global/gyts/questionnaire.htm, ac- cessed 13 march 2011). smith Dr, Leggat PA. An international review of tobacco smok-20. ing among medical students. Journal of Postgraduate Medicine, 2007, 53:55–62. Jarallah Js. smoking habits of medical students at King saud 21. university, riyadh. Saudi Medical Journal, 1992, 13:510–513. Al-turki YA. smoking habits among medical students in central 22. saudi Arabia. Saudi Medical Journal, 2006, 27:700–703. saeed AA, Khoja t, Khan sb. smoking behavior and attitudes 23. among adult saudi nationals in riyadh city, saudi Arabia. To- bacco Control, 1996, 5:215–219. mumtaz b et al. comparison of smoking behaviour among 24. medical and other college students in rawalpindi. Journal of the College of Physicians and Surgeons--Pakistan, 2009, 19:7–10. senol Y et al. the incidence of smoking and risk factors for 25. smoking initiation in medical faculty students: cohort study. BMC Public Health, 2006, 6:128. singh sK et al. smoking habits of the medical students. 26. Indian Journal of Chest Diseases & Allied Sciences, 1989, 31:99–103. Kumari r, Nath b. study on the use of tobacco among male 27. medical students in Lucknow, India. Indian Journal of Commu- nity Medicine, 2008, 33:100–103. World No Tobacco Day On 31st May each year WHO celebrates World No Tobacco Day, highlighting the health risks associated with tobacco use and advocating for effective policies to reduce consumption. Tobacco use is the second cause of death globally (after hypertension) and is currently responsible for killing one in 10 adults worldwide. The World Health Assembly created World No Tobacco Day in 1987 to draw global attention to the tobacco epidemic  and its lethal effects. It provides an opportunity to highlight specific tobacco control messages and to promote adherence to the WHO Framework Convention on Tobacco Control. Tobacco use is the number one preventable epidemic that the health community faces. Book 17-4.indb 316 4/27/2011 11:00:40 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 317 High prevalence of vitamin D deficiency in the sunny Eastern region of Saudi Arabia: a hospital-based study M.Y. Elsammak,1 A.A. Al-Wossaibi,2 A. Al-Howeish 3 and J. Alsaeed 2 AbstrAct this study evaluated the vitamin D status of a cohort of healthy young saudi Arabians in the Eastern region of saudi Arabia. A sample of 139 blood donors (87 males and 52 females) answered a questionnaire about their clinical history, including intake of vitamin D supplements and calcium-rich foods and exposure to sunshine. blood samples were taken for routine biochemistry, serum 25-hydroxyvitamin D [25(OH)3] and plasma parathyroid hormone (PtH) levels. serum 25(OH)D levels did not differ significantly between males and females, although the levels were low [10.1 (sD 4.6) ng/mL and 9.9 (sD 4.5) ng/mL respectively]. When subjects with elevated PtH levels were excluded, serum 25(OH)3 levels were still in the deficiency range. there was a high prevalence of a vitamin D deficiency in this sample of saudi Arabians despite > 65% of participants having adequate exposure to sunlight and > 90% reporting adequate intake of dairy products. 1Department of Pathology and Laboratory Medicine; 2Department of Endocrinology, King Fahd Hospital, Dammam, Saudi Arabia (Correspondence to M.Y. Elsammak: myelsammak@doctors.org.uk). 3Department of Internal Medicine, King Fahd University Hospital, Al-Khobar, Saudi Arabia. received: 26/07/09; accepted: 05/10/09 ىفشتسلما اهُزكترم ةسارد :ةيدوعسلا في ةسمشلما ةيقشرلا ةقطنلما في D ينماتيفلا زَوَع راشتنا لّدعم عافترا ديعسلا لاجم ،شيولحا للها دبع ،يبـياصولا زيزعلا دبع ،كماسلا دممح تباجأ ثيح ،ةيدوعسلا نم ةيقشرلا ةقطنلما في ءاحصلأا ينيدوعسلا راغص نم ةيبارتأ ةعوممج في D ينماتيفلا ةلاح ةساردلا هذه تمّيق :ةـصلالخا ةينغلا ةيذغلأاو D ينماتيفلا تلاّمكم لوانت كلذ في ماب ،ةيريسرلا قباوسلا لوح نايبتسا لىع )ىثنأ 52و ،ًاركذ 87( مدلاب ينعبرتلما نم 139 ّمضت ةنيع ،لصلما في D ينماتيف سيكورديه - 25 سايقو ،ينيتورلا يئايميكلا صحفلل مدلا نم تانيع تذخُأ دقو .سمشلا ةعشلأ ضّرعتلاو مويسلاكلاب ولو ،ثانلإاو روكذلا ينب هب ُّدَتْعُي ًافلاتخا فلتيخ لم ليصلما D ينماتيفلا سيكورديه - 25 ىوتسم نأ دجوو .امزلابلا في يقْيَر ُّدلا نومرلها تايوتسمو دعب امأ .]لياوتلا لىع لم/مارغ ونان )4.5 يرايعلما فارحنلاا( 9.9و ،لم/مارغ ونان )4.6 يرايعلما فارحنلاا( 10.1[ نم لقأ تناك تايوتسلما نأ لّدعم ناكو .زَوَعلا دودح في ليصلما D ينماتيفلا سيكورديه- 25 لظ دقف ،يقيردلا نومرلها نم ةعفترم تايوتسم ميهدل نيذلا صاخشلأا داعبتسا منهأ مهنم %90 نم رثكأ ركذو ،سمشلا ةعشلأ نوضّرعتي اوناك ينكراشلما نم %65 نم رثكأ نأ عم ينيدوعسلا ةنيع في ًاعفترم D ينماتيفلا زوع راشتنا .نابللأا تاجتنم نم ةيفاك تايمك نولوانتي Prévalence élevée de carence en vitamine D dans la région ensoleillée de l’est de l’Arabie saoudite : une étude en milieu hospitalier résumé La présente étude a évalué le statut en vitamine D d’une cohorte de jeunes saoudiens en bonne santé résidant dans la région de l’est de l’Arabie saoudite. Les 139 donneurs de sang de l’échantillon (87 hommes et 52 femmes) ont rempli un questionnaire portant sur leurs antécédents médicaux. Les répondants devaient aussi préciser s’ils prenaient des compléments en vitamine D, quelle était leur consommation d’aliments riches en calcium et dans quelle mesure ils s’exposaient au soleil. Des échantillons sanguins ont été recueillis pour des analyses biochimiques classiques, à savoir le dosage sérique de la 25-Hydroxyvitamine D [25(OH)3] et les taux plasmatiques de l’hormone parathyroïde. Les valeurs sériques de la 25-Hydroxyvitamine D n’étaient pas significativement différentes entre les hommes et les femmes, même si ces valeurs étaient faibles (10,1 ng/ml [E.t. 4,6] et 9,9 ng/ml [E.t. 4,5], respectivement). Lorsque les patients présentant des taux élevés d’hormone parathyroïde ont été exclus, les taux sériques de la 25-Hydroxyvitamine D se situaient toujours dans la plage correspondant à une carence. L’échantillon de saoudiens étudié présentait une prévalence élevée de carence en vitamine D en dépit d’une exposition solaire adéquate pour plus de 65 % des participants et d’une consommation appropriée de produits laitiers pour plus de 90 % d’entre eux. Book 17-4.indb 317 4/27/2011 11:00:41 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 318 Introduction Vitamin D is an important nutrient for healthy bones and a deficiency of the vitamin may result in metabolic bone diseases leading to rickets in children or osteomalacia in adults [1,2]. The vitamin  D level is regulated through the interac- tion of various factors, including intes- tinal absorption, renal function, serum calcium level and parathyroid hormone (PTH) [3]. The 2 main sources for vita- min D are dietary intake and synthesis in the skin on exposure to ultraviolet-B (UVB) light from sunlight [4]. Skin pigmentation may play an important role in determining vitamin D levels as darker skin colour may limit the amount of UVB light that penetrates, thereby reducing the cutaneous synthesis of vitamin D [5]. Serum  25-hydroxyvitamin  D  [25(OH)D]  level  is  considered  to be  the best indicator of vitamin D status, with  reference  ranges  from 15 or  16  ng/mL to more  than 40 or 48 ng/mL  [6].  A  25(OH)D  level  below  8  ng/ mL (the threshold for development of  rickets/osteomalacia)  has  usually  been  termed vitamin D  insufficiency  [7]. Another important measure is the serum PTH level which increases in response to insufficient calcium in order  to stimulate bone resorption and in- crease the serum calcium necessary for the different biological processes in the body, e.g. muscle contraction and nerve conduction [8]. Many studies have re- ported an inverse association between serum PTH concentrations and serum 25(OH)D concentrations [9–11]. In areas such as Saudi Arabia where there is plentiful sunlight and many food products are fortified with vitamin D, it would be expected that the vitamin D level would be adequate in the majority of the population. Despite some cul- tural factors that may negatively affect serum vitamin D levels of Saudi women (e.g. high gravidity and clothing that limits skin exposure to the sun), these factors do not apply to males and hence vitamin D ranges may be expected to be different between males and females. In our practice in the Eastern region of Saudi Arabia we noted that a substantial proportion of patients as well as healthy subjects coming for routine screening have subnormal levels of vitamin D. The aim of this study was to measure the vitamin D level in a cohort of blood do- nors in order to evaluate the vitamin D status of healthy adult Saudi Arabians. Methods Sample Subjects included in this study were coming for routine checkups before blood donation at King Fahd hospital, Dammam, Saudi Arabia. All of them were Saudi nationals living in the East- ern region of Saudi Arabia and were apparently healthy with no associated medical problems. The study was ap- proved by King Fahd University hospi- tal ethical committee. All subjects gave their consent to participate in the study. The sample was 139  subjects  (87  males and 52  females). A  total of 176  subjects were initially included in the study,  139 met  the  inclusion  criteria  and 61 were excluded  from  the  study  due to various reasons (7 had recent viral infection, 15 were taking vitamin D  and calcium supplements, 10 had unex- plained elevation of liver function, 3 had elevated serum creatinine and 2 were on  lithium therapy). The study was carried out during winter between December 2008 and March 2009. Average winter  temperatures in the Eastern region are 18–25 °C during daytime.  A full clinical examination and clini- cal history were taken from all subjects participating in the study. Exclusion criteria included: any acute or chronic illness, liver or renal, endocrine or au- toimmune disease, taking any regular medication which can affect vitamin D level (e.g. vitamin D or calcium supple- mentation, phenytoin), elevated PTH level or impaired renal function. Data collection In addition to the clinical examination, participants were given a questionnaire addressing their frequency of sun ex- posure, daily intake of dairy products, history of vitamin D or calcium sup- plementation, history of bone aches or pains and intake of any medications that could affect vitamin D metabolism. Adequate intake of dairy products was defined as 200 mL of fortified milk, 50 g  of cheddar cheese and 1 pot of yoghurt. Adequate exposure to sunlight was de- fined as regular exposure at least twice a week between 09.00–12.00 hours for 40  minutes with at least forearms and legs exposed to direct sunlight. Weight, height and blood pressure were recorded. A 10 mL blood  sample was  taken  from each participant. An aliquot of blood was taken on EDTA for haemo- globin measurement. Blood was cen- trifuged and serum was separated and analysed promptly. Laboratory studies included measurement of random glu- cose, urea, creatinine, uric acid, calcium, phosphorous, alkaline phosphatase, total protein and albumin and alanine transaminase (ALT). These parameters were measured using a clinical chemis- try analyser (Dimension RxL, Siemens Diagnostics). Serum intact PTH level was measured using an immunoassay analyser  (Architect  2000i,  Abbott),  while  serum 25(OH)D was measured  using a chemiluminescence immu- noassay analyser (Liaison, Diasorin) The intra-assay coefficient of variation  was 11.6%. Both high and  low quality  control materials were included with each run and verified to be within the expected quality control ranges before accepting the results. The reference ranges used in our laboratory for 25 OH vitamin D were as  follows: 0–5 ng/mL (deficiency), 5–39  ng/mL  (insufficiency)  and  40–100  ng/mL  (sufficiency). The  reference  range for other variables were: PTH 15–68.3 pg/mL, haemoglobin 12–17  g/dL, urea 2.7–7.2 mmol/L, creatinine  71–115  µmol/L,  uric  acid  155–357  Book 17-4.indb 318 4/27/2011 11:00:41 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 319 µmol/L,  calcium 2.22–2.64 mmol/L,  phosphorous 0.7–1.5 mmol/L, alkaline  phosphatase 54–144 U/L, ALT 17–49  U/L, total protein 64–82 g/L and albu- min 34–50 g/L. Statistical analysis Normally distributed variables were expressed as mean and standard de- viation (SD), while variables with non- Gaussian distribution were expressed as median, range and 25 to 75 percentiles.  The statistical software package SPSS, version 11.0, was used for statistical test- ing of the data. Results The clinical and biochemical data of the participants are shown in Table 1. There was no significant age difference between males and females: mean age 30.0  (SD 8.5)  years  versus  31.0  (SD  7.2) years respectively. A substantial per- centage of male and female participants (90% and 93% respectively) reported a  sufficient regular intake of dairy products  to satisfy their daily need for calcium. The percentage of females and males reporting regular exposure to sunlight were 68% and 65% respectively. The serum creatinine level of males was significantly higher than in females, which is expected due to the higher body mass index of males. However, this elevated level of serum creatinine [85.6  (SD 12.5) µmol/L] was still within the  laboratory reference ranges for males in this age group (71–115 µmol/L). There  was no significant difference between males and females regarding fasting se- rum glucose, serum uric acid, total pro- tein, albumin, phosphorous, calcium or alkaline phosphate levels. However, the mean values of serum calcium in both groups were towards the lower level of normal (< 2.2 mmol/L). ALT was sig- nificantly higher in males than females, which may be due to a mild degree of fatty liver disease in some overweight males in the sample. Serum PTH levels were significantly higher in males than females (P < 0.01):  67.0 (SD 35.3) versus 47.5 (SD 19.6)  pg/mL respectively. For males the range  for PTH was from 19.8–204 pg/mL and  for females from 12.5–93.8 pg/mL. Serum 25(OH)D  levels were  low;  mean levels in males and females were 10.1 (SD 4.6) ng/mL and 9.9 (SD 4.5)  ng/mL respectively (Figure 1). These  25(OH)3  levels did not differ  signifi- cantly between males and females. PTH levels did not correlate with serum 25(OH)D levels  in either male  or female groups (r = 0.35, P = 0.75 and  r = 0.11, P = 0.44 respectively). However,  the serum 25(OH)D levels correlated  with the serum calcium levels in both groups (r = 0.34, P = 0.040 and r = 0.302,  P = 0.03 respectively). As elevated serum PTH level reflects a state of either clinical or subclinical vi- tamin D deficiency to maintain normal serum calcium, subjects with increased PTH level above the upper part of the reference ranges for PTH assay (i.e. > 68.0  pg/mL)  were  excluded  (30  males and 10 females) and the 25(OH) D data were reanalysed. The adjusted figures showed a serum 25(OH)D level  of 10.1 (SD 4.5) ng/mL  in males and  10.2 (SD 4.8) ng/mL in females, which  was still within the deficiency range for serum  25(OH)D  (Figure  2). There  were no significant differences between males and females in these adjusted serum 25(OH)D levels (P > 0.05). Serum alkaline phosphatase levels were not increased in either males or females participating in the study de- spite  the  low  serum 25(OH)D  level  reported. Discussion The current study evaluated serum 25(OH)D and  its  relationship  to PTH  Table 1 Clinical and biochemical characteristics of the study groups of male and female Saudi Arabians Parameter Males (n = 87) Females (n = 52) mean (sD) age (years) 30.0 (8.5) 31.0 (7.2) mean (sD) bmI (kg/m2) 27.2 (2.3) 26.2 (2.4) mean (sD) blood pressure (mmHg) 77.5 (5.9) 72.0 (8.3) % with regular sun exposure 65 68 % with regular intake of dairy products 90 93 Laboratory parameters [mean (SD) values] Haemoglobin (g/dL) 16.1 (1.5) 14.8 (0.9) random glucose (mmol/L) 5.8 (0.5) 5.5 (0.6) urea (mmol/L) 4.2 (2.7) 5.1 (1.5) creatinine (mmol/L) 85.6 (12.5)* 56.6 (14.8) uric acid (µmol/L) 200.3 (64.8) 191.4 (46.3) calcium (mmol/L) 2.12 (0.08) 2.14 (0.07) Phosphorous (mmol/L) 1.10 (0.15) 1.01 (0.20) Alkaline phosphatase (u/L) 93.1 (29.6) 74.4 (19.2) ALt (u/L) 46.1 (10.6)* 28.1 (7.0) total protein (g/L) 74.6 (4.4) 68.8 (4.9) Albumin (g/L) 42.7 (2.4) 39.3 (3.3) PtH (pg/mL) 67.0 (35.3)* 47.5 (19.6) 25(OH)D (ng/mL) 10.1 (4.6) 9.9 (4.5) *P < 0.05. PTH conversion factor: pg/mL × 0.1053 = pmol/L; 25(OH)D conversion factor: ng/mL × 2.5 = nmol/L. SD = standard deviation; BMI = body mass index; ALT = alanine transaminase; PTH = parathyroid hormone; 25(OH)D = 25-hydroxyvitamin D. Book 17-4.indb 319 4/27/2011 11:00:41 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 320 in a cohort of healthy Saudi subjects. Vitamin D plays a critical role in bone metabolism and many cellular and im- munological processes [12]. Low levels  of vitamin D have been associated with various chronic diseases, especially osteoporosis [13,14]. Vitamin D is syn- thesized in the skin through exposure to UVB radiation, and solar radiation is the primary source of vitamin D for most people [15]. Vitamin D is also ac- quired from the diet from sources where it occurs naturally (such as fatty fish, fish oil and eggs), from fortified products (such as milk and orange juice) and from supplements [16].  In areas  far  from the  equator the amount of UVB available from sunlight during the winter months is inadequate to allow cutaneous vitamin D synthesis. However, in Saudi Arabia there should be  sufficient  sunlight  to  allow  for vitamin D synthesis [17]. Different factors can affect serum vitamin D level, including skin pigmentation (synthesis decreases in dark skin), ageing (vitamin D synthetic capacity decreases with ageing), the use of sun blocking agents, chronic renal, liver and gastrointestinal tract diseases and the use of certain medi- cations (e.g. anticonvulsants) [18]. Low levels of serum vitamin D and calcium exert a positive feedback on serum PTH to increase serum calcium level that stimulates the conversion of 25(OH)D  to vitamin D and to increase the absorp- tion of vitamin D from the gut. Different 93.75 87.50 81.25 75.00 68.75 62.50 56.25 50.00 43.75 37.50 31.25 25.00 18.75 12.50 6.25 Group Females males n = 52 n = 87 10.04 10.16 25 (O H )D (n g/ m L) 210.0 210.0 210.0 180.0 150.0 120.0 90.0 60.0 30.0 0.0 Group Females males PT H (p g/ m L) Figure 1 Serum levels of 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone (PTH) in the study groups of male and female Saudi Arabians. Boxplots show median values with 25th to 75th percentiles and minimum and maximum values [O = outliers (values larger than the upper quartile plus 1.5 times the interquartile range); * = extremes (values larger than the upper quartile plus 3 times the interquartile range)] 56.25 52.50 48.75 45.00 41.25 37.50 33.75 30.00 26.25 22.50 18.75 15.00 11.25 7.50 3.75 0.00 Group Females males n = 42 n = 57 10.23 10.07 25 (O H )D (n g/ m L) Figure 2 Serum levels of serum 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone (PTH) in the study groups of male and female Saudi Arabians after exclusion of subjects with elevated PTH level (> 68 pg/mL). Boxplots show median values with 25th to 75th percentiles and minimum and maximum values 210.0 210.0 210.0 180.0 150.0 120.0 90.0 60.0 30.0 0.0 Group Females males PT H (p g/ m L) Book 17-4.indb 320 4/27/2011 11:00:41 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 321 studies that have evaluated the status of vitamin D in different ethnic populations suggest concentrations < 10–11 ng/mL  as deficiency [19,20]. Lower  levels are  expected to be associated with calcium malabsorption and hypocalcaemia, se- vere hyperparathyroidism and vitamin D rickets or osteomalacia [21]. The current study found a marked deficiency in the serum 25(OH)D level  in both male and female blood donors. Importantly, serum 25(OH)D did not  correlate with PTH level. The low level of 25(OH)D found in the current study  could not be explained by low intake or poor sun exposure, as a substantial pro- portion of the participants in this study (90%  of males  and  93%  of  females)  reported a  sufficient nutritional  intake  of  vitamin D and nearly 67% of  them  had regular exposure to UV sunlight. A possible explanation of this markedly low 25(OH)D level in both males and  females is a racial difference in vitamin D concentration or a genetic predispo- sition to vitamin D deficiency among Saudi Arabians. Pal et al. reported an ex- tremely high prevalence of 25(OH)D  deficiency in Asian populations living in the United Kingdom and hypothesized that there is a genetic predisposition to 25(OH)D deficiency  among Asians  [22]. Similarly Maeda et al. and Peters et  al. have reported deficient levels of vita- min D in healthy adults and adolescents in Brazil  [23,24]. They attributed  these  low levels to poor intake of vitamin D as there is abundant exposure to sunlight in Brazil. Vieth et al. studied a cohort of young healthy Canadian women (aged 18–35  years)  in Toronto  and  found  similarly  low  levels of vitamin D (< 40  nmol/L,  16 ng/mL)  in  a  substantial  proportion of participants during the winter months  [25]. Rucker  et  al.  re- ported similar results in Canadians of European ancestry [26]. Another possible explanation of these  low 25(OH)D  levels  in our co- hort of patients is that women in Saudi Arabia wear the traditional Islamic veil, which prevents the penetration of the UVB light needed for the synthesis of vitamin D. Certainly Hobbs et al. re- ported severe vitamin D deficiency in Arab–American women who wear the veil [27]. However, this does not explain  why Saudi Arabian men had similarly low levels of vitamin D. Even if we hy- pothesize that Saudi Arabians have a mildly dark skin which could limit the penetration of UVB  light, over 90% of  participants reported an adequate in- take of calcium and vitamin D rich food products which should compensate for a lack of cutaneous synthesis of vitamin D. This suggests that there are racial differences in the absorption of calcium and vitamin D from the gut. An important finding is that we could not find a correlation between serum 25(OH)D and PTH levels, and  the mean  serum 25(OH)D  level was  still in the lower end of the reference range even after exclusion of patients with high PTH levels. In other words, although vitamin D levels were mark- edly reduced, the PTH level was not increased in the majority of participants. This finding agrees with Haarburger et al., who found that the subnormal 25(OH)D  level  in  their  South  Af- rican cohort was also not related to hypocalcaemia or a significant rise in PTH. They  suggested  that  25(OH) D measurements should be requested when vitamin D deficiency is clinically suspected, irrespective of calcium and PTH biochemical results [28]. This study has presented a prelimi- nary evaluation of vitamin D status in young, apparently healthy Saudi Ara- bians. Our data showed that the preva- lence of 25(OH)D deficiency was high  among Saudi Arabians and suggest the need to increase the fortification of food products with vitamin D and screening for vitamin D deficiency among not only the elderly but also young Saudi adults to prevent future morbidity. Fu- ture studies should include evaluation of bone mineral density and comparison with the reference range for adults of similar age and sex. Another important point is to stratify the reference ranges according to factors such as season and ethnic background. Other studies are needed to measure the degree of skin pigmentation quantitatively and its correlation to vitamin D level and to monitor biochemical parameters after vitamin D supplementation. These may help to establish if there are racial differ- ences in vitamin D handling. References Food and Nutrition board, Institute of medicine. 1. Dietary reference intakes for calcium, magnesium, phosphorus, vitamin D, and fluoride. Washington Dc, National Academy Press, 1997. trivedi DP, Doll r, Khaw Kt. Effect of four monthly oral vitamin 2. D3 (cholecalciferol) supplementation on fractures and mortal- ity in men and women living in the community: randomised double blind controlled trial. BMJ (Clinical Research Ed.), 2003, 326:469–474. Eastell r et al. relationship of early changes in bone resorption 3. to the reduction in fracture risk with risedronate. Journal of Bone and Mineral Research, 2003, 18:1051–1056. chan J, Jaceldo-siegl K, Fraser GE. serum 25-hydroxyvitamin D 4. status of vegetarians, partial vegetarians, and nonvegetarians: the Adventist Health study-2. American Journal of Clinical Nu- trition, 2009, 89:1686s–1692s. Aloia JF et al. Vitamin D intake to attain a desired serum 25-5. hydroxyvitamin D concentration. American Journal of Clinical Nutrition, 2008, 87:1952–1958. Heaney rP. Functional indices of vitamin D status and rami-6. fications of vitamin D deficiency. American Journal of Clinical Nutrition, 2004, 80(suppl.):1706s–1709s. Vieth r. Vitamin D supplementation, 25-hydroxyvitamin D 7. concentrations, and safety. American Journal of Clinical Nutri- tion, 1999, 69:842–856. Book 17-4.indb 321 4/27/2011 11:00:42 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 322 Lips P et al. A global study of vitamin D status and parathyroid 8. function in postmenopausal women with osteoporosis: base- line data from the multiple outcomes of raloxifene evaluation clinical trial. Journal of Clinical Endocrinology and Metabolism, 2001, 86:1212–1221. Lips P et al. A global study of vitamin D status and parathyroid 9. function in postmenopausal women with osteoporosis: base- line data from the multiple outcomes of raloxifene evaluation clinical trial. Journal of Clinical Endocrinology and Metabolism, 2001, 86:1212–1221. sahota O et al. the relationship between vitamin D and par-10. athyroid hormone: calcium homeostasis, bone turnover, and bone mineral density in postmenopausal women with estab- lished osteoporosis. Bone, 2004, 35:312–319. Nakamura K et al. Vitamin D status, bone mass, and bone 11. metabolism in home-dwelling postmenopausal Japanese women: Yokogoshi study. Bone, 2008, 42:271–277. macDonald PN. molecular biology of the vitamin D receptor. 12. In: Holick mF, ed. Vitamin D: molecular biology, physiology, and clinical applications. totowa, new Jersey, Humana Press; 1999:109–128. Holick mF. Vitamin D: important for prevention of osteoporo-13. sis, cardiovascular heart disease, type 1 diabetes, autoimmune diseases, and some cancers. Southern Medical Journal, 2005, 98:1024–1027. Holick mF. the vitamin D epidemic and its health consequenc-14. es. Journal of Nutrition, 2005, 135:2739s–2748s. Grant Wb, Holick mF. benefits and requirements of vitamin D 15. for optimal health: a review. Alternative Medicine Review, 2005, 10:94–111. Holick mF. Vitamin D deficiency. 16. New England Journal of Medi- cine, 2007, 357:266–281. Webb Ar, Kline L, Holick mF. Influence of season and latitude 17. on the cutaneous synthesis of vitamin D3: exposure to winter sunlight in boston and Edmonton will not promote vitamin D3 synthesis in human skin. Journal of Clinical Endocrinology and Metabolism, 1988, 67:373–378. macLaughlin J, Holick mF. Aging decreases the capacity of 18. human skin to produce vitamin D3. Journal of Clinical Investiga- tion, 1985, 76:1536–1538. Vieth r et al. Wintertime vitamin D insufficiency is common 19. in young canadian women, and their vitamin D intake does not prevent it. European Journal of Clinical Nutrition, 2001, 55:1091–1097. standing committee on the scientific Evaluation of Dietary 20. reference Intakes. Dietary reference intakes for calcium, phos- phorus, magnesium, vitamin d, and fluoride. Washington Dc, National Academy Press; 1997. Need AG et al. Vitamin D status: effects on parathyroid hor-21. mone and 1, 25-dihydroxyvitamin D in postmenopausal wom- en. American Journal of Clinical Nutrition, 2000, 71:1577–1581. Pal br et al. Distribution analysis of vitamin D highlights dif-22. ferences in population subgroups: preliminary observations from a pilot study in uK adults. Journal of Endocrinology, 2003, 179:119–129. maeda ss et al. the effect of sun exposure on 25-hydroxyvita-23. min D concentrations in young healthy subjects living in the city of são Paulo, brazil. Brazilian Journal of Medical and Biologi- cal Research, 2007, 40:1653–1659. Peters bs et al. Prevalence of vitamin D insufficiency in brazil-24. ian adolescents. Annals of Nutrition and Metabolism, 2009, 54:15–21. Gozdzik A et al. Low wintertime vitamin D levels in a sample of 25. healthy young adults of diverse ancestry living in the toronto area: associations with vitamin D intake and skin pigmentation. BMC Public Health, 2008, 8:336. rucker D et al. Vitamin D insufficiency in a population of 26. healthy western canadians. Canadian Medical Association Jour- nal, 2002, 166:1517–1524. 27. Hobbs rD et al. severe vitamin D deficiency in Arab-Amer-27. ican women living in Dearborn, michigan. Endocrine Practice, 2009, 15:35–40. Haarburger D et al. relationship between vitamin D, calcium 28. and parathyroid hormone in cape town. Journal of Clinical Pathology, 2009, 62:567–569. Book 17-4.indb 322 4/27/2011 11:00:42 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 323 ةظفامح ناكس ىدل جذومنك ةيئيبلا ةحصلا لامج في تاسرمالماو فقاولماو فراعلما مييقت ينطسلف – ةيربلاو للها مار بيطلخا دحمأ ماصع Assessment of the environmental health knowledge, attitudes and practices in Ramallah and Al-Bireh District Palestine AbstrAct We assessed the knowledge, attitudes and practices of some aspects of environmental health among residents of ramallah and Al-bireh district, Palestine. We found that few residents had attended sessions of awareness in environmental health but 83.6% were willing to participate in such events to raise public awareness. most residents (91.2%) were aware of the relationship between water and human health, but only 39.7% reported that they or their families cleaned their water tanks more than once a year. Only 76.3% of the respondents reported that they always washed their hands before eating and only 67.0% reported that they checked the safety of food before eating. Only 33.7% felt reassured when they ate in restaurants. this was due to lack of cleanliness of the restaurants, staff and utensils, and the uncertainty regarding the source of the food. ikhatib@brizeit.edu :نورـتكلإ ديرب ،ينطسلف ،ةيبرغلا ةفضلا ،تيزيرب ةعماج ،ةيئالماو ةيئيبلا تاساردلا دهعم .10/02/21 :لوبقلا ،09/12/01 :ملاتسلاا Issam A. Al-Khatib. Institute of Environmental and Water Studies, Birzeit University, West Bank, Palestine. ينطسلف – ةيربلاو للها مار ةظفامح ناكس ىدل جذومنك ةيئيبلا ةحصلا لامج في تاسرمالماو فقاولماو فراعلما مييقت ناكسلا ضعب نأ فشتكاو .ينطسلف في ةيربلاو للها مار ناكس ينب ةيئيبلا ةحصلا هجوأ ضعبل تاسرمالماو فقاولماو فراعلما ثحابلا مّيق :ةـصلالخا يننطاولما بلغأ ناكو .ماعلا يعولا ءاكذلإ تابسانلما هذه لثم في ةكراشلما في نوبغري نوناك %83.6 نكلو ،ةئيبلا ةحصب ةيعوتلا تاسلج اوضرح دق ةدحاو ةرم نم رثكأ هايلما تانازخ فيظنتب مهسرأ وأ مه نوموقي منهأ طقف %39.7 مهنم غلبأ نكلو ،ةحصلاو هايلما ينب ةقلاعلا نوكردي )%91.2( دكأتلل ماعطلا رارمتساب نوصحفي منهأ طقف %67 غلبأو ،ماعطلا لوانت لبق ميهديأ لسغ لىع نوبظاوي منهأ ينبيجتسلما نم طقف 76.3% غلبأو .ًايونس ،اهيف ينلماعلاو ،معاطلما ةفاظن ىوتسم ِّندت لىإ دوعي اذهو .معاطلما في ماعطلا لوانت لىع نونئمطي منهأ طقف %33.7 غلبأو .هلوانت لبق هتملاس نم .ماعطلا ردصم ةدوج نم مهد ُّكأت مدعلو ،اهيف ةمدختسلما ناولأاو Évaluation des connaissances, attitudes et pratiques en matière de salubrité de l’environnement dans le district de Ramallah et Al-Bireh (Palestine) résumé Nous avons évalué les connaissances, attitudes et pratiques des résidents du district de ramallah et Al-bireh, en Palestine, concernant certains aspects de la salubrité de l’environnement. Nous avons constaté que peu de résidents avaient assisté à des sessions de sensibilisation à la salubrité de l’environnement, mais que 83,6 % étaient volontaires pour participer à de tels événements destinés à sensibiliser le public. La plupart des résidents (91,2 %) connaissaient le lien qui existe entre l’eau et la santé humaine, mais seuls 39,7 % nettoyaient (eux-mêmes ou leur famille) leur citerne d’eau plus d’une fois par an. seuls 76,3 % des répondants déclaraient se laver toujours les mains avant un repas et 67,0 % seulement vérifiaient si les aliments étaient propres à la consommation avant de les manger. Ils n’étaient que 33,7 % à se sentir rassurés lorsqu’ils mangent au restaurant. ce faible pourcentage s’explique par le manque d’hygiène du personnel et de propreté des ustensiles utilisés dans les restaurants, et par l’origine incertaine des aliments. Book 17-4.indb 323 4/27/2011 11:00:42 AM المجلد السابع عشرالمجلة الصحية لشرق المتوسط العدد الرابع 423 مقدمة تتَّصل الصحة البيئية بعّدة جوانب من صحة الإنسان، بما في ذلك نوعية الحياة بجوانبها الفيزيائية والكيميائية والبيولوجية، والاجتماعية والعوامل النفسية في البيئة. وتشمل أيضا الجوانب النظرية والعملية لتقييم العوامل المختلفة في البيئة التي يحتمل أن تؤثر سلبا على صحة الأجيال الحاضرة واُلمقبلة، وتصحيحها، ومكافحتها وَتَوقِّ يها. ومن أهم المواضيع التي تهتم بها صحة البيئة: المياه، وسلامة الاغذية، والحشرات والقوارض، والمبيدات، وما إلى ذلك من المواضيع الهامة. تزداد الحاجة للمياه كًما ونوعًا لمختلف الاستعمالات على نطاق عالمي يومًا بعد يوم؛ بسبب زيادة عدد سكان العالم، وانتشار الصناعة، وارتفاع مستوى المعيشة، وزيادة الرقعة الزراعية المروية، وغير ذلك من العوامل. وُيَعدُّ معدَّ ل استهلاك الفرد للمياه مؤشرًا على مستوى حياة الفرد، إذ إن معدَّ ل استهلاك الأفراد للمياه في الُبلدان النامية هو أقل من معدَّ ل استهلاكهم في الُبلدان الصناعية [1]. ويؤكد هذا ما جاء في دراسة للبنك الدولي، إذ تبينِّ أن نصيب المواطن الفلسطيني من المياه في غزَّ ة أقل من 51 جالون في اليوم، بينما يبلغ نصيب المواطن الأمريكي زهاء 008 جالون يوميًا، ويبلغ نصيب استهلاك الفرد الإسرائيلي في المستوطنات من 046—0841 م3 في العام، بينما لا يزيد استهلاك الفرد الفلسطيني عن 701— 651 م3 سنويًا [2]. ونتيجًة لتلوث المياه العذبة، يتعرَّ ض عشرات الملايين من الناس للأمراض الخطيرة التي ُتْودي سنويًا بحياة خمسة ملايين نسمة، معظمهم من أطفال الُبلدان النامية، ففي عام ألَفْين وجد أن حوالي %71 من سكان العالم (حوالي مليار نسمة) لا يحصلون على مياه نظيفة للشرب [3]. إن حماية مصادر مياه الشرب من خلال إدارة حكيمة، وتعاُون ِجدِّ ي بين الدول المختلفة؛ للعمل على توافره، والحدِّ من َهْدره وتلوُّ ثه، ومن خلال رقابة جودة مياه الشرب، لهي من أهم العوامل التي تساعدنا على رفع مستوى الصحة العمومية، والتزوُّ د بمياه شرب مأمونة. ولا يتأتَّى ذلك إلا بالتقصِّ المستمر لأوضاع جودة المياه من خلال الفحوصات الكيميائية والفيزيائية والحيوية. أما َحلُّ مشاكل المياه فلابد فيه من إشراك المجتمعات المحلية في حملات التوعية والتثقيف الصحية حول المياه، ومغبَّة تلوُّ ثها في نقل الأمراض، وبيان خطورة هذه الأمراض [4]. ثم إن من حق الناس أن يتوقعوا أن تكون الأغذية التي يتناولونها مأمونة وصالحة للاستهلاك. فالأمراض التي تنقلها الأغذية والأضرار التي تنتج عنها مزعجة، بل إنها قد تكون مميتة. فضًلا عن العديد من النتائج الأخرى غير المباشرة التي قد تترتب على تناول أغذية غير مأمونة أو غير صالحة للاستهلاك. فتفشِّ الأمراض التي تنقلها الأغذية يمكن أن يلحق أضرارًا بالتجارة والسياحة، مما قد يؤدِّ ي إلى فقدان الدخل، وانتشار البطالة وكثرة التقاضي. كما أن َتَلف الأغذية يؤدى إلى تبديد الموارد بما في ذلك من تكلفة، ويمكن أن ُيضرَّ بالتجارة وُيضعف من ثقة المستهلك [5-8]. ثم إن للحشرات والقوارض كذلك صلة مباشرة بصحة المواطن وسلامته، فهي تنقل العديد من الأمراض للإنسان من جانب، وتدمِّ ر العديد من المحاصيل والمواد الغذائية واَلأعلاف المخزَّ نة من جانب آخر. مما يستوجب العمل على مكافحة الحشرات والقوارض بطرق علمية سليمة [9]. ولاُبدَّ من الاهتمام بسلامة العاملين في مكافحة الحشرات والقوارض في البلديات والتجمعات السكانية، وكذلك المزارعين الذين يستخدمون المبيدات، فالأصل أن يكونوا على دراية جيدة بأسلوب َرشِّ المبيدات، وأن يكونوا متفهِّ مين لمدى ُسمِّ ية هذه المركبات؛ لتجنب مخاطرها. فلا يقومون مثًلا بعملية الرش في أوقات هبوب رياح ذات سرعة عالية، إْذ يقلِّل من تعرضهم لرذاذ المبيدات إلى أقصى حدٍّ ممكن باتباع كافة تعليمات الرِّ شِّ الصحيحة. ولاُبدَّ أن يكون العامل مدرَّ بًا على أعمال الصيانة الأولية للمعدَّ ات أو الأجهزة التي يعمل عليها، وأن يلتزم بارتداء الملابس الواقية الكاملة، مع اتباع كافة وسائل السلامة الأخرى، مثل عدم ارتداء أيِّ ملابس غير مغسولة جيدا،ً وعدم تناول أيِّ أغذية أو مشروبات أو التدخين أثناء العمل [9]. كذلك يعتبر التخلص السليم من الأوان الفارغة ومتبقِّ يات المبيدات، من أهم مراحل السلامة في التعامل مع هذه المبيدات، حيث إن الأوعية الفارغة يمكن أن تؤدي لحدوث أضرار وخيمة بالإنسان وما يربي من حيوانات أو طيور. وكذلك نظرًا لما تتميز به تلك الأوان في العادة من أشكال ُمْغِرَية للإنسان بمحاولة إعادة استخدامها في أغراض أخرى وما ينطوي ذلك عليه من أخطار. وُيلاَحظ أحيانًا عدم قيام المزارعين أو غيرهم من المواطنين بالتخلص السليم من تلك الأوان والعبوات الفارغة، مع عدم توخي الحذر والحرص الكافَيين في التعامل معها ومع المتبقِّ يات القليلة من المبيدات فيها، أو مع ما يرتشح أو يتسرَّ ب من بعض هذه الأوعية لسبب أو لآخر. إن كل جانب من جوانب تداول المبيدات له نوع ودرجة معينة من الاختطار المحتمل. وفي حالة التحكم السيِّئ في بقايا المبيدات وعبواتها فإن التدابير العملية القاصرة قد تؤدي إلى حدوث تأثيرات متفاوتة، ابتداًء من السمية الحادة، وحتى التعرُّ ض للسمِّ ية المزمنة للبالغين والأطفال والحيوانات الأليفة المنزلية والماشية والحياة البرية. والعادة أن يكون الأثر الناتج عن التعرُّ ض لبقايا ومخلفات المبيدات، مماثًلا للتعرض الذي يحدث في أيِّ ظروف أخرى، سواًء كان التعرض لمبيدات مركَّ زة أو مخفَّ فة أو من عبوات تتسرَّ ب منها المبيدات أو َتَتَناثر نتيجًة للتخزين غير المناسب، أو التخلُّ ص غير الجيد من مخلفات المبيدات. ومن أجل ذلك ُيَعدُّ التخلُّ ص المأمون من هذه المراّد أمرًا أساسيًا وجزءًا هامًا من المسئولية العمومية لكل فرد له علاقة بتداُول المبيدات أو استعمالها [9]. المنهجية تعتبر هذه الدراسة وصفية، إذ اعتمدت بشكل أساسي على مسح منزلي لمَِئَتْين واثنين وستين منزًلا في محافظة رام الله والبيرة. وشمل المجتمع الـَمْدروس جميَع المنازل في محافظة رام الله والبيرة. أما عينة الدراسة فكانت عشوائية استهدفت أربع فئات هي: الطلبة (طلبة المدارس من الصف التاسع الأساسي حتى الصف الثان الثانوي وطلبة الجامعات)، والمزارعين، والمدرِّ سين في المدارس الثانوية، وَربَّات المنازل. وكانت أداُة جمع البيانات استمارًة تم تصميمها لهذا الغرض، وشملت أربع جوانب أساسية من جوانب الصحة البيئية وهي: المياه، وسلامة الأغذية، والحشرات والقوارض، والمبيدات الكيميائية، والسلامة المهنية للمزارعين. وتطرَّ قت الاستمارة إلى عدة جوانب من هذه المجالات من حيث المعارف والمواقف والممارسات. وفي سبيل التأكد من ملائمة أداة جمع المعلومات، ُروِجَعت الاستمارة من قبل ثلاثة مختصين في مجال الصحة البيئية، وُعدِّ َلْت بناًء على ملاحظاتهم. وكذلك تم التأكد من مدى صلاحية الاستمارة عن طريق MA 34:00:11 1102/72/4 423 bdni.4-71 kooB lanruoJ htlaeH naenarretideM nretsaE 1102  •  4 .oN  71 .loV  •  JHME elatneiro eénarretidéM al ed étnaS ed euveR aL 523 تعبئتها من خلال إجراء المقابلة الشخصية مع أربعة أشخاص، ثم ُأجرَيْت تعديلات طفيفة عليها. وبعد تحديد عينة الدراسة ُوزِّ عت أداة الدراسة للحصول على المعلومات المطلوبة من خلال عمل ميدان، قام به باحثون ميدانيون تم تدريبهم على ذلك قبل البدء في جمع المعلومات. واشتمل تدريبهم على عمليات جمع البيانات، وأدبيات العمل الميدان بما في ذلك طرح الأسئلة، وتسجيل الإجابات، وأدبيات إجراء المقابلات، بالإضافة إلى جزء خاص حول خصوصيات جمع المعلومات الخاصة بالصحة البيئية، بما في ذلك الاستمارة، والأسئلة الخاصة بها، والمصطلحات والمفاهيم المستخدمة في جمع المعلومات. وتم تحليل البيانات من خلال المضمومة الإحصائية للعلوم الاجتماعية rof egakcaP lacitsitats ecneics laicos. وقد تم جمع المعلومات خلال شهَرْي كانون الأول/ديسمبر من العام 8002 وكانون الثان/ يناير من العام9002، حيث ُجمَِعْت بيانات الدراسة بأسلوب المقابلة الشخصية للفئات المستهدفة من ِقَبل الباحثين الميدانيين، وكانت نسبة الرفض للإجابة على أسئلة الاستمارة 4.4% (َرَفَض الإجابة21 شخصًا من أصل 472). نتائج الدراسة ومناقشتها َتَوزُّ ع عينة الدراسة يوضح الجدول رقم 1 َتَوزُّ ع عينة الدراسة حسب مستوى التعليم، والعمر، والجنس، ومكان الإقامة، والحالة الاجتماعية، والمهنة. ويلاحظ أن المستوى العلمي لأعلى نسبة (9.83%) أجابت على الاستمارة كان هو المستوى الجامعي. أما من حيث العمر، فقد مثَّلت الفئة العمرية 02-92 أكبر نسبة مئوية (7.92%)، وكانت نسبة الإناث بين أفراد العينة 1.16%. وأما من حيث مكان الإقامة فكانت أعلى نسبة هي من سكان القرى (6.75%). أما من حيث الحالة الاجتماعية للعينة التي أجابت على أسئلة الاستمارة فقد كانت نسبة المتزوجين بين أفراد العينة (7.55%). وكانت النسبة العليا بين الذين أجابوا على أسئلة الاستمارة مؤّلفة من الطلبة (8.13%)، تليهم ربات البيوت(1.92%) ثم المدرسون (4.32%)، وكانت أقل نسبة من المزارعين (7.51%). حضور دورات تدريبية في مجال الصحة البيئية يعتبر حضور دورات توعية في مجالات صحة البيئة المختلفة من الأمور الهامة التي تسهم إلى حد كبير في المحافظة على صحة السكان، وَتِقي من العديد من الأمراض ذات العلاقة. ويلاحظ أن نسبًا قليلة من أفراد المجتمع الفلسطيني قد حضرات دورات توعية في مجالات صحة البيئة المختلفة. وكانت أقل هذه النسب في مجال حضور دورات خاصة بالمياه (3.62%) وأكثرها في مجال حضور دورات خاصة بالسلامة المهنية (5.53%) كما هو موضح في الجدول 2. وقد لوِحَظ أن نسبة مرتفعة من المواطنين (6.38%) لديها استعداد للمشاركة في ما إذا وجدت فرصة لنشاٍط َتْوَعِوي في مجال صحة البيئة، ممَّا يؤكد أهمية إشراك المواطنين في دورات التوعية في مجال الصحة البيئية. الجدول 1 توزُّ ع عينة الدراسة (العدد والنسبة المئوية) بحَسب مستوى التعليم، والعمر، والجنس، ومكان الإقامة، والحالة الاجتماعية، والمهنة. المجموععدد الذين أجابوا ونسبتهم المئويةالمتغير جامعيدبلوم متوسطثانويإعداديابتدائيأميمستوى التعليم 262 )0.001%(201 )9.83%(83 )5.41%(96 )3.62%(72 )3.01%(31 )0.5%(31 )0.5%( سنة أو أكثر0504-9403-9302-9251-91العمر 952 )0.001%( 13 )0.21%(74 )1.81%(85 )4.22%(77 )7.92%(64 )8.71%( انثىذكرالجنس 262 )0.001%( 061 )1.16%(201 )9.83%( مخيم لاجئينقريةمدينةمكان الإقامة 262 )0.001%( 33 )6.21%(151 )6.75%(87 )8.92%( مطلقأرملمتزوجأعزبالحالة الاجتماعية 262 )0.001%( 3 )1.1%(8 )1.3%(641 )7.55%(501 )1.04%( ربة منزلمدرِّ سُمزارعطالبالمهنة 38 162 )0.001%( )8.13%( 14 )7.51%( 16 )4.32%( 67 )1.92%( الجدول 2 توزُّ ع عينة الدراسة (العدد والنسبة المئوية) بحَسب حضور دورات توعية في مجال صحة البيئة المجموعالجواب (العدد والنسبة المئوية)السؤال لانعم 262 )0.001%(161 )5.16%(101 )5.83%(هل حضرت دورة توعية في مجال الصحة البيئية بشكل عام؟ 262 )0.001%(391 )7.37%(96 )3.62%(هل حضرت دورة توعية في مجال المياه؟ 262 )0.001%(871 )9.76%(48 )1.23%(هل حضرت دورة توعية في مجال السلامة المهنية؟ 262 )0.001%(961 )5.46%(39 )5.53%(هل حضرت دورة توعية في مجال سلامة الغذاء؟ 262 )0.001%(24 )0.61%(022 )0.48%(إذا وجدَت فرصًة لنشاط توعية في مجال صحة البيئة فهل لديك استعداد للمشاركة؟ MA 34:00:11 1102/72/4 523 bdni.4-71 kooB المجلد السابع عشرالمجلة الصحية لشرق المتوسط العدد الرابع 623 أما طبيعة أنشطة التوعية في مجال صحة البيئة التي يرغب المواطنون في حضورها فقد تنوعت، وكانت أعلى نسبة هي حضور التدريب العملي الميدان (9.52%)، َتَلْتها حضور ندوات حوارية (5.41%)، ومن ثم حضور أنشطة على شكل مسرحيات أو أنشطة فنية أخرى (8.11%) بالإضافة إلى حضور أنشطة خاصة بالتوعية وبنسب أقل كما هو موضح في الجدول رقم 3. فالتدريب العملي يسهم إلى حد كبير في ترسيخ المفاهيم، وزيادة الوعي لدى المواطنين. أما الندوات الحوارية فتساهم في عرض الأفكار المختلفة من قبل خبراء ومختصين، وطرح التساؤلات من قبل المواطنين، ومن ثم الحصول على المعلومة المفيدة والهامة في الارتقاء بمستوى الوعي لدى المواطنين. مدى معرفة المواطنين وممارساتهم لبعض الجوانب ذات العلاقة بالصحة البيئية المياه والاصحاح من المعلوم وجود علاقة وثيقة بين الصحة وبين المياه بسبب نوعيتها أو قلة كميتها. ونعني بتلوث الماء كلَّ تغير في الصفات الطبيعية أو الكيميائية أو البيولوجية للماء، يجعله مصدرًا حقيقيًا أو محتمًلا للأذى أو للإضرار بالاستعمالات المختلفة للمياه، وذلك عن طريق إضافة مواد غريبة تعكر الماء أو تكسبه رائحة أو لونًا أو طعًما. وقد يتلوَّ ث الماء بالمكروبات من جراء اختلاطه بفضلات آدمية أو حيوانية، أو قد يتلوث باختلاطه بمواد سامة بحيث يصبح غير صالح للكائنات الحية التي تعتمد عليه في استمرار بقائها [01]. ويمكن تقسيم َتَلوُّ ث المياه إلى ثلاثة أقسام: التلوُّ ث البيولوجي، التلوُّ ث الكيماوي، التلوُّ ث الفيزيائي. وُيقصد بالملوِّ ثات البيولوجية وجود كائنات حية غير مرئية بالعين أو مرئية ُتَلوِّ ث الوسط البيئي (هواء، ماء، تربة). ومن هذه الكائنات الحية التي تسبب التلوث البيولوجي للأوساط البيئية المختلفة: الجراثيم والفيروسات والفطريات والحيوانات اَلأَوالى – كما قد توجد مراحل (أطوار) دقيقة (ُبَوْيضات – َيَرقات ) من دورة حياة بعض الكائنات نباتيًة كانت أم حيوانيًة في الوسط البيئي مثل بعض الطفيليات كالبلهارسيا والدودة الكبدية، وديدان القناة الهضمية، وبعض الحشرات كالبعوض وغيره [01]. وهذه الملوِّ ثات البيولوجية هي الملوثات الأكثر شيوعًا وخاصة في الجدول 3 توزُّ ع المواطنين الذين لديهم استعداد للمشاركة في أنشطة التوعية في مجال صحة البيئة إذا وجدت فرصة لذلك حسب طبيعة النشاط طبيعة النشاط العدد (%) النسبة المئوية حضور محاضرة نظرية 02 1.9 تدريب عملي ميدان 75 9.52 نشاط على شكل مسرحية أو نشاط فني آخر 62 8.11 نشرة فنية تلخص الموضوع 31 9.5 حضور فيلم فيدو 22 0.01 الاستماع إلى المذياع 6 7.2 برنامج تعليمي محوسب 12 5.9 ندوات حوارية تشارك فيها بالحوار والأسئلة 23 5.41 نشاط المسابقات البيئية 9 1.4 حضور أكثر من نشاط 41 3.5 المجموع 022 0.001 الجدول 4 توزيع عينة الدراسة (العدد والنسبة المئوية) حسب معرفة المواطنين وممارساتهم لبعض الجوانب ذات العلاقة بالمياه المجموعالجواب (العدد والنسبة المئوية)السؤال هل توجد علاقة بين المياه والصحة؟ لا أدريلانعم )0.001%( 262 )0.5%( 31)8.3%( 01)2.19%( 932 هل تعتقد بوجود كمية دنيا من المياه مطلوبة يوميًا للشرب ولأغراض النظافة الشخصية والعامة؟ لا أدريلانعم )0.001%( 262 )5.41%( 83)2.33%( 78)3.25%( 731 منذ متى تم تنظيف خزان المياه المنزلي (سنة)؟ = <43-41-2اقل من سنة 401 )0.001%( 262 )7.93%( )4.31%( 53)6.71%( 64)4.92%( 77 هل تعتقد بضرورة غسل اليدين قبل الأكل؟ لاأحيانادائما 352 )0.001%( 262 )6.69%( )0.0%( 0)4.3%( 9 هل تقوم بتنظيف يديك قبل الأكل؟ لاأحيانادائما 002 )0.001%( 262 )3.67%( )5.1%( 4)1.22%( 85 هل لديك معرفة حول إعادة استخدام المياه العادمة الرمادية )0.001%( 262لانعمالتي تنتج عن الغسَّ الة والمطبخ والاستحمام لأغراض زراعية؟ MA 44:00:11 1102/72/4 623 bdni.4-71 kooB lanruoJ htlaeH naenarretideM nretsaE 1102  •  4 .oN  71 .loV  •  JHME elatneiro eénarretidéM al ed étnaS ed euveR aL 723 البلدان النامية. وهي تدخل إلى المياه غالبًا من خلال براز المرضى وبولهم وكذلك من الحيوانات المريضة والمياه العادمة ومدافن القمامة، وكذلك من خلال محطات معالجة المياه العادمة [11]. أما المواد الكيماوية التي تسبب تلوث المياه فتقسم إلى قسمين: المواد العضوية والمواد غير العضوية. وللمياه بشكل عام أثر كبير على استمرارية ونوعية الحياة، كونها العامل الرئيسي والأول في نقل وانتشار مجموعة واسعة من الأمراض في حالة تلوثها. وقد لوحظ وجود وعي كبير لدى المواطنين بوجود علاقة بين المياه وصحة الإنسان، إذ أفاد الجدول 5 توزيع عينة الدراسة (العدد والنسبة المئوية) بحسب معارف المواطنين وممارساتهم لبعض الجوانب ذات العلاقة بسلامة الأغذية المجموعالجواب (العدد والنسبة المئوية)السؤال هل تتأكد من سلامة الأغذية التي تتناولها؟ لاأحيانًانعم دائًما )0.001%( 162 )4.5%( 41)6.72%( 27)0.76%( 571 هل تطمئن للأكل في المطاعم؟ لاأحيانًانعم دائًما )0.001%( 162 )4.82%( 47)9.73%( 99)7.33%( 88 2.19%، من أفراد العينة بوجود هذه العلاقة بشكل عام كما هو موضح في الجدول 4. وعند التطرق لمواضيع أكثر تخصصية تربط العلاقة بين الصحة والمياه، تبينَّ أن مستوى هذا الوعي أقل، فمثًلا عندما تم سؤالهم عن اعتقادهم بضرورة وجود كمية ُدنيا من المياه يوميًا للشرب ولأغراض النظافة الشخصية والعامة، أفاد 3.25% منهم فقط بضرورة ذلك. تتواجد خزانات المياه المنزلية في جميع المنازل المربوطة بشبكة المياه العامة، أو المنازل التي تتوافر لديها آبار جمع لمياه الأمطار مع وجود شبكة مياه داخل المنزل. وعادة ما توجد خزانات المياه المنزلية فوق أسطح المنازل، حيث يتم استخدامها في تخزين المياه أثناء فترة انقطاع المياه من شبكة المياه العامة، أو لرفع المياه من آبار الجمع لإعادة توزيعها على المنزل. وعادة ما تترسب بعض المواد في خزانات المياه الموجودة على أسطح المنازل، ولذلك فهي بحاجة إلى تنظيفها بشكل دوري، وأفاد 7.93% من المواطنين بأنهم هم أو أسرهم قد قاموا بتنظيف هذه الخزانات خلال أقل من عام، علًما بأن المختصين في دائرة صحة البيئة في وزارة الصحة يوصون بضرورة تنظيف خزان اَلجْمع كل ستة أشهر، وهذا يتطلب زيادة توعية السكان بمثل هذه المواضيع. وعند سؤال أفراد عينة المسح عن ضرورة غسل الأيدي قبل البدء بالأكل، أجابت الغالبية العظمى بالإيجاب (6.69%)، بالرغم من وجود نسبة قليلة لا ترى ضرورة لذلك. أما الممارسات العملية فتتنافى قليلا مع ما ذكرناه، إذ أفاد 3.67% منهم فقط بأنه يقوم بتنظيف يديه قبل الأكل. ويمكن تفسير ذلك بنقص الوعي الكافي لدى أفراد عينة المسح بأهمية غسل الأيدي قبل الأكل، بما أن عدم غسل الأيدي قد يؤدِّ ي إلى حدوث تلوث للأغذية عند تحضيرها أو تناولها. أما معارف المواطنين حول إعادة استخدام المياه العادمة الرمادية ، فتبين أن أقل من نصف المواطنين (9.34%) لديهم معرفة بهذا الموضوع. سلامة الأغذية ينتج عن الأغذية الملوثة أمراض مختلفة، واعتلالات لمستهلكها قد تؤدي إلى انخفاض مستوى الأداء، وعدم الراحة. ويعتبر عدد الحالات المرضّية الناتجة عن تلوث الأغذية متغّيرً ا من بلد لآخر، ويعتمد على عدة عوامل منها ظهور أنواع جديدة من الجراثيم الممرضة، وطرق حفظ الأغذية، وتواُفر الإصحاح المناسب، ومدى وعي الناس بطرق الحفاظ على سلامة الأغذية، وتشخيص الحالات المرضّية الناتجة عن تلوث الأغذية، وتسجيلها، والمناخ حيث أن الدول التي يغلب عليها ارتفاع الجدول 6 توزيع المواطنين الذين يطمئنون أحيانًا أو لا يطمئنون للأكل في المطاعم بحسب الأسباب (نسبة مئوية) النسبة المئوية (%) أسباب عدم اطمئنان المواطنين للأكل في المطاعم عدم نظافة المطاعم 1.12 عدم غسل الأطعمة جيدًا 3.1 عدم ضمان مصدر الأكل 3.5 عدم نظافة الأوان 3.3 عدم الثقة بالمطعم 9.5 استخدام المواد الحافظة 7. عدم نظافة العاملين في المطعم 2.7 الخوف من الأمراض 3.1 قلة الرقابة 7. عدم نظافة المطعم والعاملين فيه 9.7 عدم نظافة المطعم والعمال وعدم غسل الأطعمة 9.3 عدم نظافة المطعم وعدم ضمان مصدر الأكل 2.7 عدم نظافة المطعم والأوان المستخدمة 0.2 عدم نظافة العاملين والأوان و عدم ضمان مصدر الأكل 6.8 عدم الطبخ الجيد وعدم غسل الأطعمة 6.2 عدم نظافة المطعم والعمال وعدم ضمان مصدر الأكل 3.5 عدم نظافة العاملين وعدم الطبخ الجيد 3.1 عدم نظافة المطعم وعدم ضمان مصدر الأكل وعدم الطبخ الجيد 3.1 عدم نظافة المطعم والأوان المستخدمة وعدم ضمان مصدر الأكل 3.1 عدم نظافة المطعم والعاملين وقلة الرقابة 3.3 عدم نظافة العاملين وعدم غسل الأطعمة 3.3 عدم نظافة العاملين وعدم ضمان مصدر الأكل 3.5 المجموع 0.001 MA 44:00:11 1102/72/4 723 bdni.4-71 kooB المجلد السابع عشرالمجلة الصحية لشرق المتوسط العدد الرابع 823 درجات الحرارة ترتفع فيها فرص تلوث الأغذية [21،31] ومن نتائج المسح، تبين أن 0.76% فقط من أفراد العينة أفادوا بأنهم يتأكدون من سلامة الأغذية التي يتناولوها كما هو موضح في الجدول 5. والأصل أن يقوم بذلك جميع أفراد المجتمع الذين يستطيعون التمييز بين الصالح والفاسد من الأطعمة، والانتباه بشكل خاص إلى تاريخ انتهاء صلاحية الأغذية المختلفة سواء المواد الأولية، أو تلك الجاهزة للأكل. وإضافًة لما ُذكر، فإن للأمراض الناتجة عن تناول الأغذية الملوَّ ثة لها تأثيرًا اقتصاديًا مهًما. فهي تكلِّف المجتمع الكثير من الأموال كل عام، على شكل مصاريف على العلاج، وتعطُّ ل العمل، وتخفيض مستوى الإنتاجية لضحايا المرض. كذلك تقّل ثقة المستهلك إلى حد كبير بالمطعم الذي يحدث فيه انتشار وبائي لحالات مرضية للمستهلكين نتيجة تناولهم الأطعمة فيه. كذلك فإن زيارات مفتش وزارة الصحة وغيرها من المؤسسات ذات العلاقة تزداد بكثرة للمطعم عندما يتبين وجود حالات مرضّية ناتجة عن تناول أطعمة ملوثة منه. وفي بعض الحالات يتم إغلاق المطعم إذا تبين أن هذه هي الطريقة المثلى في المحافظة على صحة عامة الناس. وفي المجمل، فإن أيَّ خَلل في المطاعم سوف يكون له تأثير سلبي على أصحابها، وعلى الإداريين والموظفين فيها [8] . وعادة يتوجه المستهِلك لتناول الوجبات في المطعم الذي تتوفر فيه النظافة، وجودة الغذاء. فالزبائن يريدون طعاًما ذا طعم جيد من جهة، وخاليُاً من التلوث الذي قد يؤدي للمرض من جهة أخرى. وبالتالي فإن تحضير الطعام وتقديمه بشكل آمن، والمحافظة على ثقة الزبائن، تعتبر مسؤولية كلٍّ من صاحب المطعم، ومديره، والعاملين فيه [41] وهذا يتنافى مع ما أفاد به الأشخاص الذين تمَّت مقابلتهم، إذ أفاد 7.33% فقط منهم بأنهم يطمئنون دائًما للأكل في المطاعم. أما الذين لا يطمئنون دائًما للأكل في المطاعم فقد ذكروا عدة أسباب لذلك كما هي موضحة في الجدول 6. وأهم هذه الأسباب هي عدم نظافة المطاعم، وعدم نظافة العاملين والأوان وعدم ضمان مصدر الأكل. وهذا يستدعي مزيدًا من الرقابة والتفتيش من قبل مفتش دائرة صحة البيئة في وزارة الصحة، وتشجيع أصحاب المطاعم وتوعيتهم بأهمية النظافة سواًء للعاملين أو المكان أو الأوان، أو لمصادر المواد التي يستخدمونها في تحضير الطعام. الحشرات والقوارض والسلامة المهنية وث َـ مَّ َة علاقٌة وثيقٌة بين الحشرات والقوارض وبين نقل الأمراض. وقد أفاد 9.88%من أفراد العينة بوجود هذه العلاقة كما هو موضح في الجدول 7، والأصل أن يعرف جميع السكان بوجود تلك العلاقة. وأفاد 0.85% فقط بأنهم يعرفون مرضًا محددًا تسببه الحشرات والقوارض. وأفاد 5.56% من السكان بأن مستوى تواجد الحشرات والقوارض في المنطقة التي يعيشون فيها هو أمر مزعج أو مزعج جدًا، وهذا يؤكد وجود مشكلة حقيقية يعان منها الكثير من السكان. ونظرًا لكثرة انتشارها في المجتمع الفلسطيني، فقد أفاد 8.59%منهم بأنهم يكافحونها. وُيلاَحظ من الجدول 7 أن 6.38% من الذين يستخدمون المبيدات لمكافحة الحشرات والقوارض سواًء في المنزل أو الحقل، يقرؤون التعليمات الموجودة عليها، وأن 3.68% فقط من الذين يقرؤون التعليمات الموجودة على عبوات المبيدات، يلتزمون بها. على أنه لاُبدَّ من التأكيد على أهمية قراءة التعليمات المتعلقة باستخدام المبيدات، وذلك للمحافظة على سلامة مستخِدميها وعائلاتهم وجيرانهم، وكذلك الثمار التي يتم رشها. ويلاحظ أن المبيدات الكيميائية هي أكثر الطرق استخدامًا لمقاومة الحشرات والقوارض في الجدول 7 توزُّ ع عينة الدراسة (العدد والنسبة المئوية) حسب معرفة المواطنين وممارساتهم لبعض الجوانب ذات بالحشرات والقوارض المجموعالجواب (العدد والنسبة المئوية)السؤال هل تعتقد بوجود علاقة بين الحشرات والقوارض والأمراض؟ لا أدريلانعم )0.001%( 262 )8.8%( 32)3.2%( 6)9.88%( 332 هل تعرف مرضًا محددًا تسببه الحشرات والقوارض؟ لانعم )0.001%( 262 )0.24%( 011)0.85%( 251 كيف َتِصف تقيم مستوى تواجد الحشرات والقوارض في المنطقة التي تعيش فيها؟ مزعج جدامزعجعادي )0.13%( 18)5.43%( 09)5.43%( 09 هل تكافح الحشرات والقوارض في منزلك؟ لانعم )0.001%( 262 )2.4%( 11)8.59%( 152 إذا كنت تستخدم المبيدات لمكافحة الحشرات والقوارض سواًء في المنزل أو الحقل فهل تقرأ التعليمات الموجودة عليها؟ لانعم )0.001%( 262 )4.61%( 34)6.38%( 912 إذا كنت تقرأ التعليمات الموجودة على عبوات المبيدات، فهل تلتزم بهذه التعليمات؟ لاأحيانانعم دائما )%001( 912 )2.31%( 92)5.%( 1)3.68%( 981 الجدول 8 توزُّ ع المواطنين الذين يقاومون الحشرات والقوارض في منازلهم حسب طرق مقاومتها (العدد والنسبة المئوية) طرق مقاومة المواطنين للحشرات والقوارض العدد النسبة المئوية (%) رش مبيدات كيماوية 821 0.15 استخدام المصائد 41 6.5 استخدام الشبك لمنع دخولها للمنزل 46 5.52 رش مبيدات كيماوية، واستخدام المصائد والشَبك لمنع دخولها للمنزل 01 0.4 رش مبيدات كيماوية، واستخدام الشَبك 72 8.01 رش مبيدات كيماوية، واستخدام المصائد 5 0.2 غير ذلك 3 2.1 المجموع 152 0.001 MA 54:00:11 1102/72/4 823 bdni.4-71 kooB lanruoJ htlaeH naenarretideM nretsaE 1102  •  4 .oN  71 .loV  •  JHME elatneiro eénarretidéM al ed étnaS ed euveR aL 923 المنازل، كما هو موضح في الجدول 8. ولم يتم ذكر جوانب وقائية لمكافحة الحشرات والقوارض سوى استخدام الشَّ َبك (السِّ لك) لمنع دخول الحشرات والقوارض إلى المنزل. فالأصل هو القيام بالأعمال الوقائية التي تحول دون تكاثر الحشرات والقوارض في المناطق الفلسطينية المختلفة أو تقلِّل من وجودها، وذلك من خلال توجيه الجهد الرئيسي لعمال النظافة العامة مع ما يستتبعه ذلك بالضرورة من خفض كثافة الحشرات والقوارض ، وخفض حجم المبيدات المستعملة، مع التركيز على مكافحة الحشرات في بؤر تكاُثرها، كالمكبَّات العشوائية، وحاويات جمع النفايات، والمستنقعات، وغيرها... مع التركيز على إزالة أماكن التكاثر، وتنظيف َزَرائب الحيوانات بشكل دوري، ورشِّ الجدران الخارجية للمنازل والأسوار بالمبيدات الحشرية المسموح باستخدامها في المناطق السكنية [9]. أما أكثر الحشرات والقوارض انتشارًا فهي الذباب والبعوض كما هو موضح في الجدول 9. وهذا مؤشر قوي على أهمية الاهتمام بالنظافة العامة على مستوى التجمعات السكانية، وعلى مستوى المنازل، بالإضافة إلى النظافة الشخصية؛ وذلك حتى يتم التقليل من تواجد الحشرات والقوارض. الخلاصة والتوصيات تمَّ في هذه الدراسة َعْرٌض للمعارف والمواقف والممارسات في مجال بعض جوانب الصحة البيئية لدى سكان محافظة رام الله والبيرة في فلسطين، حيث تم التركيز على بعض الجوانب الخاصة بالمياه، وسلامة الأغذية، ومكافحة الحشرات والقوارض، والسلامة المهنية لمستخدمي المبيدات. وقد تبّين من خلال نتائج هذه الدراسة أن نسبًا قليلة من أفراد المجتمع الفلسطيني قد حضروا دورات توعية في مجالات صحة البيئة المختلفة. ووجدت نسبة مرتفعة من المواطنين (6.38%) الجدول 9 أهم أنواع الحشرات والقوارض الممرضة في فلسطين حسب وجهة نظر المواطنين(العدد والنسبة المئوية) أهم أنواع الحشرات والقوارض الممرضة العدد النسبة المئوية(%) الذباب 33 6.21 البعوض 36 0.42 الصراصير 1 4.0 الجراد 7 7.2 ذبابة الخيل 2 8.0 القوارض والفئران 1 4.0 الذباب والبعوض 58 4.23 الذباب والبعوض والدبابير 3 1.1 الذباب والبعوض والصراصير 4 5.1 الذباب والبعوض والجراد 01 8.3 الذباب والبعوض والقمل 4 5.1 الذباب والقوارض 1 4.0 الذباب والبعوض والقوارض 1 4.0 لا أدري 74 9.71 المجموع 262 0.001 لديها استعداٌد للمشاركة إذا وجدت فرصة لنشاط توعية في مجال صحة البيئة. وتبين وجود وعي كبير لدى المواطنين بوجود علاقة بين المياه وصحة الإنسان، إذ أفاد 2.19%، من أفراد العينة بوجود هذه العلاقة بشكل عام. وأفاد 7.93% من المواطنين بأنهم هم أو أسرهم قد قاموا بتنظيف خزانات المياه الخاصة بمنازلهم خلال أقل من عام. وأفاد 3.67% منهم فقط بأنه يقوم دائًما بتنظيف يديه قبل الأكل. وتبين أن 0.76% فقط من أفراد العينة أفادوا بأنهم يتأكدون من سلامة الأغذية التي يتناولوها. وأفاد 7.33% فقط منهم بأنهم يطمئنون دائما للأكل في المطاعم وذلك لعدم نظافة المطاعم، وعدم نظافة العاملين والأوان و عدم ضمان مصدر الأكل. تنتشر الحشرات والقوارض بكثرة، علًما بأن الذباب والبعوض هما أكثر الحشرات انتشارًا. وقد أفاد 8.59%من المواطنين بأنهم يكافحون الحشرات والقوارض. وأن 6.38% من الذين يستخدمون المبيدات لمكافحة الحشرات والقوارض سواًء في المنزل أو الحقل يقرؤون التعليمات الموجودة عليها، وأن 3.68% فقط من الذين يقرؤون التعليمات الموجودة على عبوات المبيدات، يلتزمون بها. ومن خلال ما تمَّ من تحليل للنتائج، ومناقشتها، فإنه من الضروري التركيز على جوانب التوعية، وتنويع الأنشطة ذات العلاقة من ِقَبل دائرَتيْ صحة البيئة والتثقيف الصحي في وزارة الصحة، ومن ِقَبل الجامعات الفلسطينية، والمنظمات والجمعيات الأهلية ذات العلاقة، مع الاهتمام بالمراقبة والتفتيش من ِقَبل مفتش الصحة في وزارة الصحة والبلديات وخاصة على المطاعم، والاهتمام بتوجيه الإرشادات لأصحابها، مع ضرورة توعية المزارعين والسكان حول مكافحة الحشرات والقوارض على مستوى المنازل والمزارع بالطرق السليمة، مع الاهتمام بالجوانب الوقائية وجوانب السلامة العمومية في استخدام المبيدات. .1الخطيب، عصام أحمد، الريماوي، إيمان سليمان، غيث، لينا إبراهيم، التكروري، عبير عبد المجيد. جودة المياه وسبل الحصول عليها في الأرض الفلسطينية المحتلة. المجلة .الصحية لشرق المتوسط، منظمة الصحة العالمية، الورقة مقبولة للنشر، 9002 eht ni ti ot ssecca dna retaw fo ytilauQ .la te AI bitahK-lA( htlaeH naenarretideM nretsaE .yrotirret nainitselaP deipuccO .2551-2451( :)6(51 ,9002 ,lanruoJ الخطيب، عصام أحمد، شقير، عائشة عبد الرحمن، مناصرة، نعمة خليل، 8002 .2. العوامل المؤثرة على جودة المياه في الضفة الغربية وقطاع غزة من فلسطين. مجلة -lA(.دراسات، الجامعة الأردنية، المجلد 23، العدد 2، الصفحات131-141، 8002 knab tseW eht ni ytilauq retaw gnitceffa srotcaF .la te AI bitahK ,ytisrevinU nadroJ ,lanruoJ tasariD .enitselaP fo pirts azaG dna .)141-131:)2(23 ,8002 المراجع MA 54:00:11 1102/72/4 923 bdni.4-71 kooB طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 330 World Health Organization. 10 facts about water scarcity. 3. (http://www.who.int/features/factfiles/water/ar/index.html, accessed 11 February 2010). Al-Khatib IA et al. Water-health relationships in develop-4. ing countries: a case study in tulkarem district in Palestine, International Journal of Environmental Health Science, 2003, 13:199–206. barrett b et al. Hazard analysis critical control point training for 5. food service operators in Kansas. Dairy, Food and Environmen- tal Sanitation, 1998, 18:206–211. Henson s, Holt G, Northern J. costs and benefits of implement-6. ing HAccP in the uK dairy processing sector. Food Control, 1999, 10:99–106. mortlock mP, Peters Ac, Griffith cJ. A national survey of food 7. hygiene training and qualification levels in the uK food in- dustry. International Journal of Environmental Health Research, 2000, 10:111–123. mcswane D, rue Nr, Linton r. 8. Essentials of food safety and sanitation, 3rd ed. uppersaddle river, New Jersey, Pearson Education Inc., 2003. خي ر اتل ا ( . ةي د وعسل ا ةيب رعل ا ةكلملم ا - ةي و رقل ا و ةي دلبل ا ن وئشل ا ة ر ا ز و9. لامج في ةكلملما تايدلب في ةئيبل ا ةحص تمايلعتو ةمظنأ )دوجوم يرغ ةحفصل ا . ة ر اضل ا ت ان ا ويلح ا و ض ر ا وقل ا و ت ا شرلح ا ةحف اكم ل ماع أ ةيلم اعل ا ةين و تركل لا ا: h t t p : / / w w w . j e d d a h . g o v . s a / r e g u l - tions/policies/policy_6.pdf 2010/1/21 خيراتب عقولما لوخد مت. (ministry of municipal and rural Affairs - Kingdom of saudi Ara- bia. regulations and instructions of the environmental health in the municipalities of the Kingdom in the field of action to combat insects and rodents and dangerous animals (http:// www.jeddah.gov.sa/regulations/policies/policy_6.pdf, ac- cessed 21 January 2010). 199510. ،صرم :ةرهاقلا ،عيزوتلاو شرنلل ةيبرعلا رادلا ،ةبذعلا هايلما ثولت .دحمأ ،داولجا دبع (Abd al-Gawad A. Pollution of fresh water. cairo, Egypt, Arab House for Publishing and Distribution, 1995). :نماع ،قوشرلا راد ،ةيئيبلا مولعلا لىإ لخدلما .ييح ،ناحرفلا و ،حماس ،ةبيارغ11. 1998 ،ندرلأا.(Gharaibeh s, Farhan Y. Introduction to environme - tal sciences. Amman, Jordan, sunrise House, 1998). في مع اطلم ا عق ا و . دممح ن ا ز وس ، لي وتم ، دحم أ م اصع ، بيطلخ ا12. دهعم . اهيف اته د وج و ةي ذغ لأ ا ةم لاس ى دم و ة يربل ا و لله ا م ا ر ةظف امح 2 0 0 6 ، ينطسلف – تي ز يرب ةعم اج ، ةيعمتجلم ا و ةم اعل ا ةحصل ا (Al-Khatib IA, Al-mitwalli sm. The current situation of restaurants in the Governorate of Ramallah and Al-Bireh and the extent of food safety and quality in it. Palestine, birzeit university, Institute of community and Public Health, 2006). mead Ps et al. Food-related illness and death in the united 13. states. Emerging Infectious Diseases, 1999, 5(5):607–625. JD Power and Associates reports. 14. Combination of excellent service and a quality meal is common among restaurant chains that achieve top marks in customer satisfaction. (http://www. jdpa.com/studies_jdpower/pressrelease3.asp?ID=2004090 accessed 1 February 2009). يميلقلإا بتكلما .سرادلما بلاطل يبيردت ليلد :ةئيبلا ةحص .ةيلماعلا ةحصلا ةمظنم15. 1999 ،ندرلأا-نماع ،ةئيبلا ةحص ةطشنلأ يميلقلإا بتكلما ،طسوتلما قشرل (Environmental health: a training manual for school students. Amman, Jordan, WHO regional Office for the Eastern medi- terranean, regional Office for Environmental Health Activities, 1999). Book 17-4.indb 330 4/27/2011 11:00:45 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 331 Knowledge about standard precautions among university hospital nurses in the United Arab Emirates J. Sreedharan,1 J. Muttappillymyalil 1 and M. Venkatramana 2 AbstrAct standard/universal precautions reduce the risk of transmission of bloodborne infections among patients and health care workers. this study was conducted to assess the awareness and knowledge of standard precautions among nurses in a university teaching hospital in Ajman, united Arab Emirates. All nurses working in the hospital were given a structured, self-administered, anonymous questionnaire: 101 nurses participated (range of experience from < 1 to 22 years). Overall 97.0% of respondents were familiar with the concept of standard precautions. Of these 61.2% believed that the blood and body fluids of all patients are potentially infectious irrespective of their diagnostic status, while 27.6% thought only diagnosed patients and 11.2% only suspected cases are potentially infectious. Less than half agreed that standard precautions aimed to protect both health care workers as well as patients (45.9%). the study highlights a need to implement a programme to improve knowledge on standard precautions. 1Research Division; 2Department of Surgery, Gulf Medical University, Ajman, United Arab Emirates (Correspondence to J. Sreedharan: jayadevans@rediffmail.com/jayadevans@hotmail.com). received: 16/06/09; accepted: 05/10/09 ةيرايعلما تاطايتحلاا لوح ةدحتلما ةيبرعلا تاراملإا في يعماج ىفشتسم في ضيرمتلاب ينلماعلا فراعم انامارتاكنيف ادنام ،ليلايميلباتوم يراموكاياج ،ناراهديسر نفيداياج هذه تَيرجُأ دقو .ةيحصلا ةياعرلا في ينلماعلا ينبو ضىرلما ينب مدلاب ةلوقنلما ىودعلا تلااح رطخ نم ةيلودلا ةيرايعلما تاطايتحلاا ُّد َُتح :ةصلالخا ةيبرعلا تاراملإا في نماجع في يميلعتلا ىفشتسلما في ضيرمتلاب ينمئاقلا ينب ةيرايعلما تاطايتحلاا لوح فراعلماو يعولا ةجرد سايقل ةساردلا ةساردلا في كراش دقو .همسا نيودت نودبو ًايتاذ صخشلا هيفوتسي يجهنم نايبتسا ىفشتسلما اذه في ضيرمتلاب ينلماعلا عيجم لىع ع ِّزُو دقو .ةدحتلما موهفمب ةيارد لىع نايبتسلاا نع اوباجأ نم لممج نم %97.0 ناكو .)ةنس 22 ىتح ةنس نم لقأ ينب متهبرخ لامج َحَواَرَت( ضيرمتلاب ينلماعلا نم 101 ،صيخشتلا نع رظنلا ِّضغب ىودعلل ًلامتمح ًاردصم لِّثتم ضىرلما عيملج مسلجا لئاوسو مدلا نأب نودقتعي مهنم %61.2 ناكو .ةيرايعلما تاطايتحلاا نم لقأ قفاوو .ىودعلل لمتحلما ردصلما مه طقف مهتباصإ في هبتشلما نم %11.2 نأو طقف ينصخشلما ضىرلما نأ نونظي مهنم %27.6 ناك ينح في ىريو .ءاوس ٍّدح لىع ضىرلماو ةيحصلا ةياعرلا في ينلماعلا نم لك ةياحم لىإ فدته ةيرايعلما تاطايتحلاا نأ لىع )%45.9( ضيرمتلاب ينلماعلا فصن .ةيرايعلما تاطايتحلاا لوح فراعلما ينسحتل جمانرب ذيفنت لىإ ةجالحا لىع ءوضلا طّلست ةساردلا هذه نأ نوثحابلا Connaissance des précautions standard chez le personnel infirmier d’un hôpital universitaire aux Émirats arabes unis résumé Les précautions standard/universelles réduisent le risque de transmission d’infections véhiculées par le sang chez les patients et les agents de santé. La présente étude a été conduite pour évaluer la sensibilisation du personnel infirmier de l’hôpital universitaire d’Ajman (émirats arabes unis) aux précautions standard et ses connaissances en la matière. L’ensemble du personnel infirmier a reçu un auto-questionnaire structuré et anonyme, et 101 d’entre eux (dont l’expérience allait de moins d’un an à 22 ans) ont participé à l’étude. Globalement, 97,0 % des répondants connaissaient bien le concept des précautions standard. Parmi ceux-ci, 61,2 % pensaient que le sang et les liquides organiques de tous les patients étaient potentiellement infectieux quel que soit le diagnostic, alors que 27,6 % croyaient que seuls les patients ayant reçu un diagnostic d’infection étaient potentiellement infectieux et 11,2 % considéraient que les cas suspects uniquement présentaient un risque d’infection. moins de la moitié d’entre eux (45,9 %) était d’accord sur le fait que les précautions standard étaient destinées à protéger à la fois les agents de santé et les patients. La présente étude souligne le besoin de mettre en œuvre un programme d’amélioration des connaissances sur les précautions standard. Book 17-4.indb 331 4/27/2011 11:00:45 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 332 Introduction Health care workers (HCWs) are at risk of various occupational hazards in the hospital, including exposure to bloodborne infections such as HIV and hepatitis B and C virus (HBV and HCV) infection from sharps injuries and contact with body fluids [1–3]. De- veloping countries, which account for the highest prevalence of HIV-infected patients in the world, also record the highest rate of needle-stick injuries [4]. The World Health Organization esti- mates that about 2.5% of HIV cases and  40% of HBV and HCV cases  among  HCWs worldwide are the result of these exposures [5]. The risk of seroconver- sion following a needle-stick injury from an HCV-antigen-positive patient is estimated to range from 1.2% to 10%  [6] and, as there is no immunization currently available for HIV and HCV infection, it is therefore important to prevent infection by preventing expo- sure to infection. Standard or universal precautions are a set of measures formulated to prevent transmission of bloodborne pathogens when providing health care. Since identification of patients infected with these pathogens cannot be reliably made by medical history and physical examination, the Centers for Disease Control (CDC) has recommended that standard precautions be used on all patients, regardless of knowledge about their infection status [7]. Compliance with standard precautions has been shown to reduce the risk of exposure to blood and body fluids [8]. Gershon et al. observed that better knowledge of universal precautions among HCWs was one of the correlates of good com- pliance [9]. Michalsen et al. observed the same among physicians [10]. Knowledge of standard precautions by HCWs may be influenced by their type of training [9,11–13]. Nurses are faced with professional hazards such as needle-stick injuries and bloodborne infections in their day-to-day activities in the work place. Jeong et al. in Korea observed that nurses who were working in the operating room need training to increase their compliance with stand- ard precautions [14]. Awareness about standard precautions among HCWs in Ajman, United Arab Emirates (UAE) has not been assessed before. This study therefore aimed to assess the knowledge about standard precautions among nurses in a teaching hospital in Ajman. Methods This cross-sectional study was conduct- ed from February to May 2009 among  nurses involved in virtually every aspect of nursing duties in the Gulf Medical College hospital, Ajman, UAE. This is a 110-bed  teaching hospital  involved  in both undergraduate and postgradu- ate teaching and training and is one of the  teaching hospitals  affiliated  to  the  Ministry of Higher Education in the UAE. All  118  nurses working  in  the  hospital were included in the study. All of the nurses (except 1 newly appointed nurse) had been professionally active for 1 year or more, in direct patient care and hospital hygiene. The hospital has a policy on use of standard precautions, and nurses receive training in standard precautions when they are hired. A pre-tested, structured, anony- mous, self-administered questionnaire was used to assess the nurses’ aware- ness of and knowledge about standard precautions in addition to collecting so- ciodemographic information and their lifetime duration of clinical experience. This was a 12-item questionnaire with  both open-ended and closed ques- tions in English; it took 10–15 minutes  to complete. The questionnaire was developed after a thorough review of the literature and was sent to 3 experts in public health to check for face and content validity. After revision, the questionnaire was piloted on a group of nurses who attended a breast cancer awareness programme and who were not included in the main study. Any necessary modifications were made. Questionnaires were distrubuted to nurses by the nursing superintendant and were completed during their duty time. Before administration of the ques- tionnaire, the purpose of the study was explained  to each  respondent and he/ she was assured about the confidentiality of the information. Informed consent for partipcation was obtained from each nurse. The data from the questionnaire were coded and entered into a Microsoft Excel spreadsheet and analysis was done using SPSS, version 17. The chi-squared test was used to test the association between variables. Results All 101 nurses present on the day of  the  study agreed  to participate: 10.9%  males and 89.1% females (Table 1). The  mean age of  the  respondents was 29.6  [standard deviation  (SD) 6.0]  years,  range 19–48 years. Lifetime work expe- rience varied between 10 months and  22 years. The mean duration of clinical  experience was 79.4 (SD 50.3) months.  Half of  the  respondents  (51.5%) had  been professionally active for between 1 and 5 years. Overall,  98  (97.0%)  nurses  had  heard about standard precautions; 3 had not, despite being in daily prac- tice; all had professional experience < 5  years. The remaining knowledge questions were answered by those who were aware of standard precautions. Among them 51 (52.0%) had obtained  information  about the concept of standard precau- tion from seminars and workshops, 31 (31.6%) from classroom lectures given  by  their  teachers and only 16 (16.3%)  got their knowledge of standard precau- tions from books. Less  than half  the nurses  (45.9%)  agreed that the aim of standard precau- tions was to protect both HCWs and Book 17-4.indb 332 4/27/2011 11:00:46 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 333 patients from transmission of infection (Table 2); 58.2% thought that standard  precautions were intended to protect HCWs from getting infections from patients. A quarter (25.5%) agreed that  standard precautions aimed to protect HCWs while handling infectious waste. All respondents knew the importance of HBV vaccination and all had been vaccinated. With regard to knowledge about infectious blood and body fluids, 61.2%  of nurses agreed that all patients were potentially infectious irrespective of their diagnostic  status, 27.6% believed  that only those diagnosed were infec- tious  and  11.2%  believed  that  those  suspected of being infected are poten- tially infectious (Table 3). Among  those who had   < 5  years  work experience, 63.3% agreed  that all  patients were potentially infectious; 75.0% of  those with > 10 years experi- ence had correct knowledge of standard precautions guidelines (Table 3). Discussion Standard precautions are aimed at preventing transmission of infectious agents via blood and body fluids. A study conducted in western Algeria observed that lack of adherence to standard precautions was primarily due to lack of knowledge [15]. More than 97% of  teaching hospital nurses  in  the  present study had heard about stand- ard/universal  precautions.  A  study  conducted among nurses in Nigeria observed  that  only  34.2% had heard  about  standard/universal precautions  [16]. Kermode et al. conducted a study among HCWs in rural north India and observed that knowledge of standard precautions was correct among only 56% of  respondents  [17]. In a study among postgraduate nurses in Spain, a high degree of confusion and a lack of knowledge regarding standard precau- tions were observed [18]. Although almost all the nurses had heard of standard precautions, a much lower proportion (61.2%) agreed  that  the blood and body fluids of all patients were potentially infectious irrespective of their diagnostic status, according to CDC guidelines [7]. The remainder thought that only diagnosed patients or only suspected cases should be consid- ered potentially infectious. In the current study, 58.2% of nurses  believed that standard precautions are aimed at protecting HCWs from get- ting  infections  from  patients,  23.5%  thought they were to prevent patients getting infected from HCWs and 45.9%  that they aimed to protect both HCWs as well as patients from infections. In a study among 82 nurses in a public hos- pital in Brazil, 11.0% understood stand- ard precautions as protective measures for professionals only, 52.4%  for both  professionals and patients, 7.3% for pa- tient care independent of the diagnosis, and 9.8%  for patients with diagnosed  infection [19]. Another study in Bra- zil had similar finding with regard to knowledge about standard precautions among nurses involved in pre-hospital care [12]. Conclusion Although over  95% of  nurses  in  this  hospital in Ajman were aware of stand- ard precautions, knowledge about standard precautions guidelines and their implementation was not up to standard. Table 1 Sociodemographic characteristics of the nurses (n = 101) Characteristic No. % Age (years) < 25 11 10.9 25–29 48 47.5 30–34 24 23.8 35–39 6 5.9 ≥ 40 12 11.9 Sex male 11 10.9 Female 90 89.1 Work experience (years) < 5 52 51.5 5–10 33 32.7 > 10 16 15.8 Table 2 Nurses’ knowledge about reasons for use of standard precautions by duration of work experience for those who had heard of standard precautions (n = 98) Aims of standard precautions Work experience (years) Total (n = 98)a< 5 (n = 49)a 5–10 (n = 33) > 10 (n = 16) No. % No. % No. % No. % Protect HcWs 29 59.2 17 51.5 11 68.8 57 58.2 Protect patients getting infected from HcWs 14 28.6 6 18.2 3 18.3 23 23.5 Prevent mutual transfer of infection 22 44.9 16 48.5 7 43.8 45 45.9 Protect HcWs while handling infectious waste 12 24.5 9 27.3 4 25.0 25 25.5 Protect HcWs while handling sharp waste 11 22.4 7 21.2 4 25.0 22 22.4 Total exceeds 100% due to multiple answers. a3 nurses were unaware of standard precautions. HCWs = health care workers. Book 17-4.indb 333 4/27/2011 11:00:46 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 334 The findings of this study highlight the need to implement a programme to improve knowledge on standard precautions. Acknowledgements We gratefully acknowledge the partici- pation of all the nurses, without whose contribution the study would not have been completed. The official support from the univer- sity is also acknowledged. References Gerberding JL. Incidence and prevalence of human immu-1. nodeficiency virus, hepatitis b virus, hepatitis c virus, and cytomegalovirus among health care personnel at risk for blood exposure: final report from a longitudinal study. Journal of Infectious Diseases, 1994, 170:1410–1417. ramos-Gomez F et al. Accidental exposures to blood and 2. body fluids among health care workers in dental teaching clin- ics: a prospective study. Journal of the American Dental Associa- tion, 1997, 128:1253–1261. ruben FL et al. Epidemiology of accidental needle-puncture 3. wounds in hospital workers. American Journal of the Medical Sciences, 1983, 286:26–30. Pruss-Üstün A, rapiti E, Hutin Y. 4. Sharps injuries: global burden of disease from sharps injuries to health-care workers. Geneva, World Health Organization, 2003. The world health report 2002: reducing risks, promoting health 5. life. Geneva, World Health Organization, 2002. mizuno Y et al. study of needlestick accidents and hepatitis c 6. virus infection in healthcare workers by molecular evolution- ary analysis. Journal of Hospital Infection, 1997, 35:149–154. update: universal precautions for prevention of transmission 7. of human immunodeficiency virus, hepatitis b virus, and other bloodborne pathogens in health-care settings. Morbidity and Mortality Weekly Report, 1988, 37(24):377–388. chan r et al. Nurses’ knowledge of and compliance with 8. universal precautions in an acute care hospital. International Journal of Nursing Studies, 2002, 39:157–163. Gershon rr et al. compliance with universal precautions 9. among health care workers at three regional hospitals. Ameri- can Journal of Infection Control, 1995, 23(4):225–236. michalsen A et al. compliance with universal precautions 10. among physicians. Journal of Occupational and Environmental Medicine, 1977, 39(2):130–137. Ofili AN, Asuzu mc, Okojie OH. Knowledge and practice of 11. universal precautions among nurses in central hospital, benin- city, Edo state, Nigeria. Nigerian Postgraduate Medical Journal, 2003, 10:26–31. Oliveria Ac et al. Knowledge and attitude regarding standard 12. precautions in a brazilian public emergency service: a cross sectional study. Revista da Escola de Enfermagem da USP, 2009, 43(2):313–319. Askarian m, mcLaws mL, meylan m. Knowledge, attitude and 13. practices related to standard precautions of surgeons and physicians in university-affiliated hospitals of shiraz, Iran. Inter- national Journal of Infectious Diseases, 2007, 11(3):213–219. Jeong I, cho J, Park s. compliance with standard precautions 14. among operating room nurses in south Korea. American Jour- nal of Infection Control, 2008, 36:739–742. beghdadli b et al. respect des “précautions standards” par 15. le personnel infirmier d’un centre hospitalo-universitaire de l’ouest algérien [“standard precautions” practices among nurses in a university hospital in Western Algeria]. Sante Pub- lique, 2008, 20:445–453. Ofili AN. Asuzu mc, Okojie OH. Knowledge and practice of 16. universal Precautions among nuses incentral hospital, benin- city, Edo state, Nigeria. Nigerian Postgraduate Medical Journal, 2003, 10:26–31. Kermode m et al. compliance with universal/standard Pre-17. cautions among health care workers in rural north India. American Journal of Infection Control, 2005, 33:27–33. López c et al. standard precautions: are these known? Are 18. they applied? Revista de Enfermeria (Barcelona, Spain), 2006, 29:16–20. melo Dde s et al. Nurses’ understanding of standard precau-19. tions at a public hospital in Goiania—GO, brazil. Revista Latino- Americana de Enfermagem, 2006, 14:720–727. Table 3 Nurses’ knowledge about potentially infectious blood and body fluids by duration of work experience for those who had heard of standard precautions (n = 98) Potentially infectious blood and body fluids Work experience (years) Total (n = 98)< 5 (n = 49) 5–10 (n = 33) > 10 (n = 16) No. % No. % No. % No. % All patients 31 63.3 17 51.5 12 75.0 60 61.2 Only those diagnosed as infectious 12 24.5 12 36.4 3 18.8 27 27.6 those suspected 6 12.2 4 12.1 1 6.3 11 11.2 Book 17-4.indb 334 4/27/2011 11:00:46 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 335 Validity and reliability of the Persian (Farsi) version of the Job Content Questionnaire: a study among hospital nurses A. Choobineh,1 H. Ghaem 2 and P. Ahmedinejad 3 AbstrAct stress is an increasingly important occupational health problem, even in developing countries such as the Islamic republic of Iran. the Job content Questionnaire (JcQ) is a widely used self-administered instrument to measure dimensions of job stress in the workplace. this study describes the preparation of a Persian (Farsi) language version of the questionnaire (P-JcQ). In the first stage, linguistic validation was done by forward and backward translation. In the psychometric evaluation stage, the reliability and validity of the P-JcQ were explored among 107 hospital nurses in shiraz city. cronbach alpha coefficients for decision latitude and psychological job demands scales were 0.54 and 0.58 respectively and ranged from 0.64 to 0.85 for other scales. Exploratory factor analysis showed 3 meaningful factors that could explain support, psychological job demands and physical loads and hazard exposure. the P-JcQ has satisfactory linguistic validity and psychometric properties, provided the recommended factor pattern is used. Research Centre for Health Sciences; 2Department of Epidemiology; 3Department of Occupational Health, School of Health and Nutrition, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to A. Choobineh: alrchoobin@sums.ac.ir). received: 19/06/09; accepted: 11/10/09 تايفشتسلما في ضيرمتلاب ينلماعلا ينب ةسارد :يفيظولا ىوتحلما نايبتسلا ةيسرافلا ةخسنلا ةيلّوعمو ةّيقودصم قيثوت داجن يدحمأ نيورب ،مئاق ةلاه ،هنيبوج اضيرلع نايبتسا مَدختسُيو .ةيملاسلإا ناريإ ةيروهجم لثم ةيمانلا نادلبلا في ىتح كلذو ،ةينهم ةيحص ةلكشم لِّثمي بْرَكلا نوك ةيهمأ ديازتت :ةصلالخا ةيسرافلا ةغللاب ةخسن دادعإ ةساردلا هذه فصتو .لمعلا عقاوم في يفيظولا بْرَكلا داعبأ سايقل ةيتاذ ةادأك عساو قاطن لىع يفيظولا ىوتحلما سايقلا مييقت ةلحرم فيو .اهيلإو ةيسرافلا ةغللا نم نايبتسلاا ةجمرت قيرط نع ةّيقودصملل قيثوت يرجأ ،لىولأا ةلحرلما فيو .نايبتسلاا اذله افلأ خابنورك لماعُم ناكو .زايرش ةنيدم ىفشتسم في ضيرمتلاب ينلماعلا نم 107 ينب سيرافلا نايبتسلاا ةّيل َّوعمو ةّيقوثوم فاشكتسا ىرج ،سيفنلا 0.85و 0.64 ينب لماعُمـلا َحَواَرَت ينح في لياوتلا لىع 0.58و 0.54 :ةفيظولل ةيسفنلا تابلطتلماو رارقلا ذاّتخا ةيرح نم ٍّلك سايقل cronbach alpha ،ندبلا ءبعلاو ،ةفيظولل ةيسفنلا تابلطتلماو ،معدلا يرسفتل ،ابه ُّدتعُي لماوع ةثلاث ةيفاشكتسلاا لماوعلا ليلتح رهظأو .ىرخلأا سايقلا لملاس في لماعلا زارط مادختسا ةطيشر ةّيسفنلا ةيسايقلا صئاصلخاو ةّيوغللا ةّيقودصلما نم ةلوبقم ةجردب فصّتي سيرافلا نايبتسلاا .رطاخملل ض ُّرعتلاو .هب صىولما Validité et fiabilité de la version en langue perse (farsi) du Questionnaire de Karasek : une étude chez le personnel infirmier en milieu hospitalier résumé Le stress représente un problème de santé au travail de plus en plus important, même dans les pays en développement comme la république islamique d’Iran. Le Questionnaire de Karasek, en anglais Job Content Questionnaire (JcQ), est un auto-questionnaire très utilisé pour mesurer les dimensions du stress professionnel. La présente étude décrit la préparation de la version en langue perse (farsi) du questionnaire (P-JcQ). Lors de la première étape, une validation linguistique a été conduite aux moyens d’une traduction vers la langue cible puis d’une rétro-traduction vers la langue source. À l’étape de l’évaluation psychométrique, la fiabilité et la validité du questionnaire P-JcQ ont été explorées auprès de 107 membres du personnel infirmier de la ville de chiraz. Les coefficients alpha de cronbach pour les échelles concernant la latitude décisionnelle et les demandes psychologiques au travail étaient de 0,54 et 0,58, respectivement, et allaient de 0,64 à 0,85 pour les autres échelles. une analyse de facteur exploratoire a révélé trois facteurs significatifs capables d’expliquer les résultats concernant le soutien, les demandes psychologiques, les charges physiques et l’exposition au danger au travail. Le questionnaire P-JcQ possède une validité linguistique et des propriétés psychométriques satisfaisantes, dans la mesure où la structure factorielle recommandée est utilisée. Book 17-4.indb 335 4/27/2011 11:00:47 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 336 Introduction Stress has become an increasingly im- portant occupational health problem and a significant cause of economic loss throughout the world [1]. A number of studies with a cross-sectional or pro- spective design have shown a variety of adverse health outcomes to be positively associated with job stress [1–8]. The Job Content Questionnaire (JCQ) is a widely used self-adminis- tered instrument to measure the social and psychological structure of the work situation [9]. The well known demands– control–support model of job strain, as proposed by Karasek, predicts that job strain will occur when the psychological job demands are high and the worker’s decision latitude is low, and that low support would  increase  the  risk  [1,9].  The core scales of the JCQ therefore consist of 3 elements: decision latitude, psychological job demands and social support. Two other aspects of work demands are also assessed: physical job demands and job insecurity. The instrument has a recommended length of 49 questions [9]. Based on the condi- tions and aims of any given study, other questions may be included to measure other aspects of the job. For instance, to control for physical hazards at work, the 9-item physical hazard and exposure  scale is recommended. These result in a 58-item questionnaire which can be  used to analyse job characteristics and assess the relative risks of individual exposure to different work settings and thus to predict job-related illness such as psychological distress, coronary heart diseases, musculoskeletal disorders and reproductive disorders  [9]. The  JCQ  has been translated into over a dozen languages. An international board of research, the JCQ Center based at the University of Massachusetts, United States of America, is responsible for the development of the questionnaire [9]. As the JCQ has been developed and applied mostly in industrialized countries, its usability is yet to be tested in different cultures where traditional societies are being affected by rapid technological  changes  [10]. With  in- creasing industrialization in the Islamic Republic of Iran job stress is becoming a risk factor for the health and safety of the workforce. Preparation of a Per- sian (Farsi) language version of the questionnaire is therefore an important step to enable systematic studies on job stress that can inform occupational health interventions among Iranian workers. The aims of the present study were: to develop a Persian version of the JCQ (P-JCQ) and make it available to the Iranian scientific community; and to investigate the psychometric proper- ties of selected scales of the P-JCQ on a sample of nurses employed in Shiraz city hospitals. Methods The questionnaire As the questionnaire was intended to be used in the occupational health context, 39  relevant  items,  covering  the  core  set of items, were selected from the full version of the JCQ [11]. They were as  follows: decision  latitude (9  items);  psychological  job demands (9  items);  social support (8 items); physical exer- tion (3 items); and physical isometric loads (2 items). Questions about physi- cal hazard and exposure (8  items),  as  recommended by Karasek [11], were added to the questionnaire to control for physical hazards at work that may contribute to the outcomes. Each of the questions had a 4-point response ranging from 1 (strongly disagree) to 4 (strongly agree). In some cases, less than 4 responses (i.e. physi- cal hazards and exposure questions) or more than 4 responses (i.e. social support questions) were provided. The scale calculations were performed in accordance to the JCQ user’s guide [11]. In addition to items from the P-JCQ, the self-administrated ques- tionnaire also contained questions on demographic characteristics, i.e. race, sex, age, education, marital status, work history and medical status. Linguistic validation The first step was translation to ensure the linguistic validity of the question- naire in the new language. The 39-item  JCQ was translated into Persian by a qualified translator, who was a na- tive speaker of Persian and proficient in English (forward translation), and then translated back into English by a qualified English translator, blind to the original English questions (backward translation). The JCQ Center reviewed the back-translated English version for comparison with the original version. Based on the reviews, some items were corrected. To check the understanding and interpretation of the translated items among a group of the Iranian workforce and thereby validate the conceptual equivalence between the English and the Persian version (cognitive debrief- ing), the P-JCQ was administered to 20  hospital nurses. The nurses were asked to put a note beside any ambiguous questions. Based on the JCQ Center amendments and the nurses’ notes, the final P-JCQ was prepared. The process of linguistic validation of the P-JCQ has been presented in detail elsewhere [12]. Psychometric evaluation The second step was to evaluate the psychometric properties of the ques- tionnaire. In this stage of the study conducted  from March  to  July 2008,  the 39-item P-JCQ was administered  anonymously to 107 randomly selected  nurses employed  in 6 university hospi- tals located in Shiraz city, in the south of the Islamic Republic of Iran. The study protocol was reviewed and approved by Shiraz University of Medical Sciences ethics committee and the study was conducted in accordance with the revised Helsinki Declaration of 1989. All of  the participants  signed  Book 17-4.indb 336 4/27/2011 11:00:47 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 337 an informed consent form before the study began. A cover note guaranteed the  subjects’  confidentiality.  She/he  was informed of the aims, methods and anticipated benefits of the study and that  she/he was  at  liberty  to  abstain  from participation in the study and that she/he was  free to withdraw her or his  consent to participation at any time. Each subject received the questionnaire in person  in her/his workplace. Each  subject was given 30 minutes  to com- plete the questionnaire and return it to the researcher. The internal consistency of the scores on the scales was assessed using Cronbach alpha  coefficients  (recom- mended value α ≥ 0.70) [13]. Spearman correlation coefficient was used to assess  assessing convergent validity between items within scales and between-scale correlations as well as scaling success. Construct validity was assessed through factor analysis. All analyses were conducted using SPSS, version 13. Results Demographic characteristics The demographic characteristics of the subjects are presented in Table 1. Of the 107 nurses in this study, 89.7% were  female. The mean (standard deviation) age and job tenure of the participants were 32.3 (SD 7.3) and 9.9 (SD 6.7)  years respectively. Among the subjects, 41.0% were single, 53.3% were married  and 1.9% and 3.8% were divorced and  widowed respectively. Of the nurses 91% had a BSc degree and the remain- der had an MSc or PhD. Of all subjects, 19.8% were day workers and the others  worked a shift system. P-JCQ scores The mean scores for each P-JCQ scale gained by the study nurses are shown in  Table  2.  The  minimum  and  the  maximum scores that a subject could gain in each scale are also presented for comparison. Internal consistency reliability As shown in Table 3, the Cronbach alpha  coefficients  for  the  social  sup- port scale (0.85), physical exertion scale  (0.64), physical  isometric  loads  scale  (0.81) and total physical hazards (0.85)  were ≥ 0.64, indicating acceptable inter- nal consistency, whereas the coefficient  for decision latitude and psychological job demands scales were only 0.54 and  0.58 respectively. Convergent validity Table 4 shows the Spearman correla- tions for assessing convergent validity: between items within scales and be- tween-scale correlations as well as scal- ing success. The scaling success rate for the psychological job demands, social support, physical exertion, physical Table 1 Demographic characteristics of the study nurses (n = 107) Characteristic Value Sex (%) Female 89.7 male 10.3 Age (years) mean (sD) 32.3 (7.3) min–max 22–52 Job tenure (years) mean (sD) 9.9 (6.7) min–max 2–28 Marital status (%) single 41.0 married 53.3 Divorced 1.9 Widowed 3.8 Education (%) bsc degree 91.0 msc or PhD degree 9.0 Shift schedule (%) Day (fixed) 19.8 Evening (fixed) 5.6 Night (fixed) 0.9 rotation 73.7 SD = standard deviation. Table 2 Means scores for the Persian version of the job content questionnaire scales (39 items) Scale Mean (SD) scores Min–Max scores Min–Max attainable score Decision latitude (n = 9) 64.2 (7.3) 44–80 24–96 skill discretion (n = 6) 33.7 (5.0) 16–48 12–48 Decision authority (n = 3) 30.5 (4.3) 20–40 12–48 Psychological job demands (n = 9) 12.3 (2.9) 5–19 –6–21 social support (n = 8) 21.7 (4.1) 10–30 8–48 supervisor support (n = 4) 10.6 (2.9) 4–16 4–32 coworker support (n = 4) 11.2 (2.0) 4–15 4–16 Physical exertion (n = 3) 9.8 (1.6) 6–12 3–12 Physical isometric loads (n = 2) 6.3 (1.3) 4–8 2–8 total physical hazards (n = 8) 9.0 (4.2) 0–16 0–16 Hazardous conditions (n = 5) 5.3 (2.7) 0–10 0–10 toxic exposures (n = 3) 3.7 (1.7) 0–6 0–6 SD = standard deviation; n = number of items. Book 17-4.indb 337 4/27/2011 11:00:47 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 338 isometric loads and total physical haz- ards scales were all above 75%, indicat- ing high convergent validity, whereas the rate for the decision latitude scale was below 75%. Statistical analysis used for assess- ing disconvergent validity revealed a correlation only between physical exertion and physical isometric loads scales (r  =  0.66),  which  was  justifi- able because both scales were related to physical activity and measured nearly similar dimensions of the job. For the other scales, a negative or very weak positive correlation was found, showing acceptable disconvergent va- lidity of the P-JCQ. Construct validity Exploratory  factor analysis of 39  items  produced 3 factors (Table 5). Factor 1 (F1): items of the supervi- sor support subscale, 3 items of decision latitude  scale  (i.e. q4, q6 and q8) and  3 items of psychological job demands scale (i.e. q22, q23 and q26) formed the  first  factor (loading  range: 0.42–0.79)  reflecting social support. Factor 2 (F2):  items of  the hazard- ous conditions, toxic exposures and physical isometric loads scales together with 2  items of physical exertion scale  (i.e. q24 and q25) and 2  items of psy- chological  job demands (i.e. q28 and  q32) formed the second factor (loading  range: 0.23–0.80),  reflecting physical  loads and hazards exposure. Factor 3 (F3): items of the skill dis- cretion and coworker support subscales together with 4 items of psychological job demands  scale  (i.e. q19, q20, q27  and q29) and one item of physical exer- tion  scale  (i.e.  q21)  formed  the  third  factor  (loading  range: 0.23–0.74),  re- flecting psychological job demands. As shown in Table 5, item q10 (lots  of say) was not associated with any factor. Discussion With the development of industrializa- tion in the Islamic Republic of Iran job stress has grown as an occupational health issue and is attracting increasing concern. In this situation, conducting systematic studies on job stress us- ing valid, applicable instruments for measuring job stress dimensions are essential. Since Karasek published the results of his  studies  [2,9,11],  the  job  demands–control–support model has been an extremely important model in Table 3 Internal consistency of the Persian version of the job content questionnaire scales (n = 107) Scale Cronbach alpha coefficient Decision latitude (n = 9) 0.54 skill discretion (n = 6) 0.59 Decision authority (n = 3) 0.48 Psychological job demands (n = 9) 0.58 social support (n =8) 0.85 supervisor support (n = 4) 0.90 coworker support (n = 4) 0.79 Physical exertion (n = 3) 0.64 Physical isometric loads (n = 2) 0.81 total physical hazards (n = 8) 0.85 Hazardous conditions (n = 5) 0.78 toxic exposures (n = 3) 0.70 n = number of items. Table 4 Items scaling tests: convergent validity for the Persian version of the job content questionnaire scales Scale Convergent validity (range of correlation) Scaling successa Scaling success rate (%) Decision latitude (n = 9) 0.13–0.64 4/9 44.4 skill discretion (n = 6) 0.25–0.68 5/6 83.3 Decision authority (n = 3) 0.32–0.66 2/3 66.7 Psychological job demands (n =9) 0.27–0.61 8/9 88.9 Social support (n = 8) 0.40–0.84 7/8 87.5 supervisor support (n = 4) 0.78–0.92 4/4 100.0 coworker support (n = 4) 0.59–0.83 4/4 100.0 Physical exertion (n = 3) 0.62–0.85 3/3 100.0 Physical isometric loads (n = 2) 0.92–0.93 2/2 100.0 Total physical hazards (n = 8) 0.45–0.82 8/8 100.0 Hazardous conditions (n = 5) 0.64–0.82 5/5 100.0 toxic exposures (n = 3) 0.46–0.90 3/3 100.0 aNumber of correlations between items and hypothesized scale corrected for overlap > 0.4/total number of convergent validity tests. n = number of items. Book 17-4.indb 338 4/27/2011 11:00:48 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 339 the research into work environment, stress and health in recent decades [1]. Occupational health psychological studies mostly using the JCQ, revealed that a poor psychosocial environment and job stress led to a wide range of health problems [1–8]. In the linguistic validation stage of our study, the main objective was to ob- tain a conceptual equivalence between the original and translated version of the JCQ, allowing, among other things, a pooling and comparison of data from local and international studies. The translation of the JCQ into Persian was carried out within the framework of internationally accepted methodolo- gies. We found that there was no major ambiguity in the translated version and, with few exceptions, the participants understood the questions. Suggestions from the JCQ Center also contributed to the removal of problematic transla- tions and the preparation of an accept- able, equivalent Persian translation of the questionnaire. The translated JCQ therefore went through successful cog- nitive debriefing. In psychometric evaluation stage of the study among hospital nurses, the pat- tern of scores was similar to studies in other Asian countries. The mean score of decision  latitude  (64.2) was  close  to that of the Asian countries of Japan (64.5)  [14], South Korea (60.6)  [10]  and China (63.8) [1]. The mean score  of the psychological job demands scale consisting of 9  items were 12.3. Since  in other studies this scale consisted of 5  items, the results of our study were not comparable with those of other studies. The mean score of social support in the present study (21.7) was compara- ble  to  that of  Japan (23.7) [14], Korea  (23.3) [10] and China (22.3) [1]. The  mean scores of the physical exertion, physical isometric loads and total physi- cal hazards scales were 9.8, 6.3 and 9.0  respectively. As these scales were not investigated in other studies, we could not compare our results with others. Table 5 Factor analysis of the 39-item Persian version of the job content questionnaire using principal axis extraction and varimax rotation (n = 107 nurses) Scale/item F1 F2 F3 Decision latitude Learn new things – – 0.51 repetitive work 0.47 – – requires creativity – – 0.23 High skill level – – 0.49 Variety – – 0.42 Develop own abilities – – 0.43 Allow own decision 0.46 – – Little freedom of decision 0.47 – – Lots of say – – – Psychological job demands Work fast – – 0.60 Work hard – – 0.74 Intensive concentration – 0.44 Interrupted tasks – 0.23 – Hectic job – 0.43 Waiting for others – 0.44 – No excessive work 0.53 – – Enough time 0.42 – – conflicting demands 0.48 – – Social support supervisor is concerned 0.72 – – supervisor pays attention 0.71 – – Helpful supervisor 0.79 – – supervisor good organizer 0.62 – – coworkers competent – – 0.42 coworkers interested in me – – 0.69 Friendly coworkers – – 0.68 coworkers helpful – – 0.63 Physical exertion Physical effort – – 0.59 moving/lifting heavy loads – 0.57 – rapid/continuous physical activity – 0.46 – Physical isometric loads Awkward working postures – 0.44 – Head/arm awkward working postures – 0.45 – Total physical hazards Exposure to things stored dangerously – 0.71 – Exposure to dirty areas – 0.62 – Exposure to dangerous tools, equipment – 0.73 – Exposure to fire, burn or shock – 0.63 – Exposure to dangerous work method – 0.64 – Exposure to dangerous chemicals – 0.79 – Exposure to air pollution – 0.80 – catching diseases – 0.44 – Book 17-4.indb 339 4/27/2011 11:00:48 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 340 For the nurses in this study, internal consistency was low for skill discretion (Cronbach alpha = 0.59) and decision  authority (α = 0.48). Li et al.  and Eum  et al. reported a low internal consist- ency for skill discretion among health care workers  [1,10].  In our  study  in- ternal consistency for decision latitude scale and its subscales was lower than that of other Asian countries, but to- tally the result of our study was in line with those studies, for they reported relatively low internal consistency for this scale. Psychological job demands had a  low alpha (α = 0.58). According  to other studies, the Cronbach alpha coefficient  for  this  scale  ranged  from  0.5 to 0.7. Our result  for this scale was,  therefore, in agreement with previous studies [1,10,14]. Consistent with Li et  al. [1] and Kawakami et al. [14], inter- nal consistency for the social support scale was highly acceptable (α = 0.85).  Eum et al. reported lower Cronbach alpha coefficient for social support (α =  0.71) among South Korean health care  workers  [10].  Internal consistency  for  the physical exertion scale was satisfac- tory (α = 0.64) and highly acceptable for  physical isometric loads (α = 0.81) and  total physical hazards (α = 0.85). Since  these scales were not investigated in the previous studies, the results could not be compared to any other populations or occupational groups. The results of convergent validity assessment of the P-JCQ showed that except for decision latitude scale and one of its subscale (decision authority) in which scaling success rate was less than 75%,  in other  scales,  the  scaling  success rate was higher than 75% and in  7 scales was 100%. This  indicated high  convergent validity of the P-JCQ. In Li et al.’s study, 2 of 6  items of the skill  discretion scale and 3 of 5  items of the  psychological job demands scale had correlation  coefficients  less  than 0.4,  indicating scaling success rate to be less than 75% [1]. Our results also showed  that the disconvergent validity was ac- ceptable. This is in agreement with Li et al. [1]. Exploratory factor analysis showed that among the study nurses the first factor was associated with items of the supervisor support subscale, decision latitude scale and psychological job demands scale, reflecting social sup- port, whereas in South Korean [10] and  Chinese [1] health care workers it was items of the social support scale that formed this factor. The results of factor analysis also revealed that the second factor was clearly associated with the items of physical exertion, physical iso- metric loads, total physical hazards and psychological job demands scales. The results also indicated that the third factor was associated with items of skill discre- tion and coworker support subscales as well as the psychological job demands scale reflecting psychological job de- mands. Whereas the psychological job demands  scale consisted of 5  items  in  Li et al.  [1] and Eum et al.  [10],  in  the  present study, there were 9 items in this  scale, which were loaded onto 3 factors (3 on  the first  factor, 2 on  the  second  factor and 4 on the third factor). Based on the results of factor analysis, it could be inferred that only in the psychologi- cal job demands scale, the related items were not associated to 1 certain factor and loaded on more than 1 factor. Items of other scales were found to be associ- ated to the related factor. The major limitation of this study was that the subjects were from a cer- tain occupational group (i.e. hospital nurses) and the study population did not include a variety of occupations. The P-JCQ should be applied to workers in other occupations in future studies. On the whole, these findings suggest that the P-JCQ has satisfactory linguis- tic validity and psychometric proper- ties and can be applied for assessing psychosocial job stress among Iranian workers, provided the recommended factor pattern is used. Further research is needed to reach conclusive results for the psychological job demands scale of the P-JCQ. Acknowledgements The authors wish to thank Bongkyoo Choi and Sandra Gibson from the JCQ Center for their suggestions in develop- ment of the Persian version of the JCQ. The authors also wish to thank Dr Shokrpour for her assistance in forward translation and Mrs. Sedigh for her hard work in backward translation. Funding through Shiraz University of Medical Sciences, Contract No. 85- 2941, supported this investigation. References Li J et al. Psychometric evaluation of the chinese (mainland) 1. version of Job content Questionnaire: a study in university hospitals. Industrial Health, 2004, 42:260–267. theorell t, Karasek rA. current issues relating to psychosocial 2. job strain and cardiovascular disease research. Journal of Oc- cupational Health Psychology, 1996, 1:9–26. Levi L et al. stressors at the workplace: theoretical models. 3. Oc- cupational Medicine, 2000, 15:69–106. cole Dc et al. Work correlates of back problems and activity 4. restriction due to musculoskeletal disorders in the canadian national population health survey (NPHs) 1994–5 data. Occu- pational and Environmental Medicine, 2001, 58:728–734. Ariëns GA et al. High physical and psychosocial load at work 5. and sickness absence due to neck pain. Scandinavian Journal of Work, Environment and Health, 2002, 28:222–231. schnall PL, Landsbergis PA, baker D. Job strain and cardiovas-6. cular disease. Annual Review of Public Health, 1994, 15:381–411. Kristensen ts. Job stress and cardiovascular disease: a theo-7. retic critical review. Journal of Occupational Health Psychology, 1996, 1:246–260. Book 17-4.indb 340 4/27/2011 11:00:48 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 341 cheng Y, Luh Wm, Guo YL. reliability and validity of the chi-8. nese version of the Job content Questionnaire in taiwanese workers. International Journal of Behavioral Medicine, 2003, 10:15–30. Karasek rA et al. the Job content Questionnaire (JcQ): an 9. instrument for internationally comparative assessments of psy- chosocial job characteristics. Journal of Occupational Health Psychology, 1998, 3:322–355. Eum KD et al. Psychometric properties of the Korean version 10. of the job content questionnaire: data from health care work- ers. International Archives of Occupational and Environmental Health, 2007, 80:497–504. Karasek rA. 11. Job Content Questionnaire and user’s guide. Lowell, massachusetts, Department of Work Environment, university of massachusetts, 1985. choobineh Ar, Ghaem H, Ahmadi Nejad P. Development 12. of the Persian version of the Job content Questionnaire: assessment of job stress among hospital nurses of shiraz city. In: Proceedings of the 1st International Conference on Ergonom- ics, 7–8 May 2008, Tehran, Islamic Republic of Iran. tehran, Iranian Ergonomics society, 2008:62–69. cronbach LJ. coefficient 13. α and the internal structure of tests. Psychometrika, 1951, 16:297–334. Kawakami N et al. Assessment of job stress dimensions based 14. on the job demands- control model of employees of telecom- munication and electric power companies in Japan: reliability and validity of the Japanese version of the Job content Ques- tionnaire. International Journal of Behavioral Medicine, 1995, 2:358–375. World Conference of Science Journalists, Doha, Qatar 27–29 June 2011 The organizers have taken the decision to relocate this conference from Cairo to Doha, Qatar, on the invitation of the Qatar Foundation. The conference dates remain the same. The programme covers a wide variety of topics, incuding sessions on topics relevant to the health issues in our Region such as: Reporting on Climate Change and Biodiversity,• Teaching Science Journalism;• Bioethics in the Media;• Clinical Trials in Developing Countries: Undue Exploitation or Mutual Benefit?• Disaster Reporting: Lessons from Japan;• Can You Hear Me Now? Writing for a Non-English Audience;• How to Read Medical Studies (and Avoid Pitfalls).• Further information and complete details of the programme can be found on the conference website at: http://www.wcsj2011.org/ Book 17-4.indb 341 4/27/2011 11:00:48 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 342 Clinical guidelines Clinical management guidelines for pandemic (H1N1) 2009 virus infection in the Eastern Mediterranean Region: technical basis and overview S. Al Hajjar,1 M.R. Malik,2 Z. Hallaj, 2 H. El-Bushra,2 M. Opoka 2 and A.R. Mafi 2 AbstrAct During the spring of 2009, a novel influenza A (H1N1) virus of swine origin caused human infection and acute respiratory illness in mexico. After initially spreading in North America, the virus spread globally resulting in the first influenza pandemic since 1968. While the majority of illnesses caused by pandemic (H1N1) 2009 were mild and self-limiting, severe complications, including fatalities, were also reported. In view of the increasing number of laboratory-confirmed cases and deaths from pandemic (H1N1) 2009 in the Eastern mediterranean region of the World Health Organization, the regional Office convened a consultation meeting of experts involved in the clinical management of patients infected with pandemic (H1N1) 2009 virus. the consultation resulted in developing an interim guidance and algorithm for clinical management of pandemic (H1N1) 2009 virus infection in health-care settings. this paper describes the process, the technical basis and the components of this interim guidance. 1Infectious Diseases Section, Department of Paediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. 2Communicable Disease Surveillance and Response Unit, Division of Communicable Diseases, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to M.R. Malik: malikm@emro.who.int). received: 15/12/10; accepted: 09/03/11 سويرف ةحئالج يريسرلا يربدتلل ةيداشرلإا لئلادلا (H1N1) 2009 ةماعلا ةرظنلاو ينقتلا ساسلأا :طسوتلما قشر ميلقإ في فيام اضيرلع ،اكوبوأ نترام ،ىَشرُبلا نسح ،جلاح يرهز ،كلام نحمرلا نومأم ،راجلحا يماس .كيسكلما في داح سيفنت للاتعاب مهتباصإو شربلا ىودع لىإ ريزنلخا نم هردصمو ديدلجا A (H1N1 سويرف ىدأ ،2009 عيبر للاخ :ةـصلالخا ةيبلاغ نأ عمو .1968 ماع ذنم ازنولفنأ ةحئاج لوأ روهظ لىإ ىّدأو ،ًايلماع هراشتنا حبصأ ام ناعسر ،اكيرمأ لماش في ليولأا سويرفلا راشتنا دعبو ةدايزل ًارظنو .تايفولا اهيف ماب ةميخو تافعاضم ًاضيأ تلجس انهأ لاإ ،ًايتاذ ةدودمحو ةفيفخ تناك H1N1) 2009 سويرف نع ةجمانلا تلالاتعلاا عماتجلا يميلقلإا بتكلما اعد ،ةيلماعلا ةحصلا ةمظنلم طسوتلما قشر ميلقإ في ًايبرتمخ ةدكؤلماو H1N1) 2009 نع ةجمانلا تايفولاو تلاالحا دادعأ يربدتلل ةيمزراوخو تقؤم يداشرإ ليلد دعُأ ةرواشملل ةجيتنو .ةحئالجا سويرفب ينباصلما ضىرملل يريسرلا يربدتلاب ينّينعلما ءابرخلل يراشتسا ليلدلا تانّوكمو ،ينقتلا ساسلأاو ،ةيلمعلا كلت ثحبلا اذه فصيو .ةيحصلا ةياعرلا عقاوم في H1N1) 2009 ةحئاج سويرفب ىودعلل يريسرلا .تقؤلما Lignes directrices pour la prise en charge clinique de l'infection par le virus de la grippe pandémique (H1N1) 2009 dans la Région de la Méditerranée orientale : données techniques initiales et présentation générale résumé Au cours du printemps de l'année 2009 au mexique, un nouveau virus grippal A (H1N1) d'origine porcine a été la cause d'infections et de pathologies respiratoires aiguës chez l'homme. Après s'être d'abord propagé en Amérique du Nord, le virus s'est étendu mondialement pour devenir la première pandémie grippale depuis 1968. Alors que la majorité des pathologies causées par la grippe pandémique (H1N1) 2009 était modérée et à guérison spontanée, des complications graves, y compris des décès, ont également été signalés. compte tenu du nombre croissant d'infections et de décès par le virus de la grippe pandémique (H1N1) 2009 confirmés en laboratoire dans la région Oms de la méditerranée orientale, le bureau régional a convoqué une réunion consultative d'experts impliqués dans la prise en charge clinique de patients infectés par ce virus. La consultation a permis d'élaborer des lignes directrices temporaires et un algorithme pour la prise en charge clinique de l'infection par le virus de la grippe pandémique (H1N1) 2009 en milieu de soins. Le présent article décrit le processus, les données techniques et les composantes de ces lignes directrices temporaires. Book 17-4.indb 342 4/27/2011 11:00:48 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 343 Background At  the  beginning  of  April  2009,  hu- man infections with a novel strain of influenza A (H1N1) virus emerged in Mexico [1]. After initially spreading among persons in the United States, Mexico and Canada, the virus spread globally, resulting in the first influenza pandemic since 1968 [2,3].  As  of  6  August  2010,  worldwide  more  than  214  countries  and  over- seas territories or communities have reported laboratory-confirmed cases of  pandemic  (H1N1)  2009  virus  infection, and there have been around 18 500 deaths [4]. Kuwait and the United Arab Emir- ates were  the  first  2  countries  in  the  World Health Organization Eastern Mediterranean Region (WHO-EMR) reporting confirmed cases of pandemic (H1N1) 2009 on 25 May 2009. Up  to 6 August 2010, all 22 countries had  reported laboratory-confirmed cases of infection, and 1019 deaths had been  recorded [5].  Epidemiology Infection and illness Globally, most illnesses caused by the pandemic  (H1N1)  2009  virus were  acute and self-limiting, with the highest attack rates reported among children and young adults  [6]. The median age  of most of the reported cases was 12–25  years,  and over 80% of cases occurred  among the age group of 5–49 years [7]. The overall case fatality rate amongst the laboratory-confirmed cases was less than 0.5% [8]. Transmission The mechanism of person-to-person transmission of pandemic (H1N1) 2009  virus  appeared  to  be  similar  to  those  of  seasonal  influenza  [6].  The main route of transmission was reported to be respiratory through inhalation of large-particle respiratory droplets, and possibly via droplet nu- clei [9]. Explosive outbreaks and am- plifications of cases have been noted in schools and closed community settings [10].  Clinical features Incubation period The incubation period was approxi- mately 1.5–3 days, which  is  similar  to  that of seasonal influenza [6,9]. Children and immunocompromised or immuno- suppressed persons were contagious for longer periods. Clinical presentation The clinical manifestations of pandemic (H1N1) 2009  virus  infection  varied,  ranging from afebrile upper respiratory illness to fulminant viral pneumonia. Most patients presenting for care showed typical influenza-like illness with fever and cough, sometimes ac- companied by sore throat and rhinnor- rhoea [11,12]. Risk groups and risk factors for severe disease Underlying medical conditions which are associated with complications from seasonal influenza were also risk fac- tors for complications from pandemic (H1N1) 2009 virus infection. Globally,  nearly three quarters of cases requiring hospitalization involved one or more underlying medical conditions includ- ing asthma, diabetes, heart or lung disease, neurologic disease, pregnancy, morbid obesity, autoimmune disorders and associated immunosuppressive therapies [13,14]. Clinical management The majority of individuals infected with  pandemic  (H1N1)  2009  virus  were treated with simple supportive care at home using antipyretics (e.g. acetaminophen or ibuprofen). The pandemic (H1N1) 2009 virus  infection was susceptible to the neu- raminidase inhibitors oseltamivir and zanamivir, but was almost always re- sistant to amantadine and rimantadine [15–17]. Early empirical treatment with  neuraminidase inhibitors in patients with pandemic (H1N1) 2009 infection  has been shown to have reduced the duration  of  hospitalization  [18]  and  the risk of progression to severe disease requiring ICU admission or resulting in death [14]. Empiric antiviral therapy needs to be started for persons with suspected, probable or confirmed cases of pan- demic (H1N1) 2009 infection for: Illness requiring hospitalization• Progressive, severe or complicated • illness regardless of previous health status and/or High risk groups for severe disease, • which include: Children younger than 2 years – Pregnant women  up  to  2 weeks  – post partum (regardless of how the pregnancy ended) Adults 65 years of age or older – Persons  younger  than  19  years  – who are having long-term aspirin therapy Persons with medical conditions – including asthma, neurological and neurodevelopmental conditions (including disorders of the brain, spinal cord, peripheral nerves and muscles, such as cerebral palsy) chronic obstructive lung disease, cardiac disease, diabetes mellitus, immunosuppressive conditions (in- cluding HIV/AIDS, and cancer). Clinicians should consider empiric treatment with antibacterial drugs if bacterial co-infections are suspected during or after influenza. The use of high dose corticosteroids for pandemic (H1N1) 2009  infection  is  controver- sial; low-dose steroids may, however, be Book 17-4.indb 343 4/27/2011 11:00:49 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 344 considered in patients with septic shock who require vasopressors [19–21].  Development of guidelines: expert consultation In order to support the countries of the WHO EMR to manage human cases infected with pandemic (H1N1) 2009 virus  in  a  standardized way,  the  Regional Office  convened  an  inter- national expert consultation meeting from  9  to  10  September  2009. The  purpose of this meeting was to develop a clinical management guideline in or- der to optimize clinical care for human infections with pandemic (H1N1) 2009 virus  across  all  countries  in  the  Region. Medical experts in the field of pul- monology, infectious diseases, public health, epidemiology, internal medi- cine, intensive care, microbiology and virology came together and reviewed the available international guidelines [22,23],  published  evidence  and un- published data on epidemiology and clinical manifestations of the disease. Following this expert consultation, an interim guidance and algorithms were developed on clinical management of pandemic (H1N1) virus infection [24]. The algorithms were intended to  be used as a decision tree by clinicians to exercise their clinical judgment for treatment and care of patients with pandemic H1N1 virus infection. The interim guidance on clinical management of pandemic (H1N1) 2009 virus  infection used 4 case defi- nitions of influenza (Table 1) for the purpose of clinical diagnosis and initial treatment decisions. These include (i) influenza-like illness (ILI), (ii) severe acute respiratory infection (SARI), (iii) acute respiratory infection (ARI) and (iv) influenza caused by pandemic (H1N1) 2009 virus infection.  Three categories of clinical manifes- tations have been seen during the cur- rent pandemic [13,14] and these have been presented in the WHO Regional Office Interim Guidance:  Mild illness characterized by fever • (some patients had no fever), cough, sore throat, diarrhoea, myalgias, head- ache. Other frequent findings have included chills and malaise. Vomiting and diarrhoea have been reported in some patients, but no shortness of breath, dyspnoea, or severe dehydra- tion. Progressive illness characterized • by mild illness with clinical signs or symptoms suggesting a progression to severe illness, which include the fol- lowing signs and symptoms (Table 2  shows differentiation between clinical signs in adults and in children under 5 years) : chest pain, tachypnoea, or laboured – breathing in children hypotension – confusion or altered mental status – severe dehydration or exacerba- – tions of a chronic conditions (e.g. asthma, cardiovascular conditions) Table 1 Case definition of influenza caused by pandemic (H1N1) 2009 virus infection Influenza-like illness (ILI) A person with sudden onset of fever > 38 °c and ≥ 1 of the following 2 respiratory symptoms in the absence of other known causes: dry cough, sore throat severe acute respiratory illness (sArI) A person meeting the case definition of influenza-like illness (above) AND shortness of breath Or difficulty in breathing requiring hospital admission. Acute respiratory infection (ArI) Acute respiratory tract illness that is caused by an infectious agent transmitted from person to person. the onset of symptoms is typically rapid, over a period of hours to several days. symptoms include fever, cough, and often sore throat, coryza, shortness of breath, wheezing, or difficulty breathing. confirmed case of Pandemic (H1N1) 2009 An individual with an influenza-like illness with laboratory confirmed pandemic (H1N1) 2009 virus infection by ≥ 1 of the following tests: real time reverse-transcription polymerase (rt-Pcr) viral culture. Probable case of Pandemic (H1N1) 2009 An individual with an influenza-like illness who is positive for influenza A that is unsubtypable by real-time Pcr, Or An individual with a clinically compatible illness or who died of an unexplained acute respiratory illness who is considered to be epidemiologically linked to a probable or confirmed case. suspected case of Pandemic (H1N1) 2009 An individual with acute respiratory illness and fever (reported or documented fever), and one of the followings; cough, sore throat, shortness of breath, difficulty in breathing or chest pains with onset: within 7 days of close contact with a person who is a probable or confirmed case of pandemic (H1N1) 2009 virus infection, Or within 7 days of travel to a country/community where there has been one or more confirmed cases of pandemic (H1N1) 2009 virus infection, Or resides in a community where there is one or more confirmed cases of pandemic (H1N1) 2009 virus infection. Book 17-4.indb 344 4/27/2011 11:00:49 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 345 Severe illness characterized by the • following: profound hypoxemia, abnormal – chest radiograph, and mechanical ventilation encephalitis or encephalopathy – shock, multisystem organ failure – myocarditis and rhabdomyolysis – invasive secondary bacterial infec- – tion (e.g. pneumococcal disease). When influenza viruses are known to be circulating in the community, patients presenting with mild influenza can be diagnosed on clinical and epide- miological grounds alone. Based on the clinical evidence and judgment, the In- terim Guidance recommends empirical antiviral therapy with a neuraminidase inhibitor in appropriate dose (Table 3) as soon as possible (i) whenever the illness requires hospitalization; (ii) whenever the person shows signs of progressive  illness;  (iii)  and/or when- ever the person belongs to the high risk group for severe disease. The clinical algorithms (Figures 1 and 2)  for management of patients  with  pandemic  (H1N1)  2009  virus  infection, as presented in the Interim Guidance, can be applied to every pa- tient diagnosed on the basis of clinical suspicion alone without waiting for laboratory confirmation. The Interim Guidance, however, emphasizes that all patients treated at home need to be in- structed to return for follow-up should they develop any signs or symptoms of progressive disease or fail to improve within 72 hours of  the onset of  symp- toms. Future directions As of 10 August 2010,  the world has  moved into the post-pandemic period [25]. Based on  the  knowledge  about  past influenza pandemics, pandemic (H1N1) 2009 virus is expected to con- tinue to circulate as a seasonal virus for  some  years  to  come  [25]. While  the level of concern might have greatly diminished, vigilance on the part of national health authorities as well as treatment of all suspected influenza cases with standard care remain criti- cal in the immediate post-pandemic Table 2 Clinical signs indicating rapid progression and need for urgent medical care In adults In children Difficulty in breathing or shortness of breath tachypnoea or laboured breathing Pain or pressure in the chest or abdomen skin colour change, grey or blue Episodes of sudden dizziness Inadequate intake of oral fluids severe or continuous vomiting severe or continuous vomiting Influenza-like illness that improves but then returns with fever and cough Influenza-like illness that improves but then returns with fever and cough confusion Irritable or not waking up Table 3 Treatment regimen for Oseltamivir and Zanamivir for human infection caused by pandemic (H1N1) 2009 virus Age group Treatment (5 days) Chemoprophylaxis (10 days) Oseltamivir Adults 75 mg twice per day 75 mg once per day children (≥ 12 months) ≤ 15 kg 30 mg twice per day 30 mg once per day 15–23 kg 45 mg twice per day 45 mg once per day 20–40 kg 60 mg twice per day 60 mg once per day > 40 kg 75 mg twice per day 75 mg once per day children 3 – < 12 months 3 mg/kg/dose twice per day 3 mg/kg/dose once per day 0 – < 3 months 3 mg/kg/dose twice per day Not recommended, unless situation judged critical (limited data) Zanamivir Adults 2 × 5 mg inhalations (10 mg total) twice per day 2 × 5 mg inhalations (10 mg total) once per day children ≥ 7 years for treatment; children ≥ 5 years for chemoprophylaxis 2 × 5 mg inhalations (10 mg total) twice per day 2 × 5 mg inhalations (10 mg total) once per day Book 17-4.indb 345 4/27/2011 11:00:49 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 346 period since the behaviour of pandemic (H1N1) 2009 virus can not be reliably  predicted. The Interim Guidance and the algorithms for clinical management of human infection with pandemic (H1N1) 2009  virus were  developed  in September 2009 based on  clinical  evidence and best clinical outcome fol- lowing available treatment practices known globally at that time. The Interim Guidance and its clinical algorithms were adopted by many countries in the Region. It is expected that this Interim Guidance will pave the way towards de- veloping national clinical management protocols for influenza as well as other epidemic- and pandemic-prone acute respiratory infections in the countries of the Region. The uncertain evolution of the pandemic virus, however, high- lights the importance that the treatment guidelines and the supplementary algorithms need to be revised and continuously updated as soon as new evidence on clinical manifestation of influenza in the post-pandemic period, antiviral resistance pattern, effective- ness of the currently available antivirals, and virulence of the circulating seasonal influenza virus become available in the post-pandemic period. No symptoms of ILI Assess and treat as indicated Direct patient to triage area for assessment Assess general state and hydration, measure body temperature (> 38 °c/100.4 °F)1. measure respiratory rate2. Observe colour of skin, nails and mucosa3. Perform pulmonary auscultation to identify crepitation4. Does patient have influenza-like illness (ILI) (temperature > 38 °c + dry cough or sore throat)? Patient has clinical signs of severe illness indicating rapid progression (detailed in table-2) Apply home isolation and manage the patient at home DO NOT AUTHORIZE ANTIVIRAL TREATMENT AUTHORIZE ANTIVIRAL TREATMENT IMMEDIATELY Apply home isolation and manage the patient at home Immediately refer the pa- tient to secondary level care for hospitalization and further necessary treatment Standard and droplet precautions Patient: surgical mask Staff: Hand hygiene, mask, gown and gloves Community protection Patient: wears surgical mask, covers mouth and nostrils when coughing or sneezing and frequently washes hands The patient: Avoids public transport . uses a surgical mask . covers mouth and . nostrils during coughing and sneezing Avoids close contact . Patient has mild ILI with no signs of severe illness but is in a high risk group for complications Patient has mild ILI (i) without any signs of severe illness and (ii) not in a high risk group YesNo Yes Yes Yes Infection control measures Figure 1 Algorithm for clinical management of patients at the primary health care level Assessment of patients Book 17-4.indb 346 4/27/2011 11:00:49 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 347 Figure 2 Algorithm for clinical management of patients at secondary or tertiary health care level One of the best ways to evaluate this Interim Guidance would be to assess the diagnostic validity of its clinical algorithms prospectively in some selected clinical settings that should include both resource-inten- sive and resource-limited countries. The effectiveness of clinical algorithms in truly detecting patients with sus- pected influenza needs to be assessed. Solid data on such an evaluation will in- crease the sensitivity and specificity of the clinical algorithms of the guidelines in detecting and identifying patients with suspected influenza, guide treat- ment decisions in the post-pandemic period, and ensure that no cases with potentially fatal outcome are missed by clinicians when using these algorithms as a decision tree to exercise their clini- cal judgement. YesNo Yes Infection control measuresAssessment of patients the patient is showing clinical signs of illness indicating rapid progression and need for urgent medical care (Detailed in table 2) refer case for home management Immediately hospitalize patient manage case at home AUTHORIZE ANTIVIRAL TREATMENT immediately along with other supportive treatment Patient’s condition is improving and responding to treatment as indicated by: becoming afebrile; . tolerating oral fluid; . Absence of dyspnoea; . No evidence of dehydration; . respiratory rate ≤ 30 bpm . Oxygen saturation ≥ 92% . underlying chronic health condi- . tions not exacerbated (for patients in high risk group for complica- tions) Patient’s condition is not improving and not responding to treatment as indicated by: Progressive pulmonary infiltrates . Persistent hypoxia (sp O . 2 < 92%) despite maximum oxygen saturation; Progressive hypercapnoea; . Presence of compromised . haemodynamics; signs of sepsis and imminent . shock consult specialist for advice and admission to Intensive care unit (Icu) Standard and droplet precautions Patient: surgical mask and strict isolation or cohorting. Isolation precaution may be discontinued after the patients has received anti- viral treatment for 72 hours and remained afebrile for 24 hours even in the absence of antipyretics. Staff: Hand hygiene, mask, gown, gloves and eye protection if there is a risk of splash. Standard and droplet precautions Patient: surgical mask Staff: Hand hygiene, mask, gown and gloves In addition to the above, patient is presenting with: refractory hypoxaemia . compromised haemo- . dynamics signs of sepsis and immi- . nent shock Discharge criteria met Discharge the patient with proper advice (Patients should be discharged after receiving the full 5-day course of antivirals or 24 hours after becoming afebrile, whichever is earlier) consider admission to Icu on advice from specialists Book 17-4.indb 347 4/27/2011 11:00:50 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 348 References López-cervantes m et al. On the spread of the novel influ-1. enza A (H1N1) virus in mexico. Journal of Infection in Developing Countries, 2009, 3:327–330. Influenza-like illness in the United States and Mexico, 2009.2. Geneva, World Health Organization, 2009 (http://www.who. int/csr/don/2009_04_24/es/index.html, accessed 26 may 2009). Pandemic (H1N1) 2009—update 60.3. Geneva, World Health Organization, 2009 (http://www.who.int/csr/ don/2009_10_02/en/index.html, accessed 5 October 2009). Pandemic (H1N1) 2009—update 112.4. Geneva, World Health Organization, 2009 ( http://www.who.int/csr/ don/2009_1204/3n/index.html, accessed 10 August 2010). Pandemic (H1N1) 2009 update.5. cairo, World Health Organiza- tion. Eastern mediterranean regional Office, 2009. (http:// www.emro.who.int/csr/h1n1/index.html, accessed 10 June 2010). Writing committee of the WHO consultation on clinical as-6. pects of pandemic (h1n1) 2009 influenza. clinical aspects of pandemic 2009 influenza A (H1N1) virus infection. New Eng- land Journal of Medicine, 2010, 362:1708–1719. Pandemic influenza A (H1N1) 2009 virus. 7. Weekly Epidemiologi- cal Record, 2009, 85(49):505–516. Wilson N, baker mG. the emerging influenza pandemic: esti-8. mating the case fatality ratio. Euro Surveillance, 2009, 14(26):pii 19255. Yang Y et al. the transmissibility and control of pandemic influ-9. enza A (H1N1). Science, 2009, 326:729–733. Lessler J et al. Outbreak of 2009 pandemic influenza A (H1N1) 10. at a New York city school. New England Journal of Medicine, 2009, 361:2628–2636. cao b et al. clinical features of the initial cases of 2009 pan-11. demic influenza A (H1N1) virus infection in china. New England Journal of Medicine, 2009, 361:2507–2517. Hackett s et al. clinical characteristics of paediatric H1N1 ad-12. missions in birmingham, uK. Lancet, 2009, 374:605–606. Human infection with new influenza A (H1N1) virus, clinical 13. observation from mexico and other affected countries. Weekly Epidemiological Record, 2009, 84(21):185–196. Jain s et al. Hospitalized patients with 2009 H1N1 influenza 14. in the united states, April–June 2009. New England Journal of Medicine, 2009, 361:1935–1944. Itoh Y et al. In vitro and in vivo characterization of new swine 15. origin H1N1 influenza viruses. Nature, 2009, 460:1021–1025. Oseltamivir-resistant pandemic (H1N1) 2009 influenza virus16. . stockholm, European centre for Disease Prevention and control, 2009 (http://www.ecdc.europa.eu/en/activities/ sciadvice/tests, accessed 10 December 2009). Antiviral treatment options including intravenous peramivir for 17. treatment of influenza in hospitalized patients for 2009–2010 season. Atlanta, united states centers for Disease control and Prevention, 2009 (http://www.cdc.gov/ h1n1flu/EuA/ Peramovir-recommendations.html, accessed 2 December 2009). Patients hospitalized with 2009 pandemic influenza A (H1N1) 18. — New York city, may 2009. MMWR Morbidity and Mortality Weekly Report, 2010, 58:1436–1440. Intensive care patients with severe novel influenza A (H1N1) 19. virus infections. michigan, June 2009. MMWR Morbidity and Mortality Weekly Report, 2009, 58:(27):749–752. Gomez-Gomez A et al. severe pneumonia associated with 20. pandemic (H1N1) 2009 outbreak, san Luis Potosí, mexico. Emerging Infectious Diseases, 2010, 16(1):27–34. Al Hajjar s, mcIntosh. the first influenza pandemic of the 21st 21. century. Annals of Saudi Medicine, 2010, 30(1):37–46. Clinical management of human infection with Pandemic H1N1: 22. revised guidance. Geneva, World Health Organization, 2009 (www.who.int/entity/csr/resources/publications/swineflu/ clinicalmanagement/en, accessed 07 November 2009 Updated interim recommendation from the use of antiviral 23. treatment and prevention of influenza from 2009–2010 season. Atlanta, Georgia, centers for Disease control and Prevention, 2009 (http://www.cdc.gov/h1n1flu/recommendations.htm, accessed 7 December 2009). Clinical management of pandemic H1N1 2009 virus infection. 24. Interim guidance from Expert Consultation. cairo, World Health Organization, Eastern mediterranean regional Office, 2009 (http://who.emro.who.int/csr/h1n1/clinical_management. htm, accessed 10 October 2009). Recommendations for the post-pandemic period. 25. Geneva, World Health Organization, 2009 (Pandemic (H1N1) 2009 brief- ing note 23) (http://www.who.int/csr/disease/swineflu/ notes/briefing_20100810/en/index.html, accessed 5 Octo- ber 2010). Book 17-4.indb 348 4/27/2011 11:00:50 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 349 Review Smoking and normative influence among Egyptian youth: a review of the literature C. Harbour 1 AbstrAct Youth aged 15–24 years form 21% of Egypt’s population. tobacco smoking among the young is a health priority in Egypt. this paper reviews the literature on smoking among Egyptian youth, focusing on factors related to social normative influences. the PubMed and PsycInfo databases were searched for articles related to youth, Egypt and smoking; and grey literature from the World Health Organization, Population council and the Egypt Demographic and Health survey were also accessed. the PubMed and PsycInfo searches returned 52 and 3 publications respectively, of which 14 were retained. smoking is more common among male youth and older youth. Peer smoking is consistently associated with youth smoking, but family smoking is not consistently associated. Employment and educational factors appear to be important. the limitations of the review and recommendations for future research are discussed. 1Johns Hopkins University, Center for Communication Programs, Baltimore, Maryland, United States of America (Correspondence to C. Harbour: charbour@jhsph.edu; ckharbour@gmail.com). received: 20/07/09; accepted: 03/03/10 ةروشنلما ثوحبلل ضارعتسا :يصرلما بابشلا ينب تاداعلا رئاسو ينخدتلا رَبراه ليِك نيرثاك .صرم في ةيحصلا لكاشلما تايولوأ نم بابشلا ينب غبتلا ينخدت ُّدعُيو .صرم في ناكسلا نم ةئلماب ينثلاث ةنس 24 - 15 رمع في بابشلا فِّلؤي :ةصلالخا ىرج دقو .ةيعماتجلاا تاداعلا يرثأتب ةقلعتلما لماوعلا لىع زيكرـتلا عم ،يصرلما بابشلا ينب ينخدتلا نع ةروشنلما ثوحبلا ثحبلا اذه ضرعتسيو ماك ؛ينخدتلاو ،صرمو ،بابشلاب ةقلعتلما تلااقلما نع PsychInfo ةيسفنلا ةيبطلا تامولعلماو Pubmed ةيبطلا تايشرنلا تايطعم دعاوق في ثحبلا ثحبلا ضفأ دقو .صرلم فيارغوميدلاو يحصلا حسلماو ،ناكسلل يموقلا سلجلماو ،ةيلماعلا ةحصلا ةمظنلم ةيمسرلا يرغ تايشرنلا في ثحبلا ىرج ينبت دقو .ةلاقم 14 تلااقلما هذه ينب نم يرتخاو ،تلااقم 3 لىع روثعلا لىإ PsychInfo فيو ةلاقم 52 لىع روثعلا لىإ Pubmed تايطعم دعاوق في ينب ينخدتلا ينبو ءلامزلا ينب ينخدتلا ينب ًمائاد طُبارت كانه ناكو .ًانس بركأ مه نيذلا بابشلا ينبو روكذلا ناّبشلا نم ينب ًاعويش رثكأ ينخدتلا نأ ثحبلا ماتخ في تشقون دقو .ميلعتلاو ةفيظولاب ةطبترلما كلت ،كلذك ةمهلما لماوعلا نمو .ةسرلأا في ينخدتلا عم ًمائاد كلذ طباتري لم ينح في ،بابشلا .ةيلبقتسلما ثوحبلل ةمدقلما تايصوتلاو ،ةيضارعتسلاا ةساردلا هذه قاطن تد َّدح يتلا ُلماوعلا Tabagisme et influence de la norme sociale chez les jeunes égyptiens : une synthèse de la littérature résumé Les jeunes âgés de 15 à 24 ans représentent 21 % de la population égyptienne. La consommation de tabac chez les jeunes est une question de santé publique prioritaire en égypte. Le présent article analyse la littérature traitant du tabagisme chez les jeunes égyptiens, en se polarisant sur les facteurs liés aux influences de la norme sociale dans ce domaine. Les bases de données PubMed et PsycInfo ont été utilisées pour rechercher des articles contenant des mots clés tels que les jeunes, l’égypte et le tabagisme. La littérature grise provenant de l’Organisation mondiale de santé, Population council et l’Enquête démographique et de santé en égypte ont également été consultées. Les recherches dans PubMed et PsycInfo ont généré 52 et 3 publications respectivement, parmi lesquelles 14 ont été retenues. Le tabagisme est plus fréquent chez les jeunes de sexe masculin et dans les tranches d’âges plus avancés. Le tabagisme des pairs est associé de manière constante au tabagisme des jeunes, contrairement au tabagisme familial. Les facteurs concernant l’activité professionnelle et le niveau d’études semblent également importants. Les limites de la présente analyse et la rédaction de recommandations pour les prochaines recherches sont actuellement en discussion. Book 17-4.indb 349 4/27/2011 11:00:50 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 350 Introduction Youth aged 15–24 years are estimated  to  constitute  21% of Egypt’s  popula- tion  and by 2025,  their population  is  projected  to  reach  almost 18 million  [1]. This “youth bulge” offers Egypt a “demographic gift” of a large number of working-age citizens with a relatively low number of older and younger non- working people to support [2]. Conse- quently, tobacco smoking among youth is a serious health issue in Egypt. Egypt has reported the highest rate of tobacco use of all the countries of the Middle East and North Africa [3]. Although population growth  is 2%,  the number  of smokers in Egypt has increased by 8%–9% each year for the past 30 years,  and tobacco advertisers have targeted youth in order to grow the tobacco industry  [4,5]. The  long-term health  effects of smoking on Egypt’s great- est human resource—its youth—and the future health care costs of a large population of smokers threaten to transform the demographic gift into a demographic burden. Social norms are “group identity- based codes of conduct that are under- stood and disseminated through social interaction,” and can encourage or dis- courage behaviours such as smoking [6]. Norms are an essential component  of peer group  identity [6]. Perceptions  of norms and normative influences are important components of well- established theories of behaviour change and of communication, such as the Theory of Planned Behaviour and Social CognitiveTheory [7,8]. Objectives This article reviews the literature on Egyptian youth tobacco smoking so as to identify the attributes of youth that research has found to be associated with smoking behaviours and that may also be related to youth peer groups and social norms. Few studies have explicitly researched the relationships between social norms and smoking behaviours among youth in Egypt. However, many studies have described the prevalence and habits of youth smoking according to one or more demographic character- istics such as sex and age. Particularly among youth in school with friends of the same age, these demographic characteristics are likely to correspond to social networks and friendship groups and the concomitant social norms pertinent to these groups. This article first summarizes the relation- ships identified between the smoking behaviour of Egyptian youths and selected demographic characteristics, and then summarizes the relationships identified in research between youths’ tobacco smoking behaviours and their household and peer social normative environments. Sources The literature selected for this review was identified through key word searches of the PubMed and PsycInfo databases. The searches were conducted in October 2009. PubMed is a service of the US Na- tional Institutes of Health and provides citations from the biomedical literature [9]. PsycInfo is a database service of the American Psychological Association, with citations from the psychological literature and the psychological aspects of  related disciplines  [10]. Additional  “grey literature” resources from the World Health Organization (WHO), Population Council, and Egypt Demo- graphic and Health Surveys (DHS) were also reviewed. Methods of selection The PubMed and PsycInfo databases were accessed using the search terms “(youth or adolesc*) AND Egypt AND (smok* or tobacco).” When “norm*” was added to these search terms, no articles were returned on PubMed . The PubMed search returned 52 articles, of which 14  were retained. Articles excluded were those that were: published before 1997  (15 articles); primarily about waterpipe  smoking (2 articles); research conduct- ed on Egyptians living outside of Egypt (1 article); or reports discussing smok- ing status as an independent variable related to other health outcomes and not as the primary focus of the article (e.g. hepatitis C, abortion, and levels of cadmium and arsenic) (21 articles).  The PsycInfo search returned 3 articles: 2 articles that were also returned in the  PubMed search and 1 dissertation (by S. Islam) that appeared to report the same research as  the 2 articles [11,12].  Other “grey literature” on Egyptian youth smoking was accessed from the Population Council, the WHO and the Egypt DHS websites. Compilation and interpretation of data Smoking behaviours Several national studies and a number of local or regional research studies have looked at smoking among Egyptian youth. National studies include WHO’s global youth tobacco survey (GYTS), conducted in 2001, 2004 and 2005; the  Population Council’s survey of young people in Egypt (SYPE), conducted in  2009;  the  Population  Council’s  adolescence and social change in Egypt (ASCE)  survey,  conducted  in  1998;  and the Egypt DHS, which collected information on  tobacco use  in 2000,  2005 and 2008 [2,13–17]. The  2005  GYTS  surveyed  4196  Egyptian  students  in  the 2nd and 3rd  level of preparatory school and the 1st level of secondary school and found that 13.6% of students had ever smoked  cigarettes and 14.4% reported currently  using a tobacco product [13]. The ASCE found that among a nationally- representative  sample of  9128  youth  aged 10–19 years,  5.5% were  current  smokers and 23.0% reported  that  their  peers smoked [14]. Book 17-4.indb 350 4/27/2011 11:00:50 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 351 Sex and age Sex and age play important roles. Re- search consistently finds that smok- ing in Egypt is more prevalent among male youth than among female youth, and that smoking prevalence increases with  age  [4,11,13,17–23]. The  2005  GYTS  found  that 19.7% of males had  ever used a tobacco product and 17.6%  currently used tobacco, compared with 5.7%  and  8.6%  respectively  among  female students in the same grades [13]. The Population Council’s  2009  SYPE  found  that 26% of male  youth  aged 15–29 years  reported  smoking,  most of whom were aged 18–29 years  [2]. The Council’s earlier ASCE survey  found  that 11.2% of male adolescents  reported smoking, compared with only 0.3% of females. The researchers suggest  that these figures underestimate the actual percentage of youth smoking, since 42.2% of  young men  and 5.1%  of young women reported that their peers  smoked [14].  In  the 2008 DHS,  0.3% of women aged 15–19  reported  smoking, although 56.2% said they lived  with a smoker. Among men in the 2008  DHS, 18.9% of those aged 15–19 years  reported  that  they  smoked and 50.9%  reported living with a smoker. As in the SYPE data, smoking was more prevalent among the older youth cohort: 43.2% of  men aged 20–29 years reported smok- ing, while  41.9%  said  they  lived with  a  smoker,  and 0.6% of women 20–29  years  reported  smoking, while 54.2%  reported living with a smoker [17]. Local and regional studies tell a similar  story. A 2003  survey of  1930  high-school  students (51% male, 49%  female)  aged  13–19  years  in  school  grades 7, 9, and 12 in Alexandria found  that  25% of  youth had  ever-smoked,  12% had smoked in the previous 30 days  and 6% were current smokers. These 3  smoking behaviours were more preva- lent among males than females, and the differences were statistically significant. In that study 34% of males and 16% of  females  reported  ever-smoking,  16%  of males  and 7% of  females  reported  having smoked in the previous 30 days,  and 8% of males and 4% of  females re- ported current smoking [11]. A study of 635 students in rural secondary schools  in Qualyobia governorate in the Nile Delta region found that 11.5% of males  and 0% of female students reported cur- rent smoking, defined as having smoked at  least once  in  the 30 days preceding  the survey; and 60% of males and 93%  of females reported never smoking [19].  A study of 600 University of Alexandria  hostel  residents  found  that  17.5% of  males (46 out of 263) and 0% of females  (0 out of 337) were  current  smokers  [24].  In a  survey of 559 University of  Cairo students aged 15–27 years, 50.9%  of males had ever  smoked and 22.0%  were current smokers, compared with 11.9% of females who had ever smoked  and  1.7%  of  females  who  currently  smoked [4]. A similar sex disparity was reported in a survey of a convenience sample  of  302  students  aged  14–18  years from Cairo, Giza and Qualyobia: the overall prevalence of current smok- ing was 8.3%, but  smoking was more  prevalent among male students (13.2%)  than among females (3.3%) [23]. The lower rates of smoking noted among women may reflect social tra- ditions and women’s lesser economic resources compared to men’s [18]. Gadalla et al. also emphasized the link between sex roles and smoking, not- ing that “smoking among females is not socially accepted in Egypt, especially in rural communities, where they con- sider  it  a male behaviour”  [19]. Other  researchers suggest that young women may underreport smoking behaviour in surveys because of a taboo against female smoking, so the actual prevalence among young women may be higher than the available data suggest [4,11]. Based on their 2003 survey of Alexandria  high-school students, Islam and Johnson performed a mediation analysis of ado- lescent smoking behaviour and expo- sure to Western media, assessed through an index developed from responses to 6  self-reported  questions,  including  “I watch Western movies  and/or TV  shows,” “I read Western magazines and newspapers,” and “How much do you enjoy listening to Western music?” They found that exposure to Western media was associated with an increased risk of 30-day  smoking behaviour  among  Egyptian males but not females. The differential influence was due only to the effect that the Western media had on increasing adolescent males’ positive be- liefs about smoking. The authors suggest that the differential influence may relate to “gender-differentiated cultural norms associated with Islamic Arab patriarchal societies, such as Egypt”, where smoking is socially acceptable for adult males but not for females, and the greater preva- lence of male movie stars than female movie stars shown smoking in Western films [11]. Young men may initiate smoking earlier than young women, and youth seem to smoke less heavily than adults. In a community-based survey of 2120  people  aged 15 years  and over  in Al- exandria, 48.5% (586 of 1162) of  the  men were current smokers and their average age of  initiation was 18.1 years.  Among women, 1.5% (14 of 958) were  current smokers, and their average age of initiation was 22.6 years [18]. Younger  smokers may smoke less frequently than older smokers. As part of the Communi- ty Trial for Prevention of Environmental Tobacco Smoke, 7657 adults aged 18  and over  in 6  villages  in 2 districts  in  Qualyobia governorate were surveyed. The researchers  found that 1401 males  (37.6%)  and  5  females  (0.1%)  were  smokers, and that those who smoked less than daily tended to be younger. Of those respondents 18–24 years who  were smokers, about 10% smoked  less  than once a day compared with only 4% of those aged 25–44 years and 2% of  those over 45 years who reported smok- ing less than once a day and not more frequently [25]. ASCE also found that heavy smoking was less common than was light smoking. Among those young men who reported that they smoked Book 17-4.indb 351 4/27/2011 11:00:51 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 352 (n = 474), 35.9% had not smoked any- thing the week before the survey, 16.8%  had smoked 1 cigarette, and 20.1% had  smoked 10 or fewer cigarettes in the pre- vious week [14]. In a study of University of Cairo students, 28.8% reported smok- ing less than once a day. The average age of initiation of smoking in that study was 19 years for males and 20 years for  females [4]. Education In addition to sex and age, factors such as level of education, characteristics of the educational environment and school performance have been associated with smoking behaviour. The DHS, SYPE and ASCE reported smoking status by level of education, but did not adjust for age, which is likely to be highly correlat- ed with level of education among youth who may  still  be  in  school  [2,14,17].  In  the DHS sample of 1826 men aged  15–49 years,  58.3% of  those with no  education and 62.0% of those who had  not completed primary school reported smoking, compared with 38.5% of men  who had completed primary or second- ary school [17]. A community-based survey of 1162 men and 958 women  in Alexandria found that among males, current smokers tended to be less edu- cated than never smokers, whereas the opposite was true for females: current smokers were better educated than never smokers, and of the 14 women in the study who were current smokers, 6  had a university degree [26]. A survey in rural Qualyobia second- ary schools found that attending a male- only school was a protective factor for smoking compared with attending a coeducational  school (OR = 0.4, 95%  CI: 0.2–0.8). The authors attribute  this  difference to boys thinking that smok- ing makes them look attractive to their female schoolmates [19]. In the study on University of Cairo students, smok- ing was less prevalent among those who had attended foreign language schools than among those who had attended Egyptian public or private schools or schools in other Arab countries. The author attributed this to greater health awareness among the higher socioeco- nomic groups in society, who can afford foreign language schools [4]. Although smoking is restricted on university campuses, enforcement may be lax and students may be unaware of these policies or reluctant to aid their en- forcement by discouraging their peers’ smoking. Allam interviewed a random sample of 108 male students at Cairo’s  Ain Shams University student unions, which ban smoking, and found that 27.8% of students thought that smoking  was permitted in the unions. Research- ers noticed a “low attitude regarding advising or asking friends or relatives to [extinguish] their cigarettes, not to smoke in his presence or to quit smok- ing” [27]. Students living in University of Alexandria hostels who smoked were more likely to have poor academic per- formance than good performance (χ2 = 4.54, OR = 4.39) and the difference was  statistically significant [24]. Students in the faculty of agriculture at Suez Canal University were  found  to be 2.7  times  more likely to report smoking than were students at the faculty of medicine [22]. Employment Smoking behaviour has also been re- lated to youth employment. In an analy- sis of 4353 Egyptian boys aged 10–19  years in the ASCE data, those who did paid work were more likely to smoke than were those who did not work. For current paid workers, the likelihood of ever smoking was 1.71 times greater than those who had never worked, and for current smoking, the odds were 2.36  times greater for current paid workers compared with those who had never worked [28]. The authors note that, “as- suming paid workers were more likely to work outside the home, they could have been exposed to a new network of smokers, people tolerant of smoking… Paid adolescents may also have more disposable income for cigarettes.” [28]. Similarly, among 687 students surveyed  at Suez Canal University in Ismailia, current tobacco use was more prevalent among students with a higher monthly allowance (OR = 3.4, 95% CI: 2.2–5.2),  and among working students (OR = 3.6, 95% CI: 2.3–5.6) [22]. Parents Both nationally and locally conducted research has examined the characteris- tics of parents and their association with youth smoking. An analysis of the 2001  GYTS of 3792 public  school  students  aged 13–15 years across Egypt showed  that more than half of current smokers were exposed to smoke from others in their household, whereas only about one third of never-smokers were exposed to smoke at home [20]. However, the Population Council’s ASCE study of youth across Egypt found that parental smoking was not significantly correlated with adolescent smoking [14]. Islam and Johnson’s 2003 survey of  high-school students in Alexandria is one of the few studies that explicitly re- searched Egyptian youths’ social norms and their smoking behaviour. The study identified a strong association between youth smoking and social norms estab- lished by siblings and household adults [11]. In a multivariate analysis adjusted for sex, age and socioeconomic status (SES), students whose siblings smoked were  3.5  times more  likely  to  report  ever-smoking (95% CI: 2.3–5.2)  and  3.9  times more  likely  to  report having  smoked within  the  previous  30 days  (95% CI: 2.6–6.1) compared with stu- dents whose siblings did not smoke. Those whose parents smoked were 2.3  times more likely to be ever-smokers (95% CI: 1.6–3.2) and 2.1 times more  likely to have smoked within the past 30  days (95% CI: 1.4–3.1)  in multivariate  analysis. Perception of the proportion of adults who smoke was significantly as- sociated with ever-smoking behaviour (OR = 1.7, 95% CI: 1.6–1.9) and 30-day  smoking behaviour (OR = 1.2, 95% CI:  1.1–1.4) in multivariate analysis [11]. Book 17-4.indb 352 4/27/2011 11:00:51 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 353 In a  survey of 2000  students  aged  12–18  years  attending  schools  near  Ain Shams University, 47.5% reported  that  their  father  smoked,  and  1.1%  reported that their mother smoked, but the study did not report the cor- relation between parental smoking behaviour and respondents’ smoking behaviour  [21]. Among  students  in- terviewed in rural secondary schools in Qualyobia governorate, male students whose mothers had graduated from university were 3.7 times more likely to be current smokers than were the sons  of  illiterate mothers  (95% CI:  1–12), which the authors attributed to  less maternal supervision if the mother worked outside the home and to higher  family  income. About 62% of  the students were exposed to smoke at home, and 55% of the students’ fathers  smoked; however neither parents’ nor siblings’ smoking status was found to be significantly related to male youth’s smoking status. Citing earlier studies that did link parental smoking with youth smoking, the authors suggest that the high degree of exposure to smoking from all sources may con- ceal a link between parental and youth smoking [19]. In the same study, those  males whose fathers had professional and semi-professional jobs were more likely to have ever smoked than were those whose fathers worked in skilled, semi-skilled or unskilled labour. Smok- ing also appeared to be more common among young men whose fathers were less educated, and these differences were statistically significant in bivariate analysis  [19]. Nassar’s  study of Uni- versity of Cairo students found that smoking was more prevalent among students whose parent was working or had worked abroad, which the author attributes to the higher economic sta- tus of the family allowing more dispos- able income for the respondent [4]. Peers Research strongly and consistently links adolescent smoking in Egypt with smoking among their peers. Analysis of the 1997 ASCE data  found  that  those  who reported that their peers smoked were 7.99  times more  likely  to be cur- rent  smokers  (95% CI:  4.82–13.23),  and were 6.00  times  as  likely  to have  ever  smoked (95% CI: 4.49–8.04),  in  models adjusted for work status and education  status  [28]. Gadalla  found  that students who reported 1 or more peers as smokers were 3 times more likely  to be  smokers  themselves (95%  CI: 2–5) [19].  Similarly,  research on 302 14–18  year old students in Cairo, Giza and Qualyobia found that peer norms was one predictor of current smoking; oth- ers were perceived benefits of smoking and knowledge that smoking is addic- tive  [23].  Islam and  Johnson’s  survey  of high-school students in Alexandria identified a strong association between smoking and social norms established by peers. Having peers who smoked in- creased the likelihood of ever-smoking by 2.1 (95% CI: 1.4–2.9) and increased  the likelihood of having smoked within the past 30 days by a factor of 2.6 (95%  CI: 1.4–4.6)  in a multivariate analysis  adjusted for sex, age and SES. Perceptions of what proportion of their peers were smokers was also important: those who had a higher per- ceived peer norm for smoking were 1.3 times more  likely  to ever-smoke (95%  CI: 1.2–1.4) and 1.3  times more  likely  to have smoked within the previous 30  days (95% CI: 1.2–1.5) [11]. Conclusions This review of the literature on youth smoking in Egypt has identified sev- eral characteristics that are consistently associated with smoking behaviour and that are related to youths’ identity groups and social normative environ- ments: male sex, older age and peers who smoke. Working has also been linked to a greater prevalence of smok- ing behaviour, and may be related to the social normative environment of the workplace. Several studies have looked at the relationship between living with smokers (parents or siblings) and smoking among youth, but the results are not consistent across studies. This review of the literature has sev- eral limitations. The review was limited to materials published in English. It did not attempt to examine relationships between youths’ SES and their smoking behaviour, although SES is often studied in relation to adult smoking behaviour and may relate to social norms. Some studies created social class indices. For example, Abolfotouh et al. created a 3-level SES status score based on educa- tion and occupation of parents, family size, housing conditions and family in- come [24].  Islam and Johnson created  a wealth index based on 3 questions about parents’ education levels and student’s weekly spending money [11]. Other studies referred to characteristics related to class, such as parents’ educa- tion  [19,22]  and parents’ work  status  [4,19]. Overall, however, the methodol- ogy was inconsistent across studies and a meaningful summary of social class and youth smoking was beyond the scope of this article. Suggestions for future research Several areas of further research could yield useful information about youth smoking and the normative envi- ronments that encourage or discourage youth smoking. Research on religion and religiosity with relation to smok- ing behaviour would be informative. Islamic religious scholars have found smoking to be either “completely pro- hibited or abhorrent to such a degree as  to be prohibited” [29]. Among Ain  Shams students, 80.6% reported know- ing about the fatwa ruling on smoking [27].  Radwan  et  al.  interviewed  322  youth aged  less  than 18 years  in  rural  Qualyobia  and  found  that  77.2%  of  Book 17-4.indb 353 4/27/2011 11:00:51 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 354 males  and 69.3% of  females  knew of  the fatwa on smoking. Similarly, among 635 secondary  school  students 87.4%  of males  and 69.6% of  females  knew  about the fatwa  [30]. Future  research  should examine how Egyptian youths’ participation in religious activities and their social groupings based on religion relate to their smoking behaviour. One study suggested that smoking was less prevalent among students in male-only schools in Qualyobia, and another suggested that smoking was less prevalent among students from foreign language schools who matriculated to the University of Cairo [19]. Additional  research or secondary analysis of exist- ing data would be helpful in determin- ing whether these trends hold true in other samples of Egyptian youth, and to try to explain what social norma- tive mechanisms related to the school environment might influence youth smoking behaviour. Another study sug- gested that among women, those who smoke tend to be more educated than those who do not smoke [26]. It would be interesting to study social norms about cigarette smoking among female university students and university graduates. Research is also needed on out-of-school youth, particularly those who are not likely to be included in household surveys. Several of the studies reviewed here used definitions of youth smoking that were the same or close to the GYTS definitions of never smoking (not even a puff or 2), ever smoking and current  smoking (at least once in the previoous 30 days). Consistent  terminology and  use of validated survey items will help to ensure the comparability and generaliz- ability of future research. None of the studies reviewed here reported findings from longitudinal (panel) data, and few reported the re- sults of multivariate analyses that were adjusted for known correlates. Future research should use more powerful research designs and sophisticated analyses to generate specific and action- able research findings and make policy recommendations. Egypt signed the WHO Framework Convention on Tobacco Control in 2003  and  ratified  the  agreement  in  2005  [31]. The  Framework  encour- ages tobacco prevention, cessation and research programmes among its signatories. Youth’s social normative environments should be included in research agendas and in prevention and cessation programmes for youth in Egypt. Social norms powerfully influ- ence human behaviour [32] and offer a  means to defend against tobacco mar- keting targeted at youth [5]. Acknowledgements The author gratefully acknowledges the support of the Fulbright Bi-National Committee and thanks the Population Council Western Asia and North Af- rica Regional Office and the Center for  Communication Programs at Johns Hopkins Bloomberg School of Public Health  for providing office  space and  encouragement during the preparation of this article. References Assaad r, roudi-Fahimi F. 1. Youth in the Middle East and North Africa: Demographic opportunity or challenge? Washington Dc, Population reference bureau, 2007. 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Survey (GYTS) Egypt. centers for Disease control and Preven- tion [website] (http://www.cdc.gov/tobacco/global/GYts/ factsheets/emr/2005/Egypt_factsheet.htm, accessed 23 Janu- ary 2011). Transitions to adulthood: a national survey of Egyptian adoles-14. cents. cairo, Population council, 2000. El-Zanaty F, Way A. 15. Egypt demographic and health survey 2000. calverton, maryland, Orc macro/cairo, ministry of Health and Population and National Population council, 2001. El-Zanaty F, Way A. 16. Egypt demographic and health survey 2005. calverton, maryland, Orc macro/cairo, ministry of Health and Population and National Population council, 2006. Book 17-4.indb 354 4/27/2011 11:00:51 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 355 El-Zanaty F, Way A. 17. Egypt demographic and health survey 2008. calverton, maryland, macro International and cairo, ministry of Health and El-Zanaty and Associates, 2009. Youssef rm, Abou-Khatwa sA, Fouad Hm. Prevalence of smok-18. ing and age of initiation in Alexandria, Egypt. Eastern Mediter- ranean Health Journal, 2002, 8 (4/5):626–637. Gadalla s et al. Prevalence of smoking among rural secondary 19. school students in Qualyobia governorate. Journal of the Egyp- tian Society of Parasitology, 2003, 33(suppl.):1031–1050. Dous Nm. 20. Report on the results of the Global Youth Tobacco Sur- vey in Egypt. National comprehensive tobacco control program. Egypt, ministry of Health and Population, 2003. Aboul-Fotouh A et al. university advocacy on tobacco pre-21. vention in Egypt: partnership between Ain shams univer- sity and the Egyptian smoking Prevention research Institute (EsPrI). Journal of the Egyptian Society of Parasitology, 2003, 33(suppl.):1103–1110. refaat A. Practice and awareness of health risk behaviour 22. among Egyptian university students. Eastern Mediterranean Health Journal, 2004, 10:72–81. Ahmed O Jr et al. tobacco education in cairo, Egypt: is there 23. an effect on adolescent smoking? Tobacco Control, 1999, 8:440–441. Abolfotouh mA et al. Health-related lifestyles and risk behav-24. iours among students living in Alexandria university Hostels. Eastern Mediterranean Health Journal, 2007, 13:376–391. boulos DN et al. Nondaily, light daily, and moderate-to-heavy 25. cigarette smokers in a rural area of Egypt: a population-based survey. Nicotine & Tobacco Research, 2009, 11:134–138. Youssef rm, Abou-Khatwa sA, Fouad Hm. current and nev-26. er smokers: differentials in characteristics, knowledge and perceptions. Eastern Mediterranean Health Journal, 2003, 9:923–934. Allam mF, Abd Elaziz Km. role of members of university 27. students’ unions in tobacco prevention. Journal of Preventive Medicine and Hygiene, 2007, 48:136–140. sitrin D, bishai D. the association between cigarette smok-28. ing and work status among Egyptian adolescent males. In- ternational Journal of Tuberculosis and Lung Disease, 2008, 12(6):670–676. Khayat mH. 29. Islamic rulings on smoking. Health education through religion series. The right path to health. Alexandria, World Health Organization regional Office for the Eastern mediterranean, 2000. radwan GN et al. Impact of religious rulings (fatwa) on smok-30. ing. Journal of the Egyptian Society of Parasitology, 2003, 33(suppl.):1087–1101. El-bakry r. New legislation aims to snuff out smoking. 31. Busi- ness Monthly, cairo, American chamber of commerce in Egypt, 2007 (http://www.amcham.org.eg/resources_publica- tions/publications/business_monthly/issue.asp?sec=4&im=8 &iy=2007&subsec=New%20Legislation%20Aims%20to%20 snuff%20Out%20smoking Accessed 14 April 2011) . Yanovitzky I, rimal rN. communication and normative influ-32. ence: An introduction to the special issue. Communication Theory, 2006, 16:1–6. Weekly Iron-Folic Acid Supplementation (WIFS) in women of reproductive age: its role in promoting optimal maternal and child health (WHO/NMH/NHD/MNM/09.2) These guidelines are based on the consensus of a World Health Organization (WHO) Global Consultation on Weekly Iron and Folic Acid Supplementation (WIFS) for Preventing Anaemia in Women of Reproductive Age held in Manila, Philippines, 25-27 April 2007 and summarizes recommendations based on a desk review commissioned by the WHO  Regional Office for the Western Pacific (WPRO) and additional evidence presented and discussed in the expert  consultation. It is intended for a wide audience including program implementing partners, scientists and governments involved in the design and implementation of micronutrient programs as public health interventions. The guidelines are published in six langrages, including English and Arabic; they can be accessed at: http://www.unaids.org/documents/20101123_GlobalReport_em.pdf Book 17-4.indb 355 4/27/2011 11:00:52 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 356 Review Adherence to medication among chronic patients in Middle Eastern countries: review of studies A. Al-Qasem,1 F. Smith1 and S. Clifford 1 AbstrAct this paper reviewed studies that have investigated adherence to medication among patients with chronic conditions in middle Eastern countries. A comprehensive literature search yielded 19 relevant studies. these focused on the extent and predictors of nonadherence to medication across different conditions, including hypertension, chronic obstructive pulmonary disease, asthma, diabetes, depression, schizophrenia and epilepsy. Estimated rates of nonadherence to medication ranged from 1.4% to 88%. this review confirms the existence of nonadherence as a problem among patients with chronic diseases and examines our understanding about the reasons and variables affecting patients’ adherence to their medication in the middle Eastern countries. However, the studies employed a wide range of methods, sometimes with limitations. Further work to determine the prevalence and causes of patients’ nonadherence to medication in middle Eastern countries is needed in order to recommend the best interventions to improve adherence. 1Department of Practice and Policy, School of Pharmacy, University of London, London, United Kingdom (Correspondence to A. Al-Qasem: ayesha. alqasem@pharmacy.ac.uk). received: 21/07/09; accepted: 18/10/09 تاساردلل ةعجارم :طسولأا قشرلا نادلب في يننمزلما ضىرلما ينب يئاودلا جلاعلاب مازتللاا درفيلك هراس ،ثمس يتسلف ،مساقلا دحمأ ةشئاع قشرلا نادلب في ةنمزم تلااحب ينباصلما ضىرلما ينب يئاودلا جلاعلاب مازتللاا ىوتسم تّصقت يتلا تاساردلا ثحبلا اذه ضرعتسا :ةـصلالخا تائِـ بنُمو رادقم لىع تز َّكر ثوحب يهو ،عوضولماب ةلص تاذ ةسارد 19 لىع روثعلا نع ةروشنلما ثوحبلا في ضيفتسلما ثحبلا رفسأ دقو .طسولأا ،ماَصُفلاو ،بائتكلااو ،يرّكسلاو ،وبرلاو ،نمزلما ّدِسُلما يوئرلا ءادلاو ،مدلا طغض طرف كلذ في ماب ،تلاالحا فلتمخ في يئاودلا جلاعلاب مازتللاا مدع مدع ةلكشلم ليعفلا دوجولا لىع ةساردلا هذه دكؤتو .%88 لىإ %1.4 نم يئاودلا جلاعلاب مازتللاا مدعل ةيريدقتلا تلادعلما تحوارتو .عصرلاو نادلب في يئاودلا مهجلاعب ضىرلما مازتلا لىع رثؤت يتلا تاّيرغتلماو بابسلأل انكاردإ ىدم ىرحتتو ،ةنمزلما ضارملأاب ينباصلما ضىرلما ينب مازتللاا لمعلا نم ديزلم ةجاح دوجو لىع لدي امم ،ًانايحأ ةدودحلما يرغ بيلاسلأا نم ًاضيرع ًاعاطق تمدختسا دق تاساردلا هذه نأ لاإ .طسولأا قشرلا اذه ىوتسم ينسحتل تلاخدتلا لضفأب ةيصوتلا نكمي ىتح طسولأا قشرلا نادلب في يئاودلا جلاعلاب ضىرلما مازتلا مدع بابسأو راشتنا ديدحتل .مازتللاا Observance thérapeutique chez les patients atteints d’affections chroniques dans les pays du Moyen- Orient : analyse de plusieurs études résumé Le présent article a analysé des études ayant pour objet de recherche l’observance thérapeutique chez les patients atteints d’affections chroniques dans les pays du moyen-Orient. une recherche exhaustive de la littérature a permis de sélectionner 19 articles pertinents. ces derniers étaient axés sur l’étendue de la non-observance thérapeutique et les facteurs prédictifs en la matière, par types de pathologies telles que l’hypertension, la bronchopneumopathie chronique obstructive, l’asthme, le diabète, la dépression, la schizophrénie et l’épilepsie. Les taux estimés de non-observance thérapeutique allaient de 1,4 % à 88 %. La présente analyse confirme l’existence d’un problème de non-observance chez les patients atteints d’affections chroniques et présente nos conclusions sur les raisons et variables influant sur l’observance thérapeutique des patients dans les pays du moyen-Orient. toutefois, les études analysées ont utilisé un large éventail de méthodes, et présentaient parfois des limites. une recherche plus approfondie pour déterminer la prévalence et les causes de la non-observance des patients dans les pays du moyen-Orient est nécessaire pour être en mesure de recommander les interventions les plus efficaces afin d’améliorer l’observance. Book 17-4.indb 356 4/27/2011 11:00:52 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 357 Introduction Adherence is defined by the World Health Organization (WHO) as “the extent to which a person’s behaviour— taking medication, following a diet, and/or  executing  lifestyle  changes— corresponds with agreed recommenda- tions from a health care provider” [1]. Nonadherence remains a major prob- lem in patient care, despite the large number of research studies that have been conducted in this area in recent decades. Patients’ poor adherence to their medication is a complex problem for health care services, especially in the care of chronic illness, for which the correct, effective treatment is essential for a patient’s quality of life and survival rate. Failure to take the appropriate drug regimen as recommended may lead to poor therapeutic outcomes, wasted health care resources and inappropriate changes to treatment by prescribers. A report by the WHO estimated that the average rate of adherence to medi- cation  is  around 50% among patients  suffering from chronic diseases in devel- oped countries, and this is assumed to be lower in developing countries where there is limited access to health care and medicines [1]. Although there might be similarities in the rate and reasons for nonadherence in the Middle East compared with the rest of the world, there may also be important differences. This is because reasons for nonadher- ence are complex. They are affected by operational factors in the health care system (including access to medicines), by relationships between health care professionals and patients, by cultural perceptions about the use of medica- tion and by patients’ beliefs. The aim of this paper was to review the relevant research into adherence to medication regimens among patients with chronic conditions in the Middle East region. The objectives were to es- tablish the extent to which adherence to medication regimens has been studied in this region of the world, and review evidence regarding adherence rates, the reasons for nonadherence and the variables found to influence adherence/ nonadherence behaviours. Search strategy A systematic search of studies related to medication adherence in chronic diseases in the Middle East region was performed using the following databases: EMBASE, MEDLINE, PSYCHINFO, CINAHL, PubMed, International Pharmaceutical Abstracts and the Web of Knowledge. The search terms were: (adherence or compliance AND therapeutic alliance or nonad- herence to medication or therapy re- fusal AND Middle East or United Arab Emirates or Saudi Arabia or Kuwait or Bahrain or Qatar or Oman or Jordan or Egypt), with or without the combina- tion of the keywords: (treatment or regi- men). A further search with the Google search engine was carried out to identify all health care and clinical journals in Middle East countries. All journals were searched for relevant papers and the citations of relevant papers were hand searched for further articles. All the studies were analysed for their findings and the quality of the re- search. In this review, the definition or classification (level) of adherence, study setting, population and sampling, meth- ods of data collection and measurement of adherence were taken into account. Results A  total  of  19  studies were  identified  from all regions of Middle East (Table 1): Egypt (4 studies), Sudan (1), Libyan Arab Jamahiriya (1), Saudi Arabia (6),  Kuwait (3), United Arab Emirates (1), Palestine (1), Turkey (1) and Pakistan (1). Of the studies 17 were conducted among adult populations and 2 among  children [2,3]. The studies focused on different disease and illness groups, including hy- pertension [4–10], diabetes [11–14], mental illness [15–17], asthma [3,18], epilepsy [2,19] and chronic obstruc- tive pulmonary disease [20]. They were conducted in primary health care centres, outpatient clinics and diabetes centres. The sample sizes ranged from 104 to  1000, with a median of 278 patients. Measures employed for data collection on adherence to medication Adherence to medication was measured using self-reports, pill counts and out- come measures. Almost all of the studies (17 of 19) used patients’ self-reporting  either alone [2–7,11,12,14,17,18,20] or combined with other methods, especially pill counts [8,9,13,15,16]. In one study of epileptic patients pill counts only were used [19] and in an- other study of hypertensive patients pill counts were combined with blood pressure measurements [10]. In 12  studies  self-reports were ob- tained using structured questionnaires [2–6,9,11,12,14,17,18,20]. Two stud- ies [4,5] used a previously validated measure: the Morisky medication adherence scale [21]. However, in 1 of these studies [4] details were not provided on the translation or cross- cultural validity of the tool. In another 2  studies,  the  authors  reported  that  they had adapted a questionnaire from earlier relevant published studies [18] or from a medical textbook [6], but details of this adaptation process were not provided. In 7 studies, respondents were di- rectly asked about their adherence to medication, e.g. the total number of tablets they had been prescribed per week and how many pills they took and missed  in  the  last 3, 5 and 7 days  [4] or previous month [7] or whether they had taken their medication as di- rected by the physician [13,15,16,19] Book 17-4.indb 357 4/27/2011 11:00:52 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 358 or whether they were taking their drugs regularly or not [8]. In 4 studies, questionnaires were administered by the patient’s physician [3,11–13]. Definition or classification (level) of adherence/ nonadherence Different definitions of adherence or nonadherence were employed; 14 studies provided information on these definitions. In 6  studies patients were  consid- ered to be adherent if they reported taking ≥ 80% of their doses as prescribed  [4,5,8,10,15,16]. In a further study the cutoff used was 75% [14]. In another study, adherent patients were those who used their medication correctly (knowledge  about  at  least  2  of  their  bronchodilator medication doses and correct inhalation technique) and regularly (every day) [20]. In 1 study the doctors made a judgement about patients’ compliance based on their an- swers to questions, the details of which were unspecified in the paper [3]. Conversely, nonadherence was de- fined variously as: missing a total of 1 day of doses/week [2], or < 90% of their  pills [7], or 4 doses per month [13] or a total of 3 days’ doses/month [19]. One study did not report actual values but in- stead defined nonadherence as “failure to take medications as prescribed for a period greater than a week” [17]. Adherence/nonadherence rates Overall, the estimated rates of nonad- herence to medication in these Middle East  countries  ranged  from 1.4% and  88%  in  the different studies. Studies  in  which questionnaires were completed by the patient’s physicians tended to re- port low nonadherence rates compared with the other studies [3,11,13,15]. In one study in which data on adherence were collected both by patients’ self- reports and by physicians, the physicians overestimated the level of their patients’ adherence to medication; physicians estimated the nonadherence rate as 29%, whereas patients’ self-reports gave  an estimate of 48% [5]. Within the same illness group, 7 studies among hypertensive patients re- ported medication nonadherence rates between 23% and 49.5% and 4  stud- ies among diabetic patients reported nonadherence rates between 1.4% and  27.1%. However, 2  studies conducted  with patients with depression reported nonadherence  rates of 24%  to 30%  in  one study [16]  and  88%  in  another  [15]. Reasons for nonadherence A wide range of reasons were given by patients for nonadherence to medica- tions. These included: forgetfulness [2,7,10,15,18,19], drug side-effects [7,10,15,17,19], wanting a “drug holi- day” [7], concerns about drug depend- ency [15,17],  feeling well [7,10,15,18], medication was not helping them feel better [15,18], irregularity of follow-up [9], lack of health education [10], short- age of drugs [10,19], unawareness of the chronicity of the disease [20], busy parents [2], not having been told to continue the treatment [19], disbelief about the value and need for adherence [19], social stigma [17], complexity of the treatment regimen [17], inability to see their usual doctor [15], only using the medication as needed [18], feeling better (with bronchodilators) [18], in- ability to afford the drugs [8] and feeling lazy [18]. Discussion The results of this review indicate that, as elsewhere in the world, there is a problem of nonadherence to medica- tion among patients with chronic con- ditions in a number of Middle Eastern countries. However, caution must be taken before drawing a conclusion about the rate of nonadherence due to the wide discrepancy in the estimates of nonadherence rates between these studies, which varied from 1.4% to 88%.  This variation could be due to the differ- ent disease conditions studied, different patient populations, differences in the definitions of adherence/nonadherence  to medications used or to differences in the methods employed. All methods of measurement have their advantages and limitations and therefore there is no “gold standard” for the assessment of adherence. The nonadherence rate was higher among hypertensive patients than those with diabetes, which could be due to the nature of hypertension disease (asymp- tomatic) or to different perceptions of the seriousness of the condition. Also findings from a small number of studies must be viewed with caution. This is supported by the international litera- ture, as WHO reports [1] that estimates of the extent to which patients adhere to pharmacotherapy for hypertension vary  from 50%–70%,  compared with  an estimated 36%–93% adherence  to  hypoglycaemic agents [22]. The 4 studies where interview-based questionnaires were administered by physicians reported lower nonadher- ence rates compared with other studies, ranging from 1.4% to 27.1% [3,11–13]. This could be as a result of patients ex- aggerating their degree of medication adherence to their treating physician for fear that admitting poor adherence would affect the quality of care they would receive or to gain their physi- cian’s approval. Many variables were suggested to affect patients’ adherence to their medi- cation (Table 1), but there were some contradictory results. For example, in 2 studies nonadherence was  shown to  be higher in younger patients [9,17] and in 1 study it was higher in older age groups [10]. The reasons reported by patients for nonadherence to their medication varied  across  the  studies  but  the  2  most frequently reported reasons were Book 17-4.indb 358 4/27/2011 11:00:52 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 359 Ta bl e 1 St ud ie s of a dh er en ce /n on ad he re nc e to c hr on ic m ed ic at io n in M id dl e Ea st er n co un tr ie s St ud y/ se tt in g/ co un tr y Sa m pl e D efi ni ti on o f pa ti en ts ’ a dh er en ce / no na dh er en ce M et ho ds /m ea su re s St ud y fin di ng s an d co nc lu si on s A l-F ar is e t a l. 20 0 2 [2 ] O ut pa tie nt c lin ic s, sa ud i A ra bi a 14 7 ch ild re n w ith ep ile ps y N on co m pl ia nt : m is se d a to ta l o f 1 d ay do se s/ w ee k c ro ss -s ec tio na l s tu dy A dh er en ce to m ed ic at io n m ea su re d by p at ie nt s’ se lf- re po rt u si ng de ta ile d qu es tio nn ai re 14 % o f p at ie nt s n on co m pl ia nt w ith m ed ic at io n Va ria bl e lin ke d to n on co m pl ia nc e: ty pe o f s ei zu re s Va ria bl es n ot li nk ed to n on co m pl ia nc e: a ge ; n at io na lit y; se x; fa m ily si ze ; a re a of re si de nc e; fr eq ue nc y of m ed ic at io n; si de -e ffe ct s o f m ed ic at io n ba ss ili e t a l. 19 98 [3 ] O ut pa tie nt c lin ic s, Eg yp t 25 0 c hi ld re n w ith br on ch ia l a st hm a c om pl ia nt , p oo rly co m pl ia nt o r no nc om pl ia nt (p hy si ci an s’ ju dg em en t) c ro ss -s ec tio na l s tu dy A dh er en ce to m an ag em en t m ea su re d us in g qu es tio nn ai re fi lle d by p hy si ci an s 2. 8% o f p at ie nt s p oo rly c om pl ia nt o r n on co m pl ia nt w ith sy m pt om at ic m an ag em en t d ur in g ac ut e at ta ck s. 38 .4 % p oo rly c om pl ia nt o r n on co m pl ia nt w ith p ro ph yl ac tic m an ag em en t H as hm i e t a l. 20 0 7 [4 ] O ut pa tie nt c lin ic s, Pa ki st an 43 8 pa tie nt s w ith hy pe rt en si on A dh er en t: to ok ³ 80 % o f d os es a s pr es cr ib ed c ro ss -s ec tio na l s tu dy A dh er en ce to m ed ic at io n m ea su re d by 2 se lf- re po rt m et ho ds : t ot al nu m be r o f t ab le ts p re sc rib ed / w ee k an d ho w m an y pi lls ta ke n an d m is se d; m or is ky sc al e [2 1] 23 % o f p at ie nt s n on co m pl ia nt w ith m ed ic at io n. Va ria bl es li nk ed to n on co m pl ia nc e: in cr ea si ng a ge ; b et te r a w ar en es s; h ig he r nu m be r o f p ill s p re sc rib ed . Va ria bl es n ot li nk ed n on ad he re nc e: d ep re ss io n. Fa he y et a l. 20 0 6 [5 ] 2 pr im ar y he al th c ar e (P H c ) c en tr es , u A E 20 3 pa tie nt s w ith hy pe rt en si on N on co m pl ia nt : to ok < 8 0 % o f d os es co rr ec tly c ro ss -s ec tio na l s tu dy A dh er en ce to m ed ic at io n m ea su re d by : 7 -it em q ue st io nn ai re m od ifi ed fro m m or is ky sc al e [2 1] to d et er m in e pa tie nt s’ a dh er en ce ; a nd 10 -it em qu es tio nn ai re to e lic it ph ys ic ia n’ s es tim at e of p at ie nt s’ a dh er en ce N on ad he re nc e: p at ie nt s’ se lf- re po rt ) 4 8% ; p hy si ci an s’ e st im at e 29 % N on ad he re nc e (p at ie nt s’ re po rt ): ne ga tiv el y co rr el at ed w ith : a ch ie vi ng ta rg et bl oo d pr es su re ; a nd p os iti ve ly c or re la te d w ith p hy si ci an ’s ev al ua tio n of se rio us ne ss o f d is ea se N on ad he re nc e (p hy si ci an s’ e st im at e) : n eg at iv el y co rr el at ed w ith tr ea tm en t ef fe ct iv en es s: p at ie nt s’ k no w le dg e, c om m un ic at io n qu al ity ; s er io us ne ss o f co nd iti on ba un e et a l. 20 0 4 [6 ] O ut pa tie nt a nd P H c cl in ic s, P al es tin e 33 6 pa tie nt s: ca se g ro up o f 1 12 w ith a cu te st ro ke an d hy pe rt en si on an d co nt ro l gr ou p of 2 24 w ith hy pe rt en si on on ly N o cl ea r c la ss ifi ca tio n c as e– co nt ro l s tu dy .A dh er en ce to m ed ic at io n m ea su re d us in g qu es tio nn ai re 25 % o f c as e pa tie nt s n on co m pl ia nt 4. 5% o f c on tr ol p at ie nt s n on co m pl ia nt Yo us se f a nd m ou ba ra k, 2 0 0 2 [7 ] PH c c en tr es , E gy pt 31 6 pa tie nt s w ith hy pe rt en si on Fu lly c om pl ia nt : no d os es m is se d Pa rt ia lly c om pl ia nt : to ok ³ 90 % o f d os es N on co m pl ia nt : t oo k < 90 % o f d os es c ro ss -s ec tio na l s tu dy A dh er en ce to m ed ic at io n m ea su re d by p at ie nt s’ se lf- re po rt u si ng qu es tio nn ai re 22 .2 % o f p at ie nt s p ar tia lly c om pl ia nt a nd 2 5. 9% n on co m pl ia nt Va ria bl es li nk ed to n on co m pl ia nc e: e du ca tio n le ve l; co m pl ic at io ns re la te d to h yp er te ns io n; si de -e ffe ct s; sm ok in g; re st ric tio n of d ie ta ry sa lt an d fa t; kn ow le dg e ab ou t n at ur e of d is ea se ; a ss oc ia te d co m pl ic at io ns a nd id ea l m an ag em en t p la n; p er ce pt io n of b en efi ts o f a dh er en ce to tr ea tm en t; bl oo d pr es su re c on tr ol ; s us ce pt ib ili ty to u nf av ou ra bl e ev en ts re la te d to hy pe rt en si on Va ria bl es n ot li nk ed to n on co m pl ia nc e: p at ie nt s’ d em og ra ph ic ch ar ac te ris tic s; d ur at io n of th e or ig in al il ln es s; p re se nc e of c oe xi st in g he al th pr ob le m s; n um be r o f h yp er te ns iv e dr ug s; fr eq ue nc y of d os e; p at ie nt s’ pe rc ep tio n of d an ge r o f o rig in al d is ea se ; c om pl ia nc e to id ea l e xe rc is e an d id ea l b od y w ei gh t Book 17-4.indb 359 4/27/2011 11:00:53 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 360 Ta bl e 1 St ud ie s of a dh er en ce /n on ad he re nc e to c hr on ic m ed ic at io n in M id dl e Ea st er n co un tr ie s (c on ti nu ed ) St ud y/ se tt in g/ co un tr y Sa m pl e D efi ni ti on o f pa ti en ts ’ a dh er en ce / no na dh er en ce M et ho ds /m ea su re s St ud y fin di ng s an d co nc lu si on s El zu bi er e t a l. 20 0 0 [8 ] O ut pa tie nt c lin ic , su da n. 19 8 pa tie nt s w ith hy pe rt en si on . N on co m pl ia nt : t oo k < 80 % o f p ill s. c ro ss -s ec tio na l s tu dy . A dh er en ce to m ed ic at io n m ea su re d by : p at ie nt s’ se lf- re po rt o f w he th er ta ki ng m ed ic at io n re gu la rly o r n ot ; pi ll co un ts ; a nd v er ifi ed b y bl oo d pr es su re m ea su re m en t. 49 .5 % o f p at ie nt s n on co m pl ia nt (4 0 % w ith th e pi ll co un t m et ho d) . Va ria bl es li nk ed to n on co m pl ia nc e: in ab ili ty to b uy d ru gs ; a sy m pt om at ic na tu re o f h yp er te ns io n; c om pl ic at io ns o f h yp er te ns io n; b lo od p re ss ur e le ve l. Va ria bl es n ot li nk ed to n on co m pl ia nc e: la ck o f b el ie f i n dr ug s; si de -e ffe ct s fro m d ru gs ; n um be r o f d ru gs ta ke n; d os ag e re gi m en . A l-s ow ie le m a nd El zu bi er , 1 99 8 [9 ] 4 PH c c en tr es , s au di A ra bi a. 19 0 p at ie nt s w ith hy pe rt en si on . N o cl ea r d efi ni tio n of ad he re nc e. c ro ss -s ec tio na l s tu dy . A dh er en ce to m ed ic at io n m ea su re d by : p at ie nt s’ se lf- re po rt u si ng a qu es tio nn ai re ; a nd v er ifi ed b y th er ap eu tic o ut co m e (d ia st ol ic bl oo d pr es su re > 9 0 m m H g) . 25 .3 % o f p at ie nt s n on co m pl ia nt b as ed o n se lf- re po rt a nd 6 5. 8% b as ed o n th er ap eu tic o ut co m e (d ia st ol ic b lo od p re ss ur e) . Va ria bl es li nk ed to n on co m pl ia nc e: ir re gu la r f ol lo w -u p; y ou ng er a ge ; b et te r ed uc at ed . Va ria bl es n ot li nk ed to n on co m pl ia nc e: se x; n at io na lit y; d iffi cu lty w ith co m pl ia nc e; p re se nc e of o th er d is ea se s; c on tin ui ty o f c ar e w ith sa m e ph ys ic ia n; p re fe re nc e of p la ce o f c ar e; n um be r o f d ru gs ta ke n fo r hy pe rt en si on ; m od e of d ia gn os is o f h yp er te ns io n. Kh al il an d El zu bi er , 19 97 [1 0 ] 5 PH c c en tr es a nd 2 ou tp at ie nt c lin ic s, sa ud i A ra bi a. 34 7 pa tie nt s w ith hy pe rt en si on . Pi ll co un t ( av er ag e of 2 vi si ts 3 w ee ks a pa rt ). N on co m pl ia nt : t oo k < 80 % o f m ed ic at io ns , ba se d on th e av er ag e. c ro ss -s ec tio na l s tu dy . A dh er en ce to m ed ic at io n m ea su re d by : p ill c ou nt ; a nd v er ifi ed b y bl oo d pr es su re m ea su re m en t. 47 % o f p at ie nt s n on co m pl ia nt . Va ria bl es li nk ed to n on co m pl ia nc e: a ge ; s ex (f em al e) ; n at io na lit y (s au di A ra bi an n at io na ls h ad h ig he r n on co m pl ia nc e) ; d ur at io n of d is ea se ; pr es en ce o f c om pl ic at io ns ; f ol lo w -u p in P H c ra th er th an h os pi ta l; si de - ef fe ct s; d ur at io n of tr ea tm en t; nu m be r o f d ru gs ; e du ca tio n ab ou t d is ea se of fe re d by h ea lth c ar e pr ov id er ; i lln es s- as so ci at ed sy m pt om s. ro ae id & K ab la n, 20 0 7 [1 1] D ia be te s c en tr e, Li by an A ra b Ja m ah iri ya . 80 5 pa tie nt s w ith d ia be te s (ty pe 1 an d 2) . N o cl ea r d efi ni tio n or cl as si fic at io n. c ro ss -s ec tio na l s tu dy . A dh er en ce to tr ea tm en t m ea su re d by p at ie nt s’ se lf- re po rt th ro ug h in te rv ie w s a nd q ue st io nn ai re fi lle d by p hy si ci an s. 27 .1% o f p at ie nt s n ot ta ki ng tr ea tm en t r eg ul ar ly . El -s ha zl y et a l. 20 0 0 [1 2] 14 o ut pa tie nt c lin ic s an d di ab et ic c en tr es , Eg yp t. 10 0 0 p at ie nt s w ith d ia be te s (ty pe 1 an d 2) . N o cl ea r d efi ni tio n or cl as si fic at io n. c ro ss -s ec tio na l s tu dy . A dh er en ce to m ed ic at io n m ea su re d us in g qu es tio nn ai re fi lle d by ph ys ic ia ns . 11 .4 % o f p at ie nt s n on co m pl ia nt (1 5. 1% in n on -h ea lth in su re d pa tie nt s a nd 5. 7% in h ea lth in su re d pa tie nt s) . Va ria bl e lin ke d to n on co m pl ia nc e: n ot h av in g he al th in su ra nc e. Kh at ta b et a l. 19 99 [1 3] PH c c en tr e, s au di A ra bi a. 29 4 pa tie nt s w ith d ia be te s (ty pe 1 an d 2) . c om pl ia nc e: g oo d - to ok m ed ic at io ns a s pr es cr ib ed ; f ai r - m is se d 1– 3 do se s/ m on th ; p oo r - m is se d 4 do se s/ m on th c ro ss -s ec tio na l s tu dy A dh er en ce to m ed ic at io n m ea su re d by : s el f-r ep or t q ue st io nn ai re fi lle d by p hy si ci an s ( di ab et ic fo llo w -u p ca rd ); an d pi ll co un t 1.4 % o f p at ie nt s h ad p oo r c om pl ia nc e, 14 % fa ir co m pl ia nc e an d 84 .2 % g oo d co m pl ia nc e. Va ria bl es n ot li nk ed to n on co m pl ia nc e: so ci od em og ra ph ic c ha ra ct er is tic s of p at ie nt s; c ar e ch ar ac te ris tic s; a nd d is ea se c ha ra ct er is tic s. Book 17-4.indb 360 4/27/2011 11:00:53 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 361 Ta bl e 1 St ud ie s of a dh er en ce /n on ad he re nc e to c hr on ic m ed ic at io n in M id dl e Ea st er n co un tr ie s (c on ti nu ed ) St ud y/ se tt in g/ co un tr y Sa m pl e D efi ni ti on o f pa ti en ts ’ a dh er en ce / no na dh er en ce M et ho ds /m ea su re s St ud y fin di ng s an d co nc lu si on s Ka m el e t a l. 19 99 [1 4] D ia be tic c lin ic , E gy pt 30 0 p at ie nt s w ith d ia be te s (ty pe 1 an d 2) Po or c om pl ia nc e: to ok < 50 % . s at is fa ct or y co m pl ia nc e: to ok 50 % –7 5% . V er y go od co m pl ia nc e: to ok > 7 5% o f m ed ic at io ns c ro ss -s ec tio na l s tu dy A dh er en ce to m ed ic at io n m ea su re d by p at ie nt s’ se lf- re po rt u si ng a qu es tio nn ai re 1.7 % o f p at ie nt s h ad p oo r, 20 % sa tis fa ct or y an d 78 .3 % v er y go od co m pl ia nc e Va ria bl es n ot li nk ed to n on co m pl ia nc e: u se o f i ns ul in in je ct io ns , m ed ic at io n na m es a nd m ed ic at io n ty pe s. A l-s af fa r e t a l. 20 0 5 [1 5] O ut pa tie nt c lin ic , Ku w ai t 27 8 pa tie nt s w ith de pr es si on N on co m pl ia nt : t oo k < 80 % o f e xp ec te d pi ll co un t a nd se lf- re po rt ed fa ilu re to ta ke m ed ic at io n as p re sc rib ed Ed uc at io na l i nt er ve nt io na l s tu dy A dh er en ce to m ed ic at io n m ea su re d at 2 m on th s a nd 5 m on th s b y pa tie nt s’ se lf- re po rt a nd ta bl et c ou nt 88 % o f p at ie nt s n on ad he re nt in th e co nt ro l g ro up a t b ot h fo llo w -u ps . Va ria bl es n ot li nk ed to n on co m pl ia nc e: c on ce rn th at th er ap y w ou ld im po se re st ric tio ns o n pa tie nt s’ li fe st yl e or h av e an a dv er se a ffe ct o n th ei r w or k; p at ie nt s’ b el ie f t ha t t he ir ph ys ic ia ns re al ly u nd er st oo d th e na tu re o f th ei r p ro bl em ; a nd si de -e ffe ct s o f m ed ic at io ns . A l-s af fa r e t a l. 20 0 3 [1 6] O ut pa tie nt c lin ic , Ku w ai t 17 6 pa tie nt s w ith de pr es si on G oo d co m pl ia nc e: di ve rg en ce fr om pr es cr ib ed tr ea tm en t t im e. N on co m pl ia nc e: se lf- re po rt ed fa ilu re to ta ke m ed ic at io n as d ire ct ed c ro ss -s ec tio na l s tu dy A dh er en ce to m ed ic at io n m ea su re d by : p at ie nt s’ se lf- re po rt ; a nd pr es cr ip tio n re fil l a dh er en ce 30 % o f p at ie nt s n on co m pl ia nt (v ia p ill c ou nt s) a nd 2 4% (v ia se lf- re po rt ) Va ria bl es li nk ed to n on co m pl ia nc e: u nd er ly in g in te nt io n to ta ke m ed ic at io ns ; l itt le o r n o co nfi de nc e th at sy m pt om s w er e am en ab le to m ed ic al in te rv en tio n; v ie w s a bo ut w he th er d ep re ss io n w as m or e of a ps yc ho lo gi ca l t ha n a m ed ic al p ro bl em ; f em al e se x; b el ie f t ha t d ep re ss io n w as a d is ea se b es t t re at ed b y m ed ic at io n; c on ce rn a bo ut th e ad di ct iv e na tu re o f t he ra py ; a nd u nc er ta in ty w he th er o r n ot p hy si ci an s c an d o an yt hi ng to h el p Va ria bl es n ot li nk ed to n on co m pl ia nc e: p at ie nt s’ c ha ra ct er is tic s a nd si de - ef fe ct s o f m ed ic at io n Fi do a nd H us se in i, 19 98 [1 7] O ut pa tie nt c lin ic , Ku w ai t 12 0 p at ie nt s w ith ps yc hi at ric pr ob le m s N on ad he re nt : f ai lu re to ta ke m ed ic at io n as pr es cr ib ed fo r > 1 w ee k c ro ss -s ec tio na l s tu dy A dh er en ce to m ed ic at io n m ea su re d by p at ie nt s’, c ar et ak er s’ o r r el at iv es ’ se lf- re po rt u si ng q ue st io nn ai re (c he ck lis t) 55 % o f p at ie nt s p re m at ur el y di sc on tin ue d m ed ic at io n Va ria bl es li nk ed to n on -c om pl ia nc e: m al e se x; p re vi ou s m ul tip le h os pi ta l ad m is si on ; d ia gn os is o f s ch iz op hr en ia a nd m an ia ; a ge ; b ei ng si ng le ; a nd ed uc at io na l l ev el A l-J ah da li et a l. 20 0 7 [1 8] O ut pa tie nt c lin ic , sa ud i A ra bi a 33 4 pa tie nt s w ith a st hm a N o cl ea r d efi ni tio n or cl as si fic at io n c ro ss -s ec tio na l s tu dy A dh er en ce to in ha le d co rt ic os te ro id s m ea su re d by pa tie nt s’ se lf- re po rt th ou gh st ru ct ur ed q ue st io nn ai re in te rv ie w s 38 % o f p at ie nt s n on co m pl ia nt Va ria bl es li nk ed to n on co m pl ia nc e: e du ca tio n; n eg at iv e pe rc ep tio n of th e ro le o f i nh al ed c or tic os te ro id s i n m an ag em en t o f b ro nc hi al a st hm a; a nd ne ga tiv e pe rc ep tio n re ga rd in g in ha le d co rt ic os te ro id s s af et y e. g. le ad in g to ad di ct io n Va ria bl es n ot li nk ed to n on co m pl ia nc e: d ur at io n an d se ve rit y of a st hm a Book 17-4.indb 361 4/27/2011 11:00:53 AM EMHJ  •  Vol. 17  No. 4  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 362 Ta bl e 1 St ud ie s of a dh er en ce /n on ad he re nc e to c hr on ic m ed ic at io n in M id dl e Ea st er n co un tr ie s (c on cl ud ed ) St ud y/ se tt in g/ co un tr y Sa m pl e D efi ni ti on o f a dh er en ce / no na dh er en ce M et ho ds /m ea su re s St ud y fin di ng s an d co nc lu si on s Ja bb ar a nd A l- sh am m ar i, 19 93 [1 9] O ut pa tie nt c lin ic , sa ud i A ra bi a. 10 4 pa tie nt s w ith e pi le ps y N on co m pl ia nt : m is se d a to ta l o f 3 d ay ’s do se s/ m on th c ro ss -s ec tio na l s tu dy A dh er en ce to m ed ic at io n m ea su re d by p ill c ou nt 30 .8 % o f p at ie nt s n on co m pl ia nt Va ria bl es li nk ed to n on co m pl ia nc e: e du ca tio na l l ev el ; a nd a dv er se e ffe ct s o f di se as e on p at ie nt s’ a ca de m ic p er fo rm an ce Va ria bl es n ot li nk ed to n on co m pl ia nc e: se x; m ar ita l s ta tu s; a ge ; f am ily h is to ry of d is ea se ; d ur at io n of d is ea se ; t yp e of th e ep ile ps y; le ve l o f c on tr ol ; a nd th er ap eu tic re gi m en G ul ba y et a l. 20 0 6 [2 0 ] O ut pa tie nt c lin ic , tu rk ey 14 0 a du lts w ith c hr on ic ob st ru ct iv e pu lm on ar y di se as e u se d m ed ic at io n “c or re ct ly ”: p at ie nt s w ho ha d co rr ec t k no w le dg e on ≥ 2 o f t he ir br on ch od ila to r d os es & w ho u se d co nv en ie nt in ha la tio n te ch ni qu e u se d m ed ic at io n “r eg ul ar ly ”: p at ie nt s w ho sa id th ey to ok m ed ic at io n ev er y da y. A dh er en t: us ed m ed ic at io n co rr ec tly a nd re gu la rly c ro ss -s ec tio na l s tu dy A dh er en ce to m ed ic at io n m ea su re d by p at ie nt s’ se lf- re po rt u si ng qu es tio nn ai re 10 % –2 0 % o f p at ie nt s d id n ot u se m ed ic at io n co rr ec tly a nd re gu la rly ri sk o f p oo r a dh er en ce b y in cr ea se d 44 .4 fo ld w ith : l ow er e du ca tio na l l ev el ; fe m al e se x; u na w ar en es s o f c hr on ic ity o f d is ea se ; a nd b ei ng u ni nf or m ed forgetfulness  (6  studies)  and drug  side-effects  (5  studies). The reasons reported by patients in the Middle East are similar to those reported in the inter- national literature. However, some common reasons reported by the international literature were not re- ported by these patients, such as patient satisfaction and/or lack of trust in health care providers and lack  of social support. The reason for this could be that patients in the Middle East may be more afraid to complain about their doctors in order to avoid prob- lems that might compromise their treatment. These studies were not designed to explore barriers to medication adherence (intentional/nonintentional)  and beliefs about the perceived value of medication and concerns regarding side-effects. There is a need for a more qualitative approach to explore how factors such as the context of the health care system, access to medication and beliefs affect nonadherence to medication for patients with chronic illness in the Middle East. Limitation of the review The literature search found only 1 article through databases searches and the rest were found by hand searching. Therefore some relevant papers in this field could have been missed. Although most of the journals in the Middle East publish in English language, studies published in other languages may have been missed papers as only English language papers were included in the search. Conclusions This review confirms the existence of nonadherence to medication as a problem among patients with chronic diseases in the Middle East. However, there was great variation in the reported rates of nonadher- ence, probably due to differences in the definitions of adherence/nonadherence used as well  as other  differences in the study methods. Some barriers and predictors of nonadherence among patients in this region were identified. However, these 19 studies did  not enable meaningful conclusions regarding level of adherence to be drawn. The review findings highlight the need to expand this area of research in the region and to improve the quality of such research. There- fore, there is a need for further research on the rate of nonadherence and barriers to patients’ adherence to their medications in order to identify the type of interventions that may be needed for improving adherence. Book 17-4.indb 362 4/27/2011 11:00:53 AM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عبارلا ددعلا 363 References Adherence to long-term therapies: evidence for action1. . Geneva, World Health Organization, 2003. Al-Faris EA et al. compliance with appointments and medi-2. cations in a pediatric neurology clinic at a university Hos- pital in riyadh, saudi Arabia. Saudi Medical Journal, 2002, 23:969–974. bassili A et al. current health care of childhood bronchial 3. asthma in Alexandria, Egypt. Eastern Mediterranean Health Journal, 1998, 4:575–584. Hashmi sK et al. Factors associated with adherence to anti-4. hypertensive treatment in Pakistan. PLoS ONE, 2007, 2:e280. 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A systematic review of adherence with medications 22. for diabetes. Diabetes Care, 2004, 27:1218–1224. Book 17-4.indb 363 4/27/2011 11:00:53 AM 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: khayat@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. 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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 17-8.indd 2 8/8/2011 10:11:18 AM Contents V olum e 17 N um ber 4 A pril 2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 17 / No. 4 April / Avril 2011 4 ددع / شرع عباسلا دلجلما ليربأ / ناسين Letter from the Editor .............................................................................................................................................................. 265 Research articles Evaluation of two doses of triclabendazole in treatment of patients with combined schistosomiasis and fascioliasis ........................................................................................................................................................................ 266 Female spouses of injection drug users in Pakistan: a bridge population of the HIV epidemic? .......................... 271 Low rate of placental pathological examination in a tertiary care hospital in Sana’a, Yemen ................................ 277 Relationship between maternal characteristics and neonatal birth size in Egypt ................................................... 281 Relationship between birth weight and domestic maternal passive smoking exposure ....................................... 290 Knowledge and attitude about antismoking legislation in Morocco according to smoking status ...................... 297 Parental smoking and risk of childhood cancer: hospital-based case–control study in Shiraz ............................. 303 Smoking among Saudi university students: consumption patterns and risk factors ............................................... 309 High prevalence of vitamin D deficiency in the sunny Eastern region of Saudi Arabia: a hospital-based study .................................................................................................................................................... 317 ينطسلف – ةيربلاو للها مار ةظفامح ناكس ىدل جذومنك ةيئيبلا ةحصلا لامج في تاسرمالماو فقاولماو فراعلما مييقت ............................................... 323 Knowledge about standard precautions among university hospital nurses in the United Arab Emirates ............ 331 Validity and reliability of the Persian (Farsi) version of the Job Content Questionnaire: a study among hospital nurses ...................................................................................................................................... 335 Clinical guidelines Clinical management guidelines for pandemic (H1N1) 2009 virus infection in the Eastern Mediterranean Region: technical basis and overview ............................................................................ 342 Reviews Smoking and normative influence among Egyptian youth: a review of the literature ............................................ 349 Adherence to medication among chronic patients in Middle Eastern countries: review of studies ............................................................................................................................................................. 356 Tobacco harvest, Pakistan (photo copyright: WHO) Tobacco is the leading preventable cause of death and disability. However, it affects not only the smoker, but others subjected to 2nd hand smoke, including the unborn child. Low birth weight and low Apgar scores in neonates and SIDS are considered to be directly related to passive exposure of the mother to smoke. Cover 17-4.indd 1 4/19/2011 12:01:39 PM