Eastern Mediterranean Health Journal [2008; Vol.14, Issue 3]

8002 3 .oN 41 .loV iaM/yaM 3 .oN 41 .loV niuJ/enuJ 8002 حزيران/يونيوالمجلد الرابع عشر، العدد ٣، أيار/مايو

502 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما National health research system mapping in 10 Eastern Mediterranean countries A. Kennedy,1 T.A.M. Khoja,2 A.H. Abou-Zeid,3 H. Ghannem4 and C. IJsselmuiden1 on behalf of the WHO-EMRO/COHRED/GCC NHRS Collaborative Group 1Council on Health Research for Development (COHRED), Geneva, Switzerland (Correspondence to A. Kennedy: Kennedy@cohred.org). 2Health Ministers’ Council for Cooperation Council States, Riyadh, Saudi Arabia. 3Research Policy and Cooperation Unit, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 4Department of Epidemiology, University Hospital Farhat Hached, Sousse, Tunisia. Received: 25/04/07; accepted: 07/08/07 ABSRACT Health research systems in the Eastern Mediterranean Region are not well developed to generate and use knowledge to improve health, reduce inequity and contribute to economic develop- ment. This study aimed to provide core data on National Health Research Systems (NHRS) in 10 Eastern Mediterranean countries in order to inform actions to strengthen health research system gov- ernance and management. Whilst there were examples of good practice, few countries had a formal NHRS and many basic building blocks needed for an effective system had not been put in place. Al- though limited in focus, the study provides useful information for countries to initiate action to strengthen their NHRS. ¢›ÍÉVr¶=PÇVF·¶{Ƕ=½>Ÿ¿¶=>ìJ]=œiÇJ™=±fm¼É·®C›Á=b·EÌfn (ÍQÇ]b—?°ÉªÇI(ËbɿɲÆeb¾?bÈgÇE?ÐØ¢( >¦ÀjU(ÀÈaÇÉ»·Éi¹e>²  „=Í[qØ6Í[¯·£J™=­e>£™=T>J¾ÝÊ«³IeÇìJ¶=ÀºÍQea‘CœiÇJ™=±fm¼É·®C›ÍÉVr¶=PÇVF¶=¼Ÿ¾f¯J«I ×=Í[É»¿J¶=›Í»Â>j™=Æ­>VQÝ=sÉ·¯IÆÍVr¶=jVJEÍÈa>r[J®*L>[É죙=ªÇ[IÍ[i=eb¶=Åd[­bÃJj[IÆ Ìb¿Jj[™=Íìn[¾Ù=Ð>[¿F¶ð>[É]ÇI(œ[iÇJ™=±f[m¼É·®C›Á=b·EÌfn¢›ÍÉVr¶=PÇVF·¶ÍÉ¿{Ƕ=¼Ÿ¿·¶ÍÉi>iÙ= ÍÉVr¶=PÇVF¶=ͺ>³UÆÌe=aChÈh£IÆL>ºÇ·£™=η¢*ÁD[ª(Ìb[ɂ=L>[ie>»™=η¢Í·Nº?fª=ÇIÀº¼¦f¶=η¢Æ b·EÍ£vE¹>[磪½>[Ÿ¾Ð>¿F¶ÍÉi>iÙ=b¢=ǯ¶=ÀºN³¶=‘CÆÍÉVr¶=PÇVF·¶ÍÉeÍÉ¿{ƼŸ¾‘Cf¯J«IÁ=*¤[ºÆ Í[É¿{Ƕ=¼Ÿ¿¶=hÈh£Iη¢¸»£¶=›?bFIʳ¶Á=b·F·¶ͺ>ÂL>ºÇ·£º½b¯I>þ?×C(±>쿶=ÌaÆb†Íi=eb¶=ÅdÂÁ? >ÃɪÍÉVr¶=PÇVF·¶*  Cartographie des systèmes nationaux de recherche en santé dans dix pays de la Méditerranée orientale RÉSUMÉ Les systèmes de recherche en santé dans la Région de la Méditerranée orientale ne sont pas suffisamment développés pour produire et utiliser les connaissances nécessaires à l’amélioration de la santé, à la réduction des inégalités et au développement économique. Cette étude visait à fournir des données essentielles sur les systèmes nationaux de recherche en santé dans dix pays de la Méditerranée orientale, afin de guider des actions destinées à renforcer la gouvernance et la gestion des systèmes de recherche en santé. Il existait certes des exemples de bonnes pratiques, mais peu de pays étaient dotés d’un système national de recherche en santé officiel et la plupart des composantes élémentaires nécessaires à des systèmes efficaces n'avaient pas été mises en place. Bien que limitée dans sa portée, cette étude apporte aux pays des informations utiles pour engager une action visant à renforcer leur système national de recherche en santé. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 503 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction “Research and Development” (R&D) is an acknowledged catalyst for socioeconomic development and demands have increased for investment in R&D on the one hand and for evidence to measure the return on these investments on the other. Tradition- ally, monitoring and evaluating research and innovation systems has been done using macro level indicators of inputs (usually financial and human) and outputs (research papers and patents) [1]. This approach has severe limitations in measuring the returns from “research for health”, as it neglects the most important outcomes of: improved health, more efficient health systems and reduced health inequities. The concept of National Health Re- search Systems (NHRS) emerged from the International Conference on Health Re- search for Development held in Bangkok in 2000 [2,3]. In attempting to understand the relation between health and health research, it was recognized that health research sys- tems involve not only the health sector but also other key sectors such as science and technology, education, and development, and sometimes international or private sec- tor organizations. Thus, decision-makers within a NHRS often have little direct au- thority over the entire range of institutions and individuals that need to act if change is to result in health system improvements, health gains and reduced health inequity. Improvements to NHRS depend therefore to a large extent on transparent, inclusive and evidence-based decision-making. This is especially relevant to countries in the Eastern Mediterranean Region, where in spite of significant human capacity in the research sector, there are low levels of research production and application [4,5]. In 2002 and 2003, the World Health Or- ganization Regional Office for the Eastern Mediterranean (WHO-EMRO) sponsored 5 country-based studies to describe the health research situation in the Region [6]. This was the first study of its kind in the Region and it provided much useful information on the health research systems of the countries involved. However, as each country team developed its own approach to the assess- ment, there was a limited potential for com- parative analysis and for the development of a common model for system strengthening. The Islamic Republic of Iran and Pakistan from the Eastern Mediterranean Region participated in a global health research system analysis study, started in 2002 [3], but which has yet to report its findings. The current collaboration was formed to strengthen the capacities of health research systems in the Region to address national health research needs, specifically health sector changes that would improve health and reduce health inequities. WHO-EMRO and the Council on Health Research for Development (COHRED) decided in 2005 to conduct a study with several countries in the Region that had not been included in the earlier work. Subsequently, the Executive Board of the Health Ministers’ Council of the Gulf Cooperation Council (GCC) States asked to be included in this effort as a way to support development of national health research in their member countries. A key demand from all parties involved was rapid and actionable results. The aim of the study was to collect key information needed for NHRS strengthen- ing, which would allow each country to initiate action at the policy and governance level at relatively short notice. This paper provides a summary of the information col- lected, and constitutes a first step towards NHRS strengthening. Further information from the study is available on the COHRED Health Research Web (www.cohred.org/ 504 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما HealthResearchWeb) and, for the 7 GCC States, in Khoja and Hussein 2006 [7]. Methods The collaboration started with a planning meeting in Riyadh, Saudi Arabia, in Novem- ber 2005 which included 10 Eastern Medi- terranean Region or GCC countries that had expressed a strong interest in strengthening their national systems of health research (Table 1). The project leaders from each country met again in Muscat, Oman, in May 2006. The aim was to involve each project leader in defining the scope of the study, in outlin- ing the problems facing the NHRS in their countries, and in deciding on the study approach needed to address these problems, and in jointly designing the mapping ques- tionnaire to be used. COHRED employs a “process” model for NHRS strengthening. It is designed not as a “one-off, data collection event”, but rather as an action-oriented, ongoing proc- ess of system development. In this approach, compiling and analysing the evidence are complementary “process” activities and need to be iterative with actual interventions made in support of NHRS development. The COHRED model can therefore be phased, depending on resources available, on the level of sophistication of the existing systems, and on actions taken following analysis. NHRS analysis is conducted at 4 levels: 1. Mapping: of the people, structures, in- stitutions and policies that make up the NHRS; 2. Profiling: of the human, institutional, financial, production and utilization ca- pacities of the system; 3. Performance assessment: of the NHRS and its impact on health sector decision- making, health and health equity; 4. Evaluation: of interventions, which is a long-term commitment to a cycle of evidence-based management of the NHRS based on routine and ad hoc monitoring and evaluation. During the Oman workshop, the na- tional project leaders decided on a phased approach, i.e. a NHRS mapping study as the first phase to decide on priorities for strengthening the health research system. A shortened version of the COHRED NHRS mapping form was prepared (available from: www.cohred.org/NHRSsupport/em2006). The form elicits mostly qualitative informa- tion, and consists of a series of questions to guide a standardized description of a NHRS in 4 key areas: 1. Governance and management of the NHRS 2. Institutions engaged in research for health 3. Key stakeholders involved in research for health 4. Available literature and data review. The form was to be completed by the project leader from each country, based on information gained from document review and interviews with senior staff engaged in health research in the countries. Due to the considerable variation in NHRS set-ups, in- formation was collected in an open question format and the responses were then coded for analysis. Data collection took place dur- ing July and August 2006. In coding the responses, 2 principles were observed. First, the main focus of the study was on structures, policies or statements dealing with the overall national research and health research system rather than on specific parts of the system, e.g. sections of the Ministry of Health or re- search in specific institutions. Second, the questions were intended to gauge the formal system and not to deal comprehensively Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 505 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ta bl e 1 C o u n tr y ch ar ac te ri st ic s (2 00 4) a C h ar ac te ri st ic B ah ra in Jo rd an K u w ai t L eb an o n O m an Q at ar S au d i Tu n is ia U n it ed A ra b Y em en A ra b ia E m ir at es H um an d ev el op m en tb H D I 0. 85 9 0. 76 0 0. 87 1 0. 77 4 0. 81 0. 84 4 0. 77 7 0. 76 0 0. 83 9 0. 49 2 H D I r an k 39 86 33 78 56 46 76 87 49 15 0 N at io na l c om m itm en t t o he al th a nd ed uc at io nb P ub lic h ea lth e xp en di tu re s (% G D P ) 2. 8 4. 2 2. 7 3. 0 2. 7 2. 0 3. 0 2. 5 2. 5 2. 2 P ub lic e du ca tio n ex pe nd itu re s 20 02 –0 4 (% G D P ) – – 8. 2 2. 6 4. 6 – – 8. 1 1. 6 – Te ch no lo gy a nd k no w le dg e cr ea tio nb P at en ts g ra nt ed to r es id en ts ( pe r m ill io n pe op le ) – – – – – – – – – – R ec ei pt s of r oy al tie s an d lic en ce fe es (U S $ pe r pe rs on ) – – < 0 .0 – – – < 0 .0 1. 8 – – R & D e xp en di tu re 2 00 0– 03 ( % G D P ) – – 0. 2 – – – – 0. 6 – – R es ea rc he rs in R & D 1 99 0– 20 03 ( pe r m ill io n pe op le ) – 1 92 7 69 – – – – 1 01 3 – – A ca de m ic r es ea rc h ou tp ut R es ea rc h pu bl ic at io ns in de xe d by IS I ( N o. ) 85 56 8 48 9 41 2 26 1 10 9 13 51 89 8 49 8 43 H ea lth r es ea rc h pu bl ic at io ns in de xe d by IS I [ N o. ( % o f a ll re se ar ch pu bl ic at io ns )] 43 ( 51 ) 18 1 (3 2) 24 5 (5 0) 22 9 (5 6) 93 ( 36 ) 47 ( 43 ) 63 1 (4 7) 29 8 (3 3) 18 7 (3 8) 20 ( 47 ) a D at a re fe r to 2 00 4 un le ss o th er w is e st at ed b A da pt ed fr om th e U N D P H um an D ev el op m en t R ep or t 2 00 6 [8 ]. – da ta n ot a va ila bl e. H D I = h um an d ev el op m en t i nd ex ; G D P = g ro ss d om es tic p ro du ct ; R & D = r es ea rc h an d de ve lo pm en t; IS I = In te rn at io na l S ci en ce In st itu te . 506 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما with ad hoc or occasional examples of good practice. The following definitions and distinc- tions were used to guide coding: • “NHRS governance” is concerned with the relationships, systems, processes and rules for making decisions within the system. It also provides the struc- ture through which the objectives of the system are set, and performance and achievement of these objectives are monitored. “Research management” was defined for the purposes of this study as being concerned with the planning and execution of the activities required to achieve the objectives of the system in an effective and efficient manner. • As there is a wide range of ways in which countries create policies to deal with research, any formal plan or strat- egy providing direction for the health research system of the country was accepted. Such plans could be part of broader policy documents, for example focused on health, research, science and technology or national development. In such cases, these documents were classi- fied as “health research policies” if they had significant health research content, as opposed to the simple identification of health research as a strategy with no further elaboration. • “Values” were defined as guiding prin- ciples for the system. Stipulations to adhere to ethical or other principles, but without an explicit statement of under- lying values, were not considered as a valid value statement. • “Aims” were identified from statements of aims, goals or objectives, or from a vision or mission statement for the sys- tem. The responses for all countries were coded by COHRED to provide consistency (AK), the results were then circulated to the national project leaders for verification and clarification on areas of uncertainty. To classify participating countries in terms of socioeconomic development, the United Nations Development Programme (UNDP) Human Development Report clas- sification was used [8] (Table 1). An impression of national academic research output and of the proportion re- lated to health research was obtained by extracting data on published articles and reviews from the Science Citation Index, Social Science Citation Index and the Arts and Humanities Citation Index, published by the International Science Institute (ISI) for each country. The ISI classifies each indexed journal according to subject matter and those fully focused on health were iden- tified using the classification developed by Paraje and colleagues [9,10]. An inherent limitation of this approach is that journals indexed by the ISI form only a subset of all academic research journals and that journal publications constitute just one of many outputs of NHRS [11]. Results Country characteristics The 10 countries in this study fall within the high [Bahrain, Kuwait, Oman, Qatar and the United Arab Emirates (UAE)] and middle (Jordan, Lebanon, Saudi Arabia and Tunisia) categories of the human develop- ment index (HDI); only Yemen has a low HDI score (Table 1). Figure 1 shows the scores for the HDI sub-components. Life expectancy is broadly comparable across the countries, except in Yemen. The differences are greater for edu- cation and gross domestic product (GDP). Public sector commitments to health mostly fall in the range of 2.5% to 3.0% of GDP, Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 507 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما with only Qatar and Yemen falling below this level and Jordan considerably exceed- ing it with a commitment of 4.2% (Table 1). There is greater variation in commitment to education, which ranges from 1.6% to 8.2% of GDP. There has been a considerable increase in public sector commitment to education since 1991 in 3 countries: Kuwait (4.8% to 8.2% of GDP), Oman (3.4% to 4.6% of GDP) and Tunisia (6.0% to 8.1% of GDP). Data are lacking on education commitment for half the countries and on commitment to technology and knowledge creation for even more. In all fields of research, Saudi Arabia and Tunisia produced the most academic research papers of the 10 countries in 2004. If only health-related research publications are considered, then Kuwait and Lebanon join Saudi Arabia and Tunisia as the major producers (Table 1). NHRS governance Four countries (Jordan, Lebanon, Oman, and Tunisia) described formal governance structures for their NHRS (Table 2). In 3, (Lebanon, Oman and Tunisia), governance is located within a general research coun- cil, covering all fields of research, not just health. In Lebanon, the Board of Adminis- trators of the National Council for Scientific Research, appointed by the Council of Min- isters, carries out the governance function for the whole research system. In Tunisia this function is carried out by the Superior Council for Research, which is chaired by the Prime Minister and has representatives of all ministries involved in research as Figure 1 Human development index sub-components for 10 Eastern Mediterranean countries, 2004 (adapted from the UNDP Human Development Report 2006 [8]) 508 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما members. Jordan reported multiple formal governance structures based within differ- ent government ministries depending on the type of research or where it was conducted. In Bahrain, the Health Research Com- mittee, and in Saudi Arabia, the Ministry of Health structures, act as proxies for national structures of health research governance. Kuwait reported structures at the institu- tional level only and the UAE described an ad hoc role played by government health “departments”. Qatar is reported to be in the process of establishing a formal governance structure for its NHRS. NHRS management Lebanon (General Secretariat of the Na- tional Council for Scientific Research) and Oman (Scientific Research Council) have NHRS management structures within their general research councils. Jordan and Tu- nisia have multiple structures that conduct NHRS management functions within dif- ferent ministries based upon the type of research carried out and the institution con- ducting the project. For Jordan, the institu- tions involved include their Higher Council for Science and Technology. In Bahrain technical sub-committees of the Ministry of Health’s Health Re- search Committee act as proxy for a na- tional research management structure. In Kuwait, as with the NHRS governance, the management structures are at the level of institutions. Qatar is working to establish a formal NHRS management mechanism. Saudi Arabia has multiple structures within its Ministry of Health and the King Abdel Aziz City for Science & Technology, but these do not constitute a formal “mecha- nism” covering the NHRS as a whole. In Yemen, the Department of Research and Information, within the Ministry of Public Health and Population, fulfils some of the functions related to the day-to-day manage- ment of the NHRS. Ministry of Health research “office” All 10 countries reported that there was some mechanism through which the Min- istry of Health coordinated its role in health research. For 7 countries this mechanism Table 2 Aspects of national health research system (NHRS) governance and management Component No. Countries Formal NHRS governance structure (e.g. health research committee) 4 Jordan, Lebanon, Oman, Tunisia Formal NHRS management structure (e.g. research council) 4 Jordan, Lebanon, Oman, Tunisia National health research policy/plan/strategy 2 Oman, Tunisia National health priorities 6 Bahrain, Oman, Qatar, Saudi Arabia, Tunisia, Yemen National health research priorities 3 Lebanon, Oman, Yemen Statement of values for the NHRS 2 Oman, Tunisia Statement of aims for the NHRS 5 Jordan, Lebanon, Oman, Tunisia, Yemen Monitoring and evaluation system for the NHRS 1 Oman Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 509 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما took the form of a directorate or depart- ment of research. Jordan and Lebanon have assigned this responsibility to their gen- eral research councils but with ministry of health representation on the research coun- cils’ health sub-committee. The Ministry of Health in Bahrain is in the process of estab- lishing a position/unit to fulfil this role. National health research policy Two countries in the Region have a dedi- cated national health research policy (Table 2). Oman has a research plan formally inte- grated within its 5 year national health plan. In Tunisia, the focus of the health research plan is not to direct the type of research conducted, but rather to develop its health research capacity and research systems as an integral part of a broad plan of economic and social development for the country. In Lebanon and Qatar, the issue of a pol- icy for health research has been identified as a priority but it has yet to be realised. In Lebanon, the development of the Science, Technology and Innovation Strategy has been postponed due to the current political situation. In Qatar, the development of the plan will be the responsibility of the health research governance and manage- ment structure being developed. For Bahrain and Saudi Arabia, health research is included as a strategy within national health plans, but there is no for- mal health research policy. Similarly, for Yemen there is health research content in the National Health Plan, the Health Sector Reform Strategy and the National Research Plan but this does not constitute a framework for a national health research policy. In Jordan, health research is ad- dressed in the National Development Plan, the National Science and Technology Plan and the National Health Plan, but the health research coverage in these documents is unclear. In Kuwait, research strategies have been developed at the institutional level only and in the UAE institutions are given the re- sponsibility of deciding their own research directions. National health priorities Six countries have national health priorities (Table 2). Table 3 gives the priorities for 5 of the 6 countries that had set health priorities. The health priorities for Bahrain have been adopted by the Ministry of Health and in- cluded in the Ministry’s budget for 2007–08, but had not been made publicly available by the time the study was completed. In developing its priorities, Oman conducted a number of participatory workshops as part of its Health Development Plan. In Lebanon, the Ministry of Health started a process of setting national health priorities but this was postponed because of the recent conflict in the country. In the UAE, health priorities are dealt with at the department level within the Ministry of Health. National health research priorities Only 3 countries (Lebanon, Oman and Yemen) have set national health research priorities (Table 4). In Lebanon, 8 of the 16 priority research themes set by the Na- tional Research Council focused on health- related topics. These priorities were set by the health sub-committee of the Na- tional Council for Scientific Research even though the country does not have formally adopted national health priorities. This con- trasts with Yemen where research priorities were developed to closely match national health priorities. In Oman, national health research priori- ties were first established for the fifth and sixth 5-year national health plan 1996–2000 510 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ta bl e 3 N at io n al h ea lt h p ri o ri ti es fo r 5 co u n tr ie s O m an Q at ar S au d i A ra b ia Tu n is ia Ye m en V is io n 1: D el iv er y (p ro vi di ng ) P re m at ur e de at h an d A ct ua l a ct iv at io n of m ed ic al R ei nf or ce m en t o f F ig ht a ga in st c om m on of th e be st h ea lth ca ta st ro ph ic in ju ry fr om se rv ic es p ro vi si on b y al l re pr od uc tiv e he al th an d en de m ic d is ea se s ca re to th e co m m un ity ro ad tr au m a, w or kp la ce ho sp ita ls a nd fa ci lit ie s at re su lts , f am ily h ea lth ac ci de nt s, a nd in fa nt a nd K in g Fa ha d M ed ic al C ity an d th e de m og ra ph ic ea rly c hi ld ho od m or ta lit y po lic y V is io n 2: Q ua lit y as su ra nc e E ar ly o ns et o f p re ve nt ab le C om pl et io n of te rt ia ry P re se rv at io n of s an ita ry C om ba tin g m al nu tr iti on of h ea lth s er vi ce s an d lo ng -t er m c on di tio ns , re fe rr al h os pi ta l p ro gr am m e se cu rit y ca pa ci ty a nd pa tie nt s af et y pa rt ic ul ar ly th os e w he re re in fo rc em en t o f t he ge ne tic fa ct or s m ay m ak e su rv ei lla nc e sy st em a nd th e lo ca l p op ul at io n m or e di se as e co nt ro l vu ln er ab le , e .g . d ia be te s an d ce rt ai n fo rm s of c an ce r V is io n 3: M in im iz in g th e Li fe st yl e di se as es th at E ra di ca tio n of m al ar ia C on tr ol o f n on co m m un ic ab le R ed uc tio n in h ig h ris ks th re at en in g ris k fa ct or s re du ce li fe e xp ec ta nc y an d di se as es th re at en in g m ot he r an d to p ub lic h ea lth qu al ity o f l ife , s uc h as ch ild h ea lth ob es ity a nd c ar di ov as cu la r di se as e, r es pi ra to ry d is ea se re la te d to s m ok in g, a nd st re ss -r el at ed m en ta l i lln es s V is io n 4: P ro m ot in g w om an C om pl et io n of r eb ui ld in g Im pr ov em en t o f t he h ea lth o f S tr en gt he ni ng c ur at iv e an d ch ild h ea lth an d re ne w al o f 4 50 P C C s hi gh -r is k gr ou ps a nd p eo pl e an d su pp or t s er vi ce s ou t o f t he 2 00 0 in cl ud ed w ith p ar tic ul ar p ro bl em s in T he K in g Fa ha d N ew 20 00 P C C s In iti at iv e V is io n 5: P ro pa ga tio n of Im pl em en ta tio n of h ea lth D ev el op m en t o f c ap ac iti es E nv iro nm en ta l h ea lth he al th y lif es ty le in th e in su ra nc e to a ss ur e sa fe ty o f m ed ic in es , co m m un ity va cc in es a nd n ee ds o f bl oo d tr an sf us io n Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 511 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ta bl e 3 N at io n al h ea lt h p ri o ri ti es fo r 5 co u n tr ie s (c on cl ud ed ) O m an Q at ar S au d i A ra b ia Tu n is ia Ye m en V is io n 6: B et te r qu al ity o f N at io nw id e im pl em en ta tio n H um an r es ou rc es nu tr iti on fo r al l of in fo rm at io n te ch no lo gy pr om ot io n in M oH h ea lth s er vi ce s as pa rt o f t he N at io na l E le ct ro ni c G ov er nm en t P ro je ct . V is io n 7: J oi nt a ct io n fo r C on tr ol o f t he h ea lth be tte r co m m un ity h ea lth bu dg et g ro w th a nd th e de ve lo pm en t o f t he h ea lth sy st em V is io n 8: D is cr im in at io n in th e ac ce ss to a dm in is tr at iv e pr ac tic es V is io n 9: A h ea lth in fo rm at io n an d re se ar ch s ys te m to m ee t th e ne ed s of th e he al th s ys te m V is io n 10 : S uf fic ie nt a nd q ua lif ie d hu m an r es ou rc es w or ki ng in th e he al th in st itu tio ns P C C s = p rim ar y he al th c ar e ce nt re s. M oH = M in is tr y of H ea lth . 512 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما and 2001–05. A scoring system method developed in collaboration with WHO was used to prioritize the research topics. Crite- ria scored included: relevance, avoidance of duplication, feasibility, political accept- ance, application of results, urgency of data needed and ethical acceptability. In the seventh health development plan 2006–10, research priorities were directed towards the identified health priorities. In Qatar, the NHRS governance and management structures being established will have the responsibility of setting na- Table 4 National health research priorities for 3 countries Lebanon Oman Yemen • Research and development towards • Malnutrition • Communicable and the exploitation of new agricultural • Anaemia in pregnant endemic disease opportunities with clear economic women • Maternal and child benefits, including animal stocks, • Cardiovascular diseases health health and nutrition and lifestyle risk factors • Health systems • Research in biotechnologies: quality • AIDS • Health-enhanced and specifications of Lebanese • Cancer behaviour and ethnic diet and of locally produced • Road traffic accidents environments food • Diabetes • Noncommunicable • Research on nutritional systems and • Blindness diseases their impact on public health • Viral hepatitis in Lebanon • Tuberculosis • Research in basic and experimental • Hospital management sciences with promising societal • Primary health care benefits and applications • Environmental health • Research in molecular and cellular • Health systems research biology and related genomic applications • Research on chronic diseases prevalent in Lebanon and the region, and development of suitable treatments • Research on new genetic diseases and epidemics in Lebanon and the region • Research on the forecasting of natural disasters in Lebanon and the region, and mitigation approaches of economic, social and environmental impacts tional health research priorities. Saudi Ara- bia has no national health research priorities but priorities have been set for the King Abdel Aziz City for Science & Technology. Tunisia leaves decisions on health research priorities to individual institutions. Stated values for the NHRS Only Oman and Tunisia have formal value statements to guide their NHRS (Table 5). Saudi Arabia has a proposed value state- ment for the system, but this has yet to be adopted. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 513 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما In Bahrain, the Ministry of Health has committed to ensure that research adheres to good ethical practices and is relevant to policy, service and equity. These values cover the Ministry of Health and external bodies if they use the Ministry’s facilities, funds, patients or records. A number of other countries (Jordan, Kuwait, Lebanon and Saudi Arabia) commit researchers to adhere to ethical principles, but have no wider statement of underlying values for the system. In Qatar, a values statement will be incorporated into the principles of the NHRS structure they will establish. Stated aims of the NHRS Five countries (Table 2) have stated the major aims for their research systems. In Jordan, the aims are expressed in the gen- eral vision for science and technology, “Our vision is the achievement of internationally reputable capacity in frontier sciences and technologies, and maximum benefit of their applications for the sustainable socioeco- nomic development of Jordan”. Similarly, in Lebanon aims have been stated for the National Council for Scientific Research but not separately for the sub-committee that focuses on health. Oman states the aims of its NHRS as to: i) conduct studies and research necessary to provide data and information that are required by the health system; ii) develop the technical capabilities and skills of the health research team on research design and methodology and also develop and improve the capacity of research users at different levels to utilize the information as a tool for evidence-based planning; iii) develop the infrastructure of the health research system and ensure the quality of research. For Tunisia the health research aims are the promotion of health, the resolution of health problems and the development of the health system to better face present and future health problems. Bahrain and Saudi Arabia still have to adopt the aims proposed for their NHRS. In Bahrain, the following objectives have been proposed for the Ministry of Health: i) to improve the quality of health information; ii) to increase the number of policies and decisions that are based on the best avail- able evidence. In Saudi Arabia, the proposed aims include the promotion of individual and community health. The NHRS should adopt an evidence-based research policy as a base for the generation of health regulations and policies intended to achieve improvement and further promotion of health services quality. A further aim is to implement the best quality measures in research execution and dissemination of these concepts. Monitoring and evaluation of NHRS Only Oman has established a system of monitoring and evaluation for its NHRS. This is related to the implementation of research within the 5-year Health Develop- ment Plan. The specific research objectives are assigned measurable indicators and progress is reported on an annual basis. In Tunisia, institutions are required to submit annual reports of their activities, but no further analysis of the documentation that would constitute a monitoring and eval- uation system is reported. Jordan describes an institutional system of monitoring and evaluation, but there is no activity to collate this information and examine the system at the national level. Research utilization None of the countries reported system- atic efforts to feed research results into decision-making within the health sector. Oman did cite some interesting examples 514 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما of dissemination and utilization activities, including: conferences and workshops for dissemination and utilization of research output; workshops for training on utiliza- tion of research findings; and dissemination of results or recommendations through the Public Relations Department of the Min- istry of Health to journalists and television and radio programmes. Oman also highlighted how an effective research priority-setting process significant- ly aided research utilization – because most of the research priorities were identified by the research users. In Bahrain, clinical practice guidelines developed in conjunc- tion with the Bahrain branch of the United Kingdom Cochrane Centre have been used to increase the use of evidence in Ministry of Health decision-making. Jordan, Kuwait and Lebanon reported ad hoc dissemination activities of a less comprehensive nature. Other data The data collected on institutions and rel- evant literature did produce some useful information; for example, a bibliometric Table 5 National health research system values Oman Tunisia Saudi Arabia (proposed) • Quality of the research conducted • Ethics • Adoption of agreed research • Directed to meet the planning needs • Excellence ethics and professional health (for the priority problems of the • Equity and fairness values community and health programmes, • Consideration of special • Strict following of the strategic vulnerable groups and health gender needs and social • targets adopted by the systems problems) values of the Saudi society National Centre for • Encouragement of community • Adoption of decentralization Research participation and nongovernmental measures when conducting • Equity and justice organization involvement health researches • Continuous development and adoption of quality control measures • Best control and use of available resources, with consideration of efficacy and efficiency in the process of health research financing • Adoption of multidisciplinary and multisector team approach • Strict following of measures for transparency and open communication • Adopti n f agreed research ethics and professional health values • Strict following of the strategic • targets adopted by the National Cen re for H alth Research • Equity and justice • Consideration of special gender needs and social values of the Saudi society • Adoption of decentralization measures when conducting health researches • Continuous development and adoption of quality control measures • Best control and use of available resources, with consideration of efficacy and efficiency in the process of health research financing • Adoption of multidisciplinary and multisector team approach • Strict following of measures for transparency and open communication Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 515 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما analysis of health research in Tunisia by Ben Abdelaziz and colleagues [12]. Howev- er as there was considerable variation in the methods used by country teams to identify institutions, literature and other informa- tion, this is not reported in our paper. Discussion This mapping of governance and manage- ment mechanisms of national health re- search has provided information that can be used by all countries involved to improve on key aspects of their NHRS. This study has identified that few countries have a formal NHRS, and that there is considerable frag- mentation and limited coordination between the parts of the system that need to collabo- rate if health-related research is to be pro- duced and used. The basic building blocks required for a responsive and needs-driven health research system are missing in many places. At the same time, there is growing interest in developing and strengthening na- tional health research. With few exceptions, the most effective means to stimulate health research and the systems to manage this is through the following actions. These repre- sent core features of good research systems that can be applied in almost all countries in this study. 1. Set national health research priorities through a credible and regularly updated process; 2. Develop a national health research pol- icy, on its own or as part of the policy frameworks for science, technology and innovation; 3. Establish governance and management structures that will facilitate implemen- tation of policies and actions. With these in place, further strengthen- ing of health research can be achieved by: • Defining the underlying values and aims of the NHRS; • Establishing an effective monitoring and evaluation system to increase account- ability, relevance to research priorities and quality of research; • Developing systems to include research knowledge in decision-making proc- esses at all levels of the health sector. The issue of ingraining science in society and effectively using research knowledge and capacity for development has been identified as a significant problem in the Eastern Mediterranean region [4,5]. The gaps in routine data observed in this study support this claim, as does the finding that 4 of the countries have not yet identified their national health priorities. A functioning health research system with strong leader- ship at the governance and management levels can help to ensure that demand for research in the health sector and produc- tion and utilization of such research can be realised. A number of the countries that took part in this study have recognised the limita- tions of their current systems and are in the process of establishing formal mechanisms to better coordinate their systems of health research. Both Tunisia and the Gulf States have decided to engage in national health research priority setting in 2007, while WHO-EMRO plans to start this process in other countries. The study also identi- fied interesting examples of good practice, notably in Oman and Tunisia, that can serve as models for others. In addition to the immediate actions that countries can now take to improve govern- ance and management, there is considerable scope for all the countries to extend their NHRS assessment and focus on capacity and performance assessments and the extent 516 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما to which the NHRS delivers research that can be used to improve health and health systems. The countries with established govern- ance and management structures for their NHRS had built these within the general research councils. Further research on these systems will be useful to assess whether these structures fulfil the needs of the health sector, or whether such systems favour research on priority areas for science and technology and economic development at the expense of research to inform health- related decision-making. In spite of the limitations of data collec- tion caused by the need to obtain rapid and actionable results, the methods employed in our study provide valuable evidence to allow country teams to assess the prior- ity areas for further development of the governance and management of their health research systems. However, it is clear that once the large governance and management issues have been dealt with, further detailed mapping, profiling and performance as- sessment will be required to provide more specific information, including on how the NHRS can identify and address the issue of health equity. The political and professional com- mitment to systematically analyse health research systems is a core requirement of NHRS building. Countries in the Region that have not yet examined their NHRS are encouraged to do so. The study shows that a phased action-oriented approach can enable decision-makers to quickly move to system improvement initiatives. Acknowledgements The Collaborative Group would like to thank all the policy-makers, researchers and other stakeholders who provided the information collected as part of this initia- tive. In particular, we would like to thank Dr Mohammed Abdur Rab, the immediate past head of the Research Policy and Coopera- tion Unit of WHO-EMRO, who initiated the discussions that led to this project. Additional members of the WHO- EMRO/COHRED/GCC NHRS Collaborative Group Dr Mohamed S. Hussein, Health Ministers’ Council for Cooperation Council States, Kingdom of Saudi Arabia; Dr Jamal Al- Sayyad, Ministry of Health, Bahrain; Dr Mai Saob, Ministry of Health, Jordan; Dr Abdullah M. Al-Bedah, Ministry of Health, Kingdom of Saudi Arabia; Dr Ab- dulaziz Khalaf Abdullah Karam, Ministry of Health, Kuwait; Dr Salim Adib, Faculty of Medicine St Joseph University (USJ) Lebanon; Dr Asya Al-Reyami, Ministry of Health, Oman; Dr Naser Ali Asad Al-An- sari, Hamad Medical Corporation, Qatar; Dr Noureddine Bouzouaia, Ministry of Health, Tunisia; Dr Abdullah Al-Naimi, Ministry of Health, United Arab Emirates; Dr Tarek Salah Asaad, Ministry of Health and Population, Yemen. References 1. King D. The scientific impact of nations. Nature, 2004, 430:311–6. 2. Report of the International Conference on Health Research for Development, Bang- kok, 10–13 October 2000. Geneva, Inter- national Organizing Committee, 2001. 3. Pang T et al. Knowledge for better health: a conceptual framework and foundation for health research systems. Bulletin of the World Health Organization, 2003, 81(11):815–20. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 517 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 4. Maziak W. Health in the Middle East. Brit- ish medical journal, 2006, 333(7573):815– 6. 5. United Nations Development Programme Regional Bureau for Arab States. The Arab human development report 2004. New York, United Nations Development Programme, 2005. 6. A study of national health research sys- tems in selected countries of the WHO Eastern Mediterranean Region. Cairo, World Health Organization Regional Of- fice for the Eastern Mediterranean, 2004. 7. Khoja T, Hussein M. Glimpse on health re- search in the Cooperation Council States. Riyadh, Executive Board of the Health Ministers’ Council for the Gulf Coopera- tion Council, 2006. 8. Human development report 2006: beyond scarcity: power, poverty and the global water crisis. New York, United Nations Development Programme, 2006. 9. Paraje G. Production of scientific articles in the Region of the Americas 1992–2001. In: 39th Advisory Committee on Health Research (ACHR). Santiago, Pan Ameri- can Health Organization, 2005. 10. Paraje G, Sadana R, Karam G. Increasing international gaps in health-related publi- cations. Science, 2005, 308:959–60. 11. Hanney SR et al. Proposed methods for reviewing the outcomes of health re- search: the impact of funding by the UK’s “Arthritis Research Campaign”. Health research policy and systems, 2004, 2:4. 12. Ben Abdelaziz A et al. Typologie de la recherché médicale Tunisienne indexée dans Medline de 1965 à 1999 [Typology of Tunisian medical research indexed in Medline from 1965 to 1999]. La Tunisie Médicale, 2002, 80:548–55. 518 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Risk of Mycobacterium tuberculosis infection in Somalia: national tuberculin survey 2006 A. Munim,1 Y. Rajab, 1 A. Barker,2 M. Daniel2 and B. Williams3 1World Health Organization, Hargeisa, Somalia (Correspondence to A. Munim: munima@som.emro.who.int). 2Desmond Tutu Tuberculosis Centre, University of Stellenbosch, Cape Town, South Africa. 3World Health Organization, Geneva, Switzerland. Received: 31/01/07; accepted: 25/06/07 ABSTRACT To estimate the annual risk of tuberculosis (TB) infection (ARTI) in Somalia a tuberculin survey was conducted in February/March 2006. Stratified cluster sampling was carried out within the 18 regions and 101 randomly selected primary schools. Tuberculin testing was done in 10 680 grade 1 schoolchildren. Transverse tuberculin reaction size was measured 72 hours later. The number of children with a satisfactory test read was 10 364. The overall BCG coverage was 54%. Based on fre- quency distribution of tuberculin reaction sizes, the ARTI in Somalia was estimated at 2.2% (confidence interval: 1.5%–3.2%). There was an annual decline of 2.6% comparing with a previous study in 1956. Risque d’infection à Mycobacterium tuberculosis en Somalie : enquête tuberculinique nationale 2006 RÉSUMÉ Afin d’estimer le risque annuel d’infection tuberculeuse en Somalie, une enquête tuberculinique a été réalisée en février-mars 2006. Un échantillonnage en grappes stratifié a été effectué dans les 18 régions et dans 101 écoles primaires choisies au hasard. Un test tuberculinique a été pratiqué sur 10 680 écoliers de première année. Le diamètre de la réaction tuberculinique a été mesuré 72 heures plus tard. Le nombre d’enfants pour lesquels la lecture du test était satisfaisante était de 10 364. La couverture globale par le BCG était de 54 %. D’après la distribution de fréquence du diamètre de la réaction tuberculinique, le risque annuel d’infection tuberculeuse en Somalie a été estimé à 2,2 % (intervalle de confiance : 1,5 % - 3,2 %). Il y a eu une baisse annuelle de 2,6 % par rapport à une étude antérieure de 1956. ¹>ºÇr¶=›ÍÉ·j¶=L=fùì«J™>EÏÆb£¶=e>ìJ]=6½>¢¶Ç²fEÇJ·¶{Ƕ=Xj™=2006 ¼É¶ÆÀÈ=fE(¹>ɾ=aËe>º(f²e>E>¾A(GQe¬iÇÈ(¼£¿ºbÈ>¢  „=Í[qØ6>F[m[E>[º›¹>ºÇr[¶=›¶Ç[²fEÇJ·¶{Ç[¶=Xj[™=ËfQ?+e=cAÆf[È=ª+le>[º2006fÈb[¯J¶ ¸ j¶>EÏÆb£·¶ËÇ¿j¶=e>ìJ]×=*›Í[ÉI>¯F{L>¢Ç»…ÀºL>¿É¢Ld]?Æ18ÆÍ[¯ì¿º101Í[ÉÑ=bJE=Í[iebº ð>ÉÑ=Çn¢>Âe>ÉJ]=*Ïb[¶¶Ç[²fEÇJ¶=e>FJ]=ËfQ?Æ68610›le=b[™=HØ[{À[ºl>[É®¤[º(‘ÆÙ=Í[·Uf™= b£E¸¢>«J¶=ÍU>jº72Í¢>i*Í[¶ÇF¯ºÌÐ=f[®¼ÃÈb[¶ÀÈd[¶=¹>[«{Ù=ab[¢Á>[²Æ36410ðØ[«{*¹b[£ºÁ>[²Æ ÊQÊiÊE\>¯·EÍÉì§J·¶ʶ>–Ý=54!¨[·Fȹ>ºÇr[¶=›¸j[¶>EÏÆb[£·¶ËÇ¿j[¶=e>ìJ]×=Á?eb¯ÈÆ(2.2! ÇJ¶=¸¢>«IL>U>jº¥çgÇIe=f³Iη¢ð=a>¿Ji=¶Ç²fE%ͯN¶=Í·q>ª1.5!)3.2*$!ËÇ¿[iz>[«Š=PbUb®Æ Åe=b¯º2.6!½>¢ð>¯E>iKÈfQ?¶=Íi=eb¶=¤ºð;e>¯™>E1956*  Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 519 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Somalia is a country in a complex emer- gency situation due to the long-lasting civil conflict and natural disasters. Somalia had an overall human development index (HDI) of 0.299 in 2002, which places the country among the 5 least developed countries in the world according to United Nations Devel- opment Programme (UNDP)/World Bank Socioeconomic Survey 2002 Somalia [1]. The extensive movement of people in So- malia, the low literacy rate and widespread poverty have left the country in a precarious state. In the past Somalia has had an excep- tionally high incidence and prevalence of pulmonary tuberculosis (TB) [2,3]. In a survey carried out by the World Health Or- ganization (WHO) in 1955 and 1956 among children aged 8 to 12 years, the annual risk of TB infection (ARTI) was estimated at 8% [2]. In a survey carried out among Somali refugees in the Ogaden region of Ethiopia in 1984 the ARTI was 4.8%, [4] and in a Finnish project carried out in 1986 in Burao, Somaliland, and Kismayo, South and Central zone, the ARTI at the age of 10 years was 3.7% (3.3%–4.1%) per year (here and elsewhere intervals given are 95% confidence intervals) with a cut-off at 5 mm and 2.9% (2.5%−3.3%) per year with a cut- off at 10 mm [5]. From the 1986 survey, and assuming a Stýblo constant of 50 (40−60), the smear-positive incidence was then 185 (143−228) per 100 000 population per year using a cut-off at 5 mm, or 145 (105−180) per 100 000 population per year using a cut-off at 10 mm. The TB programme in Somalia currently assumes that the inci- dence is 162/100 000 population per year for smear-positive cases and 324/100 000 population per year for all forms of TB [6]. According to the United Nations Popula- tion Division, the population of Somalia was 6.3 million in 1995 and 8.2 million in 2005 [7]. Over this period, smear-positive notifications increased from 1572 to 7068 [8] so that the notification rate increased from 25/100 000 population to 86/100 000 population and the smear-positive case- detection rate increased from 15% (12%−18%) to 53% (43%−63%). Because of the extent of the TB burden in the community, all Somalia Aid Coor- dination Body (SACB) health partners, including health authorities, WHO, World Food Programme, and international non- governmental organizations (NGOs) have given priority to TB control. In 2003 a joint proposal was developed by SACB under the auspices of the Health Sector Com- mittee and approved by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Part of this proposal required that a tuberculin survey be carried out at year 1 of its implementation so as to asses the ARTI (and to adjust the programme targets accordingly) and to be repeated at year 5 so as to asses the impact of the TB control activities. The Somalia TB Programme started implementing directly observed treatment, short-course (DOTS) in 1995, and achieved the regional targets of DOTS all over, based on the presence of at least 1 TB centre in each of the 18 regions of Somalia. How- ever, the presence of vast regions where the people are nomadic combined with the security problems related to the protracted political crisis contribute to the inaccessibil- ity of some of these centres. The expansion of the TB centres, so that there is more than 1 centre in the larger regions and towns, is expected to contribute to improving the case-detection rate in places where detec- tion is low. The treatment outcomes are good. In 2005, 58% of cases were smear- positive, 24% were smear-negative, 17% were extra-pulmonary and 4% were relapse cases. The treatment success rate was 90% 520 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما with 2% dying, 1% failing treatment and 4% defaulting. Tuberculin skin test surveys can be used to assess the size of the TB problem as well as to determine trends over time provided it is possible to collect good data. In addition tuberculin skin test surveys can provide important information that helps us to un- derstand the epidemiology of TB [9–12]. In order to assess the current levels of TB in Somalia, the trends in the prevalence of TB infection since the earlier surveys, and the progress towards the Millennium Development Goals for TB, a national sur- vey of TB infection was carried out in late February and early March 2006 by WHO Somalia in collaboration with the Ministry of Health, and the Expanded Programme on Immunization, the women’s federation in each zone, and all partners from the SACB TB working group. This survey was spon- sored by GFATM through World Vision (principal recipient). The objectives of the study were to: • Determine the ARTI. This will be used as baseline for re-setting the programme targets and to evaluate the impact after 5 years. • Determine the trend in TB infection by comparing the current ARTI with the results of previous surveys. • Determine BCG scar coverage among a cohort of Somali first-grade primary- school students in Somalia. Methods Organization of the survey First-grade primary-school pupils for the academic year 2006–2007 were the tar- get population for this survey. Somalia is in a protracted and complex emergency situation and for the purposes of the sur- vey the country was divided into manage- ment teams for each of 3 zones (South and Central Zone, Puntland and Somaliland) and each team was supported by qualified supervisory teams according to the sample size and operating scenarios. All supervi- sory teams were instructed as trainers of trainees (TOT) [12] The survey was done using stratified cluster sampling within the 18 regions of the country; 32 districts within these regions and 101 schools out of 1172 operating schools within these districts according to the UNICEF Survey of Primary Schools in Somalia for 2003–2004 were selected. Thir- ty (30) teams, each consisting of 2 people, and 15 supervisors were employed to carry out the testing and to read the indurations. The teams were trained by internationally recognized trainers in February, 2006, and a pilot project was carried out in Hargeisa in order to validate the test and the training of the staff. The antigen used was purified protein derivate (PPD) RT-23 tuberculin Tween 80 (vial of 5 mL, batch number 1461K obtained directly from the Statens Serum Institute, Copenhagen, Denmark). Tuber- culin was transferred to Somalia by air and immediately stored in a temperature controlled refrigerator at WHO warehouses in Hargeisa, Mogadishu and Garowe, from which only the required number of vials were made available for each survey day. Vials were transported in cold boxes packed with ice and once opened were used within a few hours to minimize decay of the active substance. The Mantoux technique was used with disposable 1 mL tuberculin syringes and 26 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 521 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما gauge needles. PPD antigen (2 tuberculin units as recommended by WHO, in a volume of 0.1 mL) was injected intradermally into the volar surface of left forearm [9,11,13]. The induration was measured transverse to the long axis of the arm after 72 hours fol- lowing international recommendations [2]. If the injection was given too deeply or a loss of tuberculin occurred, it was repeated on the right arm. In addition to the children included in the main survey, 14 adults sputum smear- positive tuberculosis patients were tested to assess the expected mode in the distribution of reaction sizes [2]. A special form was used for data collection and data were en- tered using Epi-Info, version 3.2. Ethical considerations Verbal informed consent was obtained from the parents of the children and an official letter was circulated from the Ministries of Education and Health to all schools in- volved in the survey. We explained to them the procedure and the objectives of the test. This procedure was organized by members of the tuberculin survey committee in each zone in collaboration with local community elders. Data entry and cleaning The data were entered by 2 trained data entry staff and each record was double- checked individually by 4 teams of people. When the data had been checked, the entire data set was checked for consistency. SPSS, version 10.0 was used to make the final check on consistency. We started by examining the proportion of responses that were greater than zero for each of the testers as shown in Figure 1. We could be confident that the annual risk of infection is between 1% and 10% so that the lowest point could be excluded and the 12 highest points could be excluded. We also examined the distribution of induration measurements for each tester and excluded 6 testers for which the distribution was significantly different from the overall aver- age. Because the 2 categories overlapped only 15 readers were excluded. The age range was 3 years to 37 years old but since 93% of those tested were between 6−12 years, we retained only those 6−12 years old inclusive. Results A total of 10 680 people were tested; absent students and refusals were excluded. In the entire data set only 28 ages, 52 readings of the BCG and 316 readings of the induration were missing and these were excluded; thus 10 364 indurations were read. Of the total number sampled, 59% were male and 41% were female. The mean ages of males and females in the sample were 9.3 years (interquartile range: 8 to 11 years) and 9.2 years (interquartile range: 8 to 11 years) respectively. Annual rate of tuberculosis infection The ARI of infection for Somalia was es- timated as follows. For the data shown in Figure 1 the proportion of positive respond- ers was 0.30 (0.29−0.31) From the fit in Fig- ure 1 the proportion of these that were due to Mycobacterium tuberculosis was 0.61 (0.17−0.85) so that the prevalence of M. tu- berculosis infection was 0.18% (0.05−0.26). The average age of those tested and not ex- cluded was 9.09 years giving an annual rate of decline of 2.22% (0.58%−3.18%). The 1986 study followed the recommen- dations of the WHO in which all indurations of 10 mm or more were taken as indicating M. tuberculosis infection [12]. If we apply this criterion to the present survey, the prevalence of M. tuberculosis infection is 522 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 2.21%, very close to the value estimated above. Fitting the data The distribution of induration measure- ments, after excluding the readers as noted above, are shown by the blue dots in Figure 2. There was significant digit preference, especially at 10 mm, and no clear indication of 2 separate underlying distributions corre- sponding to the response to environmental mycobacterium and to TB. We were guided by the data from the 1956 tuberculin survey in Somalia [2] that showed 2 clear peaks at 5 mm and at 15 mm each of which approximates a normal distribution function in shape. We therefore proceeded as follows. We started from 2 Normal distribution functions whose sum will give the total distribution. To allow for digit preference, we then added a further 8 parameters which gave the probability that a point at 3 or 7 mm is misreported as 5 mm, that 4 or 6 mm is misreported as 5 mm, and then did the same for the points on either side of 10 mm, 15 mm, and 20 mm. While there are a total of 11 parameters, the last 8 do not change the area under the curve but only the distribution of the points around 5, 10, 15 and 20 mm. (A more sophisticated way of doing this has been explored by Eilers et al. [14]). The solid blue line is then the maximum likelihood fit to the data as- suming Poisson statistics and the red line is the underlying sum of normal distributions. Assuming that the area under the green Figure 1 Log odds of the prevalence of positive (non-zero) indurations as measured by each tester and sorted in order of increasing prevalence. The 3 points for which the log odds are 5 had a prevalence of 1 so that the log odds is infinite. The solid line indicates an annual risk of infection of 10% and the dotted line of 1%. – Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 523 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما curve represents the response to M. tuber- culosis and the area under the black curve represents the response to environmental bacteria we can then determine the propor- tion of all positive (non-zero) reactors that are due to M. tuberculosis. To determine confidence intervals on the estimated pro- portions we then find the maximum and minimum values of the area under the green curve for which the deviance differs from the minimum value by c2n (0.05) where n is the number of free parameters [15] which we vary to minimize the deviance for the given area under the green curve. Hospital patients As a final check, 14 patients, hospitalized with TB, were given a tuberculin skin test and the size of the indurations was meas- ured over the following 3 days; the results are shown in Table 1. The size of the indu- ration did not vary significantly among the days or between the sexes, and the average induration size over all days and patients was 18.1 (1.69−19.3) mm. Assuming that the peak induration among people who are not TB patients is close to 18 mm, a cut-off in the region of 10 mm is not unreasonable. However, we note that the implied peak of the tuberculosis response in Figure 2 was at 12 mm, significantly lower than the value measured in the TB patients, which was 18 mm. Dependence of responses on testing delay The indurations were read 3 or 4 days after the tuberculin test was administered. The proportion of positive reactors when the tests were read on day 4 (36%; 33%−39%) was about 25% greater than the proportion when the tests were read on day 3 (29%; 27%−28%). This could introduce a further uncertainty of about 25% into the estimates of ARTI. Dependence of response on age Figure 3 shows the dependence of the pro- portion of positive reactors (scaled down by a factor of 0.61, the estimated proportion of Figure 2 Distribution of indurations by size: blue dots, data points; black and green lines, Normal distributions; red line, sum of the 2 Normal distributions; blue line fitted curve allowing for digit preference. The parameters of the 2 Normal distributions are: m1 = 7.92; s1 = 2.34; N1 = 1357; m2 = 12.18; s2 = 4.01; N2 = 1458. 524 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما positive reactors that are infected with tu- berculosis) by age showing an increase with age which is more or less as expected as- suming a constant annual risk of infection. Dependence of ARTI on BCG scar The overall mean proportion of positive reactors to tuberculin was 0.3%. The pro- portion of positive reactors was signifi- cantly lower in those with a BCG scar (0.283%; 0.270%−0.296%) than those without a BCG scar (0.326%; 0.309% − 0.343%). The proportion of positive reac- tors with uncertain BCG status was 0.302% (0.257%−0.347%). In order to estimate the ARTI for those with and without a BCG scar we fitted the data separately for those with and without BCG scars as described above. However, we kept the mean (SD) of the 2 normal distribu- tions fixed and varied only the normalization constants; the results are shown in Table 2 from which we can obtain an estimate of the odds ratio of TB infection for those with and without a BCG scar. The value obtained in this way is 1.37 (1.30−1.44) suggesting that BCG vaccination gives significant protec- tion against TB infection. Both estimates of ARTI are of course uncertain (as indicated above) but provided the biases are in the same direction, the odds ratio will still differ significantly. Prevalence of infection Table 3 shows the prevalence of infection in males and females, in each of the 3 zones, and for urban and rural schools assuming that everyone with an induration of 10 mm or more is positive. There were more males than females in the sample but females were at significantly greater risk of infection than males. Nearly two-thirds of the sample were in the South and Central Zone with about a Table 1 Sex, age and induration for adult smear-positive tuberculosis patients. Indurations were measured 1, 2 and 3 days after being challenged with tuberculin Sex Age Induration (mm) (years) Day 1 Day 2 Day 3 M 33 18 20 20 M 24 25 16 16 M 25 25 17 17 M 25 15 25 20 M 27 20 20 16 M 28 23 21 17 M 20 19 25 20 M 16 10 20 17 F 37 16 20 16 F 50 7 15 12 F 33 20 22 19 F 35 13 15 16 F 24 15 17 20 F 40 13 22 22 Mean (SD) 17.1 (3.1) 19.6 (1.9) 17.7 (1.5) The average induration over the 3 days was 18.1 (SD 1.2) mm. M = male; F = female; SD = standard deviation. Figure 3 Dependence of the proportion of positive reactors (scaled down by 0.61, the estimated proportion of positive reactors that are infected with tuberculosis) as a function of age Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 525 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما quarter in Puntland and just over one-tenth in Somaliland. There were statistically sig- nificant differences in TB infection and ARTI between the 3 zones with the highest prevalence and ARTI in South and Central zone and the lowest in Puntland. The ARTI in Puntland was only half that in South and Central zone. The sample was predomi- nantly urban but there was no significant difference between the prevalence of infec- tion in urban and rural areas. Figure 4 shows the trend in the ARTI over time using data from the 3 surveys. Fitting an exponential trend line to the data shows that over the period from 1958 to 2006, the ARTI has fallen at a rate of about 2.6% per year over the last 50 years. Figure 5 shows the trend in the prevalence of infection with age for males and females combined (the trend was not significantly different between males and females, P = 0.4). The data suggest that the ARTI, aver- aged over each person’s life time, is less for older than it is for younger people and that there is a declining annual risk of infection of about 10% per year of age. Table 2 Tuberculosis (TB) infection for those with and without a BCG scar. The table gives the proportion of those that had positive reactions, of these the proportion that were due to TB, the prevalence of TB infection, the mean age of each group and the corresponding annual risk of infection BCG scar Proportion Proportion Prevalence Mean age Annual risk of positive due to TB of TB (years) of infection reactors (95% CI) (95% CI) (95% CI) % % No 0.67 0.33 (0.32–0.34) 0.22 (0.21–0.23) 9.0 2.7 (2.5–2.9) Yes 0.61 0.28 (0.26–0.30) 0.17 (0.16–0.18) 9.4 2.0 (1.9–2.1) CI = confidence interval. Table 3 Estimated prevalence and annual risk of tuberculosis infection (ARTI) by sex, region and residence Variable No. (%) Prevalence ARTI (95% CI) P-value (95% CI) (%) (% per year) Sex 0.0022 Male 6280 (59) 17 (12–24) 2.0 (1.4–3.0) Female 4399 (41) 20 (14–28) 2.4 (1.7–3.5) Region < 0.0001 Somaliland 1236 (12) 14 (10–20) 1.6 (1.1–2.4) Puntland 2491 (23) 10 (7–15) 1.2 (0.8–1.7) South and Central 6952 (65) 22 (16–31) 2.7 (1.9–3.9) Residence 0.44 Urban 9266 (87) 18 (13–26) 2.2 (1.5–3.2) Rural 1413 (13) 19 (14–27) 2.3 (1.6–3.3) National 10 679 18 (13–26) 2.2 (1.5–3.2) CI = confidence interval. 526 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما BCG coverage The overall BCG coverage was 54% with a further 5% recorded as doubtful. This is near to the EPI programme coverage reported by WHO/UNICEF in 2005, which was 60%. The coverage varied significantly by zone with the lowest coverage in Somaliland (38%) and significantly higher coverage in Puntland (62%) and South and Central zone (58%); coverage did not differ significantly between males (53%) and females (54%). Figure 6 gives the BCG coverage by age. Reading back then, the coverage of BCG appeared to fall 14 years ago, increased over the next 4 years but then fell again over the following 4 years. This finding matches the WHO/UNICEF report of 2005 which was 37% in 1992 and 37% in 1997. The preva- lence of infection was no different between those with or without a BCG scar. Estimates of the case-detection rate Using the estimated values of the ARTI in Table 3 we used the Stýblo rule to estimate incidence and hence the case-detection rate. However, converting notification numbers to notification rates depends on the popula- tion. Using the current estimate of the total population from the United Nations Popula- tion Division noted above [7] and allowing for a population increase between 2005 and 2006 gives a total population of 8.65 million. In 2006 there were 7040 notified cases of TB in Somalia giving a notifica- tion rate of 81/100 000 population per year (Table 4). The ARTI gives an estimated in- cidence of 111/100 000 population per year (75−160/100 000 population per year) or a case-detection rate of 74% (51%−108%). Discussion Because of the prolonged civil war and the complex situation in Somalia, it has been difficult to obtain reliable data about the actual incidence and prevalence of TB. Nevertheless, if the prevalence of infection with TB can be successfully estimated and repeat surveys are available, it should be possible to draw some conclusions about the transmission in the community and thus Figure 4 Annual risk of infection as estimated by the 3 surveys (1956, 1986, 2006). The rate of decline is 2.6% per year Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 527 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما the development of the epidemiology of TB over time. Two surveys were previously conducted in Somalia, one in 1956 and the other in 1986 [3,5], in addition to a survey among Somali refugees in the Ogaden re- gion of Ethiopia in 1984 in which the ARTI was 4.8% [4]. The participation rate was very high with only 3% of people who were tested not hav- ing a successful reading of their induration. By way of comparison, in a recent survey in Malawi, 21% of those tested did not have a successful reading of their induration [16]. The best estimate of the national ARTI in Somalia is 2.2% per year (1.5%−3.2% per year). Comparing this with the results of earlier surveys suggests an average annual rate of decline in the prevalence of infection between 1956 and 2006 of about 2.6% per year. If the present rate of decline in the prevalence of infection is maintained, then Figure 5 Trend in the prevalence of infection and the annual risk of infection with age Figure 6 BCG coverage as a function of age 528 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما between 1990 and 2015 the prevalence will fall by 46%. The decline in ARTI over time is similar to the decline found in surveys carried out in Kenya, Ethiopia and Egypt [17–19]. There was significant variation in the ARTI in the 3 zones of the country with the highest rates in the South and Central zone. In the country as a whole BCG coverage was 54% but it was highest in Puntland (62%), then in South and Central zone (58%), and lowest in Somaliland (38%). There was no significant difference in the prevalence of infection between males and females or urban and rural areas. There are some important caveats that need to be taken into account when con- sidering our results. First, the testing of TB patients suggests that the mode of the distribution should be at 18 mm but in fact only 2.2% of indurations exceed 18 mm so that the corresponding ARTI would only be 0.5% per year using a mirror method. If, on the other hand, we were to assume that all non-zero indurations were due to TB, then the prevalence would be 38% and the ARTI 5.1%, which would roughly halve the case-detection rate. It is important to understand the reasons for the low peak and to decide definitively how best to apportion the positive indurations to TB infection. Second, the estimate of the notification rate per 100 000 population and hence the case- detection rate depends on the population size, which in Somalia is very uncertain given the social and political uncertainty in the country. Third, there was a variance in grade 1 enrolment between boys and girls (61% for boys and 39% for girls according to a UNICEF survey of primary schools in Somalia 2004) and finally there was a refusal in one region which included about 5% of the sample size. Recommendations A further survey should be carried out in 5 years and again in 10 years to help monitor progress towards the Millennium Develop- ment Goals. Further analysis should be done to ex- plore the variation in the distribution of indurations spatially as well as by age, tester and BCG status in order to understand the determinants of the distribution. Table 4 Population, number of notified cases, notification rates, annual rate of infection, estimated incidence and corresponding case-detection rate by region Region Population Cases Notification Annual Incidence Case- (millions) notified rate rate of (no. of detection (/100 000 infection cases/ rate (%)a population) (95% CI) year) (% per year) Somaliland 2.30 1418 62 1.64 (1.46–1.82) 82 75 Puntland 1.38 579 42 1.20 (1.10–1.30) 60 70 Central and South 4.96 5043 102 2.71 (2.66–2.76) 136 75 Total 8.65 7040 81 2.21 (2.16–2.26) 111 74 aAssuming a total population in Somalia of 8.7 million. CI = confidence interval. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 529 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Acknowledgements Carrying out a survey of this kind in a complex emergency setting like Somalia was a daunting task. Many people provided substantial support and the authors would like to acknowledge in particular the So- mali health authorities and the members of the tuberculin survey committees, Dr Ismail Adan, Dr Abukar Ali Hilowle, Dr Bashir Suleiman and Dr Ali Hassan. Special thanks go to Dr Imanol Berakoetxea for his support during preparation and implemen- tation. We also extend our gratitude to all testers and readers for their distinguished efforts despite the harsh and difficult situ- ation, and to all members of the TB work- ing group, especially CCM Italy teams (Mr Peter Wilson, Dr Pardeep Kapoor, Dr Harun I. Hassan, Dr Said Adan, Mr Ismail Arte Rage, Mrs Ahadha Abdi and Mr Ab- dirahman Ibrahim), and to all TB partners, Ministry of Health, Ministry of Education, Women’s Federation and elders for their support and authorization to carry out the survey. We would also like to thank Dr Ibrahim Betelmal, WHO Representative in Somalia, and his team for continuous sup- port and leadership; also Dr Akihiro Seita, Dr Samiha Baghdadi, Dr Zoheir Hallaj, Dr Hans Reider and Dr Christopher Dye for their guidance and support. This survey was made possible through funding provided by the Global Fund through the principle recipient World Vi- sion, but especially Dr Vianney Rusagara and his team. References 1. United Nations Development Programme (UNDP)/World Bank. Socioeconomic Sur- vey 2002 Somalia (http://mirror.undp.org/ somalia/docs/whole%20SWB%20book. pdf, accessed 21 January 2008). 2. Tuberculosis survey in the Somalilands. Copenhagen, World Health Organization Regional Office for Europe, 1956. 3. Young K. Impressions of tuberculosis in Somaliland. Tubercle, 1957, 38:273–9. 4. Shears P. Tuberculosis control in Somali refugee camps. Tubercle, 1984, 65:111– 6. 5. Peltola H et al. Risk of infection with My- cobacterium tuberculosis among children and mothers in Somalia. Clinical infec- tious diseases, 1994, 18:106–11. 6. Global tuberculosis control: surveillance, planning, financing. WHO report 2007. Geneva, World Health Organization, 2007 (WHO/HTM/TB/2007.376). 7. World migrant stock: The 2005 revision population database. New York, United Nations Population Division, 2006. 8. Munim A. Summarized progress report on WHO supported TB control programme in Somalia 2005. Somalia, World Health Organization Somalia, 2005. 9. Styblo K. The relationship between the risk of tuberculous infection and the risk of developing infectious tuberculosis. Tuber- cle and lung disease, 1985, 60(3–4):117– 9. 10. Palmer CE et al. Experimental and epide- miologic basis for the interpretation of tu- berculin sensitivity. Journal of pediatrics, 1959, 55:413–29. 11. Wijsmuller G et al. On the nature of tu- berculin sensitivity in South India. Ameri- can review of respiratory disease, 1968, 97:429–43. 12. The standard tuberculin test. Geneva, World Health Organization, 1963 (WHO Technical Guide, 3). 530 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 13. Arnadottir T et al. Guidelines for conduct- ing tuberculin skin test surveys in high prevalence countries. Tubercle and lung disease, 1996, 77(Suppl. 1):1–19. 14. Eilers PH, Borgdorff MW. Modelling and correction of digit preference in tuberculin surveys. International journal of tubercu- losis and lung disease, 2004, 8:232–9. 15. Williams B et al. Estimating HIV incidence rates from age prevalence data in epi- demic situations. Statistics in medicine, 2001, 20:2003–16. 16. Salaniponi FM et al. Risk of infection with Mycobacterium tuberculosis in Malawi: national tuberculin survey 1994. Inter- national journal of tuberculosis and lung disease, 2004, 8:718–23. 17. Bosman MC et al. National tuberculin sur- vey of Kenya, 1986–1990. International journal of tuberculosis and lung disease, 1998, 2:272–80. 18. Azbite M. National tuberculin test survey in Ethiopia. Ethiopian medical journal, 1992, 30:215–24. 19. El Ibiary S et al. Trend in the annual risk of tuberculous infection in Egypt, 1950– 1996. International journal of tuberculosis and lung disease, 1999, 3:294–9. Anti-tuberculosis drug resistance in the world. Fourth global report This is the fourth report of the WHO/IUATLD Global Project on Anti-Tu- berculosis Drug Resistance Surveillance. It is based on data collected between 2002 and 2006 on 91 577 TB patients in 81 countries, including 33 countries that have never previously reported. Multidrug-resistant tuberculosis (MDR-TB) was recorded at the highest rates ever and extensively drug-resistant tuberculosis (XDR-TB), a vir- tually untreatable form of the disease, was recorded in 45 countries. Based on analysis of the data, WHO estimates there are nearly half a million new cases of MDR-TB a year, about 5% of 9 million new TB cases of all types. The true scale of the problem remains unknown in some parts of the world. Only 6 countries in Africa, the region with the highest incidence of TB in the world, were able to provide drug resistance data. WHO estimates that US$ 4.8 billion is needed for overall TB control in low- and middle-income countries in 2008, with US$ 1 billion for MDR-TB and XDR-TB. But there is a total finance gap of US$ 2.5 billion, including a US$ 500 million gap for MDR-TB and XDR-TB. Further information about this and other WHO publications is available from http://www.who.int/bookorders/anglais/home1.jsp?sesslan=1 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 531 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Case-finding tuberculosis patients: diagnostic and treatment delays and their determinants F. Maamari1 1National Programme of Tuberculosis, Ministry of Health, Damascus, Syrian Arab Republic (Correspondence to F. Maamari: ntpsyria@mail.sy). Received: 13/07/04; accepted: 18/07/05 ABSTRACT This study in the Syrian Arab Republic assessed the frequency and determinants of de- lays in diagnosis and treatment of new smear-positive tuberculosis cases at DOTS treatment centres. Among 800 patients, the mean delay due to patient care-seeking behaviour was 52.7 days (range 15–698) and the health system delay before diagnosis was 24.8 days; thus the mean total delay be- fore diagnosis was 77.6 days. The mean delay from diagnosis to start of treatment was very short at 2.9 days. Significant risk factors for total delay were: living far from the health facility, feeling a high degree of stigma, seeking initial care at a non-health care provider and having more than 1 health care encounter before diagnosis. Dépistage de la tuberculose : les retards au diagnostic et au traitement et leurs déterminants RÉSUMÉ Cette étude, conduite en République arabe syrienne, avait pour objectif d’évaluer la fré- quence et les facteurs déterminants des retards dans le diagnostic et le traitement de nouveaux cas de tuberculose à bacilloscopie positive (TPM+) dans les centres DOTS (traitement de brève durée sous surveillance directe). Sur un effectif de 800 patients, le retard moyen dû au comportement de re- cours aux soins du patient était de 52,7 jours (fourchette : 15-698) et le retard du diagnostic imputable au système de santé était de 24,8 jours, soit un délai total moyen avant diagnostic de 77,6 jours. Le délai moyen entre l’établissement du diagnostic et l’instauration du traitement est apparu très bref, à savoir 2,9 jours. Si l’on considère le retard global, les facteurs de risque significatifs sont l’éloignement du domicile par rapport au centre de soins, le poids de la stigmatisation, le recours dans un premier temps à une personne autre qu’un prestataire de soins et la multiplication des consultations médicales avant l’établissement du diagnostic. ¸j¶=L×>U¬n²6ÄI=ab†Æ͂>£™=ÆsÉ^nJ¶=›fè]@J¶= Ëe>»£º>Èa>ª  „=Í[qØ6]@[J¶=L=aëb[†Æßfà[[I=ßÇß[I(ÍÈeÇj¶=ÍÉEf£¶=ÍÈeÇû‚=›KÈfQ?¶=Íi=eb¶=ÅdÂK»çÉ®sÉ^n[I›f f[m>F™=­=f[mÝ=K[€bºÙ=Ìr¯¶=͂>£™=h²=fº›(Í]>ì·¶=ÍÉE>‹Ý=ÌbÈb‚=¸j¶=L×>UDOTS*K[¿çÉEÆ K·¶=Íi=eb¶=ÅdÂ800¨·Eb®ÍÈ>¢f¶=l>ß»åJï¶>E°ù·£J™=f]@J¶=œiÇJºÁ?(xÈfº52.7ð>ºÇÈ%¹>=6À[º15 ‘C698$£J™=f]@J¶=œiÇJºÆ(¨[·Eb[®sÉ^n[J·¶ͯE>j[¶=ÊVr[¶=½>[Ÿ¿¶=L=Ð=fQDE°ù·24.8¸[£Q>[º(ð>[ºÇÈ sÉ^nJ¶=¸F®Êù·³¶=f]@J¶=ÌbºœiÇJº77.6ð>ºÇÈ*͂>£™=ÐbEEÆsÉ^nJ¶=EÌf[J«¶=œiÇJºÁ>²U› gÆ>RJÈácCð=bQð=r®2.9ð>ºÇÈ*¶=À¢ͶÆÖj™=ͺ>=e>ìJ]×=¸º=Ç¢K·ç[N“ÆÊ[·È>[º›Ê·³¶=f]@J6oÉ[£¶= [¦À[ºs^[mÏb[¶Í[È=bF¶=›Í[È>¢f¶=l>[ß»åJï¶=Æ(Í»qǶ>E¨¶>F¶=eÇ£n¶=Æ(ÊVr¶=°ªf™=À¢ÌbÉ£EÀ²>º?› sÉ^nJ¶=¸F®bU=ÆÊVq°ªfºÀºfN²?Í£Q=fºÆ(ÍÉVr¶=ÍÈ>¢f¶=ʺëb¯º*  532 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction In 1993, the World Health Organization (WHO) declared a state of global emer- gency for tuberculosis (TB), due to the steady increase of the disease worldwide [1]. In 1995, the directly observed treat- ment, short-course (DOTS) strategy was established as a key plan to achieve TB control worldwide. The global targets of TB control are to achieve 70% case detec- tion and 85% cure rates by 2005. According to the latest WHO global report [1], DOTS programmes successfully treated 82% of all registered new smear-positive patients in 2002, but detected only 45% of the esti- mated TB cases in the world in 2003. The report indicated that the target of 70% case detection might not be reached until 2015, unless interventions were used to increase the case detection rate. The situation in the Syrian Arab Repub- lic is similar. In 2003, 1545 cases of new smear-positive pulmonary TB were de- tected, and 1353 of them were successfully treated [2]. As the estimated incidence of TB in the country is 20/100 000 population, the case detection rate is 44%, while the treatment success rate is 88%, and DOTS coverage of 100% was reached in April 2000. Therefore improving case-finding is a priority, and operational research is needed. One important research area in this regard is the assessment of the delays be- tween the start of symptoms and making the diagnosis of TB and between making the diagnosis and starting treatment, and what causes delays. The delay in diagnosis and treatment of TB patients can be caused by patients or by the health system, or both. The problems of delay in TB case- finding have been studied to some extent in other countries, both in developing and in developed countries, since delays in diagnosis have been noted in both high and low TB prevalence countries [3–6]. In high prevalence countries delays build up due to prolonged patient and doctor delays [3]. Several factors have been identified as influencing delay in diagnosis and start of treatment including the individual patients’ perception of the disease, the severity of the disease, patients’ access to health services and the expertise of health personnel. Some previous studies have suggested that the determinants of a longer delay include specific patient groups (e.g. women in Viet Nam and Nepal, rural residents in Tanzania, nationality in Los Angeles, USA [3–6]). Other studies suggest that the most important factors for delays were availabil- ity and accessibility of health services. All these studies highlighted the importance of delay in increasing costs and mortality due to TB. The multiple factors causing delay in diagnosis must be clearly identified and addressed locally in order to improve the quality and effectiveness of the national TB control programmes (NTPs). Studies of case-finding, particularly analysing delays and their determinants, would allow good assessment of case-finding success under DOTS. This study of TB case-finding in the Syrian Arab Republic made an in-depth analysis of various types of delay and their determinants. The goal was to identify gaps in case-finding under DOTS in order to as- sist in planning future interventions. Methods A cross-sectional study was conducted in all 13 NTP centres implementing DOTS in the country. The study covered new patients seen during the period 1 February 2003 to 30 September 2003. The number enrolled Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 533 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما from each centre was proportional to the number recorded in that centre in 2001. A total of 800 new smear-positive pul- monary TB patients aged more than 15 years old were interviewed consecutively according to a structured and pre-tested questionnaire. The sample size was based on the estimated incidence of TB. The ques- tionnaire included information about the time intervals between onset of symptoms and each of the following events: initial health-seeking, first visit to a health care provider, making the diagnosis of TB and starting DOTS treatment. Health workers, including doctors and paramedical staff, were given intensive training on interview and probing techniques. They interviewed the patients during the first 2 weeks of their treatment, after obtaining informed consent. The patients were also interviewed about factors that might influence health-seeking behaviour and accessibility to timely and appropriate care: • Sociodemographic status (measured using a summation score of education, occupation and incomes; best = 0 and worst = 7). • Satisfaction with care (measured on a 4-point Likert scale; 0 = best and 3 = worst). The variables included avail- ability of services in TB centres, prompt action from primary care personnel, adequacy of equipment and free medi- cation in these centres, proper coverage of TB centres in the area, health facility workload, and waiting time. The cut-off for satisfied/unsatisfied was the median value. • Knowledge (measured on a 3-point Lik- ert scale; 0 = best and 2 = worst). The variables included knowledge about the type of disease, its causes, curability, ex- isted of a vaccine, type of anti-TB drugs and duration of treatment. The cut-off for adequate/inadequate knowledge was the median value. • Feelings of stigma about TB (measured on a 5-point Likert scale; 0 = highest, 4 = lowest degree of stigma). The variables included feeling ashamed of having TB, having to hide TB diagnosis from others and having problems with family rela- tions, work performance, marriage pros- pects, family responsibilities, infertility, pregnancy or breastfeeding. The cut-off for high/low stigma was the median value. Definitions The following definitions of delay were used: • Diagnostic delay: time interval between onset of symptoms and diagnosis of pulmonary TB. This consists of 2 com- ponents: • Patient related diagnostic delay: time interval between onset of symptoms and first seeking care at a health care provider. • Health system related diagnostic de- lay: time interval between seeking care at a health care provider and diagnosis of pulmonary TB. • Treatment delay: time interval between diagnosis and start of DOTS treatment. • Health system delay: time interval be- tween seeking care at a health care pro- vider and start of DOTS treatment. • Total delay: time interval between onset of symptoms and start of DOTS treat- ment. Statistical analysis Data from questionnaires were checked be- fore data entry. Data analysis was performed using SPPS, version 11, and Epi-Info 2000. Descriptive statistics were used such as fre- quency, mean and standard deviation (SD). 534 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Comparisons between groups were made using the chi-squared test. A multivariate logistic regression analy- sis was performed to analyse the determi- nants of delay. The median was used as a cut-off to compare patients in 2 groups with low delay (≤ the median) and high delay (> the median value). Results Demographic characteristics More than two-thirds of the 800 newly di- agnosed pulmonary TB patients were aged ≤ 35 years old and the mean age was 27.5 years (range 15–95 years). The male to fe- male ratio was 510:290 (1.8). Demographic data showed that 34.6% were illiterate, 44.1% were unemployed or housewives, 67.3% had income that covered their ex- penses, 34.4% were residing in urban areas, 20.3% in suburbs and 42.9% in rural areas, 75.9% of the patients lived within 5 km of a health facility and 9.3% had to travel more than half an hour to reach a health facility. Half of the patients had a history of cur- rent or past smoking, whether cigarettes or nargila (waterpipe) (Table 1). The majority (80.8%) of patients had “optimal” satisfaction with care and only a few had (19.2%) had “suboptimal” satisfac- tion. The great majority of patients (94.4%) felt a high degree of stigma attached to TB. Knowledge about TB was poor, with a high proportion of patients (91%) scoring “in- adequate” knowledge. Almost all patients (99.6%) had previously heard about TB, mainly from Ministry of Health campaigns (51.7%) or from information from a sick relative or friend (27.0%). There was in- adequate knowledge among many patients regarding the presence of a vaccine for the disease (45.3% incorrect), types of drugs (30.2% incorrect) and duration of treatment (14.8% incorrect). Table 1 Demographic and clinical characteristics of 800 smear-positive tuberculosis patients in the Syrian Arab Republic, 2003 Variable No. of % patients Age at diagnosis (years) ≤ 35 516 64.5 > 35 284 35.5 Sex Male 510 63.8 Female 290 36.2 Marital status Married 432 54.0 Single 332 41.5 Widowed 17 2.1 Divorced/separated 19 2.4 Residence Urban 275 34.4 Suburban 162 20.2 Rural 343 42.9 Homeless/displaced 20 2.5 Educational level University or higher 20 2.5 Primary/middle/senior 503 62.9 Illiterate/read & write 277 34.6 Occupation Technical/professional 33 4.1 Clerical/manual worker 383 47.9 Student 31 3.9 Unemployed/housewife 353 44.1 Financial status Have savings 66 8.2 Income = expenses 538 67.2 In debt 196 24.5 Travelling time to a health facility (h) < 0.5 722 90.2 0.5–1 50 6.2 > 1 28 3.5 Travelling distance to health facility (km) ≤ 5 607 75.9 > 5 193 24.1 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 535 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 1 Demographic and clinical of 800 smear-positive tuberculosis patients in the Syrian Arab Republic, 2003 (concluded) Variable No. of % patients History of smoking Never 396 49.5 Current smoker 213 26.6 Ex-smoker 191 23.9 Previous chronic disease No 701 87.6 Yes 99 12.4 Satisfaction with care Optimal (score < 1) 619 80.8 Suboptimal (score ≥ 1) 147 19.2 Stigma Low (score > 2 ) 43 5.6 High (score ≤ 2 ) 723 94.4 Knowledge Adequate (score < 1 ) 66 8.6 Inadequate (score ≥ 1) 697 91.4 Totals that do not sum to 800 are due to missing data. Health-seeking behaviour before diagnosis When asked about symptoms before diag- nosis, cough was reported by almost all the patients (98.3%), followed by fever (76.6%) and weight loss (73.6%). Cough was the main symptom motivating the patients to seek health care (80.4%) (Table 2). The main health-seeking behaviour after the onset of symptoms was to visit a health care provider (91.9% of patients) (Table 2). The majority of patients sought care at the private sector (79.1%) or public hospitals (17.9%) rather than the NTP centre (1.1%). The health care provider where patients first sought care was most commonly a chest specialist (50.4%), followed by general practitioner (19.3%) and internist (25.8%). The majority of patients visited 1 health care provider before diagnosis, but 41.4% Table 2 Health-seeking behaviour of 800 tuberculosis (TB) patients before diagnosis Variable No. of % patients TB symptoms at diagnosisa Cough 786 98.3 Fever 613 76.6 Weight loss 589 73.6 Chest pain 527 65.9 Haemoptysis 250 31.3 Other 38 4.8 Symptoms causing patients to seek care Cough 643 80.4 Fever 27 3.4 Haemoptysis 66 8.3 Chest pain 50 6.3 Weight loss 6 0.8 Other 8 1.0 First place of seeking advice for care after onset of symptoms Health care provider 733 91.9 Pharmacy 35 4.4 None (self-medication) 21 2.6 Traditional medicine 7 0.9 Primary care worker at home 2 0.3 Other 0 0.0 First health care provider visited before diagnosis Private clinic or hospital 633 79.1 Public hospital 143 17.9 Primary health centre 14 1.8 NTP centre 9 1.1 Chest hospital 0 0.0 Other 0 0.0 Specialty of private health care provider visited before diagnosis (n = 633) Chest specialist 319 50.4 General practitioner 122 19.3 Internist 163 25.8 Other 29 4.5 No. of health care providers consulted before diagnosis 0 1 0.1 1 467 58.4 2 189 23.6 3 89 11.1 4 41 5.1 5 13 1.6 536 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما visited more than 1 and up to 5 health care providers (Table 2). The main reason for delayed care seek- ing was hoping that symptoms would re- solve without treatment (30.3%), while half of patients did not admit to a delay in seeking care (Table 2). Initial TB diagnosis in the health care system Despite their initial health-seeking behav- iour, almost half the patients were diagnosed Table 3 Pattern of health services delivered to 800 tuberculosis patients Variable No. of % patients Health provider who made first diagnosis Health care provider 386 48.2 None (self-medication) 3 0.4 Traditional medicine 0 0.0 Primary care worker at home 145 18.1 Pharmacy 266 33.3 Other 0 0.0 Specialty of private health care provider making initial diagnosis (n = 300) Chest specialist 45 15.0 Internist 164 54.7 General practitioner 74 24.7 Other 17 5.7 Diagnostic actions X-ray and sputum 762 95.3 Referral 19 2.4 X-ray only 14 1.8 Sputum only 5 0.6 Other 0 0.0 X-ray result Positive 795 99.4 Negative 0 0 Not performed 5 0.6 with TB in an NTP centre (48.2%). Within the private sector, diagnosis was mainly done by internists (54.7%). The first action after suspecting TB was to request a spu- tum smear examination and X-ray (95.3%). Diagnosis was rarely based on sputum smear examination only (0.6%) and referral accounted for 2.4% of cases (Table 3). Reasons for consulting the NTP centre were: free services (30.5%), confidence in getting cured (27.6%), and accessibility (short travel distance) (22.0%). Delay in Table 2 Health-seeking behaviour of 800 tuberculosis (TB) patients before diagnosis (concluded) Variable No. of % patients Reason for choosing a health care provider Free service 244 30.5 Confidence in getting cured 221 27.6 Accessible (short travel distance) 176 22.0 Services available anytime 45 4.6 Referred by previous health service 14 1.6 Free service 66 8.3 Recommended by somebody 34 4.3 Other 0 0.0 Reason for not visiting a health care provider at onset of symptoms Too busy/long waiting time 233 30.0 Bad experience 231 28.4 Too far 133 17.1 Other 180 23.3 Reason for delay in seeking care No delay 414 51.8 Hoped to recover 242 30.3 Fear of diagnosis 51 6.4 Economic constraints 55 5.8 Poor quality of health services 7 0.9 Fear of social isolation 6 0.8 Poor staff attitude 1 0.1 Other 24 3.0 aMultiple answers possible. NTP = national TB control programme. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 537 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما consulting the NTP centre was attributed to bad experiences (28.4%) and the distance from residence (17.1%). Determinants of delay Table 4 summarizes the mean and median delays at all stages between onset of symp- toms and start of DOTS treatment. Patient related diagnostic delay The mean duration between onset of symp- toms and first seeking care was 52.7 days (range 0–426) and the median was 31 days (Table 4). To establish the determinants of de- lay due to patient related factors, patients were analysed in 2 groups: delay ≤ the median and > the median. The significant risk factors for delay in seeking care were: inadequate knowledge regarding the disease (1.07-fold increased risk), seeking care at a non-specialized provider (not a health care provider) (5.66-fold increased risk com- pared with health care provider) and more than 1 health care encounter before diagno- sis (1.20-fold increased risk) (Table 5). Diagnostic delay The mean duration between onset of symp- toms and diagnosis was 77.6 days and the median diagnostic delay was 55 days (Ta- ble 4). Again, patients were grouped into 2 groups for analysis: ≤ median and > me- dian. The significant risk factors for diag- nostic delay were: older age (1.02-fold increased risk for each year), living far from the health facility (2.20-fold increased risk), high degree of stigma (1.22-fold increased risk), inadequate knowledge regarding the disease (1.07-fold increased risk), seeking care at a non-specialized provider (not a health care provider) (3.22-fold increased risk compared to health care provider); and more than 1 health care encounter before di- agnosis (2.14-fold increased risk) (Table 6). Treatment delay The mean duration between diagnosis and start of treatment was 2.9 days and the median treatment delay was 1 day from diagnosis (Table 4). Health care system delay The mean duration between seeking health care in the health system and start of treat- ment was 27.6 days and the median health care system delay was 15 days (Table 4). Table 4 Average delay for tuberculosis patients at different stages from onset of symptoms to start of treatment (see text for definitions) Variable Mean (SD) Median Range 25th 75th (days) (days) (days) percentile percentile (days) (days) Patient related diagnostic delay 52.7 (62.1) 31 0–426 28 61 Health system related diagnostic delay 24.8 (39.4) 11.5 0–372 3 29 Diagnostic delay (total) 77.6 (78.6) 55 2–698 34 93 Treatment delay 2.9 (5.6) 1 0–89 0 3 Health system delay 27.6 (39.6) 15 1–372 6 31 Total delay 79.0 (80.4) 57 2–702 36 97 SD = standard deviation. 538 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 5 Determinants of patient related diagnostic delay in patients delaying above and below the median (31 days) Variable Delay ≤ median Delay > median Crude OR Adjusted OR No. % No. % (95% CI) (95% CI) (n = 450) (n = 316) Age (years) ≤ 35 323 62.4 195 37. 6 1 1 > 35 127 51.2 121 48.8 1.58 (1.16–2.14)* 1.01 (0.99–1.03) Sex Male 283 58.2 203 41.8 1 1 Female 167 59.6 113 40.4 0.94 (0.70–1.27) 1.20 (0.78–1.86) Marital status Married 239 57.6 176 42.4 1 1 Single 197 62.3 119 37.7 0.82 (0.60–1.12) 0.91 (0.61–1.37) Widowed/divorced 14 40.0 21 60.0 2.04 (0.96–4.36) 1.58 (0.73–3.44) Residence Urban 152 57.1 114 42.9 1 Suburban 98 63.6 56 36.4 0.76 (0.50–1.17) 0.90 (0.57–1.41) Rural 189 57.8 138 42.2 0.97 (0.69–1.37) 1.07 (0.74–1.55) Homeless 11 57.9 8 42.1 0.97 (0.34–2.70) 1.21 (0.42–3.46) Education University or higher 11 55.0 9 45.0 1 1 Primary/senior 288 59.5 196 40.5 0.83 (0.31–2.23) 1.78 (0.59–5.34) Illiterate/read &write 151 57.6 111 42.4 0.90 (0.33–2.45) 1.29 (0.87–1.93) Occupation Technical/professional 20 60.6 13 39.4 1 1 Clerical/worker 215 58.6 152 41.4 1.09 (0.50–2.40) 0.53 (0.22–1.27) Students 20 69.0 9 31.0 0.69 (0.21–2.24) 0.91 (0.60–1.38) Unemployed/housewife 195 57.9 142 42.1 1.12 (0.51–2.48) 0.80 (0.32–2.00) Financial status Savings 26 41.3 37 58.7 1 1 Income = expenses 309 59.9 207 40.1 0.47 (0.27–0.83) 0.40 (0.23–0.71)* In debt 115 61.5 72 38.5 0.44 (0.24–0.82) 0.38 (0.20–0.71)* Crowding index ≤ 2 232 59.2 160 40.8 1 1 > 2 218 58.3 156 41.7 1.04 (0.78–1.38) 1.02 (0.92–1.12) Travelling time to health facility (h) < 0.5 411 59.3 282 40.7 1 1 0.5–1 26 54.2 22 45.8 1.23 (0.66–2.30) 1.28 (0.68–2.41) > 1 13 52.0 12 48.0 1.35 (0.57–3.19) 1.30 (0.54–3.16) Chronic disease No 404 60.2 267 39.8 1 1 Yes 46 48.4 49 51.6 1.61 (1.05–2.48) 1.30 (0.78–2.15) Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 539 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Total delay The mean duration between onset of symp- toms and start of DOTS treatment was 79.0 days for all patients and the median total delay was 57 days. Analysing patients above and below the median, the significant risk factors for total delay were living far from the health facility (2.51-fold increased risk), high degree of stigma (1.17-fold increased risk), seeking care at a non-specialized provider (not a health care provider) (3.56-fold increased risk compared to health care provider) and more than 1 health care encounter before diagnosis (2.04-fold increased risk) (Table 7). Discussion Delays in diagnosis and treatment of TB can occur at a number of points, from the time a patient develops symptoms until treatment is started on anti-TB drugs. Delays caused by the patient can occur during the process of noticing symptoms, deciding if one is ill, assessing the need for professional care, and overcoming social, personal, and physical barriers to obtaining care from the health care system. Delays in diagnosis can be be- cause the differential diagnosis can broaden or become more focused depending on key Table 5 Determinants of patient related diagnostic delay in patients delaying above and below the median (31 days) (concluded) Variable Delay ≤ median Delay > median Crude OR Adjusted OR No. % No. % (95% CI) (95% CI) (n = 450) (n = 316) Satisfaction with care Optimal 367 59.3 252 40.7 1 1 Suboptimal 83 56.5 64 43.5 1.12 (0.78–1.62) 1.02 (0.92–1.12) Stigma Low 29 67.4 14 32.6 1 1 High 421 58.2 302 41.8 1.49 (0.77–2.86) 1.06 (0.92–1.23) Knowledge Adequate 41 62.1 25 37.9 1 1 Inadequate 408 58.5 289 41.5 1.16 (0.69–1.95) 1.07 (1.01–1.14)* First place of seeking care Health care provider 435 61.8 269 38.2 1 1 Other 15 24.2 47 75.8 5.07 (2.69–9.67) 5.66 (3.02 –10.6)* Health care provider at first consultation NTP 15 65.2 8 34.8 1 1 Public 78 58.2 56 41.8 1.35 (0.49–3.75) 1.22 (0.45–3.32) Private 357 58.6 252 41.4 1.32 (0.52–3.46) 1.30 (0.51–3.32) No. of health care provider encounters before diagnosis 1 276 61.7 171 38.3 1 1 >1 174 54.5 145 45.5 1.35 (1.01–1.80) 1.20 (1.02–1.40)* *P < 0.05 NTP = national tuberculosis control programme; OR = odds ratio; CI = confidence interval. n = total number of respondents. 540 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 6 Determinants of diagnostic delay in patients delaying above and below the median (55 days) Characteristic Delay ≤ median Delay > median Crude OR Adjusted OR No. % No. % (95% CI) (95% CI) (n = 390) (n = 376) Age (years) ≤ 35 290 56.0 228 44.0 1 1 > 35 100 40.3 148 59.7 1.88 (1.38–2.56) 1.02 (1.00–1.03)* Sex Male 252 51.9 234 48.1 1 1 Female 138 49.3 142 50.7 1.11 (0.83–1.49) 1.11 (0.71–1.74) Marital status Married 202 48.7 213 51.3 1 1 Single 177 56.0 139 44.0 0.74 (0.55–1.01) 0.96 (0.63–1.45) Widowed/divorced 11 31.4 24 68.6 2.07 (0.94–4.63) 1.47 (0.64–3.37) Residence Urban 135 50.8 131 49.2 1 1 Suburban 84 54.5 70 45.5 0.86 (0.57–1.30) 0.79 (0.50–1.26) Rural 163 49.8 164 50.2 1.04 (0.74–1.45) 0.96 (0.65–1.40) Homeless 8 42.1 11 57.9 1.42 (0.51–4.00) 1.40 (0.46–4.19) Education University or higher 11 55.0 9 45.0 1 1 Primary/senior 260 53.7 224 46.3 1.05 (0.40–2.82) 0.97 (0.32–2.94) Illiterate/read & write 119 45.4 143 54.6 1.47 (0.54–4.01) 1.06 (0.71–1.60) Occupation Technical/professional 18 54.5 15 45.5 1 Clerical/worker 193 52.6 174 47.4 1.08 (0.50–2.34) 0.71 (0.29–1.71) Student 17 58.6 12 41.4 0.85 (0.27–2.62) 0.93 (0.60–1.43) Unemployed/housewife 162 48.1 175 51.9 1.30 (0.60–2.81) 1.04 (0.44–2.49) Financial status Have savings 24 38.1 39 61.9 1 1 Income = expenses 259 50.2 257 49.8 0.61 (0.34–1.08) 0.46 (0.25–0.83)* In debt 107 57.2 80 42.8 0.46 (0.25–0.86) 0.37 (0.20–0.72)* Crowding index ≤ 2 209 53.3 183 46.7 1 1 > 2 181 48.4 193 51.6 1.22 (0.92–1.62) 1.08 (0.97–1.19) Chronic disease No 354 52.8 317 47.2 1 1 Yes 36 37.9 59 62.1 1.83 (1.18–2.85) 1.51 (0.88–2.58) Time to reach the health facility (h) < 0.5 361 52.1 332 47.9 1 1 0.5–1 17 35.4 31 64.6 1.98 (1.04–3.82) 2.20 (1.12–4.34)* > 1 12 48.0 13 52.0 1.18 (0.50–2.80) 1.28 (0.52–3.15) Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 541 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما pieces of information. For example, a phy- sician who has a high clinical suspicion of TB and a smear-positive sputum result will probably initiate treatment more quickly than one with a low clinical suspicion and a smear-negative result. Furthermore, the clinic may be considering diagnoses other than TB. The total delay to treatment could be related to the method of estimating the time from onset of symptoms to initiation of treatment, but could also be a true difference in delay to diagnosis. The estimation of the date of onset of symptoms is liable to error, due to recall bias and individual variations in the perception of disease. In addition, what has been defined as the onset of symptoms by the patient could in fact be related to an- other disease that either coincided with the beginning of TB or had favoured it. Indeed, patients frequently reported symptoms sug- gesting viral infection or other disease at the onset of disease. The estimate of the delay to treatment therefore lies within a wide range, the limits of which are defined by the Table 6 Determinants of diagnostic delay in patients delaying above and below the median (55 days) (concluded) Characteristic Delay ≤ median Delay > median Crude OR Adjusted OR No. % No. % (95% CI) (95% CI) (n = 390) (n = 376) Satisfaction with care Optimal satisfaction 313 50.6 306 49.4 1 1 Suboptimal satisfaction 77 52.4 70 47.6 0.93 (0.65–1.33) 0.94 (0.85–1.05) Stigma Low degree 27 62.8 16 37.2 1 1 High degree 363 50.2 360 49.8 1.67 (0.89–3.16) 1.22 (1.05–1.42)* Knowledge Adequate 33 50.0 33 50.0 1 1 Inadequate 356 51.1 341 48.9 0.96 (0.58–1.59) 1.07 (1.01–1.14)* HSB with onset of symptoms (first place of seeking health care) Health care provider 372 52.8 332 47.2 1 1 Other 18 30.0 44 70.0 2.74 (1.50–5.03) 3.22 (1.74–5.96)* Health care facility at first consultation NTP centre 14 61.0 9 39.0 1 1 Public 73 54.5 61 45.5 1.30 (0.49–3.53) 0.98 (0.37–2.63) Private 303 49.8 306 50.2 1.57 (0.63–4.00) 1.20 (0.48–3..02) No. of health provider encounters before diagnosis 1 273 61.1 174 38.9 1 1 > 1 117 36.7 202 63.3 2.71 (2.01–3.44) 2.14 (1.77–2.60)* *P < 0.05. NTP = national tuberculosis control programme; OR = odds ratio; CI = confidence interval. n = total number of respondents. 542 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما occurrence of main events over the year and the individual’s perception of disease. This study highlights the prolonged de- lay from the onset of patients’ symptoms Table 7 Determinants of total delay in patients delaying above and below the median (57 days) Characteristic Adjusted OR (95% CI) Age 1.02 (1.00–1.04)* Sex Male 1 Female 1.01 (0.65–1.57) Marital status Married 1 Single 1.04 (0.69–1.58) Widowed/divorced 1.39 (0.60–3.19) Residence Urban 1 Suburban 0.84 (0.53–1.35) Rural 0.92 (0.63–1.35) Homeless 1.36 (0.45–4.13) Education University or higher 1 Primary/senior 1.06 (0.37–3.03) Illiterate/read &write 0.96 (0.32–2.91) Occupation Technical/professional 1 Clerical/worker 1.29 (0.56–2.99) Students 1.47 (0.47–4.61) Unemployed/housewife 1.42 (0.59–3.42) Financial status Have savings 1 Income = expenses 0.45 (0.25–0.80)* In debt 0.39 (0.20–0.74)* Chronic disease No Yes 1.28 (0.75–2.20) Time to reach the health facility (h) < 0.5 1 0.5–1 2.51 (1.27–4.98)* > 1 1.34 (0.54–3.27) Crowding index 1.10 (0.99–1.22) Characteristic Adjusted OR (95% CI) Satisfaction with care 0.96 (0.86–1.06) Stigma 1.17 (1.01–1.37)* Knowledge 1.06 (1.00–1.13) First place of seeking care Health care provider 1 Other 3.56 (1.91–6.64)* Health care facility at first consultation NTP centre 1 Public 1.21 (0.44–3.38) Private 1.25 (0.49–3.21) Health care facility at first diagnosis NTP centre 1 Public 1.01 (0.62–1.65) Private 1.01 (0.70–1.45) Specialty of health provider at first diagnosis Chest 1 Internist 0.93 (0.62–1.42) General practitioner 1.64 (0.95–2.84) Other 1.48 (0.48–4.54) No. of health provider encounters before diagnosis 1 > 1 2.04 (1.68–2.47)* *P < 0.05. NTP = national tuberculosis control programme; OR = odds ratio; CI = confidence interval. n = total number of respondents. until a diagnosis of smear-positive pulmo- nary TB is made. In this study the mean patient related diagnostic delay was 52.7 days. The mean patient related diagnostic delay in our study was longer than those reported in simi- lar studies in Egypt, Pakistan and Yemen [8–10], and less than those reported from Somalia [11,12]. Patient related diagnostic delay represented the main part (66%) of the total delay to treatment (79.0 days), Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 543 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما whereas the delays in diagnosis and treat- ment accounted on average for 34% of the total delay. This long patient delay was significantly associated with inadequate knowledge regarding the disease, seeking inital care at non-specialized individuals (not a health care provider) and having more than 1 health care encounter before diagnosis. Residence, sex and age showed no significant association and this may suggest that the most important determining factor for patients taking action about TB is knowledge about the disease; this is similar to what was observed in Yemen [10]. When asked why they had delayed seeking care, 28.4% of patients said that they delayed consulting the national TB control centre due to previous bad experiences and 17.1% because it was far from their residence, 30.3% were hoping that symptoms would resolve without treatment, while half of patients did not admit a delay in seeking care. There is a need to increase awareness of chest symptoms among patients. The mean diagnostic delay was 77.6 days, which is higher than the mean diag- nostic delay in Yemen (57.4 days) and in Egypt (55.9 days) [8,10] and lower than in Pakistan (96.3 days) [9] but similar to Somalia (76.6 days) [11]. A long distance between the patient’s home and the health facility was a signifi- cant risk factor for diagnostic delay. Most patients (90.3%) were living within half an hour of the health facility prior to imple- mentation of DOTS, but patients in some rural areas had to travel more than 1 hour to reach a health centre with microscopy facilities. The other significant risk factors for diagnostic delay were: older age, high degree of stigma, inadequate knowledge regarding the disease, seeking care at non- specialized individuals (not a health care provider), and more than 1 health care en- counter before diagnosis. The short treatment delay reflects the standard practice to start treatment as soon as a positive diagnosis is made. The mean treatment delay was 2.9 days: this is longer than in Egypt (1.2 days), Yemen (1.7 days), but less than in Somalia (4.5 days) and Pakistan (4.2 days) [8–11]. The mean health care system delay was 27.6 days. This is longer than in Yemen (20 days), Somalia (19.5 days), but less than in Egypt (33.9 days) and Pakistan (49 days) [8–11]. There are several limitations to this study. First, we were not able to determine the time of onset of symptoms in all patients in the study. Second, the medical records of some patients who sought care from pri- vate physicians were not available, which may have resulted in an underestimation of health care system delay in this group. Third, there may have been some recall bias from patients regarding the type, severity and onset of symptoms. Since health work- ers generally interview patients after they have begun TB treatment, patients may be more likely to report TB rather than non-TB symptoms. Fourth, it can be difficult to dif- ferentiate between patient and health care system delays; for example, a patient may have to wait to obtain an appointment with a health care provider. While this may be classified as a patient delay (the patient did not obtain the appointment) it may be more appropriate to classify this as a health care system delay (the patient sought care but it was not immediately available). This study is valuable for improving the quality of services and strengthening the ob- jectives of disease control; it highlights the importance of improving referral systems and access to diagnostic facilities for TB, at the same time as improving access to treat- ment if one wishes to reduce transmission of TB in the community. It shows also the importance of increasing awareness of the 544 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما signs and symptoms of TB in the general population and working closely with health care providers at all levels, including phar- macists, other drug sellers and traditional healers. The research results were presented at a meeting of the NTP committee and doctors in TB centres, and a series of recommen- dations based on these results have been made. These recommendations include the provision of on-the-job training to health providers working within and outwith the government health services and the pro- motion of a concerted effort to increase awareness of signs and symptoms of TB in the general population to encourage self- referral to the health services and thereby increase passive case detection. Conclusion and recommendations The long time interval between onset of symptoms and treatment reported in this study was mainly attributed to patient relat- ed diagnostic delay rather than delay within the health care system. The main study recommendations are to increase awareness of the community about chest symptoms and the availability of free diagnostic and therapeutic services, educating public and private health care providers about NTP guidelines, and increasing collaboration between both sectors. Acknowledgements We would like to express our sincere ap- preciation to the Syrian Minister of Health for kind approval to carry out the study and for support. Our gratitude is due to the staff of Tropical Diseases Research and Stop TB at the WHO Regional Office (EMRO) who backed this work with interest and support. This study received technical and finan- cial support from the joint WHO Eastern Mediterranean Region (EMRO), Division of Communicable Diseases (DCD) and the WHO Special Programme for Research and Training in Tropical Diseases (TDR): the EMRO DCD/TDR Small Grants Scheme for Operational Research in Tropical and Other Communicable Diseases. References 1. Stop TB partnership. Annual report 2005. Geneva, World Health Organization, 2006. 2. Annual report 2004. Damascus, Ministry of Health, Syrian Arab Republic, 2005. 3. Long NH. Longer delays in tuberculosis diagnosis among women. International journal of tuberculosis and lung disease, 1999, 3:388–93. 4. Safer MA et al. Determinants of three stages of delay in seeking care at a medi- cal clinic. Medical care, 1979, 17:11–29. 5. Acki M, Mori T, Shimao T. Studies on fac- tors influencing patients, doctors and total delay of tuberculosis case-detection in Japan. Bulletin of the International Union against Tuberculosis, 1985, 60:128–30. 6. Raj R et al. Factors associated with pa- tient and health system delays in the diagnosis of tuberculosis in south India. International journal of tuberculosis and lung disease, 2002 6:789–95. 7. Long NH. Longer delays in tuberculosis diagnosis among women in Vietnam. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 545 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما International journal of tuberculosis and lung disease, 1999, 3:388–93. 8. Soliman SS. Case-finding in tuberculosis patients: diagnostic and treatment delays and their determinants. Egypt nationwide. In: Operational research in tropical and other communicable diseases. Final re- port summaries 2001–2002. Cairo, WHO Regional Office for the Eastern Mediter- ranean, 2004 (WHO-EM/TDR/007/E). 9. Agoatwala M. Case-finding in tuberculosis patients: diagnostic and treatment delays and their determinants. Pakistan, Karachi. In: Operational research in tropical and other communicable diseases. Final re- port summaries 2001–2002. Cairo, WHO Regional Office for the Eastern Mediter- ranean, 2004 (WHO-EM/TDR/007/E). 10. Al-Absi A. Case-finding in tuberculosis patients: diagnostic and treatment delays and their determinants. Yemen nation- wide. In: Operational research in tropical and other communicable diseases. Fi- nal report summaries 2001–2002. Cairo, WHO Regional Office for the Eastern Med- iterranean, 2004 (WHO-EM/TDR/007/E). 11. Abdilahi AI. Case-finding in tuberculo- sis patients: diagnostic and treatment delays and their determinants. Somalia. In: Operational research in tropical and other communicable diseases. Final re- port summaries 2001–2002. Cairo, WHO Regional Office for the Eastern Mediter- ranean, 2004 (WHO-EM/TDR/007/E). 12. Wandwalo ER, Morkve O. Delay in tu- berculosis case-finding and treatment in Mwanaza, Tanzania. International journal of tuberculosis and lung disease, 2000, 4(2):133–8. Global tuberculosis control: surveillance, planning, financing Global tuberculosis control: surveillance, planning, financing is WHO’s twelfth annual report on global tuberculosis control in a series that started in 1997. This report presents WHO’s latest assessment of the epidemiological burden of TB (numbers of cases and deaths), as well as progress towards the 2015 targets for global TB control that have been established within the context of the Millennium Development Goals. It also includes a thorough analysis of implementation and financing of the WHO’s Stop TB Strategy and the Stop TB Partnership’s Global Plan to Stop TB. The report gives particular attention to the period 2005–2008, but selected epidemiological, implementation and financial data are presented for previous years as well. Bringing together data reported by 202 out of 212 countries and territories in 2007, as well as data collected from these countries and territories in previous years, this report is the definitive source of information about the national and international response to the worldwide TB epidemic. Further information about this and other WHO publications is available from http://www.who.int/bookorders/anglais/home1.jsp?sesslan=1 546 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Nosocomial pneumonia: risk factors, rates and trends M.M. Abdel-Fattah1 1Epidemiology and Research Unit, Department of Preventive Medicine, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia (Correspondence to M.M. Abdel-Fattah: mezo106@yahoo.com). Received: 20/12/05; accepted: 23/02/06 ABSTRACT This study aimed to estimate the rate of and risk factors for nosocomial pneumonia of pa- tients admitted to hospitals in Taif, Saudi Arabia. A case–control study was conducted of 211 discharged patients with confirmed pneumonia and 633 controls without pneumonia and a review was made of hospital records during 1999–2003. Multiple logistic regression showed that duration of hospital stay, unit of admission, chronic obstructive pulmonary diseases, coma, nasogastric tube, endotracheal tube, debilitating diseases and mechanical ventilation were independently associated with increased risk of pneumonia. The mean incidence of overall nosocomial infection in the period 1999–2003 was 3 per 100 discharged patients, while the mean incidence of nosocomial pneumonia was 0.88. @n¿™=èËÇí«nJj™=ËÇÑf¶=H>ÃJ¶×=6L>Â>×=ÆL×b£™=Æe>ìJ]×=¸º=Ç¢ \>J«¶=bF¢b»†hJ£º  „=Í[qØ6¸ [º=Ç¢ÆL×b[£ºfÈb[¯IÍ[i=eb¶=ÅdÂKªbÃJi==Ç[·]a?ÀÈd[¶=Î[uf™=›ËÇ[Ñf¶=H>[ÃJ¶×=f[ì] ÍÈaÇ£j[¶=ÍÉEf£¶=ͳ·»™=›¬Ñ>ì¶=›L>É«nJj™=*K[·bÂ=Çn[¶=ÆL×>[V·¶Í[i=eaK[ÈfQ?b[®Æ211À[º ÆËÇÑf¶=H>ÃJ¶×>E¼ÃJE>qCÀºKFNJ¶=¤ºL>É«nJj™=Àº=ÇQfÀÈd¶=Îuf™=633E>r[™=[¦bÂ=Çn[¶=Àº ËÇÑf¶=H>ÃJ¶×>EE>ºÌf[J«¶=¹Ø]LØRj·¶Í£Q=fºKÈfQ?Æ(1999Æ2003*j[QÇ·¶=¸É·VJ¶=fÞ?b®Æ ËÇÑf¶=H>ÃJ¶×=e>ìJ]=a>Èag>EœFIfº(ÌbUη¢Íɶ>J¶=¸º=Ç£¶=Àº¸º>¢¸²Á?­èÇVJ·¶ab£J™=6›Ð>¯F¶=Ìbº ºh™=ÍÈa=bj¾×=ÍÈÇÑf¶=z=fºÙ=(>ÃɶC¸]a?¶=ÌbUǶ=(ΫnJj™=HÇ[F¾Ù=(Ëb£™=Ê«¾Ù=HÇF¾Ù=(ÍEÇFɧ¶=(Í¿ ʳɾ>³É™=k«¿J¶=Æ(ͳÿ™=z=fºÙ=(ʺ>¦f¶=*Ìf[[J«¶=¹Ø[]ÍçÈÇí«n[Jj™=ÏÆb[£¶=¸[»Êì[iǶ=¹b[£™=>[º? ¨ ·Eb¯ªÌeDzd™=63Qçf[^™=Î[uf™=›äËÇí«n[Jj™=ËÇ[Ñf¶=H>[ÃJ¶×=PÆb[ƒÊì[iǶ=¹b£™=¨·EU›( >ÿº60.88¸³¶100Tçf‡xÈfº*  Pneumonie nosocomiale : facteurs de risque, taux et tendances RÉSUMÉ Cette étude visait à estimer le taux et les facteurs de risque de pneumonie nosocomiale chez les patients admis dans les hôpitaux de Ta’if (Arabie saoudite). Une étude cas-témoins a été menée sur 211 malades sortants présentant une pneumonie confirmée et sur 633 témoins ne présentant pas de pneumonie, et l’on a examiné les dossiers hospitaliers sur la période comprise entre 1999 et 2003. Une analyse de régression logistique multiple a montré que la durée de l’hospitalisation, le service dans lequel le patient a été admis, les bronchopneumopathies chroniques obstructives, le coma, les sondes gastriques (mises en place par le nez), les sondes endotrachéales, les maladies débilitantes et la ventilation artificielle étaient indépendamment associés à l’augmentation du risque de pneumonie. L’incidence moyenne de l’infection nosocomiale en général pendant la période comprise entre 1999 et 2003 était de 3, alors que l’incidence moyenne de la pneumonie nosocomiale était de 0,88 pour 100 malades sortants. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 547 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Nosocomial infection is becoming recog- nized as a major problem in developing countries. As well as its contribution to the morbidity and mortality of hospital- ized patients, nosocomial infection is an economic burden due to the extra days of hospitalization and the more expensive therapy that is required [1,2]. Up to 10% of all hospital patients develop nosocomial infections [3,4]. Nosocomial pneumonia (NP) is a significant cause of morbidity and mortality among hospitalized patients [5]. It is defined as pneumonia that was neither present nor incubating when the patient was admitted to the hospital [6]. NP is the 2nd most common nosocomial infection in the United States and worldwide [6] and is the most frequent nosocomial infection in in- tensive care units (ICUs). In recent studies, the incidence was reported to range from 6.8% to 27% [7–11]. Patients with NP tend to stay 1 to 2 weeks longer in hospital than those without NP and result in higher costs [12]. Prevention and management of such infections require an intimate knowledge of the epidemiology of the infection, includ- ing risk factors [13,14]. Hospital infection control programmes can prevent 33% of nosocomial infections including pneumonia [15]. Studies on NP have mainly been re- ported from the United States and European countries, and studies from around the world are scarce. This study aimed to estimate the rates of overall nosocomial and pneumonia and their linear trends over the last 5 years (1999–2003) and to determine the potential risk factors for NP of patients admitted to hospitals in Taif, Saudi Arabia, in order to establish a plan for reducing the incidence of NP in these hospitals. Methods To fulfil the objectives of this study, 2 strat- egies were adopted: a case–control study to determine the risk factors for NP and a record review to calculate NP rates. Case–control study The case–control study was carried out between April 2003 and March 2005 at Al- Hada (351 beds), Al-Rehab (100 beds) and Prince Sultan (50 beds) military hospitals, Taif, Saudi Arabia. These 3 hospitals are under the same administrative programme and serve military people and their families. All patients hospitalized at these hospitals for at least 72 hours throughout the study pe- riod were considered eligible for the study. Among these, patients proven to have pneu- monia were considered cases. Nosocomial pneumonia was considered when new and persistent (more than 48 hours) pulmonary infiltrates not otherwise explained appeared on chest radiographs. Moreover, at least 2 of the following criteria were also required: (1) fever > 38 ºC; (2) peripheral leukocyte count > 10 000/mm3; (3) purulent endotra- cheal secretions with a Gram stain showing 1 or more types of bacteria [6]. Ventilator- associated pneumonia was considered when the onset of pneumonia was after 48 hours of mechanical ventilation [16]. After exclusion of patients who did not fulfil the eligibility criteria, 3 controls for each case were enrolled by simple random selection from a list of patients hospitalized for more than 72 hours who did not develop any type of nosocomial infections. Nosoco- mial infections were diagnosed based on the Centers for Disease Control and Prevention criteria for diagnosis of nosocomial infec- tions [17]. For all participants (cases and controls), the following information was col- 548 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما lected: age, sex, unit of admission, smoking history, nasogastric tube, endotracheal tube, mechanical ventilation, history of surgery (head, neck, or thoracoabdominal), chronic obstructive pulmonary diseases (COPD), coma, diabetes mellitus, history of immu- nosuppressive drug intake, inappropriate use of antibiotics, history of debilitating diseases (cancer, liver failure, uraemia) as well as duration of hospital stay. Appropriate antibiotic therapy included the administration of at least 1 empirical an- tibiotic with in vitro activity against the bac- terial pathogens isolated from the patient’s respiratory secretions, as well as from blood and pleural fluid when applicable [18]. The data from the patients’ records were collected during the hospital stay of the patients by a trained nosocomial infection surveillance team from the Department of Preventive Medicine. Record review Hospital records, providing the number of hospitalized patients and the numbers of nosocomial infections (crude and site- specific) per month were reviewed. The overall annual nosocomial infection rate and NP rates were calculated during the period 1999–2003 by dividing the total number of nosocomial infections (crude and pneumonia) pooled throughout all months by the total number of hospital patients dis- charged including hospital deaths (× 100). Critically ill patients (those admitted to the medical, surgical, neonatal or burns ICUs), were treated as a separate group. Overall nosocomial infection and NP rates were calculated for this particular group. Statistical analysis Statistical analysis was carried out with SPSS, version 11.0. A linear trend was ap- plied to search for evidence of change in the incidence rate of overall nosocomial and pneumonia over time. Age, sex, duration of stay in hospitals, unit of admission, smok- ing, nasogastric tube, endotracheal tube, mechanical ventilation, surgery, COPD, coma, diabetes mellitus, underlying debili- tating diseases and history of immunosup- pressive drugs were treated as categorical variables. The crude measure of association between single putative risk factors and NP was expressed as the odds ratio (OR) with 95% confidence interval (95% CI). Multi- ple associations were evaluated in multiple logistic regression models based on the backward stepwise selection. This process allowed the estimation of the strength of the association between each independent vari- able and the dependent variable, taking into account the potential confounding effects of the other independent variables. The covariates were removed from the model if the likelihood estimates had a probability > 0.10. Each category of the predictor varia- bles was contrasted with the initial category (reference category). An adjusted odds ratio with 95% CI that did not include 1.0 was considered significant. The significance level of the P value was set at 0.05. Results A total of 211 discharged patients with NP and 633 controls without NP were re- cruited. Their baseline characteristics (age and sex) are reported in Table 1. The age of cases ranged from 2 days to 91 years [mean 42.8 (standard deviation 29.3) years; median 47.0 years], while for controls it ranged from 2 days to 87 years [mean 40.7 (SD 29.4) years; median 46.0 years]. The difference between the 2 groups was not statistically significant (P = 0.27). Females represented 49.3% and 45.2% of cases and controls, with no significant difference (P > 0.05). Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 549 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The results of univariate analysis of risk factors for NP are summarized in Table 2. Patients aged > 65 years were more liable to develop NP compared with those aged ≤ 15 years (OR = 1.80; 95% CI: 1.13–2.88). Nosocomial pneumonia was significantly associated with stay in hospital > 3 weeks as opposed to < 1 week (OR = 5.44; 95% CI: 3.14–9.42). Patients admitted to surgi- cal, ICU or burns units were more liable to develop NP than those admitted to medi- cal units (OR = 2.15; 95% CI: 1.39–3.32; OR = 3.96; 95% CI: 2.38–6.59; and OR = 3.09; 95% CI: 1.77–5.36 respectively). Presence of nasogastric tube and insertion of endotracheal tube were also associated with NP. Patients with a history of presence of nasogastric tube had an increased risk of NP as compared with patients with no history of nasogastric tube (OR = 2.35; 95% CI: 1.45–3.80). Patients with a history of insertion of endotracheal tube had a 3-fold risk as opposed to those with no history of endotracheal tube (OR = 3.14; 95% CI: 1.71–5.77). Mechanical ventilation history was strongly and positively related to NP (OR = 6.69; 95% CI: 4.40–10.19). The presence of underlying debilitating disease and COPD were also significantly associ- ated with an increased NP risk (OR = 3.08; 95% CI: 1.91–4.97 and OR = 3.52; 95% CI: 1.15–10.93 respectively). Comatose patients had a 4-fold increased risk of NP (OR = 4.60; 95% CI: 1.14–19.59). History of inappropriate use of antibiotics was asso- ciated with a higher risk of NP (OR = 1.75; 95% CI: 1.02–2.99). Patient’s sex, history of smoking, history of immunosuppressive drugs, presence of diabetes mellitus, as well as history of surgery were not independ- ently associated with NP. The results of multivariate logistic re- gression analysis of the studied risk factors for NP are summarized in Table 3. Nosoco- mial pneumonia was significantly associ- ated with stay in hospital for > 3 weeks as opposed to < 1 week (OR = 2.18; 95% CI: 1.24–3.29). Regarding unit of admission, patients admitted to the ICU or burns unit were more liable to develop NP than those Table 1 Baseline characteristics of participants in the case–control study of risk factors for nosocomial pneumonia Baseline Cases Controls Total characteristics (n = 211) (n = 633) (n = 844) No. % No. % No. % Age (years)a ≤ 15 38 18.0 156 24.6 194 23.0 > 16–45 53 25.1 162 25.6 215 25.5 > 46–65 40 19.0 133 21.0 173 20.5 > 65 80 37.9 182 28.8 262 31.0 Mean (SD) 42.8 (29.3) 40.7 (29.4) 41.8 (29.1) Median 47.0 46.0 46.0 Range 2 days–91 years 2 days–87 years 2 days–91 years Sexa Male 107 50.7 347 54.8 454 53.8 Female 104 49.3 286 45.2 390 46.2 aP > 0.05. SD = standard deviation. 550 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 2 Risk factors for nosocomial pneumonia from the univariate analysis (211 cases and 633 controls) Risk factors No. of cases/ Crude 95% CI controls OR Age (years) ≤ 15a 38/156 1.0 16–45 53/162 1.34 0.82–2.21 46–65 40/133 1.23 0.73–2.10 > 65 80/182 1.80 1.13–2.88* Sex Malea 107/347 1.0 Female 104/286 1.18 0.85–1.63 Duration of stay in hospitals (weeks) < 1a 125/453 1.0 1–3 44/152 1.05 0.70–1.58 > 3 42/28 5.44 3.14–9.42* Unit of admission Medicala 78/369 1.0 Surgical 50/110 2.15 1.39–3.32* Intensive care unit 41/49 3.96 2.38–6.59* Burns 30/46 3.09 1.77–5.36* Other 12/59 0.96 0.47–1.95 Smoking Noa 166/515 1.0 Yes 45/118 1.18 0.79–1.77 Inappropriate use of antibiotics Noa 185/586 1.0 yes 26/47 1.75 1.02–2.99* Nasogastric tube Noa 175/582 1.0 Yes 36/51 2.35 1.45–3.80* Endotracheal tube Noa 186/607 1.0 Yes 25/26 3.14 1.71–5.77* Mechanical ventilation Noa 133/582 1.0 Yes 78/51 6.69 4.40–10.19* Surgery b Noa 204/617 1.0 Yes 7/16 1.32 0.49–3.48 Coma Noa 205/629 1.0 Yes 6/4 4.60 1.14–19.59* Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 551 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما admitted to medical units (OR = 2.73; 95% CI: 1.68–4.01 and OR = 3.05; 95% CI: 1.74–4.13 respectively). Presence of na- sogastric tube and insertion of endotracheal tube were associated with NP. Patients with history of presence of NG tube had an increased risk of NP as compared to patients with no history of NG tube (OR = 2.18; 95% CI: 1.22–5.14). Patients with history of insertion of endotracheal tube had a 3-fold risk as opposed to those with no history of insertion of endotracheal tube (OR = 3.01; 95% CI: 1.87–6.21). Mechanical ventilation history was strongly and positively related to NP (OR = 6.27; 95% CI: 2.22–9.52). The presence of underlying debilitating disease and COPD were also significantly associ- ated with an increased NP risk (OR = 3.11; 95% CI: 1.29–8.18 and OR = 2.96; 95% CI: 1.98–14.13 respectively). Comatose patients had a 3-fold increased risk of NP (OR = 3.99; 95% CI: 2.87–17.03). Age, sex, history of smoking, history of immu- nosuppressive drugs and inappropriate use of antibiotics, diabetes mellitus, as well as history of surgery were not independently associated with NP. The incidence of overall nosocomial in- fection during the study period (1999–2003) ranged from 2.1 to 3.5 per 100 discharged patients with a mean of 3.0, while the in- cidence of NP ranged from 0.6 to 1.1 per 100 discharged patients with a mean of 0.88 with no significant trend (P > 0.05) (Table 4). NP represented approximately 30.9% of overall nosocomial infection during the study period. Regarding critically ill patients as a separate group, the mean overall nosoco- mial infection and NP rates were 15.42 and 8.0 per 100 patients respectively throughout the study period (Table 4). There was an Table 2 Risk factors for nosocomial pneumonia from the univariate analysis (211 cases and 633 controls) (concluded) Risk factors No. of cases/ Crude 95% CI controls OR Chronic obstructive pulmonary disease Noa 203/626 1.0 Yes 8/7 3.52 1.15–10.93* Diabetes mellitus Noa 147/470 1.0 Yes 64/163 1.26 0.88–1.79 Underlying debilitating diseasec Noa 170/587 1.0 Yes 41/46 3.08 1.91–4.97* Immunosuppressive drugs Noa 198/612 1.0 Yes 13/21 1.91 0.89–4.09 aReference category. bHead, neck, thoracoabdominal. cCancer, liver failure, uraemia. *P < 0.05. OR = odds ratio; CI = confidence interval. 552 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 0.05). NP represented around half of overall nosocomial infections (51.7%). Discussion Hospital-acquired pneumonia represents a significant impairment in the quality of health care. The reported incidence of NP in ICUs varies across different studies, which may be explained by the presence of different populations with variable ages, underlying diseases and other associated risk factors. Incidence ranges from 6.8% to 27% [7–11,19]. In this study it was 8%. Independent risk factors associated with NP included prolonged hospital stay, endotra- cheal tube, nasogastric tube, mechanical ventilation, underlying debilitating diseas- es, coma and COPD. Those risk factors could prove useful in identifying patients at high risk for NP, as well as in develop- ing preventive measures such as avoiding unnecessary nasogastric feeding or endotra- cheal intubations. Mechanical ventilation increases the risk of NP 3- to 10-fold [7,20–22]. Gener- ally, the duration of mechanical ventilation increases the risk: Cook et al. reported that the rate of ventilator-associated pneumonia increased 3% per day in the 1st week of ventilation, 2% per day in the 2nd week, and 1% per day in the 3rd week [23]. In our study, patients on mechanical ventilation had a 6-fold higher risk for developing NP than the non-ventilated patients. Conse- quently, the use of noninvasive mechanical ventilation should be preferred whenever possible since it has lower rates of nosoco- mial infections [24]. Coma was described as another impor- tant risk factor for NP. In these patients, local defence mechanisms of the respiratory airway are altered, allowing microorgan- isms to better attach to and colonize the Table 3 Risk factors for nosocomial pneumonia from the multivariate analysis Risk factor Adjusted 95% CI OR Duration of stay in hospitals (weeks) < 1a 1.0 1–3 1.06 0.68–2.14 > 3 2.18 1.24–3.29* Unit of admission Medicala 1.0 Surgical 1.91 0.96–4.01 Intensive care unit 2.73 1.68–4.01* Burns 3.05 1.74–4.13* Others 1.16 0.71–1.52 Nasogastric tube Noa 1.0 Yes 2.18 1.22–5.14* Endotracheal tube Noa 1.0 Yes 3.01 1.87–6.21* Mechanical ventilation Noa 1.0 Yes 6.27 2.22–9.52* Underlying debilitating diseaseb Noa 1.0 Yes 3.11 1.29–8.18* Coma Noa 1.0 Yes 3.99 2.87–17.03* Chronic obstructive pulmonary disease Noa 1.0 Yes 2.96 1.98–14.13* *P < 0.05. aReference category. bCancer, liver failure, uraemia. OR = odds ratio; CI = confidence interval. Age and history of prolonged inappropriate use of antibiotics were removed from the final model. increasing trend in the incidence of NP and in the ratio of NP to total nosocomial infec- tions during the entire study period (P < Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 553 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ta bl e 4 D is tr ib u ti o n o f to ta l d is ch ar g ed p at ie n ts a n d c ri ti ca lly il l p at ie n ts a cc o rd in g t o t h e p re se n ce o f n o so co m ia l in fe ct io n a n d p n eu m o n ia , A l- H ad a, S au d i A ra b ia ( 19 99 –2 00 3) Ye ar A ll p at ie n ts C ri ti ca lly il l p at ie n ts a To ta l N o so co m ia l N o so co m ia l N o so co m ia l To ta l N o so co m ia l N o so co m ia l N o so co m ia l d is ch ar g ed in fe ct io n p n eu m o n ia p n eu m o n ia / d is ch ar g ed in fe ct io n p n eu m o n ia p n eu m o n ia / to ta l to ta l n o so co m ia l n o so co m ia l in fe ct io n r at e in fe ct io n r at e N o . N o . % N o . % % N o . N o . % N o . % % 19 99 14 3 91 29 8 2. 1 86 0. 6 28 .9 90 1 13 6 15 .1 64 7. 1 47 .1 20 00 10 6 72 37 3 3. 5 11 6 1. 1 31 .1 68 6 10 1 14 .7 49 7. 1 48 .5 20 01 9 1 14 27 4 3. 0 93 1. 0 33 .9 57 2 89 15 .6 44 7. 7 49 .4 20 02 9 7 82 22 4 2. 9 81 0. 8 36 .2 62 0 98 15 .8 55 8. 9 56 .1 20 03 1 2 68 5 44 1 3. 5 10 8 0. 9 24 .5 88 5 14 1 15 .9 81 9. 2 57 .4 a C rit ic al ly il l p at ie nt s w er e th os e ad m itt ed to th e m ed ic al , s ur gi ca l, ne on at al o r bu rn s in te ns iv e ca re u ni ts . mucosal surface. Furthermore, depression of the level of consciousness significantly increases the chance of aspiration and can result in development of NP [19]. In the cur- rent study, comatose patients had a 4-fold increased risk of NP. As Gram-negative bacteria are docu- mented to be the most common causative agents of NP [25], prior antibiotic therapy and COPD (leading to colonization with Gram-negative aerobic pathogens) were re- ported to be risk factors for the development of NP [26,27]. In our patient population, univariate analysis suggested that previous prolonged antibiotic treatment and COPD increased the risk of pneumonia, but only COPD was an independent risk factor in the multivariate analysis. Furthermore, the presence of a nasogastric tube was found to be a risk factor in our study popula- tion. NG tubes impair the function of the gastroesophageal sphincter and increase the risk of maxillary sinusitis, oropharyngeal colonization and reflux, all of which may lead to migration of bacteria [28]. However, to reduce the risk of NP, it is important to avoid unnecessary enteral nutrition [29]. The highest rates of NP were observed in ICUs, which are also the units in which the most severely ill patients are treated and in which the highest mortality rates are observed. Similar findings were found in another study [30]. In the literature, the insertion of an endotracheal tube is de- scribed as a significant risk factor for NP. Bronchial colonization during the proce- dure and prolonged continuation of sedation after the procedure will further increase the occurrence of NP [27], which is what was seen in the current study. Patients with endotracheal tube had a 3-fold increased risk of NP. In accordance with our find- ings, numerous studies have demonstrated that severe underlying illness predisposes 554 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما patients in the ICU to the development of pneumonia [22,31]. 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Catheter-associated urinary tract infections: epidemiology, pathogen- esis, and prevention. American journal of medicine, 1991, 91(Suppl. 3B):65S–71S. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 555 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 14. Mayhall G, Mayhall CG, eds. Hospital epidemiology and infection control, 2nd ed. Baltimore, Lippincott Williams and Wilkins, 1999. 15. Haley RW et al. The efficacy of infection surveillance and control programs in pre- venting nosocomial infections in US hos- pitals. American journal of epidemiology, 1985, 121:182–205. 16. Bonten MJM. Controversies on the diag- nosis and prevention of ventilator-associ- ated pneumonia. Diagnostic microbiology and infectious disease, 1999, 34:199– 204. 17. Garner JS et al. CDC definitions for no- socomial infections. In: Olmsted RN, ed. APIC infection control and applied epide- miology: principles and practice. St Louis, Mosby, 1996:A1–A20. 18. Blot S, Vandewoude K, Colardyn F. No- socomial bacteremia involving Acineto- bacter baumannii in critically ill patients: a matched cohort study. Intensive care medicine, 2003, 29:471–5. 19. Rello J et al. Nosocomial respiratory tract infections in multiple trauma patients. Influence of level of consciousness with implications for therapy. Chest, 1992, 102:525–9. 20. Celis R et al. Nosocomial pneumonia: a multivariate analysis of risk and progno- sis. Chest, 1988, 93:318–24. 21. Cross AS, Roup B. Role of respiratory as- sistance devices in endemic nosocomial pneumonia. American journal of medi- cine, 1981, 70:681–5. 22. Chastre J, Fagon JY. Ventilator-associ- ated pneumonia. American journal of respiratory critical care medicine, 2002, 165:867–903. 23. Cook DJ et al. Incidence of and risk fac- tors for ventilator associated pneumonia in critically ill patients. Annals of internal medicine, 1998, 129:433–40. 24. Girou E et al. Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients. Journal of the American Medical Association, 2000, 284:2361–7. 25. Abdel-Fattah M. Surveillance of nosoco- mial infections at a Saudi Arabian military hospital for a one-year period. German medical science, 2005, 3:Doc06. 26. Kollef MH. Ventilator-associated pneu- monia. A multivariate analysis. Journal of the American Medical Association, 1993, 270:1965–70. 27. Ewig S et al. Bacterial colonization pat- terns in mechanically ventilated patients with traumatic and medical head injury. American journal of respiratory critical care medicine, 1999, 159:188–98. 28. Leal-Noval SR et al. Nosocomial pneumo- nia in patients undergoing heart surgery. Critical care medicine, 2000, 28:935–40. 29. Memish ZA et al. The incidence and risk factors of ventilator-associated pneumo- nia in a Riyadh Hospital. Infection control and hospital epidemiology, 2000, 21:271– 3. 30. Alp E et al. Incidence, risk factors and mortality of nosocomial pneumonia in intensive care units: a prospective study. Annals of clinical microbiology and antimi- crobials, 2004, 3:17–27. 31. Rello J, Diaz E. Pneumonia in the in- tensive care unit. Critical care medicine, 2003, 31:2544–51. 556 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Antibacterial susceptibility of uropathogens in 3 hospitals, Sari, Islamic Republic of Iran, 2002–2003 M.J. Saffar,1 A.A. Enayti,1 I.A. Abdolla,1 M.S. Razai1 and H. Saffar1 1Department of Paediatrics, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran (Cor- respondence to M.J. Saffar: saffar@softhome.net). Received: 27/12/05; accepted: 14/03/06 ABSTRACT To determine the frequency and pattern of antibiotic susceptibility of uropathogens in urinary tract infection (UTI) from 3 university hospitals we carried out a retrospective review of urine culture and antibiotic sensitivity testing from symptomatic outpatients and inpatients during 2002–2003. Of 5600 samples, 703 (12.6%) were culture positive, 38.7% of which were from hospitalized patients. Escherichia coli was the leading cause of UTI in both groups of patients. The rates and roles of other pathogens, including Pseudomonas spp. (5.3%–10.4%), Enterobacter spp. (0%–5.7%), Staphylococ- cus spp.) 5.4%–26.4%), differed in each hospital. Differences in antibacterial susceptibility patterns were observed. Ampicillin (82%–100%) and co-trimoxazole (50%–90%) resistance were the most frequent. Methicillin resistance in Staphylococcus spp. ranged from 17% to 60%. Sensibilité aux antibactériens des uropathogènes dans trois hôpitaux de Sari (République islamique d’Iran), 2002-2003 RÉSUMÉ Afin de déterminer la fréquence et les caractéristiques de la sensibilité aux antibiotiques des uropathogènes lors d’une infection urinaire dans trois hôpitaux universitaires, nous avons effectué un examen rétrospectif des urocultures et des tests de sensibilité aux antibiotiques pratiqués sur des malades symptomatiques non hospitalisés et hospitalisés en 2002 et 2003. Sur 5600 échantillons, 703 (12,6 %) étaient positifs à la culture, et 38,7 % de ceux-ci provenaient des patients hospitalisés. Escherichia coli était la principale cause d’infection urinaire dans les deux groupes de patients. Les taux et le rôle des autres agents pathogènes, notamment Pseudomonas spp. (5,3 % à 10,4 %), Enterobacter spp. (0 % à 5,7 %) et Staphylococcus spp. (5,4 % à 26,4 %), n’étaient pas les mêmes dans chaque hôpital. Des différences ont été observées dans les profils de sensibilité aux antibactériens. La résistance à l’ampicilline (82 % à 100 %) et au cotrimoxazole (50 % à 90 %) était la plus fréquente. La résistance à la méthicilline de Staphylococcus spp. était comprise entre 17 % et 60 %. F¶= ÏÆb£¶=L>FFjº ÍE>RJi=Á=fÈC ÍÈeÇÖ (Ëe>i›L>É«nJjº ÍMØM› ¼ÉM=fR·¶ Ìa>v™= ÍÈÆaÚ¶ ÍÉ¶Ç (ÍɺØiÝ=2002–2003 e>«q=ÇÉÂ(ÊÈ>ue±a>qb»†(Ê÷¶=bF¢l>F¢(È>¿¢Ê·¢b—?(e>«qf«£Qb»†  „=Í[qØ6a>v™=ÍÈÆaÚ¶ÍɶÇF¶=ÏÆb£¶=L>FFjºÍE>RJi=Tc>”Æe=f³Iη¢­f£J¶=¸ÉFi›Í[MØM›¼ÉM=fR·¶Ì Í[ÈÇɃ=L=a>v[»·¶ÍE>RJi×=ƹÇF¶=¥e=hº>ÃɪÁÇNU>F¶=zf£Ji=ÍÈa>£Ji=Íi=eaKÈfQ?(ÍÉ£º>QL>É«nJjº Ìb[™=¹Ø[]z=f¢?ÀºÁdznÈÀÈd¶=É·]=b¶=ƐÉQe>„=Îuf™=Ïb¶2002–2003*Í[i=eb¶=K[·b[®Æ 5600>ÿº(Í¿É¢703Í¿É¢%12.6$!>EÍÉE>‹CÁ>²b®Æ(¥eh¶38.7!É[·]=aÎuf™>ÿº*ÍɳÈf[mÝ=K[·çNºÆ ÉQe>[„=Ɛɷ]=b¶=Îuf™=›ÍɶÇF¶=Ëe>=H>ÃJ¶×ÊjÉÑf¶=ßGFj¶=ÍɾǶǯ¶=*Ïf[]Ù=ÍFFj[™=¼ÉM=f[‚=>[º? ¬Ñ=Æh¶=Àºð>¢=Ǿ?Kç»vª%5.3!)10.4$!L>[ÈÇ£™=À[[ºð>¢=Ǿ?Æ(%0!-5.7$!ð>[¢=Ǿ?Æ(L>[[Èaǯ¿£¶=À[[º %5.4!)26.4$!L>É«nJj™=­ØJ]>EL×b£™=Æ¥=ǾÙ=Åd¬·JÆ(*›ð>v[È?L>[ªØJ]×=K[ŸUǶb[®Æ ·j[ÉFºÚ¶ð>[ºÆ>¯º>[ÿºÁ>[²>[º(>[ÿÉEð=fI=ÇIfN²Ù=Á>²Æ(¼ÉM=fR·¶Ìa>v™=ÍÈÆaÚ¶ÍE>RJi×=>”?%82!) 100$!¹Æg>j²Ç•fIdz·¶Æ%50!)90*$!º?À[[ÉEK[[UÆ=fIb¯ª·ÉjÉNÉ»·¶ͺÆ>¯™=L>Èaǯ¿£¶=¥=Ǿ?>17! Æ60*!  Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 557 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Urinary tract infection (UTI) remains a worldwide therapeutic problem, not only as a nosocomial disease but also as a community-acquired infection [1–5]. It poses a significant health risk because it can lead to urosepsis and/or renal scarring, progressive kidney damage with associated high mortality, morbidity, and economic loss [5,6]. Early diagnosis and prompt an- timicrobial treatment are required to mini- mize these complications [7]. The etiology of UTI and the antibi- otic susceptibility of urinary pathogens in both the community and hospitals have been changing, and in recent years antibi- otic resistance has become a major problem worldwide [8–12]. Resistant organisms have emerged owing to several factors related to the genetic nature of the organisms and selective antimicrobial pressure in humans and animals [13]. To ensure appropriate treatment, knowledge of the organisms that cause UTI and their antibiotic susceptibility is mandatory. As both temporal and local variables can modify these data, they need to be constantly re-evaluated to achieve maximum clinical response before the anti- bacterial sensitivity profiles of the isolated uropathogen is known [8–12]. The aim of this study was to determine the relative role of each uropathogen and their antibacterial sensitivity patterns in nosocomial and community-acquired UTI in 3 university hospitals in Sari, Islamic Republic of Iran. Methods Laboratory diagnosed UTIs in symptomatic patients were evaluated retrospectively over a period of 12 months (July 2002–July 2003) to document the common uropathogens and their antimicrobial susceptibility patterns. The study was conducted in 3 university hospitals in Sari, capital of Mazandaran province: • Boali-Cina Hospital; a general hospital with ~300 active beds and various out- patient clinics, the main medico-surgical centre serving neonatal and paediatric patients. Annual activity is 9300 admis- sions (4000 < 14 years), 3500 major surgeries and 315 000 outpatient visits; • Imam Hospital; the main surgical hos- pital (general surgery; gynaecological; neurological; urological; orthopaedic) with ~400 active beds and yearly activ- ity of 17 100 admissions, 7500 major surgeries and 200 000 outpatient visits; • Zaree Hospital; the sole burn centre, with ~100 beds, yearly admissions ~800 patients and 8000 outpatients and emer- gency visits. All the information recorded for each patient in the log books of each of the laboratories was reviewed. This included demographic data, urine culture results (type of bacterial growth and susceptibility patterns). The tests are routine procedures undertaken in a similar manner by profes- sional laboratory technicians in the univer- sity hospital laboratories. The antibacterial policy for empirical treatment of UTI in each setting since 1992–93 is shown in Table 1. Quantitative urine culture was performed at the microbiology laboratories within each hospital with a 0.01 mL calibrated loop to inoculate a blood agar base plate (Merck, Germany) and eosin methylene blue agar plate (ATD-Antec Diagnostic, UK). The plates were incubated at 37 °C for 24 hours. Bacterial isolates were identified by conventional procedures [14]. A positive urine culture was defined as the growth of ≥ 10 000 colony forming units/mL of a single uropathogen for specimens obtained 558 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما by suprapubic or catheterization methods and > 100 000 colony forming units/mL for samples collected by the clean-catch midstream technique. Antibiotic sensitivity testing was per- formed using the Kirby–Bauer disc diffusion method (Padtan–Teb, Tehran). Antibiotics tested for were: ceftriaxone, cefotaxime ceftazidime (in Imam and Zaree hospitals), amikacin, gentamicin, nalidixic acid, cipro- floxacin, norfloxacin (in Imam and Zaree hospitals), ampicillin and co-trimoxazole and for Gram-positive bacteria cefazolin, cephalexin, methicillin, vancomycin and clindamycin. The collected data were recorded and analysed using descriptive statistical meth- ods: percentile for relative role of each uropathogen and antibacterial susceptibility pattern and chi-squared test to compare dif- ferences between relative roles of antibiotic susceptibility both within and between each hospital. Results Of 5600 urine samples 703 (12.6%) were culture positive, 272 (38.7%) of which were from hospitalized patients. Distribution of samples collected from the 3 hospitals is shown in Table 2. Overall female/male ratio was 2.7. Escherichia coli was the leading cause of UTI in this study but its relative role was lower in inpatients (54.8%) compared Table 1 Antibacterial policy for empirical treatment of urinary tract infection at 3 hospitals in Sari, 2003 Hospital Complicated, inpatients Uncomplicated, outpatients Children Adults Children Adults Boali-Cina & Imam 1993–2000 Cephalosporina Ampicillin + Nalidixic acid Co-trimoxazole gentamicin 2000– …… Cephalosporina Cephalosporina Cefixime Co-trimoxazole/ ciprofloxacin Zaree No specific policy a3rd generation (mainly ceftriaxone). Table 2 Distribution of positive cultures for urine samples at 3 hospitals in Sari, 2003 Hospital Total samples Positive samples No. % No. % Inpatient/ Females/ outpatient males Boali-Cinaa 3363 60.0 404 57.5 166/238 2.3/1 Imamb 2036 36.4 261 37.1 68/193 2.4/1 Zareec 201 3.6 38 5.4 38/0 3.0/1 Total 5600 100.0 703 12.6 272/431 2.7/1 aAge distribution: 80.0% < 20 years; 54.5% < 5 years; 35.9% < 12 months. bAge distribution: 7.6% < 20 years; 27.4% > 70 years. cAll > 12 years. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 559 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما to outpatients (70.0%), and the relative rates of other uropathogens were higher. As shown in Table 3, the rank order of isolated uropathogens and their relative roles in different settings (inpatients and outpa- tients) in the 3 hospitals were as follows: Boali-Cina Hospital: most patients were neonates/children with a first episode of UTI, even in hospitalized patients. In Imam Hospital, most patients were adults. In Za- ree Hospital all cases were nosocomial. Urine cultures positive for fungi (Candida spp.) were reported from 3 (1.1 %) hospital- ized patients (2 neonates, 1 adult) who had urinary catheter. Most of the nosocomial UTI cases were adults with burns or patients with medical or surgical problems having short dura- tion urinary tract catheterization and/or antibacterial treatment, or children with febrile UTI. Although there were no significant differ- ences in antibacterial susceptibility patterns for samples from inpatients and outpatients for each uropathogen in each hospital, there were significant differences between hos- pitals. Most isolates were highly resistant to ampicillin (82%–100%) and cotrimoxa- zole (50%–90%). Conversely, most of the uropathogens isolated showed acceptable sensitivity to nitrofurantoin (57%–90%). E. coli, the leading pathogen, was highly sensitive to amikacin, gentamicin, ceftri- axone, and ciprofloxacin (Table 4). Other Gram-negative uropathogens except for Pseudomonas spp. showed moderate to high susceptibility to these drugs. Pseudomonas spp. were highly sensitive to amikacin and intermediate to gentamicin and quinolo- nes. High levels of resistance to the third generation cephalosporins (ceftriaxone, cefotaxime, ceftazidime) were detected in Pseudomonas spp. isolates (100% in Zaree Hospital, even for ceftazidime). The sensitivity testing profiles of Staphylo- coccus spp. (Table 5) showed high levels of sensitivity to clindamycin, vancomycin, and aminoglycosides, moderate to high susceptibility to methicillin and first gen- eration cephalosporins (cephazolin and ce- phalexin). The highest levels of resistance to methicillin, (60%) first generation ceph- alosporins (60%) and vancomycin (30%) were reported for Staph. aureus isolated from Zaree Hospital. However, complete resistance to ampicillin was noted (data not shown). Discussion In some previous studies, the relative role for E. coli varied between 32.4% [15] for nosocomial UTI and > 85–90% in patients with uncomplicated infections [10,11]. In 2 studies on children with nosocomial- complicated UTI, results indicated that E. coli, with 32.4% and 40.3% isolation rates, was the leading uropathogen followed by other Gram-negative bacilli, Gram- positive cocci and fungi [15,16]. Studies on adult patients with nosocomial UTI showed similar results: 26.6%–35.6% in catheter- ized patients [17] and 47% in hospitalized patients [12]. Studies on cases of uncompli- cated community-acquired UTI in children and adults also indicated that E. coli with 47% [18], 63% [16] and more than 86% [10,11] isolation rates was the most com- mon uropathogen, followed by other Gram- negative bacilli, Gram-positive cocci, and, rarely, fungi. Except for Candida spp. and enterococci in hospitalized patients, the results of this study are comparable with those of other studies. UTI caused by these microbes, usually occurred with long-term urinary tract catheterization and/or prolonged anti- 560 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ta bl e 3 R el at iv e ro le s o f is o la te d u ro p at h o g en s in 3 h o sp it al s in S ar i, 20 03 H o sp it al E sc h er ic h ia P se u d o m o n as E n te ro b ac te r P ro te u s S ta p hy lo co cc u s O th er a co li sp p . N o . % N o . % N o . % N o . % N o . % N o . % B oa li- C in a In pa tie nt s (n = 1 66 ) 10 5 63 .3 21 12 .7 13 7. 8 9 5. 4 10 6. 0 8 4. 8 O ut pa tie nt s (n = 2 38 ) 18 5 77 .7 21 8. 8 10 4. 2 6 2. 5 12 5. 0 4 1. 7 Im am In pa tie nt s (n = 6 8) 25 36 .8 4 5. 9 3 4. 4 2 2. 9 7 10 .3 27 39 .7 O ut pa tie nt s (n = 1 93 ) 11 7 60 .6 8 4. 1 10 5. 2 3 1. 6 11 5. 7 44 22 .8 Z ar ee In pa tie nt s (n = 3 8) 19 50 .0 2 5. 3 7b 18 .4 0 0. 0 10 26 .3 0 0. 0 To ta l ( n = 7 03 ) 45 1 64 .2 56 8. 0 43 6. 1 20 2. 8 50 7. 1 83 11 .8 E . c ol i r ol e: B oa li- C in a H os pi ta l i np at ie nt s vs . B oa li- C in a H os pi ta l o ut pa tie nt s P = 0 .0 01 ; I m am H os pi ta l i np at ie nt s vs . I m am H os pi ta l ou tp at ie nt s P = 0 .0 00 6. a B oa li- C in a H os pi ta l i np at ie nt s: 2 c as es C an di da , 3 c as es e nt er oc oc ci ; I m am H os pi ta l i np at ie nt s: 2 3 ca se s ot he r G ra m -n eg at iv e ba ci lli , 1 c as e C an di da , 1 c as e en te ro co cc i; Im am H os pi ta l o ut pa tie nt s: 4 2 ca se s ot he r G ra m -n eg at iv e ba ci lli , 1 c as e en te ro co cc i. b C itr ob ac te r. bacterial therapy, especially in patients in neonatal or paediatric intensive care units or in elderly patients [19,20]. In our study, the majority of the noso- comial UTI cases were adult patients with burns or patients with medical or surgical problems with shorter duration of urinary tract catheterization and/ or antibacterial treatment, or children with febrile UTI who were admitted for therapy. This may explain the rarity of fungal or enterococcal UTI cases in our study. The antibacterial sensitivity patterns showed some inter-hospital variation among isolated uropathogens. Activity of ampicillin and co-trimoxazole were the lowest. Studies in Trinidad and Israel obtained similar resistance levels to ours [21,22]. However, other studies have found lower levels [11,12,16]. Based on this, empirical therapy with these drugs for UTI is not satisfactory and is not recommended. In contrast to ampicillin and co- trimoxazole, the antibacterial activ- ity of nitrofurantoin against isolated uropathogens was acceptable, so, as noted in a previous study [9], it can be recommended in cases of simple afebrile UTI and/or for completion of therapy. In this study, E. coli and other Gram-negative bacilli (except Pseu- domonas spp.) showed high levels of sensitivity to most tested third genera- tion cephalosporins, aminoglycosides, and quinolones. Accordingly, until the results of sensitivity testing are avail- able, empirical therapy of UTI with one of these drugs is recommended. The results showed that 7.1% of uropathogen isolates were Staphylococ- cus spp. Staph. aureus was the second commonest cause of nosocomial UTI Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 561 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما in Zaree Hospital. There was little variation among centres in prevalence of resistance to tested antibiotics except for methicillin and cephazolin. More than 60% of iso- lates at Zaree Hospital were resistant to methicillin and cephazolin. The rates of resistance to methicillin and first generation cephalosporins, especially at Zaree Hospi- tal, are among the highest figures reported [18,23,24]. The highest anti-staphylococ- cal activity was seen for clindamycin and vancomycin. Table 4 Antibacterial sensitivity patterns of uropathogens isolated at 3 hospitals in Sari, 2003 Pathogen & Boali-Cina Hospital Imam Hospital Zaree Hospital antibiotic Inpatients Outpatients Inpatients Outpatients Inpatients % % % % % Escherichia coli Ceftriaxone 96 97 75 82 73 Amikacina 98 98 80 91 95 Gentamicin 95 97 85 92 90 Ciprofloxacin 98 99 97 97 79 Nitrofurantoin 90 90 57 57 73 Ampicillin 7 6 16 17 16 Co-trimoxazole 30 20 44 47 10 Pseudomonas spp. Ceftriaxoneb 38 48 25 50 0 Ceftazidime NT NT 67 67 0 Amikacina 80 86 50 75 100 Gentamicin 71 67 50 50 50 Ciprofloxacin 76 76 50 75 50 Enterobacter spp.c Ceftriaxone 85 90 67 90 28 Amikacina 85 90 66 90 86 Gentamycin 85 100 100 100 86 Ciprofloxacin 92 100 100 100 59 Nitrofurantoin 69 80 67 70 71 Ampicillin 8 10 0 10 0 Co-trimoxazole 23 30 0 10 14 Proteus spp.d Ceftriaxone 89 100 50 72 – Amikacina 100 100 72 69 – Gentamicin 100 100 54 67 – Ciprofloxacin 100 100 50 72 – Nitrofurantoin 66 67 50 67 – Ampicillin 22 17 0 33 – Co-trimoxazole 33 33 50 33 – aBoali-Cina Hospital, Imam Hospital: P = 0.02. bBoali-Cina Hospital, Imam Hospital: P = 0.005. cCitrobacter in Zaree Hospital. dOther Gram-negative bacilli in Imam Hospital. NT = not tested. 562 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 5 Antibacterial susceptibility patterns for Staphylococcus spp. in 3 hospitals in Sari, 2003 Antibiotic Boali-Cina Hospital Imam Hospital Zaree Hospital Inpatients Outpatients Inpatients Outpatients Inpatients % (n = 10) % (n = 12) % (n = 7) % (n = 11) % (n = 10) Methicillin 80 83 72 82 40 Cefazolin 80 75 72 73 40 Vancomycin 90 95 86 91 70 Clindamycin 100 92 86 91 90 Amikacin 90 83 86 82 90 Gentamicin 90 72 56 73 80 Boali-Cina Hospital vs. Zaree Hospital: P = 0.38. Boali-Cina Hospital inpatients vs. Zaree Hospital inpatients: P = 0.04. Boali-Cina Hospital outpatients vs. Imam Hospital outpatients: P = 0.45. Conclusion The results of this study emphasize the necessity of monitoring the relative roles of each uropathogen in community- and nosocomial-UTI, and the antibiotic resist- ance level varies between centres. Initia- tion of optimal empirical antibiotic therapy should be based on local knowledge of the most likely infecting microorganisms and their sensitivity to antimicrobial drugs. Acknowledgement We would like to thank L. Barati MD and F. Qasalsoflu MD for their critical help in data collection for this project. References 1. Bacheller CD, Bernstein JM. Urinary tract infection. Medical clinics of North Ameri- ca, 1997, 81(3):719–30. 2. Kalsi J et al. Hospital-acquired urinary tract infection. International journal of clinical practice, 2003, 57(5):388–91. 3. Hoberman A, Wald ER. Urinary tract infection in young febrile children. Pedi- atric infectious disease journal, 1997, 16(1):11–7. 4. Orrett FA et al. Paediatric nosocomial urinary tract infection at a regional hospi- tal. International urology and nephrology, 1999, 31(2):173–9. 5. Gupta K et al. Antimicrobial resistance among uropathogens that cause com- munity-acquired urinary tract infections in women: a nationwide analysis. Clinical infectious diseases, 2001, 33(1):89–94. 6. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and eco- nomic costs. Disease-a-month, 2003, 49(2):53–70. 7. Committee on Quality Improvement. Sub- committee on Urinary Tract Infection. The diagnosis, treatment, and evaluation of the initial UTI in febrile infants and young children. Pediatrics, 1999, 103:843–52. 8. Sefton AM. The impact of resistance on the management of urinary tract infec- tion. International journal of antimicrobial agents, 2000, 16:489–91. 9. Gupta K. Emerging antibiotic resistance in urinary tract infections. Infectious disease Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 563 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما clinics of North America, 2003, 17(2):243– 59. 10. Chomarat M. Resistance of bacterial in urinary tract infections. International journal of antimicrobial agents, 2000, 16:483–7. 11. Prais D et al. Bacterial susceptibility to oral antibiotics in community acquired uri- nary tract infections. Archives of disease in childhood, 2003, 88(2):215–8. 12. Gordon KA, Jones RA, SENTRY Par- ticipant Groups Europe, LA. Susceptibility patterns of orally administered antimicro- bials among urinary tract infection patho- gens from hospitalized patients in North America: comparison report to Europe and Latin America. Results from the SEN- TRY Antimicrobial Surveillance Program (2000). Diagnostic microbiology and in- fectious disease, 2003, 45:295–301. 13. Opal SM, Mayer KH, Medioras AA. Mech- anisms of bacterial resistance. In: Mandell GL, Bennet JE, Dolin R, eds. Principles and practice of infectious diseases, 5th ed. New York, Churchill Livingstone, 2000:239–53. 14. Reisner BS et al. Specimen processing. In: Murray PR et al. Manual of clinical microbiology, 7th ed. Washington DC, American Society for Microbiology Press. 1999:75–6. 15. Leblebicioglu H, Esen S, Turkish Nosoco- mial Urinary Tract Infection Study Group. Hospital-acquired urinary tract infection in Turkey: a nationwide multicenter point prevalence study. Journal of hospital in- fection, 2003, 53(3):207–10. 16. Landhani S, Grandsen W. Increasing antibiotic resistance among urinary tract isolates. Archives of disease in childhood, 2003, 88(5):444–5. 17. Wazait HD et al. Catheter-associated urinary tract infections: prevalence of uropathogens and pattern of antimicrobial resistance in a UK hospital (1996–2001). BJU international, 2003, 91(9):806–9. 18. Daza R, Gutierrez J, Piedrola G. Antibiotic susceptibility of bacterial strains isolated from patients with community-acquired uri- nary tract infections. International journal of antimicrobial agents, 2001, 18:11–5. 19. Sobel JD, Vazquez JA. Fungal bacterial susceptibility to oral antibiotics in commu- nity infections of the urinary tract. World journal of urology, 1999, 17(6):410–4. 20. Fegin RD et al., eds. Textbook of pediatric infectious diseases, 5th ed. Philadelphia, WB Saunders, 2004:1175–92, 2573. 21. Orrett FA, Shurland SM. The changing patterns of antimicrobial susceptibility of urinary pathogens in Trinidad. Singapore medical journal, 1998, 39:256–9. 22. Raz R et al. Demographic characteris- tics of patients with community-acquired bacteriuria and susceptibility of urinary pathogens to antimicrobials in Northern Israel. Israel medical association journal, 2000, 2(6):426–9. 23. Gur D, Unal S. Resistance to antimicrobial agents in Mediterranean countries. Inter- national journal of antimicrobial agents, 2001, 17:21–6. 24. Dietrich DW, Auld BB, Mermel LA. Community-acquired methicillin-resist- ant Staphylococcus aureus in southern New England children. Pediatrics, 2004, 113:347e. 564 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Increased isolation of Vibrio cholerae O1 serotype Inaba over serotype Ogawa in Pakistan K. Jabeen,1 A. Zafar1 and R. Hasan1 1Department of Pathology and Microbiology, Aga Khan University, Karachi, Pakistan (Correspondence to K. Jabeen: kausar.jabeen@aku.edu). Received: 04/01/06; accepted: 09/03/06 ABSTRACT Although the predominant Vibrio cholerae serotype in Pakistan is Ogawa and serotype Inaba is rare, there has been a significant increase in the isolation of Inaba in our referral laboratory in Karachi. This paper reports this observation and further analysis of previous cholera data from 1993 to 2005 to assess the trend of occurrence and resistance pattern of V. cholerae strains. From January to September 2005, 245/3292 (7.4%) specimens yielded growth of V. cholerae. Of these, 243 were serotype Inaba, outnumbering serotype Ogawa. This recent Inaba strain is 100% resistant to co- trimoxazole, 3% resistant to chloramphenicol and not resistant to ampicillin, tetracycline and ofloxacin. This sensitivity pattern is almost similar to that of the previous predominant serotype Ogawa. Accroissement de l’isolement du sérotype Vibrio cholerae O1 Inaba par rapport au sérotype Ogawa au Pakistan RÉSUMÉ Bien que le sérotype de Vibrio cholerae prédominant au Pakistan soit Ogawa et que le sérotype Inaba soit rare, on a constaté une augmentation significative de l’isolement d’Inaba dans notre laboratoire de référence de Karachi. Le présent article porte sur cette observation ainsi que sur une analyse plus poussée des précédentes données sur le choléra pour la période 1993-2005, afin d’évaluer la tendance de l’apparition et le schéma de résistance des souches de V. cholerae. De janvier à septembre 2005, 245/3292 (7,4 %) échantillons ont donné une culture de V. cholerae. Sur ces échantillons, 243 étaient du sérotype Inaba, donc plus nombreux que le sérotype Ogawa. Cette récente souche d’Inaba est résistante à 100 % au cotrimoxazole, à 3 % au chloramphénicol et non résistante à l’ampicilline, à la tétracycline et à l’ofloxacine. Ce profil de sensibilité est pratiquement identique à celui du sérotype Ogawa autrefois prédominant. ™=œ»¿¶=a=f«Ji=a>Èag=>E>¿ÈCÊ·rO1Á>Jj²>E›=Æ>¦Æ?Ê·r™=œ»¿¶=Àºð×bE=¶Ç³¶=L>»uÀº fí«ížÄÉ«¢(FQfMDzÀjUĿɺÆe(  „=Í[qØ6Á>Jj²>E›bÑ>j¶=Ê·r™=œ»¿¶=Á?Àº¼¦f¶=η¢Ê·r™=œ»¿¶=Á?Æ(=Æ>¦Æ?ÇÂ=¶Ç³¶=L>»uÀº Ä[E¸[»£IËd[¶=Ê[£Qf™=[J^™=›>E>¿ÈCÊ·r™=œ»¿¶=a=f«Ji=›ð>ÉÑ>rUCÄEbJ£Èa>Èag= UǶb¯ª(ea>¾>E>¿ÈC ÊnI=f²›L>NU>F¶=*[£I[¶=ÆͯE>j[¶=L>É죻·¶›>uC¸É·€¤º͟Uؙ=ÅdÂÀ¢ð=fÈf¯IÍ®eǶ=Åd½b¯IÆaÇ [E>[ºÌf[J«¶=‘C1993–2005L>»[uËe=ecÍ[ºÆ>¯ºœ[”ÆPÆb[ƒ=Å>[=¼É[ɯJ¶´[¶cÆ(=¶Ç[³¶=¹Ç[U =¶Ç³¶=*K[”b®Æ245[EÀ[ºÍ[¢ehº3292Í[¢ehº%7.4$!ÁǾ>[²[EÌf[[J«¶=›=¶Ç[³¶=L>»[uSJ[¿J¶ ʾ>N¶=+¹Ç·È?ÆfÈ>¿È+»JFi2005Á>²Æ243¿¶=Àº¥e=h™=´·IEÀºÀ[º>”>º­>£u?ÇÂÆ(>E>¿ÈCÊ·r™=œ» =Æ>¦Æ?Ê·r™=œ»¿¶=*ÍFj[¿E½Æ>¯ºʶ>ƒ=>E>¿ÈCÊ·r™=œ»¿¶=Á? UǶÆ100!ÍFj[¿EÆ(¹Æg>j[²Ç•fIdz·¶3! L=a>v[»·¶ÍE>RJ[i×=œ[”Á?Æ(i>j[²Ç·ªÆÙ=Æ?·³Éi=f[JJ¶=Æ?·ÉjÉFºÚ¶½Æ>¯º¦Æ(¹Ç³É¿É«º=eÇ·³·¶ ¶¸M>šÍÈÇɃ==Æ>¦Æ?bÑ>j¶=Æ°E>j¶=Ê·r™=œ»¿·*  Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 565 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Vibrio cholerae, the causative agent of cholera, is subdivided into serogroups based on the somatic O antigen. Only the O1 and O139 serogroups are reported to cause epidemic and pandemic disease. Each of the O1 biotypes can be further subdivided into 2 major serotypes, Ogawa (VCO) and Inaba (VCI). Hikojima, a 3rd serotype also exists but is rare and unstable [1]. V. cholerae O1 strains can undergo serotype conversion or switching between the Inaba and Ogawa serotypes related to a mutation in the wbeT region, a gene responsible for O1 antigen biosynthesis [2]. The predominant serotype in Pakistan is Ogawa and serotype Inaba is rare. Vari- ous centres from Pakistan have published reports about V. cholerae isolates and in all of them isolation of Inaba serotypes are infrequent [3 –5]. In India and Bangladesh also the predominant serotype is Ogawa. However, 2 reports of the emergence of VCI have been published from India (Delhi and Chandigarh) showing increased isola- tion of VCI in their cholera isolates [6,7]. This phenomenon is not yet reported from Pakistan. Recently, however, there has been a sig- nificant increase in the isolation of serotype Inaba in our laboratory, which has even outnumbered serotype Ogawa. This paper reports this observation and further analysis and comparison with previous cholera data at our institution to assess the trends of occurrence and resistance pattern of V. cholerae Ogawa and Inaba strains. Methods Setting This descriptive study was conducted dur- ing 1993–2005 at Aga Khan University, a tertiary care centre located in Karachi, Pakistan. The microbiology laboratory of the university receives specimens from both inpatients and outpatients from clinics and hospitals within the city and all over the country. Specimen selection All stool samples yielding growth of V. cholerae were selected from both inpatients and outpatients. Data was retrieved from a centralized computer database. Duplicate specimens from the same patients were excluded. Microbiological methods All stool samples for the isolation of V. cholerae were plated on tellurite taurocho- late gelatin agar (TTGA) and incubated at 37 ºC. In addition samples were inoculated in alkaline peptone water (APW) and after 6 hours of incubation at 37 ºC were further subcultured on TTGA. After 24 hours of incubation, suspect colonies from TTGA were confirmed as V. cholerae using stand- ard methods [8]. Serogroups were identified by slide agglutination with polyvalent anti- sera for Ogawa and Inaba strains (Murex Diagnostic Limited), and for serogroup O139 (Dienka Sieken Co. Limited, Japan). Antimicrobial susceptibility testing was performed by Kirby Bauer disc sensitivity technique on Mueller–Hinton agar [9]. An- tibiotics that were tested included ampicillin (10 μg), tetracycline (30 μg), cotrimoxazole (1.25/23.75 μg), chloramphenicol (30 μg) and ofloxacin (5 μg). The zone sizes (mm) for resistant (R), indeterminate (I) and sen- sitive (S) strains were defined as follows: for ampicillin (R if ≤ 13, I if 14–16, S if ≥ 17), for tetracycline (R if ≤ 14, I if 15–18, S if ≥ 19), for co-trimoxazole (R if ≤ 10, I if 11–15, S if ≥ 16), for chloramphenicol (R if ≤ 12, I if 13–17, S if ≥ 18) and for ofloxacin (R if ≤ 12, I if 13–15 S if ≥ 16). Escherichia coli ATCC25922 was used as the control. 566 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Statistical analysis Data was entered and analysed using SPSS. P values were calculated using the t-test for 2 independent samples. Results From January to September 2005 a total of 3290 stool samples were received for culture at Aga Khan University laboratory. Of these 245 (7.4 %) yielded growth of V. cholerae. The total number of V. cholerae serotype Inaba (VCI) strains isolated were 243 which greatly outnumbered serotype Ogawa (VCO) (2 strains). Over the period 1993–2005 the fre- quency of isolation of VCI varied from year to year (Figure 1). However, there was a significant upsurge in the years 2004–05. In 2004, isolation of VCI was first observed in the month of November and there was an increase in the trend of isolation of VCI over the months. The mean age of patients with VCO was 20 years compared with 23 years for patients with VCI (P = 0.06). This recent VCI strain was 100% resist- ant to cotrimoxazole, 3% resistant to chlo- ramphenicol and not resistant to ampicillin, tetracycline and ofloxacin (Figure 2a). This susceptibility pattern was very similar to the previous predominant serotype Ogawa (Figure 2b). Discussion This is the first report of increased isolation of serotype Inaba from Pakisatan. We have evaluated the data of Aga Khan University laboratory for the past 13 years and this increased pattern of VCI was never seen before. In a previous report by Jabeen et al., apart from predominant serotype Ogawa, there were increased numbers of cholera cases related to O139 serotype during the years 1993–1994 and 2000–2003 [3]. How- Figure 1 Distribution of Vibrio cholerae, serotypes Ogawa (VCO) and Inaba (VCI) Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 567 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Figure 2a Antibiotic resistance of Vibrio cholerae, serotype Ogawa. AMP = ampicillin (10 µg), C = chloramphenicol (30 µg), OFX = ofloxacin (5 µg), TE = tetracycline (30 µg), SXT = co- trimoxazole (1.25/23.75 µg) Figure 2b Antibiotic resistance of Vibrio cholerae, serotype Inaba. AMP = ampicillin (10 µg), C = chloramphenicol (30 µg), OFX = ofloxacin (5 µg), TE = tetracycline (30 µg), SXT = co- trimoxazole (1.25/23.75 µg) 568 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ever, serotype Ogawa was never overtaken by any other serotype as it was in 2005 by VCI. Two recent communications from India have reported the predominance of VCI in their cholera strains. One report was from Delhi in which 52% VCI were isolated in the year 2004, outnumbering VCO, the predominant strain in the past [6]. Taneja et al. from Chandigarh have reported the emergence of VCI in north India from a border security force camp [7]. In previous years, the isolation of VCI was rare and the most recent predominant outbreak was observed in 1989 in Calcutta [10]. Later, there were sporadic reports of outbreaks of VCI; one was from Ma- lawi in 1990 which affected Mozambican refugees causing 1931 cases [11], another outbreak was in 1991 in which 8 patients in New Jersey, United States of America, developed cholera due to VCI after eating crabmeat [12]. Another outbreak of 12 cholera cases caused by VCI was reported from Hong Kong in 1994, which was linked with consumption of seafood [13]. A report of an outbreak from southern India in 1996 reported 13 nontoxigenic strains of VCI isolated from patients [14]. However, none of the above reports suggested continuous transmission, as in our study. In 1984, there was a reported outbreak of nosocomial cholera involving 11 cases of VCI in southern Thailand [15]. A history of receiving tube-fed liquid diets was signifi- cantly more common among cholera cases than in matched controls. Cases were also significantly more likely than controls to be on oral antacid medication, which could increase the risk of infection by neutralizing gastric acidity. In our hospital, however, we have not seen any case of nosocomial cholera. The susceptibility pattern of our recent VCI isolates is more-or-less similar to the previously predominant serotype Ogawa. Increased resistance to cotrimoxazole sug- gests the possibility of the presence of the SXT element, which is a self-transmissible, chromosomally integrated genetic element which carries cross-resistance to sulfam- ethoxazole, trimethoprim, streptomycin and furazoloidine [16]. However, we did not test the latter 2 antibiotics in our study. Another study by Garg et al. also reported that the antibiogram and pulsed-field gel electro- phoresis pattern of their current VCI strains were similar to that of the prevailing VCO strains, suggesting seroconversion due to mutation in the wbeT region [17]. We sug- gest that there has been a serotype switching between the prevailing VCO strain and the current VCI strain due to mutation in the wbeT region, possibly because of immune pressure in the Pakistani population. How- ever, we have not confirmed this fact as we have not performed molecular analysis of our VCI isolates. Quinolone resistance in V. cholerae has never been reported from Pakistan and 100% of our cholera isolates were sensitive to ofloxacin. However Das et al. from Delhi, India have reported that 18% of their VCI isolates were resistant to ciprofloxacin [6]. The mean age of both VCI and VCO patients was similar, involving a younger age group. This again suggests serotype conversion as the same age group is af- fected in both cases. This is in contrast to the outbreaks of VCO139 in Pakistan in 1993–94 and 2000–01 in which an older age group was affected [3]. In conclusion, we are reporting for the first time increased isolation of VCI from Pakistan and suggest that these VCI strains are wbeT mutants from the previously pre- dominant VCO and presumably have arisen as a result of selection due to the immune response against VCO in the Pakistani population. However, molecular analysis is Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 569 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما needed, as done by Garg et al. in Calcutta [17], to confirm our hypothesis. The ef- fective transmission of this strain in the community suggests a decreased immune response in the population against this mu- tant VCI strain. Government intervention and active health education campaigns on water and food safety and personal hygiene are immediately required to reduce the risk of a major public health disaster as this strain has been involved in many outbreaks of cholera in recent months. References 1. Sack AD et al. Cholera. Lancet, 2004, 363:223–33. 2. Colwell RR et al. Serogroup conversion of Vibrio cholerae. Canadian journal of microbiology, 1995, 41:946–50. 3. Jabeen K, Hasan R. Re-emergence of Vibrio cholerae O139 in Pakistan: report from a tertiary care hospital. Journal of the Pakistan Medical Association, 2003, 53:335–58. 4. Alam M et al. Seasonal variation in bacte- rial pathogens isolated from stool sam- ples in Karachi, Pakistan. Journal of the Pakistan Medical Association, 2003, 53:125–9. 5. Nizami S, Farooqui B. Cholera in children in Karachi from 1990 through 1995: a study of cases admitted to a tertiary care hospital. Journal of the Pakistan Medical Association, 1998, 48:171–3. 6. Das S et al. Fluroquinolone resistance in Vibrio cholerae O1: emergence of El Tor Inaba. Annals of tropical paediatrics, 2005, 25:211–2. 7. Taneja N et al. Emergence of Vibrio chol- erae O1 biotype El Tor serotype Inaba in north India. Japanese journal of infectious diseases, 2005, 58:238–40. 8. Koneman EW et al. Color atlas and text book of diagnostic microbiology, 5th ed. Philadelphia, Lippincott, 1997. 9. Performance standards for antimicrobial susceptibility testing. 15th information- al supplement. Volume 25(1). Wayne, Pennsylvania, Clinical and Laboratory Standards Institute, 2005. 10. Ramamurthy T et al. Serovar, biotype, phage type, toxigenicity and antibiotic susceptibility patterns of Vibrio cholerae isolated during two consecutive chol- era seasons (1989-90) in Calcutta. In- dian journal of medical research, 1992, 95:125–9. 11. Swerdlow DL et al. Epidemic cholera among refugees in Malawi, Africa: treat- ment and transmission. Epidemiology and infection, 1997, 118:207–14. 12. Finelli L et al. Outbreak of cholera associ- ated with crab brought from an area with epidemic disease. Journal of infectious diseases, 1992, 166:1433–5. 13. Kam KM et al. Outbreak of Vibrio chol- erae 01 in Hong Kong related to contami- nated fish tank water. Public health, 1995, 109:389–95. 14. Saha PK et al. Nontoxigenic Vibrio chol- erae 01 serotype Inaba biotype El Tor associated with a cluster of cases of chol- era in southern India. Journal of clinical microbiology, 1996; 34:1114–7. 15. Swaddiwudhipong W, Kunasol P. An out- break of nosocomial cholera in a 755-bed hospital. Transactions of the Royal So- ciety of Tropical Medicine and Hygiene, 1989, 83:279–81. 16. Waldor MK, Tschäpe H, Mekalanos JJ. A new type of conjugative transposon encodes resistance to sulfamethoxazole, trimethoprim and streptomycin in Vibrio 570 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما cholerae O139. Journal of bacteriology, 1996, 178:4157–65. 17. Garg P et al. Emergence of Vibrio choler- ae O1 biotype El Tor serotype Inaba from the prevailing O1 Ogawa serotype strains in India. Journal of clinical microbiology, 2000, 38:4249–53. Since 2005, the re-emergence of cholera has been noted in parallel with the ever-increasing size of vulnerable populations living in unsani- tary conditions. Cholera remains a global threat to public health and one of the key indicators of social development. While the disease is no longer an issue in countries where minimum hygiene standards are met, it remains a threat in almost every developing country. The num- ber of cholera cases reported to WHO during 2006 rose dramatically, reaching the level of the late 1990s. A total of 236 896 cases were notified from 52 countries, including 6311 deaths, an overall increase of 79% compared with the number of cases reported in 2005. This in- creased number of cases is the result of several major outbreaks that occurred in countries where cases have not been reported for several years. It is estimated that only a small proportion of cases – less than 10% – are reported to WHO. The true burden of disease is therefore grossly underestimated. Source: WHO Fact sheet No. 107, revised September 2007 (http://www.who.int/mediacentre/factsheets/fs107/en/index.html) Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 571 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Factors associated with acute diarrhoea in children in Dhahira, Oman: a hospital-based study P.K. Patel,1 J. Mercy,2 J. Shenoy3 and B. Ashwini3 1Department of Health Affairs, Epidemiology Section, Director-General of Health Services, Ministry of Health, Dhahira, Oman (Correspondence to P.K. Patel: pakki_kp@hotmail.com). 2Department of Laboratories; 3Department of Paediatrics, Ibri Regional Referral Hospital, Ministry of Health, Dhahira, Oman. Received: 24/10/05; accepted: 26/03/06 ABSTRACT To elucidate the bacterial etiology of childhood diarrhoea in Dhahira, 856 children < 12 years admitted for diarrhoea to Ibri Regional Referral Hospital from 2000 to 2002 were studied. The mean age was 2.4 (SD 2.3) years; the majority (92.9%) were < 5 years. Bacterial etiology was found in 15.2% of cases; 10.6% due to Shigella and 2.1% to Salmonella. Sh. sonnei was the commonest Shig- ella serogroup isolated. Salmonella infection was significantly associated with cramps, while Shigella infection was associated with fever, bloody stools and cramps. Antibiotics were prescribed in 36.2% of cases and the resistance to the common antibiotics tested was low. Á>»à¢Í¿ì·jE(Ì߶=›¹>«{Ù=Ïb¶a>ƒ=¹>ÃiÝ=L>FFjº6ΫnJjº›Íi=ea µp>²=fE*ÊiºÁÇQ(¸I>EÉ«m?>ÉI>ÃE(ËÇ¿ÉmÁ=af¿Q(  „=Í[qØ6›¹>«{Ù=Ïb¶¹>ÃiÞ¶ÍFFj™=¼ÉM=f‚=XÉuÇJ¶Î[·¢Í[i=eb¶=Åd[ÂÁÇNU>[F¶=Ïf[Q?(Ì߶=856 À¢¼Âe>»¢?¸¯IÀšðØ«{12>[º›¹>ÃiÝ>E¼ÃJE>qCGFjEʻɷ®Ý=Ê£Qf™=ËfECΫnJjº‘C=Ç·å]a?ð>º>¢ E2000Æ2002*f»£¶=œiÇJºÁ>²b®Æ2.4ð>º>¢%Ëe>É£™=­=f‰×=2.3$¼Ã»Ÿ£ºÁ>²Æ%92.9$!¸¯IÀš À¢¼Âe>»¢?5L=Ç¿i*›ÍɺÇMf‚=L>FFj™=K«nàJ²=b®Æ15.2!Á>²Æ(L×>ƒ=Àº10.6!À[¢ð>[–>¾>ÿº ÆØɧÉn¶=2.1!ËfÈh[[¿„=Ê·r[™=œ»¿[¶=Á>[²Æ(ØɾǙ>j[¶=À¢ð>–>¾>ÿºsonneiÍÉ·r[™=>[”Ù=f[N²?Ç[ EèbßJá£àȹçb£’LØɾǙ>j¶>EÏÆb£¶=K¯ª=fIÆ(ð>¢ÇÉmLØɧÉn·¶ÏÆb[£¶=K[¯ª=fI[U›(s§™=¤ºð>ÉÑ>rUCÄ s§™>[EÆÎçºb[™=g=¶=Æλƒ>ELØɧÉn¶>E*›Í[ÈÇɃ=L=a>v[™=K«[qÆb[®Æ36.2!K[¾>²ÆL×>[ƒ=À[º Ív«^¿ºÍ£Ñ>n¶=ÍÈÇɃ=L=a>v»·¶ͺÆ>¯™=*  Facteurs associés à la diarrhée aiguë chez les enfants de la province de Dhahira (Oman) : étude en milieu hospitalier RÉSUMÉ Afin d’élucider l’étiologie bactérienne de la diarrhée chez l’enfant dans la Dhahira, 856 enfants de moins de 12 ans admis pour diarrhée à l’hôpital de recours régional d’Ibri entre 2000 et 2002 ont fait l’objet d’une étude. L’âge moyen des enfants était de 2,4 ans (écart type 2,3) ; la majorité des enfants (92,9 %) avaient moins de 5 ans. L’étiologie bactérienne a été établie dans 15,2 % des cas ; 10,6 % étaient dus à Shigella et 2,1 % à Salmonella. Parmi les sérogroupes de Shigella isolés, Sh. sonnei était le plus courant. L’infection à Salmonella était associée de façon significative à des crampes, alors que l’infection à Shigella était associée à de la fièvre, des selles sanglantes et des crampes. Des antibiotiques ont été prescrits dans 36,2 % des cas et la résistance aux antibiotiques courants testés était faible. 572 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Diarrhoea is one of the leading causes of mortality and morbidity in developing countries. Annually 1.5 billion diarrhoea episodes and 4 million deaths caused by this disease occur in children under 5 years of age [1]. Diarrhoea can be caused by wide range of bacteria (e.g. Shigella spe- cies, Salmonella species, Escherichia coli and Vibrio cholerae), enteroparasites (e.g. Giardia species and Entamoeba histolytica) and viruses (rotavirus, adenovirus and Nor- walk virus) [1]. There has been a marked decline in diarrhoea-related mortality as well as mor- bidity in Oman, ever since the introduc- tion of the control of diarrhoeal diseases (CDD) programme in 1985. The CDD pro- gramme is now incorporated in the inte- grated management of childhood illnesses (IMCI) programme. The main aim of the CDD programme is to reduce the morbidity and mortality due to diarrhoea especially among children under 5 years. In Oman, the morbidity and mortality from diarrhoeal diseases decreased from 745 episodes/1000 children < 5 years and 12 deaths in 1991 to 314 episodes/1000 children < 5 years and zero deaths in 1999. The CDD programme as well as general socioeconomic develop- ment, improvement in environmental sani- tation, safe water and health education have contributed to this decrease [2]. In Dhahira region the incidence of diarrhoeal diseases in the year 2000 was 265 episodes/1000 children < 5 years and there were no deaths reported with diarrhoea as the primary cause [3]. The annual incidence and the etiologic profile of diarrhoea in different popula- tions may vary with several risk factors. In industrialized countries, rotavirus is the predominant cause, while bacterial causes are commonly found in children from de- veloping countries [4]. Studies on the etio- logic profile of diarrhoea cases are lacking in Oman and Dhahira region. To further reduce the incidence of diarrhoea among children, epidemiological information on cause-specific morbidity and mortality is necessary in order to devise appropriate intervention measures. Therefore, in the year 2000 diarrhoeal disease surveillance was established in sentinel sites (regional hospitals) in Oman including Dhahira re- gion to study the morbidity pattern of all admitted cases of diarrhoea and to elucidate the bacterial enteropathogens responsible for diarrhoea among hospitalized children. This study was carried out as a part of this sentinel surveillance and analyses data obtained over 2 years of surveillance. Methods This was a prospective hospital-based study of all patients under the age of 12 years ad- mitted for diarrhoea to the paediatric wards of Ibri Regional Referral Hospital, Dhahira from 1 November 2000 to 31 October 2002. Dhahira region has 207 015 inhabitants. Ibri Regional Referral Hospital is the only secondary hospital in Dhahira and serves 68.8% of the population of the region. Diar- rhoea was defined as 3 or more watery or loose stools in a 24-hour period prior to the hospital admission. The data about the patients and their illness were recorded during hospitalization on a proforma pretested in a pilot study. Personal details (name, age, sex, nationality and residence), clinical history, present- ing symptoms and laboratory details were documented in the proforma by the at- tending staff of the paediatric department (doctor and nurse). A doctor and nurse were the focal points to collect the data and supervise the surveillance activities in Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 573 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما the hospital. The regional epidemiologist coordinated the implementation and data management of the surveillance. A regional workshop was conducted prior to the study to explain the study to the paediatric staff and to standardize the data collection and procedures. Stool samples were collected in a wide- necked sterile container before antibiotic administration and bacterial culture was carried out using routine standard microbi- ology laboratory methods. The specimens were subjected to microscopic examination in saline and iodine preparation. Motility tests and Gram stained smears were done in cases where cholera was suspected. Faeces were cultured directly on MacConkey agar, salmonella–shigella agar (SSA) and thiosul- fate citrate bile sucrose (TCBS) agar. After overnight incubation at 37 °C the plates were observed for Salmonella and Shigella colonies. At the same time, approximately 1–2 g of stool sample was inoculated in selenite F broth and incubated overnight. Next day, thin subcultures were done on MacConkey and SSA for suspected Salmo- nella and Shigella colonies. Suspected cholera samples were inocu- lated on alkaline peptone water and incubat- ed for 6–8 hours and then further inoculated onto TCBS selective media and incubated for 18–24 hours at 37 °C. The suspected colonies were subcultured in nutrient/blood agar and incubated overnight at 37 °C. Presumptive Vibrio cholerae identification was based on positive oxidase test and read- ing from the analytical profile index (API) 20 E system (bioMérieux, Marcy l’Etoile, France). Grouping was done by using poly- valent antiserum (MAST GROUP, United Kingdom) by slide agglutination method. All the cases positive for bacterial infec- tion were sent to the Central Public Health Laboratory, Muscat for reconfirmation and serotyping. Antibiotic sensitivity of all the posi- tive cultures was done by disc diffusion (Kirby–Bauer) method using diagnostic sensitivity test agar. The following anti- biotic discs were tested: ampicillin, ce- fotaxime, ceftriaxone, chloramphenicol, ciprofloxacin, nalidixic acid, tetracycline and trimethoprim/sulfamethoxazole. These are the antibiotics commonly prescribed for childhood diarrhoea according to hospital policy. The level of dehydration was recorded by the paediatrician according to the child’s presenting signs. Mild to moderate dehy- dration was recorded when the child had 2 of the following signs: restlessness and irritability, sunken eyes, thirst and eager drinking, and slow return of skin pinch. Severe dehydration was recorded when the child had 2 of the following signs: lethargy or unconsciousness, sunken eyes, inability to drink or drinking poorly, and very slow return of skin pinch [5]. Associated illness, such as malnutrition and acute respira- tory illness, was also noted by the paediatri- cian. Prior antibiotic administration for the present episode was recorded by consulting the referral records and also by asking the mother. The data were computed and analysed by using SPSS, version 9. Descriptive sta- tistics were expressed as proportion, and mean and standard deviation (SD). Propor- tions were compared using the chi-squared test. Adjusted odds ratios (OR) with 95% confidence interval (CI) (regression analy- sis) were calculated to compare bacterial isolation and various characteristics of the episode. The dependent variable was bacte- rial positivity. Independent variables used in the regression analysis were age, sex, level of dehydration, number of stools per day, blood in stool, any associated illness and prior antibiotic administration. For statistical significance, a P-value < 0.05 574 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما was considered significant. Assuming 50% prevalence, the sample size required to obtain a representative sample with 95% CI and 5% margin of error was 400. Results A total of 880 diarrhoea cases were recorded in the pretested proforma during the study period. Complete data were available for 856 cases (97.2%) and these were included in the analysis. The majority of the children (830/856, 97.0%) were Omanis and 53% were male (male:female ratio = 1.1:1). The peak incidence of diarrhoea was during November–January in both study years. There were no deaths among the study sub- jects. The majority (92.9%) of the children were < 5 years of age and of these, 55% were under 1 year; the mean age was 2.4 (SD 2.3) years. The mean number of stools per day per child was 6.8 (SD 3.3). Table 1 shows the frequency of different character- istics of the diarrhoea episodes among the study subjects. The majority (97%) of the children had mild to moderate dehydration. The bacterial pathogens isolated are shown in Table 2. Overall, a potential pathogen was found in 15.2% of cases. Shigella species was the commonest bacte- rial pathogen, found in 10.6% of cultures, identified in 70.0% of cases where bacteria were isolated. Prior antibiotics were given in 11.2% of cases and antibiotics were prescribed in 36.2% of the study patients upon admission. Only 3 antibiotics were prescribed in the treatment of diarrhoea in this study: ampi- cillin, nalidixic acid and chloramphenicol (Table 1); ampicillin was the most com- monly prescribed antibiotic, prescribed in 67.1% of cases where antibiotics were given. Approximately 10% of the Salmonella isolates were resistant to ampicillin and 7.1% were resistant to nalidixic acid and trimethoprim/sulfamethoxazole. With the Shigella isolates, 20% were resistant to ampicillin, nalidixic acid and trimethoprim/ sulfamethoxazole. Both organisms were sensitive to cefotaxime, ceftriaxone, cipro- floxacin, chloramphenicol and tetracycline. Bacterial infection was more commonly (although not statistically significantly) as- sociated with age 3–5 years, being female, and having an associated illness. However, it was significantly associated with bloody stools (adjusted OR = 3.0; 95% CI: 1.6–5.7) (Table 3). Salmonella infection was sig- Table 1 Distribution of various characteristics of diarrhoea among the study subjects Characteristics No. of children % (n = 856) Onset of symptoms Acute 787 91.9 Chronic 69 8.1 Presenting symptomsa Watery stool 830 97.0 Vomiting 708 82.7 Fever 635 74.2 Blood and mucus 150 17.5 Abdominal cramps 239 27.9 Number of stools per day 1–5 328 38.3 6–9 361 42.2 10–19 151 17.6 20–30 16 1.9 Associated illness 96 11.2 Respiratory illness (n = 96) 70 72.9 Othersb (n = 96) 26 27.1 Antibiotics prescribed 310 36.2 Ampicillin (n = 310) 208 67.1 Nalidixic acid (n = 310) 94 30.3 Chloramphenicol (n = 310) 8 2.6 aNumbers and percentages do sum to 856 and 100% as the patients could present with multiple symptoms. bProtein–energy malnutrition, sickle-cell disease, glucose-6-phosphate dehydrogenase deficiency, impetigo and seizures. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 575 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما nificantly associated with cramps and Shig- ella infection with fever, bloody stools and cramps (P < 0.05). Bloody diarrhoea was significantly as- sociated with age > 5 years compared to age < 5 years (χ2 = 15.7, P < 0.05) but was not significantly associated with sex (χ2 = 0.21, P = 0.3) and number of stools per day (χ2 = 3.3, P = 0.1). Salmonella infection was commoner among children > 5 years compared to those < 5 years, however this difference was not significantly significant (χ2 = 2.8, P = 0.09). Shigella infection was significantly commoner in children > 5 years (χ2 = 6.4, P = 0.01). Discussion The prevalence of diarrhoea with a known etiology was 15.2%. The prevalence of bacterial infection in cases of diarrhoea among children in other countries varies between 5.3% and 54% [6–10]. Similar to other studies [10,11] Shigella species was the commonest pathogen isolated in our study, but other studies reported Salmonella species was commoner [8,9]. In our sample, enteropathogenic E. coli was not frequently associated with diarrhoea; however, it is more important in the epidemiology of diar- rhoea in other countries [11,12]. Sh. sonnei was the predominant serogroup followed by Sh. flexneri in our study, which is different from other studies where Sh. flexneri was the predominant species followed by Sh. sonnei [10,13,14]. Approximately 84% of the diarrhoea cases had no bacterial pathogen, suggestive of probable viral origin. Antibiotics were prescribed in 36.2% of cases in our study, which is high when the bacterial positiv- ity was only 15.2%. Most cases of acute gastroenteritis in children are viral, self- limiting and need only supportive treatment. Appropriate fluid and electrolyte therapy, with close attention to nutrition, remains central to treatment. Antibacterial therapy serves as an adjunct to shorten the clini- cal course, eradicate causative organisms, reduce transmission and prevent invasive complications. Selection of antibacterials to use in acute bacterial gastroenteritis is based on clinical diagnosis of the likely patho- gen prior to definitive laboratory results [15]. Given that Shigella and Salmonella species were the predominant organisms responsible for bacterial diarrhoea in our study, school health and diarrhoeal disease control programmes should focus on the prevention and control of these infections in Dhahira region. This can be done through health education regarding general personal hygiene, sanitation and safe water. Further studies are needed to investigate the viral causes of diarrhoea in Dhahira. In our study bloody diarrhoea was sig- nificantly associated with age > 5 years compared to < 5 years and not significantly associated with sex and number of stools per day. Another report found bloody diarrhoea was significantly associated with different age groups (P < 0.001) and also sex (P = Table 2 Prevalence of bacterial pathogens among the study subjects Culture result No. % 95% CI (n = 856) No bacteria isolated 726 84.8 82.2–87.0 Bacteria isolated 130 15.2 12.9–17.7 Shigella sonnei 73 8.5 6.8–10.6 Sh. flexneri 18 2.1 1.3–3.3 Salmonellaa 18 2.1 1.3–3.3 Vibrio cholerae 2 0.2 – Monganella 6 0.7 – Enteropathogenic Escherichia coli 14 1.6 – aSalmonella serogroups were: B (4 cases), C (2), D (4), E (2). In 6 cases the serogroup was not evident. CI = confidence interval. 576 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 0.02) [16]. Salmonella infection was not significantly associated with age. However, Shigella infection was significantly higher in children older than 5 years compared with those younger than 5 years, which is similar to a study conducted in Brazil, where Shigella was the most frequent pathogen isolated from the stools of children between 5 and 15 years old [11]. On the other hand our results differ from those of other studies that reported Shigella was more commonly associated with younger age groups [6,14]. Cramps was significantly associ- ated with Salmonella infection while fever, bloody stools, and cramps were associated with Shigella infection. This indicates there should be a strong suspicion of bacterial infection if these symptoms are present and that antibiotic treatment may be required. A study in Egypt also showed that blood in stools was significantly associated with Shigella infection [14]. Antibiotic resistance was low in our study, in contrast to a Yemen study where Table 3 Bacterial isolation according to characteristics of the patients with the diarrhoea episode Characteristic Bacterial culture result Adjusted 95% CI Negative Positive odds No. % No. % ratio Age group (years) < 1 445 94.7 25 5.3 0.2 0.08–0.50 1–3 145 75.9 46 24.1 1.3 0.5–3.2 3–5 84 62.7 50 37.3 2.4 0.9–6.1 > 5a 47 77.0 14 23.0 Sex Male 396 87.2 58 12.8 0.5 0.3–1.0 Femalea 330 82.1 72 17.9 Level of dehydration Mild to moderate 706 84.9 126 15.1 1.4 0.3–8.3 Severea 20 83.3 4 16.7 Number of stools/day 1–5 278 84.8 50 15.2 0.7 0.3–1.6 6–9 311 86.1 50 13.9 0.7 0.3–1.6 10–30a 136 81.4 31 18.6 Associated illness Yes 74 77.1 22 22.9 1.8 0.8–4.2 Noa 652 85.8 108 14.2 Prior antibiotics given No 650 85.5 110 14.5 0.4 0.2–1.1 Yesa 76 79.2 20 20.8 Blood in stool Yes 98 65.3 52 34.7 3.0 1.6–5.7 Noa 628 89.0 78 11.0 aReference group. CI = confidence interval. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 577 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما more than two-thirds of the Salmonella iso- lates were resistant to nalidixic acid, chlo- ramphenicol, co-trimoxazole, gentamicin and amoxicillin, while 42% were resistant to cefotaxime. Most of the Shigella isolates were susceptible to nalidixic acid and cefo- taxime, and resistant to the other antibiotics [12]. Resistance in our study was probably low because of the controlled antibiotic use in the Ministry of Health in Oman. A surveillance system in the region would be useful to maintain this and monitor the situation in other countries. Conclusion This study suggests that Shigella, Salmo- nella and enteropathogenic E. coli are the most important bacterial pathogens among paediatric diarrhoea cases admitted to hos- pital in Dhahira region. These pathogens were also found in association with bloody diarrhoea. Diarrhoea in a child < 12 years associated with cramps, fever, and bloody stools strongly suggests bacterial infec- tion. Shigella-associated diarrhoea remains relatively common in children in Dhahira and supports the need for additional con- trol measures. While antibiotic resistance was relatively low, such resistance needs monitoring. Studies to determine the cost- effective algorithms for diarrhoea diagnosis and antibiotic treatment are warranted as are studies to determine the etiology of viral, unexplained diarrhoea which is clearly the commonest cause for diarrhoea. References 1. Martha V et al. Etiology of diarrhea in chil- dren less than five years of age in Ifakara, Tanzania. American journal of tropical medicine and hygiene, 2004, 70(5):536– 9. 2. Ministry of Health. Diarrhoeal disease sur- veillance. Community health and disease surveillance newsletter, 2000, 9(2):5–7. 3. Control of diarrhoeal diseases. In: Annual Health Report 2000. Oman, Ministry of Health, 2000:8–32. 4. Souza EC et al. Perfil etiologico das di- arreias agudas de criancas atendidas em Sao Paulo [Perfil etiologico das di- arreias agudas de criancas atendidas em Sao Paulo]. Jornal de pediatria, 2002, 78(1):31–8. 5. World Health Organization. Child and ado- lescent health and development web site. Assessing the diarrhoea patient (http:// www.who.int/child-adolescent-health/ New_Publications/CHILD_HEALTH/ Meded/3med.htm, accessed 12 Septem- ber 2007). 6. Denno DM et al. Etiology of diarrhea in pediatric outpatient settings. Pediatric in- fectious disease journal, 2005, 24(2):142– 8. 7. Ahmetagic S et al. Acute infectious di- arrhea in children. Medicinski arhiv, 2003, 57(2):87–92. 8. Battikhi MN. Epidemiological study on Jor- danian patients suffering from diarrhoea. New microbiologica, 2002, 25(4):405–12. 9. Olesen B et al. Etiology of diarrhea in young children in Denmark: a case– control study. Journal of clinical microbiol- ogy, 2005, 43(8):3636–41. 10. Oyofo BA et al. Surveillance of bacterial pathogens of diarrhea disease in Indo- nesia. Diagnostic microbiology and infec- tious disease, 2002, 44(3):227–34. 11. Diniz-Santos DR et al. Epidemiological and microbiological aspects of acute bac- terial diarrhoea in children from Salvador, Bahia, Brazil. Brazilian journal of infec- tious diseases, 2005, 9(1):77–83. 578 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 12. Banajeh SM, Ba-Oum NH, Al-Sana- bani RM. Bacterial aetiology and anti- microbial resistance of childhood diar- rhoea in Yemen. Journal of tropical pedi- atrics, 2001, 47(5):301–3. 13. Zafar A, Sabir N, Bhutta ZA. Frequency of isolation of Shigella serogroups/sero- types and their antimicrobial susceptibil- ity pattern in children from slum areas in Karachi. Journal of the Pakistan Medical Association, 2005, 55(5):184–8. 14. Abu-Elyazeed RR et al. Epidemiology of Shigella-associated diarrhea in rural Egyptian children. American journal of tropical medicine and hygiene, 2004, 71(3):367–72. 15. Phavichitr N, Catto-Smith A. Acute gas- troenteritis in children: what role for antibacterials? Paediatric drugs, 2003, 5(5):279–90. 16. Battikhi MN. Bloody diarrhoea cases caused by Shigella and amoeba in Jor- dan. New microbiologica, 2004, 27(1):37– 47. Planning for IMCI implementation at district level: a capacity-building workshop, Suez, Egypt, 16–19 February 2008 A workshop to build capacity of national IMCI coordinators and district staff in planning for IMCI implementation at district level was con- ducted in Suez, Egypt, from 16 to 19 February 2008. Technically and financially supported by the WHO Regional Office for the Eastern Medi- terranean (EMRO) and conducted in Arabic, the 4-day workshop was an opportunity not only to introduce the newly developed WHO/EMRO Regional guide on planning for IMCI implementation at district level to national coordinators from 6 countries (Egypt, Jordan, Morocco, Sudan, Tunisia and Yemen), but also to use it at the same time with 49 staff of 6 districts and with the participation of high-level officials of their respective governorates in Egypt. The outcome of the workshop was one-year plans of action for IMCI implementation developed for each district, including human resources development, health sys- tems support elements and community component. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 579 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Measles epidemiology and its implications for a vaccination programme in Oman P.K. Patel,1 S.T. Al-Awaidy,2 S. Bawikar,2 S. Al-Busaidy 3 and S. Al-Mahrooqi 2 1Department of Health Affairs, Directorate-General of Health Services, Dhahira, Ministry of Health, Oman (Correspondence to P. K. Patel: pakki_kp@hotmail.com). 2Department of Communicable Disease Surveillance and Control; 3Central Public Laboratory (CPHL), Ministry of Health, Muscat, Oman. Received: 04/02/06; accepted: 27/03/06 ABSTRACT To describe the epidemiology of measles in Oman and the implications for a vaccination programme, we conducted a retrospective record-based study from 1 January 2000 to 31 December 2003 using data from the national epidemiological surveillance system. All cases notified as suspected measles during the study period were included. Of the 185 notified cases, 19.4% were confirmed measles positive. Blood samples for measles IgM were collected in 97.3% of cases. The mean age of measles cases was 8.0 (SD 10.7) years. The estimated overall incidence rate of measles for the study period was 0.53 per 100 000 person-years. Regression analysis indicated measles was significantly commoner among non-Omanis and children who had not been vaccinated. Á>»à¢Í¿ì·i›¤É¿»J¶=Sº>¾fEη¢>ÃI=M@IÆÍFrƒ=L>ÉÑ>EÆ µp>²=fE*Ê®Æf=>i(ËbÉ£iÇF¶=Á>»É·i(f²Æ>E½>Ém(ËbÈÇ£¶=KE>MÀE\Øq(¸I>E  „=Í[qØ6ºÍÈa>£Ji=Íi=eaÁÇNU>F¶=ÏfQ?ʾ>N¶=ÁǾ>²Àº¹ÆÙ=ÀºLØRj¶=η¢Ìb¿Jj+fÈ>¿È2003Î[JUÆ 31¹ÆÙ=ÁǾ>²+»jÈa2003ÀÈb»Jj[º(¤[É¿»J¶=Sº>[¾fEÎ[·¢>[ÃI=M@IÆÁ>[»à¢›ÍFr[ƒ=L>[ÉÑ>EƬ[qǶ [ƒ>E>ÃJE>[qDEÅ>FJ[m×=À[¢¨[·E?[¶=L×>ƒ=¤É–Íi=eb¶=›=ÇQea@ª(ÊÑ>EǶ=bèqf[J¶=½>Ÿ¾ÀºL>É죙=ÍFr L×>ƒ=ÅdÂab¢¨·Eb®Æ7Íi=eb¶=Ìf[Jª¹Ø]185ÀºKèFNJ¶=(Ͷ>U19.4!ðØ£ªÍFrU>þ?η¢>ÿº*b®Æ Ê¢>¿™=¶ÇEÇ·§¶=ËfVJ¶½aL>¿É¢ÁÇNU>F¶=¤–MÀ[º97.3!L×>[ƒ=À[º*L×>[ƒÊì[iǶ=f[»£¶=Á>[²Æ ÍFrƒ=8L=Ç¿i%Åeb®Ëe>É£º­=f‰>E10.7L=Ç¿i*$²ÆÌf[[Jª›ÍFrƒ=¥Ç®Ç¶ʶ>–Ý=ËfÈb¯J¶=¹b£™=Á> Íi=eb¶=0.53s^m¬¶?ÍÒº¸³¶–Í¿i*>[ÃEèb[ßJá£àÈÍ[Qeb¶ð>¢ÇÉmfN²?ÍFrƒ=Á?η¢›äÇVJ¶=¸É·VJ¶=ç¹aÆ >ÂbuXɯ·J¶==ǯ·JÈÀÈd¶=¹>«{Ù=EƐɾ>»à£¶=¦Eð>ÉÑ>rUC*  Épidémiologie de la rougeole et ses implications pour un programme de vaccination à Oman RÉSUMÉ Afin de décrire l’épidémiologie de la rougeole à Oman et ses implications pour un programme de vaccination, nous avons mené une étude rétrospective à partir des registres, du 1er janvier 2000 au 31 décembre 2003, en utilisant les données du système national de surveillance épidémiologique. Tous les cas suspects de rougeole notifiés pendant la durée de l’étude ont été pris en compte. Sur les 185 cas notifiés, 19,4 % ont été confirmés positifs. Des échantillons de sang destinés à la détection d’IgM spécifiques de la rougeole ont été prélevés dans 97,3 % des cas. L’âge moyen des cas de rougeole était de 8,0 ans (écart type 10,7) . Le taux global d’incidence de la rougeole estimé pour la période sur laquelle portait l’étude était de 0,53 pour 100 000 personnes-années. L’analyse de régression a permis d’établir que la rougeole était significativement plus courante parmi les non-Omanais et les enfants qui n’avaient pas été vaccinés. 580 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Measles is an acute highly infectious dis- ease of childhood. It has been assumed the disease may be eliminated because of the following reasons: humans are the sole reservoir of the virus; transmission can only be between humans; the virus is very stable; a human carrier state does not exist; and there is a vaccine of proven high efficacy [1]. Initially it was thought that measles elimination could be achieved quickly with a routine one-dose programme but experi- ence has shown that at the very least high coverage of 2 doses is required to achieve elimination [2]. In spite of the availability of and ef- fective vaccine, measles remains a public health problem worldwide especially in developing countries with 30–40 million cases occurring annually. In 2002, there were an estimated 610 000 deaths due to measles worldwide, 540 000 of them in children under the age of 5 years, represent- ing 30%–40% of the burden of vaccine-pre- ventable diseases in childhood. Target dates of 2000, 2007 and 2010 for the elimination of measles were established for the region of the Americas, the European Region and the Eastern Mediterranean Region (EMR) respectively [3]. Several strategies are now being adopted to increase coverage of im- munization including a 2-dose schedule, mopping up, supplementary immunization with vitamin A, national and regional mass immunizations, and development of high- quality case-based measles surveillance supported by regional measles laboratory [4]. Oman is one of the EMR countries to adopt these elimination strategies. Elimination does not equate to zero cases because when elimination has been achieved, imported cases may still occur, with limited spread to susceptible persons. Eventually there will be enough suscepti- bles from the small proportion of vaccine failures to allow an epidemic [5]. Thus there is a continued need for surveillance even when no cases are reported. Occurrence of measles cases has de- creased drastically in Oman from 40 679 cases in 1981 to a mere 15 cases in 2001, which is largely due to sustained high cov- erage of routine immunization, catch-up campaigns and intense case-based surveil- lance. Measles vaccination was formal- ly launched in Oman in 1981 under the Expanded Programme on Immunization (EPI) programme with a single dose of the measles vaccine given at 9 months. In March 1994, a second dose of measles was introduced at 15 months as measles/rubella (MR) vaccine, and a catch-up campaign with this vaccine was done in March 1994 for all individuals aged 15 months to 18 years. The MR vaccination was replaced by measles/mumps/rubella (MMR) vaccine during 1997 and in October 2001 measles vaccination and MMR vaccination were re- scheduled at 12 and 18 months respectively [6]. Figure 1 shows the number of measles cases reported between 1993 and 2003 with the 2-dose vaccination coverage and catch- up campaigns in Oman [7]. Oman has 2 340 815 inhabitants with a 23.9% expatriate population. Approxi- mately 10.3% of the total population is below 5 years of age (2003 census) [8]. In Oman, measles has been a notifiable disease (individual case-based notification) since March 1991, when communicable disease surveillance was established. All the cases that satisfy the case definition of measles are recorded in a disease notification form along with the mandatory information form. Blood samples are also collected and sent for measles IgM testing routinely. To assess progress in measles control, it is recommended that immunization pro- grammes be evaluated by means of specific Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 581 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما epidemiological surveillance involving investigation of all reported cases. Further- more, the epidemiological characteristics of a disease may vary according to geographi- cal area, age group and transmission set- ting, thereby calling for the implementation of different purpose-designed preventive strategies [2]. Hence, this study aimed to describe the series of measles cases notified in Oman over a 4-year period through the epidemiological surveillance system. Methods For the purpose of this study, the database of case-based notification and mandatory information forms for measles was used; this is available within the national epide- miological surveillance system. This retro- spective review of records was carried out from 1 January 2000 to 31 December 2003 (4 years); data became available in elec- tronic format in 2000. All the cases notified by the attending physicians during this pe- riod were included in the study. Information was collected on: patient’s identification data (name, sex, age, address, region and nationality), presenting symptoms, labora- tory data, record of vaccination, source of infection and link with any outbreak. Physi- cians (paediatricians, general practitioners and general medicine doctors) had been trained in collecting this information during regional seminars conducted periodically. The Ministry of Health (MOH) in Oman has written guidelines (communicable dis- ease surveillance and control manual) for the surveillance of communicable diseases including measles and there is mandatory case notification from all health institutions, including primary care, and wide health care access and utilization (97%) [9]. It is unlikely therefore that measles cases remain undetected by the surveillance system for an extended period. In addition, measles surveillance in Oman is sensitive enough to consistently detect imported cases, isolated cases, and small outbreaks. However, cases that are mild and do not approach a health facility may go unnoticed. The regional epidemiologist/commu- nicable disease focal point in the regional Figure 1 Measles cases and vaccination coverage of MMR/MR in Oman from 1993 to 2003 582 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما headquarters oversees the activities of the surveillance and validates the data. A for- mal epidemiological investigation is car- ried out by the focal point upon receipt of notification and all the positive cases are actively followed up to search for the source of infection and other measles cases among the contacts and the community. Epidemio- logical links to any case and to an imported case are also evaluated. A weekly negative report of measles is also made in sentinel sites, including the private clinics, as a part of the elimination strategy. The clinical case definition used was: disease displaying the following charac- teristics: (a) maculo-papular rash, (b) fever ≥ 38.3 °C, and (c) cough, coryza or conjunc- tivitis. Cases are classified: as “probable” if they fulfil the clinical definition, or as “confirmed”, if, in addition, there is an epi- demiological link to another case of measles or laboratory evidence (demonstration of specific serum IgM antibodies). A measles outbreak is defined as presentation of 2 or more epidemiologically linked cases within a maximum period of 14 days (incubation period). Imported cases are those in persons infected outside Oman and the illness can- not be linked to local transmission. The 0.5–1 mL serum samples collected for each suspected case all over Oman are transported to Central Public Health Laboratory (CPHL), Darsiet, Muscat at 4–8 °C within 24–48 hours. The CPHL is also a reference laboratory for measles surveillance in the Eastern Mediterranean Region of the World Health Organization (WHO) Demonstration of specific IgM antibodies is done using the Behring Enzyg- nost enzyme-linked immunosorbent assay (ELISA) kit (Marburg, Germany). Labora- tory validation is routinely done by sending samples to the WHO reference laboratory in Cairo, Egypt. The data extracted in our study were analysed using SPSS, version 9. Univariate analysis was done to calculate frequencies and proportions. Age-specific incidence rates were calculated per 100 000 popu- lation, using the 2003 population-census as denominator. Association between the different age groups and risk of measles among cases was studied with reference to the relative risk (RR) (incidence rate ratio) and 95% confidence interval (CI). To determine the independent contribution of each variable among the notified cases, adjusted odds ratios (OR) and 95% CI were calculated by means of a logistic regression model. Results Over the 4-year study period, 190 cases of measles were notified from all the regions in Oman. Of these, 185 cases met the clini- cal case definition (97.4%). Of these 185 cases, 19.5% were found to be positive for measles, 11.9% (22/185) were labora- tory confirmed by testing IgM positive and 7.6% (14/185) were epidemiologically confirmed on being associated with another case of measles that was later laboratory confirmed. There were 145 (78.4%) labora- tory-confirmed negative cases. Although the remaining 4 cases fulfilled the clinical definition, no additional laboratory evi- dence was forthcoming, and they were duly classified as “probable” cases (Table 1). Overall, blood samples for measles IgM were collected in 97.3% (180/185) of cases. All the 185 cases had presented with fever and rash as a symptom. Cough, coryza and conjunctivitis were associated with 65%, 68% and 32% of notified cases respectively. The positive predictive value for measles of cough, coryza and conjunctivitis was 25.9%, 28.3% and 40.0% respectively. Information on the gender of the cases was obtained for 60 notified cases. Of these 60, 35.8% were male and 49.2% female. There was no Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 583 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما significant difference in the measles cases between males (6 positive) and females (5 positive) (χ2 = 0.64, P = 0.7). For the purpose of analysis, confirmed and probable positive cases were consid- ered as measles cases (40 cases, 21.6%). The mean age and standard deviation (SD) was 8.0 (SD 10.7) years as shown in Fig- ure 2. The largest proportion (37.5%) of the measles cases was in the < 1 year age group followed by 1–4 years age group (20.0%); altogether the under 5 years age group represented 57.5% of the cases. The estimated overall incidence rate of measles for the study period was 0.53 per 100 000 person years. The incidence was higher in those aged < 1 year (RR = 14.8; 95% CI: 9.7–24.4); 1–5 years (RR = 2.0; 95% CI: 1.0–3.7); and 5–9 years (RR = 1.3; 95% CI: 0.6–2.6) as shown in Table 2. The probable source of infection was es- tablished in 35.0% (14/40) of cases. Eleven of the 14 cases were linked to an epide- miological outbreak and later laboratory- confirmed and the other 3 cases were clas- sified as imported. During the outbreak the Table 1 Distribution of notified cases according to case classification Type of case No. % Probable (clinically diagnosed) 4 2.2 Confirmed positive 36 19.4 Epidemiologically confirmed 14 7.5 Laboratory confirmed 22 11.9 Confirmed negative 145 78.4 Total 185 100.0 Figure 2 Age distribution of the 40 measles cases, 2000–2003 [Mean 8 (SD 10.7) years] 584 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما place of transmission was the school and the secondary transmission occurred at home. Of the remaining cases where the source of infection was not established, 4 were prob- ably vaccine-related and 22 were sporadic cases. There were 2 outbreaks during the study period, one each in North Sharqiya and Dhahira regions of Oman. In North Sharqiya, 10 cases were reported from 8 April 2000 to 23 June 2000. Epidemiologi- cal investigation suggested that the reason for the outbreak was inconclusive with no established chains of transmission. In Dhahira there were 12 cases reported from 10 September 2001 to 9 January 2002. The outbreak was linked to an imported case and the source was evident in 11 cases, with 3 chains of transmission, mostly involving expatriate children. Table 3 illustrates the measles cases with respect to vaccination status. Half of the cases had either not received the measles vaccine or did not know their vaccination status. The majority (75%) of these cases were expatriates and vaccination records were not available for them. The remaining 25% had received some vaccine (7 cases, a single dose; 3 cases, 2 doses). It is notewor- thy that 25% (10 cases) of the measles cases were younger than the eligible age for vac- cination under the current EPI schedule for measles vaccination; 70% of these 10 were Omani and 30% were expatriate children. The measles risk among the notified cases was compared with various factors such as age, nationality and vaccination status at the time of notification as shown in Table 4. Among the notified cases from all the regions in Oman, measles cases were higher among children < 5 years and non-Omanis. Similarly, cases who were not due for measles vaccines and who were not vaccinated also had a higher risk of measles. However, regression analysis indicted that measles was significantly commoner only among notified individuals who were non- Omani (OR = 2.8; 95% CI: 1.0–8.0), who had not received measles vaccination (OR = 23.6; 95% CI: 4.4–125.0) and who had Table 2 Age-specific incidence rates of measles cases for the study period Age group Cases Rate per Relative 95% CI (years) 100 000 risk person No. (%) years < 1 15 (37.5) 7.78 14.8 9.7–24.4 1–4 8 (20.0) 1.03 2.0 1.0–3.7 5–9 7 (17.5) 0.67 1.3 0.6–2.6 10–40 10 (25.0) 0.18 0.3 0.1–1.3 Total 40 (100) 0.53 Reference – CI = confidence interval. Table 3 Distribution of measles cases by vaccination status Vaccination status No. % Not due for measles vaccine 10 25.0 Received 1 dose 7 17.5 Received 2 doses 3 7.5 Not vaccinated/unknown 20 50.0 Total 40 100.0 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 585 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما received 1 dose of the measles vaccine (OR = 7.3; 95% CI: 1.5–34.6). North Sharqiya and Dhahira regions had a higher risk of measles compared to other regions possibly because of the outbreaks that occurred during the study period in these 2 regions. However, there was no statistically significant difference in the occurrence of measles cases between the various regions in Oman (P > 0.05). Discussion The routine epidemiological measles sur- veillance system implemented in Oman provides the major characteristics of mea- sles cases registered in all the regions. The proportion of measles IgM-positive cases among the blood samples collected was 20.0% (36/180), which is low compared to a study conducted in Catalonia, Spain (70.1%) [2]. This is possibly due to a de- cline in incidence of measles over the years in Oman which tends to produce a reciprocal effect of an increase in the number of false notifications (over-diagnosis) [10]. Also in the Catalonia study, cases were confirmed using blood and nasopharyngeal secretions which could account for the higher posi- tivity. The proportion of confirmed (IgM- positive and linked to an outbreak) cases in the present study was 19.4% (36/185), which again is low compared to the study conducted in Catalonia, Spain (30%) [2], but higher compared to southern African countries [11]. In situations marked by low number of cases, such as in our study, serum-based di- agnostic confirmation is the choice, as was the case in Oman [12]. On the other hand, if large numbers of cases are reported, rapid, non-aggressive salivary determination of type-specific IgM antibody can enhance the reporting reliability and accelerate control measures [13]. The proportion of associated symptoms like cough, coryza and conjunc- tivitis was low in our study compared to the Spanish study [2]. The positive predictive Table 4 Measles risk among notified cases (n = 185) according to age, nationality and vaccination status Variable Measles Adjusted 95% CI P-value No Yes OR No. % No. % Age group (years) < 5 95 80.5 23 19.5 1.3 0.2–7.0 0.7 5–10 24 77.4 7 22.6 0.6 0.1–3.6 0.6 ≥ 10 26 72.2 10 27.8 reference Nationality Non-Omani 18 50.0 18 50.0 2.8 1.0–8.0 0.04 Omani 127 85.2 22 14.8 reference Vaccination Not due 41 80.4 10 19.6 3.9 0.9–17.1 0.06 1 dose 18 72.0 7 28.0 7.3 1.5–34.6 <0.05 Not vaccinated/ unknown 17 45.9 20 54.1 23.6 4.4–125.0 0.01 2 doses 69 95.8 3 4.2 reference OR = odds ratio; CI = confidence interval. 586 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما value for conjunctivitis was 40%, suggest- ing conjunctivitis is an important clinical feature in measles diagnosis in Oman. The proportion of cases under the age of 5 years was higher (57.5%) in our study compared to the 24% and 38% in other studies [2,14]. The greatest proportion of the cases (37.5%) was in the age group < 1 year. The age-specific incidence rates indicted that the age groups <1 year and 1–4 years were at the highest risk of presenting with measles; among 87% (20/23) of these cases no transmission pathway could be established. Correspondingly, outbreak- related cases did not exceed 50% and in the majority of cases there was insufficient evidence for reconstruction of the transmis- sion pathway. This might be due to the existence of measles virus circulation via mild cases among vaccinated individuals [15,16]. However, estimation of suscepti- bles according to the mathematical model of WHO in Oman gives a figure below the critical < 5% for the birth cohort since 1994 [17]. Hence, the reason for outbreaks due to unlinked imported cases and sporadic cases was not apparent. The majority (71.4%) of the measles cases with a chain of transmission were in the > 4 years age group (10/14) and 90% of them were unvaccinated expatriate children. Three cases were imported cases. Likewise, a significant number of mea- sles cases occurred among unvaccinated non-Omanis compared to Omanis who had received some vaccination. Hence, vaccina- tion requirement at school entry [2,15] and mass campaigns, especially among expatri- ate children, may help to prevent measles outbreaks in Oman due to imported cases. Mandatory measles vaccination require- ments for expatriate children entering the country could also be considered. With respect to place of infection, an appreciable proportion of cases, 47.5% (19/40), were associated with school and the home. Similarly, as described in other studies, home and schools must be viewed as settings that pose a risk of transmission [18,19]. The mingling of cohorts of infants and young children with a high proportion of susceptibles (due for vaccination and un- vaccinated) constitutes an ideal situation for the occurrence of outbreaks in such places [20,21]. Despite control measures, second- ary cases occurred during the outbreak thus signifying continued transmission [22]. In our study, 25% of the cases were yet to be vaccinated. However, a change in the current routine immunization (2 doses of MMR at 12 and 18 months) is not indicated in Oman during its elimination phase, be- cause it is suggested that if MMR coverage at 12 months of age can reach > 90%, it would be worth changing the policy to 2 doses at 12 months and 6 years of age to induce higher antibody titres and prevent primary vaccine failure [23–25]. During the elimination phase, multi- ple imported sources of measles virus will result in an increase in susceptibility to measles among those < 12 months. Hence, routine vaccination of children > 6 months during outbreaks and who are travelling to endemic countries could be considered [26,27]. Further genotypic studies of the measles virus in Oman could provide clues as to whether measles is endemic in Oman or not; if a diversity of measles virus geno- types is observed this will reflect multiple imported sources of the virus and indicate that no genotype of measles is endemic. However, lack of endemic transmission is evident by the limited secondary transmis- sion from imported cases [28]. The 3 measles cases in our study who had received 2 doses of vaccine represent the small proportion of primary vaccine failures that fail to seroconvert despite re- vaccination with a second dose [29,30]. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 587 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Similarly, in Britain, over a tenth of cases occurred in children who had been vacci- nated [31] because vaccine failure is known to sustain transmission in populations with high vaccine coverage [29]. Complementary measures, such as ad- ministration of a further dose of vaccine over a short period of time to the whole population of a given age group, regardless of prior vaccination status, by catch-up campaigns can also be considered [32]. However, it is a costly strategy and one that is difficult to sustain over an extended period of time. All such measures will have to be assessed within a regional context of measles eradication in the short term [33]. In the Americas, sustained interruption of indigenous measles virus transmission has been achieved through a 3-tiered vac- cination strategy that includes a) “catch-up” vaccination of all persons aged 1–14 years, regardless of disease history or vaccination status; b) “keep-up” vaccination of greater than or equal to 90% of children in each successive birth cohort at age 12 months; and c) “follow-up” campaigns designed to vaccinate all persons within a specific age range whenever the number of susceptible persons in the preschool-aged population approximates the size of a typical birth cohort (every 3–5 years) [34]. Conclusion The incidence of measles is low in Oman. Children under 5 years, especially unvac- cinated expatriate children, could present as imported cases of measles leading to lim- ited spread to the susceptible population in Oman. Continued effort to bring down the susceptibles by high vaccination coverage, sensitive investigation of all reported posi- tive cases, identification of clusters linking them geographically or by time, and supple- mentary vaccination measures will assist in the further reduction of measles incidence in Oman. Acknowledgements We would like to thank Dr Ali Jaffer Mo- hammed, DGHA, for his valuable guidance and support. We also thank all the disease surveillance staff and study subjects in- volved in the study. References 1. Duclos P et al. Measles in adults in Cana- da and the United States: implications for measles elimination and eradication. In- ternational journal of epidemiology, 1999, 28:141–6. 2. Godoy P et al. Measles epidemiology in Catalonia (Spain): implications for a regional vaccination programme. Inter- national journal of epidemiology, 1999, 28:558–62. 3. Progress toward global measles con- trol and regional elimination, 1990–1997. Morbidity and mortality weekly report, 1998, 47(48):1049–54. 4. World Health Organization. Initiative for vaccine research (IVR) website. Acute respiratory infections. Measles. (http:// www.who.int/vaccine_research/diseases/ ari/en/index1.html, accessed 4 October 2007). 5. World Health Organization, Department of Vaccines and Biologicals. Measles technical working group: strategies for measles control and elimination. Report of a meeting, Geneva, 11–12 May 2000. (www.who.int/vaccine_research/dis- eases/measles/en/Measles_TechWork- Group_110502.pdf, accessed 4 October 2007). 588 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 6. The milestones of EPI in Oman. Manual on Expanded Programme on Immuniza- tion, 3rd ed. Muscat, Ministry of Health, 2003:3. 7. Communicable disease surveillance and control. A standard operating procedures manual, 2nd ed. Muscat, Ministry of Health, 2005:42. 8. Ministry of National Economy. General Census for population, housing and es- tablishments (http://www.omancensus. net/english/index.asp, accessed 16 Octo- ber 2007). 9. World Health Organization, Regional Office for the Eastern Mediterranean. Country profiles. Oman (http://www.emro. who.int/emrinfo/index.asp?Ctry=oma, ac- cessed 4 October 2007). 10. Brown DWG et al. Salivary diagnosis of measles: a study of notified cases in the United Kingdom, 1991–93. British medi- cal journal, 1994, 308:1015–17. 11. Southern African countries eliminate measles death in 2000. Vaccine prevent- able diseases bulletin, 2001, 8:1–2 (http:// www.afro.who.int/ddc/vpd/bulletins/2001/ feb2001.pdf, accessed 22 October 2007). 12. Ramsay M, Cohen B, Brown D. Serum IgM testing is needed in all cases of sus- pected measles British medical journal, 1996, 313:23l. 13. Miller E. The new measles campaign. Im- munization should prevent an epidemic predicted by modelling. British medical journal, 1994, 309:1102–3. 14. Centers for Disease Control and Preven- tion. Measles – United States, 1995. Mor- bidity and mortality weekly report, 1996, 45:305–7. 15. Peltola H et al. The elimination of indig- enous measles, mumps, and rubella from Finland by a 12-year, two-dose vaccina- tion program. New England journal of medicine, 1994, 331:1397–402. 16. Pederson IR et al. Subclinical measles infection in vaccinated sero-positive in- dividuals in arctic Greenland. Vaccine, 1989, 7:345–8. 17. Ministry of Health. Oman’s progress to- wards measles elimination. Community health and disease surveillance newslet- ter, 2000, 9(1):1–4. 18. Gindler JS et al. Epidemiology of measles in the United States in 1989 and 1990. Pediatric infectious diseases journal, 1992, 11:841–6. 19. Hutchins S et al. Measles outbreaks in the United States, 1987 through 1990. Pedi- atric infectious diseases journal, 1996, 1:31–8. 20. Centers for Disease Control and Preven- tion. Progress toward elimination of mea- sles from the Americas. Morbidity and mortality weekly report, 1998, 47:189– 93. 21. Marwick C. National effort to immunize adolescents begins. Journal of the Ameri- can Medical Association, 1996, 276:766– 8. 22. Davis RM et al. A persistent outbreak of measles despite appropriate prevention and control measures. American journal of epidemiology, 1987, 126:438–49. 23. Min-Shi Lee, D James Nokes. Predict- ing and comparing long-term measles antibody profiles of different immunization policies. Bulletin of the World Health Or- ganization, 2001, 79(7):615–24. 24. Lee MS et al. Post mass-immunization measles outbreak in Taoyuan County, Taiwan: dynamics of transmission, vac- cine effectiveness and herd immunity. International journal of infectious disease, 1999, 3(2):64–9. 25. Ceyhan M et al. Immunogenicity and effi- cacy of one dose measles-mumps-rubella (MMR) vaccine at twelve months of age as compared to monovalent measles vac- Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 589 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما cination at nine months followed by MMR revaccination at fifteen months of age. Vaccine, 2001, 19(31):4473–8. 26. Papania M et al. Increased susceptibility to measles in infants in the United States. Pediatrics, 1999, 104:59. 27. Watson JC, Hadler SC, Dykewicz CA, Reef S, Phillips L. Vaccine use and strat- egies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and mortality weekly report, 1998, 47(8):1–57 28. Centers for disease control and preven- tion (CDC). Measles outbreak associ- ated with an imported case in an infant – Alabama, 2002. Morbidity and mortality weekly report, 2004, 53(2):30–3. 29. Cutts F, Markowitz L. Successes and failures in measles control. Journal of infectious diseases, 1994, 170(Suppl. 1):32–42. 30. Poland GA et al. Measles re-immuniza- tion in children sero-negative after initial immunization. Journal of the American Medical Association, 1997, 277:1156–8. 31. Ramsay M et al. The epidemiology of measles in England and Wales: rationale for the national vaccination campaign. Communicable disease report. CDR re- view, 1994, 4(12):141–6. 32. Quadros de CA et al. Measles elimina- tion in the Americas. Evolving strategies. Journal of the American Medical Associa- tion, 1996, 275:224–9. 33. Bellini WJ, Rota PA. Genetic diversity of wild-type measles viruses: implications for global measles elimination programs. Emerging infectious diseases, 1998, 4:29–35. 34. Centers for disease control and preven- tion (CDC). Measles Eradication: Recom- mendations from a Meeting Cosponsored by the World Health Organization, the Pan American Health Organization, and CDC. Morbidity and mortality weekly re- port, 1997, 46(11):1–20. 590 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Rubella serology in pregnant women attending health centres of Tehran University of Medical Sciences F. Majlessi,1 A. Batebi,1 M. Shariat,2 A. Rahimi1 and T.M. Azad1 1Department of Public Health Sciences, School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: dr_F_ majlessi@yahoo.com). 2Vali-e-Asr Reproductive Health Research Centre, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. Received: 31/12/05; accepted: 23/02/06 ABSTRACT This study was performed in 2003–05 to determine the serological status of a sample of pregnant women as a preliminary study for the rubella vaccination programme. Out of 965 pregnant women attending health centres affiliated to Tehran University of Medical Sciences for prenatal care, the estimated rubella immunity rate was 91.1% (95% CI: 89.3%–92.9%) and the nonimmunity rate was 8.9% (95% CI: 7.1%–10.7%). The rubella immunity rate differed in different areas of Tehran but not significantly so. However, there was a significant difference in the level of rubella immunity by the number of persons per household and by age, but no significant relationship with economic status, oc- cupation or level of education. Sérologie de la rubéole chez des femmes enceintes fréquentant des centres de santé de l’Université des Sciences médicales de Téhéran RÉSUMÉ Cette étude a été réalisée de 2003 à 2005 pour déterminer l’état sérologique d’un échantillon de femmes enceintes ; il s’agissait d’une étude préliminaire en vue du programme de vaccination contre la rubéole. Sur 965 femmes enceintes fréquentant les centres de santé rattachés à l’Université des Sciences médicales de Téhéran dans le cadre de la surveillance prénatale, le taux estimé d’immunité contre la rubéole était de 91,1 % (IC 95 % : 89,3 % - 92,9 %) et le taux de non-immunité de 8,9 % (IC 95 % : 7,1 % - 10,7 %). Le taux d’immunité contre la rubéole n’était pas le même dans les différentes parties de Téhéran, mais pas de façon significative. Il existait en revanche une différence significative de niveau d’immunité contre la rubéole selon le nombre de personnes par foyer et l’âge, mais pas de relation significative avec la situation économique, l’activité professionnelle ou le niveau d’instruction. ÍÉFì¶=½Ç·£·¶Á=fÃ{Í£º>‚ÍÉVr¶=h²=f»·¶L>£åQ=f™=¸º=ǃ=Ïb¶Íɾ>™Ù=ÍFrƒ=>ÉQǶÆi ‡K£·{(Ê»ÉUel>F¢(K£Èfm´º>º({>E=hÈh¢(Êj·…ÄJmfªa=gAËe>J  „=Í[qØ6Ìb™=›Íi=eb¶=ÅdÂKÈfQ?2003–2005(¸[º=ǃ=½aÀºL>¿É£¶ÍÉQǶÆj¶=Ͷ>ƒ=η¢­èf£J·¶ Íɾ>™Ù=ÍFrƒ=bu¼É£ìJ¶=Sº>¾¶ÍÈbÉÓÍi=ea´¶ce>FJ¢=Æ*[EÀ[ºÆ965ÍÉVr[¶=h[²=f™=À[£Q=eðغ>[U ¢f¶=Àj»J·ÈÍÉFì¶=½Ç·£·¶Á=fÃ{Í£º>‚Í[ɾ>™Ù=ÍFr[ƒ=b[uÍ[¢>¿»·¶ËfÈb[¯J¶=¹b£™=Á>²(Ìa×Ç·¶ÍÉVr¶=ÍÈ> 91.1%!ͯMÍ·q>«E95![E\àÆ=fIÆ(89.3!Æ92.9$!Í[ɾ>™Ù=ÍFr[V·¶Í[¢>¿™=Á=b[¯ª¹b[£ºÁ>[²[U›( 8.9%!ͯMÍ·q>«E95!E\àÆ=fIÆ7.1!Æ10.7*$![EÍ[ɾ>™Ù=ÍFr[ƒ=b[uÍ[¢>¿™=¹b£º¬·J]=b®Æ­ØJ]> ð>ÉÑ>rUCÄEèbßJá£àÈ×­ØJ]=Ä¿³¶Æ(Á=fÃ{Í¿Èbº°{>¿º*ÏÇJj[º›ð>ÉÑ>rUCÄEèbßJá£àÈ­ØJ]= UǶ(´¶c¤ºÆ µ>[¿ÂÀ[³IÆ(Àj¶=Gj}ÆbU=ÆÀ³jº›ÁÇ¿ì¯ÈÀÈd¶=t>^mÙ=ab¢Gj}Íɾ>™Ù=ÍFrƒ=buÍ¢>¿™= J®×=¤uǶ=¤ºð>ÉÑ>rUC>ÃEèbßJá£àÈͮآ¼É·£J¶=ÏÇJjºÆ?ͿÙ=Æ?Ëa>r*  Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 591 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Rubella infection is one of a group of uter- ine infectious diseases that can be acquired by women during pregnancy (TORCH in- fections) and which are associated with complications such as abortion, delivery of a dead fetus and fetal anomalies. Thus it is important to know the proportion of rubella- sensitive women in a community in order to estimate the risk of a child developing con- genital rubella syndrome (CRS). The World Health Organization (WHO) considers a rubella-sensitivity rate of more than 10% of all women in a community as a predispos- ing factor for CRS, and a value of more than 20% as very high risk [1]. In communities where rubella vacci- nation is performed erratically without a specific programme, the serologic pattern of that society will be disrupted and it may even lead to rubella infection occurring after childhood (in teenage or pregnancy), thereby increasing the risk of CRS [1]. WHO has drawn up guidelines for an organized programme of CRS surveillance and care for countries that have included rubella vaccination in their national immu- nization programme as well as for countries that are willing to do so [1]. It has proposed 3 stages of rubella con- trol [1]. The Islamic Republic of Iran is now at stage 1, planning for rubella vaccine, which is when a country wishes to include rubella vaccination in its national immuni- zation programme and requires some basic information. The WHO has suggested 4 methods for assessing the impact of CRS in these countries [1]. One method is to perform serological studies in pregnant women prior to delivery in order to estimate the risk of developing rubella and the proportion of women in the community who are sensitive to the infec- tion during pregnancy. Serological studies in 45 developing countries showed that in 13 countries the percentage of nonimmume women was < 10%, in 20 countries between 10%–25%, and in 12 countries > 25% [2,3]. Also in Oman a study in 1989 showed that 80% of women who were of reproductive age were nonimmune. In addition in the 1992–94 ru- bella epidemic of this country the incidence of CRS was 3.5 per 1000 live births [2]. Surveys on rubella immunity rates have been carried out in the Islamic Republic of Iran and other central Asian countries. A study on 946 women aged 15–39 years in Kyrgyzstan showed that 13% were nonim- mune [4]. Various studies in the Islamic Re- public of Iran showed that the proportion of reproductive age women without immunity towards rubella was between 10% and 24%. In 1986–90 in Shiraz the sensitivity rate to rubella after childhood was estimated to be 15% [5]. In 1996, 20% of high-school girls in Tehran were not immune [6]. In Shariati hospital in Tehran in 2000, around 24% of pregnant women were nonimmune [7]. A study in Urmieh in 2002 showed that 10% of fertile urban and rural women were not immune towards rubella [8]. Women are considered at risk of devel- oping rubella infection when specific serum rubella IgG levels are absent or inadequate to cause immunity [1]. In the Islamic Re- public of Iran, information about the rubella status of women of fertile age is patchy. Thus a study was performed with the aim of determining the rubella-specific IgG sen- sitivity rate in a sample of pregnant women attending prenatal care in Tehran. Methods In this cross-sectional study the rubella- specific IgG level was determined in the serum of 15–49-year-old pregnant women. To estimate the sample size, we considered the results of a study performed in Urmieh in 2002 which found the sensitivity rate to be 10% in women of fertile age [8]. Thus 592 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما for estimating the sensitivity rate of women in Tehran with an error of less than 2% and confidence level of 95%, the sample size was calculated to be 865 women, which increased to 970 when 10% loss was taken into account. In this way, we studied 972 pregnant women attending for prenatal care at all treatment centres affiliated to Tehran Uni- versity of Medical Sciences (Imam Kho- meini, Shariati, Arash and Mirza Koochak Khan hospitals and Islam Shahr health cen- tre). In addition to taking a venous blood sample, a questionnaire containing demo- graphic, regional and vaccination history data was completed for each subject. The blood samples were sent to the laboratory of the respective hospitals under cold temperature conditions and were kept at –20 ºC until testing. The samples were tested by enzyme-linked immunosorbent assay (ELISA, Dade Behring kit) and the antibody titre was calculated in relation to the control sera. Titres < 15 IU/mL, 15–30 IU/mL and > 30 IU/mL were considered as negative, borderline and positive respec- tively. Of the total sample (972), 7 women were excluded from the study due to borderline values. In order to study the relationship between factors causing lack of immunity in the different regions, the chi-squared test was used and data were analysed using SPSS software, version 10. Results The estimated immunity rate of the women in the study was 91.1% (95% CI: 89.3%– 92.9%). Thus the proportion of women susceptible to rubella was 8.9% (95% CI: 7.1%–10.7%). The results showed that among the 965 women, 280 (29%) had a titre of 260 IU/mL, 125 (13%) had 240 IU/mL and the rest had titre < 240 IU/mL. The results also showed that the most frequent antibody titre was 260 IU/mL. The logarithmic mean rubella antibody titre in our subjects after translat- ing these values to decimal values was 2.13 (standard deviation 0.32, range 0–2.47). The descriptive data of Table 1 show that the rate of immunity differed in differ- ent areas of Tehran, so that the estimated rubella sensitivity rate of pregnant women ranged from 17.5% in north Tehran to 6.3% in central Tehran and 7.1% in the suburbs. In order to study the relationship be- tween age and immunity towards rubella, the women were divided into 2 groups (Table 1). Lack of immunity in women ≤ 25 years and > 25 years was 11.0% and 6.8% respectively. Statistical tests show that there was a significant statistical difference in the level of immunity towards rubella between the 2 groups (P < 0.02). The results also show that the number of family members per household affected the rate of immunity (P = 0.004); this effect was not linear, in that families with < 3 members had a 9.3% rate of rubella sensi- tivity, which decreased to 3.6% in families with 4–5 members and rose slightly to 8.5% for households with ≥ 6 members (Table 1). There was no significant statistical relation- ship between socioeconomic status and rubella immunity (Pearson χ22 = 0.19, P = 0.91). In addition, living space area (m2) (Pearson χ21 = 0.17, P = 0.68) and history of vaccination did not show any relationship (Pearson χ21 = 0.003, P = 0.96). Discussion In countries such as the Islamic Republic of Iran, which have been placed in stage 1 by the WHO, the key factors in identifying rubella disease in the region and determin- ing immunization strategies are the sero- logic evaluation of women of fertile age, the estimation of the rate of sensitivity for Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 593 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما acquiring rubella and, if possible, complete assessment of the country in order to assess the sensitivity rate of different groups. The aim of our mostly descriptive study was to estimate the sensitivity (nonimmune) rate of pregnant women to rubella and we found that in our study population 8.9% of women were nonimmune, i.e. sensitive to rubella. According to the WHO definition [1], countries that are at risk of developing CRS are those in which the rate of sensitiv- ity to rubella is ≥ 10% among women of fertile age. Serological tests related to 45 developing countries showed that < 10% of women of fertile age were unvaccinated against rubella in 13 countries, 10%–24% in 20 countries and > 25% in 12 countries [1]. Past studies in the Islamic Republic of Iran have reported the rubella sensitivity rate to be in the range of 10%–25% (15% in 1986 [5], 20% in 2000 in high-school girls [6], 24% in pregnant women at Shariati Hospital in Tehran in 2000 [7] and 10% in 2001 in nonimmune fertile women in Urmieh [8]). Our study therefore shows a lower rate than previous studies in our country. In 1986 in Taiwan all 15-year-old high- school girls were vaccinated and in another programme in 1992 fertile-aged females were given rubella vaccination [9]. In the year 2000 a serologic study on 15–44-year- old women showed that 5.7% of nonim- mune women were from this age group [9]. Our sensitivity rate of fertile women was much lower than in other developing countries such as Jamaica and Panama, 43% and 38% respectively [2]. However, our rate is slightly higher than in some Gulf countries which, like the Islamic Republic Table 1 Frequency distribution of immunity to rubella in pregnant women (n = 965) attending prenatal care centres affiliated to Tehran University of Medical Sciences in 2004, by area of Tehran, age and number of family members in household Variable Immune Non-immune Total No. % No. % No. % Tehran area North 33 82.5 7 17.5 40 100.0 West 102 90.3 11 9.7 113 100.0 East 43 91.5 4 8.5 47 100.0 Central 89 93.7 6 6.3 95 100.0 South 191 88.0 26 12.0 217 100.0 Suburbs 421 92.9 32 7.1 453 100.0 Age (years) ≤ 25 437 89.0 54 11.0 491 100.0 > 25 442 93.2 32 6.8 474 100.0 Pearson χ2 = 5.359, df = 1, P < 0.02 No. of family members 1–3 660 90.7 68 9.3 728 100.0 4–5 159 96.4 6 3.6 165 100.0 ≥ 6 60 83.3 12 8.5 72 100.0 A total of 879 (91.1%) women were immune, while 86 (8.9%) were not. 594 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما of Iran, are included in the Eastern Mediter- ranean Region of WHO (Yemen 4%, Oman 8%) [10]. In our study the rate of immunity clearly increased in women aged > 25 years, especially those 31+ years (P < 0.02), with no relationship to history of vaccination. Similar to our study, a 6-year retrospec- tive study of fertile-age women in Senegal showed that 90.1% were immune and there was no significant statistical difference with regard to age group or socioeconomic status [11]. Complementary studies, especially con- cerning the frequency of CRS in the Islamic Republic of Iran, may be required in the future in order to determine the rate of risk of developing CRS in the country, so that better decisions can be made about mass vaccination against rubella. Acknowledgements In this article we used some information from study proposal number 130/8293 which had been approved by the Deputy of Research of Tehran University of Medical Sciences. References 1. Guidelines for surveillance of congenital rubella syndrome and rubella. Field test version May 1999. Geneva, World Health Organization, 1999 (WHO/V&B/99.2). 2. Castillo-Solórzano C, Andrus JK. Rubella elimination and improving health care for women. Emerging infectious diseases, 2004, 10(11):2017–21. 3. Castillo-Solórzano C et al. New horizons in the control of rubella and prevention of congenital rubella syndrome in the Ameri- cas. Journal of infectious diseases, 2003, 187(Suppl. 1):SI46–52. 4. Malakmadze N et al. Development of a rubella vaccination strategy: contribu- tion of a rubella susceptibility study of women of childbearing age in Kyrgyzstan, 2001. Clinical infectious diseases, 2004, 38(12):1780–3. 5. Kabiri M, Moattari A. The rubella immuno- surveillance of Iranian females: an indica- tion of the emergence of rubella outbreak in Shiraz, Iran. Iranian Journal of medical sciences, 1993, 18(384):134–7. 6. Rahimi F et al. [Level of rubella immu- nity in the high schools of Tehran] [the- sis]. School of Pharmacology, Islamic Azad University, Islamic Republic of Iran, 1995. 7. Saidi S. Epidemiological survey of rubella immunity in Iran. Bulletin of the World Health Organization, 1995, 46:563–5. 8. Islamloo FHR et al. [Serology levels in patients with rubella. Determination of epidemiologic indices and recommenda- tion of the best strategy for rubella im- munization in Iran (in the non-vaccinated population of Urmieh aged 0–45 years in 2001] [thesis]. School of Health, Tehran University of Medical Sciences, Islamic Republic of Iran, 2002 [In Farsi]. 9. Su SB, Guo HR. Seroprevalence of ru- bella among women of childbearing age in Taiwan after nationwide vaccination. American journal of tropical medicine and hygiene, 2002, 67(5):549–53. 10. Rubella and congenital rubella syndrome (CRS) in developing countries. Part 1: Burden of disease from CRS. Bulletin of the World Health Organization, 1997, 75 (1):55–68. 11. Dromigny JA al. Evaluation of the se- roprevalence of rubella in the region of Dakar (Senegal). Tropical medicine and international health, 2003, 8(8):740–3. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 595 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Patterns and determinants of maternity care in Damascus H. Bashour,1 A. Abdulsalam,2 W. Al-Faisal1 and S. Cheikha2 1Department of Family and Community Medicine; 2Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Damascus, Damascus, Syrian Arab Republic (Correspondence to H. Bashour: hbashour@scs-net.org). Received: 23/08/05; accepted: 23/02/06 ABSTRACT This descriptive study was designed to describe the patterns and determinants of maternity care among Syrian women living in Damascus. All 39 birth registers in 2 large provinces were used to recruit 500 mothers of healthy newborns. Mothers were interviewed in their homes using a semistruc- tured questionnaire. Multivariate analysis of the determinants of the frequency of use of antenatal care showed the following variables were significant: urban residence and visit to antenatal care in the 1st trimester. The significant variables for an early visit to antenatal care were the woman’s level of educa- tion; being pregnant with the 1st baby; and number of visits to antenatal care. Being young (age < 20 years) also correlated with early timing of the 1st antenatal visit. Caractéristiques et déterminants des soins de maternité à Damas RÉSUMÉ Cette étude descriptive avait pour but d’exposer les caractéristiques et les déterminants des soins de maternité chez des femmes syriennes vivant à Damas. L’ensemble des 39 registres des naissances de deux grandes provinces ont été utilisés pour recruter 500 mères de nouveau-nés en bonne santé. Celles-ci ont été interrogées à leur domicile sur la base d’un questionnaire semi-structuré. L’analyse multivariée des déterminants de la fréquence d’utilisation des soins prénatals a montré que les variables suivantes étaient significatives : résidence en milieu urbain et visite prénatale au cours du premier trimestre. Les variables significatives influençant une visite prénatale précoce étaient le niveau d’instruction de la femme, le fait qu’il s’agissait d’une première grossesse et le nombre de visites prénatales. La jeunesse (âge < 20 ans) était également corrélée à une date précoce de première visite prénatale. °nºa›ÍÈbɶÇJ¶=ÍÈ>¢f¶=L=ab†ÆTc>” Í^Ém\Øq(¸rÉ«¶=bɶÆ(½Øj¶=bF¢Ð>?(eÇnE½>É  „=Í[qØ6J¶=ÍÈ>¢f¶=L=aëb†ÆTc>”¬qǶÍÉ«qǶ=Íi=eb¶=ÅdÂáKß»ë»àq°n[ºa›L=bÉj·¶½çb¯I¶=ÍÈbɶÇ* ÀºL>É죙=K£–b®Æ39K»[uÆ(IF[²JŸª>[†›L=a×Ç[·¶ðØR[i500Ð>V[q?ð×>[«{?ßÀáF[íˆ?ð>[º?* ð>ÉÑhQ¼É»rJ¶=°Fjºð>¾>ÉFJi=ºb^JjºÀÃIÇÉE›L>úÙ=¤ºLØE>¯ºÁÇNU>F¶=ÏfQ?Æ*¸[É·VJ¶=f[Þ?b[®Æ L=fëɧJ™=ab£J™=ð>ÉÑ>rUC>»ÃEbJ£È[ɶ>J¶=ÀÈߧJ™=Á?Ìa×Ç·¶ͯE>j¶=ÍÈ>¢f¶=½=b^Ji=e=f³IL=aëb6>»ÂÆ×? ¸ »ƒ=Àº¹ÆÙ=PÇ·MÙ=›Ìa×Ç·¶ͯE>j¶=ÍÈ>¢f¶=°ªfºÌe>ÈgÆÍ¿Èb™=›ο³j¶=*>[ÃEèb[ßJá£àÈ[¶=L=§J[™=>[º? Ù=>ÃE½Ç¯I¶=Ìf²>F¶=Ìe>Èh·¶ð>ÉÑ>rUC¸[»ƒ=Æ(½Ù=Ïb[¶Ê[»É·£J¶=ÏÇJj™=ÊêÌa×Ç·¶ͯE>j¶=ÍÈ>¢f¶=°ªf™½ Ìa×Ç·¶ͯE>j¶=ÍÈ>¢f¶=°ªf™L=e>Èh¶=ab¢Æ(¹ÆÙ=*H>Fn[¶=À[iœFIf[È>[»²%ð>[º>¢ÀÈfn[¢À[º¸[®?f[»£¶=$ Ìa×Ç·¶ͯE>j¶=ÍÈ>¢f¶=°ªf™Ìe>Èg¹Æ?›>ÃJÉ®ÇIÆÌf²>F¶=Ìe>Èh¶>E*  596 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction There is general consensus that the use of maternal health care services reduces maternal and child mortality and improves the reproductive health of women. The es- sence of maternity care is that it should be provided at all phases: pregnancy, birth and postpartum. This care is essential for both high- and low-risk pregnancies. Over the past 2 decades, the Syrian Arab Republic has made remarkable progress in improving health outcomes among its population, particularly for children and pregnant women. From 1993 to 1999, the infant mortality rate dropped by 48% (from 34.6/1000 live births to 18/1000 live births), and the maternal mortality ratio dropped by 50% from 1990 to 2001 (from 143/100 000 live births to 65.4/100 000 live births) [1,2]. Although there have been no studies that explain the mortality decline, improve- ments in socioeconomic status, health serv- ices and individual factors may have been responsible. Although considerable efforts have been made to improve maternity care in the coun- try, government and professional priorities have dominated care, rather than the wom- en’s needs. Women’s access to informa- tion, and their choice and involvement in decision-making are neglected. Maternity care is very much fragmented, and mater- nity practices deviate from evidence-based best practice [3,4]. Access to health services, traditional beliefs and cultural practices, individual qualities and health-care-seeking behav- iour, as well as other factors, all contribute to the use of maternal health care. Several studies have been carried out to identify and understand the use of maternal health care services, especially in developing countries, where the services are underutilized [5–10]. As expected, there is no universal explana- tion that applies to all places and times; the determinants of utilization of maternal health care services are not the same across socioeconomic and cultural contexts. Since the way in which maternity care is provided is influenced by policies, avail- ability and quality of services, and, most importantly, the health-care-seeking be- haviours of the women, the current study aimed to describe the patterns of maternity care among Syrian women and to study its determinants. We hoped to contribute to the body of research on the use of maternal health services, and to articulate the policy implications of the findings. Methods Study design and data collection All 39 birth registers in 2 large provinces in the country were used to recruit women for this descriptive study: 4 from Damascus, the capital city, and 35 from Rural Damas- cus (which is not in fact rural). A total of 500 mothers of healthy newborns (< 90 days old) were identified from those regis- ters. Non-probability sampling (quota sam- pling) was used to select women. The quota sample was stratified by register and the number of births in each register during the previous year. Random selection of women from the birth register was then used to meet the target sample size. Houses in the relevant areas were traced using phone numbers and/or moukhtars (civil registrars at the smallest administra- tive unit). Women were approached and their verbal informed consent was obtained; none refused to participate. Interviews were carried out by trained young female social scientists, to avoid any potential bias if medical personnel interviewed the women. The interviews were based on a pre- designed and pretested semistructured Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 597 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما questionnaire that collected data on the sociodemographic characteristics of the women; their obstetric history; and on their use of care during the 3 stages of pregnancy and childbirth, namely antepartum, intra- partum and postpartum. Other data were also collected on the practices women ex- perienced during their delivery, and also on their preferences about the place of delivery and birth attendant (reported elsewhere). The questionnaire was piloted on 20 women not included in the study, and necessary modifications were made. Statistical analysis The questionnaires returning from the field were coded, and data were entered into a personal computer. The data were cleaned and checked using range checks and valid- ity checks. Analysis was done using the sta- tistical package SPSS for Windows, version 10 [11]. Missing values were allowed for in the analysis. Frequencies were calculated from the univariate analysis. Four selected dichoto- mous dependent variables were then con- structed to indicate major relevant items of maternal care. They were as follows: • If the woman received antenatal care, whether she had at least 4 visits or fewer than 4. This cut-off point was used in accordance with the 1994 World Health Organization recommendation [12]. • If the woman received antenatal care, whether the 1st visit was during the 1st trimester or later during the pregnancy. • Place of delivery, whether at home or a health facility. • Care provider who attended the deliv- ery, whether a midwife or doctor, apart from the place of delivery. Bivariate analysis was used to describe the relationships between different variables of interest and the dependent variables. To study the determinants of maternal care use, a multivariate analysis was carried out and a logistic regression model estimated the likelihood. Multivariate analysis included only variables that showed a significant relationship with the outcomes of interest, as demonstrated by the bivariate analysis. Results Characteristics of the women Table 1 presents the background characteris- tics of the women. Socioeconomic variables showed that 12.0% were highly educated and only 8.4% were working. Only 18.2% were primiparous, and 36.2% has a history of medical or obstetric problems during her last pregnancy. Patterns of maternal health care Tables 2–4 show the patterns of care as reported by women during their most re- cent experience of pregnancy and delivery that resulted in a live birth. Only 3.6% (18/500) of the women reported no use of antenatal care services. Of those, 14 women said that their pregnancy was normal and thus there was no need for them to visit the antenatal service. The mean number of ultrasound scans taken during pregnancy was 5.5 (standard deviation 3.2). Nearly 80% of those women who had an ultrasound said that it was done on request of the care provider, and only 15% requested the ultra- sound themselves. The majority of women had a normal de- livery and gave birth at hospital. The rate of caesarean section was 13.6%. Midwives at- tended 91.0% of home deliveries. A quarter of those who paid for the delivery admitted that the payment was expensive for them. The mean length of stay at hospital af- ter a normal delivery was 7.4 hours, 28.5 hours for caesarean sections. Only 8.6% of 598 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما women reported that a postpartum visit was scheduled for them; however, this propor- tion increased to over 25% among women who had problems after delivery. Table 1 Background characteristics of the study women (n = 500) Characteristic No. % Place of residence Urban 236 47.2 Rural 264 52.8 Parity Primiparous 91 18.2 Multiparous 409 81.8 History of spontaneous abortion Yes 154 30.8 No 346 69.2 History of induced abortion Yes 10 2.0 No 490 98.0 History of stillbirth Yes 33 6.6 No 467 93.4 History of perinatal death Yes 51 10.2 No 449 89.8 History of non-normal deliverya Yes 167 33.4 No 333 66.6 Interval from last pregnancy (years) (n = 400) ≤ 1 49 12.3 2–3 206 51.5 4+ 245 36.2 History of medical or obstetric problems during last pregnancy Yes 181 36.2 No 319 63.8 Characteristic No. % Woman’s age (years) < 20 54 10.8 20–29 280 56.0 30–39 133 26.6 40+ 33 6.6 Family size 3 115 23.0 4–5 235 47.0 6+ 150 30.0 Housing ownership Own house 288 57.6 Share house 212 42.4 Woman’s education (years) ≤ 6 147 29.4 7–9 191 38.2 10–12 102 20.4 13+ 60 12.0 Woman’s status Husband’s only wife 466 93.2 Husband has more than 1 wife 44 6.8 Husband’s education (years) ≤ 6 140 28.0 7–9 207 41.4 10–12 61 12.2 13+ 92 18.4 Woman’s work status Not working 458 91.6 Working and earning 42 8.4 Husband’s work Professional 69 13.8 Labourer 228 45.6 Small industry 80 16.0 Other 123 24.6 Family income (monthly, Syrian pounds) < 5000 39 7.8 5000–10 000 239 47.8 10 000+ 222 44.4 aRefers to both caesarean sections and instrument delivery. Determinants of maternal health care use Tables 5 and 6 show the results from the bivariate analysis. Results from multivari- Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 599 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 2 Antenatal care status of the study women Item No. % No. of antenatal visits 0 18 3.6 1–3 140 28.0 4+ 342 68.4 Timing of 1st antenatal visit 1st trimester 386 80.1 2nd or 3rd trimester 96 19.9 Reasons for antenatal visits Follow up 388 80.5 Medical problem 86 17.8 Other 8 1.7 Location attended Health centre 16 3.3 Private clinic 452 93.8 Other 14 2.9 Antenatal care provided by Male obstetrician 123 25.5 Female obstetrician 334 69.3 Other 25 5.2 Got the care from Same person 396 82.2 Different people 86 17.8 Had an ultrasound Yes 472 97.9 No 10 2.1 Had multivitamins and minerals Yes 461 95.6 No 21 4.4 Had an antenatal card Yes 29 6.0 No 453 94.0 Had a companion None 22 4.6 Husband 144 30.1 Sister/mother 122 25.5 In-law 83 17.4 Other 107 22.4 Paid for visits Yes 471 97.7 No 11 2.3 Totals are different due to missing values and/or inapplicable data. ate logistic regression analysis showed that the main determinants of having delivery at a heath facility were the woman’s level of education (OR = 2.04; 95% CI: 1.25–3.34); having a medical problem during the last pregnancy (OR = 1.7; 95% CI: 1.01–2.75); and, as expected, use of antenatal care (hav- ing 4+ antenatal care visits during preg- nancy) (OR = 2.2; 95% CI: 1.3–3.7). The 2nd model estimated the likelihood of being attended at birth by a doctor rather than a midwife. The significant variables in the model were: having a medical problem during the last pregnancy (OR = 1.57; 95% CI: 1.01–2.5); and the use of antenatal care, as previously defined (OR = 1.93; 95% CI: 1.2–3.2). When we modelled the variables as to predict the determinants of the frequency of use of antenatal care, the following vari- ables were significant: urban residence (OR = 1.73; 95% CI: 1.1–2.8); and early visit to antenatal care (in the 1st trimester) (OR = 9.1; 95% CI: 5.3–15.8). It should be noted that we excluded from this analysis the 18 women who did not have any antenatal care. As for the determinants of timing, the 1st antenatal visit in the 1st trimester of pregnancy showed that the significant variables in the model were the woman’s level of education (OR = 1.93; 95% CI: 1.1–3.4); being pregnant with the 1st baby (OR = 6.3; 95% CI: 1.4–28.8); and also the number of visits to antenatal care (OR = 9.0; 95% CI: 5.3–16.7). Being young (age < 20 years) also correlated with early timing of the 1st antenatal visit (OR = 2.9; 95% CI: 1.1–7.7). Discussion This study examined the maternal health care use among 500 women in Damascus 600 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما and Rural Damascus provinces and the main determinants of that use. Our results do not represent women throughout the country since we only targeted women in the capital and its surroundings. The women in our study had a higher proportion of deliver- ies at health care facilities and were more frequently attended by doctors at birth, as compared to the national figures [1]. This is due to fact that we covered a better served area of the country. However, we do not think that this will bias our findings since the main aim of our study was to investigate the determinants of maternal health care use; this is a factor of the availability of the health services as well as the health-care- seeking behaviour of women. Item No. % Type of delivery Normal 418 83.6 Caesarean section 68 13.6 Instrument 14 2.8 Place of delivery Public hospital 160 32.0 Private hospital 174 34.8 Clinic 60 12.0 Home 102 20.4 Other 4 0.8 Person attending delivery Male obstetrician 141 28.2 Female obstetrician 223 44.6 Midwife 120 24.0 Other, including traditional birth attendant 16 3.2 Reasons for choosing care provider Accessibility 32 6.5 Cost 43 8.7 Skilfulness 240 48.7 Other 33 6.7 Nonea 145 29.4 Table 3 Intrapartum care status of the study women Item No. % Delivered by the same person as in antenatal period Yes 180 37.3 No 302 62.7 Delivered by the same person as last delivery Yes 110 27.6 No 289 72.4 Companion at labour None 212 42.4 Husband 7 1.4 Sister/mother 97 19.4 In-law 67 13.4 Other 117 23.4 Companion at birth None 315 63.0 Husband 2 0.4 Sister/mother 71 14.2 In-law 44 8.8 Other 68 13.6 Paid for delivery Yes 404 80.8 No 96 19.2 Totals are different due to missing values and/or inapplicable data. aFor those who sought care from public hospitals, there was no choice of care provider. Our results showed that women who had received more than 6 years education at school were more likely to have their births at a health facility and to have better use of antenatal services in terms of numbers of visits and also the timing of the 1st visit. In their study of the use of maternal health services in Jordan, Obermeyer and Potter found that higher levels of education were associated with greater use of antenatal care, while larger numbers of children in the household and rural residence were associated with less use of antenatal care [8]. Urban residence was also associated with the use of antenatal care in our study. In India, Bhatia and Cleland confirmed Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 601 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما the association between socioeconomic factors, including maternal education, and the use of maternal health services [7]. Educated women are considered to have greater awareness of the existence of ma- ternal health care services and the benefits of using such services. They are likely to enjoy more autonomy within and outside the household and the skills acquired from schooling enable women to communicate with health professionals and be more de- manding about health care services. This study showed that having a medical or obstetric problem in the last pregnancy increased the likelihood of having a deliv- ery at a health facility and being attended at delivery by an obstetrician, after controlling for other confounders. This finding is very important, since it implies that the women’s experience can explain a change in their be- haviour. Magadi et al. argued that the vari- ations in the use of maternal health services can be present at the level of the individual woman, depending on the circumstances of the pregnancy [6]. However, in normal circumstances, there is an expectation that health-seeking behaviour will be homog- enous at the individual level. Important findings from this study in- clude the extensive use of private health services. This is a critical issue that needs further attention at the country level. The importance of working with as well as supervising the private sector was recently stressed [13]; however, when thinking about this issue one should also think of the disproportionate number of health care facilitates between urban and rural areas. The absence of continuity of care from pregnancy through the postnatal period was also evident. Studies of continuity of care demonstrate the beneficial effects of such continuity [14]. Our results also indicated some deviation from the best-evidence practice where, for example, the services did not allow companionship at labour and delivery, and also when extensive use of ultrasound was noted. Enkin et al. classified the physiological and psychosocial support at labour and delivery as a proven beneficial form of care, and they did not recommend having routine and frequent ultrasounds during pregnancy [15]. Table 4 Postpartum care status of the study women Item No. % Postpartum visits scheduled Yes 43 8.6 No 457 91.4 Length of stay in hospital (hours) 1–2 74 22.2 3–11 168 50.3 12–24 81 24.2 25+ 11 3.3 Support to initiate breastfeeding Yes 97 19.4 No 403 80.6 Informed about contraceptive use Yes 18 3.8 No 452 96.2 Informed about potential problems for which to seek care Yes 42 8.4 No 458 91.6 Problems encountered in postnatal perioda Yes 336 67.2 No 164 32.8 Sought care for complications after delivery Yes 151 44.9 No 185 55.1 Person sought for care Doctor 134 88.7 Midwife 17 11.3 Totals are different due to missing values and/or inapplicable data. aPain was included in this item; this explains the high proportion. 602 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Another interesting finding is that the use of antenatal care explained the place of delivery and the person attending the delivery as seen from the tables. One can argue that antenatal care encourages women to seek delivery assistance by doctors and also to have the birth at a health facil- ity. It is well known that regular antenatal Table 5 Results of bivariate analysis for potential determinants of place of delivery and birth attendants Variable Place of delivery Birth attendant Home Health facility P- Midwife Doctor P- No. % No. % value No. % No. % value Woman’s age (years) 0.036 0.065 < 20 8 7.5 46 11.7 12 8.8 42 11.5 20–29 52 49.1 228 57.9 70 51.5 210 57.7 30–39 34 32.1 99 25.1 39 28.7 94 25.8 40+ 12 11.3 21 5.3 15 11.0 18 4.9 Woman’s education (years) < 0.001 < 0.001 ≤ 6 49 46.2 98 24.9 53 39.0 94 25.8 7+ 57 53.8 296 75.1 83 61.0 270 74.2 Woman’s working status 0.408 0.351 Yes 11 10.4 31 7.9 14 10.3 28 7.7 No 95 89.6 363 92.1 122 89.7 336 92.3 Husband’s education (years) 0.074 0.046 ≤ 6 37 34.9 103 26.1 47 34.6 93 25.5 7+ 69 65.1 291 73.9 89 65.4 271 74.5 Ever had abortion or stillbirth or a prenatal death 0.727 0.363 No 62 58.5 223 56.6 82 60.3 203 55.8 Yes 44 41.5 171 43.4 54 39.7 161 44.2 Medical problem during last pregnancy 0.033 0.032 None 77 72.6 242 61.4 97 71.3 222 61.0 Yes 29 27.4 152 38.6 39 28.7 142 39.0 Birth order 0.224 0.845 1st 15 14.2 76 19.3 24 17.6 67 18.4 2nd or higher 91 85.8 318 80.7 112 82.4 297 81.6 Area of residence 0.656 0.659 Urban 48 45.3 188 47.7 62 45.6 174 47.8 Rural 58 54.7 206 52.3 74 54.4 190 52.2 No. of antenatal visits < 0.001 < 0.001 < 4 43 44.8 97 25.1 52 41.6 88 24.6 4+ 53 55.2 289 74.9 73 58.4 269 75.4 Time of first antenatal visit 0.024 0.018 1st trimester 69 71.9 317 82.1 91 72.8 295 82.6 2nd or 3rd trimester 27 28.1 69 17.9 34 27.2 62 17.4 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 603 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 6 Results of bivariate analysis for potential determinants of number of antenatal visits and timing of the first antenatal visit Variable No. of antenatal visits Timing of the first antenatal visit < 4 4+ P-value 1st 2nd or 3rd P-value trimester trimester No. % No. % No. % No. % Woman’s age (years) 0.003 < 0.001 < 20 12 8.6 42 12.3 50 13.0 4 4.2 20–29 78 55.7 196 57.3 229 59.3 45 46.9 30–39 33 23.6 92 26.9 94 24.4 31 32.3 40+ 17 12.1 12 3.5 13 3.4 16 16.7 Woman’s education (years) < 0.001 < 0.001 ≤ 6 58 41.4 77 22.5 90 23.3 45 46.9 7+ 82 58.6 265 77.5 296 76.7 51 53.1 Woman’s working status 0.904 0.176 Yes 11 7.9 28 8.2 28 7.3 11 11.5 No 129 92.1 314 91.8 358 92.7 85 88.5 Husband’s education (years) 0.491 0.739 ≤ 6 42 30.0 92 26.9 106 27.5 28 29.2 7+ 98 70.0 250 73.1 280 72.5 68 70.8 Ever had abortion or stillbirth or a prenatal death 0.453 0.004 No 83 59.3 190 55.6 231 59.8 42 43.8 Yes 57 40.7 152 44.4 155 40.2 54 56.3 Medical or obstetric problem during last pregnancy 0.79 0.663 None 89 63.6 213 62.3 240 62.2 62 64.6 Yes 51 36.4 129 37.7 146 37.8 34 35.4 Birth order 0.002 < 0.001 1st 14 10.0 76 22.2 88 22.8 2 2.1 2nd or higher 126 90.0 266 77.8 298 77.2 94 97.9 Area of residence 0.03 0.617 Urban 56 40.0 174 50.9 128 47.2 48 50.0 Rural 84 60.0 168 49.1 204 52.8 48 50.0 No. of antenatal visits < 0.001 < 4 73 18.9 67 69.8 4+ 313 81.1 29 30.2 Time of first antenatal visit < 0.001 1st trimester 73 52.1 313 91.5 2nd or 3rd trimester 67 47.9 29 8.5 care is important for identifying women at increased risk of adverse pregnancy out- comes and for establishing good relations between the women and their health care providers [12]. Assistance during delivery is an important component in reproductive 604 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما health care services. Although assistance during delivery is associated with the place of delivery, those variables were treated separately in our study. Midwives attended births at hospitals and homes. The results provide a basis for a number of policy implications. First, education was found to have an important impact on the use of maternal care, suggesting that im- proving maternal education should have an impact on the use of maternal care services. Secondly, the use of antenatal care services needs to be encouraged, and an evidence- based antenatal package should be given to all pregnant women. The findings suggest that maternal care programmes at the coun- try level should be reviewed and revisited. Acknowledgements This study was supported by the contribu- tion of the American University of Beirut award (Regional Changing Childbirth Re- search Program at the Faculty of Health Sciences, supported by Wellcome Trust Grant). We thank colleagues at the FHS/ AUB, especially Dr Hala Tamim, for their support, and all colleagues and friends who shared their comments with us. References 1. The PAPFAM study: a preliminary report. Damascus, Syrian Central Bureau of Sta- tistics, 2002. 2. A progress report on the national Millenni- um Development Goals. Damascus, Syr- ian State Planning Commission, 2003. 3. A study on maternity hospitals routines in Syria. Damascus, Syrian Ministry of Health, 2001. 4. Abdulsalam A et al. Routine care of nor- mal deliveries as applied in Syrian mater- nity wards. Journal of the Arab Board of Medical Specializations, 2004, 6:134–40. 5. Hundley V et al. A national survey of women’s views of their maternity care in Scotland. Midwifery, 2000, 16:303–13. 6. Magadi MA, Madise NJ, Rodrigues RN. Frequency and timing of antenatal care in Kenya: explaining the variations between women of different communities. Social science and medicine, 2000, 51:551–61. 7. Bhatia JC, Cleland J. Determinants of maternal care in a region of South India. Health transition review, 1995, 5:127–42. 8. Obermeyer CM, Potter J. Maternal health care utilization in Jordan: a study of pat- terns and determinants. Studies in family planning, 1991, 22:177–87. 9. Celik Y, Hotchkiss D. The socio-economic determinants of maternal health care uti- lization in Turkey. Social science and medicine, 2000, 50(12):1797–806. 10. Navaneetham K, Dharmalingam A. Utili- zation of maternal health care services in Southern India. Social science and medi- cine, 2002, 55:1849–69. 11. Coakes SJ, Steed LG. SPSS for Win- dows. New York, John Wiley, 1996. 12. Antenatal care. Report of a technical working group. Geneva, World Health Or- ganization, 1994 (WHO/FRH/MSM/96.8). 13. Brugha R, Pritze-Aliassim S. Promoting safe motherhood through the private sec- tor in low- and middle-income countries. Bulletin of the World Health Organization, 2003, 81:616–23. 14. Hodnett ED. Continuity of caregivers for care during pregnancy and childbirth. Co- chrane database of systematic reviews, 2000, Issue 1. Art. No.: CD000062. DOI: 10.1002/14651858.CD000062. 15. Enkin M et al. A guide to effective care in pregnancy and childbirth, 3rd ed. Oxford, Oxford University Press, 2000. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 605 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Assessment of women’s satisfaction with reproductive health services in Urmia University of Medical Sciences H. Nanbakhsh,1 S. Salarilak,1 F. Islamloo2 and S. Aglemand 2 1Department of Community Medicine; 2Department of Public Health, Urmia University of Medical Sciences, Urmia, Islamic Republic of Iran (Correspondence to H. Nanbakhsh: hanabakhsh@hotmail.com). Received: 01/12/05; accepted: 23/02/06 ABSTRACT We assessed women’s satisfaction with the reproductive health services in the population laboratory of Urmia University of Medical Sciences in 2003. A random sample of 600 married women aged 15–49 years completed a satisfaction questionnaire based on Bruce’s criteria. Overall 76.2% of women were satisfied and 15.8% were completely satisfied with the total reproductive health service; however 34.0% of women were unsatisfied or completely unsatisfied with their health care provider. Factors that needed be improved were: providing all modern contraception methods in the health cen- tres; using educational materials (e.g. pamphlets and brochures) at reproductive health consultations; and improving information given to clients to ensure informed choice of family planning method. Évaluation de la satisfaction des femmes à l’égard des services de santé génésique à l’Université des Sciences médicales d’Ourmia RÉSUMÉ Nous avons évalué la satisfaction des femmes à l’égard des services de santé génésique au laboratoire de population de l’Université des Sciences médicales d’Ourmia en 2003. Un échantillon aléatoire de 600 femmes mariées âgées de 15 à 49 ans a rempli un questionnaire de satisfaction fondé sur les critères de Bruce. Globalement, 76,2 % des femmes étaient satisfaites et 15,8 % étaient totalement satisfaites de l’ensemble du service de santé génésique ; en revanche, 34,0 % étaient insatisfaites ou totalement insatisfaites de leur prestataire de soins de santé. Des efforts devraient être faits pour : proposer toutes les méthodes de contraception modernes dans les centres de santé ; utiliser du matériel éducatif (dépliants et brochures) dans le cadre des consultations de santé génésique ; et améliorer les informations fournies aux utilisatrices pour qu’elles puissent choisir une méthode de planification familiale en connaissance de cause. ÍÉFì¶=½Ç·£·¶ÍɺeÆ?Í£º>Q›ÍÉE>ˆÝ=ÍVr¶=L>ºb]À¢L=bÉj¶=Îue¼É[ɯI b¿»·¯¢´º>Éi(Ç·ºØiC`fª(´¶Ëe×>if²>m(o~Á>¾ÀjU  „=Í[qØ6­bÃJjIÍ[£º>Q›½>[£¶=[J^™=›ÍÉE>ˆÝ=ÍVr¶=L>ºb]À¢L=bÉj¶=Îue¼É[ɯIÍi=eb¶=Åd ½>¢›ÍÉFì¶=½Ç·£·¶ÍɺeÆ?2003*À[ºÍ«¶ÖºÍÉÑ=Çn¢Í¿É¢KªÇJi=b®Æ600Ê[Iض=L>[QÆhJ™=L=bÉj[¶=À[º EÀÂe>»¢?\Æ=f[JI15Æ49f[E[[È>£ºη¢ð=b¿JjºÎuf¶=¹ÇUð>¾>ÉFJi=ð>º>¢lÆ*Ïb[E?b[®Æ76.2!Àÿ[º ÆÀÂ>ue15.8ÏbE?U›(ÍÉE>ˆÝ=ÍVr¶=L>ºb]¸»…À¢½>J¶=ÀÂ>ueÀÿº34.0!ÀÂ>[ue½b[¢Àÿº ÍÉVr¶=ÍÈ>¢f¶=ʺb¯ºη¢½>J¶=ÀÃì^iÆ?*Ê·È>º›jVJ·¶T>J€¶=¸º=Ç£¶=K·çN“Æ6¸Ñ>iǶ=¤É–ªÇI ¶=h²=f™=›¸»ƒ=¤¿™ÍNÈbƒ=ÍɫɯNIa=Ǻ½=b^Ji=Æ(ÍÉVr%L=fn[¿¶=ÆL>ÈÇì™=¸Nº$›ÌeÇn[™=¼Èb[¯Ib[¿¢ η¢b¿JjIÌfiÙ=¼ÉŸ¿IHÇ·iÙÀÃI=e>É]Á?Á>»v¶L>£Q=f»·¶Îì£I¶=L>ºÇ·£™=j€Æ(ÍÉE>ˆÝ=ÍVr¶= ÍVÉVqL>ºÇ·£º*  606 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Women and their health are central to the primary health care agenda, not only as the focus of family planning and maternal and child health programmes, but also as conduits for improving the health of their children [1]. In their biological reproductive role, women are obviously and directly tied to the health of the fetus and newborn child [2]. One of the most important services which are delivered for women is reproduc- tive health [3]. Reproductive health is an important component of public health. It is a prerequisite for social, economic and hu- man development. After the International Conference on Population and Develop- ment held in Cairo in 1994, the terms re- productive and sexual health were widely disseminated among all community sectors. The definition of reproductive health in- cludes many components, among which are family planning (FP), maternal and child health, prevention of harmful practices, reduction of the spread of reproductive tract infections and other sexually transmitted diseases (STDs) including HIV/AIDS, and provision of treatment for STDs and their complications [4]. Attempts to understand women’s re- productive health needs have shown that the interaction between clients and the service is a critical and neglected dimen- sion of programme efforts [5]. Concern for clients’ rights in the provision of repro- ductive health in developing countries has promoted intense efforts by international experts to promote client-centred models of communication as a replacement for more provider-centred approaches [6]. Moreover, communication between service providers and clients is an essential component in the delivery of family planning services and the vehicle for information exchange, report- ing, and informed choice of family planning methods [7,8]. Clients want quality services and pro- viders strive to offer this quality. However, definitions of quality can differ. Higher sat- isfaction levels result in more involvement of the client, and consequently increase the effectiveness of health care services. Evaluation of clients’ satisfaction plays a significant role in the improvement of health care quality. In general, a patient’s satisfaction is a complicated phenomenon that is influenced by different factors, and patient feedback is the foundation for im- provement of quality programmes. The main objective of this research was to assess women’s satisfaction with the re- productive health services in the population laboratory of Urmia University of Medical Sciences. Urmia is the centre of West Az- erbaijan province of the Islamic Republic of Iran and the population laboratory in this city was founded in 2001 with a target population of about 45 000 comprising 11 756 households. Methods The study design was descriptive and cross- sectional. Selection of population and study sample The Urmia city population laboratory in- cludes 3 health centres which were chosen for the study: Aghdash, Shahrokhabad and Jalili. The study population was all women aged 15–49 years who had been married at least once and were referred to the health centre. The sample size was estimated to be nearly 400 using the statistical formula, P (proportion of women’s satisfaction) = 50%, Z = 1.96, d = 0.05 and confidence level α = 0.05. To adjust for sample loss, e.g. from unusable responses, the sample size was increased by 50% to 600. The target group was 6300 married women in the age 15–49 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 607 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما years in the 3 health centres. A total of 600 married women were divided into 3 parts due to nearly equal populations in the se- lected health centres; 200 women from each centre were selected by systematic random sampling from the household files and inter- views were carried out with selected women who were referred to each health centre and continued until completion of the target sample size. Questionnaire design Bruce’s key points regarding quality in re- productive health were chosen in designing the questionnaire [9]. These are: (1) selec- tion of a FP method, (2) technical skill of service providers, (3) relationship between service providers and client, (4) consist- ency and follow-up, (5) comprehensiveness of service and (6) presenting information to the clients. A total of 30 questions were prepared for all 6 aspects and these were tested for their validity and reliability. A Likert scale was used for responses to ques- tions about satisfaction with aspects of services (completely satisfied = 5, satisfied = 4, no view = 3, unsatisfied = 2, completely unsatisfied = 1). Reliability analysis of the questionnaire showed that Cronbach’s alpha coefficient = 0.8316. Selection and training interviewers A group of 10 volunteer female students from the School of Public Health of Urmia University of Medical Sciences were cho- sen, trained and supervised by researchers to interview the selected women. All 600 women (100%) responded to the questions in the interview. Data entry and statistical analysis SPSS software was used for data entry and analysis based on response codes 1–6 in the questionnaire. The quality score of each factor in separate health centres was calculated. Descriptive analysis such as frequency, means, standard deviation (SD) and analytical tests (Spearman correlation and chi-squared tests) were used to study the relationship between variables. Results Population study and women’s profiles The results showed that the majority (51.0%) of the 600 women in the study were aged 25–35 years and a minority (37.0%) were aged 15–25 years. The mean age was 29 (SD 18) years, range 16–48 years. Concern- ing the education level of women, 36.5% had diploma or high-school education, 34.8% guidance (pre-high-school level), 17.5% primary school, 6.2% were illiterate and 5.0% university level. Family size showed that 47.5% of women had 0 children, 36.2% had 1 child, 12.7% had 2 children, 3.0% had 3 children and 0.6% had 4+ children. All the women surveyed were using contraception: most of them (49.5%) were using oral contracep- tive pills, 20.7% intrauterine device (IUD), 13.2% condoms, 9.7% natural methods, 3.5% tubectomy and 3.5% injectable con- traceptives. Women’s satisfaction The assessment of women’s overall satis- faction with the reproductive health service indicated that 76.2% were satisfied, 15.8% were completely satisfied, 7.3% had no view and 0.7% were unsatisfied. Table 1 shows the results of women’s satisfaction with the reproductive health services regarding informed choice of fam- ily planning method and service provider skills. Almost all the women (93.3%) in- dicated satisfaction (completely satisfied or satisfied) that their choice of FP method 608 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 1 Satisfaction of the women (n = 600) with reproductive health services: informed choice of family planning method and provider skills Questions Completely Satisfied No view Unsatisfied Completely satisfied unsatisfied No. % No. % No. % No. % No. % Informed choice about FP method Choice of method was free and informed 356 59.3 204 34.0 19 3.2 14 2.3 7 1.2 Given names of all preventive methods 327 54.5 210 35.0 32 5.3 27 4.5 4 0.7 Preventive methods were explained 286 47.7 208 34.7 60 10.0 43 7.2 3 0.5 Information about location of other contraceptive services 188 31.3 207 34.5 124 20.7 72 12.0 9 1.5 Information about limitations of contraceptive methods 155 25.8 182 30.3 93 15.5 138 23.0 32 5.3 Information about referral service 140 23.3 149 24.8 133 22.2 147 24.5 31 5.2 Provider skills Provider selected by client 93 15.5 112 18.7 191 31.8 151 25.2 53 8.8 Knowledge of provider 282 47.0 216 36.0 72 12 23 3.8 7 1.2 Experience of provider 297 49.4 223 37.2 62 10.3 15 2.5 3 0.5 Promptness of provider 265 44.2 231 38.5 58 9.7 40 6.7 6 1.0 Skilfulness of provider 283 47.2 233 38.8 68 11.3 13 2.2 3 0.5 FP = family planning. was free and informed. More than half the women (56.1%) were completely satisfied or satisfied with the information about the limitations of the FP service and the preven- tive methods, while 28.3% of them were completely unsatisfied or unsatisfied. The most unsatisfactory aspects of reproductive health services were the items “information about limitations of contraceptive service” (28.3% of women unsatisfied) and “infor- mation about referral services” (29.7%). Concerning provider skills, the majority of women (86.6%) had high satisfaction with the experience of the FP provider, while one-third (34.0%) were completely unsatisfied or unsatisfied with the provider they had selected. Table 2 indicates the results of women’s satisfaction with the reproductive health services concerning the categories inter- personal relationship and consistency and follow-up. The great majority of women (92.5%) were completely satisfied or satis- fied that the behaviour of the service pro- vider was polite, while 29.2% of them were unsatisfied or completely unsatisfied with the item about the use of educational tools in the consultation. The majority (83.0%) of women had satisfaction (completely satisfied and satisfied) that they had enough information about follow-up visits. Concerning consistency and follow-up of service, 8.2% of women were unsatis- fied (completely unsatisfied or unsatisfied) about the item “I know where to go if side- effects occur”. Table 3 identifies the women’s satis- faction about the comprehensiveness of services and information given to clients. The great majority of women (94.1%) had Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 609 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما high satisfaction (completely satisfied or satisfied) with the vaccination service, while 32.8% of women were completely unsatisfied or unsatisfied about the Pap smear service. Concerning the information given to clients, the majority of women (88.3%) had high satisfaction (completely satisfied and satisfied) with information they received about the use of their chosen FP method, while one-third of women (32.3%) were unsatisfied or completely unsatisfied with the item about distribution of information from pamphlets and booklets. Table 4 shows the Spearman correlation between the mean total of women’s satisfac- tion and the 6 reproductive health services factors, adjusted based on the correlation co- efficient from maximum to minimum. The results showed that the highest Spearman test coefficients were related to information given to clients (r = 0.606) and informed choice about FP method (r = 0.527) and the lowest was related to comprehensiveness of the service (r = 0.436). Table 5 shows a comparison of wom- en’s satisfaction between the 3 health cen- tres. Women’s satisfaction (satisfied or completely satisfied) with the reproductive health services were 95.1% in Agdash, 89.5% in Shahrokhabad and 91.0% in Jalili. Moreover, chi-squared tests showed that there was a significant difference between the total percentage women’s satisfaction Table 2 Satisfaction of the women (n = 600) with the reproductive health services: interpersonal relationship and consistency and follow-up Questions Completely Satisfied No view Unsatisfied Completely satisfied unsatisfied No. % No. % No. % No. % No. % Interpersonal relationship Felt able to ask questions 355 59.2 197 22.8 22 3.7 19 3.2 7 1.2 Behaviour of provider was polite 364 60.7 191 31.8 26 4.3 12 2 7 1.2 Had confidence in provider 341 56.8 203 33.8 41 6.8 13 2.2 2 0.3 Was asked about problems and aims of FP 260 43.3 218 36.3 74 12.3 39 6.5 9 1.5 Consultation was easy and understandable 308 51.3 229 38.2 42 7.0 14 2.3 7 1.2 Consultation used educational tools 130 21.7 178 29.7 116 19.3 111 18.5 64 10.7 Consistency and follow-up FP methods are always available in health centres 320 53.3 216 36.0 30 5.0 25 4.2 9 1.5 Have enough information about follow-up visits 344 57.3 214 35.7 29 4.8 10 1.7 3 0.5 Follow-up given by health centre 226 37.7 247 41.2 81 13.5 35 5.8 11 1.8 Know where to go when side-effects occur 264 43.8 212 35.5 75 12.5 42 7.0 7 1.2 Would like to come to this centre again 299 49.8 222 37.0 62 10.3 11 1.8 6 1.0 Would be supported and guided if side-effects occur 266 44.3 226 37.7 79 13.2 18 3.0 11 1.7 FP = family planning. 610 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما and health centre (χ2 = 15.798, df = 6, P < 0.015). Discussion The satisfaction questionnaire survey was conducted among a specific target group: clients of health centres that provide FP and other reproductive health services. The great majority of the study women (92%) were satisfied or completely satisfied with the reproductive health services in Urmia. Other studies have been conducted in the Islamic Republic of Iran: a study in health houses in rural areas of Urmia showed 94% satisfaction [10] and in Tonkabon the majority of the study group were satisfied with the reproductive health services [11]. Research carried out in rural women in Bali Indonesia showed 73.1% of respondents were satisfied with women’s health serv- ices available in their area and 94.5% of ever-users of contraception were satisfied with family planning services [12]. An- other study carried out in Cape Town, South Africa showed that 72% of women were satisfied with reproductive health services [13]. Respondents in that study listed 3 im- portant satisfaction factors: good relation- ship between clients and health workers; comfortable and free discussion during the consultation; and less waiting time than they expected. In Alexandria, Egypt, 69% of the nearly 600 women interviewed said they were satisfied with their most recent FP methods [14]. Our results agree with the above studies and show that the total percentage of women’s satisfaction with the reproductive health services were 76.2% satisfied and 15.8% completely satisfied. A study in Egypt in 1994 showed that 69% of the women surveyed were using FP methods, 91% of them were using the IUD, 5% were using oral contraceptives, Table 3 Satisfaction of the women (n = 600) with reproductive health services: comprehensiveness of service and information given to clients Questions Completely Satisfied No view Unsatisfied Completely satisfied unsatisfied No. % No. % No. % No. % No. % Comprehensive service Monitoring of child growth 384 63.9 172 28.7 37 6.2 5 0.8 2 0.3 Sexually-transmitted diseases service 131 21.8 166 27.7 230 38.3 61 10.2 12 1.9 Medical service 286 47.6 224 37.3 64 10.7 24 4.0 2 0.3 Vaccination service 379 63.3 185 30.8 29 4.8 5 0.8 2 0.3 Antenatal care service 374 62.3 177 29.5 33 5.5 9 1.5 7 1.2 Pap smear service 86 14.3 51 8.5 266 44.3 119 19.8 78 13.0 Information given to clients All preventive methods 308 51.3 207 34.5 46 7.7 35 5.8 4 0.7 Use of chosen method 293 48.8 237 39.5 47 7.8 18 3.0 5 0.8 Choice of method 274 45.5 234 39.0 65 10.8 25 4.2 2 0.3 Problems of forgotten pills and side-effects 277 46.2 214 35.7 71 11.8 26 4.3 12 2.0 Pamphlets and booklets 83 13.8 144 24.0 179 29.8 134 22.3 60 10.0 Side-effects of chosen method 248 41.3 229 38.2 62 10.3 44 7.3 17 2.8 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 611 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 2% were using injectable contraceptives, and only 2% were using condoms and other methods [14]. In our study 49.5% of women were using oral contraceptives, 20.7% con- doms, 3.5% injectable contraceptives and 3.5% tubectomy. With regard to client’s satisfaction with informed choice of FP method, statistical analysis showed there was a significant difference between the total percentage of women’s satisfaction and informed choice of FP method. The most unsatisfactory aspects of reproductive health services were the items “information about limitations of contraceptive service” (28.3% of women unsatisfied) and “information about referral services” (29.7%). In a study in Egpyt, cli- ents said that counselling about their choice of FP method and side-effects was a major element of quality services, as were costs and access. Clients said they were satisfied when they received information about only 1 method or a limited number of methods [14]. According to Bruce, reproductive health providers should have good experience, knowledge and skills [9]. Our findings about provider skills showed that the major- ity of women (86.6%) had high satisfac- tion with the provider’s experience in FP. Satisfaction with these services was 49.4% completely satisfied and 37.2% satisfied. Spearman correlation showed there was significant correlation between satisfaction and the provider’s skill. But, among these services in detail, 34.0% of women were unsatisfied or completely unsatisfied with the provider selected by them and 7.7% with the promptness of the service provider. A study in Nairobi, Kenya showed more than three-quarters of 900 women interviewed were satisfied with FP services. However, 20% listed problems with service delivery including long distance to clinics, long waiting times, unfriendly providers, lack of access to desired FP methods, unskilled providers and insufficient information [15]. Table 4 Correlation between mean total women’s satisfaction and reproductive health services Reproductive health Spearman P-value service coefficient Information given to clients 0.606 < 0.001 Informed choice about FP method 0.527 < 0.001 Interpersonal relationship 0.525 < 0.001 Provider skills 0.510 < 0.001 Consistency and follow-up 0.439 < 0.001 Comprehensive service 0.438 < 0.001 FP = family planning. Table 5 Comparison of women’s satisfaction in different health centres Satisfaction Agdash Sahrokhabad Jalili Total No. % No. % No. % No. % Unsatisfied 0 0.0 3 1.5 1 0.5 4 0.7 No view 9 4.5 18 9.0 17 8.5 44 7.3 Satisfied 145 72.5 155 77.1 157 78.5 457 76.2 Completely satisfied 45 22.6 25 12.4 25 12.5 95 15.8 Total 199 100.0 201 100.0 200 100.0 600 100.0 χ2 = 15.798, df = 6, P < 0.015. 612 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Women’s satisfaction from the point of view of interpersonal relationships is of great importance. In this regard, Bruce pointed to the quality of relationship between clients and health providers, such as consideration given to respect and confidentiality [9]. In a study carried out in Egypt, clients said that the important element of quality was that the providers treated them with respect (regardless of education or income) and that FP services should be integrated with other health services, be affordable and accessible and that they have a choice of FP methods [14]. Our findings concerning interpersonal relationships showed that the great major- ity of women were completely satisfied or satisfied with the behaviour of the service provider. The quality of reproductive health serv- ices is very important from the point of view of consistency and follow-up [16]. Our findings showed a significant correlation between total mean women’s satisfaction and consistency and follow-up. More- over, among these services 83% of women had high satisfaction with the item “I have enough information about follow-up visits” while 8.2% were unsatisfied with the item “I know where to go if side-effects occur”. Comprehensiveness of services in the health centre is important. Our findings showed that the majority of women (94.1%) had high satisfaction with the vaccination service, while 32.8% of them were unsatis- fied with the Pap smear service. The Spear- man test showed that there was a significant correlation between women’s satisfaction and comprehensiveness of services. Bruce pointed out that information given to clients is important with regard to acces- sibility, availability and variety of printed information such as pamphlets and booklets, and also that human and physical resources for counselling should be considered [9]. In our study, overall 32.3% of women were completely unsatisfied or unsatisfied with the distribution of educational materials. A study in central and eastern Java showed when women were asked what informa- tion they would like to help them make contraceptive decisions, more than one- third said they wanted information on side- effects, while 23% wanted information about method safety and 21% wanted infor- mation on efficiency [17]. Lack of informa- tion was a concern expressed by women in the Egypt quality care study [4]. A study conducted in Tanzania showed that 50% of women were unsatisfied with lack of communication and nonexistent distribu- tion of educational materials [18]. Patten et al. studied reproductive health in Bali and Indonesia and found that 73.1% of respond- ents were satisfied with the women’s health services available in their area and 94.5% of ever-users of contraception were satisfied with FP services. However, women indi- cated a need for more information on AIDS and other STDs; 52.2% had never received any information about AIDS and 69% had not been counselled about STDs [19]. Our analysis of correlations between the mean total women’s satisfaction and repro- ductive health services showed the high- est correlations with the categories about information given to clients (r = 0.606) and informed choice about FP method (r = 0.527). These factors are therefore im- portant for increasing women’s satisfaction with reproductive health services in the health centres of Urmia population labora- tory. Comparison of the total percentage of women’s satisfaction across different health centres showed that women were generally satisfied with reproductive health services, but women in Agdash health centre were the most satisfied. There are some limitations to the study. Quality is a broad concept that no single approach can adequately and fully measure. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 613 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Client satisfaction interviews are just one part of an overall quality evaluation effort. They should be used in conjunction with other quality evaluation instruments such as direct observation, reviews of client records or focus group discussions. The most important limitation of this study is that the quality elements of service pro- vision and client satisfaction in Bruce’s criteria were designed for FP services, but in this research these elements were applied to all reproductive health services. Client satisfaction is the most important reason for the quality of services, but does not cover all aspects of service quality. The strengths of our study are that it raises some useful ideas for the imple- mentation of programmes of quality care in reproductive health units. The meaning of quality care for the women who receive reproductive health services was examined to describe the service from the women’s point of view. Conclusion This study demonstrated the importance of using a questionnaire which was prepared based on Bruce’s 6 key measures of quality in assessing the reproductive health services [9]. The majority of women in the popu- lation laboratory of Urmia University of Medical Sciences were satisfied with repro- ductive health services and considered that the services in these health centres were ef- fective. The following factors affecting the women’s satisfaction need to be improved: providing all modern contraception meth- ods in health centres; using educational materials (e.g. pamphlets and brochures) at reproductive health consultations; and improving information given to clients to ensure an informed choice of family plan- ning method. Acknowledgements This study was funded by the World Health Organization Regional Office for the East- ern Mediterranean (RPC.3/45, R6/81/1, 23/Marcg/2003).The authors wish to thank Mrs S. Rabipoor and J. Amirzadeh for their technical support. Special thanks are due for Dr E.I. Fatih El Samani, former WHO rep- resentative in the Islamic Republic of Iran. References 1. Glenn C al. Seeking women’s voices: set- ting the context for women’s health inter- ventions in two rural counties in Yunnan, China. Social science & medicine, 1995, 41(8):1147–57. 2. Leslie J, Lycette M, Buvinic M. Weath- ering economic crisis: the crucial role of women in health. In: Bell DE, Reich MR, eds. Health, nutrition and economic crises: approaches to policy in the third world. Dover, Massachusetts, Auburn House Publishing Company, 1988. 3. Downie RS, Tonnahill A. Health promo- tion models and values, 2nd ed. Oxford, Oxford University Press, 1966. 4. Jain A, Bruce J. A reproductive health approach to the objectives and assess- ment of family planning programmes. New York, Population Council, 1994. 5. Simmons R, Elias C. The study of cli- ent–provider interactions: a review of methodological issues. Studies in family planning, 1994, 25(1):1–17. 6. Abdel-Tawab N, Roter D. The relevance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience. Social science & medicine, 2002, 54(9):1357–68. 614 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 14. Megeid AA et al. Knowledge and at- titudes about reproductive health and HIV/AIDS among family planning clients. Eastern Mediterranean health journal, 1996, 2(3):459–69. 15. Starrs A. Preventing the tragedy of mater- nal deaths: a report on the International Safe Motherhood Conference, Nairobi, Kenya, February 1987. Washington, World Bank, 1987. 16. Donabedian A. Defining and measuring the quality of health care. In: Wenzel RP, ed. Assessing quality health care: perspectives for clinicians. Baltimore, Wil- liams & Wilkins, 1992. 17. El-Deeb B. Makhlouf H. The role of wom- en as family planning employees in Egypt. Family Health International, Women Stud- ies Project Final Report, 1998. (http:// www.fhi.org/en/RH/Pubs/wsp/fctshts/ Egypt6.htm, accessed 17 August 2007). 18. Stein K. Service quality among women receiving MCH and family planning serv- ices. African journal of fertility, sexuality, and reproductive health, 1996, 1(2):146– 52. 19. Patten J et al. Reproductive health in Bali, Indonesia: findings from a needs assess- ment survey among rural women. Vener- eology, 1998, 11(1):11–8. 7. Bruce J. Fundamental elements of the quality of care: a simple framework. New York, Population Council, 1989. 8. Kumar S, Jain A, Bruce J. Assessing the quality of family planning services in de- veloping countries. New York, Population Council, 1989. 9. Bruce J. Fundamental elements of the quality of care: a simple framework. Stud- ies in family planning, 1990, 21(2):61–91. 10. Nanbakhsh H, Porali R. Study of rural satisfaction from the health and treating services of health houses of Urmia City, Iran. Journal of Urmia University of Medi- cal Sciences, 2003, 14(1):20–6 [in Farsi]. 11. Malekafzali H, Kayghobadi K. [Study of the effectiveness of health houses of Tonkabon City, Iran through calculation of mortality and birth of children index]. Journal of pharmacy and treatment, 1984, 8(4):41–3 [in Farsi]. 12. Patten J et al. Reproductive health in Bali, Indonesia: findings from a needs assess- ment survey among rural women. Vener- eology, 1998, 11(1):11–8. 13. Magwaza S. Progress of integrating re- productive health services at district level in Sough Africa. Cape Town, University of Cape Town Women’s Health Research Unit, 1999 (http://legacy.hst.org.za/re- search/seminar2000/integration.pdf, ac- cessed 15 August 2007). Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 615 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Implementing a quality improvement programme in a family planning centre in Monastir, Tunisia M. Letaief,1 A. Ben Hmida,2 B. Mouloud,3 B. Essabbeh,3 R. Ben Aissa2 and N. Gueddana 2 1Preventive Medicine and Epidemiology Unit, University Hospital of Monastir, Monastir, Tunisia (Correspondence to M. Letaief: mondher.letaief@rns.tn). 2Family Planning National Board, Tunis, Tunisia. 3Family Planning and Reproductive Health Centre of Monastir, Monastir, Tunisia. Received: 24/10/05; accepted: 23/02/06 ABSTRACT We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were sur- veyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures. Mise en place d’un programme d’amélioration de la qualité dans un centre de planification familiale à Monastir (Tunisie) RÉSUMÉ Notre objectif était d’améliorer la qualité des services de planification familiale et de santé génésique dans un centre de planification familiale grâce à la mise en place d’un programme d’amélioration de la qualité. Une enquête a été menée auprès des utilisateurs et utilisatrices afin de recenser les problèmes relatifs à la qualité. Les équipes de soins ont ensuite analysé les causes des problèmes, élaboré des solutions pour répondre à trois problèmes particuliers et mis en place un cadre d’assurance de la qualité. Les problèmes retenus étaient : la longueur du temps d’attente au centre ; le regroupement insuffisant des services de planification familiale et de santé génésique ; et l’absence de démarche globale. La phase finale visait à tester puis appliquer des mesures correctives. (Ji>¾Ç™=›ÌfiÙ=¼ÉŸ¿J¶h²fº›Ìaǂ=j€Sº>¾fEdÉ«¿Ik¾ÇI ;=b®ÍÃÉF¾(ÎjÉ¢ÀE¼Èe(\>Fr¶=ÏfnE(aǶǺÍ»jE(ÌbɗÀEbÉ=bF¢(¬Éì·¶=ed¿º  „=Í[qØ6Ìf[iÙ=¼É[Ÿ¿Ih²=fºbU?›ÍÉE>ˆÝ=ÍVr¶=ÆÌfiÙ=¼ÉŸ¿IL>ºb]ÌaÇQj€Íi=eb¶=KªbÃJi= ÌaÇ[‚=j[VJ¶Sº>[¾fEd[É«¿I¹Ø]Àº*ºb[]À[ºÀÈbÉ«Jj[™=Ïb[¶Xj[ºËf[Q?ÆÎ[·¢­f[£J·¶h[²f™=L> PØN[¶¹Ç[·ƒ=>F¿J[i=ÆLسn[™=H>F[i?¸[É·VJEÍÉVr[¶=Í[È>¢f¶=Ð>[®fª½>[®¼M(Ìaǂ>Eͯ·£J™=Lسn™= Ìaǂ=Á>»v¶e>{Ca=b¢DEÆÌ>¯J¿ºLسnº*Ê·È>º›Ì>¯J¿™=Lسn™=K·çN“b®Æ6›Í[·ÈÇì¶=e>[ŸJ¾×=Ìf[[Jª b]E¸º>³J¶=eÇr®Æ(h²f™=ʶÇ[HÇ·i?‘Ce>¯Jª×=Æ(ÍÉE>ˆÝ=ÍVr¶=ÆÌfiÙ=¼ÉŸ¿IL>º*­b[ÂÁ>[²Æ ÍÉVÉVrIL=Ð=fQCdÉ«¿IÆe>FJ]=ÇÂÍÉÑ>ÿ¶=Í·Uf™=*  616 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Promoting family planning and sexual health have been a priority in Tunisia for 40 years. Indeed, a family planning programme has been in place since 1966 and has been revised to include the broader definition of sexual and reproductive health according to the United Nations (UN) International Con- ference on Population and Development in Cairo 1994 [1]. To some extent important milestones have been achieved and this has been shown by the sexual and reproductive health indi- cators, i.e. prevalence of contraceptive use over 65%, synthetic fertility index of 2.00, birth rate of 17‰ [2]. Over the next decades, challenges facing health care systems and facilities will be re- lated to health care quality. Thus, improving the delivery and the quality of reproductive health services is becoming crucial to ad- dress reproductive health problems and to enhance effective use and management of such facilities [3]. Client satisfaction, defined as the degree of discrepancy between expectations and perceived performance [4], represents an important indicator of perceived quality of services, and obviously would allow more efficient use of health care and reproductive health facilities [5,6]. Quality improvement refers to the use of appropriate methodologies to narrow the gap between the current and expected levels of quality; it uses quality management tools and principles to understand and address system deficiencies. Quality improvement activities are con- ducted using variations on a 4-step method: identify (determine what to improve), analyse (understand the problem), develop hypotheses (determine what change(s) can improve the problem) and finally test and implement, or Plan Do Study and Act (PDSA) [7]. Despite the important emphasis on im- proving the quality of reproductive health services, client satisfaction surveys and quality improvement programmes are in- frequent in Tunisia. Our study is a pilot quality-operation study [8] which aimed at improving the quality of family and repro- ductive health services in a family planning centre. This paper presents the design and implementation of the programme. Methods We carried out a 4-phase quality operation study. The phases were: identifying the problems (client satisfaction survey), ana- lysing the causes of problems and develop- ing solutions for the selected ones (quality methods and tools), establishing a quality assurance framework, and testing and im- plementing corrective measures. First phase: evaluation of the clients’ perceived quality The first stage was a client satisfaction sur- vey which was performed in order to assess the current level of care provided by the services in relation to the expectations and preferences of the clients. We carried out a descriptive study of 215 women attending Monastir family plan- ning centre from March to June 2004 for reproductive health services. The women were selected by systematic random sam- pling (every fourth woman attending during the study period). The study tool was a questionnaire (exit interview) which was developed by a multidisciplinary committee (2 epidemiologists, 2 family planning centre managers, 1 gynaecologist, 1 psychologist and 3 general practitioners). It was de- veloped in Tunisian Arabic dialect and oriented towards sexual and reproductive health services. Our conceptual framework for evaluation of the services was based on Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 617 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما the following elements: accessibility and availability of the services; availability of basic equipment and essential facilities; information supplied by the practitioners to the clients; choice of contraceptive methods available at the centre; perceived technical services provided; relationship between health care professionals and client; conti- nuity of services; provision of a holistic ap- proach (e.g. social, psychological concerns addressed); and integration of preventive care, e.g. cervical screening, screening and early detection of breast cancer and treat- ment of sexually transmitted infections (STIs). The final version of the questionnaire required the response to 31 items related to reproductive health client satisfaction using an ordinal Likert scale. Some additional user information (age, level of education, occupation, socioeconomic status, gynae- cological and obstetric history) were also noted. The questionnaire was filled in by external interviewers using a structured approach. The clients were clearly informed about the objectives and the procedure of the study. Their participation was voluntary and they were free to withdraw without any negative consequences, with respect to information privacy and confidentiality. If a client refused to participate then we invited the next client at the exit point. A pre-test period was carried out on a sample of 30 clients to test the feasibility of the study and to assess the validity of the questionnaire so as to prevent future operational problems. Data were coded and entered using SPSS, version 11. Data analysis was per- formed by using descriptive parameters [mean, median, standard deviation (SD) quartiles, percentages] according to vari- able categories (quantitative or qualitative) and distribution. Priorities were listed using relative frequency (%) of gaps perceived by the clients in the reproductive health services provided. Second phase: analysing the problem causes and developing solutions To achieve this objective, we organized 3 seminars aimed at training the local team about quality improvement methods and tools. Brainstorming is a way for a group to generate as many ideas as possible and requires participants to be willing to express their ideas without evaluating them. This was used both for listing the possible causes and developing solutions to a specific prob- lem. Solutions were selected using a simple rating scale. Setting the priority of problems was done by multivoting and weighted vot- ing methods. Third phase: establishing a quality assurance framework Different elements of the quality assurance framework were developed by the local team, following their training on the quality improvement methods and tools. The survey results were shown and dis- cussed by the team. Quality-related prob- lems were then prioritized according to their relative frequency of perceived inappropri- ateness according to the clients’ preferences and expectations. The quality assurance framework starts with the quality-related problem to be ad- dressed by the quality assurance programme, e.g. long waiting time at the centre. Then, the problem is quantified by reference to the client satisfaction survey results (% of clients perceiving long waiting time). The reasons for considering the problem as a priority are explained (frequent health serv- ice problem, organizational problem, team- based problem, health behaviour related problem, etc.). The framework also includes the programme objective, the activities to be carried out, the person(s) responsible, the indicator(s) to measure the activity and the source(s) of verification, and the indicator standard (norm) to be achieved. 618 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Fourth phase: testing and implementing corrective measures With reference to the PDSA cycle, the fol- lowing steps were carried out: • Make a plan of action of the test and verify that all the persons involved in the solution understand the change. • Document modifications made by the intervention or the solution. • Verify that the intervention was tested according to the original plan and com- pared observed results with desired re- sults • Take appropriate action based on the results of the study to see whether to maintain, develop another solution or correct and adapt the proposed solution. Results Study sample general characteristics All the 215 randomly selected clients ac- cepted to voluntarily participate in the study. The mean age of the study sample was 32 (SD 7) years (minimum 20 years, maximum 48 years). Urban residents of Monastir constituted 94% of the study sample and 45% had completed primary school educa- tion. The majority of the clients were mar- ried (91.1%); only 7.5% were single. They had a median of 3 children (minimum 0, maximum 7, interquartile range 2 children). They had a median number of previous pregnancies of 4 and a median number of previous induced abortions of 1. As regards attendance, 45% of the clients attended the clinic for unwanted pregnancies, 5% for a control visit after an induced abortion, 20% for contraception, 17% for prenatal visits, 8% for information about STI prevention and 5% for other preventive issues. Evaluation of the perceived quality of reproductive health and family planning services We used an ordinal Likert scale in the ques- tionnaire to evaluate the quality of the serv- ices as perceived by the clients. Table 1 shows the frequency of the issues that were rated as unsatisfactory by the clients. Team-selected problems for improvement The results were presented to the team and after discussion and using a multi-voting method, they came up with a list of issues to be addressed by the quality assurance programme (Table 2). During the next sessions, the team se- lected 3 problems that would be addressed in a quality assurance framework. Their selection was based on the importance of the problem, its feasibility, it requiring a team-dependent solution and the potential for improvement. The 3 problems were: the perceived long waiting time, the lack of integrated services and lack of a holistic approach. Perceived long waiting time Through discussion, the team devised a fishbone diagram of the possible causes of the problem (Figure 1). Afterwards, they were invited to develop a specific quality assurance framework to address the issue of waiting time (Table 3). The objective was to reduce the waiting time inside the clinic. A set of activities were developed and imple- mented. They were assessed by noting the length of time between registration at the re- ception desk and seeing the doctor. After 1 month, the evaluation of this indicator using the lot quality assurance sampling (LQAS) method on a small sample of records will indicate whether the activities implemented Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 619 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 1 Proportion of clients unsatisfied by various aspects of family planning and reproductive health services Item % Received unclear information at the reception desk 95.8 Received no (or incomplete) information about the cervical cancer prevention 91.1 Received no information about the social assistance 88.3 Received no (or incomplete) information about sexually transmitted infections and their prevention 87.4 Doctor did not introduce himself before examination 87.0 Received no (or incomplete) information about the services at the centre 84.2 Health professionals did not attend to clients’ psychological and social concerns 82.7 Received no information about the 2 methods of induced abortion (surgical and medical) 76.6 Received no (or incomplete) information about breast cancer prevention 72.4 Received no information about what to do in case of urgent post-abortion problems 67.0 Doctor was not interested in the patients’ health problems 65.9 Received incomplete information about the side-effects of contraceptive methods 62.4 Received incomplete information about the effectiveness of contraceptive methods 56.4 Experienced long waiting time in the centre 55.8 Received no information about the different contraceptive methods 55.8 Health professional did not discuss with the clients their reasons for the unwanted pregnancy 38.5 Received incomplete information about the chosen contraceptive method 32.5 Received no advice about the decision of abortion 32.0 Unclear road signs to the centre 28.4 Client choice of contraceptive method not offered at the centre 25.8 No apparent access signs for the centre 24.0 Perceived an unwelcoming attitude from the doctor 15.8 Experienced difficulty accessing the centre 14.4 Experienced very long administrative procedures 12.1 Perceived an unwelcoming attitude from health professionals 05.5 Centre lacked organization 04.7 should be maintained, corrected or replaced by other solutions (PDSA cycle). Lack of integrated services In a similar way, the possible causes for a lack of integrated services were listed and pre- sented in a fishbone diagram (Figure 2). The objective was to improve the proportion of integrated preventive services. Activities were related to providing information, edu- cation and communication for the clients about preventive measures. Health profes- sionals were invited to note on the medical 620 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما records the occurrence of cervical screening and breast self-examination training (Table 4). Lack of a holistic approach Social and psychological concerns are im- portant issues according to the clients’ pref- erences and expectations. The summary of the possible causes of this shortcoming is shown in Figure 3. The objective was to improve the awareness of health-care professionals about the clients’ social and psychological concerns. The quality assur- ance framework is shown in Table 5. Discussion In the first phase, the study showed a list of problems related to the clients perceived quality of reproductive health and family planning services. These concerns were then included in a quality improvement interven- tion. We used quality assurance methods and principles to construct a quality as- Table 2 Issues to be addressed by the quality assurance programme as selected by the team Item Not informed about the prevention of cervical cancer and sexually transmitted infections Not informed about social assistance Not informed about the different services provided in the centre Psychological problems of the clients not addressed by health care providers Not informed about the 2 methods of induced abortion (medical and surgical) Not informed about breast cancer prevention Lack of information about choice of contraceptive and integration of clients’ preferences Not informed about what to do and where to go in case of a medical problem after an induced abortion Experienced long waiting time at the centre Unclear signs in the centre Figure 1 Fishbone diagram of possible root causes of clients’ perceived long waiting time Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 621 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ta bl e 3 Q u al it y as su ra n ce f ra m ew o rk fo r th e is su e o f lo n g w ai ti n g t im e P ro b le m P er ce iv ed lo n g w ai ti n g t im e at t h e ce n tr e C ur re nt s itu at io n 55 .8 % o f c lie nt s re po rt ed a lo ng w ai tin g tim e at th e ce nt re P rio rit y cr ite ria P ro bl em o rg an iz at io na l, fr eq ue nt , f ea si bl e an d te am -s el ec te d; s ol ut io n te am -d ep en da nt O bj ec tiv e R ed uc e th e cl ie nt s’ p er ce iv ed w ai tin g tim e A ct iv iti es R es po ns ib le m em be r( s) S ta rt A dd iti on al In di ca to r S ou rc e S ta nd ar d re so ur ce s ne ed ed A rr an ge a s ec on d of fic e fo r m id w ife v is its M an ag er Ju ne 2 00 5 N o P ro vi de e du ca tio na l N ur se s, m id w iv es Ju ne 2 00 5 N o N o. o f e du ca tio na l A ct iv iti es ’ r ep or t 80 % ac tiv iti es to th e cl ie nt s se ss io ns p er w ee k in th e w ai tin g ro om P rio r se le ct io n of th e R ec ep tio n de sk n ur se s Ju ne 2 00 5 N o N o. o f c lie nt s re fe rr ed D ai ly a ct iv iti es ’ 10 0% cl ie nt s ac co rd in g to th e fo r m id w ife o r do ct or r eg is te r ne ed fo r a vi si t w ith m id w ife vi si t/t ot al n o. o f or p hy si ci an re gi st er ed c lie nt s A rr an ge a no th er m id w ife if M an ag er , m id w iv es Ju ne 2 00 5 N o N o. o f s ec on d vi si ts D ai ly r ep or t 10 0% th e nu m be r of c on su lta tio ns w he n th e no . e xc ee ds ex ce ed s 30 /d ay 30 /d ay 622 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Figure 2 Fishbone diagram of possible root causes of insufficient integration of services surance framework that was implemented in the Family Planning and Reproductive Health Centre of Monastir. The success of our experience will be valuable for the local team. It will constitute an important incentive for sustaining the quality improvement experience. Similar teams in other such centres could be mo- tivated to start a similar approach. Thus a constructive and positive view of the qual- ity assessment will be shared among these facilities. In the field implementation of the study, we noted that in the pre-test phase most of the clients interviewed gave biased re- sponses, i.e. saying that services were very good and appropriate. This bias is often encountered in this type of survey and was corrected by underscoring the importance of presenting and explaining the study ob- jectives to the clients. Health care quality assessment gener- ally uses 2 approaches, either from the “technocrat” perspective of the health care professionals or from the lay perspective of the clients [9]. With the first approach, the technocrat perspective, the services are classified as good when they are in accordance with the standards and norms defined by health professionals. In the second approach, the clients play an important role in defining and assessing the quality of care [10–12]. Despite its benefits, measuring client satisfaction has been criticized for rep- resenting both a measure of care and a reflection of the respondent. To overcome this problem, some organizations prefer measuring clients’ perceptions instead. For example, the Joint Commission on Ac- creditation of Healthcare Organizations has replaced the term “satisfaction” with the term “perception of service” [13]. Then the client’s perceived quality is a subjective dynamic perception of the extent to which expected health care is received [14]. The client satisfaction assessment could represent a part of a multidimensional ap- proach for conducting a quality improve- ment intervention. This is particularly used in the client-oriented provider efficient Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 623 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ta bl e 4 Q u al it y as su ra n ce f ra m ew o rk fo r th e is su e o f in su ff ic ie n t in te g ra ti o n o f fa m ily p la n n in g a n d r ep ro d u ct iv e h ea lt h s er vi ce s P ro b le m In su ff ic ie n t in te g ra ti o n o f fa m ily p la n n in g a n d r ep ro d u ct iv e h ea lt h s er vi ce s C ur re nt s itu at io n 88 % o f c lie nt s no t i nf or m ed a bo ut th e pr ev en tio n of c er vi ca l c an ce r an d se xu al ly tr an sm itt ed in fe ct io ns ; 7 1% n ot in fo rm ed a bo ut b re as t c an ce r pr ev en tio n P rio rit y cr ite ria P ro bl em o rg an iz at io na l, fr eq ue nt , q ua lit y- re la te d O bj ec tiv e Im pr ov e th e in te gr at io n of r ep ro du ct iv e he al th a nd fa m ily p la nn in g se rv ic es A ct iv iti es R es po ns ib le S ta rt A dd iti on al In di ca to r S ou rc e S ta nd ar d m em be r( s) re so ur ce s ne ed ed P ro vi de c lie nt s w ith e du ca tio n M id w iv es , Ju ne 2 00 5 N o N o. o f r ec or ds in di ca tin g M ed ic al r ec or ds 80 % ab ou t b re as t s el f- ex am in at io n re ce pt io n th at th e cl ie nt r ec ei ve d be fo re m ed ic al v is its ag en ts ed uc at io na l i nf or m at io n/ to ta l n o. o f r ec or ds Id en tif y el ig ib le w om en a nd P hy si ci an s, Ju ne 2 00 5 N o N o. o f r ec or ds in di ca tin g M ed ic al r ec or ds 80 % pr ov id e th em w ith m id w iv es th e id en tif ic at io n of a n ce rv ic al s cr ee ni ng el ig ib le w om an /to ta l no . o f r ec or ds O ffe r vi de o pr ev en tio n ed uc at io n M id w iv es , Ju ne 2 00 5 N o C lie nt s’ k no w le dg e an d S ur ve ys 6 m es sa ge s ab ou t s ex ua lly nu rs es at tit ud es r eg ar di ng s ex ua lly m on th s af te r tr an sm itt ed in fe ct io ns fo r tr an sm itt ed in fe ct io ns ad ol es ce nt s E st ab lis h an in fo rm at io n, e du ca tio n M an ag er s, Ju ne 2 00 5 N o Fa m ily p la nn in g ce nt re an d co m m un ic at io n ho tli ne he al th ac tiv iti es a nn ua l r ep or t un it pr es en tin g th e sp ec tr um ed uc at or s of p re ve nt iv e se rv ic es D ev el op a w eb si te p re se nt in g M an ag er s, O ct ob er 2 00 5 N o – th e di ffe re nt r ep ro du ct iv e ph ys ic ia ns he al th s er vi ce s Id en tif y an d re fe r hi gh -r is k cl ie nt s to P hy si ci an s Ju ne 2 00 5 N o N o. o f H IV s cr ee ni ng a vo lu nt ar y fr ee an d an on ym ou s re fe rr al s H IV s cr ee ni ng v is it 624 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما (COPE) method, which is a process and set of tools designed to help health-care staff at a service delivery site to continuously assess and improve their services [15]. It is built on a framework of client rights and staff needs. The method encourages staff to review the way they perform their daily tasks and serves as a catalyst for analysing the problems they identify [16]. In our study there was a list of quality- related problems. They were mainly related to the integration of reproductive health and family planing services. For example, over 90% of the clients reported that they were not informed about cervical cancer prevention. Clients also did not receive clear information about the prevention of the STIs (87%) and breast cancer (72%). These results are in accordance with those published by other authors, reporting that in most cases, clients only received services for which they presented at the health facil- ity [17]. These results underscore the need for implementing integrated reproductive health and family planing services. In prac- tice this requires changing the attitudes and approaches of providers from a paternalistic to client-centred one [3,18]. According to our clients’ perceptions, there was a need to improve the communi- cation and interaction between health-care professionals and clients. For example, doctors frequently do not introduce them- selves before examination (87%), health professionals do not attend to the psycho- logical and social concerns of the clients (83%), doctors are not interested in the patients’ health problems (66%). The is- sue of improving the communication and interaction should be considered a priority in the quality assurance framework, pro- moting the implementation of a holistic and comprehensive approach. The results also highlighted the need to improve the perceived quality regarding the service provision for clients attending the clinic for induced abortion. Further actions are required to standardize the technical process of care to tackle inappropriate vari- ations [19]. A database was created which included some indicators that could be used for future Figure 3 Fishbone diagram of possible root causes of lack of a holistic approach Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 625 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Ta bl e 5 Q u al it y as su ra n ce f ra m ew o rk fo r th e is su e o f a la ck o f a h o lis ti c ap p ro ac h P ro b le m L ac k o f a h o lis ti c ap p ro ac h C ur re nt s itu at io n 82 .7 % o f c lie nt s in di ca te d he al th p ro fe ss io na ls d id n ot a dd re ss th ei r ps yc ho lo gi ca l an d so ci al c on ce rn s; 3 8. 5% o f c lie nt s in di ca te d he al th p ro fe ss io na l d id n ot di sc us s th ei r re as on s fo r in du ce d ab or tio n P rio rit y cr ite ria P ro bl em fr eq ue nt , q ua lit y- re la te d; s ol ut io n w ou ld le ad to e nh an ci ng c on tin ui ty o f c ar e O bj ec tiv e Im pr ov e th e he al th p ro fe ss io na ls ’ a w ar en es s of th e ne ed to a dd re ss c lie nt s’ ps yc ho lo gi ca l a nd s oc ia l c on ce rn s A ct iv iti es R es po ns ib le S ta rt A dd iti on al In di ca to r S ou rc e S ta nd ar d m em be r( s) re so ur ce s ne ed ed Im pl em en t a s cr ee ni ng a pp ro ac h N ur se s Ju ne 2 00 5 N o N o. o f c lie nt s re fe rr ed R ef er ra l 80 % to id en tif y an d re fe r cl ie nt s to th e ps yc ho lo gi st /n o. sh ee ts ne ed in g ps yc ho lo gi ca l s up po rt of c lie nt s el ig ib le fo r ps yc ho lo gi ca l s up po rt Id en tif y an d as si st c lie nt s P hy si ci an s, Ju ne 2 00 5 N o Le ve l o f s at is fa ct io n C lie nt 80 % re qu iri ng s oc ia l h el p ps yc ho lo gi st s, w ith h ea lth p ro fe ss io na ls sa tis fa ct io n m id w iv es aw ar en es s of c lie nt s’ so ci al c on ce rn s 626 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما assessment of service performance. The database also helps health professionals to file the medical records. The data will also be used to monitor and assess the success of the different activities of the 3 quality frameworks implemented. The local team was asked to develop an indicator for each activity, its source of control and operational standard. The latter was developed accord- ing to the field features. For the monitoring of the quality indicators the LQAS method was used. This was developed to meet in- dustrial quality control needs and has been applied to health surveys. Lot sampling is a simple and efficient procedure for quality assurance and WHO has used this method to assess immunization coverage [20]. Finally, to improve the performance and quality of reproductive health and family planning services, we recommend the fol- lowing strategies. • Widen the experiences of quality im- provement interventions to the other family planning and reproductive health clinics. The point is to build the capacity of healthcare teams to use appropriate quality improvement tools and meth- ods. This requires the creation of a core group of quality improvement experts whose mission is to help and coach teams willing to start quality improve- ment initiatives. • Encourage teams and clinics to begin quality improvement exercises, with the attention being given to create incentive measures (certification, accreditation). • Promote benchmarking, i.e. the use of information and the development of in- dicators that could be used to implement a culture of quality and to share experi- ences among similar health facilities. • Complete the approach of quality as- sessment by the evaluation of the per- formance of healthcare professionals and develop and use protocols that are evidence-based, for the spectrum of re- productive and family planning serv- ices. • Promote communication and interaction between healthcare professionals and clients. This point can be done by adopt- ing a client-centred approach. • Promote the integration of preventive care by targeting interventions accord- ing to clients’ needs rather than vertical programmes. • Develop and promote future research about the economic evaluation of repro- ductive health interventions, which will raise the awareness of health profession- als about the cost of interventions and enhance the efficient use of reproductive health services [21]. Acknowledgements We would like to acknowledge the support of the World Health Organization Regional Office for the East Mediterranean (Research Policy and Cooperation Unit) and the WHO Representative’s Office in Tunisia. We are also grateful for the help and continuous assistance of managers and healthcare pro- fessionals in the Family Planning Centre of Monastir. References 1. Programme of Action of the United Na- tions International Conference on Popu- lation & Development 5–13 September 1994 Cairo, Egypt (http://www.iisd.ca/ Cairo/program/p00000.html, accessed 25 July 2007). Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 627 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 2. Conférence Internationale sur la popula- tion et le développement plus 10 ans. République Tunisienne, Ministère de la santé publique, Office national de la famille et de la population, 2004. 3. Kols AJ, Sherman JE. Family planning programs: improving quality. Baltimore, Johns Hopkins University School of Pub- lic Health, Population Information Pro- gram, 1998 (Population Reports, Series J, No. 47). 4. Williams B. Patient satisfaction: A val- id concept? Social science & medicine, 1994, 38(4):509–6. 5. Pascoe GC. Patient satisfaction in pri- mary health care: A literature review and analysis. Evaluation and program plan- ning, 1983, 6:185–210. 6. Fitzpatrick R. Surveys of patient satisfac- tion. I. Important general considerations. British medical journal, 1991, 302:31–7. 7. Shewhart W. The economic control of quality of manufactured products. New York, D. Van Nostrand, 1934 (reprinted by the American Society of Quality Control, 1980). 8. Expanding capacity for operations re- search in reproductive health: summary report of a consultative meeting: WHO, Geneva, Switzerland, December 10–12, 2001. Geneva, World Health Organiza- tion, 2001. 9. Wouters A. Essential national health re- search in developing countries: health care financing and the quality of care. In- ternational journal of health planning and management, 1991, 6:253–71. 10. Brook RH, McGlynn EA, Cleary PD. Qual- ity of health care. Part 2. Measuring quality of care. New England journal of medicine, 1996, 335:966–70. 11. Brook RH, McGlynn EA, Shekelle PG. Defining and measuring quality of care: a perspective from US researchers. Inter- national journal for quality in health care, 2000, 12:281–95. 12. Donabedian A. The quality of care. How can it be assessed? Journal of the Ameri- can Medical Association, 1988, 260:1743– 8. 13. Hospital accreditation standards. Oak- brook Terrace, IL, Joint Commission on Accreditation of Healthcare Organiza- tions,1999. 14. Larrabee JH, Bolden LV. Defining patient- perceived quality of nursing care. Journal of nursing care quality, 2001, 16:34–60, 74–5. 15. COPE®: client oriented, provider efficient services. New York, AVSC International, 1995. 16. Huezo C, Diaz S. Quality of care in fam- ily planning: clients’ rights and providers’ needs. Advances in contraception, 1993, 9:129–39. 17. Maharaj P, Munthree C. The quality of integrated reproductive health services: perspectives of clients in KwaZulu-Natal, South Africa. Curationis, 2005, 28(1):52– 8. 18. Alden DL, Do MH, Bhawuk D. Client satisfaction with reproductive health-care quality: integrating business approaches to modeling and measurement. Social sci- ence & medicine, 2004, 59(11):2219–32. 19. Say L, Foy R. Improving induced abor- tion care in Scotland: enablers and con- straints. Journal of family planning and reproductive health care, 2005, 31(1):20– 3. 20. Jutand M, Salamon R. La technique de sondage par lots appliquée à l’assurance qualité (LQAS): methodes et applications en santé publique [Lot quality assurance sampling: methods and applications in public health]. Revue d’épidémiologie, médecine sociale et santé Publique, 2000, 48:401–8. 21. Ǿvertveit J. The economics of quality: a practical approach. International journal of health care quality assurance, 2000, 13:200–7. 628 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Outcome and management of pregnancy in women with thalassaemia in Cyprus M. Toumba,1 C. Kanaris,1 K. Simamonian2 and N. Skordis1 1Paediatric Endocrine Unit, Department of Paediatrics, Makarios Hospital, Nicosia, Cyprus (Correspondence to N. Skordis: nskordis@cytanet.com.cy). 2Thalassaemia Centre, Nicosia, Cyprus. Received: 04/12/05; accepted: 13/02/06 ABSTRACT We describe the management and clinical outcome of pregnancies among 100 Greek Cyp- riot women with thalassaemia: 88 with thalassaemia major and 12 with thalassaemia intermedia. A total of 152 successful pregnancies and 161 deliveries were included. All patients had endocrine assess- ment and frequent ferritin measurements. Multiple successful pregnancies included 7 twins and 1 triple pregnancy. Pregnant thalassaemics required significantly larger amount of total blood transfusion dur- ing pregnancy. There was a statistically significant increase in the ferritin levels during pregnancy, and levels remained significantly higher after pregnancy. Most pregnancies resulted in delivery of full-term healthy babies, and obstetric complications were rare, although some problems were encountered. Issue et prise en charge de la grossesse chez les femmes atteintes de thalassémie à Chypre RÉSUMÉ Nous décrivons la prise en charge et l’évolution clinique de la grossesse chez 100 Chypriotes grecques atteintes de thalassémie : 88 de thalassémie majeure et 12 de thalassémie intermédiaire. Au total, 152 grossesses menées à terme et 161 accouchements ont été pris en compte. Toutes les patientes étaient surveillées sur le plan endocrinien et faisaient fréquemment l’objet d’un dosage de la ferritine. Parmi les grossesses multiples menées à terme, on a compté 7 grossesses gémellaires et 1 grossesse triple. Pendant la grossesse, les femmes atteintes de thalassémie ont nécessité des quantités de transfusions de sang total significativement plus élevées. On a observé une augmentation statistiquement significative des taux de ferritine pendant la grossesse, et ces taux sont restés significativement plus élevés après la grossesse. La majorité des grossesses se sont achevées par la mise au monde de bébés nés à terme et en bonne santé, et les complications obstétricales ont été rares, en dépit de certains problèmes. t®›ÍÉ»ÉiØN¶>EL>E>r™=Ïb¶¸»ƒ=EbI¸Ñ>rU kÈaedzildzɾ(Á>ɾǺ>»ÉiedzÈf²(kÈe>¾>²lǿɾ>Jj¾Ç²(>FºÇIÊEƺ  „=Í[qØ6EbJ¶ð>«qÆÍi=eb¶=Åd½b¯IL>E>r[™=L>ɾ>¾Çɶ=L>Éq¯¶=ÀºÍÒºÏb¶ÍÈfÈfj¶=Ä·Ñ>rUƸ»ƒ= Àÿº7ÍÉ»ÉiØN¶>E88Æϳ¶=ÍÉ»ÉiØN¶>EÍE>rº12Íi=eb¶=K·b®Æ7ÍìiÇJ™=ÍÉ»ÉiØN¶>EÍE>rº152ðؗ Æ\>R¿¶>E¸õ·³I161Ìa×Æ*·¶Ìef³JºL>i>É®ÆÐ>»r¶=ab§·¶¼ÉɯIL×>ƒ=¤É»‚ËfQ?b®ÆJ[Èë«*Kç»[uÆ Í¿Q?PØNEðؗƼÑ=ÇIÍ£Fi\>R¿¶>EK··³I¶=Ìab£J™=¹>—Ù=*Í[É»²¸[¯¾ÍÉ»ÉiØN¶>EL>E>r™=KF·ìIb®Æ K[ɯE>[»²(¸[»ƒ=Ð>[¿M?¸r[™=JÈëªL>ÈÇJj™ð>ÉÑ>rUCÄEbJ£Èa>Èag=µ>¿ÂÁ>²Æ(¸»ƒ=Ð>¿M?½b¶=Àº²? «Ie=Í£«IfºL>ÈÇJj™=´·I¸ [»ƒ=b[£Eð>ÉÑ>rUCÄEbJ£Èð>¢>*¸[»ƒ=½>[“›Ìa×Ç[E¹>[—Ù=¼[Ÿ£ºK[ÃJ¾=b[®Æ ab£¶=Í·É·¯¶=Lسn™=x£EÐ>¿NJi>E(Ìea>¾ÍÈbɶÇJ¶=L>«¢>v™=K¾>²Æ(Ð>Vq?¹>«{Ù*  Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 629 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Normal sexual activity and reproductive capacity has become a demanding task for women suffering from thalassaemia major (TM). Modern advances in medical care have enabled patients with TM to survive successfully into adulthood. The prolonged life expectancy and improvement in quality of life of thalassaemia patients has rede- fined the challenges that couples face as they now have a realistic chance of creating a family. Patients with TM are characterized by severe haemolytic anaemia and are depend- ent on multiple blood transfusions, which consequently result in tissue haemosidero- sis. Patients with thalassaemia intermedia (TI), a clinically milder disorder, present with variable clinical features, from ab- sence of symptoms to moderate and se- vere anaemia. TI patients can also have splenomegaly, skeletal deformities due to bone marrow expansion and haemosidero- sis due to increased iron absorption from the gastrointestinal tract. In both cases iron deposition affects the cardiac, hepatic and endocrine systems [1]. Endocrine complications have been shown to be the result of iron deposition on the endocrine glands. Hypogonadotrophic hypogonadism, which is the commonest endocrinopathy, is the result of iron depo- sition on the pituitary gonadotroph cells and the hypothalamus, which both seem to be extremely sensitive to haemosiderosis [2–4]. TM patients often suffer from com- plete failure of pubertal development or develop hypogonadism later in their life. Female thalassaemia patients may have primary or secondary amenorrhoea, which leads to failure of the reproductive axis with chronic anovulation. Despite severe haemo- siderosis, ovarian function is preserved in most of the patients, as they are still able to increase the oestradiol level following gonadotrophin stimulation resulting in ova production [5,6]. Early recognition and treatment of hy- pogonadotrophic hypogonadism is man- datory in order to preserve fertility and to increase the chances of parenthood in thalassaemic patients. Spontaneous preg- nancies in women with preserved hypotha- lamic–pituitary–gonadal axis, who have normal menstrual cycles is a reality. Fur- thermore, women with primary or second- ary amenorrhoea are able to conceive after proper treatment [7]. The purpose of this study was to describe the management and clinical outcomes of 100 pregnant women with thalassaemia attending thalassaemia centres in Cyprus in order to document the effectiveness of modern therapeutic advances. Methods This retrospective study over the period 1990–2004 included 100 pregnant women who were attending the 4 thalassaemia centres (Nicosia, Limassol, Larnaca and Paphos) in Cyprus. All thalassaemic women who were followed up in our clinics since their birth and who conceived, with treat- ment or spontaneously, and had successful deliveries were included in the study. At the time of pregnancy all were between ages 20 and 35 years. Of the 100 women, 88 suffered from TM and had been regularly transfused since infancy to maintain haemo- globin at the level of 10 g/dL. Treatment with chelating agents was initiated around the age of 2 years in the majority of these patients. Another 12 women had TI and required no transfusions. For the purpose of the study the patients were divided into 4 groups. 630 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما • Group 1 (n = 60): TM and normal sex- ual development, attained menarche and normal menstrual function. • Group 2 (n = 12): TI and normal men- strual cycles. • Group 3 (n = 11): TM and primary amenorrhoea. • Group 4 (n = 17): TM and secondary amenorrhoea before pregnancy. All patients had endocrine assessment, which included measurement of free thy- roxine (T4), thyroid stimulating hormone (TSH), prolactin, follicle stimulating hor- mone (FSH), luteinizing hormone (LH), oestradiol and a.m. cortisol. They also un- derwent gonadotropin-releasing hormone (GnRH) test by using the standard method before pregnancy and an oral glucose toler- ance test was performed annually. Infor- mation about the method of conception, the mode of delivery and the outcome of pregnancy was collected from the patients’ medical records and from personal inter- views. Nine (9) of the patients had their cardiac function evaluated by serial echocardio- graphy (M-mode, 2-dimensional, Doppler) during pregnancy and after delivery. The following indices were measured: end systolic dimension, end diastolic dimension and ejection fraction. Statistical analysis To evaluate transfusion requirements and ferritin levels before, during and after preg- nancy the Student t-test for paired data was used for group 1 and the Wilcoxon signed rank test for paired data was used for groups 3 and 4. Results Conception The majority of our patients who had normal menstrual cycles conceived spontaneously. Induction of ovulation was performed in those who failed to conceive after 1 year of sexual intercourse with their partner and in those who wished a planned preg- nancy. Women with amenorrhoea achieved conception after ovulation was induced. Surprisingly 1 patient with primary amen- orrhoea conceived spontaneously, while she was on replacement combined treat- ment with oestrogen and progesterone. In 8 of the couples included in the study, both members were thalassaemia patients. Following genetic counselling, 6 couples decided to proceed to sperm donation. One couple where the female partner suffered primary amenorrhoea and type 1 diabetes mellitus proceeded to ovum donation after failure of conception with sperm donation. In the remaining couple where the female had intact gonadal function, pregnancy was spontaneously achieved. Number of successful pregnancies A total of 100 Greek Cypriot women with TM and TI were able to achieve pregnancy and successfully deliver babies. These 100 women had 152 successful pregnancies between them, which resulted in the deliv- ery of 161 babies. The mean birth weight of the full-term babies was 2700 g, which is considered appropriate for gestational age. Overall, there were only 4 babies who were classified as small-for-gestational-age and in these cases there was a correlation between the level of maternal haemoglobin during pregnancy and the birth weight of the baby. There were 5 twin pregnancies in women with primary amenorrhoea and sec- ondary amenorrhoea (induced) and 2 twin pregnancies in patients with normal men- strual cycles (1 induced and 1 spontaneous) and also 1 triple pregnancy in a patient with primary amenorrhoea (induced). The majority of pregnancies (79.9%) resulted in successful deliveries of full- term babies, whereas 13.3% resulted in Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 631 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما premature deliveries, half of which were not singleton births. From all the pregnancies, 7 (4.7%) resulted in spontaneous abortions and 3 (2.1%) in very premature delivery of stillborn babies. Transfusion requirements As expected, pregnant TM patients required significantly larger amounts of total blood transfusion during pregnancy (P < 0.005 for group 1 and P < 0.05 for groups 3 and 4) as shown on Figure 1. In all 3 groups there was no difference between the amounts of blood required before pregnancy compared with that required after delivery. There was also no difference between the haemoglobin level before, during and after pregnancy in all 3 groups. Ferritin levels The mean ferritin levels 1 year before, dur- ing each of 3 trimesters and 1 year after pregnancy are shown on Figure 2. There was a statistically significant increase of the ferritin levels during pregnancy when they were compared to those before pregnancy for group 1 (P < 0.01) and for groups 3 and 4 taken together (P < 0.01). The ferritin levels remained significantly increased after pregnancy in all 3 groups (P < 0.01). Complications Two of our patients developed ovarian hyperstimulation syndrome, and were suc- cessfully recovered. The 28-year-old patient who carried a triple pregnancy developed congestive cardiac failure, as the conse- quence of cardiac tamponade following pericarditis. She was successfully treated and an elective premature caesarean section was performed. One patient who developed an uneventful episode of pericarditis also recovered. There were no other endocrine complications noted, nor any case of gesta- tional diabetes. None of the patients showed impairment of renal function. Two of the patients with primary amenorrhoea, includ- ing the one with the triple pregnancy, de- veloped pre-eclampsia, for which they had a premature caesarean delivery. Cardiological evaluation A transient increase in left ventricular (LV) end diastolic dimension, minimal change in LV end systolic dimension, and increase in systolic function, as measured with ejection Figure 1 Amount of blood required for transfusion of pregnant women with thalassaemia major (n = 88), before, during and after pregnancy 632 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما fraction was observed in all the patients. All cardiac indices returned to the pre- pregnancy values following delivery (Fig- ure 3). Interestingly, women who started pregnancy with a higher ferritin level had a more attenuated increase in LV end systolic dimension, accompanied by a decrease in- stead of an increase in systolic function. An expected elevation of their cardiac output was documented but no other significant changes in end systolic dimension and de- viation in the indices for LV diastolic func- tion were identified. Figure 2 Mean ferritin levels 1 year before, during the 3 trimesters and 3 months after pregnancy for pregnant women with thalassaemia major (n = 88) Figure 3 Transient rise in ejection fraction in pregnant women with thalassaemia major (n = 88) with low and high ferritin levels Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 633 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Discussion Women with thalassaemia who are regu- larly transfused and are well chelated can now become pregnant either spontaneously or by inducing ovulation. The presence of gonadal dysfunction can be overcome with proper combination treatment. It is necessary that all pregnant thalassaemia patients be followed up very closely. Apart from the routine pregnancy follow-up, the thalassaemic pregnant woman needs ad- ditional medical care. Haemoglobin levels should be maintained at 10 g/dL and careful monitoring of vital signs during transfusion is required. Ferritin levels should also be measured and observed to avoid iron over- load. Careful monitoring of the transfusion regime and regular evaluation of cardiac function should be done in all pregnant tha- lassaemic women to prevent fluid overload. Cardiac function should be evaluated peri- odically by a cardiologist. The increase in ferritin levels during pregnancy is attributed to the discontinu- ation of iron chelation therapy and the in- creased amount of blood required for their transfusions. Increased ferritin levels during the last trimester of pregnancy and after delivery have not been reported before. Pre- vious studies show that serum ferritin levels rise by 10% or less after delivery when compared to the prepregnancy level [6]. Iron chelation therapy, due to its possible teratogenic effects, is withheld as soon as the pregnancy is planned or identified. It has been assumed that pregnancy is an efficient chelator of iron due to its haemodilution ef- fect and the fetal consumption of free iron. Although desferrioxamine therapy has not been implicated for any deleterious effect on the fetus, the current recommendation is its discontinuation, both once pregnancy is identified and during the induction period [8–10]. Chronic maternal anaemia in the thalas- saemic pregnant woman may result in fetal hypoxia, which predisposes to premature la- bour, intrauterine growth retardation (IUGR) and death. In our study the incidence of such complications was smaller compared to a similar study which reported 2 abortions, 2 stillbirths and 3 pre-term deliveries (1 of which was in a twin pregnancy) in 17 pregnancies [11]. The percentage of IUGR babies in our series (4.5%) is also smaller compared to other reports [11,12]. During the induction of ovulation there is always the risk of ovarian hyperstimula- tion syndrome, a rare but life-threatening complication. It presents with ascites, hydrothorax, embolism and coagulation disturbances. Furthermore, both the renal and liver functions are affected due to in- creased vascular permeability; this results in fluid shifting from the intravascular to the extravascular compartment. Since this is a potentially life-threatening condition, all pro-ovulatory medication should be discontinued, and the patient must be care- fully monitored and treated in the intensive care unit [13]. The pregnant woman with thalassaemia faces possible deleterious consequences in cardiac function as a result of myocardial haemosiderosis and changes in the haemo- dynamic state. Accelerated erythropoiesis and expansion of the total red cell volume occur, which consequently increase the cardiac output. This may well lead to car- diac failure. There were no severe cardiac complications reported previously, except for 1 case with early infiltrative cardio- myopathy [5]. In a previous report, with a larger number of pregnant women, there were no clinical or electrocardiographic changes during cardiac examination [14]. It is important for women to start pregnancy with low ferritin levels in order not to have a decrease in their systolic function indices. 634 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما A small number of women (8.8%) de- veloped secondary amenorrhoea after deliv- ery, although they attained menarche, had had normal menstrual cycles and became pregnant spontaneously. Pregnancy cannot be implicated as the causative factor as most women with TM develop secondary amen- orrhoea at some stage in their life [15]. The desire of the thalassaemia woman to procreate should to be viewed with special caution and sensitivity by all physicians who are involved in her medical care. Medi- cal reasons often impose a barrier to this wish. Based on experience in our clinic we have devised a protocol for follow-up of pregnant thalassaemic women: Eligibility • Cardiac function: electrocardiogram, echocardiogram • Liver function: liver function test, ultra- sound • Vessels: clotting factors, Doppler • Pancreas: oral glucose tolerance test • Viral infections: hepatitis B and C virus, HIV • Iron status Feasibility • Hypothalamic–pituitary–gonadal axis • Ultrasound of uterus and ovaries • Postcoital test • Hysterosalpingography • Complete endocrine assessment • Genetic counselling: partner’s carrier status and fertility During pregnancy there are a number of issues that need to be taken into con- sideration. Accumulated knowledge over the years from our clinic has helped us to formulate guidelines regarding the manage- ment of the pregnant thalassaemia patient, as follows: • Maintenance of haemoglobin level at 10 g/dL • Frequent low volume blood transfu- sions • Discontinue iron chelation therapy • Regular cardiac monitoring every 3 months • Assessment of endocrine function, in- cluding oral glucose tolerance test • Multidisciplinary approach by all spe- cialists involved in the medical care of thalassaemia. The strong desire of the thalassaemic woman to become pregnant must not be viewed as an emotional defiance of the stig- ma of her chronic disease, but recognized, respected and approached with sensitivity by all specialties involved in her medical care. Acknowledgements The authors wish to thanks Drs Soteroulla Christou, George Skordos, Evi Pangalou, Michael Hadjigavriel, Maria Sitarou and Annita Kolnakou for their contribution to this paper. References 1. Olivieri NF. Medical progress: the (beta)- thalassaemias. New England journal of medicine, 1999, 341:99–109. 2. Berkovitch M et al. Iron deposition in the anterior pituitary in homozygous beta- thalassaemia: MRI evaluation and cor- relation with gonadal function. Journal of pediatric endocrinology and metabolism, 2000, 13:179–84. 3. Charttejee R, Katz M, Cox TF. Prospec- tive study of the hypothalamic–pituitary axis in thalassaemic patients who de- Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 635 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما veloped secondary amenorrhea. Clinical endocrinology, 1993, 39:278–96. 4. De Sanctis V et al. Gonadal function in patients with β thalassemia major. Journal of clinical pathology, 1988, 41:113–37. 5. Skordis N et al. Fertility in female thalas- saemics. Journal of pediatric endocrinol- ogy and metabolism, 1998, 11(Suppl. 3):935–43. 6. Jensen CE, Tuck SM, Wonke B. Fertil- ity in β thalassemia major: a report of 16 pregnancies, pre-conceptual evaluation and review of the literature. British jour- nal of obstetrics and gynaecology, 1995, 102:625–9. 7. Skordis N et al. Update on fertility in tha- lassaemia major Pediatric endocrinology reviews, 2004, 2(Suppl. 2):296–302. 8. Meadows K. A successful pregnancy outcome in transfusion dependent Tha- lassaemia major. Australian New Zea- land journal of obstetrics and gynecology, 1984, 24:43–4. 9. Martin K. Successful pregnancy in beta- thalassaemia major. Australian paediatric journal, 1983, 19(3):182–3. 10. Voskaridou E et al. Desferrioxamine treat- ment during early pregnancy: absence of teratogenicity in two cases. Haemato- logica, 1993, 78:183–4. 11. Savona-Ventura C, Grech ES. Pregnancy complications in homozygous thalassae- mia patients. Journal of obstetrics and gynecology, 1991, 11:175–6. 12. Tampakoudis P et al. Transfusion- dependent homozygous beta-thalassae- mia major: successful pregnancy in five cases. European journal of obstetrics, gynecology and reproductive biology, 1997, 74:127–31. 13. Negri P et al. Preliminary observations about assisted reproduction in thalas- saemia. Journal of pediatric endocrinol- ogy and metabolism, 1998, 11(Suppl. 3):929–33. 14. Aesopos A et al. Pregnancy in patients with well-treated beta-thalassaemia: out- come for mothers and newborn infants. American journal of obstetrics and gyne- cology, 1999, 180:360–5. 15. Skordis N et al. The impact of iron over- load and genotype on gonadal function in women with thalassaemia major. Pediat- ric endocrinology reviews, 2004, 2(Suppl. 2):292–5. 636 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما An audit of diabetes care at 3 centres in Alexandria N.Y. Abou El-Enein1 and M.A. Abolfotouh2 1Department of Health Administration and Behavioural Sciences; 2Department of Family Health, High Institute of Public Health, University of Alexandria, Alexandria, Egypt (Correspondence to M.A. Abolfotouh: mabolfotouh@yahoo.com). Received: 26/12/04; accepted: 15/03/06 ABSTRACT Selected indicators for structure, process and outcome of care were used to audit diabetes care in 3 centres in Alexandria. Structure was poor: main problems included absence of appointment and recall system, deficiencies in laboratory resources and lack of educational material. Process of care was poor for 69.2% of patients: deficiencies included absence of essential information in records and missing some essential clinical examinations. Degree of control was poor for 49.2% of patients and only 30.6% had no complications. Compliance to appointment was good for about 80% of patients. Better outcome (fewer complications and higher compliance) was significantly associated with poor process of care. This cannot, however, be considered a valid predictor of outcome as good care might be initiated by the presence of complications. Audit des soins aux diabétiques dans trois centres d’Alexandrie RÉSUMÉ Un certain nombre d’indicateurs de structure, de processus et de résultats des soins ont été utilisés pour réaliser un audit des soins aux diabétiques dans trois centres d’Alexandrie. La structure s’est avérée médiocre : les principaux problèmes étaient l’absence de système de rendez- vous et de rappel, des insuffisances en termes de ressources de laboratoire et le manque de matériel pédagogique. Le processus de soins était déficient pour 69,2 % des patients : les points faibles étaient l’absence d’informations essentielles dans les dossiers et l’omission de certains examens cliniques essentiels. Le degré de contrôle était mauvais pour 49,2 % des patients, et seuls 30,6 % n’avaient pas de complications. Le respect des rendez-vous médicaux était bon pour environ 80 % des patients. On a observé une association significative entre de meilleurs résultats (moins de complications et meilleur respect des rendez-vous médicaux) et un mauvais processus de soins. Toutefois, cette association ne peut pas être considérée comme un facteur prédictif de résultats valable, dans la mesure où la mise en place de soins de qualité peut être motivée par la présence de complications. °É®bIÍÈeb¿³iÝ=›h²=fºÍMØM›Ëf³j¶=ÍÈ>¢eη¢ \ÇJ«¶=ÇE?\>J«¶=bF¢Ϋìrº(¿É£¶=ÇE?k¾ÇÈÏLj  „=Í[qØ6Ê[ÂL=f[mÖºÍ[MØMe>[ÉJ]=ÍÈeb¿³iÝ=›h²=fºÍMØM›Èf³j·¶ͺb¯™=L>ºb„=η¢°É®bJ·¶ ¸ Ñ>rƒ=ÆL=Ð=fQÝ=ÆÍÉ¿F¶=*¹>r[I×=ÆbÉ¢=Ç»·¶½>Ÿ¾aÇQƽb¢ÍÉjÉÑf¶=>÷²>nºÀºÆ(ÍÒÉiÍÉ¿F¶=K¾>²b®Æ L=J^™=ae=Ǻ›eÇr®Æ(Îuf™>E]¸º>£™=[ÍɫɯNJ¶=a=Ǚ=aÇQƽb¢Æ*›ð>vÈ?ÍÒÉiK¾>²b¯ªL=Ð=fQÝ=>º? 69.2!>[ÃɪeÇr[¯¶=ÄQÆ?ÀºÆ(Îuf™=Àº6H>[ɦL>[qÇV«¶=¥>É[uÆ(LØRj[¶=›ÍÉ[i>iÙ=L>[ºÇ·£™= fŸ¾ÍÃQÆÀºÍÒÉizf™=›¼³VJ¶=ÍQeaK¾>²>»²(ÍÉi>iÙ=ÍÈfÈfj¶=49.2!Ç[R¿ÈÆ(Î[uf™=À[ºÀ[º ÏÇiL>«¢>vºÍÈ@EÍE>qÝ=30.6!Îuf™=Àº*Ë?e›ð=bÉQbÉ¢=Ç»·¶¹>NJº×=Á>²b®Æ80!Îuf™=Àº*>º? ¸Ñ>rƒ=Ù=¸vª%fN²?¹>NJº=Ƹ®?L>«¢>vº$ð>ÉÑ>rUCÄEèbßJá£àÈð>¯îª=fIK¯ª=fIb¯ª*Í[È>¢f¶=L=Ð=f[QCÐÇ[i¤º* aÇ[QƤ[º>[ÃE¥fn[àÈb[®Ìb[ɂ=Í[È>¢f¶=ÁÙ¸Ñ>r[V·¶ÍÉ®=br[™=L=cL>[ÒF¿™=À[º´[¶c[J£¾Á?À[³•×Æ L>«¢>v™=*  Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 637 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Diabetes is one of the major world health problems: prevalence for all age groups worldwide was estimated to be 2.8% in 2000 and projected to be 4.4% in 2030 [1]. The 10 countries estimated to have the high- est numbers of people with diabetes in 2000 and 2030 are listed by The International Diabetes Federation Diabetes atlas 2000 [2]. The top 3 countries are the same as those identified for 1995 (China, India and the United States of America) [3]. Bangla- desh, Brazil, Indonesia, Japan, and Pakistan also appear in the lists for both 2000 and 2030. Italy and the Russian Federation ap- pear in the list for 2000 but are replaced by Egypt and the Philippines for 2030, reflect- ing anticipated changes in population and structure in these countries. The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. The urban popula- tion in developing countries is projected to double between 2000 and 2030. For Egypt, the total projected number of people with diabetes is 6.7 million [1]. Treatment and preventive care in per- sons with diabetes can slow the progression of end-stage complications and reduce the risk of cardiovascular and other diabetes- related disease [4–6]. On the basis of these findings, there has been substantial recent interest in diabetes disease management interventions, guidelines and care practice [7,8]. As the vast majority of diabetes care occurs in primary care settings, to promote proper management, standards for care and clinical practice guidelines targeting prima- ry care providers (among others) have been published by professional organizations such as the Canadian Diabetes Association [9], the American Diabetes Association [10] and the World Health Organization (WHO) [11]. Quality of medical practice and record registration are related. A medical audit is “a detailed review and evaluation of selected clinical records by qualified pro- fessional personnel for evaluating quality of medical care” and it is one of the most im- portant functions of the medical staff. The audit committee reviews medical records to determine whether the appropriate action was taken and examine the processes, and to determine whether if the process had been different, i.e. investigation, diagnosis, etc., the outcome would have been different [12]. Audit of diabetes care is now becom- ing common in general practice [13]. The aim of this study was to assess the care provided at 3 diabetes centres in Al- exandria in terms of structure, process and outcome in accordance with documentation and adherence to WHO guidelines [14] for primary diabetes care. Methods The study was conducted from March 2003 to end of May 2003. Out of the total of 6 diabetes centres affiliated to Ministry of Health and Population in Alexandria city, 3 centres having higher attendance rate were selected: Abu-Qir Hospital (El Montaza re- gion), Farouk Hospital (middle region) and Ras El-Ten Hospital (El Gomerk region). Returning patients who had been diabetic for ≥ 1 year and who visited the centre dur- ing the period of the study (3 months) were the target of the study. During the pilot study, it was noted that the usual number of patients at each centre was 40–50/month. Therefore, using an equal allocation method of sampling, the study included 360 patients registered at and regularly attending the 3 centres. The first 120 consecutive patients attending each centre during the study pe- 638 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما riod were selected. There were no refusals to participate. All patients were interviewed using structured questionnaires for collection of information about patient characteristics (age, sex, education, employment), disease characteristics (duration of diabetes, pres- ence of complications) and treatment char- acteristics (type of treatment). Interviews were carried out by the first author in the clinic immediately after clinical examina- tion. Selected indicators for structure, process and outcome of care were based on the qual- ity assurance protocol and the WHO manual on diabetes mellitus [14,15] Assessment of structure Structure of diabetes care was assessed using 2 checklists: one for the essential items of care (13 items) and the second for the less-essential items (10 items). The checklist on essential items was scored on a 3-point scale: item available all the time scored 2; item available sometimes scored 1; item not available scored 0. The checklist of less-essential items of care was scored on a 2-point scale: item available scored 1 and item not available scored 0. The total score of all items for structure of diabetes care ranged from 0 to 36. If the total score was > 28, i.e. > 80% of the total score, structure of care was considered good; if score was 21–28, i.e. 60%–80%, it was considered fair; if total score was < 21, i.e. < 60%, it was considered poor. Assessment of process Process of care was assessed by a modified scoring system [16]. This depended on the fulfilment of 10 items for good diabetes care by physicians in the previous year by reviewing the medical records. Score ranged from 0 to 10 points. Process was categorized as good (8–10 points), moder- ate (5–7 points) or poor (< 4 points). Assessment of outcome Outcome indicators included degree of diabetes control, degree of compliance with appointment and presence of complications. Control of diabetes was defined as good if the previous 2 readings for fasting blood sugar were 70–120 mg/dL and poor if they were > 120 mg/dL. Degree of compliance with appointment was based on the number of visits of diabe- tes patients during a 6-month period. Good compliance (2 points) was recorded for attending the centre on > 2 occasions, fair compliance (1 point) when they attended for 1 occasion and poor compliance (0 points) when they had never attended the centre during the previous 6 months. The total score for outcome of diabetes care ranged from 0 to 6 points, categorized as good (4–6 points), fair (2–3 points) or poor (< 2 points) outcome. Analysis Data analysis was done using SPSS statis- tical package, version 10. Statistical sig- nificance for difference between rates was tested by chi-squared test and independent sample means by the Student t-test. The F- test was also used to compare between the 3 groups for some variables, e.g. age, duration of illness and compliance. Significance was denoted at the ≤ 0.05 level. Results Males constituted 52.2% of the sample and females 41.8%; mean age was 53.36 [stand- ard deviation (SD) 10.83] years. Type I dia- betes patients constituted 22.9% and type II diabetes patients 77.1%. Mean duration of diabetes was 1.48 (SD 0.50) years. There was no significant difference between the 3 centres for patient characteristics except for age (F = 10.897; P < 0.01): mean age was highest among Ras El Ten Hospital Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 639 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما patients, 55.35 (SD 11.45) years and low- est among those at Abu-Qir Hospital, 49.70 (SD 8.45) years (Table 1). The average total score for structure of diabetes care in the 3 centres was 15, 16 and 16 points of a total possible 36 points (Table 2), i.e. < 60% of total score, reflect- ing poor care in all 3 centres. The essential items that were available all the time were: effective referral system, coordination with the district hospital diabetes clinic, direct access to an eye specialist, 1 doctor in the practice who had a special interest in diabe- tes and a diabetes register. Essential items that were never available included: internal quality assurance system in the practice, appointment system and system for recall of defaulters (Table 2). Most of the less-essential items were never available apart from direct access to a hospital laboratory, cholesterol measure- ments, carrying out electrocardiography and funduscopy in the practice and direct access to a dietitian (Table 2). Audit of process of care recorded in patients’ files for the previous year showed that over 60% of patients had not had their feet examined, nor had they been clinically examined for weight, peripheral sensation and pulse (Table 3). Also, they had not been Table 1 Distribution of characteristics for return diabetes patients attending 3 diabetes centres in Alexandria Characteristic Abu-Qir Farouk Ras El-Ten Total Statistical test Hospital Hospital Hospital (n = 360) (n = 120) (n = 120) (n = 120) No. % No. % No. % No. % χ2 P Age (years) 220.9 < 0.001 ≤ 40 19 15.8 12 10.0 8 6.7 39 10.8 > 40 101 84.2 108 90.0 112 93.3 321 89.2 Mean (SD) 49.70 (8.45) 50.03 (11.43) 55.35 (11.45) 53.36 (10.83) 10.897a < 0.001 Sex Male 66 35.1 64 34.0 58 48.3 188 52.2 1.157 0.056 Female 54 31.4 56 32.6 62 51.7 172 41.8 Employment Unemployed 93 77.5 93 77.5 85 70.8 271 75.3 1.910 0.384 Employed 27 22.5 27 22.5 35 29.2 89 24.7 Education Illiterate 84 70.0 80 66.7 73 60.8 237 65.8 2.297 0.317 Literate 36 30.0 40 33.3 47 39.2 123 34.2 Type of diabetes 2.455 0.292 Type I 35 29.2 26 21.7 26 21.7 87 22.9 Type II 85 70.8 94 78.3 94 78.3 273 77.1 Duration (years) 0.357 0.837 ≤ 5 62 32.6 66 34.7 62 32.6 190 52.8 > 5 58 34.1 54 31.8 58 34.1 170 47.2 Mean (SD) 1.48 (0.50) 1.45 (0.50) 1.48 (0.50) 1.48 (0.50) 0.177a 0 .838 Treatment type for all patients was diet plus drugs. aF-test value. SD = standard deviation. 640 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما referred for annual ophthalmic examina- tion, urea and electrolytes. The glycosylated haemoglobin test had not been performed for anyone. This situation was similar in all 3 centres with no statistically significant differences. Regarding overall degree of care, 69.2% of patients received poor care, 26.4% fair care and 4.4% good care. Mean score was lowest at Ras El Ten Hospital and highest at Farouk Hospital (P = 0.004). Outcome of diabetes care is shown in Ta- ble 4. Degree of control was poor for 49.2% of patients; only 30.6% had no complica- tions. Compliance to appointment was good Table 2 Score of essential and less essential items of structure of diabetes care in 3 diabetes centres in Alexandria Item Score Abu-Qir Farouk Ras El-Ten Hospital Hospital Hospital Essentiala Effective referral system 2 2 2 Coordination with district hospital diabetes clinic 2 2 2 Health education materials 0 0 0 Direct access to eye specialist 2 2 2 Internal quality assurance system in the practice 0 0 0 Blood sugar measurement 0 0 0 Urine protein measurement 0 0 0 Essential drugs for diabetes 1 1 1 ≥ 1 doctor in practice has special interest in diabetes 2 2 2 Diabetes follow up cards 0 0 0 Diabetes register 2 2 2 Appointment system 0 0 0 System for recall of defaulters 0 0 0 Total (26 points) 11 11 11 Less-essentialb Mini diabetes clinic 0 0 0 Specialist diabetes nurse 0 0 0 Direct access to chiropodist 0 0 0 Direct access to dietitian 0 1 1 Direct access to hospital laboratory 1 1 1 Funduscopy in the practice 1 1 1 Glycosylated haemoglobin measurement 0 0 0 Cholesterol measurements 1 1 1 ECG in the practice 1 1 1 Diabetes identity cards 0 0 0 Total (10 points) 4 5 5 a2 = available all the time; 1 = available sometimes; 0 = not available. b1 = available; 0 = not available. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 641 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما for about 80%. There was no statistically significant difference between the 3 centres as regards outcome items (P > 0.05). Regarding the relationship between process of care and outcome, with worse degree of care compliance was better than with good care (87.3% vs 50.0%) and there were fewer complications (Figure 1). Discussion Diabetes is a chronic illness that requires continuing medical care and patient self- management education to prevent acute complications and to reduce the risk of long- term complications [17,18]. Monitoring and careful recording of important clinical data are considered to be a vital part of diabetes care [19], making it possible to compare past and present status, to review the course of the disease and to justify continuing or changing treatment [20]. However, there is evidence that “usual care” for individu- als with diabetes falls short of these ideals [21–24]. Despite the broadly distributed di- abetes care guidelines, in the present study, the majority of patients did not have proper documentation of adequate management to optimize control or prevent target organ damage: degree of care was poor for 69.2% of patients. Our findings are comparable with those of other studies in Saudi Arabia [25], Lebanon [26], the United States of America [27,28] and England [29]. Table 3 Audit of recorded items of process of care in diabetes patient files in the previous year in 3 diabetes centres in Alexandria Process item Abu-Qir Farouk Ras El-Ten Total Statistical test Hospital Hospital Hospital (n = 360) (n = 120) (n = 120) (n = 120) No. % No. % No. % No. % χ2 P Blood pressure 60 50.0 61 50.8 59 49.2 180 50.0 0.066 0.967 Weight 120 100 .0 – – – – 120 33.3 360.0 < 0.001 Blood glucose 120 100.0 120 100 120 100 360 100 – – Test for proteinuria 32 26.7 36 30.3 38 31.7 106 29.4 0.748 0.687 Peripheral sensation 40 33.3 24 20.0 21 17.5 85 23.6 9.46 < 0.001 Peripheral pluses 40 33.3 21 17.5 24 20.0 85 23.6 9.64 < 0.001 Foot examination 29 24.2 22 18.3 18 15.0 69 19.2 3.33 0.188 Ophthalmic examination 38 31.7 44 36.7 47 39.2 129 35.8 1.522 0.467 Urea & electrolytes 32 26.7 36 30.0 38 31.7 106 29.4 0.748 0.687 Glycosylated haemoglobin 120 100.0 120 100.0 120 100.0 360 100.0 – – Degree of care Good (8–10) 7 5.8 4 3.3 5 4.2 16 4.4 17.81 0.001 Fair (5–7) 28 23.3 20 16.7 47 39.2 95 26.4 – – Poor (0–4) 85 70.8 96 80.0 68 56.7 249 69.2 – – Mean score (SD) 2.65 (0.59) 2.77 (0.50) 2.53 (0.58) 3.44 (2.01) 7.891a 0.004 SD = standard deviation. aF-test value. 642 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The structural criteria are considered antecedents of quality, and outcome criteria are considered consequences of quality [30]. There should be a direct relationship between processes and outcomes of care; less than optimal outcomes have their roots in inappropriate or poorly implemented processes [31]. In the present study, degree of control was poor for more than half the patients. It was interesting, however, to note that better outcome—in terms of fewer complications and higher compliance—was associated with poor process of care, con- tradictory to what would be expected. This finding could be explained by the fact that many of the elements of process of care were not being carried out except when there were signs of poor outcome in terms of complications, etc. The physician was possibly initiated to provide care only in case of complaint regarding complications, and this may be why there are fewer compli- cations with poor care. Thus poor outcome in terms of more complications and lower rate of compliance acted in the present study as a cause rather than an effect, lead- ing to upgrading the process of care. Poor outcome in the present study may have been a result of factors such as lack of some essential structural items for care. The shortage of laboratory strips was compen- sated by cooperation between the clinic and the hospital central laboratory. Actually, the patient is referred for urine analysis Table 4 Outcome of diabetes care in 3 diabetes centres in Alexandria Outcome Abu-Qir Farouk Ras El-Ten Total Statistical test Hospital Hospital Hospital (n = 360) (n = 120) (n = 120) (n = 120) No. % No. % No. % No. % χ2 P Degree of control Good (2) 64 53.3 63 52.5 56 46.7 183 50.8 1.27 NS Poor (0 ) 56 46.7 57 47.5 64 53.3 177 49.2 Mean (SD) 1.07 (1.00) 1.05 (1.00) 0.93 (1.00) 1.02 (1.00) 1.064a 0.303 Degree of compliance to appointment Good (2) 88 73.3 96 80.0 103 85.8 287 79.9 6.203 NS Fair (1) 21 17.5 15 12.5 9 7.5 45 12.5 Poor (0) 11 9.2 9 7.5 8 6.7 27 7.5 Mean (SD) 1.34 (0.63) 1.28 (0.59) 1.21 (0.55) 1.28 (0.59) 1.527a 0.219 Presence of complications Yes (0) 80 66.7 83 69.2 87 72.5 250 69.4 8.738 NS No (2) 40 33.3 37 30.8 33 27.5 110 30.6 Mean (SD) 1.40 (1.34) 1.49 (1.38) 1.38 (1.21) 1.43 (1.31) 0.237a 0.789 Total outcome Good (4–6) 65 54.2 65 54.2 58 48.4 188 52.2 2.848 NS Fair (2–3) 39 32.5 38 31.7 49 40.8 126 35.0 Poor (0–1) 16 13.3 17 14.2 13 10.8 46 12.8 Mean (SD) 3.39 (1.78) 3.38 (1.84) 3.28 ( 1.82) 3.34 (1.81) 1.836a 0.091 aF-test value. NS = no statistically significant difference. SD = standard deviation. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 643 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما for glucose every visit to the clinic (every 10–20 days) and referred for fasting and postprandial blood glucose only every 3rd visit. Access to a coordinated, interdiscipli- nary, diabetes care team to offer appropriate care, whether the need is self-management, education, medical advice, or psychosocial support, has been identified as an important factor for improving treatment outcomes in diabetes [31]. The team should include, but not be limited to, physicians, nurses, dietitians and mental health professionals with a special interest in diabetes [32]. In the present study there was lack of some essential items in the structure of care such as a diabetes nurse, and this could influence the process and outcome of care. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment [33,34]. A dietitian was available in only 2 of the 3 centres in this study, even though it is known that a registered dietitian, knowl- edgeable and skilled in implementing nutri- tion therapy into diabetes management and education, is the team member who evalu- ates the patient’s food intake, metabolic status, lifestyle, readiness to make changes, goal-setting, dietary instruction and evalu- ation [35]. Compliance to appointment in the present study was rated good for most of the patients. Fair or poor compliance by the oth- ers may be a consequence of the absence of an appointment system for diabetes patients or a system for identifying and recalling defaulters. Our results are comparable to those of similar studies in Saudi Arabia [25] and Lebanon [26]. Some studies have shown that organizational interventions that improve regular prompted recall and review of patients (central computerized tracking systems or nurses who regularly contact the Figure 1 Relation between process of care and outcome in 3 diabetes centres in Alexandria 644 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما patient) can improve diabetes management [33,36]. Glycaemic control is fundamental to the management of diabetes. In some de- veloped countries, at least half of those diagnosed with diabetes do not achieve satisfactory glycaemic control, despite the availability of effective treatments [37]. In the present study the degree of control was poor for about half the patients. Prospective randomized clinical trials have shown that achieving glycaemic control is associated with decreased rates of retinopathy [30,38], nephropathy and neuropathy, and epide- miological studies support the potential of intensive glycaemic control in the reduction of cardiovascular disease [30]. The most important issues in diabetes care, besides good metabolic control, are to reduce the high risk of macrovascular com- plications by adequate treatment of high blood pressure and to convince diabetes patients to stop smoking [39]. In the present study, 69.4% were suffering from complica- tions. In spite of this, only 35.8% of patients were referred for ophthalmic examination and only 29.4% were referred for protein urea testing, even though direct access to an ophthalmologist and laboratory services were available. Moreover, blood pressure measurements, ECG and lipid profile were only requested in case of complaint. This applied for foot examination also, although all individuals with diabetes should receive an annual foot examination to identify high- risk conditions [32]. Conclusion and recommendations It is recommended that a special clinic protocol for diabetes care should be de- veloped, based on the standards guidelines and intensive training of physicians. There is a need for the introduction of a diabetes flow-sheet in the patient records to facilitate documentation, there is also a need for a diabetes nurse, educational materials and other essential structure care in each diabe- tes centre. The level of process of care cannot be considered a valid predictor of outcome as good care might be initiated by the presence of complications, as seen in the present study. The diabetes care team must be trained not to wait till there is poor outcome to provide quality care. References 1. Wild S et al. Global prevalence of dia- betes—estimates for the year 2000 and projections for 2030. Diabetes care, 2004, 27:1047–53. 2. Diabetes atlas 2000. Brussels, Interna- tional Diabetes Federation, 2000. 3. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995–2025: preva- lence, numerical estimates, and projec- tions. Diabetes care, 1998, 21:1414–31. 4. Bertoni AG. Achieving control of dia- betic risk factors in primary care settings. American journal of managed care, 2001, 7(4):411–21. 5. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long term complica- tions of insulin dependent diabetes mel- litus. New England journal of medicine, 1993, 329:977–86. 6. UK Prospective Diabetes Study Group (UKPDS). Tight blood pressure control and risk of macrovascular and micro- vascular complications in type 2 dia- betes. British medical journal, 1998, 317(7160):703–13. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 645 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 7. Glasgow RE et al. Diabetes care practices in primary care: results from two samples and three measurement sets. Diabetes educator, 1999, 25(5):755–63. 8. American Diabetes Association. Clinical practice recommendations 2000. Diabe- tes care, 2000, 23 (6):S1–116. 9. Canadian Diabetes Association. Clinical practice guidelines for diabetes mellitus in Canada. Canadian diabetes, 1992, 5:1–4. 10. American Diabetes Association. Stand- ards of medical care of patients with di- abetes mellitus. Diabetes care, 1989, 12(5):365–8. 11. Management of diabetes mellitus. Stand- ards of care and clinical guidelines. Ge- neva, World Health Organization, 1994. 12. Shaw CD, Costain DW. Guidelines for medical audit: seven principles. British medical journal, 1989, 299(6697):498–9. 13. Dunn N, Pickering R. Does good practice organization improve the outcome of care for diabetic patients? British journal of general practice, 1998, 48(434):1237– 40. 14. Manual on diabetes mellitus in primary health care. Alexandria, World Health Organization, 1995. 15. Quality assurance in primary health care manual. Riyadh, Ministry of Health/World Health Organization Regional Office for the Eastern Mediterranean, 1994 (WHO- EM/PHC/81-A/G/93). 16. Chesover D, Tudor-Miles P, Hilton S. Sur- vey and audit of diabetic care in general practice in South London. British journal of general practice, 1991, 41:282–5. 17. Ferris FL. How effective are treatments for diabetic retinopathy? Journal of the American Medical Association, 1993, 269:1290–1. 18. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complica- tions in insulin-dependent diabetes mel- litus. New England journal of medicine, 1993, 329:977–86. 19. O’Connor PJ. Organizing diabetes care: identify, monitor, prioritize, intensify. Dia- betes care, 2001, 24:1515–6. 20. Goudswaard AN et al. Quality of recording of data from patients with type 2 diabetes is not a valid indicator of quality of care. A cross-sectional study. Family practice, 2003, 20:173–7. 21. Bell RA et al. Quality of diabetes care among low-income patients in North Carolina. American journal of preventive medicine, 2001, 21:124–31. 22. Beckles GL et al. Population-based as- sessment of the level of care among adults with diabetes in the U.S. Diabetes care, 1998, 21:1432–8. 23. Bloom SA et al. Tracking clinical preven- tive service use: a comparison of the health plan employer data and informa- tion set with the behavioral risk factor surveillance system. Medical care, 2000, 38(2):187–94. 24. Engelgau MM et al. Use of services by diabetes patients in managed care or- ganizations: development of a diabetes surveillance system: CDC Diabetes in Managed Care Work Group. Diabetes care, 1998, 21:2062–8. 25. Khattab M et al. Audit of diabetic care in an academic family practice center in Asir region, Saudi Arabia. Diabetes research, 1996, 31:243–54. 26. Akel M, Hamadeh G. Quality of diabetes care in a university health center in Leba- non. International journal for quality in health care, 1999, 11(6):517–21. 27. Kell SH et al. Measures of disease control in Medicare beneficiaries with diabetes mellitus. Journal of the American Geriatric Society, 1999, 47(4):417–22. 646 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 28. Weiner JP et al. Variation in office-based quality: a claims-based profile of care pro- vided to Medicare patients with diabetes. Journal of the American Medical Associa- tion, 1995, 273(19):1503–8. 29. Dunn NR, Bough P. Standards of care of diabetic patients in a typical English com- munity. British journal of general practice, 1996, 46:401–5. 30. Attree M. Towards a conceptual model of quality care. International journal of nurs- ing studies, 1996, 33:13–28. 31. Skovlund SE, Peyrot M. The diabetes attitudes, wishes, and needs (DAWN) program: a new approach to improving outcomes of diabetes care. Diabetes spectrum, 2005, 18:136–42, 32. American Diabetes Association. Stand- ards of medical care in diabetes. Diabetes care, 2004, 27:S15–35. 33. Hansen LJ, Drivsholm TB. Interventioner til forbedring af diabetesbehandlingen i det primaere sundhedsvaesen og pa diabetesambulatorier [Interventions to improve the management of diabetes mellitus in primary health care and outpa- tient community settings]. Ugeskr laeger, 2002, 164(5):607–9. 34. Lim TO. Diabetes care: is it adequate? An audit of diabetes care in a hospital. Medi- cal journal of Malaysia, 1990, 45(1):18– 22. 35. Purnell B. The role of the dietitian in dia- betes care. Diabetes primary care, 1999, 1:84–7. 36. Scott RS, Brown LJ, Clifford P. Use of health services by diabetic persons. II. Hospital admissions. Diabetes care, 1985, 8(1):143–7. 37. Kristensen JK et al. HbAlc in an unse- lected population of 4438 people with type 2 diabetes in a Danish county. Scandina- vian journal of primary health care, 2001, 19:241–6. 38. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of com- plications in patients with type 2 diabetes (UKPDS 33). Lancet, 1998, 352:837–53. 39. Färnkvist LM, Lundman BM. Outcomes of diabetes care: a population-based study. International journal for quality in health care, 2003, 15:301–7. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 647 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Association of diabetes mellitus and dyslipidaemias in the Tehran population K. Ghoddusi,1 J. Ameli,2 H. Kachuee,2 V. Pourfarziani,3 A. Saadat4 and Q. Karami5 1Department of Endocrinology and Metabolism; 2Department of Neurology; 3Department of Nephrology; 4Department of Haematology; 5Department of Psychiatry, Baqyatallah University of Medical Science, Tehran, Islamic Republic of Iran (Correspondence to J. Ameli: javad_ameli@yahoo.com). Received: 14/12/05; accepted: 09/03/06 ABSTRACT The aim of this survey was to evaluate the role of diabetes in the lipid profiles of the Teh- ran population. Measurements were carried out on 10 136 people aged 20–69 years for blood sugar, triglycerides, total cholesterol, LDL cholesterol, and HDL cholesterol and data were collected on medi- cal history, physical activity, smoking and obesity. The prevalence of any type of dyslipidaemia in the whole group was 68.5% and of diabetes mellitus was 11.0% (10.6% in men and 11.3% in women). The prevalence of dyslipidaemia in diabetics was 88.9%. There was strong association between diabetes mellitus and dyslipidaemia (P < 0.05). In regression analysis, diabetes was the second most important factor after obesity in secondary dyslipidaemia. Á=fÃ{Á>³iÏb¶½b¶=L>É»VmL×ØJ]=¤ºËf³j¶=°ª=fI u·¢(ʾ>ÈgfªeÇEbÉUÆ(ÊÈÇR²jU(Ê·º>¢a=ÇQ(ÊiÆb®¼ž>²Êºf²>ufºØ¦(La>£i>  „=Í[qØ6b[®ÆÁ=f[Ã{Á>³[iÏb[¶½b[¶=L>É»V[m¼j[Ifºη¢Ëf³j¶=M@I¼É[ɯIÍi=eb¶=ÅdÂKªbÃJi= L>[¿ÉIƶ=¹ÆJj[ɶDzÆ(ʶ>[–Ý=¹ÆJjɶdz¶=Æ(ÍÉMØN¶=L=bÈfjÉ·§¶=Æ(½b¶=f³j¶L>i>É®ÁÇNU>F¶=ÏfQ? ¶=¹ÆJjɶDzÆͪ>N³¶=Ív«^¿™=ÍÉ»Vn¶=Ïb¶ͪ>N³¶=ͣɪf¶=ÍÉ»Vn¶=L>¿ÉIÆ13610ÀÈd[¶=t>^[mÙ=À[º E¼Âe>»¢?\Æ=f[J[I20Æ69Í[ɾbF¶=Íìn[¾Ù=ÆÍ[ÉFì¶=°E=Çj[¶=À[¢L>[ºÇ·£º¼Ã¿[ºÁÇNU>F¶=¤–>»²(ð>º>¢ ;=bF¶=Ɛ]bJ¶=Æ*Í[¢Ç»=¸[»…›½b[¶=L>É»V[m¹ØJ[]=>”?Àºœ”úË?e>nJ¾=¹b£ºÁ>²Æ68.5!(› Ëf³j[¶=e>n[J¾=¹b£ºÁ>²U11%!10.6ƹ>[Qf¶=Ïb[¶11.3!Ð>[j[¿¶=Ïb[[¶*$e>[n[J¾=¹b[[£ºÁ>[[²Æ [Èf³j¶=E½b¶=L>É»Vm¹ØJ]=88.9!½b[[[¶=L>[É»Vm¹Ø[J]=À[[ÉEÆËf³j¶=EËÇ®œàE=fI UÇ¶Æ %0.05<P*$bF¶=b£Eʾ>N¶=¸º>£¶=ÇÂËf³j¶=Á>²­èÇVJ¶=¸É·€›Æ¹ØJ[]ضÍFëFj[™=¸[º=Ç£¶=¼[Â?[E;= ½b¶=L>É»Vn¶ËǾ>N¶=*  Association de diabète sucré et de dyslipidémies dans la population de Téhéran RÉSUMÉ Cette étude avait pour but d’évaluer le rôle du diabète dans les profils lipidiques de la population de Téhéran. Des mesures de la glycémie, des triglycérides, du cholestérol total, du cholestérol LDL et du cholestérol HDL ont été effectuées chez 10 136 sujets âgés de 20 à 69 ans et des données ont été recueillies sur les antécédents médicaux, l’exercice physique, le tabagisme et l’obésité. La prévalence de tous les types de dyslipidémie dans l’ensemble du groupe était de 68,5 % et celle du diabète sucré de 11,0 % (10,6 % chez les hommes et 11,3 % chez les femmes). La prévalence de la dyslipidémie chez les diabétiques était de 88,9 %. Il existait une forte association entre le diabète sucré et la dyslipidémie (p < 0,05). L’analyse de régression a démontré que le diabète était le deuxième facteur le plus important de dyslipidémie secondaire après l’obésité. 648 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction No other life-threatening disease is as prev- alent or expensive to society and individuals as coronary artery disease (CAD). Athero- sclerosis is responsible for almost all cases of CAD. Risk factor assessment is useful in adults to guide therapy and multivariate analysis can be used to help estimate the risk of coronary disease events [1]. Many of the important risk factors for cardiovascular disease are modifiable by specific preven- tive measures. In the INTERHEART study, 9 potentially modifiable factors accounted for over 90% of the attributable risk in the population [2]. In the same study, diabetes mellitus accounted for 10% of the popula- tion attributable risk of a first myocardial infarction. The reports of the National Health and Nutrition Examination Survey (NHANES) have shown that between 1960 and 2000 the prevalence of diagnosed diabetes increased from 1.8% to 5.0% [3]. In contrast, the proportion of people with hypercholes- terolaemia (serum total cholesterol ≥ 240 mg/dL) declined substantially in the same period (from 34% to 17%). Serum lipid abnormalities have been clearly shown to be risk factors for CAD; these include elevated low-density lipopro- tein cholesterol (LDL-C), low high-density lipoprotein cholesterol (HDL-C), increased total-to-HDL-cholesterol ratio and hyper- triglyceridaemia. The frequent coexistence of diabetes and hypercholesterolaemia fur- ther raises the risk for CAD and its associ- ated morbidity [4]. In the Islamic Republic of Iran the age- adjusted mortality due to CAD increased by 20%–45% during 1971–91 [5,6]. Previous studies have reported the prevalence of car- diovascular risk factors among the Iranian population [7,8] and the aim of the present study was to evaluate the relationship be- tween diabetes and hyperlipidaemia in the Tehran population. The data reported here are a part of more extensive study in which many confounding factors were evaluated, including hypothyroidism, physical ac- tivity, renal failure, nephrotic syndrome, smoking, obesity, lipogenic medications, and pregnancy. This paper focuses on the association of diabetes and dyslipidaemia. Methods Sample In a cross-sectional, multi-stage, stratified cluster, random sampling technique, 10 136 people aged 20–69 years were selected from the Tehran population. The list of all house- holds covered by the district’s 3 health care centres (the official bodies responsible for the vaccination programmes and collection of health-related statistics in a district) was used to choose a random sample of house- holds. In each household, all members aged 20–69 years were recruited. The district is located in the centre of Tehran and the age distribution of its population is representa- tive of the overall population of Tehran. Data collection The participants were evaluated at the Te- hran Lipid and Glucose Study clinic be- tween September 2004 and March 2005 by trained physicians according to a standard protocol. After giving informed consent, personal, demographic, physical activity, smoking, and anthropometric information was obtained. Personal information includ- ed age, sex, past medical history and medi- cations. The level of physical activity was defined according to the lipid research clin- ic criteria. Then subjects were divided into 3 groups: low, moderate and high physical activity. Smoking was defined as a person who continuously smoked at least 1 ciga- Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 649 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما rette per day. Smokers were divided into 5 groups of 1–5, 6–10, 11–15, 16–20 and > 20 cigarettes per day. Anthropometric data were obtained after empting the bladder and bowel. Weight was measured with the participant wearing underwear and without shoes. Height was determined with a wall measure in the standing position. Body mass index (BMI) was calculated by the equation: weight (kg)/height (m2). People were excluded if they had: a history of antilipidaemic medication or any other drugs interfering with lipid metabo- lism within the previous 3 months; signifi- cant hepatic, renal or thyroid dysfunction; acute or chronic inflammatory diseases; immobilization; recent surgical operations; myocardial infarction or cerebrovascular accident; or pregnancy. Blood samples were drawn between 07:00 and 09:00 hours from all study par- ticipants after 12–14 hours of overnight fasting. Total cholesterol (TC), HDL-C, LDL-C, triglycerides (TG), fasting blood sugar (FBS), creatinine, thyroid-stimulat- ing hormone (TSH), alkaline phosphatase, and bilirubin levels were assayed. Then, 2-hour postprandial plasma glucose was measured after 75 g oral glucose. Having 2 repeated creatinine levels > 2 mg/dL was defined as renal failure; 5 females and 8 males (total 13) had renal failure and all of them were dyslipidaemic. TSH level was assayed with an immunoradiometric assay method. TSH level > 10 μU/L was defined as hypothyroidism; 16 female and 8 males (total 24) had hypothyroidism. All of the hypothyroid males and 15 females were dyslipidaemic. Alkaline phosphatase was tested with enzymatic calorimetry; none of the subjects had abnormal levels. Bilirubin was checked if alkaline phosphatase was above the normal limit. A creatinine level above 2 mg/dL for at least 2 months was considered as chronic renal failure. Dyslipidaemia was defined by the presence of high TC (≥ 240 mg/dL), high LDL-C (≥ 160 mg/dL), low HDL-C (< 35 mg/dL) or high TG (> 400 mg/dL) ac- cording to the Adult Treatment Panel (ATP) II criteria. Dyslipidaemia was defined as primary if none of the known contributing factors (low physical activity, nephrotic syndrome, hypothyroidism, obesity, smok- ing, diabetes mellitus and use of dyslipi- daemia-inducing medications) was present. Diabetes was defined as FBS ≥ 126 mg/dL or 2-hour postprandial plasma glucose ≥ 200 mg/dL, according to American Diabe- tes Association criteria Analysis The analysis was done with SPSS, version 10.05 software package and using the t-test, chi-squared test and logistic regression. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI) for physical activity, renal failure, hypothyroidism, BMI, smoking and diabetes mellitus. P-values < 0.05 were considered significant. Results A total of 9632 adults (4013 men and 5619 women) matched the inclusion and exclu- sion criteria. There were 1059 people with diabetes (425 men and 643 women), giving a prevalence of diabetes in our population of 11.0%. The prevalence of diabetes was 10.6% in men and 11.3% in women The prevalence of any type of dysli- pidaemia in the total study population was 68.5% (n = 6598). This was slightly higher in men (72.3%, n = 2901) than women (65.8%, n = 3697). The prevalence of dys- lipidaemia in diabetics was 88.9% (n = 941), which was significantly higher than in the general population (P < 0.05). The prevalence of dyslipidaemia was lower in diabetic men (86.0%, n = 365) than diabetic 650 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما women (90.9%, n = 576). The prevalence of primary dyslipidaemia was 35.4% (39.8% of men and 31.9% of women). High TC was the most common dyslipidaemia in women (26.9%) and low HDL-C (31.4%) was the most common in men. The mean levels of serum TG, TC and LDL-C in diabetic people were significantly higher than in nondiabetic people (Tables 1 and 2). Not surprisingly, HDL-C also was higher in diabetics than nondiabetics (P < 0.05). High TC was the most common dyslipi- daemia in diabetic women (52.8%) and high LDL-C was the most common in diabetic men (37.4%). Table 3 shows the number of patients with and without dyslipidaemia by diabetes mellitus, hypothyroidism, renal failure, smoking and obesity. Table 4 shows the variables that were significant when the individual odds were evaluated with lo- gistic regression analysis. Obesity (BMI > 30 kg/m2) had the greatest association with lipid profile (OR = 2.71; 95% CI: 1.97–3.75). Diabetes mellitus was strongly associated with dyslipidaemia (OR = 2.38; 95% CI: 1.42–3.98). Smoking (OR = 1.85; 95% CI: 1.29–2.66) and age (OR = 1.07; 95% CI: 1.06–1.08) were also significantly associated. Because of the low frequency of nephropathy and hypothyroidism, their roles in dyslipidaemia were not significant. Table 5 shows more details of the relation- ship of lipid profiles with age and sex. In the general population, the preva- lence of low physical activity was 62.6% (n = 6029), moderate activity 13% (n = 1253) and vigorous physical activity 24.4% (n = 2351). Although dyslipidaemia was prevalent in all 3 groups, the prevalence decreased with increasing physical activity: 68% in the low physical activity group, 66% in the moderate physical activity group and 62% in the vigorous physical activity group. Ta bl e 1 P re va le n ce o f d ys lip id ae m ia s in t h e st u d y p o p u la ti o n a n d d ia b et ic g ro u p L ip id G en er al p o p u la ti o n D ia b et ic s To ta l M en W o m en To ta l M en W o m en (n = 9 63 2) (n = 4 01 3) (n = 5 61 9) (n = 1 05 9) (n = 4 25 ) (n = 6 43 ) N o . % N o . % N o . % N o . % N o . % N o . % D ys lip id ae m ia ( an y ty pe ) 65 98 68 .5 29 01 72 .3 36 97 65 .8 94 1 88 .8 36 5 85 .9 57 6 89 .6 H ig h tr ig ly ce rid es ( ≥ 40 0 m g/ dL ) 40 1 4. 2 21 1 5. 3 19 0 3. 4 12 2 11 .5 52 12 .2 70 10 .8 H ig h to ta l c ho le st er ol ( ≥ 24 0 m g/ dL ) 23 08 24 .0 79 4 19 .8 15 14 26 .9 48 6 45 .9 14 6 34 .3 34 0 52 .8 H ig h LD L- ch ol es te ro l ( ≥ 16 0 m g/ dL ) 21 38 22 .2 12 63 31 .5 73 3 13 .0 26 4 24 .9 15 9 37 .4 10 5 16 .3 Lo w H D L- ch ol es te ro l C ( < 3 5 m g/ dL ) 19 94 20 .7 77 6 19 .3 13 64 24 .3 36 1 34 .1 11 4 26 .8 24 7 38 .4 n = to ta l n um be r of p ar tic ip an ts ; L D L = lo w -d en si ty li po pr ot ei n; H D L = h ig h- de ns ity li po pr ot ei n. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 651 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Discussion The prevalence of diabetes in our sample of the Tehran population was 11.0%, which is higher than previous reports in Brazil [9], the Netherlands [10] and Germany [11]. In Australia, the AusDiab study reported that 7.4% of the population aged 25 years or over had diabetes mellitus, 90% of whom had type 2 diabetes [12]. The prevalence of diabetes increases progressively with age. The prevalence of type 2 diabetes has more than doubled in Australia since 1981, and the total number of cases has increased threefold. A high prevalence of diabetes in the Tehran population could be attributed to industrialization in the Islamic Republic of Iran, leading to modification of lifestyles, unhealthy diets, decreased physical activ- ity and an increased prevalence of obesity. In addition, increased attention of patients and physicians and widespread screening to identify undiagnosed cases could be other reasons for the high prevalence of diabetes. Among the diabetics in our study, the frequency of hypercholesterolaemia was 45.9%, high LDL-C was 24.9%, low HDL-C was 34.1% and hypertriglyceridaemia was 11.5%. All of these rates were significantly higher than in the general population. This suggests an important influence of diabetes on the lipid profile of our diabetic popula- tion. Lipid abnormalities are common in patients with diabetes mellitus, and un- doubtedly contribute to the increased risk of cardiovascular disease. The lipid pattern in patients with type 1 diabetes is largely related to glycaemic control. Several stud- ies have shown that type 2 diabetes, poor glycaemic control and insulin resistance are associated with hypertriglyceridaemia, high Table 2 Mean serum lipid levels in the general study population and the diabetic group Lipid (mg/dL) General Diabetics population (n = 9632) (n = 1059) Mean (SE) Mean (SE) Total cholesterol 226.0 (0.5) 244.0 (2.0) Triglycerides 196.0 (6.0) 264.5 (6.0) LDL-cholesterol 148.3 (0.5) 155.0 (1.5) HDL-cholesterol 40.7 (0.1) 41.1 (0.5) n = total number of participants; SE = standard error; LDL = low-density lipoprotein; HDL = high-density lipoprotein. Table 3 Number of patients with and without dyslipidaemia by diabetes mellitus, hypothyroidism, renal failure, smoking and obesity Patient group Dyslipidaemia No dyslipidaemia No. No. Diabetes Yes 941 118 No 5657 2916 Hypothyroidism Yes 23 1 No 6575 3033 Renal failure Yes 13 0 No 6585 3034 Current smoking Yes 538 547 No 6060 2487 Obesity Yes 978 1979 No 5620 1055 Table 4 Factors significantly associated with secondary dyslipidaemia Variable Odds ratio 95% CI Diabetes 2.38 1.42–3.98 Obesity 2.71 1.97–3.75 Current smoking 1.85 1.29–2.66 Age (years) 1.07 1.06–1.08 CI = confidence interval 652 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 5 Serum lipids by age and sex Lipid/age (years) Males Females Percentile Percentile 75th 50th 25th Mean 75th 50th 25th Mean Total cholesterol (mg/dL) 20–29 200 177 153 180 201 177 155 181 30–39 229 202 175 204 225 198 173 201 40–49 238 212 184 213 239 212 187 215 50–59 237 213 186 214 275 243 212 246 60–69 242 213 186 216 275 244 216 247 Triglycerides (mg/dL) 20–29 170 114 81 144 130 91 68 110 30–39 229 161 112 191 180 121 86 145 40–49 253 176 122 214 220 156 111 180 50–59 234 169 122 195 255 184 134 215 60–69 219 149 106 180 251 177 129 205 LDL-cholesterol (mg/dL) 20–29 129 110 90 112 131 109 92 113 30–39 153 129 107 130 149 126 104 128 40–49 159 135 111 137 157 134 113 137 50–59 158 137 116 138 183 156 132 159 60–69 164 139 116 142 185 159 133 161 HDL-cholesterol (mg/dL) 20–29 46 39 32 39 53 46 39 46 30–39 42 35 32 38 53 42 39 45 40–49 42 35 32 38 49 42 35 43 50–59 42 39 32 38 53 46 39 46 60–69 46 39 32 40 53 46 39 46 LDL = low-density lipoprotein; HDL = high-density lipoprotein. LDL-C and low HDL-C concentrations [13–15]. In our study the mean HDL-C level in diabetics was slightly higher than in the general population (41.1% versus 40.7%). This is an unusual and new finding and we have no explanation for it. The low prevalence of hypertriglyceridaemia in our diabetic population could be due to our diagnostic criteria (ATP II) which defined hypertriglyceridaemia as TG level > 400 mg/dL. If we had chosen the ATP III criteria (TG > 200 mg/dL), hypertriglyceridaemia would probably become the most common metabolic disorder in diabetics. This study revealed that hyperlipidaemia is a major problem in the Tehran population and secondary causes may have a role in its occurrence. Many of our participants had more than one CAD risk factor. However, logistic regression and odds ratios dem- onstrated that after obesity, diabetes was the most important factor associated with secondary dyslipidaemia in this population. We know that about half of diabetics are un- aware of their disease. Therefore, screening programmes for diabetes and lipid profile testing of diabetics is recommended. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 653 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Acknowledgements We express appreciation to the participants of Tehran Lipid and Glucose Study unit, the Health Department of Shahid Beheshti University of Medical Sciences and Mrs S. Sadeghi. References 1. Ridker PM. Evaluating novel cardiovas- cular risk factors: can we better predict heart attacks? Annals of internal medi- cine, 1990, 130(11):933–7. 2. Yusuf S et al. Effect of potentially modi- fiable risk factors associated with my- ocardial infarction in 52 countries (the INTERHEART study): case–control study. Lancet, 2004, 364:937–52. 3. Gregg EW et al. Secular trends in cardio- vascular disease risk factors according to body mass index in US adults. Journal of the American Medical Association, 2005, 293(15):1868–74 (Erratum in: JAMA, 2005, 294(2):182). 4. Grundy SM et al. Primary prevention of coronary heart disease: guidance from Framingham. A statement for healthcare professionals from the AHA Task Force on Risk Reduction. American Heart Associa- tion. Circulation, 1998, 97(18):1876–87. 5. Alwan A, ed. Prevention and control of cardiovascular diseases. Alexandria, World Health Organization Regional Office for the Eastern Mediterranean, 1995:24 (WHO EMRO Technical Publica- tions Series, 22). 6. Zali M, Kazem M, Masjedi MR. [Health and disease in Iran]. Tehran, Deputy of Research, Ministry of Health, 1993 (Bul- letin No. 10) [in Farsi]. 7. Azizi F et al. Cardiovascular risk factors in an Iranian urban population: Tehran lipid and glucose study (phase 1). Sozial- und Präventivmedizin, 2002, 47(6):408–26. 8. Sheikholeslam R et al. Non communi- cable disease risk factors in Iran. Asia Pacific journal of clinical nutrition, 2004, 13(Suppl.):S100. 9. Castanho VS et al. Sex differences in risk factors for coronary heart disease: a study in a Brazilian population. BMC public health, 2001, 1(1):3. 10. Ubink-Veltmaat LJ et al. Prevalence, in- cidence and mortality of type 2 diabetes mellitus revisited: a prospective popu- lation-based study in The Netherlands (ZODIAC-1). European journal of epide- miology, 2003, 18(8):793–800. 11. Clemens A, Reimann JF, Seigel EG. Optimierte Diabetestherapie beim Typ-2- Diabetiker [Optimized diabetes therapy in type 2 diabetics]. Medizinische Klinik (Mu- nich, Germany: 1983), 2003, 98(9):484– 92. 12. Dunstan DW et al. The rising prevalence of diabetes and impaired glucose toler- ance: the Australian Diabetes, Obesity and Lifestyle Study. Diabetes care, 2002, 25(5):829–34. 13. Pérez A et al. Prevalence and pheno- typic distribution of dyslipidemia in type 1 diabetes mellitus: effect of glycemic con- trol. Archives of internal medicine, 2000, 160(18):2756–62. 14. Battisti WP, Palmisano J, Keane WE. Dy- slipidemia in patients with type 2 diabetes. Relationships between lipids, kidney dis- ease and cardiovascular disease. Clinical chemistry and laboratory medicine, 2003, 41(9):1174–81. 15. Stalder M, Pometta D, Suenram A. Re- lationship between plasma insulin levels and high density lipoprotein cholesterol levels in healthy men. Diabetologia, 1981, 21(6):544–8. 654 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Periodontal status of type 2 diabetics compared with nondiabetics in north Jordan Y.S. Khader,1 Z.S.M. Albashaireh2 and M.M. Hammad 3 1Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine; 2Department of Restorative Dentistry, Faculty of Dentistry; 3Department of Preventive Dentistry, Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan (Correspondence to Z.S.M. Albashaireh: albashaireh@yahoo.com). Received: 16/12/05; accepted: 23/02/06 ABSTRACT The periodontal status of 106 type 2 diabetic patients was assessed and compared with that of 106 age-matched nondiabetics. Patients older than 20 years with type 2 diabetes mellitus were recruited from the outpatient internal medicine clinics at the 2 main hospitals in Irbid governorate, Jor- dan. Periodontal disease was more severe in type 2 diabetic patients than in nondiabetics, as indicated by significantly mean higher gingival index, periodontal pocket depth, clinical attachment level and tooth mobility. There was no significant difference in the mean plaque index between diabetics and nondia- betics. The severity of periodontal disease was significantly higher in patients with diabetes > 5 years than those with duration ≤ 5 years. ÁaeÙ=¹>›Èf³j¶=§E;e>¯ºʾ>N¶=œ»¿¶=ÀºÈf³j¶=›Àj¶=¼¢=ÆaͶ>U =>Èf²g(fv]¬iÇÈa>—b»†(ÅfÈ>nF¶  „=Í[qØ6›Àj¶=¼¢=Æb¶ð>»É[ɯIÍi=eb¶=Åd›ÁÇNU>F¶=ÏfQ?106=Ǿe>®Æ(ʾ>N¶=œ»¿¶=Àº[Èf³j¶=Àº ¤ºSÑ>J¿¶=106f[»£¶=›¼Ã¾ÇÂ>vÈ>š[Èf³j¶=¦Àº*b[ÈhIÀ[šʾ>[N¶=œ»¿[¶=À[º[Èf³j[¶==Ç[£–b[®Æ η¢¼Âe>»¢?20L=a>É£¶=Àºð>º>¢ÁaeÙ=›b[EeCÍ[Ÿª>†›[ßÉjÉÑf¶=[ßÉ«nJj™=›{>F¶=Gì·¶ÍÉQe>„=* ¹b[ÈÆ([Èf³j[¶=[¦Ïb¶ÄÉ·¢ÇÂ>šʾ>N¶=œ»¿¶=Àº[Èf³j¶=Ïb¶bm?Àj¶=¼¢=ÆazfºÁ? UǶb®Æ HÇ[ɂ=°[»¢Æ(ð>ÉÑ>r[UCÄ[EèbßJá£àÈð>¢>«Ie=¼ÃÈb¶ËÇN·¶=Gßjá¿ß»[¶=¥>«Ie=´¶cη¢ÏÇJj[ºÆ(Àj[¶=¼[¢=Æa› Àj¶=ÍɲfUÆËfÈfj¶=>FIe×=*EÍÉ¿j¶=L>ŒÇ·¶=Gßjá¿ßºœiÇJº›ð>ÉÑ>rUCÄEèbßJá£àÈ­ØJ]=µ>¿ÂÀ³ÈÆ [Èf³j¶=¦Æ[Èf³j¶=*ÀÈd[¶=[Èf³j[¶=Ïb¶ð>ÉÑ>rUC>ÃEèbßJá£àÈÍQebEÌbmfN²?Àj¶=¼¢=ÆazfºÁ>²Æ E¼ÃJE>qCÌf[JªbÈhIη¢Ëf³j¶>5À¢¼ÃJE>qCÌf[Jª¸¯IÀÈd¶=b¿¢>ÿºL=Ç¿i5L=Ç¿i*  Comparaison de la santé parodontale de diabétiques de type 2 et de non-diabétiques dans le nord de la Jordanie RÉSUMÉ La santé parodontale de 106 diabétiques de type 2 a été évaluée et comparée à celle de 106 non-diabétiques appariés sur l’âge. Des patients âgés de plus de 20 ans et souffrant de diabète sucré de type 2 ont été recrutés dans les services de consultations externes de médecine interne des deux hôpitaux principaux du gouvernorat d’Irbid (Jordanie). Les parodontopathies étaient plus graves chez les diabétiques de type 2 que chez les non-diabétiques, comme le démontrent des valeurs significativement plus élevées en termes d’indice gingival moyen, de profondeur de poche(s) parodontale(s), de niveau d’attache clinique et de mobilité dentaire. En ce qui concerne l’indice de plaque moyen, il n’y avait pas de différence significative entre les diabétiques et les non-diabétiques. La parodontopathie présentait un niveau de gravité significativement plus élevé chez les patients atteints de diabète depuis plus de 5 ans que chez ceux atteints de diabète depuis 5 ans ou moins. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 655 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Periodontal disease has been ranked 6th among the complications of diabetes mel- litus [1] and is the most prevalent oral com- plication in patients with type 2 diabetes mellitus [2–4]. It has been found to be more common and more severe in diabetic pa- tients than in controls [5–10]. The evidence of a direct relationship between periodontal disease and diabetes, gathered from thor- ough reviews, is strong [8,10]. Diabetes mellitus has been shown to be positively as- sociated with clinical attachment loss [11]. A cross-sectional study of risk factors for periodontal disease in 1426 people found that diabetics had 2.32 times increased risk for attachment loss [12]. Diabetes affected all periodontal parameters, including bleed- ing scores, probing depths, loss of attach- ment and missing teeth [9]. It appears that diabetics have an in- creased susceptibility to periodontitis that is related to diabetes control [13] and dura- tion of disease [14]. A substantial body of evidence has begun to emerge suggesting a bidirectional relationship between both types of diabetes and periodontal disease [15,16]. Nonsurgical periodontal treatment is associated with improved glycaemic con- trol in type 2 diabetic patients and could be undertaken along with the standard meas- ures for care of the diabetic patient [17]. Although this finding is intriguing, some reports showed that periodontal treatment had no effect on diabetes control [18,19]. As implicated in the literature, there may be a genetic component to type 2 diabe- tes. The relationship between diabetes and periodontal disease also appears to be very strong within certain populations, such as Aborigines [20,21]. Other factors are in- volved in the high prevalence of periodontal diseases in association with diabetes. A re- cent study found that smoking increases the risk of periodontal disease nearly 10-fold in diabetic patients [22]. Age is another factor, and researchers have documented that the differences between diabetic and control subjects with respect to periodontal disease may not be evident until the age of 30 to 40 years [23]. While diabetes mellitus is a common disease in Jordan with a prevalence of 13.4%, [24], no attempts have been made to explore the association between periodontal diseases and diabetes in Jordanian patients. This study was therefore conducted to as- sess the periodontal status of patients with type 2 diabetes mellitus attending outpa- tient clinics in Irbid compared with that of nondiabetics. Methods Sample All consecutive patients older than 20 years with type 2 diabetes mellitus who attended the outpatient internal medicine clinics at the 2 main hospitals in Irbid governorate, Jordan, during a 4-month period in 2002 were included in the study. These central hospitals provide services to about 1 mil- lion inhabitants and the majority of diabetic patients are referred to them for special- ized treatment. Simultaneously, another nondiabetic subject of the same or similar age was randomly selected and recruited from patients attending the orthopaedic and accident and emergency unit in the same hospital. Subjects were excluded if they had insulin-dependent diabetes mellitus, rheu- matic arthritis, malignant blood disorders, allergy, asthma, or if they were pregnant or taking long-term medication other than diabetes therapy. Nondiabetics with a first sibling with diabetes were also excluded. Informed consent for the interview and examinations were obtained from each 656 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما participant in advance. The study was ap- proved by the administration of the hospi- tals selected. Data collection The plaque index (PI) of Silness and Loe [25] was measured for 6 selected teeth, namely the maxillary right first molar, the maxillary right lateral incisor, the maxillary left first bicuspid, the mandibular left first molar, the mandibular left lateral incisor and the mandibular right first bicuspid. Missing teeth were not substituted. Thereafter, the periodontal status of all teeth excluding 3rd molars were assessed by the following parameters: gingival index (GI) of Loe and Silness [26], probing pocket depth (PPD), clinical attachment level (CAL), mobility of teeth using Miller mobility index, and number of missing teeth. All measurements were carried out on all participants. Sterile dental mirrors and explorers were used to assess plaque accumulation and gingival conditions, while a standardized Michigan 0 periodontal probe with Wil- liams’s markings (Diatech, Switzerland) were used to measure PPD and CAL. Mo- bility was assessed by applying pressure on the tooth in different directions using 2 hard instruments. Probing pocket depth was measured to the nearest millimetre from the gingival margin to the bottom of the crevice. CAL was measured to the nearest millime- tre in cases of exposure of cement–enamel junction (CEJ) by reading off the distance from the CEJ or the margin of fixed restora- tion to the base of the pocket, and in other cases indirectly by subtracting the distance from the gingival margin to the CEJ from the pocket depth. The level of the CEJ was determined by feeling for it with the probe tip. Six (6) representative teeth and 4 surfaces of each studied tooth (mesiofacial, midfacial, distofacial and midlingual) were assessed and scored for PI. Other clinical parameters were collected at 6 sites per tooth for all teeth (mesiofacial, midfacial, distofacial, mesiolingual, midlingual and distolingual). The average PI, GI, PPD, and CAL for each participant were computed by adding scores over all examined surfaces or sites and dividing by the total number of exam- ined surfaces or sites. The average mobility score was computed over all examined teeth for each subject. The averages of these clini- cal parameters were used in the analysis. All participants were interviewed for personal data including: age, sex, education, income, oral hygiene and smoking habit. Diagnosis and duration of diabetes were retrieved from the medical records of the patients. This was judged as a more reliable method as patients may not recall correctly the onset of the disease. The patients were classified according to the duration of dia- betes as follows: ≤ 5 years and > 5 years. All clinical examinations were carried out by 1 examiner, for which intraobserver reliability was determined in 20 participants by re-examining them on 2 subsequent days. Of the total number of duplicate PPD measurements, 96% were within ± 1 mm of each other and 89% fell within the same depth (exact agreement). Of the duplicate CAL measurements, 98% fell within ± 1 mm of each other and the exact agreement was 88%. Blinding the examiner to the health of the patient or their duration of diabetes was not possible. Analysis For a power of 80% and level of signifi- cance of 0.05, the sample size that would find a significant difference of 0.75 mm in the average CAL between the 2 groups, with a standard deviation of 1.8 was calculated as approximately 94 per group. The character- istics of participants by categorized demo- graphic, oral hygiene and smoking variables were described using frequency distribu- tions and analysed using the chi-squared Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 657 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما test. The differences in plaque score and periodontal parameters between diabetics and nondiabetics were analysed using the Wilcoxon signed-rank test. Kruskal–Wallis H test was used to test the differences in clinical parameters between the 3 groups that were produced based on diabetic status and duration of diabetes. Pairwise multiple comparisons to test the differences between each pair were conducted by calculating the minimum significant difference (MSD) in mean ranks for pairwise comparisons ac- cording to the formula: MSD = where N refers to the total sample size and n refers to the size of the specific group. The analysis was done using SPSS, version 11.5. Comments about statistical signifi- cance refer to probabilities < 0.05. Results Characteristics of the study group The present study involved 106 patients with diabetes mellitus (49 males and 57 females) and 106 people not suffering from diabetes (54 males and 52 females). The participants were age-matched; thus, the age distribution of diabetics was similar to that of nondiabetics. The characteristics of dia- Table 1 Characteristics of type 2 diabetics and nondiabetics by demographic and oral hygiene variables Variable Diabetic Nondiabetic P-valuea (n = 106) (n = 106) No. % No. % Sex Male 49 46.2 54 50.9 0.492 Female 57 53.8 52 49.1 Education < high school 73 68.9 68 64.2 0.467 ≥ high school 33 31.1 38 35.8 Smoking habit Yes 32 30.2 45 42.4 0.063 No 74 69.8 61 57.6 Toothbrushing Yes 95 89.6 95 89.6 1.000 No 11 10.4 11 10.4 Use of auxiliary aids Yes 4 22.6 23 21.7 0.869 No 82 77.4 83 78.3 Average plaque index 0–1 42 39.6 37 34.9 0.478 > 1 64 60.4 69 65.1 Mean (SD) age (years) 46.9 (7.2) 47.0 (7.2) 0.949 aWilcoxon signed-rank test for age and chi-squared test for other variables. n = total number of participants; SD = standard deviation.     ++ 21 11 12 )1( nn NNz 2 658 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما betic patients and nondiabetics according to demographic and oral hygiene variables are given in Table 1. Diabetic and nondiabetic groups had a similar distribution according to sex, level of education, smoking habit, brushing of teeth, use of auxiliary dental aids other than toothbrush (e.g. miswak, in- terdental brush and dental floss) and plaque index (Table 1). The proportion of diabetics with duration of disease since diagnosis ≤ 5 years was 52.8% and that of diabetics with duration > 5 years was 47.2%. Effect of diabetes on periodontal status Bivariate analysis demonstrated that there was no significant difference in the mean PI between diabetics and nondiabetics (P = 0.242). The mean GI, PPD, CAL, mobil- ity score and number of missing teeth were significantly higher in diabetics compared with nondiabetics (Table 2). Diabetics with disease duration > 5 years had significantly higher mean PI, PPD, CAL and mobility score than diabetics with disease duration ≤ 5 years (Table 3). The mean GI and mean number of missing teeth were not significantly different between the 2 diabetic groups. When the diabetics were compared with nondiabetics, both dia- betic groups had a significantly higher mean PPD, CAL, mobility score and number of missing teeth. However, only diabetics with the disease duration > 5 years had higher mean GI than controls. Discussion This age-matched study was carried out to assess the periodontal status in a group of type 2 diabetes mellitus patients and com- pare it with that of a group of nondiabetics. Participants of this study were recruited from 2 referral hospitals which maintain appropriate records for their patients. Thus, the details of diabetic patients were extract- ed from their records as some may not recall the onset, duration or other details of their diabetes. The duration of diabetes was clas- sified arbitrarily in 2 groups, ≤ 5 years and > 5 years, in order to make the methodology and the results of this study more compara- ble with those reported in the literature. It must be emphasized that the results of this study may not be directly compa- Table 2 Periodontal and oral hygiene variables for diabetics and age-matched nondiabetics Variable Diabetic Nondiabetic P-valuea (n = 106) (n = 106) Mean SE Mean SE Plaque index 1.82 0.08 1.73 0.07 0.2418 Gingival index 1.67 0.07 1.25 0.08 0.0006 Probing pocket depth (mm) 3.65 0.08 2.82 0.08 < 0.001 Clinical attachment level (mm) 6.19 0.23 3.26 0.22 < 0.001 Mobility score 1.14 0.09 0.28 0.04 < 0.001 Missing teeth (No.) 5.35 0.52 3.07 0.32 0.0430 aWilcoxon signed-rank test. n = total number of participants; SE = standard error of the mean. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 659 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما rable with the results of others. This is due to many differences such as the popula- tion size, selection criteria for diabetic and nondiabetic groups, types of periodontal assessment performed, number of examin- ers, blinding of examiners and intra- and intersubject variations in measurements. There was no significant difference in the average PI between diabetics and non- diabetics, a finding which contradicts some studies [6,9,27,28], but is accordance with another [2]. PPD and CAL were signifi- cantly greater in diabetics than nondiabet- ics, indicating that diabetics are at greater risk for developing periodontal disease than nondiabetics. These results are in accord- ance with some other reports [6,9,25]. The severity of periodontal disease was more prevalent in diabetics who had the disease for > 5 years. This finding is consistent with some reports [14,23] but not with another [27]. Although the exact role of diabetes in periodontal deterioration is still obscure, diabetes had been linked to increased sus- ceptibility to periodontal disease through a number of hypotheses. Several interacting factors such as altered polymorphonuclear cell function and derangements of inflam- matory protein response coverage at the periodontium result in a higher prevalence and severity of periodontitis [29]. Other factors, such as subgingival microflora and an alteration in host defences in diabetics may play a role in the association between periodontal disease and diabetes [30,31]. Grossi and Genco proposed a model for the biological association between peri- odontal disease and diabetes mellitus [15]. They mentioned that both the “infection- mediated” pathway of the periodontium and state of insulin resistance amplify the classical pathway of diabetic connective tissue destruction [advanced glycation end products (AGEs)-mediated]. The severity of diabetes and periodontal disease seem to be connected indirectly through health behaviours such as diet, frequency of meals, smoking and oral health behaviour [32]. It has been found that nonadherence with diabetes self-care instructions as a cause of poor metabolic Table 3 Mean periodontal and oral hygiene variables for nondiabetics and diabetics by duration of diabetes Variable Group 1 Group 2 Group 3 Significance of difference Nondiabetics Diabetics Diabetics between pairs of groupsa ≤ 5 years > 5 years (n = 106) (n = 56) (n = 50) Mean SE Mean SE Mean SE 1 vs 2 1 vs 3 2 vs 3 Plaque index 1.73 0.07 1.62 0.09 2.05 0.12 NS NS 0.027 Gingival index 1.25 0.08 1.54 0.08 1.81 0.10 NS < 0.001 NS Probing pocket depth (mm) 2.82 0.08 3.42 0.11 3.92 0.11 0.020 < 0.001 0.028 Clinical attachment level (mm) 3.27 0.22 5.30 0.25 7.19 0.34 < 0.001 < 0.001 < 0.001 Mobility score 0.28 0.04 0.84 0.10 1.48 0.13 < 0.001 < 0.001 < 0.001 Missing teeth (No.) 3.07 0.32 6.40 0.07 8.22 0.72 0.006 < 0.001 NS aPairwise multiple comparisons, Kruskal–Wallis H test. n = total number of participants; SE = standard error of the mean; NS = not significant. 660 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما balance was associated with not bothering to clean proximal surfaces as a cause of gingivitis [33]. Thus, while biological fac- tors are certainly important, poor oral health behaviour leads to periodontal disease, and correspondingly poor adherence to diabetes metabolic control measures leads to com- plications including those related to the periodontium. Because the severity of periodontal dis- ease and tissue destruction of the periodon- tal apparatus may be accelerated as diabetes progresses, there is an obvious need for educational campaigns and intervention programmes for diabetic patients. Peri- odontal disease has to be managed and oral infections brought under control. Conclusions This study demonstrated that periodontal disease, as measured by mean GI, PPD, CAL and mobility scores, was more severe in diabetics than nondiabetics. It was also shown that diabetics had more missing teeth than nondiabetics. Diabetics with dura- tion of diabetes > 5 years had significantly higher mean PI, PPD, CAL and mobility scores than in diabetics with disease dura- tion ≤ 5 years. 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Periodontology 2000, 1997, 14:33–53. 32. Moore PA. The diabetes–oral health connection. Compendium of continuing education in dentistry, 2002, 23(12 Sup- pl.):14–20. 33. Kneckt MC, Syrjälä AM, Knuuttila ML. Attributions to dental and diabetes health outcomes. Journal of clinical periodontol- ogy, 2000, 27(3):205–11. 662 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ىضرلما ىدل ةيفرعلماو ةيلاعفنلاا ةلالحا ينسحتل جمانرب يولكلا ءافصتسلال ينعضالخا Programme for improving emotional and cognitive changes in patients under renal dialysis in Egypt ABSTRACT We investigated the effect of chronic renal failure on the emotional status, social and psychological adaptation and the cognitive status of patients and the effect of a programme to improve the psychosocial state of the patients; 40 renal dialysis patients and 40 healthy controls were included. We used the Emotional Status Scale, Psychosocial Adaptation Scale, the Primary Mental Abilities Test and the Memory Processes Scale for assessment of the participants. The controls had better emo- tional/cognitive status and psychosocial adaptation than the dialysis patients, a statistically significant difference. There were also statistically significant differences between the patients before and after the application of the programme. ͪ>¼ÉÂAfECA zâ 1 ,«ìrº b—?ΰÉN£ªA 1, a>»ƒA Ê«ìrº b»†Ë2, ·¢ ÌbQ>ºÊ¸º>² 3 Íq؄=6 KªÆ>¿I ÍmAebªA Ê¢>»NQ‹A °ªAÃNªAÆ ,Íɪ>£«¾‹A ͪ>ƒA η¢ Àºh™A Ë÷³ªA ¸n«ªA e>MAªAÆÊj«¿Îuf»·ª ¼ÃÈbª Íɪf£™A ͪ>ƒA ÍmAea η¢ ÌÆ›¢ ,ÄE E>r™A * K“ >»²ÍmAeaK·Æ ,Îuf»·ª ÍÉj«¿ªA ͪ>ƒA j€ Sº>¾fE M@I 40ð>vÈfº Ë÷³ªA ¸n«ª>E Æ40 Í¿É£² Ð>VqÙA ÀºÌbÂ>m* b®Æ Kºb^NmA›çb¢ ÍmAebªAÈ>¥º Ì[É¥Nª kÉ[Îuf™A ¼É £™A ͪ>ƒA l>É¥º >ÿº Á>² l>É¥ºÆ ,Íɪf°ªAÃNªAfÈb¥I l>É¥ºÆ ,ÍɪÆÙA ÍÉ·¥£ªA LAeb¥ªA l>É¥ºÆ ,Ê¢>»NQ‹AÆ Êj«¿ªA L>É·»¢f²AdªAÌ*A Í¿É£ªA Á? À¢ ÍmAebªA Lf«m?ÆÌbÂ>nª ;ó™A Í¿É£ªA Àº ¸vª? >ãuÆ Á>² Àº ÎufºªAË÷³ªA ¸n« ÍÉÑ>rUC L>¿È>JI LfÃžÆ ,ʪ>£«¾‹AÆ ›f£™A ¼Ã£uÆ OÉU ÀºÍVuAÆ Î·¢ÍÉ»ÂÙA Àº ÌJ² ÍQea* >»² KVuÆ? ð>®Æfª ÍmAebªA >ÃE èbN£àÈÉÑ>rUCð>Åb£EÆ Sº>¾ªA °ÉJìI ¸J® Îuf™A E * hala_awadalla@yahoo.com :نيورتكللإا ديبرلا ،رصم ،ةرهاقلا ،سشم ينع ةعماج ،ةيئيبلا ثوحبلاو تاساردلا دهعم (1)رصم ،قيزاقزلا ،قيزاقزلا ةعماج ،بطلا ةيلك (2)رصم ،مويفلا ،ناكسلاو ةحصلا ةيريدم (3) 07/04/30 :æÃJ¥ªA ,07/01/24 :¬›Nm‹A Hala I. Awadalla, Institute of Environmental Studies and Research, Ain Shams University, Cairo, Egypt. Ahmed M. El-Ateek, Institute of Environmental Studies and Research, Ain Shams University, Cairo, Egypt Mohamed M. Elhammady, Faculty of Medicine, Zagazig University, Zagazig, Egypt. Magda A. Kamel, Fayoum Directorate of Health and Population, Fayoum, Egypt. Programme d’amélioration des changements émotionnels et cognitifs chez les patients sous dialyse rénale en Égypte RÉSUMÉ Nous avons étudié les effets de l’insuffisance rénale chronique sur l’état émotionnel, l’adaptation sociale et psychologique et l’état cognitif des patients, et les effets d’un programme visant à améliorer l’état psychologique de ces patients ; 40 patients hémodialysés et 40 sujets sains ont été pris en compte. Afin d’évaluer les participants, nous avons utilisé l’Échelle de l’état émotionnel, l’Échelle d’Adaptation Psychosociale, le test des Aptitudes Mentales Primaires et l’échelle des processus mnésiques. Les sujets témoins présentaient un meilleur état émotionnel/cognitif et une meilleure adaptation psychosociale que les sujets dialysés, avec une différence statistiquement significative. Il existait également des différences statistiquement significatives entre les patients avant et après la mise en place du programme. 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Ad SN¾ b®Æ ÄN²e>nº› ,ÍÉ¢>»NQ‹A Íìn¾ÙA Æ ¤QfÈ ´ªd²‘C e>³ªÙA ¸Èb£IÆ xÈf™A Ïbª ÍÒ{>„A ¼ÉÂ>«™AÆ ¼³VNªA›‹A L‹>£«¾ªA Ím>£NªA ο£º ¸»€ K¾>² Æ eúÙA œÉjJIƬb¢ >ûÉ^vIÆ ÊE>‹C [ɧI PÆbU› Îuf™A e>³ª? Æ ÍÉ»ÂÙ>E ¼ÂeãmÆÍÉVrªA ͪ>ƒA Àèj€ ÍRÉN¾ k«¿ª>E Í¥NªA Æ eAf»Nm‹A› Ð>]m‹A L>¿Èf“ Ƹº@NªA *ÆSºAªA ͺßb^Nj™A›«¿ªA ¼·¢ km@E ¬hN·I ,Êj«¿ªA æ>A kÆ Î£jI‘C Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 673 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ,ĪAbÂ? °É¥€Æ ¸Ñ>mêA ÏbUC Ê SºAªA ÁC æÃ¥ªA >¿¿³•ªA ÍÉj«¿ªA Ìb¢>j™A L>ºb] >ÃNìmAÃE ¬çb¥I ÆfN²? >÷£ª Í®a ÍÉj«¿ªA ¸Ñ>mêAÆ ðAbÈb€Æ;Æfº *Æ ¼ç»rI ¸»¢ Íì] ľ? η¢ ­f£È Sº>¾ªAÆ ¼õŸ¿I›¼Èb¥Nª ÍÉ»·¢ kàmî? ÐÃu Ìfm>J™A ÍÉj«¿ªA L>ºb„A Æ ÍÉÑ>”ÝA k«¿ªA ¼·¢ ­AbÂ? °É¥€ ¸Q? Àº Ìfm>J™A ¦Æ ÍÉÑ>®ÃªAÆÍÉQ›£ªA]34[* Æ >ûɻrI ¼NÈ ¸»¢ Íì] ľ? η¢ Sº>¾ªA ­f£ÈÆ >ûɟ¿I›Ìfm>J™A ÍÉj«¿ªA L>ºb„A ¼Èb¥Nª ÍÉ»·¢ kàmî? ÐÃu Æ ÍÉÑ>”ÝA k«¿ªA ¼·¢ ­AbÂ? °É¥€ ¸Q? Àº Ìfm>J™A ¦Æ ÍÉÑ>®ÃªAÆÍÉQ›£ªA* ÆSºAªA ͺßb^Nj™A›¬hN·I Êj«¿ªA æ>A k«¿ªA ¼·¢ kàmî@EÆ Î£jI‘C ,ĪAbÂ? °É¥€ Æ ¸Ñ>mêA ÏbUC Ê SºAªA ÁC æÃ¥ªA >¿¿³•ªAL>ºb] >ÃNìmAÃE ¬çb¥I ÍÉj«¿ªA Ìb¢>j™AÆ Í®a ÍÉj«¿ªA ¸Ñ>mêA fN²? >÷£ªÆ ðAbÈb€Æ;Æfº]34[* L>ÉqÇJ¶= 1. zAfº? À¢ f³J™A ¬n³ªA 糪AÆ Í¿ºh™A zAfºÙA Í£E>N’ ´ªcªA ÏëaÖI ‘C ¸n«ªA Ë÷³ªA* 2. Êj«¾ ÊÑ>r]C aÃQÆ ÌeÆfuÆ ¸Éj§ªA LAbUÃE t>] Ê¢>»NQAË÷³ªA* 3. xÈf»·ª ÍÉj«¿ªA ­ÆfŸª>E Îuf™A fßmî? ÍÉ¢ÃNª L>É«nNj™>E LAÆb¾ ¼ÉŸ¿IÆ>㺠¸º>£NªA Íɫɲ* 4.uf™A ¤º ¸º>£NªA Íɫɲ η¢ xÈf»NªA ÍÒÉ GÈebIÍÉj«¿ªA ¼ÃJ¢>Nº η¢ Gö·§NªA η¢ ¼ÃIb¢>j™ Î* 5. ¸n«ª>E ÍE>qÝA ÍɫɳE ¤»NA aAfª? ÍÉ¢ÃNª Íɺ›¢C SºAfE aAb¢CË÷³ªA ÆÍÈ>®ÃªA ±f{* 6. ¤èmÃNªA› ͺb„ ÍÈeÃû‚A L>Ÿª>† ¤É»| 糪A Îufº Ð>®bq? L>É£– ¥Æfª Ð>n¾C ÆЋÖ L›³nº ¸U Îuf™A* ¤Q=f™=References يملعلا رتمؤلما ،يولكلا لشفلاب ينباصلما لافطلأل ،ةرهاقلا ةعماج ،ةيعامتجلاا ةمدلخا ةيلك ،سمالخا .1992 ،نياثلا دلجلما ،مويفلا عرف 8. Koutsopoulou V et al. Personality dimen- sions of haemodialysis patients related to initial renal disease. EDTNA/ERCA journal, 2002, 28(1):21–4. 9. Kelly M. Chronic renal failure. American journal of nephrology, 1996, 96(1):36–7. 10. Monhan FD, Darke T, Neighbors M. Nurs- ing care of adults. Philadelphia, WB Saun- ders Company, 1998. 11. ةبتكم ،يجولويسفلا سفنلا ملع :ةشاكع دحمأ .2002 ،ةرهاقلا ،ةيرصلما ولنجلاا 12. ملع في ةرصاعم تاهاتجا :لماك دممح باهولا دبع .2002 ،ةيرصلما ولنجلأا ةبتكم ،سفنلا 13. ةيعامتجلاا ةدناسلما :يلع ملاسلا دبع ىلع عم قفاوتلاب اهتقلاعو ةطغاضلا ةايلحا ثادحأو ثلاثلا ددعلا ،سفنلا ملع ةلمج ،ةيعمالجا ةايلحا .2000 ،باتكلل ةماعلا ةئيلها ،نوسملخاو 1. Atkins RC. The epidemiology of chronic kidney disease. Kidney international sup- plement, 2005, 94:S14–8. 2. Katz I. Kidney and kidney related chronic diseases in South Africa and chronic dis- ease intervention program experiences. Advances in chronic kidney diseases, 2005, 12(1):14–21. 3. Shaheen FA, Al-Khader AA. Preventive strategies of renal failure in the Arab world. Kidney international supplement, 2005, 98:S37–40. 4. راد ،ةماعلا ةحصلا ئدابم :دحمأ ديس ليوتم برج .1991 ،ةرهاقلا ،ةعابطلل دجلما وبأ 5. ةباقنلا (133) ددعلا ءابطلأا ةلمج :ديسلا يدحم .1999 ،ربوتكأ ،ءابطلأل ةماعلا 6. اياضق) ةركاذلا ةيجولوكيس :اللها دبع مساق دممح نيطولا سلجلما ،ةفرعلما لماع ،(ةثيدح تاهاتجاو .2003 ،تيوكلا ،بادلآاو نونفلاو ةفاقثلل 7. ميظنت ةقيرط ماهسإ :فيطللا دبع دحمأ داشر ةيعامتجلاا ةياعرلا جمارب ميمصت في عمتجلما 674 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 14. ،ةيلولأا ةيلقعلا تاردقلا رابتخا :لحاص ىكز دحمأ .1987 ،ةيرصلما ةضهنلا ةبتكم 15. ةطبترلما ةيسفنلا تارِّيغتلما :ليلخ ليدنق دممح ةميعن ةيرتموكيس ةسارد رصم في يولكلا لشفلا ضربم ةيلك ،ةروشنم يرغ هاروتكد ةلاسر ،ةيكينيلك .1998 ،رهزلأا ةعماج ،ةيناسنلإا تاساردلا 16. Wuerth D et al. Identification and treat- ment of depression in a cohort of patients maintained on chronic peritoneal dialy- sis. American journal of kidney diseases, 2001, 37(5):1011–7. 17. ىلع ةر ـِّ ثؤلما لماوعلا :بيطلا دحمأ هدبع ةمطاف تتح نمزلما يولكلا لشفلا ىضرم ةايح ةيعون يرتسجام ةلاسر ،يومدلا ءافصتسلااب جلاعلا ،سشم ينع ةعماج ،ضيرمتلا ةيلك ،ةروشنم يرغ .2000 18. Theodora K et al. Looking into the factors affecting renal patients’ quality of life. EDTNA/ERCA journal, 1996, 22(3):19– 21. 19. Weisbord SD et al. Prevalence, severity, and importance of physical and emotional symptoms in chronic hemodialysis pa- tients. American journal of social nephrol- ogy, 2005, 16(8):2487–94. 20. Mok E, Tam B. Stressors and coping methods among chronic haemodialysis patients in Hong. Journal of clinical nurs- ing, 2001, 10(4):503–11. 21. White Y, Grenyer BF. The biopsychoso- cial impact of end-stage renal disease: the experience of dialysis patients and their partners. Journal of advanced nurs- ing, 1999, 30(6):1312–20. 22. Roccella M et al. [The quality of life in developing age subjects with chronic re- nal diseases]. Minerva pediatrics, 2005, 57(3):119–28. 23. Bath J, Tonks S, Edwards P. Psycho- logical care of the haemodialysis patient. EDTNA/ERCA journal, 2003, 29(2):85–8. 24. Njah M, Nasr M, Ben Dhia N. Anxiety and depression in the hemodialysis patients. Nephrologie, 2001, 22(7):353–7. 25. Bawden HN et al. Neuropsychological functioning in end-stage renal disease. Archives of disease in childhood, 2004, 89(7):644–7. 26. Jassal SV et al. Improvements in cogni- tion in patients converting from thrice weekly hemodialysis to nocturnal hemo- dialysis: A longitudinal pilot study. Kidney international, 2006, 70(5):956–62. 27. Mendley SR, Zelko FA. Improvement in specific aspects of neurocognitive per- formance in children after renal trans- plantation. Kidney international, 1999, 56(1):318–23. 28. Burn DJ, Bates D. Neurology and the kid- ney. Journal of neurology, neurosurgery and psychiatry, 1998, 65(6):810–21. 29. تابارطضلاا ضعبل ةسارد :ىطعلما دبع دممح نىم يولكلا لشفلاب ينباصلما لافطلأا في ةيسفنلا دهعم ،ةروشنم يرغ يرتسجام ةلاسر ،نمزلما .1992 ،سشم ينع ةعماج ،ةلوفطلا تاسارد 30. Griva K et al. Acute neuropsychologi- cal changes in hemodialysis and perito- neal dialysis patients. Health psychology, 2003, 22(6):570–8. 31. Williams MA et al. Temporal effects of di- alysis on cognitive functioning in patients with ESRD. American journal of kidney diseases, 2004, 43(4):705–11. 32. Griva K et al. Cognitive functioning pre- to post-kidney transplantation – a prospec- tive study. Nephrology, dialysis, trans- plantation, 2006, 21(11):3275–82. 33. لماع ،يجلاعلا سفنلا ملع :يرس دممح للاجإ .1999 ،ةرهاقلا ،بتكلا 34. جلاعلاو ةيسفنلا ةحصلا :نارهز ملاسلا دبع دماح .2001 ،ةرهاقلا ،بتكلا لماع ،يسفنلا Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 675 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Attitudes of dental students towards using computers in education—a mixed design study M.M.A. El Tantawi1 and S.M. Saleh1 1Department of Paediatric and Community Dentistry, Faculty of Dentistry, University of Alexandria, Alexandria, Egypt (Correspondence to M.M.A. El Tantawi: maha_tantawy@hotmail.com). Received: 26/12/05; accepted: 20/03/06 ABSTRACT This mixed design study explored attitudes of dental students towards use of computers. It employed quantitative analyses of a questionnaire answered by 979 students and qualitative analysis of suggestions by a subgroup of 339. Positive attitudes towards computers were predicted by “compu- ter use for > 1 year” and “year of study”. Qualitative analysis of students’ suggestions confirmed these findings and brought up new issues such as the need for establishing a website for the faculty. The results indicate that careful planning is needed to improve students’ skills and incorporate computer applications in educational curricula. Attitudes des étudiants en dentisterie envers l’utilisation de l’ordinateur dans l’enseignement – étude qualitative et quantitative RÉSUMÉ Cette étude de conception mixte a permis d’examiner les attitudes des étudiants en dentisterie envers l’utilisation de l’ordinateur. Elle était fondée sur l’analyse quantitative d’un questionnaire complété par 979 étudiants et sur l’analyse qualitative des suggestions d’un sous- groupe de 339 étudiants. Les réponses aux questions « utilisation d’un ordinateur > 1 an » et « année d’étude » permettaient de prédire les attitudes positives à l’égard de l’ordinateur. L’analyse qualitative des suggestions des étudiants a confirmé ces résultats et a soulevé de nouvelles questions telles que la nécessité de créer un site Web pour la faculté. Les résultats montrent qu’une planification rigoureuse est nécessaire pour améliorer les compétences des étudiants et intégrer les applications informatiques dans les programmes d’études. ¼É·£J¶=›GÉi=ǃ=½=b^Ji=Å>Á>¿iÙ=G{ÍF·{¬®=Ǻ*cÍi=eaœ·J‡¼É»rIL= >qb»†Á=gÇi(ËÆ>ì¿ì¶=Ê·¢b»†>ú  „=Í[qØ6¼É[·£J¶=›GÉ[i=ǃ=½=b^Ji=Å>Á>¿iÙ=G{ÍF·{¬®=ǺÍi=eb¶=ÅdÂÊr¯JjI*Lçb»J[i=b[®Æ ºÊ»³¶=¸É·VJ¶=Ð>«ÉJi=À979°[Èfª>[ÃE½çb[¯IL>U=f[J®=Àºʫɳ¶=¸É·VJ¶=Lçb»Ji=>»²(L>¾>ÉFJiضð>F¶>{ Àº¬õ¶@JÈÊ¢fª339ð>F¶>{*ƶÀºÍFiǃ=ljÍÉE>‹Ý=¬®=Ǚ=¤ö®ÇISJá¿àJi=b¯¸ [Nº¸[º=Ç£¶=x[£E6%%½=b^J[i= bÈhIÌb™GÉi=ǃ=À¢Í¿i$$Æ%%Í®f«¶=¶=ÍÉi=eb$$*ÆL=aÇ[QǙ=Åd[ÂHØ[ì¶=L>U=f[J®×ʫɳ¶=¸É·VJ¶=bõ²? K¾f[[J¾Ý=Î[·¢ÍÉ·³·¶¤®ÇºÐ>n¾C‘CÍQ>ƒ=¸NºÌbÈbQ>È>v®e>M?Æ*‘CÍ[i>ºÍ[Q>ƒ=Á?Î[·¢SÑ>[J¿¶=¹b[IÆ ÊjÈebJ¶=Sÿ™=›ÍÉEÇi>ƒ=L>¯ÉFìJ¶=T>ºaCÆHØì¶=L=e>újVJ¶¼³†œÉì*  676 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Information and communication technol- ogy (ICT) provides automation, creative tools, local and global communications, and support for education [1,2]. The need for computer literacy and incorporation of computers into medical/dental education has been acknowledged for many years [3]. The advantages of ICT in undergraduate dental education include Internet, online databases, e-mail, digital video, computer- assisted learning and virtual classrooms [4]. The exponential growth in ICT and its applications in education sometimes exceed the adaptive power of students or staff, creating negative impressions [5]. Obser- vations on students’ competence in ICT are few, nonsystematic and pertain mostly to countries where the use of informatics is well developed [4]. Ascertaining the opinions of students is necessary to correct deficiencies and address negative attitudes [3]. As a part of a general plan for introducing e-government and the “computer for every house” project, the Ministry of Telecom- munications and Information Technology offers Egyptian universities well equipped computer laboratories connected to the Internet. This offer was made to the Fac- ulty of Dentistry, Alexandria University in 2004. At the same time, the faculty received a grant for a project for the use of ICT and computers in the educational process. The present study was carried out to investigate computer attitudes of students in the Faculty of Dentistry, University of Alexandria, their need to learn computer skills, the most preferred modality for using ICT in education, and perceived barriers for this use. This was deemed a necessary step for analysing the background of students’ ICT skills before teaching an elective com- puter course aimed at preparing students to use computers for submitting written as- signments, searching the Internet and using simple statistical software packages. Methods Sample Undergraduate students in all years in the Faculty of Dentistry were invited to par- ticipate in the study in December 2004. The students were approached in clinical/ laboratory sessions and the purpose of the study explained to them. Participation was voluntary. The total number of students in the school was 1316. The number of stu- dents in years 1, 2, 3 and 4 were 365, 320, 370 and 261 respectively. Response rates for completing the questionnaire for years 1 to 4 were 64.7%, 74.7%, 76.8% and 84.6% respectively, with an overall rate of 74.4%. Instrument A questionnaire was developed by the au- thors to assess the attitudes of undergradu- ate students towards using computers in education. It was then tested on a sample of 20 students in the fourth year. Questions that were difficult to answer or needed ex- planation were modified. Ethical approval for the study was obtained from the faculty research committee. The final questionnaire was administered to students in all years. A blank space was provided at the end where students could add relevant suggestions in their own words. Analytic strategy Responses to the questionnaire were ana- lysed using quantitative analysis strategies for categorical data. Logistic regression analysis was used to determine predictors of positive computer attitudes. Those who in- dicated that they wanted or strongly wanted to use computers in education were con- Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 677 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما sidered as having positive attitudes while those who indicated that they were worried or hoped never to use computers were con- sidered as having negative attitudes. Those who were not sure of how they felt were not included in the regression analysis. Suggestions provided by the students at the end of the questionnaire were the basis for qualitative analysis. Several advantages have been suggested for such open-ended questions, among which is the reassurance that all relevant issues have been covered in the original questionnaire [6]. In addi- tion, using both quantitative and qualitative analytic strategies ensures the validity of the study by using a methodological triangula- tion technique where data obtained by one method is compared to that obtained by the other to see if they agree [7]. Themes emerging from students’ sug- gestions were grouped in 2 categories: one converging with the responses to the ques- tionnaire and the other category containing new themes and the frequency of different themes was counted. Results The total sample was compared with a sub- sample that used the space at the end of the questionnaire to provide suggestions as regards different variables (Table 1). The 2 samples were comparable in all factors except year where there was a statistically significant smaller proportion of third year students for the sample providing sugges- tions. The variables used to compare the whole sample and the sub-sample were the same as the independent variables (predic- tors) used for logistic regression analysis. Table 2 shows the response to each item on the questionnaire. The majority of students (88.1%) wanted/strongly wanted to use computers in education. Most (63.3%) viewed computers as a supplemental tool to traditional educational activities. The most popular use (70.3%) was to view lectures as PowerPoint presentations. The major- ity of students (71.7%) preferred computer applications to be used for clinical courses. Computer courses were desired by 70%. The 2 most frequently cited obstacles for using computers were lack of time and inadequate computer skills. Using logistic regression analysis to predict positive computer attitudes, statisti- cally significant predictors were using a computer for > 1 year (P = 0.004) and year of study (P = 0.03) (Table 3). Students in the third year had the highest chance of hav- ing a positive attitude [odds ratio (OR) 1.73; P = 0.03]. Differences for other variables were not statistically significant. Table 4 lists some of the themes that emerged from the suggestions and which agreed with the overall study sample results. Nearly a quarter of the comments expressed a positive attitude. This was based on sever- al perceived benefits for using computers in education, such as increasing concentration in lectures through using imaginative ap- proaches to the subject, increasing the speed of accessing information, decreasing the pressure on the teaching staff and helping Egypt to catch up with the modern world. Ten students (3.0%) indicated the necessity of using computers immediately, although some made comments of the “don’t rush” type, advising thorough study of the advan- tages and disadvantages before committing. Other negative comments included limited resources, that there were no computers at all in the faculty, or questioned the serious- ness of the intention to use computers. Some objectors mentioned that the education sys- tem itself needed to be put in order before computers were introduced, or that comput- ers were not suitable for all curricula. Only 1 student, a female in fourth year with a grade of “very good” for the previous year, 678 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما and who owned a computer, frankly said, “I do not care about using computers because I do not like them.” Some comments expanded on topics mentioned in the questionnaire, adding more uses to computers in the faculty, such as patient care and recording student ab- sences. Table 5 displays themes that emerged from the suggestions which differed from the questionnaire items. These included having computers available in the faculty, which was expressed by 43.4% of those providing suggestions, and that the Internet should be available in the faculty. The main reason given for this was to help students who could not afford a computer although some suggested that reasonable fees could be charged for use or that there could be a system whereby computers were made available for purchase through instalments: “Provide enough computers for students who cannot afford to buy them due to their high price which is greater than the income of the students and make these computers available through in- stalments”. Table 1 Comparison between main sample of questionnaire and sub-sample of suggestions as regards some studied variables Variable Whole sample Suggestions χ2 (P)a sample No. % No. % Sex Male 303 30.9 119 35.4 2.09 (0.15) Female 676 69.1 217 64.6 Have computer Mine 748 76.4 256 76.2 0.10 (0.95) Not mine 143 14.6 48 14.3 No 88 9.0 32 9.5 Used computer for > 1 year Yes 465 47.5 168 50 0.53 (0.47) No 514 52.5 168 50 Year First 236 24.1 101 30.1 111.95 (< 0.0001) Second 239 24.4 122 36.3 Third 284 29.0 5 1.5 Fourth 220 22.5 108 32.1 Grade achieved last yearb Excellent 70 7.2 24 7.1 5.77 (0.12) Very good 335 34.2 122 36.3 Good 423 43.2 113 33.6 Fair 151 15.4 38 11.3 Total 979 336 aTest of difference between whole sample and sample that provided suggestions. bFor the suggestions sample, numbers do not sum to 336 because 39 questionnaires had missing answers. P < 0.05 considered significant. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 679 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 2 Attitudes of students to computers as obtained by quantitative analysis of questionnaire responses (n = 979)a Question/response No. % How much do you want to use computers in education? Strongly want 524 53.5 Want 339 34.6 Not sure 53 5.4 Worried 45 4.6 Hope never to use them 13 1.3 How would you like computers to be used in education? Supplement to other activities 620 63.3 For distance education 284 29.0 Instead of other educational activities 91 9.3 Other 40 4.1 For what purpose would you like computer technology to be used in education? Lectures available as PowerPoint presentations 688 70.3 Using e-mail to ask staff members questions about courses 439 44.8 Text of lectures available on the Internet 411 42.0 Questions, tests, model answers & quizzes on the Internet 411 42.0 Resources related to study subject on the Internet as references, scientific journals and websites 355 36.3 Assignments about research questions using computers 336 34.3 What courses do you prefer computers to be used in? Clinical 702 71.7 Pre-clinical laboratory 561 57.3 Basic sciences 340 34.7 All 208 21.2 Do you want to take computer courses? Yes, through special courses in the faculty 346 35.3 Yes, through special courses outside the faculty 340 34.7 There is no need because I can use computers based on my own experience 281 28.7 What are the obstacles that may prevent you from using computers and the Internet in education? Not enough time 459 46.9 Inadequate computer skills 314 32.1 Fear of viruses and hackers 127 13.0 No computers available 161 16.4 High cost 123 12.6 Not trusting information on the Internet 63 6.4 aNumber of responses to each question differs due to item non-response and selecting > 1 answer to the same question. 680 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 3 Logistic regression model to predict positive attitudes among dental students towards using computers in education Variable χ2 P-value Category OR P-value Sex 0.005 0.94 Female vs male 0.98 0.94 Computer ownership 4.12 0.13 Mine vs not mine 0.34 0.06 None vs not mine 0.51 0.81 Used computer for > 1 year 8.28 0.004 No vs yes 0.37 0.004 Year 8.99 0.03 First vs fourth 0.63 0.24 Second vs fourth 0.48 0.01 Third vs fourth 1.73 0.03 Grade achieved last year 1.95 0.58 Excellent vs fair 2.76 0.25 Very good vs fair 1.11 0.36 Good vs fair 1.40 0.93 P < 0.05 considered significant. OR = odds ratio. Table 4 Themes identified from the qualitative analysis in agreement with results of questionnaire (n = 339) Main theme/category No. % Attitude towards using computer in education Computer should be used in different courses 37 10.9 Computer is useful in education 35 10.3 Use computers immediately 10 2.9 Total positive attitude 82 24.2 Negative attitude 15 4.4 Modalities for using computer in education Supplement/substitute 14 4.1 Distance education 3 0.9 Uses of computer technology in education Online courses 45 13.3 CDs of lectures, demonstrations, etc. 36 10.6 Resources such as references, journals & websites 29 8.6 Communication with staff members for questions, feedback and discussion 19 5.6 Assignments for research projects 19 5.6 Quizzes, questions and tests 15 4.4 Other (patient care; recording attendance; security system) 5 1.5 Courses where computers may be used Lectures 90 26.5 Practical (clinical and laboratory) 73 21.5 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 681 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The availability of computers as suggest- ed by students included providing enough units (29 students, 8.55%) (Table 5). They also commented on the location of computers. The greatest number suggested a separate computing laboratory (25 students, 7.4%). Others considered that the natural place was the library or the laboratories and clinics: “There must be a computer laboratory in the faculty so that it will be easy to do research for those who do not have computers at home.” “Having computers in the library will be very practical in addition to the books there. The presence of the Internet will make a great difference.” “Old educational methods and aids should be substituted by new methods, e.g. patient sheets should be taken by means of computers attached to every dental unit in the clinic because this is what is used now and I intend to do that after my graduation.” “In the laboratory and clinical sessions, there must be computers and datashow so that all students can see (demonstra- tions).” The questionnaire asked if students wanted to take computer courses. Respons- es indicated a desire to study the Internet in addition to different computer programs (Table 5). Just over a tenth of the students made suggestions related to constructing a web- site for the faculty. This was considered necessary since it could be used for the dissemination of educational materials, publishing academic rules, announcing lec- ture and exam schedules and promoting ac- tivities such as conferences and workshops. It could also be used for communication with other dental faculties and the academic community in general, or for strengthening Table 5 Themes identified from the qualitative analysis differing from the results of questionnaire (n = 339) Main theme/category No. % Computer accessibility on campus Faculty should make computers available for educational purposes 26 7.7 Faculty should make Internet available 21 6.2 Availability Adequate no. of machines 29 8.6 Good condition 11 3.2 Time to use 10 3.0 Computer location in faculty Computer laboratory 25 7.4 Library 14 4.1 Laboratories & clinics 11 3.2 All 147 43.4 Teaching computer Computer skills 22 6.5 Mandatory/elective 9 2.7 Personnel to teach computer 6 1.8 Free courses 5 1.5 Practical only 4 1.2 Internet 3 0.9 Courses in summer 3 0.9 For informatics diploma 1 0.3 All 53 15.6 Website for faculty Includes educational materials 11 3.2 Communication with rest of world 7 2.1 Academic rules 6 1.8 Website is necessary 5 1.5 Schedule for exams and lectures 4 1.2 Announcement of activities & conferences 4 1.2 All 37 10.9 “I hope that the faculty provides comput- ers as a reward for excellent students, especially those who cannot afford to buy them. I want very much to own a computer but I have financial barriers which I hope can be overcome.” 682 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ties between members of the faculty and alumni. Discussion The present study explored computer at- titudes of dental students in Alexandria University. It used a mixed design employ- ing both quantitative and qualitative analy- sis techniques. A number of studies used the mixed quantitative–qualitative analysis strategy to extract the maximum benefit from available data. Sometimes new issues might arise from open-ended questions [8]. In the present study, the interest of students in a website was expressed as new theme in their suggestions. Our results confirmed that students had positive attitudes. This seems to be the general attitude of students in differ- ent countries; students at universities in northern and southern Europe were equally positive about using computers in educa- tion [9]. The same situation also existed at King Abdul Aziz University, Jeddah where medical students were surveyed and 53% considered that computers and the Internet could improve studies and professional skills “very much” [10]. In most studies, however, a minority of students expressed negative attitudes. In our study, the number of students who indicated that they hoped never to use computers in their studies was minimal. It has been reported that a small minority of all college students experience some type of technophobia, which is a genuine aversion toward computers and computer use [11–13]. The majority of students thought that computers should supplement and not sub- stitute traditional educational activities. This might be because students expect in- struction and education to follow the tradi- tional format of professor teaching directly to students and they feel they are owed this and anything else—even if provided by computers—is inferior [2,14]. The most popular suggested use of com- puters was to display lectures as PowerPoint presentations in the same form they were delivered in the lecture room. This seems to be a general attitude of students in a number of countries [15,16] which they claim would not influence lecture attendance. Making lectures available for students on the Inter- net or on CDs would allow students who missed the lecture to review it. In addition, it could partly solve the problem of the great number of students enrolled in the faculty. Qualitative analysis of students’ sugges- tions showed that students wanted to learn computer skills through courses that did not add to their current study burden. They suggested summer courses or electives suit- able for their schedule. A limited computer course is already offered in the first prepara- tory year in the faculty. The major drawback for expanding this course to teach practical computer skills is the length of time elapsed between giving the course in the preparatory year and application of the acquired skills in the third and fourth years where clinical courses are given. Greenhalgh commented that students tend to use “just in time learn- ing”: most of them try to learn the required features of software when they actually use them. Thus, much initial training may not be popular or effective [17]. Review of re- lated studies in different countries indicates that limited courses for basic computer skills are taught, that students acquire their competence from sources outside the uni- versity but that they would like to receive computer training mostly in the university [4,16,18,19]. It has been suggested that the lack of experience with computers may be addressed by including suitable computing courses at the secondary school level [20]. Mattheos et al. suggested that basic compu- ter literacy should be a requisite for dental Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 683 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما school admission so that students are able to handle applications in the field of dentistry effectively [4]. As a more realistic alterna- tive, they suggested categorizing students’ competence with ICT on entry to dental school so that less competent students could receive appropriate training. Considering that a third of the students in our study felt that lack of adequate skills was a barrier to using computers in education and two- thirds indicated a need and desire to have computer courses, careful planning to im- prove and upgrade the skills of students is needed to avoid increasing the study burden of students and cost and time implications for teaching staff. Sex was not a significant predictor of computer attitude in the logistic regression model. The issue of gender and attitude to computers is controversial. Macleod et al. concluded that as the use of ICT becomes regular within higher education, sex dif- ferences disappear [9]. While in the early 1990s, more males than females felt the importance of computer in education, by the late 1990s, the views of both sexes had converged [21,22]. As regards previous experience with computers, the consensus is that it pre- disposes to a positive computer attitude [23,24], a finding encountered in our study also. Year of study was also a significant predictor of positive attitudes, with third year students most likely to have positive attitudes. These students are in a good posi- tion to realize the potential of computers in helping them in their studies and can afford the time to use them more than fourth year students, who are under a lot of stress to complete clinical requirements and to col- lect study materials for the final examina- tion. In a generally similar finding, Rajab and Baqain found that significantly more clinical than preclinical students used the Internet for dentistry [16]. Lack of time was the most important barrier to using computers in education in our study and in others [15,16]. This emphasizes the need to avoid duplication of educational material through traditional and computer-based routes, leading to waste of students’ time [25]. Lack of availability was an important barrier in our study and in others [15,16]. Although nearly three- quarters of the students in our study and that of Walmsley et al. owned a computer or had access to one at home, they still felt the need for a computer presence in the faculty [15]. Inadequate skill was the second most frequent barrier in our study. In contrast Walmsley et al. found that lack of confidence in ability was the least important barrier [15]. In view of the prevailing positive at- titudes of dental students towards using computers in education, there is a pressing need to revise the current curriculum so that shortcomings in the educational process can be redressed by appropriate computer technology. While computers are neither in- tended nor desired to replace the traditional role of the teaching staff, they can help in various aspects of didactic and practical education. The immediate tasks requiring attention and planning are managing the upgrading of students’ computer skills and establishing a website for the faculty. References 1. Survey of European universities skills in ICT of students and staff: results (SEU- SISS Report). European Commission, Socrates Programme, 2003 (www.inter- media.uib.no/seusiss/1-Introduction.pdf, accessed 25 September 2007). 684 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 2. Nattestad A et al. Web-based interactive learning programmes. European jour- nal of dental education, 2002, 6(Suppl. 3):127–37. 3. Lang WP. Trends in students’ knowledge, opinions and experience regarding dental informatics and computer applications. Journal of the American Medical Informa- tion Association, 1995, 2:374–82. 4. Mattheos N et al. Computer literacy and attitudes among students in 16 European dental schools: current aspects, regional differences and future trends. European journal of dental education, 2002, 6:30– 5. 5. Oliver R et al. Towards a global superstore of quality-assured modularized learning programs. European journal of dental education, 2002, 6(Suppl. 3):147–51. 6. O’Cathain A, Thomas KJ. “Any other comments?” Open questions on ques- tionnaires—a bane or a bonus to research? BMC Medical research meth- odology, 2004, 4:25 (www.biomedcentral. com/1471-2288/4/25, accessed 9 Sep- tember 2007) 7. Guion LA. Triangulation: establishing the validity of qualitative studies. Gainesville, Florida, University of Florida, Coopera- tive Extension Service, 2002 (Publication FCS6014: http://edis.ifas.ufl.edu/pdffiles/ FY/FY39400.pdf, accessed 9 September 2007). 8. Goldacre MJ, Evans J, Lambert TW. Me- dia criticism of doctors: review of UK junior doctors’ concerns raised in surveys. Brit- ish medical journal, 2003, 326:629–30. 9. Macleod H et al. Gender and ICT—a 10 year study of new undergraduates. Ed- inburgh, University of Edinburgh (http:// www.homepages.ed.ac.uk/jhaywood/pa- pers/techtrends.pdf, accessed 9 Septem- ber 2007). 10. Mansoor I. Computer skills among medi- cal learners: a survey at King Abdul Aziz University, Jeddah. Journal of Ayub Medi- cal College Abbottabad, 2002, 14(3):13– 5. 11. Rosen LD, Weil MM. What we have learned from a decade of research (1983– 1993) on “the psychological impact of technology”. ACM SIGCAS Computers and society, 1994, 24(1):3–9. 12. Lehmann HP et al. An ethnographic con- trolled study of the use of a computer based histology atlas during a laboratory course. Journal of the American Medical Information Association, 1999, 6:38–52. 13. Dorup J. Experience and attitudes to- wards information technology among first year medical students in Denmark: lon- gitudinal questionnaire survey. Journal of medical internet research, 2004, 6(1): e10. 14. Varnhagen S. Introducing technology in the classroom: some observations from focus groups. In: Irons GA, Medowcroft TR, eds. Challenges in materials edu- cation. Montreal, Quebec, Metallurgical Society of CIM, 2005. 15. Walmsley AD et al. The use of the Internet within a dental school. European journal of dental education, 2003, 7:27–33. 16. Rajab LD, Baqain ZH. Use of information and communication technology among dental students at the University of Jor- dan. Journal of dental education, 2005, 69:387–98. 17. Greenhalgh T. Computer assisted learn- ing in undergraduate medical education. British medical journal, 2001, 322:40–4. 18. Grigg P et al. Computing facilities avail- able to final year students at 3 UK dental schools in 1997/8: their use, and students’ attitudes to information technology. Euro- pean journal of dental education, 2001, 5:101–8. 19. Gouveia-Oliveira A, Rodrigues T, de Melo FG. Computer education: attitudes and Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 685 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما opinions of first-year medical students. Medical education, 1994, 28:501–7. 20. Ray NJ, Hannigan A. A survey of the computer literacy of undergraduate dental students at a University Dental School in Ireland during the academic year 1997– 98. European journal of dental education, 1999, 3:56–63. 21. Busch T. Gender difference in self-effica- cy and attitude toward computers. Journal of educational computing research, 1995, 1(1):37–54. 22. Corston R, Colman AM. Gender and social facilitation effects on computer competence and attitudes toward com- puters. Journal of educational computing research, 1996, 14:171–83. 23. Levine T, Donitsa-Schmidt S. Commit- ment to learning: effects of computer experience, confidence and attitudes. Journal of educational computing re- search, 1997, 16:83–105. 24. Necessary J, Parish T. The relationships between computer usage and computer- related attitudes and behaviors. Educa- tion, 1996, 116:384–6. 25. Keene DR, Norman GR, Vickers J. The in- adequacy of recent research on computer assisted instruction. Academic medicine, 1991, 66:444–8. Survey of the use of the Internet and e-mail by physicians in the Region We would like to draw the kind attention of our readers to the above- mentioned survey that the WHO Regional Office for the Eastern Mediterranean is conducting as part of its effort to assess needs of physicians for health and biomedical information on the Internet. The data will be used to help the Regional Office in drawing up plans for future health information support in the Region. Your participation in this survey would be most appreciated. The survey can be accessed at: http://www.emro.who.int/useinternet/ 686 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Attitudes des étudiants tunisiens en médecine vis-à-vis de la pratique médicale : différences en fonction du sexe Th. Nabli Ajmi,1 M.I. Bougmiza1 et A. Mtiraoui1 1 Unité de recherche « Pratique Médicale Ambulatoire », Département de médecine communautaire, Faculté de médecine de Sousse, Sousse (Tunisie) (Correspondance à adresser à T.N. Ajmi : Thourayaajmi@yahoo.fr). Reçu : 01/02/06 ; accepté : 21/09/06 RÉSUMÉ Afin de mieux comprendre l’impact de l’entrée de plus en plus importante des femmes en médecine sur les soins de santé en Tunisie, nous avons mené une étude transversale sur les attitudes de 512 étudiants (40 % de sexe féminin) de la faculté de médecine de Sousse. Les femmes valorisent généralement plus que les hommes les aspects intrinsèques du rôle du médecin tels que le désir d’aider autrui et de travailler avec les gens. Les écarts entre les femmes et les hommes sont nettement marqués en ce qui a trait aux différentes dimensions de la globalité des soins (aspects psychosociaux du traitement, éducation sanitaire, approche centrée sur le patient et prévention en situation clinique). En fin de formation, les femmes et les hommes accordent systématiquement moins d’importance à ces différentes facettes qu’en début de formation. Attitudes of Tunisian medical students to medical practice: gender differences ABSTRACT To better understand the impact of gender change in medical practice on health care in Tunisia, we conducted a cross-sectional study on the attitudes of 512 medical students (40% female) to medicine and medical practice in the Faculty of Medicine, Sousse. Female students attached more value than males to the intrinsic aspects of a physician’s job, such as the desire to help others and to work with people. Regarding the dimensions of comprehensive care (psychosociological aspects of care, health education, patient-centred approach and medical prevention), there were wide differences between men and women. At the end of their training cycles, both male and female students ascribed less importance to these aspects than in the beginning. ÍÉFì¶=Íie>»™=Àº[Éj¾ÇJ¶=Gì¶=ÍFí·í{¬®=Ǻ6j¿‚=E±Æf«¶= ÈfMËÆ=ì™=Ê·¢(ÌhÉ»®ÇEH>ÃÈCb»†(Ê»R£¶=Ê·E>¿¶=>  „=Í[qØ6h[²=fº›Í[ÉFì¶=Í[ie>»™=›j[¿‚=[E±Æf[«·¶¸v[ª?¼[ê‘C¹ÇqǶ=Íi=eb¶=ÅdÂKªbÃJi= ¬®=ǺK¶Æ>¿IÍuf£JjºÍi=eaÊÂÆ(k¾ÇI›ÍÉVr¶=ÍÈ>¢f¶=512Gì¶=ÍFí·í{Àº%¼Ã¿º40!L>[F¶>ì¶=À[º$ ÆGì¶=¹ÇUÍiÇi›Gì¶=ÍÉ·²›ÍÉFì¶=Íie>»™=*G¾=ǂ>EHØì¶=œEe>š²?ͻɮL>F¶>ì¶=KìEeb®Æ l>¿¶=¤º¸»£¶=ÆÀÈf]Û=Ìb¢>j’ÍF¦f¶=¸NºGÉFì¶=¸»£¶ÍÉ·]=b¶=*Íɶǻn¶=ÍÈ>¢f¶>E°·£JÈ>º›>º?%G[¾=ǂ= ³If™=HÇ·iÙ=(ÊVr¶=¬É¯NJ¶=(ÍÈ>¢f·¶ÍÉ¢>»JQ×=ÆÍÉj«¿¶=Í[ÉFì¶=Í[È>®Ç¶=ÆÎ[uf™=η¢h$µ>[¿ÂÁ>[²b[¯ª( L>F¶>ì¶=ÆHØì¶=E¤i=Æ­ØJ]=*ßk[«¾L>F¶>ì¶=Æ?HØì¶=ÀºêË?ʶÇÈتÍÉFÈebJ¶=¼ÃI=eÆaÍÈ>þ›>º? ÍÈ=bF¶=›G¾=ǂ=Åd½>»JÂ×=ÀºÅáÇí¶áÆ?>º*  Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 687 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction En Tunisie, la profession médicale était jusqu’il y a deux décennies presque exclu- sivement réservée aux hommes. Depuis le milieu des années quatre-vingt, les femmes sont néanmoins de plus en plus nombreuses à entreprendre une carrière en médecine. À la faculté de médecine de Sousse, la propor- tion des étudiantes en médecine inscrites en première année est passée de 18 % en 1974 (première promotion) à 43 % en 1995 et plus de 57 % en 2003 [1]. Des études, pour la majorité nord- américaines, menées auprès des premiè- res femmes en médecine, montrent que celles-ci sont animées par des valeurs et des attitudes différentes de celles de leurs collègues masculins. Elles accordent plus d’importance à la qualité de la relation avec leurs patients et démontrent plus d’empa- thie et une meilleure écoute envers eux [2]. Les valeurs et les attitudes des médecins sont déterminées en grande partie par trois grandes catégories de socialisation : • la formation médicale : depuis l’étu- de longitudinale d’Eron [3], plusieurs autres études montrent l’augmentation du cynisme des étudiants au fur et à mesure qu’ils avancent dans leurs étu- des médicales [4-7]. Fox [8] et Parsons [9] suggèrent que cette élévation du cynisme est un simple fait adaptatif aux situations stressantes dans lesquelles vivent les étudiants dans les facultés de médecine. • Le mode et les conditions de travail : un nombre d’heures de travail chez les médecins dépassant 90-100 heures par semaine, une privation de sommeil, une responsabilité excessive et la lutte contre leurs émotions en face de certaines situa- tions stressantes des malades font très peu, d’après Conrad, pour nourrir leurs attitu- des et leurs « valeurs humanistes » [10]. • Finalement vient la socialisation préco- ce des futurs médecins, bien avant leur arrivée dans les facultés de médecine. Ce déterminant semble être le plus im- portant pour Reilly qui se demande s’il ne fallait pas, dès le départ, sélectionner les étudiants bien avant leur arrivée dans les facultés de médecine [11]. Sélection qui, selon Conrad, serait basée non seu- lement sur le versant scientifique mais aussi sur un autre versant qui garantirait compassion et empathie [10]. Il est clair qu’on ne peut pas extrapoler les résultats de la littérature internationale au contexte tunisien. C’est à cet effet que nous avons mené le présent travail de recherche durant l’année universitaire 1995-1996 à la faculté de médecine de Sousse (Tunisie) pour examiner la nature des attitudes et des valeurs professionnelles des médecins en formation. Notre étude s’est intéressée, d’une part, à relever l’éventuelle existence d’une dés- humanisation de la formation médicale telle que perçue dans la littérature, et d’autre part à identifier les attitudes des étudiants en médecine selon le sexe envers la globalité des soins. Méthode Type d’étude Il s’agit d’une étude descriptive, de nature transversale, qui vise à mesurer l’évolution des attitudes professionnelles des futurs médecins au cours de leur formation mé- dicale afin de susciter quelques hypothèses étiologiques pouvant être vérifiées par des recherches ultérieures sur ce sujet. La me- sure des attitudes s’est faite par un question- 688 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما naire auto-administré comprenant des items répartis en quatre sections principales. Population de l’étude La présente enquête a été menée auprès des étudiants en médecine et des internes issus de la faculté de médecine de Sousse. La population de l’étude se répartit en quatre groupes : • 2e année de médecine qui représente le premier contact avec le malade ; • 3e année de médecine qui représente la première année de formation clinique ; • 5e année de médecine qui représente la dernière année de formation clinique ; • 2e année d’internat qui représente la fin de la formation pratique. La population initiale visée par l’étude se compose de l’ensemble des étudiants de ces différentes cohortes, soit 750 étudiants. L’identification des personnes devant com- poser les différents groupes a été effectuée à partir des listes fournies par le service de scolarité de la faculté de médecine de Sousse. Les sollicitations à participer à l’en- quête ont été effectuées par contact direct. Les personnes des différentes cohortes ont pu être sollicitées à trois reprises durant une période de deux mois. Description de l’instrument de mesure et définition des variables Le questionnaire d’enquête se subdivise en quatre sections portant respectivement sur : • la formation médicale, les raisons du choix de la carrière médicale et les per- ceptions des valeurs prédominantes véhiculées dans le milieu de formation ; • les soins de santé et les orientations en médecine ; • le rôle du médecin auprès des patients ; • les caractéristiques socio-démographi- ques des répondants. Les échelles de mesure faisant l’objet du présent travail sont réparties à travers les sections du questionnaire. Certaines échel- les de mesure ont déjà été soumises à des tests de validation lors de deux pré-enquêtes réalisées au cours de l’année universitaire 1994-1995 auprès d’étudiants et d’internes en médecine [12]. Analyse des données Fiabilité et validité des échelles de mesure : les attitudes adoptées par les futurs mé- decins sont mesurées à l’aide d’échelles composées d’au moins quatre énoncés. La composition des échelles est validée par des analyses factorielles. Les analyses com- paratives ont été faites sur la base du score factoriel. Le seuil de 5 % a été retenu pour évaluer la signification statistique tout au long des analyses. L’analyse des données a été faite en utilisant le logiciel SPPS. Résultats La population finale, après trois sollicita- tions à participer à l’enquête, comprend 512 sujets, soit 67,5 % de la population ciblée. Les taux de non-répondants sont répartis à peu près de manière homogène entre les différentes cohortes. Caractéristiques socio-démographiques des répondants Ils sont en majorité des Tunisiens (96,8 %), issus d’un milieu urbain dans un cas sur deux. Quatre personnes sur 10 sont de sexe féminin. L’âge varie de 22 ans à 27 ans. Deux personnes sur trois déclarent qu’elles sont issues d’un niveau socio-économique moyen. Le niveau d’instruction des parents est très variable. La non-scolarisation varie de 10,4 % à 21,0 % chez les pères et de 21,7 % à 36,8 % chez les mères des étu- diants enquêtés. Par contre, le niveau Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 689 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما supérieur varie de 22,7 % à 47,9 % chez les pères et de 6,8 % à 22,4 % chez les mères (Tableau 1). Attentes et perceptions des étudiants vis-à-vis de la formation médicale Les perceptions et les attentes des dé- butants (2e et 3e année) et des finissants (5e année de médecine et 2e année d’internat) à l’égard de l’humanisation des soins et des aspects biotechniques ont été évaluées par des échelles de 5 et de 4 items respective- ment. Les répondants donnent, d’une part, leurs perceptions de l’importance accordée par la faculté de médecine à ces différents aspects de la formation médicale et expri- ment, d’autre part, leurs attentes face à l’im- portance qu’eux-mêmes souhaiteraient voir accorder par la faculté à ces mêmes aspects de la formation (Tableaux 2 et 3). Ces don- nées indiquent d’abord que les femmes et les hommes, qu’il s’agisse de débutants ou de finissants, perçoivent la formation médi- cale sensiblement de la même façon (score variant de -0,21 à 0,25). Seule une diffé- rence significative apparaît chez les internes (p < 0,05). À la sortie de la faculté, les fem- Tableau 1 Profil socio-démographique des futurs médecins selon l’année de formation Caractéristiques socio- 2e année 3e année 5e année 2e année démographiques médecine médecine médecine internat (n = 154) (n = 95) (n = 165) (n = 98) % % % % Sexe (% femmes) 41,6 42,1 36,1 40,1 Scolarité du père Non scolarisé 10,4 19,1 21,0 18,1 Primaire 13,9 10,6 18,5 21,1 Secondaire 27,8 34,0 27,1 38,1 Universitaire 47,9 36,2 34,4 22,7 Scolarité de la mère Non scolarisée 21,7 36,8 34,3 28,6 Primaire 17,5 20,0 30,6 39,5 Secondaire 38,5 29,5 23,7 25,2 Universitaire 22,4 13,7 11,3 6,8 Niveau socio-économique En dessous de la moyenne 3,4 6,7 12,5 12,9 Dans la moyenne 67,1 65,2 64,8 70,1 Au-dessus de la moyenne 29,5 28,1 22,7 17,0 Milieu de naissance Rural 10,9 15,1 13,5 21,8 Urbain 53,7 61,3 56,3 50,3 Semi-urbain 35,4 23,7 30,2 27,9 Nationalité Tunisienne 90,5 95,8 96,8 96,6 Étrangère 5,5 4,2 3,3 3,4 Âge moyen : 2e année = 22,5 ans, 3e année = 23,2 ans, 5e année = 25,4 ans et 2e année internat = 26,9 ans. 690 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما mes perçoivent que la faculté accorde plus d’importance aux aspects biotechniques que ne le font les hommes (score 0,25 chez les finissants de sexe féminin versus 0,01 chez leurs homologues de sexe masculin). Les femmes et les hommes ont égale- ment des attentes comparables en ce qui a trait aux aspects biotechniques de la forma- tion ; par contre, les attentes sont différentes lorsqu’il s’agit des aspects humains de la formation. Dans les différents moments de la scolarité (étudiants en 2e année, en 5e an- née et au moment de l’internat), les femmes possèdent des attentes plus élevées que les hommes à l’égard des aspects humains de la formation. Il faut noter par ailleurs que ces attentes s’affaiblissent au fur et à mesure que les étudiants avancent dans leur pro- cessus de formation. Les internes femmes échappent à cette règle. Raisons du choix de la carrière médicale Deux dimensions composent cette échelle. La dimension intrinsèque correspond à l’utilisation des aptitudes personnelles, au développement des aptitudes scientifiques, à la possibilité de travailler avec les gens et d’être utile aux autres. La dimension ex- trinsèque se rattache au prestige, au revenu, à la sécurité escomptée. On note que les hommes accordent systématiquement plus d’importance que leurs collègues femmes aux aspects extrinsèques de la profession (Tableaux 2 et 3). Les différences sont présentes tout au long du processus de formation et sont plus prononcées chez les finissants (score 0,14 avec p < 0,01 chez les débutants et 0,30 avec p < 0,001 chez les finissants). Par ailleurs, les hommes et les femmes accordent une importance assez comparable en ce qui a trait aux aspects intrinsèques de la profession. Bien que le score obtenu par les femmes soit supérieur à celui des hommes, les différences ne sont pas statisti- quement significatives. Attitudes professionnelles Notre question d’intérêt est de savoir si les femmes accordent plus d’importance que leurs confrères masculins à l’éducation des patients, aux comportements psychosociaux de leur rôle, à la prévention et à l’approche centrée sur le patient (Tableau 4). Les ré- sultats indiquent des différences d’attitu- des significatives entre les femmes et les hommes des trois dernières cohortes. Les étudiants de 2e année n’ayant pas de contact avec les malades ont été exclus. Les femmes accordent en général plus d’importance que les hommes à l’éducation des patients, bien que cette différence ne soit statistiquement significative qu’en 5e année. Elles accor- dent plus d’importance que leurs confrères masculins aux aspects psychosociaux du traitement, ainsi qu’à l’orientation sur le patient. Par ailleurs, elles possèdent des scores équivalents en ce qui concerne la prévention en situation clinique. Elles sont même devancées par les hommes en fin de formation et cette différence est statistique- ment significative (p < 0,05). L’intérêt pour la globalité des soins diminue au fur et à mesure que les étudiants avancent dans le cursus de formation. Au total, les écarts entre les femmes et les hommes sont nettement marqués en ce qui a trait aux différentes dimensions de la globalité des soins : les aspects psychoso- ciaux du traitement, l’éducation sanitaire, l’approche centrée sur le patient (en faveur des femmes) et la prévention en situation clinique (en faveur des hommes). En fin de formation, les femmes aussi bien que leurs collègues masculins accordent systémati- quement moins d’importance à ces diffé- rentes facettes qu’en début de formation. Les orientations préventives échappent à cette règle. On assiste à un regain d’intérêt Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 691 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما dans ce domaine au fur et à mesure que la formation avance. Bien que les données avancées soient cohérentes avec une influence positive du sexe féminin sur les attitudes des médecins vis-à-vis de la globalité des soins, plusieurs facteurs confondants peuvent entrer en li- gne de compte dans cette relation. Nous avons pu explorer les corrélations entre les attitudes professionnelles et certaines variables socio-démographiques (l’origine socio-économique, le niveau d’instruction des parents) et le moment du choix de la médecine comme profession. Tableau 2 Perceptions, attentes et motivation des débutants à l’égard de la médecine selon le sexe Perceptions, attentes, motivation 2e année 3e année médecine médecine F H F H Perceptions de la formation Aspects biotechniques -0,14 0,21 -0,01 0,07 Aspects humains 0,15 0,12 -0,17 0,09 Attentes à l’égard de la formation Aspects biotechniques 0,05 0,09 0,06 -0,13 Aspects humains 0,48 0,11*** 0,11 0,04 Raisons du choix de la médecine Aspects intrinsèques 0,30 0,12 0,21 0,02 Aspects extrinsèques -0,24 -0,10 -0,13 0,14** Score factoriel variant de -1,0 à +1,0. ** p < 0,01 ; *** p < 0,001. F : femmes ; H : hommes. Tableau 3 Perceptions, attentes et motivation des finissants à l’égard de la médecine selon le sexe Perceptions, attentes, motivation 5e année 2e année médecine internat F H F H Perceptions de la formation Aspects biotechniques -0,04 -0,11 0,25 0,01* Aspects humains -0,15 -0,02 -0,07 0,09 Attentes à l’égard de la formation Aspects biotechniques -0,15 -0,19 -0,09 -0,08 Aspects humains -0,05 -0,9** 0,25 -0,25*** Raisons du choix de la médecine Aspects intrinsèques 0,26 0,13 0,14 0,04 Aspects extrinsèques 0,04 0,19 -0,17 0,30*** Score factoriel variant de -1,0 à +1,0. * p < 0,05 ; ** p < 0,01 ; *** p < 0,001. F : femmes ; H : hommes. 692 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Facteurs associés aux différences d’attitudes professionnelles Aucune différence statistiquement signi- ficative n’est décelée entre les scores des différentes échelles d’attitudes après avoir bloqué l’effet du sexe. Le niveau de scola- rité des pères ne semble pas intervenir dans les différences d’attitudes observées lors de la première phase d’analyse. Par contre, comme le montre le tableau 5, il s’avère que seuls les étudiants dont la mère est d’un niveau de scolarité secondaire ou univer- sitaire ont significativement des attitudes plus orientées vers l’éducation des patients. Cette différence d’attitude s’observe plutôt chez les étudiantes que chez les étudiants avec p < 0,001 (Tableau 5). Lorsqu’on prend en compte l’origine socio-économique dans l’analyse, il existe une différence d’attitude concernant les quatre composantes de la globalité des soins. Les scores factoriels moyens des étudiants issus d’un milieu socio- économique supérieur à la moyenne sont plutôt faibles comparés aux étudiants issus d’un niveau socio-économique en dessous de la moyenne. Les différences enregistrées n’atteignent le degré de signification que pour la dimension « aspects psychosociaux du traitement » avec p < 0,001 (Tableau 6). L’analyse montre que les étudiants qui choisissent très tôt de faire carrière en médecine, à un âge inférieur à 15 ans, ont des attitudes beaucoup plus favorables Tableau 4 Valeurs moyennes des scores d’attitudes professionnelles des étudiants selon le sexe à différents niveaux de formation Attitudes professionnelles 3e année 5e année 2e année médecine médecine internat F H F H F H Éducation des patients 0,18 0,15 0,14 -0,05* 0,06 -0,08 Approche psychosociale 0,37 0,15* 0,39 0,10*** 0,02* -0,18 Prévention en situation clinique -0,15 -0,17 0,13 0,12 0,17 0,38* Approche centrée sur le patient 0,26 0,18 0,15 0,03 0,10 -0,09* Score factoriel variant de -1,0 à +1,0 * p < 0,05 ; *** p < 0,001. F : femmes ; H : hommes. Tableau 5 Comparaison des attitudes professionnelles des étudiants selon le sexe en fonction de la scolarité de la mère Attitudes professionnelles Hommes Femmes Ensemble S1 S2 S1 S2 S1 S2 p Éducation du patient -0,03 0,16 0,01 0,25** -0,04 0,20 <0,001 Approche psychosociale 0,10 0,06 0,30 0,15 0,20 0,10 0,37 Prévention en situation clinique -0,24 -0,32 -0,30 -0,15 -0,36 -0,26 0,40 Approche centrée sur le patient 0,18 -0,01 0,06 0,04 0,11 0,00 0,42 S1 : mères n’ayant pas été à l’école et mères de niveau de scolarité primaire. S2 : mères de niveau de scolarité secondaire ou universitaire. ** p < 0,01. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 693 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما quant à l’éducation sanitaire, l’approche psychosociale et l’orientation sur le patient (Tableau 7). Néanmoins, la différence n’est statistiquement significative que pour les deux dernières dimensions. Ces différences persistent lorsqu’on introduit la variable sexe. Le moment pendant lequel on décide de choisir la médecine comme carrière sem- ble être un facteur contributif dans la genèse des attitudes professionnelles. Discussion Il est à noter que nous avons étudié les attitudes des futurs médecins plutôt que leurs comportements cliniques. Ainsi nos résultats n’impliquent pas nécessairement que les femmes médecins ont des comporte- ments cliniques qui sont différents de ceux des futurs médecins hommes. Toutefois, ceci semble vraisemblable puisque plu- sieurs différences de comportements clini- ques sont déjà documentées dans d’autres études. Un autre point méthodologique concerne les non-répondants. Malgré la sollicitation à participer à l’enquête, nous n’avons pu join- dre que 67,5 % de la population visée. Cette difficulté est mentionnée dans la plupart des travaux de ce genre. Elle ne semble pas entraver la qualité de nos résultats, d’autant plus que la répartition des non-répondants est à peu près homogène à travers les diffé- rents groupes. À leur entrée à la faculté de médecine, les étudiants se révèlent animés d’un grand idéalisme qui leur inspire le désir de s’occu- per des autres, d’être avec eux, de les pro- téger, de leur prêter attention et de subvenir à leurs besoins avec compassion, tendresse et sentiment de devoir et de respect et non d’indifférence. Mais il s’avère qu’au fur et à mesure que les étudiants avancent dans leurs études, cet intérêt s’affaiblit peu à peu pour laisser émerger un nouvel intérêt pour Tableau 6 Comparaison des attitudes professionnelles des étudiants selon le sexe en fonction du niveau socio- économique Attitudes professionnelles Hommes Femmes NSE < NSE > NSE < NSE > moy. moy. moy. moy. Éducation des patients 0,24 0,20 0,17 0,21 Approche psychosociale 0,32 0,18 0,37 0,15** Prévention en situation clinique 0,12 0,00 -0,00 -0,12 Approche centrée sur le patient 0,18 0,08 0,08 0,02 NSE < moy. : niveau socio-économique inférieur à la moyenne. NSE > moy. : niveau socio-économique supérieur à la moyenne. ** p < 0,01. Tableau 7 Comparaison des attitudes professionnelles des étudiants en fonction de l’âge de décision de faire carrière en médecine Attitudes professionnelles Âge (ans) p < 15 > 15 Éducation des patients 0,16 0,03 0,38 Approche psychosociale 0,27 0,00 0,00 Prévention en situation clinique 0,20 0,31 0,44 Approche centrée sur le patient 0,38 0,14 0,00 694 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما les aspects biotechniques de la profession qu’Eron désigne par l’ « augmentation du cynisme » des étudiants au cours de leur for- mation [3]. Le service offert par ces futurs médecins risque alors de ne correspondre que rarement à la vraie tâche du médecin et leur fonction sera de plus en plus limitée, professionnellement menacée et idéologi- quement contestée. Dans notre étude, nous avons noté une baisse de l’intérêt pour les différentes dimensions de la globalité des soins, au fur et à mesure que les étudiants avancent dans leurs études. Au début de la formation clinique, les scores sont assez élevés, mais ils deviennent de plus en plus faibles à travers les années d’études. Les étudiants enquêtés pensent que la faculté de médecine accorde plus d’im- portance aux aspects biotechniques de leur future profession qu’à ceux humanitaires, et cette perception se renforce au fur et à mesure qu’ils avancent dans leurs études. Il semble que la formation médicale soit impliquée dans « l’augmentation du cy- nisme ». D’après Reilly, rien dans les écoles de médecine ne peut encourager chez les étudiants compassion et empathie [11]. L’enseignement, d’après Rezler [13] et Mahler [14], est focalisé, d’une part, sur les centres hospitalo-universitaires, visant des cas exceptionnels et des maladies rares, et d’autre part, sur l’université qui, désormais, ne semble fournir qu’un savoir fragmenté et juxtaposé, conduisant tout droit à la spé- cialisation. Par ailleurs, et malgré cette détérioration des attitudes constatées, un regain d’intérêt pour la prévention en situation clinique est noté. Maheux, Dufort et Beland n’ont pas rapporté les mêmes résultats puisqu’aucune détérioration n’a été notée spécialement chez les étudiants à orientation préven- tive [15]. Rezler, de son côté, voit que seul l’aménagement de la fonction préventive lutte contre le cynisme [13]. Notre enquête révèle qu’à leur entrée à la faculté de médecine, nos enquêtées féminines se montrent animées par plus d’idéalisme que leurs collègues masculins, et quoiqu’elles obéissent au « processus de déshumanisation », elles restent à la fin de leurs études encore plus animées d’idéalisme que leurs collègues masculins. Ces résultats confirment ceux de l’étude de Leserman [16] et de Maheux, Dufort et Beland [15]. En plus, elles accordent plus d’importan- ce à l’éducation des patients (bien que cette différence ne soit statistiquement significa- tive qu’en 5e année d’études médicales) et aux aspects psychosociaux du traitement. Leserman [16], Maheux, Dufort et Beland [15] et Shapiro, Mc Grath et Anderson [17] ont retrouvé des résultats pareils. D’un autre côté, les femmes perçoivent de façon différente leur rôle professionnel. En effet, l’aspect intrinsèque est mieux apprécié par elles que par les hommes. Elles aiment plus aider, écouter et travailler avec les gens. Par contre, elles attribuent moins d’importance aux composantes extrinsè- ques de leur rôle, notamment le prestige et la sécurité au poste. Ces résultats sont conformes à l’étude de Scadron et al. [2]. L’étude des autres facteurs confon- dants, pouvant entrer en ligne de compte avec l’influence positive du facteur sexe, montre : 1) une tendance significative vers l’approche psychosociale pour les étudiants dont la mère est d’un niveau de scolarité élevé ; 2) que les étudiants qui choisissent d’être médecin à un âge inférieur à 15 ans ont des attitudes beaucoup plus favorables quant à l’éducation sanitaire, à l’approche psychosociale et à l’orientation centrée sur le patient. Ces différences persistent lors- qu’on introduit la variable sexe. Le moment auquel on décide d’être médecin semble être un facteur contributif dans la genèse des attitudes professionnelles. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 695 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Conclusion Cette étude éclaire partiellement le débat sur l’entrée massive des femmes en mé- decine. Elle permet de documenter l’effet bénéfique de cette tendance sur un aspect important de la pratique médicale, à savoir la globalité des soins (éducation sanitaire, aspects psychosociaux, prévention, etc.). Les écarts entre les femmes et les hom- mes sont nettement marqués pour ce qui a trait aux différentes dimensions de la globa- lité des soins : les aspects psychosociaux du traitement, l’éducation sanitaire, l’approche centrée sur le patient et la prévention en situation clinique. En fin de formation, les femmes et les hommes accordent systéma- tiquement moins d’importance à ces diffé- rentes facettes qu’en début de formation. Les orientations préventives échappent à cette règle ; on assiste à un regain d’intérêt dans ce domaine au fur et à mesure que la formation avance. Bien que la nature transversale de l’en- quête ne permette pas d’attribuer automati- quement les variations observées entre les différentes cohortes à la nature du cursus des études médicales, ces résultats ne peu- vent être expliqués, du moins en partie, que par les lacunes de la formation médicale, puisqu’au fur et à mesure que les étudiants avancent dans leurs études, les scores de- viennent de plus en plus faibles. Ainsi, on peut supposer que l’entrée massive des fem- mes en médecine, bien que celles-ci soient animées d’un grand idéalisme à l’entrée, n’entraînera pas nécessairement l’émer- gence d’une conception plus globale du rôle du médecin. Références 1. Rapport de la commission externe d’éva- luation de la CIDMEF. Sousse, Faculté de Médecine Ibn El Jazzar , 2005. 2. Scadron Arlene et al. Attitudes towards women physicans in medical academia. Journal of the American Medical Associa- tion, 1982, 247:2803–8. 3. Eron LD. Effect of medical education on attitudes. A follow-up study. Journal of medical education, 1958, 33:25–32. 4. Merton RR, Readerly, Rendall P, eds. The student physican : Introductory studies in the sociology of medical education. Cam- bridge, Harvard University Press, 1957. 5. Reissman L et al. The motivation and socialisation of medical students. Journal of health and human behavior, 1960, 1(3):174–82. 6. Nathanson CA. Learning the doctor’s role; a study of first and fourth year medical students [thesis]. Chicago, University of Chicago, 1958. 7. Rosenberg PP, Weber RG. The effect of curriculum change on the “new medical student”. Journal of medical education, 1973, 48(4):366–8. 8. Fox R. Training for uncertainty. In: The student-physician : introductory studies in the sociology of medical education. Cam- bridge, Harvard University Press, 1957: 207–41. 9. Parsons T. The social system. New York, The Free Press, 1951, 10:428–79. 10. Conrad P. Learning to doctors: reflections on recent accounts of the medical school years. Journal of health and social beha- vior, 1988, 29(4):323–32. 11. Reilly P. To do harm : A journey through medical school. Dover, Auburn House, 1987. 12. Marnaoui M. Approche centrée sur le patient : validation d’un instrument de mesure. [Thèse de Diplôme d’État de 696 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Doctorat en Médecine]. Sousse, Faculté de Médecine de Sousse, 1996: 92. 13. Rezler AG. Attitude changes during medical school: a review of the litera- ture. Journal of medical education, 1994, 49:1023–30. 14. Mahler H. Médecine et médecins de de- main. Chronique OMS, 1977, 31:66–9. 15. Maheux B, Dufort F, Beland F. Professio- nal and sociopolitical attitudes of medical students: gender differences reconsi- dered. Journal of the American Medical Women’s Association, 1988, 43(3):73–6. 16. Leserman J. Men and women in medical school. New York, Praeger, 1981. 17. Shapiro J et al. Patients’, medical stu- dents’ and physicians’ perceptions of male and female physicians. Perceptual and motor skills, 1983, 56(1):179–90. Premier Forum mondial sur les ressources humaines pour la santé L’Alliance mondiale pour les personnels de santé a organisé le premier Forum mondial sur les ressources humaines pour la santé à Kampala (Ouganda) du 2 au 7 mars 2008. Ce forum a réuni plus de mille participants parmi des chefs de gouvernement et des personnalités éminentes du monde de la santé et du développement, de la société civile ou des milieux universitaires du monde entier, et il a représenté une excellente occasion d’échanger et de rechercher des solutions, de rapprocher leurs points de vue et de renforcer leurs capacités, tout en insufflant une vigueur nouvelle au vaste élan mondial suscité par la pénurie de plus en plus flagrante de personnels de santé. L’Alliance mondiale pour les personnels de santé est un partenariat axé sur la recherche et la mise en œuvre de solutions à la crise des personnels de santé, qui est accueilli et géré par l’OMS. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 697 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Occupational stress and work- related unintentional injuries among Iranian car manufacturing workers H. Soori,1 M. Rahimi 2 and H. Mohseni 2 1Safety Promotion and Injury Prevention Research Centre, Faculty of Public Health, Shaheed Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to H. Soori: hsoori@ yahoo.com). 2Iran-Saipa Car Manufacturing Company, Tehran, Islamic Republic of Iran. Received: 12/09/05; accepted: 07/03/06 ABSTRACT This study in 2004 and 2005 aimed to present the pattern of job stress among car manu- facturing workers in one factory in the Islamic Republic of Iran, and to assess its relationship with oc- cupational injuries. Data were collected from 608 male workers (508 at-risk general workers and 100 with injuries in the last year). Job stress was assessed by the Belkic occupational stress index. The prevalence of job stress was 21.3%. The main occupational stressors were time pressure (78.5%), mode of payment and evaluation (56.4%), and interaction with people and machines (41.3%). The risk of injury among those with job stress was significantly higher than those without job stress (OR = 2.0; 95% CI: 1.20–3.30). Job stress was responsible for 11.9% of all occupational injuries in this group. Stress professionnel et traumatismes non intentionnels liés au travail chez des ouvriers iraniens de l’industrie automobile RÉSUMÉ Cette étude réalisée en 2004 et 2005 visait à présenter les caractéristiques du stress professionnel chez les ouvriers d’une usine automobile de la République islamique d’Iran, et à évaluer ses rapports avec les accidents du travail. Les données ont été recueillies auprès de 608 ouvriers (508 ouvriers exposés au risque en général et 100 ayant subi des accidents au cours de l’année précédente). Le stress au travail a été évalué à l’aide de l’Occupational Stress Index (indice de stress professionnel) de Belkic. La prévalence de ce stress était de 21,3 %. Les principaux facteurs de stress étaient les contraintes de temps (78,5 %), le mode de rémunération et d’évaluation (56,4 %), et les relations avec les personnes et les machines (41,3 %). Le risque d’accident chez les sujets souffrant de stress professionnel était significativement plus élevé que chez ceux qui n’en souffraient pas (odds ratio 2,0 ; IC 95 % : 1,20 - 3,30). Le stress professionnel était responsable de 11,9 % de l’ensemble des accidents du travail dans ce groupe. ¯™=¦¸»£¶=L>E>qCÆÙ=Hf³¶=Íɾ=fÈÝ=L=e>Éj¶=Í¢>¿q›·º>£¶=EÌaÇr j†jU(Ê»ÉUeÀj†(ËeÇibɗ  „=Í[qØ6½>¢KÈfQ?¶=Íi=eb¶=ÅdÂKªbÃJi=2004Æ2005¿M?Hf³¶=Tcǔzf¢·º>[£¶=E¸»£¶=Ð> ¸ [»£¶=L>E>[qDEÄ[J®Ø¢¼É[[ɯIÆ(ÍɺØiÝ=Á=fÈCÍÈeÇÖ›¤¾>r™=bU?›L=e>Éj¶=Í¢>¿q›*K[£–b[®Æ ÀºL>É죙=608eDzd[¶=·º>£¶=Àº%¼Ã¿[º508ÆÀÈf[íìßJ^™=·º>[£¶=À[º100=Ç[uf£IÀÈd[¶=·º>[£¶=À[º ͺfr¿™=Í¿j¶=¹Ø]L>E>qÝ*$®b®Æ[Ù=Hf[³·¶´[É·ÉEGßj[á¿ßº½=b^J[i>E¸»£¶=Ð>¿M?Hf³¶=ÁÇNU>F¶=¼çÉ* ¸»£¶=Ð>¿M?Hf³¶=e>nJ¾=¹b£ºÁ>²b®Æ21.3!K[®Ç¶=œ§[u›ÍÉj[ÉÑf¶=Hf[³¶=ea>r[ºK·çN“Æ%78.5$!( ¼É[ɯJ¶=ÆeÇQÙ=Êu>¯Iœ”Æ%56.4$!L×Û=Æl>¿¶=¤º¸¢>«J¶=Æ(%41.3*$!Ý=e>ìJ]=¹b£ºÁ>²ÆEÍE>q Ä¿ºÁǾ>£È×ÀÈd¶=Ïb¶Ä¿ºð>ÉÑ>rUC>ÃEbJ£ÈÍQebEη¢?¸»£¶=Ð>¿M?Hf³¶=ÀºÁǾ>£ÈÀÈd¶=%Í[ÉVQeÙ=ÍFj¾ 2.0ͯMÍ·q>«E(95![E\àÆ=fIÆ1.20Æ3.30*$À[¢ð×ÆÖj[º¸[»£¶=Ð>[¿M?Hf[³¶=Á>[²Æ11.9!¤[ɖÀ[º E>qÝ=>͢ǻ=Åd›ÍɿÙ=L*  698 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction The incidence of occupational injuries is high in many sectors of industry, and in many developing countries the number is increasing. Yearly more than 250 million workplace nonfatal injuries and 300 000 fatal injuries occur worldwide [1,2]. Work- place fatal injury rates are 3–4 times greater in less economically developed countries compared to more developed countries and they are mainly unintentional [3]. There are about 14 100 severe occupational injuries in the Islamic Republic of Iran annually, mainly among car manufacturing workers [4]. Human error is responsible for up to 80% of occupational injuries and they are often the result of job stress [5]. Occupational stress is associated with many problems in the workplace [6]. It has been reported to be related to occupational diseases such as high blood pressure and an unfavourable cardiovascular profile [7], musculoskeletal disorders [8,9] and other health outcomes [10–12]. The association between job stress and work-related unintentional injuries has not been studied adequately. Previous studies have been mainly focused on particular jobs [13–16], and no attempt has been made to describe the association between job stress and occupational injuries among car manufacturing workers. The aim of this study was to describe the pattern of job stress among the workers of the Iran-Saipa car manufacturing com- pany, to explore the association between job stressors and work-related unintentional injuries, and to clarify whether job stressors affecting injury due to work accidents differ between different age groups and workers with different job experience background, educational attainment and marital status. Methods The study was conducted on workers aged between 18 and 65 years who were em- ployed full-time at the Iran-Saipa car manu- facturing company, one of the largest car companies in the Islamic Republic of Iran. There were 2 parts to this research: a study of the incidence of occupational injuries in the factory and a study of risk factors for job stress. Occupation injuries All occupational injuries occurring in the year 2004 in the Iran-Saipa company to 6199 workers at risk were registered. The injury severity coefficient (ISC) was cal- culated according to the number of days off work in every 1000 working hours. The injury repetitive coefficient (IRC) was measured as the number of injuries per 1 000 000 working hours and the incidence rate as the number of injured workers per 1000 exposed workers. Stress study Data about job stress were collected over 2004 and 2005 from 608 workers. The case group was 100 workers who had suffered at least 1 injury within the previous year, selected randomly from each month of the year proportionate to the number of occupa- tional injuries in that month from the medi- cal records out of 761 injured cases during this period of time. The control group was 508 at-risk general workers selected by proportional random sampling from the list of workers names according to the number of workers in each department of the com- pany (e.g. montage, painting, etc.). Only occupational injuries needing medical treat- ment or first aid were included and non- occupational injuries were excluded. Those Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 699 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما with a background of mental disorders were excluded from the study. Job stress was assessed by the Belkic occupational stress index (OSI) [17]. Eight trained interviewers completed the ques- tionnaires. The job stress questionnaire included 56 questions with demographic details and 10 job stressor scales: time pressure, mode of payment and evaluation, interaction with people and machines, work tasks, physical working conditions, injuries at work, decision-making at work, working hours and scheduling, recent changes in working conditions and problems at work. For each item, the frequency or amount of occurrence of domains was assessed. These stressors were defined according to the OSI scales and derived from the questionnaire. Items were scored by assigning a value of 1 or 2 for “most frequently a cause of stress” to 0 for “never or rarely a cause of stress”. There were 56 questions in the question- naire and the maximum score was 112, with higher scores indicating more job stress; the minimum–maximum range of scores obtained by participants in this study was 18–72. Subjects were analysed in 2 groups, those above and those below the median score (46.5), i.e. workers with low and high job stress. A 24-hour-urine test of creatinine, cor- tisol, and 17 ketosteroid levels was carried out to test the validity of OSI questionnaires among 51 subjects who were randomly se- lected from all the general workers. The tests were carried out in Tehran Resalat Hospital laboratory using radio-immunoassay tech- niques. The creatinine test was carried out to correct the stress hormone concentrations in cases of diuresis. Analysis The data were analysed using SPSS for Windows, version 11.5. The chi-squared and Mann–Whitney tests were used to identify differences between job stress and population groups. Odds ratios (OR) and 95% confidence interval (CI) were em- ployed to show the relationship between the job stress and occupational injuries. Cron- bach alpha assessed the internal consist- ency of measures. Multivariate analyses and Mantel–Haenszel summary test were em- ployed to justify the associations where appropriate. Results There were 761 injuries for 6199 exposed workers in the study period, giving an inci- dence of occupational injuries in the factory of 122.8 per 1000. Overall, there were 7579 days off work in this company. The ISC and IRC were 0.64 and 38.3 respectively. There was a significant association between the monthly number of injuries and the fre- quency of cars produced (P < 0.001) (data not shown). Younger workers were more likely to be injured than older ones [mean age for the injured group was 23.5 years (SD 9.4) and for the control group was 34.1 years (SD 9.9)]. Those with less job experience were more likely to be injured than those with high job experience [mean years of current job experience among the injured group was 1.8 years (SD 1.1) and for the control group was 2.7 years (SD 1.0)]. Human errors was the main cause of oc- cupational injuries, more than environmen- tal limitations. Unsafe behaviour (61.6%) and unsafe situations (18.3%) were the most common causes of injuries. All participants in the stress study were males and the mean age of all participants was 33.8 years (range 21–65 years). Table 1 shows the characteristics of the case and control groups. 700 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The internal consistency of the total OSI using Cronbach alpha was 0.78. The sensi- tivity and specificity of the OSI using the 24-hour urine examinations of creatinine, cortisol, and 17 ketosteroid were 92% and 87% respectively. The prevalence of job stress among the control group of workers (i.e. the gen- eral sample of at-risk workers) was 21.3% (Table 2). The main occupational stressors among the workers were time pressure (78.5%), mode of payments and evalua- tion (56.4%), interaction with people and machines (41.3%) and the stress of work tasks (37.7%). The prevalence of job stress among the case group of workers (i.e. those with at least 1 occupational injury during the year) was higher than the control group, 35.1%. The risk of injury among those with high job stress was significantly higher than those with low job stress (OR 2.00; 95% CI 1.2–3.3) (Table 2). The stress score among the case group was more than in the control group (P = 0.004). Using the formula: overall, job stress was responsible for 11.9% (attributable risk) of all occupational inju- ries in this community. Using multivariate logistic analyses to justify the associations showed that among the control group, job stress was more common among less-ex- perienced workers (P = 0.022) and younger groups (P = 0.012). However, there was no significant difference by marital status and educational status. In the case group, job stress was more common among the younger groups (P = 0.029) and those with less job experience (P = 0.002) (Table 3). Discussion This study was the first in the Islamic Re- public of Iran and its findings might be compared to similar communities in de- veloping countries. The prevalence of job stress in this study was 21.3%, which is very similar to Korean workers (20%) [18]. However, job stress was much higher (40%) among workers in the north-west of the United States but lower (10%) among work- ers of European Union countries [1]. Nowadays, many people work during “non-standard” working hours, including shift and night work, which is a recognized risk factor for health, safety and social well- being. Job stress results from the interaction of the worker and the conditions of work. It has been found that working under time pressure and stressful conditions leads to increased physiological and psychological Table 1 Background characteristics of workers in the control group (at-risk of injury) and case group (suffered injury in the previous year) Variable Control group (n = 508) Case group (n = 100) Mean SD Median Mode Mean SD Median Mode P-value Age (years) 34.1 9.9 30 26 33.5 9.4 30 26 NS Job experience (years) 10.4 4.5 12 12 10.9 4.3 12 12 NS Experience in current job (years) 5.7 6.7 3 3 5.5 6.2 3 3 NS Total work hours per week 51.9 15.7 54 54 53.9 12.3 54 54 NS SD = standard deviation; n = total number of respondents. NS = no statistically significant difference between means of case and control groups. ( )% APexp = OR–1.0 × 100 OR Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 701 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما reactions [15,16,19] and a worse health condition [19–23]. Stressful job events and work tasks are associated with a low quality of work life. Zautra et al. found that workers tend to stay at work even if the job is stress- ful when the work, tasks are interesting [21]. Suitable preventive and interventional measures are required to ensure that the worker can cope satisfactorily. These are based mainly on the organization of shift schedules according to ergonomic criteria and on specific modes of payments and evaluation and work tasks. Differences in individual characteristics such as personal- ity, age, job dissatisfaction, work experi- ence and education level are associated with job stress and occupational injuries as shown by other studies [1,15,16]. Although more research is needed, our study showed that stressful working conditions interfere with safe work practices and set the stage for injuries at work, particularly among younger workers and those with less job experience who are more at-risk of job stressors. Stress management treats only the symptoms of the problem not the causes. Therefore efforts to control risk factors and promote quality of work life at the worksite are also important. In conclusion, human error is one of the major factors of occupational injuries that result from job stress. It highlights the im- portance of the problem and reinforces job stress prevention programmes as a priority in occupational injury prevention. Interven- tion studies to recognize the implications for occupational injury prevention among those who are more at-risk of occupational stress are recommended. The effort to increase job safety in car manufacturing companies needs to go be- yond risk behaviour and risk perception of Table 2 Prevalence of stress for different types of job stressors and odds ratios for total job stress score for workers in the control group (at-risk of injury) and case group (suffered injury in the previous year) Type of stress Control group Case group OR (95% CI) P-value (n = 508) (n = 100) % with % with high high stress stress Time pressure 78.5 85.0 1.55 (0.83–2.92) NS Work tasks 37.7 66.0 3.21 (2.00–5.17) < 0.001 Recent changes in working conditions 12.0 53.0 8.26 (5.00–13.67) < 0.001 Interaction with people and machines 41.3 50.0 1.42 (0.90–2.23) NS Physical working conditions 20.7 40.0 2.55 (1.58–4.12) < 0.001 Mode of payment and evaluation 56.4 22.0 0.22 (0.13–0.37) < 0.001 Working hours and scheduling 11.4 16.2 1.50 (0.78–2.83) NS Decision-making at work 12.5 16.0 1.34 (0.71–2.52) NS Work injuries and accidents 14.3 15.2 1.07 (0.56–2.02) NS Problems at work 4.0 16.2 4.63 (2.15–9.94) < 0.001 Total stress 21.3 35.1 2.00 (1.20–3.30) 0.004a aStratified analyses (Mantel–Haenszel summary for all strata (OR = 1.43; 95% CI: 1.24–1.72, P < 0.001). n = total number of respondents; OR = odds ratio; CI = confidence interval; NS = not significant. 702 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما References workers, particularly for younger and less experience workers. Job stress should be recognized as a main factor of occupational injuries among car manufacturing workers. Full commitment and participation of all managers at all levels and also behavioural and environmental modifications in the fac- tory line are a start in promoting safety and injury prevention. Acknowledgements This study was performed with the financial support of Iran-Saipa car manufacturing company. The authors would like to thank Eng. Ghalehbani and Mr Fathi and all others who assisted us in this research. Table 3 Prevalence of job stress by educational attainment, marital status, age group and job experience for workers in the control group (at-risk of injury) and case group (suffered injury in the previous year) Variable Control group P- Case group P- P- (n = 108a) valueb (n = 33) valueb valuec No. with % No. with % stress stress Educational attainment NS NS Primary 12 13.2 3 17.6 NS Middle 4 9.8 20 44.4 < 0.001 High school 58 23.6 5 55.6 0.029 University 26 28.6 5 21.7 NS Marital status NS NS Single/divorced/separated 27 23.1 7 26.9 NS Married 73 20.7 26 38.2 0.002 Age (years) 0.012 0.029 < 25 12 18.2 1 7.7 NS 25–35 54 25.2 22 44.9 < 0.001 36–45 16 21.3 8 47.1 0.03 > 46 7 9.6 2 13.3 NS Job experience (years) 0.022 0.002 < 1 3 7.0 7 70.0 < 0.001 1–5 46 24.6 20 41.7 0.019 6–10 25 27.5 5 31.3 NS > 11 26 17.6 1 5.0 NS aFigures are less than the total due to missing responses. bUsing multivariate logistic analysis to justify associations between case and control groups. cSignificant differences between cases and controls. n = total number of respondents with high stress; NS = not significant at 5% level. 1. 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Clinical biomechanics, 2000, 15(6):389–406. 704 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Sport practice among private secondary-school students in Dubai in 2004 A.S. Wasfi,1 A.A.M. El-Sherbiny,1 E. Gurashi1 and F.U. Al Sayegh1 1Primary Health Care, Department of Health and Medical Service, Dubai, United Arab Emirates (Correspondence to A.S. Wasfi: dabraham@dohms.gov.ae). Received: 02/10/05; accepted: 08/02/06 ABSTRACT A study was made of sport practice and of knowledge, attitude and practice towards sport among 1475 private secondary-school students in Dubai, United Arab Emirates (UAE) in 2004. UAE students practised sport more than non-UAE students (33.9% versus 18.7% had good levels of activity) but there was no significant difference in positive attitudes towards sport practice (87.1% and 86.2% respectively). A good level of sport (vigorous exercise ≥ 3 times per week for 20 min) was higher among males (26.0%) than females (14.7%). There was a significant association between overweight and obesity as well as tobacco smoking and low levels of sport practice. Health education intervention is needed to improve sport practice among young people. ÊEa›Íq>„=ÍÈǾ>N¶=le=b™=HØ{EÍu>Èf¶=Íie>š½>¢›2004 ¨È>r¶=Í»{>ª(Êmf®ʷɂ=(ÉEfn¶=b»†Ê·¢Ê·¢(Ê«qÆÁ>»É·ib—?  „=Í[qØ6E>ÇU¬®=Ǚ=Æ­e>£™=ÆÍu>Èf¶=Íie>š¹ÇUÍi=eaÁÇNU>F¶=ÏfQ?1475le=b[™=HØ[{À[º Í¿i(ÌbVJ™=ÍÉEf£¶=L=e>ºÝ>E(ÊEa›Íq>„=ÍÈǾ>N¶=2004*f[N²?Í[u>Èf¶=ÁÇie>•ÁÇÉI=e>ºÝ=HØì¶=Á>²Æ ÉI=e>ºÝ=¦Àº%Ïb[¶Íìn[¾Ù=ÀºÌbÉQL>ÈÇJjº33.9!¸[E>¯ºÉI=e>[ºÝ=HØ[ì¶=À[º18.7![¦À[º ÉI=e>[ºÝ=$­ØJ[]=µ>[¿ÂÀ[³ÈÆ(Í[u>Èf¶=Í[ie>šÇ[‰¬[®=Ǚ=Í[ÉE>‹C›ð>ÉÑ>r[UCÄ[Eèb[ßJá£àÈ%87.1!À[º ¸E>¯ºÉI=e>ºÝ=86.2!ÉI=e>ºÝ=¦Àº*$Íu>Èf¶=Àºbɂ=ÏÇJj™= UǶÆ%Æ?L=f[ºPØ[MÍ[«É¿¢ÀÈe>[“ fn¢Ìb™¥ÇFiÙ=›fN²?ÀÈͯɮa$eDzd¶=EfN²?%26.0$!P>[¾Ý=[EÄ[¿º%14.7*$!ƜE=f[Iµ>[¿ÂÁ>[² Í[u>Èf¶=Í[ie>šÀ[ºÍv[«^¿™=L>ÈÇJj[™=[Eƨ[FJ¶=]bIÆ;=bF¶=ÆÁgǶ=Ìa>ÈgEð>ÉÑ>rUCÄEèbßJá£àÈ*k[“Æ H>Fn¶=EÍu>Èf¶=Íie>šjVJ¶ÍÉVqÍɫɯNILØ]bI‘CÍQ>ƒ=*  Activité sportive chez les élèves des établissements d’enseignement secondaire privés à Dubaï en 2004 RÉSUMÉ Une étude a été menée en 2004 sur la pratique d’une activité sportive et sur les connaissances, les attitudes et les pratiques en matière de sport chez 1475 élèves des établissements d’enseignement secondaire privés à Dubaï (Émirats arabes unis). Les élèves des Émirats arabes unis faisaient plus de sport que les autres (33,9 % contre 18,7 % avaient de bons niveaux d’activité), mais il n’y avait pas de différence significative en ce qui concerne les attitudes positives vis-à-vis de la pratique sportive (respectivement 87,1 % et 86,2 %). Le pourcentage d’élèves ayant un bon niveau sportif (exercice énergique au moins 3 fois par semaine pendant 20 minutes) était plus élevé chez les garçons (26,0 %) que chez les filles (14,7 %). Il existait une association significative entre le surpoids et l’obésité mais aussi le tabagisme et les faibles niveaux de pratique sportive. Une action en matière d’éducation pour la santé doit être menée afin d’améliorer la pratique sportive chez les jeunes. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 705 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Physical activity has considerable health benefits for children and adolescents. Regu- lar physical activity improves aerobic en- durance and muscle strength [1,2]. Among healthy young people, physical activity and physical fitness may favourably affect risk factors for cardiovascular disease such as body mass index (BMI), blood lipid pro- files and resting blood pressure [3]. Also, weight-bearing exercise increases bone mass density among young people [4]. Reg- ular physical activity among children and adolescents with chronic disease risk fac- tors decreases blood pressure in adolescents with borderline hypertension [5], increases physical fitness in obese children [6], and decreases the degree of overweight among obese children [7]. Physical activity among adolescents is consistently related to higher levels of self- esteem and self-concept and lower levels of anxiety and stress [8]. Healthy active living benefits both individuals and society in many ways, for example, by increasing productivity, improving morale, decreasing absenteeism, reducing health-care costs, and heightening personal satisfaction. Other benefits include improved psychological well-being, physical capacity, self-esteem and the ability to cope with stress [9]. During the 20th century, the leading causes of death shifted from infectious to chronic diseases: cardiovascular disease, cancer, and diabetes are now among the most prevalent, costly and preventable of all health problems. The Youth Risk Be- havior Surveillance System (YRBSS) in the United States of America monitors priority health risk behaviours that contribute mark- edly to the leading causes of death, disabil- ity and social problems among youth [10]. These behaviours, often established during childhood and early adolescence, include tobacco use, unhealthy dietary behaviours, inadequate physical activity, alcohol use and others. In 2003 the World Health Organiza- tion (WHO) emphasized the importance of behaviour risk factor surveillance as a first step for prevention of noncom- municable diseases, including obtaining data on tobacco and alcohol use, dietary habits and physical inactivity [11]. Our study in the United Arab Emirates (UAE) was conducted to get information about sport practice and to determine some of the risk factors of physical inactivity to inform future intervention programmes. Specifically, the aims were to: study sport practice among private secondary- school students in Dubai; compare the knowledge, attitude and practice of students towards sports for local (UAE national- ity) and non-local (expatriate, non-UAE) students; and study some of the risk factors that affect sport practice. Methods Sample A survey study using a stratified random sample was carried out in Dubai city in 2004. Stratification was based on the geo- graphical distribution of schools in Bur Dubai sector and Deira sector of the city, language spoken (Arabic or non-Arabic), sex (male or female) and also according to secondary-school level (grades 10, 11 or 12). A random selection was made of 10 schools (5 from Deira and 5 from Bur Dubai), with 25 students randomly chosen from each grade of male or female sectors taking into consideration the proportion of both sexes. The sample size for assessment of sport non-practice was calculated as 1500 students using the Minitab statistical computer pro- gram, version 12, taking into consideration that the sample size for random sampling 706 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما was 1475 as a minimal sample size, non- response or absenteeism (1.67%), power of the test 80.04%, alternative probability 33% [12], and hypothesized probability, es- tablished through a pilot study, was 36.1%; the alternative probability was less than the hypothesized probability. Questionnaire The selected sample of students was given a questionnaire about personal history and questions to assess knowledge level about sport practice. Also assessed were 6 at- titudes and 3 practices of students towards sport practice, according to time and fre- quency (regular or irregular) and also ac- cording to nature of practice (vigorous or non-vigorous). The knowledge questionnaire included 8 closed-ended questions; 3 about the ben- efit of sport on physical, mental and social health and 5 to assess knowledge regarding the dangerous effects of not practising sport on body weight, diabetes, hypertension, lipid profile and coronary heart disease. Each question was evaluated with a score of 10 as a full mark where the maximum sum of all questions was 100%. Level of knowl- edge regarding sport benefit was classified as high (66%–100%); acceptable (33% – < 66%); and low (< 33%) [13]. Attitude towards sport practice was classified as: positive (student agreed that sport practice has an effect on obesity or diseases such as diabetes or heart disease); negative (student agreed that sport practice leads to loss of money, effort or time); and indifferent (student neither agreed that there were beneficial effects nor that there were disadvantages). Actual sport practice of students was classified into: good (student did vigor- ous exercise ≥ 3 times/week for about 20 min/session and also > 30 min of moderate physical activity most days of the week [14]); acceptable (student did vigorous ex- ercise < 3 times/week for about 60 min and > 30 min of moderate physical activity most days of the week); poor (student did no vigorous activity or irregularly prac- tised vigorous exercise < 60 min/week and < 30 min of moderate physical activity most days of the week; and none (did not practise physical activity at all). Time trends of sport practice were clas- sified into: regular (student practised sport regularly every day or every other day or at least 3 times/week every month throughout the year); irregular (student practised sport in an irregular manner, not constantly and not every week or month throughout the year); and occasional (student practised sport occasionally ≤ 1 time/month through- out the year). Smoking habits were classified as: smoker (currently smoked at least 1 ciga- rette/day or 1 cigar/week or 1 ounce of tobacco/month for at least 1 year); passive smoker (exposed to tobacco smoke exhaled by smokers in an enclosed environment); ex-smoker (smoked at least 1 cigarette/day over the year and had not smoked for 6 months or more at the time of study); and non-smoker (never smoked or exposed to passive smoke [15]). BMI measures were the Centers for Disease Control and Prevention criteria for children and adolescents [16]: obese (BMI ≥ 95th percentile); overweight (BMI ≥ 85th percentile); average (BMI 5th–85th percentile); and underweight, suggesting acute malnutrition (low weight-for-height, BMI < 5th percentile [17]). Data analysis The data were analysed using chi-squared for categorical data, likelihood ratio when the chi-squared test was not valid and the Student t-test for comparison of 2 means. After data collection the power of the test Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 707 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما for sport non-practice was 100% for a single proportion. The data were analysed using SPSS, version 9. Results Characteristics of study groups The response rate was 98.3% (1475 out of 1500 secondary-school students). The stud- ied sample was 233 UAE nationality stu- dents and 1242 non-UAE students, with no statistically significant difference between them according to sex. The study sample comprised similar numbers from grades 10, 11 and 12 of secondary school. There were 640 females and 835 males. Overall, 73.8% of UAE students and 68.2% of non-UAE nationalities had fathers with university level of education, with no significant difference between them. Simi- larly, 51.9% of UAE students and 56.0% of non-UAE students had mothers with university education (not significant). Knowledge about sport Table 1 shows that the mean [standard deviation (SD)] score for knowledge about the benefits of sport was 77.8% (SD 32.3%) for the total sample. The scores for level of knowledge about the benefits of sport showed that 22.0% had a low level, 13.3% an acceptable level, while 64.7% had a high level. There was no statistically significant difference in knowledge score between UAE and non-UAE students: 81.2% (SD 31.1%) and 77.2% (SD 32.5%) respec- tively. Attitude towards sport Table 2 shows that the majority of UAE and non-UAE students had a positive at- titude towards the practice of sports (87.1% and 86.2% respectively), with no signifi- cant difference between them. Table 2 also shows that 21.2% of the sample reported not practising sport and 48.8% had poor practice. On the other hand, 21.1% and 8.9% of schoolchildren reported practising sport to a good and acceptable level respec- tively. Good and acceptable sport practice among UAE nationality students (33.9% and 12.9% respectively) was significantly better than among non-UAE (18.7% and 8.1% respectively). Practice of sport More than three-quarters (80.2%) of fe- male secondary-school students and less than two-thirds (62.3%) of male secondary school students had none or poor practice of sport (Table 3). Also, this table showed that among high-school students, only 14.7% of girls and 26.0% of boys reported a good level of sport practice (i.e. they exercised vigorously for 20 min on at least 3 of the previous 7 days). Table 4 shows that the mean time spent per week in practising vigorous exercise was significantly higher among UAE na- tionality females and males [1.62 (SD 1.84) h and 2.89 (SD 3.21) h respectively] than non-UAE females and males [0.95 (SD 1.35) h and 2.21 (SD 2.71) h respectively]. A high percentage of students of illiterate fathers did no sport or a low level of sport- spractice (31.8 % and 63.7 % respectively) compared with those of other education levels (Table 5). On the other hand, more than one-fifth of students of secondary- or Table 1 Knowledge score about the benefits of sport according to nationality Nationality No. Mean (SD) Significance knowledge score (%) UAE 233 81.2 (31.1) t = 1.81; P > 0.05 Non-UAE 1242 77.2 (32.5) Total 1475 77.8 (32.3) UAE = United Arab Emirates; SD = standard deviation. 708 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما higher-educated fathers practised sport to a good level, with a statistically significant difference between them (P < 0.05). A higher proportion of students with illiterate mothers did no sport or a poor amount of sport practice (25.8% and 61.3% respec- tively) compared with other educational levels (Table 5). On the other hand, those with secondary- or high-school level moth- ers had a higher rate of acceptable or good sport practice. There was no statistically significant difference in sport practice ac- cording to mother’s education. About two-thirds of UAE and non-UAE students said they did not practise any kind of sports due to lack of time from study workload (Table 6). Also, health, social and economic problems played a role in not practising sport. Table 6 shows the regularity of sport practice among local and non-local students. Regular sport practice among UAE students (50.6%) was significantly higher than non- UAE students (39.5%) (P < 0.05). Table 6 also shows that 35.2%, 31.1% and 31.2% of the students practised sport at home, school Table 2 Attitude towards sport practice and reported level of sport practice according to nationality Variable Nationality UAE Non-UAE Total No. % No. % No. % Attitude towards sport Negative 16 6.9 54 4.3 70 4.7 Indifferent 14 6.0 118 9.5 132 8.9 Positive 203 87.1 1070 86.2 1273 86.3 Total 233 100.0 1242 100.0 1475 100.0 χ22 = 5.32; P > 0.05 Sport practice None 44 18.9 269 21.7 313 21.2 Poor 80 34.3 640 51.5 720 48.8 Acceptable 30 12.9 101 8.1 131 8.9 Good 79 33.9 232 18.7 311 21.1 Total 233 100.0 1242 100.0 1475 100.0 χ23 = 39.14; P < 0.05 UAE = United Arab Emirates. Table 3 Reported level of sport practice according to sex Sex Sport practice None Poor Acceptable Good Total No. % No. % No. % No. % No. % Female 224 35.0 289 45.2 33 5.2 94 14.7 640 100.0 Male 89 10.7 431 51.6 98 11.7 217 26.0 835 100.0 Total 313 21.2 720 48.8 131 8.9 311 21.1 1475 100.0 χ23 = 143.87; P < 0.05 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 709 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما and clubs respectively. UAE nationality stu- dents practised sport more than non-UAE in clubs, at home and at school. Comparing reported level of sport prac- tice by nutritional status (Table 7) showed that 22.3% of average weight students had a good level of sport practice compared with 17.6% of obese students. Sport practice among average weight students was signifi- cantly better than among obese ones. More than two-thirds (69.5%) of female smokers had no or a poor level of sport practice compared with less than one-third (30.6%) who had acceptable or good level (Table 8). On the other hand, 61.9% of male smokers had no or a poor level of sport practice compared to 38.1% who had a good or acceptable level. The association between sport practice and smoking habit was significant among male students, but not females. Discussion The Department of Health and Medical Service of Dubai supervises only private schools. By law expatriates are not allowed Table 4 Mean time spent in sport practice among female and male students according to nationality Sex Mean (SD) time in sport Significance practice (hours/week) UAE Non-UAE Female 1.62 (1.84) 0.95 (1.35) t = 3.66; P < 0.05 Male 2.89 (3.21) 2.21 (2.71) t = 2.50; P < 0.05 UAE = United Arab Emirates; SD = standard deviation. Table 5 Relation between reported level of sport practice and parent’s education level Parent’s Sport practice education None Poor Acceptable Good Total No. % No. % No. % No. % No. % Father Illiterate 7 31.8 14 63.7 0 0.0 1 4.5 22 100.0 Literate 49 25.0 106 54.1 16 8.1 25 12.8 196 100.0 Secondary 49 20.6 109 45.8 24 10.1 56 23.5 238 100.0 High 208 20.4 491 48.2 91 8.9 229 22.5 1019 100.0 Total 313 21.2 720 48.8 131 8.9 311 21.1 1475 100.0 Likelihood ratio9 = 22.82; P < 0.05 Mother’ Illiterate 8 25.8 19 61.3 1 3.2 3 9.7 31 100.0 Literate 60 23.2 137 52.9 18 6.9 44 17.0 259 100.0 Secondary 75 20.4 166 45.1 44 12.0 83 22.5 368 100.0 High 170 20.8 398 48.7 68 8.3 181 22.2 817 100.0 Total 313 21.2 720 48.8 131 8.9 311 21.1 1475 100.0 Likelihood ratio9 = 15.66; P > 0.05 710 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما to attend government schools. However, the private schools in Dubai include all social categories (high and low socioeconomic groups) and also national and international schools. According to school health regis- try office statistics, expatriates formed the bulk of private school children in 2004 in Dubai. The present study showed that the over- all mean knowledge score about the benefits of sport among the study sample was high, and was not significantly different between local UAE and non-UAE students. No knowledge is more crucial than knowledge about health. Without it, no other life goal can successfully be achieved [18]. Table 6 Reason for not practising sport, regularity of sport practice and place of sport practice according to nationality Variable Nationality UAE Non-UAE Total No. % No. % No. % Reason for not practising sport Health problem 6 13.6 19 7.1 25 8.0 Social problem 3 6.8 6 2.2 9 2.9 Economic problem 2 4.5 5 1.9 7 2.2 Family problem 0 0.0 6 2.2 6 1.9 Study workload 29 65.9 177 65.8 206 65.8 Study workload and health problem 0 0.0 5 1.9 5 1.6 Not interested 2 4.5 19 7.1 21 6.7 Other 2 4.5 32 11.9 34 10.9 Total 44 100.0 269 100.0 313 100.0 Likelihood ratio7 = 10.93; P > 0.05 Regularity of sport practice None 44 18.9 269 21.7 313 21.2 Regular 118 50.6 490 39.5 608 41.2 Irregular 62 26.6 472 38.0 534 36.2 Occasional 9 3.9 11 0.9 20 1.4 Total 233 100.0 1242 100.0 1475 100.0 χ23 = 23.46; P < 0.05 Place of sport practice None 44 18.9 269 21.7 313 21.2 School 24 10.3 179 14.4 203 13.8 Club 42 18.0 152 12.2 194 13.2 Home 44 18.9 233 18.8 277 18.8 Road 2 0.9 63 5.1 65 4.4 School and club 20 8.6 73 5.9 93 6.3 School and home 2 0.9 68 5.5 70 4.7 School, club and home 53 22.7 119 9.6 172 11.7 Other 2 0.9 86 6.9 88 6.0 Total 233 100.0 1242 100.0 1475 100.0 χ28 = 68.38; P < 0.05 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 711 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The majority of UAE and non-UAE students had positive attitudes towards sport practice (87.1% and 86.2% respectively) with no significant difference between them. In agreement with our study Zakarian et al. in 1994 revealed that positive attitudes toward physical education was positively associated with physical activity among young people [19]. Biddle’s research found that a number of motives exist for sport, including fun, social aspects and skill de- velopment [20]. Gill, Gross and Huddleston assessed the major participation motives through the Participation Motivation Ques- tionnaire [21]. Factor analysis revealed that basic motives for involvement in sport were: achievement/status, team atmosphere, fitness, energy release, skill development, friendship and fun. Simple descriptions of motives, however, will not necessarily pro- vide information about how young people view the sport experience, hence further Table 7 Relation between reported level of sport practice and nutritional status among study sample Nutritional Sport practice status None Poor Acceptable Good Total No. % No. % No. % No. % No. % Underweight 12 26.7 28 62.2 3 6.7 2 4.4 45 100.0 Average 177 23.1 347 45.2 72 9.4 171 22.3 767 100.0 Overweight 87 18.8 239 51.5 35 7.5 103 22.2 464 100.0 Obese 37 18.6 106 53.3 21 10.6 35 17.6 199 100.0 Total 313 21.2 720 48.8 131 8.9 311 21.1 1475 100.0 Likelihood ratio9 = 21.73; P < 0.05 Table 8 Relation between reported level of sport practice and smoking habit according to sex Sex and Smoking habit sport Non-smoker Passive Ex-smoker Smoker Total practice No. % No. % No. % No. % No. % Female None 165 35.0 35 33.0 9 34.6 15 41.7 224 35.0 Poor 216 45.8 50 47.2 13 50.0 10 27.8 289 45.2 Accepted 26 5.5 4 3.8 2 7.7 1 2.8 33 5.2 Good 65 13.8 17 16.0 2 7.7 10 27.8 94 14.7 Total 472 100.0 106 100.0 26 100.0 36 100.0 640 100.0 Likelihood ratio9 = 9.69; P > 0.05 Male None 43 9.3 23 9.7 11 26.2 12 13.0 89 10.7 Poor 254 54.7 116 48.9 16 38.1 45 48.9 431 51.6 Accepted 52 11.2 32 13.5 1 2.4 13 14.1 98 11.7 Good 115 24.8 66 27.8 14 33.3 22 23.9 217 26.0 Total 464 100.0 237 100.0 42 100.0 92 100.0 835 100.0 Likelihood ratio9 = 18.58; P < 0.05 712 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما exploration of motivation is required using a theoretical approach. The current study revealed that 21.2% of the students did no sport and 48.8% had a poor level of sport practice. Only 21.1% of schoolchildren had a good level of sport practice and this was significantly better among UAE than non-UAE students. In concordance, Sallis demonstrated that although children and adolescents are more physically active than adults, many young people do not engage in moderate or vigor- ous physical activity (at least 3 days a week) [22]. Also, the United Nations Interagency Task Force on Sport for Development and Peace revealed that about one-third of youth are physically inactive [12]. Among our high-school students in Du- bai, 80.2% of females and 62.3% of males were not practising sport or had a poor level of sport practice. Significantly fewer girls than boys reported that they exercised vigorously for 20 min on at least 3 of the previous 7 days. In the United States, the Centers for Disease Control in the Youth Risk Behavior Surveillance found that girls were less active than boys [10]. Similarly, UAE nationality girls spent less time on average practising sport than UAE boys, as did non-UAE girls and boys. Fewer children of illiterate fathers and mothers practised sport to a good level than did children of higher educated fathers and mothers. The level of sport practice was sig- nificantly related to father’s but not moth- er’s level of education. The results can be explained on the basis that socioeconomic level and economic accessibility to sport practice mainly depends on the father’s education level. A high study workload was the main reason given for not practising any kind of sport among both UAE and non-UAE nationalities. Also, health, social and eco- nomic problems played a role in lack of sport practice. The explanation for social and economic problems limiting sport prac- tice in our community is mainly due to the unavailability of places for sport practice at home due to the small size of apartments, the high cost of sport clubs and the high temperature and humidity outside for much of the year. In agreement with the present study, Kelder et al. concluded that lack of time is negatively associated with physical activity among adolescents [23]. WHO revealed that many factors prevent young people from regular physical activity, in- cluding lack of time and motivation, insuf- ficient support and guidance from adults, feeling of embarrassment or incompetence, lack of safe facilities and locales for physi- cal activity and simple ignorance of the benefit of physical activity [24]. Hamlin and Ross found that social, be- havioural and physical changes that charac- terize adolescence act as barriers to physical activity during this period. Major barriers included a reduction in active transport, altered community design, less physical education time at school, a rise of the 2- income family, an increase in labour-saving appliances, and a shift away from active to passive leisure and entertainment pursuits [25]. It was concluded that society must work to decrease the influence of these bar- riers and, wherever possible, enhance and support opportunities for young people to become physically active. Regular sport practice among local UAE students (50.6%) was significantly higher than among non-UAE students. UAE na- tionality students practised sport more than non-UAE students at home, in clubs and at school. The results can be explained on the basis that sports clubs are more affordable for UAE than expatriate students. Also, the UAE students’ houses are larger and more suitable for sport practice than many expa- triate houses. The level of knowledge about the benefits of sport was also higher among UAE than non-UAE students. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 713 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Our study found that sport practice among average weight students was sig- nificantly better than obese ones. Henry et al. concluded that the amount of physi- cal activity undertaken by adolescents in the UAE was very low [26]. Cultural and weather restrictions and social change of the community in the UAE are not conducive to physical activity and play a major role in levels of physical inactivity. This may explain, in part, the rise in the incidence of obesity in this population [27]. More than twice as many female and male smokers practised no sport or a poor level of sport than an acceptable or good level of sport. The association between sport practice and smoking habit was sig- nificant among male students but not female students. The practice of physical exercise during adolescence as part of a health pre- vention programme might interfere with the factors that lead young people to start smoking and thereby contribute to a reduc- tion in the prevalence of tobacco use in the population as a whole [28]. Conclusion The current study concluded that there was a strong relationship between sport practice and ideal body weight and also smoking. The present work indicates the need for a health education intervention programme to improve sport practice among young people. References 1. Sallis JF, McKenzie TL, Alcaraz JE. Ha- bitual physical activity and health-related physical fitness in fourth-grade children. American journal of diseases of children, 1993, 147:890–6. 2. Aaron DJ, Kriska AM, Dearwater SR. The epidemiology of leisure physical activ- ity in an adolescent population. Medicine and science in sports and exercise, 1993, 5(7):847–53. 3. Shea S et al. The rate of increase in blood pressure in children 5 years of age is related to changes in aerobic fitness and body mass index. Pediatrics, 1994, 94(4):465–70. 4. Rubin K et al. Predictors of axial and pe- ripheral bone mineral density in healthy children and adolescents, with special attention to the role of puberty. Journal of pediatrics, 1993, 123:863–70. 5. Alpert BS, Wilmore JH. Physical activity and blood pressure in adolescents. Pedi- atric exercise science, 1994, 6:361–80. 6. Gutin B et al. Physical training, lifestyle education, and coronary risk factors in obese girls. Medicine and science in sports and exercise, 1996, 28(1):19–23. 7. Epstein LH, Valoski AM, Vara LS. Effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Health psychology, 1995, 14(2):109–15. 8. Calfas KJ, Taylor WC. Effects of physi- cal activity on psychological variables in adolescents. Pediatric exercise science, 1994, 6:406–23. 9. Health and physical education. The Ontario curriculum, Grade 11 and 12. Ontario, Canada, Ministry of Education, 2000. 10. Youth Risk Behavior Surveillance––Unit- ed States, 1995. Morbidity and mortality weekly report, 1996, 45:1–84. 11. WHO STEPwise approach to surveil- lance. World Health Organization [internet resource] (http://www.who.int/chp/steps/ en/, accessed 29 July 2007). 12. Sport for development and peace. To- wards achieving the Millennium Devel- 714 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما opment Goals. Geneva, United Nations, Interagency Task Force on Sport for De- velopment and Peace, 2003:1–30. 13. El-Sherbiny AAM et al. Health education as a preventive tool for management of asthmatic children [Masters thesis]. Tan- ta, Department of Public Health, Social and Preventive Medicine, Tanta Univer- sity, Egypt, 1996. 14. Guidelines for promoting physical activ- ity and reducing sedentary living among youth. Atlanta, Georgia, US Department of Health and Human Services, Cent- ers for Disease Control and Prevention, 1997. 15. Welty C et al. The relationship of air- ways responsiveness to cold air, cigarette smoking and atopy to respiratory symp- toms and pulmonary function in adults. American review of respiratory disease, 1984, 130:198–203. 16. National Health and Nutrition Examination Survey. Clinical growth charts. Hyattsville, Maryland, National Center for Health Sta- tistics, 2000. 17. Waterlow JC. Classification and defini- tion of protein–calorie malnutrition. British medical journal, 1972, 3:566–9. 18. Standard 2.6 (fitness): all students will ap- ply health-related and skill-related fitness concepts and skills to develop and main- tain a healthy, active lifestyle. In: Core curriculum content standard for compre- hensive health and physical education. Trenton, New Jersey, Department of Education, 2005 (http://www.state.nj.us/ njded/cccs/s2_chpe.htm#26, accessed 29 July 2007). 19. Zakarian JM et al. Correlates of vigorous exercise in a predominantly low SES and minority high school population. Preven- tive medicine, 1994, 23:314–21. 20. Biddle SJH. Cognitive theories of moti- vation and the self. In: Fox KR, ed. The physical self: from motivation to well- being. Champaign, Illinois, Human Kinet- ics, 1997:59–82. 21. Gill DL, Gross JB, Huddleston S. Partici- pation motivation in youth sports. Interna- tional journal of sport psychology, 1983, 14:1–14. 22. Sallis JF. Epidemiology of physical activi- ty and fitness in children and adolescents. Critical reviews in food science and nutri- tion, 1993, 33(4/5):403–8. 23. Kelder SH et al. Gender differences in the class of 1989 study: the school compo- nent of the Minnesota Heart Health Pro- gram. Journal of health education, 1995, 26(2 Suppl.):S36–44. 24. Physical activity and youth. Geneva, World Health Organization [fact sheet]. (http://www.who.int/moveforhealth/advo- cacy/information_sheets/youth/en/index. html, accessed 29 July 2007). 25. Hamlin M, Ross J. Barriers to physical activity in young New Zealanders. Youth studies Australia, 2005, 24(1):31–7. 26. Henry CJ, Lightowler HJ, Al-Hourani HM. Physical activity and levels of inactivity in adolescent females ages 11–16 years in the United Arab Emirates. American jour- nal of human biology, 2004, 16(3):346– 53. 27. Malik M, Bakir A. Prevalence of overweight and obesity among children in the United Arab Emirates. Obesity reviews, 2007, 8(1):15–20. 28. Nerin I et al. Encuesta sobre tabaquismo en estudiantes universitarios en relación con la prácticade ejercicio fisico [A sur- vey on the relationship between tobacco use and physical exercise among univer- sity students]. Archivos de bronconeu- mología, 2004, 40(1):5–9. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 715 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Short communication Ten-year mortality from Creutzfeldt– Jakob disease in Cyprus S. Papacostas,1 A. Malikides,2 M. Petsa3 and T. Kyriakides1 1Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus (Correspondence to S. Papacostas: savvas@ cing.ac.cy). 2Limassol General Hospital, Limassol, Cyprus. 3Nicosia General Hospital, Nicosia, Cyprus. Received: 03/11/05; accepted: 20/03/06 ABSTRACT We report the mortality from sporadic Creutzfeldt–Jakob disease in Cyprus for a 10-year surveillance period (1995–2004). In that time, 5 cases were identified out of a population of 749 000, giving an incidence of 0.7 cases per million population per year. Our sporadic incidence matches that expected according to global epidemiological surveillance. No cases of variant Creutzfeldt–Jakob dis- ease were found but 1 familial case was diagnosed. t®›¿ifn¢¹Ø]HDz>Qb·É«jIf²zfºÀ¢͖>¿¶=L>ɪǶ= >jJE>JÈf¦e>º(lbɳɶ>ºËeb¾=(l>JiDz>E>El>ª>ilbɲ>ȲlÆeÆaÇÉM(  „=Í[qØ6b·É«j[If²zf™ÍÈa=f=L×>ƒ=À¢͖>¿¶=L>ɪǶ=Íi=eb¶=Åd›ÁÇNU>F¶=zf£JjÈ–HDz>[Q bèqf[[J¶=ÀºL=Ç¿ifn¢Ìf[Jª¹Ø]t®›%1995–2004*$k[˜à­>n[J²=Ìf[[J«¶=Åd[¹Ø[]b[®Æ EÀºL×>U000749ºÊ[ì£È>[š(Á>³j[¶=Àº¥Ç[®Æ¹b[£0.7½>[£¶=›Á>³j[¶=À[ºÁÇ[É·º¸[³¶Í[¶>U* ʙ>£¶=ÊÑ>EǶ=bèqf[J¶=>ÂfÞ?¶=L>£®ÇJ¶=¤ºÁÇNU>F¶=ÄɶC¸qÆËd¶=¥Ç®Ç¶=¹b£ºÎm>»JÈÆ*Î[·¢fN£àÈÆ b·É«jIf²zfºÀºHÆfuÍÈ?–ÌbU=ÆÍÉ·Ñ>¢Ͷ>U×C¼Ã·¶=(HDz>Q*  Surveillance sur dix ans de la mortalité due à la maladie de Creutzfeldt-Jakob à Chypre RÉSUMÉ Nous présentons ici la mortalité imputable à la maladie de Creutzfeldt-Jakob sporadique à Chypre pendant une période de surveillance de dix ans (1995-2004). Au cours de cette période, 5 cas ont été recensés dans une population de 749 000 habitants, soit une incidence de 0,7 cas par million d’habitants et par an. Notre chiffre de l’incidence de la maladie sporadique correspond à celui auquel on pouvait s’attendre d’après la surveillance épidémiologique mondiale. Aucun cas de la variante de la maladie de Creutzfeldt-Jakob n’a été détecté, mais un cas familial a été diagnostiqué. 716 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Creutzfeldt–Jakob disease (CJD) is a trans- missible spongiform encephalopathy which occurs in distinct etiologic subtypes [1]. These include the sporadic form, which is the most common and occurs with an in- cidence of about 0.5–1.5 cases per million population per year, and constitute approxi- mately 85% of all CJD cases [2]; iatrogenic forms that can be linked to contaminated surgical instruments or human tissue trans- plantation and, theoretically, blood products [3]; familial forms which are associated with mutations of the prion protein gene (PRNP) [3]; and variant CJD (vCJD) which was first identified in 1996 [4], which occurs pre- dominantly in the United Kingdom [4] and has been linked to the bovine spongiform encephalopathy (BSE) epidemic [5,6]. In response to BSE, the British government, the European Union (EU) and the World Health Organization (WHO) recommended a number of measures including initiation of systematic surveillance of CJD and BSE [7,8]. Results from this collaborative EU surveillance on CJD have been published recently [9]. The Republic of Cyprus adopted the recommended measures including CJD sur- veillance in 1998. At that time, Cyprus was a candidate state for admission into the EU [10] and full EU membership was achieved in 2004. The population of the government- controlled area, for which surveillance data are available [11], was estimated at 749 000 at the end of 2004 and a case of sporadic CJD would be expected to be identified about every one and a half to two years. We report the incidence of CJD in the Cyprus for the 10-year period between 1995 to 2004. We have no available accurate and reliable data for the northern area of Cyprus which has been under Turkish occupation since 1974. Methods A surveillance system was set up, according to the WHO and EU directives [8], and sus- pected cases were referred to a surveillance centre where the first author acted as focal point. Diagnostic criteria formulated by the WHO and EU collaborative study were used [8]. Data collected between 1995 (the year for which records were available) and 2004 were analysed. The aim was to harmonize disease surveillance in accordance to EU practice, to collect accurate epidemiological data, and to monitor for the possible appear- ance of vCJD, especially in view of the fact that large numbers of British Cypriots relo- cated to Cyprus during the 1980s and 1990s [11]. Among them were many children and adolescents who would have lived in Eng- land during the BSE epidemic. Determination of the presence of protein 14-3-3 in cerebrospinal fluid was carried out in all cases, either at the University of Gottingen, Germany or at the University of Edinburgh, Scotland. Magnetic resonance imaging and electroencephalograms (EEGs) were also obtained in all cases. Postmortem examination was performed in 2 cases. The patients were followed up closely until their death. Genetic analysis was obtained for a familial case. The mutational analysis for the familial case was performed at the Prion Unit at the National Hospital for Neurology and Neurosurgery in London. Results Two definite, 2 probable and 1 possible spo- radic CJD cases were identified during the 10-year period. In addition, 1 familial case was diagnosed. No vCJD cases were found in Cyprus during the period of surveillance. Demographic and laboratory characteristics of the patients are shown on Table 1. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 717 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The first case died in July 1995, and the fifth in February 2004, with 3 other deaths in the interim; 3 cases were female and 2 male, one of which was the possible case. Age onset ranged from 60 to 79 years with an average age of 65 years. Duration of illness averaged 2.25 months for the definite/probable cases with a range of 2 to 3 months; the possible case lived for almost 8 months. The familial case was alive at the time of this writing. He presented in January 1999 aged 45 years with a 4-year history of progressive forgetfulness, behavioural change and ataxia. His father had a similar illness and for the last 8 years of his life he was unable to stand. A paternal uncle was similarly affected. On examination there was nystagmus and truncal ataxia, and the Mini Mental Status Examination was 25/30. MRI showed generalized and cerebellar atrophy. Genetic testing of PRNP showed methionine homozygosity codon 129 and a novel insertional mutation. He has deterio- rated gradually to the point that he is totally dependent on carers, severely dysarthric and dysphasic. All definite/probable cases had typical EEGs characterized by periodic sharp and slow wave complexes. The EEG in the pos- sible case was not typical showing diffuse slowing and disorganization. The EEG in the familial case showed semi-periodic triphasic waves. All definite and probable cases were positive for protein 14-3-3. In the one case of possible sporadic CJD, protein 14-3-3 was negative. Place of birth was also determined in order to establish whether any refugee cases had a common geographical origin. The 2 cases from Nicosia, in the centre of the island, were refugees and came from 2 villages (Kythrea and Lapithos), located in the north of the island. The remaining 3 originated and resided in non-occupied parts of Cyprus. Occupationally, of the 3 females, 2 were housewives and the third a manual worker. Of the male cases, 1 was a carpenter and the other (possible case) was a lawyer. The familial case was a teacher. No other significant factors or medical history were identified that would have in- creased the risk for CJD. None had received tissue transplants. None had thalassaemia major requiring transfusions of blood prod- ucts. None had neurosurgical procedures. Discussion The adjusted incidence of CJD in Cyprus for the 10-year period of surveillance was Table 1 Characteristics of the patients with sporadic Creutzfeldt–Jakob disease Date of Sex Date of Age at Date of Level of Typical Protein PrP Brain birth onset onset death diagnosisa EEG 14-3-3 analysis biopsy (years) 09/09/35 F April 1995 60 04/07/95 1 Yes Positive No Yesb 25/05/26 M October 1997 71 25/05/98 3 No Negative No No 22/04/34 F December 2000 65 05/02/01 1 Yes Positive Not known Yesb 27/01/32 F March 2003 69 20/05/03 2 Yes Positive No No 01/02/44 M February 2004 60 04/04/04 2 Yes Positive No No a1 = definite, 2 = probable, 3 = possible. bDiagnostic of sporadic Creutzfeldt–Jakob disease. EEG = electroencephalogram, F = female, M = male. 718 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 0.7 cases per million population per year. In other words, our sporadic incidence matched that expected [12,13] and there was no evidence for an increased risk of CJD in comparison to other countries. The clinical features were also as expected, except for a short average illness duration which may simply reflect the small number of cases identified. Cyprus is an island of approximately 1000 square kilometres [14]. Following 1974, its 2 main communities were sepa- rated and since then the Greek-speaking population resides in the southern part whereas the Turkish-speaking population is in the northern part. The island’s small size and the small number of cases detected does not allow meaningful clustering or statisti- cal analysis. Another confounding factor is the issue of the aforementioned forceful separation of its 2 main communities in 1974; this has resulted in population shifts so that about 40% of the surveyed Greek population resides in parts of Cyprus other than their origin. Of our cases, 2 came from the city of Nicosia, 1 from Larnaca and 2 from Limassol. These are approximately equidistant from each other. The familial case also came from Limassol. CJD surveillance appears to have worked fairly well for Cyprus. One important factor is the small size of the country, which al- lows adequate monitoring of the whole population in government-controlled areas of the country. Improved coordination is still needed, however, between the Ministry of Health, government and private neu- rologists, and neuropathologists, in order to ensure that most, if not all, cases receive a postmortem examination for a final, and definite, diagnosis. Of the 5 cases studied only 2 were examined neuropathologically even though the issue was discussed with all families. A possible factor for not obtaining permission for a postmortem may have been the perceived stigma, and one of the concerns of relatives after the diagnosis was made was the issue of confidentiality. In addition, a degree of reluctance was noted at times on the part on the pathologists, prob- ably reflecting their own concerns about the transmissibility of CJD. Furthermore, genotypic analysis of PRNR should be car- ried out in order to identify genetic cases that might otherwise be labeled as sporadic. A recent Italian study showed that many genetic cases would have been classified as sporadic without mutation analysis [15]. The incidence of CJD in Cyprus is within the expected range and we believe that our cases were sporadic. With Cyprus attaining full EU member- ship in 2004, the country has to follow certain decisions with regards to disease surveillance and epidemiology. This ena- bles government to upgrade its policies and extend the investigations that are carried out in suspected CJD cases. vCJD has not been identified in Cyprus. However, health authorities should remain vigilant with respect to this type of CJD as many Cypriots who used to live in England, a high-risk area for vCJD, moved back to the island after 1980. Acknowledgement The authors thank Professor Robert G. Will of Edinburgh University for his review and editorial assistance. References 1. Brown P et al. Creutzfeldt–Jakob disease: clinical analysis of a consecutive series of 230 neuropatholopgicalyy verified cases. Annals of neurology, 1996, 20:597–602. 2. Will RG et al. Descriptive epidemiology of Creutzfeldt–Jakob disease in six Eu- ropean countries, 1993–1995. Annals of neurology, 1998, 43:763–7. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 719 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 3. Brown P et al. Iatrogenic Creutzfeldt– Jakob disease: an example of the inter- play between ancient genes and modern medicine. Neurology, 1994, 44(2):291–3. 4. Will RG et al. A new variant of Creut- zfeldt–Jakob disease in the UK. Lancet, 1996, 347:921–5. 5. Anderson RM et al. Transmission dynam- ics and epidemiology of BSE in British cattle. Nature, 1996, 382(6594):779–88. 6. Nathanson N et al. Bovine spongiform en- cephalopathy (BSE): causes and conse- quences of a common source epidemic. American journal of epidemiology, 1997, 145(11):959–69. 7. Budka H et al. Tissue handling in suspect- ed Creutzfeldt–Jakob disease (CJD) and other human spongiform encephalopa- thies (prion diseases). Brain pathology, 1995, 5(3):319–22. 8. WHO manual for strengthening diagnosis and surveillance of Creutzfeldt–Jakob disease. Geneva, World Health Organiza- tion, 1998:1–75. 9. Ladogana A et al. Mortality from Creut- zfeldt–Jakob disease and related disor- ders in Europe, Australia and Canada. Neurology, 2005, 64:1586–91. 10. Republic of Cyprus website (http://www. cyprus.gov.cy/cyphome/govhome.nsf/ Main, accessed 4 September 2007). 11. Statistical Service of the Republic of Cy- prus website (http://www.mof.gov.cy/cy- stat/, accessed 4 September 2007). 12. Brown P et al. The epidemiology of Creut- zfeldt–Jakob disease: conclusion of a 15- year investigation in France and review of the world literature. Neurology, 1987, 37(6):895–904. 13. EUROCJD Group. Genetic epidemiology of Creutzfeldt–Jakob disease in Europe. Revue neurologique, 2001, 157:633–7. 14. Republic of Cyprus. Government web portal (http://www.cyprus.gov.cy/por- ta l /porta l .nsf /dmlc i t izen_en/dmlci - tizen_en?OpenDocument, accessed 4 September 2007). 15. Ladogana A et al. High incidence of ge- netic human transmissible spongiform en- cephalopathies in Italy. Neurology, 2005, 64:1952–7. 720 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Report Maternal mortality in Bahrain 1987–2004: an audit of causes of avoidable death A.K. Sandhu1 and F.E. Mustafa2 1Department of Obstetrics and Gynaecology, Salmaniya Medical Centre, Ministry of Health, Bahrain (Correspondence to A.K. Sandhu: sandhuak@batelco.com.bh). 2College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain. Received: 20/12/05; accepted: 23/02/06 ABSTRACT The aim of this report was to establish the national maternal mortality rate in Bahrain over the period 1987–2004, to identify preventable factors in maternal deaths and to make recommenda- tions for safe motherhood. There were 60 maternal deaths out of 243 232 deliveries giving an average maternal mortality rate of 24.7 per 100 000 total births. The main causes of death were sickle-cell dis- ease (25.0%), hypertension (18.3%), embolism (13.3%), haemorrhage (13.3%), heart disease (11.7%), infection (8.3%) and other (10.0%). In an audit of care, 17 (28.3%) out of 60 deaths were judged to be avoidable, nearly half of which were due to a shortage of intensive care beds. We recommend that a confidential enquiry of maternal deaths be conducted at the national level every 3 to 5 years. Mortalité maternelle à Bahreïn entre 1987 et 2004 : examen des causes de décès évitable RÉSUMÉ L’objectif de ce rapport était d’établir le taux national de mortalité maternelle à Bahreïn sur la période comprise entre 1987 et 2004, afin de recenser les facteurs de décès maternel évitables et de formuler des recommandations pour une maternité sans risque. On a dénombré 60 décès maternels sur 243 232 accouchements, soit un taux moyen de mortalité maternelle de 24,7 pour 100 000 naissances au total. Les causes de décès étaient les suivantes : drépanocytose (25,0 %), hypertension (18,3 %), embolie (13,3 %), hémorragie (13,3 %), cardiopathie (11,7 %), infection (8,3 %) et autres causes (10,0 %). Lors d’un audit des soins, 17 (28,3 %) des 60 décès ont été jugés évitables, près d’un sur deux étant du à un manque de lits de soins intensifs. Nous recommandons la réalisation d’une enquête confidentielle sur les décès maternels à l’échelle nationale tous les 3 à 5 ans. áÊߺ>¢EÀÈfVF¶=›L>úÙ=L>ɪÆ1987–20046H>FiÙ=›°É®bI>ÃÈa>«IÀ³•¶= Ϋìrº¼ÉÂ=fECÍÈf³ª(Æb¾>ieDzKÉQfº?  „=Í[qØ6áÊߺ>[¢[E>º›ÀÈfVF¶=›L>úÙ=L>ɪƹb£ºη¢­f£J¶=fÈf¯J¶==d­bÃJjÈ1987–2004 ºÙ=L>ɪƸº=Ç¢η¢ÆÍ[¾Çº@™=Í[ºÇºÙ>EÍ[q>]L>É[qÇIe=b[qCη¢Æ(>ÃÉù®ÇIÀ³•¶=L>Ã*Lb[QÆb[®Æ L>úÙ=L>ɪÆab¢Á?Á>JNU>F¶=60EÀºÌ>ªÆ232243¹b£’Ë?(Ìa×Æ24.7¸[³¶Ì>ªÆ000100Ìa×Æ* Í[É·R¿™=>[È؄=zfºÌ>ªÇ¶=H>Fi?¼Â?ÀºÆ%25.0$!½b[¶=œ§[u¥>[«Ie=Æ(%18.3$![¾×=Æ(½>»r%13.3$!( ­Æh¿¶=Æ%13.3$!G·¯¶=z=fº?Æ(%11.7$!ÏÆb£¶=Æ(%8.3$!Ïf[]?H>Fi?Æ(%10.0*$!›°É®b[J¶=Ïb[¶Æ Á?bQÆ(ÍÈ>¢f¶=17Åd[¬r[¾Á?Æ(>[ÃɪØIÀ[³•Á>[²>[þ@E>ÃÉ·¢¼³ƒ=À³•Jj¶=L>ɪǶ=EÀºÌ>ªÆ Ìhõ²f™=ÍÈ>¢f¶=Ìçfi?›s¯¾À¢͖>¾L>ɪǶ=*ÆL>[úÙ=L>ɪƹÇU¼ëJ³JºÐ>r¯Ji=Ð=fQDEÁ>JNU>F¶=ÊqÇI ¸²{Ƕ=ÏÇJj™=η¢3Æ?5L=Ç¿i*  Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 721 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction Each case of maternal death in this re- port represents an individual tragedy, as pregnancy is not a disease and as pregnancy-related mortality is almost al- ways preventable. Yet more than half a million women die each year due to pregnancy-related complications and 99% of these are from the developing world [1]. For example, in northern England there are 2–9 maternal deaths for every 100 000 births, whereas in Africa there is 1 maternal death for every 1000 births [2]. The overall maternal mortality rate in Bahrain has dropped from 42.3 per 100 000 total births in the period 1977–1981 to 24.7 per 100 000 in the period 1987–2004 [3]. While some maternal deaths occurring in this country may not be included in the statistics, their number is negligible as the population is only 707 160, with 62.0% Bahraini, 38.0% non-Bahraini and the crude birth rate is 21.1 per 1000 population [4]. Over 80% of deliveries take place in the main government hospitals and the rest are in the Bahrain Defence Force hospital and other private hospitals. The main objective of this paper was to report the national maternal mortality rate in Bahrain over an 18-year period and the main causes of maternal death, and to compare these data with regional and in- ternational data. The other objective was to establish the causes of avoidable death and to highlight where improvements in care and services can be made. Methods Salmaniya Medical Complex is the main government hospital in Bahrain where most high-risk deliveries take place with an an- nual number of births of about 5000–6000. There are 2 other peripheral maternity hos- pitals (Jidhafs and Muharraq), both run by the staff of Salmaniya Medical Complex. The number of deliveries at Jidhafs is about 3500 per year, while in Muharraq about 1500–2000 per year. The second largest hospital in Bahrain is the Bahrain Defence Force hospital where the number of deliv- eries is about 3000 per year. This hospital serves mainly military families, emergency cases and private patients. There are sev- eral private hospitals in Bahrain where the number of deliveries varies from 30–300 per year. So Salmaniya Medical Complex is the main referral centre for all other hospi- tals in Bahrain, because a blood bank and all key facilities are available here. In Bahrain all maternal deaths are re- ported to the Health Information Directory at the Ministry of Health (MOH). There were 60 maternal deaths during the 18 years 1987–2004. With the help of the administration department of Salmaniya Medical Complex and Bahrain Defence Force hospitals all the medical files were obtained and reviewed by the authors. Out of 60 cases, 1 patient had arrived in the accident and emergency department dead, at term, and her medical file could not be traced in any hospital. However, some data were available from the data processing office in Bahrain and from interviews with the relatives of the patient. The information extracted from the files included the following: date of admission, date of death, age, parity, period of gestation, diagnosis, mode of delivery, management and outcome. All maternal deaths were dis- cussed at the departmental meetings along with a maternal mortality meeting at both these hospitals and decisions were made as to whether the death was avoidable or unavoidable. Where avoidable, factors were identified such as a fault with the clinical management, failure of medical facilities or a failure on the part of the patient. The im- 722 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما mediate cause of death was classified into direct and indirect causes. Direct causes were deaths resulting from obstetric com- plications due to interventions, omissions or incorrect treatment. Indirect causes of death were due to an existing disease or disease aggravated during pregnancy, as defined by the World Health Organization. The deaths were studied in relation to age, parity, pe- riod of gestation and mode of delivery. For religious reasons, autopsies were not performed. We followed the definition of maternal death in the International statisti- cal classification of diseases and related health problems, 10th revision [5] and the denominator was the total births, which includes live births and stillbirths. Results There were a total of 243 232 deliveries during the study period 1987–2004 and 60 maternal deaths, giving an average mater- nal mortality rate of 24.7 per 100 000 total births. Figure 1 shows the annual distribu- tion. Table 1 shows maternal deaths by age and parity. The proportion of maternal deaths was highest in patients in the age group 35–39 years (30.0%) and in those with parity 5+ (28.3%). Of the maternal deaths, 81.7% were in the MOH hospitals and 18.3% were in the Bahrain Defence Force hospital. Of all deaths, 40.0% were at term, 21.7% at 30–36 weeks, 28.3% at 21–29 weeks and 10.0% at 20 weeks or less. There were 20 antenatal deaths and of the remaining postnatal deaths 18 women had a vaginal delivery, 16 had caesarean section and 6 had an abortion. Out of 60 deaths, 43 (71.7%) were judged to be unavoidable and 17 (28.3%) were avoidable due substandard care provided by the medical team in 8 deaths (47.1%), administrative problems (lack of an ICU bed) in 7 (41.1%) and failure on the part of the patient in 2 (11.8%) (Table 2). The main causes of death were sickle- cell disease (25.0%), hypertensive diseases Figure 1 Maternal deaths in Bahrain, 1987–2004 (average 3.3 deaths/year) Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 723 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما (18.3%), haemorrhage (13.3%), embolism (13.3%), heart disease (11.7%), infection (8.4%) and other (10.0%). Direct causes were responsible in 32 (53.3%) cases and indirect causes in 28 (46.7%) cases (Table 3). Sickle-cell disease was the leading cause of death (15 cases) and the main indirect cause of death. In this group 7 (46.7%) deaths were due to acute chest syndrome, 7 (46.7%) due to vaso- occlusive crises and 1 (6.6) due to haemo- lytic crises. Of these women 8 (53.3%) died in the antenatal period, 6 (40.0%) in the postnatal period and 1 (6.7%) following abortion. Hypertensive disease was the 2nd com- monest cause of maternal death (11 cases) and the leading direct cause of death. The age of these women varied from 29 to 44 years; parity was 0–5 in 4 cases (36.3%) and 6+ in 7 cases (63.7%). The cause of death was encephalopathy in 4 (37.4%) cases, haemolytic elevated liver enzymes and platelets (HELLP) in 3 (27.2%) cases, pulmonary oedema and heart failure in 2 (18.2%) and disseminated intravascular coagulopathy in 2 (18.2%). There were 5 (45.4%) cases of eclampsia; 1 of the women was not booked into hospital and suffered a fit after home delivery. Out of these cases of hypertensive disease, 3 (27.2%) women died undelivered and 8 (72.8%) died in the postnatal period. Table 1 Maternal deaths according to age and parity in 60 patients in Bahrain, 1987–2004 Age (years) No. of maternal deaths by parity Total no. % 1 2 3 4 5–8 9+ > 19 4 1 1 1 0 0 7 11.7 20–24 2 1 0 0 1 0 4 6.7 25–29 3 1 4 2 1 0 11 18.3 30–24 1 2 3 3 4 2 15 25.0 35–39 0 0 3 2 10 3 18 30.0 40+ 0 0 2 0 1 2 5 8.3 Total no. 10 5 13 8 17 7 60 100.0 % 16.7 8.3 21.7 13.3 28.3 11.7 Table 2 Details of maternal deaths due to avoidable and unavoidable causes in Bahrain, 1987–2004 Causes of maternal death Unavoidable causes (43 cases, 71.6%) Avoidable causes (17 cases, 28.4%) Lack of intensive care bed (7 cases, 41.1%) Sickle-cell disease (2) Hypertensive disease (2) Pulmonary embolism (3) Failure of clinical management (8 cases, 47.1%) Haemorrhage (3): due to failure to do timely hysterectomy Cardiac (2): due to failure to perform termination (1) and inadequate heparinization (1) Bowel injury (3): due to undetected bowel injury at the time of caesarean section Patient’s failure to attend antenatal clinic (2 cases, 11.8%) Severe hypertension (1) Cardiac disease (1) 724 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Table 3 Details of maternal deaths due to direct and indirect causes in Bahrain, 1987–2004 Direct causes (32 cases, 53.3%) Indirect causes (28 cases, 46.7%) Hypertensive disease (11 cases, 18.3%) Diagnosis Pre-eclampsia (6) Eclampsia (5) Cause of death Intracranial haemorrhage (4) HELLP syndrome (3) Disseminated intravascular coagulation (2) Pulmonary oedema (2) Stage of delivery at death Antenatal (3) Postpartum (8) Haemorrhage (8 cases, 13.3%) Diagnosis Atonic uterus (3) Placenta accreta (2) Delayed postpartum haemorrhage (1) Abruptio placenta (2) Delivery Caesarean section hysterectomy (6) [delayed decision for hysterectomy (3)] Pulmonary embolism (8 cases, 13.3%) Diagnosis Pulmonary embolism (5) Amniotic fluid embolism (3) Risk factors for embolism Overweight (8) Grand multiparity (5) Sickle-cell disease (3) Caesarean section (5) Pre-eclampsia (2) Stage of delivery at death Antenatal (2) Postnatal (6) Genital tract sepsis (5 cases, 8.3%) Diagnosis Peritonitis (1) Encephalopathy (1) Septicaemia (3) Sickle-cell disease (15 cases, 25.0%) Diagnosis Acute chest syndrome (7) Vaso-occlusive (7) Haemolytic crises (1) Cause of death Pulmonary embolism & septicaemia (14) Stage of delivery at death Antenatal (8) Postnatal (6) Postabortion (1) Cardiac disease (7 cases, 11.7%) Diagnosis Valvular disease (5) Atrial myxoma (1) Cardiomyopathy (1) Stage of delivery at death Antenatal (3) Postnatal (2) Caesarean section (2) Other causes (6 cases, 10.0%) Diagnosis Intracranial haemorrhage (1) Liver cirrhosis (1) Encephalopathy (1) Adult respiratory distress syndrome (1) Unknown (1) Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 725 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Obstetric haemorrhage was the 3rd com- monest direct cause of death in this study (8 cases) and the age of the women varied from 28 years to 44 years and parity from 0–5 in 3 cases (37.5%) and 6+ in 5 cases (62.5%). The cause of bleeding was atonic haemor- rhage due to placenta praevia with previ- ous caesarean section in 3 (37.5%) cases, placenta accreta in 2 (25.0%), abruptio pla- centa in 2 (25.0%) and delayed postpartum haemorrhage in 1 (12.5%). Six of these women (75.0%) needed hysterectomy. Discussion Conducting audits of maternal deaths is one of the key steps towards improving mater- nity services. Every minute a woman dies from complications related to pregnancy and childbirth worldwide, which means 1500 deaths every day, more than half a million deaths every year; 99% of these deaths occur in the developing world [6]. The causes of maternal mortality are mul- tiple, complex and inter-related and almost always preventable. When compared with other Gulf countries, such as Saudi Arabia and Oman, our results are similar [7,8]. The recording and auditing systems for these deaths need attention at the national level. A committee needs to be constituted to review each case of maternal mortality and identify preventable factors without blaming any individual. Sickle-cell disease Sickle-cell disease was the leading cause of death in our study (15 cases) and has remained the leading cause of indirect ma- ternal deaths for the last 3 decades in this country [9,10], as this condition is endemic in this region. Since sickle-cell disease is a hereditary disease, it needs public educa- tion, frequent antenatal checkups, delivery in tertiary hospitals, family planning advice and compulsory premarital screening, which has been started already in this country. Pul- monary embolism and septicaemia was the ultimate cause of death in the majority of these women. Almost half the women with sickle-cell disease died due to acute chest syndrome and half due to vaso-occlusive crises; the remainder were due to haemo- lytic crises. Acute chest syndrome is known to be a common problem causing significant morbidity and mortality that may reach 50% [11]. Cases usually present with symptoms and signs of pneumonia, which could be due to infection, infarction, pulmonary se- questration or in situ thrombosis [12]. The cases with vaso-occlusive crises were due to ischaemia in the long bones and joints. So far there is no effective long-term method to reduce these crises. Combined care with the haematologist is required during the antena- tal period or if there are any complications. Controversy surrounds prophylactic blood transfusion but we followed the policy of therapeutic transfusion [13]. An ICU bed was not available for 2 cases due to a short- age of beds, so we considered these deaths avoidable. Hypertensive diseases Hypertensive diseases are the commonest medical disorder affecting 7%–10% of all pregnancies in the United States [14]. They are known as one of the main causes of ma- ternal death in both the developed and de- veloping world. It was found to be the 2nd cause of maternal death in our study and the main direct cause (11 cases). The majority of cases were intracranial haemorrhage fol- lowed by HELLP, pulmonary oedema and heart failure and disseminated intravascular coagulopathy. The largest single cause of death with pre-eclampsia and eclampsia was intracranial haemorrhage, reflecting a failure in effective antihypertensive treat- ment [13]. 726 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما There were 5% of patients who had eclampsia, which contributed to 8.3% of maternal mortality and this is comparable to some reported studies [15,16]. Three-quar- ters of the women had seizures in the intra- partum or postnatal period with one-quarter in the antenatal period. Magnesium sulfate has been the anticonvulsant of choice in eclampsia for the last 7 years [17]. A total of 3 out of 11 cases had HELLP syndrome, which is similar to some studies reported elsewhere [18]. HELLP is a rare but poten- tially serious complication of hypertension and in such cases the delivery of the baby should be commenced as the liver function can deteriorate rapidly. There were 2 avoidable hypertensive disease deaths; 1 due to failure on the part of the patient to book into the clinic despite having very high blood pressure and the other died due to intracranial haemorrhage in a peripheral hospital as there was no ICU bed. Haemorrhage Life-threatening haemorrhage may occur in 6.7 in 1000 deliveries and can occur rapidly [19]. Worldwide, haemorrhage remains the most important cause of maternal mortal- ity and almost 130 000 women bleed to death each year [20]. In 75% of women with haemorrhage there are no risk factors identified and some studies indicate that 90% could be due to uterine atony [21]. In our study we found that obstetric haemor- rhage was the 2nd equal direct cause of death (8 cases). It is known that risks of haemorrhage rise significantly with age and parity as two-thirds of our patients were grand multiparas. The causes of bleeding were atonic haemorrhage due to placenta praevia, placenta accreta, delayed postpar- tum haemorrhage and abruptio placenta; 75% of patients needed hysterectomy. All the women who died with placenta prae- via had had a previous caesarean section. Life-threatening haemorrhage occurs in 1 in 1000 deliveries with previous caesarean section and may need caesarean hysterecto- my or uterine artery ligation or internal iliac artery ligation or uterine artery emboliza- tion [22]. Avoidable factors were identified in 3 cases due to delay in taking decisions for hysterectomy or to perform internal iliac artery ligation and in 1 case it was also due to delivery in the peripheral hospital where the facilities for blood transfusion were not adequate. Isolated maternity units distant from blood transfusion services and the lack of ICU present a particular risk when major haemorrhage occurs. Pulmonary embolism (amniotic fluid embolism) Pregnancy is a state of hypercoagulability and therefore there is an increased risk of thromboembolism. Pulmonary embolism is still the leading direct cause of maternal death in United Kingdom [23] and in our study it was the 2nd equal direct cause of maternal death (8 cases), out of which 3 cases were due to amniotic fluid embolism. All patients weighed more than 100 kg, so women with obesity, caesarean section and past history of pulmonary embolism should be considered as high-risk for pulmonary embolism [24]. Since the clinical diagnosis is unreliable, we suggest Doppler ultra- sound and ventilation–perfusion scanning of the lungs as an important test to detect this disease, and the Royal College of Ob- stetricians and Gynaecologists guidelines for thromboprophylaxis should be followed strictly [25]. We lost 3 patients with the probable di- agnosis of amniotic fluid embolism, which is a rare, unpredictable, unpreventable and often lethal condition [26[. The incidence in our institution is 1 in 12 000, which is comparable with the global incidence of 1 Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 727 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما in 8000 to 1 in 80 000 pregnancies with a maternal mortality rate of 86% [27]. It was suspected in these patients as they suddenly developed marked cardiopulmonary distress in the absence of any other pathology. Substandard care was identified in 3 cases as there was no ICU bed available for such cases and in 1 case there was also fail- ure to give thromboprophylaxis to a patient with so many risk factors. Cardiac disease Haemodynamic changes during pregnancy are stressful to the cardiovascular system and become complicated with congestive heart failure in patients with heart lesions. The incidence of heart disease in Bahrain is about 0.7% [28]. Heart disease was re- sponsible for 7 cases of indirect maternal deaths and similar results have been report- ed where cardiac disease still accounts for 15% of pregnancy-related mortality [29]. Valvular heart disease was once more com- mon than congenital heart disease but now the ratio is 1 to 1.5 in favour of congenital heart disease. Valvular heart disease, either alone or in combination, was diagnosed in 5 cases and 1 case had atrial myxoma and 1 had postpartum cardiomyopathy. In the presence of heart disease, careful cardiac and obstetric management in a tertiary referral centre is recommended. Good patient compliance and high quality ante- natal care may reduce mortality. Substandard care was identified in 2 patients, in 1 due to inadequate hepariniza- tion in a patient with prosthetic valvular disease and in the other failure to terminate the pregnancy in the 1st trimester of preg- nancy so that she could have valvotomy for tight mitral stenosis. Although surgery can be performed in pregnancy, most authors recommend early intervention in the non- pregnant state [30]. Genital tract sepsis Maternal mortality due to sepsis is de- finitively decreasing and this change is attributed to good hygiene, less illegal abortion and use of broad-spectrum anti- biotics [31]. However, sepsis can be life- threatening and can be of sudden onset. Infection was the direct cause of death in 5 patients in our study; 1 case had enceph- alopathy in the postpartum period, 3 had severe haemorrhage due to septicaemia and 1 had peritonitis due to undetected bowel injury following caesarean section. The risk of sepsis was increased as they had prolonged rupture of the membranes and the same findings have been seen by other studies [32]. We followed the policy of prophylactic antibiotics for all major surgery. Avoidable death was found in 1 case where it was due to undetected bowel injury causing peritonitis after caesarean section in a patient who had previous 3 caesarean sections. Timely detection and management could have avoided this death. Other causes Six of the maternal deaths were due to various causes such as myeloid leukaemia, intracranial haemorrhage, liver cirrhosis, respiratory obstruction due to stricture in the neck and restricted mandibular mo- ment, which made intubation impossible. We had no deaths due to ectopic preg- nancy, multiple gestations or anaesthesia, and no late maternal deaths. Conclusion and recommendations We recommend that a confidential en- quiry into maternal deaths be carried out at the national level every 3–5 years. 728 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما In view of the fact that nearly half of avoidable deaths in this audit were due to lack of availability of ICU beds, we recommend that special ICU beds are made available for every sick patient near the labour room. Guidelines or protocols should be prominently placed in all wards and delivery suites and implementation of guidelines should be the subject of regular audit. The following guidelines are suggested for the main categories of maternal death established in this study. • Sickle-cell disease. Combined care is needed with the haematologist. Patients should deliver in a tertiary hospital and emphasis should be given to family planning. • Hypertensive diseases. Educational ma- terial should be available to make wom- en aware of symptoms associated with gestational hypertension. Protocols for the use of magnesium sulfate should be available for the prophylaxis of seizures, and strict attention given to fluid balance to avoid pulmonary oedema. • Pulmonary embolism. Basal body mass index should be calculated in all preg- nant patients and the Royal College of Obstetricians and Gynaecologists guide- lines for thromboprophylaxis should be followed. • Haemorrhage. An experienced con- sultant, anaesthetist and haematolo- gist should be involved in any case of haemorrhage and the role of timely hys- terectomy or internal iliac ligation or embolization should be emphasized. • Cardiac diseases. Termination, if indi- cated, should be done at an early stage of pregnancy without delay. Protocols for adequate heparinization for prosthetic valve disease along with combined care with the cardiologist should be prac- tised. • Genital infections. Signs and symptoms of septicaemia should be recognized and adequate doses of antibiotics adminis- tered. References 1. Maternal mortality in 2000: estimates developed by WHO, UNICEF and UN- FPA. Geneva, World Health Organization, 2004. 2. Ghosh MK. Maternal mortality. A glo- bal perspective. Journal of reproductive medicine, 2001, 46:427–33. 3. El-Shafei AM, Sandhu AK, Dhaliwal JK. A review of maternal death in Bahrain 1977–1986. Bahrain, Government Press, Ministry of Information, 1989. 4. Health statistics 2004. Bahrain, Health In- formation Directorate, Ministry of Health, 2004. 5. International statistical classification of diseases and related health problems, 10th revision. Geneva, World Health Or- ganization, 1992. 6. Reducing maternal deaths, The challenge of the New Millennium in Africa Region. Brazzaville, Congo, WHO Regional Office for Africa, 2002. 7. Al-Meshari A et al. Epidemiology of ma- ternal mortality in Saudi Arabia. Annals of Saudi medicine, 1995, 15(4):317–23. 8. Suleiman AJM. Review of maternal mor- tality in Oman, 1992–2000. Community health and disease surveillance newslet- ter, 2000, 4:1–3. 9. El-Shafei AM, Sandhu AK, Dhaliwal JK. Maternal mortality in Bahrain with special reference to sickle cell disease. Austral- Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 729 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 19. Rizvi F et al. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. British journal of obstetrics and gynaecology, 2004, 111:495–8. 20. Chong YS, Su LL, Arulkumaran S. Cur- rent strategies for the prevention of post- partum haemorrhage in the third stage of labour. Current opinion in obstetrics and gynecology, 2004, 16:143–50. 21. O’Leary JA. 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Bahrain medical bulletin, 2004, 26(3):95–8. 29. Faiz SA, Al-Meshari AA, Sporrong BG. Pregnancy and valvular heart disease. ian and New Zealand journal of obstetrics and gynaecology, 1988, 28:41–4. 10. El-Shafei AM, Dhaliwal JK, Sandhu AK. Pregnancy in sickle cell disease in Bah- rain. British journal of obstetrics and gy- naecology, 1992, 99:101–4. 11. Al-Dabbous IA. Acute chest syndrome. Saudi medical journal, 2002, 23(9):1037– 44. 12. Al-Hawsawi ZM. Acute chest syndrome in sickle cell disease. Saudi medical journal, 2004, 25(1):116–7. 13. El-Shafei AM et al. Indications for blood transfusion in pregnancy with sickle cell disease. Australian and New Zealand journal of obstetrics and gynaecology, 1995, 35(4):405–8. 14. August P, Lindheimer MD. Pathophysiol- ogy of preeclampsia. In: Laragh JL, Bren- ner BM, eds. Hypertension, 2nd ed. New York, Raven Press, 1995:2407–26. 15. Davies JA, Prentice CRM. Coagulation changes in pregnancy-induced hyperten- sion and growth retardation. In: Greer IA, Turpie AGG, Forbes CD, eds. Haemosta- sis and thrombosis in obstetrics and gy- naecology. London, Chapman and Hall, 1992:143–62. 16. Granger JP et al. Pathophysiology of hypertension during preeclampsia linking placental ischemia with endothelial dys- function. Hypertension, 2001, 38:718–23. 17. Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their ba- bies, benefit from magnesium sulphate? The Magpie Trial: a randomized placebo– controlled trial. Lancet, 2002, 359:1877– 90. 18. Rajab KE, Abdull AA, Skerman JH. Help syndrome: incidence and management of such cases in the Kingdom of Bahrain. Bahrain medical bulletin, 2003, 24:141– 6. 730 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Saudi medical journal, 2003, 24(10):1098– 101. 30. Thilen U, Olsson SB. Pregnancy and heart disease: a review. European journal of obstetrics, gynecology, and reproduc- tive biology, 1997, 75:43–50. 31. Chabra K, Kaipa A, Kakani A. Reduction in maternal mortality due to sepsis. Jour- nal of obstetrics and gynaecology, 2005, 25(2):140–2. 32. Giles M, Garland S, Oats JJ. Manage- ment of preterm prelabour rupture of membranes: an audit. How do the results compare with clinical practice guidelines? Australian and New Zealand journal of obstetrics and gynaecology, 2005, 45(3):201–6. The Countdown to 2015 The mission of The Countdown to 2015 is to track progress made towards the achievement of the United Nations’ Millennium Develop- ment Goals 1, 4 and 5 and promote evidence-based information for better health investments and help decision- and policy-makers to better target health needs at the country level. Scheduled for pub- lication in 2008 is Tracking progress in maternal, newborn and child survival: Countdown to 2015 - The 2008 Report which will contain country profiles of key coverage indicators for maternal, newborn and child health (MNCH). Further information about The Countdown to 2015 can be found at: http://www.countdown2015mnch.org/ Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 731 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Report Introducing the IMCI community component into the curriculum of the Faculty of Medicine, University of Gezira S.H. Abdelrahman1 and S.M. Alfadil2 1Department of Community Medicine, Faculty of Medicine, University of Gezira, Wad Medani, Sudan (Correspondence to S.H. Abdelrahman: samhamid2002@yahoo.co.uk). 2World Health Organization Regional Office for the Eastern Mediterranean, WR Office, Khartoum, Sudan. Received: 18/10/05; accepted: 20/03/06 ABSTRACT In 2001 the Faculty of Medicine of the University of Gezira (FMUG) started to introduce the Integrated Management of Childhood Illness (IMCI) strategy into its medical curriculum. The emphasis was on pre-service training that addresses standard case management and the IMCI community compo- nent. This report presents the experience of FMUG in integrating such a training package into the medi- cal curriculum. It explains the rationale for introducing the IMCI community component and the guiding principles for doing so. It describes the community-based courses into which the community component was integrated, the implementation and impact of the programme and the constraints faced. Í£º>Q›Gì¶=ÍÉ·³¶Êi=eb¶=ef¯™=À»u¹>«{Ù=ÍVr¶¸º>³J™=EbJ·¶Ê£»J=Áëdz™=¹>]aC Á=aÇj¶=(ÌfÈh‚= ¸u>«¶=b»†ÍÉ(À—f¶=bF¢bº>UÌ  „=Í[qØ6½>¢d¿ºÁ=aÇj¶=›ÌfÈh‚=Í£º>Q›Gì¶=ÍÉ·²áKߢßfßm2001¸[º>³J™=Eb[J¶=ÍÉRÉI=f[[Ji=¹>]aDE ì¶=Êi=eb¶=ef¯™=›¹>«{Ù=ÍVr¶*Ïbr[JÈËd[¶=ÆÍ[ºb„=¼Èb¯J¶°E>j¶=GÈebJ¶=¹ÇUhɲf[J¶=Á>²b®Æ ¶=ÍÉRÉI=f[Ji×Ê£»J=Ádz™=À»uËe>É£™=L×>ƒ=EbJ¶¹>«{Ù=ÍVr¶¸º>³J™=EbJ*fÈf¯J¶==dÂzf£JjÈÆ ([ì¶=Ê[i=eb¶=ef[¯™=À»[uÍÉFÈebJ¶=ͺhƒ=ÅdÂT>ºaC›ÌfÈh‚=Í£º>Q›Gì¶=ÍÉ·²>ÃJFjJ²=¶=L=„= dÉ«¿J¶ÍÉÃÉQÇJ¶=Ôa>F™=ƹ>«{Ù=ÍVr¶¸º>³J™=EbJ·¶Ê£»J=½ëǯ™=¹>]aÝðØÉ·£Ið>vÈ?½ëb¯ÈƬr[È>»²(> [¶=¸É®=f£¶=ÆSº>¾¶=η¢>ÂfM?Æ(>ÂdÉ«¿IÆ(Ê£»J=Ádz™=>Ãɪ¸]a?¶=Æhí³If™=ÍÉ£»J=ÍÉi=eb¶=L=eÆb¶= >ÃJªa>q*  Intégration de la composante communautaire de la PCIME dans le programme d’études de la Faculté de Médecine de l’Université de Gezira RÉSUMÉ En 2001, la Faculté de Médecine de l’Université de Gezira a inscrit la stratégie PCIME (Prise en charge intégrée des maladies de l’enfant) à son programme d’études de médecine. L’accent était mis sur la formation avant l’emploi, qui porte sur la prise en charge standard des cas ainsi que sur la composante communautaire de la PCIME. Ce rapport montre comment la Faculté de Médecine a intégré ce module de formation dans son programme d’études. Il explique ce qui justifie l’introduction de la composante communautaire de la PCIME et les principes directeurs pour y parvenir. Il décrit ensuite les cours en communauté dans lesquels la composante communautaire a été intégrée, la mise en œuvre et les effets du programme, ainsi que les contraintes rencontrées. 732 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Introduction The Integrated Management of Childhood Illness (IMCI) strategy encompasses a range of interventions for the prevention and man- agement of major childhood illnesses in health facilities, in the home and within the community [1]. It also empowers families and communities to acquire skills necessary for the survival of their children and to have an active role in taking care of the health of their children. IMCI implementation involves 3 com- ponents [1]. • Improvement of the case management skills of health workers at primary health care (PHC) facilities. • Improvement of the health systems to ensure effective management of child- hood illnesses both by health workers and families. • Improvement of family and community practices to support child health and de- velopment. Successful implementation of IMCI in countries requires and facilitates active and sustained collaboration between the health sector and institutes involved in the educa- tion of health professionals. Such collabora- tion exists in countries which are currently working to include IMCI into the curricula of medical, nursing and other health profes- sionals at educational institutes [2]. This is thus expected to increase the number of IMCI-trained health workers working within the health systems in a cost-effective and sustainable manner [2]. The Faculty of Medicine of the Univer- sity of Gezira (FMUG) is one of 6 Sudanese universities that started in 2001 the process of introducing IMCI into their medical curricula. From the outset, as proposed and later developed by the first author, the plan of the FMUG emphasized the importance of pre-service training that addresses standard case management together with the IMCI community component. The aim of this paper is to describe the experience of integrating a training package addressing the IMCI community compo- nent into the medical faculty curriculum of FMUG. Background FMUG is the second oldest medical school in Sudan. It follows an innovative community-oriented, problem-based, in- tegrated curriculum, the first of its kind in Sudan, and students are trained in families, rural communities, health centres and rural hospitals. In order to introduce the IMCI com- munity component into the curriculum the following steps were undertaken. • Identifying a rationale for the process. • Establishing principles to ensure that the process would contribute to the achieve- ment of both FMUG philosophy of community orientation and IMCI objec- tives. • Defining specific learning objectives and content areas that cover what stu- dents should learn regarding the role of IMCI in improving health systems’ performance and improving family and community practices affecting child health. • Identifying suitable educational meth- ods to assist students in achieving the defined learning objectives. • Identifying courses and modules that could accommodate the content of the IMCI community component. • Determining methods and tools neces- sary for students and programme assess- ment. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 733 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما • Identifying the necessary resources (both human and material). • Assessing the outcomes and short-term impact of students’ activities (such as the improvement in family and commu- nity practices). Rationale for introducing the community component into the curriculum According to Fulop, the quality and quan- tity of health personnel has to be planned in response to the specific needs of national health systems and through this to the health needs and demands of the population [3]. FMUG is one of the founders of commu- nity-oriented medical education in Sudan and the Eastern Mediterranean Region. It uses educational strategies such as commu- nity-based education, integration of basic, clinical, social and behavioural sciences and problem-based learning. So, introducing IMCI into the curriculum reflects its phi- losophy, assists in fulfilling its objectives and ensures efficient use of its educational strategies and existing resources. Educational institutions for health pro- fessionals do not only train health care workers to work in health facilities. In fact, part of their role is to equip students with managerial skills, including health financ- ing skills, which are necessary for future policy-makers and health planners who are capable and ready to work at different levels of the health system [4]. Medical students need to understand IMCI and that all 3 components of IMCI are integrated and inter-related and the ef- fective implementation of each component supports the achievement of the set objec- tives of the other 2 components. Learning how to plan interventions related to the 3 main components of the IMCI strategy is of vital importance [5]. The focus of IMCI standard case man- agement should be outpatient clinics and health facilities providing primary health care. Success in reducing childhood mor- tality and morbidity and improving child health requires more than the availability of adequate health services staffed with IMCI- trained health workers. As families have a major responsibility to care for their chil- dren, such success requires a partnership between health service providers, families and community organizations that influence family practices related to child health [6]. Guiding principles for the planning and implementation of the proposed curriculum Based on the stated rationale to introduce the IMCI community component into pre- service training, the following principles were followed for structuring the training package. • The proposed curriculum should be based on publications and reference material produced by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) that cover issues related to different IMCI components including pre-service train- ing. • In order to achieve the goals and objec- tives of both the IMCI programme and FMUG, students must understand the inter-relation and integration of the 3 IMCI components. So, in addition to giving training in the IMCI standard case management skills, the learning objectives should include basic concepts and skills related to the role of IMCI in 734 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما improving health systems’ performance, promoting child health services and im- proving family and community practices that affect child health and survival. • The teaching of IMCI standard case management should not be limited to inpatient sessions conducted in Wad Medani Paediatrics Hospital. As part of the faculty programme, students must be trained in health centres and rural hospi- tals all over Gezira state that implement IMCI. • Students should understand and ap- preciate the responsibility of families to care for their children both in health and during illness. Family attachment and field training in villages should be used to reinforce concepts of “partner- ship” and “unity for health” to students, as these community-based education activities provide a suitable environment for students to practise and consolidate communication and counselling skills. It also helps them to acquire other nec- essary competencies that enable them to initiate and support partnerships with families and communities in their future career. • IMCI-related content should use educa- tional activities (such as field activities) and resources to the maximum to assist students to understand that linking IMCI to strategies that improve the health sys- tem’s performance ensures effective and sustainable implementation of all IMCI components. Based on these principles and on relevant WHO and UNICEF reference material, a training package was developed by the first author. The objectives and content areas of all community-based courses were revised to identify areas into which the content of the IMCI community component could be integrated. The following learning objec- tives were proposed to ensure coverage of the necessary content areas. Students should be able to: 1. Discuss the epidemiology of the major causes of mortality and morbidity of under-5s in Sudan (diarrhoeal diseases, pneumonia, malaria, measles and mal- nutrition). 2. Discuss the rationale, objectives, ben- efits and components of IMCI strategy. 3. Describe IMCI programme in Sudan: objectives, strategies, activities, prob- lems of implementation and strategies to improve performance. 4. Explain the role of IMCI in ensuring the effectiveness, efficiency, equity, quality of care and sustainability of essential child health services. 5. Correctly perform the IMCI standard case management skills in outpatient settings. 6. Conduct needs assessment at primary health care facilities to identify IMCI service delivery problems in order to assist programme managers ensure the availability of essential supplies, equip- ment and training needs. 7. Plan interventions at first-level health facilities (based on needs assessment) to improve IMCI service delivery. The proposed plans should include: setting of objectives, strategies, plan of action (including health education to commu- nity members, training of health work- ers, monitoring, supervision, evaluation) and budgeting. 8. Identify, propose and (when feasible) implement interventions needed at dif- ferent levels to support the improvement of family and community practices re- lated to child health and development. Such interventions may include: Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 735 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما a. The provision of referral facilities that make it easier for families in rural areas to take their severely ill children to the referral facilities; b. Improvements at first-level health facilities, e.g. provision of IMCI guidelines, equipment and supplies necessary to perform the standard case management; c. Health education and counselling to mothers of children under 5 years, and other family and community members. 9. List and explain nationally adapted key family and community practices of IMCI to protect and promote child health. 10. Identify, plan and (when feasible) im- plement necessary actions within the family and community to support the improvement of key family and com- munity practices. 11. Communicate to families and communi- ties the necessary practices to protect and promote their children’s health. 12. Use locally adapted counselling aids (e.g. mother cards) to counsel family and community members Community-based courses into which the proposed content of the IMCI community component was integrated (Table 1) Introduction to medicine The first module in the whole programme of FMUG emphasizes to students the multi- disciplinary and multisectoral nature of health. Students conduct field visits to a variety of health-related governmental and nongovernmental institutions with the ob- jective of collecting data on their role(s) in community health. Students are required to present that information in a seminar and poster session. Among student groups that work in the Ministry of Health, one group is assigned to work in the IMCI programme. Such early exposure to IMCI is meant to orient students about the importance of comprehensive approaches to promote child health (objective 2) Integrated programme of field training, research and rural development The objective of this course is to provide practical field training to students in rural communities. Each group of 15–18 students Table 1 Modules in which community-based education is emphasised and into which the IMCI community component was integrated Module Semester(s) No. of weeks Credit hours Introduction to medicine 1 2 2 Integrated programme of field training, research and rural development 2, 4, 6 4, 5, 4 5, 4, 4 Doctor and society 3 3 3 Primary health care centre practice and family medicine 4, 5, 6, 7 Continuous 3, 3, 3, 3 Primary health care clerkship 7, 8, 9, 10 4 5 Rural residency 7 4 8 736 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما is posted in a village (population of a few hundred to a few thousand) where they conduct their field activities supervised by faculty staff. The course consists of the fol- lowing 3 phases. 1. Community diagnosis, through field surveys in which students use different data collection tools to identify priority health and related problems and associ- ated factors. These include a pre-tested questionnaire that addresses the knowl- edge, attitudes and key practices of fam- ilies regarding different dimensions of child health, according to the guidelines set by the Federal Ministry of Health. 2. Implementation of interventions ad- dressing identified problems and their determinants. 3. Evaluation of the outcomes and impacts of interventions. During all phases of the course, students conduct health education sessions targeting mothers and other carers of children under 5 years regarding key family and community practices affecting child health (objectives 7, 8, 9, 10, 11, 12). Doctor and society This module focuses on the teaching of: socioeconomic and demographic determi- nants of health and illness, communication methods and skills, health care services and providers, patient–doctor relationship, professional ethics and medicolegal aspects of the medical practice. Training on IMCI counselling skills (including role play) was introduced to the module content. IMCI literature was used to enrich the teaching of evidence-based determinants of child health (objective 12). Primary health care centre practice and family medicine A longitudinal programme is offered in 4 phases (semester 4, 5, 6 and 7), each with 3 credit hours. It consists of: • A theoretical component in the form of lectures, group discussions and dis- cussion of family problems. It covers: primary health care, general epidemiol- ogy, epidemiology of major diseases in Sudan, primary health care programmes and community-based initiatives in- volved in child health development (ob- jectives 1, 2, 3, 8, 9, 10, 11). • Primary health care centre training. Each group of 12–15 students are trained in 1 of 15 health centres in Wad Medani town where they perform all primary health care activities routinely delivered at the health centre, including growth monitoring, vaccination of children and IMCI standard case management (objectives 3, 10). • Family attachment. Each student is as- signed a family in the catchment area served by the health centre in which he/ she receives primary health care train- ing. A total of 500–600 families are covered by this programme annually. The student conducts scheduled visits to the family (4 times/semester) where he/she conducts assessment of health and related needs of the family and pro- vides health education and counselling according to the family needs. In case a family has 1 or more child under 5 years, the student should provide neces- sary support to assist the family adopt correct practices. Students use the IMCI mother card as an educational tool for family members (objectives.9, 10, 11). Primary health care clerkship This is offered as a block (5 credit hours) in semester 7. It comprises: • A theoretical component (lectures/dis- cussion) covering different aspects of the health system, principles and func- tions of health service management and Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 737 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما different health programmes in Sudan (objectives 2, 4, 5, 12). • Field training. Each group of 12–15 students conducts needs assessment of a certain health issue/problem using different methods of data collection, such as observation (using a checklist), review of the records, interview with health workers, focus group discussion with attendants in the health centre, and knowledge, attitude and practice surveys of families in the catchment area of the centre. One group of students assesses IMCI service delivery in one centre to identify factors related to IMCI serv- ice problems and the determinants of the existing practices of families in the catchment area (objectives. 6, 7, 8). • Exercises. Students construct a com- prehensive plan to solve the identified problems. The plan should include objec- tives, strategies, timetable of activities, training programme, health education programme for families, supervision, monitoring, budgeting and evaluation. • Seminars. Students present their work to the rest of the class and staff in a seminar and they write a comprehensive report of their work. Rural residency Students are distributed in groups of 5–10 to receive training in 25–30 rural hospital in Gezira state. The course objective is to expose students to real life situations of working in rural areas. Students are sup- posed to observe, assist and participate in all activities of the doctor(s) in charge and other medical staff, including supervision of primary health care units in the health dis- trict. Students should receive training in the IMCI standard case management (objective 4). Students are also required to conduct a small scale research project on a priority problem in the local communities. Many students study the issues of service delivery and the knowledge, attitudes and practices of community members regarding child health and development including care dur- ing illness (objectives 5, 6, 7, 8, 10, 12). Implementation of the curriculum Implementation of the described curriculum started on June 2001. All student batches (Table 2), to whom the above-mentioned courses were offered, received the new content areas and implemented the newly introduced activities. Implementation of the training package developed was facilitated by a committee that coordinated the role of the Gezira State Ministry of Health in the implementation of community-based cours- es of the FMUG. The Committee is headed by the dean of the faculty and includes in its membership staff from the Department of Community Medicine of FMUG, manag- ers of IMCI and other primary health care programmes, and directors of the preventive medicine and pharmacy directorates of the Gezira State Ministry of Health. The role of Gezira State Ministry of Health included the provision of information, education and communication (IEC) material (e.g. mother cards), IMCI wall charts and chart booklet. Also, student training in primary health care facilities and rural hospitals is exclusively provided by staff of the Gezira State Min- istry of Health. Impact of student interventions on family practices A study conducted in Wad Medani town (2001–2002) compared the performance of certain IMCI key family practices between 738 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما families visited by students from FMUG (cases) as part of their training in primary health care centre practice and family medi- cine and families that were not visited by students (controls); 240 students were in- volved in the study [7]. Each student usually collects baseline sociodemographic data to identify the health and related problems and analyses associated factors with family members with the objective of identifying and planning necessary actions. During the regular planned family visits, the student should provide follow-up, reinforcement and support to family members to enable them to acquire recommended behaviours. Results of the study are presented in Table 3 and clearly indicate the significant improve- ment in family practices in families visited by students compared with those families who were not visited. Discussion Since all 3 components of IMCI are inter- related and integrated, this concept should be understood and accepted by medical students who are future policy-makers and planners of health development. This ap- proach is expected to produce graduates who are committed to the implementation of all IMCI components together in support of each other. It is also expected to influ- ence the attitudes and performance of future health professionals at different levels of the health system in support of the improve- ment of child health care services and the protection and promotion of child health and development. The innovative curriculum of FMUG provided a suitable environment to imple- ment the IMCI community component in pre-service training because of the follow- ing factors. • Specific learning objectives of the whole FMUG programme (including commu- nity-based education) are well written and documented. The objectives are flexible and thus can accommodate new health concepts and initiatives, such as IMCI. Table 2 Numbers of students for whom the IMCI community component was integrated in pre-service training and the number of community settings in which they were trained Name of module Number of student Total number of batches (students/ families/villages/ batch = 250–270) health centres in which students were trained Introduction to medicine 6 NA Interdisciplinary field training research and rural development programme 4 63 villages Doctor and society 3 NA Primary health care centre practice and family medicine 6 1200–1320 families Rural residency 3 24–28 rural hospitals Primary health care clerkship 6 15–18 health centres NA = not applicable. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 739 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما • Community-based courses already in- cluded educational activities in families, communities and primary health care facilities in both urban and rural areas. • Existing community-based education activities were well planned, organized and supervised by faculty staff and field supervisors. • The early exposure of students to the community (see Table 1) facilitated their acquisition of communication, leader- ship, teamwork and competencies in community mobilization. Before going into the family attachment, students are trained in communication skills in semester 3 in the module Doctor and society. Training in counselling has been added recently to this module, including role plays from the IMCI module Coun- sel the mother. • Training in standard case management skills in the health centres (semesters 6 and 7) in the module Primary health care centre practice and family medi- cine precedes the consolidation of this process in the paediatric clerkship (se- mesters 8,9 and 10). The curriculum implemented has the following characteristics. • It reflects the flavour and essence of IMCI: the integration of case manage- ment, improvement of the health sys- tems and primary health care facilities, and improvement of family and com- munity practices. • Specific learning objectives cover the 3 main cognitive, affective and psycho- motor domains of learning objectives. • Maximum use was ensured of differ- ent educational activities such as health centre training, family attachment, resi- dence in villages and rural hospitals, problem-based learning and lectures. • The long duration of contact between students and families (a minimum of 16 family visits, 2 hours each and 3 residenies in rural communities, 7, 5 and 4 days each) greatly facilitated the stu- dents’ learning and impact on families and communities. • Incorporation of the new package did not result in an extra academic load on the students, nor did it create additional Table 3 Practices of families visited by students compared with those of families not visited by students Indicator Families visited Families not P-value by students visited by (cases) (%) students (controls) (%) Families in which children under 5 years and pregnant women sleep under an insecticide- treated bed net 58.0 26.3 0.002 Mothers practising exclusive breastfeeding 54.2 35.7 0.0129 Families following correct nutritional practices for their children under 5 years 69.1 40.2 < 0.0001 Children under 5 years who completed their immunization (according to age) 87.0 68.3 0.0027 Children under 5 years who received timely vitamin A supplementation 69.1 27.6 < 0.0001 740 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما educational activities in the already con- gested faculty programme. • The teaching of currently existing ob- jectives (e.g. objective 1), regarding the epidemiology of the major causes of mortality and morbidity in under-5s in Sudan, which already existed in the curriculum, was strengthened by giving the students examples of evidence from IMCI literature. • Assessment of the students on the con- tent related to the IMCI community component made use of the same meth- ods and tools that are routinely used in all the courses. The National and Gezira State IMCI programmes provided support in the form of: mother cards and case management wall charts in all health centres where stu- dents receive training. Another aspect of partnership between FMUG and the health authorities is that students are trained and supervised in the health centres by Ministry of Health staff. As part of their health cen- tre training, students perform vaccination, vitamin A supplementation and growth monitoring of under-5s which are all core activities in IMCI standard case manage- ment. Constraints Although no extra human resources were needed through all stages of the implemen- tation of this programme, the training in the IMCI case management skills in the health centres and rural hospitals was handicapped by the fact that some doctors and medical assistants working in those facilities did not routinely implement the IMCI algorithm even if they were trained in IMCI standard case management. This greatly affected students’ achievement in that important is- sue in spite of the fact that students work in smaller groups in the health centres (3–4) and rural hospitals (5–12), and therefore have better opportunities to practise the clinical skills of the standard case manage- ment. Such training, if well implemented, could provide a strong foundation of clini- cal competence for the students, which would be reinforced later during the paedi- atric clerkship where students are trained in bigger groups (15–20). Rapid turnover of trained staff is another major impediment to both service delivery and pre-service training. Furthermore, for those still in service the increased demand on their time related to training students on the IMCI approach is a constraint, espe- cially in maintaining quality. Training materials were always avail- able on time because of the assistance of the federal and Gezira state ministries of health, but FMUG faced a considerable fi- nancial burden for the repeated photocopy- ing of mother cards and other IEC material which students used to give to families and community members during their family attachment and village posts. FMUG have used IMCI-trained part-time staff from the Ministry of Health which added more costs. These financial outlays may have an impact on the sustainability of the programme. A final constraint was the number of students. Due to the large numbers in the different batches, it was difficult to provide enough opportunities for the students for practical training in counselling skills. Conclusion Students within the community-based edu- cation programme made an effective con- tribution to the target of improving IMCI family and community practices. Moreover, this programme provided the students with both theoretical and practical field training in different aspects of the management of Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 741 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما IMCI services, which is necessary for future policy-makers and programme managers. Ensuring the availability of learning mate- rials and overcoming a shortage of IMCI- trained instructors and tutors are the main challenges to sustaining this programme. References 1. IMCI information. Planning national im- plementation of IMCI. Geneva, World Health Organization, 1999 (WHO/CHS/ CAH/98.1C) (http://www.who.int/child-ad- olescent-health/New_Publications/IMCI/ WHO_CHS_CAH_98.1/Rev99.C.pdf, ac- cessed 6 September 2007). 2. IMCI information. Introducing IMCI into pre-service training for health profes- sionals. Geneva, World Health Organ- ization, 1999 (WHO/CHS/CAH/98.1J) (http://www.who.int/child-adolescent- health/New_Publications/IMCI/WHO_ CHS_CAH_98.1/Rev99.J.pdf, accessed 9 September 2007). 3. Fulop T. Health personnel for tomorrow; the great challenge of the health for all movement. Manila, World Health Ogani- zation Regional Office for the Western Pacific, 1985 (WHO/WRP/HMD/NF.4). 4. Magzoub MM. Studies in community- based education programme implemen- tation and student assessment at the Faculty of Medicine, University of Gezira, Sudan [thesis]. Maastricht, Maastricht University, 1994. 5. IMCI information. Update on development projects to support IMCI. Geneva, World Health Organization, 1999 (WHO/CHS/ CAH/98.1H) (http://www.who.int/child-ad- olescent-health/New_Publications/IMCI/ WHO_CHS_CAH_98.1/Rev99.H.pdf, ac- cessed 9 September 2007). 6. IMCI information. The role of IMCI in im- proving family and community practices to support child health and development. Geneva, World Health Organization, 1997 (WHO/CHS/CAH/98.1G) (http://www.who. int/child-adolescent-health/New_Pub- lications/IMCI/WHO_CHS_CAH_98.1/ Rev99.G.pdf, accessed 9 September 2007). 7. Abdelrahman SH, Yousif MEA. The pro- motion of family health through an inno- vative training programme in the Faculty of Medicine University of Gezira, Sudan. Paper presented at the 6th Scientific Meeting of the Saudi Society of Family and Community Medicine, Riyadh, Saudi Arabia, 2003. 742 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Case report Perforated tuberculous appendicitis and peritoneal tuberculosis T. Dogru,1 A. Sonmez,1 I. Tasci,1 G. Yagci2 and M.R. Mas1 1Department of Internal Medicine; 2Department of Surgery, Gulhane Medical School, Ankara, Turkey (Correspondence to I. Tasci: ilkertasci@yahoo.com). Received: 18/01/06; accepted: 27/03/06 Introduction Appendicitis caused by Mycobacterium tuberculosis is extremely rare and its pres- entation is atypical [1]. We describe a pa- tient with peritoneal tuberculosis (TB) and perforated tuberculous appendicitis, who was investigated for vague abdominal dis- tention and weight loss. The presentation of types of TB of the appendix and the role of cancer antigen-125 (CA-125) in the diagno- sis and follow up of gastrointestinal TB are discussed. Case report A 48-year-old man was admitted to the Department of Internal Medicine, Gulhane School of Medicine in September 2003. He had a 2-month history of fatigue, ano- rexia, marked weight loss and progressive abdominal swelling. His medical history was unremarkable. The physical examina- tion showed paleness of the conjunctiva and skin, and diffuse non-tender abdominal distention. Abnormal laboratory results were: hae- moglobin 10 g/dL, erythrocyte sedimenta- tion rate 80 mm/h, eosinophil count 16%, and serum CA-125 196 U/L (normal < 35 U/L). Urine and sputum TB cultures and tuberculin skin test were negative. Chest roentgenogram was normal. Abdominal ultrasonography showed extensive ascites and septations but no masses. Computed tomography did not reveal any additional findings. Ascites was haemorrhagic in appearance and the following results were found: white blood cell count 0.4 × 109/L (80% lym- phocytes), glucose 41 mg/dL, total protein 5.4 g/dL, albumin 2.5 g/dL and amylase 10 U/L. The serum/ascites albumin gradient was 1. The following tests in the ascites fluid were also negative: microbiological analy- sis including acid-fast bacilli, polymerase chain reaction test for M. tuberculosis, and cytological examination. Upper gastrointestinal endoscopy and colonoscopy were normal. Exploratory laparotomy disclosed massive haemorrhag- ic ascites, and a thickened, inflamed and adhesive peritoneum. The appendix was perforated and a plastron was observed. Multiple biopsies were obtained, and omen- tectomy, debridement and appendectomy were performed. Histological examination of the specimens from the appendix and peritoneum revealed numerous caseating granulomas with acid-fast bacilli (Figures 1 and 2). The patient was diagnosed with gas- trointestinal TB and underwent 2 months intensive treatment with 4 antituberculous drugs (isoniazid 300 mg, rifampin 600 mg, ethambutol 1000 mg and pyrazinamide Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 743 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 2000 mg daily) followed by a 4-month course of isoniazid 300 mg and rifampin 600 mg daily. Serum CA-125 levels re- turned to normal at the end of the third month of therapy (18 U/L). He adhered fully to the treatment. The drugs were well tolerated and no side-effects were observed during the entire course of therapy. During the 12-month follow-up all complaints of the patient resolved, he gained weight and no ascites was detected. Discussion Tuberculous appendicitis is an extraordi- nary clinical condition, which is more prev- alent in regions with endemic TB [1]. When a site of infection is detected elsewhere in the body, the case is named as “second- ary” tuberculous appendicitis; otherwise the condition is called “primary” tuberculous appendicitis. Our patient had tuberculous peritoni- tis accompanied by perforated appendix proven by biopsy to be TB. Because of this coincidence it is not easy to determine whether this was a complicated case of primary tuberculous appendicitis or the appendicitis occurred secondary to tuber- culous peritonitis. Tuberculous appendicitis usually presents a nonspecific clinical pic- ture such as mild intermittent right iliac pain or is diagnosed incidentally after a latent asymptomatic period [2]. Therefore, tuber- culous appendicitis secondary to peritoneal TB seems to be more likely in our case. Culture of the ascitic fluid, sputum and urine for TB as well as the tuberculin skin test were all negative, and the chest X- ray was normal. Thus, diagnosis of TB could only be established by detection of caseating granulomas and acid-fast bacilli in the appendix and peritoneum. Difficul- ties in demonstrating the bacilli have been reported and histopathological examination may offer a more definite diagnosis in gas- trointestinal TB [3]. The presence of high CA-125 levels also strengthened the diagnosis of TB in our patient. CA-125 is a high molecular weight glycoprotein, which is mostly used as a marker for the diagnosis of gynaeco- logical and non-gynaecological malignant disorders and relapses [4]. Moreover, we and others have demonstrated that serum CA-125 can also increase in tuberculous peritonitis and will decrease and even nor- Figure 1 Granuloma with caseous necrosis of the appendix (H&E × 25) Figure 2 Caseating necrosis with inflammatory infiltration of the peritoneum (H&E × 25) 744 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما malize with anti-TB therapy [5]. Indeed, serum CA-125 levels in our patient returned to normal after 12 weeks of treatment. Thus, current data indicate that determination of serum CA-125 concentration can be used in tuberculous peritonitis, not only to make an accurate diagnosis and ascertain the activity of the disease but also to follow the response to treatment. In conclusion, we report an atypical presentation of a perforated tuberculous appendicitis accompanying peritonitis. TB, a highly prevalent disease in low-income countries, can mimic many other chronic diseases, and should always be considered in patients with abdominal pain of undeter- mined origin. References 1. Singh MK, Arunabh V, Kapoor VK. Tu- berculosis of the appendix. A report of 17 cases and a suggested etiopathologi- cal classification. Postgraduate medicine journal, 1987, 63:855–7. 2. Askari A, Coventry P, Perks WH. Primary tuberculous appendicitis. Postgraduate medicine journal, 1993, 69:411–2. 3. Uygur-Bayramicli O, Dabak G, Dabak R. A clinical dilemma: abdominal tubercu- losis. World journal of gastroenterology, 2003, 9:1098–101. 4. Bergmann JF et al. Elevation of CA-125 in patients with benign and malignant ascites. Cancer, 1987, 59:213–7. 5. Mas MR et al. CA-125: a new marker for diagnosis and follow-up of patients with tuberculous peritonitis. Digestive and liver disease, 2000, 32:595–7. World TB Day 2008 The slogan for World TB Day 2008 on 24 March was “I Am Stopping TB”. It marked the start of a 2-year campaign that belongs to people everywhere who are doing their part to Stop TB. It reflects the reality that every one of us – health leaders, health workers, patients, fami- lies and community members – has a role to play to stop TB. The Stop TB unit in the WHO Regional Office for the Eastern Mediterra- nean is planning this year to launch the Regional STOP TB partnership aimed at gathering the efforts of all partners in the Region to partici- pate in stopping TB. Further information about the fight against TB in the Region can be found at: http://www.emro.who.int/stb/ Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 745 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Case report Alkaptonuria in a 5-year-old boy in Iraq S.H. Al-Mefraji 1 1Genetic Subspeciality Clinic, Department of Paediatrics, College of Medicine, Al-Nahrain University, Baghdad, Iraq (Correspondence to S.H. Al-Mefraji: sabeehamefraji12@yahoo.com). Received: 13/12/05; accepted: 15/02/06 Introduction Alkaptonuria is a rare inherited genetic dis- order of tyrosine metabolism that causes the urine to turn black on contact with the air when homogentisic acid is oxidized to form a pigment-like polymer material [1,2]. The earliest sign of the disorder is the tendency for babies’ diapers to stain black; later on in childhood and early adulthood, there is an asymptomatic, progressive deposition of the polymer into collagenous tissues [2–4]. One report suggests an incidence as high as 1 in every 25 000 live births, although worldwide it is certainly far lower [1,4–6]. Our objective in reporting this case study is to highlight the importance of early detec- tion of the disease by paediatricians, to raise awareness and to prevent late complications by simple treatment. Case report Our patient was a 5-year-old boy, from a first-cousin consanguineous couple. The mother had a full-term normal vaginal de- livery at hospital, with routine labour and a healthy postnatal period. After the first few months of the baby’s life, the mother noticed a dark black colour on the diapers, some time after urination or a change of urine colour on ferric material when he uri- nated outside the bathroom; otherwise, the child was normal. The couple consulted our subspecialty clinic in Al Kadhimia hospital for genetic counselling because they had suffered secondary infertility with 2 abor- tions. They became increasingly anxious about the dark-coloured urine when the new baby was 6 months of age. They became concerned that he might have the same problem, so they finally consulted our clinic for investigation and counselling. Clinical examination recorded a boy, 5 years old, active, alert, with no pallor and no jaundice. Development was normal. All growth parameters on the chart were within the normal range for age. Chest, heart and abdominal examinations were normal. Ex- amination of joints was normal, so too was the neurological examination. Investigations were performed as fol- lows. On testing urine for reducing sub- stance, Benedict’s reagent gave a strong positive. For urine and serum chromatogra- phy, the homogentisic acid level was very high. Other items were normal. After urina- tion on a diaper, we observed the colour change to black. We talked to the parents and informed them that the diagnosis was alkaptonuria. We referred the child to the ophthalmolo- gist for baseline examination, which was normal, showing no depositions. Echocar- diography results were also normal. Treatment was started with vitamin C (1 g/day). This is a large amount since if there is a delay in diagnosis and treatment of this disease it can result in arthritis and ochronosis (darkening of the tissues) due 746 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما to the slow accumulation of the dark poly- mer of homogentisic acid in cartilage and other mesenchymal tissue; this leads to dark blackened spots in the sclera, cornea, ear cartilage and arthritis with advancing age especially in men, with a high incidence of heart disease [4,6]. Discussion Alkaptonuria is a rare autosomal recessive disorder of inborn error of metabolism as a result of deficiency of the homogentisic acid oxidase enzyme [7]. A literature re- view for the last 3 years revealed that the reported cases are few and often present late; for example, Yoshikai et al. reported a 65-year-old male with aortic valve re- gurgitation and inferior myocardial infarc- tion [8,9]. Another study presented 5 cases with ochronosis and joint pain [10], while Kazancioglu presented a 33-year-old male with end-stage renal failure [11]. Others like Chevez present pigmented conjunctival lesions [12]. Our patient was also male, only 5 years old, and with early detection we can protect him from all the above-mentioned complications of ochronosis by giving him high doses of vitamin C. Early detection is better than treating late complications. It is recommended that families investigate sus- pected cases in new babies to ensure early detection. References 1. Biochemical genetics, disorder of me- tabolism. In: Jorde LB et al., eds. Medi- cal genetics, 3rd ed. St. Louis, Missouri, Mosby, 2003:136. 2. Roth KS et al. Alkaptonuria, last updated 22 May 2007. emedicine [website] (http:// www.emedicine.com/ped/topic 1464.htm, accessed 12 August 2007). 3. Phornphutkul C, Introne WJ, Perry MB. Natural history of alkaptonuria. New Eng- land journal of medicine, 2002, 347:2111– 21. 4. Iraj RDS. Metabolic diseases. In: Klieg- man B, ed. Nelson textbook of pediatrics, 16th ed. Philadelphia, WB Saunders, 2000:349. 5. Mueller RFD, Young ID. Emery’s ele- ments of medical genetics, 10th ed. Edin- burgh, Churchill Livingstone, 1998:155. 6. Connor JM, Ferguson-Smith M. Essential medical genetics, 5th ed. Oxford, Black- well Scientific, 1997. 7. Elcoglu N et al. Alkaptonuria caused by compound heterozygote mutations. Ge- netic counselling, 2003, 14(2):207–13. 8. Yoshikai M, Murayama J, Yamada N. Aortic valve regurgitation in alkaptonuria. Journal of heart valve disease, 2004, 13:863–5. 9. Erek E, Vanermen H. Cardiac ochronosis: valvular heart disease with dark green discoloration of the leaflets. Texas Heart Institute journal, 2004, 31(4):445–7. 10. Suwannarat P et al. Minocycline- induced hyperpigmentation masquerad- ing as alkaptonuria in individual with joint pain. Arthritis and rheumatism, 2004, 50(11):3698–701. 11. Kazancioglu R et al. Alkaptonuria and renal failure: a case report. Journal of nephrology, 2004, 17(3):441–5. 12. Chévez-Barrios P, Font RL. Pigmented conjunctival lesion as initial manifestation of ochronosis. Archives of ophthalmology, 2004, 122(7):1060–3. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 747 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Letter to the Editor Sir I have read various articles on community health in the Eastern Mediterranean health journal. I have also noticed that many of the universities in the Eastern Mediterranean Region offer programmes in public health/ public health dentistry. I would like to bring to your notice the situation in India. In India, postgraduate degrees are provided in various specialties, community medicine or public health being one among them. Doctors and dentists are trained for a period of 3 years mainly in epidemiology and prevention of diseases with an emphasis on preventive methods. Other core areas of training in the specialty include planning, management, survey pro- cedures, sociology and biostatistics. The field training involves conducting regular treatment camps where the postgraduate students and staff in the specialty of com- munity medicine visit various rural and remote areas using mobile units and provide treatment free of charge to the needy who do not have access to medical/dental care. They also deliver health education. The camps usually provide both medical and dental treatment. The dental camps are sponsored by various organizers and are conducted in various public places, such as government schools, which are accessible to the general public. In the field of commu- nity medicine, common ailments are treated and immunization is provided The treatment provided in the dental camps is mainly extractions, restorative procedures like amalgam and temporary fillings, sealant applications, paedodontic procedures and oral prophylaxis. Atrau- matic restorative treatment procedures are also performed. It would be useful if a component of medical/dental outreach camp training and medical/dental health education delivery were made mandatory in the curriculum of students in the Eastern Mediterranean Region. It would not only benefit patients in rural areas, but would help the students to become competent in field training and prepare them for success as public health professionals. Meghashyam Bhat Assistant Professor, Department of Community Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka State, India (msyamb@yahoo.com). 748 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Guidelines for authors 1. Papers submitted for publication must not have been published or accepted for publication elsewhere. The Eastern Mediterranean Regional Office reserves all rights of reproduction and republication of material that appears in the Eastern Mediterranean health journal (EMHJ). 2. Original papers written in Arabic, English or French may be sent for consideration to the Editor-in-chief, Eastern Mediterranean health journal, WHO Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City (11371), Cairo, Egypt. Papers can also be submitted by email to EMHJ@emro.who.int. Papers will be abstracted in all three languages. 3. The subject of the paper should pertain to public health or some other related technical and scientific subject within the field of interest of the World Health Organization, with special reference to the Eastern Mediterranean Region. 4. Three copies of each manuscript should be provided. The text, together with the accompanying tables and figures, should not exceed 15 double-spaced typewritten or printed A4 pages (4500 words) and should be printed on one side only. When the manuscript is accepted or conditionally accepted, the author will be requested to submit a 3.5 inch computer diskette containing the text, tables, graphs and illustrations. For English and French papers, please provide the text, upon the editor’s request, in both wordprocessed format (we prefer Microsoft Word for the PC but can translate most other formats) and also saved as a text/ASCII file. Papers submitted in Arabic should follow the same guidelines as papers written in English or French. If the paper is a translation of all or part of another unpublished work, a copy in the original language should be submitted too. Where possible, graphs should be provided in Harvard Graphics under Windows or Excel, and the illustrations and photographs should be provided in EPS or TIFF format. However, it is necessary to provide three sets of original photographs and figures with the background data. If there is any text or lettering on the photographs, an additional clean set should be provided without the text/lettering. 5. All papers received will be peer reviewed, and on the basis of the reviewer’s comments, the Editorial Board reserves the right to accept or reject any paper. Papers are accepted on the understanding that they are subject to statistical and editorial revision as deemed necessary, including abridgement of the text and omission of tabular or graphic material. 6. The title of the paper should be as concise as possible, preferably around 10 words, and should be placed on a separate sheet, together with the full name(s) of the author(s), institutional affiliations(s) and highest scientific degrees obtained. The mailing address, as well as any other contact information (email address, fax, telephone) of the corresponding author should be provided. The number of authors should not exceed five. All authors should have made material contribution to either the design, analysis or writing of the study and have approved the final version submitted. Authors may be asked to verify their contribution. Other names may be included in the acknowledgements. 7. To facilitate the translation of abstracts and authors’ names, authors whose mother tongue is written in Arabic characters and writing in English or French should supply their full names in Arabic script and provide transliterations. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 749 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 8. Papers reporting original research findings should follow the IMRAD format: Introduction; Materials (subjects) and methods; Results; Analysis; and Discussion. An abstract of no more than 100 words should be supplied, clearly and briefly stating the objectives, context, results and conclusions. 9. Authors should verify where appropriate that all persons on whom research has been carried out have given their informed consent, and where participants (living or dead) were unable to give such consent, that surrogate consent was obtained. 10. Review articles should contain sections dealing with objectives, sources, methods of selection, compilation and interpretation of data and conclusions. 11. In-text citations of published works should be limited to essential up-to-date references. Apart from review articles, a maximum of 25 references is advisable. They should be numbered separately as they occur in the text with sequential Arabic numerals in parentheses [square brackets]. These references should appear in a numbered list on a separate page at the end of the paper. They should contain the following elements of information as appropriate: name(s) and initial(s) of author(s); title of paper or book in its original language plus translation; complete name of journal plus volume number and page range; name of publisher (commercial or institutional) and place of publication (city and country); and date of publication. Papers with inadequate references or references not arranged according to these principles will be returned to the author for correction. The following are examples of the Journal’s preferred style: Book: Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990. Journal article: Jones A et al. One day in Tibet. Journal of tautology, 1993, 13(5):23–7. Document: Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization, 1985 (document WHO/DOC/537). 12. Figures and tables with appropriate captions should each be on a separate sheet, numbered sequentially with arabic numerals and attached to the end of the paper. Each figure and table should be referred to in the text and its placement in the text should be clearly indicated where appropriate. Where appropriate, sources should be given for each figure or table. If any figures, tables or other materials have been copied from other sources, authors have the sole responsibility for securing the necessary permission. In order to avoid layout problems in final production tables and figures should be limited as far as possible. Not more than one table or figure per 1000 words is preferable. Figures derived from data must be accompanied by those data to enable redrawing if necessary. 13. 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Requests for further reprints and pricing information may be obtained from the Editor-in-chief. 750 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما œiÇJ™=±fn¶ÍÉVr¶=Í·=  «¶Ö»·¶ÍÈa>meC¸Ñ×a  .3f[]AÁ>[³ºË?›f[n¿·¶K·F®Æ?Lfn¾b®(fn¿·¶ͺçb¯™=L>®eǶ=ÁdzI×Á?ʧF¿È*Ê[»É·®Ý=G[J³™= «J[ŒÆ ›f[n¿I[¶=a=Ç[™=fn¾Ìa>¢CÆ?`>j¿Ji=±Ç¯U¤É»|œiÇJ™=±fn¶Íə>£¶=ÍVr¶=Í»Ÿ¿™[r¶=Í[·=±f[n¶ÍÉV œiÇJ™=* .4f[Èf€kÉ[Ñe¸ßFå®Àº>ÃɪfŸ¿·¶(ÍÉj¾f«¶=Æ?(ÍÈhÉ·³¾Ý=Æ?(ÍÉEf£¶>EÍEÇJ³™=(ÍÉ·qÙ=L>®eǶ=¸ifIÁ?À³•Í[·= œiÇJ™=±fn¶ÍÉVr¶=t(œ[iÇJ™=±f[n¶Íə>£¶=ÍVr¶=Í»Ÿ¿™ʻɷ®Ý=GJ³™>E(*H%*98<:$f[r¾Í[¿Èb’( %33593$(ÌfÂ>¯¶>E(frº›*PØN¶=L>§·¶>E(L>®eÇ·¶L>qØ]¼Èb¯I¼JÈÆ* .5L×>[>EÍ·[qÄ[¶(f[]AÊ[»·¢Æ[¯IÁ=bɺË?Æ?(Íɺǻ£¶=ÍVr¶=¹>ð>É»J¿ºL>®eǶ=¥ÇuǺÁdzÈÁ?ʧF¿È œiÇJ™=±fm¼É·®C‘Ct>]¸³nEÌe>mÝ=¤º(Íə>£¶=ÍVr¶=Í»Ÿ¿™ÍÉ»ÂÙ=L=c* .6ØM¼Èb¯IʧF¿ÈÍ[¢ÇFìºÆ?Í{Ç쇸²Àº_j¾P*L>ºÇ[if¶=Æ(¹Æ=b[‚=¤[º(s¿[¶=Ïb[£JÈ×Á?Ê[§F¿È>[»² (ͯª=f™=37¤[쯶=À[º(f[ìi¸[²À[ÉEÀ[É·q>ªµfI¤ºÍFI>³¶=ͶÛ=η¢Í¢ÇFìºÍV«qA4%67<<Í»·²$( ÍV«r¶=Àºœ¯ªbU=ÆÄQÆη¢Í¢>Fì¶=ÁdzIÁ?Æ*™=Á@E¬¶Ö™=ÁØ¢C¼JÈ>ºb¿¢Æ>[ÇF®b[®>úçb®¶=Í¢ÇFì ÊEÇi>Utf®½ëb¯ÈÁ?ʧF¿È(ÆfnE>ÇF®Æ?(fmÁÆaÀº%5,7ÍqÇE$½Ç[if¶=Æ(¹Æ=b[‚=Æ(s¿¶=À»vJÈ( ÍÉVÉuÇJ¶=ÆÍɾ>ÉF¶=*Á?(fÈfVJ¶=kÉÑeG·{η¢âÐ>¿E(ÎQfÈ(ÍÉj¾f«¶=ÆÍÈhÉ·³¾Ý=J§·¶>Eͺçb¯™=L>®eÇ·¶ÍFj¿¶>EÆ ¼Èb¯I¼JÈL>[»·³¶=Í[‚>£ºÍ[§Éq(Àºú¸ ²›(s¿¶=%Í[¯É®b¶=Í[¿É·¶=L>[»·³¶=Sº>[¾fE½=b^J[i=À[³º?Ç[¶=dçFUÆ Microsoft WordÏf[]Ù=¨É[r¶=Í[ÉF¶>¦¼[Q¾Á?À[³•>[¿¾?¦(Êr^n¶=HÇi>V·¶ÍFj¿¶>E($¸³[m›Æ( s¿²žÇ«†+L>ºÇ·£™=¹a>FJ¶Êi>ɯ¶=ʳÈfºÙ=adz¶=¬·ºASCII%ʳi?$*›L=a>[meÝ=k[«¾¥>[FI=ʧF¿ÈÆ ÍÉEf£¶=ͧ·¶>Eͺb¯™=L>®eǶ>E°·£JÈ>º*(f[n¿Èf[]A¸[»£¶Í[ÉÑhQÆ?Í[É·²Í[–fIÊÂ(ͺb¯™=Í®eǶ=K¾>²=cCÆ ÍÉ·qÙ=ÄJ§¶›(¸»£¶==dÂÀºÍ^j¾¼Èb¯IʧF¿Éª*½Ç[ie¸³[m›Í[ɾ>ÉF¶=½Çif¶=ÁdzIÁ?¸v«È(À³º?>»NÉUÆ F¶=ae>ªe>Âdª=Ç¿¶=Sº>¾fE½=b^Ji=¤º(Í[ɾ>ÉWindows¸ j²CÆ?ExceleÇ[r¶=ÆÍ[[ÉVÉuÇJ¶=½Ç[if¶=¼Èb¯IÆ( ͧÉq›Íɪ=f¦ÇIÇ«¶=EPSÆ?TIFF*Í[ɪ=f¦ÇIÇ«¶=eÇ[r¶=À[ºL>[¢Ç»…PØ[M¼Èb[¯IËeÆf[v¶=À[ºÄ[¾?>[»² ÍÉi>iÙ=L>É죙=¤º(ÍÉ·qÙ=L>ºÇif¶=Æ*J³º­ÆfUÆ?s¾Ë?aÇQÆͶ>U›Æ¼Èb[¯IʧF¿Éª(eÇr¶=η¢ÍEÇ ÍEÇJ³º­ÆfUË?Æ?¥ÇFìºs¾Ë?ÀºÍɶ>]Íɪ>uCÍ^j¾* .7°[}f[ÈfVJ¶=Í[ÒÉ «J[€(Í[£Q=f™=Åd[ÂÐÇu›Æ(Ðغh¶=¸ßFå®ÀºͯɮaÍ£Q=fºͺçb¯™=L>®eǶ=¤É–Í£Q=fº¼JÈ Í®eÆË?xªeÆ?¹ÇF®*¼Jȶ=L>®eǶ=¤É–Á?ÄÉ·¢°«J™=ÀºÆ(Í[ÈfÈfVJ¶=ÆÍÉÑ>[rUÝ=Í[£Q=f»·¶¤[v(>ÇF® Íɾ>ÉF¶=½Çif¶=Æ?¹Æ=b‚=x£E­dUÆ?(s¿¶=e>rJ]=´¶c›>’(½h·È>ºGj}* .8ʶ=ÇUÁ>²Ƕ=dçFUÆ(¥>ìJj™=eb®η¢ð=frJ‡Í®eǶ=Á=Ç¿¢ÁdzÈÁ?ʧF¿È3<Í[®eÆη¢GJ³ÈÁ?Æ(L>»·² ¬¶Ö™=¼i=bÈb€¤º(Í·r«¿º%«¶Ö™=Ð>?Æ?$[¶=Í[É»·£¶=L>Qeb[¶=η¢?Æ(Í«·J^™=L>ji֙=›¼ÃJÈÇv¢Æ( >ÃÉ·¢=Ç·rU*¬¶Ö™>[E¹>[rIضͺgض=Ïf]Ù=L>ºÇ·£™=Æ(Ëbȶ=Á=Ç¿£¶=f²cʧF¿È(´¶d²%(Ê[¾Æ³¶Cb[ÈfE ¬I>Â(k²>ª*$Íj˜η¢«¶Ö™=ab¢bÈhÈ×Á?G‹Æ*ib®=ǾdzÈÁ?bE×ÆÆ?O[VF¶=¼É»rI›ð>£É–=Ç»Â> Í[ºçb¯™=Í[ÉÑ>ÿ¶=Í^j¿¶=η¢ð>£É–(=ǯª=Æb®=ǾdzÈÁ?Æ(ÄJE>J²Æ?ÄRÑ>J¾¸É·€*L>[FMC«¶Ö[™=À[ºG[·ìÈb[®Æ ÅǺçb®Ëd¶=½>ÃiÝ=*Í®eǶ=ͺëb¯º›ÁdzI¶=f³n¶=L=e>F¢‘CÏf]?Ð>?T=eaCÀ³•Æ* .9ÆÁÇFJ³ÈÆ(ÍÉEf¢­Æf}GJ³I½Ù=¼ÃJ§¶ÁdzIÀÈd¶=«¶Ö™=η¢(«¶Ö™=Ð>?ÆL>q؄=͖fIjÉI¸Q?Àº ­Æfƒ>[E¼[M(ÍÉEf£¶=­Æfƒ>EÍEÇJ³º(Í·º>²¼ÃÑ>@EfÈfVJ¶=ÊjÉÑe=ÆaÆhÈÁ?(ÍÉj¾f«¶=Æ?ÍÈhÉ·³¾Ý>E¼ÃI>«¶Öº ÍÉ¿ÉIض=* Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 751 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما .:Èe>¯I¸ëN“¶=L>®eǶ=ʶ>[J¶=G[ÉI¶>EG[J³IÁ?ʧF¿È(ÌbÈb‚=PÇVF¶=SÑ>J¾¹ÇUf6a=Ç[™=7Í[ºb¯™=%¤É[u=Ǚ=$ Ín®>¿™=Æ7¸É·VJ¶=7SÑ>J¿¶=7±fì¶=Æ*Î[·¢b[ÈhI×(>ÿº¸³¶ÍqØ~L>®eǶ=Åd¤«nIÁ?ʧF¿ÈÆ3<<(Í[»·² L>Q>J¿Ji×=Æ(SÑ>J¿¶=Æ(±>Éj¶=Æ(­=bÂÙ=(g>‹DEÆ(\ÇuÇEÀäÉFI* .;η¢ÍÉ¢=Æͯª=Ǻ=ǯª=Æb®(OVF¶=¼ÃÉ·¢ËfQ?ÀÈd¶=t>^mÙ=¤É–Á?(½h·È>ºGj}(ÁÇ«¶Ö™=KFNÈÁ?ʧF¿È ²e>n™=ͯª=Ǻη¢¹Çrƒ=ed£IͶ>U›Æ(´¶c%L=Ǻ?Æ?Ð>ÉU?$¹Ç[rƒ=b[®Ä[¾?ÁÇ«¶Ö™=KFNÈÁ?ʧF¿È( ¼ÃJMeÆÆ?¼ÃÑزÆͯª=Ǻη¢* .3<IÁ?ʧF¿ÈÍ[ɶ>J¶=>[¯¿¶=(ÍÉ[u>™=Í[£Q=f™=Æz=f£Ji×=L×>¯º¹Æ>¿J6¤[É»(Ð>[¯J¾×=±f[{(ea>[r™=(­=b[ÂÙ= L>Q>J¿Ji×=Æ>Âj«IÆL>É죙=* .33ÍÉ[i>iÙ=Í[NÈbƒ=¤[Q=f™=Î[·¢(s¿[¶=›(ÌeÇ[n¿º¹>[»¢?Ë?Àºa>ÃnJi×=frJ¯ÈÁ?ʧF¿È*Ìa>[ÈhEX[r¿È×Æ η¢¤Q=f™=47·¢ð>£QfºÍÈb¯¿¶=L×>¯™=Ð>¿NJi>E(fN²Ù=Î*Á?Æ(s¿[¶=›Lf[Þ>[»·²(¤[Q=f™=¼É®f[I½h[·ÈÆ l=Ç®?EÍÉEf¢a=b¢?>ÃÉ·ÈYÍ£Efºl=Ç®?*W›(Í·[r«¿ºÍV«[q›(Í[»®fºÍ»Ñ>®›¤Q=f™=ÅdÂÀÈÆbIʧF¿È>»² À³º?ÁC(Íɶ>J¶=L>ºÇ·£™=À»vJIÁ?Æ(Í®eǶ=ÍÈ>þ6[?Æ?¬¶Ö™=¼i=(¼ÃÑ>[?À[º‘ÆÙ=­Æf[ƒ=Æ(«¶Ö[™=Ð> 7L>V«[r¶=ab[¢Æ(b·=¼®e¤º(¸º>³¶>EÍ·=¼i=Æ7ÄJ–fI‘Cͪ>uC(ÍÉ·qÙ=ͧ·¶=›H>J³¶=Æ?Í®eǶ=Á=Ç¿¢Æ fm>¿¶=¼i=Æ%Êji֙=Æ?Ëe>RJ¶=$fn¿¶=Á>³ºÆ7%b·F¶=ÆÍ¿Èb™=$fn¿¶=_Èe>IÆ7*[¶=L>[®eǶ=Ìa>[¢C¼J[È­ÇiÆ >ÃVÉVrJ¶(¬¶Ö™=‘C(Ôa>F™=ÅdÂGj}ÍFIfº¦Æ?(Í·º>²¦¤Q=f™=>ÃɪÁdzI*HÇ·[iڶͷNº?Ê·È>º›Æ ¤FJÈÁ?œiÇJ™=±fn¶ÍÉVr¶=Í·=¸v«IËd¶=6  H>J²6  Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990. ›Ͷ>¯ºÍ·…6  Jones A et al. One day in Tibet. Journal Of tautology, 1993,13(5): 23-7. ͯÉMÆ6  Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization, 1985 (document WHO/DOC/537). .34™=\Æfn¶>E͢ǫn™=(¹Æ=b‚=ÆL>ºÇif¶>E°·£JÈ>º›Æ(Í·[r«¿ºÍV«[q›>[ÿº¸[²af[IÁ?Ê[§F¿ÈÄ[¾Dª(Í»ÑØ Í®eǶ=ÍÈ>þ›ͯV·ºÆ(ÍÉEf£¶=a=b¢Ù>Eʶ=ÇJ¶=η¢Í»®fºÆ*e>[nȹÆb[Q¸[²Æ¼[ie¸²‘CÌe>mÝ=ʧF¿È>»² ¹Æb[Q¸[²Æ¼[ie¸[²eb[rºb[Èb€À³º?Ƕ=dçFUÆ(½h·È>ºGj}(\ÇuÇEľ>³ºbÈb€Æ(s¿¶=›ÄɶC*›Æ ¾Ͷ>UÀ[¢Í[·º>³¶=ÍɶÆÖ[j™=(«¶Ö[™=Æ?(¬[¶Ö™=°I>[¢η¢¤¯IľDª(Ïf]?a=ǺÀº¹Æ=bQÆ?L>ºÇieË?¸¯ ͺgض=ÁÆcÙ=η¢¹Çrƒ=*eb®η¢e>rJ®×=ʧF¿ÈľDª(ÊÑ>ÿ¶=SJ¿™=°Éj¿IͯÈf{›LسnºË?Gè¿íÍÉá§àEÆ L>ºÇif¶=ƹÆ=b‚=T=eaC›Á>³ºÝ=*?Ƕ=dçFUƸ[³¶b[U=Ƽ[ieÆ?b[U=ƹÆbQη¢e>rJ®×=À³º3<<< Í»·²*=cC(>[ÃeÌa>[¢CÎç¿[jJÈÁ?Æ(L>É죙=ÅdÂGU>rIÁ?ʧF¿È(L>É죙=x£FEͯ·£J™=L>ºÇif¶=Á@Eð>»·¢ fºÙ=Gõ·ìI*  .35ÊjÉÑf¶=¬¶Ö™=ÀºG·{η¢âÐ>¿E×C(ÍÉ·qÙ=L>rÈf¯¶=ÆL>®eǶ=afI×*  .36n¿¶=b£EÎ[[·¢Ê[[jÉÑf¶=¬[[¶Ö™=¸[[rŒ>[[»¿ÉE(Í[[¶>¯™=ÄɪafIËd¶=ab£¶=ÀºÍ^j¾η¢ÁÇ«¶Ö™=¸rŒ(f7< eÇn¿™=OVF¶=ÀºÍ^j¾*‘C(e>£[iÙ=¹Ç[UL>[ºÇ·£ºÎ[·¢Æ?(_[j¿¶=À[ºb[Èh™=η¢¹ÇrV·¶L>F·ì¶=½çb¯IÆ fÈfVJ¶=kÉÑe* 752 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Directives à l’intention des auteurs 1. Les articles soumis pour publication ne doivent pas avoir été publiés ou acceptés pour publication dans d’autres revues. Le Bureau régional de la Méditerranée orientale se réserve tous les droits de reproduction ou de republication des matériels qui paraissent dans La Revue de Santé de la Méditerranée orientale. 2. Les articles originaux en anglais, arabe ou en français peuvent être soumis pour considération au Rédacteur en chef de La Revue de Santé de la Méditerranée orientale, Bureau régional de l’OMS pour la Méditerranée orientale, BP 7608, Cité Nasr (11371), Le Caire (Égypte). Les articles peuvent également être envoyés par courriel à l’adresse suivante : EMHJ@emro.who.int. Ils seront résumés dans les trois langues. 3. Le sujet de l’article doit concerner la santé publique ou d’autres domaines techniques et scientifiques connexes dans le champ d’intérêt de l’Organisation mondiale de la Santé, se rapportant plus particulièrement à la Région de la Méditerranée orientale. 4. Chaque manuscrit doit être fourni en trois exemplaires. Le texte, avec les tableaux et les figures qui l’accompagnent, ne devrait pas dépasser 15 pages, format A4, dactylographiées ou imprimées en double interligne (4500 mots) et devrait être imprimé sur le recto seulement. Lorsque le manuscrit est accepté, avec ou sans conditions, l’auteur doit soumettre une disquette informatique de 3,5 pouces, contenant le texte, les tableaux, les graphiques et les illustrations. Pour les articles en anglais et en français, à la demande de l’éditeur, le texte devra être fourni en format traitement de texte (de préférence Microsoft Word pour PC, mais la plupart des autres formats peuvent être convertis) et sauvegardé également dans un fichier texte ASCII. Les articles soumis en arabe devraient suivre les mêmes directives que les articles rédigés en anglais ou en français. Si l’article est une traduction, dans son intégralité ou en partie, d’un autre document non publié, une copie de ce document dans la langue d’origine devrait également être soumise. Si possible, les graphiques devraient être fournis en format Harvard Graphics pour Windows ou Excel, et les illustrations et photographies devraient être en format EPS ou TIFF. Toutefois, il est nécessaire de fournir trois jeux des photographies et figures d’origine avec les données de base. Si les photographies comportent un texte ou lettrage, un jeu supplémentaire doit être fourni sans ce texte/lettrage. 5. Tous les articles seront revus par des pairs, et sur la base des commentaires du réviseur, le Comité de rédaction se réserve le droit d’accepter ou de rejeter tout article. Les articles sont acceptés sous réserve de la révision dont ils feront l’objet au plan statistique et rédactionnel, comme jugé nécessaire, ce qui peut amener à abréger le texte et supprimer certaines données présentées sous forme de tableaux ou de graphiques. 6. Le titre de l’article devrait être aussi concis que possible, de préférence 10 mots environ, et devrait être mis sur une page séparée, avec le nom complet de l’auteur (ou des auteurs), l’organisme (ou les organismes) d’appartenance et le diplôme scientifique le plus élevé obtenu. L’adresse pour la cor-respondance, ainsi que toute autre information nécessaire (adresse courriel, télécopie, téléphone) pour contacter l’auteur correspondant devraient être fournies. Le nombre des auteurs ne devrait pas dépasser cinq. Tous les auteurs devraient avoir apporté une contribution matérielle à la conception, à l’analyse ou à la rédaction de l’étude et avoir approuvé la version finale soumise. Une vérification de cette contribution peut être demandée aux auteurs. Les noms d’autres personnes peuvent être inclus dans les remerciements. Eastern Mediterranean Health Journal, Vol. 14, No. 3, 2008 753 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 7. Afin de faciliter la traduction des résumés et du nom des auteurs, les auteurs dont la langue maternelle s’écrit en caractères arabes et qui rédigent en anglais ou en français doivent fournir leur nom complet en écriture arabe ainsi qu’une transcription. 8. Les articles présentant des résultats de recherche originale devront suivre le format IMRAD : introduction, matériel (sujets) et méthodes ; résultats ; analyse ; et discussion. Un résumé de 100 mots maximum sera fourni, mentionnant clairement les objectifs, le contexte, les résultats et les conclusions. 9. Les auteurs devront vérifier, le cas échéant, que toutes les personnes sur lesquelles la recherche porte ont donné leur consentement éclairé, et lorsque des participants (vivants ou décédés) n’ont pas pu donner ce consentement, qu’un consentement de substitution a été obtenu. 10. Les articles d’analyse devront comporter des sections portant sur les objectifs, les sources, les méthodes de sélection, la compilation et l’interprétation des données et des conclusions. 11. Les citations dans le texte de travaux publiés devraient être limitées aux références essentielles récentes. Hormis les articles d’analyse, il est conseillé de ne pas dépasser 25 références. Elles devraient être numérotées en chiffres arabes placés entre parenthèses [crochets] selon l’ordre dans lequel elles apparaissent dans le texte. Ces références devraient figurer sous forme de liste numérotée sur une page séparée à la fin de l’article. Elles devraient contenir les éléments d’information suivants, selon le cas : nom(s) et initiale(s) de l’auteur/des auteurs ; titre de l’article ou de l’ouvrage dans sa langue originale ainsi que la traduction ; nom complet de la revue ainsi que le numéro du volume et les pages concernées ; nom de la maison d’édition (commerciale ou institutionnelle) et lieu de publication (ville et pays) ; et date de la publication. Les articles comportant des références inadéquates ou dont les références ne sont pas organisées conformément à ces principes seront renvoyés aux auteurs pour correction. Exemples du style préféré de La Revue : Livre : Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990. Article de Revue : Jones A et al. One day in Tibet. Journal of tautology, 1993, 13(5):23–7. Document : Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization, 1985 (document WHO/DOC/537). 12. Les figures et les tableaux avec les légendes appropriées devraient être placés chacun(e) sur une feuille séparée, numérotés en chiffres arabes selon l’ordre et joints à la fin du document. Chaque figure et chaque tableau devraient avoir une référence dans le texte et son emplacement dans le texte devrait être indiqué clairement le cas échéant. Au besoin, les sources devraient être mentionnées pour chaque figure ou tableau. Si des figures, tableaux ou d’autres matériels ont été copiés d’autres sources, les auteurs portent l’entière responsabilité d’obtenir l’autorisation nécessaire. Afin d’éviter les problèmes de mise en page lors de la production finale, le nombre de tableaux et figures devrait être limité autant que possible. Il est préférable de ne pas avoir plus d’un tableau ou d’une figure pour 1000 mots. Les figures établies à partir de données doivent être accompagnées de ces données pour permettre une recomposition, le cas échéant. 13. Les articles originaux et les disquettes ne seront pas renvoyés sauf si l’auteur principal en fait la demande. 14. Lors de la publication, les auteurs recevront chacun un exemplaire du numéro dans lequel l’article paraît et l’auteur principal recevra 50 tirés à part. Les demandes de tirés à part supplémentaires et les informations sur le prix peuvent être obtenues auprès du Rédacteur en chef. 754 La Revue de Santé de la Méditerranée orientale, Vol. 14, No 3, 2008 ٢٠٠٨ ،٣ ددعلا ،رشع عبارلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما WHO sales and discount policy Objective Within the financial obligations of the pub lish ing and distribution process, prices of WHO pub li - ca tions are kept as low as pos si ble in order to maximize their dissemination and reach read ers for whom they are intended. The price and discount policies for WHO/EMRO and WHO/HQ publications are as fol lows: Price and discount policy for WHO/EMRO publications • EMRO publications are priced in US dol lars. • Sales agents receive a 40% discount and 30 days credit. Credit limit is US$ 500.00. • Bulk orders of individual books, i.e. 1000 copies per title, qualify the agent for a 50% dis- count instead of a 40% dis count; how ev er, pay ment of total value must be made before dispatch of pub li ca tions is effected. • Dispatch charges are calculated at 25% of cover prices. • Present delivery time average is two weeks from date of receipt of firm order. Price and discount policy for WHO/HQ publications • WHO/HQ publications and sub scrip tions are priced in Swiss francs. Clients in de vel op ing coun tries are eligible for a spe cial tar iff which in all cases is 30% less than the Swiss francs regular prices. • Sales agents receive a 40% discount for book or ders and 20% for subscription orders. Cred it limit is Swiss francs 1000.00. • Bulk or ders qualify the agents for a spe cial higher dis count, provided the dispatch of the whole or der is done to the same consignee. In this case, a proforma invoice will be issued by WHO/HQ, and the order will be dis patched only upon receipt of payment. No re turn of books or periodicals will be accepted. • Payment of invoices may be made in US dol lars at the official rate of exchange at the date of payment. • Present delivery time av er age is four weeks from date of receipt of orders. A WHO/EMRO Publications Price List is available on request. ISSN 1020-3397 © WORLD HEALTH ORGANIZATION, 2008 Publications of the World Health Organization enjoy copyright protection in accordance with the pro visions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the ex- pression of any opinion whatsoever on the part of the Secretariat of the World Health Organization con cerning the legal status of any country, territory, city or area or of its authorities, or concerning the de limi tations of its frontiers or boundaries. 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 men tioned. The authors alone are responsible for the views expressed, which do not necessarily reflect the opin ion of the World Health Organization or of its Member States. Cover designed by Ahmed Hassanein Printed on acid-free paper Printed by League of Arab States Printshop EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Re gional 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, concepts, epidemiological data, re search findings and other in for mation, with special reference to the Eastern Mediterranean Region. It addresses all members of the health pro fession, medical and other health educational in sti tutes, interested NGOs, WHO Collabo rating 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 ini tiatives 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 collaborateurs de l’OMS et personnes concernés au sein et hors de la Région. The Eastern Mediterranean Health Journal is abstracted/indexed in the Index Medicus and MEDLINE (Medical Litera- ture Analy sis and Retrieval Systems on Line) and the ExtraMed-Full text on CD-ROM, the Cu mu lative Index to Nursing and Allied Health Lit era ture (CINAHL), CAB International, Lexis Nexis™, Scopus and the Index Medicus for the WHO Eastern Medi terra nean Region (IMEMR). EMHJ is also available on the World Wide Web: http://www/emro.who.int/emhj.htm ALL ARTICLES ARE PEER REVIEWED COVER: Remote sensing image of the area of the world that includes the Eastern Mediterranean Region. Cover image pro duced by the Canada Centre for Remote Sensing, Ottawa, Canada. (NOAA AVHRR Com pos ite) Re pro duced with permission œiÇJ™=±fn¶ÍÉVr¶=Í·=  Í[ə>£¶=ÍVr¶=Í»Ÿ¿’œiÇJ™=±fn¶ʻɷ®Ý=GJ³™=À¢ebrI¶=ÍÉf¶=ÍÉVr¶=Í·=ÊÂ*[¿ºÊ[ÂÆ L>[É죙=ƼÉÂ>[«™=ÆÐ=eÛ=¹a>[FJ¶Æ(>[S[Èƶ=ÆÍÉVr[¶=L>ºb[„=›ÌbÈb‚=L=ea>F™=ÆL>i>Éj¶=¼Èb¯J¶ ¦ÆP>}Ù=SÑ>J¾ÆÍÉÑ>EǶ=™=Àº´¶cœiÇJ™=±fm¼É·®DE>ÿº°·£JÈ>ºðÍq>]Æ(L>ºÇ·£*‘CÍ[ÃçQǺÊ[ÂÆ (Í[É¿£™=Í[ɺdzƒ=[¦L>[»Ÿ¿™==d[²Æ(Í[ɻɷ£J¶=b[Â>£™=fÑ>[iÆÍ[ÉFì¶=L>É·³¶=Æ(ÍÉVr¶=ÀÙ=Ð>v¢?¸² ÄQe>]Ƽɷ®Ý=›ÍVr¶>E»JÙ=a=fªÙ=ÆÍə>£¶=ÍVr¶=Í»Ÿ¿º¤º;Æ>£J™=h²=f™=Æ* Member States of the World Health Organization Eastern Mediterranean Regional Committee 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 États Membres du Comité régional de la Méditerranée orientale de l’Organisation mondiale de la Santé 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 WHO Eastern Mediterranean Regional Office P.O. Box 7608 Tel: (202) 2670 2535 Fax: (202) 2670 2492 Nasr City, Cairo 11371 email: khayat@emro.who.int (202) 2670 2494 Arab Republic of Egypt emhj@emro.who.int Subscription details Individual copies: US$ 15.00 Annual subscription: US$ 60.00 There is a 50% discount for orders from developing countries Prices include cost of dispatch ةيلماعلا ةحصلا ةمظنم في طسوتلما قرشل ةيميلقلإا ةنجللا ءاضعأ نادلبلا سنوت نيرحبلا ناتسكاب ةدحتلما ةيبرعلا تاراملإا ناتسناغفأ ندرلأا ةيروسلا ةيبرعلا ةيروهملجا ةيملاسلإا ناريإ ةيروهجم ةيبيللا ةيبرعلا ةييرهاملجا رطق ينطسلف نامُع قارعلا لاموصلا نادوسلا تيوبيج ةينميلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما برغلما رصم نانبل تيوكلا