Eastern Mediterranean Health Journal [2022; Vol.28, Issue 10]

La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Volume 28 No. 10 October/Octobre 10 ددع / نوشرعلاو نماثلا دلجلما لولأا نيرشت/ربوتكأ 2022 The 69th Session of the WHO Regional Committee for the Eastern Mediterranean was held from 10 to 13 October 22, with the theme “Together for a healthier and sustainable tomorrow”. Representatives of the 22 Member States and territories agreed that the most cost- effective protection is to invest in strong, integrated, and people-centered health systems that reach everyone everywhere, at home, on the streets, in the communities, and at schools and workplaces. The Session was preceded by a Walk the Talk activity on 10 October, attended by the WHO Director-General, the WHO/EMRO Regional Director and some representatives of Member States. 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 public health and health services; and for the exchange of ideas, concepts, 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 Collaborating Centres and individuals within and outside the Region. طسوتلما قشرل ةيحصلا ةلجلما ةماعلا ةحصلا في ةديدلجا تاردابلماو تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخاو ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا 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 de la santé publique et des services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa- tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes concernés au sein et hors de la Région. 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 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 طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا برغلما . صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةيروسلا ةيبرعلا ةيروهملجا نميلا . ةيدوعسلا ةيبرعلا ةكلملما 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 . 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EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ 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). Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. EMHJ articles are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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ISSN 1020-3397 Cover image Credit: ©WHO Cover 28-10.indd 4,6 31/10/2022 9:04 AM Vol. 28 . 10 – 2022 La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Editorial Reaching the Sustainable Development Goals in the post-COVID-19 era – the 69th Session of the WHO Regional Committee for the Eastern Mediterranean Region Ahmed Al-Mandhari ..................................................................................................................................................................................................................705 Research articles Mental health impact of the first wave of COVID-19 pandemic on healthcare workers in 12 Arab countries Maher Titi, Hayfaa Wahabi, Hala Elmorshedy, Zeinab Shata, Yasser Amer, Hossam Elamir, Samia Esmaeil, Amr Jamal, Amel Fayed and Collaborative Group ............................................................................................................................................................707 Effects of the COVID-19 pandemic on healthcare delivery to an immigrant population in the Islamic Republic of Iran Keihan Golshani and Hamed Akhlaghi ............................................................................................................................................................................... 719 Presentation and management of female breast cancer in Egypt Yousri Rostom, Salah-Eldin Abdelmoneim, Marwa Shaker and Nayera Mahmoud ...........................................................................................725 Attitudes and practices of postnatal mothers and their accompanying relatives to breastfeeding in public at a university hospital in Turkey İlkay Güngör Satılmış, Büşra Yılmaz and Zehra Acar .................................................................................................................................................... 733 Assessment of gender gap in surgical specialties among Lebanese medical personnel: the need for involvement of women in surgery Said El Hage, Elias Wakim, Georgio Sayde, Dany Akiki and Pascale Salameh .......................................................................................................743 Assessing the Impact of Small-Research Grants Supported by WHO in the Eastern Mediterranean Region 2010–2018 Bahareh Yazdizadeh, Ahmed Mandil, Sima Nikooee and Arash Rashidian .............................................................................................................751 Spatial distribution and temporal trend of drug-related death in the Islamic Republic of Iran during 2014–2017 Abbas Alipour, Mehran Zarghami, Sajjad Rahimi Pordanjani, Ardeshir Khosravi, Mehdi Saberi and Masoudeh Babakhanian ...........................................................................................................................................................................................................758 15-year evaluation of changes in the HBsAg positivity rate in pregnant women in Turkey: the prominent effect of national vaccination Selma Tosun, Ayşegül Erdoğan, Ayşe Torun, Selma Sever, Sibel Altuntas, İlknur Yildiz, Hüseyin Kutlu, Mehmet Ceylan, Pembe Yesilbag, Bayhan Bektore, Nefise Oztoprak, Buket Gungor, Sezen Koparan, Gülnur Kul, Ali Olut, Bülent Altuntaş and Multicenter Study Group ......................................................................................................................768 Short research communication COVID-19 excess deaths in Eastern European countries associated with weaker regulation implementation and lower vaccination coverage Alban Ylli, Genc Burazeri, Yan Yan Wu and Tetine Sentell ...........................................................................................................................................776 WHO event addressing public health priorities Webinar on improving access to diabetes medicine and care in the Eastern Mediterranean Region .................................781 Ahmed Al-Mandhari Editor-in-Chief Arash Rashidian Executive Editor Ahmed Mandil Deputy Executive Editor James Ayodele Managing Editor Editorial Board Mahmoud Fahmy Fathalla Akbar Fotouhi Rita Giacaman Rana Hajjeh Ahmed Mandil Ziad Memish Arash Rashidian Abla Mehio Sibai Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Zulfiqar Bhutta Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editorial assistants Nadia Abu-Saleh, Suhaib Al Asbahi (graphics), Diana Tawadros (graphics) Editorial support Guy Penet (French editor) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Technical editors) Abbas Rahimiforoushani, Manar El Sheikh Abdelrahman (Statistics editors) Administration Iman Fawzy, Marwa Madi Web publishing Nahed El Shazly, Ihab Fouad, Hazem Sakr Library and printing support Gehane Al Garraya, Mariam Zaki, Fouad Abdelghaffar Ahmed Magdy, Amin El Sayed Cover and internal layout designed by Diana Tawadros and Suhaib Al Asbahi Printed by WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt 705 Editorial EMHJ – Vol. 28 No. 10 – 2022 Reaching the Sustainable Development Goals in the post-COVID-19 era – the 69th Session of the WHO Regional Committee for the Eastern Mediterranean Region Ahmed Al-Mandhari1 1Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: Ahmed Al-Mandhari: almandharia@who.int). Citation: Al-Mandhari A. Reaching the Sustainable Development Goals in the post-COVID-19 era – the 69th Session of the WHO Regional Committee for the Eastern Mediterranean Region. East Mediterr Health J. 2022;28(10):705–706. https://doi.org/10.26719/2022.28.10.705 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). After nearly 3 years of increasingly successful response to the COVID-19 pandemic, policymakers and other stakeholders need to broaden their focus to deal with other public health challenges too. That was the message of the 69th Session of the WHO Regional Committee for the Eastern Mediterranean Region, which took place at WHO Regional Office for the Eastern Mediterranean (WHO/EMRO) in Cairo, Egypt, from 10 to 13 October 2022. The Regional Committee is the WHO’s main governing body in the Eastern Mediterranean Region (EMR) (1). Its 2022 annual session brought together ministers of health, other representatives of Member States, WHO experts, partner organizations, civil society groups, and other stakeholders to discuss a wide range of health policy issues, review achievements and challenges, and chart a course for the region. For the first time in 3 years, Member State delegations were able to meet in person, with many other participants joining virtually. The session was convened under the theme “Reaching the Sustainable Development Goals in the post-COVID-19 age: accelerating universal health coverage and health security – Health for All by All”(2). Participants focused on the opportunity to build on the momentum and lessons learned from the pandemic response. Foremost among these lessons is the need to build stronger health systems that are better able to respond to emergencies (3): the huge economic and social costs of the pandemic have highlighted the value of investing in health. The Regional Committee endorsed a regional agenda for building resilient health systems, which will guide countries in systematically addressing gaps and weaknesses exposed by COVID-19 through action in seven priority areas: (i) strengthening health emergency and disaster risk management; (ii) optimizing ministries of health and building public health institutions; (iii) establishing primary healthcare-oriented models of care; (iv) enhancing health workforce; (v) promoting equity and enhancing financial protection; (vi) improving access to medicines, vaccines and health products; and (vii) fostering an integrated approach to policy, planning and investment (4). The pandemic also demonstrated the potential of digital technologies for improving access to health care. Member States are now stepping up efforts to harness that potential for longer-term improvements in the accessibility, quality, efficiency, and cost-effectiveness of their health systems. To support such efforts, the Regional Committee endorsed a new regional strategy and action plan for fostering digital health, which has 4 objectives: (i) strengthening digital health governance, norms and standards at regional, national and subnational levels; (ii) advocating for people-centred digital health systems and networks; (iii) advancing the development, implementation and evaluation of national digital health strategies; and (iv) promoting regional and national stakeholder collaboration towards advancing digital transformation, knowledge translation and innovation (5). Another important area for development in the coming years is health and wellbeing promotion. The Seventy-fifth World Health Assembly called for the development of a framework on achieving wellbeing, including an implementation and monitoring plan (6); and the Regional Committee requested WHO to propose a regional roadmap to guide Member States in implementing the wellbeing agenda in the region (7), based on a detailed technical paper prepared for the session (8). Coverage of highly cost-effective HIV, tuberculosis, malaria, and immunization interventions has either stagnated in recent years or been severely affected by the COVID-19 pandemic. To address this, the Regional Committee endorsed a strategic framework and framework for action to coordinate and integrate support from 2 of the most important global health initiatives: Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (9). Member States were requested to accelerate the prevention, control and elimination of communicable diseases through integration and optimization of the support from Gavi and the Global Fund by implementing strategic directions in six areas: governance, financing, service delivery, health workforce, access to commodities, and health information systems. 706 Editorial EMHJ – Vol. 28 No. 10 – 2022 The Regional Committee endorsed actions to reduce and mitigate future health risks. Notable among these actions are the endorsement of a new regional operational framework for One Health, setting out guiding principles, strategic objectives, actions for implementation at country level, and expected deliverables (10). They requested Member States to adapt the framework to their national contexts and implement it with WHO support, prioritizing interventions on zoonotic diseases of public health concern, antimicrobial resistance, and food safety, and requested WHO to establish a regional Quadripartite One Health Coordination Mechanism (11,12). The Regional Committee received updates on important global and regional issues, including, among others, proposals from the WHO Director-General for strengthening the global architecture of health emergency preparedness, response and resilience (13). This is a critical concern in the EMR, given the huge scale of emergencies that we face. WHO’s regional team will be working hard to support Member States in engaging with several global bodies that are currently shaping reforms, in particular the Intergovernmental Negotiating Body to draft and negotiate a WHO convention, agreement or other international instrument on pandemic prevention, preparedness and response (14) and the Working Group on Amendments to the International Health Regulations (2005) (15). We look forward to progressing this and other elements of the regional health agenda in the years ahead. References 1. Al-Mandhari A. Rebuilding better and fairer in the Eastern Mediterranean Region – the 68th session of the WHO Regional Com- mittee. East Mediterr Health J. 2021;27(10):945–946. https://doi.org/10.26719/2021.27.10.945. 2. Al-Mandhari A; Hamelmann C; Rashidian A; Mabry R; Mandil A; Nasher J; et al. Addressing the health-related SDGs in the Eastern Mediterranean region: Regional Health Alliance strengthens collaboration towards better health. East Mediterr Health J. 2022;28(1):3−4. https://doi.org/10.26719/2022.28.1.3. 3. Al-Mandhari A; Kodama C; Abubakar A; Hajjeh R; Brennan R. Monkeypox outbreak and response efforts in the Eastern Mediter- ranean Region. East Mediterr Health J. 2022;28(7):465–468. https://doi.org/10.26719/2022.28.7.465 4. World Health Organization. Building resilient health systems to advance universal health coverage and ensure health security in the Eastern Mediterranean Region. Cairo: WHO Regional Office for the Eastern Mediterranean; 2022 (EM/RC69/4). https:// applications.emro.who.int/docs/Build-resilient-health-systems-UHC-EMR-eng.pdf?ua=1. 5. World Health Organization. Regional strategy for fostering digital health in the Eastern Mediterranean Region (2023–2027). Cairo: WHO Regional Office for the Eastern Mediterranean; 2022 (EM/RC69/8). https://applications.emro.who.int/docs/Digital- Health-EMR-2023-2027-eng.pdf?ua=1. 6. World Health Organization. Resolution WHA75.2. Well-being and health promotion. Geneva: World Health Organization; 28 May 2022. https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_R19-en.pdf. 7. World Health Organization. Resolution EM/RC69/R.4. Promoting health and well-being in the Eastern Mediterranean Region: moving from theory to action to achieve the health-related Sustainable Development Goals. Cairo: WHO Regional Office for the Eastern Mediterranean; 2022. https://applications.emro.who.int/docs/Promoting-health-D-eng.pdf. 8. World Health Organization. Promoting health and well-being in the Eastern Mediterranean Region: moving from theory to action to achieve the health-related Sustainable Development Goals. Cairo: WHO Regional Office for the Eastern Mediterranean; 2022 (EM/RC69/6). https://applications.emro.who.int/docs/Promoting-health-well-being-EMR-eng.pdf?ua=1. 9. World Health Organization. Accelerating the prevention, control and elimination of communicable diseases through integra- tion: optimizing support from Gavi and the Global Fund. Cairo: WHO Regional Office for the Eastern Mediterranean; 2022 (EM/ RC69/5). https://applications.emro.who.int/docs/Acceler-Commun-Diseases-Gavi-GF-eng.pdf?ua=1. 10. World Health Organization. Advancing the implementation of One Health in the Eastern Mediterranean Region. Cairo: WHO Regional Office for the Eastern Mediterranean; 2022 (EM/RC69/7). https://applications.emro.who.int/docs/One-Health-EMR- eng.pdf?ua=1. 11. World Health Organization. Resolution EM/RC69/R.5. Advancing the implementation of One Health in the Eastern Mediterra- nean Region. Cairo: WHO Regional Office for the Eastern Mediterranean; 2022. https://applications.emro.who.int/docs/Advanc- ing-One-Health-D-eng.pdf. 12. Al-Mandhari A; Al-Yousfi A; Malkawi M; El-Adawy M. “Our planet, our health”: saving lives, promoting health and attaining well-being by protecting the planet – the Eastern Mediterranean perspectives. East Mediterr Health J. 2022;28(4):247−248. https://doi.org/10.26719/2022.28.4.247. 13. World Health Organization. Update on the Director-General’s proposals for strengthening the global architecture of health emergency preparedness, response and resilience. Cairo: WHO Regional Office for the Eastern Mediterranean; 2022 (EM/ RC69/14-Rev.1). https://applications.emro.who.int/docs/Upd-Dir-Gen-prop-str-glob-arch-eng.pdf?ua=1. 14. World Health Organization. Intergovernmental Negotiating Body to draft and negotiate a WHO convention, agreement or other international instrument on pandemic prevention, preparedness and response. Geneva: WHO; 2022. https://inb.who.int. 15. World Health Organization. Review Committee regarding amendments to the International Health Regulations (2005). Geneva: WHO; 2022. https://www.who.int/teams/ihr/ihr-review-committees/review-committee-regarding-amendments-to-the-interna- tional-health-regulations-(2005). 707 Research article EMHJ – Vol. 28 No. 10 – 2022 Mental health impact of the first wave of COVID-19 pandemic on healthcare workers in 12 Arab countries Maher Titi,1,2 Hayfaa Wahabi,1,3 Hala Elmorshedy,4,5 Zeinab Shata,5 Yasser Amer,1,2 Hossam Elamir,6 Samia Esmaeil,1 Amr Jamal,1,3 Amel Fayed4,5 and Collaborative Group* 1Research Chair for Evidence-Based Health Care and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia (Correspondence to: M. Titi: mahertiti1980@gmail.com). 2Corporate Quality Management Department, King Saud University Medical City, Riyadh, Saudi Arabia. 3Department of Family and Community Medicine, King Saud University Medical City and College of Medicine, Riyadh, Saudi Arabia. 4College of Medicine, Clinical Department, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia. 5High Institute of Public Health, Alexandria University, Alexandria, Egypt. 6Quality and Accreditation Directorate, Ministry of Health, Kuwait. Introduction The COVID-19 pandemic poses a threat to the physical and mental health of individuals, particularly healthcare workers (HCWs), in low- and high-income countries (1,2). Several studies have identified factors that exacerbate psychological morbidity among HCWs during infection outbreaks. The sudden increase in workload due to extraordinary infection control and quarantine measures that result in severe staff shortages are among the most relevant factors worsening HCWs’ mental health (3–5). The associated mortality and morbidity, and rapidly changing recommendations and preventive procedures also contribute to psychological morbidity (3,5). There are many changes in the social life of HCWs that contribute to psychological distress, such as fear of exposing their families to infection, avoidance of interaction with colleagues, changes in eating and drinking habits, and lack of face-to-face communication (3,5). Moreover, comprehensive media coverage of the outbreak and financial problems due to work restrictions can increase the psychological burden (3). The psychiatric morbidity related to the 2002–2003 SARS outbreak persisted for up to 2 years following the outbreak, with worrying levels of depression, anxiety, post-traumatic symptoms, and high levels of stress among HCWs. The outbreak had important consequences for quality of care, such as missing work shifts, reduced face-to-face communication with patients, and behavioural problems (e.g. increased smoking and alcohol consumption) (6). There are limited data available for the psychological impact of COVID-19 on HCWs in the Arab world. Abstract Background: The COVID-19 pandemic has had a significant impact on public health, including healthcare workers and healthcare systems, worldwide. Aims: To investigate COVID-19-related psychological impact on healthcare workers in 12 Arab countries. Methods: This was a cross-sectional, hospital-based online survey conducted between 4 May and 8 June 2020. We evaluated stress, depression, anxiety, and insomnia using the Depression Anxiety Stress Scale and Insomnia Severity Index. Results: A total of 2879 respondents from 12 Arab countries completed the survey. Anxiety, depression, stress, and insomnia were reported by 48.9%, 50.6%, 41.4% and 72.1% of respondents, respectively. Lower-middle- and lower-income countries had a significantly higher prevalence of all the psychological outcomes than high-income countries. The prevalence of mental health symptoms was higher among healthcare workers aged 30–39 years, those who worked > 44 hours per week, and those in contact with COVID-19 cases, as well as healthcare workers who were not satisfied with the preventive measures. The prevalence of mental health symptoms was lower among male healthcare workers. Conclusion: COVID-19 had a considerable impact on the mental and psychological health of healthcare workers in Arab countries. This was aggravated by the geopolitical location of some Arab countries and social norms usually observed during the month of Ramadan. Being a physician or a young healthcare worker, and long working hours were risk factors for greater psychological impact of the outbreak. Keywords: healthcare workers, COVID-19, anxiety, depression, stress, insomnia, mental health Citation: Titi M; Wahabi H; Elmorshedy H, Shata Z; Amer Y; Elamir H; et al. Mental health impact of the first wave of COVID-19 pandemic on healthcare workers in 12 Arab countries. East Mediterr Health J. 2022;28(10):707–718. https://doi.org/10.26719/emhj.22.065 Received: 19/10/21; accepted: 29/05/22 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). *Collaborative Group Members: Dr. Hazem Titi, Jordan; Dr. Ala’a Al-Tamimi, Jordan; Mr. Rami Naif, UAE; Dr. Jose Arnold Tariga, UAE; Mrs. Amal Ibrahim, Palestine; Mrs. Latifa Albinali, Bahrain; Mrs. Ferdaws Halaouet, Tunisia; Dr. Lamia Abdelgawad Ahmed Ali, Egypt; Dr. Fathia Ibrahim Elsayed, Egypt; Ms. Hala Ali Selim, Egypt; Mr. Moataz S. Genedy, Egypt 708 Research article EMHJ – Vol. 28 No. 10 – 2022 Therefore, this study aimed to establish the risk factors and measure the impact of the first wave of the COVID-19 pandemic on the mental health of HCWs in hospital environments in Arab countries. Methods Study design and setting The study protocol was approved by the Institutional Review Board of the College of Medicine, King Saud University (Approval No. E-20-4848), Riyadh, Saudi Arabia. The study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines (7). It was a cross-sectional, hospital-based online survey among HCWs to assess their mental health during the first wave of the COVID-19 pandemic, using an anonymous questionnaire in Arabic and English languages. The study targeted HCWs in hospitals in 12 Arab countries: high-income countries (HICs) represented by the Gulf Cooperation Countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates); upper-middle-income countries (UMICs) represented by Lebanon and Jordan; lower-middle-income countries (LMICs) including Egypt, Tunisia and Palestine; and low- income countries (LICs) like Sudan (8). The one-time web survey link was sent to the employees. Study data were collected and managed using REDCap (Research Electronic Data Capture) (9). To ensure consistency and privacy of the study data and avoid duplication in the analysis, a unique identifier was generated by the software and used to collect and store data pertaining to each respondent. The survey was conducted between May 4 and June 8, 2020. Supplementary Figures 1 and 2 show the number of confirmed cases/country and the case fatality during data collection (10). Sampling technique and sample size This was a cross-sectional study using a snowball convenient sampling technique. The starting points were the collaborators in each of the 12 countries that started independently a snowballing through a network of acquaintances. All HCWs who reported working in hospitals were eligible to participate. Because of the self-selected and nonprobabilistic nature of the sample, invitations and response rates could not be quantified and we did not need a list for the participants, as reported by American Association for Public Opinion Research reporting guidelines (11). The sample size was estimated using STATA-16. The proportion of HCWs with psychological comorbidities was estimated at 35% (6), study power was 99% (β = 0.01, α = 0.05 and δ = 0.05). The estimated minimal sample size was 2000, and we increased the sample size to 2897 to allow for subgroup analyses and to compensate for incomplete data. Variables and data measurement Depression, anxiety and stress We measured depression, anxiety and stress using the Arabic and English short version of the Depression Anxiety Stress Scale (DASS-21), which measured the symptoms over the week preceding data collection (Supplemental Survey Questionnaire) (12). DASS-21 is a valid and reliable screening instrument both in English (13) and Arabic (14). The scale includes 21 items measured on a 4-point Likert scale ranging from 0 to 3. The scores were multiplied by 2 to calculate the final score after summing up the scores for each of the 3 components. Each subscale includes 7 items and the depression, anxiety and stress subscale scores are described in Figure 1. The cutoff scores for detecting symptoms of depression, anxiety and stress were > 9, > 7 and > 14, respectively (1,15). Insomnia We used the Arabic (16) and English (17) versions of Insomnia Severity Index (ISI) to assess insomnia over the 2 weeks preceding the survey. The instrument has robust psychometric proprieties and is a reliable tool for quantifying perceived insomnia severity (18). The ISI is a 7-item self-reported questionnaire with 5 ordinal scales: the first 3 questions are measured on a 5-point Likert scale ranging from 0 (no problem) to 4 (very severe problem). The responses of the last 4 questions range from 0 (very satisfied) to 4 (very dissatisfied). A total score range of 0–28, categorized into 4 levels, is described in Figure 1 (17). The cutoff score for detecting symptoms of insomnia was > 7 (19). Other data like sociodemographic and occupational data were included. Statistical methods We used SPSS for Windows version 21 (IBM Corp., Armonk, NY, USA) for data analysis. Descriptive analysis was used to describe demographic characteristics. The ranked data, derived from counts of each level for symptoms of depression, anxiety, stress and insomnia, were presented as numbers and percentages. The ꭓ2 test was used to determine the association between variables. We used multivariable logistic regression analysis to determine potential risk factors for symptoms of depression, anxiety, stress and insomnia. The associations between risk factors and outcomes are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs), after adjustment for confounders, including, country and sociodemographic and occupational factors. Using two-tailed tests, P < 0.05 was considered statistically significant. Although the Eastern Mediterranean Region countries share similar cultural values and beliefs, and all participants were HCWs, these countries have economic differences. Therefore, we selected Saudi Arabia as the reference country because it is the most populated HIC in the region. 709 Research article EMHJ – Vol. 28 No. 10 – 2022 Results Data were complete for 2879 HCWs from 12 Arab countries. The highest response was from Saudi Arabia (27.3%), followed by Egypt (14.2%) and Jordan (12.8%), while participants from Sudan, Oman and Lebanon had the least response. Most participants were female (61.9%), Figure 1 Anxiety, depression, stress and insomnia by contact with COVID-19 cases. Psychological domains were measured using Depression Anxiety Stress Scale, and insomnia was measured using Insomnia Severity Index. Cutoff scores: mild anxiety (8 or 9), mild depression (10–13), mild stress (15–18), and insomnia (0–7); moderate anxiety (10–14), moderate depression (14–20), moderate stress (19–25), subthreshold insomnia (8–14), and moderate clinical insomnia (22–28); severe anxiety (15–19), severe depression (21–27), severe stress (26–33), and clinically severe insomnia (≥ 22); very severe anxiety (≥ 20), very severe depression (≥ 28), and very severe stress (≥ 34). 0 20 40 60 80 100 Very severeSevereModrateMildNormal Stress Depresion Anxiety Anxiety, depression stress among contacts with COVID-19 Very severeSevereModrateMildNormal 0 20 40 60 80 100 Stress Depresion Anxiety Anxiety, depression, stress among non-contacts 0 20 40 60 80 100 clinically sever insomniamoderate insomnia sub-threshold insomnianot clinically significant No Yes Co nt ac ts w ith C O V ID -19 Insomnia 710 Research article EMHJ – Vol. 28 No. 10 – 2022 Table 1 Univariate analysis of personal and occupational characteristics, anxiety, depression, stress and insomnia among healthcare workers in Arab countries during the COVID-19 pandemic (n = 2879) Characteristics Anxiety N=1407, 48.9% Depression N = 1456, 50.6% Stress N = 1192, 41.4% Insomnia N = 2075, 72.1% N (%) P N (%) P N (%) P N (%) P Gender Female 938 (52.7) <0.001 885 (49.7) 0.228 712 (40.0) 0.048 1232 (69.2) <0.001 Male 469 (42.7) 571 (52.0) 480 (43.7) 843 (76.8) Age category, yr 20–29 228 (48.4) <0.001 260 (55.2) <0.001 210 (44.6) <0.001 363 (77.1) <0.001 30–39 816 (54.7) 816 (54.7) 673 (45.1) 1147 (76.9) 40–49 265 (42.4) 274 (43.8) 224 (35.8) 408 (65.3) ≥ 50 98 (33.7) 106 (36.4) 85 (29.2) 157 (54.0) Marital status Married 948(47.4) 0.015 978 (48.9) 0.006 812 (40.6) 0.176 1400 (70.0) <0.001 Single 459(52.3) 478 (54.4) 380 (43.3) 675 (76.9) Children Yes 905(48.0) 0.228 936(49.7) 0.213 776 (41.2) 0.80 1327 (70.4) 0.007 No 497(50.4) 514(52.1) 411 (41.7) 741 (75.2) Living with family during COVID-19 Yes 1041(49.6) 0.162 11109 (52.9) <0.01 943 (45.0) <0.01 1541 (73.5) 0.005 No 361(46.7) 341(44.1) 244 (31.6) 527 (68.2) Profession Physicians 440(53.7) 0.001 519 (63.3) <0.001 462 (56.3) <0.001 669 (81.6) <0.001 Nurses 637(48.7) 563 (43.0) 422 (32.3) 872 (66.7) Others 330(43.9) 374 (49.8) 308 (41.0) 534 (71.1) Smoking status Never smoked 1035(48.5) <0.01 1042 (48.8) <0.01 831 (38.9) <0.01 1482 (69.4) <0.01 Previous smoker 113(50.2) 113 (50.2) 92 (40.9) 170 (75.6) Smoking as before COVID-19 110(43.7) 131 (52.0) 115 (45.6) 202 (80.2) Smoking less than before COVID-19 51(43.2) 63 (53.4) 57 (48.3) 93 (78.8) Smoking more during COVID-19 72(72.0) 79 (79.0) 75 (75.0) 96 (96.0) Started smoking after COVID-19 6(75.0) 6 (75.0) 6 (75.0) 7(87.5) Working hours ≤ 20 121(45.3) 0.463 125 (46.8) 0.017 111 (41.6) 0.484 183 (65.5) 0.005 21–44 644(49.5) 696 (53.5) 554 (42.5) 977 (75.0) ≥ 45 642(49.0) 635 (48.5) 527 (40.2) 915 (69.8) Working experience, yr 1–5 278 (54.2) <0.001 291 (56.7) <0.001 246 (48.0) <0.001 393 (76.6) <0.001 6–10 403 (50.9) 416 (52.5) 350 (44.2) 602 (76.6) 11–15 365 (51.2) 365 (51.2) 289 (40.5) 535 (75.0) > 15 361 (41.9 384 (44.6 307 (35.7) 545 (63.3) Type of hospital Tertiary 717 (48.9 0.953 695 (47.4) 0.001 539 (36.8) <0.001 1011 (69.0) <0.001 Secondary 690 (48.8) 761 (53.9) 653 (46.2) 1064 (75.3) COVID-19 hospitals Yes 963 (50.8) <0.01 952 (50.2) 0.589 772 (40.7) 0.299 1337 (70.5) 0.01 No 444 (45.2) 504 (51.3) 420 (42.7) 738 (75.1) 711 Research article EMHJ – Vol. 28 No. 10 – 2022 aged < 40 years (68.2%), and nurses outnumbered (45.4%) physicians and other allied healthcare professionals. Of all participants, 50.9% worked in tertiary hospitals, and ~50% worked > 45 hours. More than 50% had work experience of 6–15 years, and about a third > 15 years. About two thirds of participants worked in hospitals equipped for treatment of COVID-19 patients (Supplementary Table 1). Using the defined cutoffs of the DASS-21 and ISI revealed that anxiety, depression, stress and insomnia were identified in 48.9%, 50.6%, 41.4% and 72.1% of respondents, respectively. Distribution of these psychological outcomes was highest in LMICs, except for Palestine, where all the psychological outcomes and insomnia were lower than in most other countries regardless of economic status. For an example of an LMIC, in Egypt, the percentages of those positive for anxiety, depression, stress and insomnia were 65.0%, 69.0%, 58.0% and 87.0%, respectively, versus 43.0%, 36.0%, 24.0% and 60.0% in Saudi Arabia. In comparison to other Gulf countries, Saudi Arabia had the lowest prevalence of all the psychological outcomes and insomnia (Figure 2). The psychological outcomes and insomnia were substantially higher in countries with higher than lower case fatality rates (Supplementary Figure 2). It was common to have > 1 mental health problem; > 40% of physicians scored positive for 3 mental health disorders, compared to about 33% of nurses and allied HCWs. Multiple mental health disorders were more frequent among HCWs who had contact with COVID-19 cases (Supplementary Figure 3). Table 1 shows distribution of anxiety, depression, stress and insomnia among all studied groups. All psychological outcomes and insomnia were more common in physicians; HCWs with direct contact with COVID-19 patients; HCWs with family members or friends diagnosed with COVID-19; HCWs not satisfied with hospital safety measures; HCWs who believed they were at high risk of acquiring COVID-19; HCWs who felt stigmatized by the community; and HCWs who smoked more during the pandemic. All the psychological outcomes and insomnia were significantly less frequent in HCWs who were married, aged ≥ 50 years, and with work experience > 15 years. Stress and insomnia were significantly higher among male HCWs, while anxiety was significantly higher among female HCWs. Living with family was associated with a higher rate of depression, stress and insomnia. Insomnia and depression were lower among HCWs who worked ≤ 20 hours/week. The prevalence of severe and very severe forms of anxiety, depression and stress and clinically severe insomnia was 21.2%, 17.9%, 16.6% and 9.7%, respectively. The severity of anxiety, depression, stress and insomnia was greater among HCWs who had contact with COVID-19 patients (Figure 1). Adjusted analysis revealed that, anxiety, depression and stress were independently associated with feeling stigmatized, perceived higher risk of getting infection, dissatisfaction with hospital preventive measures, and working > 44 hours/week (Table 2). Also, the odds of anxiety, depression and stress were significantly higher Characteristics Anxiety N=1407, 48.9% Depression N = 1456, 50.6% Stress N = 1192, 41.4% Insomnia N = 2075, 72.1% N (%) P N (%) P N (%) P N (%) P Contact with COVID-19 cases Yes 528 (58.1) <0.001 511 (56.2) <0.001 435 (47.9) <0.001 697 (76.7) <0.001 No 879 (44.6) 945 (48.0) 757 (38.4) 1378 (69.9) Relative/friend with COVID-19 Yes 534 (57.7) <0.01 535 (57.8) <0.01 429 (46.4) <0.01 715 (77.3) <0.01 No 852 (44.6) 898 (47.0) 764 (39.0) 1333 (69.7) Satisfied by hospitals safety measures Satisfied 426 (37.6) <0.01 405 (35.7) <0.01 316 (27.9) <0.01 679 (59.9) <0.01 Neutral 452 (52.3) 448 (51.9) 341(39.5) 642 (74.3) Not satisfied 524 (60.1) 597 (68.5) 530 (60.8) 747 (85.7) How likely you may get COVID-19 Very unlikely 76 (30.0) <0.01 73 (28.9) <0.01 52 (20.6) <0.01 109 (43.1) <0.01 Unlikely 292 (35.5) 292 (35.5) 236 (28.7) 511 (62.2) likely 704 (53.7) 737 (56.3) 596 (54.5) 1044 (79.7) Very likely 312 (69.5) 329 (73.3) 289 (64.4) 384 (85.5) Feeling stigmatized Yes 637 (58.8) <0.01 678 (62.6) <0.01 567 (52.4) <0.01 891 (82.3) <0.01 No 765 (42.8) 772 (43.2) 620 (34.7) 1177 (65.9) Cutoff scores for anxiety (> 7), depression (> 9), stress (> 14) and insomnia (> 7). Table 1 Univariate analysis of personal and occupational characteristics, anxiety, depression, stress and insomnia among healthcare workers in Arab countries during the COVID-19 pandemic (n = 2879) (concluded) 712 Research article EMHJ – Vol. 28 No. 10 – 2022 Figure 2 Prevalence of anxiety, depression, stress and insomnia of clinical significance among healthcare workers by country. Psychological outcomes were measured using Depression Anxiety Stress Scale, and insomnia was measured using Insomnia Severity Index. Cutoff scores of anxiety (> 7), depression (> 9), stress (> 14), and insomnia (> 7). 0 10 20 30 40 50 60 70 80 anxiety Eg yp t Em ira tes Ku wa it Qa tar Jor da n Su da n Tu nis ia Om an Le ba no n Sa ud i A rab ia Ba hra in Pa les tin e % 0 10 20 30 40 50 60 70 80 Depression Eg yp t Jor da n Su da n Ku wa it Tu nis ia Qa tar Om an Em ira tes Ba hra in Le ba no n Sa ud i A rab ia Pa les tin e 0 10 20 30 40 50 60 Stress Jor da n Eg yp t Tu nis ia Ku wa it Su da n Em ira tes Le ba no n Qa tar Om an Ba hra in Pa les tin e Sa uid Ar ab ia 0 20 40 60 80 100 Insomnia of clinical significance Jor da n Eg yp t Tu nis ia Ku wa it Ba hra in Em ira tes Qa tar Su da n Le ba no n Om an Sa ud i A rab ia Pa les tin e 713 Research article EMHJ – Vol. 28 No. 10 – 2022 Table 2 Logistic regression analysis of personal and occupational characteristics, anxiety, depression, stress and insomnia among healthcare workers in Arab countries during COVID-19 pandemic (n = 2879) Variable N (%) Anxiety (48.9 %, 95 % CI 46.9–50.7%) Depression (50.6%, 95 % CI 48.7–52.3%) Stress (41.4%, 95 % CI 39.6–43.2%) Insomnia (72.1%, 95 % CI 70.5–73.7%) OR 95% CI OR 95% CI OR 95% CI OR 95% CI Gender Male 1098 (38.1) 0.49 0.41–0.59* 0.77 0.65–0.92* 0.79 0.66–0.95* 1.07 0.87–1.31 Female 1781(61.9) ref ref ref ref Age, yr 20–29 471 (16.4) 1.20 0.75–1.93 1.99 1.23–3.20* 1.32 0.81–2.15 2.33 1.40–3.89* 30–39 1492 (51.8) 2.21 1.52–3.22* 2.40 1.64–3.50* 1.9 1.29–2.90* 2.57 1.74–3.79* 40–49 625 (21.7) 1.35 0.98–1.87 1.36 0.99–1.88 1.29 0.92–1.81 1.50 1.08–2.07* ≥ 50 291(10.1) ref ref ref ref Marital status Single 878 (30.5) 1.34 0.93–1.39 1.21 0.99–1.49 1.12 0.91–1.38 1.35 1.07–1.71* Married 2001 (69.5) ref ref ref ref Living with family Yes 2097 (73.1) 1.09 0.89–1.33 1.11 0.90–1.37 1.44 1.16–1.79* 0.97 0.77–1.22 No 773 (26.9) ref Profession Physicians 820 (28.5) 1.30 1.05–1.60* 2.21 1.70–2.62* 2.38 1.92–2.95* 1.74 1.36–2.25* Others* 751 (26.1) 1.06 0.86–1.31 1.64 1.33–2.02* 1.77 1.43–2.20* 1.46 1.06–1.84* Nurses 1308 (45.1) ref ref ref ref Working hours/week ≥ 45 1310 (45.5) 1.42 1.05–1.92* 1.67 1.24–2.26* 1.4 1.03–1.92* 1.46 1.05–2.03* 21–44 1302 (45.2) 1.39 1.04–1.87* 151. 1.11–2.05* 1.30 0.96–1.76 1.69 1.22–2.34* ≤20 267(9.3) ref ref ref ref Working experience, yr 1–5 513 (17.8) 1.37 0.94–2.01 0.85 0.58–1.26 1.22 0.82–1.81 0.91 0.59–1.40 6–10 792 (27.5) 0.89 0.65–1.21 0.69 0.51–0.95* 0.92 0.67–1.27 0.93 0.66–1.32 11–15 713 (24.8) 0.96 0.72–1.27 0.80 0.60–1.07 0.89 0.66–1.20 1.05 0.77–1.43 > 15 861 (29.9) ref ref ref ref Type of hospital Secondary 1413 (49.1) 0.87 0.73–1.02 1.02 0.86–1.21 1.11 0.93–1.32 1.08 0.89–1.30 Tertiary 1465 (50.9) ref ref ref ref COVID-19 hospitals Yes 1896 (65.9) 0.99 0.82–1.19 0.92 0.76–1.11 0.92 0.76–1.11 0.72 0.58–0.89* No 983( 34.1) ref ref ref ref Contact COVID-19 Yes 909(31.6) 1.40 1.16–1.70* 1.09 0.90–1.33 1.29 1.10–1.57* 1.15 0.92–1.43 No 1970(68.4) ref ref ref ref Relative/friend with COVID-19 Yes 925 (32.6) 1.36 1.14–1.62* 1.21 1.01–1.44* 1.01 0.85–1.22 1.13 0.92–1.39 No 1912 (67.4) ref Satisfied with hospital preventive measures Satisfied 1134 (39.4) ref ref Neutral 864 (30.1) 1.58 1.30–1.93* 1.66 1.37–2.02* 1.47 1.20–1.80* 1.53 1.24–1.89* Not satisfied 872 (30.4) 2.03 1.64–2.49* 2.69 2.18–3.32* 2.71 2.19–3.35* 2.37 1.85–3.04* How likely you may get COVID-19 Very unlikely 253 (8.9) ref Unlikely 822 (29.0) 1.22 0.88–1.67 1.13 0.82–1.56 1.30 0.91–1.86 1.97 1.45–2.67* likely 1310 (45.5) 2.03 1.49–2.76* 2.15 1.57–2.95* 2.20 1.56–3.11* 3.91 2.87–5.31* Very likely 449 (15.6) 3.25 2.26–4.67* 3.84 2.65–5.56* 3.95 2.68–5.84* 4.75 3.20–7.05* Feeling stigmatized Yes 1083 (37.7) 1.76 1.49–2.07* 2.07 1.75–2.46* 1.87 1.57–2.21* 2.28 1.86–2.79* No 1787 (62.3) ref Cut-off scores for anxiety (> 7), depression (> 9), stress (> 14), and insomnia (> 7). *Statistical significant results. 714 Research article EMHJ – Vol. 28 No. 10 – 2022 among physicians than other professions, and in HCWs aged 30–39 years than other age groups. Direct contact with COVID-19 cases was independently associated with anxiety and stress, but not with depression, while living with family during the pandemic was independently associated with stress. Male gender significantly decreased the odds of anxiety. Age < 50 years, physicians, allied health professionals, increased workload, dis- satisfaction with hospital preventive measures, feeling stigmatized by the community, and perceived higher risk of infection were independently associated with insomnia. The psychological outcomes and clinically significant insomnia according to country was tested by logistic regression adjusted for all variables (Table 3). We considered Saudi Arabia as a reference because it had the largest number of participants. Among HICs, Oman and Qatar did not differ significantly from Saudi Arabia, while Kuwait and United Arab Emirates had higher levels of stress. Among LMICs, Egypt had significantly higher levels of all the psychological outcomes, and odds of anxiety, depression and stress were about 2-fold higher than those of Saudi Arabia. Tunisia had a higher prevalence of depression and stress, while Sudan had a lower prevalence of insomnia. Among UMICs, Jordan had significantly higher prevalence of depression, stress and insomnia, while Lebanon had higher prevalence of stress. Palestine had significantly lower prevalence of anxiety, depression and insomnia. Discussion This study investigated mental health symptoms in 2879 HCWs from 12 Arab countries during the first wave of the COVID-19 pandemic. Anxiety, depression, stress and insomnia were identified in 48.9%, 50.6%, 41.4% and 72.1% of respondents, respectively. The prevalence of mental health symptoms was higher in HCWs aged 30–39 years; those who were working > 44 hours/week; those in contact with COVID-19 patients, including family and friends; those who were not satisfied with the preventive measures; those who felt stigmatized; and those who perceived themselves to have higher susceptibility to infection. The prevalence was lower in HICs, male HCWs, and nurses. The spectrum of mental health problems found in this study was similar to that reported for the previous SARS outbreak in 2002–2003 (20). Our results are consistent with 2 previous studies that investigated the psychological responses of HCWs to COVID-19 in China and Italy (2, 21). However, the prevalence of anxiety, depression and insomnia was higher than that reported in a systematic review on the current pandemic that included studies from China and Singapore (22). The higher prevalence of psychological problems may be attributed to the new experience of a pandemic as severe as COVID-19 for most Arab countries compared to other nations. The exception was Saudi Arabia, which had previous experience with an outbreak of Middle East respiratory syndrome (23). This observation is further supported by the low prevalence of all psychological problems among Saudi respondents compared to those from other countries. Nevertheless, the higher rate of mental health problems than in other studies may be explained by the high rate preceding COVID-19 due to armed conflict in many Arab countries. However other factors like reduced accessibility to formal psychological support (24), lack of medical information on the outbreak, lack of intensive training on personal Table 3 Anxiety, depression, stress, and insomnia among healthcare workers during the COVID-19 pandemic by country: (n = 2874)a Variable N (%) Anxiety (48.9 %, 95 % CI 46.9–50.7%) Depression (50.6%, 95 % CI 48.7–52.3%) Stress (41.4%, 95 % CI 39.6–43.2%) Insomnia (72.1%, 95 % CI 70.5–73.7%) OR 95% CI OR 95% CI OR 95% CI OR 95% CI Saudi Arabia 787 (27.3) 1 — 1 — 1 Jordan 369 (12.8) 1.24 0.90–1.73 1.85 1.32–2.57* 2.19 1.57–3.07* 2.06 1.37–3.11* Lebanon 35 (1.2) 1.21 0.58–2.53 1.62 0.78–3.37 2.46 1.18–5.12* 1.34 0.59–3.02 Egypt 410 (14.2) 1.85 1.33–2.57* 1.95 1.40–2.71* 1.94 1.39–2.71* 1.27 0.87–1.85 Sudan 48 (1.7) 0.80 0.40–1.60 0.64 0.32–1.30 0.88 0.44–1.78 0.38 0.18–0.82* Palestine 159 (5.5) 0.45 0.23–0.70* 0.54 0.35–0.83* 0.77 0.49–1.21 0.60 0.18–0.82* Tunisia 175 (6.1) 1.29 0.87–1.94 1.50 1.01–22.25* 2.41 1.60–3.63* 1.53 0.96–2.45 Oman 41 (1.4) 1.16 0.57–2.36 1.29 0.633–2.63 1.37 0.66–2.84 0.78 0.37–1.65 Qatar 132 (4.6) 0.96 0.63–1.49 1.14 0.63–2.63 1.13 0.722–1.78 0.97 0.60–1.56 Bahrain 103 (3.6) 0.55 0.33–0.89* 1.13 0.70–1.83 1.16 0.70–1.90 1.46 0.85–2.51 Kuwait 354 (12.3) 1.11 0.82–1.52 1.34 0.98–1.82 1.85 1.35–2.55* 1.35 0.96–1.92 UAE 261 (9.1) 1.11 0.81–1.54 1.36 0.82–1.58 1.68 1.21–2.35* 1.02 0.71–1.46 OR adjusted for all personal and occupational characteristics. Cutoff scores for anxiety (> 7), depression (> 9), stress (> 14), and insomnia (> 7). aOut of the 2879 participants, country was missing for 5 participants. *statistical significant results. CI = confidence interval; OR = odds ratio; UAE = United Arab Emirates. 715 Research article EMHJ – Vol. 28 No. 10 – 2022 protective equipment (PPE) and lack of infection control measures may have contributed (22). Two recent studies that used DASS-21 among HCWs in Turkey and China reported a similar prevalence for severe and very severe anxiety (12.6–22.1%), depression (9.3–19.7%) and stress (19.1–19.4%) (15, 25). The prevalence was clearly higher than that reported among the general population of China (8.4%, 4.3% and 2.6% for very severe anxiety, depression and stress, respectively) (1). In this study, the prevalence of clinically severe insomnia (72.1%) was higher than that reported by 2 studies from China (1.4% and 1%) (2, 26). A possible confounder to this high prevalence of insomnia relevant to our region was that most of the Muslim nations were observing Ramadan during the data collection. Fasting during Ramadan is associated with change in lifestyle and sleeping habits. We were surprised by our finding that the odds of developing insomnia were lower among HCWs who worked in hospitals for COVID-19 patients than in other hospitals. This may be explained by the longer period of work and off-work (14 days) in most hospitals for COVID-19 patients than other hospitals (27). This pattern of work may have allowed regulation of sleep pattern during the long period off work. We noted variation in the prevalence of psychological morbidities between the participating Arab countries in our study. The data showed that LMICs and LICs like Egypt and Sudan had a significantly higher prevalence of all the psychological outcomes than HICs such as Saudi Arabia, Oman and Qatar. The exception to this observation was the LMIC Palestine, where HCWs reported lower rates of mental health problems. This difference between LMICs and HICs may be explained by the differences in the availability of PPE, healthcare resources, hospital settings, and availability of intensive care unit beds, in addition to the existence of occupational health programmes that may have contributed to the lower prevalence of psychological problems in HICs (28, 29). Again, the exception was HCWs from Palestine, who showed a prevalence of mental health problems comparable to those in HICs rather than LMICs as expected. This may be explained by the fact that the epidemic had just started in Palestine with few patients and fatalities when the study was conducted. This explanation is supported by previous findings that Palestinian emergency HCWs in regions with more armed conflicts were more resilient than those in regions with fewer conflicts (30). In contrast to earlier studies (2,28), our results showed that physicians had a higher level of mental health problems than nurses and other HCWs. These results may be confounded by the fact that the burden of examining and managing hospitalized patients in Arab countries lay heavily on their shoulders (31), as well as the possible shortage of physicians and higher workload than other countries (8), and their greater involvement in high-risk procedures such as intubation than other HCWs (32). It is also notable that all the psychological outcomes and insomnia were more common in those who smoked more during the pandemic. It has been suggested that the impact of long working hours and rotational shift patterns on work-related stress is mediated by a set of maladaptive behaviours and coping responses such as increased smoking (33,34). All the psychological outcomes and insomnia were significantly less frequent in married participants. Similar results were reported during previous outbreaks such as SARS (35). This may be explained by the fact that married individuals are in a supportive relationship that may provide protection from mental health problems (36). However, individuals living with their families, married or unmarried, can develop fear of transmitting infection to their families, as demonstrated by our results. In this study, age and gender were significantly associated with adverse mental health outcomes. Younger age (30–39 years) was independently associated with depression, anxiety, stress and insomnia. Fewer years of experience and working > 44 hours/week were associated with adverse psychological outcomes, as reported previously (37). This is further supported by our finding that longer work experience of 6–10 years was protective against depression. Male HCWs showed fewer symptoms of depression, anxiety and stress, which is consistent with other studies in which women were at higher risk than men for mental health symptoms (2, 28). We identified a group of risk factors that were related to increased perception of danger of infection for HCWs or their families. Being in direct contact with patients was a source of anxiety and stress, while having a relative or friend with COVID-19 was associated with anxiety and depression. Dissatisfaction with preventive measures, and perceived higher risk of infection were associated with all outcomes. These results are consistent with studies from other countries (2,38). Other possible contributing factors included the high infectivity, long incubation period, potential fatality of COVID-19, shortage of and lack of training in PPE (5), in addition to rapid changes in infection control measures with emerging knowledge about the virus (38). The impact of COVID-19 on mental health of HCWs was related to being stigmatized by the neighbourhood community. More than 37% of HCWs in our study felt stigmatized, and this was associated with adverse mental health outcomes. Similar findings from previous studies have been reported (4). The findings of our survey could be a valuable source for the development of national or regional guidelines with the aim of reducing psychological problems among HCWs during pandemics. Additional measures may include increased staffing levels through task shifting and directed training and general education on management of epidemics. Social media could make a major contribution to reducing stigmatizing reports in the public domain. Although hospitals are required to have protocols for emergency mental health services, research is needed to address the gap in knowledge about mental and occupational health in Arab countries. 716 Research article EMHJ – Vol. 28 No. 10 – 2022 The large coverage of 12 Arab countries, including HICs and LMICs, highlighted the unique features of the impact of the COVID-19 pandemic on HCWs as a single group who share many geopolitical conditions, as well as its impact on different nations with different socioeconomic characteristics. The limitations of this survey included the low response from some countries, which may have skewed our results towards countries with higher response. However, low responses could not be avoided at the time of data collection because different countries were at different stages of the pandemic as well as at different stages of preparedness. Collecting data during Ramadan may have confounded some outcomes like insomnia; however, the study was conducted to advise policy and strategic planning at the outset of the pandemic. Furthermore, there may have been a selection bias due to the voluntary participation of respondents in the study. Conclusions The first wave of the COVID-19 pandemic had a considerable impact on the mental health of HCWs in Arab countries, and this was aggravated by particular geopolitical situations of some of the countries and social norms during Ramadan. Being a physician, a young HCWs, and long working hours are risk factors for greater psychological impact . Acknowledgement This study was supported by the Deanship of Scientific Research, Research chairs, Research Chair for Evidence-Based Health Care and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia. We are grateful for all the respondents who took time during the epidemic to complete the survey. Funding: This study is funded by the Deanship of scientific research, Research chairs, at King Saud University, Riyadh, Saudi Arabia. No. E-20-4848 (2020). Competing interests: None declared. Impact de la première vague de la pandémie de COVID-19 sur la santé mentale des agents de soins de santé dans 12 pays arabes Résumé Contexte : La pandémie de COVID-19 a eu un impact important sur la santé publique dans le monde entier, notamment sur les agents de santé et les systèmes de soins de santé. Objectifs : Étudier l'impact psychologique associé à la COVID-19 sur les agents de santé dans 12 pays arabes. Méthodes : Il s'agissait d'une enquête transversale en ligne, réalisée en milieu hospitalier entre le 4 mai et le 8 juin 2020. Nous avons évalué le stress, la dépression, l'anxiété et l'insomnie à l'aide de l'échelle Dépression Anxiété Stress et de l'Index de Sévérité de l'Insomnie. Résultats : Au total, 2879 participants de 12 pays arabes ont répondu à l'enquête. L'anxiété, la dépression, le stress et l'insomnie ont été respectivement signalés par 48,9 %, 50,6 %, 41,4 % et 72,1 % des répondants. La prévalence de tous les résultats psychologiques était significativement plus forte dans les pays à revenu intermédiaire de la tranche inférieure et les pays à revenu faible que dans les pays à revenu élevé. La prévalence des symptômes de santé mentale était plus élevée chez les agents de santé âgés de 30 à 39 ans, ceux qui travaillaient plus de 44 heures par semaine et ceux qui étaient en contact avec des cas de COVID-19, ainsi que chez les agents de santé qui n'étaient pas satisfaits des mesures de prévention. La prévalence des symptômes de santé mentale était plus faible chez les agents de santé de sexe masculin. Conclusion : La COVID-19 a eu un impact considérable sur la santé mentale et psychologique des agents de santé dans les pays arabes. Cette situation a été aggravée par la situation géopolitique de certains pays arabes et les normes sociales habituellement observées pendant le mois de Ramadan. Le fait d'être médecins, jeunes agents de santé et les longues heures de travail étaient des facteurs de risque d'un plus grand impact psychologique de la pandémie. ا ًّيبرع اًدلب 12 في ةيحصلا ةياعرلا لامج في ينلماعلل ةيسفنلا ةحصلا لىع 19-ديفوك ةحئاج نم لىولأا ةجولما رثأ *ةينواعت ةعوممج ،دياف لمأ ،لاجم ورمع ،ليعماسإ ةيماس ،رماعلا ماسح ،رماع سراي ،اطش بنيز ،يدشرلما ةلاه ،يبهو ءافيه ،يتيت رهام ةصلالخا .ةيحصلا ةياعرلا مُظُنو ةيحصلا ةياعرلا لامج في نولماعلا كلذ نمو ،لماعلا ءاحنأ ىتش في ةماعلا ةحصلا لىع ٌيربك ٌرثأ 19-ديفوك ةحئالج ناك :ةيفللخا .ا ًّيبرع اًدلب 12 في ةيحصلا ةياعرلا لامج في ينلماعلا لىع 19-ديفوك ضرمب طبترلما سيفنلا رثلأا ءاصقتسا لىا ةساردلا هذه تفده :فادهلأا 717 Research article EMHJ – Vol. 28 No. 10 – 2022 References 1. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. 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Gen Hosp Psychiatry. 2005 Sep–Oct;27(5):352–8. https://doi.org/10.1016/j.gen- hosppsych.2005.04.007 PMID:16168796 719 Research article EMHJ – Vol. 28 No. 10 – 2022 Effects of the COVID-19 pandemic on healthcare delivery to an immigrant population in the Islamic Republic of Iran Keihan Golshani1 and Hamed Akhlaghi2,3,4 1Emergency Department, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran (Correspondence to: Keihan Golshani: k_golshani@ med.mui.ac.ir). 2Emergency Medicine Research, Emergency Department, St Vincent’s Hospital, Melbourne, Australia. 3Melbourne Medical School, University of Melbourne, Melbourne, Australia. 4Faculty of Health, Deakin University, Melbourne, Australia. Introduction Background Individual health outcomes can be significantly influenced by nonmedical factors: the social determinants of health (1). Providing efficient, consistent, safe, equitable and high-quality emergency care is essential to improve access to optimal care. Structural inequities and social determinants have an impact on health care delivery. Several studies have shown disparities, limited resources and poor health outcomes among marginalized communities, including individuals with different backgrounds, race/ethnicity and im/migrants (2–5). Data from the United Kingdom confirmed that in 2020, 34% of critically ill patients admitted to intensive care units were from ethnic/racial minorities although this group comprised only about 14% of the general population (6). The term “im/migrant” was used to refer to immigrants, refugees, asylum seekers and undocumented persons (5). This is fundamental to addressing healthcare disparities to improve health equity for im/migrants (7). Since the declaration of the COVID-19 pandemic by the World Health Organization, there have been challenges in delivering equitable care globally and several studies have reported significant disparities and inconsistencies between communities (8,9). In the United States of America, higher case numbers and mortality rates have been reported among the Black and Hispanic populations. In Michigan, around 40% of fatalities were reported in Black patients although they accounted for only 14% of the population (10). In a recent Spanish study, being an immigrant was independently associated with higher in-hospital mortality among patients admitted for COVID-19 (11). The shortage of healthcare workers and limited medical resources in low- and middle-income countries is well established, and the burden of the COVID-19 pandemic accentuated the problem (12). Appropriate and fair allocation of scarce and limited health resources has instigated ethical and legal challenges in these countries (13). The COVID-19 pandemic has created a unique opportunity to expose unfair and unjust public health inequities among racial and ethnic minority groups, including im/migrants. In this study, we performed a multi-centre retrospective study to evaluate the effect of the COVID-19 pandemic on health care delivery to im/ migrant population in Isfahan Province, Islamic Republic of Iran. Abstract Background: Healthcare inequity has widely affected marginalized and immigrant communities globally during the COVID-19 pandemic. Aims: This study assessed the effect of COVID-19 pandemic on health care delivery to immigrant populations in Isfahan Province, Islamic Republic of Iran. Methods: All 67 hospitals across Isfahan Province were included in this study conducted from 1 March to 31 May 2020. Data on clinical manifestations, comorbidities, patient management, and outcomes of patients during hospital admission were extracted from medical records and analysed using SPSS for chi-square and odds ratio (OR). Results: One hundred and sixty-eight (3.3%) of 5128 PCR-confirmed COVID-19 cases during the study period were immigrants and were included in the study. There were no differences in sex, clinical presentation, comorbidities, and length of hospital stay between the non-immigrant and immigrant groups. Immigrant patients were significantly younger and had poorer outcomes, including tracheal intubation [OR = 1.9, 95% confidence interval (CI): 1.2–3.1); P = 0.009] and in-hospital mortality (OR = 1.6; 95% CI: 1.1–2.4; P = 0.02). Conclusion: Adverse health outcomes among immigrant communities may be an indication of health inequity and should be addressed by the relevant policymakers. Keywords: health care delivery, migrants, COVID-19, health equity, Iran Citation: Golshani K; Akhlaghi H. Effects of the COVID-19 pandemic on healthcare delivery to an immigrant population in the Islamic Republic of Iran. East Mediterr Health J. 2022;28(10):719–724. https://doi.org/10.26719/emhj.22.075 Received: 15/12/21; accepted: 29/06/22 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 720 Research article EMHJ – Vol. 28 No. 10 – 2022 Objectives of the study Our primary aim was to illustrate the demographic and clinical presentations of COVID-19 patients among non- immigrants and im/migrant populations. The secondary aim was to compare the need for invasive management, orotracheal intubation and in-hospital mortality between im/migrant and non-immigrant COVID-19 patients. Methods Study design This was a retrospective multi-centre observational study that assessed the differences between clinical presentations, management and primary outcome of COVID-19 among non-immigrant and im/migrant populations. The primary clinical outcomes were defined as the need for orotracheal intubation and in-hospital mortality. Setting and participants There are 67 hospitals in Isfahan Province. We analysed a cohort of COVID-19-positive patients who required admission to one of these hospitals between 1 March 2020 and 31 May 2020. A confirmed COVID-19 patient was defined as having at least one positive nasopharyngeal swab determined by real-time reverse transcriptase- polymerase chain reaction (PCR) assay as defined by the World Health Organization protocols (14). Data source and variables The data were collected by reviewing completed COVID-19 forms from the medical records. The following information was collected from each patient’s medical records: patient demographics, presenting complaint at triage (e.g. cough, shortness of breath, myalgia, prior contact to a COVID positive case), clinical manifestations [O2 saturation, fever (temperature > 38° C), etc.], comorbidities, need for orotracheal intubation and clinical outcome (length of stay and in-hospital mortality). Quantitative variables and statistical methods Categorical variables are presented as frequency (percentage) and continuous variables as median [interquartile range (IQR)]. Chi-square and odds ratio (OR) were used to analyse associations between categorical variables and an independent t-test was used for continuous variables. We used a non-parametric Fisher’s exact test when the value of a variable was less than 5. We used SPSS, version 27. Ethics Ethical considerations for the study were reviewed and approved by the ethics committee of Isfahan University of Medical Sciences, approval number: IR.MUI.MED. REC 1399.423, dated 22/08/2020. Results In Isfahan Province, 5128 PCR-confirmed COVID-19 patients presented to 67 hospitals during the study period; 562 were re-presentations and 3.3% (168) were im/migrants. All re-presentations were among the non- immigrant population (P < 0.001). The characteristics and management of patients are summarized in Table 1. During the first presentation (excluding re- presentations), 54.4% of non-immigrant and 60.1% im/ migrant patients were male. Im/migrant patients were significantly younger than non-immigrant patients, median age 54 (IQR 31) years and 58 (IQR 27) years respectively (t(175.6) = 2.51, P = 0.013). There were no significant differences in the clinical manifestations and comorbidities between the 2 groups (Table 2). Length of stay in hospital did not differ between im/migrant Table 1 Epidemiology and management of confirmed COVID-19 patients admitted to hospital in Isfahan, 2020 Demographics Non-immigrants (n = 4960) Im/migrants (n = 168) P-value Odds ratio (95% CI) Agea, median (IQR) (years) 58 (27) 54 (31) 0.013b No. (%) No. (%) Sexa Female 2261 (45.6) 67 (39.9) Male 2966 (54.4) 101 (60.1) 0.144 Re-presentation 562 (11.3) 0 (0.0) < 0.001 Disposition In-hospital death 614 (12.4) 31 (18.5) Discharged alive 4346 (87.6) 137 (81.5) 0.02 1.6 (1.1–2.4) Orotracheal intubation Yes 311 (6.3) 19 (11.3) No 4649 (93.7) 149 (88.7) 0.009 1.9 (1.2–3.1) aExcluding re-presentations. bEqual variances not assumed; Levene’s test for equality of variances was significant (P < 0.001). CI = confidence interval. IQR = interquartile range. 721 Research article EMHJ – Vol. 28 No. 10 – 2022 [median 8 (IQR 14) days] and non-immigrant [median 8 (IQR 19) days] groups (P = 0.437). Considering both initial presentation and re- presentations among im/migrant as opposed to non-immigrant patients, the likelihood of having an orotracheal intubation (90%) [OR = 1.9, 95% confidence interval (CI): 1.2–3.1; P = 0.009] and in-hospital mortality (60%) (OR = 1.6, 95% CI: 1.1–2.4; P = 0.02) was higher. Discussion Equitable access to proper, high-quality emergency care during the COVID-19 pandemic has been a global challenge that affects clinical outcomes (15,16) Therefore, we designed this study to address the gaps in delivering equitable and efficient emergency care to im/migrant populations affected by the COVID-19 disease. The hospitals in this study cover more than 5 million people (50.76% male, 49.24% female) including at least 185 000 im/migrants (51.8% male, 48.2% female) over about 107, 018 km² and a population density of 49.45/km² (17). The Islamic Republic of Iran was one of the few countries after China and Italy which were severely affected by the SARS-CoV-2 virus during the early stages of the pandemic (18). During the study period, 151 466 cases of laboratory-confirmed COVID-19 positive patients were reported, with a mortality of 7797. Our study comprised 3.4% of the whole country’s cases. Although we have demonstrated that the clinical presentations, baseline observations and past medical history between the 2 groups were not significantly different, the likelihood of requiring orotracheal intubation during hospital stay was significantly higher among im/migrant patients. Besides, the im/migrant group showed a higher mortality rate despite being significantly younger than the non-immigrant patients. This study confirms previous findings that marginalized and vulnerable groups had been affected more severely by the COVID-19 pandemic. A 2020 observational study demonstrated a higher mortality rate among Black patients (19). Similar studies showed a higher rate of hospitalization and mortality in low socioeconomic and racial/ethnic minority populations in the United States of America (20–22). Im/migrants have been shown to be particularly vulnerable to the COVID-19 pandemic. Social determinants such as homelessness, living in highly populated areas, inability to work from home, lack of physical distance (space), poor hand hygiene and failure to self-isolate are a few contributing factors to severe outcomes in im/migrant communities (5,23,24) A 2021 study in the United States of America convincingly demonstrated the substantial influence of social determinants on racial/ethnic disparities (22). The higher likelihood of orotracheal intubation and in-hospital mortality among im/migrant groups highlights that im/migrant and vulnerable communities are at elevated risk of adverse outcomes due to the COVID-19 disease. The median age of mortality is slightly lower among the im/migrant group in our study, emphasizing the non-clinical factors and the importance of social determinants in marginalized and vulnerable communities. Therefore, we urge that clinicians should be aware of non-clinical risk factors when assessing patients with COVID-19 disease. Interestingly, all re-presentation patients were non- immigrants, which is an unexpected finding. We can only speculate that social factors, financial difficulties and lack of health insurance may be contributing factors. Further studies are needed to assess and evaluate behaviours and other social factors among these communities to understand their perception of the healthcare system. This was a retrospective study conducted using medical records of confirmed COVID-19 cases at the time of their presentation to hospital. Due to the nature of the study, there are certain well-known limitations of this method, including the possibility of missing cases due to Table 2 Clinical manifestations and comorbidities of confirmed COVID-19 patients admitted to hospital at first presentation in Isfahan, 2020 Patient situation Non-immigrants (Total: 4398) Im/migrants (Total: 168) P-value No. (%) No. (%) Clinical manifestation Fever 2298 (52.3) 87 (51.8) 0.906 Cough 2331 (53.0) 83 (49.4) 0.359 Shortness of breath 2353 (53.5) 92 (54.8) 0.748 Myalgia 911 (20.7) 27 (16.1) 0.144 Previous COVID exposure 712 (16.2) 31 (18.5) 0.413 O2 saturation < 93% 2833 (64.4) 109 (64.9) 0.902 Comorbidity Diabetes 755 (17.2) 26 (15.5) 0.567 Hypertension 445 (10.1) 12 (7.1) 0.207 Asthma 96 (2.2) 4 (2.4) 0.506a aFisher’s exact test. 722 Research article EMHJ – Vol. 28 No. 10 – 2022 a false positive or a false negative result of a COVID-19 PCR test. Data for clinical manifestations such as fever and O2 saturation below 93% were recorded in a binary “yes” or “no” format rather than with a quantitative measurement. The recorded data lacked other important clinical measures such as blood pressure, heart rate and respiratory rate at the time of presentation. The low proportion of the im/migrant population included in the study may have affected the significance of the results. In this study, there was no assessment of inter-rater reliability between hospitals. We only assessed the patient cohort who required hospital admission, thus data from mild COVID-19 outpatient cases were not collected. We did not have access to the social circumstances such as socioeconomic status, health literacy and annual income of immigrant patients in this study. A further nationwide study assessing social determinants of im/ migrant community is needed to address these critical health issues. Conclusion This study revealed that among our hospital admitted COVID-19 cases, marginalized and minority communities were more vulnerable to adverse outcomes with a higher rate of orotracheal intubation and in-hospital mortality. Healthcare policymakers should pay more attention to the social determinants and financial difficulties of the racial and ethnic minority groups, including im/ migrants, to have an efficient and equitable emergency and healthcare system. Availability of data and materials: The dataset supporting the conclusions of this article is available in the osf.io (https://osf.io/pfdvc/?view_ only=71bdddbe054946cbb715c571fc476c6d). Funding: None Competing interests: None declared. Effets de la pandémie de COVID-19 sur la prestation de soins de santé dans une population immigrée en République islamique d'Iran Résumé Contexte : Les inégalités en matière de soins de santé ont largement touché les communautés marginalisées et immigrantes dans le monde entier pendant la pandémie de COVID-19. Objectifs : La présente étude a évalué l'effet de la pandémie de COVID-19 sur la prestation de soins de santé aux populations immigrées dans la province d'Ispahan (République islamique d'Iran). Méthodes : Les 67 hôpitaux de la province ont tous été inclus dans la présente étude menée entre le 1er mars et le 31 mai 2020. Des données sur les manifestations cliniques, les comorbidités, la prise en charge et les résultats des patients pendant leur hospitalisation ont été extraites des dossiers médicaux et analysées à l'aide du logiciel SPSS pour le test du khi carré et l'odds ratio (OR). Résultats : Cent soixante-huit (3,3 %) des 5128 cas de COVID-19 confirmés par PCR pendant la période de l'étude étaient des immigrants et ont été inclus dans l'étude. Aucune différence n'a été constatée entre les groupes de non- immigrants et d'immigrants en ce qui concerne le sexe, le tableau clinique, les comorbidités et la durée du séjour à l'hôpital. Les patients immigrants étaient significativement plus jeunes et présentaient des résultats moins favorables, notamment en ce qui concerne l'intubation trachéale [OR = 1,9, intervalle de confiance (IC) à 95 % : 1,2-3,1) ; p = 0,009] et la mortalité hospitalière (OR = 1,6 ; IC à 95 % : 1,1-2,4 ; p = 0,02). Conclusion : Les résultats sanitaires négatifs dans les communautés d'immigrants peuvent être une indication d'inégalité sur le plan sanitaire et devraient être traités par les responsables de l'élaboration des politiques concernés. ةيملاسلإا ناريإ ةيروهجم في نيرجاهلما ناكسلل ةيحصلا ةياعرلا ميدقت لىع 19-ديفوك ةحئاج راثآ یقلاخا دماح ،ینشلج ناهيك ةصلالخا .19-ديفوك ةحئاج للاخ يلماعلا ديعصلا لىع نيرجاهلماو ينش َّمهُلما تاعمتمج لىع ا ًّيبلس اًيرثأت رَّثأ دق ةيحصلا ةياعرلا لامج في ةاواسلما مدع نإ :ةيفللخا ناريإ ةيروهجم ،ناهفصأ ةظفامح في نيرجاهلما ناكسلل ةيحصلا ةياعرلا ميدقت لىع 19-ديفوك ةحئاج راثآ مييقت لىا ةساردلا هذه تفده :فادهلأا .ةيملاسلإا لىإ راذآ /سرام 1 نم ةساردلا تدتماو ،ىفشتسم 67 اهددع غلابلا ناهفصأ ةظفامح في تايفشتسلما عيجم ةساردلا هذه تلمش :ثحبلا قرط لىإ ملهوخد ءانثأ في ضىرلما جئاتنو ،ضىرلما جلاعو ،ةبحاصلما ةضارلما تلااحو ،ةيريسرلا رهاظلما تانايب تصلخُتساو .2020 رايأ /ويام 31 .ةيحجرلأا ةبسنب جورلخاو χ 2 ياك عبرم رابتخا ءارجلإ ،SPSS جمانرب مادختساب تانايبلا كلت تلِّ لُحو ،ةيبطلا تلاجسلا نم ،ىفشتسلما 723 Research article EMHJ – Vol. 28 No. 10 – 2022 References 1. 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Health Educat Behav. 2021:10901981211011581. doi:10.1177/10901981211011581 725 Research article EMHJ – Vol. 28 No. 10 – 2022 Presentation and management of female breast cancer in Egypt Yousri Rostom,1 Salah-Eldin Abdelmoneim,1 Marwa Shaker2 and Nayera Mahmoud1 1Oncology and Nuclear Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt (Correspondence to: Y. Rostom: rostomy@ hotmail.com). 2Oncology Department, Gamal Abd Elnasser Hospital, Alexandria, Egypt. Introduction Noncommunicable diseases (NCDs) constitute 71% of worldwide mortality, and 80% of them are due to cancer (1). NCD prevention and management is anticipated to reduce mortality, increase productivity gains and enhance achievement of economic Sustainable Development Goals (SDGs) (2). Egypt ranks 114 on the SDG index, with less than average NCD score (3). Breast cancer is the second most common cancer, and it is the most common in women worldwide, with variations in incidence and mortality among regions. In Egypt, it is the most common cause of cancer mortality in women. Egypt has a value of 57/100 on the index of effective coverage in breast cancer treatment (4). The 25-year mortality trends in the 7 super regions, encompassing 195 countries, have shown an increase, except in rich countries (defined by the Health Metrics and Evaluation: 1) Sub-Saharan Africa; 2) North Africa and Middle East; 3) South Asia; 4) Southeast Asia, East Asia and Oceania; 5) Latin America and Caribbean; 6) Central Europe, Eastern Europe and Central Asia; and 7) High-income). This poses a significant public health risk for low- and middle-income countries (like Egypt) that needs attention and effective intervention (5). With the introduction of modern treatments, survival of metastatic breast cancer has improved, but the mortality figures are still high (6). Risk factors for breast cancer development and mortality have been investigated to reduce its incidence, to detect it earlier, allowing more successful treatment, and to develop treatment strategies to increase curability (7). Lifestyle modifications have been proposed to reduce breast cancer incidence and morbidity (8). Screening for breast cancer has a well-established role and has resulted in an increase in detection of earlier stage disease and improved survival (at least in rich countries) (9). Awareness of breast cancer screening, management options and correcting misconceptions play a role in using relevant health services at an appropriate time for early diagnosis and management (10). Awareness is especially low among older and less-educated people, resulting in variable degrees of delay (11). Nonmedical university students have lower breast cancer awareness than medical students, except for nonmedical students who have a relative with breast cancer (12). Abstract Background: There have been system inefficiencies in the profiling and management of female breast cancer in Alexandria, Egypt. Aims: To identify barriers to full implementation of international guidelines for the management of female breast cancer patients. Methods: Female breast cancer data were extracted from records of 3 public oncology services in Alexandria, Egypt, from 2007 to 2016 and analysed. Results: A total of 5236 of the available 7125 records were usable. Median age of the patients was 54 years, and the median duration of pre-diagnosis complaint was 3.1 months. Some 522 (31.5%) of the patients had a family history of cancer. For tumour stage, 2527 (55.2%) were early, 1717 (37.6%) were locally advanced, and 331 (7.2%) were at stage IV. Estrogen receptor, progesterone receptor, and HER2 were positive in 3869 (85%), 3545 (78%), and 461 (15.3%) patients, respectively. Chemotherapy started after a median 1.03 months. Adjuvant chemotherapy was given to 3667 (91.7 %) patients and neoadjuvant chemotherapy to 333 (8.3%); 3686 (92.1%) received anthracycline-based combination chemotherapy, and 3613 (86%) received hormonal treatment. One hundred and eighty of 317 eligible patients received Trastuzumab. Local and/or distant recurrence was seen in 1109 (21.2%) patients. In nonmetastatic cases, median overall and disease-free survival were 149.1 and 77.1 months, respectively. In metastatic cases, median progression-free survival was 19.6 months. Conclusion: We observed defects in the record system, there was delay in diagnosis and treatment, and nonadherence to targeted therapy in many patients. Strengthening of national and hospital-based registries is needed in Alexandria, Egypt, with a robust patient navigation system and targeted information, education and communication strategies. Continuous outcomes monitoring and adaptation to implementation needs should be sustained. Keywords: breast cancer, disease management, service delivery, implantation, Egypt Citation: Rostom Y; Abdelmoneim S-E; Shaker M; Mahmoud N. Presentation and management of female breast cancer in Egypt. East Mediterr Health J. 2022;28(10):725–732. https://doi.org/10.26719/emhj.22.076 Received: 20/10/21; accepted: 29/05/22 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 726 Research article EMHJ – Vol. 28 No. 10 – 2022 A breast cancer screening project was inaugurated as a “Women Health Outreach Program” in July 2019. The screening programme has now matured into a full national programme, as a part of the “100 Million Healthy Individuals”. Despite full governmental support, economic factors and sustainability are important issues to be addressed (13). Breast cancer management practice guidelines are based on evidence obtained from efficacy trials or meta-analyses of multiple clinical trials, to homogenize and standardize clinical practice, according to the best available evidence and balancing between several intrinsic and extrinsic factors that prevail in the implementation setting. A comparison of 4 well-known clinical practice guidelines showed that all scored poorly on applicability and 2 scored lower on methodological rigor (14). Clinically efficacious interventions, proved by clinical trials, can result in implementation problems, when applied outside the controlled environment of the study. The problems are more evident when implementing guidelines developed in high-income countries in lower-income countries. The consensus statement from the Breast Health Global Initiative supports cost-effectiveness studies and implementation research to identify system inefficiencies and patient barriers, aiming to develop patient navigation systems, and strengthen functional early detection and treatment programmes (15). Implementation research helps build strategies for successful implementation, to bridge the gaps between clinical trial results, international guidelines and implementation in the local community. Five dimensions need to be explored: actors (who), actions (what), action targets (for whom or for what), temporality (when), and dose (how much) (16). The objective of this study was to identify barriers to the full implementation of international guidelines in female breast cancer patients from 3 major public oncology centres in Alexandria, Egypt, differing in their administrative and financial systems. Methods This was a retrospective, observational cohort study, planned as the exploratory phase of an implementation study, with the objective of identifying gaps in the delivery of services to breast cancer patients. The data for different patient cohorts were retrieved from the records to identify the different clinical pathways of the patients. The clinical records were retrieved from 3 major public oncology services: (1) Alexandria Clinical Oncology Department (ACOD), Main University Hospital: the first established oncology centre that has served Alexandria and Northwest Egypt for several decades and patients are managed under a government sponsored system. There were 1562 records (21.9%). (2) Gamal Abd-elnasser Insurance Hospital (GAN) Clinical Oncology Department: the second oncology centre that was established 3 decades ago and serves patients with employment health insurance. There were 4047 records (56.8%). (3) Alexandria Ayadi Almostakbel Oncology Center (AAAOC): the first nongovernmental- organization-sponsored oncology centre. There were 1516 records (21.2%). The surveyed records covered the period January 2007 to December 2016. After approval from Alexandria University Institutional Review Board (IRB00012098), the medical records were anonymously reviewed for demographic data: age at presentation, residence, family history of breast cancer, history of contraceptive pills, associated diabetes or hypertension, cancer stage, histological type and grade, hormone receptor status, Ki67, lymphovascular invasion (LVI), extracellular extension (ECE), type of surgery, duration of complaint before presentation, radiotherapy and chemotherapy details, and delay before start of treatment. Treatment outcome measures were analysed from the data in the records: 1) overall survival (OS): time from presentation to the treatment centre until death from any cause; 2) disease-free survival (DFS): time between diagnosis and detection of local or distant recurrence; 3) progression-free survival (PFS): time between diagnosis of metastatic breast cancer to relapse of tumour at distant site including lungs, liver, bone and brain; and 4) local recurrence rate (LRR): rate of recurrence of completely resected nonmetastatic breast cancer in the breast/chest wall or regional lymph nodes. Statistical analysis was conducted using SPSS version 20.0 (IBM, Armonk, NY, USA). The findings were reported as numbers and percentages. The median, range and interquartile range (IQR) were used to report central tendency and dispersion, as appropriate. Survival was reported as median survival and percentage of patients alive at 5 years. Kaplan–Meier survival curves were plotted for HER2-positive patients with or without trastuzumab therapy. The log rank test was used to compare the survival curves. The significance of the obtained results was judged at the 5% level. Results Patient characteristics From January 2007 to December 2016, 7125 records were registered at ACOD, GAN and AAAOC, and 5236 (73.4%) contained usable information. Further analysis was conducted based on available data. Most of the patients (73.3%) were from Alexandria, while 12.9% of the patients were from outside Alexandria. Table 1 shows the residence of the patients registered at the 3 centres and the 2019 population estimates of districts in Alexandria. The number of cases from the eastern districts was the largest and the numbers diminished westwards. The median age was 54 years (range 21–95 years). Patients with positive family history accounted for 522 (31.5%) of the total. Two hundred and eighty-one (30.8%) patients had a history of oral contraceptive use, 355 had hypertension, 216 had diabetes, and 306 had both diabetes and hypertension. The duration of complaint before 727 Research article EMHJ – Vol. 28 No. 10 – 2022 diagnosis was recorded in 1184 cases, with a median of 3.1 months (range 0.1–105 months, IQR 1.6–7.5 months). Surgery Breast surgery was performed in 4835 patients: modified radical mastectomy in 3593 and breast conservative surgery in 1242 (Table 2). Axillary surgery was performed in 4945 patients: axillary lymph node dissection in 4782 and sentinel lymph node dissection in 163. Thirty-one had no axillary surgery. Tumour stage Data on tumour stage were recorded in 4566 cases and were missing in 12.8% of cases (Table 2). The majority (55.2%) of patients were diagnosed at early stages (0–II), 37.6% had locally advanced stage III and only 7.2% had stage IV. The most common histological subtype was infiltrating duct carcinoma and most specimens were classified as grade II. Most cases were hormone receptor positive but most were negative for HER2. LVI and ECE were detected in 2829 of 3533 (80%) and 1657 of 3666 (45.2%) cases, respectively. Ki67 was recorded in 775 cases and was low in 28% intermediate in 10% and high in 61.8%. Treatment Duration to start of chemotherapy was < 1 month in 1490 (45.6%) of 2734 patients, 1–3 months in 1672 (51.2%) and > 3 months in 102 (3.1%), and the median was 1.03 months (IQR 0.7–1.6 months). Adjuvant chemotherapy was given to 3667 of 4000 (91.7%) patients and neoadjuvant chemotherapy to 333 (8.3%). Some 3686 (92.1%) received anthracycline-based combination chemotherapy. Non- anthracycline-based chemotherapy was used in 206 (5.6%) of patients receiving adjuvant chemotherapy and 45 (13.6%) of those receiving neoadjuvant chemotherapy. Out of 4199 patients, 3613 (86%) received hormonal treatment, either tamoxifen alone 1878 (44.7%), aromatase inhibitor (AI) alone 1111 (26.4%), sequential tamoxifen and AI 570 (13.6%), LHRH agonist with tamoxifen 12 (0.3%) or LHRH agonist with AI 42 (1%). Out of 317 eligible HER2-positive patients, 180 (56.8%) patients received trastuzumab treatment. Trastuzumab improved the long-term overall survival compared with those who could not afford the treatment (Figure 1), although the difference was not significant (log rank test: P = 0.373). By the end of the survey period, 3144 patients remained disease free and 1109 developed relapse: 155 with local recurrence, 130 with distant metastasis and 794 with both local and distant metastases. Median overall survival was 149.1 months in 3952 of 5236 nonmetastatic cases and 90.7% were alive at 5 years, and median DFS was 77.1 months in 2167 cases and 59.6% were alive at 5 years. Median PFS was 19.6 months in 127 of 329 metastatic cases and 7.9% were alive at 5 years. Discussion ACOD, GAN and AAAOC are 3 out of the 6 public oncology centres serving Alexandria Governorate and parts of the population of the adjacent governorates. The patients’ names and breast cancer as a diagnosis were the only data reported in 1889 records and those records were excluded from further study. The remaining 5236 records had some missing data and were excluded from reporting of those specific points. Missing records, missing data in available records and nonstandardized input in available data were the first implementation gaps met by the data collection team. This reduced the certainty of the outcome analysis and improvement efforts. Implementation of good health services in oncology, and in healthcare in general, depends on the adequacy of available data, to evaluate the quality of services, monitor bottlenecks in the implementation process, guide better strategic planning for successful implementation, and assess the success of the implementation strategy. National registries and hospital-based registries have both benefits and limitations (15). The median age of patients at presentation was 54 years (17). This is higher than the median age of 49–52 years of breast cancer patients in Arab countries Table 1 Residential locations of patients registered at 3 centres over a 10-year period and population density of districts in Alexandria Residential location Population estimatea Residential location Population estimatea Outside of Alexandria 673 Almontazah 1025 1 629 132 Alexandria 4512 5 325 227 Sharq 712 1 190 675 Wasat 786 558 360 Algomrok 277 161 091 Gharb 363 366 416 Alagamy 284 485 078 Alamreya 135 774 014 Borg El Arab 22 159 831 Alexandria District not recorded 235 Total 5185 aCentral Agency for Public Mobilization and Statistics (CAPMAS), Egypt. 728 Research article EMHJ – Vol. 28 No. 10 – 2022 (including Egypt) and lower than 61 years in the United States of America (USA) (9,18). The median age at diagnosis varied by race and ethnicity. The age difference between the USA and Egypt may be partially explained by the younger population in the latter (19) or cultural differences. Egyptian older women are less likely to seek medical advice than younger women, compared to their counterparts in the USA (20). Patients residing in the east of Alexandria, which is the most populous area with a paucity of oncology services, represent the largest cluster of patients. This finding is in accordance with an earlier report, partially overlapping the current report in regard to the covered duration and the data source (17). In developing countries, a large proportion of patients with breast cancer present at a late stage (21). In this study, 48% of patients presented with localized disease, 32.8% had locally advanced stage, 6.3% presented with metastases and 12.8% had no recorded stage. The increase in early stage presentation compared to earlier Egyptian studies is probably a reflection of increased awareness by women, resulting from governmental and nongovernmental efforts for screening and early detection, with a favourable impact on the estimated cost of management (22). According to the Surveillance, Epidemiology, and End Results (SEER) database, 62% of patients presented with localized disease, 30% at an advanced stage, 6% with metastases and only 2% of patients had no recorded stage (23). In this study, pathological specimens stained positive for estrogen receptor in 73.9% of patients and positive for progesterone in 67.7% of patients, and 12.2% of patients were negative for both receptors. HER2/neu testing was not available in the first 4 years of the study. HER2/neu status was not documented in 41.1% of the studied cases. In the documented records, 15.3% showed HER2/neu strong positivity and 86.7% showed HER2/neu negativity. Table 2 Surgical management and pathological features Number (%) Breast surgery Breast conserving surgery 1242/4976 (25) Modified radical mastectomy 3593/4976 (72.2) Not recorded 141/4976 (2.8) Axillary surgery No axillary dissection 31/4976 (0.6) Sentinel lymph node dissection 163/4976 (3.3) Axillary lymph node dissection 4782/4976 (96.1) Staging (n = 4566) Stage 0 39/4566 (0.8) Stage I 556/4566 (12.3) Stage II 1923/4566 (42.1) Stage III 1717/4566 (37.6) Stage IV 331/4566 (7.2) Histological type (n = 4459) Intraductal carcinoma 3960/4459 (88.8) Invasive lobular carcinoma 222/4459 (5.0) Mixed 116/4459 (2.6) Others 161/4459 (3.6) Grade (n = 4107) I 104/4107 (2.5) II 3425/4107 (83.4) III 578/4107 (14.1) Presence of LVI (n = 3533) 2829/3533 (80.0) ECE (n = 3666) 1657/3666 (45.2) ER (n =4550) Negative 681/4550 (15.0) Positive 3869/4550 (85.0) PR (n =4550) Negative 1005/4550 (22.0) Positive 3545/4550 (78.0) HER2 status (n =3066) Negative 2605/3006 (86.7) Positive 461/3006 (15.3) Ki67(n =775) Low (<14) 217 (28.0) Moderate (≥14 – 20) 79 (10.0) High (≥20) 479 (61.8) ECE = extracapsular extension; ER = estrogen receptor; LVI = lymphovascular invasion; PR = progesterone receptor. 729 Research article EMHJ – Vol. 28 No. 10 – 2022 In SEER, 78% of cases were HER2/neu negative, 14% were HER2/neu positive and 8% were unknown (23). The time between the first symptom and first specialist consultation was < 1 month in 10.7% of cases, 1–6 months in 58.6% and > 6 months in 30.7%, which contradicts the belief that our patients are not aware of breast cancer and always present at advanced stages. More than 75% of patients started chemotherapy within 1.6 months (IQR 0.7–1.6 months). Radiotherapy was started within 6 months in 30% of the patients. In many cases, this was not an actual treatment delay, as early and locally advanced cases were scheduled for adjuvant or neoadjuvant chemotherapy, before radiotherapy, and cases with metastatic disease received systemic treatment upfront and radiotherapy was given when localized symptoms developed. Care delay has been subdivided into patient delay and healthcare system delay (24). According to Caplan et al., patient delay is a delay in seeking medical attention after self-discovery of a potential breast cancer symptom, whereas system delay is a delay within the healthcare system (25). Patient delay was mainly defined as > 3 months between symptom detection and first medical consultation, and the socioeconomic and cultural background of patients can contribute to patient delay (25). System delay can refer to access barriers, such as long distance to healthcare centres, unavailability of specialized centres, and intrinsic problems of an established healthcare system, such as disease management, problems in obtaining or scheduling diagnostic tests and communication problems between patients and physicians (21,26). To reduce system delay, health services must fit with the socioeconomic and cultural background of patients (27,28). Several groups reported a worse survival rate, regardless of the type of cancer operation, for delays in diagnosis and referral for treatment (29–31). The 5-year PFS, DFS and overall survival were 7.9%, 59.6% and 90.7%, respectively. The 5-year survival for breast cancer in England, Australia and the USA is 84%, 89.5% and 90.2%, respectively, compared to 66.1% for India (32). Although the overall survival figures in Alexandria are comparable to or exceed those of rich countries, they cannot be taken as an indicator of a perfect healthcare system. This survey included a smaller number of records than the American, English and Australian studies, confounded by gaps in the recording data, which would have reduced the accuracy of survival estimation. Conclusion Strategies have been proposed to improve the implementation of an effective programme for prevention, screening, early detection, and treatment of breast cancer that reduces delays and unnecessary expenditure and improves outcomes (15,34,35). The elements of an implementation strategy would include: 1) strengthening of national and/or hospital-based registries and use of centralized electronic health records, indexing patients with their national number; 2) defining subgroups of women at higher risk of developing breast cancer and educating them about health-modifying behaviour to reduce the risk of breast cancer and increase adherence to a healthy lifestyle; 3) educating the public and primary care physicians about screening pathways; 4) establishing a patient navigation system for diagnosis and treatment; 5) expanding the coverage of health insurance to the sectors of the population at risk, guided by cost-efficiency studies; and 6) continuous monitoring of outcomes to see the effect of these strategies and improve the interventions. Funding: None Competing interests: None declared. Figure 1 Kaplan–Meier survival curve for overall survival in HER2-positive patients, with and without trastuzumab therapy (log rank test: P = 0.373). <caption>Figure 1. Kaplan–Meier survival curve for overall survival in HER2-positive patients, with and without trastuzumab therapy (log rank test: P = 0.373). 730 Research article EMHJ – Vol. 28 No. 10 – 2022 صرم في نهجلاعو ثانلإا ىدل يدثلا ناطسر تاي ِّدبت لىع فوقولا دوممح ةيرن ،ركاش ةورم ،معنلما دبع نيدلا حلاص ،متسر يسري ةصلالخا .صرمب ةيردنكسلإا في نهجلاعو يدثلا ناطسر تاضيرم تماس ديدتح في ماظنلا في روصق هجوأ دجوُت :ةيفللخا .يدثلا ناطسر تاضيرم جلاع نأشب ةيلودلا ةيهيجوتلا ئدابملل لماكلا ذيفنتلا نود لوتح يتلا تابقعلا ديدتح لىإ ةساردلا هذه تفده :فادهلأا ماع نم ةدلما في ،صرمب ةيردنكسلإا في مارولأا جلاعل ةماع تامدخ 3 تلاجس نم ثانلإا ىدل يدثلا ناطسر تانايب تصلخُتسا :ثحبلا قرط .تانايبلا كلت تل ِّلُح مث ،2016 ماع لىإ 2007 ةدم طسوتمو ،اًماع 54 تاضيرلما رمع طسوتم ناكو .مادختسلال ًلاباق ًّلاجس 5236 اهنم ناكو ،7125 ةحاتلما تلاجسلا ددع غلب :جئاتنلا 2527 دجوُي ناكف ،مرولا ةلحرم امأ .ناطسرلاب ةباصلإل ليئاع خيرات نيهدل )%31.5( ةضيرم 522 وحنو .ارهش 3.1 صيخشتلا لبق ىوكشلا نومره تلابقتسم تناكو .)%7.2( ةعبارلا ةلحرلما في ةلاح 331و ،)%37.6( مدقتم يعضوم مرو ةلاح 1717و ،)%55.2( ةركبم مرو ةلاح 461و )%78( ةضيرم 3545و )%85( ةضيرم 3869 ىدل ةيبايجإ نياثلا ةشربلا ومن لماع تلابقتسمو نوترسجوبرلا تلابقتسمو ينجوترسلإا ،)%91.7( ةضيرم 3667 لىإ دعاسم يئايميك جلاع يطُعأو .طسوتلما في رهش 1.03 دعب يئايميكلا جلاعلا أدبو .بيتترلا لىع )%15.3( ةضيرم ،ينلكيسارثنأ لىع دمتعم يومايك جلاع جيزم لىع )%92.1( ةضيرم 3686 تلصحو ،)%8.3( ةضيرم 333 لىإ ةيلْبَق ةمعاد ةيئايميك ةلجاعمو تدصُرو .ةلهؤم ةضيرم 317 لصأ نم باموزوتسارت ءاود ةضيرم نونماثو ةئام ت َّقلتو .نيومره جلاع لىع )%86( ةضيرم 3613 تلصحو ديق لىع ءاقبلا ةدم لياجمإ طسوتم غلبف ةّيِليقَّنلا يرغ تلاالحا في امأ .)%21.2( تاضيرم 1109 في ىرخأ عضاوم وأ/و هتاذ عضولما في ضرلما ةدوع ةايلحا ديق لىع ءاقبلا طسوتم ناكف ةّيِليقَّنلا تلاالحا في امأو .اًرهش 77.1 ضرلما نم وللخا عم ةايلحا ديق لىع ءاقبلا ةدم طسوتمو اًرهش 149.1 ةايلحا .اًرهش 19.6 ضرلما مقافت مدع عم تلااح نم يرثكلا في فَدهتسُلما جلاعلاب مازتلا مدعو ،جلاعلاو صيخشتلا في اًر ُّخأتو ،ليجستلا ماظن في بويع دوجو انظحلا :تاجاتنتسلاا ةجالحا لىإ ةفاضلإاب ،صرمب ةيردنكسلإا في تايفشتسلما تانايب لىإ ةدنتسلما تلاجسلاو ةينطولا تلاجسلا زيزعت لىإ ةجاح ةمث اذل .تاضيرلما دصر ةلصاوم يغبنيو .تامولعلما لئاسلم ةه َّجوم تايجيتاترساو ،لاصتاو فيقثت تايجيتاترساو ،تاضيرلما تلااح ِّصِّيقتل يوق ماظن دوجو لىإ .ذيفنتلا تاجايتحا عم فُّيكتلاو رارمتساب جئاتنلا Présentation et prise en charge du cancer du sein chez les femmes en Égypte Résumé Contexte : Des lacunes dans le système ont été constatées en ce qui concerne le profilage et la prise en charge du cancer du sein chez les femmes à Alexandrie (Égypte). Objectifs : Identifier les obstacles à la mise en œuvre complète des lignes directrices internationales pour la prise en charge des patientes atteintes d'un cancer du sein. Méthodes : Des données sur le cancer du sein chez les femmes ont été extraites des dossiers de trois services publics d'oncologie à Alexandrie, en Égypte, de 2007 jusqu'à 2016 et ont fait l'objet d’une analyse. Résultats : Au total, 5236 des 7125 dossiers disponibles étaient utilisables. L'âge médian des patientes était de 54 ans et la durée médiane des plaintes avant le diagnostic était de 3,1 mois. Près de 522 (31,5 %) des patientes avaient des antécédents familiaux de cancer. En ce qui concerne le stade de la tumeur, 2527 (55,2 %) étaient de stade précoce, 1717 (37,6 %) étaient localement avancés et 331 (7,2 %) étaient au stade IV. Les récepteurs d'œstrogènes, de progestérone et de HER2 étaient respectivement positifs chez 3869 (85 %), 3545 (78 %) et 461 (15,3 %) patientes. Une chimiothérapie a été mise en route après un délai médian de 1,03 mois. Une chimiothérapie adjuvante a été administrée à 3667 patientes (91,7 %) et une chimiothérapie néoadjuvante à 333 patientes (8,3 %) ; 3686 patientes (92,1 %) ont reçu une chimiothérapie combinée à base d'anthracycline et 3613 patientes (86 %) étaient sous traitement hormonal. Cent quatre-vingt des 317 patients éligibles se sont vu administrer le trastuzumab. Une récidive locale et/ou à distance a été observée chez 1109 patientes (21,2 %). Dans les cas non métastatiques, la survie médiane globale et la survie sans maladie étaient de 149, 1 et 77, 1 mois, respectivement. Dans les cas métastatiques, la survie médiane sans progression était de 19,6 mois. Conclusion : Nous avons observé des défauts dans le système d'enregistrement, un retard dans le diagnostic et le traitement, et une non-adhésion à la thérapie ciblée chez de nombreuses patientes. 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Introduction The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) recommend that babies should be exclusively breastfed for the first 6 months and mothers should continue breastfeeding together with supplementary food until the age of 2 years (1,2). Women are often demotivated from exclusive breastfeeding when they have to breastfeed in public places, including shopping malls, public transport, and workplaces, where women feel anxious about privacy. Breastfeeding in public can cause the woman to be embarrassed and feel ashamed (3). Women who hesitate to breastfeed in public are often unable to practice exclusive breastfeeding, making them to bottle-feed or to cover up their breast while breastfeeding (4). Although the general attitude towards breastfeeding is positive, attitudes and practices towards breastfeeding in public differ between societies. Support for breastfeeding in public is 65.0% in China, 75.0% in Canada, 66.0% in Germany and 72.0% in Africa (5–8). Mulready-Ward and Hackett reported that older women have a more negative attitude towards breastfeeding in public than younger women (9). In an online survey in the United Kingdom of Great Britain and Northern Ireland (UK), acceptance of public breastfeeding increased with educational level and was lower among males and older adults, particularly over 40 years (10). Breastfeeding in public has become more accepted in developed countries in recent years following media (11), reports that women breastfeeding in public were subjected to verbal and physical violence (12). However, there are not enough studies reflecting attitudes to breastfeeding in public in developing societies (11). In a recent integrative review of women’s experience with breastfeeding in public, most publications were from developed countries such as Australia, the United States of America (USA) and UK. The review recommended further research to increase knowledge of what women want and to support breastfeeding in public (13). The literature states that Muslim societies tend to breastfeed longer and that they generally support breastfeeding (14). However, no specific study has been found on the attitudes and practices towards breastfeeding in public in Turkey. Patient companions are common in antenatal clinics of Turkish hospitals and in all other units. (15). Mothers, mothers-in-law, sisters, etc. usually support mothers at the hospital and in the first weeks at home after birth. Abstract Background: Mothers face social and cultural obstacles to breastfeeding in public. Aims: This study evaluated the attitudes and practices of Turkish women regarding breastfeeding in public. Methods: This cross-sectional, descriptive study was carried out in a university hospital among 200 new postnatal mothers and their 200 accompanying female relatives. Data were obtained using a questionnaire and the Infant Feeding Attitude Scale (IIFAS). Results: Respondents mostly believed that there was nothing wrong with breastfeed in public and almost half of them thought the society would perceive breastfeeding in public negatively. Some 56.5% of the mothers who had previously had children and 37.2% of their relatives had breastfed in public before. The acceptance of breastfeeding in public increased “if the breast is covered” and “if a private space is provided”. The mean total IIFAS score was 61.53 (6.19) in the mothers and 60.65 (6.69) in their relatives. Based on IIFAS, the mothers (92.0%) and their relatives (89.5%) were neutral to breastfeeding, but age, education, employment status, and opinions regarding breastfeeding in public affected the IIFAS scores. IIFAS score was significantly higher in women who had breastfed in public before. Conclusion: Although the women knew the importance of breastfeeding, they mostly did not breastfeed in public because of the cultural implications and the lack of private breastfeeding areas. Awareness-raising, availability of breastfeeding rooms, and education of supporting relatives can help the increase willingness of mothers to breastfeed even if it is in public. Keywords: attitudes, public breastfeeding, mothers, relatives, university hospital Turkey Citation: Satılmış I; Yılmaz B; Acar Z. Attitudes and practices of postnatal mothers and their accompanying relatives to breastfeeding in public at a university hospital in Turkey. East Mediterr Health J. 2022;28(10):733−742. https://doi.org/10.26719/emhj.22.073 Received: 11/08/21; accepted: 29/05/22 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 734 Research article EMHJ – Vol. 28 No. 10 – 2022 Family members have important supportive roles in breastfeeding and can guide and influence mothers’ breastfeeding practices and motivations (16–18). For these reasons, our study aimed to determine the attitudes and practices of new mothers and their accompanying relatives towards breastfeeding in public. Methods Study design This cross-sectional descriptive study assessed Turkish women’s attitudes and practices around breastfeeding in public. Study sample The study population consisted of new mothers and their accompanying female relatives at Istanbul University Hospital in 2019. Inclusion criteria for mothers were: age ≥ 18 years; giving birth to a healthy child; not having a high- risk postpartum complication, or mental or language barriers; having an accompanying female relative during the hospital stay; and agreement to participate in the study. Inclusion criteria for accompanying relatives were: being the main unpaid female companion for the mother during the hospital stay; age ≥ 18 years; not having physical, mental or language barriers for the interview; and agreement to participate in the study. The following sample size calculation formula for known population was used to determine the research sample size (19). While the minimum sample size calculated for mothers was 194, considering possible missing data, 200 new mothers were included in the study. The same number of accompanying female relatives was included, with 1 for each mother. n=[918×0.80×0.20 ×(1.96)2]/ (918–1)×(0.050)2+(1.96)2×0.80 ×0.20=194 n: Number of individuals to be sampled. N: Population (number of births at the hospital in the previous year) (918). P: Incidence (acceptance rate for breastfeeding in public in Turkey). According to a global survey including Turkey (20), breastfeeding in public was viewed as wrong by 20.0% of Turkish mothers and the remaining 80.0% viewed it as natural, unavoidable etc. and accepted it completely or partly (0.80). Q: 1–P (0.20). d: margin of error (0.050). Z: z score for 95% significance level (1.96). Measurement instruments A questionnaire was prepared by the researchers in accordance with the literature, which included questions about demographic characteristics, obstetric history, breastfeeding history, and attitudes and practices around breastfeeding in public (8, 10). Iowa Infant Feeding Attitude Scale (IIFAS) The scale developed by De La Mora and Russell in 1999 evaluates women’s attitudes towards breastfeeding and estimates the duration of breastfeeding, as well as the choice of feeding methods (21). The scale is a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree) and consists of 17 items. Nine items show a positive attitude towards breastfeeding, while 8 show a positive attitude towards formula and bottle feeding. The formula feeding items are scored in reverse (1 = 5, 2 = 4, 4 = 2 and 5 = 1). The total attitude score ranges from 17 (indicating a positive attitude towards bottle feeding) to 85 points (indicating a positive attitude towards breastfeeding). Total IIFAS scores can be further categorized into groups: 70–85 shows a tendency towards breastfeeding; 49–69 a neutral stance; and 17–48 a tendency towards formula and bottle feeding (22–24). Reliability and validity tests of IIFAS were conducted by De La Mora and Russel in three studies in Iowa, and they reported Cronbach’s alpha coefficient of 0.86 in the first 2 studies and 0.68 in the third study (21). The scale was adapted adapted to Turkish language in 2016 by Ekşioğlu et al. and the Cronbach alpha coefficient was 0.71, and is a reliable and valid instrument to determine whether mothers are at risk of early breastfeeding cessation (25). In this study, the Cronbach alpha coefficient was 0.63 for the Turkish version of IIFAS. Data collection New mothers at the hospital usually remain in hospital for 24–48 hours after childbirth. The data were collected by the researchers through face-to-face interviews with the mothers and their accompanying female relatives in the mothers’ rooms before discharge. Ethical considerations Approval was obtained from the Clinical Research Ethics Committee of the related Istanbul University Faculty of Medicine (No: 79174, Date: 16 March 2018). Informed consent was obtained from the participants who met the inclusion criteria and information about anonymity and confidentiality were explained to the participants. Data analysis Percentage, mean, median, standard deviation, and minimum and maximum values were used in descriptive statistics. The Kolmogorov–Smirnov test was used to test for normality of the main dependent IIFAS score. The IIFAS scores deviated significantly from normality (Kolmogorov’s D statistic, D(400) = 0.59, P = 0.002). Although skewness (–0.470) and kurtosis (0.523) values were acceptable for normal distribution, a histogram showed a tendency to left-skewed distribution, and detrended normal graphs showed that the variable was not normally distributed. Therefore, nonparametric tests were used for the comparisons. The Mann–Whitney U test was performed for the analysis of the difference between the median of the non-normally distributed data for 2 groups. Kruskal–Wallis variance analysis was 735 Research article EMHJ – Vol. 28 No. 10 – 2022 performed for > 2 groups. The Cronbach alpha coefficient was calculated to analyse the reliability of the scale. The level of significance was P < 0.05. Results Sociodemographic characteristics of the mothers and their female relatives are shown in Table 1. Characteristics of pregnancy and birth are shown in Table 2. Most of the mothers and relatives (both 71.0%) said that breastfeeding in public would draw attention (Table 3). When asked how they thought the public would respond to breastfeeding in public, 50.0% of mothers and 48.5% of relatives said they anticipated negative responses. Most mothers (72.0%) and relatives (63.5%) thought a woman has the right to breastfeed in public, but only 62.0% and 56.5%, respectively, said that breastfeeding in public would be acceptable. However, if a private room were provided, breastfeeding in public would be acceptable to 75.0% of mothers and 83.0% of relatives. Most of the mothers (74.5%) and relatives (69.0%) said they had seen a woman breastfeeding in public and were comfortable with that (67.7% and 57.9%, respectively). It was determined that 56.5% of the mothers with previous children and 37.2% of relatives had breastfed in public. Some 32.9% of first-time mothers experienced a form of breastfeeding in public (in hospital in the presence of others/visitors, etc.) during their postpartum hospital stay. Although 40.8% of the mothers who had breastfed in public thought they were drawing attention, only 37.6% felt comfortable. For relatives, 46.2% who had breastfed in public felt comfortable, and 32.8% felt they were drawing attention. Some 81.5% of mothers and 77.0% of relatives said they would breastfeed in the breastfeeding room located in shopping malls. The total IIFAS scores were similar in mothers [mean 61.53 (6.19); median 62] and their relatives [mean 60.65 (6.69); median 61) (P > 0.05) (Table 4). It showed that 3.0% of mothers and 4.0% of relatives showed a tendency towards breastfeeding, while 5.0% of mothers and 6.5% of relatives tended towards formula bottle feeding. Most mothers (92.0%) and relatives (89.5%) were undecided. Variables about the birth in postnatal mothers including type of birth, planned pregnancy, perception of birth experience and sex of baby were not found to be related with the IIFAS score (P > 0.05). Among mothers, mean IIFAS score was significantly higher among those who had a university degree (P < 0.000), who were employed (P = 0.003) and had a good income (P = 0.016). Relatives aged 25–34 years (P = 0.008) and who had a university degree (P < 0.000) had higher IIFAS scores, while the mean IIFAS score was lower in relatives who were from Eastern Table 1 Sociodemographic characteristics of the participants Characteristics Mother (N=200) Relative (N=200) Mean age (SD), yr 29.97 (5.03) (range: 18–46) 38.96 (11.30) (range: 18–70) Age group 18–24 25–34 35–44 ≥45 n (%) 26 (13.0) 133 (66.5) 38 (19.0) 3 (1.5) n (%) 18 (9.0) 60 (30.0) 59 (29.5) 63 (31.5) Place of birth Western Anatolian Region Central Anatolian Region Eastern Anatolian Region 106 (53.0) 49 (24.5) 45 (22.5) 68 (49.5) 89 (33.0) 33 (17.5) Longest place of residence Western Anatolian Region Central Anatolian Region Eastern Anatolian Region 130 (64.5) 37 (18.5) 33 (17.0) 136 (68.0) 52 (26.0) 12 (6.0) Educational status Primary school Secondary school High school University and above 49 (24.5) 28 (14.0) 52 (26.0) 71 (35.5) 66 (33.0) 31 (15.5) 51 (25.5) 52 (26.0) Working status Employed Unemployed 77 (38.5) 123 (61.5) 67 (33.5) 133 (66.5) Perceived income status according to the income/expense balance Poor Medium Good 21 (10.5) 142 (71.0) 37 (18.5) 32 (16.0) 134 (67.0) 34 (17.0) Family type Nuclear family Extended family 165 (82.5) 35 (17.5) 163 (81.5) 37 (18.5) Number of living children 0 1 2 and more — 85 (42.5) 115 (57.5) 20 (10.0) 57 (28.5) 123 (61.5) Total 200 (100.0) 200 (100.0) SD = standard deviation. Table 2 Characteristics of pregnancy and birth Postnatal mothers (N=200) n % Type of birth Normal birth Caesarean section 84 116 42.0 58.0 Planned pregnancy Yes No 148 52 74.0 26.0 High risk pregnancy (diagnosed & monitored because of a maternal/ fetal risk) Yes No 68 132 34.0 66.0 Prolonged birth (>24 h) with interventions such as vacuum delivery Yes No 22 178 11.0 89.0 Personal perception of birth experience Positive Neutral Negative 129 38 33 64.5 19.0 16.5 Sex of baby Female Male 110 90 55.0 45.0 Total 200 100.0 736 Research article EMHJ – Vol. 28 No. 10 – 2022 Table 3 The attitudes and practices about breastfeeding in public Attitudes and practices Mother N (%) Relative N (%) Feeding of previous child during the first 6 months Only breastmilk Breastmilk+formula/additional nutrition n=115a 68 (59.1) 47 (40.9) n=180b 109 (60.5) 71 (39.5) Would breastfeeding in public draw attention? Yes Not sure No N=200 142 (71.0) 23 (11.5) 35 (17.5) N =200 142 (71.0) 21 (10.5) 37 (18.5) What kind of attention would breastfeeding in public draw? Positive Neutral Negative N=200 39 (19.5) 61 (30.5) 100 (50.0) N=200 48 (24.0) 55 (27.5) 97 (48.5) Do you think women have the right to breastfeed in public? Yes Not sure No N=200 142 (72.0) 31 (15.5) 27 (13.5) N=200 127 (63.5) 37 (18.5) 36 (18.0) Is breastfeeding in public acceptable? Yes Not sure No N=200 124 (62.0) 39 (19.5) 37 (18.5) N =200 113 (56.5) 39 (19.5) 48 (24.0) In which situations is breastfeeding in public acceptable? (More than one option) If the mothers turns away If the mothers covers her breast If a special environment/room is provided N=200 76 (38.0) 139 (69.5) 150 (75.0) N=200 77 (38.5) 141 (70.5) 166 (83.0) Is it appropriate to show a breastfeeding woman on TV shows? Yes Not sure No N=200 95 (47.5) 39 (19.5) 65 (32.5) N=200 71 (35.5) 44 (22.0) 84 (42.0) Have you encountered a breastfeeding mother in public? Yes No N=200 149 (74.5) 51 (25.5) N=200 138 (69.0) 62 (31.0) How did you feel while encountering a breastfeeding mother in public? Comfortable Worried/anxious Uncomfortable Ashamed N=149 101 (67.7) 20 (13.4) 15 (10.0) 13 (8.9) N=138 80 (57.9) 22 (15.9) 25 (18.1) 13 (8.1) Have you breastfed at home in the presence of another woman? (only those with a previous child) Yes No N=115a 66 (57.4) 49 (42.6) N=180b 127 (70.6) 53 (29.4) If yes, how did you feel? Comfortable Worried/anxious Uncomfortable Ashamed N=66 42 (63.5) 9 (13.9) 8 (11.9) 7 (10.7) N=127 76 (59.8) 15 (11.5) 16 (12.9) 20 (15.8) Have you breastfed at home in the presence of a man? (only those with a previous child) Yes No N=115a 42 (36.5) 73 (63.5) N=180b 55 (30.5) 125 (69.5) If yes, how did you feel? Comfortable Worried/anxious Uncomfortable Ashamed N=42 38 (90.4) 17 (40.4) 10 (23.8) 8 (19.0) N=55 26 (47.2) 17 (30.9) 8 (14.5) 10 (18.1) Have you breastfed in public? (only those with a previous child) Yes No N=115a 65 (56.5) 50 (43.5) N=180b 67 (37.2) 113 (62.8) Have you breastfed the current newborn in public? (in hospital in the presence of others/ visitors, etc)? (only for mothers having their first child) N=85 Non Applicable Yes 28 (32.9) No 57 (67.1) 737 Research article EMHJ – Vol. 28 No. 10 – 2022 Anatolia (P = 0.046) and had ≥ 2 children (P = 0.008). Mothers and relatives who thought it was their right to breastfeed in public (P = 0.001) and found the practice acceptable (P < 0.000) had higher total IIFAS scores than women who were undecided or had negative perceptions regarding the issue. Discussion In the current study, new mothers and their accompanying relatives mostly believed that it was their right to breastfeed in public; however, their breastfeeding experiences in public were limited because of cultural concerns and lack of suitable environments. Positive infant feeding attitudes were related to sociodemographic characteristics and breastfeeding experiences in public. The attitudes and practices of female relatives about breastfeeding influence mothers’ decisions to initiate and continue breastfeeding (16). In Turkish culture, maternal grandmothers/mothers-in-law are prominent during breastfeeding as well as in raising children, and share many experiences with mothers. One study showed that mothers, regardless of their age and education level, were affected by the experiences of the older generation and felt pressure during breastfeeding (18). It is considered important to examine the opinions of women who are family members and have the potential to influence and support maternal decisions about breastfeeding in public. One of the factors that determine the continuation of breastfeeding is the necessity of breastfeeding in public spaces. A study in Ghana reported that while 77.0% of women thought that mothers have the right to breastfeed in public, only 62.7% stated that it is acceptable (8). In a study in China, 65.0% of the participants stated that breastfeeding in public is acceptable (5). In a global survey conducted by a leading manufacturer of breastfeeding accessories that included 13 000 mothers from Brazil, China, France, Germany, Hungary, Mexico, Turkey, UK and USA in 2014, breastfeeding in public was viewed as wrong by 20.0% of Turkish mothers, which was the highest rate among the countries (20). In this study, although 72.0% of mothers and 63.5% of relatives believed in the right to breastfeed in public, only 62.0% and 56.5%, respectively, found it acceptable. The closeness of the acceptance rates in the different studies indicates that many women in different cultures have similar cultural, religious and environmental concerns that affect their attitudes towards breastfeeding in public. Seeing a woman breastfeed in public often raises complex and negative emotions. A recent review of women’s experiences with breastfeeding in public across diverse international contexts revealed the challenges to include drawing attention, sexualization of breasts, awareness of others’ discomfort, and efforts not to be seen, while women’s perceptions of what enhanced their experience were confidence and a supportive audience (13). In another recent online survey on women in Australia, Ireland and Sweden, challenges to breastfeeding in public included unwanted attention, no comfortable place to sit, unsuitable environment, awkward audience, and not wearing appropriate clothing, while supportive network, quiet private environment, comfortable seating, understanding and acceptance of others, and seeing other mothers breastfeeding were helpful (26). A study conducted in the USA found that 33.2% of participants felt uncomfortable when they saw a woman breastfeeding in public (5). In another study in China, 47.0% said that seeing a woman breastfeeding in public was embarrassing (5). In a study conducted in the UK, participants did not know where to look when they saw a breastfeeding mother and they felt shame (10). Attitudes towards breastfeeding in public are mostly related to perceived cultural norms (27). In a meta- synthesis, grandmothers thought that breastfeeding in public causes embarrassment or disapproval of mothers because the breast represents sexuality (17). In this study, feeling anxious (mothers 13.4%, relatives 15.9%), uncomfortable (mothers 10.0%, relatives 18.1%) and ashamed (mothers 8.9%, relatives 8.1%) were reported. However, these negative attitudes may be evaluated as low because mothers use breastfeeding covers and prefer breastfeeding cabins/rooms when in public. Attitudes and practices Mother N (%) Relative N (%) How did you feel when breastfeeding in public? Comfortable I felt like I was drawing attention I thought I would draw negative responses Ashamed N=93 35 (37.6) 38 (40.8) 3 (3.2) 17 (18.4) N=67 31 (46.2) 22 (32.8) 7 (10.5) 7 (10.5) Where would you breastfeed? In a nursing room within a shopping mall Anywhere in a shopping mall Restaurant/Cafe Public transportation Park At another person's house, in the presence of other people None N=200 163 (81.5) 49 (24.5) 50 (25.0) 32 (16.0) 48 (24.0) 69 (34.5) 24 (12.0) N=200 154 (77.0) 37 (18.5) 26 (13.0) 29 (14.5) 31 (15.5) 42 (21.0) 36 (18.0) a85 mothers had the first child. b20 relatives did not have a child. Table 3 The attitudes and practices about breastfeeding in public (concluded) 738 Research article EMHJ – Vol. 28 No. 10 – 2022 Table 4 IIFAS scores of the participants and related factors IIFAS Mother (N=200) Relative (N=200) IIFAS total score (min–max) 42–75 36–77 Mean (SD) 61.53 (6.19) 60.65 (6.69) Median (Q1–Q3)a 62.0 (57–67) 61.0 (57–65) Mean rank 208.47 192.53 Test and P value z = –1.380 P=0.167 IIFAS groups n (%) n (%) Tendency to breastfeed 6 (3.0) 8 (4.0) Undecided 184 (92.0) 179 (89.5) Tendency to formula feeding 10 (5.0) 13 (6.5) Test and P value χ2=0.746 P=0.689 Sociodemographic variables Mother (N=200) IIFAS score Med (Q1–Q3)* mean rank Relative (N=200) IIFAS score Med (Q1–Q3)* mean rank Age 18–24 years 25–34 years 35–44 years 45 and older Test and P value 59 (55–66) 83.52 62 (58–66) 101.83 63 (57–67) 106.41 64 (58–67) 113.83 KW χ2=2.873/0.412 60 (56–63) 88.11a 63 (58–68) 119.58b 62 (56–66) 99.32c 60 (54–63) 85.15d KW χ2 = 11.867/0.008 b>c Longest place of residence Western Anatolian Region Central Anatolian Region Eastern Anatolian Region Test and P value 62 (57–67) 100.36 62 (58–68) 107.75 61 (57–64) 90.00 KW χ2=1.878/0.391 60 (56–65) 97.02a 62 (59–67) 111.82b 59 (53–60) 71.17c KW χ2=6.140/0.046 b>c Educational status Primary school Secondary school High school University and above Test and P value 61 (57–66) 93.23a 59 (54–64) 76.55b 61 (57–63) 85.41c 64 (61–68) 126.01d KW χ2= 2.965/<0.000 d> a, b and c 60 (55–63) 88.05a 59 (54–63) 80.69b 61 (58–63) 98.29c 64 (60–68) 130.27d KW χ2=20.582/<0.000 d> a, b and c Working status Employed Unemployed Test and P value 63 (59–67) 115.94 61 (57–65) 90.83 z = –2.990/0.003 62 (57–67) 107.41 60 (56–64) 97.02 z = –1.20/0.230 Perceived income status Bad Medium Good Test and P value 59 (57–62) 70.43a 62 (57–67) 100.96b 64 (61–67) 115.80c KW χ2=8.290/ 0.016 c>a 62 (58–66) 109.42 60 (56–65) 98.15 61 (53–67) 101.37 KW χ2=0.992/0.609 Family type Nuclear family Extended family Test and P value 62 (57–67) 101.95 61 (58–66) 93.67 z = –0.770/0.441 61 (57–66) 103.68 59 (53–63) 86.50 z = –1.633/0.103 Number of living children 0 1 2 and more Test and p value — 62 (58–66) 102.39 63 (58–67) 99.10 z = –399/0.690 61 (57–66) 94.45a 63 (58–67) 104.49b 61 (58–64) 82.94c KW χ2 = 6.348/0.042 b>c Variables about attitudes/practices towards breastfeeding in public Mother (N=200) IIFAS score (mean, SD) Relative (N=200) IIFAS score (mean, SD) What kind of attention would breastfeeding in public draw? Positive Neutral Negative Test and P value 63 (59–67) 98.04 62 (58–67) 90.57 61 (57–66) 117.03 KW χ2=3.056/0.217 61 (59–66) 93.39 63 (58–67) 113.98 60 (55–64) 120.12 KW χ2=5.294/0.071 739 Research article EMHJ – Vol. 28 No. 10 – 2022 Women who breastfeed in public can be accused of having bad ethical values and of being bad parents (28). It is expected that women would take necessary precautions due to reactions from other people when breastfeeding in public places, to minimize the problems that may occur, and keep themselves safe (12). Mothers are expected to work, do the shopping, and take their babies to hospital. In such situations, mothers prefer to prepare breastmilk beforehand or use formulae, use unsuitable environments such as bathrooms or toilets, and/or cover their breast while breastfeeding in public places to avoid embarrassment (27,28). In Ghana, 81.0% of participants said that women should cover their breast and 70.3% that mothers should breastfeed in specially designated places and rooms (8). A study in Romania showed that mothers need a secluded and safe environment when breastfeeding outside their homes, and not being able to find such a place can create tension for mothers who want to breastfeed in public (29). In this study, the acceptability of breastfeeding in public increased when the breast was covered (mothers 69.5%, relatives 70.5%) and when a private area was provided (mothers 75.0%, relatives 83.0%). Breastfeeding is restricted to the home environment or expected to be performed in environments such as public toilets due to lack of suitable conditions. It should be a mother’s choice whether to use a cover or private room, and depends on their own values and perception of privacy. Beyond covering the breast, mothers’ attitudes before and during breastfeeding are important for the acceptability of breastfeeding in public (10). A study determined that mothers felt pried upon while breastfeeding and that this made them feel anxious. Many mothers feel comfortable when breastfeeding in the presence of other women but uncomfortable when breastfeeding next to their fathers, friends of their husband, or strangers (30). Hauck et al reported that, women who had to breastfeed in front of someone they felt uncomfortable, most often tried not to be seen, moved to a private place, turned away and just got on with breastfeeding (13). Similarly, in this study, more mothers felt uncomfortable breastfeeding in the presence of a man. This can be explained by the fact that the breast is associated with sexuality, and the mothers’ perception of privacy. Mothers’ infant feeding attitudes may affect their views on breastfeeding in public (27). A study conducted in Korea found a positive relationship between breastfeeding in public and breastfeeding continuation (31). Another study reported that people with knowledge about breastfeeding or who have seen people breastfeed in public had greater positive attitudes towards breastfeeding in public (5). Similarly, our study found that mothers and relatives with positive attitudes towards breastfeeding in public and mothers who breasfed in public were more positive. In addition, higher Variables about attitudes/practices towards breastfeeding in public Mother (N=200) IIFAS score (mean, SD) Relative (N=200) IIFAS score (mean, SD) Do you think women have the right to breastfeed in public? Yes I am not sure No Test and P value 63 (59–67) 110.00a 58 (55–63) 75.94b 59 (54–65) 78.72c KW χ2=13.280/0.001 a> b and c 62 (58–67) 112.01a 59 (53–63) 83.82b 58 (54–62) 77.03c KW χ2=14.063/0.001 a>b and c Is breastfeeding in public acceptable? Yes I am not sure No Test and P value 63 (59–67) 114.00a 58 (54–63) 71.05b 61 (56–64) 86.31c KW χ2=19.126/<0.000 a>b and c 63 (58–67) 115.23a 59 (55–63) 83.03b 59 (55–63) 80.01c KW χ2=16.950/<0.000 a> b and c Have you breastfed at home in the presence of another woman? (only those with a previous child) Yes No Test and P value 62 (57–67) 100.84 60 (56–66) 90.63 z = –1.062/0.288 62 (58–66) 101.99 58 (54–63) 73.30 z= –3.014/0.003 Have you breastfed at home in the presence of a man? (only those with a previous child) Yes No Test and P value 63 (58–67) 109.17 61 (57–65) 91.32 z = –2.142/0.032 63 (59–67) 119.66 60 (55–63) 83.25 z = –4.286/<0.000 Have you breastfed in public before? Yes No Test and P value 63 (57–67) 104.00 61 (57–66) 90.49 z = –1.682/0.093 64 (59–67) 114.35 60 (55–63) 81.76 z = –3.970/ <0.000 Mann–Whitney U test – z value; Kruskal Wallis variance analysis – KW χ2 value, P < 0.05. a,b,c,d are subgroup names in the question and used to indicate which group the difference originated from when comparing IIFAS score (for example a>b) *Q1–Q3 are quartiles for 25th and 75th percentile. IIFAS = Iowa Infant Feeding Attitude Scale; KW = Kruskal Wallis; SD = standard deviation. Table 4 IIFAS scores of the participants and related factors (concluded) 740 Research article EMHJ – Vol. 28 No. 10 – 2022 IIFAS scores in mothers who had a university degree, who were employed or had a good income demonstrate the importance of social status of women for increased awareness about breastfeeding. In the same way, relatives aged 25–34 years with higher IIFAS scores or who had a university degree were the most effective for supporting mothers, with their positive attitudes about breastfeeding. Health professionals must be aware that older relatives from less developed regions with ≥ 2 children may need more education to increase their awareness and positive attitudes while supporting mothers. Most mothers and relatives were neutral/undecided towards breastfeeding and health professionals can help them become more positive through education. Positive role models and social values that support breastfeeding in a normal and desired manner contribute positively to breastfeeding attitudes. Within the scope of the 2016 Breastfeeding Week, the WHO and UNICEF created many brochures with the slogan “Support mums to breastfeed anytime, anywhere”. An online pilot study showed that brief exposure to 4 different images of public breastfeeding resulted in a marginal increase in positive attitudes toward public breastfeeding (32). Similarly, every country should use this power of the media to create social awareness in line with its own social and cultural values. This study had some limitations. The results from this hospital-based sample in Istanbul cannot be generalized to the country. Questioning the views of new mothers may have caused them to display a more positive attitude towards breastfeeding in public. In addition, the accompanying relatives of the mothers were mostly their mothers and were within a certain age category. Conclusion This study found that women generally believe it is their right to breastfeed in public. There were negative attitudes towards breastfeeding in public but it was acceptable if the breast was covered or when a special environment was provided. Positive infant feeding attitudes were related to sociodemographic characteristics and breastfeeding experiences in public. Besides informing about the health benefits of breastfeeding, addressing common attitudes towards breastfeeding in public can help promote breastfeeding. Media support can help raise awareness and eliminate negative perceptions. Availability of breastfeeding rooms will also contribute to sustaining breastfeeding. Mothers’ own values and perceptions of privacy should be evaluated and mothers should be encouraged to breastfeed when and where they and their babies need it. Health professionals should be aware of the importance of relatives in breastfeeding support, and should provide opportunities for the accompanying support person to participate in breastfeeding education with mothers. Funding: None Competing interests: None declared. Attitudes et pratiques des mères en période postnatale et de leurs accompagnatrices de l'entourage proche vis-à-vis de l'allaitement en public dans un hôpital universitaire en Turquie Résumé Contexte : Les mères font face à des obstacles sociaux et culturels concernant l'allaitement en public. Objectifs : La présente étude a évalué les attitudes et les pratiques des femmes turques en matière d'allaitement en public. Méthodes : Cette étude transversale et descriptive a été menée dans un hôpital universitaire auprès de 200 nouvelles mères en période postnatale et de leurs 200 accompagnatrices de l'entourage proche. Les données ont été obtenues au moyen d'un questionnaire et de l'échelle d'attitude à l'égard de l'alimentation des nourrissons (IIFAS). Résultats : La plupart des personnes interrogées pensaient qu'il n'y avait rien de mal à allaiter en public et près de la moitié d'entre elles étaient d'avis que la société perçoit négativement l'allaitement en public. Près de 56,5 % des mères qui avaient déjà eu des enfants et 37,2 % de leurs proches avaient déjà allaité en public. L'acceptation de l'allaitement en public était renforcée « si le sein est couvert » et « si un espace privé est prévu ». Le score total moyen de l'échelle d'attitude à l'égard de l'alimentation des nourrissons était de 61,53 (6,19) chez les mères et de 60,65 (6,69) chez leurs proches. Selon cette échelle, les mères (92,0 %) et leurs proches (89,5 %) étaient neutres vis-à-vis de l'allaitement, mais l'âge, le niveau d'éducation, le statut professionnel et les opinions concernant l'allaitement en public affectaient les scores IIFAS. Ces derniers étaient significativement plus élevés chez les femmes qui avaient déjà allaité en public. Conclusion : Même si les femmes connaissaient l'importance de l'allaitement, elles n'allaitaient généralement pas en public en raison des implications culturelles et du manque d'espaces privés pour l'allaitement. La sensibilisation, la disponibilité de salles d'allaitement et l'éducation des proches qui soutiennent les mères peuvent contribuer à accroître la volonté des mères d'allaiter, même dans un lieu public. 741 Research article EMHJ – Vol. 28 No. 10 – 2022 References 1. Breastfeeding infographics. Geneva: World Health Organization; 2016 (https://www.who.int/nutrition/topics/breastfeeding_in- fographics/en/, accessed 16 March 2020). 2. Breastfeeding: a key to sustainable development. UNICEF Executive Director Anthon Lake, WHO Director General Margaret Chan World Breastfeeding Week 2016 Message. Geneva: World Health Organization; 2017 (https://www.who.int/mediacentre/ events/2016/2016-world-breastfeeding-week-letter.pdf, accessed cited 17 March 2020) 3. Hvatum I, Glavin K. Mothers’ experience of not breastfeeding in a breastfeeding culture. J Clin Nurs. 2017 Oct;26(19–20):3144– 55. doi:10.1111/jocn.13663 PMID:27875035 4. Chopel A, Soto D, Joiner B, Benitez T, Konoff R, Rios L, et al. 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Int Breastfeed J. 2019 Jun 11;14:24–35. https://doi. org/10.1186/s13006-019-0216-y PMID:31205479 اذه في نتهاسراممو ةماعلا نكاملأا في ةيعيبطلا ةعاضرلا ةشرابم نم تاقفارلما نتهابيرقو ةدلاولا دعب تاهملأا تاهاتجا ايكرت في ةيعمالجا تايفشتسلما دحأ في ةسارد :ددصلا راكأ ةرهز ،زملي اشرب ،زمليتاس روجنوج ياكلإ ةصلالخا .ةماعلا نكاملأا في ةيعيبطلا ةعاضرلا ةشرابم نأشب ةيفاقثو ةيعماتجا تابقع تاهملأا هجاوت :ةيفللخا نأشلا اذه في نتهاسراممو ةماعلا نكاملأا في ةيعيبطلا ةعاضرلا ةشرابم ءازإ تايكترلا ءاسنلا تاهاتجإ مييقت لىا ةساردلا هذه تفده :فادهلأا نتهابيرق نم 200و ةدلاولا تاثيدح تاهملأا نم 200 تمضو ،يعماج ىفشتسم في ةيعطقلما ةيفصولا ةساردلا هذه تيرجُأ :ثحبلا قرط .ع َّض ُّرلا ةيذغت تاه ُّجوت سايقمو نايبتسا مادختساب تانايبلا تعُِجُم دقو .تاقفارلما نأ اًبيرقت نهُفصن ىأر نكلو ،ةماعلا نكاملأا في ةيعيبطلا ةعاضرلا ةشرابم في أطخ لاو يرض لا هنأ ثحبلا في تاكِراشلما تأر ام اًبلاغ :جئاتنلا %37.2و باجنلإا نله قبس تيلالا تاهملأا نم %56.5 وحن نأ َّيَّنبتو .ةيبلس ًةرظن ةماعلا نكاملأا في ةيعيبطلا ةعاضرلا ةشرابم لىإ رظنيس عمتجلما يرفوت«و »يدثلا ةيطغت« ةلاح في ةماعلا نكاملأا في ةيعيبطلا ةعاضرلا ةشرابم لُّبقت دازو .لبق نم ةماعلا نكاملأا في نلهافطأ نعضرأ دق نتهابيرق نم ىدل )6.69( 60.65و تاهملأا ىدل )6.19( 61.53 ع َّض ُّرلا ةيذغت تاه ُّجوت سايقم لىع ةجيتنلا لياجُمإ طسوتم ناكو .»رملأل صاخ ناكم ةعاضرلا ةشرابم نم ديامح فقوم نيهدل نتهابيرق نم %89.5و تاهملأا نم %92.0 نإف ،ع َّض ُّرلا ةيذغت تاه ُّجوت سايقم بسحو .نتهابيرق في جئاتنلا لىع اًعيجُم ترَّثأ ةماعلا نكاملأا في ةيعيبطلا ةعاضرلا ةشرابمب ةقلعتلما ءارلآاو يفيظولا عضولاو ميلعتلاو رمعلا لماوع نكلو ،ةيعيبطلا ةيعيبطلا ةعاضرلا ةشرابم نله قبس تيلالا ءاسنلا ىدل اًيرثك لىعأ ع َّض ُّرلا ةيذغت تاه ُّجوت سايقم لىع جئاتنلا تناك .ع َّض ُّرلا ةيذغت تاه ُّجوت سايقم .ةماعلا نكاملأا في ،ةيفاقثلا لماوعلا ببسب ةماعلا نكاملأا في نلهافطأ نعضرُي لا بلاغلا في ننهإف كلذ عمو ،ةيعيبطلا ةعاضرلا ةيهمأ نفرعي ءاسنلا نإ :تاجاتنتسلاا نأ ،يَّنمعادلا براقلأا فيقثتو ،ةيعيبطلا ةعاضرلا ةشرابلم فَرُغ ر ُّفوتو ،يعولا ةدايزل نكمي اذل .ةيعيبطلا ةعاضرلا ةشرابلم ةصاخ قطانم بايغو .ةماعلا نكاملأا في كلذ ناك نإو ،ةيعيبطلا ةعاضرلا ةشرابلم تاهملأا دادعتسا ةدايز في دعاسي 742 Research article EMHJ – Vol. 28 No. 10 – 2022 13. 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Health Commun. 2022 Feb;37(2):185–90. https://doi.org/10.1080/10410236.2020.1830511 PMID:33019836 743 Research article EMHJ – Vol. 28 No. 10 – 2022 Assessment of gender gap in surgical specialties among Lebanese medical personnel: the need for involvement of women in surgery Said El Hage,1,2,3 Elias Wakim,1 Georgio Sayde,1 Dany Akiki1 and Pascale Salameh1,3,4,5 1Department of Medicine, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon (Correspondence to: D. Akiki: danyakiki@live.com). 2Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon. 3Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie, Sector of Public Health and Epidemiology, Department of Public Health, Beirut, Lebanon. 4Department of Basic Science, Faculty of Pharmacy, Lebanese University, Beirut, Lebanon. 5Department of Primary Care and Population Health, Medical School, University of Nicosia, Nicosia, Cyprus. Introduction In the last century, the implementation of gender equality has faced several obstacles. Gender disparity manifests as social, educational, financial, and workplace discrimination. Numerous crucial milestones were achieved in the last 200 years, such as the ratification of the Nineteenth Amendment of the American Constitution in 1920 and the Equal Pay Act signed by President Kennedy in 1963 (1). Despite much progress in closing the gender gap, the patriarchal mindset is still a serious impediment to ensuring gender fairness in the workplace. Medicine has long been a male-dominated field. Fortunately, over the last 30 years, the number of female physicians and medical students has witnessed a remarkable increase (2). In 2019, for the first time in the United States of America (USA), women represented the majority of medical students (50.5%). However, some specialties remain tenaciously male-oriented, with surgical specialties being the most affected by gender disparity. Despite an increase in the number of female surgical residents, the total number of female surgeons remains low (3). Although discrimination and harassment are common among both male and female general surgery residents, rates are markedly higher among women (4). Gender-based discrimination is perceived at different stages of medical careers, from medical school to surgical practice (5). Arab countries in particular have long had gender inequality, and have the lowest female participation in the labour force worldwide, with female unemployment rate 3 times higher than the global average (6). Patricentric standards and stereotypes, harassment, and legal restraints are among the problems encountered daily by women in Arab countries (6). The medical field is no exception, and female physicians in Arab countries suffer from discrimination on the cultural, social and structural levels (7). Surgical specialties in particular are male dominated with a limited place for female surgeons (8). Lebanon has long been known as one of the most liberal Arab countries (9), and women and men have the same opportunities to choose any career path. However, Lebanon ranks 132 out of 156 countries in the Global Gender Index (10). According to the United Nations, only 29% of women participate in the Lebanese employment market, compared to 76% of men (11). To date, no study has described the status of female physicians in Lebanon Abstract Background: Little is known about gender disparity in the surgery specialty in Lebanon. Aims: To assess the status of female surgeons and possible gender gaps in surgery specialty in Lebanon. Methods: The study was conducted in May 2021. Data were retrieved from the Lebanese Order of Physicians website, indicating the number of physicians in the different specialties, their gender, hospitals, and locations. The c2 test of homogeneity was used to establish whether the gender distribution was equal. Results: Women only accounted for 21.84% (3,370) of physicians in Lebanon, with surgery having the lowest number of female physicians in (n = 65; 2.30%). Women accounted for 1.63% of all surgeons in Lebanese hospitals, there were more female plastic and reconstructive surgeons (n = 12; 7.14%), while neurosurgery, oncological surgery and vascular surgery had no females. There was no significant difference in gender between academic and non-academic institutions (χ2 = 2.164, P = 0.149), or between public and private hospitals (χ2 = 1.277, P = 0.234). Conclusion: The surgical specialty had the widest gender gap among all the medical fields in Lebanon. Therefore, the healthcare systems, including public and private hospitals, have a long and difficult road in narrowing the gender gap. Different strategies to incorporate women into surgery should be explored to assure equitable opportunities for all physicians, based on competency rather than gender. Keywords: women, physicians, gender gap, surgery, Lebanon. Citation: El Hage S; Wakim E; Sayde G; Akiki D; Pascale Salameh. Assessment of gender gap in surgical specialties among Lebanese medical personnel: the need for involvement of women in surgery. East Mediterr Health J. 2022;28(10):743–750. https://doi.org/10.26719/emhj.22.077 Received: 09/08/21; accepted: 29/05/22 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 744 Research article EMHJ – Vol. 28 No. 10 – 2022 and the possible gender gap in surgery. Our objective was to show the gender gap in surgery in Lebanon. Methods Data collection and cleaning This was an epidemiological cross-sectional study. Data were retrieved from the Lebanese Order of Physicians website (https://lopbeirut.org/en/homepage-en/) in January 2019. Two authors independently reviewed 15 429 physicians for inconsistencies, duplications, hospitals, and assigned gender. Specialties were grouped into 7 domains: general medicine, internal medicine, obstetrics– gynaecology, paediatrics, psychiatry, surgery, and others. The latter included specialties that did not fit into the classical domains of medicine. The surgical domain included the following specialties: general surgery, neurosurgery, oncological surgery, orthopaedic surgery, otorhinolaryngology, plastic and reconstructive surgery, thoracic and cardiovascular surgery, urological surgery, and vascular surgery. The numbers of physicians in the different specialties, as well as physicians’ specialties, gender and hospitals, were retrieved. Each hospital was assigned its appropriate location in Lebanon (Beirut, Metn-Baabda, North Region, Keserwan-Jbeil, Chouf-Aley, South and Nabatiyeh, and Beqaa Region). Hospitals were also divided into academic and nonacademic centres/ hospitals. Academic hospitals included the Al Makassed, Al Sahel and Al Zahraa Hospitals, American University of Beirut Medical Center, Baabda Governmental Hospital, the Lebanese American University Medical Center, Hotel-Dieu de France, Libanais-Geitaoui, Notre Dame de Secours Hospital, President Martyr Rafic Baha eddin Hariri Hospital, and Saint George Orthodox Hospital. Ethical clearance The data were available publicly on the Lebanese Order of Physicians website; therefore, no ethical clearance was needed. In addition, physicians’ names or IDs were blinded during the study and are not mentioned in the manuscript. Statistical analysis Univariate analysis was conducted for all the variables. SPSS for Windows version 23.0 was used to collect data, calculate P values, and analyse the data. Physician gender distribution in each surgical specialty, hospitals, regions, academic centres, and nonacademic centres were retrieved. A χ2 test of homogeneity was used to test whether gender distribution was equal. A χ2 test was used to assess whether gender distribution among academic hospitals was equal to that of nonacademic centres. It should be noted that when assessing physician distribution in hospitals, a single physician could occur in several hospitals and each post in the hospital was taken individually, even if there was a duplicate in another hospital. Results Gender distribution of Lebanese physicians in the different domains in Lebanon is shown in Table 1. Most physicians in Lebanon were male (12 059; 78.2%) and only 21.8% (3370) were female. Women accounted for 39.3% (n = 558) of physicians in paediatrics; the domain with the highest frequency of female physicians. The lowest frequency of female physicians was in surgery, with only 2.30% (n = 65). In all of these results, test of homogeneity revealed unequal gender distribution skewed towards male physicians (P < 0.001). Among all the surgical specialties, the highest frequency of female physicians was in plastic surgery (n = 12; 7.1%) followed by otolaryngological surgery (n=19; 4.7%) and general surgery (n = 19; 2.1%). The same pattern was reported in the USA, Canada, Brazil, and Argentina, where female surgeons were most involved in plastic, otolaryngological and general surgery (Table 2). There were no female physicians in neurosurgery, vascular surgery or oncological surgery. Regarding the gender distribution of surgeons between hospitals, there were 46 female surgeons in 37 of 157 hospitals in Lebanon (Table 3). Al Zahraa hospital had 4 female surgeons, which was the highest number among all the hospitals. Six hospitals had 2 female surgeons and 30 had only 1. The highest percentage of female surgeons was in Beydoun (20.0%) and Hasbaya Governmental Table 1 Gender distribution of physicians in the different domains of medicine in Lebanon Domain Gender Total Female (%) Male General medicine 1092 (23.0) 3653 4745 Internal medicine 445 (17.7) 2069 2514 Obstetrics/gynaecology 383 (31.0) 852 1235 Others 794 (30.5) 1807 2601 Paediatrics 558 (39.3) 862 1420 Psychiatry 33 (23.2) 109 142 Surgery 65 (2.3) 2707 2772 Total 3370 (21.8) 12059 15429 745 Research article EMHJ – Vol. 28 No. 10 – 2022 Hospital (18.2%). This high percentage was because of the low number of surgeons overall in the investigated hospital. The total percentage of female surgeons in all Lebanese hospitals was 1.6%, which was significantly lower than the percentage of male surgeons (P < 0.001). Academic centres had 14 (2.3%) females surgeons, while nonacademic centres had 32 (1.4%) (Table 4). The χ2 test showed no significant gender difference between the 2 types of centres (χ2 = 2.164, P = 0.149). Public hospitals had only 5 (2.6%) female surgeons, whereas private hospitals had 41 (1.5%). The χ2 test showed equal distribution of male and female surgeons in public and private hospitals (χ2 = 1.277, P = 0.234). Bekaa, Keserwan, and Beirut Regions had the highest percentage of female surgeons at 2.33%, 2%, and 1.8%, respectively (Table 5). In contrast, Chouf-Aley and the North Region had no female surgeons. However, the χ2 test revealed no significant difference between males and females in the different regions of Lebanon (χ2 = 4.17, P = 0.394). Discussion In summary, 21.8% (n = 3370) of physicians and 2.3% (n = 65) of surgeons in Lebanon were women. Among the surgical specialties, the highest frequencies of women were in otolaryngological surgery with 4.7% (n = 19) and general surgery with 2.1% (n = 19). Female surgeons were present in 37 of 157 hospitals in Lebanon. The highest number was at Al Zahraa Hospital (n = 4), while the highest frequency was at Hasbaya Governmental Hospital (18.2%). Distribution of female surgeons did not differ significantly between academic (n = 14; 2.3%) and nonacademic (n = 32; 1.4%), and public (n = 5; 2.6%) and private (n = 41; 1.5%) hospitals. Bekaa Region had the highest percentage of female surgeons (2.33%). In agreement with our results, several studies have shown that obstetrics and gynaecology, and paediatrics have the highest rates of female physicians, while surgical specialties are more male-oriented (12,13). However, the gender gap observed in surgical specialties is less obvious in more developed countries. Among the surgical specialties, orthopaedic, cardiothoracic and urological surgery had the lowest proportions of female surgeons in Lebanon. Remarkably, there were no female physicians in neurosurgery and vascular surgery. Compared with other countries, orthopaedics, urological surgery and cardiothoracic surgery were largely male-dominated specialties in Lebanon. The highest percentage of female surgeons in Lebanon was in plastic surgery and otorhinolaryngological surgery, with 7.1% and 4.7%, respectively. The trends in other countries show that the highest female ratio is also in plastic surgery and otorhinolaryngological surgery, in addition to general surgery. The domains with the highest rates of female physicians in Lebanon hardly exceeded the rates of female physicians in the most male-oriented specialties in the USA, Canada, Brazil, Argentina, Germany, and Sweden. There is an erroneous misconception that women cannot balance between career and sociomarital life. It is seen particularly in the residency years, which coincide with the prime childbearing age; thus, female physicians tend to avoid a surgical specialty to establish a healthy sociomarital life (14). Although the number of female surgical residents and physicians is increasing, gender disparity is still obvious in healthcare leadership positions in the most advanced countries (15). In the countries where the gap is at its narrowest, women are rarely in chief executive positions. Healthcare systems in Lebanon still have a long way to go in assisting women to climb the leadership ladder and break the glass ceiling. Many studies have discussed the impact of gender on the choice of medical students’ specialties. A systemic review of 751 studies suggested that women opt for specialties that require more social skills, whereas men favour more technical disciplines, notably surgery (16). A possible reason for this choice could be the difference Table 2 Gender distribution of physicians among surgical specialties in different countries worldwide including Lebanon Lebanon USA (2019) Canada (2018) Brazil (2018) Australia (2019) New Zealand (2019) Argentina (2016) Germany (2007/2009) Sweden (2006) Romania (2008) Specialty F (n) F (%) F (%) F(%) F (%) F (%) F (%) F (%) F (%) F (%) F (%) General surgery 19 2.1 22 27 21 15 14 15.5 17.6 16 15 Neurological surgery 0 0 9.3 11.1 8.6 — — 10.4 — — — Orthopedic surgery 9 1. 6 5.8 12.2 6.5 4 5 7.8 12.1 9 9.4 Otolaryngology 19 4.7 18.3 23.2 38.8 — — 33.5 — — — Plastic surgery 12 7.1 17.2 24.6 23.3 — — 22.7 — — — Cardiothoracic and Cardiovascular surgery 3 2.4 8 12.5 10.1 — — 4.6 — — — Urology 3 0.8 9.5 11.2 2.2 — — 3.4 11.8 14 9 Vascular surgery 0 0 14.6 14.4 23.3 — — 9.6 — — — Surgical oncology 0 0 — 50 13.4 — — — — — — F = female. 746 Research article EMHJ – Vol. 28 No. 10 – 2022 in work–life balance and salary between surgical and nonsurgical specialties. Students for whom work–life balance is the most important parameter avoid surgical specialties, whereas students that focus most on financial compensation choose surgery (17). It is important to discuss reasons why women focus on the quality of life when choosing their future specialty. Hamid et al. found that female students favoured minimum working hours and convenient on-call schedules over higher salaries (18). Stability at work and less-strict hours mean that women focus more on psychological well-being and having more family or personal time. Men focus more on being well remunerated for choosing their career path. Another motivating factor for women to opt for nonsurgical specialties is the extensive patient contact and opportunities for private practice. Nonsurgical differ from surgical specialties because of the loss of patient Table 3 Gender distribution of physicians practicing a surgical specialty in Lebanese hospitals Gender Total Hospital F (n) F (%) M (n) Al Zahraa 4 3.2 121 125 Lebanese American University Medical Center-Rizk Hospital 2 2.9 67 69 Notre Dame de Secours 3.4 56 58 Bahman 3.6 53 55 Al Sahel 3.8 51 53 Bahmad and El-Fakih 6.7 28 30 Hasbaya Governmental 18.2 9 11 Hayat 1 1.2 84 85 American University of Beirut – Medical Center 1.4 72 73 Najjar 1.4 72 73 Hotel-Dieu de France 1.6 60 61 Saint George Orthodox 1.7 58 59 Saint Charles 1.9 53 54 Saint Joseph 2.0 49 50 Jabal Amel 2.0 48 49 Dahr Al Bachek Governmental 2.2 44 45 Nabih Berri University Governmental Hospital in Nabatiyeh 2.5 39 40 Haroun 2.6 38 39 Monseigneur Cortbawi-Soeurs des Saints-Coeurs 2.6 38 39 Al Rassoul Al Aazam 2.9 34 35 President Martyr Rafic Bahaeddin Al-Hariri 3.1 31 32 Hikmat Al Amine-Secours Populaire (Al Najda) 3.7 26 27 Bekhazi 4.0 24 25 Sheikh Ragheb Harb 4.5 21 22 Dr. Hamed Farhat-Kamed El Loz 5.0 19 20 Al Batoul 6.3 15 16 Rayak 6.3 15 16 Libano-Français 6.7 14 15 Notre Dame Maritime 7.1 13 14 Belle Vue Medical Center 9.1 10 11 Eye and Ear International Hospital 10.0 9 10 Middle East 10.0 9 10 Middle East Institute of Health 11.1 8 9 Al Borj 12.5 7 8 Rachaiya Governmental 12.5 7 8 Temnine 14.3 6 7 Beydoun 20.0 4 5 Total 46 1.6 2822 2868 F = female. 747 Research article EMHJ – Vol. 28 No. 10 – 2022 contact and an exclusively hospital-based career (19). This idea suggests that women generally opt for jobs that require more social skills like nursing and teaching, while men prefer more technically inclined jobs such as engineering and software development. Beirut is the capital and largest city in Lebanon and the most cosmopolitan and culturally diverse in the country (20). Most female civil societies are located in Beirut and the largest female-led movements and protests take place in the city (21). Surprisingly, only 16 of 913 (1.8%) surgeons located in Beirut were female, which merely reflected the numbers found in the country as a whole. The North and Chouf-Aley Regions did not have any female surgeons, which may have been caused by poverty, disparity in gender education or career orientation, and illiteracy. Tripoli, the northern capital and the second largest city in Lebanon is the poorest in the country and hosts a large number of refugees (22,23). Poverty is a major obstacle to gender equality in surgery because lower-income countries perceive female surgeons as being less capable than their male counterparts, compared with higher- income countries (24). However, compared with male physicians, female physicians provide better quality of care and have a lower patient mortality rate (25, 26). The countries with the best healthcare are predominantly rich, and have the highest number of female physicians (27). Another aspect that could explain this gender disparity in surgery is the influence of society and culture. Stereotypes, patriarchy, and the impact of religion, notably Islam, belittle the role of women in society (28). In a country where religion, customs and tradition play a big role in framing society, female participation could be limited to domestic chores and maternal duties. Thus, women are seen as incapable of balancing between a highly demanding job such as surgery and their everyday life. The idea of a work–life imbalance associated with familial, cultural and peer pressure may lead the most determined and skilled female medical students away from surgical specialties. Women have more restraints and barriers than their male counterparts when climbing the social ladder. Discrimination and sexual harassment are other obstacles that women face at work and in everyday life. Another barrier to the inclusion of women in surgery is the lack of role models, and ineffective mentorship (24). The lack of female senior surgeons discourages aspiring female students and may influence their choice in residency. Thus, there is a lot of missed opportunities to defy these social norms. The number of female surgeons did not vary between academic and nonacademic centres. There is no strategy to encourage more female surgeons in academic hospitals, which are centres for research and education. Thus, they need to set a good example for their residents, students and researchers, especially in lowering the gender gap to keep up with larger institutions. Private hospitals boasting nongovernmental funding sources should have a plan to attract and recruit more women into surgery to assure equitable opportunities to all competent physicians. Thus, they can optimize the quality of care for their patients. Half of Lebanese adults have no gender preference when choosing their surgeon, and the surgeon’s skills and competence are of greater importance (29). Lebanese society welcomes female surgeons, hence the pivotal role of private institutions in integrating women into surgical specialties. Therefore, it is necessary for academic hospitals in Lebanon to set an example in breaking the glass ceiling and delivering a suitable workplace. We should follow a multitier approach to involve women in surgery. We need cooperation between academic hospitals, governmental and nongovernmental institutions, and researchers to reduce inequality. It is important to increase female interest in surgery by assuring better working conditions and increasing the number of role models (24). There is a need to make the patriarchal society aware of the importance of defying cultural and religious boundaries. More research and data are needed in Arab countries about gender inequality to narrow the gap. Future research should focus on the role and importance of women in medicine, particularly in surgical specialties. The Arab world consists of 22 countries that are members of the League of Arab States located in the Middle East and North Africa (MENA) Region. Bahrain, Iraq, Jordan, Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia, Syrian Arab Republic, United Arab Emirates Table 4 Gender distribution of physicians practicing surgery in academic and nonacademic medical centres, in private and public medical centres in Lebanon, and among Lebanese hospitals Hospitals Gender Total Female Male Nonacademic 32 (1.4%) 2217 2249 Academic 14 (2.3%) 605 619 Total 46 (1.6%) 2822 2868 Private hospitals 41 (1.5%) 2634 2675 Public hospitals 5 (2.6%) 188 193 Total 46 (1.6%) 2822 2868 Table 5 Geographical gender distribution of surgeons in Lebanon Location Gender Total Female Male Beirut 16 (1.8%) 897 913 Metn-Baabda 12 (1.5%) 774 786 Beqaa 8 (2.3%) 335 343 South and Nabatiyeh 6 (1.2%) 484 490 Keserwan-Jbeil 4 (2.0%) 196 200 Chouf-Aley 0 98 98 North 0 83 83 Total 46 (1.6%) 2822 2868 748 Research article EMHJ – Vol. 28 No. 10 – 2022 (UAE), and Yemen are located in the Middle East. Algeria, Comoros, Djibouti, Libya, Mauritania, Morocco, Sudan, Somalia, and Tunisia are located in North Africa. According to the 2021 Global Gender Gap ranking, Arab countries had the highest gender disparity. Out of 156 countries, Syrian Arab Republic, Iraq and Yemen ranked 152, 153 and 155, respectively. The only Arab country in the upper half of the list was UAE, ranking 72 (10). The healthcare systems in Arab countries are among the worst worldwide. Part of the problem is due to the limited investment in public health. Arab countries spend only 5% of their gross domestic product on health, which is lower than the average for low-income countries (30). In this region, starvation, infant and maternal mortality, and mental illness are above average, along with military expenditure (30). The leading cause of illness for women in the region is depression (31). The highest rate for female depression globally is in Arab countries. Gender inequality in surgical fields seems to be narrowing in some Arab countries, notably Gulf countries. In Oman, Bahrain and Saudi Arabia, 63%, 39% and 27% of surgical residents are female, respectively (32). Moreover, Kuwait established the first female surgical group in the Gulf Region in 2018 – the “Women Surgeons of Kuwait”. Regrettably, the same is not the case in less- fortunate Arab countries; notably those in conflict, war and crisis, such as the Syrian Arab Republic, Iraq and Yemen. It is not uncommon to encounter gender disparity in a region constantly at war. Emergencies, conflicts and wars widen the gender gap. Yemen is currently facing the worst humanitarian crisis in the world. Women suffer from gender inequality in a patriarchal society with strict gender roles. In terms of education, sending girls to school is considered shameful in some regions, and finding a female teacher is a challenge (33). In the Syrian Arab Republic, for example, 75% of girls living in camps do not attend school, and more than a third of Syrian women suffer domestic violence (34). Child and forced marriages are increasing at an alarming rate; thus, female illiteracy increases. As a result, the role of women is limited to marital duties. There is no involvement of women in social and economic life. In the long-term, an increase in gender-based violence and a decrease in female literacy and social participation will further deprive women of their rights. In these countries in crisis, we need to facilitate transport and access to schools for both genders, notably for girls. We need educational campaigns that focus on the role of women in the community in these patriarchal societies. One limitation of our study was that it did not investigate the cause of the gender disparity. Thus, we could not assess the reasons for female physicians’ preference in their choice of specialty. Conclusion Among all medical domains in Lebanon, surgery had the widest gender gap, with only 2.3% of surgeons being female. Some specialties, such as neurosurgery and vascular surgery, had no female surgeons. A total absence of female surgeons was also noted in some locations, particularly North and Chouf-Aley Regions. Poverty, lack of gender education, influence of a patriarchal society, and erroneous misconceptions about women’s capacity to balance their professional career and sociomarital life were the major causes of the low female participation in surgical specialties. No significant gender gap could be noticed between academic and nonacademic hospitals, or between private and public hospitals. Healthcare systems in Lebanon must elaborate strategies to incorporate more women into surgical specialties to assure an equitable opportunity to all competent physicians, and to optimize the quality of care. Funding: None Competing interests: None declared. Évaluation des inégalités fondées sur le genre dans les spécialités chirurgicales parmi le personnel médical libanais : la nécessité d'impliquer les femmes dans le domaine de la chirurgie Résumé Contexte : Il existe peu d'informations sur la disparité entre les genres dans les spécialités chirurgicales au Liban. Objectifs : Évaluer le statut des chirurgiennes et les éventuelles disparités entre les genres dans la spécialité chirurgicale au Liban. Méthodes : L'étude a été menée en mai 2021. Des données ont été extraites du site de l'Ordre des Médecins du Liban, indiquant le nombre de médecins dans les différentes spécialités, leur genre, les hôpitaux dans lesquels ils travaillent et leur emplacement. Le test du khi-deux d'homogénéité a été utilisé pour déterminer si la répartition entre les genres était à égalité. Résultats : Les femmes ne représentaient que 21,84 % (3 370) des médecins au Liban, le domaine de la chirurgie étant celui qui comptait le moins de femmes médecins (n = 65 ; 2,30 %). Les femmes représentaient 1,63 % de l'ensemble des chirurgiens dans les hôpitaux libanais, le nombre de femmes spécialisées en chirurgie plastique et reconstructive était plus élevé (n = 12 ; 7, 14 %), tandis que la neurochirurgie, la chirurgie oncologique et la chirurgie vasculaire ne comptaient aucune femme. Aucune différence significative relative au genre n'a été constatée entre les établissements universitaires et non universitaires (χ2 = 2,164, p = 0,149), ou entre les hôpitaux publics et privés (χ2 = 1,277, p = 0,234). 749 Research article EMHJ – Vol. 28 No. 10 – 2022 References 1. Women’s history milestones: a timeline. Sky History. 26 February 2019 (https://www.history.com/topics/womens-history/wom- ens-history-us-timeline, accessed 27 August 2022). 2. McKinstry B. 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American Medical Association. 1 October 2019 (https:// www.ama-assn.org/medical-students/specialty-profiles/these-medical-specialties-have-biggest-gender-imbalances, accessed 27 August 2022). Conclusion : Les spécialités chirurgicales présentaient les plus importantes inégalités fondées sur le genre parmi tous les domaines médicaux au Liban. Par conséquent, les systèmes de soins de santé, y compris les hôpitaux publics et privés, ont encore un chemin long et difficile à parcourir pour réduire ces inégalités. Différentes stratégies visant à intégrer les femmes dans le domaine de la chirurgie devraient être envisagées pour garantir des opportunités équitables à tous les médecins, sur la base des compétences plutôt que du genre. ةحارلجا في ةأرلما كاشرإ لىإ ةجالحا :ينينانبللا ينيِّبطلا ينلماعلا ينب ةيحارلجا تاص ُّصختلا في ةيناسنلجا ةوجفلا مييقت ةملاس لاكساب ،يقيقع نياد ،يديس ويجروج ،ميكاو سايلإ ،جالحا ديعس ةصلالخا .نانبل في ةحارلجا ص ُّصتخ في ينسنلجا ينب توافتلا نع يرثكلا فرعُي لا :ةيفللخا .نانبل في ةحارلجا ص ُّصتخ في ةلمتحلما ةيناسنلجا تاوجفلاو تاحا َّرلجا ثانلإا عضو مييقت لىا ةساردلا هذه تفده :فادهلأا لىإ تانايبلا كلت يرشتو ،نانبل ءابطأ ةباقنل نيوتركللإا عقولما نم تانايبلا تصلخُتساو .2021 رايأ /ويام في ةساردلا هذه تيرجُأ :ثحبلا قرط في ٍواست ةمث ناك اذإ ام ريرقتل سناجتلل )χ2( ياك عبرم رابتخا مدخُتساو .مهعقاومو متهايفشتسمو مهسنجو تاص ُّصختلا فلتمخ في ءابطلأا ددع .لا مأ سنلجا بسحب عيزوتلا ةبسنب ؛65 = نهددع( ةحارلجا ص ُّصتخ في تابيبطلل ةبسن لقأ تناكو ،نانبل في ءابطلأا نم 21.84% )3370( ءاسنلا ةبسن زواجتت لم :جئاتنلا نهددع( ىبركلا ةبسنلاب ةيميمترلاو ةيليمجتلا تاحارِلجا تيظحو ،ةينانبللا تايفشتسلما في ينحا َّرلجا عوممج نم %1.63 ءاسنلا تلَّثمو .)%2.30 ينب يربك فلاتخا دجوي لمو .ةيومدلا ةيعولأا ةحارجو مارولأاو باصعلأا ةحارج تاص ُّصتخ في ثانإ دجوت لم ينح في ،)%7.14 ةبسنب ،12 = رابتخا( ةصالخاو ةماعلا تايفشتسلما ينب وأ ،)0.149 = ةيلماتحلاا ةميقلا ،2.164 = ياك عبرم رابتخا( ةيميداكلأا يرغو ةيميداكلأا تاسسؤلما .)0.234 = ةيلماتحلاا ةميقلا ،1.277 = ياك عبرم مُظُن مامأ بعصو ً ليوط قيرط ةمث نإف اذل .نانبل في ةيبطلا تلااجلما عيمجب ًةنراقم ةيناسنج ةوجف عسوأ ةحارلجا ص ُّصتخ دهشي :تاجاتنتسلاا ةأرلما جامدلإ ةفلتمخ تايجيتاترسا نع ِّصِّيقتلاو ثحبلا يغبنيو .ةيناسنلجا ةوجفلا قييضتل ،ةصالخاو ةماعلا تايفشتسلما كلذ نمو ،ةيحصلا ةياعرلا .سنلجا لا ةءافكلا ساسأ لىع كلذ نوكي نأو ،ءابطلأا عيملج صرفلا ؤفاكت نماضل ،ةحارلجا ص ُّصتخ في 750 Research article EMHJ – Vol. 28 No. 10 – 2022 13. 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New York: UN Women; 2018 (https://arab- states.unwomen.org/en/news/stories/2018/8/why-syrian-women, accessed 27 August 2022). 751 Research article EMHJ – Vol. 28 No. 10 – 2022 Assessing the impact of small-research grants supported by WHO in the Eastern Mediterranean Region 2010–2018 Bahareh Yazdizadeh,1 Ahmed Mandil,2 Sima Nikooee1 and Arash Rashidian2 1Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 2World Health Organization Office for the Eastern Mediterranean, Cairo, Egypt. (Correspondence to: Ahmed Mandil: mandila@ who.int) Introduction Since the 1940s and the inception of WHO, 3 of its core functions have been dedicated to health research. These include shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; articulating ethical and evidence- based policy options; and providing technical support, catalysing change, and building sustainable institutional capacity. Over the decades, several publications related to health research were produced by WHO and these could be accessed at: http://www.emro.who.int/rpc/ publications/. The World Health Assembly (WHA) in its resolution WHA63.21 (WHO’s role and responsibilities in health research) called on Member States to establish governance mechanisms for research for health; to ensure rigorous application of good research norms and standards, including protection for human subjects involved in research; and to promote open dialogue between policymakers and researchers on national health needs, capacities, and constraints. One of the activities to achieve WHO objectives is the provision of funds for local evidence. In the Eastern Mediterranean Region (EMR), WHO has been providing targeted funding for health research on priority areas of public health for decades. Applications are being received through open calls for proposals via different grant schemes, including: Research in Priority Areas in Public Health (RPPH), Tropical Disease Research – Small Grant Scheme (TDR-SGS), and occasionally improving Programme Implementation through Embedded Research (iPIER). Since 2020, new small grant schemes have been initiated focusing on migration health research, International Health Regulations (IHRs), and COVID-19- related priority research (1). These grant schemes are very popular, and every biennium, WHO receives about 10 times more proposals than can be supported in response to each call. These grant schemes are very important for producing local evidence, which has been emphasized in recent reports (2-4). EMR has implemented some interventions to empower countries to use the local evidence, such as asking principal investigators to share Abstract Background: For decades, WHO has been providing targeted funding for health research on priority areas of public health in the Eastern Mediterranean Region through different grant schemes. Aims: This paper investigated the impact of WHO/EMRO’s funding schemes and factors facilitating or hindering such impact. Methods: We assessed the impact of health research funded by WHO/EMRO during 2010–2018 from the health, economic, decision-making, and knowledge translation perspectives, emphasizing accountability and analysis, using the Payback framework, mixed-method approach (quantitative, qualitative), and triangulation. Results: Principal investigators of 45 (45.9%) out of the 98 funded projects responded to the questionnaire. Almost all (88.0%) the 45 projects reported developing at least one decision-making document. Less than half reported producing peer-reviewed documents and conducting target group empowerment, while 24.0% said they secured research funds from other organizations. For 23 projects (51.0%), research results could have had a direct impact on health and on economy, and 25 (56.0%) projects conducted at least one active knowledge translation activity. Using multiple logistic regression, there was no significant association between the country of research and impact on decision-making and implementation of result if health or economic impact was expected. Conclusion: To strengthen the impact of research, WHO/EMRO should embark on a series of interventions to guide and empower countries in the use of research results. Discrepancies between health research systems in the Eastern Mediterranean Region and differences in individual and organizational capacities in the different countries require targeted interventions. Keywords: Research, small grant, Eastern Mediterranean, WHO/EMRO, health systems Citation: Yazdizadeh B; Mandil A; Nikooee S; Rashidian A. Assessing the impact of small-research grants supported by WHO in the Eastern Mediterranean Region in 2010–2018. East Mediterr Health J. 2022;28(10):751–757. https://doi.org/10.26719/emhj.22.072 Received: 02/12/21; accepted: 14/08/22 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 752 Research article EMHJ – Vol. 28 No. 10 – 2022 a “manuscript for consideration for publication”, instead of the final grant report, thus encouraging principal investigators to publish and share outcomes of their research with the scientific community. To improve these funding schemes, it is important to investigate their impact in the region and understand factors that facilitate or hinder their performance. Generally, the impact assessment is conducted to facilitate advocacy, accountability, fund allocation, and analysis (5). As funding agencies are often at the core of strategies to improve “implementation to impact”(6), this assessment is very important for EMR to tailor it’s research policymaking and processes. Hence, this study aimed to investigate the impact of WHO/EMRO’s funding schemes and understand factors facilitating or hindering such impact as a first step towards refining grant programmes and tailoring capacity-building activities to countries context. While studies have been carried out to map health research institutions and assess evidence to policy and practices and health research outputs in the EMR (9–11,18– 20), we are not aware of any regional studies assessing the impact of WHO-funded research. Methods Health research impact assessment can be both top-down (ecologic studies) and bottom-up (case studies) (6). In top- down studies, the variables are collected and analysed in aggregated levels, such as evaluating the relationship between the expenditure on research and the impact of that research on reducing mortality burden attributed to specific diseases. In bottom-up studies, a set of research studies is selected, examining their impact over time via intense data collection (desk review and interview), where attribution of impact to specific research is more possible (although a big challenge in the top-down method). The payback framework for health research impact assessment was developed in 1996 for conducting case study approach (7–9). It introduces the impact of health research in 5 categories: knowledge advancement, capacity-building, informing decision-making, as well as impact on health, society and economy. In 2009, detailed indicators for each of the areas covered by the payback framework were suggested by the Canadian Academy of Health Sciences, helping in the measurement of impact (10). Based on this framework and related indicators, several studies have been conducted to evaluate the impact of research in different countries, including Australia, Hong-Kong SAR China, and United Kingdom (11–14). In this study we chose the case study approach using the payback framework as a base and mixed- methods approach (triangulation design with validating quantitative data) for data collection (12). The data collection tool included quantitative and qualitative questions, where narrative responses were used to validate quantitative responses. For example, in one question we asked, “Have the research outcomes been utilized in policymaking outside the health system (directly or indirectly)?”, and we asked principal investigator, “If your answer is yes, please explain how”. The study targeted principal investigators of health research projects funded by WHO/EMRO during the period 2010 to 2018, under 3 grant schemes, i.e. iPIER (14 projects), TDR-SGS” (36 projects), and “RPPH” (48 projects). This period was selected to allow for sufficient time from the completion of the studies, as most research impact requires time to materialize. To assess the impact of funded health research in the EMR, an updated version of a data collection tool used in previous studies (7,8) and had been designed according to the payback framework, was used. The tool included sections enquiring about project objectives; expected impact; impact domains, including “knowledge advancement; capacity-building achieved by conducting research (empowering target group during research, using the outcome of research to define the following projects, to facilitate securing of research funds from other organizations); impact on decision-making (producing systematic reviews, clinical practice guidelines, public health guidelines, health technology assessment, policy briefs, legislation, health policymaking); health and economic impact (using the outcome of research to change some decisions)”; knowledge translation activities; and stakeholder engagement. For each question, we asked about the relevance of the research to making the impact, firstly, and if the response was “yes”, we asked principal investigators to continue. These two last variables were chosen because they increase the probability of changing practice (13). For each claimed impact, we requested attachment of related documents to the online questionnaire. An online version of the questionnaire was prepared, using SurveyMonkey platform and the link to the online tool was sent to all the principal investigators. Two reminders were sent at regular intervals to researchers who did not respond. To verify responses to the quantitative questions, one of the researchers examined the narrative responses and the attached documents, then “perceived invalid responses to quantitative questions” were discussed with another research team member, to reach consensus. Descriptive and analytical statistical methods were used for analysis. For the field “advanced knowledge”, attached documents were peer-reviewed and bibliometric information (impact factor and number of citations) checked using Scopus database. The aggregation variables were defined as follows: Active knowledge translation interventions: including sending a summary or full report to potential users; providing findings to media reporters or participating in interviews; organizing a meeting with potential users; preparing or submitting outcomes in plain language for suitable audience; and taking necessary measures to commercialize the findings. 753 Research article EMHJ – Vol. 28 No. 10 – 2022 Impact on decision-making through decision- making document (IDMD): if research outcomes were used in one of the decision-making documents. Impact on health or the economy (IHE): if the response to one of the 8 questions related to the real use of research results and the impact on health or economy was “yes”. The relationship between some predictor variables and the two variables “IDMD” and “IHE” was investigated. Predictor variables were, the type of grant, the year of proposal approval, active knowledge translation intervention, and order-oriented research subject. First, bivariate analysis was performed by using chi- square test (and if necessary Fisher’s exact test), then, the variables that had significant relationship were entered into multivariable analysis using logistic regression method. Results The questionnaire was sent to the principal investigators of 98 funded studies, of whom 45 responded (response rate: 45.9%). To clarify the selection bias, we compared the response and non-response cases based on the three variables, i.e. type of grant, year of grant approval, and country. Only year of grant approval was found to be statistically different, the response rate was more in the new approved proposals. Respondents reported 10 peer-reviewed publications, 2 factsheets, 1 national roadmap, 1 national strategy document, and 1 preprint paper. For the 10 peer-reviewed publications, the mean citation was 2.83 (minimum 0 and maximum 8) and the mean impact factor of journals that published the works was 2.87 (minimum 2 and maximum 3.29) We observed more visible impact on capacity- building, as summarised in Table 1. Twenty-two research studies (out of 45) reported enhanced capacity (change in awareness, attitudes, skills) of the target groups as a result of the funded study. Fifteen research studies (out of 45) were conducted in response to expressed needs of the policymakers. Tables 2 and 3 present the results of other questions in this section. Despite being relevant, the results of 10 studies were not used in any policymaking. In 17 cases, despite being relevant, the results were not used in national policies and in 3 cases they were used in the local organizational policy. Generally, after omitting missing values, 36 studies had at least been relevant enough to use their results for one of three levels of policymaking. In 20 cases, they were used for decision-making in at least 1 level. Respondents for 23 projects (out of 45) reported that the results of their research could have had direct impact on health if the stakeholders used them, of which 13 research studies were reportedly used (56.5% of 23 projects). For 23 research studies (51%), research results could have had direct impact on economy if the stakeholders used them, of which 7 (30.4%) research results were reported to have been used. Generally, 29 projects (64.4%) could have had direct impact on health or economy; for 14 projects (48%) the results were reported to have been used. For 25 research studies (out of 45), at least one active knowledge translation activity was reported to have been performed; but for 12 projects (27%) no knowledge translation activity was done. Regarding stakeholder engagement, for 26 studies (57.8%), the identified stakeholders did not play a role in research question formulation and proposal writing. Using Chi-squared test, the relationship between IDMD and health or economic impact with predictor variables was examined. None of the variables was found to be associated with the impact on decision-making, however, in terms of the impact on health or economy, the variable related to conducting research in response to policymaker demand was found to be significantly linked (p-value: 0.002 (Table 4). All variables which their P-values were less than 0.1 were entered to the logistic regression (14) (Table 5). No significant association between the country of research and impact on decision-making and implementation of result if health or economic impact was expected. Discussion The objective of this study was to assess the impact of the research projects that were funded by WHO/EMRO from 2010 to 2018 to enable improvements in research policymaking and processes in this organization. There was only a modest potential impact in generating (and sharing) new knowledge, as only 10 research studies (about 1 in 5) reported publishing their results in peer- reviewed publications. The impact on capacity-building was more prominent, as half of research studies reported empowerment of their target groups. The main premise of the enquiry in our study was that condcuting participatory research and integrated collaboration (in which the target group is included in the research team) will empower target groups and increase the probability of using research results (15). A recent WHO study on Table 1 Capacity building in target groups, WHO/EMRO funded research, 2010–2018 Yes (%) No (%) Missing Empowerment of target group 22 (48.9) 21 (46.7) 2 Defining subsequent projects 19 (42.2) 12 (26.7) 14 Facilitating securing of research funds from other organizations 11 (24.4) 32 (71.1) 2 754 Research article EMHJ – Vol. 28 No. 10 – 2022 EMR health research institutions shows that training on this kind of research is rare in the region (16). It is therefore necessary to implement special capacity-building on how to conduct participatory research. One in 4 of the research teams reported that the WHO small grant helped them in receiving subsequent research fundings. This is important in several ways, as it helped gain the trust of relevant organizations (getting credit from providers or executive agencies), and the research results have led to new research questions (which are needed to solve health problems). Regarding impact on decision-making, reported documentation of research outcomes to inform decision- making was very low, usually assessed by the production of decision-making documents in respective countries (11). Less than half of the respondents reported publishing a peer-reviewed article. Further efforts are required to link research to policy and enhance evidence-informed policymaking. A little above half of the respondents (55%) reported using the research outcomes for policymaking. About two-thirds of respondents (64%) reported that their research outcomes had potential to make direct impact on health or economy, while about half (48%) Table 2 Use of research outcomes for decision-making documents, WHO/EMRO-funded research, 2010–2018 No. of relevant cases No. of projects which have been used Unclear Systematic reviews 18 0 3 Clinical practice guidelines 22 1 2 Public health guidelines 41 3 2 Health technology assessment 19 0 2 Educational content for healthcare facility visitors and/or the public 30 2 2 Educational content for professionals 36 1 5 Policy brief development 44 3 5 National/provincial/local legislation 44 1 6 Table 3 Using research outcomes for policy making, WHO/EMRO-funded research, 2010–2018 No. of relevant cases No. of projects which have been used (%) Missing Used for the Ministry of Health policymaking processes 43 14 (32.6) 8 Used for policymaking outside the health system 41 3 (07.3) 8 Used for policymaking within the organization 37 13 (35.1) 8 Table 4 Bivariate analysis of IDMD and health or economic impact with predictor variables Impact on decision- making P-value (χ2) Impact on health/ economy P-value (χ2) Type of grant Yes No 0.330 Yes No 0.125 iPIER 1 5 4 2 RPPH 5 13 5 13 SGS 2 19 5 16 Approval year 0.388 0.734 2014 2 11 5 8 2016 3 6 3 6 2018 3 20 6 17 Active KTE 0.714 0.065 Yes 1 5 4 10 No 7 32 2 29 Conducted upon demand of a specific order 0.444 0.003 Yes 3 12 10 5 No 3 20 4 19 755 Research article EMHJ – Vol. 28 No. 10 – 2022 reported that their research outcomes were used to support health and wellbeing. Regarding impact on decision-making and impact on health and organization, the relevance of research proposals to the impact observed was related to the funding agency’s vision, mission and criteria to accept the proposals, and an impact is looked at as a consequence of contextual factors within each country of implementation. Based on the result of this study, it is essential to change some criteria for accepting proposals to promote the use of evidence in decision-making in countries. On the factors influencing the probability of using research for decision-making, our findings demonstrate the importance of conducting research in response to decision-makers’ needs. One-third of the research studies included in this assessment were conducted in response to policymakers’ needs, and the results were more likely to be adopted for subsequent decisions. About two-thirds of respondents (58%) reported that the stakeholders did not play a role in the formulation of the research question(s) and the writing of the proposal. It therefore seems that it is necessary to improve the research priority-setting in countries and in EMR, and encourage stakeholders to get involved in shaping the research question. One major limitation of our study was that more than half of the study population (those receiving WHO/ EMRO small grants) did not respond to our online survey, in spite of repeated reminders. If non-response could be explained by recall difficulties, then the selection bias by the variable “time” would result in underestimating the impact. If non-response could be attributed to non- impact, then the selection bias has forced overestimation. Another limitation was that during the verification of responses, we found that respondents did not understand some questions properly. A third limitation is insufficient evidence required to compare the health research systems of countries in the region. To be able to assess research impact and its influencing factors and make appropriate recommendations, countries should be compared in terms of health system building blocks, relationship between the health research system and health system, and the situation of KTE components. The main strength of this study was the data collection tool, which included questions about the relevance of the research to making an impact, and the qualitative questions about claimed impact, which helped in verifying the quantitative responses. To strengthen implementation and the impact of research outcomes, we recommend the following actions: • An integrated knowledge translation approach should be observed when approving proposals for funding, i.e. principal investigators should ensure that stake- holders will actively participate in the research cycle from the beginning to the end, and that its outcomes will indeed be used by relevant health policymakers. • Research questions should be based on national, pro- vincial or public health priorities. Therefore, WHO/ EMRO’s calls for proposals, including the small grant schemes, should relate to national priorities, taking into account outcomes of national research priority setting exercises, like the ones conducted in Jordan and Pakistan (17,18). • To strengthen the use of research-generated evidence by health systems, we recommend that countries should regularly conduct research impact assessment and interventions to increase the skills of researchers to identify challenges of the health systems and im- prove their skills regarding the importance of active participation of stakeholders. • To identify factors affecting the implementation of research outcomes, in-depth studies of the research cycle (from the time of planning to the implementa- tion/non-implementation of outcomes) are needed (qualitatively and quantitatively). • It is important to review and compare studies that had impact on health and/or economy and/or deci- sion-making (using the decision-making documents). • We need to conduct situation analysis of the nation- al health research systems in each country, which would help identify gaps, challenges, and priorities and allow better use of resources and facilitate evi- dence-based decision-making. Table 5 Logistic regression for impact on health or economy, WHO/EMRO-funded research, 2010–2018 Independent variables B SE P-value Active KTE 0.568 1.081 0.601 Conducting by demand 0.122 0.818 0.010 Constant 2.953 0.947 0.253 Acknowledgement We thank the principal investigators of WHO-funded grants in the EMR during 2010–2018, who responded to our data collection tool, and hence supported the outcomes and recommendations of this study. We also acknowledge the contributions of Mr Ahmed Elarousy, Mr Hosam Younes, and Ms Fatma Abdel-Megeed for their assistance in developing/ testing the online data collection form. Funding: This study was supported by the Division of Science, Information & Dissemination, WHO/EMRO, Cairo, Egypt. Competing interests: This study was ethically cleared by the EM-Research Ethics Review Committee in June 2020. 756 Research article EMHJ – Vol. 28 No. 10 – 2022 Évaluation de l'impact des petites subventions à la recherche financées par l'OMS dans la Région de la Méditerranée orientale de 2010 à 2018 Résumé Contexte : Depuis des décennies, l'OMS fournit un financement ciblé pour la recherche en santé dans des domaines prioritaires de la santé publique dans la Région de la Méditerranée orientale à travers différents programmes de subventions. Objectifs : Le présent article examine l'impact des programmes de financement du Bureau régional de l'OMS pour la Méditerranée orientale et les facteurs qui facilitent ou entravent cet impact. Méthodes : Nous avons évalué l'impact de la recherche en santé financée par le Bureau régional de l'OMS pour la Méditerranée orientale entre 2010 et 2018 du point de vue de la santé, de l'économie, de la prise de décision et de l'application des connaissances, en mettant l'accent sur la responsabilisation et l'analyse, au moyen du cadre de récupération, de l'approche mixte (quantitative, qualitative) et de la triangulation. Résultats : Les chercheurs principaux de 45 (45,9 %) des 98 projets financés ont répondu au questionnaire. La plupart de ces chercheurs (88,0 %) ont indiqué avoir élaboré au moins un document de prise de décision. Moins de la moitié d'entre eux ont déclaré avoir produit des documents évalués par des pairs et avoir mené des actions d'autonomisation des groupes cibles, tandis que 24,0 % ont signalé avoir obtenu des fonds de recherche par le biais d'autres organisations. Les résultats de recherche de 23 projets (51,0 %) ont pu avoir un impact direct sur la santé et l'économie, et 25 projets (56,0 %) ont permis de mener au moins une activité d'application des connaissances. À l'aide d'une régression logistique multiple, aucune association significative n'a été trouvée entre le pays sur lequel porte la recherche et l'impact sur la prise de décision ainsi que sur la mise en œuvre du résultat lorsqu'un impact sur la santé ou l'économie était attendu. Conclusion : Pour renforcer l'impact de la recherche, le Bureau régional de l'OMS pour la Méditerranée orientale devrait entreprendre une série d'interventions visant à orienter et à autonomiser les pays dans l'utilisation des résultats des recherches. Les disparités entre les systèmes de recherche en santé de la Région de la Méditerranée orientale et les différences dans les capacités individuelles et organisationnelles des différents pays nécessitent des interventions ciblées. 2018و 2010 ْيَماع ينب ام ةدلما في طسوتلما قشر ميلقإ في ةمظنلما اهمعدت يتلا ةيرغصلا ةيثحبلا حَِنلما رثأ مييقت نايديشر شرأ ،يوكين مايس ، ليدنم دحمأ ،هدازدزي ةرابه ةصلالخا قشر ميلقإ في ةماعلا ةحصلل ةيولولأا تاذ تلااجلما في ةيحصلا ثوحبلل اًفَدهتسُم ًلًايوتم ،دوقع ىدم لىع ،ةيلماعلا ةحصلا ةمظنم تم َّدق :ةيفللخا .حَنِملل ةفلتمخ طَطُخ للًاخ نم طسوتلما ءاقترلاا لماوعو ،ةيلماعلا ةحصلا ةمظنلم عباتلا ،طسوتلما قشرل يميلقلإا بتكملل ةيليومتلا ططلخا رثأ صيقت لىا ةساردلا هذه تفده :فادهلأا .هقوعي ام وأ رثلأا اذبه ْيَماع ينب ام ةدلما للًاخ ،طسوتلما قشرل يميلقلإا بتكلما /ةيلماعلا ةحصلا ةمظنم اهتل َّوم يتلا ةيحصلا ثوحبلا يرثأتل ًماييقت انيرجأ :ثحبلا قرط جنهو دئاعلا راطإ مادختساب ،ليلحتلاو ةلءاسلما لىع ديكأتلا عم ،تامولعلما ةجمرتو رارقلا عنُصو داصتقلااو ةحصلا روظنم نم ،2018و 2010 .ثيلثتلاو ،)يعونو يمك( بيلاسلأا ددعتم ينعبرلأاو ةسملخا عيراشلما عيجم تدافأو .)%45.9( ًلاومم اًعوشرم 98 لصأ نم 45 نم نويسيئرلا نوثحابلا نايبتسلاا في كراش دقل :جئاتنلا ءارجإو ،نارقلأا ةعجارلم تعضخ تادنتسم عضوب ينكراشلما فصن نم لقأ دافأو .لقلأا لىع ةدحاو رارق عنُص ةقيثو تعضو انهأ )%88.0( اًبيرقت نأ نكملما نم ناك ،)%51.0( اًعوشرم 23 ةلاح فيو .ىرخأ تماظنم نم ليوتم لىع اولصح منهإ %24.0 لاق ينح في ،ةفَدهتسُلما ةعومجلما ينكتم تامولعلما ةجمرت ةطشنأ نم لقلأا لىع اًدحاو اًطاشن )%56.0( اًعوشرم 25 ذ َّفن مانيب ،داصتقلااو ةحصلا لىع شرابم يرثأت ثوحبلا جئاتنل نوكي ،جئاتنلا ذيفنتو رارقلا ذاتخا ةيلمع لىع عقاولا رثلأاو ثحبلا دلب ينب هب ُّدتعُي طابترا دوجو مدع َّينبت ،ددعتلما يتسجوللا رادحنلاا مادختسابو .ةلاعفلا .اًع َّقوتُم يداصتقلاا وأ يحصلا رثلأا ناك اذإ اهنيكتمو نادلبلا هيجوتل تلًاخدتلا نم ةلسلس ءدب طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم يميلقلإا بتكملل يغبني ،ثوحبلا رثأ زيزعتل :تاجاتنتسلاا ةيدرفلا تاردقلا في توافتلاو ،طسوتلما قشر ميلقإ في ةيحصلا ثوحبلا مُظُن ينب توافتلا نإف ،كلذ لىع ًةولًاعو .ثوحبلا جئاتن نم ةدافتسلاا نم .ةه َّجوُم تلًاخدت بَّلطتت ،نادلبلا فلًاتخاب ةيميظنتلاو 757 Research article EMHJ – Vol. 28 No. 10 – 2022 References 1. 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East Mediterr Health J. 2021;27(4):319-20. 758 Research article EMHJ – Vol. 28 No. 10 – 2022 Spatial distribution and temporal trend of drug-related deaths in the Islamic Republic of Iran during 2014–2017 Abbas Alipour,1 Mehran Zarghami,2,3 Sajjad Rahimi Pordanjani,4,5 Ardeshir Khosravi,6 Mehdi Saberi7 and Masoudeh Babakhanian4 1Department of Social Medicine, School of Medicine; 2Psychiatry and Behavioural Sciences Research Centre, Addiction Institute; 3Department of Psychiatry, Faculty of Medicine, Mazandaran University of Medical Sciences, Mazandaran, Sari, Islamic Republic of Iran. 4Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran. 5Department of Epidemiology and Biostatistics, School of Medicine, Semnan University of Medical Sciences, Semnan, Islamic Republic of Iran (Correspondence to: Masoudeh Babakhanian: babakhanian.m@gmail.com). 6Department of Public Health, Ministry of Health and Medical Education, Tehran, Islamic Republic of Iran. 7Legal Medicine Research Centre, Legal Medicine Organization, Tehran, Islamic Republic of Iran. Introduction Substance intoxication is dangerous and often fatal (1). Drug-related death is defined as any psychological or behavioural disorder due to psychoactive substance misuse (ICD-10: F11–F16, F19) leading to intentional or unintentional self-intoxication with substances for unknown intentions or exogenous causes (2). Research suggests that there is a generally increasing trend in the drug-related deaths rate worldwide (1). According to a World Health Organization estimate, 69 000 individuals lose their lives due to substance overdose every year (3). Although older age is one of the risk factors for substance overdose (4), studies conducted in the United States of America (USA) have shown increasing rates of substance- related suicide and intoxication in adolescents and adults (5,6). According to the national trends in the USA, during 1999–2016 the drug-related deaths rate in children and adolescents increased by 268.2% (7). The mortality rate due to substance intoxication among children in developing countries is 4 times greater than that in other countries (8). Although substance intoxication in the Islamic Republic of Iran is one of the main causes of poisoning among children and adolescents (2,9), a 5-year longitudinal study showed that substance intoxication was most common in adult men aged 30–39 years (10). Our study was designed and conducted to investigate the trend for drug-related deaths rates in different population groups (children, adolescents, young adults, adults, older adults) during 2014–2017, with a special focus on identifying high- and low-risk regions (provinces) in the Islamic Republic of Iran. Methods Study design An ecological design was used for this study, conducted in 2021. We describe the spatial distribution and trend of disease incidence rates (11). Using this design, the spatial patterns (multiple-group study) and the time trends were investigated simultaneously (12). Abstract Background: Research suggests that there is an increasing trend in drug-related deaths worldwide: an estimated 69 000 individuals lose their lives due to substance abuse annually. Aims: To determine the geographical pathology of drug-related deaths in the Islamic Republic of Iran and to evaluate incidence trends, with a focus on identifying high- and low-risk regions. Methods: For this ecological study, we collected data from the 2 main sources (the Legal Medicine Organization and the Ministry of Health and Medical Education) responsible for registering substance-related deaths during 2014–2017. Data analysis was conducted using Joinpoint regression analysis, Global Moran’s I and Anselin Local Moran’s I. Results: Of the 12 386 drug-related deaths in 2014–2017, most occurred during the summer months; 7162 of these were among middle-aged individuals. The mean age of children and adolescents who died of substance abuse was 5.2 [standard deviation (SD) 4.6] years. In the young adult group, mean age at death was 20.7 (SD 2.5) years; it was 34.2 (SD 5.4) years for adults and 55.6 (SD 9.8) years for older adults. Changes in mortality rate peaked in 2017 (annual percentage change = 0.52); in the last months of the study period there was a nonsignificant decrease (annual percentage change = –6.99) in the incidence (average annual percentage change = –0.5; 95% confidence interval: –3.2, 2.3). Conclusion: Deaths due to substance abuse will remain a huge public health problem unless policy- and decision-makers determine why this problem continues to increase despite the extensive efforts on regulation and find ways to mitigate it. Keywords: drug-related death, incidence, spatial distribution, temporal trend, substance abuse, Iran Citation: Alipour A; Zarghami M; Pordanjani S; Khosravi A; Saberi M; Babakhanian M. Spatial distribution and temporal trend of drug-related deaths in the Islamic Republic of Iran during 2014–2017 East Mediterr Health J. 2022;28(10):758–767. https://doi.org/10.26719/emhj.22.079 Received: 22/11/21; accepted: 29/06/22 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 759 Research article EMHJ – Vol. 28 No. 10 – 2022 Data sources We surveyed 3 main types of data sources covering 2014–2017. Data from the 2 main sources of drug-related deaths registers in the Islamic Republic of Iran: the Legal Medicine Organization and the Ministry of Health and Medical Education, were examined. The capture– recapture method was used to calculate number of deaths. The third data source, the geographic coordinates of the patients, was obtained using the most recent information available on the Google Map software and the georeferenced layers of the Iranian provinces. We used aggregate data and compared the distributions of the disease in different provinces and areas (13,14). Spatial and descriptive information related to the study area The Islamic Republic of Iran is located in the Middle East, in the southwestern region of Asia between 25°3′ and 39°47′ north and 44°5′ and 63°18′ east. It has 31 provinces and an area of 1 648 195 km2. Based on the last census, carried out in 2016, the population is estimated at 79 927 270 (15). Target and study population This study was designed to cover all cases of poisoning with drugs, and all met the eligibility criteria of the study. The inclusion criteria were: a known place of residence and diagnosis of drug-related deaths according to ICD-10 codes (2) in terms of the type of poisonous substance. The age classification was based on the large demographic classifications of the Statistical Center of Iran that regards age up to 14 years as child and adolescent, 15–24 years as young adult, 25–44 years as adult and 45–64+ years as older adult (16). Statistical analysis The statistical analysis covered 3 main parts: descriptive analysis of the epidemiological and demographic indicators of patients; analysis of the temporal trends of incidence of DRD; and spatial analysis of poisonous substance Crude death rates (No. of cases per 100 000 population) were estimated during 2014–2017 (based on the 2016 census). Adjusted death rates were determined using a direct method based on the standard population of the USA in 2000 (17). The age-adjusted rate for each province was compared with the national age-adjusted rate using the Z-test. Statistical tests were carried out at a significance level of 0.05. We used StataMP, version 13, Excel and SPSS, version 23, for this section. The second part was the time trend analysis: the analyses related to the crude death rate time trend were performed according to year, month and age group of the person. To analyse the trend for deaths caused by drug abuse, the mortality rates were considered the dependent variables and year and month were considered the independent variables. The rate for drug-related deaths was calculated separately for each age group. Along with detecting the exact time of joinpoints, the average annual percent change, annual percent change and slope changes of the regression line were estimated at 95% confidence interval (95% CI) for the annual trend for incidence of death from the disease during 2014–2017. These were determined using regression analysis of the endpoints on the Joinpoint regression statistical program, version 4.9.0.0. The third part of the statistical analysis was the spatial pattern and cluster analysis. The spatial pattern of clustering was analysed using 2-sided α and 0.05 significance level. To evaluate the spatial distribution of incidence of disease, the cumulative drug-related deaths incidence rate was initially calculated for each province. To assess spatial autocorrelation of the disease, we used the Global Moran’s I index. The values related to this index range from −1 to +1, with the latter showing a more clustered and the former indicating a more dispersed distribution of the variable (18). The “zero” values are an indication of the randomly spatial distribution of the phenomenon under study (18). Anselin Local Moran’s I index was used for locating the high- and low-risk clusters or spots for drug-related deaths, it divides the polygons into 5 parts: high–high, low–low, low–high, high–low and not significant. High– high indicates a high incidence rate within a zone and its neighbouring areas, i.e. high-risk clusters of disease incidence, or, to use a more literal term, its hotspots; low–low indicates a low incidence of disease within a zone and its surrounding areas, i.e. the low-risk disease clusters or the cold spots (15,19,20). Results Descriptive Of the 12 386 drug-related deaths during 2014–2017, the greatest number, 3513, occurred during the summer, and middle-aged people accounted for 7162 deaths. The age- adjusted drug-related deaths rate was 7.8 times greater in men than in women. Adults accounted for the highest number of drug-related deaths. The drug-related deaths rate increased in all age groups except for the child– adolescent group, which showed a significant increase in 2015 and a sharp decrease in 2016. The mean age of children and adolescents who died of substance use was reported as 5.2 (SD 4.6) years. Mean age was 20.7 (SD 2.5) years among the young adult group, 34.2 (SD 5.4) years for adults and 55.6 (SD 9.8) years for older adults. Over the 4-year period, the crude death rate per 100 000 persons was 15.14 and the age-adjusted death rate was 14.76 (Table 1). Hamedan and Kermanshah provinces had the highest age-adjusted drug-related deaths rates, while Golestan, Bushehr and West Azarbaijan had the lowest rates (Table 2). The provinces where drug-related deaths was higher or lower than the national age-adjusted rate are shown in Table 2: the difference was statistically significant for the 760 Research article EMHJ – Vol. 28 No. 10 – 2022 9 provinces with the highest rates and the 12 provinces with the lowest rates (P < 0.001). Spatial autocorrelation and identifying the clusters To analyse the spatial distribution of the disease, first the cumulative rate of incidence was calculated in 100 000 individuals. The 8 provinces with the highest 8 cumulative incidence rates were: Khorasan Razavi (18.7), Semnan (18.7), Tehran (21.2), Alborz (21.2), Hamedan, 25.8), Kermanshah (32.3), Lorestan (23.8) and Zanjan (22.9). The provinces with the lowest cumulative incidence rates were: Bushehr (5.6), Khouzestan (7.9), Azarbayjan Sharghi (5.7), Golestan (6.3) and Mazandaran (5.8) The results obtained via Global Moran’s I analysis gave a value for this index of 0.269, indicating the intensity of autocorrelation and the high tendency to clustering. The z-score value of 4.9 (P < 0.001) shows that the rate of spatial autocorrelation in these types of deaths was statistically significant, even at 0.99 level of confidence. In other words, the probability that the spatial distribution of the disease is not cluster-based and there is no high autocorrelation and that the cluster distribution and autocorrelation have been wrongly recognized as high was only 0.0004. After finding that spatial autocorrelation was high, and given the spatial clustering of the disease, we decided to identify cold spots and hotspots using the Local Moran’s I index. We found that Zanjan, Hamedan, Loretan and Kermanshah provinces form the high–high cluster, showing that the rate of drug-induced deaths was higher than the national average and that since these provinces are geographically close to each other, they formed a high risk (hotspot) cluster. In other words, the incidence of drug-induced deaths was high in these provinces and their neighbouring provinces. Conversely, the provinces of Kordestan and Mazandaran were detected as a low– Table 1 Distribution of number of drug-related deaths and the substance-related death rate, Islamic Republic of Iran, 2014–2017 Sex/age Deaths Specific death ratea Age-adjusted death rate Relative risk No. % Sex Female 1 379 11.0 0.87 0.44 1b Male 10 889 88.0 6.80 3.33 7.80 Unknown 118 1.0 – – – Total 12 386 100.0 3.90 3.78 – 2014 < 14 years 82 2.8 0.64 0.10 1b 15–24years 373 12.8 1.98 0.13 3.09 25–44 years 1 733 59.5 6.10 0.27 9.53 45–60 years 724 24.9 4.01 1.38 6.26 Total 2 912 100.0 4.23 3.64 – 2015 < 14 years 81 2.8 0.62 0.13 1b 15–24years 462 16.2 2.52 0.35 4.06 25–44 years 1 655 58.0 5.71 1.72 9.20 45–60 years 658 23.0 3.52 1.21 5.67 Total 2 856 100.0 3.57 3.42 – 2016 < 14 years 82 2.5 0.33 0.07 1b 15–24years 428 13.0 3.49 0.48 8.11 25–44 years 1 903 57.7 6.46 1.90 15.02 45–60 years 886 26.9 4.59 1.58 10.67 Total 3 299 100.0 4.13 4.09 – 2017 < 14 years 86 2.6 0.43 0.09 1b 15–24years 532 16.0 4.61 0.64 10.72 25–44 years 1 879 56.6 6.32 1.91 14.69 45–60 years 822 24.8 4.08 1.40 9.48 Total 3 319 100.0 4.09 4.05 – aPer 100 000 persons bReference group. 761 Research article EMHJ – Vol. 28 No. 10 – 2022 high, or cold spot, cluster, indicating that the drug-related deaths incidence was lower than the national average and that these regions are surrounded by high-risk areas. The geographical specifications related to provinces identified as high–high and low–high clusters of drug- induced death are presented in Table 3. No low–low or high–low clusters were observed. Temporal trend The results of the analysis time trend are presented in Figure 1 and Table 4. The raw death incidence trend for the whole country showed an initial increasing, but nonsignificant, rate during 2014–2017 (48 months) (APC = 0.52) (Figure 1, part A). At the end of the study period (second half of 2017), there was a decreasing, but nonsignificant, incidence rate (P = 0.310) for the disease (APC = –6.99) (average annual percent change = –0.5; 95% CI: –3.2, –2.3). The number of deaths for each month was calculated for the 4 years covered by the study, and the trend of death registration was examined (Figure 1, part B). This chart indicates the number of new cases of deaths registered separately for each month during 2014–2017, which has 3 joinpoints. In the spring months (Jan, Feb, Mar) of 2014– 2017, an intense and significant decrease was observed (MPC = –11.47, 95% CI: –21.0, –0.6), (P = 0.04) (Table 4). Then, according to the Joinpoint regression analysis, in the next 3 months, there was an increasing trend such that in the summers of 2014–2017 (Apr, May, Jun), the number of registered deaths reached a peak (APC = 18.31, Table 2 Comparison of provincial rates (crude death rates and age-adjusted death rates using direct method) with the national rate, Islamic Republic of Iran, 2014–2017 Province Crude death ratea Age-adjusted death ratea Difference rate (Province – whole country) (95% CI) P-value Kermanshah 32.22 31.02 16.20 (13.8, 18.7) < 0.001 Hamedan 12.81 24.90 10.14 (8.49, 11.79) < 0.001 East Azarbaijan 14.79 23.76 8.99(7.43, 10.55) < 0.001 Lorestan 23.52 23.48 8.72 (6.48, 10.96) < 0.001 Zanjan 22.57 21.53 6.77 (3.97, 9.57) < 0.001 Razavi Khorasan 18.33 19.50 4.74 (3.63, 5.86) < 0.001 Tehran 20.96 19.48 4.72 (3.91, 5.53) < 0.001 Alborz 20.37 18.85 4.09 (2.41, –5.78) < 0.001 Sistan & Balochistan 13.16 18.65 3.88 (2.27, 5.5) < 0.001 Semnan 18.27 17.11 2.34 (–7.79, 5.47) 0.111 Qazvin 16.16 15.94 1.18 (–1.04, 3.41) 0.280 Isfahan 16.92 15.81 1.05 (–8.15, 2.17) 0.002 Fars 15.48 15.27 –5.06 (–6.31, 1.64) 0.371 Qom 16.06 15.14 0.38 (–1.8, 2.55) 0.733 Iran (total) 15.14 14.76 – – Ardabil 13.80 14.52 –2.42 (–2.34, 1.86) 0.820 Chahar–Mahal Bakhtiari 14.29 13.35 –1.41 (–3.77, 9.44) 0.261 Gilan 13.44 12.67 –2.10 (–3.5, –0.69) 0.007 Hormozgan 11.23 12.46 –2.30 (–3.99, –0.61) 0.014 Kohgilouyeh & Boyerahmad 10.72 10.54 –4.22 (–6.62, –1.81) 0.004 Markazi 11.16 10.20 –4.56 (–6.21, –2.91) < 0.001 Kurdistan 9.54 10.15 –4.61 (–6.23, –3.00) < 0.001 South Khorasan 9.43 10.11 –4.65 (–6.9, –2.39) < 0.001 Ilam 10.27 9.92 –4.84 (–7.41, –2.28) < 0.001 Kerman 10.16 9.67 –5.09 (–6.21, –3.97) < 0.001 North Khorasan 8.86 8.94 –13.87 (–14.54, –13.2) < 0.001 Khuzestan 7.77 8.51 –6.26 (–7.12, –5.39) < 0.001 Yazd 10.00 8.45 –6.31 (–8.05, –4.57) < 0.001 Mazandaran 5.72 7.24 –7.52 (–8.49, –6.55) < 0.001 Golestan 6.20 6.43 –8.33 (–9.5, –7.17) < 0.001 Bushehr 5.46 6.06 –8.71 (–10.1, –7.25) < 0.001 West Azarbaijan 5.27 5.53 –9.23(–10.08, –8.38) < 0.001 aPer 100 000 persons. 762 Research article EMHJ – Vol. 28 No. 10 – 2022 Table 3 Geographical specifications related to provinces identified as high–high and low–high clusters of drug-induced death (n = 100 000), 2014–2017 CIR Altitude (m) Longitude (°E) Latitude (°N) Area (km2) District centre District Cluster type 32.3 1374 46.683 34.433 24 998 Kermanshah Kermanshah High–high 23.8 4050 48.353 33.487 29 308 Khoram Abad Lorestan 25.8 1850 48.510 34.790 19 546 Hamedan Hamedan 22.9 1638 48.384 36.496 21 773 Zanjan Zanjan 5.8 5600 51.301 36.453 23 842 Sari Mazandaran Low–high 9.6 1463 46.984 35.682 64 054 Sanandaj Kordestan CIR = cumulative incidence rate. Table 4 Temporal analysis with Joinpoint regression models fitted to crude incidence rate and count of drug-related deaths (DRDs) in the Islamic Republic of Iran, 2014–2017 Factor APC P-value AAPC Point estimate 95% CI Point estimate 95% CI Temporal trend of the crude incidence rate of DRD for whole country 1–43 months 0.50 –0.1, 1.1 0.073 –0.33 –1.8, 1.3 44–48 months –6.99 –19.3, 7.2 0.310 Temporal trend of new cases of count by month Jan, Feb, Mar –11.47a –21.0, –0.6 0.04 –0.51 –3.2, 2.3 Apr, May, Jun 18.31a 5.3, 32.9 0.011 Jul, Aug, Sep, Oct, Nov, Dec –5.09a –6.9, –3.2 0.002 Temporal trend of crude incidence rate of DRD according to age (years) ≤ 14 –16.6 –49.1, 36.6 < 0.1 – – 15–24 33.11a 27.0, 39.5 < 0.1 – – 25–44 2.32 –8.3, 14.2 < 0.1 – – 45–60+ 3.21 –18.3, 30.4 1.0 – – APC = annual percent change. AAPC = average annual percent change. aAPC and slope are significantly different from zero at α = 0.05. 95% CI: 5.3, 32.9). In the next 6 months of 2014–2017, i.e. autumn and winter (Jul, Aug, Sep, Oct, Nov, Dec), the trend for registration of drug-related deaths showed a decrease (APC = –5.09, 95% CI: –6.9, –3.2). Therefore, it can be concluded that deaths due to drug abuse exhibit seasonal changes (average annual percent change = –0.33, 95% CI: –1.8, 1.3) (Table 4). The raw drug-related deaths rate for the age group ≤ 14 years during the 4 years under study showed a nonsignificant decreasing trend without noticeable changes (APC = –16.6) (Figure 1, part C). For the age group 14–25 years, there was an increasing trend over the 4 years (APC = 33.11) (Figure 1, part D). In the 25–44 age group, the incidence of death showed a moderate but nonsignificant increase (APC = 2.32) (Figure 1, part E; Table 4). The DRD rate for the age group 45+ years during the 4 years of the study also showed a moderate but nonsignificant increasing trend (APC = 3.21) (Figure 1 part F; Table 4). Discussion A total of 12 386 drug-related deaths were registered over the 4-year period in 2 archives. Mortality was higher in the adult age group and during the summers. The mean age of the substance-related deaths was 5.2 years among children and adolescents, 20.7 years among young adults, 34.2 years among adults and 55.6 years among older adults. The highest mortality rates were attributed to the east–west substance transit belt. The Islamic Republic of Iran bears the greatest burden among all substance transit countries (21): the regions around the east–west route through the country has the highest mortality due to substance use. Substance transit from Afghanistan to the Islamic Republic of Iran has been one of the country’s biggest problems since the 20th Century. Khorasan Razavi and Sistan and Baluchistan provinces are the starting points for the transit of substance shipments into the country. The east–west route directs substances to the Middle East, the northern route to Turkey and Russia and the southern route to the Persian Gulf countries. Around 37% of the heroin 763 Research article EMHJ – Vol. 28 No. 10 – 2022 Figure 1 The changing trend of substance-related deaths rate in the Islamic Republic of Iran during 2014–17 764 Research article EMHJ – Vol. 28 No. 10 – 2022 produced in Afghanistan enters the Iranian market and 83% of Afghanistan’s opium is transited through the Islamic Republic of Iran, of which approximately 40% is used domestically. In our study, adults showed the highest mortality rate. According to demographic studies conducted in the Islamic Republic of Iran, the third and fourth decades of life are the most common ages for substance dependence (22,23). Similar studies conducted in the USA confirm this: although substance use disorders have been decreasing among adolescents, the mortality rate due to illicit substance use increased among adults (26–34 and ≥ 35 years) during 1999–2015 (24). The most important risk factors in this age group include: being single, having no proper job, unemployment, lack of financial security and homelessness (25). Death among adults (45–54 years) adds to the years of potential life lost compared to later ages in life (55+ years) (26). A USA study calls these kinds of death as “deaths of despair” (27), common among those aged 45–54 years. A wide range of socioeconomic factors are implicated in increased substance abuse and overdose of lethal substances in this age group (27). Substance abuse is common among older adults in the Islamic Republic of Iran (28), leading to a variety of disorders among this group (29). Some disorders come with aging: previous studies have shown that infection, liver disease and prescription of opium by doctors to relieve the pain of cancerous or noncancerous diseases are the most common causes of substance use disorders among adults and older adults, and these are associated with increased odds of death (28–30). The most important Figure 1 The changing trend of substance-related deaths rate in the Islamic Republic of Iran during 2014–17 (concluded) 765 Research article EMHJ – Vol. 28 No. 10 – 2022 reasons for substance abuse in this age include job loss, retirement, physical pain, loss of health and loss of relatives, as well as reduced social relationships (29). Our findings showed that mortality was lower in women than in men. Although the results from similar studies indicate that the risk of death due to substance intoxication is greater in men (22,30,31), it is important to note that a low mortality rate due to substance abuse should not be interpreted as low burden of substance use in women (31). The results of our study indicated that most deaths due to substance abuse occurred during summer. This is confirmed by the results of previous research conducted in the Islamic Republic of Iran (32). Although holidays make summer a fun season, adolescents are at risk due to substance and alcohol abuse. Some of the study limitations were linked to under- reporting. First, this study was based on data collected from death certificates in the Ministry of Health and Medical Education and the Legal Medicine Organization, the quality of which depends on the accuracy and completeness of the registration process. Second, the Legal Medicine Organization refrained from providing the names of substances that caused death, thus an accurate description or report of such substances could not be provided. Another limitation of the study was that age was not recorded for 50 deceased people in the 2015 statistics and 60 in the 2014 statistics; the data for these were therefore excluded from the study. The advantages of this study over similar studies conducted in the Islamic Republic of Iran (10) include the use of 2 sources by the capture–recapture method to find the precise statistics for number of deaths due to substance abuse in each year, and that the crude and age- adjusted mortality rates in the provinces were reported using the direct method. Conclusion The Islamic Republic of Iran has the shortest substance transit route to Europe and other countries. There is a high demand for substance use in this country, and the provinces which lie on the east–west substance transit routes suffer the most damage from substance abuse complications. Death due to substance abuse will remain a huge public health problem unless policy- and decision- makers, physicians and parents identify the reasons for the increase of this problem despite the extensive regulatory efforts and find ways to protect children and families . Funding: This study was funded by the Mazandaran University of Medical Sciences. Competing interests: None declared.. Distribution spatiale et tendance temporelle des décès liés à la consommation de drogues en République islamique d'Iran entre 2014 et 2017 Résumé Contexte : Les recherches indiquent une tendance à la hausse des décès liés à la consommation de drogues dans le monde : selon les estimations, 69 000 personnes perdent la vie chaque année du fait de l'abus de substances psychoactives. Objectifs : Déterminer la pathologie géographique des décès liés à la consommation de drogues en République islamique d'Iran et évaluer les tendances de l'incidence, en mettant l'accent sur l'identification des régions à haut et à faible risque. Méthodes : Pour cette étude écologique, nous avons recueilli des données auprès des deux principales sources chargées de l'enregistrement des décès liés à la consommation de substances psychoactives (l'Organisation de médecine légale et le ministère de la Santé et de l'Enseignement médical) entre 2014 et 2017. L'analyse des données a été réalisée à l'aide de l'analyse de régression Joinpoint, Global Moran's I et Anselin Local Moran's I. Résultats : Sur les 12 386 décès liés à la consommation de drogues enregistrés entre 2014 et 2017, la plupart se sont produits pendant les mois d'été ; 7162 d'entre eux sont survenus chez des personnes d'âge moyen. L'âge moyen des enfants et des adolescents décédés du fait de la consommation de substances psychoactives était de 5, 2 ans [écart type (ET) 4, 6]. Dans le groupe des jeunes adultes, l'âge moyen au décès était de 20,7 ans (ET 2, 5) ; il était de 34, 2 ans (ET 5, 4) pour les adultes et de 55,6 ans (ET 9, 8) pour les adultes plus âgés. Les variations du taux de mortalité ont culminé en 2017 (variation annuelle en pourcentage = 0,52) ; au cours des derniers mois de la période de l'étude, on a observé une diminution non significative (variation annuelle en pourcentage = –6, 99) de l'incidence (variation annuelle moyenne en pourcentage = –0, 5 ; intervalle de confiance à 95 % : –3, 2, 2, 3). Conclusion : Les décès dus à la consommation de substances psychoactives resteront un énorme problème de santé publique à moins que les législateurs, les responsables de la santé publique, etc. ne puissent déterminer les raisons pour lesquelles ce problème s'aggrave encore malgré les efforts considérables déployés en matière de réglementation et que ces derniers puissent trouver des moyens d'en atténuer l'impact. 766 Research article EMHJ – Vol. 28 No. 10 – 2022 References 1. Martins SS, Sampson L, Cerdá M, Galea S. Worldwide prevalence and trends in unintentional drug overdose: a systematic review of the literature. Am J Public Health. 2015;105(11):e29–49. doi:10.2105/AJPH.2015.302843 2. International statistical classification of diseases and health related problems, 10th revision (ICD-10). Geneva: World Health Organization; 2004. 3. Overdose death rates. 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J Res Med Sci. 2021 Feb 27;26:18. doi:10.4103/jrms.JRMS_662_20 2014 نم ةترفلا للاخ ةيملاسلإا ناريإ ةيروهجم في تاردخلما نع ةجمانلا تايفولل ينمزلا هاتجلااو فيارغلجا عيزوتلا ةيئيب ةسارد :2017 لىإ نایناخاباب هدوعسم ،يبرص يدهم ،يوسرخ يرشدرأ ،یناجندروب یمیحر داجس ،يماغرز نارهم ،روبیلع سابع ةصلالخا داوم يطاعت ببسب متهایح نودقفي نيذلا ددع ر َّدقُي ذإ ،لماعلا ءاحنأ عیجم في تاردخلما نع ةجمانلا تایفولا هاتجا ديازت لىإ ثوحبلا يرشت :ةيفللخا .اًّيونس صخش فلأ 69 وحنب نامدلإا عم ،تایفولا تاهاتجا مییقتو ةیملاسلإا ناريإ ةيروهجم في تاردخلما نع ةجمانلا تایفولل فيارغلجا عيزوتلا ديدتح لىإ ةساردلا هذه تفده :فادهلأا .ةضفخنلماو ةیلاعلا رطاخلما تاذ قطانلما ديدتح لىع زیكترلا ةسسؤم اهمو( نامدلإا داوم يطاعت نع ةجمانلا تایفولا لیجست نع ينلوؤسلما ينیسیئرلا نيردصلما نم تانایب انعجم ،ةیئیبلا ةساردلا هذه ءارجلإ :ثحبلا قرط ،Joinpoint رادحنا لیلتح مادختساب لیلحتلل تانایبلا تعضخو .2017 لىإ 2014 ماع نم ةدلما للاخ )يبطلا میلعتلاو ةحصلا ةرازوو ،يعشرلا بطلا .Anselin Local Moran’s I ةادأو Global Moran’s I ةادأو ناكو ؛فیصلا رهشأ في ةافولا تلااح مظعم تعقو ،2017 لىإ 2014 ماع نم ةترفلا في تاردخلما نع ةجمان ةافو ةلاح 12386 ينب نم :جئاتنلا يرایعلما فارحنلاا[ 5.2 نامدلإا داوم يطاعت ببسب اوفوُت نيذلا ينقهارلماو لافطلأا رمع طسوتم ناكو .رمعلا فصتنم في مهنم اًصخش 7162 ةئف في ةنس )5.4 يرایعلما فارحنلاا( 34.2و ،بابشلا ةئف في ةنس )2.5 يرایعلما فارحنلاا( 20.7 ةافولا دنع رمعلا طسوتم ناكو .ةنس ]4.6 يرغتلل ةيوئلما ةبسنلا( 2017 ماع في اتهورذ تایفولا لدعم في تايرغتلا تغلبو .نسلا رابك ةئف في ةنس )9.8 يرایعلما فارحنلاا( 55.6و ،رابكلا ةافولا لدعم في )6.99- = يونسلا يرغتلل ةيوئلما ةبسنلا( ظوحلم يرغ اًضافخنا ةساردلا ةترف نم ةيرخلأا رهشلأا تدهشو ،)0.52 = يونسلا .)2.3 ،3.2- :%95 ةقثلا دودح ؛0.5- = يونسلا يرغتلل ةيوئلما ةبسنلا طسوتم( نولوؤسلما وأ نوع ِّشرُلما نكمتي لم ام ،ةماعلا ةحصلا تلاكشم نم ةمخض ةلكشم نامدلإا داوم يطاعت نع ةجمانلا تایفولا لظتس :تاجاتنتسلاا .نلآا ىتح تلذُب يتلا ةفثكلما دوهلجا نم مغرلا لىع ةلكشلما هذه ديازت رارمتسا ببس ديدتح نم مهيرغ وأ ةماعلا ةحصلا نع 767 Research article EMHJ – Vol. 28 No. 10 – 2022 13. 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Spat Spatiotemporal Epidemiol. 2018;25:19–24. doi:10.1016/j.sste.2018.01.001 768 Research article EMHJ – Vol. 28 No. 10 – 2022 15-year evaluation of changes in the HBsAg positivity rate in pregnant women in Turkey: the prominent effect of national vaccination Selma Tosun,1 Ayşegül Erdoğan,2 Ayşe Torun,3 Selma Sever,4 Sibel Altuntas,5 İlknur Yildiz,6 Hüseyin Kutlu,7 Mehmet Ceylan,8 Pembe Yesilbag,9Bayhan Bektore,10 Nefise Oztoprak,11 Buket Gungor,12 Sezen Koparan,13 Gülnur Kul,14 Ali Olut,1 Bülent Altuntaş15 and Multicenter Study Group 1Department of Infectious Diseases and Clinical Microbiology, Bozyaka Education and Research Hospital, University of Health Sciences, İzmir, Turkey. 2Department of Public Health, Faculty of Medicine, Sütçü İmam University, Kahramanmaraş, Turkey (Correspondence to: Ayşegül Erdoğan: ayseguldr@ hotmail.com). 3Department of Infectious Diseases and Clinical Microbiology, Şanlıurfa Education and Research Hospital, Şanlıurfa, Turkey. 4Department of Infectious Diseases and Clinical Microbiology, Uşak Banaz State Hospital, Uşak, Turkey. 5Department of Family Medicine, Başakşehir Çam and Sakura State Hospital, İstanbul, Turkey. 6Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey. 7Department of Medical Microbiology, Faculty of Medicine, Uşak University, Uşak, Turkey. 8Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Harran University, Şanlıurfa, Turkey. 9Department of Obstetrics and Gynaecology; 10Department of Medical Microbiology, Kars Harakani State Hospital, Kars, Turkey. 11Department of Infectious Diseases and Clinical Microbiology, Antalya Education and Research Hospital, Antalya, Turkey. 12Department of Pharmacology; 13Department of Public Health, Antalya Provincial Health Directorate, Antalya, Turkey. 14Department of Infectious Diseases and Clinical Microbiology, Kırıkhan State Hospital, Hatay, Turkey. 15Esenyurt Family Health Center, İstanbul, Turkey. Introduction Worldwide, approximately 90% of people with chronic hepatitis are not aware of their illness (1). They may consequently spread the hepatitis B virus (HBV) to others and experience progression of the disease. Perinatal exposure is a significant mode of HBV transmission, resulting in chronic disease in approximately 90% of infected infants. Exposure to HBV in infancy or early childhood is associated with an increased risk of developing cirrhosis and hepatocellular carcinoma (1,2). It is, therefore, crucial to notify HBsAg positive pregnant women and take necessary precautions to prevent mother-to-child transmission of HBV. These precautions include routine prenatal screening for HBsAg in combination with the administration of hepatitis B hyper immunoglobulin (HBIG) within the first 12–24 hours after delivery, followed by HBV vaccination of infants born of HBsAg positive mothers (3–5). Despite adequate prophylaxis with hepatitis B vaccination and HBIG, HBV transmission may occur at a rate of 5–10% in infants of HBeAg-positive mothers with a detectable HBV DNA level > 10 IU/mL (6,7). Some strategies, especially therapy with antiviral drugs, are therefore recommended in those with high viral load during pregnancy to reduce the amount of virus (viral load) in the blood. This strategy is essential to protect unborn babies from mother-to-child transmission (1,6–8). Nowadays, even in most countries where HBV is endemic, HBsAg screening using an ELISA test during pregnancy is far below desirable levels. The US Centers Abstract Background: The detection of hepatitis B surface antigen positivity in pregnant women before delivery is crucial to preventing mother-to-child transmission of hepatitis B virus. Aims: This study aimed to evaluate the status and rate of testing for hepatitis B surface antigen, rate of hepatitis B surface antigen positivity, hepatitis B surface antigen positivity distribution rate by age, and changes in hepatitis B surface antigen positivity rate in pregnant women over the study period. Methods: We conducted a multicentre, cross-sectional, descriptive study covering the period January 2005 to June 2019 for 2 145 668 pregnant women from 27 provinces in all 7 regions of Turkey, collected using Microsoft Excel before statistical analysis. Results: We found that 1 012 593 (47.1%) pregnant women were tested for hepatitis B surface antigen over the 15-year period, out of which 11 471 (1.1%) were hepatitis B surface antigen-positive. Overall, 97% of the hepatitis B surface antigen positive women were born before 1998, the year that national HBV vaccination was launched in Turkey. The rate of hepatitis B surface antigen positivity in that group was 1.1%, compared with 0.3% among women born after 1998. Conclusion: There was a downward trend in the hepatitis B surface antigen positivity rate among pregnant women in the younger age groups, especially among those born after universal hepatitis B vaccination was inaugurated, and low rate of HBsAg testing during pregnancy. Keywords: HBsAg positivity, pregnancy, vaccination, women Turkey Citation: Tosun S; Erdoğan A; Torun A; Seve S; Altuntas S; Yildiz I; et al. 15-year evaluation of changes in the HBsAg positivity rate in pregnant women in Turkey: the prominent effect of national vaccination. East Mediterr Health J. 2022;28(10):768–775. https://doi.org/10.26719/emhj.22.071 Received: 26/08/21; accepted: 29/06/22 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 769 Research article EMHJ – Vol. 28 No. 10 – 2022 for Disease Control and Prevention recommends that each pregnant woman should be tested for HBsAg during the first prenatal visit in each pregnancy and further recommends HBsAg testing for all pregnant women, even if they had been previously vaccinated or tested (9–12). The recommendations on the necessity of testing for HBsAg in pregnancy were first defined in Turkey in the antenatal care guidelines published by the Ministry of Health in 2014 (13). A considerable lack of knowledge or awareness of this guideline among physicians led to poor compliance with screening for HBsAg and insufficient requests for HBsAg testing during pregnancy; HBsAg testing, therefore, could not be done among pregnant women at the desired levels throughout the country. There was no legal obligation in Turkey to screen pregnant women for HBsAg during pregnancy until 2018. Thus, until 2018 physicians tested pregnant women for HBsAg only as a recommended option (13). Turkey is among the moderately endemic countries in terms of HBV, located in the European continent and adjacent to the Asian continent. Its universal HBV vaccination programme started in 1998. Adolescent vaccination campaigns (catch-up campaigns) were carried out in schools between 2005 and 2009. Health workers and adults in the high-risk group are vaccinated free of charge by the Ministry of Health. Children born in 1998 and 1999 who were vaccinated at birth were revaccinated during the catch-up campaign. Catch-up vaccinations have not been administered since 2000. Within the scope of safe injection practices, the use of disposable syringes started in 1985 and safe blood transfusion practices are carried out meticulously. For this reason, the incidence of acute HBV cases in Turkey has decreased over the years, and chronic HBV infection has decreased significantly, especially in children and adolescents (14). The World Health Organization initiated a programme (the Global Health Sector Strategy) to eliminate viral hepatitis throughout the world by 2030 and to reduce the number of cases and the number of deaths due to this disease (2). In compliance with this programme, the Turkish Ministry of Health created and implemented the Chronic Viral Hepatitis Prevention and Control Programme in October 2018 (14). The programme made it legally obligatory for physicians to order HBsAg testing during pregnancy for all pregnant women, in addition to adopting the strategies included in the Global Health Sector Strategy in Turkey (14). Since implementation of this programme just began in Turkey, this study assessed the rates of HBsAg screening in pregnant women and the situation before the programme started. We conducted this study to determine the changes in the status and rate of testing for HBsAg and the HBsAg positivity rate among pregnant women during 2005–2019. We especially wanted to do this before the implementation of the Viral Hepatitis Prevention and Control Programme, which will continue for 5 years (14). Methods Study design We performed this multicentre, retrospective, cross- sectional study between 1 July 2019 and 1 July 2020; the data included in the study were obtained between 2005 and 2019. We created an Excel form and sent it to all health centres, followed by the agreement of the centres to participate in the study. Data were collected from 50 primary, secondary and tertiary health centres in 27 of the 81 provinces in Turkey (Adana, Aksaray, Ankara, Antalya, Batman, Çanakkale, Denizli, Edirne, Gaziantep, Giresun, Hatay, Iğdır, İstanbul, İzmir, Kahramanmaraş, Kars, Kütahya, Manisa, Mersin, Muş, Rize, Şanlıurfa, Şırnak, Tekirdağ, Trabzon, Uşak, Yozgat), distributed throughout the country. Each participating centre recorded its data in the Excel form and sent it to our centre for each year. The data included: the number of pregnant women admitted to the centres, number of pregnant women tested for HBsAg, number confirmed to be HBsAg-positive and the birth dates of the pregnant women. We subsequently stratified the data for HBsAg- positive pregnant women by age group and year and analysed the data in terms of the annual rate of HBsAg positivity. The pregnant women in our study were divided into 5-year age groups. Since the mothers who were born in 1998 and 1999 were revaccinated in the catch-up campaign, these and the other mothers who were born in 2000 and after (who were vaccinated at birth only) were evaluated in separate groups. We evaluated all of the data separately for each institution per year of the study. The study physician responsible for each centre deleted duplicate records. The patients’ data were anonymized under the privacy policy to prevent disclosing personal information. We recorded only the initial letters of the first and last names, date of birth and test results in the Excel form before sending the data for statistical analysis. Statistical analysis The data were analyzed using the JASP software, version 9.2.0, using descriptive statistical methods (number, percentage, frequency). Simple linear regression analysis was performed to determine changes in the rate of HBsAg positivity over time. P < 0.05 was considered statistically significant. Ethical considerations We obtained ethical approval from the institutional ethics boards of the University of Health Sciences, Izmir Bozyaka Education and Research Hospital (08.09.2016, No. 430) and the Turkish Public Health Institution Presidency (05.05.2016, No. 45202601). Results The data for 2 145 668 pregnant women admitted into 50 primary, secondary or tertiary healthcare centres from 27 provinces and all 7 regions of Turkey were analysed. 770 Research article EMHJ – Vol. 28 No. 10 – 2022 Of these women, 3729 (0.2%), 47 1928 (22.0%) and 1 670 011 (77.8%) were followed up in primary, secondary and tertiary health care units, respectively. Among those who received care in primary, secondary and tertiary health care units, HBsAg testing was carried out in 1545 (41.4%), 174 347 (36.9%) and 83 670 (50.1%) pregnant women, respectively. The rate of testing for HBsAg during pregnancy was reported to be ≥ 90% in 8 centres. The distribution of the status and rate of testing for HBsAg and the rate of HBsAg positivity in pregnant women is shown in Table 1. In total, 1 012 593 (47.1%) pregnant women were tested for HBsAg; 11 471 (1.1%) were found to be HBsAg positive (Table 1). The largest group of the HBsAg positive patients (35.8%) were in the 29–35 years age group followed by the 36–40 years (22.0%), 25–28 years (15.2%) and 41–45 years (12.3%) age groups (Table 2). Of the 11 471 pregnant women included in our study, 11 138 (97.1%) were born in or before 1997, and only 333 (2.9%) were born in or after 1998 (after the start of the universal HBV vaccination programme). Turkey comprises 7 geographical regions, and HBsAg positivity rates were determined for these regions: Marmara (1.46%), Black Sea (3.30%), Aegean (1.40%), Central Anatolia (0.28%), Eastern Anatolia (1.51%), Mediterranean (1.10%) and South-Eastern Anatolia (1.63%). The number of pregnant women attending a health centre, the number of HBsAg tests and the rate of HBsAg positivity in pregnant women in each province are shown in Table 3. HBsAg positivity was partially higher in Eastern Anatolia, South-Eastern Anatolia and Black Sea regions. However, due to internal migration the rates may differ in other regions as well. The centre in the Black Sea region, which participated in our study, is a university hospital that closely monitors HBsAg positivity cases in pregnant women referred from the surrounding area. This region receives immigrants from some countries in the Black Sea region where HBsAg positivity is higher, and from Eastern. The numbers of pregnant women attending health centres, numbers of HBsAg tests and numbers of HBsAg positivity according to year are shown in Table 4. Accordingly, the rates of HBsAg screening in pregnant women did not change significantly over the years. However, HBsAg positivity in pregnant women tended to decrease over the years and has decreased below 1% in recent years. Simple linear regression analysis showed that the rate of HBsAg positivity decreased significantly over the years (r = –0.798, standard error of the mean = 0.332, P < 0.001) (Figure 1) and the trend is projected to continue over the next 5 years. Discussion The HBsAg positivity rate worldwide is estimated to be approximately 3.6% and geographic variations in the natural history of HBV infection are well documented (2,4,6,15,16). There has been a widespread reduction in acute viral hepatitis B cases in recent years. A favourable change in the epidemiology of HBV infection is observed mainly at younger ages – children, adolescents and young adults (1,2). In a 2017 review of studies published during 2005–2015, the rate of HBsAg positivity was estimated to be 1.0–4.4% in the general community in European countries (17). A number of meta-analyses of HBV epidemiological studies from Turkey have reported similar rates and as a common finding of all these surveys, a significant decrease was observed over time in HBsAg positivity rates in the general population (17–20). Studies published between 2000 and 2016 in the Eastern Mediterranean and Middle Eastern regions were included in a meta-analysis which evaluated HBsAg positivity in pregnant women recruited from the countries in these regions. In that report, data on 89 452 pregnant women were examined in 49 articles; HBsAg positivity was reported to range from 1.0% (Qatar) to 10.8% (Yemen) in 12 countries, including Turkey (2.8%) (21). The HBsAg positivity rate (1.1%) for pregnant women in our study is comparable to the rates in other studies. In more recent studies performed after 2005 involving pregnant women, the rate was reported to vary between 1.2% and 12.3% (mean 4%) (18). A 2016 review from Turkey that examined 64 studies carried out between 1975 and 2016 found that HBsAg positivity among pregnant women was 1.2%–19.2%; it also emphasized that the rate had decreased over the years (22). Another study from Turkey examining the HBsAg positivity rate in pregnant women found rates of 2.6% (n = 3010) between 1995 and 2001, 0.8% (n = 2995) between 2002 and 2008 and 0.8% (n = 1600) between 2009 and 2015 (23). Araz et al. found Table 1 Distribution of the status and rate of testing for HBsAg and the rate of positivity in pregnant women according to type of health care unit in 27 provinces of Turkey, 2005–2019 Type of health care unit Total No. pregnant women admitted No. (%)a Total No. pregnant women tested No. (%)b No. pregnant women HBsAg positive No. (%)b Primary 3 729 (0.) 1 545 (41.4) 25 (1.6) Secondary 471 928 (22.0) 174 347 (36.9) 3 164 (1.8) Tertiary 1670 011 (77.8) 836 701 (50.1) 8 082 (1.0) Total 2 145 668 (100.0) 1 012 593 (47.1) 11 471 (1.1) aColumn percentage. bRow percentage. 771 Research article EMHJ – Vol. 28 No. 10 – 2022 the rate to be 2% in 11 840 pregnant women (mean age 25.5, range 19–43 years) in Gaziantep, southern Turkey, between 2003 and 2005 (24). Later, Tanrıverdi et al. reported an HBsAg positivity rate of 1.2% among 35 295 pregnant women aged 18–45 years in the eastern region of Turkey between 2013 and 2016 (25). Our findings support this downward trend in the HBsAg positivity rate among pregnant women in recent years. According to the analysis of a survey conducted in the United States of America between 2011 and 2014 that included 819 752 pregnant women aged 10–50 years, the rate of testing for HBsAg was 82% and 0.14% (n = 1190) were diagnosed with HBV infection. In comparison with that study, the rate of testing for HBsAg in pregnant women was extremely low (47.1%) in our study (26). Table 2 Distribution of HBsAg-positive pregnant women according to age in 27 provinces of Turkey, 2005–2019 Age group (years) (birth year) No. % 56 ≥ (1963 and before) 23 0.2 46–55 (1964–1973) 501 4.4 41–45 (1974–1978) 1 413 12.3 36–40 (1979–1983) 2 527 22.0 29–35 (1984–1990) 4 102 35.8 25–28 (1991–1994) 1 745 15.2 22–24 (1995–1997) 827 7.2 20–21 (1998–1999) 236 2.1 17–19 (2000–2003) 97 0.8 Total 11 471 100.0 Table 3 Laboratory examination and HBsAg positivity in pregnant women in 27 provinces of Turkey, 2005–2019 Province No. pregnant women attending a health centre No. laboratory tests for HBsAg No. pregnant women HBsAg +ve Laboratory testing for HBsAg (%)a HBsAg positivity (%)a İstanbul 311 418 125 655 1 879 40.35 1.50 Hatay 47 805 25 471 281 53.28 1.10 Giresun 9 004 6 168 61 68.50 0.99 Kütahya 16 655 15 557 206 93.41 1.32 Tekirdağ 10 843 5 158 68 47.57 1.32 Antalya 120 694 66 100 943 54.77 1.43 Trabzon 35 248 9 208 167 26.12 1.81 Aksaray 22 103 13 175 173 59.61 1.31 Adana 1 435 1 435 15 100.00 1.05 Şırnak 15 267 7 632 83 49.99 1.09 Iğdır 38 339 8 474 145 22.10 1.71 Kahramanmaraş 87 345 40 765 499 46.67 1.22 Mersin 62 434 56 432 362 90.39 0.64 Edirne 6 612 6 475 80 97.93 1.24 Batman 140 787 50608 1 435 35.95 2.84 Şanlıurfa 258 670 111 334 1 327 43.04 1.19 Çanakkale 40 556 8 975 117 22.13 1.30 İzmir 62 172 29 764 505 47.87 1.70 Muş 43 208 13 679 304 31.66 2.22 Ankara 279 066 269 760 600 96.67 0.22 Rize 131 787 16 504 826 12.52 5.04 Yozgat 68 404 20 266 81 29.63 0.40 Denizli 4 013 1 196 15 29.80 1.25 Gaziantep 138 554 28 239 386 20.38 1.37 Kars 122 905 45 734 582 37.21 1.27 Uşak 62 234 21 814 232 35.05 1.06 Manisa 8110 7 015 99 86.50 1.41 Total 2 145 668 1 012 593 11 471 47.19 1.13 aRow percentage. 772 Research article EMHJ – Vol. 28 No. 10 – 2022 Table 4 Laboratory examination and HBsAg positivity by year in pregnant women in 27 provinces of Turkey, 2005–2019 Year No. pregnant women attending a health centre No. laboratory tests for HBsAg No. pregnant women HBsAg +ve Laboratory testing for HBsAg (%)a HBsAg positivity (%)a 2005 4 500 2 136 36 47.47 1.69 2006 4 500 2 753 62 61.18 2.25 2007 6 635 3 711 113 55.93 3.05 2008 45 929 28 071 238 61.12 0.85 2009 55 402 28 689 350 51.78 1.22 2010 64 409 29 090 331 45.16 1.14 2011 98 914 35 087 470 35.47 1.34 2012 124 525 46 565 670 37.39 1.44 2013 195 141 68 607 975 35.16 1.42 2014 230 663 100 933 1 163 43.76 1.15 2015 219 191 106 220 1 286 48.46 1.21 2016 340 231 150 898 1 642 44.35 1.09 2017 367 187 192 610 2 005 52.46 1.04 2018 320 006 182 425 1 821 57.01 1.00 2019b 68 435 34 798 309 50.85 0.89 Total 2 145 668 1 012 593 11 471 47.19 1.13 aRow percentage. bJanuary–July. Figure 1 Change in rate of HBsAg positivity among pregnant women tested in 27 provinces of Turkey, 2005–2019 (regression equation Yt = 2.529–0.0949 × t) (using Minitab, trial version: raw data available from corresponding author on request) 16 <caption>Figure 1. Change in rate of HBsAg positivity among pregnant women tested in 27 provinces of Turkey, 2005–2019 (regression equation Yt = 2.529–0.0949 × t) (using Minitab, trial version: raw data available from corresponding author on request) 773 Research article EMHJ – Vol. 28 No. 10 – 2022 Only 8 of the 50 centres included in our study were recorded as having an HBsAg testing rate of ≥ 90%. When the data for HBsAg-positive pregnant women were analysed according to age group, the greatest number were in the 29–35 years age group (35.8%), with 22.0% of the 36–40 years age group testing positive. The incidence of acute and chronic HBV infection decreased significantly, especially in children and adolescents, due to the impact of the ongoing national HBV immunization programme since 1998 in Turkey (18,27). According to Public Health Agency data, the rate of vaccination for hepatitis B increased from 64% in 1999 to 98% in 2018 in Turkey (14). As a supplement to the national HBV immunization, children born between 1994 and 1999 and 1991 and 1993 were vaccinated with second doses of hepatitis B vaccine in primary and high schools within the scope of the catch-up vaccination campaign implemented between 2005 and 2009 (28). The catch-up activity was partially implemented for children born between 1991 and 1993. Since the catch-up campaign was applied only to in-school children, it is not clear whether children who did not attend school that day or who were absent for different reasons were vaccinated, nor how many doses they were given. For this reason, it is assumed that students received 1–3 doses of HBV vaccine during this campaign. The lowest rate of HBsAg-positivity in the 16–21 years age group may be an indication of the success of the national and catch-up hepatitis B immunization programmes and support the positive impact of such immunization programmes in pregnant women. People who are exposed to HBV at a younger age are more likely to develop chronic infection and subsequent cirrhosis and hepatocellular carcinoma; the prevention of HBV transmission at younger ages is, therefore, of great importance. Screening of pregnant women for HBsAg and national immunization against HBV in the newborn in combination with the administration of hepatitis B immunoglobulin at the right time are the easiest and most economical means of preventing hepatitis B. Our study is crucial to ensuring comprehensive and extensive data at the national level, rather than local data in a particular region, on the status and rate of testing for HBsAg and the rate of HBsAg positivity in pregnant women It is gratifying that, although the rates of HBsAg testing in pregnant women have increased, the rates of HBsAg positivity in pregnant women have decreased significantly over the years. We recommend a new vaccination programme for this population, especially in the national action plan of the Turkish Viral Hepatitis Prevention and Control Programme. We support the creation of a legal obligation to carry out HBsAg testing in pregnant women. Such efforts will help prevent mother- to-child transmission of HBV and lead to a subsequent reduction in the prevalence of HBV infection. Acknowledgement We would like to express our gratitude to all the persons who participated in this study. Funding: None Competing interests: None declared. Quinze ans d'évaluation de l'évolution du taux de positivité de l'AgHBs chez les femmes enceintes en Turquie : l'effet majeur de la vaccination nationale Résumé Contexte : La détection d'une positivité à l'antigène de surface de l'hépatite B chez les femmes enceintes avant l'accouchement est cruciale pour prévenir la transmission mère-enfant du virus de l'hépatite B. Objectifs : La présente étude visait à évaluer le statut et le taux de dépistage de l'antigène de surface de l'hépatite B, le taux de positivité à l'antigène de surface de l'hépatite B, le taux de distribution de l'antigène de surface de l'hépatite B selon l'âge, et l'évolution du taux de positivité de l'antigène de surface de l'hépatite B chez les femmes enceintes au cours de la période d'étude. Méthodes : Nous avons mené une étude multicentrique, transversale et descriptive couvrant la période allant de janvier 2005 jusqu'à juin 2019 pour 2 145 668 femmes enceintes de 27 provinces dans les sept régions de Turquie, collectée à l'aide de Microsoft Excel avant l'analyse statistique. Résultats : Nous avons constaté que 1 012 593 (47, 1 %) femmes enceintes avaient été testées pour l'antigène de surface de l'hépatite B au cours de cette période de 15 ans, dont 11 471 (1,1 %) étaient positives. Globalement, 97 % des femmes positives à l'antigène de surface de l'hépatite B étaient nées avant 1998, année où la vaccination nationale contre le VHB a été lancée en Turquie. Le taux de positivité à l'antigène de surface de l'hépatite B dans ce groupe était de 1,1 %, contre 0,3 % chez les femmes nées après 1998. Conclusion : On a constaté une tendance à la baisse du taux de positivité à l'antigène de surface de l'hépatite B chez les femmes enceintes des groupes d'âge plus jeunes, en particulier chez celles nées après le lancement de la vaccination universelle contre l'hépatite B, et un faible taux de dépistage de l'AgHBs pendant la grossesse. 774 Research article EMHJ – Vol. 28 No. 10 – 2022 References 1. Global hepatitis report 2017. Geneva: World Health Organization; 2017 (https://www.who.int/publications/i/item/global-hepati- tis-report-2017, accessed 28 July 2022) 2. Global health sector strategy on viral hepatitis 2016–2021. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/ handle/10665/246177, accessed 10 October 2020) 3. Vodkin I, Patton H. Management of Hepatitis B virus infection during pregnancy. Minerva Gastroenterol Dietol. 2014;60(4):205- 14. 4. Guidelines for the prevention care and treatment of persons with chronic hepatitis B infection, March 2015. 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A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: لياترسلأا دضتسلما /B يدبكلا باهتللال يحطسلا ِّدَضتسُملل ةيبايجلإا جئاتنلا لدعم في تايريغتلا نم اًماع 15 مييقت ينطولا ىوتسلما لىع ميعطتلل زرابلا يرثأتلا :ايكرت في لماولحا ءاسنلا ىدل ناهيب ،جابليسي يبميب ،نلايس دممح ،ولتوك ينسح ،زيدلي رونكلإ ،ساتنوتلأ ليبيس ،رفيس ىملس ،نروت شئاع ،ناغودرأ ةشئاع ،نوسوط ىملس زكارلما ددعتم ةسارد قيرف ،شاتنوتلأ تنلوب ،تولوأ ليع ،لوك رونلوج ،ناربوك نيزيس ،روجنوج تيكوب ،كاربوتزوأ سيفن ،يروتكب ةصلالخا ،ةدلاولا لبق ام ةلحرم في اًركبم اًفاشتكا B يدبكلا باهتللال ةيحطسلا تادضتسملل تايبايجلإا لماولحا ءاسنلا فاشتكلا ىبرك ةيهمأ ةمث :ةيفللخا .لفطلا لىإ ملأا نم B يدبكلا باهتللاا سويرف لاقتنا ي ِّقوَتل ،تادضتسلما هذله ةيبايجلإا تلاالحا لدعمو ،B يدبكلا باهتللال ةيحطسلا تادضتسلما رابتخا لدعمو ةلاح مييقت لىإ ةساردلا هذه تفده :فادهلأا .ةساردلا ةترف دادتما لىع لماولحا ءاسنلا ىدل تادضتسملل ةيبايجلإا جئاتنلا لدعم في تا ُّيرغتلاو ،رمعلا بسح تلاالحا عيزوتو هعوممج ام تلمشو ،2019 ناريزح /وينوي لىإ 2005 نياثلا نوناك /رياني نم ةدلما نع زكارلما ةددعتم ةيعطقم ةيفصو ةسارد انيرجأ :ثحبلا قرط ءارجإ لبق ليسكإ تفوسوركيام جمانرب مادختساب تانايبلا تعُجُمو ،ايكرت في عبسلا قطانلما عيجُم في ةظفامح 27 نم ًلاماح ةأرما 2145668 .يئاصحلإا ليلحتلا نهنيب ءاجو ،اًماع 15 ىدم لىع B يدبكلا باهتللال يحطسلا دضتسلما رابتخلا نعضخ دق )%47.1( ًلاماح ةأرما 1012593 نأ اندجو :جئاتنلا ماعلا وهو ،1998 ماع لبق ندلُو دق تادضتسملل تايبايجلإا ءاسنلا نم %97 نأ َّينبت ،ًلااجُمإو .تادضتسلما هذله )%1.1( ةيبايجإ ةنيع 11471 هذه في B يدبكلا باهتللال ةيحطسلا تادضتسلما هاتج ةيبايجلإا لدعم غلبو .ايكرت في B دبكلا باهتلا سويرف دض ينطولا حيقلتلا هيف َن ِّشُد يذلا .1998 ماع دعب ندلُو تيلالا ءاسنلا ينب %0.3 ةبسنب ةنراقم ،%1.1 ةعومجلما تائفلا في لماولحا ءاسنلا ينب B يدبكلا باهتللال ةيحطسلا تادضتسلما هاتج ةيبايجلإا جئاتنلا لدعم في ضافخنلا هاتجا دوجو َّينبت :تاجاتنتسلاا تادضتسلما رابتخا لدعم ضافخناو ،B دبكلا باهتلا دض لماشلا ميعطتلا ينشدت دعب ندلُو دق تيلالا كئلوأ ينب مايس لاو ،رغصلأا ةيرمعلا .لملحا ءانثأ في B يدبكلا باهتللال ةيحطسلا 775 Research article EMHJ – Vol. 28 No. 10 – 2022 recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents. 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In: Tabak F, ed. Viral Hepatit. Istanbul: Viral Hepatit Savasim Derneği; 2007 1:10–50. 21. Malekifar P, Babanejad M, Izadi N, Alavian S M. The frequency of HBsAg in pregnant women from Eastern Mediterranean and Middle Eastern countries: a systematic review and meta-analysis. Hepat Mon. 2018;18(9):e58830. https://doi.org/10.5812/hepaty- mon.58830 22. Bakar RZ, Dane B. Hepatitis B seropositivity of pregnant women and the review of Turkish literature. Perinatal J. 2016;24(2): 83–88. https://dx.doi.org/10.2399/prn.16.0242005 23. Furuncuoglu Y, Bolukbas FF, Bolukbas C, Torun P, Ozturk R. Changes in the prevalence of HBV infection in pregnant women in Turkey between 1995 and 2015: a 20-year evaluation. Postgrad Med J. 2016;92(1091):510–3. https://doi.org/10.1136/postgrad - medj-2015-133876 24. Araz NC, Dikensoy E. Seroprevalence of hepatitis B among pregnant women in southern Turkey. J Pak Med Assoc. 2011;61(2): 176–7. https://jpma.org.pk/PdfDownload/2589 25. 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Euro Surveill. 2013;18(47):20636. https://doi.org/10.2807/1560-7917.es2013.18.47.20636 776 Short research communication EMHJ – Vol. 28 No. 10 – 2022 COVID-19 excess deaths in Eastern European countries associated with weaker regulation implementation and lower vaccination coverage Alban Ylli,1,2 Genc Burazeri,1,3 Yan Yan Wu4 and Tetine Sentell4 1Department of Public Health, Faculty of Medicine, University of Medicine, Tirana, Albania; 2Institute of Public Health, Tirana, Albania; 3Department of International Health, School CAPHRI (Care and Public Health Research Institute), Maastricht University, Maastricht, The Netherlands; 4Office of Public Health Studies, University of Hawai‘i at Mānoa, Honolulu, Hawaii, United States of America. (Correspondence to: albanylli@yahoo.co.uk) Introduction COVID-19 incidence and confirmed death rate are the most widely used epidemiological parameters to describe differences between countries in the level of risk and health outcomes during the pandemic (1). Both outcomes may be highly affected by the testing and data collection capacities of countries (2). Excess death rate is a more complex indicator, but it may show the true impact of the pandemic across a population, especially in the long-term (3). It may also serve as a better comparative measure across countries with differences in health system and surveillance resources (4). In Eastern European countries, where extensive spread of COVID-19 started later than in the West, public health measures were very effective during the first half of 2020. Excess death rates in most of these countries were negligible at a time when most of Western Europe had exceeded expected rates by 15–35% (5). During the second wave in autumn/winter 2020, excess mortality in Eastern Europe was higher than in most parts of Western Europe and this difference continued throughout 2021 (6). Eastern European countries started vaccination within a similar timeframe with Western Europe, but the vaccination rates in Eastern Europe have been comparatively lower (7). Comparing and quantifying cumulative COVID-19 impacts across country-level public health metrics can be challenging from an outcomes and a public health policy perspective. Efforts to measure the association between COVID-19 cases and vaccination rate (8) have indicated low efficacy of the vaccination programmes. Excess mortality may provide a better indicator of the measurement of long-term health impact differences across countries, especially in the context of different vaccination rates. Publications analysing differences in the effectiveness of government interventions exist (9), but they take for granted the full implementation of the measures in various countries. Differences in enforcement of measures between countries are a known challenge for the international analysis of country response measures to COVID-19 (10,11). Government regulatory enforcement levels generally likely impact the intensity of public health measures enforcement and can thus serve as a proxy for this measurement. Regulatory enforcement is a component of the Rule of Law index, calculated every year by the World of Justice Project (WJP). It is a standardised estimate of how well government regulations are implemented for situations such as environmental restrictions, public health requirements, workplace safety conditions, business activities, etc (12). Regulatory enforcement may therefore be a potential factor in explaining country differences in pandemic outcomes. The objective of this analysis was to assess the association between excess COVID-19 mortality, vaccination rate, and regulation enforcement, controlling Abstract Background: Since winter 2020, excess deaths due to COVID-19 have been higher in Eastern Europe than most of Western Europe, partly because regulatory enforcement was poor. Methods: This paper analysed data from 50 countries in the WHO European Region, in addition to data from USA and Canada. Excess mMortality and vaccination data were retrieved from “Our World In Data” and regulation implementation was assessed using standard methods. Multiple linear regression was used to assess the association between mortality and each covariate. Results: Excess mortality increased by 4.1 per 100 000 (P = 0.038) for every percentage decrease in vaccination rate and with 6/100 000 (p=0.011) for every decreased unit in the regulatory implementation score a country achieved in the Rule of Law Index. Conclusion: Degree of regulation enforcement, likely including public health measure enforcement, may be an important factor in controlling COVID-19’s deleterious health impacts. Keywords: COVID-19, European Region, excess mortality, regulation enforcement, rule of law, vaccination coverage. Citation: Ylli A; Burazeri G; Wu YY; Sentell T. COVID-19 excess deaths in Eastern European countries associated with weaker regulation and lower vaccination coverage. East Mediterr Health J. 2022;28(10):776–780. https://doi.org/10.26719/emhj.22.074 Received: 06/02/22; accepted: 11/08/22 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 777 Short research communication EMHJ – Vol. 28 No. 10 – 2022 for health care utilization. We hypothesized that higher excess mortality rates in Eastern European countries are associated with lower regulatory enforcement scores, which impact government non-pharmaceutical interventions and vaccination programmes. Thus, higher excess mortality can be explained by poorer implementation of public health measures and vaccination programmes. Methods This analysis included 50 countries in the WHO European Region, in addition to USA and Canada. Excess mortality was calculated as observed deaths minus expected deaths per 100 000 population. Expected deaths estimates were based on historical deaths data. Excess mortality was for the period 1 January 2020 to 2 January 2022. Excess mortality country estimates for this analysis were retrieved from Our World in Data (OWID) database (13), which uses data from WHO or verifiable government sources. The excess mortality estimates were originally calculated by The Economist and updated weekly on OWID. The primary mortality data for countries included in this analysis were sourced from Eurostat and national statistical agencies. Not all countries reported mortality in the same way. Where there were delays in reporting, an estimate was used in the database for the period of delay. For this analysis, we used the central estimate provided for 2 January 2022. In a separate analysis we also used excess mortality estimates as of 3 January 2021, before the mass vaccinations. Vaccination rate was calculated as the percentage of the total population that had received at least two doses of vaccine as reported by national programmes. The rates for 10–15 January 2022 were retrieved from OWID (14). The regulation implementation indicator was based on the Rule of Law Index estimations developed by WJP, a well-regarded index compiled from standardized surveys of the general public and local legal experts in 139 countries. It measures 9 dimensions of the rule of law, namely, limited government powers, absence of corruption, order and security, fundamental rights, open government, effective regulatory enforcement, access to civil justice, effective criminal justice, and informal justice (12). This analysis used the component, effective regulatory enforcement, as the index item that most closely relates to the mitigation of the pandemic. The values of the index are between 0 and 1, with 1 being the most effective regulation enforcement. In this analysis, scores were transformed into point percentage to allow for meaningful interpretation of linear regression, using the 2020 data from the WJP database (15). Outpatient visits (per capita per year) were included in the analyses to control for different healthcare system utilization patterns. Data for the latest year were retrieved from WHO dataset (16) for countries in the WHO European Region. USA and Canada were included as the only 2 North American members of the Organization for Security and Cooperation in Europe (17). We computed Pearson’s correlation coefficients, including P-values, between the pairs of variables. Multiple linear regression analysis was conducted to assess the association between explanatory variables and the outcome variable (excess death). Results Mean excess mortality rate on 2 January 2022 among 50 countries included in the analysis was about 326±222 deaths per 100 000 population; mean vaccination rate was about 59%±18%; mean regulation enforcement was about 65±15 points percentage; and mean outpatient visits (per capita/year) was 6.3±2.5. Excess death rate was strongly inversely correlated with regulation enforcement (r= -0.69, P<0.001) and vaccination coverage (r= -0.70, P<0.001). Vaccination coverage was strongly positively correlated with the regulatory implementation index (r=0.73, P<0.001). Excess death rate and regulation enforcement were correlated for 3 January 2021, before mass vaccination started, but the observed association was comparatively weaker (r=0.60, P<0.001). No correlation was found between outpatient visits and each of the three other variables in the analyses: excess mortality (r= 0.31, P=0.031), regulation enforcement (r=-0.13, P=0.406), or vaccination rate (r=0.001, P=0.997). The correlation of excess mortality and vaccination coverage for different scores of regulation enforcement is presented in Figure 1. Excess mortality rate increased by 4.1 per 100 000 for every percentage decrease in vaccination rate, irrespective of regulation enforcement and health care utilization (Table 1). Excess mortality increased with 6 per 100 000 for every unit less in the regulatory implementation index score. Regulation enforcement, vaccination coverage, and outpatient visits accounted for about 62% of the variance of excess death (Table 1). Discussion This short report provides a global perspective on comparative COVID-19 outcomes and policy solutions as of January 2022. Regulation enforcement differences provide a richer understanding of the impact of the pandemic in the context of associated political and societal factors that can influence the management of the crises. Specifically, this study revealed that implementation of the not-always-popular government non-pharmaceutical interventions and, later, vaccination were more effective in more law-abiding societies. This provides key insights for Eastern Europe, which is understudied on this critical policy and public health topic. The focus of most international research and the global media has often being primarily on outcomes of Western countries and associated factors – especially the resistance to vaccination and public health measures 778 Short research communication EMHJ – Vol. 28 No. 10 – 2022 (18) – pandemic outcomes have been poorer in Eastern Europe than Western Europe. In the early phases of the pandemic, urgent short-term measures were effective in preventing deaths in Eastern Europe (19), but over the longer-term, other factors played a more important role in mitigating the pandemic. The degree of enforcement of government regulations is independently correlated to the excess mortality observed during 2020 and 2021 pandemic years. Regulation enforcement may have affected mortality directly, because of less effectively implemented social distancing regulations and mask mandates. This may be especially true in the pre-COVID-19 vaccination period. In the second half of 2020, during the second wave of COVID-19 in Europe, when vaccination was not yet a factor, excess mortality in many Eastern European countries surpassed the numbers recorded in the countries where the pandemic first started (6). Regulation enforcement may also have affected mortality through a less successful vaccination programme during 2021, as countries with a lower regulation implementation index had lower vaccination rates. Vaccine provision was centralized (20) and uniform for all European Union Member States, while Russia was one of the first countries in the world to produce a vaccine (21). Hence, the lower success of vaccination campaigns in many Eastern European countries cannot be explained by variations in supply. Regulation implementation may be influenced by several underlying social factors, including community trust, population education, public patience, etc. Other more specific factors related to present or past models of government may also play a role. Most Eastern European countries have been governed by authoritarian regimes in recent history and many citizens there may be more suspicious towards government regulations or mandates (22). We discuss here only major factors related to regulation enforcement and implementation of vaccination programmes. Other more complex factors may have been involved and the results of this ecological study at country level cannot be generalized for patients. However, we expect this short report to encourage more discussion and especially further research in this policy Figure 1 Association between COVID-19 related excess mortality, vaccination rate and regulation enforcement in 50 countries in January 2022 Regulation enforcement with excess mortality -0.69 (p<0.001) Vaccination rate with excess mortality -0.70 (p<0.001) Regulation enforcement with vaccination rate 0.73 (p<0.001) Table 1 Association of excess mortality with regulation enforcement, vaccination coverage, and outpatient visits Variable Model 2 (R2=61.8%)* Coefficient p-value Intercept 831.9 (596.7, 1067.1) <0.001 Regulation Enforcement -6.0 (-10.5, -1.5) 0.011 Vaccination Rate -4.1 ( -8.0, -0.2) 0.038 Outpatients Per Capita 22.5 ( 5.3, 39.8) 0.012 * Multiple linear regression analysis: excess death (outcome variable); regulation enforcement, vaccination coverage, and outpatient visits/capita (predictors) 779 Short research communication EMHJ – Vol. 28 No. 10 – 2022 area of regulation enforcement during the COVID-19 pandemic. We recommend that implementation enforcement factors should be considered by governments when considering population-wide public health measures, and by experts when measuring real- world impact of the measures. Funding: None Competing interests: None declared. Surmortalité due à la COVID-19 dans les pays d'Europe de l'Est en lien avec une mise en œuvre moins rigoureuse des réglementations et avec une couverture vaccinale plus faible Résumé Contexte : Depuis l'hiver 2020, la surmortalité due à la COVID-19 est plus élevée en Europe de l'Est que dans la plupart des pays d'Europe de l'Ouest, en partie du fait de la mise en œuvre insuffisante des réglementations. Objectifs : Le présent article analyse des données fournies par 50 pays de la Région OMS de l'Europe, ainsi que des données provenant des États-Unis et du Canada. Méthodes : Les données relatives à la surmortalité et à la vaccination ont été extraites du site Web « Our World In Data » et la mise en œuvre des réglementations a été évaluée à l'aide des méthodes standard. La régression linéaire multiple a été utilisée pour évaluer le lien entre la surmortalité et chaque covariable. Résultats : La surmortalité a augmenté de 4,1 pour 100 000 (p = 0,038) pour chaque baisse en pourcentage du taux de vaccination et de 6 pour 100 000 (p = 0,011) pour chaque unité en moins dans le score de mise en œuvre des réglementations obtenu par un pays dans l'indice de l'état de droit. Conclusion : La rigueur de l'application des réglementations, y compris l'application des mesures de santé publique, peut être un facteur important pour atténuer les effets négatifs de la COVID-19 sur la santé. ضافخناو حئاوللا ذيفنت في اًفعض دهشت يتلا ةيقشرلا ابوروأ نادلب في 19-ديفوك سويرف نع ةجمانلا تايفولا ةدايز ميعطتلاب ةيطغتلا ليتنيس ينت ،وو ناي ناي ،يريزاروب كنيج ،ليي نَبلأ ةصلالخا كلذ ىزعُيو ،ةيبرغلا ابوروأ مظعم نم لىعأ ةيقشرلا ابوروأ في -19ديفوك نع ةجمانلا تايفولا في ةدايزلا تناك ،2020 ماع ءاتش ذنم :ةيفللخا .حئاوللا ذيفنت فعض لىإ ا ًّيئزج ةدحتلما تايلاولا نم تانايب لىإ ةفاضلإاب ،ةيلماعلا ةحصلا ةمظنلم بيورولأا ميلقلإا في اًدلب 50 نم تانايب ليلتح لىا ةساردلا هذه تفده :فادهلأا .ادنكو ةيكيرملأا حئاوللا ذيفنت مِّيُقو ،"Our World In Data" نيوتركللإا عقولما نم تايفولا في ةدايزلاو ميعطتلا تانايب صلاختسا ىرج :ثحبلا قرط .كترشم يرغتم لكو ةدئازلا تايفولا ينب طابترلاا مييقتل ددعتلما يطلخا ءافكنلاا مدخُتساو .ةيرايعم قرط مادختساب ،ميعطتلا لدعم ضافخنا نم ةيوئم ةبسن لكل )0.038 = ةيلماتحلاا ةميقلا( 100000 لكل 4.1 ةبسنب تايفولا في ةدايزلا لدعم عفترا :جئاتنلا .نوناقلا ةدايس شرؤم لىع دلبلل حئاوللا ذيفنت في ضافخنا ةجرد لكل )0.011 = ةيلماتحلاا ةميقلا( 100000 لكل 6 ةبسنبو راثلآا نم فيفختلا في ًّماهم ًلاماع نوكي مابر ،ةماعلا ةحصلا يربادت ذافنإ اهنمو ،هيلع ديدشلا صرلحاو حئاوللا ذافنإب كسمتلا نإ :تاجاتنتسلاا .-19ديفوك سويرفل ةيبلسلا ةيحصلا 780 Short research communication EMHJ – Vol. 28 No. 10 – 2022 References 1. 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Trust and Democratic Transition in Post-Communist Europe. Edited by Ivana Markova. DOI: 10.5871/ bacad/9780197263136.003.0007. WHO event addressing public health priorities 781 EMHJ – Vol. 28 No. 10 – 2022 Webinar on improving access to diabetes medicine and care in the Eastern Mediterranean Region1 Citation: World Health Organization. Webinar on improving access to diabetes medicine and care in the Eastern Mediterranean Region. East Mediterr Health J. 2022;28(10):781–782. https://doi.org/10.26719/2022.28.10.781 Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Introduction Diabetes is a major public health challenge globally. It has reached epidemic proportions in the WHO Eastern Mediterranean Region (EMR), which has the highest diabetes prevalence, affecting 14% of the population aged 18 years and above (1-3). More than 50 million people aged 20–79 years in the region lived with diabetes in 2019, imposing a heavy burden on public health and socioeconomic development (2). Diabetes causes premature death and other health challenges such as increased risk of heart attack, stroke, diabetic retinopathy, blindness, kidney failure, and lower limb amputation (3). People living with diabetes (PLWD) require continuous care and support, based on attaining and maintaining good glycaemic control, to manage their condition and avoid complications. However, less than 50% of patients with diabetes in most EMR countries achieve the target levels of glycaemic control, and the COVID-19 pandemic has caused partial or complete disruption of 42% of diabetes care in the region (3,4). This indicates the need to improve access to diabetes care and medicine in the region and accelerate implementation of the regional framework for action on diabetes prevention and control. Major reasons for diabetes recurrence in EMR are related to unequal and limited access to medicines including insulin, limited access to quality care, complications associated with diabetes, limited data and research, and limited awareness of PLWD about the disease and its complications (3). To mark the World Diabetes Day 2021 and the 100th year anniversary of the discovery of insulin, WHO/ EMRO, in partnership with the International Diabetes Federation (IDF) Middle East and North Africa (MENA) Region, held a webinar on improving access to diabetes medicine and care in the EMR for officials of health ministries, IDF network members, diabetes care and research experts, primary healthcare workers, nurses, PLWD, and relevant institutions. The webinar presented diabetes prevention and control initiatives globally and in the EMR, identified barriers and facilitators to diabetes care and management, and made recommendations to optimize diabetes outcomes. Summary of discussions The estimated annual economic burden of diabetes in the EMR is US$ 60 billion, equivalent to an average loss of 1.7% GDP (3). Although international guidelines recommend the use of SGLT2 inhibitors or GLP-1 receptor agonists for the management of high-risk diabetes patients, only 15% of patients with chronic kidney disease and 16% with cardiovascular disease receive them (3). Pakistan has been providing insulin free for type 1 diabetes patients through partner-funded initiatives in different provinces. However, insulin, glucometer, and glucose test strip distribution have decreased, especially in 2020, due to the COVID-19 travel restrictions. Jordan has been promoting diabetes care through primary health centres. However, 18% (60 000) of PLWD in the country were reported not to take their medication for unknown reasons (5). Diabetes cases increased in the Islamic Republic of Iran among individuals aged 25 years and above during the COVID-19 pandemic, from 10% in 2005 to 14% in 2021 (6). Insulin is manufactured locally, therefore, access to insulin is not a major problem, however, one-third of PLWD reported insufficient access to health care. The country has adapted national plans and guidelines for diabetes and complications and has been providing education and information on diabetes care and COVID-19 online, leading to an increase in PLWD registration. Barriers to the implementation of preventive foot care among PLWD in Alexandria, Egypt, were reported to include lack of podiatry education; few qualified podiatrists; focus of physicians on controlling blood glucose; limited time for screening, early detection, and better care for complications in public and private facilities; non-involvement of nurses in patient care; lack of funding for preventive foot care; and lack of referral systems for complications (7). In an online poll conducted for participants in the meeting, the majority (67%) recommended price reduction to increase access to medicines, followed by improving education for policymakers, procurers, health professionals, and PLWD (50%); health insurance (50%); investment in health systems (33%); and improving evidence to enhance evidence-based decision-making (17%). To increase access to quality of care, the majority (78%) recommended capacity development for primary healthcare workers, followed by integration of diabetes 1 This is a summary of the report on a webinar on improving access to diabetes medicine and care in the Eastern Mediterranean Region, available at: https://applications.emro.who.int/docs/ WHOEMNCD150E-eng.pdf?ua=1 782 WHO event addressing public health priorities EMHJ – Vol. 28 No. 10 – 2022 care and management into primary healthcare (56%); ensuring that care systems support team-based care, community involvement, patient registries, and decision support tools to meet patient needs (56%); facilitating engagement with the private sector, including capacity development (56%); and ensuring that health facilities implement patient-centred communication that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care (44%). Key recommendations Member States should promote access to medicines by reducing prices, improving education to increase resource-use efficiency and enhance policy- and decision- making, and implementing health insurance schemes. They should promote access to care by building the capacity of primary healthcare workers to make timely and evidence-based decisions; integrate diabetes care and management into primary healthcare during routine and emergency situations; ensuring that healthcare systems support team-based care, community involvement, patient registries, and decision-making; and facilitate engagement with the private sector. Member States should strengthen diabetes surveillance and research. WHO should facilitate meaningfully involvement of PLWD at all levels of diabetes programming; support capacity-building for programme managers and primary healthcare workers, including nurses, to enhance team- based care; strengthen collaboration and cooperation by fostering existing regional partnerships and initiatives and initiating new partnerships; and support countries to apply new technologies to diabetes care. References 1. World Health Organization. Number of deaths attributed to non-communicable diseases, by type of disease and sex. The Global Health Observatory, https://www.who.int/data/gho/data/indicators/indicator-details/GHO/number-of-deaths-attributed-to-non- communicable-diseases-by-type-of-disease-and-sex. 2. Moradinazar M, Babakhani M, Rostami R, Shakiba M, Moradi A, Shakiba E. Epidemiological status of type 2 diabetes melli- tus in the Middle East and North Africa, 1990–2019. East Mediterr Health J. 2022;28(7):478–488. DOI: https://doi.org/10.26719/ emhj.22.050. 3. World Health Organization. Addressing diabetes as a public health challenge in the Eastern Mediterranean Region. Cairo: WHO Regional Office for the Eastern Mediterranean, September 2021. https://applications.emro.who.int/docs/EMRC687-eng.pdf. 4. Abd-Elraouf MS. Factors Affecting Glycemic Control in Type II Diabetic Patients. Egyptian J Hosp Med 2020; (81)2:1457-1461. https://ejhm.journals.ekb.eg/article_114454_57df17cb9a67e17bc64ac44f1d622be3.pdf. 5. Joseph S. Iraqi refugees manage their diabetes in Jordan. Cairo: WHO Regional Office for the Eastern Mediterranean. https:// www.emro.who.int/jor/jordan-infocus/iraqi-refugees-diabetes-jordan.html. 6. Khodakarami R, Abdi Z, Ahmadnezhad E, Asadi-Lar M. Prevalence, awareness, treatment and control of diabetes among Iranian population: results of four national cross-sectional STEPwise approach to surveillance surveys. BMC Public Health 2022;22:1216. https://doi.org/10.1186/s12889-022-13627-6. 7. Kassab HS, Ismaeal MT, Elfattah TA, Elaaty A. Diabetic foot care knowledge and practice in type 2 diabetes and relation to micro- vascular complications in Alexandria (Egypt). Endocr Regul. 2022;56(2):95-103. DOI: 10.2478/enr-2022-0011. 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 public health and health services; and for the exchange of ideas, concepts, 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 Collaborating Centres and individuals within and outside the Region. طسوتلما قشرل ةيحصلا ةلجلما ةماعلا ةحصلا في ةديدلجا تاردابلماو تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخاو ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا 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 de la santé publique et des services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa- tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes concernés au sein et hors de la Région. 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 Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . 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ISSN 1020-3397 Cover image Credit: ©WHO Cover 28-10.indd 4,6 31/10/2022 9:04 AM La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal EMHJ – Vol. 28 No. 10 – 2022 Volume 28 No. 10 October/Octobre 10 ددع / نوشرعلاو نماثلا دلجلما لولأا نيرشت/ربوتكأ 2022 Eastern M editerranean H ealth Journal Vol. 28 N o. 10 – 2022 The 69th Session of the WHO Regional Committee for the Eastern Mediterranean was held from 10 to 13 October 22, with the theme “Together for a healthier and sustainable tomorrow”. Representatives of the 22 Member States and territories agreed that the most cost- effective protection is to invest in strong, integrated, and people-centered health systems that reach everyone everywhere, at home, on the streets, in the communities, and at schools and workplaces. The Session was preceded by a Walk the Talk activity on 10 October, attended by the WHO Director-General, the WHO/EMRO Regional Director and some representatives of Member States. Editorial Reaching the Sustainable Development Goals in the post-COVID-19 era – the 69th Session of the WHO Regional Committee for the Eastern Mediterranean Region Ahmed Al-Mandhari ...............................................................................................................................................................................................................................................705 Research articles Mental health impact of the first wave of COVID-19 pandemic on healthcare workers in 12 Arab countries Maher Titi, Hayfaa Wahabi, Hala Elmorshedy, Zeinab Shata, Yasser Amer, Hossam Elamir, Samia Esmaeil, Amr Jamal, Amel Fayed and Collaborative Group ........................................................................................................................................................................................707 Effects of the COVID-19 pandemic on healthcare delivery to an immigrant population in the Islamic Republic of Iran Keihan Golshani and Hamed Akhlaghi .............................................................................................................................................................................................................719 Presentation and management of female breast cancer in Egypt Yousri Rostom, Salah-Eldin Abdelmoneim, Marwa Shaker and Nayera Mahmoud ........................................................................................................................ 725 Attitudes and practices of postnatal mothers and their accompanying relatives to breastfeeding in public at a university hospital in Turkey İlkay Güngör Satılmış, Büşra Yılmaz and Zehra Acar ................................................................................................................................................................................. 733 Assessment of gender gap in surgical specialties among Lebanese medical personnel: the need for involvement of women in surgery Said El Hage, Elias Wakim, Georgio Sayde, Dany Akiki and Pascale Salameh ................................................................................................................................... 743 Assessing the Impact of Small-Research Grants Supported by WHO in the Eastern Mediterranean Region 2010–2018 Bahareh Yazdizadeh, Ahmed Mandil, Sima Nikooee and Arash Rashidian..........................................................................................................................................751 Spatial distribution and temporal trend of drug-related death in the Islamic Republic of Iran during 2014–2017 Abbas Alipour, Mehran Zarghami, Sajjad Rahimi Pordanjani, Ardeshir Khosravi, Mehdi Saberi and Masoudeh Babakhanian .......................................................................................................................................................................................................................................758 15-year evaluation of changes in the HBsAg positivity rate in pregnant women in Turkey: the prominent effect of national vaccination Selma Tosun, Ayşegül Erdoğan, Ayşe Torun, Selma Sever, Sibel Altuntas, İlknur Yildiz, Hüseyin Kutlu, Mehmet Ceylan, Pembe Yesilbag, Bayhan Bektore, Nefise Oztoprak, Buket Gungor, Sezen Koparan, Gülnur Kul, Ali Olut, Bülent Altuntaş and Multicenter Study Group ...................................................................................................................................................768 Short research communication COVID-19 excess deaths in Eastern European countries associated with weaker regulation implementation and lower vaccination coverage Alban Ylli, Genc Burazeri, Yan Yan Wu and Tetine Sentell ........................................................................................................................................................................ 776 WHO event addressing public health priorities Webinar on improving access to diabetes medicine and care in the Eastern Mediterranean Region ..............................781 Cover 28-10.indd 1,3 31/10/2022 9:04 AM