Eastern Mediterranean Health Journal [2017; Vol.23, Issue 7]

Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 23 / No. 7 July/Juillet 7 ددع / نوشرعلاو ثلاثلا دلجلما زوتم/ويلوي2017 Contents V o lu m e 2 3 N u m b er 7 Ju ly 2 0 1 7 The Eastern Mediterranean Region presents the highest prevalence of hepatitis C in the world, while gaps in hepatitis B birth-dose vaccination remain higher than the global average. “Eliminate Hepatitis” is the theme of World Hepatitis Day 2017, and reflects the priority the World Health Organization has given to eliminating hepatitis B and C in the Region and globally. Editorial Eliminating hepatitis from the Eastern Mediterranean Region ...............................................................................459 Research articles Patients' attitudes and perceptions regarding research and their rights: a pilot survey study from the Middle East ................................................................................................................................................. 461 Urbanization and noncommunicable disease (NCD) risk factors: WHO STEPwise Iranian NCD risk factors surveillance in 2011 ................................................................................................................................................................................. 469 Implementation of a peer-mediated health education model in the United Arab Emirates: addressing risky behaviours among expatriate adolescents .................................................................................. 480 Prevalence of attention deficit hyperactivity disorder among school-aged children in Jordan .......................... 486 Prevalence and preventability of sentinel events in Saudi Arabia: analysis of reports from 2012 to 2015 ........... 492 Health-related quality of life of patients with asthma: a cross-sectional study in Semnan, Islamic Republic of Iran ............................................................................................................................................ 500 Epidemiological characteristics and trends in the incidence of animal bites in Maku County, Islamic Republic of Iran, 2003−2012 ....................................................................................................................... 507 Short communication Reprocessing practices for gastrointestinal endoscopes: a multicentre study in Egyptian university hospitals .................................................................................................................................................... 514 WHO events addressing public health priorities Prevention of re-establishment of local malaria transmission in malaria-free countries ...................................... 520 Cover 23-07.indd 5-7 8/22/2017 12:16:09 PM EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). © World Health Organization (WHO) 2017. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Disclaimer. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. 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ISSN 1020-3397 تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا .هجراخو ميلقلإا فى ةحصلاب ينمتهلما طسوتلما قشرل ةيحصلا ةلجلما Correspondence Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen Subscriptions and Permissions Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: emrgoksp@who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: emrgoegp@who.int. Cover 23-07.indd 8-10 8/22/2017 12:16:09 PM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 23 No. 7 7 ددع نوشرعلاو ثلاثلا دلجلما• 2017 • Editorial Eliminating hepatitis from the Eastern Mediterranean Region Mahmoud Fikri ........................................................................................................................................................................................................................................................................................... 459 Research articles Patients' attitudes and perceptions regarding research and their rights: a pilot survey study from the Middle East Tamer Hifnawy, Samer Kobrosly, Hillary Edwards, Manal Anwar, Dalia Zahran and Henry Silverman ................................................................................................................. 461 Urbanization and noncommunicable disease (NCD) risk factors: WHO STEPwise Iranian NCD risk factors surveillance in 2011 Zahra Khorrami, Koorosh Etemad, Shahin Yarahmadi, Soheila Khodakarim, Mohammadesmail Kameli, Alireza Mahdavi Hezaveh and Ebrahim Rahimi ............. 469 Implementation of a peer-mediated health education model in the United Arab Emirates: addressing risky behaviours among expatriate adolescents Zachary D. Stanley, Leena W. Asfour, Michael Weitzman and Scott E. Sherman ................................................................................................................................................................. 480 Prevalence of attention deficit hyperactivity disorder among school-aged children in Jordan Manar Al Azzam, Mohammed Al Bashtawy, Ahmad Tubaishat, Abdul-Monim Batiha and Loai Tawalbeh ......................................................................................................... 486 Prevalence and preventability of sentinel events in Saudi Arabia: analysis of reports from 2012 to 2015 Salem Al Wahabi, Fayssal Farahat and Ahmed Y. Bahloul .......................................................................................................................................................................................................... 492 Health-related quality of life of patients with asthma: a cross-sectional study in Semnan, Islamic Republic of Iran Naim S. Kia, Farhad Malek, Elaheh Ghods and Mona Fathi..................................................................................................................................................................................................... 500 Epidemiological characteristics and trends in the incidence of animal bites in Maku County, Islamic Republic of Iran, 2003−2012 Seyed Morteza Shamshirgaran, Hamid Barzkar, Saber Ghaffari-Fam, Ahmad Kosha, Parvin Sarbakhsh and Pari Ghasemzadeh ................................................................ 507 Short communication Reprocessing practices for gastrointestinal endoscopes: a multicentre study in Egyptian university hospitals Rehab H. El-Sokkary, Ahmed A. Wegdan, Ahmed A. Mosaad, Rasha H. Bassyouni and Wael M. Awad .................................................................................................................. 514 WHO events addressing public health priorities Prevention of re-establishment of local malaria transmission in malaria-free countries .................................................................................................................... 520 Book 23-07.indb 457 8/23/2017 8:01:55 AM Mahmoud Fikri, Editor-in-chief Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editors Phillip Dingwall Guy Penet (French) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Freelance) Manar Abdel-Rahman, Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics) Graphics Suhaib Al Asbahi, Diana Tawadros Administration Nadia Abu-Saleh, Yasmeen Sedky, Iman Fawzy, Dalya Mostafa Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean Book 23-07.indb 458 8/23/2017 8:01:55 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 459 As we mark World Hepatitis Day on 28 July, our attention naturally focuses on the relentless battle to eliminate viral hepatitis from populations suffering under the heavy toll of this commu- nicable disease. The theme for World Hepatitis Day this year is “Eliminate Hepatitis”. Currently an estimated 325 million people worldwide are living with chronic hepatitis B or hepatitis C virus infection. In 2015 alone, viral hepatitis caused 1.34 million deaths, while 1.75 million people were newly infected with hepatitis C (1). It would appear on the face of it that eliminating hepatitis is an insurmountable task, but substan- tial attention and resources have been directed to promoting hepatitis preven- tion and treatment, and with heartening results. The Eastern Mediterranean Region (EMR) continues to have the highest prevalence of viral hepatitis C globally. WHO estimates that more than 15 mil- lion people in the Region are currently chronically infected with hepatitis C, and 21 million with hepatitis B (1). 80% of the regional burden of these infections lies in Egypt and Pakistan (1). Unfortunately, many people in the Region acquire hepatitis B and C in the place where they least expect it, namely health care settings due to sub-optimal infection control and pre- vention, unsafe injection practices and inadequately screened blood transfu- sions. Mother-to-child transmission is the primary cause of hepatitis B among children (2). Furthermore, many peo- ple who are at risk of HIV are also at risk of hepatitis B and C infections, due Editorial Eliminating hepatitis from the Eastern Mediterranean Region Mahmoud Fikri1 1Regional Director, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. to high-risk sexual practices or shared syringes and paraphernalia by people who inject drugs. The World Health Organization (WHO) has given special priority to hepatitis B and C prevention, diagnosis and treatment, both at the regional and global levels. Following a resolution adopted at the 67th session of the World Health Assembly (3). WHO developed the Global Health Sector Strategy for Viral Hepatitis. This strategy is rooted in the global commitment to the Sustain- able Development Goals (SDGs) and to universal health coverage, and sets out a vision towards eliminating viral hepatitis globally by 2030, and poten- tially avert 7.1 million deaths (4,5). To guide implementation of the Global Health Sector Strategy within the East- ern Mediterranean Region, a Regional Action Plan for the hepatitis response was developed as part the EMR Road- map 2017–2021 (6,7). Resolution EM/RC63/R.1 urges EMR Member States to develop or update national plans of action in line with the regional action plan (8). The vision, goal and targets of the Regional Action Plan are aligned with those of the Global Strategy. Accord- ingly, the vision is “An Eastern Medi- terranean Region free of new hepatitis infections and where people living with chronic hepatitis have access to afford- able and effective prevention, care and treatment” (6). Five core viral hepatitis interventions, i.e. hepatitis B vaccina- tion (including birth dose); injection safety; blood safety; harm reduction ser- vices for people who inject drugs; and treatment of chronic hepatitis infection, are essential to achieve the elimination of viral hepatitis B and C (9). In this respect, it is important to acknowledge the efforts of Member States in the Region. Within the span of around 2 years, over 1 million people in Egypt have been treated with direct- acting antivirals for hepatitis C. In addi- tion, a number of other countries with varied endemicity levels have set up their multi-sectoral strategies to address viral hepatitis aiming at eliminating viral hepatitis B and C by 2030. Furthermore, the successful price negotiation and generic licensing agreements between the ministries of health and the pharmaceutical indus- try resulted in major price reductions making medicines more affordable. For example, in Egypt the price for a 28-day supply of generic sofosbuvir was as low as US$ 51 in 2016. In Morocco, the price for a 28-day supply of a generic formulation of daclatasvir dropped to US$ 120, and down to US$ 7 in Egypt in 2016 (9). Similarly in Pakistan, the price of 28-day supply of sofosbuvir through generic companies has reached as low as US$ 15 (9). These prices are substantially below the originator prices in low-income countries and the price in high and upper-middle income countries that fall outside the generic licensing agreements. Nevertheless, weaknesses remain in the hepatitis responses of several region- al Member States. Blood transfusion safety, infection control and prevention as well as injection safety continue to face many challenges in countries like Book 23-07.indb 459 8/23/2017 8:01:55 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 460 References 1. World Health Organization. New hepatitis data highlight need for urgent global response. Geneva: World Health Organiza- tion; 2017 (http://www.who.int/mediacentre/news/releas- es/2017/global-hepatitis-report/en/, accessed 31 July 2017). 2. World Health Organization. Hepatitis B. Geneva: World Health Organization; 2017 (http://www.who.int/mediacen- tre/factsheets/fs204/en/, accessed 2017). 3. World Health Organization. Sixty-seventh World Health As- sembly. Geneva: World Health Organization; 2014 (http:// www.who.int/mediacentre/events/2014/wha67/en/, ac- cessed 31 July 2017). 4. World Health Organization. Global health sector strategy on viral hepatitis 2016–2021. Geneva: World Health Organization; 2016 (http://www.who.int/hepatitis/strategy2016-2021/ghss- hep/en/, accessed 31 July 2017). 5. Imperial College Applied Modelling Group. Global invest- ment case document. Unpublished report commissioned by WHO´s Global Hepatitis Programme. 6. World Health Organization. Eliminating hepatitis: WHO. Ge- neva: World Health Organization; 2017 (http://www.who.int/ mediacentre/news/releases/2017/eliminate-hepatitis/en/, accessed 31 July 2017). 7. WHO Regional Office for the Eastern Mediterranean. Regional action plan for the implementation of the global strategy for viral hepatitis 2017–2021. Cairo: WHO Regional Office for the Eastern Mediterranean; 2016 (http://www.emro.who.int/im- ages/stories/hepatitis/hepatitis_action_plan_2017_2021_for_ consulation.pdf?ua=1, accessed 31 July 2017). 8. World Health Organization. Resolution EM/RC63/R.1. Geneva: World Health Organization; 2016 (http://applications.emro. who.int/docs/RC63_Resolutions_2016_R3_19120_EN.pdf, ac- cessed 10 August 2017). 9. World Health Organization. Key facts on hepatitis C treatment. Geneva: World Health Organization; 2016 (http://www.who. int/medicines/areas/access/hepCtreat_key_facts/en/, ac- cessed 31 July 2017). Somalia, Yemen, and Pakistan (1). In several countries, birth-dose vaccina- tion against hepatitis B is either not adopted or implemented at a low cov- erage level. Although harm reduction services for people who inject drugs are well established in the Islamic Republic of Iran, such services still remain at a very low scale in most countries of the Region (1). WHO continues to support and work closely with Member States and other partners to implement and scale up all interventions for viral hepatitis control. This includes providing birth- dose vaccination against hepatitis B, enhancing prevention strategies and ensuring equitable access to quality di- agnosis and treatment, until hepatitis is eliminated from the Region. As we ob- serve World Hepatitis Day, it is reassur- ing to know that real progress is being made to prevent and control hepatitis and that many lives can be saved. Book 23-07.indb 460 8/23/2017 8:01:55 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 461 1Department of Public Health and Community Medicine, College of Dentistry, Taibah University, Saudi Arabia (Correspondence to: Tamer Hifnawy: thifnawy@yahoo.com). 2Faculty of Medicine, Beni Suef University, Beni Suef, Egypt. 3Makassed General Hospital, Beirut. Lebanon. 4University of Maryland School of Medicine, Baltimore, Maryland, United States of America. 5Faculty of Dentistry, Tanta University, Tanta, Egypt. Received: 15/3/16; accepted: 16/11/16 Patients' attitudes and perceptions regarding research and their rights: a pilot survey study from the Middle East Tamer Hifnawy, 1,2 Samer Kobrosly, 3 Hillary Edwards, 4 Manal Anwar, 2 Dalia Zahran 1,5 and Henry Silverman 4 Attitudes et perceptions des patients à l’égard de la recherche et de leurs droits : étude pilote au Moyen-Orient RESUME La surveillance éthique et réglementaire de la recherche peut ne pas être optimale dans les pays à revenu faible et intermédiaire. Afin de déterminer les attitudes et les perceptions des patients à l’égard de la participation à la recherche et des perceptions de leurs droits, nous avons recruté 202 participants dans des hôpitaux en Arabie saoudite, en Égypte, au Liban et au Soudan, et leur avons demandé de compléter un questionnaire évaluant leurs attitudes et perceptions à ce sujet. Environ 20 % croyaient qu’il arrivait que des médecins mènent des recherches sur des patients sans leur consentement, et 35 % pensaient que si les participants se retiraient du processus de recherche, ils ne bénéficieraient pas de soins médicaux de qualité. Plus de 85 % pensaient qu’ils devaient avoir droit à la confidentialité de leurs données, à des soins médicaux gratuits en cas d’incident durant la recherche et qu’ils devaient pouvoir poser des questions. Près de la moitié étaient d’avis qu’ils avaient le droit de se retirer de la recherche sans être pénalisés, et environ 75 % pensaient qu’ils pouvaient adresser des plaintes sans craindre de subir des préjudices. Les participants illettrés ou sans emploi étaient moins susceptibles d’évaluer leurs droits que les autres participants. طسولأا قشرلا نم ةيبيرتج ةيئاصقتسا ةسارد :مهقوقحو ثوحبلا ءازإ ضىرلما تاروصتو تاهاتجا نامرفليس يرنه ،نارهز ايلاد ،رونأ لانم ،زدراودإ يرلايه ،ليصبرق رماس ،يوانفح رمات دـيدحتلو .لـخدلا ةطـسوتلماو ةـضفخنلما نادـلبلا في لـثملأا ىوتـسلما نود ثوـحبلا ىـع ةـيميظنتلاو ةـيقلاخلأا ةـباقرلا نوـكت دـق :ةـصلالخا رـ م في تايفـ شتسلما نـ م ًاـ ضيرم 202 نـ م اـ نبلط ،مـ هقوقح نأـ شب مـ تهاروصتو ثوـ حبلا في ةكراـ شلما هاـ تج ضىرـ لما تاروـ صتو تاـ هاتجا مـهداقتعا نـع مـهنم % 20 وـحن برـعأو .تاروـصتلاو تاـهاتجلاا مـييقتل نايبتـسا لماكتـسا نادوـسلاو ةيدوعـسلا ةـيبرعلا ةـكلملماو ناـنبلو باحـسنا ةـلاح في هـنأب مـهداقتعا نـع مـهنم % 35 برـعأ نـح في ،مـهملع نود ضىرـلما ىـع ًاـثوحب نورـيج ناـيحلأا ضـعب في ءاـبطلأا نأـب ةـيسرب قـلعتي ماـيف قوـقح مـله نوـكي نأ يـغبني هـنأ % 85 ىـع دـيزي اـم ىأرو .ةدـيج ةـيبط ةـياعر نوـقلتي لا مـنهإف ثوـحبلا نـم نكراـشلما مـيهأر نـع مـهفصن وـحن برـعأو .ةلئـسلأا حرـطو ثـحبلا ءارـجإ ءاـنثأ مـهتباصإ ةـلاح في ًاـنامج ةـيبطلا ةـياعرلا ىـع لوـصلحاو تاـنايبلا .ىذأـل ض ُّرـعتلا نـم فوـخ نود ىواكـشلا مـيدقت نـم مـهنّكتم ةروضر نـع % 75 لياوـح برـعأو ،ةـبوقع نود باحـسنلاا مـله قـيح هـنأب .مـهئارظنب ةـنراقم مـهقوقلح ًارـيدقت لـقأ نـلماعلا رـغ وأ نوـّيملأا صاخـشلأا نأ َّنـبت دـقلو ABSTRACT Ethical and regulatory oversight of research may be suboptimal in low- and middle-income countries. To determine patients’ attitudes and perceptions toward research participation and perceptions of their rights, we recruited 202 participants from hospitals in Egypt, Lebanon, Saudi Arabia and Sudan and asked them to complete a questionnaire assessing attitudes and perceptions. Around 20% believed that doctors sometimes perform research on patients without their knowledge and 35% believed that if participants withdrew from the research they would not receive good medical care. Over 85% believed that they should have rights regarding confidentiality of data, free medical care if injured during the research and asking questions. Almost half believed they have a right to withdraw without penalty and around 75% believed they could make complaints without fear of harm. Those who were illiterate or unemployed were less likely to appreciate their rights compared with their counterparts. Book 23-07.indb 461 8/23/2017 8:01:55 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 462 Introduction The number of clinical trials conducted in low- and middle-income countries has increased worldwide (1), including the Middle East (2). Despite growing political volatility, the Middle East is poised for an escalation in the num- bers of clinical trials as pharmaceutical companies continue their search for regions with large, treatment naïve populations (3). Since medical research involves human subjects, knowledge regarding their attitudes and percep- tions vis-à-vis research would help with understanding and addressing their concerns, which would enhance the overall trust between the public and the scientific community. Studies elicit- ing the views of patients on medical research have been performed in the United States, Denmark, Australia, and Japan (4–7), however these results might not be generalizable to low- and middle-income countries that may have different cultures, religions and eco- nomic backgrounds. Currently, there is limited empirical research involving the perspectives of patients from the Middle East (8–13). Additional stud- ies would help with clarifying further the underlying assumptions of patients regarding their participation in research. Another issue that warrants further investigation is the extent to which po- tential research participants are aware of and understand their rights in the research process. Although adherence to research ethics principles and guide- lines help protect the welfare and the rights of research participants and their communities (14–16), commentators have expressed concerns regarding the regulatory framework (17), the func- tionality of research ethics committees (18), and the training of the research team regarding responsible research conduct (19) in low- and middle-in- come countries, including the Middle East. Such concerns make clear that research participants’ realization of their rights provides them with a mechanism to protect their interests and prevent potential exploitation. The concept of rights in research first developed after World War II in response to the practices of Nazi physi- cians who had experimented on un- willing subjects. The first international instrument on the ethics of medical research, the Nuremberg Code of 1947, was a direct outcome of these unethical practices, and it emphasized that the voluntary consent is “absolutely essen- tial” and that “the human subject should be at liberty to bring the experiment to an end”, i.e. a right to withdraw (20, 21). Since the Nuremberg Code, other international instruments have empha- sized either directly or indirectly the existence of human rights in biomedical research, e.g. the Declaration of Helsinki in 1964, which has since undergone multiple revisions (17), the United Na- tions’ International Covenant on Civil and Political Rights (1966) (22) the Council of Europe’s “The Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine” (1997) (23) and in 2005, the “Additional Protocol to the Convention on Human Rights and Biomedicine, concerning Biomedi- cal Research” (24). These documents make clear that the rights in research ethics are linked to ethics guidelines and governmental regulations, and emanate from fundamental ethical principles. The use of “rights” language can help apply the general ethical principles in research. For example, to secure au- tonomy investigators need to disclose adequate information to potential research participants and ensure their understanding (i.e. the doctrine of in- formed consent). Other rights include the right to privacy and confidentiality and the right to medical treatment for any trial-related injury. The correspond- ing obligations on investigators and sponsors that help secure these rights include mechanisms to respect privacy, measures to enhance confidentiality protections, and the requirement to ob- tain indemnity insurance for research- related injuries. Several studies have investigated the awareness of patients regarding their rights in clinical care in non-Western countries (25–34), but there are lim- ited data regarding the perceptions of research participants regarding their rights (13). Accordingly, this study aimed to identify attitudes and percep- tions towards research participation and awareness and understanding of the rights of potential participants from several countries in the Middle East: Egypt, Lebanon, Saudi Arabia and Su- dan. Methods Survey tool We developed a survey which contained the following sections: demographic information that included age, sex, education level, employment type and hospital type; attitudes and perceptions toward aspects of research participa- tion; the extent of agreement to receive certain types of information necessary to decide upon participation in research; and the extent of agreement with certain rights in research. Questions required either a single/multiple response or were in the form of a 5-point Likert scale (strongly agree, agree, uncertain, disagree, strongly disagree). Participants were also asked to re- spond to the following case study: Rebekah comes to the clinic to have her blood drawn for routine labora- tory examination. The investigator withdraws a little more than usual for research purposes. Which of the follow- ing are true? • The investigator does not have to tell Rebekah the purpose of taking more blood. • The investigator does not have to tell Rebekah whether the blood will be used in research. Book 23-07.indb 462 8/23/2017 8:01:55 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 463 • The investigator should have asked for permission and informed consent from Rebekah • It is expected that patients participate in research without patients’ knowl- edge If Rebekah suspects that the blood will be used in research, she can do which of the following: • Ask the investigator to withdraw this sample • Complain to the hospital director • Submit a complaint to the medical syndicate or the organization giving the license • Call the police • Go to court • Tell her family members, colleagues and friends not to go to this doctor • Tell the media in order to warn the public from dealing with this doctor and this clinic • Do nothing as nothing will be done about it The survey was developed in Eng- lish and then translated into Arabic fol- lowed by a back-translation into English to ensure accuracy of the Arabic transla- tion. We pilot tested the survey among several lay persons to assess readabil- ity and understanding. Several changes were made in response to this assess- ment. Reliability of the questionnaire was calculated using the Cronbach α test for internal consistency. Reliability of the questionnaire was judged by the internal consistency coefficient (Cron- bach α) of the 29 items using a 5 point Likert scale; this was 0.901, indicative of a good degree of internal consistency. Participants Trained coordinators recruited partici- pants from several sites at university and private-affiliated hospital outpatient clinics at the following locations: Beni Suef, Egypt; Beirut, Lebanon; Medina, Saudi Arabia; and Khartoum, Sudan. We used a convenience sampling tech- nique with a target recruitment of 50 participants per site. The only inclusion criterion was age above 18 years. Par- ticipants were recruited during January and June 2014. The questionnaire was self-administered, however, for those who could not read or write, a study team member helped these individuals by reading and explaining each ques- tions and the possible answers. Statistical analysis We entered the data into a Microsoft Excel coded file and transformed the data to SPSS, version 22. We used descriptive analysis and chi-squared analysis to determine the strength of the association of each of the independ- ent variables (sex, education levels, and employment type) with each of the responses. Statistical differences within the sex, education and employment subgroups were determined using the Fisher’s exact test. We set the signifi- cance level at P-value < 0.05. To enhance our analyses, we col- lapsed the independent variables into the following subgroups. <list> • Education: illiterate, high school or less, greater than high school • Employment status: unemployed, manual worker/merchant, profes- sional. To improve the power, we collapsed the Likert scale responses of “strongly agree” and “agree” into one category; and the combination of “uncertain”, “disagree” and “strongly disagree” into another category. Ethics review We received ethics approval from the research ethics committees at: Univer- sity of Maryland School of Medicine, Baltimore (United States); College of Dentistry, Taibah University (Saudi Arabia); Faculty of Medicine, Beni Suef University (Egypt); Makassed General Hospital (Lebanon); and the Univer- sity of Medical Sciences and Technol- ogy (Sudan). Results We enrolled 202 participants, 51 each from Egypt and Sudan and 50 each from Saudi Arabia and Lebanon. Re- sults were not significantly different between these countries and therefore, we aggregated the data into a single group. The mean age of the participants was 42.1 [standard deviation (SD) 15.6] years. Twenty-eight respondents (13.9%) had participated in medical Table 1 Demographic characteristics of the respondents of respondents from 4 Middle Eastern countries (n = 202) Characteristic No. % Sex Male 94 46.5 Female 108 53.5 Education Illiterate 19 9.4 High school or less 119 58.9 Greater than high school (university-level) 64 31.7 Employment Unemployed 67 33.2 Manual worker/merchant 88 43.6 Professional 47 23.3 Hospital type Private 50 24.8 University 152 75.2 Book 23-07.indb 463 8/23/2017 8:01:55 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 464 research, of whom 17 were currently enrolled in research. Responses from those with and those without experi- ence in research were not significantly different and hence we only present the results of the entire study sample. Table 1 shows the respondents’ demographic data. There were an al- most equal number of men and women participants (46.5% and 54.5% respec- tively). Sixty-four (31.7%) participants had an education level above high school. Approximately one-third were unemployed. The ratio of patients at- tending private and university hospital outpatient clinics was 1:3. Table 2 shows respondents’ atti- tudes toward medical research. Overall, 92.6% believed that medical research was necessary to improve health within a society. Respondents held decreas- ing preferences for participation in the following types of research: question- naire studies, blood sampling studies and drug trials (87.1%, 64.4%, and 44.6%; respectively). The top 3 reasons for enrolling in research were: to help other patients (50.0%), the belief that patients in research get better treatment (41.6%) and the chance to get better care (41.1%). Around 20% of respondents be- lieved that doctors sometimes perform research on patients without their knowledge; individuals who were illiter- ate were more likely to hold this opinion compared with those in the 2 other education groups (42.1% vs. 22.7% and 10.9%, respectively; P < 0.01) (Table 2). A little over a third of the respondents (35.0%) believed that if research partici- pants withdrew from the research they would not receive good medical care from their doctors. Actions that respondents would take if they had have a complaint about the research included: complain to the investigators (41.0%) and complain to the hospital director (28.8%) (Table 2). In response to the case study re- garding a clinic patient from whom a physician withdraws additional blood for research purposes, 80.5% believed that the investigator should have asked for the patient’s informed consent for the additional blood (Table 2). Those who were unemployed were significant- ly less likely to believe that physicians should ask for consent from the pa- tient compared with manual workers/ merchants and professionals (68.2% vs 85.24% and 89.1%, respectively; P < 0.01). When asked what the patient could do about the additional sample of blood that was withdrawn, the top choices included: ask the physician to withdraw the sample (51.0%); complain to the hospital director (25.7%); and one should do nothing as nothing would be done (22.3%) (Table 2). Those who were illiterate were more likely to believe that “one should do nothing as nothing would be done” compared with those at a higher educational levels; (36.8% vs. 25.2% and 12.5%, respectively; P < 0.05). Similarly, those who were un- employed were more likely to believe this compared with manual workers/ merchants and professionals (31.3% vs. 20.5% and 12.8%, respectively; P < 0.05). Those who were unemployed were significantly less likely to ask the physician to withdraw the sample compared with those who were manual workers/merchants and professionals (37.3% vs. 53.4% and 66.0%, respective- ly; P < 0.01). However, those who were unemployed or were manual workers/ merchants were more likely to com- plain to the hospital director compared with professionals (32.8% and 28.4% vs. 10.6%, respectively, P < 0.05). More than 75% of the respondents believed that, prior to enrolment in a study, research participants should be provided with all the information described in the questions (Table 3). More than 95% agreed that participants should be informed about the risks and side-effects and the anticipated benefits of the research. At least 85% of the respondents believed that they should be told that enrolment in research is voluntary and that they have the right to have data kept confidential; have the right to receive free medical care if injured from the research; and have the right to ask ques- tions about the study (Table 4). How- ever, only 49% thought they should have a right to withdraw from the study. Respondents who were unem- ployed were significantly less likely to believe that they should be told that enrolment is voluntary compared with manual workers/merchants and profes- sionals (80.0% vs. 92.0% and 97.9%, respectively; P < 0.01). Individuals who were illiterate were significantly less likely to believe they could file a complaint compared with the other 2 education levels (57.9% vs. 70.1% and 87.5%, respectively, P < 0.01); they were significantly less likely to believe that research data should be kept se- cret from individuals not involved in research compared with the other 2 education levels (52.6% vs. 87.2% and 90.6%, respectively); and they were also significantly less likely to believe they should have an opportunity to ask questions compared with the other two groups (78.9% vs. 93.2% and 98.4%, respectively, P < 0.01). Discussion This study reveals certain attitudes and perceptions of patients from the Middle East regarding research as well as their perceptions of their rights as research participants. In general, most of our participants expressed favourable attitudes towards research. For example, more than 90% believed that research was necessary to improve the health of society; similar findings regarding the importance of research have been reported in other studies from the Mid- dle East (9,13). We found that 50.0% of participants cited a desire to help others as a reason to enrol in research. Book 23-07.indb 464 8/23/2017 8:01:56 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 465 This, however, contrasts with other studies showing that more than 90% stated a similar reason (9,12,13). Also, the chance to get better treatment was cited by only 41.1% of our respondents as a reason to participate in research. In contrast, a recent study in Saudi Arabia reported that 80.4% of their respondents stated that “receiving best medical care” was a motivation to enrol in clinical trials (13), and in an Egyptian study 100% of the participants who were en- rolled in clinical trials were motivated to receive a “chance to get better treat- ment” (9). These 2 studies were focused on motivations for enrolling in clinical trials, which have potential direct ben- efits to participants, whereas our survey asked respondents for their reasons for enrolling in research that also included blood sampling and questionnaire stud- ies; this might explain why fewer of our participants cited better treatment/care as a motivation. Most respondents said they would participate in questionnaire studies, while significantly fewer would partici- pate in studies involving blood sampling and drugs. Khalil et al. observed similar findings in their qualitative, in-depth Table 2 Attitudes and perceptions of respondents in 4 Middle Eastern countries towards medical research (n = 202) Question Responsea No. % Medical research is necessary to improve the health of society 187 92.6 I would most likely volunteer to participate in the following types of trials a: Questionnaire studies 176 87.1 Blood sampling studies 130 64.4 Drug trialst 90 44.6 Why would you volunteer to participate in research? b Help other patients 101 50.0 Patients in research receive better treatment than those not in researcha 84 41.6 Chance to get better care 83 41.1 Participants who withdraw from the research will not receive good medical care from their doctorsa 70 35.0 Get extra attention 62 30.7 My doctor sometimes performs research on me without my knowledgea 42 20.8 Only way to get hospital care 18 8.9 Monetary incentives 15 7.4 Actions that participants could take if they have complaints about the researchc (n = 156) Complain to the investigators 64 41.0 Complain to the hospital director 45 28.8 No need to complain, nothing will be done 37 25.4 Put a paper in the complaint box 24 15.4 Complain to the research ethics committee 14 9.0 Case of patient from whom physician withdraws additional blood sample for research c Which of the following is true? Physicians should ask for consent from the patient 161 80.5 Physicians do not need to reveal the purpose of the additional blood sample 19 9.4 Other response 20 9.9 What can the patient do if she suspects that the additional blood will be used in research? Ask the physician to withdraw the sample 103 51.0 Complain to the hospital director 52 25.7 Do nothing as nothing will be done 45 22.3 Tell others not to see this doctor/tell the media 28 13.9 Complain to the physician’s board 15 7.4 Call the police or go to court 8 4.0 aPercentage of those who strongly agreed or agreed. bCheck all that apply. cChoose one best answer. Book 23-07.indb 465 8/23/2017 8:01:56 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 466 interview study in Egypt regarding preferences for participation in types of research, and attributed their findings to the increasing risk associated with questionnaire, blood sample and drug trials respectively (8). Our respondents held several problematic perceptions. For example, around one-fifth believed that research is performed on them without their knowledge and more than a third that they would not get good medical care if they withdrew from the study. In a study involving Saudi Arabian patients and their companions from the outpatient clinics of a tertiary hospital, Al-Tannir et al. reported that only 48.7% of their respondents believed that research was conducted in a responsible and ethical manner, which led the authors to conclude that potential participants held “conditional” attitudes towards participating in clinical trials and that investigators need to provide assur- ances to potential research participants that all necessary procedures would be used to enhance their welfare and rights (13). Our findings also support this proposition. Our study also demonstrated that a significant minority of respondents had a sense of futility if they had a com- plaint about a research study as 25.4% believed that nothing would be done if they complained. A similar proportion (22.3%) held a comparable attitude regarding the uselessness of filing a complaint in the case study we used in the questionnaire. This concern that no-one would respond to their com- plaints harmonizes with our finding that 74.5% of our respondents believed that research participants should have a right to make a complaint against any mem- ber of the research team without a fear of retribution. Many of our participants also ex- pressed awareness in regard to other research rights. For example, over 85% believed that there should be protection for confidentiality, compensation for research-related injury, the ability to ask questions about the research study and that they should be told that par- ticipation was voluntary. Indirectly, our respondents also believed in the right to informed consent as, when respond- ing to the case study, a large majority believed that there was a requirement for the physician to obtain informed consent from the patient for the ad- ditional blood sample being obtained for research. In contrast, just under half of our respondents believed they had a right to withdraw from the study without giving any reason. This perception might be due to potential concerns with retribu- tion after withdrawal, as 35% also be- lieved that participants who withdrew from the research would not receive good medical care from their doctors. In a study involving Saudi Arabian patients and their companions, it was reported that only 59.5% of the respondents were aware of their right to withdraw from a clinical trial at any time without conse- quences (13). Our data showed that individuals who might be vulnerable in research, e.g. those who are illiterate or unem- ployed, were less sure of their rights. For example, compared with individuals at a higher level of education, those who were illiterate were significantly less likely to believe that research partici- pants should have rights regarding con- fidentiality, filing a complaint against the research team and having the op- portunity to ask questions. Those who were unemployed were significantly less likely to believe that physicians should obtain informed consent for obtaining an additional blood sample for research purposes, and less likely to believe that they should be told that participation in research was voluntary. These findings regarding vulnerable individuals (i.e. those less able to protect their interests) may be a result of their being unaware of their rights and less optimistic that such rights can be realized, or a concern that retribution would occur if they insist on their rights. Although studies investigating per- ceptions of potential research partici- pants’ regarding their rights are limited, several studies from low- and middle- income countries have explored the awareness of patients regarding their rights in medical care. These studies Table 3 Participants’ agreement with the type of information they should receive prior to enrolment in research (n = 202) Item Responsea No. No. Participants should know the risks and side-effects of the research 197 98.5 Participants should be given an explanation of anticipated benefits from the research 191 95.5 Participants should be given an explanation of the procedures and any drugs that will be used 181 90.0 Participants should be told that enrolment in research is voluntary 179 89.5 Participants should know the purpose of the research 177 88.1 Patients should be provided with contact information if questions, concerns, or complaints about the research were to occur 176 88.0 Participants should know the alternatives of medical treatment they can receive outside of the study 157 78.9 aPercentage of those who strongly agreed or agreed. Book 23-07.indb 466 8/23/2017 8:01:56 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 467 demonstrate a wide range of variabil- ity. For example, studies demonstrating that patients have a low awareness of their rights included those from Tur- key (23%) (25), Greece (15.7%) (26), Egypt (23.3%) (31), and Saudi Arabia (25%) (29). In contrast, higher rates of awareness were demonstrated among patients in Lithuania (56%) (27), Po- land (80%) (30), Malaysia (90%) (28), and Nigeria (94.2%) (33). In a study involving patients in Greece, 25.7% would do nothing if their rights were being violated (26) and in another study involving patients attend- ing outpatient clinics in Nigeria, 25% would not seek redress if their rights were violated (33). These results are similar to our data showing that ap- proximately 25% of respondents would not file a complaint as they thought that nothing would be done in response. However, in the study in Egypt, a higher proportion of the patients or their com- panions (approximately 60%) would “do nothing” when facing problems or harm in the hospital (31). This higher result might be due to their sample population, almost half of whom were illiterate, as opposed to only 9% in our sample, indicating that illiteracy might be a surrogate marker for vulnerability. There were several limitations to our study. First, we used a convenience sampling method for recruitment and our site coordinators reported that some potential respondents did not want to participate due to their uncer- tainty regarding the informed consent process. This selection bias might have affected the validity of our results. Also, our sample size might not have been large enough to detect other significant findings. Future studies should employ a larger sample size and enrol individu- als from additional centres in the region to enhance the generalizability of our results. Finally, the conduct of research in the Middle East is limited compared with other regions in the world (3), and hence, several of the troubling percep- tions expressed by our study population might not reflect how research is actual- ly conducted and the level of safeguards associated with research that provide protection of their welfare and rights in research. Consequently, percep- tions might differ from those who have participated in research (9). Nonethe- less, the perceptions held by our study sample may represent major limiting factors for recruitment for research and impair trust in the research endeavour and hence, need to be addressed. Regarding a research agenda, we recommend additional studies regard- ing perception of rights in research in other countries in the Middle East to validate our findings and to further explore in-depth the potential role of independent factors (e.g. education, poverty) that might be associated with potential research participants’ aware- ness of rights and the likelihood that they will make a claim on their rights. Such studies should also include those currently enrolled in research studies. Furthermore, we recommend the use of qualitative studies (semi-structured interviews, focus groups) to further ex- plore the explanatory mechanisms that promote awareness and realization of rights. Regarding best practices, we recom- mend that members of the research team take affirmative action to provide assurances to potential participants that all necessary steps will be taken to protect their rights and welfare. In- vestigators and other members of the research staff should also serve as the critical link to informing participants in research about their rights. Optimizing practices regarding rights in research can help enhance and maintain trust in the research endeavour. Funding: None. Competing interests: None declared. Table 4 Participants’ perceptions regarding their rights regarding participation in research (n = 202) Item Responsea No. % Participants should be given the opportunity to ask questions about the study 187 93.5 If participants become injured, then they should receive free medical care 182 91.0 Participants should be told that enrolment in research is voluntary 179 89.5 The data obtained from participants should be kept secret from individuals not involved in the research 170 85.0 Participants should be given a copy of the informed consent form 153 76.5 Participants should be able to make a complaint against any member of the research team without fear of being harmed 149 74.5 Participants should be provided with monies to reimburse for the costs of travel 116 58.6 Participants in clinical research should be allowed to withdraw from the study without giving any reason 98 49.0 Participants should be able to receive money for their efforts that is above reimbursements 92 46.2 aPercentage of those who strongly agreed or agreed. 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Associa- tion between awareness of patient rights and patient's educa- tion, seeing bill, and age: a cross-sectional study. Glob J Health Sci. 2014;6(3):55–64. PMID:24762346 Book 23-07.indb 468 8/23/2017 8:01:56 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 469 1Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: Koorosh Etemad: etemadk@gmail.com). 2Endocrine and Metabolic Office; 3Office of Hospital Management and Clinical Service Excellence; 4Diabetes Control and Prevention Program, Center for Noncommunicable Diseases Control, Ministry of Health & Medical Education, Tehran, Islamic Republic of Iran; 5Department of Epidemiology, Mamasani Higher Education Complex for Health, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran. Received: 13/01/16; accepted: 16/11/16 Urbanization and noncommunicable disease (NCD) risk factors: WHO STEPwise Iranian NCD risk factors surveillance in 2011 Zahra Khorrami,1 Koorosh Etemad,1 Shahin Yarahmadi,2 Soheila Khodakarim,1 Mohammadesmail Kameli,3 Alireza Mahdavi Hezaveh 4 and Ebrahim Rahimi 1,5 Urbanisation et facteurs de risque de maladies non transmissibles (MNT) : approche STEPwise de l’OMS pour la surveillance des facteurs de risque de MNT en République islamique d’Iran en 2011 RÉSUMÉ La présente étude a été menée afin d’examiner la relation entre l’urbanisation et les facteurs de risque de MNT, selon le modèle de l’approche STEPwise de l’OMS pour la surveillance des maladies non transmissibles. L’étude s’inscrit dans la surveillance des facteurs de risque de MNT opérée sur 10 069 personnes âgées de plus de 20 ans dans l’ensemble des provinces de la République islamique d’Iran en 2011. À l’aide de données du recensement de 2011, les niveaux d’urbanisation ont pu être déterminés pour toutes les provinces, et la régression logistique a été utilisée afin d’examiner la relation entre l’urbanisation et les facteurs de risque. Parmi les hommes, l’urbanisation avait une corrélation positive avec une faible activité physique (OR = 1,7, IC à 95 % : 1,42-2,09), une faible consommation de fruits et légumes (OR = 1,8, IC à 95 % : 1,09-2,96) et un indice de masse corporelle élevé (OR = 1,4, IC à 95 % : 1,20-1,70). Parmi les femmes, il existait une corrélation positive et significative avec une faible activité physique (OR = 1,2, IC à 95 % : 1,08-1,49), une faible consommation de fruits et légumes (OR = 1,22, IC à 95 % : 0,78-1,91) et un indice de masse corporelle élevé (OR = 1,3, IC à 95 % : 1,14-1,53). L’urbanisation a donc une corrélation significative avec l’augmentation des facteurs de MNT en République islamique d’Iran. 2011 في نارـيإ في ةيراـسلا رـغ ضارملأاب ةـقلعتلما رطلخا لـماوع دصرت :ةيراـسلا رـغ ضارملأاب ةـقلعتلما رـطلخا لـماوعو ُّرـحتلا ةيلماعلا ةـحصلا ةمظنلم جرّدـتلما جـهنلل ًاـقفو يميحر ميهاربا ،هوازه يدودهم اضرلع ، ليماك ليعماسإ دممح ،ميركادخ لايهس ،يدحمأ اراي نهش ،دماتعا شروك ،ىمرخ ارهز جّردــ تلما جــ هنلل ًاــ قفو ةيراــ سلا رــ غ ضارــ ملأاب ةــ طبترلما رــ طلخا لــ ماوعو رــ حتلا نــ ب ةــ قلاعلا في رــ ظنلل ةــ ساردلا هذــ ه تــ يرجأ :ةــ صلالخا ضارــملأاب ةــطبترلما رــطلخا لــماوع دــصرت ةــيلمع نــمض ةــساردلا هذــه تيأــتو .ةيراــسلا رــغ ضارــملأا ةــبقارلم ةــيلماعلا ةــحصلا ةــمظنلم ماــع للاــخ ،ًاــماع 20 قوــف ةــيرمعلا ةــئفلا في ،ةيملاــسلإا نارــيإ ةــيروهجم تاــظفامح عــيجم في ًاصخــش 10,069 هــعوممج اــلم ةيراــسلا رــغ يتــسجوللا رادــحنلاا مدختــساو تاــظفاحلما عــيجم في رــحتلا تايوتــسم تددــح ،2011 ماــعل نياكــسلا دادــعتلا تاــنايب مادختــسابو .2011 نيدــبلا طاــشنلا ضاــفخناو رــحتلا نــب بــجوم طاــبترا رــهظ ،روــكذلا فوــفص فيو .رــطلخا لــماوعو رــحتلا نــب ةــقلاعلا ةــساردل OR=1.4;a( مـسلجا ةلتك شرؤم عاـفتراو ،)OR=1.8, CI %95 = 1.09 – 2.96( رـلخاو ةـهكافلا كلاهتـسا لدـعم ضاـفخناو ،)OR=1.7, CI %95 = 1.42 – 2.09( OR=1.2; CI = %95 = 1.08 –( نيدـبلا طاـشنلا ضاـفخناو رـحتلا نـب ةـللاد وذو بـجوم طاـبترا ل ِّجـُسف ،ثاـنلإا فوـفص في اـمأ .)CI %95 = 1.20 – 1.70 نمو .)OR=1.22; CI %95 = 0.78 – 1.91( مـسلجا ةـلتك شرؤم عافتراو ،)OR=1.3; CI %95 = 1.14 – 1.53( رـلخاو ةـهكافلا كلاهتـسا لدـعم ضاـفخناو ،)1.49 .ةيملاـسلإا ناريإ ةـيروهجم في ةيراـسلا رغ ضارـملأاب ةطبترلما رـطلخا لماوع ةداـيز عـم ةـللاد اذ ًاـطابترا طـبتري رـحتلا نأ حـضتي ، َّمـث ABSTRACT This study was conducted to examine the relationship between urbanization and risk factors of noncommunicable diseases (NCDs) according to the World Health Organization stepwise approach to surveillance of NCDs. This study is part of a NCD risk factor surveillance of 10 069 individuals in all provinces of the Islamic Republic of Iran, aged over 20 years, during 2011. By utilizing 2011 census data, urbanization levels were determined in all provinces and logistics regression was used to examine the relationship between urbanization and risk factors. Among males, urbanization had a positive correlation with low physical activity (OR=1.7; 95% CI: 1.42-2.09), low fruit and vegetable consumption (OR=1.8; 95% CI: 1.09-2.96), and high BMI (OR=1.4; 95% CI: 1.20-1.70). Among females there was a positive and significant correlation with low physical activity (OR=1.2; 95% CI: 1.08-1.49), low fruit and vegetable consumption (OR=1.22; 95% CI: 0.78-1.91) and high BMI (OR=1.3; 95% CI: 1.14-1.53). Thus, urbanization has a significant correlation with increases in NCD factors in the Islamic Republic of Iran. Book 23-07.indb 469 8/23/2017 8:01:56 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 470 community due to the escalation in urbanization and industrialization. The aim of this study was to investigate the association between urbanization and the risk factors for NCDs, which may lead to the identification of new, more effective interventions in the prevention of chronic diseases. Method Study population and sampling We assessed the association between urbanization and NCD risk factors us- ing the data from the 2011 survey of NCD risk factor surveillance (STEPS) conducted by the Ministry of Health and Medical Education in the 31 prov- inces of the Islamic Republic of Iran (14). The study population was 10 069 people aged 20–70 years. A multistage random cluster sampling method with probability proportional to size sam- pling was used. Measuring urbanization Principal component analysis is a multi- variate statistical method to reduce the number of variables (15). This method was used to create the urbanization vari- able; overall score is based on the score obtained using the xtile quint command in SPSS (percentiles of 33.3 and 66.7) in 3 categories low, medium and high. There is no global standard indica- tor to measure urbanization because the factors associated with urbanization in one region of a country are different from those of others countries. From analysis of previous studies, the indices that had the greatest effect on urbani- zation were identified and included in this study (13,16,17). Data on 24 variables measuring multiple aspects of urbanization (e.g. demographic and so- cioeconomic indices, human resources, communication, energy, the human development index for the province, and health and treatment indicators) were used to extract their underlying Introduction It has been predicted that over 60% of the world population in low- and middle-income countries will be living in cities by 2030 (1). Certain lifestyle and environmental factors related to urbanization have a significant effect on health and noncommunicable dis- eases (NCDs). Urbanization is one of the main socioenvironmental factors which has a relationship with chang- ing lifestyles as an important risk fac- tor for NCDs (2). Previous research in low- and middle-income countries has indicated that NCD risk factors are more common in urban than in rural areas (3). In recent years, the increase in NCDs has been a common concern as a major cause of morbidity and mortal- ity worldwide (4). It has been estimated that 33 million deaths in 2008 were due to NCDs, and this is predicted to reach 52 million by 2030 (5). Urbaniza- tion has an association with lifestyle and behavioural risk factors such as unhealthy diet and low physical activ- ity (6–8). Evidence from South-East Asia has indicated that urbanization has a is associated with NCD risk factors such as low physical activity, unhealthy diet, overweight and high blood pres- sure (9,10). In the past few decades, traditional communities in low- and middle-income countries have experi- enced rapid, unplanned urbanization, which changed lifestyles and resulted in unhealthy diets, a sedentary lifestyle and smoking (11). In the past, urban and rural environments were significantly different; however, the distinction is less clear now due to recent advances (12). Many definitions of urbanization only use the simple dichotomous variable of urban and rural, making it difficult to understand the specific changes within the urbanization process that have led to changes in the main risk factors for NCDs (13). In recent years, there has been a rap- id change in lifestyle and demographic and socioeconomic status in the Iranian constructs. The principal components analysis-based index is a simple and robust measure whose values and groupings can only be moderately af- fected by changes in the urbanization landscapes. This multivariate statistical technique is used to reduce the number of variables in a data set into a smaller number of “dimensions” that are linear combinations of the original variables. Principal components analysis provides an objective way of aggregating the in- dicators so that variation in the data can be accounted for as concisely as possible .The urbanization index for all 31 provinces was calculated using this method and every province was classified into 3 urbanization levels. Variables such as average household size, population density, urbanization rate, average floor area of the dwell- ing unit per family member, economic participation rate, unemployment rate, employment in agriculture and indus- try, internet penetration, telephone and mobile penetration rate, percentage of villages with telephone communication, gas and electricity energy use per 1000 population, percentage of cities and rural areas with gas facilities, propor- tion of physicians per 1000 population, proportion of nurses per 1000 popula- tion, proportion of specialist physicians per 1000 population, and the human development index for each province were included in the analysis. Risk factors The data from the first and second stages of the 6th survey of risk factors for NCDs in 2011 in the Islamic Republic of Iran were used in this study (14). The NCD risk factors suggested by WHO such as demographic (residential location, age, gender, education, and job), nutrition (fruit and vegetable con- sumption), behavioural (smoking and physical activity), and anthropometric and blood pressure measurements were used in this survey. Anthropometric measurements include height, weight and body mass index (BMI) as an Book 23-07.indb 470 8/23/2017 8:01:56 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 471 indicator of obesity. Blood pressure was measured 3 times at 3 minute intervals in a sitting position using an Omron electronic sphygmomanometer with an accuracy of 1 mmHg. Smoking was defined as daily cigarette and/or water- pipe consumption, low fruit and vegeta- ble consumption as < 5 units per day, and low physical activity as < 150 min of moderate intensity physical activity per week. The Global Physical Activity Questionnaire was used in this survey (18). High BMI was defined as ≥25 kg/ m2, and high blood pressure as systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg (16). Outcome variable We calculated the risk factor preva- lence for each outcome within each level of urbanization. In addition, we investigated the relationship between risk factor and level of urbanization. Following WHO guidelines (19), we calculated the average consumption unit of fruits and vegetables a day, BMI, systolic and diastolic blood pressure, and age of starting smoking. Statistical methods The principal components analysis method was used to calculate the ur- banization variable. Descriptive analysis was reported using descriptive statistics for every level of urbanization. The Kol- mogorov–Smirnov test was utilized to assess the normality of variables. The 2-way Kruskal–Wallis test was used to assess the association between every continuous exposure variable and level of urbanization. Binary logistic regres- sion analysis was used to explore the association between NCD risk factors and urbanization level. P-value < 0.05 was considered significant, and SPSS, version 21, was used for all computa- tions. Results Urbanization index Urbanization scores ranged from –1.34 to 3.83 (Table 1). These were divided based on the scores obtained from xtile quint command (percentile of 33.3 and 66.7) into 3 categories: low, medium and high. Table 1 shows the distribution of provinces according to urbanization index. In the principal components analysis, variables such as internet penetration and provincial human development index achieved the greatest weight in comparison with other variables related to urbanization. Demographic characteristics The study population was aged 20–70 [overall mean 43.00 (standard devia- tion 15.34)] years (Table 2). Individual education levels were higher with great- er urbanization: 35.7% of those living in areas of low urbanization were illiterate while only 20.2% of those living in ar- eas of high urbanization were illiterate. Table 1 Urbanization index score of each province (each province to the new index score of urbanization) Province Urbanization score Urbanization level Sistan and Baluchestan –1.348 Low North Khorasan –0.931 Ardebil –0.889 Chaharmahal and Bakhtiari –0.829 Kordestan –0.794 Lorestan –0.783 Ilam –0.695 Western Azarbayjan –0.690 SouthKhorasan –0.655 Hamedan –0.521 Kohgiloyeh and Boyerahmad –0.931 Medium Kerman –0.351 East Azarbayjan –0.436 Golestan –0.344 Kermanshah –0.342 Markazi –0.306 Gilan –0.004 Qazvin 0.012 Fars 0.013 Khuzestan 0.127 Hormozgan 0.149 Yazd 0.156 Mazandaran 0.157 Khorasan Razavi 0.259 High Zanjan 0.434 Booshehr 0.543 Semnan 0.594 Esfahan 0.757 Qom 1.000 Alborz 2.208 Tehran 3.837 Book 23-07.indb 471 8/23/2017 8:01:56 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 472 There was also a significant difference in terms of employment among different urbanization levels (P < 0.05) (Table 2). Urbanization and noncommunicable disease risk factors Tobacco The prevalence of smoking among men was similar in all 3 urbanization levels (Table 3). In univariate logistic regression analysis, there was no sig- nificant association between smoking and urbanization among men (OR = 1.02, 95% CI: 0.84–1.24 for medium and OR = 0.90, 95% CI: 0.74–1.10 for high versus low levels of urbaniza- tion) or women (OR = 0.70, 95% CI: 0.50–0.99 for medium and OR = 0.85, 95% CI: 0.61–1.19 for high versus low levels of urbanization) (Table 4). In multiple logistic regression analysis after adjustment for age, there was still no sig- nificant association between smoking and urbanization in men and women. Among those living in higher levels of urbanization, the average age of starting smoking was lower in both sexes, and Table 2 Demographic characteristics of participants in the study of noncommunicable disease risk factors according to urbanization level, Islamic Republic of Iran, 2011 Characteristic Urbanization level Total Low Medium High Participants, no. (%) 2025 (20.1) 4071 (40.4) 3973 (39.5) 10 069 Mean (SD) age (years) 42.70 (15.57) 43.03 (15.18) 43.14 (15.38) 43.00 (15.34) Age range (years) 20–70 20–70 20–70 20–70 Sex, no. (%)* Male 786 (38.8) 1712 (42.1) 1637 (41.2) 4135 (41.1) Female 1239 (61.2) 2359 (57.9) 2335 (58.8) 5933 (58.9) Education status, no.(%) Illiterate 722 (35.7) 1060 (26) 801 (20.2) 2583 (25.7) Elementary 387 (19.1) 884 (21.7) 923 (23.2) 2194 (21.8) Junior high school 270 (13.3) 663 (16.3) 583 (14.7) 1516 (15.1) Diploma 406 (20.0) 928 (22.8) 960 (24.2) 2294 (22.8) Higher education 237 (11.7) 535 (13.1) 701 (17.6) 1473 (14.6) Work status, no. (%)* Public sector employee 92 (4.5) 257 (6.3) 271 (6.8) 620 (6.2) Private sector employee 93 (4.6) 265 (6.5) 296 (7.5) 654 (6.5) Employed, self-employed 412 (20.3) 819 (20.1) 688 (17.3) 1919 (19.1) Student, soldier 129 (6.4) 237 (5.8) 292 (7.3) 658 (6.5) Housewife, retired, unpaid work, unemployed, disabled 1275 (63.0) 2490 (61.2) 2415 (60.8) 6180 (61.4) Values are expressed as mean and standard deviation (SD) for normally distributed data and % for non-normally distribute data. *Significance defined as P < 0.05. Mean age of starting smoking (year) All Female Male 25 24 23 22 21 20 A ge (y ea r) A ge (y ea r) A ge (y ea r) 35 30 25 20 24 23 22 21 20 Urbanization level Low Medium High Urbanization level Low Medium High Urbanization level Low Medium High Figure 1A Mean of noncommunicable disease risk factor variables in urbanicity groups, Islamic Republic of Iran, 2011 Book 23-07.indb 472 8/23/2017 8:01:56 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 473 smoking was more prevalent among women (Figure 1A). Low physical activity Urbanization had an inverse associa- tion with physical activity in both sexes: the prevalence of low physical activity increased significantly with increased urbanization (Table 3). In multiple logistic regression analysis after adjust- ment for age, there was a statistically significant association between low physical activity and urbanization in men (OR = 1.58, 95% CI: 1.30–1.91 for medium and OR = 1.72, 95% CI: 1.42–2.09 for high versus low levels of urbanization) and women (OR = 1.36, 95% CI: 1.15–1.60 for medium Table 3 Prevalence of noncommunicable disease risk factors according to urbanization level, Islamic Republic of Iran, 2011 Risk factor Urbanization level Males Females All No. % 95% CI No. % 95% CI No. % 95% CI Daily tobacco use Low 208 26.5 23.42–29.58 59 4.8 3.63–5.97 267 13.2 11.73–14.67 Medium 471 27.5 25.39–29.61 80 3.4 2.67–4.13 551 13.5 12.46–14.54 High 414 25.3 23.20–27.40 96 4.1 3.30–4.90 510 12.8 11.77–13.83 Low physical activitya* Low 252 32.1 30.44–33.76 536 43.3 40.56–46.04 788 38.9 36.78–41.02 Medium 666 38.9 36.61–41.19 999 42.3 40.32–44.28 1665 40.9 39.40–42.41 High 690 42.2 39.81–44.59 1103 47.2 45.19–49.21 1793 45.1 43.56–46.64 Low fruit & vegetable intakeb* Low 609 77.5 74.59–80.41 1012 81.7 79.56–83.14 1621 80.0 78.26–81.74 Medium 1455 85.0 83.31–86.96 2042 86.6 85.23–87.97 3497 85.9 84.84–86.96 High 1370 83.7 81.92–85.57 1959 83.9 82.41–85.39 3330 83.8 82.66–84.94 High BMIc* Low 356 45.3 41.83–48.77 711 57.4 54.65–60.15 1067 52.7 50.53–54.87 Medium 866 50.6 48.24–52.96 1461 61.9 59.95–63.85 2327 57.2 55.69–58.71 High 910 55.6 53.20–58.00 1488 63.7 61.75–65.65 2399 60.4 58.88–61.92 High blood Pressured* Low 125 15.9 13.35–18.45 210 16.9 14.82–18.98 335 16.5 14.89–18.11 Medium 335 19.6 17.73–21.47 489 20.7 19.07–22.33 824 20.2 18.97–21.43 High 237 14.5 12.81–16.20 310 13.3 11.93–14.67 547 13.8 12.73–14.87 Low fruit & vegetable intake significant only for men. CI = confidence interval. BMI = body mass index. a< 150 min of moderate or intense physical activity per week. b< 5 servings of fruit and vegetables per day. cBMI ≥ 25 kg/m. dSystolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. *Kruskall–Wallace test, significant at P < 0.05. Mean fruits and vegetables intake per day (servings) All Female Male 4.00 3.90 3.80 3.70 3.60 Se rv in gs Se rv in gs Se rv in gs 4.10 4.00 3.90 3.80 3.70 3.60 3.50 4.00 3.90 3.80 3.70 3.60 Urbanization level Low Medium High Urbanization level Low Medium High Urbanization level Low Medium High Figure 1B Book 23-07.indb 473 8/23/2017 8:01:57 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 474 and OR = 1.26, 95% CI: 1.08–1.49 for high versus low levels of urbanization) (Table 4). Low fruit and vegetable consumption In both sexes, the prevalence of low fruit and vegetable consumption increased with increased urbanization, but this was significant only for men (Table 3). With increasing urbanization, the odds of low consumption of fruits and vegetables increased. Men who were living in provinces with a medium level of urbanization were 2.10 times more likely (crude OR = 2.10, 95%CI: 1.26– 3.48) and those living in provinces with a high level of urbanization 1.81 times more likely (crude OR = 1.81, 95%CI: 1.10–2.98) to have low fruit and veg- etable consumption in comparison with those living in areas with a low level of urbanization. This association did not change after adjustment for age in mul- tiple logistic regression. This positive re- lationship was also seen in women, but it was not statistically significant (Table 4). We also found a small difference between the mean servings of fruits and vegetables consumed per day for both sexes at different levels of urbanization (P < 0.05) (Table 5 and Figure 1B). High body mass index The prevalence of higher BMI levels (obese and overweight) in both sexes was positively related to increased ur- banization (Table 3). The odds of men having high BMI levels in medium and high levels of urbanization were 1.18 (crude OR = 1.18, 95% CI: 0.99–1.40) and 1.44 (crude OR = 1.44, 95% CI: 1.21–1.71) in comparison with lower levels of urbanization (Table 4). There was also a significant association be- tween high BMI and urbanization in women (OR = 1.21, 95% CI: 1.05–1.29 for medium and OR = 1.30, 95% CI: 1.13–1.50 for high versus low levels of urbanization). These associations did not change after adjustment for age in multiple logistic regressions. Moreover, a statistically significant association was observed between urbanization and mean BMI in both sexes as a continu- ous variable (P < 0.001) (Table 5 and Figure 1C). High blood pressure A higher prevalence of high blood pres- sure was observed in areas with medium Mean BMI (kg/m2) All Female Male 28.00 27.50 27.00 26.50 26.00 25.50 kg /m 2 kg /m 2 kg /m 2 29.00 28.00 27.00 26.00 25.00 27.00 26.50 26.00 25.50 25.00 24.50 Urbanization level Low Medium High Urbanization level Low Medium High Urbanization level Low Medium High Figure 1C Mean systolic blood pressure (mmHg) All Female Male 128.00 126.00 124.00 122.00 m m H g m m H g m m H g Urbanization level Low Medium High Urbanization level Low Medium High Urbanization level Low Medium High 128.00 126.00 124.00 122.00 120.00 129.00 128.00 127.00 126.00 125.00 124.00 123.00 Figure 1D Book 23-07.indb 474 8/23/2017 8:01:57 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 475 of urbanization before and after age- adjusted analyses. In a study conducted in Greenland, no relationship was found between unhealthy dietary patterns and urbanization or socioeconomic status (25). In a study in 100 countries, Ez- zati et al. found that BMI increased with increasing urbanization (26). Our findings indicate that with increasing urbanization, average BMI, high blood pressure, and low physical activity in- creased, consistent with previous studies (27–29). We found the prevalence of physical activity was higher in areas with low urbanization than in areas with high urbanization, consistent with the results of other studies (30,31). In a study in Sri Lanka, men and women in areas with high urbanization had respectively 3 and 2 times lower physical activity than those living in other urban areas, which was significant after age adjustment (32). Monda et al. also found that low physical activity increased with increas- ing urbanization (33). Our findings are consistent with those of other studies in that as a result of office jobs in the city and the use of technology, physical ac- tivity is reduced and the city population has a sedentary rather than an active lifestyle. Therefore, it is suggested that in areas with high levels of urbanization, the focus should be on environmental characteristics and providing facilities such as trails, parks, swimming pools, and gyms. Walking teams, teams for levels compared with areas with low levels of urbanization for both sexes (Table 3). The same observation was not seen for areas with high levels of urbanization. In univariate logistic re- gression analysis, there was a significant association between high blood pres- sure and urbanization in men (OR = 1.25, 95% CI: 1.00–1.57) for medium versus low levels of urbanization and women for medium (OR = 1.29, 95% CI: 1.08–1.54) and for high (OR = 0.78, 95% CI: 0.64–0.94) versus low levels of urbanization. This association did not change after adjustment for age in multiple logistic regression (Table 4). In addition, using the Kruskal–Wallis test, mean systolic and diastolic blood pressure had a significant association with level of urbanization in both sexes (P < 0.001) (Table 5 and Figures 1D and 1E). Discussion Our findings support the hypothesis that there is a relationship between ur- banization and NCD risk factors: ur- banization had a positive association with low physical activity, low intake of fruit and vegetables, BMI and hyperten- sion in both sexes. In 2009, a study con- ducted in the Islamic Republic of Iran reported a relationship between urbani- zation and risk factors of NCD, such that prevalence of NCD risk factors increased with increasing urbanization, consistent with our findings (20). A study conducted in India indicated that there was a relationship between smok- ing and urbanization in men (21). In our study, however, no such significant association was observed. Nevertheless, the results showed that with increasing urbanization the age of starting smok- ing decreased; this relationship was more evident in women, suggesting that preventive measures should be taken along with education about the dangers and side-effects of smoking in high-risk groups. In Qingdao, China, researchers found that urbanization was related to a number of risk factors such as low physical activity, unhealthy diet and obesity (21), consistent with the results of this study. Liu et al. found that urban development significantly reduced daily physical activity and increased the consumption of high calorie foods (fast food) (22). It has consequently led to a rapid increase in obesity and overweight due to changes in diet and lifestyle which significantly affect health (12,23,24). A study from India showed no significant relationship between the prevalence of low fruit and vegetable consumption and different levels of urbanization in either sex (16). Unlike the Indian study, we found significant differences in the prevalence of low fruit and vegetable consumption among different levels Mean diastolic blood pressure (mmHg) All Female Male 80.50 80.00 79.50 79.00 78.50 78.00 77.50 m m H g m m H g m m H g Urbanization level Low Medium High Urbanization level Low Medium High Urbanization level Low Medium High 81.00 80.50 80.00 79.50 79.00 78.50 78.00 80.00 79.50 79.00 78.50 78.00 77.50 77.00 Figure 1E Book 23-07.indb 475 8/23/2017 8:01:57 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 476 beautifying green spaces, and increasing street lighting are effective in increas- ing physical activity (32,33). In some studies, the likelihood of having high blood pressure was greater for residents of areas with high urbanization than for residents of other areas, after age adjustment (26,29,30,34). Mathenge et al. found that likelihood of having hypertension was greater in urban residents than in rural residents after age and sex adjustment (27). A 2015 Chinese study concluded that envi- ronmental changes have a potential impact on systolic and diastolic blood pressure (35). Increased prevalence of high blood pressure can be attributed to increased environmental risk factors parallel to increased urbanization, while globally, high blood pressure is one of Table 4. Crude odds ratios and age-adjusted odds ratios for noncommunicable disease risk factors according to urbanization level, Islamic Republic of Iran, 2011 Risk factor Urbanization level Crude OR Age-adjusted OR OR 95% CI P-value OR 95% CI P-value Males Daily tobacco use Low 1.00 – – 1.00 – – Medium 1.02 0.84–1.24 0.805 1.01 0.83–1.22 0.885 High 0.90 0.74–1.10 0.330 0.90 0.74–1.09 0.299 Low physical activitya Low 1.00 – – 1.00 – – Medium 1.60 1.33–1.94 < 0.001 1.58 1.30–1.91 < 0.001 High 1.72 1.42–2.08 < 0.001 1.72 1.42–2.09 < 0.001 Low fruit & vegetable intakeb Low 1.00 – – 1.00 – – Medium 2.10 1.26–3.48 0.004 2.08 1.25–3.46 0.005 High 1.81 1.10–2.98 0.019 1.80 1.09–2.96 0.021 High BMIc Low 1.00 – – 1.00 – – Medium 1.18 0.99–1.40 0.056 1.15 0.97–1.37 0.107 High 1.44 1.21–1.71 < 0.001 1.43 1.20–1.70 < 0.001 High blood pressured Low 1.00 – – 1.00 – – Medium 1.25 1.00–1.57 0.046 1.22 0.96–1.55 0.099 High 0.90 0.71–1.14 0.386 0.85 0.66–1.09 0.214 Females Daily tobacco use Low 1.00 – – 1.00 – – Medium 0.70 0.50–0.99 0.046 0.70 0.50–1.00 0.050 High 0.85 0.61–1.19 0.370 0.85 0.61–1.19 0.360 Low physical activitya Low 1.00 – – 1.00 – – Medium 1.36 1.15–1.60 < 0.001 1.36 1.15–1.60 < 0.001 High 1.26 1.08–1.49 0.004 1.26 1.08–1.49 0.004 Low fruit & vegetable intakeb Low 1.00 – – 1.00 – – Medium 1.44 0.92–2.27 0.110 1.44 0.92–2.28 0.109 High 1.22 0.78–1.91 0.362 1.22 0.78–1.90 0.367 High BMIc Low 1.00 – – 1.00 – – Medium 1.21 1.05–1.39 0.006 1.25 1.08–1.44 0.003 High 1.30 1.13–1.50 < 0.001 1.32 1.14–1.53 < 0.001 High blood pressured Low 1.00 – – 1.00 – – Medium 1.29 1.08–1.54 0.005 1.44 1.18–1.76 < 0.001 High 0.78 0.64–0.94 0.011 0.72 0.59–0.89 0.003 OR = odds ratio. CI = confidence interval. BMI = body mass index. a< 150 min of moderate or intense physical activity per week. b< 5 servings of fruit and vegetables per day. cBMI ≥ 25 kg/m. dSystolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Book 23-07.indb 476 8/23/2017 8:01:57 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 477 (smoking and physical activity), there is the possibility that information bias may have affected the results. Our findings indicate that increasing urbanization is related to the increased prevalence of several modifiable NCD risk factors that couldn serve as a basis for future studies, planning in order to manage health problems, determining the distribution of financial resources and human resources, and coordinating prevention and intervention strategies the risk factors associated with number of deaths (36). Our study has a cross-sectional na- ture, and thus no causality association can be deduced from it. In terms of the scale of urbanization, 2 provinces can have the same urbanization level, but may differ in other environmental di- mensions that are likely to differentially affect health. Thus, more environmen- tal research is needed to understand the implications of urbanizing the environment to develop an exposure measure for NCDs. Moreover, possible differences in factors probably caused by urbanization, such as stress levels and environmental factors, were not investi- gated; these could be considered valid for future population studies. Further development is required to understand the relative contribution of internet penetration, human development in- dex, and each scale element for risk of chronic diseases. As self-reported infor- mation was received from participants regarding nutrition (fruit and vegetable consumption) and behavioural factors Table 5. Distribution of noncommunicable disease risk factors according to urbanization level, Islamic Republic of Iran, 2011 Outcome Urbanization level No. of people in group Mean SD 95% CI P-value Males No. of servings of fruit and vegetables per day Low 638 3.79 2.31 3.60–3.97 0.007 Medium 1488 3.84 1.84 3.75–3.94 High 1406 3.82 2.04 3.71–3.93 BMI (kg/m*2) Low 763 25.08 0.71 24.58–25.59 0.0001 Medium 1704 25.88 1.13 25.34–26.42 High 1632 26.28 1.28 25.65–26.90 Systolic blood pressure (mmHg) Low 763 124.57 19.12 123.21–125.92 0.0001 Medium 1693 128.06 17.36 127.23–128.89 High 1580 125.69 16.85 124.86–126.52 Diastolic blood pressure (mmHg) Low 763 78.63 12.49 77.74–79.51 0.0001 Medium 1693 77.67 11.48 77.12–78.22 High 1580 79.37 11.67 78.79–79.94 Females No. of servings of fruit and vegetables per day Low 1045 3.66 2.07 3.53–3.79 0.0001 Medium 2088 3.83 1.88 3.75–3.91 High 2011 3.95 2.39 3.84–4.05 BMI (kg/m*2) Low 1235 26.83 1.67 25.89–27.76 0.0001 Medium 2347 27.79 1.30 27.26–28.32 High 2330 28.15 2.06 27.32–28.99 Systolic blood pressure (mmHg) Low 1234 122.45 21.68 121.23–123.66 0.0001 Medium 2334 126.93 20.82 126.08–127.77 High 2247 120.85 19.96 120.03–121.66 Diastolic blood pressure (mmHg) Low 1232 80.12 13.14 79.39–80.86 0.004 Medium 2334 78.74 12.15 78.24–79.23 High 2247 78.66 12.31 78.15–79.17 Means were compared using the Kruskal–Wallis test when assumptions for analysis of variance were not met. SD = standard deviation. CI = confidence interval. BMI = body mass index. *P-value for Kruskal–Wallis test. Book 23-07.indb 477 8/23/2017 8:01:57 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 478 References 1. Godfrey R, Julien M. Clin Med (Lond). 2005;5(2):137–41. PMID:15847005 2. Global status report on noncommunicable disease. Geneva: World Health Organization; 2010. 3. Al-Moosa S, Allin S, Jemiai N, Al-Lawati J, Mossialos E. Dia- betes and urbanization in the Omani population: an analysis of national survey data. Popul Health Metr. 2006;4(1):5. PMID:16635266 4. UN high-level meeting on NCDS (New York, 19–20 September 2011): summary report of the discussions at the round tables. Geneva: World Health Organization; 2011 (http://www.who. int/nmh/events/moscow_ncds_2011/round_tables_sum- mary.pdf, accessed 7 May 2017). 5. Cheema A, Adeloye D, Sidhu S, Sridhar D, Chan KY. 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Cairo: World Health Organization; 2012 (Community- Based Initiatives Series 16). 21. Dong Y, Gao W, Nan H, Yu H, Li F, Duan W, et al. Preva- lence of type 2 diabetes in urban and rural Chinese popula- tions in Qingdao, China. Diabet Med. 2005;22(10):1427–33. PMID:16176207 22. Liu S, Wang W, Yang X, Lee ET, Zhang J, He Y, et al. Prevalence of diabetes and impaired fasting glucose in Chinese adults, China National Nutrition and Health Survey, 2002. Prev Chronic Dis. 2011;8(1)A13. PMID:21159225 23. Yarahmadi S, Etemad K, Hazaveh AM, Azhang N. Urbanization and noncommunicable risk factors in the capital city of 6 big provinces of iran. Iran J Public Health. 2013;42(Suppl. 1):113–8. PMID:23865027 24. Siddiqui ST, Kandala NB, Stranges S. Urbanisation and ge- ographic variation of overweight and obesity in India: a cross-sectional analysis of the Indian Demographic Health Survey 2005–2006. Int J Public Health. 2015;60(6):717–26. PMID:26198774 25. Bjerregaard P, Jeppesen C. 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Conclusion In this study, urbanization was de- scribed and classified using different factors instead of the known rural/ur- ban dichotomy, and a clear association was observed between different levels of urbanization and NCD risk factors. Increasing urbanization and its conse- quent complications requires policies and preparations by local governments to meet the needs of the community, which requires an intersectoral agree- ment and cooperation with other aca- demic and administrative sectors. Funding: This study was part of the MSc thesis of Zahra Khorrami, supported by Shahid Beheshti University of Medical Sciences (grant No.: /A/9294/36). Competing interests: None declared. Book 23-07.indb 478 8/23/2017 8:01:57 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 479 29. Addo J, Smeeth L, Leon D. Hypertension in sub-Saharan Af- rica: a systematic review. Hypertension. 2007;50(6):1012–8. PMID:17954720 30. Reis JP, Bowles HR, Ainsworth BE, Dubose KD, Smith S, La- ditka JN. Nonoccupational physical activity by degree of urbanization and US geographic region. Med Sci Sports Exerc. 2004;36(12):2093–8. PMID:15570145 31. Parks S, Housemann R, Brownson RC. Differential correlates of physical activity in urban and rural adults of various socioeco- nomic backgrounds in the United States. J Epidemiol Commu- nity Health. 2003;57(1):29–35. PMID:12490645 32. Allender S, Wickramasinghe K, Goldacre M, Matthews D, Katulanda P. Quantifying urbanization as a risk factor for non- communicable disease. J Urban Health. 2011;88(5):906–18. PMID:21638117 33. Monda KL, Gordon-Larsen P, Stevens J, Popkin BM. China's transition: the effect of rapid urbanization on adult occu- pational physical activity. Soc Sci Med. 2007;64(4):858–70. PMID:17125897 34. Kamadjeu RM, Edwards R, Atanga JS, Kiawi EC, Unwin N, Mbanya JC. Anthropometry measures and prevalence of obe- sity in the urban adult population of Cameroon: an update from the Cameroon Burden of Diabetes Baseline Survey. BMC Public Health. 2006;6:228. PMID:16970806 35. Attard SM, Herring AH, Zhang B, Du S, Popkin BM, Gordon- Larsen P. Associations between age, cohort, and urbanization with SBP and DBP in China: a population-based study across 18 years. J Hypertens. 2015;33(5):948–56. PMID:25668349 36. Choh AC, Nahhas RW, Lee M, Choi YS, Chumlea WC, Duren DL, et al. Secular trends in blood pressure during early-to- middle adulthood: the Fels Longitudinal Study. J Hypertens. 2011;29(5):838-45. PMID:21430562 Book 23-07.indb 479 8/23/2017 8:01:57 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 480 1University of Oklahoma School of Community Medicine, Tulsa, United States of America; 2New York University School of Medicine, New York, United States of America (Correspondence to: Leena W. Asfour: leena.asfour@med.nyu.edu). 3Departments of Pediatrics and Environmental Medicine; 4Department of Population Health, New York University School of Medicine; 6Public Health Research Center, Global Institute of Public Health, New York University, New York, United States of America. *Authors contributed equally. Received: 11/9/15; accepted: 20/11/16 Implementation of a peer-mediated health education model in the United Arab Emirates: addressing risky behaviours among expatriate adolescents Zachary D. Stanley 1*, Leena W. Asfour 2*, Michael Weitzman 3,5,6 and Scott E. Sherman 4,5 Mise en œuvre d’un modèle d’éducation en santé axé sur l'intervention des pairs aux Émirats arabes unis : lutter contre les comportements à risque des adolescents expatriés RÉSUMÉ La consommation de tabac parmi les jeunes est en augmentation aux Émirats arabes unis, et le pays se classe au quinzième rang mondial pour la prévalence du diabète de type 2. Les expatriés constituent une majorité de la population, ce qui fait d’eux un sous-ensemble important à étudier. Notre objectif consistait à déterminer si une intervention éducative serait efficace dans ce contexte culturel. Nous avons mis au point deux ateliers de santé organisés par des pairs et portant sur le tabagisme d’une part, et sur la nutrition et l’activité physique d’autre part. Dix-huit classes d’établissements privés à Abou Dhabi se sont vues attribuées l’un des deux ateliers thématiques susmentionnés. Des sondages ont été menés avant et après les ateliers afin d’évaluer l’efficacité de l’intervention. L’atelier sur le tabagisme a conduit à une amélioration significative des modifications de comportement (p < 0,05). L’atelier sur la nutrition et l’activité physique a permis une baisse de la satisfaction des participants concernant leurs niveaux personnels d’activité. Cette étude fournit des arguments en faveur de l’adoption d’un modèle d’éducation par les pairs comme intervention de lutte contre le tabagisme, mais pas pour les choix liés à la nutrition et l’activité physique. في ةرــ طلخا تايكولــ سلل ي ِّدــ صتلا :ةدــ حتلما ةــ يبرعلا تاراــ ملإا في نارــ قلأا قــ يرط نــ ع يــ حصلا مــ يلعتلا جذوــ من ذــ يفنت نــ بترغلما نــ قهارلما فوــ فص نامشر توكس ،نامزتياو لكيام ،روفصع انيل ،ليناتس يركاز ىـع ةشرـع ةـسمالخا ةـبترلما دـلبلا لـتيحو ،ةدـحتلما ةـيبرعلا تاراـملإا ةـلود في بابـشلا فوـفص في دـيازتلا في غـبتلا مادختـسا أدـب :ةـصلالخا .ةـساردلل ةـمهم ةـيعرف ةـعوممج مـهلعيج اـمم ،ناكـسلا ةـيبلغأ نوـبترغلما لّكـشيو .يرّكـسلا ءاد نـم نياـثلا عوـنلا راـشتنلا لماـعلا ىوتـسم في نارـقأل لـمع ْيـ َتقلح مـيمصتب اـنمقف .فياـقثلا راـطلإا اذـه في ةـيميلعتلا تلاـخدتلا ةـيلاعف ىدـم راـبتخا ةـساردلا هذـه في انفدهتـساو ًايـسارد ًاـفص 18 لىإ ةيئاوـشع ةروـصب لـمعلا ْيـَتقلح ىدـحإ تـصصُخو .نيدـبلا طاـشنلا/ةيذغتلاو ،غـبتلا مادختـسا :لوـح يـحصلا لاـجلما نـستح نـم غـبتلاب ةـينعلما لـمعلا ةـقلح تـن َّكتمو .لـ ُّخدتلا ةـيلاعف مـييقتل لـمعلا ْيـَتقلح دـعبو لـبق حوـسم تـيرجأو .يـبظ وـبأ ةـنيدم في نـع اـضرلا ىوتـسم ضاـفخنا نـع نيدـبلا طاـشنلاو ةـيذغتلاب ةـينعلما لـمعلا ةـقلح ترفـسأو .)p < 0.05( ظوـحلم وـحن ىـع تاباجتـسلاا يـ نطولا ىوتـ سلما ىـ ع نارـ قلأا نـ ب يـ حصلا مـ يلعتلا جذوـ من دماـ تعا مـ عدل لـ يلدلا ةـ ساردلا هذـ ه رـ ِّفوتو .صيخـشلا طاـ شنلا تايوتـ سم .نيدـبلا طاـشنلاب ةـصالخا تاراـيتخلااو ةـيذغتلا ضارـغلأ سـيل نـكلو غـبتلا مادختـسا ةـهجاولم ًلاـخدت هراـبتعاب ABSTRACT Tobacco use among young people is increasing in the United Arab Emirates, and the country is ranked 15th in the world for prevalence of type II diabetes. Expatriates comprise a majority of the population, making them an important subset to study. We aimed to test whether an educational intervention would be effective in this cultural setting. We designed 2 peer-to-peer health workshops: tobacco use and nutrition/physical activity. One workshop was randomly assigned to 18 classrooms in private schools in Abu Dhabi. Surveys were administered before and after the workshops to assess intervention effectiveness. The tobacco workshop significantly improved responses (P < 0.05). The nutrition and physical activity workshop resulted in decreased satisfaction with personal activity levels. This study provides evidence to support the national adoption of a peer-to-peer health education model as an intervention for tobacco use but not for nutrition and physical activity choices. Book 23-07.indb 480 8/23/2017 8:01:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 481 Introduction As the prevalence of noncommunica- ble diseases continues to rise, health care providers and policy-makers have begun to seek preventive measures. Prevention can be as simple as healthy lifestyle choices regarding tobacco use, diet and physical activity (1). However, these choices are heavily influenced by habits formed at very young ages (2). By targeting teenagers and educating them about the consequences of their lifestyle choices, we may be able to combat major behavioural contributors to the most burdensome health conditions. To date, however, school-based health education has not been established as a global norm. School systems in many Gulf Cooperation Council countries have yet to incorporate comprehensive health curricula as part of students’ academic experience (3). In the United Arab Emirates, high schools are not mandated to provide any sort of health education to their students (4). In an- other study using the same cohort stud- ied here, we identified not only a gap in health education but also an inefficacy of anti-tobacco laws and campaigns (5). In light of these findings, health educa- tion has unexplored potential. We chose the focus of our health workshops to be topics that are the most salient to the population of the United Arab Emirates, namely tobacco use, physical activity and nutrition. Although tobacco consumption in high- and middle-income countries has recently decreased, the Middle East has an increasing prevalence of tobacco use, especially among youth (6,7). In this cohort, 39% of males had already tried cigarette smoking, at an average age of 12–13 years (5). Furthermore, 39% of males report using waterpipe tobacco (shisha) and 7% report using dokha, a type of tobacco common around the Persian Gulf (5). Amongst females in this cohort, 19% had tried cigarette smoking, 37% had tried waterpipe tobacco and 7% had tried dokha at an average age of 11–12 years (5). With 18.8% of the population liv- ing with type II diabetes, the United Arab Emirates is ranked 15th in the world for prevalence of this condition (8). The rise in obesity and sedentary lifestyles along with increasing access to unhealthy food options has contributed to the increased prevalence (9). Even with government mandated initiatives to fight the increase in childhood obe- sity, the dramatic change in lifestyle over the past 40 years has developed a cul- ture of poor eating habits and physical inactivity that are strongly embedded in the daily routine of the average resi- dent (10). While our study focuses on expatriate youth, these data are relevant as the culture and environment of the United Arab Emirates influence the lifestyle decisions of the large expatri- ate community. Moreover it has been reported that our cohort of teens con- sumed a large amount of sugary drinks each day and are not physically active on a daily basis. Many students also self-reported eating too much or too little and going to extreme measures to lose weight (5). The purpose of this study was to evaluate the efficacy of peer-mediated health education in schools with pre- dominantly expatriate youth in Abu Dhabi, United Arab Emirates. Accord- ing to the last census information avail- able, just over 89% of the population were identified as non-nationals (11). As this is such a large majority of the population, it is an important subset for us to study and understand, especially if current migration trends continue (12). Research in other countries has shown that peer-to-peer education models which train young people to teach students are highly effective (13). As a result, peer-mediated models have seen increased utilization for topics in health education (14). A study conducted in the United Arab Emirates with 12th grade students found that a peer-to-peer workshop on HIV/AIDS was effective in improving knowledge, attitudes and perceptions of the condition (15). We decided to use this model in designing our school-based intervention. To sup- plement our study of intervention effec- tiveness on the health topics specifically, we also decided to elicit feedback from the students about the peer-to-peer model. No other studies to date have tested a health education intervention for tobacco use, nutrition and physical activity in the United Arab Emirates at the high school level. Methods Study design A pre-workshop survey was admin- istered to our cohort to establish a baseline for knowledge, attitudes and behaviours regarding tobacco use, nu- trition and physical activity. The cohort was split and given either a nutrition and physical activity workshop or a tobacco workshop. A post-workshop survey was administered. We evaluated the efficacy of each workshop by comparing the pre- and post-survey questions perti- nent to each workshop (i.e. tobacco or nutrition and physical activity) and us- ing the responses of the other workshop group as a control. We focused on 9th graders because the literature suggested that smoking tobacco becomes a highly relevant topic around this age. As noted earlier, 39% of males and 19% of females of this cohort had already tried cigarette smoking (5). Data collection and workshop implementation The cohort consisted of 9th grade students from 5 private high schools distributed throughout the city of Abu Dhabi. Schools whose curricula were not taught in English were excluded in order to ensure the students had sufficient English reading and writing skills to complete the surveys accurately (all 36 public schools in Abu Dhabi with a 9th grade teach in Arabic and Book 23-07.indb 481 8/23/2017 8:01:58 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 482 were not included). According to the Abu Dhabi Education Council website there are 80 private schools in the Abu Dhabi Emirate that have a 9th grade. Of these, 18 teach their curricula in Arabic, leaving 62 that do not teach in Arabic. We called these schools at random. The first 5 that answered our phone calls and did not have health curricula were included in the study. After calling 11 schools we had found the appropriate number of classes meeting our criteria and willing to work our study into their class schedule. We would like to point out that only 2 of the 11 schools we contacted already had health curricula. Each school had a student body primar- ily composed of students from a Middle Eastern or North African (MENA) ori- gin. Upon reaching an agreement with each partner school, both parental and minor consent forms were distributed and returned before scheduling the pre- workshop survey. Of the possible study cohort, 99% of the students agreed to participate in the study. Those who did not return the consent forms were al- lowed to study in a separate classroom during the lesson and surveys. The pre- and post-workshop sur- veys were completely anonymous and comprised questions from the World Health Organization (WHO) Global Youth Tobacco Survey (GYTS) and the Centers for Disease Control Youth Risk Behavior Surveillance System. The WHO had previously administered the GYTS in the United Arab Emirates in 2001 and 2005, yet failed to address more-regional varieties of tobacco that students might readily encounter. After administration of the pre- workshop survey, a peer-mediated to- bacco or nutrition and physical activity workshop was conducted. The tobacco workshop was organized into subsec- tions that focus on the following: the importance of talking about tobacco as a teenager, what tobacco is, long and short term effects of tobacco smoking on the human body, different types of tobacco smoking that are common in the region, influences on teen smoking, and the benefits of tobacco cessation. An analogous nutrition and physical activity workshop was also implement- ed, following the same curriculum pat- tern as listed above. The focus of each workshop was to provide accurate and useful information that students could use to make healthy decisions and to complete exercises that improved at- titudes towards healthy lifestyles. The workshop materials consisted of a brief workbook and several props to make the workshop more interactive. Power- Point presentation was not used. Two of the authors (LWA and ZDS), both university students who were trained and had experience as health educators and curriculum designers, designed and taught the workshops. Each workshop lasted the duration of 1 class period, generally 45 minutes. We taught the workshops to a total of 18 segregated classrooms (10 female, 8 male). Each classroom was randomly assigned either the tobacco or the nutri- tion and physical activity workshop (5 female tobacco workshops, 5 female nutrition and physical activity work- shops, 4 male tobacco workshops, and 4 male nutrition and physical activity workshops). The post-workshop survey was administered approximately 2–3 weeks after the workshop. The Institutional Review Board of New York University Abu Dhabi ap- proved all steps of the methodology. Statistical analysis of survey research All survey data were compiled into a database, and letter choices were con- verted according to our survey code- book using Python. Where relevant, letter choices were ranked based on which responses had the best health outcomes with the best response start- ing at zero. No sample size calculations were performed. To assess the impact of the work- shops on the participants’ beliefs on tobacco use or nutrition and physical activity, the statistical software STATA was used to calculate ordinal logistic re- gressions (proportional odds models) on responses for 29 questions. There were 22 questions mapped to the to- bacco workshop and 7 to the nutrition and physical activity workshop. The pre- workshop data acted as the baseline for the regression, and the post-workshop data were monitored for change using this baseline. Each dependent variable (survey question) was controlled for by several independent variables – age, sex and school attended. Because the post-workshop surveys were identical for each workshop group, the post- workshop data for one workshop group acted as the control for the other. For example, we could examine changes in a certain attitude on tobacco use in the nutrition and physical activity group and the tobacco group. The comparison identifies whether the information in the tobacco workshop was indepen- dently associated with the change or whether another factor was responsible. Odds ratios and 95% confidence inter- vals were calculated to interpret the coef- ficient of the ordinal logistic regression. For the 4 yes or no questions as- sessing the efficacy of the peer-to-peer model, which were only included in the post-workshop survey, the statisti- cal software R was used for perform- ing simple binomial tests on response frequencies. Results Description of intervention cohort The sample consisted of 439 respond- ents: 46.5% male and 53.5% female. The average age was 13.9 years (σ = 0.76). The average weekly disposable income of the students was AED 94.41 ($US 25.70). Analyses of workshop effectiveness We analysed 439 completed pre-sur- veys and 394 completed post-surveys, Book 23-07.indb 482 8/23/2017 8:01:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 483 with missing data accounted for by absence from school on the date of the workshop or survey. Compared to the cohort’s baseline responses in the pre- workshop survey, the tobacco work- shop effected change in 12 questions related to attitudes and perceptions of tobacco use. The specific questions, ordinal logit coefficients and odds ratios are outlined in Table 1. The answer choices within a question were ranked from healthiest to least healthy. The healthiest response was scored as 0, and the score increased by 1 for the answer choices based on their health ranking within a question. As a result of this ranking method, a negative ordinal logit coefficient demonstrates change towards a healthier perception, attitude or knowledge base. The tobacco work- shop was also significantly associated with changes in 2 nutrition and physical activity-related questions in bivariate analyses. The changes in all cases were in the desired direction, namely a healthier outcome. When compared with the baseline, the nutrition and physical activity work- shop was associated with a change in response to 1 of the 7 nutrition and physical activity-related questions, but did not affect any of the tobacco re- lated questions. Table 1 includes the 1 nutrition and physical activity question affected along with the ordinal logistic regression coefficient and correspond- ing odds ratio. Finally, we found that overall the cohort felt that the peer-to-peer work- shop model was informative, relatable, worth sharing with family and friends, and recommendable to friends. The majority of students in both the tobacco and the nutrition groups responded positively to 4 questions that evaluate how the cohort felt about the peer-to- peer model (Table 2). For the 2-sided binomial tests P < 0.01, meaning that the respondents significantly chose “yes” to each of the 4 questions. We did not evaluate our data for differences between male and female responses. Discussion Overall, the tobacco workshop was effective in improving knowledge, at- titudes and perceptions about tobacco use, resulting in improvement on 12 questions. The nutrition and physical activity workshop was not effective in improving knowledge, attitudes and perceptions of nutrition and physical activity; it only resulted in a decrease in the teenagers’ level of satisfaction with their physical activity. The success of the tobacco workshop may be attributed to the fact that tobacco use is a more salient topic at this stage in life than nutrition and physical fitness. It may also be because the gap in knowledge about tobacco use is greater than it is for eating healthily and exercising regularly. Many students were shocked to learn that shisha and dokha presented health risks just as serious as those of cigarette smoking. On the other hand, only 3 out of 10 students had not received advice about leading a healthy lifestyle (5). This suggests that another workshop or another method of disseminating information should be developed as the cohort did reveal unhealthy lifestyle habits. An examination of the questions that were not significantly impacted by the workshops reveals a number of important findings. The questions “If one of your best friends offered you shisha, would you smoke it?” and “Do you agree or disagree with the follow- ing: I think I might enjoy smoking shisha?” were significantly impacted by the tobacco workshop while the same questions about “tobacco products” and “dokha” were not. This appears to confirm that shisha was thought of as a harmless social activity and that the to- bacco workshop successfully corrected this common misconception. Other questions that did not show significant changes may be attributed to the fact that they did not have many undesirable potential responses or to a weakness in the workshop content. The 4 questions that probed the students’ opinions on the model we used confirmed that the peer-to-peer model was popular and effective in this cultural setting. An overwhelming ma- jority of students stated that they plan on using something they learned in their workshop to make a future decision regarding their health, which hits at the crux of the goals for health education for adolescents: prevention of participation in risky behaviours that increase the risk for noncommunicable diseases later in life. Engagement in the health education workshop is crucial to its success and it is encouraging that the majority of students would not only recommend a similar workshop to friends or fam- ily but would also share something that they have learned, further increasing the audience and power of the workshop. Evaluation and improvements Because self-reporting was the method used to collect data, the results are sub- ject to social desirability bias. Despite assuring our participants of the con- fidentiality of their survey responses, the cultural setting of the United Arab Emirates may have prevented some from reporting honestly. It should be noted that the surveys used were not tested for reliability or validity in this cultural context. There may also be some spillover effects between the workshops. The to- bacco workshop, for example, was able to affect 2 nutrition and physical activity questions which were not addressed in that workshop. We hypothesize that learning about how tobacco use impacts human health led to students thinking about healthier behaviours in general. Our cohort (exclusively 9th graders in private schools in Abu Dhabi whose language of instruction is English) lim- its the scope of the study. Differences Book 23-07.indb 483 8/23/2017 8:01:58 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 484 with public schools, schools with Arabic as the language of instruction, other grade levels, and schools in different parts of the United Arab Emirates may be notable. Additionally, our study did not assess changes in behaviour owing to the short time between the baseline and post-workshop surveys. Due to the relatively small sample size, we recog- nize that our attempts to randomize may have had limited effectiveness in balancing the 2 workshop groups. Future studies The sample in this study did not take into account the Emirati perspective, since we included schools predomi- nantly for expatriates rather than local public schools. Future studies on the effectiveness of peer-mediated health workshops should target local popula- tions in their native language. Moreo- ver, workshops on other health topics should be created using the peer-to-peer model and tested to see if they are also effective in this environment. Conclusion By creating, implementing and evaluat- ing a peer-mediated health education model among expatriate students in the United Arab Emirates, we have shown that simple, cost–effective interventions can have a significant impact. Tobacco Table 1. Logistic regression of knowledge, attitudes and beliefs regarding tobacco, nutrition and physical activity Question Workshop Ordinal logit coefficient (SE) Odds ratio (SE) Do you agree or disagree with the following: “I think I might enjoy smoking shisha.” N/PA 0.200 (0.165) 1.220 (0.201) Tobacco –0.525 (0.168)*** 0.592 (0.099)*** Do you think smoking shisha helps people feel more comfortable or less comfortable at celebrations, parties, or in other social gatherings? N/PA 0.126 (0.166) 1.130 (0.189) Tobacco –0.336 (0.163)** 0.715 (0.117)** Do you think smoking dokha helps people feel more comfortable or less comfortable at celebrations, parties, or in other social gatherings? N/PA –0.066 (0.167) 0.936 (0.156) Tobacco –0.345 (0.166)** 0.708 (0.118)** Once someone has started smoking tobacco, do you think it would be difficult for him or her to quit? N/PA 0.019 (0.172) 1.020 (0.175) Tobacco –0.347 (0.172)** 0.707 (0.121)** Once someone has started smoking shisha, do you think it would be difficult for him or her to quit? N/PA 0.199 (0.166) 1.220 (0.203) Tobacco –0.594 (0.167)*** 0.655 (0.134)*** Once someone has started smoking dokha, do you think it would be difficult for them to quit? N/PA 0.168 (0.170) 1.183 (0.201) Tobacco –0.284 (0.165)* 0.752 (0.124)* Do you think the smoke from other people’s tobacco smoking is harmful to you? N/PA –0.072 (0.171) 0.930 (0.159) Tobacco –0.813 (0.183)*** 0.440 (0.081)*** Do you think the smoke from other people’s shisha smoking is harmful to you? N/PA –0.028 (0.164) 0.972 (0.159) Tobacco –0.695 (0.168)*** 0.499 (0.084)*** Do you think the smoke from other people’s dokha smoking is harmful to you? N/PA 0.031 (0.170) 1.030 (0.175) Tobacco –0.516 (0.174)*** 0.597 (0.104)*** At any time during the next 12 months do you think you will use any form of tobacco? N/PA –0.124 (0.188) 0.884 (0.167) Tobacco –0.384 (0.194)** 0.681 (0.132)** If one of your best friends offered you shisha, would you smoke it? N/PA 0.111 (0.169) 1.110 (0.189) Tobacco –0.433 (0.177)** 0.648 (0.115)** Do you think smoking tobacco is harmful to your health? N/PA 0.008 (0.194) 1.010 (0.196) Tobacco –0.595 (0.217)*** 0.551 (0.119)*** How important do you think nutrition is to maintaining a healthy lifestyle? N/PA 0.139 (0.179) 1.150 (0.206) Tobacco –0.554 (0.192)*** 0.575 (0.111)*** On an average school day, how many hours do you watch TV? N/PA –0.069 (0.161) 0.933 (0.150) Tobacco –0.314 (0.160)** 0.730 (0.117)** Are you currently satisfied with your level of physical activity? N/PA 0.332 (0.163)** 1.390 (0.228)** Tobacco 0.157 (0.163) 1.17 (0.190) The n values used in the logistic ordinal regressions were s: pre-N/PA = 230, pre-tobacco = 209, post-N/PA = 196, post-tobacco = 198. SE = standard error. N/PA = nutrition and physical activity. *P < 0.1. **P <.05. ***P < 0.01. Book 23-07.indb 484 8/23/2017 8:01:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 485 use is a serious issue for young adults in the Middle East and even minimal education can have an impact on their perceptions of this life threatening habit. We believe that such an approach is a promising method for producing posi- tive changes in lifestyle decisions among the youth in Abu Dhabi, and possibly elsewhere in the United Arab Emir- ates. Moreover, one might anticipate that healthy habits formed early on will continue into adulthood, directly ad- dressing the behaviours that increase the risk for cancer, heart disease, stroke, diabetes, etc. It is our hope that these types of grass roots initiatives can be used to enhance the efficacy of legisla- tion and enforcement of laws designed to promote a healthier lifestyle. This type of model is also self-sus- taining in that university students can teach high school students at no cost. Peer education not only equips the high school students with the knowledge they need to make healthy decisions about their life but also empowers stu- dent teachers to be agents of change in their own communities and gain excel- lent communication skills. Funding: This study was funded by New York University Abu Dhabi. Competing interests: None declared. Table 2. A breakdown of cohort feedback concerning the workshop experience Question Tobacco (n = 198) N/PA (n = 196) Yes Yes No. % No. % Do you think that college students are more relatable (to yourself) than adults or medical professionals? 125 63 118 60 Would you recommend this type of workshop to your friends? 164 83 129 66 Do you plan on sharing anything you learned in the workshop with friends and/or family? 154 78 125 64 Do you think that you will use any of the information you learned in the workshop to make future decisions about your health? 164 83 137 70 N/PA = nutrition and physical activity. References 1. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, et al. Priority actions for the non-communicable disease crisis. Lancet. 2011;377(9775):1438–47. PMID: 21474174 2. Jones AM. Health, addiction, social interaction and the deci- sion to quit smoking. J Health Economics. 1994;13(1):93–110. 3. Buente M, Hashemi AA, Moujaes CN, Samman, H. GCC school health programs. Health and wellness through early interven- tion. Booz and Company; 2010. 4. Godwin SM. Globalization, education, and Emiratisation: a study of the United Arab Emirates. Electronic J Information Systems in Developing Countries. 2006;27(1):1–14. 5. Asfour LW, Stanley ZD, Weitzman M, Sherman SE. Uncover- ing risky behaviors of expatriate teenagers in the United Arab Emirates: a survey of tobacco use, nutrition and physical activ- ity habits. BMC Public Health. 2015;15:944. PMID: 2639975 6. Jha P, Chaloupka FJ, Moore J, et al. Tobacco addiction. In: Jamison DT, Breman JG, Measham AR, eds. Disease control priorities in developing countries. Washington DC: World Bank, 2006: Chapter 46. 7. Tamim H, Al-Sahab B, Akkary G, Ghanem M, Tamim N, El Roueiheb Z, et al. Cigarette and nargileh smoking practices among school students in Beirut, Lebanon. Am J Health Behav. 2007;31:56–63. PMID:17181462 8. Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract. 2011;94(3):311–21. PMID:22079683 9. Musaiger AO. Diet and prevention of coronary heart disease in the Arab Middle East countries. Med Princ Pract. 2002;11(Sup- pl. 2):9–16. PMID:12444306 10. Jayakumary M, Jayadevan S, Ranade AV, Mathew E. Prevalence and pattern of dokha use among medical and allied health students in Ajman, United Arab Emirates. Asian Pac J Cancer Prev. 2010;11:1547–9. PMID:21338195 11. Methodology of estimating the population in UAE. Abu Dhabi: United Arab Emirates National Bureau of Statistics; 2011 (http://www.uaestatistics.gov.ae/ReportPDF/Population Es- timates 2006 - 2010.pdf, accessed 15 Nov, 2014). 12. Shah NM. Arab migration patterns in the Gulf. In: Arab migra- tion in a globalized world. Geneva: International Organization for Migration and League of Arab States; 2004:91–113 (http:// publications.iom.int/system/files/pdf/arab_migration_glo- balized_world.pdf, accessed 19 April 2017). 13. Damon W. Peer education: the untapped potential. J Appl Dev Psychol. 1984;5(4):331–43. 14. Backett-Milburn K. Understanding peer education: insights from a process evaluation. Health Educ Res. 2000;15(1):85–96. PMID:10788205 15. Barss P, Grivna M, Ganczak M, Bernsen R, Al-Maskari F, El Agab H, et al. Effects of a rapid peer-based HIV/AIDS educational in- tervention on knowledge and attitudes of high school students in a high-income Arab country. J Acquir Immune Defic Syndr. 2009;52.1:86–98. PMID:19590431 Book 23-07.indb 485 8/23/2017 8:01:58 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 486 1Department of Community and Mental Health Nursing, Faculty of Nursing, Al al-Bayt University, Al-Mafraq, Jordan (Correspondence to: M. Al Azzam: alazzam@aabu.edu.jo). 2Department of Adult Health Nursing, Al al-Bayt University, Al-Mafraq, Jordan. 3Department of Adult Health Nursing, Faculty of Nursing, Philadelphia University, Amman, Jordan. Received: 01/05/16; accepted: 23/11/16 Prevalence of attention deficit hyperactivity disorder among school-aged children in Jordan Manar Al Azzam 1, Mohammed Al Bashtawy 1, Ahmad Tubaishat 2, Abdul-Monim Batiha 3 and Loai Tawalbeh 2 Prévalence du trouble de déficit de l’attention avec hyperactivité (TDAH) parmi des enfants d’âge scolaire en Jordanie RÉSUMÉ La présente étude a pour objectif de déterminer la prévalence des symptômes du trouble de déficit de l’attention avec hyperactivité (TDAH) parmi des enfants scolarisés en Jordanie, ainsi que les probables facteurs de risque associés. Une étude descriptive transversale ainsi qu’un sondage aléatoire simple ont été utilisés afin de sélectionner 480 élèves, âgés de 6 à 12 ans, dans des écoles primaires gouvernementales de la ville de Mafraq, en Jordanie. Les données de l’étude ont été collectées en utilisant la version scolaire modifiée de l'échelle d'évaluation du trouble de déficit de l’attention (ADDES) en langue arabe et un questionnaire destiné aux parents. Les résultats ont montré que les taux de prévalence du sous-type inattentif, du sous-type hyperactif/ impulsif, et du sous-type combiné étaient de 10,83 %, 9,58 %, et 20,21 % respectivement. Le fait d'être une famille nombreuse et d’être de sexe masculin était associé à une prévalence accrue des symptômes de TDAH. L’étude a révélé que le TDAH était répandu parmi les élèves scolarisés en Jordanie. Le gouvernement devrait mettre en place des programmes éducatifs afin de sensibiliser sur les aspects du TDAH. ندرلأا في ةسردلما نس في لافطلأا نب طاشنلا طرفب نترقلما هابتنلاا روصق بارطضا راشتنا ةبلاوط يؤل ،ةحيطب معنلما دبع ،تاشيبط دحمأ ،يواتشبلا دممح ،مازعلا رانم في سرادـلما لاـفطأ نـب طاـشنلا طرـفب نترـقلما هاـبتنلاا روـصق بارـطضا راـشتنا ىدـم دـيدتح وـه ةـساردلا هذـه نـم ضرـغلا :ةـصلالخا حواترـت ،ًاـبلاط 480 راـيتخلا ةطيـسب ةيئاوـشع هـنيعو ةـيعطقم ةـيفصو ةـسارد تمدخُتـساو .هـب ةـطبترلما ةـلمتحلما رـطلخا لـماوعو ،ندرلأا ةخـسنلا مادختـساب ةـساردلا تاـنايب تـعُجمو .ندرلأاـب قرـفلما ةـنيدم في ةـيموكلحا ةـيئادتبلاا سرادـلما نـم ،ةنـس 12و تاونـس 6 نـب مـهرماعأ تلادـ عم نأ جـ ئاتنلا ترـ هظأو .رـ ملأا ءاـ يلوأ نايبتـ ساو هاـ بتنلاا روـ صق بارـ طضا مـ ييقت ساـ يقلم سيردـ لما رادـ صلإا نـ م ةـ لّدعلما ةـ يبرعلا ،% 9.58 ،% 10.83 تـغلب عـّمجلما يـعرفلا عوـنلاو ،»عاـفدنلاا/ةكرلحا طرـف« يـعرفلا عوـنلاو »هاـبتنلاا تُّتـشت« يـعرفلا عوـنلا في راـشتنلاا بارـطضا راـشتنا ةـساردلا تفـشكو .بارـطضلاا اذـه ضارـعأ راـشتنا ةداـيزب ةروـكذلاو ةسرلأا مـجح ةداـيز طـبترتو .لياوـتلا ىـع % 20.21 يــ عولا ةداــ يزل ةــ يميلعت جــ مارب عــ ضو ةــ موكحلل يــ غبنيو .ةــ يندرلأا سرادــ لما بلاــ ط فوــ فص في طاــ شنلا طرــ فب نترــ قلما هاــ بتنلاا روــ صق .طاـشنلا طرـفب نترـقلما هاـبتنلاا روـصق بارـطضا بـناوجب ABSTRACT The purpose of this study was to determine the prevalence of attention deficit hyperactivity disorder (ADHD) symptoms among school children in Jordan and the probable associated risk factors. This was a cross- sectional descriptive study and simple random sampling was used to select 480 students, aged 6–12 years, from government primary schools in Mafraq City, Jordan. Data were collected using the modified Arabic version of the Attention Deficit Disorder Evaluation Scale (ADDES) school version and parental questionnaire. Prevalence rates within the inattentive, hyperactive–impulsive and combined subtypes were 10.83, 9.58 and 20.21%, respectively. Increased family size and being male were both associated with increased prevalence of ADHD symptoms. The study revealed that ADHD is common among Jordanian school children. The government should establish education programmes to increase awareness of ADHD. Book 23-07.indb 486 8/23/2017 8:01:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 487 Introduction Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental dis- order characterized by core symptoms of hyperactivity, inattention and impul- sivity, affecting children across all socio- economic strata and ethnic and regional groups (1,2). Forty to sixty percent of children with ADHD have comorbidity such as anxiety, depression and learning disabilities (1). Fifty percent of ADHD cases are associated with disruptive and aggressive behavioural characteristics as seen in oppositional defiant disorder and conduct disorder (3). ADHD may serve as a developmental precursor to increasingly problematic behav- ioural outcomes, because children with ADHD are at significantly higher risk of being involved with substance abuse, delinquency and persistent problems with social relationships, as well as aca- demic and job performance difficulties (1,4–6). The emotional and behavioural problems associated with ADHD may interfere with nearly every aspect of a child’s life, including family and sib- ling relationships, peer relationships, academic performance, planning, and task completion (1,3,7). ADHD has a significant lifelong impact on a person’s emotional, social and cognitive func- tioning. Factors that contribute to the aetiol- ogy of ADHD are still under investiga- tion (1,8). Various approaches have been used to try to explain the aetiology, including biological, neuro-psychobio- logical, trauma-based, and environmen- tally based models, or a combination of these. It is reported that several child, family and environmental risk factors might increase the severity of ADHD symptoms (3). These factors include low socioeconomic status, living in eco- nomically stressed neighbourhoods, poor family functioning, family size, age, and gender. ADHD is a complex disor- der, with genetic and environmental risk factors contributing to its onset (1,9). ADHD is one of the most com- mon neurodevelopmental disorders of childhood, with a worldwide prevalence ranging from 2.2 to 17.8% (10). The variability in prevalence might be due to several factors, such as study method- ology, diagnostic criteria, populations studied, sample size, cultural percep- tions, and informants (e.g., respondents to questionnaires) (1,6,9,10). Moreo- ver, the literature indicates that the re- ported rates might vary depending on the source of the information (1,3,11). In Arab countries there has been a shortage of studies addressing chil- dren’s behavioural problems in general and ADHD in particular (8). The prev- alence of ADHD symptoms in Arab countries varies considerably between 1.3 and 16% (8,12–14), although these rates were based on a limited number of studies that used different methods. For example, Richa and colleagues (14) conducted a study of 1000 Lebanese school children aged 6–10 years using the ADHD Rating Scale – IV School Version. They found prevalence of 3% for ADHD inattentive subtype, 12% for hyperactive–impulsive subtype and 17% for ADHD combined subtype. Jenahi and colleagues (13) used the Attention Deficit Disorders Evalu- ation Scale (ADDES) to investigate the prevalence of ADHD among 1009 Saudi students aged 6–15 years. They found prevalence of 2.1% for ADHD inattentive subtype and 5.6% for hyper- active–impulsive subtype. The main purpose of the current study was to determine the prevalence of ADHD symptoms among school children in Jordan. We also aimed to identify possible risk factors related to the symptoms associated with ADHD. It is hoped that the current study will provide baseline information that may help teachers, parents, healthcare pro- fessionals and policy-makers to design comprehensive strategies to enhance awareness of ADHD. Also, the study may be a preliminary step toward launching a large community-based study that might help to develop aware- ness and intervention programmes to deal with affected individuals and their families. Methods Research design This was a cross-sectional descriptive study to assess the prevalence of ADHD among school children in Jordan, to- gether with the associated risk factors. The study was conducted at schools in Mafraq City, Jordan from February to April 2014. Mafraq is located 80 km north of the capital Amman. It has nearly 127 830 residents. There are 30 governmental schools listed in the city, with a total of 19 000 students (15). The study was approved by the Institutional Review Board of Al al-Bayt University, Mafraq. Study population The target population was school children aged 6–12 years. A list of the primary schools in Mafraq City was obtained from the Ministry of Educa- tion. A random sample of 6 schools was chosen. Six classes, 1 from each grade in each school, were chosen using systematic random sampling to ensure representativeness of all classes of the same grade. Proportional allocation of the sample was used when choosing the children so that the sampling fractions were equal. The sample size was determined using the following formula: N = Z2 1 –α/2 × P (1 – P) / d2 where N is minimum sample size; Z2 1 − α/2 is the confidence level at 95%; P is the expected prevalence of ADHD symptoms among school-aged children (0.5%); and d is the margin of error at 0.05% (4). The minimum sample size needed was 400 students, but, to allow for non-responses and un- completed questionnaires, we increased the sample size to 500 students. Book 23-07.indb 487 8/23/2017 8:01:58 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 488 Exclusion criteria All students in the selected classes were eligible to participate in the study, except for children who were not Jorda- nian. This was because non-Jordanian children may have been refugees with other diagnoses that could have inter- fered with ADHD symptoms. We also excluded children with chronic physical illness and those attending special edu- cational classes to compensate for learn- ing disabilities, because the diagnosis of ADHD is often comorbid with other diagnoses such as learning disabilities. Study instruments Two instruments were used to assess the main variables. The modified Arabic School Version of ADDES was used to measure the prevalence of ADHD symptoms (Appendix 1). Permission to use the instrument was obtained from Hawthorne Educational Service (Co- lombia, MO, USA). The questionnaire contained two parts: Part I consisted of 29 questions that measured inattention; and Part II comprised 31 questions that measured hyperactivity–impulsivity. All 60 questions were used to diagnose combined ADHD. The same scoring procedure, as outlined in the original manual, was used by the authors. The Arabic version of the instru- ment was established by translation and back translation and the content validity was checked by a panel of experts who were interested in the research topic. The instrument was piloted with 30 stu- dents who were not included within the main sample, before the data collection process began, to assess the clarity and appropriateness of items and to test the readability of the instrument among a Jordanian sample. The results indicated that the instruments were clear and readable. The findings also showed that Cronbach’s α was 0.93. An Arabic questionnaire was de- vised to collect relevant sociodemo- graphic data for the present study, including children’s age, birth order, number of siblings, parents’ educational level, family mental health history, and consanguinity. Data collection and procedures After obtaining IRB approval, 2 research team members visited the schools and explained the aims and methods of the study to the head teacher, in order to obtain permission to distribute the study forms. A letter of invitation to participate in the study was sent to the children’s parents and the head teach- ers. The letter explained the aims and methods of the study, name and contact information of the chief researcher, and that participation was voluntary. All participants’ rights about anonymity and confidentiality were protected. The head teachers were instructed to fill out the modified Arabic school version of ADDES after they had received appro- priate training. Parents were instructed to fill out the demographic data ques- tionnaire. Data analysis The completeness and accuracy of the study data were checked and then coded, entered and analysed using SPSS version 22. Descriptive statistics were used to describe the sample character- istics and to assess the prevalence of ADHD symptoms. The χ2 test was used to assess whether there was a significant association between ADHD symptoms and demographic data. P < 0.05 was considered statistically significant. Bi- nary logistic regression was performed Table 1 Sociodemographic characteristics of study population (n = 480) Sociodemographic characteristics No. (%) Child’s age, yr 6–9 10–12 210 (43.75) 270 (56.25) Child’s gender Male Female 250 (52.08) 230 (47.92) Birth order 1–3 4–6 7–9 ≥ 10 250 (52.08) 170 (35.42) 38 (7.92) 22 (4.58) No. of siblings 1–3 4–6 > 6 154 (32.08) 209 (43.54) 117 (24.38) Maternal education Illiterate Secondary High school Undergraduate Postgraduate 31 (6.46) 98 (20.42) 244 (50.83) 87 (18.13) 20 (4.17) Paternal education Illiterate Secondary High school Undergraduate Postgraduate 6 (1.25) 24 (5) 163 (33.96) 257 (53.54) 30 (6.25) Consanguinity Yes No 231 (48.13) 249 (51.87) Family mental health problems Yes No 15 (3.13) 465 (96.87) Book 23-07.indb 488 8/23/2017 8:01:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 489 to identify the factors that may have contributed to the prevalence rate of ADHD. To assess the predictors of the prevalence rate of ADHD, the follow- ing predictors were entered into the regression equation: age, gender, birth order, number of siblings, maternal educational level, paternal educational level, consanguinity, and family mental health problems. Results Demographic characteristics <body1>Four hundred and eighty out of the 500 questionnaires were com- pleted and available for analysis, yielding a response rate of 96%, representing 250 (52.08%) boys and 230 (47.92%) girls. Demographic characteristics are shown in Table 1. There were 2 age groups of 6–9 and 10–12 years, with a mean (standard deviation; SD) of 9 (1.9) years. The number of siblings were grouped into 1–3, 4–6 and > 6, with a mean of 4.6 (3.2) and median of 5. ADHD prevalence The prevalence of ADHD in Mafraq City among school-age children was 40.62%, and the percentage of each subtype is shown in Table 2. There was a significant association between the children’s age and prevalence of ADHD symptoms [P value (χ2 test) = 0.008] (Table 2). The prevalence of the 3 subtypes of ADHD decreased with increasing age. There was a significant association between the number of sib- lings and prevalence of ADHD [P value (χ2 test) < 0.004], as demonstrated by the increasing rate of ADHD with num- ber of siblings among the 3 ADHD subtypes (Table 3). Table 4 shows the association between gender and prevalence estimates of ADHD. The prevalence estimate of all 3 subtypes of ADHD was significantly higher among boys [P value (χ2 test) < 0.001]. Of the 250 male students, 54% had ADHD distributed among the 3 subtypes. Ac- cording to Wald statistics, age, gender and family size were associated with higher prevalence of ADHD among school children in Jordan (Table 5). Discussion The purpose of the current study was to assess the prevalence of ADHD symp- toms among school children in Mafraq City, Jordan and to identify the potential associated risk factors. We found high prevalence rates of combined ADHD of 20.21%, hyperactivity–impulsivity of 9.58% and inattention of 10.83%. These rates were higher than those reported in other studies (6,13,14,16). For example, in Turkey, a study of 1508 schoolchil- dren aged 6–14 years showed a preva- lence of 8% for combined ADHD, 20% for inattentive subtype and 14.3% for hyperactive–impulsive subtype (6). In another cross-sectional study of ADHD in Nigeria among 487 school children, there was a prevalence of 3.08% for com- bined ADHD and inattentive subtype and 2.05% for hyperactive–impulsive subtype (15). These differences could be because estimates of the prevalence of ADHD worldwide vary, depending on the study methodology, diagnostic criteria, populations studied, sample size, cultural perceptions, informants, and instruments used. In the current Table 2 Prevalence of ADHD subtypes by age group (n = 480) ADHD type Total no. with disorder Overall prevalence Prevalence by age group 6–9 yr 10–12 yr n = 210 n = 270 No. % No. % Combined 97 20.21% 68 32.38 29 10.74 Hyperactivity–impulsivity 46 9.58% 32 15.24 14 5.19 Inattention 52 10.83% 35 16.67 17 6.30 P value (χ2 test) = 0.008. ADHD = attention deficit hyperactivity disorder. Table 3 Prevalence of ADHD subtypes by number of siblings (n = 480) No. of siblings Total no. of children ADHD subtype Combined Hyperactivity–impulsivity Inattention No. % No. % No. % 1–3 154 19 12.34 9 5.84 17 11.04 4–6 209 47 22.49 27 12.92 22 10.53 > 6 117 31 26.50 10 8.55 13 11.11 P value (χ2 test) < 0.004 ADHD = attention deficit hyperactivity disorder. Book 23-07.indb 489 8/23/2017 8:01:58 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 490 study, the only source of behavioural as- sessment was the teachers, which could explain the high prevalence of ADHD symptoms. If we had had multiple sources of assessment (e.g., teachers, parents and health professionals), the prevalence might well have been lower. Our results revealed that the rate of ADHD symptoms decreased with age, and the symptoms were mostly notice- able among children aged 6–9 years. For many children, ADHD behaviour is not noticed until they enter elementary school. Experts have tried to explain this by stating that almost all toddlers and preschool children exhibit behaviour or symptoms that exemplify ADHD as part of their normal development. In order to diagnose a child with ADHD, the symptoms should be present before the age of 12 years, and the child must show evidence of several symptoms in ≥ 2 settings (e.g., at home, school or work; with friends or relatives; or in other activities) (1,3). Our results are comparable to those of other studies conducted in Arab coun- tries, which have shown that ADHD is more noticeable among children aged 6–9 years and the symptoms start to regress after 11 years (8,12,13,17). The current study indicated a signifi- cant association between the number of siblings and the prevalence estimates of the 3 subtypes of ADHD, for which lower rates have been reported among children in small families compared to children in large families. These results are in line with the findings of studies conducted in Saudi Arabia, Kuwait and Qatar (8,12,13,17,18), and could be explained by the fact that children in large families receives less care, which results in behavioural problems being observed more often among these chil- dren. We found a significant gender differ- ence in the prevalence of the 3 subtypes of ADHD, with a higher prevalence in boys, which is consistent with the lit- erature, with ratios ranging from 2:1 to 9:1 (8,11–13,17,18). One commonly accepted explanation for the observed difference is that, in general, boys are more likely to exhibit aggressive and an- tisocial behaviour compared to girls (1). The present research was a prelimi- nary study that indicated that ADHD might be a problem among school chil- dren in Jordan. Our findings could be used as a guide for further investigations of ADHD in Jordan since there has been a dearth of related studies to date. Future studies should involve large ran- domized samples from all areas of the country to enable generalization of the results. Moreover, such findings should help to create health programmes to increase awareness of parents, teach- ers, policy-makers, school nurses and healthcare professionals about ADHD, particularly with regard to the signs, symptoms, causes and consequences. The present study had some limita- tions, which means that the results must be considered with caution. First, the study sample was not representative Table 4 Prevalence of ADHD subtypes by child gender (n = 480) Child gender Total no. of children ADHD subtype Combined Hyperactivity– impulsivity Inattention No. % No. % No. % Male 250 60 24 32 12.8 43 17.2 Female 230 37 16.09 14 6.09 9 3.91 P value (χ2 test) < 0.001. ADHD = attention deficit hyperactivity disorder. Table 5 Logistic regression analysis to identify significant predictors of ADHD symptoms (n = 480) Predictor B Wald Significance Odds ratio Age (yr) −0.85 06.73 0.008** 0.48 Gender −0.10 10.21 0.001** 0.95 Birth order 0.01 0.35 0.55 1.01 No. of siblings 1.50 8.34 0.004** 4.45 Maternal educational level −0.21 0.38 0.53 0.80 Paternal educational level 0.11 0.14 0.71 1.12 Consanguinity −0.17 0.09 0.75 0.84 Family mental health problems 1.09 4.87 0. 27 2.99 *P significant at ≤ 0.01. **P significant at ≤ 0.001. ADHD = attention deficit hyperactivity disorder. Book 23-07.indb 490 8/23/2017 8:01:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 491 of the population of school children in Jordan as a whole. Second, we used a screening tool and no attempt was made to establish a clinical diagnosis among the study sample. Future studies should involve screening and diagnosis in order to identify the symptoms of ADHD among school children. Third, the prevalence of ADHD was based on information that was obtained from a single source (school teachers). Fu- ture research should involve teachers, parents and health professionals to con- firm the diagnosis of ADHD. In conclusion, this study is one of the earliest efforts to assess ADHD among school children in Jordan. The preva- lence reported suggests that ADHD is more common in school children in Jordan than in other parts of the world. Furthermore, the current study showed that a variety of sociodemographic fac- tors were significantly associated with development of ADHD, including children’s age and gender, and family size. Acknowledgements The authors thank all who facilitated the conduct of this study. Additionally, many thanks are owed to the parents and teachers who participated in the study. Funding: None. Competing interests: None declared. References 1. Barkley RA. Attention deficit hyperactivity disorder: a hand- book for diagnosis and treatment. 4th edition. New York: The Guilford Press; 2014. 2. Vaziri S, Kashani FL, Sorati M. Effectiveness of family training in reduced symptoms of the children with attention deficit hyperactivity disorder. Procedia Soc Behav Sci. 2014;128:337– 42 (http://www.sciencedirect.com/science/article/pii/ S1877042814022587?via%3Dihub) 3. Diagnostic and codes. In: Diagnostic and statistical manual of mental disorders. 5th edition. Arlington, VA: American Psychi- atric Association; 2013. 4. Baheiraei A, Hamzehgardeshi Z, Mohammadi MR, Nedjat S, Mohammadi E. Alcohol and drug use prevalence and fac- tors associated with the experience of alcohol use in Iranian adolescents. Iran Red Crescent Med J. 2013 Mar;15(3):212–7. PMID:23984000 5. Michielsen M1. Comijs HC, Semeijn EJ, Beekman AT, Deeg DJ, Sandra JJ. The comorbidity of anxiety and depressive symptoms in older adults with attention-deficit/hyperactivity disorder: a longitudinal study. J Affect Disord. 2013 Jun;148(2- 3):220–7. PMID:23267726 6. Zurlo A, Unlu G, Cakaloz B, Zencir M, Buber A, Isildar Y. The prevalence and comorbidity rates of ADHD among school-age children in Turkey. J Atten Disord. 2015 Apr 6; pii: 1087054715577991 [Epub ahead of print] PMID:25846229 7. Larson K, Russ A, Kahn S, Halfon N. Patterns of comorbidity, functioning, and service use for US children with ADHD. J Pediatr. 2011 Mar;127(3):462–70. PMID:21300675 8. Alhraiwil NJ, Ali A, Househ MS, Al-Shehri AM, El-Metwally AA. Systematic review of the epidemiology of attention deficit hyperactivity disorder in Arab countries. Neurosciences. 2015 Apr;20(2):137–44. PMID:25864066 9. Parens E, Johnston J. Facts, values, and attention-deficit hy- peractivity disorder (ADHD): An update on the controversies. Child Adolesc Psychiatry Ment Health. 2009 Jan 19;3(1):1. PMID:19152690 10. Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an up- dated systematic review and meta-regression analysis. Int J Epidemiol. 2014 Apr;43(2):434–42. PMID:24464188 11. Ramtekkar UP, Reiersen AM, Todorov AA, Todd RD. Sex and age differences in attention-deficit/hyperactivity disorder symptoms and diagnoses: Implications for DSM-V and ICD-11. J Am Acad Child Adolesc Psychiatry. 2010 Mar;49(3):217–28. e1-3. PMID:20410711 12. Aboul-Ata MA, Amin FA. The prevalence of ADHD in Fay- oum City (Egypt) among school-age children: depending on a DSM-5-based rating scale. J Atten Disord.2015 Mar 26; pii:1087054715576917 [Epub ahead of print]. PMID:25814429 13. Jenahi E, Khalil M, Bella H. Prevalence of attention deficit hy- peractivity symptoms in female schoolchildren in Saudi Arabia. Ann Saudi Med. 2012 Sep-Oct;32(5):462–8. PMID:22871613 14. Richa S, Rohayem J, Chammai R, Haddad R, Hleis S, Alamed- dine A, et al. ADHD prevalence in Lebanese school-age popu- lation. J Atten Disord. 2014 Apr;18(3):242–6. PMID:22628148 15. Ministry of education. Annual statistical book. Amman, Jordan: Ministry of Education; 2014 (http://www.moe.gov.jo/MOE/ Files/Publication/report2014_2.pdf). 16. Umar MU, Obindo JT, Omigbodun OO. Prevalence and cor- relates of ADHD among adolescent students in Nigeria. J Atten Disord. 2015; Jul 28. pii:1087054715594456 [Epub ahead of print]. PMID:26220786 17. Homidi M, Obaidat Y, Hamaidi D. Prevalence of attention deficit and hyperactivity disorder among primary school students in Jeddah city, KSA. Life Sci J. 2013;10(3):280–5 (http://www.lifesciencesite.com/lsj/life1003/044_19518li fe1003_280_285.pdf) 18. Rucklidge JJ. Gender differences in attention-deficit/hyperac- tivity disorder. Psychiatr Clin North Am. 2010 Jun;33(2):357–73. PMID:20385342 Book 23-07.indb 491 8/23/2017 8:01:58 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 492 1Saudi Central Board for Accreditation of Healthcare Institutions, Riyadh, Saudi Arabia (Correspondence to: Salem Al Wahabi: salwahabi@cbahi. gov.sa). 2King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdul Aziz Medical City, Ministry of National Guard-Health Affairs, Jeddah, Saudi Arabia; and Department of Public Health and Community Medicine, Menoufia University, Menoufia, Egypt. Received: 10/12/15; accepted: 23/11/16 Prevalence and preventability of sentinel events in Saudi Arabia: analysis of reports from 2012 to 2015 Salem Al Wahabi 1, Fayssal Farahat 2 and Ahmed Y. Bahloul 1 Prévalence et possibilités de prévention des événements sentinelles en Arabie saoudite : analyse de rapports publiés entre 2012 et 2015 RÉSUMÉ La présente étude avait pour objectif d’évaluer le profil des événements sentinelles rapportés au ministère de la Santé saoudien entre janvier 2012 et juin 2015. Les caractéristiques des patients, les types d’événements, les issues, les causes et les possibilités de prévention détaillés dans les rapports sur les événements sentinelles ont fait l’objet d’un examen. Nous avons répertorié 433 événements sentinelles : 58,2 % étaient des décès, 14,8% concernaient la perte accidentelle d’un membre ou d’une fonction, 7,4 % des erreurs médicamenteuses majeures et 7,4% un oubli d’instruments ou d’éponges. Parmi les événements rapportés, 44 % étaient associés à des interventions chirurgicales et la majorité étaient classifiés comme évitables (91,6 %). Un âge compris entre 19 et 64 ans était fortement associé au risque de décéder des suites de l’événement (p = 0,02). Les événement sentinelles non évitables étaient significativement plus susceptibles de toucher les femmes que les hommes (p = 0,01). Le manque de politiques et de procédures et/ou l’inaptitude à les appliquer (55 %), ainsi que le manque de communication (35 %) et de formation (33 %) constituaient les causes principales d’événements indésirables. Les efforts devraient se concentrer sur l’amélioration du Système national de notification des événements sentinelles, en adoptant des critères en vue d’une notification efficace et en garantissant la disponibilité et la mise en œuvre de politiques et de procédures. 2015 لىإ 2012 نم ريراقتلا ليلتح :ةيدوعسلا ةيبرعلا ةكلملما في اهنم ةياقولا ةيناكمإو ةرفالخا ثادحلأا راشتنا لولبه دحمأ ،تاحرف لصيف ،بياهولا لماس /رـياني ذـنم ةيدوعـسلا ةـحصلا ةرازو ىدـل اـهنع غـلبُأ يـتلا ةرـفالخا ثادـحلأا طـمن مـييقت في ةـساردلا هذـه نـم فدـلها لـ ّثتم :ةـصلالخا اـهجئاتنو ثادـحلأا عوـنو ضىرـلما صـئاصخ ةـفرعلم ةرـفالخا ثادـحلأا رـيراقت صـحف مـت دـقو .2015 نارـيزح/وينوي لىإ 2012 نياـثلا نوـناك وأ فرـط نادـقفل ةـعقوتم رـغ ثادـحأ % 14.8و ،ةاـفو % 58.2 :ًاـثدح 433 ةرـفالخا ثادـحلأا ددـع غـلبو .اـهنم ةـياقولا ةـيناكمإو ابهابـسأو نـم 44% طـبتراو .مـسلجا لـخاد تاجنفـسا وأ تاودأ نايـسن نـع ةـجمان ثادـحأ % 7.4و ،ةميـسج يوادـت ءاـطخأ 7.4%و ،ةـيويح ةـفيظو ةـيرمعلا ةـئفلا طاـبترا تـبثو .)% 91.6( ةـياقولل ةـلباقلا ضارـملأا ةـئف تـتح اـهمظعم فـّنصو ةـيحارلجا تلاـخدتلاب اـهنع غـلبلما ثادـحلأا برـكأ لماـتحا ىوتـسم ةـياقولل ةـلباقلا رـغ ةرـفالخا ثادـحلأا تلجـسو .)p = 0.02( ةـجيتن اـهرابتعاب ةاـفولاب ةـللاد اذ ًاـطابترا ،ًاـماع 64 - 19 تاءارـجإو تاـسايس قـيبطت مدـع في ةيبلـسلا ثادـحأل ةيـسيئرلا بابـسلأا تـلَّثتمو .)p = 0.01( لاـجرلاب ًةـنراقم ءاـسنلا فوـفص في رـثكب ماـظنلا" زـيزعت ىـع دوـهلجا زـيكرت يـغبنيو .)% 33( بـيردتلا صـقنو ،)% 35( مـئلالما لاـصتلاا لىإ راـقتفلااو ،)% 55( اـهذيفنت في لـشفلا وأ/و .تاءارـجلإاو تاـسايسلا ذـيفنتو رـفوت نماـضو غلاـبلإل ةـلاعف رـياعم دماـتعاب ،"ةرـفالخا ثادـحلأا نـع غلاـبلإل يـنطولا ABSTRACT This study aimed to assess the pattern of sentinel events reported to Ministry of Health of Saudi Arabia from January 2012 to June 2015. Sentinel event reports were examined for patient characteristics, type of event, outcome, cause and preventability. There were 433 sentinel events: 58.2% were deaths, 14.8% were unexpected loss of a limb or a function, 7.4% major medication errors and 7.4% retained instruments or sponges. Among the reported events, 44% were associated with surgical interventions and most were classified as preventable (91.6%). Age 19-64 years was significantly associated with death as an outcome (P = 0.02). Non-preventable sentinel events were significantly more likely among women than men (P = 0.01). Unavailability of policy and procedures and/ or failure to implement them (55%), and lack of proper communication (35%) and training (33%) were the main causes for the adverse events. Efforts should focus on enhancing the National Sentinel Events Reporting System, adopting criteria for effective reporting and ensuring availability and implementation of policies and procedures. Book 23-07.indb 492 8/23/2017 8:01:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 493 Introduction A sentinel event is the most serious form of adverse event that can occur in health care. The Joint Commission’s Sentinel Event Policy and Procedures defines a sentinel event as any unexpected event that reaches the patient and harms the patient seriously, either physically or psychologically, such as causing death, permanent harm or disability, or severe temporary harm requiring an interven- tion to sustain life. Sentinel events can be as a result of medical errors or any other risks or hazards, e.g. a fire. They require immediate investigation and response (1). Despite increased awareness and identification of strategies to address patient safety in the past few years, medical errors and sen- tinel events continue to occur (1). The reporting of incidents, includ- ing sentinel events, is essential in order to improve and maintain the quality of health care systems (2). The major- ity of adverse medical events are man- agement-related and preventable (3). This finding is consistent with Edward Deming’s rule, which attributes 85% of problems to the system and its pro- cesses (the majority of which are related to the complexity and nature of the sys- tem itself) and only 15% to individuals (4). This means major improvement can be made by changing systems and standardizing processes with policies and procedures, protocols and clinical practice guidelines (5). According to the Joint Commission, failing to pre- pare a thorough and credible root cause analysis and implement an action plan following the occurrence of a sentinel event may affect a hospital’s accredita- tion (5). The Ministry of Health (MoH) in Saudi Arabia requires 12 sentinel events to be reported by public and private hospitals. The Saudi Central Board for Accreditation of Healthcare Institutions integrated the MoH’s list of reportable sentinel events within the 3rd edition of the national hospital standards in the form of 10 sentinel events. The Board’s policy urges the hospitals to report the sentinel event within 5 days of its occur- rence and then to report a root cause analysis and the risk reduction plan within 30 days (6). The 10 reportable events are: un- expected death, maternal death, wrong patient, procedure or site, retained in- strument or sponge, medication error leading to death or major morbidity, infant abduction or infant discharge to the wrong family, unexpected loss of a limb or a function, haemolytic blood transfusion reaction, inpatient suicide, and gas embolism (6). To date, there have been no pub- lished studies on sentinel event surveil- lance in Saudi Arabia. Therefore, the aim of this study was to review and assess the patterns and root causes of the sentinel events reported to the Saudi Ministry of Health (MoH) over 3.5 years (January 2012–June 2015). This study also as- sessed the preventability of the reported events. The findings of the study could encourage managers in health care to systematically tackle such events in their facilities and help policy-makers to take actions that could lead to a safer health care system in Saudi Arabia. Fur- thermore, the lessons learned could be useful to all health care professionals in the country. Methods This was a retrospective review of all events reported to the MoH from January 2012 to June 2015 which were given to the Saudi Central Board for Accreditation of Healthcare Institu- tions. The study is an analysis of data that are routinely collected as part of the surveillance programme, no per- sonal identifiers were reported and no institutional review board approval was required. The reports were reviewed by the study investigators, including the root cause analysis reported by the hospitals for each event. A checklist was used to record data on patient characteristics, type of intervention and hospital, outcome and preventability. The independent variables included in this study were: age, sex, type of in- tervention (surgical, non-surgical, de- livery) and type of hospital reporting the event (government, private). The dependent variables were patient out- come as a result of the event (died, sur- vived) and preventability of the event. Preventability was judged by the inves- tigators based on the available clinical information that either supported the presence of an identifiable and modifi- able cause of harm or the lack of adher- ence to guidelines. Statistical analysis Data were analysed using SPSS, version 20). Descriptive statistics (e.g. numbers and percentages) were used. The chi- squared test was used for categorical variables. Univariable logistic regression analysis was performed to determine the likelihood of death or non-prevent- able sentinel event. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. A P-value less than 0.05 was considered statistically significant. Results A total of 433 sentinel events were re- ported from January 2012 to June 2015. Figure 1 shows types of sentinel events reported. The main types of events reported were death (unexpected and maternal deaths) (58.2%), unexpected loss of a limb or a function (14.8%), major medication errors (7.4%) and re- tained instruments or sponges (7.4%). Figure 2 shows the outcomes of the different types of sentinel events (died or survived). Death as an outcome of the sentinel event was reported in 100% of suicide in the inpatient departments and intravascular gas embolism, 40.6% of major medication errors, and 6.8% Book 23-07.indb 493 8/23/2017 8:01:58 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 494 37.4 20.8 14.8 7.4 7.4 3.9 2.8 2.5 1.6 0.7 0.5 0.2 0 5 10 15 20 25 30 35 40 U ne xp ec te d de at h (n = 16 2) M at er na l d ea th (n = 9 0 ) U ne xp ec te d lo ss o f a li m b or a fu nc tio n (n = 6 4) M aj or m ed ic at io n er ro r ( n = 3 2) Re ta in ed in st ru m en ts o r a sp on ge (n = 3 2) H ae m ol yt ic b lo od tr an sf us io n re ac tio n (n = 1 7) In fa nt d is ch ar ge d to w ro ng fa m ily (n = 1 2) Su ic id e in a n in pa tie nt u ni t ( n = 11 ) W ro ng si te su rg er y (n = 7 ) W ro ng p at ie nt (n = 3 ) In tr av as cu la r g as e m bo lis m (n = 2 ) D ea d bo dy d is ch ar ge d to w ro ng fa m ily (n = 1 ) % Figure 1 Type sentinel events reported to Saudi Ministry of Health, January 2012–June 2015 4 13 0 1 11 1 0 2 55 19 27 15 0 6 3 0 0 10 20 30 40 50 60 U ne xp ec te d lo ss o f a li m b or a fu nc tio n (n = 6 4) M aj or m ed ic at io n er ro r ( n = 3 2) Re ta in ed in st ru m en ts o r a sp on ge (n = 3 2) H ae m ol yt ic b lo od tr an sf us io n re ac tio n (n = 1 7) Su ic id e in a n in pa tie nt u ni t ( n = 11 ) W ro ng si te su rg er y (n = 7 ) W ro ng p at ie nt (n = 3 ) In tr av as cu la r g as e m bo lis m (n = 2 ) % Died Survived Figure 2 Outcome of primary sentinel events (excluding death as a primary event) reported to Saudi Ministry of Health, January 2012–June 2015 Book 23-07.indb 494 8/23/2017 8:01:59 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 495 of unexpected loss of limb or function. One patient each died of haemolytic blood transfusion reaction and wrong site surgery events. Half of the reported cases were women; however, data on sex were missing for 115 (26.6%) patients. Most of the reported cases were adults (19– 64 years) (61.7%), followed by infants < 1 year (16.6%), children and adoles- cents (1–18 years) (11.7%) and elderly patients ≥ 65 years (9.9%) (Table 1). Among the reported sentinel events, 47.9% were non-surgical interventions, 44.0% were surgical interventions and 8.2% were vaginal delivery. Most of the reported events were in government hospitals (82.4%). Table 1 shows the characteristics of the cases, and type of intervention and hospital by outcome (died, survived). Age 19–64 years was significantly as- sociated with death as an outcome of sentinel events compared with infants < 1 year: OR: 2.17; 95% CI: 1.15–4.08 (P = 0.02). However, there was no signifi- cant association between death and any other age group. In addition, there was no statistically significant association between death and sex, kind of inter- vention or type of hospital (P > 0.05) (Table 1). The majority of the reported senti- nel events were classified as preventable (91.6%). Preventable causes were iden- tified in 95.3% of unexpected deaths, 78.3% of maternal deaths, 93.0% of unexpected loss of a limb or a function and 84.6% of retained instruments or sponges. Retained instruments would be 100% preventable; however, a mal- function of intravenous cannulas in some hospitals, which resulted in a bro- ken tip on application, were reported as non-preventable and the manufacturers were notified (n = 4). Other reported sentinel events (major medication er- ror, infant discharged to wrong family, suicide in an inpatient unit, wrong site surgery, wrong patient, intravascular gas embolism and dead body discharged to wrong family) were identified as 100% preventable (Figure 3). The likelihood of a non-preventable sentinel event was significantly higher among women than men: OR: 9.06; 95%CI: 1.59–194.90 (P = 0.01). How- ever, none of the other variables were significantly associated with sentinel event preventability (P > 0.05) (Table 2). Embolism occurred in 22.8% and 31.11% of cases of maternal deaths and unexpected deaths, respectively. Figure 4 shows the causes of the sentinel events as reported in the root cause analysis. An event was not nec- essarily a result of a single cause and more than one cause (e.g. availability of policy and procedures, communication, equipment) may contribute to occur- rence of one event. Hence the overall percentage of the identified causes was more than 100%. Unavailability of policy and proce- dures and/or failure to implement them was the most common cause of sen- tinel events (55.0%), followed by lack of proper communication and train- ing (35.3% and 33.0% respectively). Table 1 Factors associated with death as an outcome of the sentinel events reported to the Saudi Ministry of Health, January 2012–June 2015 Variable Patient outcome Odds ratio (95% confidence interval) P-value Died Survived No. (%) No. (%) Sex Female (n = 215) 150 (69.8) 65 (30.2) Reference Male (n = 98) 71 (72.4) 27 (27.6 ) 1.14 (0.67, 1.96) 0.64 Age group (years) < 1 (n = 55) 33 (60.0) 22 (40.0) Reference 1−5 (n = 13) 9 (69.2) 4 (30.8) 1.49 (0.41, 6.19) 0.78 6−18 (n = 26) 17 (65.4) 9 (34.6) 1.26 (0.47, 3.44) 0.66 19−64 (n = 205) 157 (76.6) 48 (23.4) 2.17 (1.15, 4.08) 0.02 ≥ 65 (n =33) 26 (78.8) 7 (21.2) 2.45 (0.92, 7.04) 0.07 Intervention Non-surgery (n = 198) 136 (68.7) 62 (31.3) Reference Surgery (n = 183) 118 (64.5) 65 (35.5) 0.83 (0.55, 1.27) 0.38 Delivery (n = 34) 27 (79.4) 7 (20.6) 1.75 (0.74, 4.56) 0.21 Hospital Government (n = 347) 235 (67.7) 112 (32.3) Reference Private (n = 75) 52 (69.3) 23 (30.7) 1.08 (0.63, 1.87) 0.80 Data were missing for some variables. Book 23-07.indb 495 8/23/2017 8:01:59 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 496 About 25% of the causes were attributed to equipment/supplies and 22.2% to staffing (shortage/misallocation and/ or work overload). Other causes rep- resented about 10% each (delay in treatment, non-adherence to clinical practice guidelines and hospital system malfunction). Discussion Our study is an analysis of sentinel events in Saudi Arabia. It relied on reports sent to the MOH and our conclusions are dependent on the quality of documentation. It could be assumed that some of the actual events are not reported (6). There- fore, conclusions about the relative frequency of events or trends in events over time should be drawn with cau- tion. There were 433 reported sentinel events; most commonly reported events were deaths (representing more than half of the events), unexpected loss of a limb or a function, major medica- tion errors and retained instruments or sponges. The incidence of adverse and sen- tinel events reported in studies varies considerably. Variations are related to study setting, methodology and un- derlying definitions. The problem of under-reporting has a major effect on the estimated incidence as well (7). Therefore, comparison with other studies may not be always possible giv- en the differences in the methodologi- cal designs and the reporting culture. In hospitals in the United States of America (USA), the total number of sentinel events reported to the Joint Commission increased from 449 cases in 2000 to a peak of 1243 cases in 2011. In the following years from 2012 to mid-2015, the number of cas- es decreased (901, 887, 764 and 474 respectively). The most commonly reported events were unintended re- tention of a foreign body, fall, suicide, delay in treatment, wrong patient, wrong site, wrong procedure, op- erative/post-operative complication, criminal event and perinatal death or injury (8). In a systematic review of 8 retrospec- tive chart review studies from the USA, Canada, the United Kingdom (UK), Australia and New Zealand, permanent disability and death were found in 7.0% (inter quartile range 6.1–11.0%) and 7.4% (inter quartile range 4.7–14.2%) of patients respectively who experienced an adverse event [the median incidence of adverse events was 9.2% (inter quar- tile range 4.6–12.4%)]. The median proportion of adverse events associ- ated with surgical procedures was 58.4% (inter quartile range 54.5–70.9%) (9). This was higher than another study which reported that 44.9% of the ad- verse events were related to surgical interventions (10). When it comes to critical areas (e.g. intensive care units), the magnitude of the problem could be underestimated, although as estimated 101 47 40 24 22 15 12 10 7 3 1 1 5 13 3 0 4 1 0 0 0 0 0 0 0 20 40 60 80 100 120 U ne xp ec te d de at h (n = 1 0 6) M at er na l d ea th (n = 60 ) U ne xp ec te d lo ss o f a li m b or a fu nc tio n (n = 4 3) M aj or m ed ic at io n er ro r ( n = 2 4) Re ta in ed in st ru m en ts o r a sp on ge (n = 2 6) H ae m ol yt ic b lo od tr an sf us io n re ac tio n (n = 1 6) In fa nt d is ch ar ge d to w ro ng fa m ily (n = 12 ) Su ic id e in a n in pa tie nt u ni t ( n = 10 ) W ro ng si te su rg er y (n = 7 ) W ro ng p at ie nt (n = 3 ) In tr av as cu la r g as e m bo lis m (n = 1 ) D ea d bo dy d is ch ar ge d to w ro ng fa m ily (n = 1 ) % Preventable Not preventable Figure 3 Distribution of the reported sentinel events according to preventability based on reports to Saudi Ministry of Health, January 2012−June 2015 Book 23-07.indb 496 8/23/2017 8:01:59 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 497 by Cullen et al., the incidence of adverse events in intensive care units was nearly twice the rate of other units (11) Our findings showed that elderly people (≥ 65 years) and adults were at higher risk of death as an outcome of sentinel events than newborns and chil- dren. In a national study in Spain, elderly people (≥ 65 years) were at a 2.5 greater risk of adverse events than younger age groups (12), while in a Moroccan study, adverse events occurred more frequently in younger patients, which the authors attributed to the increased self-medication among younger people (7). Our study showed that embolism caused 23–31% of the maternal and unexpected deaths. Attention should be given to this finding with further review of medical practices, including identi- fication of patients at risk of embolism and implementation of evidence-based prevention interventions. The Saudi Arabian MoH has published guidelines on the prevention of post-surgical pul- monary embolism; however, adherence to these guidelines is not known. We judged the preventability of an event based on the investigation of each case and assessment of the information available on the presence of a modifiable cause of harm or a lack of adherence to guidelines. We found a high frequency of preventable events (range 78.3–100%). Negligence of people and system errors that could be prevented at the time of the event were difficult to identify. In a study in the Eastern Mediterranean and African regions, 83% of adverse events were considered preventable (13). Differences in study design and types of sentinel events should be taken into consideration when comparing the findings with our study. We also found that non-preventable events were higher among women, which could be attributed to adverse effects of labour and delivery interventions. The incidence of preventable ad- verse events differs in various studies. It ranged from 18.7% to 73.2% in a review of the literature by Kanjanarat et al. (14), and it was estimated that 28% of adverse events in hospitals in the USA were preventable (15). The report of a national study in Spain showed that 42.8% of the adverse events could have been prevented (12). De Vries et al. reported a similar rate in their system- atic review, where 43.5% of the adverse events were judged preventable (inter quartile range 39.4–49.6%) (9). A wor- rying number of patients experienced permanent disability or death as a result of these events (9). In addition, events due to negligence, defined as adverse events caused by a failure to meet stand- ards reasonably expected of the average physician or institution, were not con- sidered in the preventability calculation (9). In the Harvard Medical Practice Study I, one third of the adverse events were attributed to negligence (16). A lack of policies and procedures, inappropriate communication, lack of staff training, and issues of equipment and supplies and staffing (whether because of shortages or allocation or scheduling) were all important causes of sentinel events; together they repre- sented 80% of the causes. These issues clearly need to be tackled in order to improve the health care and patient safety in the reporting hospitals. The root cause analysis of the sentinel events Table 2 Factors associated with preventability of the sentinel events reported to the Saudi Ministry of Health, January 2012– June 2015 Variable Preventability Odds ratio (95% confidence interval) P-value Not preventable Preventable No. (%) No. (%) Sex Male (n = 75) 1 (1.3) 74 (98.7) Reference Female (n = 155) 17 (11.0) 138 (89.0) 9.06 (1.59, 194.9) 0.01 Age group (years) < 1 (n = 47) 1 (2.1) 46 (97.9) Reference 1−5 (n = 9) 0 (0.0) 9 (100.0) − 6−18 (n = 19) 1 (5.3) 18 (94.7) 2.51 (0.06, 101.6) 0.58 19−64 (n = 151) 16 (10.6) 135 (89.4) 5.42 (0.93, 117.8) 0.11 ≥ 65 (n =20) 0 (0.0) 20 (100.0) − Intervention Non-surgery (n =146) 9 (6.2) 137 (93.8) Reference Surgery (n =137) 13 (9.5) 124 (90.5) 1.59 (0.65, 4.01) 0.30 Delivery (n =23) 4 (17.4) 19 (82.6) 3.17 (0.78, 11.25) 0.16 Hospital Government (n = 275) 21 (7.6) 254 (92.4) Reference 0.28 Private (n = 34) 5 (14.7) 29 (85.3) 2.08 (0.65, 5.73) Book 23-07.indb 497 8/23/2017 8:01:59 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 498 in our study showed consistency with the patient safety study conducted the Eastern Mediterranean and African regions (13) with some variations, pri- marily due to study design differences. The ultimate value of sentinel events reporting is communication of lessons learned to the stakeholders and the pub- lic. Examples are the National Patient Safety Agency which is the UK national reporting system (17) and standards/ resources by the Joint Commission for sentinel events reporting, aggrega- tion, analysis, and communication. The Saudi Central Board for Accreditation of Healthcare Institutions in combina- tion with the MoH aims to make health care facilities better equipped to actively eliminate the risk of sentinel events or at least to reduce the risk. The Saudi Arabia MoH adopted an electronic portal for reporting sentinel events which is cur- rently active; however, the effect of this portal could be improved if further ana- lytical features were included (e.g. root cause analysis, corrective or preventive action plan and communicating lessons to the health care community). It has been shown that reliance on voluntary reporting and the lack of an effective national system for adverse events reporting and investigation lead to an increased burden on the health care system (18,19). Classen et al. found that voluntary reporting in hospitals in the USA and measuring patient safety indicators did not reflect the real incidence of adverse events within the hospitals. Using the global trigger tool of the Institute for Healthcare Improvement, at least 10 times more adverse events were found (20). Increasing incident reporting does not mean increasing events, rather dissemination of non-punitive report- ing (21). The main limitations of this study are related to its retrospective design. It may be difficult to generalize the current findings because of underreporting and because most of the reported data were from MoH hospitals with only a small number from private hospitals. Health care workers tend to be suspicious about the consequences of reporting and this may result in underreporting. However, the MoH leadership has placed a strong emphasis on the mandatory reporting of sentinel events with sanctions in cases of non-reporting. In conclusion, this study is the first report of sentinel events in Saudi Ara- bia. It alerts the health care system in Saudi Arabia to the magnitude of senti- nel events and the need for immediate intervention. Ensuring availability and implementation of policies and proce- dures, fixing the flaws in the organiza- tional system and training of health care workers are central to improving patient safety in health care facilities. Efforts should focus on enhancing the National Sentinel Events Reporting System, con- ducting expert analysis of the incidents reported and building a patient safety culture that is system-oriented, non- punitive, confidential and responsive. Acknowledgement Abdulrahman Albawardi, MD, Minis- try of Health, Information and Com- munication Technology Department, Riyadh, Saudi Arabia: for providing the data reported to the MoH portal. Funding: None Competing interests: None declared. 55.0 35.3 33.0 23.6 22.2 11.6 11.1 10.6 0.0 10.0 20.0 30.0 40.0 50.0 60.0 % Figure 4 Cause of the sentinel events based on reports to Saudi Ministry of Health, January 2012−June 2015 Book 23-07.indb 498 8/23/2017 8:01:59 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 499 References 1. The Joint Commission. Sentinel Event Policy and Procedures. (http://www.jointcommission.org/Sentinel_Event_Policy_ and_Procedures/default.aspx, accessed 27 March 2017). 2. Lawtonr R, Parker D. Barriers to incident reporting in a health- care system. Qual Saf Health Care. 2002 Mar;11(1):15–8. 3. Leapel LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377–84. 4. Lynn ML, Osborn DP. Deming’s quality principles: a health care application. Hosp Health Serv Adm. 1991 Spring;36(1):111–20. 5. The Joint Commission. Comprehensive accreditation manual for hospitals. January 2013 (http://www.jointcommission.org/ assets/1/6/CAMH_2012_Update2_24_SE.pdf, accessed 27 March 2017). 6. National hospital standards. 3rd ed. Jeddah: Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI); 2014. 7. Benkirane R, Pariente A, Achour S, Ouammi L, Azzouzi A, Soulaymani R. Prevalence and preventability of adverse drug events in a teaching hospital: a cross-sectional study. East Mediterr Health J. 2009 Sep-Oct;15(5):1145–55. 8. The Joint Commission. Sentinel event data. General Information,1995–2Q 2015 (http://www.jointcommission. org/assets/1/18/General-Information_19952Q-2015.pdf, accessed: 27 March 2017). 9. De Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17:216–23. 10.1136/qshc.2007.023622 10. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000 Mar;38(3):261–71. 11. Cullen DJ1. Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized pa- tients: a comparative study of intensive care and general care units. Crit Care Med. 1997 Aug;25(8):1289–97. 12. National Study on Hospitalisation-Related Adverse Events (ENEAS). Report. Madrid: Ministry of Health and Consumer Affairs; 2006 (http://www.who.int/patientsafety/informa- tion_centre/reports/ENEAS-EnglishVersion-SPAIN.pdf, ac- cessed 27 March 2017). 13. Wilson RM, Michel P, Olsen S, Gibberd RW, Vincent C, El- Assady R, et al. Patient safety in developing countries: retro- spective estimation of scale and nature of harm to patients in hospital. BMJ. 2012 Mar 13;344:e832. 14. Kanjanarat P, Winterstein AG, Johns TE, Hatton RC, Gonzalez- Rothi R, Segal R. Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm. 2003 Sep 1;60(17):1750–9. 15. Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995 Jul 5;274(1):29–34. 16. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Law- thers AG, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991 Feb 7;324(6):370–6. 17. Vincent C. Incident reporting and patient safety: Emphasis is needed on measurement and safety improvement pro- grammes. BMJ. 2007;(334):51. 18. Brennan TA, Gawande A, Thomas E, Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005;353(13):1405–9. 19. Milgate K, Hackbarth G. Quality in Medicare: from measure- ment to payment and provider to patient. Health Care Financ Rev. 2005/06;27(2):91–101. 20. Classen DC1. Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011 Apr;30(4):581–9. 10.1377/hlthaff.2011.0190. 21. Beyea SC. Learning from sentinel event statistics. AORN J. 2004 Aug;80(2):315–8. Book 23-07.indb 499 8/23/2017 8:01:59 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 500 1Department of Community Medicine, Research Centre for Social Determinants of Health, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Islamic Republic of Iran (Correspondence to: ElahehGhods: ghodsemla@yahoo.com; elaheghods@semums.ac.ir). 2Department of Internal Medicine, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Islamic Republic of Iran. 3Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Islamic Republic of Iran. Received: 07/10/15; accepted: 20/11/16 Health-related quality of life of patients with asthma: a cross-sectional study in Semnan, Islamic Republic of Iran Naim S. Kia 1, Farhad Malek 2, Elaheh Ghods 1 and Mona Fathi 3 Qualité de vie liée à la santé de patients asthmatiques : étude transversale à Semnan, République islamique d’Iran RÉSUMÉ L’asthme peut affecter gravement la qualité de vie des personnes qui en souffrent. Les données sur la qualité de vie des personnes vivant avec l’asthme en République islamique d’Iran sont en nombre limité. La présente étude transversale avait pour objectif d’évaluer la qualité de vie des adultes asthmatiques à Semnan sur la base du SF-36, un questionnaire court d’enquête sur la santé comprenant 36 items. L’effet des caractéristiques socio-démographiques sur les scores de la qualité de vie a été examiné. L’étude incluait un échantillon de commodité de 385 patients externes souffrant d’asthme et s’étant rendus dans une clinique spécialisée pour les maladies pulmonaires entre juin et décembre 2013. Les scores moyens des composantes physiques et mentales étaient de 58,8 (ET 18,3) et 57,3 (ET 17,0) respectivement. L’échantillon de l’étude affichait des scores inférieurs pour la qualité de vie dans tous les domaines par rapport à la population de référence (p < 0,05). Les patients ayant un niveau d’instruction moindre, les habitants urbains, les patients veufs/divorcés et les travailleurs manuels obtenaient des scores de la qualité de vie plus faibles (p < 0,05). Des efforts sont requis pour améliorer la qualité de vie des patients asthmatiques parallèlement à la mise en place de plans précis pour leur prise en charge. ةيملاسلإا ناريإ ةيروهجم ،نانميس في ةيعطقم ةسارد :وبرلا ضىرلم ةيحصلا ةايلحا ةدوج يحتف انم ،سدق هلها ،كلم داهرف ،ايك تاداسلا ميعن ةيملاـ سلإا نارـ يإ ةـ يروهجم في رـ فوتت لاو .ضرـ لما اذـ به نـ باصلما دارـ فلأا ةاـ يح ةدوـ ج ىـ ع ًاـ قيمع ًارـ ثأت وـ برلا رـ ثؤي نأ نـ كمي :ةـ صلالخا نـباصلما نـغلابلا ىدـل ةاـيلحا ةدوـج مـييقت لىإ ةـيعطقلما ةـساردلا هذـه تـفدهو .وـبرلاب نـباصلما ةاـيح ةدوـج نـع ةدودـمح تاـنايب ىوـس ةــ يعماتجلاا صــ ئاصلخا رــ ثأت صــ حف مــ تو .)SF-36( ًادــ نب 36 نــ م نوــ كلما رــ صقلا يــ حصلا حــ سلما مادختــ ساب نانمــ س ةــ ظفامح في وــ برلاب ضىرـلما نـم ًاـضيرم 385 هـعوممج اـلم )ةيئاوـشع رـغ( "ةلوهـس" ةـنيع ةـساردلا تلمـشو .دارـفلأا نـم تاشرـعلا ةاـيح ةدوـج ىـع ةيناكـسلا ءاـجو .2013 لولأا نوناك/برمـسيد لىإ نارـيزح/وينوي نـم ةترـفلا في ةـيوئرلا ضارـمأل تاداـيع اوداـترا نـيذلا وـبرلاب نـباصلما نـيجرالخا تاـجرد تءاـجو .لياوـتلا ىـع )170 يراـيعم فارـحناب( 57.3و )183 يراـيعم فارـحناب( 58.8 ليـقعلاو نيدـبلا نـنوكلما تاـجرد طـسوتم لـقأ تاـجرد تلجـُس نـح في .)p < 0.05( ةـيعجرلما ناكـسلا ةـعوممج تاـجرد نـم لـقأ تلااـجلما عـيجم في ةـساردلا ةـنيع في ةاـيلحا ةدوـج لماـعلاو ،نـقّلطلما/لمارلأاو ،ةـيرلحا قـطانلما ناكـسو ،ضـفخنلما مـيلعتلا ىوتـسم يوذ ضىرـلما فوـفص في ةاـيلحا ةدوـج ىوتـسم ىـع .ةـقيقد ةـيرادإ طـطخ دادـعإ عـم يزاوـتلاب وـبرلاب نـباصلما صاخـشأل ةاـيلحا ةدوـج نـسحتل دوـهج لذـب مزـليو .)p < 0.05( نـيوديلا ABSTRACT Asthma can profoundly affect the quality of life of individuals with the disease. There are limited data on the quality of life of people with asthma in the Islamic Republic of Iran. This cross-sectional study aimed to evaluate quality of life in adults with asthma in Semnan using the 36-item short form health survey (SF-36). The effect of sociodemographic characteristics on quality of life scores was examined. The study included a convenience sample of 385 outpatients with asthma attending a pulmonary clinic from June to December 2013. The mean physical and mental component scores were 58.8 (SD 18.3) and 57.3 (SD 17.0) respectively. The study sample had lower quality of life scores in all the fields than the reference population (P < 0.05). Patients with lower education, urban residents, widowed/divorced patients and manual workers had lower quality of life scores (P < 0.05). Efforts are needed to improve the quality of life of people with asthma in parallel with precise management plans. Book 23-07.indb 500 8/23/2017 8:02:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 501 Introduction According to the latest report of the Global Initiative for Asthma (GINA), about 334 million people in the world have asthma (1). Although the data about adults over 45 years are not pre- cise, the number of asthma patients has increased considerably in the past 30 years. It is estimated that by 2025, 100 million people will have asthma glob- ally, an approximate 50% increase in every decade (1,2). The estimated global prevalence of asthma is 4.5% (3). In Asia, which is the most changing population in the world, less than 5% of adults are diag- nosed with clinical asthma (4) and in the Eastern Mediterranean region this is between 2.74% and 3.12% (3). Based on the latest report, the prevalence of asthma in the Islamic Republic of Iran was higher than the global rate of dis- ease and is estimated between 5.1% and 7.5% (5,6). The global burden of asthma is high because of its high prevalence, the prolonged duration of the disease and because it affects a considerable propor- tion of the population of working age. Asthma affects various aspects of life, including lifestyle, well-being, health, personal satisfaction, occupation and education (7,8). Quality of life (QoL) is a subjective and multidimensional in- dex of well-being from a patient’s point of view. It is defined as physical, emo- tional, social, material well-being and development, activity functional ability (9). It has become more important with increased life expectancy and changes in the pattern of disease as a result of advancements in medical sciences in or- der to evaluate cost−utility and cost−ef- fectiveness of health care programs (4). There are different instruments for assessment of QoL in adults (9). However, none of them can evaluate the effect of asthma on all of the key dimensions of QoL and none is able to provide a core assessment. Even the most disease-specific tools such as the Asthma Quality of Life Questionnaire discriminate poorly between subscales (8,10). The Short Form Health Survey (SF-36) is the most common validated, rapid, self-rated assessment tool for adult disease, despite lower inter-class correlation and minor responsive index compared with disease-specific scales such as the Asthma Quality of Life Questionnaire. It has allowed compari- son of QoL in different disease states and can be useful to evaluate patient- reported outcome measures (11−13). All of these instruments have shown lower QoL scores in people with asthma compared with those without the dis- ease (7,10). Several factors could affect QoL of people with asthma, such as age, socioeconomic status, education level and marital status. These factors could modify classification, diagnosis and treatment of asthma (14). Despite the importance of assessing QoL in chronic respiratory diseases such as asthma, there has been limited research on QoL in people with asthma in the Islamic Republic of Iran. This study therefore aimed to evaluate the QoL in adults with asthma and the sociodemographic characteristics associated with it. Methods Study setting and sample This was cross-sectional study of adult asthma patients referred to the pulmo- nary clinic of the University of Semnan from June to December 2013. A convenience sample was selected of 385 asthma patients aged 18 years or older. All patients were approached during their routine follow-up care in the pulmonary clinic and asked for their participation in the study. All those ap- proached agreed to participate. Asthma was diagnosed by a pul- monary subspecialist based on chronic persistent inflammation with acute episodic exacerbations and reduced lung function confirmed by spirom- etry, forced expiratory volume per sec- ond (FEV1) before and 15 min after administration of 400 mg (2-3 puffs) of albuterol or equivalent (8). Asthma patients who were affected by other serious chronic physical or psychologi- cal diseases, such as cancer and major depression, based on self-report, were excluded from the study. Ethical considerations The study was approved by the Semnan University Ethics Committee. Informed consent was obtained from all the par- ticipants before data collection. Data collection Demographic data, including age, marital status, occupation and educa- tion were collected by interview at the pulmonary clinic. The Persian version of SF-36 questionnaire was used to evalu- ate QoL (11,15). SF-36 has 8 domains and 36 questions and includes a physical component score (PCS) and mental component score (MCS), selected from the medical outcomes study in 1992 (16). PCS has 4 scales: Physical Functioning, Physical Role, Bodily Pain and General Health. MCS has 4 scales: Vitality, Social Functioning, Emotional Role and Mental Health (17). Par- ticipants are scored individually in each area (0 = worst to 100 = best); the lower the score the lower the QoL. The reliability and internal consistency of this tool has determined (18). It can be used in different countries and for different diseases or even for compari- son between groups with a disease and healthy groups (17).Validation of the SF-36 for measurement of QoL in people with asthma has been done and its suitability for this group established (19). The Farsi version of the SF-36 questionnaire has been validated (20) and used in different studies in our country (20−23). Statistical analysis The data were entered into SPSS, version 16. The QoL scores of the participants are presented as medians and ranges or as means and standard deviations Book 23-07.indb 501 8/23/2017 8:02:00 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 502 (SD) according to sociodemographic characteristics. Analysis was done by one-way ANOVA, one-sample t-test and independent t-test when necessary. Results A total of 385 patients with asthma [177 (45.5%) females; 208 (53.5%) males] were enrolled in the study. The mean age of the patients was 48.7 (SD 15.2) years. Of all the participants, 263 (68.6%) were married, 46 (11.9%) were widowed/divorced and 76 (19.5%) were single. Older patients with had lower QoL in all domains except for Mental Health (P < 0.001). Mean physical functioning and mental health scores of the patients with asthma were 58.8 (SD 18.3) and 57.3 (SD 17.0) respectively. The PCS score of the study group was significantly bet- ter than the MCS score (P < 0.001). Table 1 shows the mean scores of all PCS and MCS scales in the patients with asthma and the general population. The association between the patient demographic and socioeconomic char- acteristics and their QoL is shown in Table 2. The participants with lower education levels had significantly lower scores in all domains except for Physical Role and Emotional Role. Higher in- come was associated with higher scores in all the domains. Among employed patients, manual workers had lower QoL in all domains. Compared with urban residents, those living in rural areas had higher QoL scores in the areas of Physical Functioning, Bodily Pain, General Health and Emotional Role. Patients who had shorter duration of the disease also had higher QoL scores in all domains, except for Emotional Role. Single patients had significantly higher scores in all the areas of PCS but the association was significant only for Vitality. Table 3 shows the correlation be- tween the different variables based on the results obtained from the SF 36 questionnaire. The lowest PCS and MCS were among those in lowest in- come category (P = 0.001 for both) and manual workers (P = 0.001 for both). Patients with a disease duration of more than 15 years (P = 0.001), urban residence (P = 0.001) and widowed or divorced (P = 0.001) had significantly lower physical scores. Higher physi- cal score were found in patients with a master’s degree or higher (P < 0.001). There were no differences in MCS and PCS by sex. Discussion The assessment of disease outcomes based on QoL score is an important concern, particularly for chronic non- communicable diseases. Our study showed found lower QoL scores in asthma patients than in the general population, which concurs with the results of other studies in this field which used different scales (10,11). The results of our study showed that the mean PCS and MCS of individuals with asthma were 58.8 (SD 18.3) and 57.3 (SD 17.0) respectively. As expect- ed, the mean score of the asthma group was significantly lower than that of the general Iranian adult population (15). Patients with asthma have also been reported to have lower General Health but higher Emotional Role scores com- pared with pregnant women experi- encing domestic violence (20), lower Physical Functioning, Physical Role, General Health and Mental Health scores than adolescents with premen- strual disorder (21), lower scores in Emotional Role, Physical Role and Physical Functioning compared with patients with diabetes (22), and lower scores in all subdomains except General Health than patients with thalassemia major (23). Based on results of a large epide- miological study, mean PCS and MCS score in asthma patients was 45.6 and 48.1 respectively (11). In another study in France, the General Health QoL score was 65−88 for mild to moderate asthma and 63−78 for severe asthma Table 1 Mean scores of health-related quality of life as measured by SF-36 in patients with asthma and the general Iranian population Domain Asthma patients Reference population (15) P-value Mean (SD)a Mean (SD)a Physical functioning 58.4 (27.6) 85.3 (20.8) < 0.001 Physical role 49.5 (33.1)b 70.0 (38.0) < 0.001 Bodily pain 72.1 (21.2) 79.4 (25.1) < 0.001 General health 55.2 (16.7) 67.5 (20.4) < 0.001 Vitality 55.9 (17.5) 65.8 (17.3) < 0.001 Social functioning 66.6 (20.3) 76.0 (24.4) < 0.001 Emotional role 49.3 (36.1)b 65.6 (41.4) < 0.001 Mental health 57.3 (17.7) 67.0 (18.0) < 0.001 aAnalysis by one-sample t-test bMedian (IQR). SD = standard deviation. Book 23-07.indb 502 8/23/2017 8:02:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 503 Ta bl e 2 H ea lt h- re la te d qu al ity o f l ife s co re s as m ea su re d by S F- 36 o f t he a st hm a pa ti en ts a cc or di ng to s oc io -d em og ra ph ic c ha ra ct er is ti cs Va ri ab le N o. (% ) PF PR BP G H V I SF ER M H M ea n (S D ) M ed ia n (IQ R) M ea n (S D ) M ea n (S D ) M ea n (S D ) M ea n (S D ) M ed ia n (IQ R) M ea n (S D ) M ar ita l s ta tu s Si ng le 46 (1 1.9 ) 75 .9 (1 7.6 ) 73 .6 (2 8. 1) 79 .2 (1 7.0 ) 66 .9 (1 6. 3) 65 .6 (1 5. 5) 67 .12 (2 2. 7) 52 .9 (3 6. 9) 58 .9 (1 3. 0 ) M ar rie d 26 3 (6 8. 4) 60 .3 (2 7.5 ) 49 .8 (3 3. 2) 74 .4 (2 1.6 ) 55 .0 (1 6. 4) 55 .5 (1 7.8 ) 67 .6 (2 1.2 ) 50 .4 (3 7.0 ) 56 .8 (1 9. 3) W id ow ed , d iv or ce d 76 (1 9. 7) 40 .5 (2 3. 5) 34 .0 (2 5. 9) 59 .4 (1 6. 9) 48 .5 (1 4. 5) 51 .6 7 (1 5. 6) 62 .9 (1 4. 7) 43 .1 (3 1.8 ) 58 .4 (1 4. 0 ) Ed uc at io n le ve l Ill ite ra te 62 (1 6. 1) 43 .6 (2 7.3 ) 40 .7 (3 1.2 ) 68 .3 (2 2. 5) 49 .0 (1 9. 0 ) 49 .3 1( 16 .3 ) 60 .5 (2 0 .3 ) 39 .8 (3 4. 0 ) 49 .7 (1 4. 5) < 9. y ea rs 77 (2 0 .0 ) 52 .0 (2 2. 4) 44 .5 (3 1.0 ) 66 .2 (1 9. 1) 48 .2 (1 8. 3) 56 .1( 18 .2 ) 66 .0 (2 0 .2 ) 48 .0 (3 2. 2) 60 . 8 (1 7.6 ) 9- 39 (1 0 .1) 64 .9 (2 2. 4) 54 .8 (3 2. 9) 73 .1 (2 2. 6) 56 .5 (8 .0 ) 67 .5 (1 6. 8) 71 .8 (1 8. 5) 55 .5 (4 5. 4) 68 .4 (2 0 .7 ) D ip lo m a 12 5 (3 2. 5) 58 .7 (3 0 .6 ) 54 .3 0 (3 3. 4) 73 .4 (2 1.6 ) 56 .5 (1 5. 3) 56 .5 (1 8. 1) 66 .0 (1 9. 9) 51 .2 (3 6. 7) 53 .9 (1 6. 1) U ni ve rs ity , B Sc 72 (1 8. 7) 69 .1 (2 2. 6) 47 .5 (3 5. 2) 75 .7 (1 9. 2) 62 .6 (1 4. 5) 54 .2 (1 5. 1) 67 .3 (2 0 .3 ) 48 .6 (3 4. 4) 60 .1 (1 8. 8) U ni ve rs ity , ≥ M Sc 10 (2 .6 ) 90 .5 (6 .8 ) 76 .2 (1 4. 9) 95 .0 (5 .3 ) 73 .5 (3 .4 ) 57 .0 (9 .2 ) 92 .5 (6 .4 5) 73 .3 (2 6. 3) 55 .2 (5 .2 ) O cc up at io n M an ua l w or ke r 21 (5 .5 ) 58 .4 (2 0 .6 ) 33 .9 (3 6. 6) 65 .7 (1 9. 9) 57 .6 (1 4. 1) 51 .7 (7 .5 ) 63 .7 (1 8. 5) 36 .0 (3 7.8 ) 49 .7 (9 .8 ) G ov er nm en t e m pl oy ee 50 (1 3. 0 ) 69 .1 (2 0 .4 ) 60 .0 (3 .9 ) 68 .9 (1 7.0 ) 63 .3 (1 5. 0 ) 53 .9 (1 6. 9) 57 .8 (2 0 .4 ) 41 .2 (3 4. 3) 56 .5 (1 9. 4) O ffi ce w or ke r 46 (1 1.9 ) 60 .6 (3 1.3 ) 44 .6 (3 4. 8) 73 .2 (2 3. 1) 56 .0 (1 5. 3) 55 .3 (1 7.2 ) 68 .4 (1 9. 9) 51 .5 (3 6. 3) 58 .7 (1 9. 7) Re tir ed 51 (1 3. 2) 40 .8 (2 6. 2) 34 .7 (2 2. 2) 69 .1 (2 3. 6) 52 .2 (1 5. 8) 54 .7 (1 4. 0 ) 68 .6 (1 9. 3) 41 .8 (3 5. 9) 52 .9 (1 2. 2) Se lf- em pl oy ed 85 (2 2. 1) 66 .2 (2 7.2 ) 59 .9 (2 8. 8) 80 .3 (2 2. 2) 59 .7 (1 6. 3) 62 .4 (1 6. 5) 71 .4 (2 3. 1) 59 .7 (3 8. 6) 62 .5 (1 7.1 ) H ou se w ife 12 0 (3 1.2 ) 54 .9 (2 6. 4) 45 .9 (3 3. 7) 69 .4 (1 9. 5) 46 .8 (1 6. 4) 51 .7 (2 0 .1) 65 .9 (1 8. 9) 50 .6 (3 2. 5) 56 .4 (2 0 .3 ) O th er 12 (3 .1) 72 .6 (2 1.1 ) 67 .5 (3 0 .2 ) 71 .7 (1 6. 4) 63 .2 (1 2. 8) 65 .5 (1 7.8 ) 65 .9 (1 2. 2) 48 .3 (3 6. 6) 59 (1 0 .9 2) R es id en ce U rb an 10 0 (2 6. 0 ) 51 .3 (2 6. 3) 51 .0 (1 9. 6) 65 .0 (1 9. 7) 51 .0 (1 9. 6) 54 .5 (1 7.3 ) 64 .2 (1 9. 3) 44 .7 (3 2. 2) 56 .0 (1 8. 1) Ru ra l 28 5 (7 4. 0 ) 60 .9 (2 7.6 ) 51 .3 (1 5. 4) 74 .6 (2 1.7 3) 56 .7 (1 5. 4) 65 .5 (1 7.6 ) 67 .3 (2 0 .6 ) 50 .9 (3 7.3 ) 57 .8 (1 7.6 ) D ur at io n of d is ea se (y ea rs ) < 5 16 0 (4 1.5 ) 62 .5 (2 5. 6) 52 .5 (3 3. 1) 71 .9 (2 3. 1) 60 .2 (1 5. 4) 57 .9 (1 2. 8) 65 .4 (2 0 .4 ) 44 .2 (3 5. 8) 58 .2 (1 3. 1) 5- 9 71 (1 8. 4) 59 .8 (2 7.0 ) 52 .4 (3 5. 8) 69 .9 (1 9. 4) 52 .5 (1 8. 8) 50 .7 (1 6. 7) 71 .5 (2 0 .9 ) 55 .8 (3 6. 0 ) 55 .8 (2 0 .3 ) 10 -1 4 89 (2 3. 2) 59 .8 (2 8. 3) 49 .4 (2 9. 7) 78 .5 (1 8. 4) 51 .7 (1 6. 8) 55 .3 (2 3. 3) 68 .8 (2 0 .7 ) 50 .2 (3 8. 3) 52 .1( 19 .7 ) > 15 65 (1 6. 9) 44 .8 (2 8. 1) 39 .0 (3 3. 0 ) 66 .1 (2 0 .0 ) 50 .6 (1 4. 3) 57 .8 (1 8. 6) 61 .3 (1 7.2 ) 53 .3 (3 7.7 ) 63 .9 (1 9. 4) M on th ly in co m e (× 10 0 0 0 ri al s) < 50 0 13 6 (3 5. 4) 55 .3 (2 7.3 ) 48 .2 (3 3. 5) 69 .7 (1 9. 8) 48 .8 (1 6. 6) 54 .1( 20 .3 ) 65 .5 (1 7.6 ) 50 .2 (3 2. 2) 57 .0 (1 9. 3) 50 0 -9 99 39 (1 0 .1) 61 .7 (2 6. 7) 55 .4 (3 1.2 ) 75 .0 (2 0 .9 ) 57 .0 (2 2. 9) 58 .2 (9 .1) 71 .0 (2 5. 5) 39 .3 (3 8. 1) 61 .8 (1 5. 1) 10 0 0 -1 49 9 88 (2 2. 8) 46 .7 (2 7.6 ) 33 .2 (2 4. 8) 65 .2 (2 0 .6 ) 56 .1 (1 4. 3) 53 .6 (1 2. 2) 59 .1( 18 .3 ) 37 .9 (3 2. 4) 55 .9 (1 8. 1) 15 0 0 -1 99 9 74 (1 9. 2) 63 .8 (2 3. 1) 60 .3 (3 4. 1) 77 .3 (2 1.2 ) 61 .5 (1 2. 8) 55 .4 (1 8. 9) 68 .7 (1 7.8 ) 57 .2 (4 0 .7 ) 55 .0 (1 5. 3) > 20 0 0 48 (1 2. 5) 77 .5 (2 3. 2) 61 .7 (3 3. 4) 81 .0 (2 1.7 ) 60 .4 (1 5. 0 ) 64 .9 (1 8. 1) 76 .8 (2 4. 2) 63 .2 (3 6. 5) 60 .5 (1 7.4 ) PF : P hy si ca l f un ct io ni ng , P R: P hy si ca l R ol e, B P: B od ily p ai n, G H : G en er al h ea lth , V T Vi ta lit y, S F: S oc ia l F un ct io ni ng , E R: E m ot io na l R ol e, M H : M en ta l H ea lth . SD = st an da rd d ev ia tio n; IQ R = in te rq ua rt ile ra ng e. Book 23-07.indb 503 8/23/2017 8:02:00 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 504 (14). Comparing different assessment scales for health-related QoL (SF 36, Asthma Quality of Life Questionnaire and modified shortened Living With Asthma Questionnaire), there was only modest correlation between physical score SF 36 and asthma control over time, in spite of the strength of SF 36 in detecting burden of illness overall and measuring non-specific situation that affect quality of life (12,15). On the other hand, recent research has shown a good sensitivity of SF 36 for treatment efficacy of different disease states (24). Therefore, QoL assessment with SF 36 could be applicable for this case and even better for comparative studies. In our study, the highest score was observed in Physical Pain domain and the lowest score in Emotional Role functioning. Due to the type of Table 3 Mean physical and mental component scores (PCS and MCS) of the asthma patients according to demographic and socioeconomic characteristics Variable PCS P-level MCS P-level Mean (SD) Mean (SD) Marital status Single 73.9 (13.8) 0.001a 61.2 (14.0) 0.07aMarried 59.9 (18.1) 57.6 (18.5) Widowed, divorced 45.9 (12.8) 54.0 (12.6) Education level Illiterate 50.5 (18.9) 0.001a 49.9 (16.4) 0.1a < 9. years 52.7 (15.7) 57.7 (15.1) 9− 62.4 (17.1) 65.8 (18.3) Diploma 60.7 (19.2) 56.9 (17.5) University, BSc 63.8 (15.0) 57.6 (16.4) University, ≥ MSc 83.8 (5.7) 69.5 (7.4) Occupation Manual worker 51.4 (19.6) 0.001a 50.4 (13.1) 0.001a Government employee 64.6 (15.1) 51.8 (16.9) Office worker 55.3 (17.9) 57.0 (19.1) Retired 49.2 (16.4) 54.5 (13.8) Self-employed 65.8 (18.0) 63.8 (17.9) House-wife 54.3 (16.4) 56.2 (18.0) other 74.4 (15.5) 62.6 (8.9) Residence Urban 52.9 (18.3) 0.001b 54.9 (15.9) 0.1a Rural 60.9 (18.0) 58.1 (17.4) Duration of disease (years) < 5 61.8 (17.9) 0.001a 56.5 (13.6) 0.65a 5− 58.7 (18.9) 58.5 (17.5) 10− 59.9 (17.9) 56.6 (21.4) > 15 50.1 (17.5) 59.1 (18.3) Income (× 10 000 rials) < 500 55.5 (17.4) 0.001a 56.7 (16.8) 0.001a 500− 62.3 (21.9) 57.6 (15.6) 1000− 50.3 (14.4) 51.6 (14.6) 1500− 65.8 (16.9) 59.1 (17.1) > 2000 70.2 (17.2) 66.4 (18.5) Sex Male 57.9 (18.5) 0.32b 56.2 (18.3) 0.18b Female 59.8 (18.2) 58.8 (15.4) aOne-way ANOVA; bIndependent t-test. SD = standard deviation. Book 23-07.indb 504 8/23/2017 8:02:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 505 disease pathogenesis, it is expected that asthma results in little or no pain and moderately good social functioning, however dyspnea and wheezing lead to disability and subsequent negative feelings (12,20). Reid et al. reported the lowest score in Vitality (12) which is in contrast to our results. Our findings showed lower MSC scores compared with the PSC scores, which is in agreement with the results of previous research (20). Although the mental score of SF 36 concentrates more on depression, anxiety is a main factor in asthma attacks (19). It has been reported that there is a cyclical interaction between respiratory symp- toms in asthma and the likelihood of mood disorders, which limits physical and emotional functioning in people with asthma (25,26). Mental health has a strong role in the control of asthma (27). Mood disorders decrease the ef- ficacy of treatment and increase the re- currence of acute attacks, which further reduces QoL (28). In our study, PCS was significantly higher in rural residents with asthma. The higher incidence of asthma in recent years could be explained by changes in environmental and geographical factors (29). Actually the prevalence and mor- bidity of asthma is lower in rural areas than urban areas (29,30). This difference could be explained by differences in a number of environmental and lifestyle factors between urban and rural areas: for example air pollution, diet, energy sources, biomass fuel, farming, livestock and occupational exposures, dust mites, vehicle emissions, respiratory infection and a westernized lifestyle (12,29). The conflicting reports of higher morbid- ity from asthma in rural areas could be explained by a higher proportion of those aged 55 years or older (i.e. longer duration of disease too), low income, lack of health insurance coverage and college education in suburban and rural areas (29−32). Lower PCS and MCS scores in our study were associated with lower education, lower level of job and lower income. A significant correlation was observed between higher socioeco- nomic status and better QoL in indi- viduals with asthma (29). Moreira et al. in a retrospective cohort study with a large sample of 40 000 found a lower incidence of asthma in the subgroup with higher income (31). Several stud- ies are in agreement with the results of our study of a lower QoL among those with lower socioeconomic status (2,29,30). A higher level of education, a stable job and health insurance also improve the QoL of individuals with asthma (30,31). These relationships could be inter- preted in different ways. Patients with higher education and those with higher incomes are more likely to schedule regular follow-up visits and show better adherence to treatments. Lower educa- tion increases the likelihood of underes- timating the significance of control and treatment plans (32). Similar to the results of our study, a European study found significantly lower PCS scores in manual workers (11). Manual workers are more likely to be exposed to allergens than office workers (3). However, different job classifications between countries make the interpretation of contradictory re- sults difficult (11,30,31). We found some evidence of an in- verse relationship between duration of disease and QoL. Rajanandh et al. found a similar relationship in patients who had had asthma for more than 5 years (33). Another study also showed lower PCS score in older patients, who had likely had the disease for a long period (11). In our study, widowed and divorced individuals had lower QoL scores than single and married individuals. Previous studies suggest widows have a lower QoL than the general population, main- ly because of their lower incomes (34). Psychological disorders are also more common in this group of people (35). The better QoL for younger patients with asthma could be explained by a short duration of the disease and fewer complications. There was no significant sex differ- ence in QoL scores in our study. In contrast, the results of several studies in- dicate that female patients with asthma are likely to have a greater perception of dyspnea, report a poorer control and have a poorer QoL compared with males and they recommended sex- specific management protocols (11). A limitation of our study was the lack of response by some participants on some of the variables evaluated, such as monthly income and severity of asthma. In addition, we did not have access to validated Farsi version of the Asthma Quality of Life Questionnaire to use in parallel with the SF-36 health survey, which would have strengthened our assessment and allowed us to evalu- ate intra-class correlation. Conclusion The results of this study indicate that low QoL was common among our sample of asthma patients. Efforts are needed to improve the QoL of patients with asthma in parallel with precise management plans. The increase in the incidence of this chronic disease in recent decades makes this a priority. Funding: None. Competing interests: None declared. Book 23-07.indb 505 8/23/2017 8:02:00 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 506 References 1. The Global Asthma Report 2014. Auckland: Global Asthma Net- work, 2014 (http://www.globalasthmareport.org/resources/ Global_Asthma_Report_2014.pdf, accessed 20 March 2017). 2. Braman SS. 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Delara M, Ghofranipour F, Azadfallah P, Tavafian SS, Kazemne- jad A, Montazeri A. Health related quality of life among ado- lescents with premenstrual disorders: a cross sectional study. Health Qual Life Outcomes. 2012 Jan 1;10(1):1. 22. Darvish poor Kakhki A, Abed Saeedi Z. Health-related quality of life of diabetic patients in Tehran. Int J Endocrinol Metab. 2013;11(4):e7945 23. Haghpanah S, Nasirabadi S, Ghaffarpasand F, Karami R, Mahmoodi M, Parand S, et al. Quality of life among Iranian patients with beta-thalassemia major using the SF-36 question- naire. Sao Paulo Med J. 2013;131(3):166–72. 24. Atabakhsh M, Mazaheri M. Responsiveness of the SF-36 ques- tionnaire to the treatment outcome: a comparison of the mental and the physical patients. Modern Applied Science. 2016 Apr 10;10(6):183-7. 25. Wong KO, Hunter Rowe B, Douwes J, Senthilselvan A. Asthma and wheezing are associated with depression and anxiety in adults: an analysis from 54 countries. Pulm Med. 2013 Mar 17;2013. 26. Sundberg R, Palmqvist M, Tunsäter A, Torén K. Health-related quality of life in young adults with asthma. Respir Med. 2009 Oct 31;103(10):1580–5. 27. Schatz M, Mosen D, Apter AJ, Zeiger RS, Vollmer WM, Stibolt TB, et al. Relationships among quality of life, severity, and con- trol measures in asthma: an evaluation using factor analysis. J Allergy ClinImmunol. 2005 May 31;115(5):1049–55. 28. Oraka E, King ME, Callahan DB. Asthma and serious psychologi- cal distress: prevalence and risk factors among US adults, 2001- 2007. Chest. 2010;137(3):609–16. 29. Jie Y, Isa ZM, Jie X, Ju ZL, Ismail NH. Urban vs. rural factors that af- fect adult asthma. Rev Environ ContamToxicol. 2013;226:33–63. 30. Moreira P, Moreira A, Padrão P, Delgado L. The role of econom- ic and educational factors in asthma: evidence from the Portu- guese Health Survey. Public Health. 2008 Apr 30;122(4):434–9. 31. Curtis LM, Wolf MS, Weiss KB, Grammer LC. The impact of health literacy and socioeconomic status on asthma disparities.J Asthma. 2012 Mar 1;49(2):178–83. 32. Pappa E, Kontodimopoulos N, Papadopoulos AA, Niakas D. Assessing the socioeconomic and demographic impact on health-related quality of life: Evidence from Greece. Int J Public Health. 2009;54:241–9. 33. Rajanandh MG, Nageswari AD, Ilango K. Influence of demo- graphic status on pulmonary function, quality of life, and symp- tom scores in patients with mild to moderate persistent asthma. J ExpClin Med. 2014 Jun 30;6(3):102–4. 34. Wheaton AG, Ford ES, Thompson WW, Greenlund KJ, Presley- Cantrell LR, Croft JB. Pulmonary function, chronic respiratory symptoms, and health-related quality of life among adults in the United States–National Health and Nutrition Examination Survey 2007–2010.BMC Public Health. 2013 Sep 17;13:854. 35. Lavoie KL, Bacon SL, Barone S, Cartier A, Ditto B, Labrecque M. What is worse for asthma control and quality of life: Depressive disorders, anxiety disorders, or both? Chest. 2006;130:1039–47. Book 23-07.indb 506 8/23/2017 8:02:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 507 1Department of Statistics and Epidemiology, 2Road Traffic Injury Research Centre, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 3School of Nursing of Miandoab, Urmia University of Medical Sciences, Urmia, Islamic Republic of Iran. 4Department of Health Education, School of Health Sciences Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 5Maku Health Centre, Maku, West Azerbaijan, Islamic Republic of Iran. (Correspondence to: Morteza Shamshirgaran: m.shamshirgaran@hotmail.com). Received: 24/11/15; accepted: 28/11/16 Epidemiological characteristics and trends in the incidence of animal bites in Maku County, Islamic Republic of Iran, 2003−2012 Seyed Morteza Shamshirgaran 1,2, Hamid Barzkar 1, Saber Ghaffari-Fam 3, Ahmad Kosha 4, Parvin Sarbakhsh 1 and Pari Ghasemzadeh 5 Caractéristiques et tendances épidémiologiques de l’incidence des morsures d’animaux dans la préfecture de Makou (République islamique d’Iran), 2003-2012 RÉSUMÉ La présente étude a examiné les caractéristiques et l’incidence épidémiologiques dans le temps des morsures d’animaux dans la préfecture de Makou. Les données ont été obtenues à partir des registres de centres de santé portant sur les morsures d’animaux entre 2003 et 2012. Des informations sur les caractéristiques démographiques et les facteurs associés aux morsures d’animaux ont été enregistrées. Un total de 2232 personnes avaient été mordues. La fréquence des morsures était plus élevée parmi les hommes (75,4 %), les habitants ruraux (72,3 %) et les individus de moins de 20 ans (47,3 %). La plupart des morsures se situaient au niveau des jambes et des pieds (65 %) et les chiens étaient responsables de 92 % des morsures. Plus de 25 % des personnes mordues mettaient plus d’une journée à recourir à des soins, en particulier les habitants ruraux. L’incidence moyenne était de 250 pour 100 000 habitants, et on observait une tendance linéaire en hausse statistiquement significative sur la période de 10 ans. Il est nécessaire de sensibiliser le public, et particulièrement les habitants ruraux, à l’importance d’un traitement rapide. Eu égard à la tendance croissante des morsures d’animaux, une politique sanitaire pour s’attaquer à ce problème est requise. 2012 - 2003،ةيملاسلإا ناريإ ةيروهجم ،وكام ةعطاقم في تاناويلحا تاضعب ةباصلإا ةلاح في ةيئابولا تاهاتجلااو صئاصلخا هداز مساق يرب ،شخبسر نيورب ،اشوك دحمأ ،ماف يرافغ رباص ،راكزرب ديحم ،ناركرشمش ضىترم تدِمُتـساو .وـكام ةـعطاقم في نـمزلا برـع اـبه ةـباصلإا تلاّدـعمو تاـناويلحا تاـضعل ةـيئابولا صـئاصلخا ةـساردلا هذـه تـلوانت :ةـصلالخا ةيناكـسلا صـئاصلخاب ةـقلعتلما تاـمولعلما تل ِّجـُسو .2012 لىإ 2003 نـم ةترـفلل ةـيناويلحا تاـضعلل يـحصلا زـكرلما تلاجـس نـم تاـنايبلا ةـباصلإل لدـعم ىـعأ روـكذلا لّجـسو ؛ًاصخـش 2232 تاـضعل اوـضرعت نـيذلا صاخـشلأا عوـممج غـلبو .تاـضعلاب ةـلصتلما لـماوعلاو مدـ قلاو قاـ سلا في تاـ ضعلا مـ ظعم تءاـ جو .)% 47.3( نـ يشرعلا نـ س قوـ ف مـ ه نـ مو )% 72.3( فـ يرلا ناكـ س مـ ث ،)% 75.4( تاـ ضعلاب ىـع لوـصلحا في تاـضعلا كـلتب نـباصلما نـم % 25 نـم رـثكأ رـ ُّخأت ّنـبتو .تاـضعلا هذـه نـم % 92 بلاكـلا تاـضع تلّكـشو )% 65( تاذ ةداـيز تلجـُسو ،ةمـسن 100 000 لكـل ةـلاح 250 ةـباصلإا طـسوتم غـلبو .فـيرلا ناكـس مايـس لا ،موـي نـم رـثكلأ ةـمزلالا ةـياعرلا جلاـعلا ةـيهمأ نأـشب ،ةـيفيرلا قـطانلما ناكـس نـب مايـس لا ،ماـعلا يـعولا ةداـيزل ةـجاح كاـنهو .تاونـس شرـعلا ةترـف للاـخ ةـيئاصحإ ةـللاد .ةلكـشلما هذـه ةـلجاعلم ةـيحص ةـسايس عـضول ةـجاح كاـنه ،تاـناويلحا تاـضع في دـيازتلما هاـتجلاا ءوـض فيو .رـكبلما ABSTRACT This study examined the epidemiological characteristics and incidence over time of animal bites in Maku County. Data were obtained from health centre records of animal bites from 2003 to 2012. Information on demographic characteristics and bite-related factors were recorded. A total of 2232 people were bitten; the frequency of bites was highest among males (75.4%), rural residents (72.3%) and those < 20 years (47.3%). Most bites were to the legs and feet (65%) and dogs were responsible for 92% of bites. Over 25% of those bitten delayed seeking care for more than a day, particularly rural residents. The mean incidence was 250 per 100 000 population and there was a statistically significant increasing linear trend over the 10-year period. There is a need to raise public awareness, especially among rural residents, of the importance of early treatment. Given the increasing trend in animal bites, a health policy to tackle this problem is needed. Book 23-07.indb 507 8/23/2017 8:02:00 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 508 years (12–14). Recent reports from different parts of the Islamic Republic of Iran have indicated that animal bites are increasing. For instance, a study con- ducted in Rafsanjan city among 1542 patients referred to a health centre for animal bites from 2003 to 2005 esti- mated the incidence of animal bites in the area to be 180, 195 and 241 per 100 000 persons in 2003, 2004 and 2005 respectively (14). Maku County is located in West Azerbaijan province, north-west of the Islamic Republic of Iran. It has a popula- tion of about 90 000 and an area size of 5 000 square kilometres. This study was conducted to investigate the epidemiol- ogy and the time trend of animal bites in this county between 2003 and 2012. Methods Study design and population This was a cross-sectional study con- ducted among 15 health centres in Maku County which serve all of the population of the county. According to the Iran Health Network, people who are bitten by an animal are referred to the local health centre. A form is completed by trained staff for all referral cases of animal bites in each health centre. Therefore, the data of animal bites were compiled by the trained staff working in the Maku health centres. The study population in- cluded all the people who were bitten by animals and were referred to the health centres of Maku in the 10-year period from 20 March 2003 to 20 March 2012. Data collection Data were collected from the medi- cal records of animal bites at the health centres in the study period. The vari- ables of interest were: 1) Demographic variables including age, sex, occupation and education of the victims, 2) Place variables including place of residence of the person bitten and place where the bite occurred; 3) Time patterns Introduction Animal bites are a major cause of mor- bidity and mortality around the world, and are among the most important pub- lic health problems in some countries, such as in southern and eastern Medi- terranean countries as well as in Middle Eastern countries with approximately 2% of the population being bitten an- nually (1,2). Numerous animal species can cause bites, however, most bites are from dogs, snakes, cats and monkeys. For example, snake bites are more frequent in Africa and South-East Asia. Evidence shows that dogs account for 76–94% of animal bite injuries in low- and middle-income countries (3). In the Middle East, dogs are the main cause of animal bites followed by cats, cattle, sheep, goats, camels, donkeys and wild animals (1). Animal bites are an important health concern because of the risk of secondary infections and also the possibility of contracting rabies. The populations most at risk include young children and men (4). Animal bites can have a significant health impact; this depends on many factors including the type, size and location of the bite, health of the animal, health of the person bit- ten, and the health care received by the person bitten. Surveillance of animal- related injuries can help determine the extent and scope of animal bites in order to provide useful information for im- plementation and evaluation of public health prevention interventions (5). Animal bites are public health con- cern in the Islamic Republic of Iran and the pattern and frequency vary in differ- ent areas (6–10). Golestan province in the north of the country has a high incidence of animal bites (11) and the highest rate of animal bites has, recently, been reported from Aq Qala, Golestan province – 1 222 bites per 100 000 per- sons (12). Additionally, some studies have shown a change in the pattern and frequency of animal bites in the past 10 including hour, day and season of the bite; 4) Characteristics of the animals such as the type and species of the ani- mal and whether it was alive 10 days af- ter the bite; 5) Location characteristics of bites including injury site, size of the wound, lesion type (superficial or deep) and whether the bite was covered by a cloth or not; 6) Health care received after the bite, e.g. number of vaccina- tions, tetanus vaccine received or not, infusion of rabies serum received, delay in receiving medicine after the bite and previous history of animal bites. Data analysis The crude incidence rate was deter- mined on the basis of the total number of people bitten. To calculate the crude incidence rate, the population of the county by age group was obtained from the health centres of Maku. Descriptive statistics were used to summarize the data. Mean and standard deviation (SD) were determined to show distribution of the data. For cat- egorical variables, frequency was used. Age was categorized into 6 age groups: < 10 years, 10–19, 20–29, 30–39, 40–49 and ≥ 50 years. The chi-squared test was used to assess the association of cat- egorical variables; if 20% of the expected frequencies were ≤ 5, the Fisher exact test was used. To compare the mean age of victims according to sex and place of residence, the Mann–Whitney test was used because the data were not normally distributed. The chi-squared test for linear trend was used to test whether there was a statistically significant time trend in the incidence of animal bites. A P-value of less than 0.05 was con- sidered statistically significant. Ethical considerations The study protocol was reviewed and approved by the institutional Ethics Committee of Tabriz University of Medical Sciences. Book 23-07.indb 508 8/23/2017 8:02:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 509 Results A total of 2 232 victims of animal bites were included in this study from 2003 to 2012. The majority of the people bitten had only 1 bite from the animal (96.1%). The mean age of the victims was 25.11 (SD 17.47) years, ranging from 6 months to 89 years. The highest percentage of animal bites occurred in the age group of 10–19 years (28.7%). The majority of cases were men (75.4%). The mean age of the males was 24.11 (SD 16.56) years and of females was 28.17 (SD 19.72) years, which was a statistically significant difference (Mann–Whitney test, P = 0.002). More than half of those bitten (57.7%) were illiterate or had received primary school education and the majority (72.3%) were from rural areas. About one-third of the people bitten (33%) were stu- dents, 15% were self-employed and 15% were housewives (Table 1). In the univariate analysis in all age groups, the number of people bitten from rural areas was significantly higher than from urban areas (P < 0.001). The difference in mean age of the people bitten #by the area of residence was statistically significant; those from rural areas were younger than victims from urban areas [24.65 (SD 17.75) versus 26.30 (SD 16.71) years] (Mann–Whit- ney test, P = 0.001). Furthermore, there was a statistically significant association between place of residence and educa- tion level and occupation (P < 0.001) (Table 1). The majority of the bites (34.9%) occurred between 12:00–18:00. Sat- urday and Sunday, the first two days of the week in the official calendar of the country, had the most reported bites—16.1% and 15.7% respectively (data not shown in tables). Dogs accounted for 92.8% of the bites, with cats 5.2% and others 2.0%. The highest percentage of animal bites (29.2%) occurred in the summer and the lowest in the autumn (19.5%). Among all the victims, 72.6% were re- ferred to the health centre on the same day of the bite and 5.2% were referred 3 or more days after the bite (Table 2). There was a statistically significant association between place of residence and the type of animal that inflicted the bite (P < 0.001). There was also Table 1 Demographic characteristics of victims of animal bites according to place of residence, Maku County, Islamic Republic of Iran, 2003-2012 (n = 2232) Characteristic Total Rural Urban P-value1 No. % No. % No. % Age group (years) < 0.001 < 10 416 18.6 324 20.1 92 14.9 10−19 640 28.7 487 30.2 153 24.8 20−29 441 19.8 270 16.7 171 27.7 30−39 262 11.7 187 11.6 75 12.1 40−49 191 8.6 140 8.7 51 8.3 ≥ 50 282 12.6 206 12.8 76 12.3 Sex < 0.001 Male 1683 75.4 1158 71.7 525 85.0 Female 549 24.6 456 28.3 93 15.0 Education < 0.001 Illiterate 578 25.9 474 29.4 104 16.9 Primary school 709 31.8 546 33.9 163 26.5 Secondary school 512 23.0 368 22.8 144 23.4 High school and higher 429 19.3 224 13.9 205 33.3 Occupation < 0.001 Student 739 33.1 571 35.4 168 27.2 Not working + child 282 12.6 217 13.5 65 10.5 Farmer/sheep keeper 210 9.4 187 11.6 23 3.7 Paid employment 249 11.2 115 7.1 134 21.7 Self-employed 338 15.2 201 12.5 137 22.2 Housewife 334 15.0 290 18.0 44 7.1 Other 78 3.5 31 1.9 47 7.6 1Chi-squared test. Some data were missing for education and occupation. Book 23-07.indb 509 8/23/2017 8:02:01 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 510 no sex difference in wound location; both in males and females, the highest proportion of injuries was on the leg(s) (data not shown in tables). Table 3 shows the frequency of ani- mal bites over time based on place of residence (urban/rural). The average incidence rate over the 10 years was 250 per 100 000 persons. The high- est incidence of animal bites was 295 per 100 000 persons in 2010 and the lowest was 208 per 100 000 in 2005. The trend of incidence of animal bites fluctuated with time; it increased from 2005 to 2008 and decreased from 2011 to 2013. Overall, a significant increasing linear trend of animal bites was observed (chi-squared test for trend 7.21, P = 0.007) (Figure 1). Discussion In the present study, the majority of the people bitten were men, which agrees with the results of some other studies conducted in the Islamic Re- public of Iran: in Kerman 73.48% of people bitten were men (13), in Tabriz 84.68% (15), in Ardabil 75% (16), in Khuzestan 62% (17), in the East of the Islamic Republic of Iran 78.3% (18), in Tehran 79.16% (19), in Illam prov- ince 68.3% (10), in the Shush County 77.6% (20), and in Islamabad-Gharb County 72.5% (21). The higher rate of animal bites in men may be due to their job and outdoor activities. In our study, animal bites were more common in rural areas and among individuals with lower educa- tion levels, and in students, housewives and self-employed people. This is simi- lar to findings of other studies in the Islamic Republic of Iran (12,13,17,22). The majority of animal bites in our study were among people in the age group of 10–19 years in both genders, which is in line with many studies that have been conducted in the Islamic Republic of Iran (16,20,21). This might a statistically significant difference in delay time according to place of resi- dence (P = 0.02). In addition, 93.1% of the animal bites were caused by a domestic animal and 94% of the animals were alive 10 days after the bite. Only 13.2% of the victims received serum therapy and 99.4% received tetanus vaccine on the first visit. Few of the victims reported a previous history of animal bites (3%). The rabies vaccination was given once for 4.7% of the victims, twice for 14.9% and three times for 77.2%. Superficial lesions were seen in 86.4% of the injuries. In 83.6% of the bites, the bite was on clothes. The depth and extent of the wound was low in 85.7% of the injuries. Most of the injuries were on the lower extrem- ity (68%), followed by shoulder and upper limbs (Table 1). There was a statistically significant association be- tween wound location and the type of animal inflicting the bite and also place of residence (P < 0.001). There was Table 2 Characteristics of the animal bite according to place of residence, Maku County, Islamic Republic of Iran, 2003–2012 Characteristic Total Rural Urban P-value1 No. % No. % No. % Animal type < 0.001 Dog 2072 92.8 1558 96.5 514 83.2 Cat 125 5.6 41 2.6 84 13.6 Other 35 1.6 15 0.9 20 3.2 Season 0.41 Spring 602 27.0 439 27.2 163 26.4 Summer 652 29.2 465 28.8 187 30.4 Autumn 435 19.5 305 18.9 130 21.0 Winter 543 24.3 405 25.1 138 22.3 Injury site 0.02 Head and neck 67 3.1 50 3.2 17 2.8 Pelvis, abdomen 231 10.8 185 12.0 46 7.6 Shoulder, upper limbs 387 18.1 217 14.2 170 28.2 Lower limbs 1457 68.0 1087 70.6 370 61.4 Post-exposure treatment delay < 0.001 Immediate 1616 72.6 1141 70.9 475 77.0 1 day 338 15.2 258 16.0 80 13.0 2 days 154 6.9 115 7.2 39 6.3 ≥ 3 days 118 5.2 95 5.9 23 3.7 1Chi-squared test. Some data were missing for injury site and post-exposure treatment time. Book 23-07.indb 510 8/23/2017 8:02:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 511 be because this age group spends more time in outdoor activities. Most of the bites were inflicted by dogs. This is similar to the results of some other studies such as a study from Illam province where dogs accounted for 89.2% of the incidence of animal bites (10), in Northern Iran where dog bites were reported by 84.87% of the people bitten (23), in a study from Teh- ran where dogs were responsible for 65.9% of animal bites (19), in the East of the Islamic Republic of Iran where dogs caused 80.3% of animal bites (18), and in the north-west of the country where dogs were responsible for 72.4% of animal bites (15). An explanation for this finding might be the key role played by dogs in rural life and the close- ness of human beings with dogs in such places. The vast majority of the animal bites were caused by a domestic animal (93.1%). The lower frequency of animal bites from dogs in urban areas such as Tehran (19) also lends support to this hypothesis. We found that the majority of bites were to the lower limbs. Numerous studies in the Islamic Republic of Iran have reported a high frequency of animal bite injuries to the lower limbs: 75.8% of injuries were to the leg in Kas- siri (Islamabad-Gharb, Kermanshah province) (21), 81.4% were to the feet in Kassiri (Shush, Khuzestan province) (20), 71.8% were also to feet in Sab- ouri Ghannad (Illam province) (10), 52.93% were to the lower limbs in Na- jafi (northern Islamic Republic of Iran Iran) (23), 53.8% were also to the lower limbs in Eslamifar (Tehran) (19) and 70.89% were to the legs in Majidpour Table 3 Year of animal bite by residence, Maku County, Islamic Republic of Iran, 2003−2012 Year Urban Rural Total No. % No. % No. 2003 84 38.5 134 61.5 218 2004 82 32.4 171 67.6 253 2005 74 27.6 194 72.4 268 2006 56 24.2 175 75.8 231 2007 70 26.3 196 73.7 266 2008 57 25.6 166 74.4 223 2009 33 18.4 146 81.6 179 2010 64 30.9 143 69.1 207 2011 32 17.2 154 82.8 186 2012 66 32.8 135 67.2 201 Total 618 27.7 1614 72.3 2232 100 150 200 250 300 350 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 In ci de nc e pe r 1 0 0 0 0 0 p eo pl e Year Figure 1 Trend in the incidence of animal bites, Maku County, Islamic Republic of Iran, 2003−2012 Book 23-07.indb 511 8/23/2017 8:02:01 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 512 References 1. Seimenis A. The rabies situation in the Middle East. Dev Biol (Basel). 2008;131:43–53. 2. Wunner WH, Briggs DJ. Rabies in the 21 century. PLoS Negl Trop Dis. 2010;4(3):e591. 3. World Health Organization. Animal bites. Fact sheet no. 373, February 2013 http://www.who.int/mediacentre/factsheets/ fs373/en/, accessed 20 March 2017). 4. Dendle C, Looke D. Review article: Animal bites: an update for management with a focus on infections. Emerg Med Australas. 2008;20(6):458–67. 5. Emet M, Beyhun NE, Kosan Z, Aslan S, Uzkeser M, Cakir ZG. Animal-related injuries: epidemiological and meteorological features. Ann Agric Environ Med. 2009;16(1):87–92. 6. Moini M, Peyvandi AA, Rasouli MR, Khajei A, Kakavand M, Eghbal P, et al. Pattern of animal-related injuries in Iran. Acta Med Iran. 2011;49(3):163–8. 7. Ghaffari-Fam S, Hosseini SR, Daemi A, Heydari H, Malekzade R, Ayubi E, et al. Epidemiological patterns of animal bites in the Babol County, North of Iran. J Acute Dis. 2016;5(2):126–30. 8. Khazaei S, Ayubi E, Nematollahi S, Mansouri K, Ahmadi- Pishkuhi M, Mohammadian-Hafshejani A, et al. Pattern of pediatric animal bites and post exposure prophylaxis in Isfa- han Province-Iran, 2015. Int J Ped. 2016;4(6):1977–82. 9. Ansari-Moghaddam A, Martiniuk AL, Mohammadi M, Rad M, Sargazi F, Sheykhzadeh K, et al. The pattern of injury and poisoning in South East Iran. BMC Int Health Hum Rights. 2012;12:17. 10. Ghannad MS, Roshanaei G, Alikhani MY, Alijani P, Sardari MG. Animal bites in Borujerd: an overview of animal bites in Iran. Avicenna J Clin Microbiol Infect. 2014;1(1):e19568. 11. Zeinali A, Tajik P, Rad M. [Wild life diseases]. Donyaye andisheh. 2002;4:53 [In Farsi]. 12. Charkazi A, Behnampour N, Fathi M, Esmaeili A, Shahnazi H, Heshmati H. Epidemiology of animal bite in Aq Qala city, northen of Iran. J Educ Health Promot. 2013;2:13. 13. Rezaeinasab M, Rad I, Bahonar A, Rashidi H, Fayaz A, Simani S, et al. The prevalence of rabies and animal bites during 1994 to 2003 in Kerman province, southeast of Iran. Iran J Vet Res. 2007;8(4):343–50. 14. Sheikholeslami NZ, Rezaeian M, Salem Z. Epidemiology of animal bites in Rafsanjan, southeast of Islamic Republic of Iran, 2003-05. East Mediterr Health J. 2009;15(2):455–7. (Ardabil) (16).This might be explained by the type of animal, i.e. dogs, as well as by the victim’s body posture while being bitten by a dog and also by the fact that the lower limbs are an easy place for a dog to reach, especially for small dogs. The highest proportions of the ani- mal bites were in the summer and spring seasons, and on Saturdays and Sundays, which is in line with some studies in the Islamic Republic of Iran (7,14). How- ever, a study from a southern part of the country reported a higher frequency in autumn (20). This might be due to the longer day time and working hours spent on farms among people in rural areas in these regions. Most of the people who were bit- ten in our study were referred for care immediately after the biting incident. However, over a quarter of them delayed seeking care for more than a day. There was an association between place of residence and delay in seeking care, with a greater delay among rural residents. A lack of frequent public transportation in the rural areas and a lack of knowledge about the dangers of animal bites might be the reasons for this difference. The linear time trend in the inci- dence of animal bites was statistically significant. Overall, incidence rates of animal bites increased during the study period (2003–2012). Some studies in the Islamic Republic of Iran have also reported an increase in the incidence of animal bites in the past decades (14). This might be explained by an increase in awareness of people of the need to visit a health centre after a bite or it may reflect a true increase in animal bites. However, the incidence of animal bites decreased in the last 2 years examined in our study, so further study of more recent years is needed. A limitation of our study is that the data were taken from medical records of the people who were bitten. It is prob- able that there were bite victims who did not seek care, especially those with minor injuries, and no registered data were available for them. Our finding may therefore be an underestimate of the incidence of animal bites in Maku. Conclusion Based on the results of our study, there was a delay in the treatment received by the people bitten, which indicates a need to raise awareness of the public, especially those who live in rural areas, of the health risks of animal bites and the importance of early treatment. Fur- thermore, bites by domestic dogs to the lower limbs are an important problem which should be tackled. The significant increasing linear trend of animal bites points to the need for a comprehensive health policy to prevent and control this problem. Surveillance of animal bites in different areas is recommended so as to gather evidence to implement preven- tion strategies. Acknowledgements The authors gratefully thank the person- nel of the Maku health centres for their kind cooperation and the Epidemiology and Traffic Injury Prevention Research Centre of Tabriz University of Medical Sciences for their financial support. Funding: This study was funded by the Epidemiology and Traffic Injury Prevention Research Centre of Tabriz University of Medical Sciences. Competing interests: None declared. Book 23-07.indb 512 8/23/2017 8:02:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 513 15. Vahdati SS, Mesbahi N, Anvarian M, Habibollahi P, Babapour S. Demographics of rabies exposure in north-west of Iran: 5 years experience. J Anal Res Clin Med. 2013;1(1):18–21. 16. Majidpour A, Sadeghi-Bazargani H, Habibzadeh S. Injuries due to animal bites: a descriptive study. J Clin Res Gov. 2012;1(1):22– 4. 17. Alavi SM, Alavi L. Epidemiology of animal bites and stings in Khuzestan, Iran, 1997-2006. J Infect Public Health. 2008;1(1):51– 5. 18. Bijari B, Sharifzade GR, Abbasi A, Salehi S. Epidemiological survey of animal bites in east of Iran. Arch Clin Infect Dis. 2011;6(2):90–2. 19. Eslamifar A, Ramezani A, Razzaghi-Abyaneh M, Fallahian V, Mashayekhi P, Hazrati M, et al. Animal bites in Tehran, Iran. Arch Iran Med. 2008;11(2):200–2. 20. Kassiri H, Kassiri A, Lotfi M, Shahkarami B, Hosseini S-S. Ani- mal bite incidence in the County of Shush, Iran. J Acute Dis. 2014;3(1):26–30. 21. Kassiri H, Kassiri A, Pourpolad-Fard M, Lotfi M. The prevalence of animal bite during 2004–2008 in Islamabad-Gharb County, Kermanshah Province, Western Iran. Asian Pac J Trop Dis. 2014;4:S342–6. 22. Majidpour A, Arshi S, Sadeghi H, Shamshirgaran S, Habibzadeh S. Animal bites: epidemiological considerations in Ardabil Province, 2000. ARUMS. 2003;3(4):39–43. 23. Najafi N, Ghasemian R. Animal bites and rabies in northern Iran; 2001–2005. Arch Clin Infect Dis. 2009;4(4):224–7. Book 23-07.indb 513 8/23/2017 8:02:01 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 514 1Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt (Correspondence to: Rehab H. El-Sokkary: rehab_elsokkary@yahoo.com). 2Department of Medical Microbiology and Immunology, Faculty of Medicine, Fayoum University, Fayoum, Egypt. 3Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt. Received: 15/09/16; accepted: 23/11/16 Short communication Reprocessing practices for gastrointestinal endoscopes: a multicentre study in Egyptian university hospitals Rehab H. El-Sokkary 1, Ahmed A. Wegdan 2, Ahmed A. Mosaad 1, Rasha H. Bassyouni 2 and Wael M. Awad 3 ةيصرم ةيعماج تايفشتسم في زكارلما ةد ِّدعتم ةسارد :يمضلها زاهلجا رظانم ةلجاعم ةداعإ تاسرامم ضوع لئاو ،نيويسب اشر ،دعسم دحمأ ،نادجو دحمأ ،يرّكسلا باحر زاــ هلجا رــ ظانم ةــ لجاعم ةداــ عإ ءاــ نثأ ةــ يحصلا ةــ ياعرلا لاــ مج في نــ لماعلا تاــ سرامم مــ ييقت في ةــ ساردلا هذــ ه نــ م فدــ لها لــ ّثتم :ةــ صلالخا رـظانلما تادـحو في ةـيجولويبوركيلما تاراـبتخلااو تابرـتخلما في لاـثتملاا نـم قـ ُّقحتلاو ،ةـلجاعلما ةداـعإ نأـشب مـتهامولعم مـييقتو ،يـمضلها رــ ظانم ىــ ع يوــ تتح رــ ظانملل تادــ حو 10 نــ م نــ بوانلما ضــ يرمتلا ةــ ئيه دارــ فأ عــ يجم جردُأو .موــ يفلاو قــ يزاقزلا يــ تعماج تايفــ شتسم في في .)19 يراـ يعم فارـ حناب( 7.5 ةـ فرعلما ةـ جرد طـ سوتم ءاـ جو .ةـ يعجرم ةـ مئاقو نايبتـ سا ةطـ ساوب تاـ سرمالماو تاـ مولعلما تـ مّيُقو .ةـ نرم فـشتكت لم ،اـهفيظنت دـعب رـظانلما مادختـسا ةداـعإ لـبقو .رـهطتلا دـعب راـظنلما زـيهجتل % 74و مـيقعتلل ةبـسنلاب % 90 لاـثتملاا لجـس نـح رـثكلأا نـئاكلا ةـّيراجنّزلا ةـفئازلا تـناكو .نـيراظنم في تارمعتـسلم ةـّنوكم تادـحو 8 تفـشُتكا نـح في ،رـظانم ةـسخم في ةـيح تاـنئاك يأ مايـس لا ،مراـص لكـشب رـظانلما ةـلجاعم ةداـعإب ةـصالخا رـياعلما قـيبطتل ةـسام ةـجاح دوـجو لىإ ةـساردلا تـصلخ .هـلزع مـت يذـلا ًاعويـش .مادختـسلاا لـبقو نـيزختلا دـعب ىوتـسلما لياـع رـهطتلا رارـكت بـيجو .بـيسرتلا راـبتخا فيو فـيظنتلا لـبق اـم ةـلحرم في ABSTRACT The aim of this study was to assess the practices of health care workers during gasterointestinal endoscope reprocessing, evaluate their knowledge about reprocessing, and verify their compliance with laboratory and microbiological tests in endoscopy units at Zagazig University and Fayoum University hospitals. All nursing staff on duty from 10 endoscopy units, with 16 flexible endoscopes, were included. Knowledge and practice were assessed by a questionnaire and a checklist. The mean knowledge score was 7.5 (SD 1.9), which was poor. Compliance was 90% for disinfection and 74% for endoscope processing after disinfection. Before reuse after cleaning, no organisms were detected in 5 endoscopes, while 8 colony forming units were found in 2. Pseudomonas aeruginosa was the most common organism isolated. Strict implementation of the reprocessing guidelines are needed, especially the pre-cleaning stage and leak testing. Repeating high level disinfection after storage and before use must be followed. Pratiques de traitement des endoscopes gastro-intestinaux : étude multicentrique dans des hôpitaux universitaires en Égypte RÉSUMÉ La présente étude avait pour objectif d’évaluer les pratiques des agents de soins de santé lors du traitement des endoscopes gastro-intestinaux, de mesurer leur connaissance du traitement, et de vérifier leur bonne exécution des tests de laboratoire et des tests microbiologiques dans les unités d’endoscopie des hôpitaux universitaires de Zagazig et de Fayoum. Toutes les équipes de personnels infirmiers issues de 10 unités d’endoscopie, avec 16 endoscopes souples, ont été incluses dans l’étude. Les connaissances et les pratiques ont été évaluées par un questionnaire et une liste de contrôle. Le score de connaissance moyen était de 7,5 (ET 1,9). La conformité était de 90 % pour la désinfection, et de 74 % pour le traitement des endoscopes après désinfection. Après nettoyage et avant réutilisation, aucun organisme n’a été détecté pour cinq endoscopes, et huit unités formant des colonies ont été trouvées dans deux autres endoscopes. Pseudomonas aeruginosa était l’organisme le plus couramment isolé. Une application stricte des directives de traitement est requise, notamment à l’étape du pré-nettoyage et des essais d'étanchéité. Il est important d’effectuer une désinfection de haut niveau répétée après entreposage et avant utilisation. Book 23-07.indb 514 8/23/2017 8:02:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 515 Introduction Appropriate reprocessing of endo- scopes and their accessories is essential to safeguard patients and staff. Repro- cessing flexible endoscopes involves multiple steps (cleaning, disinfection and sterilization) and adherence to the guidelines on reprocessing is essential (1). In Egypt, rules for this process have been figured out in the national guide for infection prevention and control (2), which is the standard for the country. Information about staff practices in endoscopy units regarding reprocess- ing and their adherence to guidelines is needed to support the development of effective performance improvement (3). To our knowledge there have been no previous studies that have assessed these practices. Therefore, the objec- tives of this study were to: evaluate the practices of nursing staff during gas- trointestinal endoscope reprocessing, assess their knowledge about repro- cessing, and verify their compliance by laboratory and microbiological tests. Methods A cross-sectional multicentre study was carried out at the endoscopy units of Zagazig University Hospitals and Fay- oum University Hospitals from March 2015 to September 2015. The study was approved by the institutional re- view boards of the Zagazig and Fayoum universities. All functioning endoscopes were included—16 flexible endoscopes from 10 endoscopy units. A total of 59 nursing staff in the units, who were responsible for cleaning and storage of the endoscopes, were enrolled. We excluded staff members who were on leave during the study period. No staff declined to participate and all gave their written consent. The study was conducted in 2 phases: in phase one, the knowledge and compliance of health care workers were assessed and in phase two, labora- tory and microbiological verification of compliance was determined. Knowledge of the health care workers was assessed by a 21-question questionnaire (4,5) in Arabic. It was prepared in Arabic for better under- standing and to get more reliable results. The questionnaire was pilot tested on a sample of 15 nurses to determine its acceptability and the clarity of the questions, and to confirm its face valid- ity; it was then modified accordingly. These staff were excluded from the final analysis. The questionnaire included 7 questions about personal and job- related variables (age, sex, place of work, duration of work in general, duration of work in endoscopy units, and training on endoscope reprocessing and aware- ness of reprocessing guidelines) and 13 scored questions about the reprocess- ing procedures at the facility. A correct answer was assigned a score of 1, an incorrect answer was assigned a score of 0. The total knowledge score was calculated by adding the number of correct answers. A mean score equal to and above the median was considered satisfactory knowledge, and a score below the median was considered un- satisfactory knowledge. The survey was distributed to and self-completed by all participants. All surveys were anony- mous. Evaluation of the compliance of health care workers was done using another 49-point self-completed ques- tionnaire, adapted from the national guidelines (2), which were grouped under 7 areas. All criteria were marked as: compliant, not compliant or not ap- plicable, and the percentage of compli- ance was calculated (6). Laboratory verification of cleaning processes by protein assay was done as follows: 10 mL of rinse solution were collected after cleaning of the endo- scope and before high level disinfection. Protein assay was done by the biuret method. The permissible level for or- ganic and bioburden residuals is less than 6.4 µg/mL protein as described in a previous study (7). Microbiological examination of endoscopes was done after storage and before being used again. Using aseptic technique, 10 mL of rinse solution were collected (7) from reprocessed endo- scopes and a culture was done. Colony count and identification to species level was performed (8). After bacterial culture and isolation, the bioburden level was estimated as follows: counts were reported as the number of colony forming units (cfu) per mL (9). Quantification of bacterial growth was done: no growth = 0 cfu, sparse growth = <5 cfu/mL, moder- ate growth = 5–20 cfu/mL and heavy growth = ˃ 20 cfu/mL (10). Statistical analysis was done using SPSS, version 15. Quantitative data are presented as ranges, means and standard deviations (SD). For quali- tative data, numbers and percentages are presented. The Pearson correlation coefficient (r) was used to assess the significance of association between pro- tein and bioburden levels. A P-value less than 0.05 was considered statistically significant. Results A total of 46 health care workers were present at the time of the study and were enrolled: 43 were women. Their ages ranged from 25 to 53 years with a mean of 35.3 (SD 5.6) years. Duration of work in endoscopy units ranged from 3 months to 30 years. Most of the staff (78%) were aware that there were re- processing instructions available in the unit and 44% had had training courses on endoscope reprocessing (Table 1). The knowledge and compliance of health care workers are shown in Tables 2 and 3. The mean knowledge score about all reprocessing steps was 7.5 (SD 1.9), with a maximum of 13. The median score was 8.3. The mean score for cleaning processes was 2.9 Book 23-07.indb 515 8/23/2017 8:02:01 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 516 (SD 0.75). All participants thought that after mechanical cleaning, immersible equipment should be thoroughly rinsed with water. On the other hand, only 47% of participants thought that endo- scope should be checked by inspection and a leak test. The mean score for dis- infection steps was 2.1 (SD 0.08): 98% of the participants knew that repeated entry into any chemical disinfectant and retained water on equipment can lower the concentration over time. On the other hand, 67% of participants knew that internal and external surfaces of the endoscope should be in contact with disinfectant for 20 minutes. The mean score for storage processes was 1.5 (SD 0.08). Only 6% of participants knew that control valves, distal hoods, caps, etc. should be removed prior to storage of the endoscope. Table 1 Personal and job-related variables Variable Values Sex (No.) Male 3 Female 43 Age (years) Range 25−53 Mean (SD) 35.3 (5.6) Duration of work in nursing (years) Range 10−35 Mean (SD) 17.5 (6.3) Duration of work in endoscopy units (range) 3 months−30 years Previous experience in an endoscopy unit [(No. (%)] Only one unit 2 (4.3) More than one unit 44 (95.7) Aware of available instructions about reprocessing? [(No. (%)] Yes 35 (77.8) No 10 (22.2) Had training courses on endoscope reprocessing [(No. (%)] Yes 20 (43.5) No 25 (54.3) Table 2 Knowledge of endoscope reprocessing among health care workers Reprocessing step Percentage who answered the question correctly Cleaning The cleaning brushes should be disposable/thoroughly cleaned and receive a high-level disinfection or sterilization after each use 49 All channels should be brushed and irrigated with large amounts of enzymatic presoak solution or detergent and tap water 50 After mechanical cleaning, immersible equipment should be thoroughly rinsed with water 100 The endoscope should be checked by inspection and leak test 47 All detachable parts should be removed and soaked in an enzymatic presoak solution 67 Disinfection Internal and external surfaces and channels must be in contact with the disinfecting agent for at least 20 minutes 67 Repeated dipping into any chemical disinfectant and retained water on equipment can lower the concentration over time 98 All containers with glutaraldehyde solutions should be sealed or covered 85 Treatment after disinfection Rinsing should be done with sterile water. If sterile water is not available, then potable tap water should be used with a rinse of the internal lumens with alcohol 62 Drying with alcohol and compressed air should be done between each patient when tap water is being used to rinse the endoscope channels 67 Drying with alcohol and compressed air should be done before storage whether tap water or sterile water is used 79 Endoscopes should be stored vertically in a cabinet 72 Control valves, distal hoods, caps, etc. should be removed before storage of the endoscope 6 Book 23-07.indb 516 8/23/2017 8:02:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 517 The results of the laboratory and microbiological verification of com- pliance are shown in Table 4. Protein levels ranged from 4.6 to 32.8 µg/mL with a mean of 14.8 (SD 8.9) µg/mL. The highest level of protein (32.8 µg/ mL) was detected from endoscope numbers 5 and 15. Three endoscopes showed protein levels below the permis- sible level (i.e.< 6.4 µg/mL), indicating the cleaning process was effective. The number of cfu ranged from 0 to 8, with a mean of 2 (SD 5.8). Endoscope num- bers 5 and 15 had the highest number of cfu (8 each), while no growth was detected from endoscope numbers 4, 7, 8, 13 and 14. There was a statistically significant positive correlation between protein and bioburden levels (r = 0.589, P = 0.03). While, endoscope numbers 4 and 14 showed no bacterial growth, the protein level was higher than the per- missible level (< 6.4 µg/mL). Only en- doscopes numbers 7, 8 and 13 showed no bacterial growth and permissible protein levels. Pseudomonas aeruginosa was the most common isolated organism (30.8%), followed by micrococcus (15.4%), Serratia spp. (7.7%), Staphylococcus saprophyticus (7.7%) and diphtheroids (7.7%). No growth was detected in 30.7% of samples. Discussion In the current study, more than three quarters of the staff were familiar with existing reprocessing policies. A study in the United States of America (USA) re- ported that only 35% of bronchoscopists and 45% of medical directors in bron- choscope units were familiar with any national reprocessing rules (4). Only about half of our study participants had received training on endoscope repro- cessing. Continuous medical education is important for all staff members and should be considered in the planning of training programmes in the units stud- ied. Guidelines might be valuable for detailing proper practices, however they are not necessarily effective in changing behaviour (11). The participants in the current study had a poor mean knowledge score of 7.5 (SD 1.9). Similar results have been re- ported previously (4). A similar knowl- edge score about cleaning procedures was recorded in a study in the USA (3), except for the leak test step; 90% of staff in their study (3) versus 47% in our study knew the endoscope should be checked by inspection and leak test. Compliance with national guidelines was achieved for disinfection steps with partial com- pliance for treatment of the endoscope after disinfection. Another study found that most practitioners complied with the established disinfection guidelines (12), while Seoane-Vazquez and col- leagues reported that the primary cause of endoscopy-related infections was poor reprocessing practices (13). Despite the importance of the clean- ing process, minimal compliance was reported for this area in the current study. Inadequate cleaning can leave excess biomaterial on the surface of an endoscope, even after multiple repro- cessing. Appropriate cleaning reduces the amount of organic debris (14) that can interfere with high level disinfection. Missing or rushing through key steps is a common problem (15). In the present study, nearly half of the study partici- pants knew that leak testing is a required step; this is much lower than a previous study (77%) (3). The failure to per- form a proper leak test could also have serious implications. This test detects any physical breaks to the exterior or interior of the endoscope. These physi- cal breaks compromise the integrity of the endoscope and will damage the internal structures (i.e. electrical wires, light bundle, manipulation cables) of the endoscope, which are not designed to be in contact with fluids. These breaks may also create a reservoir for micro- organisms to grow. Continuing to use a damaged endoscope could result in further damage and be costly (3). The rates of compliance with guide- lines for reprocessing were 27% and 50% in 2 separate studies (16). The present Table 3 Compliance with specific policies, procedures and practices Reprocessing step Rate1 (%) Cleaning of endoscope 67 Disinfection of endoscope 90 Treatment of the endoscope after disinfection 74 Processing endoscopic accessory equipment 44 Hazardous materials’ management 0 Endoscopy personnel occupational health issues2 61 Environmental factors (storage) and design issues for the endoscopy unit 58 1Minimal compliance = ≤ 75%, partial compliance = 76–84% and satisfactory compliance = ≥ 85% (7). 2Such as thorough hand hygiene before and after each procedure, use of personal protective equipment as needed, accessible personal protective equipment, vaccination against hepatitis B. Book 23-07.indb 517 8/23/2017 8:02:01 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 518 study results showed that there was minimal compliance for processing of endoscopic accessory equipment. This agrees with the results of another study which found that a third of respondents reported that they reused disposable accessories (12). Reuse of disposable accessories should be avoided so as to limit the likelihood of cross-infection between patients and staff (17). A lack of financial resources may lead to reuse so it is essential that an adequate budget is allocated to prevent reuse. In the current study, there was minimal compliance with endoscopy personnel occupational health issues, including thorough hand hygiene be- fore and after each procedure, use of personal protective equipment, acces- sible personal protective equipment and vaccination against hepatitis B. A study in Korea found that although most respondents reported having ex- perienced occupational hazards, the majority (78%) did not wear protective eyewear (17). Unfortunately, no responses were recorded for dealing with hazardous materials. This suggests that occupa- tional safety programmes are not properly implemented in the hospitals studied. Visual inspection could be used to check for adequate cleaning. However, compliance with cleaning of flexible endoscope channels cannot be con- firmed using visual inspection (7). Therefore, in our study, verification of efficient cleaning was done by estimat- ing protein levels on the endoscope. A considerable amount of residual protein was detected, which exceeded a pro- posed standard for permissible levels (6.4 µg/mL) (7). A much lower result was obtained in a previous study, 0.1 and 0.22 µg/mL after total cleaning (7). This could be explained by poor adher- ence of the health care workers to the cleaning steps. This is supported by the low compliance rate for this step (67%). According to the national guide- lines, repeating high level disinfection after storage and before use is highly recommended, yet it is often not done. Checking for storage efficacy by mi- crobiological testing of the endoscope fluid wash was performed to confirm the importance of conducting this step. Our study showed that, on 4 out of 16 occasions, the reprocessing steps and storage conditions were sufficient to avoid bacterial contamination. In contrast, on 2 out of 16 occasions, the process was inadequate with moderate growth (8 cfu/mL) and in 10 out of 16 occasions there was sparse growth. Given the sparse growth and the nature of the organisms, most probably the cleaning protocols were not fol- lowed and/or monitored on a regular basis (18). Our laboratory and micro- biological findings confirmed the results Table 4 Results of the microbiological and protein assays1 Endoscope no. Bioburden estimation (cfu) Protein level (µg/mL)2 P-value r 1 5 16.3 0.03 0.58 2 3 15.6 3 2 28.6 4 0 10 5 8 32.8 6 4 12.3 7 0 4.9 8 0 5.1 9 5 22.2 10 2 8.1 11 3 12 12 1 15.6 13 0 4.6 14 0 9.1 15 8 32.8 16 3 28.6 Total level Range 0−8 4.6−32.8 Mean (SD) 2 (5.8) 14.8 (8.9) 1Results are the average of 3 repeated experiments. 2The proposed standard for permissible level is 6.4 µg/mL. P < 0.05 was considered as statistically significant. r = Pearson correlation coefficient; cfu = colony forming units. Book 23-07.indb 518 8/23/2017 8:02:02 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما عباسلا ددعلا 519 References 1. Kovaleva J, Meessen NE, Peters FT, Been MH, Arends JP, Borg- ers RP, et al. Is bacteriologic surveillance in endoscope repro- cessing stringent enough? Endoscopy. 2009;41:913–6. 2. [Egyptian National guide for infection control. Part 2: Infec- tion control in specialized units: Endoscopy unit. 3rd ed]. Arab Republic of Egypt: Ministry of Health and Population; 2016:40–50 [In Arabic]. 3. Ofstead CL, Wetzler HP, Snyder AK, Horton RA. Endoscope reprocessing methods: a prospective study on the impact of human factors and automation. Gastroenterol Nurs. 2010;33(4):304–11. 4. Srinivasan A, Wolfenden L, Song X, Perl T, Haponik F. Pre- vention and control: bronchoscope reprocessing and infec- tion: bronchoscopy-specific guidelines are needed. Chest. 2004;125:307–14. 5. Mortada EM, Zalat MM. Assessment of compliance to stand- ard precautions among surgeons in Zagazig University Hospi- tals, Egypt, using the Health Belief Model. J Arab Soc Med Res. 2014;9:6–14. 6. Infection Control Nurses Association. Audit tools for monitor- ing infection control guidelines within the community setting. 2005 (file:///C:/Users/Fiona/Downloads/AuditTools2005. pdf, accessed 22 March 2017). 7. Alfa M, Fatima I, Nancy Olson N. Validation of adenosine triphosphate to audit manual cleaning of flexible endoscope channels. Am J Infect Control. 2013;41:245–8. 8. Forbes BA, Sahm DF, Weissfeld AS. Bailey and Scott’s diagnos- tic microbiology. 12th ed. St. Louis: Mosby; 2007. 9. Gillespie EE, Kotsanas D, Stuart RL. Microbiological monitor- ing of endoscopes: 5-year review. J Gastroenterol Hepatol. 2008;23:1069–74. 10. Riley R, Beanland C, Bos H. Establishing the shelf life of flexible colonoscopes. Gastroenterol Nurs. 2002;25(3):114–20. 11. Measuring hand hygiene adherence: overcoming the chal- lenges [Monograph]: Oakbrook Terrace (IL): The Joint Commission;2009 (https://www.jointcommission.org/as- sets/1/18/hh_monograph.pdf, accessed 22 March 2017) 12. Park S, Jang JY, Koo JS, Park JB, Lim YJ, Hong SJ, et al. A review of current disinfectants for gastrointestinal endoscopic repro- cessing. Clin Endosc. 2013;46:337–41. 13. Seoane-Vazquez E, Rodriguez-Monguio R, Visaria J, Carlson A. Exogenous endoscopy-related infections, pseudoinfections, and toxic reactions: Clinical and economic burden. Curr Med Res Opin. 2006;22(10):2007–21. 14. Burdick JS, Hambrick D. Endoscope reprocessing and repair costs. Gastrointest Endosc Clin N Am. 2004;14:717–24. 15. Rutala WA, Weber DJ. How to assess risk of disease transmis- sion to patients when there is a failure to follow recommended disinfection and sterilization guidelines. Infect Control Hosp Epidemiol. 2007;28:146–55. 16. Seol SY, Moon JS, Kae SH. Result report of endoscope repro- cessing survey: 2002 and 2004. Korean J Gastrointest Endosc. 2005;30 S1:109S–18S. 17. Cho Y. Current Status of Endoscope Reprocessing in Korea. Clin Endosc. 2015;48:1–3. 18. Riley R, Beanland C, Bos H: Establishing the Shelf Life of Flex- ible Colonoscopes. Gastroent nursing. 2001; 25(3): 114-119. 19. Hamed MMA, Shamseya MM. Dafa Alah IDAN, El Sawaf G. Estimation of average bioburden values on flexible gastroin- testinal endoscopes after clinical use and cleaning: Assess- ment of the efficiency of cleaning processes. Alex J Med. 2015;51:95–103. about knowledge and compliance from the questionnaire, which showed de- ficiencies in the cleaning process. On the other hand, the moderate bacterial growth found and the organisms isolat- ed indicate breaches in the reprocessing steps and/or storage conditions in some cases. This is an alarming sign which needs close monitoring to ensure that the reprocessing guidelines are imple- mented and closely adhered to. In the current study, detection of Pseudomonas spp. (especially P. aeruginosa) and other non-fermenting rods indicates insuf- ficient final rinsing and incomplete dry- ing of the endoscope or contaminated flushing equipment for the air/water- channel (19). Conclusion Strict regulations are still needed for the endoscope cleaning process, especially the pre-cleaning stage and leak test- ing. Repeating high level disinfection after storage and before use should be strictly followed. An occupational safety programme is needed for staff working in endoscope units. Efforts are needed to overcome knowledge barriers and financial constraints so as to ensure proper reprocessing of endoscopes and avoid adverse health effects on patients and staff. Funding: None. Competing interests: None declared. Book 23-07.indb 519 8/23/2017 8:02:02 AM EMHJ • Vol. 23 No. 7 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 520 WHO events addressing public health priorities The battle to eliminate the scourge of malaria in the Eastern Mediterranean Region (EMR) continues unabated. To date there have been notable successes in this fight, with 14 countries so far having succeeded in eliminating malaria (1). Their main priority now is to prevent re-establishment of local malaria transmission in receptive and vulnerable areas. How- ever, local malaria outbreaks have been reported recently from some malaria-free countries in the Region (such as Egypt and Oman), as well as countries in other regions (such as Greece) from 2010 to 2014 (2). Such examples highlight the need for vigilance, continuous assessment of the eco-epidemiological situation, and readiness for prompt and appropriate interventions. Thus, a workshop was requested by these malaria-free countries in order to update, harmonize strategies and to plan for more efficient and coordinated participation of malaria- free countries in the global efforts for malaria elimination. The World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO), in collaboration with the Government of Morocco, conducted a regional workshop on updating national strategic plans for the prevention of re-establishment of local malaria transmission in malaria- free countries from 18–20 October 2016, in Casablanca, Morocco (3). The objectives of the workshop were to: • review the progress and challenges in sustaining the malaria- free status in EMR countries and agree on key priority actions; • develop updated national strategic plans for prevention of re-establishment of local malaria transmission in all malaria- free countries of the Region. In 2015, all countries globally committed to the targets of the Sustainable Development Goals (SDGs) including target 3.3 for ending the epidemic of malaria (4). Countries also adopted the WHO Global technical strategy for malaria 2016–2030 with the final goal of a malaria-free world (5). The global technical strategy provides a guide to Member States in the fight against malaria, with the aim of eliminating malaria from endemic countries and preventing re-establishment of local transmission in malaria-free areas. Situation in malaria-free countries in WHO Eastern Mediterranean Region The situation in malaria-free EMR countries was discussed during the workshop. It was noted that in North African countries, imported malarial cases are mainly from sub- Saharan Africa, where the majority of cases are due to Plas- modium falciparum. However, the number of imported cases is increasing, mainly due to recent immigration trends to European countries through North Africa (1,2). In Morocco, cases of imported P. ovale have increased in recent years. Delay in seeking care by patients and late diagnosis by health staff have resulted in some deaths due to malaria in Egypt, Libya and Morocco in the past 3 years (1,2). Malaria cases in Gulf Cooperation Council (GCC) countries were mainly imported from India and Pakistan; the majority of cases due to P. vivax (2). Oman reported only four introduced cases in 2015, while the last year with transmission of indigenous malaria was 2010. During the past 3 years, the number of imported cases in GCC countries has started to decrease due to changes in immigration policies and/or changes of burden in countries of origin (1,2). Iraq reported only two imported P. vivax cases in 2014; one P. falciparum and one P. vivax in 2015. In Jordan, the majority of cases were from sub-Saharan Africa and mainly due to P. falciparum (70%). More than 90% of malaria cases in Lebanon were due to P. falciparum, mainly from African countries. In 2015, due to problems in confirmation and reporting from the private sector, 13 cases were not classified by species. In 2015, the Syrian Arab Republic reported no local cases and all 12 reported imported cases were due to P. falciparum. Four deaths were reported in 2014, and zero deaths were reported in 2015 (1,2). Discussion Participants were provided with new and updated information on the different aspects of malaria control and elimination, Prevention of re-establishment of local malaria transmission in malaria-free countries1 1 This report is extracted from the Summary report on the Regional workshop on updating national strategic plans for the prevention of re-establishment of local malaria transmission in malaria-free countries, Casablanca, Morocco, 20–18 October 2016 (http:// applications.emro.who.int/docs/IC_Meet_Rep_2017_EN_19349.pdf?ua=1, accessed 13 June 2017). Book 23-07.indb 520 8/23/2017 8:02:02 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما عباسلا ددعلا 521 including: the WHO “Malaria microscopy quality assurance manual” (2016) (6) and availability of malaria microscopy standard operating procedures (SOPs); WHO criteria for procurement of quality rapid diagnostic tests;; raising aware- ness about malaria among travellers and health staff; provid- ing quality antimalarial medicine for both uncomplicated and severe malaria; use of primaquine for radical treatment of P. vivax and as gametocidal medicine for P. falciparum cases; artemisinin resistance; status of malaria vaccine; develop- ment of a new Global Vector Control Response; and the importance of integrated vector management strategy, noting a new trend of vector-borne diseases at global and regional levels (1–3). Participants were also informed that WHO has estab- lished a Strategic Advisory Group on malaria eradication to prepare an analysis of future malaria trends and advise WHO on the feasibility, expected cost and potential strategies for malaria eradication over the coming years (7). Recommendations To Member States 1. Reaffirm previous commitments to prevent re-establish- ment of indigenous malaria transmission; 2. Develop/update existing national strategies/plans to pre- vent re-establishment of indigenous malaria transmission; 3. Maintain a core expert group at national level for develop- ment of malaria policies and strategies, case management, surveillance and integrated vector management; 4. In collaboration with WHO/EMRO, establish sub-regional networks for malaria-free countries (GCC countries, North African countries (Morocco, Libya, Egypt, Tunisia), and Iraq, Jordan, Lebanon, Palestine and the Syrian Arab Republic) to exchange relevant information for improving intercountry collaboration. To World Health Organization 1. Support malaria-free countries both inside and outside the Region, in their efforts to develop/update national strate- gies/plans for prevention of re-establishment of indigenous malaria transmission. 2. Support countries in strengthening their capacities in surveil- lance, vector control and malaria case management. 3. Assist in establishing an effective and sustainable mechanism for procurement and supply of antimalarial drugs for countries in need. References 1. World Health Organization. Eliminating malaria. Geneva: World Health Organization; 2016 (http://www.who.int/ma- laria/publications/atoz/eliminating-malaria.pdf, accessed 13 June 2017). 2. World Health Organization. World malaria report 2015. Ge- neva: World Health Organization; 2015 (http://www.who.int/ malaria/publications/world-malaria-report-2015/wmr2015- profiles.pdf, accessed 13 June 2017). 3. WHO Regional Office for the Eastern Mediterranean. Re- gional workshop on updating national strategic plans for the prevention of re-establishment of local malaria transmission in malaria-free countries, Casablanca, Morocco, 18–20 Octo- ber 2015 (http://applications.emro.who.int/docs/IC_Meet_ Rep_2017_EN_19349.pdf?ua=1, accessed 13 June 2017). 4. United Nations. Sustainable development goal 3. New York: United Nations; 2015 (https://sustainabledevelopment. un.org/sdg3, accessed 13 June 2017). 5. World Health Organization. Global technical strategy for ma- laria 2016–2030. Geneva: World Health Organization; 2016 (http://www.who.int/malaria/areas/global_technical_strat- egy/en/, accessed 13 June 2017). 6. World Health Organization. Malaria microscopy qual- ity assurance manual – ver. 2. Geneva: World Health Or- ganization; 2016 (http://www.who.int/malaria/publications/ atoz/9789241549394/en/, accessed 13 June 2017). 7. World Health Organization. Strategic advisory group on malaria eradication. Geneva: World Health Organization; 2016 (http://www.who.int/malaria/mpac/mpac-mar2016- strategic-advisory-group-presentation.pdf?ua=1, accessed 13 June 2016). Book 23-07.indb 521 8/23/2017 8:02:02 AM EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). © World Health Organization (WHO) 2017. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Disclaimer. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. If authors are staff members of the World Health Organization, the authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions, policy or views of the World Health Organization. ISSN 1020-3397 تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا .هجراخو ميلقلإا فى ةحصلاب ينمتهلما طسوتلما قشرل ةيحصلا ةلجلما Correspondence Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. 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Cover 23-07.indd 8-10 8/22/2017 12:16:09 PM Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 23 / No. 7 July/Juillet 7 ددع / نوشرعلاو ثلاثلا دلجلما زوتم/ويلوي2017 Contents V o lu m e 2 3 N u m b er 7 Ju ly 2 0 1 7 The Eastern Mediterranean Region presents the highest prevalence of hepatitis C in the world, while gaps in hepatitis B birth-dose vaccination remain higher than the global average. “Eliminate Hepatitis” is the theme of World Hepatitis Day 2017, and reflects the priority the World Health Organization has given to eliminating hepatitis B and C in the Region and globally. Editorial Eliminating hepatitis from the Eastern Mediterranean Region ...............................................................................459 Research articles Patients' attitudes and perceptions regarding research and their rights: a pilot survey study from the Middle East ................................................................................................................................................. 461 Urbanization and noncommunicable disease (NCD) risk factors: WHO STEPwise Iranian NCD risk factors surveillance in 2011 ................................................................................................................................................................................. 469 Implementation of a peer-mediated health education model in the United Arab Emirates: addressing risky behaviours among expatriate adolescents .................................................................................. 480 Prevalence of attention deficit hyperactivity disorder among school-aged children in Jordan .......................... 486 Prevalence and preventability of sentinel events in Saudi Arabia: analysis of reports from 2012 to 2015 ........... 492 Health-related quality of life of patients with asthma: a cross-sectional study in Semnan, Islamic Republic of Iran ............................................................................................................................................ 500 Epidemiological characteristics and trends in the incidence of animal bites in Maku County, Islamic Republic of Iran, 2003−2012 ....................................................................................................................... 507 Short communication Reprocessing practices for gastrointestinal endoscopes: a multicentre study in Egyptian university hospitals .................................................................................................................................................... 514 WHO events addressing public health priorities Prevention of re-establishment of local malaria transmission in malaria-free countries ...................................... 520 Cover 23-07.indd 5-7 8/22/2017 12:16:09 PM