Eastern Mediterranean Health Journal [2022; Vol.28, Issue 2]

La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Volume 28 No. 02 February/Février 2 ددع / نوشرعلاو نماثلا دلجلما طابش / ريابرف 2022 “Discrimination on the grounds of #leprosy is without a doubt an unfinished business that States must actively and urgently address.” – UN Special Rapporteur Alice Cruz @srleprosy #United4Dignity #WorldLeprosyDay 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. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). © World Health Organization (WHO) 2022. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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ISSN 1020-3397 Cover image © WHO Vol. 28 . 02 – 2022 La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Editorial United for dignity: four strategic shifts to get to zero leprosy by 2030 Supriya Warusavithana, Mona Osman, Hoda Atta, and Yvan Hutin ..................................................................................................................... 93 Research articles COVID-19 cases and deaths after implementation of prevention strategies, Saudi Arabia Nargis Javed, Mohd. Zuber, Saba Amin, Bussma Bugis and Mohammed Al-Mohaithef ................................................................................. 95 Motivations for alcohol consumption during the COVID-19 pandemic in Islamic Republic of Iran Abolfazl Fattah, Maliheh Khalvati, Mahdi Abounoori, Nader Molavi, Fatemeh Azartash and Masoudeh Babakhanian .................. 108 Living with chronic obstructive pulmonary disease in Lebanon: a phenomenological study Rita Georges Nohra, Jean-Manuel Morvillers, Hala Sacre, Pascale Salameh and Monique Rothan-Tondeur ....................................... 114 Immunization coverage of children aged 24–35 months in the Islamic Republic of Iran: a national cluster coverage survey Seyed Mohsen Zahraei, Shahrokh Izadi, Mohammad Mehdi Gouya, Seyed Mohammad Hashemi Shahri and Mahdi Mohammadi ...................................................................................................................................................................................................... 121 Mapping of health innovations in response to the COVID-19 pandemic in Eastern Mediterranean and selected Arab Countries Ahmed Mandil, Ruth Mabry, Barbara Milani, Mohamed Nour, Mohamed Afifi and Karim Abdel-Ghani .............................................130 Effect of low-cost interventions to reduce the incidence of violent events in two public sector tertiary-care emergency departments, Pakistan Shiraz Shaikh, Hamid Shahzad, Mirwais Khan, Lubna Baig, Seemin Jamali, Ibrahim Hashmi, Athar Hussain, Uzma Qadri, Lubna Mazharullah and Samina Zaib .................................................................................................................................................. 144 Short research communications Expression of epithelial membrane antigen and cytokeratin among Indian workers exposed to cotton fibre dust in textile industries Ashish Mehta, Saud Azam, Arshad Rahmani, Moshahid Rizvi and Ashish Mandal .......................................................................................152 Use of indigenous language for clinical clerkship: a cross-sectional survey in Nigeria Oyebanji Olajuyin, Oladele Olatunya, Toye Olajide, Ademola Olajuyin, Adebola Olajuyin, Femi. Ogunboyo and Kehinde Oluwadiya ......................................................................................................................................................................................................158 Report Protecting health care workers from COVID-19: implementing a training programme on personal protective equipment in Pakistan Assad Hafeez, Ramesh Kumar, Ikhlaq Ahmed and Zaeem ul Haq .........................................................................................................................163 WHO events addressing public health priorities Nineteenth meeting of the Regional Programme Review Group and national neglected tropical diseases programme managers ............................................................................................................................................................... 169 Ahmed Al-Mandhari Editor-in-Chief Arash Rashidian Executive Editor Ahmed Mandil Deputy Executive 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 93 EMHJ – Vol. 28 No. 02 – 2022Editorial United for dignity: four strategic shifts to get to zero leprosy by 2030 Supriya Warusavithana,1 Mona Osman,2 Hoda Atta,3 and Yvan J-F Hutin4 1Regional Adviser, Neglected Tropical Disease Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2Technical Officer, Neglected Tropical Diseases, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 3Coordinator, TB, Malaria and Tropical Diseases, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 4Director, Division of Communicable Disease Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. (Correspondence to: Supriya Warusavithana: warusavithanas@who.int) Citation: Supriya W; Mona O; Hoda A; Yvan H. United for dignity: four strategic shifts to get to zero leprosy by 2030. East Mediterr Health J. 2022;28(2):93–94. https://doi.org/10.26719/2022.28.2.93 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Leprosy, or Hansen’s disease, is a curable infectious dis- ease caused by the bacillus M. leprae. In 1991, the World Health Assembly WHA44.9 set the goal for “elimination of leprosy as a public health problem” as less than one case on treatment per 10 000 population by 2000 (1). Since then, global leprosy strategies have focused on reducing the prevalence of the disease at country level and reduc- ing transmission. Early detection and prompt treatment with multidrug therapy, the keystone for leprosy control, led to the achievement of this goal at global level by 2000, and in almost all countries, at least at the national level, by 2015 (2). In 2020, globally, 127 396 new leprosy cases were reported, with a case detection rate of 16.4 per million population, a 37.1% reduction in new cases when compared with 2019. Brazil, India and Indonesia reported 74.0% detection of new cases detected in 2020 (3). In the same year, the WHO Eastern Mediterranean Region (EMR) reported 4077 new leprosy cases, 4.8% less than in 2019 (3). Ninety six percent of the new cases were reported from Egypt, Pakistan, Somalia, Sudan, and Yemen. As in previous years, Somalia reported almost two-thirds of cases because of active case detection activities conducted with the support of partners (4). The World Leprosy Day is observed as an international day on the last Sunday of January each year, providing opportunity to advocate for people who have experienced leprosy, raise awareness of the disease, and campaign for an end to leprosy-related stigma and discrimination. The theme for 2022 World Leprosy Day campaign was “United for Dignity” and it called for unity in honoring the dignity of people who have experienced leprosy (5). In many countries, the pandemic has disrupted measures to prevent and control leprosy, including case detection and treatment. However, because delays in detection and treatment of cases can lead to irreversible physical impairment, it is imperative that these services continue without interruption. WHO launched the “Don’t forget leprosy” campaign to make sure leprosy does not slip away from view amid the COVID-19 pandemic (6). In 2021, a new global leprosy strategy aimed to achieve zero leprosy by 2030 in more than 100 countries and a 70% reduction in the number of new cases detected worldwide. Compared with the previous approaches, the goal is to interrupt transmission in both high- and low- burden settings (2). Four strategic shifts should help evolve from campaign approaches to integration of services. First, all endemic countries must own and implement integrated, zero-leprosy roadmaps. Second, leprosy prevention should be scaled-up alongside integrated active case detection. Third, management of leprosy patients must include management of complications and prevention of new disabilities. Fourth, combatting stigma will ensure that human rights are respected. These 2030 targets are ambitious but achievable if national governments commit to eliminating leprosy and ending its related discrimination for patients and their families (2). The COVID-19 pandemic, despite its dramatic impact, could be an opportunity to embed greater fairness, social justice, and equity in health in the EMR (7). Although the pandemic has disrupted leprosy health services, it provides a window for strengthening digital health initiatives for diagnosis, referral, monitoring, and training of staff in several countries. Optimization of existing tools, such as for contact tracing, active case finding and post-exposure prophylaxis with single-dose rifampicin, and introduction of new diagnostic tests and preventive regimens can help us regain momentum in the reduction in new cases (3). Our progress must be decisive and sustained to rid the world of leprosy. References 1. World Health Assembly. Elimination of leprosy: resolution of the 44th World Health Assembly. Geneva: World Health Organiza- tion, 1991, https://www.who.int/neglected_diseases/mediacentre/WHA_44.9_Eng.pdf. 2. World Health Organization. Towards Zero Leprosy. Global Leprosy (Hansen’s Disease) Strategy 2021–2030. Geneva: World Health Organization, 2021, https://apps.who.int/iris/rest/bitstreams/1353867/retrieve. EMHJ 28-2 Book.indb 93 21/03/2022 5:05 PM EMHJ – Vol. 28 No. 02 – 2022Editorial 94 3. World Health Organization. Global leprosy (Hansen disease) update, 2020: impact of COVID-19 on global leprosy control. Weekly epidemiological record, 2021 September, 36(96):421–444; https://apps.who.int/iris/bitstream/handle/10665/345048/WER9636-eng- fre.pdf?sequence=1&isAllowed=y. 4. World Health Organization. Leprosy - New cases detection rate per 1 000 000 population. The Global Health Observatory, https:// www.who.int/data/gho/data/indicators/indicator-details/GHO/leprosy-new-cases-detection-rate. 5. Yohei Sasakawa. Message for World Leprosy Day 2022. Geneva: World Health Organization, 2022, https://www.who.int/news/ item/10-01-2022-message-for-world-leprosy-day-2022. 6. World Health Organization. World Leprosy Day 2022: United for Dignity. Geneva: World Health Organization, 2022, https:// www.who.int/news-room/events/detail/2022/01/30/default-calendar/united-for-dignity-wld-2022. 7. Al-Mandhari A; Marmot M; Ghaffar A; Hajjeh R; Allen J; Khan W; et al. COVID-19 pandemic: a unique opportunity to ‘build back fairer’ and reduce health inequities in the Eastern Mediterranean Region. East Mediterranean Health J. 2021;27(3):217-219 https:// doi.org/10.26719/2021.27.3.217. EMHJ 28-2 Book.indb 94 21/03/2022 5:05 PM 95 Research article EMHJ – Vol. 28 No. 2 – 2022 Introduction In December 2019, some cases of pneumonia-like illness were reported in Wuhan City, Hubei Province of China (1). On 10 January, it was confirmed that this illness was caused by a new coronavirus. Coronavirus disease 2019 (COVID-19) spread rapidly and was declared a pandemic by the World Health Organization (WHO) on 11 March 2020 (2). Thereafter, the global number of cases contin- ued to rise exponentially, and reached almost 16 million confirmed cases and more than 6.4 million deaths world- wide by the end of July 2020 (3). The common symptoms associated with COVID-19 include fever, fatigue, cough, myalgia, anorexia, and sore throat (4,5). The incubation period of the virus is reported to be less than 14 days, but the symptoms become visible after 4–5 days from first exposure to the virus (4,6). The first confirmed case of COVID-19 in Saudi Arabia was reported on two March 2020, 2 months after the emergence of the disease in China. The disease was reported in the country after a Saudi Arabian citizen returned from the Islamic Republic of Iran through Bahrain (7). Immediately after the confirmation of this case, the Government of Saudi Arabia initiated various prevention measures to control the spread of the disease (8). The first step was suspension of the Umrah and tourism for the citizens and residents. At the same time, prevention strategies, including quarantine, isolation, physical distancing, wearing of facemasks, gloves and hand hygiene measures, were imposed throughout the country (8–10). Later on, schools were closed and international flights were suspended. All these steps were implemented in the first phase of the response, i.e. 2–24 March 2020 (8–10). In Saudi Arabia, late afternoon and night-time gatherings are common so the government imposed a curfew from 15:00 to 06:00 to stop public gatherings and control the spread of the disease, fines were imposed on those not adhering to the prevention measures. This phase was for a short duration of eight days (25 March–1 April 2020). In the third phase, a complete lockdown was implemented in the main cities (2–24 April 2020) and fines were increased for non-adherence to prevention measures. In the fourth phase of the response (25 April–20 June 2020), the lockdown was replaced with a night-time curfew (20:00 to 06:00) and fines continued to be imposed for not observing the prevention strategies. On 21 June 2020, the curfew was lifted but the citizens COVID-19 cases and deaths after implementation of prevention strategies, Saudi Arabia Nargis Javed,1 Mohamed Zuber,1 Saba Amin,1 Bussma Bugis1 and Mohammed Al-Mohaithef2 1Department of Public Health, College of Health Sciences, Saudi Electronic University, Dammam, Saudi Arabia. 2Department of Public Health, College of Health Sciences, Saudi Electronic University, Riyadh, Saudi Arabia (Correspondence to: Mohammed Almohaithef: m.almohaithef@seu.edu.sa). Abstract Background: To prevent the spread of coronavirus disease 2019 (COVID-19), the Saudi Arabian Government introduced a number of measures in different phases (e.g. social distancing, curfew and lockdown). Aims: This study describes the incidence of COVID-19 in Saudi Arabia during different phases of prevention strategies and assesses their effects on controlling the spread of the disease. Methods: This cross-sectional study used COVID-19 data for 2 March–5 July 2020 from the Ministry of Health website. The period was divided into five phases based on prevention strategies implemented to control the infection. The inci- dence, point prevalence, case fatality, overall mortality rate and recovery rates for COVID-19 infection were assessed at the national, regional and city levels. Results: At the end of phase 5 on 5 July 2020, the nationwide incidence of COVID-19 was 11%, total recovery rate 70%, case fatality rate 0.9% and adjusted case fatality rate 1.4% (adjusted for time lag for mortality). The COVID-19 point prevalence increased from 2.1/100 000 population in phase 1 to 178.2/100 000 population in phase 5. A high recovery rate (68.7%) was observed in phase 4 accompanied with lower overall mortality and incidence in phase 5. The eastern region of Saudi Ara- bia had the highest point prevalence of COVID-19 infection (450.5 per 100 000 population), while Jeddah and Mecca had the highest overall mortality. Conclusions: The health system of Saudi Arabia efficiently used lockdown and curfew periods to prepare for manage- ment of confirmed cases of COVID-19, reflected by the decreased incidence and mortality rates in phase 5. Keywords: COVID-19, incidence, prevalence, government measures, Saudi Arabia Citation: Javed N; Zuber M; Amin S; Bugis B; Al-Mohaithef M. COVID-19 data after implementation of prevention strategies, Saudi Arabia. East Mediterr Health J. 2022;28(2):95–107. https://doi.org/10.26719/emhj.21.067 Received: 22/10/20; accepted: 15/06/21 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo) EMHJ 28-2 Book.indb 95 21/03/2022 5:05 PM 96 Research article EMHJ – Vol. 28 No. 2 – 2022 had to follow certain basic prevention measures: physical distancing, wearing facemasks and adhering to hand hygiene. These precautionary measures are still required until date. The development and rollout of COVID-19 vaccines has emerged as an effective control measure for now and the future through vaccination. According to the Ministry of Health, the first shipment of the COVID-19 vaccine arrived in Saudi Arabia on 16 December 2020. As of 21 February 2021, a total of 541 411 people had been vaccinated and none of the people vaccinated showed any signs of health challenges (11–13). The aim of our study was to describe the key data on COVID-19 in Saudi Arabia during the different prevention phases and to assess the effect of the prevention strategies on controlling the spread of the disease during the first 18 weeks following the first case report in Saudi Arabia. Methods We carried out a cross-sectional study to evaluate the effect of prevention strategies implemented in Saudi Arabia to control the spread of COVID-19 from 2 March to 5 July 2020 (total 18 weeks). Data were collected from the dashboard of the Saudi Arabia Ministry of Health (https:// covid19.moh.gov.sa/) (9). The sources of information for this site are the Ministry of Health, COVID-19 Command & Control Center and National Health Emergency Oper- ation Center. The target population was suspected cases of COVID-19, for example, people with: a history of travel, contact with a person confirmed to have COVID-19, and contact with a person with fever and respiratory disease symptoms. Polymerase chain reaction (PCR) tests were performed in COVID-19 certified laboratories by the Sau- di Arabian Centre for Disease Control (9). We used the following definitions in the study: (i) confirmed COVID-19 case meaning a suspected case with laboratory confirmation of COVID-19 infection; (ii) COVID-19 death meaning death resulting from a clinically compatible illness in a confirmed or suspected COVID-19 case unless a clear alternative cause of death is evident; (iii) recovered case, a) for symptomatic patients – 10 days after onset of symptoms plus at least three days without symptoms (fever and respiratory symptoms), or three days without symptoms and one negative PCR test and b) for asymptomatic patients – remaining asymptomatic for 10 days after testing positive; and (iv) Active case – [confirmed cases – total recovered cases – total deaths] (9). For the purposes of the study, Saudi Arabia was divided into five regions: eastern, western, northern, southern, and central. Five main cities of Saudi Arabia were included in the analysis: Dammam (Capital of Eastern Province), Jeddah (with the busiest international airport in the country as the entry point for pilgrims), Mecca (Islam’s holiest city, main Islamic pilgrimage site and main city of the western region), Medina (Islamic holy city, main Islamic pilgrimage site), and Riyadh (Capital of Saudi Arabia). The period of 18 weeks was divided into five phases based on the prevention strategies implemented to control the infection (Table 1). We analysed the data by COVID-19 phase at the national and regional levels and for the main cities of Saudi Arabia. The analytic measures were calculated using the following formulas: (i) incidence rate = total new cases of COVID-19 in a given time period divided by total tests performed in the same period; (ii) point prevalence on the last day of each phase = total active cases present on that day divided by the total population; (iii) case fatality rate (CFR) = total mortality due to COV- ID-19 in a given period divided by total confirmed cases; (iv) adjusted CFR = cumulative mortality divided by the total active cases present on 20 days before the date of calculation; (v) overall mortality rate = total mortality on the last day of the phase divided by the total population; and (vi) recovered rate = total recovered cases divided by total active cases. We adjusted the CFR as we observed that the first COVID-19 death was reported 20 days after the first case in Saudi Arabia had been con- firmed. Table 1 Prevention strategies used against COVID-19 by intervention phase, Saudi Arabia, 2 March–5 July 2020 Prevention strategies Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 2–24 March (23 days) 25 March–1 April (8 days) 2–24 April (23 days) 25 April–20 June (57 days) 21 June–5 July (15 days) Physical distancing Yes Yes Yes Yes Yes Use of face mask Yes Yes Yes Yes Yes Hand hygiene Yes Yes Yes Yes Yes Quarantine Yes Yes Yes Yes Yes Isolation Yes Yes Yes Yes Yes Curfew No Yes Yes Yes No Lockdown No No Yes No No EMHJ 28-2 Book.indb 96 21/03/2022 5:05 PM 97 Research article EMHJ – Vol. 28 No. 2 – 2022 Results COVID-19 data, 5 July 2020 A total of 1 934 391 COVID-19 tests (polymerase chain reaction tests) had been administered until 5 July 2020. Given that the current population of Saudi Arabia is esti- mated to be 34.85 million, this represents a testing rate of about 55 500 tests per million inhabitants. The incidence rate of COVID-19 on 5 July 2020 was 11%, CFR 0.9%, ad- justed CFR 1.4% and recovery rate 70.0%. The point preva- lence of COVID-19 on 5 July was 178.2/100 000 population and overall mortality rate was 5.7/100 000 population. The proportion of confirmed cases of COVID-19 to the population of Saudi Arabia was 612.3/100 000 population. The point prevalence of COVID-19 on 5 July 2020 was highest in the eastern region (450.5/100 000 population) and lowest in the northern region (86.0/100 000 population) (Table 2). The overall mortality was highest in the western region (11.0/100 000 population) and lowest in the southern region (0.9/100 000 population). The CFR was highest in the western region (1.5%) and lowest in the eastern region (0.3%), while the adjusted CFR was highest in the northern region (11.1%) and lowest in the eastern region (1.7%) The highest recovery rate was in the western region (83.5%) and lowest in the southern region (50.0%) (Table 2). The point prevalence of COVID-19 on 5 July 2020 was highest in Dammam (484.3/100 000 population) and lowest in Jeddah (70.4/100 000 population) (Table 2). The overall mortality was highest in Mecca (22.2/100 000 population) and lowest in Dammam (5.7/100 000 population). The CFR was highest in Jeddah (2.1%) and lowest in Dammam (0.5%), while the adjusted CFR was highest in Mecca (9.5%) and lowest in Dammam (2.4%). The highest recovery rate was in Jeddah (87.3%) and lowest in Dammam (55.9%) (Table 2). COVID data, phases 1–5 In Saudi Arabia overall, the incidence rate, mortality and recovered rate were highest in phase 4 (13.7%, 32.7/100 000 population and 68.7%, respectively) and thereafter they declined in phase 5. CFR and adjusted CFR were highest in phase 2 (1.6% and 35.5%) (Table 3, Figure 1 and Figure 3). The COVID-19 point prevalence showed increasing trends in the eastern, northern and southern regions from phase 1 to phase 5. In western and central regions, the point prevalence increased until phase 4 and then declined (Table 3 and Figure 1). In phase 5, the CFR was lower in the eastern and southern regions than western, central and northern regions. The highest CFR in the western region was in phase 2 (3.0%), while in central and northern regions the highest CFR was in phase 5 (3.6% and 1.8%, respectively). The highest overall mortality was in the western region in phases 4 (7.8/100 000 population) (Table 3and Figure 3). The highest overall mortality in phase 5 was in the central region (3.3/100 000 population). All the regions in Saudi Arabia showed the highest recovery rate in phase 4. The northern and western regions had the highest recovery rate in phase 4 (79.1% and 76.3%, respectively) (Table 3 and Figure 1). Dammam and Medina had an increasing trend in COVID-19 point prevalence from phase 1 to phase 5 (Table 3 and Figure 2). However, Dammam had a higher point prevalence (484.3/100 000 population) than Medina (130.1/100 000 population) in phase 5. In Jeddah, Mecca and Riyadh the point prevalence increased from phase 1 to phase 4 and then it declined. In phase 1, of the two patients with COVID-19 infection in Medina, one patient died, which was the first COVID-19 death reported in Saudi Arabia. The highest overall mortality was observed in most cities in phase 4 except Riyadh which had the highest overall mortality in phase 5 (4.2/100 000 population) (Table 3 and Figure 3). The highest overall mortality in phase 4 was in Mecca (15.6/100 000 population). Table 2 Key data on COVID-19 by region and city, Saudi Arabia, 5 July 2020 Location Point prevalence (per 100 000 population) Case fatality rate (%) Adjusted case fatality rate (%) Overall mortality (per 100 000 population) Recovered rate (%) Region Eastern 450.5 0.3 1.7 3.7 57.4 Western 120.9 1.5 8.3 11.0 83.5 Central 155.7 0.9 2.9 5.2 73.5 Northern 86.0 1.0 11.1 2.1 57.1 Southern 124.2 0.4 2.9 0.9 50.0 City Dammam 484.3 0.5 2.4 5.7 55.9 Jeddah 70.4 2.1 9.4 11.7 87.3 Medina 130.1 0.7 5.6 6.5 86.5 Mecca 167.9 1.8 9.5 22.2 86.5 Riyadh 143.3 1.0 3.2 6.6 78.4 EMHJ 28-2 Book.indb 97 21/03/2022 5:05 PM 98 Research article EMHJ – Vol. 28 No. 2 – 2022 Table 3 Key nationwide, regional and city data on COVID-19 by intervention phase, Saudi Arabia, 2 March–5 July 2020 Measures Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 All of Saudi Arabia Incidence (%) 0.9 0.2 5.4 13.7 10.9 Point prevalence (per 100 000 population) 2.2 4.3 37.1 158.4 178.2 CFR (%) 0.1 1.6 0.8 0.8 1.2 Adjusted CFR (%) 50 35.5 6.2 1.4 1.4 Overall mortality (per 100 000 population) 0.0 0.4 3.2 32.7 2.0 Recovery (%) 3.6 14.1 12.1 68.7 43.8 Region Eastern Point prevalence (per 100 000 population) 2.5 3.5 37.2 266.3 450.5 CFR (%) 0.0 0.0 0.3 0.3 0.4 Adjusted CFR (%) 0.0 0.0 1.9 0.8 0.7 Overall mortality (per 100 000 population) 0.0 0.0 0.1 2.0 1.5 Recovery (%) 8.0 6.9 15.6 58.0 33.6 Western Point prevalence (per 100 000 population) 2.7 5.2 86.0 147.0 120.9 CFR (%) 0.3 3.0 1.1 1.5 1.6 Adjusted CFR (%) 100.0 60.9 11.6 2.6 2.3 Overall mortality (per 100 000 population) 0.0 0.1 0.9 7.8 2.1 Recovery (%) 3.1 24.2 6.6 76.3 55.0 Central Point prevalence (per 100 000 population) 2.7 5.3 21.9 224.6 155.7 CFR (%) 0.0 0.7 0.2 0.4 3.6 Adjusted CFR (%) 0.0 50.0 1.3 1.3 1.5 Overall mortality (per 100 000 population) 0.0 0.0 0.1 1.8 3.3 Recovery (%) 2.8 6.7 23.2 54.5 50.0 Northern Point prevalence (per 100 000 population) 0.0 0.4 9.7 22.0 86.0 CFR (%) 0.0 0.0 0.4 0.9 1.8 Adjusted CFR (%) 0.0 0.0 3.4 17.0 2.5 Overall mortality (per 100 000 population) 0.0 0.0 0.0 0.9 1.1 Recovery (%) 0.0 0.0 4.8 79.1 25.3 Southern Point prevalence (per 100 000 population) 0.7 0.9 1.9 48.4 124.2 CFR (%) 0.0 0.0 1.0 0.4 0.4 Adjusted CFR (%) 0.0 0.0 2.4 1.4 1.4 Overall mortality (per 100 000 population) 0.0 0.0 0.0 0.4 0.5 Recovery (%) 0.0 7.3 51.1 51.1 36.4 City Dammam Point prevalence (per 100 000 population) 3.7 9.0 62.9 254.4 484.3 CFR (%) 0.0 0.0 0.1 0.6 0.4 Adjusted CFR (%) 0.0 0.0 0.7 0.9 0.8 Overall mortality (per 100 000 population) 0.0 0.0 0.1 4.0 1.6 Recovery (%) 6.1 12.4 12.1 64.6 22.4 Jeddah Point prevalence (per 100 000 population) 2.6 3.0 47.0 118.1 70.4 CFR (%) 0.0 1.0 1.0 2.0 3.3 Adjusted CFR (%) 0.0 100.0 8.4 2.9 2.5 EMHJ 28-2 Book.indb 98 21/03/2022 5:05 PM 99 Research article EMHJ – Vol. 28 No. 2 – 2022 Medina and Riyadh showed an increasing trend in recovery rate from phase 1 to phase 4 and then it declined in phase 5. In phase 4, the highest recovery rate was in Medina (84.6%) and lowest in Riyadh (56.2%). However, in phase 5, Dammam had the lowest recovery rate (22.4%) while Mecca had the highest recovery rate (62.4%) (Table 3 and Figure 2). Discussion This is the first study describing the geographical distri- bution, prevalence, CFR, recovery rate and overall mortal- ity rates of COVID-19 from Saudi Arabia. However, three previous studies have discussed COVID-19: one high- lighted the demographic and clinical characteristics of COVID-19 cases in the different regions of Saudi Arabia (14); another examined Saudi Arabia’s level of prepared- ness to manage COVID-19 (8); and the third described the status and management practices with regard to COV- ID-19 in the Gulf Cooperation Council countries (10). On 5 July 2020, about 55 500 COVID-19 PCR tests had been performed per million inhabitants in Saudi Arabia. This was lower than Italy which reported 93 250 tests per million inhabitants by 5 July 2020 (15). However, in Eastern Mediterranean countries, Saudi Arabia had a high testing rate along with Bahrain, Djibouti, Qatar, and United Arab Emirates (16). In addition, 11% of the tests performed in Saudi Arabia were positive for COVID-19. In contrast, by 5 July, 2020 Italy reported a lower proportion (4%) of confirmed cases from the total tests conducted (15). By the end of phase 5 on 5 July, the proportion of the population in Saudi Arabia affected with COVID-19 was 612.3/100 000 population which was higher than other countries such as the United Kingdom of Great Britain and Northern Ireland (422/100 000 population), Italy (393.3/100 000 population), France (290.1/100 000 population) and Germany (230/100 000 population) (17). The higher number of confirmed cases in Saudi Arabia may be due to the presence of two holy mosques where millions of pilgrims from around the world visit throughout the year to perform religious pilgrimage. Effect of prevention strategies The restrictions on public gatherings through lockdown followed by a curfew and rigorously implemented pre- cautionary measures resulted in containment of the in- fection in the country. This is evidenced by the decreased COVID-19 incidence rates in the phase 5. Effect of prevention strategies regionally The lockdown followed by the curfew was effective in controlling the spread of COVID-19 in western and cen- tral regions, which were greatly affected by the infec- tion. The high infection rate may be attributable to the presence of the two holy mosques in the western region, given the fact that millions of pilgrims visit the region throughout the year to perform Umrah. The reduction in new cases and mortality in the western region in phase 5, which occurred after the lockdown of the holy cities (Mecca and Medina), as well as Jeddah (the entry point for most pilgrims to Saudi Arabia), demonstrates the ef- fectiveness of the suspension of international flights in Measures Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Overall mortality (per 100 000 population) 0.0 0.0 0.5 8.9 2.3 Recovery (%) 3.2 36.6 8.0 75.4 61.8 Medina Point prevalence (per 100 000 population) 0.1 9.6 76.9 126.7 130.1 CFR (%) 50.0 6.0 0.9 0.5 0.7 Adjusted CFR (%) - - 13.7 0.9 0.8 Overall mortality (per 100 000 population) 0.1 0.6 1.5 3.3 1.1 Recovery (%) 0.0 0.0 1.6 84.6 51.5 Mecca Point prevalence (per 100 000 population) 7.3 11.1 154.1 263.8 167.9 CFR (%) 0.0 1.8 1.5 1.7 2.1 Adjusted CFR (%) 0.0 13.6 13.8 2.4 2.3 Overall mortality (per 100 000 population) 0.0 0.1 2.4 15.6 4.0 (%) 3.2 26.1 9.7 74.5 62.4 Riyadh Point prevalence (per 100 000 population) 3.8 7.3 28.9 258.4 143.3 CFR (%) 0.0 0.7 0.2 0.4 6.2 Adjusted CFR (%) 0.0 - 1.2 0.8 1.3 Overall mortality (per 100 000 population) 0.0 0.0 0.1 2.2 4.2 Recovery (%) 2.8 6.7 24.1 56.2 55.4 CFR= case fatality rate. Table 3 Key nationwide, regional and city data on COVID-19 by intervention phase, Saudi Arabia, 2 March–5 July 2020 (concluded) EMHJ 28-2 Book.indb 99 21/03/2022 5:05 PM 100 Research article EMHJ – Vol. 28 No. 2 – 2022 Figure 1 New and recovered cases nationwide and in different regions, by intervention phase, Saudi Arabia, 2 March–5 July 2020 Phase 1 Phase 3 Ph as e 2 Phase 4 Phase 5 KSA [A] Weeks New cases Recovered cases New + Recovered cases 0 5000 10000 15000 20000 25000 30000 35000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Phase 1 Phase 3 Ph as e 2 Phase 4 Phase 5 Eastern Region [B] New cases Recovered cases New + Recovered cases 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 11000 12000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 N o. o f c as es Weeks Phase 1 Phase 3 Ph as e 2 Phase 4 Phase 5 Western Region [C] 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 11000 12000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Weeks New cases Recovered cases New + Recovered cases EMHJ 28-2 Book.indb 100 21/03/2022 5:05 PM 101 Research article EMHJ – Vol. 28 No. 2 – 2022 Figure 1 New and recovered cases nationwide and in different regions, by intervention phase, Saudi Arabia, 2 March–5 July 2020 (concluded) Phase 1 Phase 3 Ph as e 2 Phase 4 Phase 5 Central Region [D] New cases Recovered cases New + Recovered cases 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 11000 12000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 N o. o f c as es Weeks % Northern Region [E] Phase 1 Phase 3 Ph as e 2 Phase 4 Phase 5 Weeks New cases Recovered cases New + Recovered cases 1 1200 1000 800 600 400 200 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Phase 1 Phase 3 Southern Region [F] Ph as e 2 Phase 4 Phase 5 New cases Recovered cases New + Recovered cases 6000 5000 4000 3000 2000 1000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 N o. o f c as es Weeks EMHJ 28-2 Book.indb 101 21/03/2022 5:05 PM 102 Research article EMHJ – Vol. 28 No. 2 – 2022 Figure 2 New and recovered cases in the main cities, by intervention phase, Saudi Arabia, 2 March–5 July 2020 Phase 1 Phase 3 Damman [G] Ph as e 2 Phase 4 Phase 5 New cases Recovered cases New + Recovered cases 6000 5000 4000 3000 2000 1000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 N o. o f c as es Weeks Jeddah [H] Phase 1 Phase 3 Ph as e 2 Phase 4 Phase 5 New cases Recovered cases New + Recovered cases 4000 3500 3000 2500 2000 1500 1000 500 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Madinah [I] Phase 1 Phase 3 Ph as e 2 Phase 4 Phase 5 New cases Recovered cases New + Recovered cases 0 1000 2000 3000 4000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 N o. o f c as es Weeks EMHJ 28-2 Book.indb 102 21/03/2022 5:05 PM 103 Research article EMHJ – Vol. 28 No. 2 – 2022 Figure 2 New and recovered cases in the main cities, by intervention phase, Saudi Arabia, 2 March–5 July 2020 (concluded) Mecca [J] Phase 1 Phase 3 Ph as e 2 Phase 4 Phase 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 New cases Recovered cases New + Recovered cases Weeks 1000 0 2000 3000 4000 N o. o f c as es Riyadh [K] Phase 1 Phase 3 Ph as e 2 Phase 4 Phase 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 New cases Recovered cases New + Recovered cases Weeks 1200 1000 800 600 400 200 0 the first phase. The COVID-19 point prevalence decreased in phase 5, which suggests that adhering to basic precau- tionary measures after lockdown and curfew helped con- trol the spread of the disease as the communicable period of the infection was managed properly during phase 3 and phase 4. However, the northern and southern re- gions of Saudi Arabia had higher point prevalence rates in phase 5, which may be due to the late introduction of infection to these regions and as a result, the propagation period may have started during or after the curfew pe- riod. However, lockdown and curfew were not effective in containing the infection in the eastern region as it re- mained the most highly affected region of Saudi Arabia in phase 5. Effect of prevention strategies in major cities Out of the five main cities, three, in which curfew and lockdown measures were implemented, reported de- creases in the number of new cases and mortality in phase 5. The only city in which lockdown followed by curfew did not lower the number of new cases was Dam- mam in the eastern region. This may be due to the pres- ence of many industries in this region as employees trav- elled frequently for their work during phase 4 (curfew) of the intervention. This may have resulted in propagation of the disease. However, the political decision to unlock towns and cities should be based on a combination of scientific evidence of outbreak control and safeguard of political economic continuity (18). Effect of prevention strategies on management of COVID-19 cases The health care system of Saudi Arabia made efficient use of the lockdown and curfew periods to enhance capacity to provide the best patient care for confirmed cases of COVID-19. This is reflected by high recovery rate (68.7%) in phase 4 accompanied with lower overall mortality in phase 5. EMHJ 28-2 Book.indb 103 21/03/2022 5:05 PM 104 Research article EMHJ – Vol. 28 No. 2 – 2022 Figure 3 Mortality from COVID-19, nationwide and in regions, by phase of prevention strategies, Saudi Arabia, 2 March–5 July 2020 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Saudi Arabia Eastern Western Central Northern Southern Pe r c en t m or ta lit y Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Figure 4 Mortality from COVID-19 in selected cities, by phase of prevention strategies, Saudi Arabia, 2 March–5 July 2020 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pe r c en t m or ta lit y Dammam Jeddah Medina Mecca Riyadh Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Similar to our findings, a number of studies have reported an enhanced effectiveness of quarantine, isolation, contact tracing, and travel bans when implemented along with lockdown to control COVID-19 (19–23). Other studies have reported that the addition of physical distancing with quarantine and isolation leads to a reduction in deaths and effectively reduces the ability of the infection to spread by half. Therefore, physical distancing can lead to remarkable reduction in incidence rate and epidemic period, and can enhance the effectiveness of prevention strategies to control the spread of COVID-19 (24,25). To measure the effectiveness of national health systems, it is important to examine the recovery rate, as well as the CFR. In our study, the recovery rate was 70%, which was higher than the global recovery rate (65%) as of 5 July 2020 (26). Similarly, the CFR was 0.9%, which was lower than the global mortality rate (4.9%) on 5 July 2020 (26). In Italy, 45 days after COVID-19 infection was first detected in the country, 1809 deaths had been recorded, while in Saudi Arabia there were 1968 deaths 120–126 days after COVID-19 infection was first detected in the country (18th week). However, the deaths in Saudi Arabia was 65 by 35-42, which was lower than Italy (15). The CFR in Saudi Arabia in the 5th week (2–35 days) was 1.1%, which was lower than other countries – Italy (12.6% on the 68th day) and China (4.03% on the 77th day) (15). Similar to the Saudi Arabia, Hungary identified the first case in the first week of March when an Iranian student returned from Tehran on 4 March 2020 (25). By 10 May 2020 (after 67 days), the cumulative number of confirmed COVID-19 cases was 3284 (33.1/100 000 population), and there were 421 deaths (crude CFR 12.8%). In the 10th week in Saudi Arabia, 6836 new cases (117.7/100 000 population) EMHJ 28-2 Book.indb 104 21/03/2022 5:05 PM 105 Research article EMHJ – Vol. 28 No. 2 – 2022 were reported with 255 deaths (CFR 0.6%) (27). The lower mortality rate in Saudi Arabia than Hungary may be due to the early detection of COVID-19 cases and proper medical management of confirmed cases. Our study has some limitations. The sources of data used for key events were from sites other than the Ministry of Health website, which may have led to a slight discrepancy in the duration of each phase of intervention. The recovery rates and CFRs were calculated using the data available on the website of the Ministry of Health of Saudi Arabia, but as the disease was so widespread, it is possible that some cases may not have been reported to the authorities; therefore these numbers may not reflect the true values for Saudi Arabia . Finally, we used only confirmed cases of COVID-19 reported by the Ministry of Health for calculating the mortality rate, some deaths occurred in people who had not been tested for COVID-19. Conclusion Our study shows that the eastern region of Saudi Arabia was most affected by COVID-19 infection. The spread of COVID-19 was higher in Saudi Arabia than other devel- oped countries. Our study indicates that curfews and lockdowns are effective in preventing the spread of in- fectious diseases. The incidence rate, recovery rate and CFRs are essential elements to monitor during an out- break response as they can provide an accurate picture of infection situation in the country. This analysis of COV- ID-19 and the effect of preventive measures on its spread will help inform planning of preventive strategies in the future. Funding: None. Competing interests: None declared. Cas et décès liés à la COVID-19 après la mise en œuvre de stratégies de prévention en Arabie saoudite Résumé Contexte : Pour empêcher la propagation de la maladie à coronavirus 2019 (COVID-19), le gouvernement saoudien a mis en place un certain nombre de mesures en plusieurs phases (par exemple, la distanciation sociale, le couvre-feu et le confinement). Objectifs : L'étude décrit l'incidence des cas de COVID-19 en Arabie saoudite au cours des différentes phases des stratégies de prévention et évalue leur effet sur la maîtrise de la propagation de la maladie. Méthodes : La présente étude transversale a été réalisée à partir des données sur la COVID-19 recueillies du 2 mars au 5 juillet 2020 sur le site Web du ministère de la Santé. La période a été divisée en cinq phases en fonction des stratégies de prévention mises en œuvre pour lutter contre l'infection. Le taux d'incidence, la prévalence ponctuelle, le taux de létalité, le taux global de mortalité et le taux de guérison de l'infection par la COVID-19 ont été évalués aux niveaux national, régional et municipal. Résultats : À la fin de la phase 5, le 5 juillet 2020, l'incidence nationale de la COVID-19 était de 11 %, le taux de guérison total de 70 %, le taux de létalité de 0,9 % et le taux de létalité ajusté de 1,4 % (ajusté en fonction du décalage temporel par rapport à la mortalité). La prévalence ponctuelle de la COVID-19 a augmenté entre la phase 1 (2,1/100 000 habitants) et la phase 5 (178,2/100 000 habitants). Un taux de guérison élevé (68,7 %) a été observé en phase 4, avec une mortalité globale et une incidence plus faibles en phase 5. C'est dans la région orientale de l'Arabie saoudite que la prévalence ponctuelle de la COVID-19 était la plus élevée (450,5 cas pour 100 000 habitants), tandis que Djeddah et La Mecque affichaient la mortalité globale la plus forte. Conclusions : Le système de santé saoudien a mis à profit de manière efficace les périodes de confinement et de couvre-feu pour se préparer à la prise en charge des cas confirmés de COVID-19, comme en témoigne la diminution des taux d'incidence et de mortalité lors de la phase 5. ةيدوعسلا ةيبرعلا ةكلملما ،ةياقولا تايجيتاترسا ذيفنت دعب 19-ديفوك ضرم نع ةجمانلا تايفولاو ةباصلإا تلااح فيذيحلما دممح ،سقوب ةمسب ،ينمأ ابص ،يربزلا دممح ،ديفوج سجرن ةصلالخا دعابتلا لثم( ةفلتمخ لحارم في يربادتلا نم اًددع ةيدوعسلا ةموكلحا تذتخا ،)19-ديفوك( 2019 انوروك سويرف ضرم راشتنا نم ةياقولل :ةيفللخا .)جورلخا رظحو لاوجتلا رظحو يعماتجلاا ،ةياقولا تايجيتاترسلا ةفلتخلما لحارلما للاخ ةيدوعسلا ةيبرعلا ةكلملما في 19-ديفوك ضرم ع ُّزَوَت فصو لىإ ةساردلا هذه تفده :فادهلأا .ضرلما راشتنا ةحفاكم لىع تايجيتاترسلاا هذه يرثأت مِّيقُتو EMHJ 28-2 Book.indb 105 21/03/2022 5:05 PM 106 Research article EMHJ – Vol. 28 No. 2 – 2022 References 1. COVID-19 China [Internet]. 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East Mediterr Health J. 2020;26(5):499–502. https://doi.org/10.26719/emhj.20.028 نيوتركللإا عقولما نم 2020 زوتم/ويلوي 5 لىإ راذآ/سرام 2 نم ةترفلا في 19-ديفوك تانايب ةيعطقلما ةساردلا هذه تمدختسا :ثحبلا قرط ىودعب ةباصلإا لدعم مييقت ىرجو .ىودعلا ةحفاكلم ةذفنلما ةياقولا تايجيتاترسا لىع ًءانب ،لحارم سخم لىإ ةترفلا هذه ميسقت متو .ةحصلا ةرازول ينطولا نيديعصلا لىع كلذو ،فياعتلا لدعمو ،تايفولل لياجملإا لدعلماو ،تلاالحا ةتامإ لدعمو ،ةنيعم طاقن في راشتنلاا لدعمو ،19-ديفوك .ندلما ديعص لىعو يميلقلإاو ليكلا فياعتلا لدعمو ،%11 ينطولا ديعصلا لىع 19-ديفوك ضرمب ةباصلإا لدعم غلب ،2020 زوتم/ويلوي 5 في 5 ةلحرلما ةيانه في :جئاتنلا ضرم راشتنا لدعم عفتراو .)تايفولل ينمزلا قرافلا ةاعارلم ح َّحَصُم( %1.4 ح َّحَصُلما تلاالحا ةتامإ لدعمو ،%0.9 تلاالحا ةتامإ لدعمو ،%70 فياعتلا لدعم عافترا َظِحوُلو .)ةمسن 100000 لكل178.2 ( 5 ةلحرلما لىإ )ةمسن100000 لكل 2.1( 1 ةلحرلما نم ةنيعم طاقن في 19-ديفوك ةيدوعسلا ةيبرعلا ةكلملما في ةيقشرلا ةقطنلما تلجسو .5 ةلحرلما في ةباصلإاو تايفولل لياجملإا لدعلما ضافخناب اًبوحصم 4 ةلحرلما في )%68.7( .تايفولل لياجمإ لدعم لىعأ ةكمو ةدج تلجس ينح في ،)ةمسن 100000 لكل 450.5( ةنيعم طاقن في 19-ديفوك ىودعل راشتنا لدعم لىعأ تلااح جلاعل بهأتلا لجأ نم ،ةيلعافب لاوجتلا رظحو جورلخا رظح تاترف ةيدوعسلا ةيبرعلا ةكلمملل يحصلا ماظنلا مدختسا :تاجاتنتسلاا .5 ةلحرلما في تايفولاو ةباصلإا تلادعم ضافخنا في سكعنا ام وهو ،19-ديفوك ضرمب ةدكؤلما ةباصلإا EMHJ 28-2 Book.indb 106 21/03/2022 5:05 PM 107 Research article EMHJ – Vol. 28 No. 2 – 2022 19. Hu Z, Cui Q, Han J, Wang X, Sha WEI, Teng Z. Evaluation and prediction of the COVID-19 variations at different input pop- ulation and quarantine strategies: a case study in Guangdong province, China. Int J Infect Dis. 2020; 95:231–40. https://doi. org/10.1016/j.ijid.2020.04.010 20. Shen M, Peng Z, Guo Y, Rong L, Li Y, Xiao Y, et al. Assessing the effects of metropolitan-wide quarantine on the spread of COV- ID-19 in public space and households. Int J Infect Dis. 2020;96:503–5. https://doi.org/10.1016/j.ijid.2020.05.019 21. Lagier JC, Colson P, Tissot Dupont H, Salomon J, Doudier B, Aubry C, et al. Testing the repatriated for SARS-Cov2: should laboratory-based quarantine replace traditional quarantine? Travel Med Infect Dis. 2020;34:101624. https://doi.org/10.1016/j. tmaid.2020.101624 22. Cheng HY, Jian SW, Liu DP, Ng TC, Huang WT, Lin HH; Taiwan COVID-19 Outbreak Investigation Team. Contact tracing as- sessment of COVID-19 transmission dynamics in Taiwan and risk at different exposure periods before and after symptom onset. JAMA Intern Med. 2020;180(9):1156–63 . https://doi.org/10.1001/jamainternmed.2020.2020 23. Wang G, Chen W, Jin X, Chen YP. Description of COVID-19 cases along with the measures taken on prevention and control in Zhejiang, China. J Med Virol. 2020;92(10):1948–55. https://doi.org/10.1002/jmv.25906 24. Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K, Baguelin M, et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand. London: Imperial College; 2020 (https://www.imperial.ac.uk/media/ imperial-college/medicine/mrc-gida/2020-03-16-COVID19-Report-9.pdf, accessed 3 August 2021). 25. Nussbaumer-Streit B, Mayr V, AIulia D, Chapman A, Persad E, Klerings I, et al. Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review. Cochrane Database Syst Rev. 2020;1(4):CD013574. https://doi. org/10.1002/14651858.CD013574 26. Statistics and research. Coronavirus pandemic (COVID-19) [Internet]. Our World in Data; 2021 (https://ourworldindata.org/corov- navirus, accessed 24 August 2021). 27. Rost G, Bartha FA, Bogya N, Boldog P, Dénes A, Ferenci T, et al. Early phase of the COVID-19 outbreak in Hungary and post-lock- down scenarios. Viruses. 2020;12(7):708. https://doi.org/10.3390/v12070708 EMHJ 28-2 Book.indb 107 21/03/2022 5:05 PM 108 Research article EMHJ – Vol. 28 No. 2 – 2022 Introduction In the field of public health, high alcohol consumption has attracted considerable attention. In the laws of the Islamic Republic of Iran, drinking alcohol is consid- ered against sharia and a crime; therefore, alcohol con- sumption in the country is a new and challenging topic. Despite the ban, alcohol is sold illegally in the Islamic Republic of Iran, either through illegally produced lo- cal products or illegal imports. This issue prevents poli- cy-makers from addressing alcohol use effectively. Some profiteers prefer methanol to ethanol because it is less ex- pensive and more readily available (1,2). According to the World Health Organization (WHO), the Islamic Republic of Iran ranks 161 in total alcohol consumption per capita globally; however, among those who consume alcohol, the country ranks 9th in terms of the amount of alcohol consumed (3). WHO estimates the per capita alcohol con- sumption in the Eastern Mediterranean region to be 0.6 L of pure alcohol a year in the population older than 15 years (3). Although a very small minority of people in the Islamic Republic of Iran consume alcohol, per capita al- cohol consumption in the country has been estimated at 1.0 L a year (4). In recent years, the age at starting to drink alcohol has dropped to 11 years in the Islamic Republic of Iran (5). Following the first official report of death due to coronavirus disease 2019 (COVID-19) in the country on 19 February 2020, the Iranian Ministry of Health and Medical Education provided information on preventive measures, including regular handwashing with soap and water or disinfection of hands and surfaces with alcohol solutions. According to the Iranian Centers for Disease Control, in 2020, a large number of people drank alcohol containing high levels of methanol (6) as a result of exposure to false information spread through social media about the role of alcohol, whether gargling or drinking, in preventing COVID-19 (7,8). Data from the Legal Medicine Organization of the Islamic Republic of Iran show that more than 700 deaths occurred because of alcohol poisoning from 20 February to 7 April 2020. Motivations for alcohol consumption during the COVID-19 pandemic in Islamic Republic of Iran Abolfazl Fattah,1 Maliheh Khalvati,2 Mahdi Abounoori,3 Nader Molavi,4 Fatemeh Azartash5 and Masoudeh Babakhanian3 1Department of Internal Medicine, School of Medicine, Semnan University of Medical Sciences, Semnan, Islamic Republic of Iran. 2Paramedical Faculty, Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran. 3Social determinants of health Research center, Semnan university of medical sciences , Semnan, Islamic Republic of Iran. 4Department of Addiction Studies, School of Medicine, Kashan University of Medical Sciences, Kashan, Islamic Republic of Iran. 5Department of Psychiatry, Islamic Azad University of Khorasgan, Isfahan, Islamic Republic of Iran. (Correspondence to: Masoudeh Babakhanian: Babakhanian.m@gmail.com). Abstract Background: High alcohol consumption is an important public health problem, and understanding factors associated with such consumption is essential. Aims: This study aimed to assess individual and social factors associated with alcohol consumption during the coronavi- rus disease 2019 (COVID-19) pandemic in the Islamic Republic of Iran. Methods: In this qualitative study, purposive sampling was used to select study participants by sharing the survey link on the Telegram application channels with an Iranian audience during COVID-19. The study was conducted from March to June 2020 and reached all Iranian provinces. We used qualitative content analysis to investigate specific concepts in the responses. Results: Of the 116 participants who responded to the survey, 34 (29.3%) were females, and 82 (70.7%) were male. The mean age of the participants was 34.8 years (standard deviation 9.9; range 17–71 years). Most of the participants (75.9%) reported having consumed alcohol, and 56.9% reported having self-medicated for an illness without a doctor’s prescription before the COVID-19 pandemic. The most common reason given for alcohol consumption was to relieve stress during home quarantining (32.3%). Based on analysis of the responses, two themes emerged: coping motivations and coping skills, with five subthemes and 14 basic codes. Coping motivations were more powerful than coping skills in relation to high alcohol consumption. Conclusion: Poor coping skills and strong motivations, combined with misinformation on social media and the internet, appear to have led to new or higher alcohol consumption among survey respondents. Keywords: Alcohol drinking, COVID-19, motivation, social media, Iran Citation: Fattah A; Khalvati M; Abounoori M; Molavi N; Azartash F; Babakhanian M. Motivations for alcohol consumption during the COVID-19 pandemic in Islamic Republic of Iran. East Mediterr Health J. 2022;28(2):108–113. https://doi.org/10.26719/emhj.22.024 Received: 12/11/20; accepted: 15/06/21 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo) EMHJ 28-2 Book.indb 108 21/03/2022 5:05 PM 109 Research article EMHJ – Vol. 28 No. 2 – 2022 From 7 March to 8 April 2020, methanol poisoning was reported in all 31 provinces of the Islamic Republic of Iran, with deaths due to methanol consumption (ages 14–78 years) in 26 provinces (6,8,9). The total number of deaths due to alcohol poisoning from February to April 2020 was almost 11 times higher than the number of confirmed deaths due to the same cause for the same period in 2019 (66 deaths). Several factors contributed to this situation. First, many people with alcohol poisoning do not go to hospitals because they are afraid of being arrested (since alcohol use is illegal in the country); if they do go, they often arrive too late. In addition, many of the alcoholic drinks available in the black market in the Islamic Republic of Iran are counterfeit and are marketed under the names of well known brands. Many people lack knowledge of the various forms of alcohol and their consequences (2,8,10). Limited knowledge about the dangers of alcohol consumption, combined with fear of COVID-19, has harmful consequences (6). Misinformation, misunderstandings and rumours on social media and the internet can create contradictory messages. When combined with a lack of trust in official information channels, this makes people more vulnerable to information coming from informal communication channels (9). In the Islamic Republic of Iran, health workers have been faced with a double burden: providing round- the-clock care for COVID-19 patients and dealing with an unprecedented wave of poisoning due to alcohol consumption, reportedly taken to prevent COVID-19 (11). Because of the significance of alcohol use during the COVID-19 pandemic, we investigated why people in the Islamic Republic of Iran consumed alcohol during the pandemic. The results of this study will help health officials, counselors, and psychologists begin to tackle this problem. Methods Study design and participants We conducted a qualitative study (from March to June 2020) with a content analysis approach to identify underlying reasons for alcohol consumption during the COVID-19 outbreak in the Islamic Republic of Iran. Participants were primarily recruited using purposive sampling. The study was conducted in all 31 provinces of the country by sharing the Telegram application interview link, a global messaging service. The interview link was shared to Telegram channels with an Iranian audience who lived in the country (almost 10 000 members). The survey in Farsi is available at: https://docs.google.com/forms/d/e/ 1FAIpQLScZAOQK6Rj0hLeDHm87CFehrIn1ZdSKUPhJ RnSJtJdSl_CurA/viewform?vc=0&c=0&w=1&usp=mail_ form_link&urp=gmail_link. The English version is available at: https://docs.google.com/forms/d/e/1FAIpQL Se1lcKQSk1JenLRoyisbjVxDS6LeSOz9M3HcisNM0KRE4 REfQ/viewform. Snowball sampling was also used whereby those interviewed were asked to send the link to other individuals who might be interested in participating in this research. Only those who had attempted to consume a large amount of alcohol of unknown type or constituent (methanol, ethanol or other alcohol types) since the start of the COVID-19 pandemic were eligible to participate. Participation was voluntary, all answers remained confidential and the names of the participants were not mentioned in the study; instead, codes were used. Interviews were in Farsi. Definitions Coping is defined as cognitive and behavioral attempts to manage particular, continually changing, external and/or internal demands that are evaluated as taxing or exceed- ing the individual’s resources (12). High alcohol consumption is described as having an average of more than two drinks a day (for women) or more than four drinks a day (for men) (13). Self-medication is defined as the application and administration of medicines by individuals (or members of their family) to treat self-diagnosed or self-recognized conditions or symptoms (14). Data analysis For data analysis, the qualitative content analysis method was used to investigate specific concepts in the respons- es. The primary data gathering method in this study was a semi-structured online text interview. We used an in- ductive approach to recognize themes within the inter- view data. The interviews were read and concepts coded. Then, the codes were classed based on their similarities. The advantage of online interviews is the possibility of conducting them individually with the research partic- ipant’s full consent. In qualitative studies, the sample size must be sufficient to have a theoretical saturation; therefore, the interviews were continued until data were saturated. Ethical considerations Respondents gave their informed consent to participate, and their privacy and right to withdraw from the study at any time were assured. This study was approved by the Student Research Committee of Mazandaran University of Medical Sciences: research ethics code IR.MAZUMS. REC.1399.131. Results Our sample consisted of 116 people: 34 (29.3%) females and 82 (70.7%) males (Table 1). The mean age of the partic- ipants was 34.8 years (standard deviation 9.9 years, range 17–71 years). Most of the participants (75.9%) reported having consumed alcohol before the survey (an average of more than two drinks a day for women or more than four drinks a day for men). In addition, 56.9% reported EMHJ 28-2 Book.indb 109 21/03/2022 5:05 PM 110 Research article EMHJ – Vol. 28 No. 2 – 2022 having self-medicated for an illness without a doctor’s prescription before the COVID-19 pandemic, which could be an indication of their susceptibility to misinformation. The most common reason for high alcohol consumption of unknown types or constituents was to relieve stress during home quarantine (32.3%). Other major reasons were relaxation to reduce the fear of catching COVID-19 (16.8%), protection from SARS-CoV-2 (16.1%) and having fun drinking alcohol (10.6%) (Table 1). All the participants were using alcohol as part of a coping mechanism. The reasons for use are as follows. First theme: coping motives In this theme, our participants gave various reasons for alcohol use during the COVID-19 pandemic (Table 2). Achieve a positive mood Achieving a positive mood during the pandemic was one of the major reasons for alcohol use. In the current pandemic, some participants believed drinking alcohol would help them not to think about everyday problems and stresses due to the pandemic and balance their mood. “Drinking alcohol relaxes me completely and makes me feel better when I’m tense,” said one participant. Many participants reported that they drank alcohol before the pandemic for fun and their drinking was not related to the pandemic. Alleviate negative emotions Some participants reported using alcohol to get rid of negative feelings. “I drink to get rid of myself,” said one participant. Another said that they drank, “Because I’m stuck in the house and can’t go out, I do it for joy without any reason.” Second theme: coping skills People who drink alcohol as a type of “coping skill” may have limited skills to adapt and confront life’s challenges. Exposure In our study, most of the participants with no history of alcohol use began drinking after the onset of the pandem- ic, mostly because of the widespread misinformation on social media about alcohol’s role in preventing COVID-19 (Table 2). For example, some participants claimed that they saw posts on Instagram that everyone was drinking alcohol in the Islaminc Republic of Iran. As a result, they started drinking and continued because they liked it. Lack of knowledge Most young alcohol users lack knowledge about the dan- gers of drinking (Table 2). The health ministry warnings are not effective. On Iranian television, alcohol was pre- sented as a good disinfectant against COVID-19, without mentioning the adverse effects of drinking alcohol. Thus, some participants thought that drinking it could prevent them from catching the disease. To their surprise, they felt happy and calm after drinking. Active coping strategies Drinking for some of the participants represented an active coping strategy (a practical plan to achieve a goal Table 1 Characteristics of the participants and reasons for high alcohol consumption during the COVID-19 pandemic, Islamic Republic of Iran, March–June 2020 Variable Males (n = 82) Females (n = 34) Total (n = 116) Age in years, mean (SD) 36.3 (9.9) 31.2 (9.02) 34.8 (9.9) (range 17–71) History of high alcohol consumption, no. (%)a Yes 68 (82.9) 20 (58.8) 88 (75.9) No 14 (17.1) 14 (41.2) 28 (24.1) History of self-medication, no. (%) Yes 48 (58.5) 18 (52.9) 66 (56.9) No 34 (41.5) 16 (47.1) 50 (43.1) Most common reasons for high alcohol consumption, no. (%)b Protection from SARS-CoV-2 18 (15.7) 8 (17.4) 26 (16.1) Having fun drinking alcohol 15 (13.0) 2 (4.3) 17 (10.6) Self-medication 8 (7) 3 (6.5) 11 (6.8) Poor warnings about the hazards of alcohol use from the health ministry 5 (4.3) 7 (15.2) 12 (7.5) Relieve stress of home quarantine 37 (32.2) 15 (32.6) 52 (32.3) Reduce fear of catching COVID-19 20 (17.4) 7 (15.2) 27 (16.8) Scarcity of disinfectants 7 (6.1) 4 (8.7) 11 (6.8) Exposure to misinformation on social media and the Internet 3 (2.6) 0 (0) 3 (1.9) Suicide or self-harm attempt 2 (1.7) 0 (0) 2 (1.2) Total, no. (%) 115 (100) 46 (100) 161 (100) COVID-19= coronavirus disease 2019. aHigh alcohol consumption was defined as an average of more than two drinks a day (for women) or four drinks a day (for men) (14). bRespondents could select more than one answer. EMHJ 28-2 Book.indb 110 21/03/2022 5:05 PM 111 Research article EMHJ – Vol. 28 No. 2 – 2022 with the belief that the strategy predicts better health outcomes). In the Islamic Republic of Iran, during the pandemic and with the resultant disinfectant shortages, some people tried to protect themselves and self-med- icated by drinking alcohol (Table 2). Some of the partic- ipants said that they could not find any disinfectant at stores and pharmacies. They then found drinkable alco- hol in the black market and started drinking it to avoid catching the disease. Discussion Our study was conducted to identify the reasons for al- cohol consumption in the Islamic Republic of Iran. We extracted two main themes and several subthemes: cop- ing motives (achieve a positive mood, alleviate negative emotions) and coping skills (exposure, lack of knowledge and active coping strategies). Since alcohol consumption is illegal in the country, most available types of alcohol are homemade or smuggled. During the pandemic, poor warnings about the harms of alcohol use by the health ministry and an abundance of misinformation may have resulted in widespread alcohol use. Because there are no guidelines on alcohol consumption or production, the risk of improper use of ethanol, adulterated ethanol and methanol poisoning increases. Alcohol consumption was more prevalent in men than women in our survey par- ticipants, which is consistent with the findings of other studies in the country (15,16). The mean age of our partic- ipants was 34.8 years (range 17 to 71 years), which was is to previous studies (38 and 33 years, respectively) (15,16). The coping motivations are the main reasons for drinking alcohol and, based on the literature, these have been associated with alcohol use disorder (17–19). Achieving a positive mood and alleviating negative emotions were part of this theme. In a 2014 study the reasons given for alcohol consumption were based on wrong attitudes and beliefs such as beliefs that drinking alcohol brings happiness and strengthens the body (10). A 2002 study reported pleasure-seeking as a reason for drinking alcohol (20). In the context of alleviating negative emotions, we are faced with an increase in suicide attempts. A survey on suicide risk during the COVID-19 pandemic found the lockdown to escalate two known suicide precipitants, domestic violence and alcohol consumption (21). Widespread exposure to social media and the internet influenced the coping skill of the study participants, in line with the previously mentioned 2014 study (10). Alcohol advertising creates a positive image in people’s minds and leads them to start drinking alcohol or to drink more alcohol (22). The literature on management of information on COVID-19 confirms the spread of misinformation about virus transmission, the disease and its treatment (23), which has led people to drink alcohol to avoid catching the virus (9). Some participants reported stress and anxiety as the reasons for drinking. According to social learning theory, in stressful situations, people with poor coping skills are drawn to drug and alcohol consumption (24). In our study, the participants had strong drinking motivation and poor coping skills, consistent with the results of a 2021 survey, which showed that people with high coping motivation and low coping skills reported higher alcohol consumption in stressful situations (24). An important problem during a crisis is the scarcity of and lack of access to necessities. Early in the COVID-19 pandemic, disinfectants, face masks and gloves were in short supply in the Islamic Republic of Iran. In this period, some people who did not have correct information about using alcohol as a disinfectant and for preventing the spread of the virus began drinking alcohol to disinfect their internal organs. Our study has some limitations. First, we did not measure the exact amount of alcohol consumed, nor the exact type of alcohol used or its proof. Second, there may be selection bias with regard to the sample because the use of snowball sampling increases this risk. Third, the semi-structured nature of the interview may have influenced the participant’s responses. Specific questions may have encouraged participants to address specific topics and not other topics. Fourth, our sample size was small and as such our results may underestimate alcohol consumption as a public health issue during the pandemic. Finally, this was a qualitative study; it is possible that our knowledge and previous experience about alcohol consumption influenced the interpretation of the interview content. Table 2 Themes and subthemes related to alcohol consumption during the COVID-19 pandemic, Islamic Republic of Iran, March– June 2020 Themes Class Basic codes Coping motives Achieve a positive mood Relaxation; Have fun drinking alcohol; Reduce the stress of home quarantine; Reduce the fear of catching COVID-19 Alleviate negative emotions Suicide attempt; Attempting self-harm Coping skills Exposure to misinformation Extensive exposure to misinformation on social media and the internet; Easy access to alcohol as a disinfectant Lack of knowledge Consumer ignorance; Poor health ministry warning about alcohol hazards; Alcohol consumption being taboo in the Islamic Republic of Iran Active coping strategies Protection from COVID-19; Self-medication; Scarcity of disinfectants COVID-19= coronavirus disease 2019. EMHJ 28-2 Book.indb 111 21/03/2022 5:05 PM 112 Research article EMHJ – Vol. 28 No. 2 – 2022 The reasons for alcohol consumption are complex and extensive and include economic, social and cultural factors (25). Poor coping skills, strong motivations and misinformation on social media and the internet appear to have resulted in high alcohol consumption, causing social harm. Coping motivations and coping skills, which are concepts extracted from the data, are new concepts in the research on alcohol consumption in the Islamic Republic of Iran. Further research in this field is recommended and will help health officials, counsellors, and psychologists to tackle this issue of alcohol consumption in the Islamic Republic of Iran. Funding: This study was supported by the Student Re- search Committee of Mazandaran University of Medical Sciences, grant number 131. Competing interests: None declared. ةيملاسلإا ناريإ ةيروهجم ،-19ديفوك ةحئاج ءانثأ لوحكلا يطاعت ءارو عفاودلا نايناخاباب دوعسم ،شاطرزأ ةمطاف ،يولم ردان ،يرون وبأ يدهم ،تيولخ ةحيلم ،حاتف لضفلا وبأ ةصلالخا .يطاعتلا اذبه ةطبترلما لماوعلا مهف يروضرلا نمو ،ةمهم ةماع ةيحص ةلكشم لوحكلا يطاعت عافترا دعي :ةيفللخا 2019 انوروك سويرف ضرم ةحئاج ءانثأ لوحكلا يطاعتب ةطبترلما ةيعماتجلااو ةيدرفلا لماوعلا مييقت لىإ ةساردلا هذه تفده :فادهلأا .ةيملاسلإا ناريإ ةيروهجم في )19-ديفوك( قيبطت تاونق برع حسلما طبار ةكراشم للاخ نم ةساردلا في ينكراشلما رايتخلا ةدوصقم تانيع تمدخُتسا ،ةيفيكلا ةساردلا هذه في :ثحبلا قرط تلصوو ،2020 ناريزح/وينوي لىإ راذآ/سرام نم ةترفلا في ةساردلا تيرجُأو .-19ديفوك ةحئاج ءانثأ نياريلإا روهملجا نم ةئف عم Telegram .تاباجلإا في ةددمح ميهافم ءاصقتسلا يفيكلا ىوتحلما ليلتح انمدختساو .ةيناريلإا تاظفاحلما عيجم لىإ يرايعلما فارحنلاا( ةنس 34.8 ينكراشلما رمع طسوتم ناكو .ثانلإا نم )%29.3( مهنم 34 ناك ،حسلما نع اوباجأ اًكراشم 116 ينب نم :جئاتنلا ضارملأا دحأ نم مهسفنأ ةاوادمب اوماق منهأب %56.9 دافأو ،لوحكلا اوطاعت منهأب )%75.9( ينكراشلما مظعم دافأو .)ةنس 71-17 قاطنلا ؛9.9 رجلحا ءانثأ رتوتلا فيفتخ وه لوحكلا يطاعتل اًعويش رثكلأا ببسلا ناكو .19-ديفوك ةحئاج لبق بيبطلا نم ةيبط ةفصو لىع لوصلحا نود ةيعرف تاعوضوم ةسخم بناج لىإ ،ملقأتلا تاراهمو ،ملقأتلا عفاود :اهم ناعوضوم رهظ ،تاباجلإا ليلتح لىإ اًدانتساو .)%32.3( ليزنلما يحصلا .لوحكلا يطاعت عافتراب قلعتي مايف ملقأتلا تاراهم نم ىوقأ ملقأتلا عفاود تناكو .اًيساسأ اًزمر 14 و لىإ تدأ ،تنترنلإاو يعماتجلاا لصاوتلا لئاسو في ةطولغلما تامولعلما بناج لىإ ،ةيوقلا عفاودلاو ملقأتلا تاراهم فعض نأ ودبي :تاجاتنتسلاا .حسلما في ينكراشلما ينب لوحكلا يطاعت نم اًعافترا رثكأ وأ ديدج ىوتسم Les motivations en matière de consommation d'alcool pendant la pandémie de COVID-19 en République islamique d'Iran Résumé Contexte : Une forte consommation d'alcool représente un problème de santé publique important ; il est donc essentiel de comprendre les facteurs qui lui sont associés. Objectifs : L’ étude visait à évaluer les facteurs individuels et sociaux associés à la consommation d'alcool pendant la pandémie de maladie à coronavirus 2019 (COVID-19) en République islamique d'Iran. Méthodes : Dans la présente étude qualitative, un échantillonnage ciblé a été utilisé pour sélectionner les participants. Pour ce faire, le lien de l'enquête a été partagé sur les canaux de l'application Telegram avec un public iranien pendant la pandémie de COVID-19. L'étude a été menée de mars à juin 2020 et a couvert toutes les provinces iraniennes. Nous avons utilisé une analyse qualitative du contenu pour étudier des concepts spécifiques figurant dans les réponses. Résultats : Sur les 116 participants ayant répondu à l'enquête, 34 (29,3 %) étaient des femmes et 82 (70,7 %) étaient des hommes. L'âge moyen des participants était de 34,8 ans (écart type 9,9 ; fourchette comprise entre 17 et 71 ans). La plupart des participants (75,9 %) ont déclaré avoir consommé de l'alcool et 56,9 % ont déclaré s'être auto- médicamentés pour une maladie sans ordonnance médicale avant la pandémie de COVID-19. La raison la plus fréquemment invoquée pour justifier la consommation d'alcool était le soulagement du stress pendant la quarantaine à domicile (32,3 %). L'analyse des réponses a permis de dégager deux thèmes : les motivations à la consommation d'alcool et les capacités d'adaptation, avec cinq sous-thèmes et 14 codes de base. Les motivations prenaient le dessus sur les capacités d'adaptation dans le cas d'une forte consommation d'alcool. Conclusion : De faibles capacités d'adaptation et de fortes motivations, associées à des informations erronées diffusées sur les médias sociaux et l'Internet, semblent avoir conduit à un nouvel usage de l'alcool ou à une consommation plus élevée chez les personnes interrogées. 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Science. 2018;359(6380):1146–1151. https://doi.org/10.1126/ science.aap9559 24. Merrill JE, Thomas SE. Interactions between adaptive coping and drinking to cope in predicting naturalistic drinking and drink- ing following a lab-based psychosocial stressor. Addict Behav. 2013;38(3):1672–8. https://doi.org/10.1016/j.addbeh.2012.10.003 25. Najafi F, Hajizadeh M, Pasdar Y, Salimi Y, Hamzeh B, Karami Matin B, et al. Socioeconomic inequalities in tobacco, alcohol and illicit drug use: evidence from Iranian Kurds. East Mediterr Health J. 2020;26(10):1294–302. https://doi.org/10.26719/emhj.20.007 EMHJ 28-2 Book.indb 113 21/03/2022 5:05 PM 114 Research article EMHJ – Vol. 28 No. 2 – 2022 Introduction Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide. Studies estimate that by 2030, COPD would be the fifth leading cause of death in high-income countries and the third leading cause of death in middle-income countries (1). Since 2016, research has shown that COPD is already established as the third leading cause of death in the world with about 3 million deaths and 251 million cases, 90% of which occurred in low- and middle-income coun- tries (2) such as Lebanon. The first, and so far only, national study to determine the prevalence of COPD in the adult Lebanese population revealed a prevalence of 9.7% according to the GOLD definition, of which 80% of cases in the smoking population are unrecognized and undiagnosed (3). Moreover, a study conducted in 10 countries in the Middle East and North Africa (MENA) region showed that in Lebanon, 71.8% of COPD patients were still smoking and only 30.6% were receiving respiratory treatment (4). Complete recovery from COPD is currently not achievable, and as the disease progresses patients experience worsening breathing difficulty and disruption that affect their quality of life (5,6). Therefore, COPD requires major changes in the daily lives of patients, who must adhere to treatment, change their lifestyle and monitor their signs and symptoms (7). Essentially, COPD has been considered a condition of accelerated lung aging; consequently, the prevalence of COPD is three times higher in people over the age of 60 years (8). Lebanon has the fastest growing older adult population in the Arab region, but few social resources to address their needs (9). To date, no study has explored the experience of patients with COPD in Lebanon. Thus, the aim of our study was to describe the phenomenon of living with COPD from the Lebanese individuals’ perspective. Methods Design A descriptive phenomenological research design was used, which is anchored in Husserl’s philosophical phe- nomenology, and developed and modified to be applica- ble as a scientific research method. The aim of phenom- enology is to seek the essence of human phenomena as lived and experienced and present them and their meanings as faithfully as possible (10), free from pre- conceptions, beliefs and knowledge of the phenomenon. Living with chronic obstructive pulmonary disease in Lebanon: a phenomenological study Rita Georges Nohra,1,2,3 Jean-Manuel Morvillers,1,4 Hala Sacre,5 Pascale Salameh5,6,7 and Monique Rothan-Tondeur1,8 1Université Sorbonne Paris Nord, Chaire Recherche Sciences Infirmières, Laboratoire Educations et Promotion de la santé, LEPS, Villetaneuse, France (Correspondence to: Rita Georges Nohra: ritag.nohra@gmail.com). 2Hôtel-Dieu de France Hospital, Beirut, Lebanon. 3Faculty of Public Health, Lebanese University, Fanar, Lebanon. 4Pôle PEPIT. GHU Paris Psychiatrie & Neurosciences, Paris. 5Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie - Liban (INSPECT-LB), Beirut, Lebanon 6Faculty of Pharmacy, Lebanese University, Hadat, Lebanon 7University of Nicosia Medical School, Nicosia, Cyprus 8AP-HP, Chaire Recherche Sciences Infirmières, Paris, France Abstract Background: Lebanon has the fastest growing older adult population in the Arab region but few social resources to ad- dress their needs. No studies have explored the experience of patients with chronic obstructive pulmonary disease (COPD) in Lebanon. Aims: Exploring the experiences of individuals living with COPD in Lebanon. Method: Using a descriptive phenomenological research design, qualitative individual semi-structured interviews were conducted with COPD patients living in Lebanon, between May 2019 and September 2019. Results: Fifty participants agreed to be interviewed. The majority were men (56%) and had moderate COPD (40%). Mean age was 71.5 (standard deviation 9.0) years. We found that COPD affects three dimensions of patients’ lives: educational, organizational and psychosocial. Conclusion: The results highlight the need for multidisciplinary strategies to address the needs of people with COPD in Lebanon, including their caregivers. Strategies include patient education and the development of new methods to facili- tate and promote partnership between health care professionals, COPD patients and their caregivers. Keywords: COPD, elderly, qualitative study, phenomenology, Lebanon,morbidity, mortality Citation: Nohra RG; l Morvillers J-M; Sacre H; Salameh P; Rothan-Tondeur M. Living with chronic obstructive pulmonary disease in Lebanon: a phenomenological study. East Mediterr Health J. 2022;28(2):114–120. https://doi.org/10.26719/emhj.22.027 Received: 08/03/21; accepted: 15/06/21 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). EMHJ 28-2 Book.indb 114 21/03/2022 5:05 PM 115 Research article EMHJ – Vol. 28 No. 2 – 2022 Throughout this study, we followed the Standards for Re- porting Qualitative Research guidelines (11). Participants The participants were recruited from four university hos- pitals in Beirut. Eligibility criterion was clinical diagno- sis by pulmonol ogists, and participation was voluntary. First, the study was explained to the pulmonologists, then 135 patients on the lists they provided were contact- ed and asked if they were willing to be interviewed at their homes. The inclusion criteria were COPD diagnosis with over 40 years old, and being able and willing to con- sent to and engage in the research study. Creswell states that “up to a maximum of 10 interviews” is sufficient for phenomenological research (12). However, because the size of a sample depends on the complexity of a phenomenon (13) and in order to create a rich understanding of the phenomenon of living with COPD in Lebanon, we included all participants who agreed to take part in the study, therefore covering and thus a broad range of people using characteristics such as sex, age and economic situation. Data collection Face-to-face, semi-structured interviews were conducted by the principal investigator between May 2019 and Sep- tember 2019 at the participants’ homes. Interviews were systematically audio and video recorded after obtaining the participant’s consent. An interview guide with open questions was developed in advance by the principal investigator and tested with one participant. The inter- views were relatively open and partly influenced by the participant’s concern. The investigator was well trained and careful to avoid leading questions. After some so- ciodemographic questions, the interview began with an opening question, “Tell me more about your experience with COPD”. Next, a series of prompts were used inviting the participants to describe their experiences and their visions for the future. The investigator then summarized the exchange so that the patient could validate whether they were in agreement with what had been said during the interview. The participants were visited a second time to present the results. All participants agreed with the results. Data analysis Analysis of the results started immediately after the in- terviews. The audio and video recordings were fully tran- scribed verbatim in Arabic and typed using Microsoft Word. Emotions, voice tone, or any changes in partici- pants’ behaviours noticed in the videos were added to the observation notes. We used ATLAS.ti, version 7, a soft- ware for qualitative data analysis, to support the analysis. The data analysis was inspired by Giorgi’s phenomenological method (10). Each interview was first read completely to gain a sense of the whole description. The interview was then reread from the start to identify key statements about the participants’ experiences, constituting “meaning units” expressed in the participants’ own everyday language. Once the meaning units were established, transformation of the participants’ everyday language was required (13). In this step, the statements of the participants were transformed by two investigators to express the insight contained in them more directly. Then the meaning units of the 50 interviews were combined inferring the general meaning structure of the experience from the transformed meaning units (14). Ethical considerations The study was authorized by the ethics committee of Hôtel-Dieu de France Hospital (CEHDF 1135). Oral and written informed consent was obtained from each par- ticipant after being provided with both written and oral information about the aim of the study. A number was randomly assigned to each patient (P1, P2, etc.) and a con- cordance table was kept to preserve anonymity. Results Demographics A total of 135 patients were contacted, and 50 agreed to be interviewed, of whom 45 were filmed and 5 were au- dio-recorded. This number of participants was necessary to gain insight into the variety of meanings of the phe- nomena of living with COPD in Lebanon. The partici- pants lived in different regions of Lebanon: 27 in Mount Lebanon, 21 in Beirut, and 2 in southern Lebanon. The age of the respondents varied between 50 and 93 years, with a mean of 71.5 (standard deviation, 9) years and a sex ratio of 1.27 male/female (28 males and 22 females). The majority of participants had moderate COPD (40%), used support from a caregiver (84%) and were retired (64%) (Table 1). Living with chronic obstructive pulmonary disease The essence of living with COPD in Lebanon, from the participants’ perspective, is to be seen as living in a “less- er world”, striving for a breath of life. Living with COPD means living with vulnerability and uncertainty influ- enced by the body’s capacity and the environmental re- sources that impose the need for support to cope with daily life (Table 2). Chronic obstructive pulmonary disease: vulnerability and uncertainty Participants described living with COPD as being forced into sedentary and solitary lifestyle. The physical impact due to COPD expressed by participants ranged from fa- tigue and dyspnoea to inactivity and dependence, either because of the inability to move or the oxygen device that impede their movement, resulting in a negative expe- rience. Living with this disease is living with dyspnoea that can worsen at any time. Difficulties in predicting the symptoms of COPD and their impact on daily life lim- it the participants’ ability to plan activities in advance. EMHJ 28-2 Book.indb 115 21/03/2022 5:05 PM 116 Research article EMHJ – Vol. 28 No. 2 – 2022 Therefore, they avoid family gatherings and activities which they think they cannot cope with, e.g. walking alone in the garden, which in itself presents a risk of be- ing sedentary. Moreover, they prefer to receive their care at home, either because it is difficult for them to move around or to preserve the same living conditions. Participants described COPD as an anxiety-provoking disease that invades all aspects of their lives. They live in constant fear; fear of everything new, fear of long journeys, and fear that the disease will have an impact on their professional lives. An older woman described her fear as “suffocating is not funny”. Concerns related to the Lebanese context, such as financial problems and the feeling of insecurity, make the participants to organize their daily lives according to their living context; which oxygen machine to use in case of a power outage; when to leave the house; what to do if the building does not have an elevator; and financial problems that prevent certain participants from visiting their doctors or even adhering to their medications. Therefore, to save on expensive physiotherapy sessions, participants taught their caregivers how to help them with breathing exercises. Some participants used computerized consultation because of the difficulty in going to meet with their physician physically. COPD has an impact on participants’ lives; it makes them feel resigned to their state of health as they struggle to maintain vital momentum. Some participants reported the impact of the disease on their physical image and some related these difficulties to the cultural context of the country. Chronic obstructive pulmonary disease: striving for a breath of life Some participants tried to continue their lives as normally as possible, taking precautions not to get sick, adhering to the recommendations of the pulmonologist, setting goals so as not to aggravate their symptoms and contacting their pulmonologist regularly. They wanted Table 1 Demographic characteristics of the participants (n = 50) Characteristic Frequency No. Patient number % Age (years) < 60 5 P8, P26, P27, P28, P34 10 60–69 15 P3, P4, P6, P15, P17, P18, P19, P21, P24, P25, P32, P36, P44, P46, P47 30 70–80 23 P1, P2, P5,P7, P10, P12, P13, P16, P20, P22, P23, P29, P30, P31, P33, P35, P37, P38, P40, P41, P43, P48, P50 46 > 80 7 P9, P11, P14, P39, P42, P45, P49 14 Sex Male 28 P1, P4, P5, P6, P7, P9, P13, P16. P18, P19, P20, P21, P22, P23, P24, P26, P27, P29, P30, P31, P32, P36, P37, P40, P41, P42, P43, P50 56 Female 22 P2, P3, P8, P10, P11, P12, P14, P15, P17, P25, P28, P33, P34, P35, P38, P39, P44, P45, P46, P47, P48, P49 44 Disease severity Mild 6 P13, P17, P18, P20, P22, P28 12 Moderate 20 P4, P6, P12, P15, P16, P19, P23, P25, P26, P29, P30, P31, P34, P35, P36, P38, P39, P44, P46, P47 40 Severe 10 P7, P9, P10, P11, P27, P33, P37, P40, P42, P45 20 Very severe 14 P1, P2, P3, P5, P8, P14, P21, P24, P32, P41, P43, P48, P49, P50 28 Age at diagnosis (years) < 5 24 P1, P6, P13, P14, P15, P17, P18, P19, P20, P25, P26, P28, P30, P32, P33, P34, P35, P36, P27, P28, P29, P40, P44, P47 48 5–9 19 P2, P3, P4, P5, P8, P9, P12, P16, P24, P27, P29, P31, P41, P43, P45, P46, P48, P49, P50 38 > 10 7 P7, P10, P11, P21, P22, P23, P42 14 Caregiver Family member 34 P1, P4, P6, P7, P9, P11, P12, P14, P16, P18, P19, P20, P21, P23, P24, P25, P27, P29, P30, P31, P32, P33, P36, P37, P39, P40, P41, P42, P43, P44, P45, P48, P49, P50 68 Non-family member 8 P2, P3, P5, P8, P10, P34, P35, P38 16 Without help 8 P13, P15, P17, P22, P26, P28, P46, P47 16 Current work Yes 15 P4,P6, P8, P18, P19, P22, P26, P30, P34, P36, P40, P42, P46, P48, P49 30 No 35 P1, P2, P3, P5, P7, P9, P10, P11, P12, P13, P14, P15, P16, P17, P20, P21, P23, P24, P25, P27, P28, P29, P31, P32, P33, P35, P37, P38, P39, P41, P43, P44, P45, P47, P50 70 EMHJ 28-2 Book.indb 116 21/03/2022 5:05 PM 117 Research article EMHJ – Vol. 28 No. 2 – 2022 to know more about their illness and some became self- sufficient and active in their own care. The experiences of participants with their disease was influenced by the support they receive, whether from family or medical personnel. They reported how helpful the motivation provided by their doctor was. For some, it was difficult to maintain compliance and set goals, so they reported their need for information and regular reassuring follow-ups. Some participants expressed their need for help to quit smoking and remain so, but rejected the idea of attending specialized centres because of their constraining conditions and because they were convin- ced that quitting is a matter of self-determination. Monitoring, whether by the doctor or the family, is a key factor that helped participants in dealing with their disease. Participants’ families and friends helped them by securing suitable tobacco-free environments and a sense of safety. Participants clearly expressed the benefits of close monitoring to ensure that the right decisions are made, to detect any deterioration in health status or simply to feel that someone is interested in their condition. Discussion Participants in this study were held back by the symp- toms of their disease, they struggled with physical move- ments (e.g. walking and in some cases even speaking), which led to a more sedentary and solitary life than they had previously or wish to have. In line with our findings, previous studies have found that many COPD patients struggle with being held back by the symptoms of their disease and the challenges of breathing, which is associ- ated with social isolation (15–20). Health care staff, par- ticularly nurses, play a major role in managing the health issues of patients with chronic illness (20,21). Nurses should be more aware that the sedentary lifestyle of COPD patients might be by necessity and not by choice, and therefore adopt a sensitive approach. Moreover, nurses are encouraged to develop strategies for patients to maintain physical and social activities and adhere to clinical recommendations. It is important to recognize that respiratory symptoms are prevalent and distressing in pulmonary disease. All participants described anxiety, fear, panic or distress with shortness of breath with having to stop to get air in. They reported being stigmatized because of their symptoms, and this is consistent with the findings from other studies (22–25). Some even isolated themselves at home to avoid the embarrassment of showing their symptoms in public. From a phenomenological point of view, moving from avoidance to acceptance of one’s own body is a crucial shift since the body is understood to be a mode of access to the world (26). From this perspective, it is understandable that the negative feelings due to the symptoms of COPD lead to a distancing from one’s own body and certain dimensions of the everyday world. This contributes to the risk of living a sedentary lifestyle and reduced social network, resulting in further deterioration. Thus, it is important to adopt a multidisciplinary approach to addressing the psychosocial needs of COPD patients. To overcome problems related to the unavailability of the doctor, the difficulty in moving around, long journeys to reach the clinic, or long waiting times at the doctor’s clinic, participants used the internet and TV shows to find out more about their disease, which exposed them to wrong information, unsuited to their state of health. Some participants reported the use of self-medication, consistent with other research (27). Even in emergency situations, participants declared the use of prescriptions collected during previous consultations. According to a previous survey, the vast majority of drugs used in self-medication came from a resumption of previously prescribed treatment, while 28% were purchased on the patient’s initiative (28); this could result in inappropriate or ineffective use of medication and consequently an unintentional non-adherence to recommendations. Thus, the importance of patient education cannot be over-emphasized. Moreover, to meet today’s demands for accessible and efficient care, it is important to develop new methods, such as eHealth strategies, to facilitate and promote partnership between health professionals and patients (29). The majority of participants relied on family members to fill the gaps in carrying out tasks they once did alone; this is contrary to findings of other research showing that COPD participants tended to rely primarily on themselves to avoid burdening their relatives and close friends (22). This is explained by social relations and support from family as well as friends which is considered “the axis of Lebanese values, beliefs and culture” (30). The Lebanese population still has relatively strong family networks, and cultural ideals continue to support intergenerational co-residence (31). According to Lebanese cultural norms, older people generally have great expectations of help from their children and family members. Caregivers in this study had no previous knowledge or experience of disease management, decision-making during complications, or interpersonal challenges, which is in line with the findings of other studies that emphasize the importance of involving caregiver in any strategies tailored for COPD patients and as contributors partnering with health care professionals (32,33). As in many other countries, Lebanon experiences economic inequalities in health; it offers few benefits in terms of welfare, health care and pensions. Economic problems were widely discussed during the interviews because they are barriers to therapeutic adherence and medical consultation. Although other American and British studies also described the financial worries of COPD participants concerning funding their care (34,35), policies to protect older adults in Lebanon are extremely weak in comparison (9). Considering the lack of formal government support, increasing attention by nongovernmental agencies is helping to address unmet needs for health care (9). Therefore, health care EMHJ 28-2 Book.indb 117 21/03/2022 5:05 PM 118 Research article EMHJ – Vol. 28 No. 2 – 2022 professionals should help participants to identify available resources that are best for them. Methodological considerations Some authors claim that credibility, authenticity, critical- ity and integrity remain the main criteria of scientificity in qualitative research (36). Credibility is respected when the research results truly describe the phenomenon. Thus, it was our intention to recruit a large group of par- ticipants with diverse socioeconomic characteristics and to conduct interviews beyond data redundancy. More- over, all prior assumptions of the authors about living with COPD were set aside throughout the process of data collection and analysis. Authenticity is used to clarify whether the results correspond to the experience as described by each of the participants. Therefore, we read the transcripts of the interviews multiple times; we made audio and video recordings of the interviews and conducted a second visit to validate our interpretation of the transcripts. Audio recordings allowed us to gather information from patients intimidated by the presence of cameras, especially those who thought that the disease had an impact on their physical image. Criticality refers to the constant critical attitude of the researcher in order to avoid bias. We followed the Giorgi methodological framework (10) throughout data collection and analysis. Integrity illustrates the researcher’s concern to validate his or her interpretations based on the data, therefore we avoided prematurely formulating the essence of the phenomenon by achieving redundancy before ending data collection and making a second visit. However, the interviews were conducted with patients living in only three governorates of Lebanon: Beirut, Mount Lebanon and South Lebanon. Excluding patients living in other more rural districts may have limited the findings of this study. Conclusion Living with COPD means living with vulnerability and uncertainty influenced by the body’s capacities and the economic challenges of a country with limited resourc- es, which imposes on patients a need for support to cope with daily life. Therefore, participants turn to their fam- ilies in a cultural context where the family continues to be seen as the primary provider of support. The results of our study show that COPD affected three dimensions of participants’ lives. These were the educational dimen- sion, where the lack of information was a need and a fac- tor that influenced the COPD patients’ experience with their disease; the coordination dimension as patients were obliged to reorganize their lives according to the Lebanese context (financial, social); and the psychosocial dimension given the impact of the disease on social life, professional life, physical image and emotional well-be- ing as expressed by the participants. Therefore, thera- peutic education has been recognized as a need for COPD patients in Lebanon. In addition, the development of in- terventions that include family caregivers and the coop- eration of all health professionals is vital. Furthermore, to respond to patients’ demands for easy access to care, it is important to develop new methods of facilitating and promoting the partnership between health professionals and patients while preserving patient comfort. Thus gov- ernmental and health care efforts are needed to improve the experiences of patients with COPD in Lebanon and to improve their quality of life. Acknowledgement The authors would like to thank the 50 persons who participated in this study for finding the time to share their expe- riences. We would also like to thank the pulmonologists (Zeina Aoun, Ihab Ibrahim, Georges Dabar, Georges Khayat, Moussa Riachi, Paul Makhlouf, Carlos Njeim, Diana Sassine) who assisted us in the recruitment by providing lists of their patients. The authors would like to also thank Elissa Naim for reviewing the article. Funding: This work was supported by a grant from the Lebanese University. Competing interests: None declared. Vivre avec une bronchopneumopathie obstructive chronique au Liban : une étude phénoménologique Résumé Contexte : Le Liban est le pays de la région arabe qui connaît la croissance la plus rapide de sa population de personnes âgées, mais il dispose de peu de ressources sociales pour répondre à leurs besoins. Aucune étude n'a examiné l'expérience des patients atteints de bronchopneumopathie obstructive chronique au Liban. Objectifs : Examiner les expériences des personnes vivant avec une bronchopneumopathie obstructive chronique au Liban. EMHJ 28-2 Book.indb 118 21/03/2022 5:05 PM 119 Research article EMHJ – Vol. 28 No. 2 – 2022 رهاوظلا ةسارد :نانبل في نمزلما يوئرلا دادسنلاا ضرمب نوباصلما رودنوت-ناثور كينوم ،ةملاس لاكساب ،رقص ةلاه ،زيريفروم ليونام ناج ،ارنه جروج اتير ةصلالخا لمو .ةئفلا هذه تاجايتحا ةيبلتل ةيعماتجلاا هدراوم ةلق لظ في كلذو ،ةيبرعلا ةقطنلما في نسلا رابك نم ناكسلل ومن لدعم عسرأ نانبل لجسي :ةيفللخا .نانبل في مهضرمو نمزلما يوئرلا دادسنلاا ضىرم ةبرتج تاسارد يأ لوانتت .نانبل في نمزلما يوئرلا دادسنلاا ضرمب ينباصلما دارفلأا براتج فاشكتسا لىإ ةساردلا هذه تفده :فادهلأا يوئرلا دادسنلاا ضرمب ينباصلما دارفلأا عم ةيعونو ةيلكيه هبش ةيدرف تلاباقم تيرجُأ ،رهاوظلا ثحبل يفصو ميمصت مادختساب :ثحبلا قرط .2019 لوليأ/برمتبسو 2019 رايأ/ويام ينب ةترفلا في ،نانبل في نوشيعي نيذلا نمزلما نمزلما يوئرلا دادسنلاا ضرمب ينباصم اوناكو )%56( لاجرلا نم مهفصن نم رثكأ ناكو .مهعم تلاباقم ءارجإ لىع اًكراشم 50 قفاو :جئاتنلا ةايح في داعبأ 3 لىع رثؤي نمزلما يوئرلا دادسنلاا ضرم نأ اندجوو .)9.0 يرايعلما فارحنلاا( ةنس 71.5 رمعلا طسوتم ناكو .)%40( طسوتلما .ةيعماتجلاا ةيسفنلاو ةيميظنتلاو ةيميلعتلا :ضىرلما ينمضت عم ،نانبل في نمزلما يوئرلا دادسنلاا ضرمب ينباصملل تاصصختلا ةددعتم تايجيتاترسا لىإ ةجالحا لىع جئاتنلا دكؤت :تاجاتنتسلاا ةيحصلا ةياعرلا يينهم ينب اهزيزعتو ةكاشرلا ليهستل ةديدج بيلاسأ ريوطتو ضىرلما فيقثت تايجيتاترسلاا لمشتو .مهتياعر لىع ينمئاقلا .مهتياعر لىع ينمئاقلاو نمزلما يوئرلا دادسنلاا ضىرمو References 1. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006 Nov;3(11):e442. doi:10.1371/journal.pmed.0030442 2. Lortet-Tieulent J, Soerjomataram I, López-Campos JL, Ancochea J, Coebergh JW, Soriano JB. International trends in chronic obstructive pulmonary disease mortality, 1995–2017. Eur Respir J. 2019 Dec 19;54(6):1901791. doi:10.1183/13993003.01791-2019 3. Waked M, Khayat G, Salameh P. Chronic obstructive pulmonary disease prevalence in Lebanon: a cross- sectional descriptive study. Clin Epidemiol. 2011;3:315–23. doi:10.2147/CLEP.S26350 4. Idrees M, Koniski M-L, Taright S, Shahrour N, Polatli M, Kheder AB, et al. Management of chronic obstructive pulmonary dis- ease in the Middle East and North Africa: Results of the BREATHE study. Respiratory Medicine. 2012 Dec 1;106(Suppl. 2):S33–44. doi:10.1016/S0954-6111(12)70013-6 5. Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al. 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Gerontologist. 2015 Aug;55(4):511–8. doi:10.1093/geront/gnu095 Méthode : À l'aide d'un modèle de recherche phénoménologique descriptive, des entretiens qualitatifs individuels semi-structurés ont été menés auprès de personnes atteintes de bronchopneumopathie obstructive chronique vivant au Liban, entre mai et septembre 2019. Résultats : Cinquante participants ont accepté d'être interrogés. La majorité étaient des hommes (56 %) et avaient une bronchopneumopathie obstructive chronique modérée (40 %). L'âge moyen était de 71,5 ans (écart type 9,0). Nous avons constaté que la bronchopneumopathie obstructive chronique a une incidence sur trois aspects de la vie des patients : éducatif, organisationnel et psychosocial. Conclusion : Les résultats soulignent la nécessité de mettre en place des stratégies multidisciplinaires pour prendre en compte les besoins des personnes atteintes de bronchopneumopathie obstructive chronique au Liban, y compris les personnes chargées de leurs soins. 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Int J Med Inform. 2017 Nov;107:11–17. doi:10.1016/j.ijmedinf.2017.08.004 29. Farhood L, Zurayk H, Chaya M, Saadeh F, Meshefedjian G, Sidani T. The impact of war on the physical and mental health of the family: The Lebanese experience. Soc Sci Med. 1993 Jun;36(12):1555–67. doi:10.1016/0277-9536(93)90344-4 30. Abdulrahim S, Ajrouch KJ, Jammal A, Antonucci TC. Survey Methods and Aging Research in an Arab Sociocultural Context—A Case Study from Beirut, Lebanon. J Gerontol B Psychol Sci Soc Sci. 2012 Nov;67(6):775–82. doi:10.1093/geronb/gbs083 31. McCabe MP, Firth L, O’Connor E. A Comparison of Mood and Quality of Life Among People with Progressive Neurological Illnesses and Their Caregivers. J Clin Psychol Med Settings. 2009 Dec;16(4):355–62. doi:10.1007/s10880-009-9168-5 32. Røthing M, Malterud K, Frich JC. Family caregivers’ views on coordination of care in Huntington’s disease: a qualitative study. Scand J Caring Sci. 2015 Dec;29(4):803–9. doi:10.1111/scs.12212 33. Gardiner C, Gott M, Payne S, Small N, Barnes S, Halpin D, et al. Exploring the care needs of patients with advanced COPD: An overview of the literature. Respir Med. 2010 Feb;104(2):159–65. doi:10.1016/j.rmed.2009.09.007 34. Norweg A, Collins EG. Evidence for cognitive–behavioral strategies improving dyspnea and related distress in COPD. Int J Chron Obstruct Pulmon Dis. 2013;8:439–51. doi:10.2147/COPD.S30145 35. Whittemore R, Chase SK, Mandle CL. Validity in Qualitative Research. Qual Health Res. 2001 Jul 1;11(4):522–37. doi:10.1177/104973201129119299 EMHJ 28-2 Book.indb 120 21/03/2022 5:05 PM 121 Research article EMHJ – Vol. 28 No. 2 – 2022 Introduction The Expanded Program on Immunization (EPI) was launched in the Islamic Republic of Iran in 1984. Thanks to national policies and the national immunization plan, vaccine coverage is > 95%. This has played a fundamen- tal role in achieving EPI goals, such as polio eradication and measles elimination. Vaccination coverage is usually monitored continuously based on the data gathered in registries; however, sometimes administrative coverage is calculated using aggregate reported data on the num- ber of doses of each vaccine administered to children in the target age group in a given period (1,2). According to the National Immunization Program of Iran, the following vaccines are given free of charge to every child. At birth: BCG (Bacillus Calmette–Guérin), hepatitis B, and bOPV zero (bivalent oral polio vaccine containing type 1 and 3 serotypes only); age 2 months: pentavalent 1 (diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenzae type b) and bOPV1; age 4 months: pentavalent 2, bOPV2 and inactivated polio vaccine (IPV); age 6 months: pentavalent 3 and bOPV3; age 1 year: MMR1 (measles, mumps and rubella); and age 18 months: MMR2, DTP1 (diphtheria, tetanus and pertussis), and bOPV. One dose of IPV was introduced in the immunization schedule in September 2015; however, it was discontinued in May 2016 because of a global vaccine shortage. In the Islamic Republic of Iran, a data quality self- assessment survey, conducted in 2017, showed good validity and reliability of routine administrative data (3). However, sometimes the quality of primary recordings, transcriptions, or compilation of data might not be high enough due to possible over- or under-reporting (4,5). Other methods for monitoring the system, such as surveys, have been introduced by the World Health Organization (WHO) to obtain more accurate estimates of immunization coverage (2,6,7). The last nationwide immunization coverage survey in the Islamic Republic of Iran was conducted in 2013 (8). After about five years, implementation of another survey was justified as a monitoring tool for managers in charge of immunization programmes. The main objective of the Immunization coverage of children aged 24–35 months in the Islamic Republic of Iran: a national cluster coverage survey Seyed Mohsen Zahraei,1 Shahrokh Izadi,2 Mohammad Mehdi Gouya,1 Seyed Mohammad Hashemi Shahri3 and Mahdi Mohammadi4 1Department of Infectious Diseases, Centre for Communicable Diseases Control, Ministry of Health and Medical Education, Tehran, Islamic Republic of Iran. 2Department of Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran (Correspondence to: S. Izadi: izadish@yahoo.com). 3Department of Infectious Diseases, School of Public Medicine, Zahedan University of Medical Sciences, Zahedan, Islamic Republic of Iran. 4Department of Biostatistics, Health Promotion Research Centre, School of Public Health, Zahedan University of Medical Sciences, Zahedan, Islamic Republic of Iran. Abstract Background: Although vaccination coverage against a disease is not exactly the same as community immunity against that disease, it is undoubtedly directly related to it and provides an estimate of the coherence and efficacy of community health infrastructure. Aims: To evaluate the vaccination coverage of children throughout the Islamic Republic of Iran in 2019. Methods: This was a cross-sectional study. A probability proportional to size cluster sampling method was used and the vaccination data of 8682 children aged 24–35 months were collected in the form of 1447 clusters, each comprising six participants. Only valid data, including vaccination card or electronic health files, were used. The results were reported in the form of descriptive tables. Results: Overall, 97.82% of Iranian participants (8068 of 8248) and 90.32% of non-Iranian participants (392 of 434) had received all essential childhood vaccination by the time of interview. In total, 93.02% of all participants had presentable vaccination cards, and the immunization history of 535 (6.16%) children was retrieved using their electronic health files. The dropout rate between receiving pentavalent vaccine 1 and pentavalent vaccine 3 was 0.01%. In 29 provinces, vaccina- tion coverage was ≥ 95%. In the other two provinces, the figure was 93.30%. Conclusion: Immunization coverage of children aged 24–35 months fully complied with eradication/elimination goals of vaccine-preventable diseases. In 2019, measles and rubella elimination was certified in the Islamic Republic of Iran. However, non-Iranian residents with immunization coverage < 95% constitute a high-risk group for possible outbreaks. Keywords: vaccination, immunization, coverage, Iran, children. Citation: Zahraei SM; Izadi S; Gouya MM; Shahri SMH; Mohammadi M. Immunization coverage of children aged 24–35 months in the Islamic Republic of Iran: a national cluster coverage survey. East Mediterr Health J. 2022;28(2):121–129. https://doi.org/10.26719/emhj.21.059 Received: 21/10/20; accepted: 15/06/21 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo) EMHJ 28-2 Book.indb 121 21/03/2022 5:05 PM 122 Research article EMHJ – Vol. 28 No. 2 – 2022 present study was to provide reliable and valid estimates of the immunization coverage in all subgroups of the population in all 31 provinces. Methods Study methods This was a cross-sectional study of vaccination coverage in all 31 provinces of the Islamic Republic of Iran. The main approach was to retrieve data recorded on the vac- cination cards of children who had been invited to partic- ipate in the study. For children whose vaccination cards were not accessible, the required data were retrieved from a newly developed health information system known as the Integrated Comprehensive Health Infor- mation System (ICHIS). ICHIS is a special health infra- structure system where the detailed vaccination history of all residents is recorded. A questionnaire specially designed for the study was used for data gathering during interview in the home or doorstep of each participant. The questionnaire contained 18 questions and a table was used to record and collect data. In addition to the data on vaccines received by the children, other data were collected during a short interview with their parents at their homes. These data included the child’s birth rank, parents’ level of education, reasons for possible delays in the implementation of the child’s vaccination programme (only in cases where delay was registered in the child’s vaccination card), and the interviewees’ opinions about the benefits of vaccination. Interviews were conducted by interviewers adept in local languages. Pilot study The pilot phase of the study was conducted between 7 and 21 January 2019. During this phase, 180 children (aged 24–30 months) were sampled in 28 clusters in urban and rural areas within Tehran and Sistan-va-Bal- uchestan Provinces, and their parents or guardians were interviewed. Based on the findings of this phase, the study methods were revised and the questionnaire was improved and finalized. Study sample Based on the latest National Population and Housing Census, conducted in 2016, the total Iranian population should be nearly 80 million (9). This population is not dis- tributed homogeneously throughout the country. There are provinces and large municipal areas (such as Tehran, Shiraz, Mashhad, etc.) with highly dense populations, and provinces with highly scattered populations and low-density areas (e.g. Yazd Province). To select the sam- ple, the probability proportional to size cluster sampling method was used (10). The mean family size is about 3.4 for rural areas and 3.3 for urban areas; therefore, the size of a cluster was decided to be six children, that is, the number of participants that were expected to be found during a working day in a given neighbourhood. To es- timate coverage of ~95%, with precision of 1.0% and 99% confidence interval (CI) (α = 0.01), and an intracluster correlation coefficient (ICC) of 0.35 (i.e., the design effect equal to 2.75), the required sample size was calculated at 8682 children, equal to 1447 clusters of size 6 (7, 10). Sampling methods An instructional pamphlet was prepared for district and provincial supervisors as well as for interviewers. The pamphlet contained details about methods of sampling and interviewing in different field situations. A short- ened version of the same instructions, containing the most important points, was printed on the second page of the questionnaire. To answer unforeseen questions and situations, the telephone numbers of two contact per- sons (district and university supervisors) for each district were included, and the staff and health workers could call them at any time. All the staff and health workers in- volved in implementing the study were in contact with one another and with the principal investigator through a WhatsApp group. This WhatsApp group provided a platform for the exchange of information, questions, and experiences of the co-workers at various levels (from the front-line interviewers up to the ministry staff). Quality assurance The field phase of the study in all provinces began on 15 June 2019 and ended by 25 July 2019. In addition to the above-mentioned instruction pamphlet, briefing ses- sions were held for all the health workers and interview- ers involved in the study. In each district, at the end of the day’s work, the supervisor responsible for overseeing the study reviewed all questionnaires delivered for the day. Data bank and analysis To minimize errors at the data entry stage, a double data entry method was used. The data were transferred from the paper questionnaires to a data bank created in Micro- soft Access using an intelligent questionnaire capable of checking for and preventing a series of data entry errors. The data were entered into two separate computer data banks twice. For the first time, the data were entered into the databases created in the Access programme in the universities implementing the project; and for the second time, they were entered into the databases created in the Access programme in the headquarters of the Centre for Disease Control of the Ministry of Health. The data were analysed using Stata version 11.2 statistical software. For analysis of the data, where applicable, the 95% CI was re- ported along with the mean and standard deviation. Ethics The Ethics Committee on Medical Research of Zahedan University of Medical Sciences reviewed and approved the study protocol (the Ethics Certification Code: IR.ZAUMS.REC.1397.329). Participation in the study was voluntary, and those who accepted the invitation were only requested to take part in the interview and present their children’s vaccination cards, without being subjected to any other request or procedure, invasive or noninvasive. EMHJ 28-2 Book.indb 122 21/03/2022 5:05 PM 123 Research article EMHJ – Vol. 28 No. 2 – 2022 Results Table 1 and Supplementary Table 1 show the general pro- file of the study sample. The age composition of the whole sample was within the defined range (24–35 months); however, 41 participants (36 Iranians and 5 non-Iranians) were younger than 1.95 years (712 days) and 82 (70 Irani- ans and 12 non-Iranians) were older than 3.05 years (1112 days). Supplementary Table 2 shows the age distribution of the sample by nationality and Supplementary Table 3 shows their sex distribution by nationality and province. Non-Iranian participants The Iranian participants comprised 95.0% of the sample (n = 8248), and the non-Iranian participants the remaining 5.0% (n = 434). Except for 10 children from Iraq and Paki- stan, the remaining 424 (4.88%) non-Iranian participants were from Afghanistan. More than 95% of the non-Ira- nian participants were residents of 10 provinces, with Tehran having the largest share (46.31%). Supplementary Table 4 shows the provincial distribution of these partici- pants. In addition to these 10 provinces, there were seven other provinces with a total share of < 2%. Vaccination cards and ICHIS Supplementary Table 5 shows vaccination card owner- ship by nationality and residential area (urban vs rural). Overall, 93.02% of participants had presentable vacci- nation cards. This proportion was highest among rural residents (95.92%). Also, 91.47% of the non-Iranian partic- ipants had vaccination cards. In total, 569 (6.90%) Irani- an participants and 37 (8.53%) non-Iranian participants could not present their vaccination cards or any other documented history of their children’s immunization sta- tus. There were 535 of these children, 516 Iranians (6.26% of the Iranian participants) and 19 non-Iranians (4.38% of the non-Iranian participants), who had documented re- cords in the ICHIS, from where their vaccination history was retrieved. Role of private sector in immunization coverage Sixty-one (0.70%) participants were immunized mostly by private sector health service providers, and only five of these participants were non-Iranians. Among the Ira- nians, 32 (57.14%) participants were from Tehran Prov- ince (Supplementary Table 6). Vaccination coverage Overall, 8068 of 8248 (97.8%, 95% CI: 97.5–98.1%) Iranian participants and 392 of 434 (90.3%, 95% CI: 87.5–93.1%) non-Iranian participants had received all essential child- hood vaccines by the time of the interview. Supplemen- tary Table 7 shows the vaccination coverage by province. Table 2 shows the vaccination coverage that, according to the National Vaccination Programme, must be received before the first birthday by residential area (urban vs ru- ral) and nationality. Supplementary Tables 8 and 9 show the coverage for each of the vaccines to be received in the first two years of life, regardless of whether they were received late or on time, and Supplementary Table 10 shows the age distribution of the Iranian participants at the time of administration of each vaccine. Table 3 shows the distribution of the sample by province, the share of the ICHIS in the completion of data, and nationality. The other parts of the questionnaire were completed with in- terview at the participants’ homes. The contribution of the ICHIS to the completion of data varied widely among the provinces. There have even been provinces (i.e. Yazd and Ilam) with no use of the ICHIS, while others (e.g. Isfahan and Tehran) had > 10% of their vaccination data Table 1 Sex, nationality and vaccination coverage of study participants Male No. (% of row) (% of column) Female No. (% of row) (% of column) P All participants 4630 (53.33) (100) 4052 (46.67) (100) — Iranian participants 4384 (53.15) (94.69) 3864 (46.85) (95.36) — Non-Iranian participants 246 (56.68) (5.31) 188 (43.32) (4.64) — Participants with full vaccination schedule 4487 (53.04) (96.91) 3973 (46.96) (98.05) 0.001c Iranian participants with full vaccination schedule 4272 (52.95) (97.45)a 3796 (47.05) (98.24)a 0.015c Non-Iranian participants with full vaccination schedule 215 (54.85) (87.40)b 177 (45.15) (94.15)b 0.021c aPercentage from only Iranian participants. bPercentage from non-Iranian participants. cTwo-sided exact test. EMHJ 28-2 Book.indb 123 21/03/2022 5:05 PM 124 Research article EMHJ – Vol. 28 No. 2 – 2022 coming from the ICHIS (Supplementary Table 5). Table 4 shows two vaccination coverage indicators: the dropout rate between receiving the 1st and 3rd pentavalent vac- cines by residential area (urban vs rural) and the dropout rate between receiving the BCG and MMR1 vaccines. Al- though the reported vaccination coverage in the first 24 hours was far from the national goals, it is one of the best among developing countries (11,12). Discussion The total vaccination coverage in children aged 24–35 months in the Islamic Republic of Iran, as well as the coverage for each of the vaccines under review can be assessed as very high and appropriate , that is, > 95% (Ta- bles 1 and 3). The percentage of children who had received their vaccines on time was acceptable in all population subgroups (Iranians vs non-Iranians and urban vs rural residents) (Table 2). These findings are consistent with the reports of routine administrative data management systems as well as with reports of the WHO and United Nation’s Children’s Fund (UNICEF) on the coverage of vaccination in the Islamic Republic of Iran over the past decade (13,14). Supplementary Table 11 shows the distribution of the age of administration of at-birth hepatitis B vaccine to Iranians by province. Supplementary Table 12 shows the completeness of vaccination for hepatitis B by nationality and residential area (of Iranians). Since perinatal or early postnatal transmission is recognized as the most important source of chronic hepatitis B infection, the WHO has set a goal of 100% coverage, that is, vaccination of all infants ideally within the first 24 hours of life (15,16). According to this guideline, if the vaccine is not given within the first 24 hours, it is still possible to prevent the disease for up to one week, although the effectiveness will decrease over time (15,17). A total of 90.41% of all participants had received at-birth hepatitis B vaccine during the first 24 hours of life, and 96.0% had received it by the end of the first week (Supplementary Table 12). Although the results for the end of the first week are favourable, more monitoring, emphasis and training should be applied to achieve the national goal of > 95% during the first 24 hours of life. Hepatitis B immunization strategy among infants and other high-risk groups has resulted in a significant decrease in hepatitis B surface antigen carrier status in the community from > 2.9% before 2010 to < 1.3% after 2010 (18). Table 1 shows the distribution of the sample by sex. Among Iranian participants, the sex difference in vaccination coverage was < 1% (97.45% male vs 98.24% female), and the coverage for both sexes was > 95%. However, in statistical analysis (Tables 1 and 2), the difference between the two sexes was significant, which was undoubtedly due to the excessive test power resulting from the large sample size. Among the non-Iranian participants, there was a difference of nearly 7% between the vaccination coverage of male and female participants (87.40% vs 94.15%). According to the WHO report on the vaccination programme in Afghanistan, depending on the security situation and health infrastructure, the vaccination coverage of Pentavalent 3 in different areas was estimated at 71–90% (19). One of the most important strengths of the present study was that all percentages were calculated and reported based on filed documents (not memory and Table 2 Number of children who received all vaccines before age one year by nationality and residential area Vaccine Iranian urban residents (% of 6093) Iranian rural residents (% of 2155) Non-Iranians (% of 434) Total (% of 8682) BCG 6005 (98.56) 2151 (99.81) 408 (94.01) 8564 (98.64) At-birth OPV 6000 (98.47) 2148 (99.68) 404 (93.09) 8552 (98.50) At-birth hepatitis B vaccine 6003 (98.52) 2149 (99.72) 407 (93.78) 8559 (98.58) 1st OPV (scheduled for age 2 months) 6028 (98.93) 2152 (99.86) 405 (93.32) 8585 (98.88) 1st Pentavalent vaccine (scheduled for age 2 months) 6027 (98.92) 2152 (99.86) 405 (93.32) 8584 (98.87) 2nd OPV (scheduled for age 4 months) 6020 (98.80) 2151 (99.81) 408 (94.01) 8579 (98.81) 2nd Pentavalent vaccine (scheduled for age 4 months) 6019 (98.79) 2151 (99.81) 407 (93.78) 8577 (98.79) 3rd OPV (scheduled for age 2 months) 6007 (98.59) 2143 (99.44) 403 (92.86) 8553 (98.51) 3rd Pentavalent vaccine (scheduled for age 4 months) 6007 (98.59) 2143 (99.44) 403 (92.86) 8553 (98.51) Children who have received all vaccines before age 1 year 5956 (97.75) 2133 (98.98) 394 (90.78) 8483 (97.71) BCG = Bacillus Calmette–Guérin; OPV = oral polio vaccine. EMHJ 28-2 Book.indb 124 21/03/2022 5:05 PM 125 Research article EMHJ – Vol. 28 No. 2 – 2022 recall); that is, they were based on the information recorded in the vaccination cards and ICHIS. In a similar study conducted in 2013, ~80% of the estimates were based on information recorded on children’s vaccination cards, and the remainder were calculated and reported based on maternal memory recall (8). The latest recommendations and guidelines of the WHO emphasize that vaccine coverage studies must be based on written and credible documents and maternal memory must not be used (7). According to the findings reported in Table 4, the dropout rates for Pentavalent 1 to Pentavalent 3 and BCG to MMR1 were practically equal to zero, and judging by these two indicators, it might be said that the adequacy of immunization services to achieve the goals of the immunization programme is acceptable (20,21). To achieve the goal of eliminating measles and rubella, the vaccine coverage of the first and second doses should be ≥ 95% (22,23). In 2019, measles and rubella elimination in the Islamic Republic of Iran was certified by the WHO Regional Office for the Eastern Mediterranean, which indicates high vaccine coverage and quality in the country (24). Even though our results indicate that the Iranian vaccination programme has been successful in achieving the goals set by WHO, it should be noted that due to the gap that usually exists between vaccination coverage and Table 3 Numbers of fully immunized participants by province, nationality and number of records retrieved from ICHIS Provinces No. of Iranian participants No. of fully immunized Iranian participants (%) No. of records retrieved from ICHIS (%) No. of non- Iranian participants No. of fully immunized non-Iranian participants (%) No. of records retrieved from ICHIS (%) Alborz 280 277 (98.9) 14 (5.0) 26 26 (100.0) 0(0.0) Ardebil 138 137 (99.3) 13 (9.4) 3 2 (66.7) 0(0.0) West Azerbaijan 336 333 (99.1) 4 (1.2) — — — East Azerbaijan 438 434 (99.1) 19 (4.3) — — — Bushehr 111 110 (99.1) 4 (3.6) — — — Chaharmahal and Bakhtiari 96 96 (100.0) 8 (8.3) — — — Isfahan 519 519 (100.0) 66 (12.7) 57 57 (100.0) 2 (2.5) Fars 494 490 (99.2) 16 (3.2) 22 22 (100.0) 0(0.0) Guilan 306 302 (98.7) 3 (1.0) — — — Golestan 194 190 (97.9) 17 (8.8) 4 2 (50.0) 1 (25.0) Kohgiluyeh and Boyer-Ahmad 66 66 (100.0) 9 (13.6) — — — Hamedan 192 190 (99.0) 4 (2.1) — — — Hormozgan 177 172 (97.2) 6 (3.4) 3 3 (100.0) 0(0.0) Ilam 60 59 (98.3) 0 (0.0) — — — Kerman 304 298 (98.0) 21 (6.9) 32 31 (96.9) 0(0.0) Kermanshah 210 206 (98.1) 3 (1.4) — — — Khuzestan 462 454 (98.3) 30 (6.5) — — — Southern Khorasan 76 72 (95.0) 7 (9.2) 2 2 (100.0) Khorasan Razavi 677 675 (99.7) 46 (6.8) 19 19 (100.0) 3 (15.8) Northern Khorasan 90 87 (96.7) 2 (2.2) — — — Kurdistan 168 167 (99.4) 2 (1.2) — — — Lorestan 180 179 (99.4) 3 (1.7) — — — Markazi 159 159 (100.0) 8 (5.0) 3 2 (66.7) 1 (33.3) Mazandaran 387 383 (99.0) 33 (8.5) 3 2 (66.7) 0(0.0) Qazvin 139 138 (99.3) 11 (7.9) 5 5 (100.0) 0(0.0) Qom 119 111 (93.3) 11 (9.2) 19 15 (79.0) 2 (10.5) Sistan-va-Baluchestan 233 221 (95.0) 4 (1.7) 19 13 (68.4) 0(0.0) Semnan 65 65 (100.0) 3 (4.6) 13 12 (92.3) 1 (7.7) Tehran 1341 1251 (93.3) 147 (11.0) 201 176 (87.6) 9 (4.5) Yazd 117 113 (96.6) 0 (0.0) 3 3 (100.0) 0(0.0) Zanjan 114 114 (100.0) 2 (1.8) — — — Total 8248 8068 (97.8) 516 (6.3) 434 392 (90.3) 19(4.4) ICHIS = Integrated Comprehensive Health Information System. EMHJ 28-2 Book.indb 125 21/03/2022 5:05 PM 126 Research article EMHJ – Vol. 28 No. 2 – 2022 Table 4 Coverage indices by residential area (urban vs rural) For urban residential areas (only Iranians) % For rural residential areas (only Iranians) % Total (only Iranians) % Pentavalent 1 – pentavalent 3 dropout rate 0.00 0.00 0.01 BCG – MMR1 dropout rate 0.00 0.00 0.00 Study of the immunization coverage of children aged 24–35 months in the Islamic Republic of Iran, spring and summer 2019. BCG = Bacillus Calmette–Guérin; MMR1 = measles, mumps and rubella vaccine 1. seroconversion rate, the vaccination coverage cannot be interpreted as the percentages of the protected. Our results show that the private sector has a minor role in providing vaccination services, which seems to be due to the extensive coverage and good development of the public health system. In India, depending on the economic situation of different states, the percentage of private sector participation in vaccination coverage varies. For example, for DTP3, it varies from ~6.1% in affluent states to < 1% in less-privileged states (25). In Pakistan, however, private sector participation in vaccination coverage does not exceed 3% (26). In some countries, nongovernmental organizations (NGOs) play an important role in vaccination. For example, almost all of Afghanistan’s vaccination coverage, ~40% of Cambodia’s, and ~20% of Bangladesh’s in rural areas is provided by NGOs (26). The role of NGOs in providing health services in the Islamic Republic of Iran is generally low. As mentioned earlier in this study, Afghan parti- cipants accounted for 4.88% of the total 5.0% of non- Iranian participants. Supplementary Tables 3 and 5 show the distribution of these participants in different parts of the Islamic Republic of Iran. In recent years, the percentage of Afghan participants has changed significantly from one study to another. For example, in a large-scale study of vaccination coverage conducted across the Islamic Republic of Iran in 2013, Afghans accounted for 11.9% of the participants. In another seroprevalence study conducted in the southeastern provinces of the Islamic Republic of Iran, non-Iranian participants accounted for only 1.4% of the total (27). It must be acknowledged that some of these differences were due to population movement and the areas in which the studies were conducted. The small number of participants taken from the non-Iranian population in our study means that we did not obtain a good estimate of their vaccination coverage, and it would be better to conduct a separate study with a suitable sample size to accurately evaluate the vaccination coverage of the non- Iranian population. In this study, we used the probability proportional to size cluster sampling method, recommended by WHO, to evaluate vaccination coverage. The most important feature of this method is that larger population centres will have a better chance of being present in the sample, and as a result, smaller and inaccessible population centres may not be well represented. Therefore, although the results of this study may provide a good assessment of vaccination coverage in the age groups covered, they may not be fully generalized to smaller population centres and remote populations. Conclusion The present study shows that, in most parts of the Islamic Republic of Iran, vaccination coverage by the national vaccination programme is good and acceptable. Taking into account the coverage rate and drop-out indicators, the Iranian vaccination programme has performed excellently, which has been confirmed by reports from WHO and UNICEF and by the WHO’s certification of measles elimination in 2019. To achieve the goal of eliminating hepatitis B, efforts and monitoring should be strengthened. Another point worth mentioning here is that although physicians in the private sector play a role in encouraging parents for immunization, their role in providing vaccination services in the Islamic Republic of Iran is trivial. The non-Iranian population with immunization coverage < 95% are considered a high-risk group for possible future outbreaks. Acknowledgement The authors would like to thank all provincial and district health managers and related health facilities for their kind cooperation and support. We appreciate the tireless efforts of Ms Fatemeh Abdoli Yaghini, who coordinated the project and field implementation. The authors wish to express their gratitude to Dr Ali Beikian, the faculty member of English Language Department of Chabahar Maritime University, for language editing and proofreading of the English text of this article. Funding: This work was supported by the World Health Organization, Tehran Office, (WHO Registration 2018/863108-1). Competing interests: None declared. EMHJ 28-2 Book.indb 126 21/03/2022 5:05 PM 127 Research article EMHJ – Vol. 28 No. 2 – 2022 References 1. Imran H, Raja D, Grassly NC, Wadood MZ, Safdar RM, O’Reilly KM. Routine immunization in Pakistan: comparison of multiple data sources and identification of factors associated with vaccination. Int Health. 2018 Mar 1;10(2):84–91. https://doi.org/10.1093/ inthealth/ihx067 PMID:29432552 يدوقنع ينطو حسم :ةيملاسلإا ناريإ ةيروهجم في اًرهش 35و 24 ينب مهرماعأ حواترت نيذلا لافطلأا ميعطت ةيطغت ةيطغتلل يدممح يدهم ،يرهش يمشاه دممح ديس ،ايوَك يدهم دممح ،يدزيإ خرهاش ،ييارهز نسمح ديس ةصلالخا ،اًشرابم اًطابترا ابه طبترت كش لاب انهإف ،ضرلما اذه دض ةيعمتجلما ةعانملل اًماتم ةلثامم تسيل ضارملأا دحأ دض ميعطتلاب ةيطغتلا نأ مغر :ةيفللخا .اهتيلعافو ةيعمتجلما ةحصلل ةيساسلأا ةينبلا طبارت ىدلم اًريدقت رفوت ماك .2019 ماع في ةيملاسلإا ناريإ ةيروهجم ءاحنأ عيجم في لافطلأا ميعطتب ةيطغتلا مييقت لىإ ةساردلا هذه تفده :فادهلأا 8682 ميعطت نع تانايب تعُجمو ،ةيدوقنعلا تانيعلا مجح عم بسانتي ليماتحا بولسأ مدخُتساو .ةيعطقم ةسارد ةساردلا هذه دعت :ثحبلا قرط اهيف ماب ،طقف ةحيحص تانايب تمدخُتساو .ينكراشم 6 نم اهنم لك فلأتت ،ةعوممج 1447 لكش في اًرهش 35و 24 ينب مهرماعأ حواترت ًلافط .ةيفصو لوادج لكش في جئاتنلا نع غلابلإا متو .ةينوتركللإا ةيحصلا تافللما وأ ميعطتلا تاقاطب لصأ نم 392( ينيناريلإا يرغ ينكراشلما نم %90.32و )8248 لصأ نم 8068( ينيناريلإا ينكراشلما نم %97.82 ناك ،ماع هجوب :جئاتنلا ميعطت تاقاطب ينكراشلما عيجم نم %93.02 ىدل ناك ،ًلااجمإو .ةلباقلما تقو لولحب ةلوفطلا ةلحرم في ةيروضرلا تمايعطتلا عيجم اوقلت دق )434 حاقللا يقلت ينب عاطقنلاا لدعم غلبو .ةينوتركللإا ةيحصلا متهافلم مادختساب )%6.16( ًلافط 535 ددعل ميعطتلا خيرات ةداعتسا تتمو ،ةلوبقم ينتظفاحلما في %93.30 ةبسنلا تغلبو .ةظفامح 29 في رثكأ وأ %95 ميعطتلاب ةيطغتلا لدعم ناكو .%0.01 ةبسن 3 سيمالخا حاقللاو 1 سيمالخا .ينيرخلأا نكمي يتلا ضارملأا لاصئتسا فادهلأ ًلاماك ًلااثتما اًرهش 35و 24 ينب مهرماعأ حواترت نيذلا لافطلأا ميعطتب ةيطغتلا تلثتما :تاجاتنتسلاا عمو .ةيملاسلإا ناريإ ةيروهجم في ةينالملأا ةبصلحاو ةبصلحا لىع ءاضقلا لىع داهشلإا مت ،2019 ماع فيو .اهيلع ءاضقلاو تاحاقللاب اهنم ةياقولا .ةلمتحلما تايشافلا رطاخلم ضرعتلا ةديدش ةئف نولثمي %95 نع ميهدل ميعطتلاب ةيطغتلا ةبسن لقت نيذلا ينيناريلإا يرغ صاخشلأا نإف ،كلذ Couverture vaccinale des enfants âgés de 24 à 35 mois en République islamique d'Iran : enquête nationale de couverture par sondage en grappes Résumé Contexte : La couverture vaccinale contre une maladie ne correspond pas tout à fait à l'immunité de la communauté contre cette maladie, mais elle y est sans aucun doute directement liée et fournit une estimation de la cohérence et de l'efficacité de l'infrastructure de santé communautaire. Objectifs : Évaluer la couverture vaccinale des enfants dans l'ensemble de la République islamique d'Iran en 2019. Méthodes : Il s'agissait d'une étude transversale. Une méthode d'échantillonnage en grappes avec probabilité proportionnelle à la taille a été utilisée et les données de vaccination de 8682 enfants âgés de 24 à 35 mois ont été recueillies sous forme de 1447 grappes composées chacune de six participants. Seules des données valides, notamment les carnets de vaccination ou les dossiers médicaux électroniques, ont été utilisées. Les résultats ont été présentés sous forme de tableaux descriptifs. Résultats : Dans l'ensemble, 97,82 % des participants iraniens (8068 sur 8248) et 90,32 % des participants non iraniens (392 sur 434) avaient reçu tous les vaccins infantiles nécessaires au moment de l'entretien. Au total, 93,02 % de tous les participants avaient des carnets de vaccination consultables, et l'historique de vaccination de 535 enfants (6,16 %) a été récupéré par le biais de leurs dossiers médicaux électroniques. Le taux d'abandon entre la première et la troisième doses du vaccin pentavalent était de 0,01 %. Dans 29 provinces, la couverture vaccinale était supérieure ou égale à 95 %. Dans les deux autres provinces, ce taux était de 93,30 %. Conclusion : La couverture vaccinale des enfants âgés de 24 à 35 mois était pleinement conforme aux objectifs d'éradication/élimination des maladies évitables par la vaccination. En 2019, l'élimination de la rougeole et de la rubéole a été certifiée en République islamique d'Iran. Cependant, les résidents non iraniens ayant une couverture vaccinale inférieure à 95 % constituent un groupe à haut risque en cas de flambée épidémique. EMHJ 28-2 Book.indb 127 21/03/2022 5:05 PM 128 Research article EMHJ – Vol. 28 No. 2 – 2022 2. 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Bennett S, Woods T, Liyanage WM, Smith DL. A simplified general method for cluster-sample surveys of health in developing countries. World Health Stat Q. 1991;44(3):98–106. PMID:1949887 11. Allison RD, Patel MK, Tohme RA. Hepatitis B vaccine birth dose coverage correlates worldwide with rates of institution- al deliveries and skilled attendance at birth. Vaccine. 2017 Jul 24;35(33):4094–8. https://doi.org/10.1016/j.vaccine.2017.06.051 PMID:28668571 12. Choconta-Piraquive LA, De la Hoz-Restrepo F, Sarmiento-Limas CA. Compliance with birth dose of Hepatitis B vaccine in high endemic and hard to reach areas in the Colombian amazon: results from a vaccination survey. BMC Health Serv Res. 2016 Jul 21;16:293. https://doi.org/10.1186/s12913-016-1542-z PMID:27443313 13. Immunization 2019. New York: United Nation’s Children’s Fund [website] (https://data.unicef.org/topic/child-health/immunizai- tion/, accessed 27 August 2021). 14. WHO vaccine-preventable diseases: monitoring system. 2019 global summary. Geneva: World Health Organization; 2020 [website] (https://apps.who.int/immunization_monitoring/globalsummary/countries?countrycriteria%5Bcouny- try%5D%5B%5D=IRN&commit=OK, accessed 27 August 2021). 15. Hepatitis B vaccines: WHO position paper – July 2017. Releve Epidemiologique Hebdomadaire. 2017 Jan 7;92(27):369–92. 16. Schillie S, Vellozzi C, Reingold A, Harris A, Haber P, Ward JW, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018 Jan 12;67(1):1–31. https:// doi.org/10.15585/mmwr.rr6701a1 PMID:29939980 17. World Health Organization. Hepatitis B vaccines: WHO position paper, July 2017 - recommendations. Vaccine. 2019 Jan 7;37(2):223–5. https://doi.org/10.1016/j.vaccine.2017.07.046 PMID:28743487 18. Salehi-Vaziri M, Sadeghi F, Almasi Hashiani A, Gholami Fesharaki M, Alavian SM. Hepatitis B virus infection in the general pop- ulation of Iran: an updated systematic review and meta-analysis. Hepat Mon. 2016 Apr 26;16(4):e35577. https://doi.org/10.5812/ hepatmon.35577 PMID:27257428 19. Afghanistan. Expanded Programme on Immunization (EPI). EPI Review Report 2017. Cairo: World Health Organization Regional Office for the Eastern Mediterranean (http://www.emro.who.int/afg/programmes/epi.html, accessed 27 August 2021). 20. Baguune B, Ndago JA, Adokiya MN. Immunization dropout rate and data quality among children 12-23 months of age in Ghana. Arch Public Health. 2017 Apr 17;75:18. https://doi.org/10.1186/s13690-017-0186-8 PMID:28428878 21. Foege W. The power of immunization. League table: the DTP3 coverage measure. In: The Progress of Nations 2000. New York: UNICEF; 2000: 22–4 (https://www.unicef.org/media/85576/file/Progress-For-Nations-2000.pdf, accessed 27 August 2021). 22. World Health Organization. Measles vaccines: WHO position paper – April 2017. Vaccine. 2019 Jan 7;37(2):219–22. https://doi. org/10.1016/j.vaccine.2017.07.066 PMID:28760612 23. Global measles and rubella strategic plan: 2012–2020. Geneva: World Health Organization; 2012. 24. Namaki S, Gouya MM, Zahraei SM, Khalili N, Sobhani H, Akbari ME. The elimination of measles in Iran. Lancet Glob health. 2020 Feb;8(2):e173–4. https://doi.org/10.1016/S2214-109X(20)30002-4 PMID:31981549 25. Sharma A, Kaplan WA, Chokshi M, Zodpey SP. Role of the private sector in vaccination service delivery in India: evidence from private-sector vaccine sales data, 2009–12. Health Policy Plan. 2016 Sep;31(7):884–96. https://doi.org/10.1093/heapol/czw008 PMID:26976803 EMHJ 28-2 Book.indb 128 21/03/2022 5:05 PM 129 Research article EMHJ – Vol. 28 No. 2 – 2022 26. Levin A, Kaddar M. Role of the private sector in the provision of immunization services in low- and middle-income countries. Health Policy Plan. 2011 Jul;26 Suppl 1:i4–12. https://doi.org/10.1093/heapol/czr037 PMID:21729916 27. Izadi S, Zahraei S, Mokhtari-Azad T. Seroprevalence of antibodies to measles and rubella eight months after a vaccination cam- paign in the southeast of Iran. Hum Vaccin Immunother. 2018 Jun 3;14(6):1412–6. https://doi.org/10.1080/21645515.2018.1436920 PMID:29420120 EMHJ 28-2 Book.indb 129 21/03/2022 5:05 PM 130 Research article EMHJ – Vol. 28 No. 2 – 2022 Introduction Promoting health innovations is one of seven accelera- tor themes in the Global Action Plan for healthy lives and wellbeing (GAP). Signed by 12 international health and development agencies, the plan aims to support coun- tries in accelerating progress on the health-related Sus- tainable Development Goals (SDGs) (9), which forms the framework of action for the recently launched “Regional Health Alliance” of 12 regional health partners (10). Map- ping health innovations was identified as a key area of joint collaboration by the research, development, access and innovation working group comprising seven UN agencies (UNAIDS, UNDP, UNESCO, UNFPA, UN Wom- en, ITU, and WHO). COVID-19 is the first pandemic in human history during which innovative digital technologies are being used at unprecedented scales to keep people connected, safe, and productive while being physically and socially apart (1-4). Innovations are being used to support population surveillance, case identification, contact tracing, risk communication, and clinical management (2). Telehealth services are being used by healthcare providers and clients to prevent, diagnose, and treat people at risk of COVID-19; they provide opportunity for continuous care while limiting direct physical contact and thus reducing morbidity and mortality (4). COVID-19 has impacted the Eastern Mediterranean Region (EMR), a region heavily affected by emergencies and armed conflicts, prior to the current pandemic (5). As in other parts of the world, countries in the region have faced numerous challenges in managing the COVID-19 response including in information sharing, protection of health workers, observation of the public health measures, and ensuring continuity of essential health services. On the other hand, there are emerging examples of how health innovations, such as telemedicine, mobile applications and social media have been critical for achieving positive health outcomes in countries of the Region (4,6-8). This study aimed to map health innovations in response to the pandemic in EMR, as a joint activity of the research, development, access and innovation working group. Mapping of health innovations in response to the COVID-19 pandemic in Eastern Mediterranean and selected Arab Countries Ahmed Mandil,1 Ruth Mabry,2 Barbara Milani,3 Mohamed Nour,1 Mohamed Afifi4 and Karim Abdel-Ghani5 1Coordinator, Research and Innovation, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt 2Independent Public Health Researcher, Muscat, Oman. 3Independent Public Health Consultant, France.4Arab States Regional Office, United Nations Populations Fund, Cairo, Egypt; 5Arab States Regional Office, International Communications Union, Cairo, Egypt. (Correspondence to: Ahmed Mandil: mandila@who.int) Abstract Background: COVID-19 is the first pandemic during which innovative technologies are being used to keep people con- nected, safe, and productive while being physically and socially apart. Aims: This study aimed to map health innovations in response to the pandemic in the Eastern Mediterranean Region. Methods: Health innovations are defined as novel methods, models, processes, products, services, or a combination that produce notable public health impact in people, families, and communities at large. We used two approaches: an online survey using a specially designed data collection tool and a review of publicly available literature using PubMed, IMEMR, Google Scholar, Google, and INSERM search engines. Data collection was conducted between September 2020 and February 2021. Results: We describe 80 innovations in this region, of which 13 were identified through the online survey and 76 via literature review. For the purposes of this paper, we subclassified two-thirds of these innovations (n = 52; 65%) as “digital health innovations”, including telehealth and telemedicine, surveillance, and contact tracing. The rest were classified as “non-digital health innovations”, including prevention and clinical management. Conclusion: This mapping exercise provides baseline information on response to the pandemic by the public and private sectors, innovation hubs within and outside the region, as well as by entrepreneurs and innovators. In-depth studies measuring the impact of health innovations will likely only become available when the pandemic is under better control and experts are able to assess the replicability, sustainability and scalability of the health innovations introduced. Keywords: Global, action plan, health, innovation, mapping, Eastern Mediterranean, pandemic Citation: Mandil A; Mabry R; Milani B; Nour M; Afifi M; Abdel-Ghani K. Mapping of health innovations in response to the COVID-19 pandemic in Eastern Mediterranean and selected Arab Countries. East Mediterr Health J. 2022;28(2):130–143. https://doi.org/10.26719/emhj.22.028 Received: 25/07/21; accepted: 06/12/21 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo) EMHJ 28-2 Book.indb 130 21/03/2022 5:05 PM 131 Research article EMHJ – Vol. 28 No. 2 – 2022 Methods For this mapping exercise, health innovations were de- fined as “novel methods, models, processes, products, services, or a combination that produce public health impact in people, families, and communities at large”. Novel refers to a new method, approach or process, or an upscaling of existing platforms and processes. Dig- ital health innovations refer to processes, products or services that use online platforms, websites and/or mo- bile applications. All other innovations were classified as non-digital. Given the variation in geographic coverage of the different UN agencies, the survey included all 22 countries of the EMR plus three Arab countries (Algeria, Comoros Islands, Mauritania) to ensure that the study covers both the Arab world and the EMR. Two approach- es were used: an online survey and a review of publicly available literature. Online Survey A specially designed data collection tool was developed and reviewed by the working group. The tool was struc- tured around 10 key areas of health innovation: edu- cation, community engagement and communication, workforce development and economic support, preven- tion, detection and testing, emergency communication, management, vulnerable groups, data platforms, and policy and practice. For each innovation, respondents were requested to provide summary information, stage of development (conceptualization, research and devel- opment, evidence-based effectiveness, upscaling and sustainability), links to background documentation, and contact details. All co-authors disseminated an invitation to complete the online survey through agency-specific networks at the country and regional levels including the Public Health in the Arab World Discussion group. The survey was available online during September 2020 and remained open for response through December 2020. All authors and acknowledged contributors disseminated information about the survey through their own national/regional networks, including sharing on the listserv of the Public Health in the Arab World (PHAW) to ensure wide coverage. Data collected was reviewed and respondents were contacted by email/phone to obtain additional information, if required. Online literature review In parallel to the online survey and using the search terms “COVID” and “innovation” and countries in the EMR/Arab region, a web-based review of publicly acces- sible literature was conducted between November 2020 and February 2021, to search for health innovations with- in the COVID-19 context. The search engines used includ- ed: Index Medicus for the Eastern Mediterranean Region (IMEMR), PubMed, Google scholar, Google, INSERM (for French speaking countries of the region), and ADELF (Association of French-Speaking Epidemiologists). The mapping process was iterative with the increase in famil- iarity of the COVID-19 health innovations in the region. Data was extracted and collated thematically according to the most common innovations reported, to facilitate synthesisation of information into a descriptive sum- mary. Whenever feasible, innovators were contacted to obtain additional information. This mapping exercise did not cover vaccines, diagnostics and therapeutics linked to the COVID-19 prevention and control, or clinical prac- tice guidelines because specific WHO teams are investi- gating these types of innovations or guidelines. Results Although over 220 people accessed the online survey, only 31 respondents provided detailed information (Sep- tember–December 2020). After eliminating partial com- pletion and duplicate files, 29 responses from 13 countries (Algeria, Bahrain, Egypt, Iran, Lebanon, Libya, Jordan, Mauritania, Palestine, Qatar, Saudi Arabia, Sudan, and United Arab Emirates) provided sufficient information covering the 13 innovations identified, including links and/or email addresses for additional information from respondents. The web search obtained over 200 published articles, press releases, weblinks, and webpages on innovations conceived and/or used in one or more of the 25 countries in response to the COVID-19 pandemic. Seventy-six innovations were identified across all countries of the EMR and the three Arab countries that are not part of EMR (Algeria, Comoros and Mauritania). Nine of these were already identified through the online survey based on similarities in names and descriptions (see asterisks in Tables 1–4). This paper describes 80 innovations identified through the two-step data collection process. We subclassified two-thirds of these (n = 52; 65%), including telehealth and telemedicine, surveillance, and contract tracing, as “digital health innovations” because they all used online platforms, websites and/or mobile applications (Tables 1–3). The remaining were classified as “non-digital health innovations”, including prevention and clinical management (Table 4). Of the 10 key areas of innovations described in the methods and online survey, all innovations came under at least one of these classifications except for policy and practice. Telehealth and telemedicine Nearly half (n = 35, 44%) of identified innovations were related to patient management, telehealth, telemed- icine and digital communication, and were used for COVID-19 pandemic response in 17 of the 25 target countries (Table 1). The platforms included websites, smartphones and mobile applications and were available in one or more of the national language(s) including Ar- abic, English, French, and Urdu. The COVID-19 web-pag- es linked to the Saudi Arabia Ministry of Health website also had information in Hindi, Indonesian, and Tagalog (among other languages) to facilitate communication with the non-national populations residing in the coun- try. EMHJ 28-2 Book.indb 131 21/03/2022 5:05 PM 132 Research article EMHJ – Vol. 28 No. 2 – 2022 Ta bl e 1 T el em ed ic in e pl at fo rm s f or C O V ID -1 9 in E as te rn M ed it er ra ne an a nd se le ct ed A ra b co un tr ie s, 2 02 0 N am e Pl at fo rm Co un tr y La ng ua ge s Se ct or Sc op e Se rv ic es P ro vi de d Cl as si fi ca ti on o f I nn ov at io n Ar ia n Te le he al th 12 Sm ar tp ho ne Af gh an is ta n Sy ri a En gl is h N G O Su b- na tio na l G ui da nc e Tr ai ni ng Ed uc at io n Co m m un ity e ng ag em en t a nd co m m un ic at io n Em er ge nc y co m m un ic at io n V ul ne ra bl e gr ou ps eT ab ib 40 * W eb si te Al ge ri a Ar ab ic Fr en ch Pr iv at e Su b- na tio na l Ap po in tm en t Co ns ul ta tio ns M an ag em en t Be Aw ar e4 1 Ap p Ba hr ai n Ar ab ic En gl is h Pu bl ic N at io na l Aw ar en es s Te st a pp oi nt m en ts Te st ce rt ifi ca te s Te st re su lts Co m m un ity e ng ag em en t a nd co m m un ic at io n D et ec tio n an d tr ac in g M an ag em en t e- se rv ic e po rt al , M in is tr y of H ea lth 41 W eb si te Ba hr ai n Ar ab ic En gl is h Pu bl ic N at io na l Ap po in tm en ts Pr es cr ip tio n Te st re su lts D et ec tio n an d tr ac in g M an ag em en t E- Cl in ic s o f A in S ha m s U ni ve rs ity 15 , 4 2 * W eb si te Eg yp t Ar ab ic Pr iv at e Su b- na tio na l Co ns ul ta tio ns Tr ai ni ng Ed uc at io n M an ag em en t Al tib bi 43 Ap p Jo rd an Ar ab ic Pu bl ic N at io na l Co ns ul ta tio ns H ot lin e Co m m un ity e ng ag em en t a nd co m m un ic at io n M an ag em en t H ar ri s H ea lth ca re 44 W eb si te Ku w ai t Ar ab ic En gl is h Pu bl ic Su b- na tio na l Co ns ul ta tio ns M an ag em en t M yA U BH ea lth 45 Ap p W eb si te Le ba no n En gl is h Pr iv at e Su b- na tio na l Ap po in tm en t Co ns ul ta tio n Pr es cr ip tio n M an ag em en t Tw in ni ng o f h os pi ta ls 13 * --- Le ba no n Pu bl ic -P ri va te N at io na l Te le m ed ic in e Ed uc at io n M an ag em en t Sp ee ta r4 6 W eb si te Li by a Ar ab ic En gl is h Pu bl ic Su b- na tio na l Co ns ul ta tio ns M an ag em en t Tb ib 24 47 Ap p W eb si te M or oc co Ar ab ic Fr en ch Pu bl ic N at io na l Co ns ul ta tio ns M an ag em en t KI M S O m an H os pi ta l, Te le H ea lth 48 W eb si te O m an Ar ab ic En gl is h Pr iv at e Su b- na tio na l Co ns ul ta tio ns O n- lin e Ch at M an ag em en t M O H V ir tu al cl in ic s3 4, 4 9 Ph on e O m an Ar ab ic En gl is h Pu bl ic Su b- na tio na l Co ns ul ta tio ns M an ag em en t O m an In su ra nc e Co m pa ny 50 W eb si te O m an Ar ab ic En gl is h Pr iv at e N at io na l Co ns ul ta tio ns M an ag em en t CO V ID 19 P or ta l51 W eb si te Pa ki st an En gl is h U rd u Pu bl ic N at io na l Aw ar en es s H ot lin e Ed uc at io n Co m m un ity e ng ag em en t a nd co m m un ic at io n M an ag em en t Ya ra n e W at an 11 W eb si te Pa ki st an En gl is h Pu bl ic Pr iv at e N at io na l Co ns ul ta tio ns H ot lin e Tr ai ni ng Ed uc at io n Co m m un ity e ng ag em en t a nd co m m un ic at io n M an ag em en t EMHJ 28-2 Book.indb 132 21/03/2022 5:05 PM 133 Research article EMHJ – Vol. 28 No. 2 – 2022 Ta bl e 1 T el em ed ic in e pl at fo rm s f or C O V ID -1 9 in E as te rn M ed it er ra ne an a nd se le ct ed A ra b co un tr ie s, 2 02 0 (co nt in ue d) N am e Pl at fo rm Co un tr y La ng ua ge s Se ct or Sc op e Se rv ic es P ro vi de d Cl as si fi ca ti on o f I nn ov at io n YA S AY D AL I37 Ap p Pa le st in e N ot y et av ai la bl e H om e de liv er y of m ed ic in es M an ag em en t 16 00 0 (C al l C en tr e se rv ic e) 52 H ot lin e Q at ar Ar ab ic En gl is h Pu bl ic N at io na l Ap po in tm en t Co ns ul ta tio ns H ot lin e H om e de liv er y of m ed ic in es Si ck le av e Co m m un ity e ng ag em en t a nd co m m un ic at io n W or kf or ce d ev el op m en t M an ag em en t An at 7 Ap p Sa ud i A ra bi a Ar ab ic En gl is h Pu bl ic N at io na l Pr es cr ip tio n M an ag em en t As ef ni 7 Ap p Sa ud i A ra bi a N G O N at io na l Em er ge nc y se rv ic es M an ag em en t CO V ID -19 53 W eb si te Sa ud i A ra bi a Ar ab ic E ng lis h H in di In do ne si an T ag al og U rd u Pu bl ic N at io na l Aw ar en es s Co m m un ity e ng ag em en t a nd co m m un ic at io n Cu ra 7 Ap p Sa ud i A ra bi a Ar ab ic En gl is h Pr iv at e Co ns ul ta tio ns M an ag em en t La ba yh 7 Ap p Sa ud i A ra bi a Pr iv at e Co ns ul ta tio ns (m en ta l he al th ) M an ag em en t M aw id 54 Ap p Sa ud i A ra bi a Ar ab ic Pu bl ic N at io na l Ap po in tm en t Se lf- as se ss m en t Co m m un ity e ng ag em en t a nd co m m un ic at io n M an ag em en t M ay aC lin ic 7 Ap p Sa ud i A ra bi a Pr iv at e Co ns ul ta tio ns M an ag em en t N al a7 Ap p Sa ud i A ra bi a Ar ab ic Pr iv at e Co ns ul ta tio ns M an ag em en t Te ta m an 53 Ap p Sa ud i A ra bi a Ar ab ic Pu bl ic N at io na l Aw ar en es s H ot lin e Q ua ra nt in e Se lf- as se ss m en t Te st re su lts Ed uc at io n Co m m un ity e ng ag em en t a nd co m m un ic at io n D et ec tio n an d te st in g M an ag em en t SC FH S W eb in ar s7 W eb si te Sa ud i A ra bi a Pu bl ic N at io na l Tr ai ni ng Se ha 53 Ap p Sa ud i A ra bi a Ar ab ic Pu bl ic N at io na l Co ns ul ta tio n M an ag em en t V ir tu al M ed ic al A ca de m y W eb si te Sa ud i A ra bi a Pr iv at e Tr ai ni ng Ed uc at io n W as fa ty 53 Ap p Sa ud i A ra bi a Ar ab ic En gl is h Pu bl ic N at io na l H om e de liv er y of m ed ic in es M an ag em en t 24 ×7 H ea lth & W el ln es s V ir tu al C lin ic 55 W eb si te U AE Ar ab ic En gl is h Pr iv at e Su b- na tio na l Co ns ul ta tio ns Re qu es t l ab te st s Pr es cr ip tio n M an ag em en t EMHJ 28-2 Book.indb 133 21/03/2022 5:05 PM 134 Research article EMHJ – Vol. 28 No. 2 – 2022 Slightly more than half of the telemedicine services (n = 19; 54%) were developed by the public sector, including 16 at the national level. COVID-19-related services provided included awareness-raising, appointments reservation including for PCR testing, healthcare consultations, online chats or hotlines, prescriptions, and home delivery of medications. Two applications, Arian Teleheal (in Afghanistan and Syria) and Yaran e Watan (in Pakistan) (11,12), provided guidance and training for health professionals. Telemedicine was established in Lebanon through partnerships by public and private healthcare institutions to train and exchange information such as management and treatment protocols between health professionals (13). Egypt and the United Arab Emirates are developing virtual hospitals; efforts which began prior to the pandemic but became a high priority during the pandemic (14-15). Digital platforms for surveillance Digital platforms for COVID-19 surveillance were available in 18 countries and used to communicate trends publicly. At least nine countries (Comoros Islands, Iraq, Lebanon, Libya, Mauritania, Pal- estine, Somalia, Sudan, and Syria) reported upscaling DHIS2 and eWARN surveillance platforms for their surveillance dashboards, as part of their response to the COVID-19 pandemic. In addition to com- municating the number of officially detected COVID-19 cases in the country, some platforms provided more comprehensive informa- tion and evidence on how countries were able to manage, analyse, interpret, and publicly communicate national trends. Five countries (Afghanistan, Algeria, Djibouti, Libya, and Yemen) used their platforms to monitor the pandemic but did not make them publicly accessible (16). At least nine countries (Bahrain, Egypt, Jordan, Kuwait, Morocco, Oman, Pakistan, Tunisia and UAE) possibly upscaled their surveillance platforms, including institutional websites or mobile applications, to monitor the COVID-19 epidemiology. Ten countries provided data at the sub- national level, including Comoros Islands, Iraq, Jordan, Lebanon, Mauritania, Oman, Pakistan, Palestine, Somalia, and Sudan. Contact tracing, detection and testing Fifteen contact tracing applications were observed to have been de- veloped in a range of public sector fields, including education, health and interior and used in 14 countries (Algeria, Bahrain, Egypt, Iran, Jordan, Kuwait, Lebanon, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Tunisia, and UAE). Majority of identified mobile applications were bilingual, providing information in Arabic and English/French. They included a system to notify users if they had been in contact with someone with COVID-19 and/or a person in quarantine. Other Innovations Twelve non-digital innovations and four innovative processes and approaches were reported. Of the 12 non-digital innovations, four were infection prevention and control (IPC) devices and eight were clinical management devices, including five ventilators and two ox- ygen solutions. Three each were from Palestine and Somalia, two each from Algeria and Morocco and one each from Jordan and Leb- anon. The IPC devices included two disinfection cabins or pass- throughs for entrance to buildings (17-19), and one was a multi-use device that could measure temperature, eject sanitizers and disinfect body and feet (20). All these innovations were developed with local N am e Pl at fo rm Co un tr y La ng ua ge s Se ct or Sc op e Se rv ic es P ro vi de d Cl as si fi ca ti on o f I nn ov at io n As te r D M V ir tu al O ut pa tie nt D ep ar tm en t ( O PD )56 W eb si te U AE Ar ab ic En gl is h Pr iv at e Su b- na tio na l Co ns ul ta tio n Pr es cr ip tio n M an ag em en t D oc to r f or e ve ry ci tiz en ' 5 7 Ap p W eb si te U AE Ar ab ic En gl is h Pu bl ic Su b- na tio na l Ap po in tm en ts Co ns ul ta tio ns Pr es cr ip tio n M an ag em en t M al af fi5 8 W eb si te U AE Ar ab ic En gl is h Pu bl ic Pr iv at e N at io na l Co ns ul ta tio n Te st in g re su lts Tr ac k an d tr ac e M an ag em en t V ir tu al h os pi ta ls 14 W eb si te U AE Ar ab ic En gl is h Pu bl ic Su b- na tio na l Re m ot e ca re v ia sm ar t m on ito rs o r A I d ev ic es M an ag em en t N ot e: *I nf or m at io n co lle ct ed th ro ug h th e o nl in e s ur ve y, Oc to be r t o D ec em be r 2 02 0 Ta bl e 1 T el em ed ic in e pl at fo rm s f or C O V ID -1 9 in E as te rn M ed it er ra ne an a nd se le ct ed A ra b co un tr ie s, 2 02 0 (co nc lu de d) EMHJ 28-2 Book.indb 134 21/03/2022 5:05 PM 135 Research article EMHJ – Vol. 28 No. 2 – 2022 Table 2 Publicly available COVID-19 surveillance platforms, in Eastern Mediterranean and selected Arab Countries, 2020-2021 Name Country Language Managed by Scope or Disaggregation Publicly available real-time dashboard MoH website Bahrain Arabic English MoH National https://healthalert.gov.bh/en/ MoH website Comoros French MoH Sub-national https://stopcoronavirus.km/ Egyptcare Egypt Arabic Government of Egypt National https://www.care.gov.eg/EgyptCare/Index.aspx https://play.google.com/store/apps/details?id=com. IDSC.EgyCare EWARN59 Iraq English WHO / MoH Sub-national/sex https://app.powerbi.com/w?r=eyJrIjoiNjljMDhiYmItZ TlhMS00MDlhLTg3MjItMDNmM2FhNzE5NmM4Ii widCI6ImY2MTBjMGI3LWJkMjQtNGIzOS04MTBiL TNkYzI4MGFmYjU5MCIsImMiOjh9 MoH website Jordan Arabic English MoH Sub-national https://corona.moh.gov.jo/ar https://corona.moh.gov.jo/en MoH website Kuwait Arabic English MoH National https://corona.e.gov.kw/en DHIS2* Lebanon English MoH Sub-national http://drm.pcm.gov.lb/Programs/Be-Informed/%D9% 81%D9%8A%D8%B1%D9%88%D8%B3-%D8%A7%D9%84 %D9%83%D9%88%D8%B1%D9%88%D9%86%D8%A7/% D8%A7%D9%84%D9%85%D9%86%D8%B5%D8%A7%D8 %AA-%D8%A7%D9%84%D8%A7%D9%84%D9%83%D8% AA%D8%B1%D9%88%D9%86%D9%8A%D8%A9 EWARN31# Libya English WHO / MoH National https://reliefweb.int/report/libya/libya-health-sector- bulletin-december-2020 DHIS2# Mauritania English MoH Sub-national https://www.sante.gov.mr/?cat=4 MoH website Morocco English MoH National http://www.covidmaroc.ma/Pages/Accueilfr.aspx http://www.covidmaroc.ma/Pages/LESINFOAR.aspx Tarassud Plus60 Oman Arabic Bengali English Hindi Urdu MoH Sub-national https://tarassud.moh.gov.om/#/login https://play.google.com/store/apps/details?id=om. gov.moh.tarassudapplication&hl=en COVID Portal Pakistan English MoH Sub-national https://covid.gov.pk/stats/pakistan DHIS2 Palestine English National Institute of Public Health https://corona.ps/details DHIS2 Somalia English WHO Sub-national https://bmgf.maps.arcgis.com/apps/opsdashboard/ index.html#/d0d9a939c5fa401caa3a7447e72b2017 DHIS216* Sudan English MoH Sub-national http://sho.gov.sd/corona/ EWARN31# Syria Arabic English Turkey WHO / MoH National https://www.acu-sy.org/en/early-warning-alert-and- response-network/ MoH website Tunisia Arabic English French MoH National https://www.onmne.tn/en/category/covid-19/ Government website UAE Arabic English National Emergency Crisis and Disasters Management Authority National https://covid19.ncema.gov.ae/en Note: *Information collected through the online survey (Ocober to December 2020); #publicly available weekly/monthly reports expertise, except for the OxyGEN ventilator, which was designed in Spain and was being tested in Jordan and other countries (21). The adapted snorkelling mask was designed in Italy and was under approval in Lebanon (22); the solar-powered oxygen concentrator was designed in Canada and was being piloted/used in Somalia (23). Five innovations were designed by groups of individuals within national academic institutions (18,24,25) or in collaboration with other national or international institutions and the private sector (17,26). Two others were designed by local entrepreneurs, including the Creators of Innovation’s Machine, a device designed by a local business that manages entry at workplaces (ejecting hand sanitizer, measuring temperatures, spraying disinfectant) and is currently being used in various settings in Gaza, Palestine (20) EMHJ 28-2 Book.indb 135 21/03/2022 5:05 PM 136 Research article EMHJ – Vol. 28 No. 2 – 2022 and a homemade ventilator, which is being used in three hospitals in Somalia (27). These two designs along with the oxygen solutions mentioned earlier are the only innovations reported to be at the implementation stage. Two additional innovations, the 100% Moroccan26 and Al Quds’ University ventilators,24 are reported to be at the production stage; while the remaining seem to be design prototypes. Based on information from the online survey, four innovative processes and approaches were being used to address risk communication and community engagement. Two focused on raising awareness through children’s play in Jordan and using existing social media platforms (https://twitter.com/sharjah_health) in Sharjah, United Arab Emirates. Palestine adapted health care policies to sustain management of patients with noncommunicable diseases. The United Nations Development Programme (UNDP) is developing a WhatsApp application related to community engagement, to assist individuals in estimating their risk of COVID-19 infection. Further details about these initiatives are needed to better understand their usefulness and replicability. Discussion This mapping exercise identified 80 COVID-19 related health innovations conceived and/or used in countries of the Arab World, including the EMR. Two-thirds of the innovations were “digital health innovations”, including telehealth and telemedicine, surveillance, and contact tracing, detection, and testing. The digital platforms, websites, smartphones and mobile applications are al- ready in use, with many mobilized at the national level. The “non-digital health innovations” included IPC devic- Table 3 Contact tracing applications developed in Eastern Mediterranean and selected Arab countries, 2020 Name Country Language Managed by Link(s)@ Coronavirus Algérie61 Algeria Arabic Ministry of Micro- Enterprise, Startup and Economy of Knowledge https://play.google.com/store/apps/details?id=com. covid19_algeria BeAware Bahrain Arabic English Urdu, Hindi, Bengali and Persian e-Governement Apps stores https://apps.bahrain.bh/CMSWebApplication/action/ howAppDetailsAction?selectedAppID =321&appLanguage=en Egyptcare Egypt Arabic MoH https://apps.apple.com/eg/ app/%D8%B5%D8%AD%D8%A9- %D9%85%D8%B5%D8%B1/id1506794318?ls=1 https://play.google.com/store/apps/details?id=com. IDSC.EgyCare Mask Iran Farsi Ministry of Health and Medical Education https://www.mask.ir Aman62* Jordan Arabic English MoH https://amanapp.jo/ClickCounter/ Goto?linkType=android&language=en https://amanapp.jo/ClickCounter/ Goto?linkType=apple&language=en Shlonik Kuwait Arabic English Central Agency for Information Technology https://play.google.com/store/apps/details?id=com. healthcarekw.app&hl=en_US&gl=US Ma3an63* Lebanon Arabic English MoH https://bit.ly/3bh9h0J https://apple.co/2QJbuJ6 Wiqaytna Morocco Arabic French MoH https://www.wiqaytna.ma/Default_Fr.aspx Tarassud +60 Oman Arabic English MoH https://play.google.com/store/apps/details?id=om. gov.moh.tarassudapplication&hl=en_US&gl=US https://apps.apple.com/om/app/tarassud/ id1502105746 COVID-19 Pakistan English National IT Board https://play.google.com/store/apps/details?id=com. govpk.covid19&hl=en_US&gl=US https://apps.apple. com/pk/app/covid-19-gov-pk/id1504847114 EHTERAZ Qatar Arabic English Ministry Of Interior https://www.acta.gov.qa/en/ehteraz/ Tabaud App Saudi Arabia Arabic English MoH https://tabaud.sdaia.gov.sa/IndexEn Tawakkalna Saudi Arabia Arabic MoH https://covid19awareness.sa/en/apps-for-your- health-2 E7mi64 Tunisia Arabic French Observatory of Emerging Diseases https://e7mi.tn/ ALHOSN UAE UAE Arabic English MoH https://www.alhosnapp.ae/en/home/ Note: @Website to access app, *Information collected through the on-line survey (October to December 2020) EMHJ 28-2 Book.indb 136 21/03/2022 5:05 PM 137 Research article EMHJ – Vol. 28 No. 2 – 2022 Ta bl e 4 N on -d ig it al h ea lth in no va ti on s i n re sp on se to C O V ID -1 9 pa nd em ic in E as te rn M ed it er ra ne an a nd se le ct ed A ra b co un tr ie s, 2 02 0 Co un tr y Ty pe N am e O w ne r/ D ev el op er St ag e of D ev el op m en t D es cr ip ti on Cl as si fi ca ti on Al ge ri a1 7 * In fe ct io n pr ev en tio n an d co nt ro l U ltr av io le t G er m ic id al Ir ra di at io n (o pe n so ur ce ) D ep ar tm en t o f P hy si cs , St oc kh ol m U ni ve rs ity ; D ep ar tm en t o f P hy si cs , Éc ol e N or m al e Su pé ri eu re de L ag ho ua t, El A m in e So la r E ne rg y Pr ot ot yp e M ob ile st an d- al on e so la r- po w er ed u ltr av io le t d is in fe ct an t de vi ce fo r o bj ec ts a nd su rf ac e di si nf ec tio n Pr ev en tio n Al ge ri a1 8 In fe ct io n pr ev en tio n an d co nt ro l O zo ca b In st itu te o f E le ct ri ca l En gi ne er in g of th e D jil la li Li ab es , U ni ve rs ity o f S id i- Be l-A bb es Pr ot ot yp e D ev ic e he rm et ic al ly se al s i nd iv id ua ls in a ca ps ul e w he re o nl y th e he ad p ro tr ud es ; a n ad ju st ab le n ec kl in e al lo w s a da pt at io n to al l b od y ty pe s. A ge ne ra to r c on ve rt s o xy ge n (O 2) in to o zo ne ( O 3) an d, a ft er a fe w m in ut es , t he g as is e va cu at ed fr om th e ca ps ul e th ro ug h a pi pe sy st em . I ni tia l b ac te ri ol og ic al te st in g in di ca te s co m pl et e st er ili za tio n of th e pe rs on a ft er a n op er at in g tim e of 5 m in ut es . Pr ev en tio n Jo rd an 21 V en til at or O xy G EN P ro je ct (o pe n so ur ce ) O xy G EN P ro je ct (S pa in ) Pr ot ot yp e O xy G EN , a pp ro ve d by th e “S pa ni sh A ge nc y fo r M ed ic in es a nd H ea lth P ro du ct s” , i s a d ev ic e th at a ut om at es th e pr oc es s o f m an ua l v en til at io n to p at ie nt s i n em er ge nc y si tu at io ns w he re no t e no ug h ve nt ila to rs a re a va ila bl e. In a dd iti on to Jo rd an , O xy G EN w eb si te in di ca te s p ro to ty pe s a re b ei ng d ev el op ed in A lg er ia , M or oc co , P ak is ta n, T un is ia , a nd Y em en (f ro m o ur Re gi on ). M an ag em en t Le ba no n2 2 a nd se ve ra l co un tr ie s i n th e re gi on 22 V en til at or Ea sy br ea th /D ec at ha lo n (o pe n so ur ce ) IS IN N O V A, It al y Im pl em en ta tio n st ag e D ec at ha lo n (a nd su bs eq ue nt ly o th er co m m er ci al m od el ) sn or ke lli ng m as k w as a da pt ed fo r u se a s s ub -in te ns iv e ca re in It al y. T he co m pa ny h as m ad e th e in st ru ct io ns fo r 3 -D p ri nt in g of th e ne w d es ig n co m po ne nt s o pe n so ur ce in M ar ch /A pr il 20 20 (i nc lu di ng A ra bi c, En gl is h an d Fr en ch ). In L eb an on , t he pr od uc t w as p re se nt ed to th e M oP H fo r a pp ro va l d ur in g Ap ri l 20 20 . M an ag em en t M or oc co 19 In fe ct io n pr ev en tio n an d co nt ro l Sa fe T ub e Pr im e Te ch Pr ot ot yp e D is in fe ct io n ca bi n th at sp ra ys d is in fe ct an t, w hi le th e pe rs on w al ks th ro ug h it. Pr ev en tio n M or oc co 26 V en til at or 10 0% M or oc ca n ve nt ila to r G IM AS Re po rt ed P ro du ct io n D ev el op ed b y G IM AS , a g ro up o f 7 in du st ri al a nd a ca de m ic in st itu tio ns (G ro up em en t d es In du st ri es M ar oc ai ne s Aé ro na ut iq ue s e t S pa tia le s) a nd a pp ro ve d by th e M oH , M or oc co . I nd us tr ia l p ro du ct io n st ar te d fr om A pr il 20 20 . M an ag em en t Pa le st in e2 0 In fe ct io n pr ev en tio n an d co nt ro l Cr ea to rs o f I nn ov at io n’ s M ac hi ne s Cr ea to rs o f i nn ov at io n Im pl em en ta tio n D ev ic es (d ep en di ng o n th e m od el ) s te ri liz e, m ea su re te m pe ra tu re , m an ag e en tr y at w or kp la ce s, ej ec t s an iti ze r t o cl ea n ha nd s, sp ra y et ha no l, an d ch lo ri ne o n th e bo dy a nd fe et . In no va tio ns a re li nk ed to sm ar tp ho ne s f or re fil lin g al er t o n m is se d st er ili sa tio n/ hi gh b od y te m pe ra tu re , w hi ch a re se nt pr iv at el y to a d es ig na te d op er at or d es k fo r f ol lo w u p m ea su re s (w hi le re sp ec tin g th e pr iv ac y of cu st om er s) . P at en te d by th e Ra m al la h- ba se d Pa le st in ia n Ec on om y M in is tr y in th e W es t Ba nk . U se d at e nt ra nc es o f h os pi ta ls , s ch oo ls , s up er m ar ke ts , re st au ra nt , b ak er ie s, pr iv at e sh op s i n G az a. Pr ev en tio n EMHJ 28-2 Book.indb 137 21/03/2022 5:05 PM 138 Research article EMHJ – Vol. 28 No. 2 – 2022 es, ventilators and oxygen generators and a few innovative process and approaches for prevention as well as chronic/noncom- municable disease management. Two years ago, Braithwaite and colleagues identified five trends shaping the future of health systems: sustainable health systems, genomics revolution, emerging technologies, global demographical dynamics and new models of care (28). The COVID-19 pandemic has impacted key industries driving the adaptation of innovative processes and infrastructure, including within the health system, to address the increasing demand for goods and services and ensure operational efficiency (2,29). The literature review provided numerous examples of innovations, including new technologies and models of healthcare in the Eastern Mediterranean Region. Digital technology enhanced capacity for real-time data availability so that countries could better monitor the COVID-19 situation whether for testing, diagnosis, or disease trends (2). Digital epidemiological surveillance platforms developed by countries or developed internationally (i.e. DHIS2) or regionally (i.e. eWARN) and adapted by countries, have improved linkages between data sources, increased information transparency through publicly available data dashboards, and supported rapid case identification; together providing the visual tools to guide decision- makers (30,31). Further assessment of the achievements, best practices, and lessons learned from the use of these products and services could provide guidance on how best countries of the region could improve response to future outbreaks, and hence strengthen health system performance. Digital innovations facilitate greater access to information by both patients and care providers allowing for more patient-centred care, through tele- consultation and e-delivery of services (28). Evidence is emerging on the potential use of digital health for healthcare services while preventing and containing COVID-19 infection, including in the EMR (4,8,32-34). Telehealth through live video conferencing, phone calls (mobile/ landline) and social media has been shown to facilitate prevention (providing sound information), screening (early detection), diagnosing (recommending C ou nt ry Ty pe N am e O w ne r/ D ev el op er St ag e of D ev el op m en t D es cr ip ti on Cl as si fi ca ti on Pa le st in e2 4 V en til at or AQ U ’s m ed ic al v en til at or – IC U Al -Q ud s U ni ve rs ity Re po rt ed P ro du ct io n M ed ic al v en til at or d es ig ne d an d pr od uc ed b y Al -Q ud s U ni ve rs ity ’s fa cu lti es o f e ng in ee ri ng a nd m ed ic in e, u si ng lo ca lly a va ila bl e lo w -c os t m at er ia ls a nd h ar dw ar e. T he p ro du ct is a pp ro ve d by th e Pa le st in ia n St an da rd s I ns tit ut io n an d th e M in is tr y of H ea lth . I nc lu de s a fu lly co m pu te ri ze d se t o f br ea th in gs m od es . M an ag em en t Pa le st in e2 5 V en til at or Pr ot ot yp e ve nt ila to r Th e Is la m ic U ni ve rs ity , G az a Pr ot ot yp e D ev el op ed b y tw o en gi ne er s a t t he Is la m ic U ni ve rs ity o f G az a. M an ag em en t So m al ia 27 V en til at or M oh am ed A da w e's v en til at or M oh am ed A da w e In u se in th re e ho sp ita ls , as o f J un e 20 20 . H om em ad e re sp ir at or in ve nt ed b y a na tio na l e ng in ee r i n Ap ri l 20 20 , f ol lo w in g th e fir st C O V ID -c au se d de at h in th e co un tr y, w he n no v en til at or s w er e re po rt ed to b e av ai la bl e. M an ag em en t So m al ia 23 O xy ge n so lu tio ns So la r- po w er ed o xy ge n co nc en tr at or G ra nd C ha lle ng es C an ad a an d th e U ni ve rs ity o f Al be rt a Im pl em en ta tio n So la r p ow er ed o xy ge n de liv er y pr ov id es re lia bl e an d su st ai na bl e ac ce ss to o xy ge n of f-t he -g ri d. B y co m bi ni ng so la r p an el s, ba tt er ie s, an d ox yg en co nc en tr at or s i nt o a se lf- su st ai ni ng sy st em , t he y ca n de liv er m ed ic al -g ra de o xy ge n 24 /7 , o ff -th e- gr id , a ny w he re a nd a ny tim e th ro ug h th e fr ee in pu ts o f s un a nd a ir . M an ag em en t So m al ia 65 O xy ge n so lu tio ns Fe de ra l M in is tr y of H ea lth D ep lo ym en t p ha se Pr oc es s t o ac ce le ra te o xy ge n so lu tio ns u si ng W H O ’s CO V ID -19 Bi om ed ic al E qu ip m en t I nv en to ry T oo l ( htt ps :/ /w w w .w ho .in t/ m ed ic al _d ev ic es /p ri or it y/ CO V ID -1 9_ m ed eq ui pm en t/ en /) to in cr ea se a cc es s t o ox yg en . B as ed o n th e as se ss m en t, 76 o xy ge n co nc en tr at or s a nd o th er e qu ip m en t f or o xy ge n de liv er y w er e ob ta in ed fo r 1 8 is ol at io n ce nt re s. In a dd iti on , 3 P SA p la nt s a re be in g in st al le d in 3 h ea lth fa ci lit ie s u si ng th e so la r p ow er ed ox yg en d el iv er y te ch no lo gy . M an ag em en t N ot e: *I nf or m at io n co lle ct ed th ro ug h th e o n- lin e s ur ve y ( Oc t-D ec , 2 02 0) Ta bl e 4 N on -d ig it al h ea lth in no va ti on s i n re sp on se to C O V ID -1 9 pa nd em ic in E as te rn M ed it er ra ne an a nd se le ct ed A ra b co un tr ie s, 2 02 0 (co nc lu de d) EMHJ 28-2 Book.indb 138 21/03/2022 5:05 PM 139 Research article EMHJ – Vol. 28 No. 2 – 2022 testing as needed) and managing users/patients during the COVID-19 pandemic (4,8,32-34). In Iran, for example, a social media platform provided faster real- time consultation and teleradiology services (4). The widespread popularity of COVID-19 hotlines led to the development of mobile applications to address the huge demand (6,7). Although innovations include novel methods, products and services, most innovations identified in this study were the introduction or upscaling of digital applications and platforms. The non-digital applications, though few and limited in implementation, show admirable collaborations across government sectors, academia and industry towards identifying solutions to address gaps in COVID-19 response, including IPC and management protocols. Innovative products such as the OXYgen and Decathalon ventilators, shared through Open Source mechanisms, inspired innovators and entrepreneurs in other countries (21,22,66). The innovation cycle from product design to implementation can take a long time, which may explain why most of the identified health innovations were not reported to be implemented (to our knowledge). Nevertheless, it is unclear if it is the short time, limited financing, regulations, or other factors that are delaying taking them to scale. Some countries in the region are encouraging innovations (7), including in response to COVID-19 (34-37); thus, assessing the replicability, sustainability and scalability of the health innovations introduced would be particularly useful. Regulations, data protection, security and privacy are central to the successful and inclusive use of digital technologies for health (2). For example, the wide use of digital proximity tracking tools, including in the EMR, can help control the spread of COVID-19; however, it threatens fundamental human rights and liberties (38). There are concerns that the COVID-19 emergency may set a precedent that will remain long after the resolution of the pandemic (2). Although efforts have been made to strengthen legislation (39), data protection and privacy laws provide the legal basis for data processing and restrictions on data use (38). This study reflects a wide variety of health innovations, digital and non-digital, and it is a good portrayal of response to the pandemic. The innovations may vary from one country to the other, they however collectively reflect the response of the public and private sectors, innovation hubs/companies (within or outside the region), and entrepreneurs/innovators. The range of response covers what we had planned for at the beginning of the exercise, including most of the planned fields for investigation, especially prevention, community engagement and communication, emergency communication, vulnerable groups, data platforms, and policy and practice support. Follow-up on identified products included in this review for their production and implementation would be useful to ascertain facilitators and barriers to their use. The utility of the digital health innovations identified in this study should be examined further to see how best they can be used to ensure continuity of essential health services during a pandemic, and their integration and institutionalization into the healthcare delivery systems, to provide greater access to and more efficient healthcare services (8,28). The strength of this mapping exercise of COVID- 19-related health innovations was in the use of two approaches, an online survey and a literature review. However, the low response rate to the online survey is a major limitation despite efforts to contact respondents for additional information about the innovations submitted. Moreover, we may have missed responses from groups that are not in the target networks and because of the definition used for the innovations. The literature review used six search engines, however, the search did not include grey literature such as clinical guidelines from the region and reports from specialized agencies. It was limited to the English language. It is highly likely that many other innovations have been updated and now being used in the region as this field continues to rapidly expand. Conclusion This mapping exercise of COVID-19 health innovations is probably the first of its kind in this region. The two ap- proaches, online survey and literature review, provided useful information, however, it is highly likely that many other innovations were used in the region. Although we obtained information from a few innovators on the products identified, detailed information on replicability, sustainability and scalability was not readily available. Nevertheless, this study can serve as baseline for further work in this area. Acknowledgement AM drafted the proposal, conceptual framework and data collection form which were reviewed and approved by all au- thors. BM compiled information from the online survey, contacted respondents and conducted the literature review. RM and AM prepared the manuscript. All authors had full access to the data. All authors reviewed the manuscript and accepted the final version. The corresponding author takes final responsibility for the decision to submit for considera- tion for publication. The authors thank UNAIDS (Simone Salem), UNDP (Mohamed El-Fateh), and UNESCO (Jana El-Baba) colleagues who are/were members of the Working Group for their support in developing the conceptual framework and promoting the on-line survey through their own networks. Funding: World Health Organization Competing interests: None declared. EMHJ 28-2 Book.indb 139 21/03/2022 5:05 PM 140 Research article EMHJ – Vol. 28 No. 2 – 2022 ةراتمخ ةيبرع نادلبو طسوتلما قشر في 19-ديفوك ةحئالج ةباجتسلاا للاخ ةيحصلا تاراكتبلاا فيصوت ينغلا دبع ميرك ،يفيفع دممح ،رون دممح ،نيلايم اربراب ،يبريم ثور ،ليدنم دحمأ ةصلالخا مايف لصاوتلا رارمتساو ،مهتيجاتنإو سانلا ةملاس لىع ظافحلل ةركتبم تايجولونكت اهيف مدختسُت ةحئاج لوأ 19-ديفوك ةحئاج دَعُت :ةيفللخا .ا ًّيعماتجاو ا ًّيندب نودعابتم مهو مهنيب .طسوتلما قشر ميلقإ في ةحئاجلل ةباجتسلاا للاخ تف ِّظُو يتلا ةيحصلا تاراكتبلاا فيصوت لىإ ةساردلا هذه تفده :فادهلأا ثِدُت يتلا بيلاسلأا هذه نم جيزم وأ ،ةديدج تامدخ وأ تاجتنم وأ تايلمع وأ جذمان وأ بيلاسأ انهأب ةيحصلا تاراكتبلاا ف َّرَعُت :ثحبلا قرط ةادأ مادختساب تنترنلإا برع اًحسم :ينجهنم ةساردلا في انمدختسا دقو .اًمومع تاعمتجلماو سرلأاو سانلل ةماعلا ةحصلا لىع اًظوحلم اًيرثأت طسوتلما قشر ميلقلإ يبطلا سرهفلاو ،PubMed ثحبلا تاكرمح مادختساب روهمجلل ةحاتلما تايبدلأل ًةعجارمو ، تانايبلا عملج اًصيصخ ةممصم لوليأ/برمتبس ينب ةترفلا في تانايبلا تعُجو .INSERM ةيبطلاو ةيحصلا ثوحبلل ينطولا سينرفلا دهعلماو ،Googleو ،Google Scholarو ،IMEMR .2021 طابش/ريابرفو 2020 ضارغلأو .اًراكتبا 67 تايبدلأا ةعجارم تددح ينح في ،اهنم اًراكتبا 13 تنترنلإا برع حسلما ددح ،ميلقلإا اذه في اًراكتبا 80 انفصو دقل :جئاتنلا نع بيبطتلاو دعُب نع ةحصلا لمشتو ،"ةيمقرلا ةحصلا لامج في تاراكتبا" انهأ لىع )%65 ؛52=ددعلا( تاراكتبلاا هذه يثلُث انفنص ، ثحبلا اذه .يريسرلا جلاعلاو ةياقولا لمشتو ،"ةيمقر يرغ ةيحص تاراكتبا" انهأ لىع ةيقابلا تاراكتبلاا تفِّنُصو .ينطلاخلما ع ُّبتتو ،د ُّصترلاو ،دعُب راكتبلاا زكارمو ،صالخاو ماعلا ينعاطقلا بناج نم ةحئاجلل ةباجتسلاا نع ًةيساسأ ٍتامولعم ةيحصلا تاراكتبلاا فيصوت رفوي :تاجاتنتسلاا دعب لاإ ةيحصلا تاراكتبلاا يرثأت سيقت يتلا ةقمعتلما تاساردلا حاتت َّلاأ حجرلما نمو .نيركتبلماو لماعلأا داور نع ًلاضف ،هجراخو ميلقلإا لخاد عيسوتل اهتيلباقو ،اهتمادتساو ،ةثَدحَتسلما ةيحصلا تاراكتبلاا راركت ةيناكمإ مييقت نم ءابرلخا نكمتي ىتحو ،لضفأ لكشب ةحئالجا لىع ةرطيسلا .اهقاطن Cartographie des innovations en matière de santé dans le cadre de la riposte à la pandémie de COVID-19 dans la Région de la Méditerranée orientale et dans certains pays arabes Résumé Contexte : La COVID-19 est la première pandémie ayant vu l'utilisation de technologies innovantes pour permettre aux personnes de rester connectées, d'être en sécurité et de continuer à être productives tout en étant physiquement et socialement séparées. Objectifs : La présente étude avait pour objectif d'établir une cartographie des innovations en matière de santé dans le cadre de la riposte à la pandémie dans la Région de la Méditerranée orientale. Méthodes : Les innovations en matière de santé sont définies comme des méthodes, des modèles, des processus, des produits ou des services inédits, ou l'association de ces éléments, qui ont un impact notable, en termes de santé publique, sur les personnes, les familles et les communautés au sens large. Nous avons utilisé deux approches : une enquête en ligne par le biais d'un outil de collecte de données spécialement conçu à cet effet et un examen de la littérature accessible au public à l'aide des moteurs de recherche PubMed, IMEMR, Google Scholar, Google et celui de l' INSERM. La collecte des données a été réalisée entre septembre 2020 et février 2021. Résultats : Nous avons identifié 80 innovations dans cette Région, dont 13 à travers l'enquête en ligne et 76 grâce à l'examen de la littérature. Aux fins du présent article, nous avons sous-classé les deux tiers de ces innovations (n = 52 ; 65 %) dans la catégorie des « innovations en matière de santé numérique », notamment la télésanté et la télémédecine, la surveillance et la recherche des contacts. Les autres ont été classées dans la catégorie des « innovations en matière de santé non numérique », qui correspond notamment à la prévention et à la prise en charge clinique. Conclusion : Cet exercice de cartographie fournit des informations de base sur la riposte à la pandémie par les secteurs public et privé, les centres d'innovation à l'intérieur et à l'extérieur de la Région, ainsi que par les entrepreneurs et les innovateurs. Des études approfondies mesurant l'impact des innovations en matière de santé ne seront probablement disponibles que lorsque la pandémie sera davantage maîtrisée et que les experts seront en mesure d'évaluer la répétabilité, la viabilité et l'évolutivité des innovations introduites dans ce domaine. EMHJ 28-2 Book.indb 140 21/03/2022 5:05 PM 141 Research article EMHJ – Vol. 28 No. 2 – 2022 References 1. Bokolo, A. J. Application of telemedicine and eHealth technology for clinical services in response to COVID-19 pandemic. Health and Technology 2021, 11 (2), 359-366. doi: 10.1007/s12553-020-00516-4. 2. Budd, J., Miller, B. S., Manning, E. M., Lampos, V., Zhuang, M., Edelstein, M., et al. Digital technologies in the public-health response to COVID-19. Nature medicine 2020, 26 (8), 1183-1192. doi: https://doi.org/10.1038/s41591-020-1011-4. 3. He, W., Zhang, Z. J., Li, W. Information technology solutions, challenges, and suggestions for tackling the COVID-19 pandemic. 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EMHJ 28-2 Book.indb 142 21/03/2022 5:05 PM 143 Research article EMHJ – Vol. 28 No. 2 – 2022 63. Ministry of Public Health Lebanon “Ma3an” Together Against Corona. https://moph.gov.lb/en/ma3an#/en/Pages/6/40882/ ma3an. 64. The New Arab, Tunisia launches virus-tracking app. The New Arab 19 May 2020, 2020. 65. Stop Pneumonia. How Somalia used WHO’s COVID-19 Biomedical Equipment Inventory Tool to increase oxygen access. Pneu- monia, S., Ed. 2020. 66. Thierry, B., Célérier, C., Simon, F., Lacroix, C., Khonsari, RH. How and why use the EasyBreath® surface snorkeling mask as a per- sonal protective equipment during the COVID-19 pandemic? European Annals of Otorhinolaryngology, Head and Neck Diseases 2020, 137 (4), 329-331. EMHJ 28-2 Book.indb 143 21/03/2022 5:05 PM 144 Research article EMHJ – Vol. 28 No. 2 – 2022 Introduction Violence was declared a major public health problem in the Forty-Ninth World Health Assembly in 1996 (1). Almost one fourth of workplace violence occurs in the health care sector and emergency care is the subsector most affected by violence in the workplace (2). Fear of vi- olence affects the performance of health care providers and decreases their responsiveness to patients’ health care needs (3). The major causes of violence reported in- clude poor resources (shortage of staff, high patient flow, unavailability of medicines), emotional reaction to a se- rious health condition or adverse outcomes, poor quality of care (long waiting time, dissatisfaction with care), irre- sponsible behaviour of clients (overcrowding, unreason- able expectations) and lack of institutional policies (4–8). In Pakistan, violence against health care workers has been widely reported by the print and electronic media. A large scale multicity study in Pakistan in 2019 found that about one third of all health care providers had experienced some kind of violence in the past six months and the emergency department was the most vulnerable in hospitals (9). Another study in Pakistan identified areas of intervention to prevent and de-escalate violence based on security assessment in some hospitals, which include health care worker training, patient education, enhancement of resources, improvement in quality of services and better security policies (10). While some interventions related to enhancing resources and facilities require substantial financial investment, others related to improving policies and changing behaviours can be implemented at low costs. This study in 2019 aimed to (i) introduce low-cost interventions to tackle violence against health care workers based on the recommendations of previous studies and (ii) gather evidence on the effectiveness of these interventions by establishing a violence surveillance system. Effect of low-cost interventions to reduce the incidence of violent events in two public sector tertiary-care emergency departments, Pakistan Shiraz Shaikh,1 Hamid Shahzad,2 Mirwais Khan,3 Lubna Baig,1 Seemin Jamali,4 Ibrahim Hashmi,1 Athar Hussain,1 Uzma Qadri,1 Lubna Mazharullah1 and Samina Zaib1 1Department Public Health, APPNA Institute of Public Health, Jinnah Sind Medical University Karachi, Pakistan. 2Emergency Department, Lady Reading Hospital, Peshawar, Pakistan. 3Health Care in Danger (HCiD) Initiative, International Committee of the Red Cross, Islamabad, Pakistan. 4Emergency Department, Jinnah Postgraduate Medical Center, Karachi, Pakistan. (Correspondence to: Shiraz Shaikh: shiraz.shaikh@jsmu.edu.pk) Abstract Background: Violence against health care workers has been widely reported in Pakistan. Aims: This study, from September 2019 to April 2020, aimed to determine the effect of low-cost interventions to reduce violent events in two tertiary-care emergency departments in Karachi and Peshawar, Pakistan. Methods. In phase one, a surveillance system was established in each department and information on violent events was recorded for three months. In phase two, low-cost interventions designed to reduce violent events were introduced, e.g. awareness-raising material on violence for patients, training for health care workers and visitor identification cards. Violent events were then recorded for another three months and the percentage difference in number of violent events was calculated. Results: In Karachi, 256 violent events occurred before the intervention and 225 after the intervention, a 12.1% reduction. Physical violence events decreased significantly by 42.9% (P = 0.044). The number of events perpetrated by health care workers decreased by 61.9% (P = 0.016) while those perpetrated by patients decreased only by 5.7% (P = 0.538). In Peshawar, 90 violent events occurred before the intervention and 45 events after, a 50.0% reduction (P = 0.009). The number of events perpetrated by health care workers was the same in both phases. Events perpetrated by patients or their companions de- creased significantly by 59.72% (P = 0.001). Conclusion: Violence against health care workers can be reduced significantly by improving their prevention and de-es- calation skills. Client educational interventions, supplemented with hospital regulations and patient guidance, can also help reduce the incidence of violent events. Key words: health personnel, violence, emergency service, hospital, Pakistan Citation: Shaikh S; Shahzad H; Khan M; Baig L; Jamali S; Hashmi I; et al. Effect of low-cost interventions to reduce the incidence of violent events in two public sector tertiary-care emergency departments, Pakistan. East Mediterr Health J. 2022; 28(2):144–151. https://doi.org/10.26719/emhj.22.026 Received: 07/01/21; accepted: 15/06/21 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo) EMHJ 28-2 Book.indb 144 21/03/2022 5:05 PM 145 Research article EMHJ – Vol. 28 No. 2 – 2022 Methods This was a pre–post quasi-experimental study carried out in the emergency departments of two public sector tertiary-care hospitals in two large cities of Pakistan, Ka- rachi and Peshawar. The two hospitals selected have the largest emergency units in the provinces of Sindh and Khyber Pakhtunkhwa with average patient inflow of 1500 to 2000 patients a day and staff of 400–500 health care workers. In the first phase, a surveillance system was establi- shed and information on violent events was gathered for three months. A violent event was defined as the experience of any verbal abuse (abusive language, shouted at or threatened), physical abuse (hitting, beating, pushing, throwing anything or attacking with any weapon) or damage to a facility (vandalizing any equipment or infrastructure). Software was developed to gather and record information on all violent events. This included information on the nature of the violent event (verbal or physical violence or damage to a facility), reason for the event, perpetrator of the event, person affected by event, and diagnosis of the patient. The possible responses to all the variables were coded based on findings of previous research (4,5) and an option for any other response was left open-ended. Three surveillance officers with a minimum qualification of a graduate degree were trained to record the information at all times, day and night. All the forms filled were printed and saved as hard copies. Back-up files of soft copies were maintained on a hard drive. During phase 2, three different sets of low-cost interventions addressing client-related, provider-related and policy-related causes of violence against health care workers were introduced in both hospitals. Client-related interventions included: awareness pamphlets and posters on the rights and responsibilities of patients, their companions and health care workers; warning posters on zero tolerance for violence; and awareness videos educating patients on trusting health care workers and following their advice played continuously on two newly installed television screens. Their content design was informed by baseline focus group discussions on the perceptions of health care workers, patients and companions. Provider-related interventions included training for health care workers. Training was for two hours and comprised of four modules that focused on de-escalation, communication and information-sharing skills, coping with post-traumatic stress, and knowing the rights and responsibilities of health care workers. The training was delivered through participatory teaching methods including group discussions, videos and role play. All health care workers responsible for patient care, including doctors, paramedics and security guards, in the emergency department were trained in groups of 15 to 20. The training was conducted by master trainers of the health care in danger project. The policy-related interventions in Karachi included: briefing health care workers on how to respond to violent events and seek help by calling security, as there was no procedure before the intervention on whom to inform in case of any event; the introduction of visitor identification (ID) cards to ensure restricted access; and training management staff on sharing information about waiting time and the progress of patients. However, in Karachi the policy-related interventions could not be implemented. There was resistance by management staff on being trained and sharing protocols on sharing information about waiting times and the progress of patients because of high work load. The management thought it was impractical to introduce visitor ID cards in an understaffed setting. Some of the security interventions that were already in place included continuous video monitoring and the presence of a security check-point near the emergency department for early response to any violent event. There was no triage system in the setting. In Peshawar, all policy-related interventions including briefing health care workers on how to respond to violent events and seek help, introduction of visitor ID cards and training management staff on sharing information about waiting times and the progress of patients were implemented. Some of the security interventions that were already in place included continuous video monitoring, a triage system which guided patients on waiting times and their treatment plan, and a panic alarm system for health care workers to seek help from security if required. Following the introduction of interventions in 2 weeks, surveillance continued for another 3 months. Statistical analysis The main outcome indicator was the number of violent events reported before and after the intervention, i.e. number of overall violent events three months before and three months after the intervention. The incidence of vi- olent events before and after the intervention was based on assessed different characteristics of the violence. This included change in number of verbal and physical events, change in the number of events according to dif- ferent perpetrators, victims, sites, timing, reasons and seriousness of the patient’s condition based on diagnosis. We used the SALT (sort, assess, lifesaving intervention, treatment and/or transport) method of triage to classify the patients as those requiring immediate, minimal or delayed care (11). Causes of violence were classified as events happening due to: (i) irresponsible behaviour of patients or their companions (i.e. overcrowding, not fol- lowing instructions, demand for care of personal choice); (ii) poor quality of care (delay in care, unavailability of staff, mistake in care); (iii) emotional reaction to serious health condition or adverse outcome; (iv) lack of resourc- es (medicines and equipment); (v) impolite behaviour of health care worker; and (vi) conflict between health care workers. We calculated the change in overall incidence of violence and incidence based on different characteristics EMHJ 28-2 Book.indb 145 21/03/2022 5:05 PM 146 Research article EMHJ – Vol. 28 No. 2 – 2022 of the violent event as percentage change in number of events. Percentage change in the incidence of events was calculated by comparing two person-time rates before and after the interventions using the mid-P exact test. The 95% confidence interval (CI) was reported for the percentage change. Open Epi software was used to compare the differences. Ethical approval The Institutional Review Board of Jinnah Sindh Medical University approved the study (IRB No: JSMU/ IRB/2019/261). The names of the hospitals have been kept confidential at their request. Results Table 1 shows the change in the overall number of events before and after the intervention based on the type of violence. In Karachi, violent events decreased overall by –12.1% after the intervention but this was not statistical- ly significantly (P = 0.157). However, physical violence events decreased significantly by –42.9% (P = 0.044). In Peshawar, violent events decreased significantly overall by –50% (P = 0.009). Verbal violence decreased signif- icantly by –47.7% (P = 0.003) and physical violence de- creased by –57.9% P = 0.035). Table 2 shows the change in number of violent events according to characteristics of the event in Karachi. After the intervention, the number of violent events perpetrated by health care workers decreased significantly (–61.9%; P = 0.016) while those perpetrated by patients or companions decreased slightly but not significantly (–5.6%; P = 0.538). The number of violent events with administrative staff and doctors as victims increased by 31.2% and 24.7%, respectively, but these differences were not statistically significant. For nurses and guards as victims, the number of violent events decreased significantly after the intervention by –34.4% (P = 0.032) and –32.6% (P = 0.015), respectively. The number of events happening in the outpatient department increased (+42.8%) though this was not statistically significant, while the number of events happening at the gate decreased significantly (–58%; P = 0.001). The number of violent events that occurred when patients required immediate care because of the seriousness of their condition increased significantly after the intervention (+24%; P = 0.039) but decreased significantly when patients’ conditions required only minimal care (–44%; P =0.001). Table 3 shows the changes in number of events according to different characteristics in Peshawar. The number of violent events perpetrated by health care workers remained the same before and after the intervention, while the number of violent events perpetrated by patients or companions decreased significantly by –59.72% (P = 0.001). The number of violent events happening in the afternoon decreased significantly by –62.5% (P = 0.001). The number of violent events that occurred when patients required immediate care because of the seriousness of their condition decreased significantly after the intervention (–63.4%; P = 0.004). The number also decreased significantly when patients’ conditions required only minimal care (–59.3%; P =0.009). Table 4 shows the number of violent events before and after the intervention based on the reasons for the violence. In Karachi, there were decreases in violent events due to quality of care and lack of resources but these were not statistically significant. In Peshawar, violent events due to irresponsible behaviour of patients or their companions and quality of care decreased significantly by –62.9% (P = 0.001) and –78.26% (P = 0.005), respectively. Discussion This is the first time that data were collected by establish- ing a continuous surveillance system on violent events in health facilities in Pakistan, therefore, the estimates are likely to be accurate. Usually, violent events in the work- place are under-reported in survey-based estimates (12). In Karachi, there was a small but statistically insignifi- cant reduction in violent events overall before and after the intervention. However, physical violence events de- creased significantly. In Peshawar, there was a signif- icant reduction in all violent events and both forms of violence. This suggests that the interventions were more effective in Peshawar than Karachi. The main reason for this difference could be the well established triage system Table 1 Violent events before and after the intervention according to type of violence, Karachi and Peshawar Variable Pre-intervention Post-intervention % change (95% CI) P-value Karachi (n = 481) Verbal violence 250 223 –10.8 (–25.5 to 6.8) 0.214 Physical violence 35 20 –42.9 (–67.0 to –1.0) 0.044 Overall 256 225 –12.1 (–26.5 to 5.1) 0.157 Peshawar (n = 135) Verbal violence 86 45 –47.7 (–63.5 to –24.9) 0.003 Physical violence 19 8 –57.9 (–81.5 to –3.8) 0.035 Overall 90 45 –50.0 (–65.0 to –28.4) 0.009 CI= confidence interval. EMHJ 28-2 Book.indb 146 21/03/2022 5:05 PM 147 Research article EMHJ – Vol. 28 No. 2 – 2022 already in place in Peshawar and the guidance given to patients at the information counter. There was a plan to train receptionists in Karachi on how to provide guidance to patient companions on waiting times, process of care and to introduce visitor ID cards, but this intervention was not implemented because the hospital was unwill- ing to adopt these interventions due to the high patient numbers. The absence of a triage and guidance system as the reason for the difference is further supported by the fact that violent events increased significantly with patients requiring immediate care in Karachi while such events decreased significantly in Peshawar. Other re- search suggests that multi-component interventions are effective in reducing violent events significantly. A large randomized controlled trial in 2017 on combined environ- mental, administrative and behaviour change strategies in the United States of America in 20 intervention hos- pital departments and 21 control hospital departments showed a 52% significant difference in violent events between intervention and control departments (13). A 2019 study in the ophthalmic emergency department of a university hospital in France attempted to address long waiting times and lack of information through imple- mentation of a computerized triage algorithm. This was linked to a waiting room patient call system, signage to help patients navigate the department, educational mes- sages broadcast in the waiting room, the presence of a mediator and video surveillance. The results showed a 53% decrease in the violence rate in the first month of the intervention (14). The study also showed that patient-per- petrated violence decreased significantly. A study of nurses in an Iranian emergency department evaluated an intervention that helped in sharing information with the patient companions on patients’ condition and waiting times, as well as debriefing sessions. It found that verbal violence decreased significantly by one third (15). In our study, physical violence events decreased at both sites. This may be due to improved ability of health care workers to de-escalate violence. Previous studies have also shown positive effects of training health care workers in communication and de-escalation skills. For example, the introduction of a programme to prevent and manage aggressive behaviour at a tertiary referral centre in Canada showed a 60% significant reduction in verbal and physical violence at three months of follow-up (16). Studies have also shown that training health care workers Table 2 Violent events before and after the intervention according to characteristics of the violent event, Karachi Variable Pre-intervention (n = 256) Post-intervention (n = 225) % change 95% CI P-value Perpetrator Health care workers 21 8 –61.9 (–83.1 to –14.0) 0.016 Patient/companion 229 216 –5.7 (–21.6 to 13.5) 0.538 Mob/group 6 1 –83.3 (–97.9 to 38.4) 0.070 Victims Doctor 64 85 +24.7 (–4.1 to 45.5) 0.086 Nurse 64 42 –34.4 (–55.5 to –3.1) 0.032 Guard 92 62 –32.6 (–51.1 to –7.0) 0.015 Administration staff 11 16 +31.2 (–68.0 to 48.1) 0.344 Patient/companion 21 15 –28.6 (–63.1 to 38.5) 0.324 Outsider 4 5 +20.0 (–74.9 to 99.0) 0.999 Site of event Gate 50 21 58.0 (–74.7 to –30.1) 0.001 Counter 25 21 –16.0 (–52.9 to 50.0) 0.560 Bedside 162 151 –6.8 (–25.3 to 16.3) 0.534 Outpatient department 8 14 +42.8 (–76.0 to 36.2) 0.210 Othera 11 18 +38.8 (–71.1 to 29.3) 0.200 Time of eventb Morning 76 67 –11.8 (–36.5 to 22.4) 0.453 Afternoon/evening 94 73 –22.3 (–42.8 to 5.4) 0.104 Night 86 85 –1.2 (–26.7 to 33.3) 0.939 Urgency of care needed Immediate 98 129 +24.0 (1.2 to 41.6) 0.039 Delayed 23 21 –8.7 (–64.9 to 49.4) 0.760 Minimal 125 70 –44.0 (–57.5 to –24.0) 0.001 CI= confidence interval. aOthers include administrator’s office, doctors’ duty room and medicolegal office and X ray room. bMorning shift: 08:00–14:00; afternoon/evening shift: 14:00–20:00; night shift: 20:00–08:00. EMHJ 28-2 Book.indb 147 21/03/2022 5:05 PM 148 Research article EMHJ – Vol. 28 No. 2 – 2022 Table 3 Violent events before and after the intervention according to characteristics of the violent event, Peshawar Variable Pre-intervention (n = 90) Post-intervention (n = 45) % change (95% CI) P-value Perpetrator Health care workers 14 14 0.0 (–52.3 to 99.8) 0.999 Patient/companion 72 29 –59.7 (–73.8 to –38.0) 0.001 Mob/group 4 2 –50.0 (–90.8 to 99.0) 0.451 Victims Doctors 27 18 –33.3 (–63.2 to 21.0) 0.180 Nurses 16 7 –56.3 (–82.0 to 6.3) 0.060 Guards 25 13 –48.0 (–73.4 to –1.6) 0.050 Administration staff 8 1 –87.5 (–98.4 to –0.1) 0.021 Patient/companion 7 3 –57.1 (–88.9 to 65.7) 0.220 Housekeeping staff 7 3 –57.1 (–88.9 to 65.7) 0.220 Site of event Gate 8 6 –25.0 (–73.9 to 116.1) 0.600 Counter 15 9 –40.0 (–73.7 to 37.1) 0.220 Bedside 9 8 –11.1 (–65.7 to 130.4) 0.810 Doctor duty room 30 10 –66.6 (–83.7 to –31.8) 0.001 Othersa 28 12 –57.1 (–78.2 to –15.7) 0.011 Time of eventb Morning 33 23 –30.3 (–59.0 to 18.6) 0.180 Afternoon/evening 48 18 –62.5 (–78.1 to –35.5) 0.001 Night 9 4 –55.6 (–86.3 to 44.3) 0.170 Urgency of care needed Immediate 41 15 –63.4 (–79.7 to –33.9) 0.004 Delayed 8 3 –62.5 (–90.0 to 41.3) 0.140 Minimal 27 11 –59.3 (–79.7 to –17.8) 0.009 CI= confidence interval. aOthers include administrator’s office, medicolegal office and X ray room. bMorning shift: 08:00–14:00; afternoon/evening shift: 14:00–20:00; night shift: 20:00–08:00. in communication and de-escalation skills decreases their perception of aggression against them and increases their confidence in dealing with aggression (17,18). However, in our study, violent events perpetrated by health care workers remained unchanged in Peshawar. This could be due to an increase in violent events between health care workers as a result of a policy change in the job structure of doctors during the study period. Violent events perpetrated by patient companions decreased significantly in Karachi but not in Peshawar. This is supported by the fact that violent events as a result of irresponsible behaviour of companions decreased significantly in Peshawar but not in Karachi. These results can be explained by the fact that in Karachi, client- centred interventions were mainly educational and did not include improvement in guidance to the patients, information-sharing and information on the waiting time to expect. It is likely that in emergency situations, educational interventions will have a greater effect when supplemented by interventions to facilitate patients’ visits as in the case of Peshawar. Regarding site and timing of the violent events, in Peshawar, violent events decreased at all sites and at all times of the day but these changes were only significant for events in doctors’ duty room and in the afternoon. In Karachi, violent events decreased at all sites and at all times of the day but these changes were only significant for events at the gate. This finding in Karachi could be due to warning posters and awareness videos at the entrance to the emergency department. Moreover, reduction of violent events in Karachi was during the morning and afternoon compared with night time. This could be because there are fewer guards during night shifts While some reactive aggression due to the patient’s condition or adverse outcome is unavoidable, other aspects of patient behaviour can be improved through interventions to facilitate patients’ visits and regulatory interventions. Our study has some limitations. This was a quasi- experimental pre–post longitudinal study without randomization into intervention and control groups. However, the expense associated with hiring staff for continuous surveillance made it impossible to conduct a multicentre study with control settings. Similarly, due to a limited budget, the duration of the study was six months, i.e. three months baseline and three months EMHJ 28-2 Book.indb 148 21/03/2022 5:05 PM 149 Research article EMHJ – Vol. 28 No. 2 – 2022 post-intervention data gathering. Therefore, it was not possible to adjust the trends for changes in situation and seasons. The client-facilitated interventions were not fully implemented in Karachi because of the practical considerations mentioned earlier. Our results showed a visible benefit of training health care workers in communication and de-escalation skills in both settings. This calls for institutionalization of de- escalation training in all the hospitals in Pakistan and similar countries, especially in emergency departments. The fact that the educational component aimed to influence the behaviour of patients and their companions did not produce the desired results in Karachi but was effective in Peshawar may be because patient and companion behaviour is influenced more by the quality of care and assistance they received. Therefore, triage and information counters to provide information to patients on the process of care and waiting times should be introduced in all emergency units and their effects studied over time. Dedicated staff should be hired for this purpose and data on violent events in these hospitals should be recorded. Acknowledgement We thank our data collectors who monitored the violence events at both facilities. Funding: This study was conducted under the framework of the Healthcare in Danger Initiative of the International Red Cross and Red Crescent Movement for protection of health care against violence. Competing interests: None declared. Table 4 Violent events before and after the intervention according to reasons for the violent event, Karachi and Peshawar Location/reasons Pre-intervention Post-intervention % change (95% CI) P-value Karachi (n = 481) Irresponsible behavior of patients/companions (overcrowding/not following instructions/demand for care of personal choice) 115 110 –4.3 (–26.3 to 24.2) 0.739 Reasons related to quality of care (delay in care/ unavailability of staff/mistake in care) 88 73 –17.0 (–39.1 to 13.1) 0.238 Reaction to adverse conditions or outcomes (death/serious condition of the patient/treatment-related complications) 33 34 +3.0 (–39.8 to 56.6) 0.903 Lack of resources (medicine/equipment) 25 13 –48.0 (–73.4 to 1.6) 0.053 Impolite behaviour of health care worker 4 2 –50.0 (–90.8 to 17.3) 0.453 Violence between health care worker 3 0 NA NA Peshawar (n = 135) Irresponsible behavior of patients/companions (overcrowding/not following instructions/demand for care of personal choice) 62 23 –62.9 (–77.0 to –40.1) 0.001 Reasons related to quality of care (delay in care/ unavailability of staff/mistake in care) 23 5 –78.3 (–91.7 to –42.8) 0.005 Reaction to adverse conditions or outcomes (death/serious condition of the patient/treatment-related complications) 17 11 –35.3 (–69.6 to 38.1) 0.260 Lack of resources (medicine/equipment) 3 1 –66.7 (–96.5 to 20.4) 0.375 Violence between health care worker 6 8 +25.0 (–73.9 to 16.1) 0.600 CI= confidence interval; NA: not applicable. Effets des interventions à faible coût visant à réduire l'incidence d'événements de violence dans deux services d'urgence publics de soins tertiaires au Pakistan Résumé Contexte : La violence à l'encontre des agents de santé a été largement signalée au Pakistan. Objectifs : La présente étude, menée de septembre 2019 à avril 2020, avait pour objectif de déterminer les effets des interventions à faible coût visant à réduire les événements de violence dans deux services d'urgence de soins tertiaires à Karachi et Peshawar (Pakistan). Méthodes : Lors de la première phase, un système de surveillance a été installé dans chaque service et les informations sur les événements de violence ont été enregistrées pendant trois mois. Au cours de la deuxième phase, des interventions à faible coût visant à réduire les événements de violence ont été introduites, notamment par le EMHJ 28-2 Book.indb 149 21/03/2022 5:05 PM 150 Research article EMHJ – Vol. 28 No. 2 – 2022 References 1. Violence: a public health priority. Global Consultation on Violence and Health, Geneva, 2–3 December 1996. Geneva: World Health Organization; 1996. 2. Guidelines on coping with violence in the workplace, Geneva: International Council of Nurses; 1999 (https://static1.squarespace. com/static/579770cd197aea84455d6908/t/57d86302d1758e16f4e0f072/1473798914990/guideline_violence.pdf, accessed 6 Septem1- ber 2021). 3. Rosenthal LJ, Byerly A, Taylor AD, Martinovich Z. Impact and prevalence of physical and verbal violence toward healthcare workers. Psychosomatics. 2018;59(6):584–90. https://doi.org/10.1016/j.psym.2018.04.007 4. Hamdan M, Abu Hamra A. Workplace violence towards workers in the emergency departments of Palestinian hospitals: a cross-sectional study. Hum Resour Health. 2015;13:28. https://doi.org/10.1186/s12960-015-0018-2 5. Algwaiz WM, Alghanim SA. Violence exposure among health care professionals in Saudi public hospitals. A preliminary investi- gation. Saudi Med J. 2012;33(1):76–82 6. Kumar M, Verma M, Das T, Pardeshi G, Kishore J, Padmanandan A. A study of workplace violence experienced by doctors and associated risk factors in a tertiary care hospital of south Delhi, India. J Clin Diagn Res. 2016;10(11):LC06–10. https://doi. org/10.7860/JCDR/2016/22306.8895 عاطقلا في ةيثلاثلا ةياعرلا ئراوطل ينمسق في فنعلا ثادحأ عوقو نم دلحا لىع ةفلكتلا ةضفخنم تلاخدتلا يرثأت ناتسكابب ماعلا دياز ةنيمس ،للهارهظم ىنبل ،يردق امزوأ ،ينسح رهطأ ،يمشاه ميهاربإ ،لياجم ينمس ،جيب ىنبل ،ناخ سيويرم ،دازهش دماح ،خيش زايرش ةصلالخا .ناتسكاب في ةيحصلا ةياعرلا في ينلماعلا دض فنع لماعأ عوقو نع عساو قاطن لىع غلبأ دقل :ةيفللخا دلحا لىع ةفلكتلا ةضفخنم تلاخدتلا يرثأت ديدتح لىإ 2020 ناسين/ليربأ ىتح 2019 لوليأ/برمتبس نم تيرجأ يتلا ةساردلا تفده :فادهلأا .ناتسكابب ،رواشيبو شيتارك في ةيثلاثلا ةياعرلا ئراوطل ينمسق في فنعلا ثادحأ نم تيرجُأ ،ةيناثلا ةلحرلما فيو .رهشأ 3 ةدلم فنعلا ثادحأ نع تامولعم تلجُسو ،مسق لك في دصرت ماظن ئشنُأ ،لىولأا ةلحرلما في :ثحبلا قرط ةياعرلا في ينلماعلل بيردتو ،ضىرلما فدهتست فنعلا نأشب يعولا ءاكذلإ داوم لثم ،فنعلا ثادحأ نم دلحا لىإ فدته ةفلكتلا ةضفخنم تلاخدت .فنعلا ثادحأ ددعل ةيوئلما ةبسنلا في قرافلا بِسُحو ىرخأ رهشأ 3 ةدلم فنعلا ثادحأ تل ِّجُس مث .نيرئازلل ةيوه تاقاطبو ،ةيحصلا نيدبلا فنعلا ثادحأ تضفخناو .%12.1 هردق ضافخناب يأ ،لخدتلا دعب 225و ،لخدتلا لبق اًفينع اًثداح 256 عقو ،شيتارك في :جئاتنلا ةميق( %61.9 ةبسنب ةيحصلا ةياعرلا في نولماعلا اهبكترا يتلا ثادحلأا ددع ضفخناو .)0.044 = ةيلماتحلاا ةميق( %42.9 ةبسنب اًيربك اًضافخنا 90 عقو ،رواشيب فيو .)0.538 = ةيلماتحلاا ةميق( طقف %5.7 ةبسنب ضىرلما اهبكترا يتلا ثادحلأا ددع ضفخنا ينح في ،)0.016 = ةيلماتحلاا في نولماعلا اهبكترا يتلا ثادحلأا ددع ىواستو .)0.009 = ةيلماتحلاا ةميق( %50.0 هردق ضافخناب ،هدعب اًثدح 45و لخدتلا لبق اًفينع اًثدح .)0.001 = ةيلماتحلاا ةميق( %59.72 ةبسنب اًيربك اًضافخنا مهقافر وأ ضىرلما اهبكترا يتلا ثادحلأا تضفخناو .ينتلحرلما في ةيحصلا ةياعرلا .ميهدل ديعصتلا فقوو ةياقولا تاراهم ينستح للاخ نم ةيربك ةجردب ةيحصلا ةياعرلا في ينلماعلا دض فنعلا نم دلحا نكمي :تاجاتنتسلاا .فنعلا ثادحأ عوقو نم دلحا لىع ،ضىرلما تاهيجوتو تايفشتسلما حئاول اهلمكت يتلا ،ءلامعلل ةيفيقثتلا تلاخدتلا دعاست نأ نكميو biais de matériels de sensibilisation à la violence destinés aux patients, de formations pour les agents de santé et de badges d'identification pour les visiteurs. Les événements de violence ont ensuite été enregistrés pendant trois mois supplémentaires et la différence en pourcentage du nombre de ces événements a été calculée. Résultats : À Karachi, 256 événements de violence se sont produits avant la mise en place de l' intervention et 225 après, soit une baisse de 12,1 %. Les événements de violence physique ont connu une baisse significative de 42,9 % (p = 0,044). Le nombre d'événements perpétrés par des agents de santé a été réduit de 61,9 % (p = 0,016) tandis que ceux causés par des patients n'ont baissé que de 5,7 % (p = 0,538). À Peshawar, 90 événements de violence se sont produits avant la mise en place de l’ intervention et 45 après, soit une baisse de 50,0 % (p = 0,009). Le nombre d'événements perpétrés par des agents de santé était le même au cours des deux phases. Les événements causés par des patients ou leurs accompagnants ont connu une baisse significative de 59,72 % (p = 0,001). Conclusion : La violence à l'encontre des agents de santé peut être réduite de manière significative en améliorant leurs compétences en matière de prévention et de désamorçage. Les interventions éducatives destinées aux patients, accompagnées de réglementations hospitalières et de conseils aux patients, peuvent également permettre de réduire l'incidence des événements de violence. EMHJ 28-2 Book.indb 150 21/03/2022 5:05 PM 151 Research article EMHJ – Vol. 28 No. 2 – 2022 7. Tohidnia MR, Rostami R, Moradi Ghomshei S, Moradi S, Abbasi Azizi S. Incidence rate of physical and verbal violence inflicted by patient and their companions on the radiology department staff of educational hospitals of medical university, Kermanshah, 2017. Radiol Med. 2019;124(1):14–8. https://doi.org/10.1007/s11547-018-0933-0 8. Baig LA, Shaikh S, Polkowski M, Ali SK, Jamali S, Mazharullah L, et al. Violence against health care providers: a mixed-methods study from Karachi, Pakistan. J Emerg Med. 2018;54(4):558–66. https://doi.org/10.1016/j.jemermed.2017.12.047 9. Shaikh S, Baig LA, Hashmi I, Khan M, Jamali S, Khan MN, et al. The magnitude and determinants of violence against healthcare workers in Pakistan. BMJ Glob Health. 2020;5(4):e002112. https://doi.org/10.1136/bmjgh-2019-002112 10. Shaikh S, Baig LA, Hashmi I, Polkowski M. Findings from Healthcare in Danger Project: Pakistan security assessment of a public and private tertiary care hospital in Karachi: gaps and way forward. J Pak Med Assoc. 2018;68(11):1672–81. 11. SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep. 2008;2(4):245–6. https://doi.org/10.1097/DMP.0b013e31818d191e 12. Arnetz JE, Hamblin L, Ager J, Luborsky M, Upfal MJ, Russell J, et al. Underreporting of workplace violence: compari- son of self-report and actual documentation of hospital incidents. Workplace Health Saf. 2015;63(5):200–10. https://doi. org/10.1177/2165079915574684 13. Arnetz JE, Hamblin L, Russell J, Upfal MJ, Luborsky M, Janisse J, et al. Preventing patient-to-worker violence in hospi- tals: outcome of a randomized controlled intervention. J Occup Environ Med. 2017;59(1):18–27. https://doi.org/10.1097/ JOM.0000000000000909 14. Touzet S, Occelli P, Denis A, Cornut PL, Fassier JB, Le Pogam MA, et al. Impact of a comprehensive prevention programme aimed at reducing incivility and verbal violence against healthcare workers in a French ophthalmic emergency department: an inter- rupted time-series study. BMJ Open. 2019;9(9):e031054. https://doi.org/10.1136/bmjopen-2019-031054 15. Hemati-Esmaeili M, Heshmati-Nabavi F, Pouresmail Z, Mazlom S, Reihani H. Educational and managerial policy making to reduce workplace violence against nurses: an action research study. Iran J Nurs Midwifery Res. 2018;23(6):478–85. https://doi. org/10.4103/ijnmr.IJNMR_77_17 16. Fernandes CM, Raboud JM, Christenson JM, Bouthillette F, Bullock L, Ouellet L, et al. The effect of an education program on violence in the emergency department. Ann Emerg Med. 2002;39(1):47–55. https://doi.org/10.1067/mem.2002.121202 17. Swain N, Gale C. A communication skills intervention for community healthcare workers reduces perceived patient aggression: a pretest–post-test study. Int J Nurs Stud. 2014;51(9):1241–5. https://doi.org/10.1016/j.ijnurstu.2014.01.016 18. Baig L, Tanzil S, Shaikh S, Hashmi I, Khan MA, Polkowski M. Effectiveness of training on de-escalation of violence and manage- ment of aggressive behavior faced by health care providers in a public sector hospital of Karachi. Pak J Med Sci. 2018;34(2):294–9. https://doi.org/10.12669/pjms.342.14432 EMHJ 28-2 Book.indb 151 21/03/2022 5:05 PM 152 Short research communication EMHJ – Vol. 28 No. 2 – 2022 Introduction People with mild byssinosis have a “Monday feeling” of chest tightness and shortness of breath on the first day of work after a weekend or holiday. As exposure contin- ues, this feeling persists throughout the week, and in advanced stages, byssinosis causes chronic, irreversible obstructive lung disease. Although cotton is by far the most common cause – accounting for such conditions as cotton-dust asthma and cotton-mill fever – flax, hemp and other organic fibres can also produce byssinosis. In India, an estimated 20 million workers are occupational- ly exposed to cotton dust in textile manufacturing indus- tries (1). Previous studies have assessed the association between the duration of employment and the emergence of respiratory symptoms, and have reported longitudinal changes in the pulmonary function test as annual decline in lung capacity, in addition to chest tightness, chronic bronchitis, and chronic cough, and sharp decline in forced expiratory volume in one second (2). Earlier studies have reported prevalence rates of byssinosis of approximate- ly 30% in Indonesia, 37% in Sudan, 40% in Ethiopia, up to 50% in India, 18% in Cameroon, 14.2% in Turkey, 6.2% in France, 5.9% in Greece, 5% in Slivakia, and 1.7% in the Czech Republic (3–9). The present study was, therefore, aimed at reporting the prevalence of byssinosis and other respiratory disorders among workers exposed to cotton dust in textile mills situated in Delhi, India. Methods The study participants exposed to cotton dust in textile stitching units in Delhi, India, were selected using a sim- ple random sampling technique. We enrolled 156 work- ers employed in these units, and their detailed history was recorded using a predesigned questionnaire, after which they provided sputum samples. The workers were asked to take a deep breath and cough hard to spit into a plastic cup that was later disposed according to the bio- medical waste regulations. All procedures performed in the study involving human participants were in accord- ance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Paraffin blocks of the sputum samples were made as described previously (10). Sections (5 µm thick) of the paraffin blocks were cut using a microtome, and stained with immunohistochemical molecular markers for epithelial membrane antigen (EMA) or cytokeratin (CK). Immunohistochemistry involved removal of the paraffin wax from the sections (10). Following this, antigen retrieval was performed using a microwave method (11). This used citrate buffer to expose the hidden antibody-binding sites. EMA marker protein (monoclonal antibody) was applied to the sections, and incubated overnight in a moist chamber at 4°C On the next day, the sections were washed in phosphate-buffered saline (PBS), secondary antibody was applied for 20 minutes, Expression of epithelial membrane antigen and cytokeratin among Indian workers exposed to cotton fibre dust in textile industries Ashish Mehta,1,2,3 Saud Azam,2,3 Arshad Rahmani,2,3 Moshahid Rizvi2 and Ashish Mandal3 1Department of Pharmacology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India (Correspondence to: A. Mehta: bio. ashish@gmail.com). 2Department of Biosciences, Jamia Millia Islamia, New Delhi, India. 3Department of Pathology, Maulana Azad Medical College, New Delhi, India. Abstract Background: In India, around 20 million workers are engaged in the textile industries. However, the prevalence of byssi- nosis has been little reported. Aims: To determine the prevalence of byssinosis and other respiratory disorders among workers exposed to cotton dust in textile mills in Delhi, India. Methods: Sputum samples were collected from 156 workers employed in 15 cotton textile mills, and expression of epithe- lial membrane antigen (EMA) and cytokeratin (CK) marker proteins was investigated. Information regarding respiratory symptoms, certain personal characteristics and occupational history was also gathered. Results: Symptoms were observed in 56.41% of the workers. Expression of EMA and CK was observed in 27.5% and 50% of the workers, respectively. Expression of EMA and CK was significantly associated with smoking and duration of em- ployment. Conclusion: Measures are needed to reduce dust levels in the workplace, and to discourage smoking and alcohol con- sumption among the textile workers. Keywords: byssinosis, cotton dust, occupational health hazard, epithelial membrane antigen, cytokeratin, textile Citation: Mehta A; Azam S; Rahmani A; Rizvi M; Mandal A. Expression of epithelial membrane antigen and cytokeratin among Indian workers exposed to cotton fibre dust in textile industries. East Mediterr Health J. 2022;28(2):152–157. https://doi.org/10.26719/emhj.21.058 Received: 26/11/20; accepted: 15/06/21 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo) EMHJ 28-2 Book.indb 152 21/03/2022 5:05 PM 153 Short research communication EMHJ – Vol. 28 No. 2 – 2022 and the sections were kept at room temperature in a moist chamber. The sections were washed again in PBS, and tertiary antibody was applied for 20 minutes at room temperature in a moist chamber. This process increased the magnitude of the antibody–antigen reaction. The sections were washed one more time with PBS after 20 minutes. Diaminobenzidine was applied for staining of the cell nuclei. The same procedure was followed for measuring expression of cytokeratin (CK), by replacing EMA with CK, and using different sections of the same samples. EpiData version 3.1 was used for quality data capture, and for univariate and bivariate analysis. The χ2 test was used to measure the association between categorical variables. Multivariate logistic regression analysis of the different factors for EMA and CK was estimated, stratified by age, smoking or alcohol consumption status, duration of smoking or alcohol consumption, or employment. P < 0.05 was considered statistically significant. Results A total of 156 workers in 15 different textile stitching in- dustries were surveyed: 150 men and 6 women; age range 16–60 years, median age 27 years. The mean duration of employment in the current section was 9.8 years, and the mean salary was INR 2881. The socioeconomic status of the workers was also recorded, and the number of work- ers earning (per month) in the range of INR 1000–2000, 2000–3000, 3000–4000 and 4000–5000 was 33, 74, 37 and 12, respectively. The prevalence of respiratory disorders among workers was found to be 56.41% [95% confidence interval (CI): 45.24–69.50%]. All workers provided individual history and answered a detailed questionnaire focused on the diagnosis of respiratory disorders. The incidence was: chest pain (10.89%), chronic bronchitis (10.25%), tuberculosis (5.77%), back pain (5.12%), cough (4.48%), chronic productive cough (3.84%), insomnia (3.20%), and difficulty in breathing (1.28%) (Table 1). Figure 1 shows the association between the number of smokers or drinkers and their economic status. Figure 2 shows the duration of smoking or drinking. There was a significant association between smoking and economic status (P < 0.01). The overall incidence of symptoms/diseases in textile stitching workers who had never smoked was < 5%. About 82% of the workers had never consumed alcohol. Most of the workers had been employed in the textile stitching industries for the last 5–10 years (Figure 3). The prevalence of symptoms such as chronic bronchitis, chest tightness, and chronic productive cough was more common among smokers and drinkers. There was a significant association between the duration of employment and prevalence of respiratory symptoms (P < 0.05). Epithe lial membrane antigen (EMA) expression was observed in 27.5% (95% CI: 19.48–37.87%) of the textile workers. The percentage of positive cells ranged from 40% to 50%, and the mean percentage positivity was 45% (Figure 4B). Logistic regression analysis revealed a significant association between EMA with smoking and its duration, alcohol consumption, and employment (P = 0.0001, 0.02, 0.02, 0.0002, respectively; Table 2). Expression of CK was observed in 50% (95% CI: 39.83– 60.17%) of textile workers. The percentage of positive cells ranged from 38% to 60%, and the mean percentage positivity was 50.6% (Figure 4C). Logistic regression analysis revealed a significant association between CK and smoking and duration of employment (P = 0.003 and 0.0001, respectively; Table 2). Discussion The findings of the present study are restricted to work- ers employed in textile stitching industries. There were fewer female workers and the age of the workers ranged from 16 to 60 years. Men within the 15–25 years age group were more sensitive to these respiratory symp- toms. Smoking and alcohol consumption played a major role in causing symptoms/diseases including chronic bronchitis, chest tightness, cough, back pain, and breath- ing difficulty. The effect of this along with the textile environment has been reported to be additive (12). Most workers were from the Muslim community (82.05%), so habitual alcohol consumption was mostly absent, but those who consumed alcohol showed symptoms/diseas- es. It has been reported that with the increased duration of exposure, the prevalence of byssinosis also increas- es (5). Moreover, symptoms such as chronic bronchitis, chest tightness, and chronic productive cough have been observed to be more prevalent among smokers than to nonsmokers (13). Several studies have identified bacteri- al endotoxin in cotton dust as the main causative agent contributing to adverse respiratory effects (14,15). A 20- year follow-up cohort study performed on workers in cotton textile mills in Shanghai, China, showed that the chronic loss of lung function was significantly associated with exposure to endotoxin rather than cotton dust (2). Proinflammatory cytokines act as stimuli for the activation of immune cells, as well as the release of further cytokines and chemokines, and their cellular Table 1 Numbers of participants showing symptoms/diseases following working in the textile stitching industry (n = 156) Symptoms/diseases No. of individuals Prevalence (%) Chest pain 17 10.89 Cough 7 4.48 Chronic bronchitis 16 10.25 Chronic productive cough 6 3.84 Difficulty in breathing 2 1.28 Insomnia 5 3.20 Pain in back bone 8 5.12 Tuberculosis 9 5.77 Others 18 11.54 EMHJ 28-2 Book.indb 153 21/03/2022 5:05 PM 154 Short research communication EMHJ – Vol. 28 No. 2 – 2022 Figure 1 Association between number of workers with smoking or drinking habits and their monthly earning capacity 18 16 14 12 10 8 6 4 2 0 N um be r o f I nd iv id ua ls 1000-2000 2001-3000 3001-4000 4001-5000 Salary (in INR per month) No. of Drinkers No. of Smokers Figure 2 Duration of smoking or drinking habits of the workers 18 16 14 12 10 8 6 4 2 0 N um be r o f I nd iv id ua ls 0-2 2-5 5-10 10-15 15-20 20-25 >25 Duration of smoking or drinking (in years) DrinkersSmokers Figure 3 Duration of working of the individuals in the textile stitching industries 60 50 40 30 20 10 0 N um be r o f I nd iv id ua ls 0-2 2-5 5-10 10-15 15-20 20-25 >25 Duration of working in the current section (in years) EMHJ 28-2 Book.indb 154 21/03/2022 5:05 PM 155 Short research communication EMHJ – Vol. 28 No. 2 – 2022 Table 2 Multivariate logistic regression analysis of the different risk factors for EMA and CK (n = 156) Variable EMA OR (95% CI), P CK OR (95% CI), P Age 0.87 (0.45–1.67), 0.679 1.00 (0.63–1.61), 0.971 Smokers 15.59 (4.04–60.09), 0.0001 5.54 (1.73–17.67), 0.003 Alcohol consumption 5.50 (1.16–26.07), 0.031 1.84 (0.57–5.97), 0.304 Duration of smoking 6.44 (1.21–34.04), 0.028 4.14 (0.81–20.95), 0.085 Duration of alcohol consumption 3.51 (0.22–55.22), 0.371 3.23 (0.33–31.10), 0.309 Duration of employment 10.01 (2.94–34.0), 0.0002 9.53 (4.01-22.65), 0.0001 CI = confidence interval; CK = cytokeratin; EMA, epithelial membrane antigen; OR = odds ratio. Age: ≥ 27 years (1), < 27 years (0); smokers or drinkers: yes (1), no (0); duration of smoking, alcohol consumption or employment: ≥10 years (1), <10 years (0). Figure 4 Expression of different immunological markers in sections of sputum blocks of (A) normal healthy, (B) EMA-positive and (C) CK-positive individuals 17 17 18 <caption>Figure 4. Expression of different immunological markers in sections of sputum blocks of (A) normal healthy, (B) EMA-positive and (C) CK-positive individuals. A B C recruitment in bronchial epithelial cells (16). An earlier study has demonstrated that reactive oxygen species may have a role in the pathogenesis of airway inflammation and asthma (17). Eosinophils and neutrophils are characteristic features of asthma and allergic respiratory diseases (18). Acute exposure to cotton dust is reported to result in increased leukocyte count (19). In the present study, immunohistochemistry was performed with EMA monoclonal antibody. EMA is useful for classifying tumours of epithelial origin and is included in the group of antibodies directed against leukocyte common antigen. A similar pattern of staining is seen in other glandular epithelia, such as sweat glands, while squamous epithelium shows an uneven pattern of antigen expression. Expression of EMA was observed in 27.5% of textile workers. The percentage of positive cells ranged from 40% to 50%, and the mean percentage positivity was 45%. CK is the major structural protein of bronchial epithelial cells. Several studies have suggested that CKs EMHJ 28-2 Book.indb 155 21/03/2022 5:05 PM 156 Short research communication EMHJ – Vol. 28 No. 2 – 2022 are proteolysed during apoptosis and can leak into the circulation as a soluble form, where they may serve as new epitopes for antibody generation (20–22). In the present study, 50% of cases were CK positive. CK is a cytoplasmic protein; therefore, monoclonal antibody binds to the antigen, leading to its expression. We ran a positive control and a normal control. The purpose of the positive control was to verify the staining procedure. CK expression in the normal control was 10%; however, in the workers, it ranged from 38 to 60%. Hence, it can be interpreted that cotton dust somehow influenced cell signalling, and this led to higher expression of CK. Multivariate logistic regression analysis of the risk factors for EMA and CK revealed that their expression was associated with smoking, alcohol consumption, and duration of smoking or employment. Moreover, EMA and CK expression was more significantly linked to smoking and duration of employment. Earlier studies have reported that smoking and duration of employment have a significant impact on workers employed in spinning mills, and coke oven workers exposed to polycyclic aromatic hydrocarbons (13,23,24). In conclusion, the present study suggests the need for implementation of protective measures such as installation of hoods, dust filters, ventilators, general cleanliness, and other safety measures, such as the use of dust masks, to reduce the risks of respiratory problems. In addition, training on safety measures, health education and welfare programmes should be organized for textile industry workers. Funding: None Competing interests: None declared. في ةينطقلا فايللأا رابغل ينضرعلما دونلها لماعلا ينب ةيوللخا تانيتايركلاو ةيراهظلا ةيئاشغلا تادضتسلما لىع ليلدلا جيسنلا تاعانص لادنام شيشأ ،فيزر دهاشم ،نياحمر دشرأ ،مازع دوعس ،اتهم شيشأ ةصلالخا )نْطُقلا جْلَح ى َُّحم( ِّينْطُقلا راحُسلا راشتنا لدعم نع غلابلإا متي لم ،كلذ عمو .جيسنلا تاعانص في لماع نويلم 20 وحن دنلها في لمعي :ةيفللخا .ًلايلق لاإ عناصم في نطقلا رابغل ينضرعلما لماعلا ينب ىرخلأا ةيسفنتلا ضارملأاو ِّينْطُقلا راحُسلا راشتنا ىدم ديدتح لىإ ةساردلا هذه تفده :فادهلأا .دنلها ،يلهد ةنيدمب جيسنلا في ينتوبرلا تاملاع لىع ليلدلا صحف متو ،ةينطقلا تاجوسنملل اًعنصم 15 في نولمعي ًلاماع 156 نم مغلبلا تانيع تعُج :ثحبلا قرط .ينهلما خيراتلاو ةيصخشلا تماسلا ضعبو ةيسفنتلا ضارعلأا نع تامولعم تعُج ماك .ةيوللخا تانيتايركلاو ةيراهظلا ةيئاشغلا تادضتسلما %50و %27.5 ىدل ةيوللخا تانيتايركلاو ةيراهظلا ةيئاشغلا تادضتسلما لىع ليلد َظِحوُلو .لماعلا نم %56.41 ىدل ضارعأ تظِحوُل :جئاتنلا .لمعلا ةدمو ينخدتلاب اًيربك اًطابترا ماهيلع ليلدلا طبتراو .لياوتلا لىع لماعلا نم .جيسنلا لماع ينب لوحكلا يطاعتو ينخدتلا نع يْنَثلاو ،لمعلا ناكم في رابغلا تايوتسم نم ّدحلل يربادت ذاتخا مزلي :تاجاتنتسلاا Expression de l'antigène de la membrane épithéliale et de la cytokératine chez les travailleurs indiens exposés à la poussière de fibres de coton dans les industries textiles Résumé Contexte : En Inde, près de 20 millions de personnes travaillent dans les industries textiles. Cependant, la prévalence de la byssinose a été peu signalée. Objectifs : Déterminer la prévalence de la byssinose et d'autres troubles respiratoires chez les travailleurs exposés à la poussière de coton dans les usines textiles de Delhi (Inde). Méthodes : Des échantillons d'expectorations ont été recueillis auprès de 156 travailleurs dans 15 usines textiles de coton, et l'expression des protéines marqueurs de l'antigène de la membrane épithéliale et de la cytokératine a été étudiée. Des informations concernant les symptômes respiratoires, certaines caractéristiques personnelles et les antécédents professionnels ont également été collectées. Résultats : Des symptômes ont été observés chez 56,41 % des travailleurs. L'expression de l'antigène de la membrane épithéliale et de la cytokératine a été observée chez 27,5 % et 50 % des travailleurs, respectivement. Celle-ci était fortement associée au tabagisme et à la durée d'emploi. Conclusion : Des mesures sont nécessaires pour réduire les niveaux de poussière sur le lieu de travail, et afin de décourager le tabagisme et la consommation d'alcool parmi les travailleurs du textile. EMHJ 28-2 Book.indb 156 21/03/2022 5:05 PM 157 Short research communication EMHJ – Vol. 28 No. 2 – 2022 References 1. Mishra AK, Rotti SB, Sahai A, Madanmohan, Narayan KA. Byssinosis among male textile workers in Pondicherry: a case-control study. Natl Med J India. 2003 Mar–Apr;16(2):70–3. PMID:12816184 2. Wang XR, Zhang HX, Sun BX, Dai HL, Hang JQ, Eisan EA, et al. A 20-year follow-up study on chronic respiratory effects of expo- sure to cotton dust. Eur Respir J. 2005 Nov;26(5):881–6. https://doi.org/10.1183/09031936.05.00125604 PMID:16264050 3. Baratawidjaja K. Byssinosis study among 250 textile mill workers in Jakarta. Am J Ind Med. 1990;17(1):71–2. https://doi. org/10.1002/ajim.4700170117 PMID:2305795 4. El-Karim MA, Sharief N el-D and Ballal MA. 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Int J Occup Saf Ergon. 2020 Jun 30:1–15. https://doi.org/10.1080/10803548.2020.175197 3 PMID:32602797 EMHJ 28-2 Book.indb 157 21/03/2022 5:05 PM 158 Short research communication EMHJ – Vol. 28 No. 2 – 2022 Introduction Given the global trend in patient-centred medical edu- cation, the need for students to acquire communication skills in the local language cannot be overemphasized (1). Patients need to perceive that the doctor is interested in knowing them by understanding their backgrounds, in- cluding their culture and language. (2). Indeed, “the most basic need of a person seeking health care is the need to be heard and understood” (3). In 2018, the Nigerian Con- sumer Protection Council enacted the patient’s bill of rights, which stipulates that: “Access to all relevant in- formation including diagnosis, treatment, prognosis and procedures must be provided in a language that the pa- tient understands” (4). Because of this, medical students and physicians should be trained to become aware of the importance of the cultural background of patients (5) and language (6). In fact, if language is a vital tool of commu- nication, if communication is a carrier of culture and if culture and disease are closely related, then the role of language in disease management cannot be overempha- sized. Recognizing the need to improve the use of indigenous language in medical communication, scholars have recommended a review of medical school curricula to incorporate languages other than English (7,8). Although research into the promotion of indigenous language among health care practitioners has been undertaken in many places, there has been little interest in this issue in developing countries, especially in Nigeria. While the cultural competence of doctors has attracted attention, the issue of indigenous language competence among doctors has largely been ignored (3,9). Little research has been published on indigenous language proficiency in other health care training programmes and language tuition for medical students (3,9). This study therefore aimed to explore the views of medical students in Nigeria on the use of Yorùbá (the indigenous language) in their clinical clerkship. Methods This was a prospective, cross-sectional survey of stu- dents in two medical colleges in Ekiti State, Nigeria, conducted in April 2019. Ekiti State has a population of more than 2 million people (10) and the main occupation in the state is farming. Thus, most people are rural dwell- ers and speak Yorùbá, the indigenous language and the main language of communication. We recruited medical students in their clinical years using a convenience sam- Use of indigenous language for clinical clerkship: a cross-sectional survey in Nigeria Oyebanji Olajuyin,1 Oladele Olatunya,2 Toye Olajide,3 Ademola Olajuyin,4 Adebola Olajuyin,5 Femi. Ogunboyo6 and Kehinde Oluwadiya7 1Department of Ear, Nose and Throat, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria. 2Department of Paediatrics, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria. 3Department of Ear, Nose and Throat, Federal Teaching Hospital, Ido Ekiti and Afe Babalola University, Ado Ekiti, Nigeria. 4Department of Family Medicine, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria. 5Department of Obstetrics–Gynaecology, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria. 6Department of Statistics, Faculty of Science, Ekiti State University, Ado Ekiti, Nigeria. 7Department of Surgery, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria. (Correspondence to: Oyebanji Olajuyin: oyebanjiolajuyin@yahoo.com). Abstract Background: Doctors’ knowledge of the native language of their patients is important to effectively communicate with them. Aims: This paper aimed to explore the views and practices of medical students in Nigeria on the use of Yorùbá (an indig- enous language) in their clinical clerkship. Methods: This was a cross-sectional survey of students in two medical colleges in Ekiti State, Nigeria. Data were collected using self-administered questionnaires. Results: The study included 312 medical students, 176 males and 136 females. Most students (70.8%) used Yorùbá in their clinical clerkship despite learning medicine in English. Only 16.0% of the students relied on interpreters. None of the students had had exposure to language training in the course of their medical education. Most of the students (73.7%) sup- ported the incorporation of indigenous language training into the medical school curriculum, and agreed that teaching indigenous languages in medical school would enhance communication skills. Conclusions: Incorporation of indigenous language training into the medical school curriculum in Nigeria is recom- mended to help overcome language barriers in clinical practice. Keywords: medical education, clinical clerkship, language, communication barriers, Nigeria, indigenous Citation: Olajuyin O; Olatunya O; Olajide T; Olajuyin A; Olajuyin A; Ogunboyo F; et al. Use of indigenous language for clinical clerkship: a cross-sectional survey in Nigeria. East Mediterr Health J. 2022; 28(2):158–162. https://doi.org/10.26719/emhj.22.029 Received: 17/03/21; accepted: 15/06/21 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). EMHJ 28-2 Book.indb 158 21/03/2022 5:05 PM 159 Short research communication EMHJ – Vol. 28 No. 2 – 2022 pling technique. The students were invited through their class supervisors. We explained the purpose of the study and only those who gave informed consent to participate were included. Refusal of any student to participate did not in any way interfere with their training. We did not give any monetary or other remuneration for participat- ing in the study. Data were collected using validated, self-administered questionnaires in English consisting of open-ended, categorical and ranking items on Likert scale. The questionnaires were completed in person and were returned immediately to the supervisors. Results We approached 338 students, 16 (5%) declined to partic- ipate. Of the 322 students who agreed to participate, 10 submitted incomplete questionnaires. Thus 312 students were included in the final analysis (92% total response rate): 176 were males and 136 were females (male:female ratio 1.3:1). Their ages ranged from 20 to 36 years with the eldest in their final year. More than half of the partici- pants (53.8%) were Yorùbá, therefore, Yorùbá was their mother tongue. None of the students had had exposure to language courses during their medical education. Of the 312 respondents, 221 (70.8%) understood Yorùbá very well and used it in their clinical clerkship. Only 50 (16.0%) of the students relied on interpreters for the clinical clerkship. The responses of the participants to the benefits of using the indigenous language and their support for its inclusion in the medical curriculum are shown in Table 1 and Figure 1. Most students (69.6%) thought clinical clerkship in the native language could enhance diagnostic accuracy and help patients and their families understand diagnosis and treatment. Most also supported the incorporation of a year-long indigenous language course into the pre-basic Bachelor of Medicine and Bachelor of Surgery (MBBS) programme for effective clinical communication (73.7%). A large majority of the students (92.3%) considered multilingual nature of Nigeria a threat to the inclusion of indigenous languages in the medical school curriculum. Discussion This study shows that 70.8% of the medical students used the Yoru ̀bá language for clinical clerkship despite learn- ing medicine in a foreign language. The finding concurs with a study of students in Lebanese medical schools, 88.5% of whom were confident to conduct medical histo- ry in their native language (Arabic), despite having their medical education in a foreign language (either English or French) (11). Our finding also agrees with a study in Egypt which reported that 70.6% of medical students in their clinical years would prefer to learn patient histo- ry-taking in Arabic (12). In our study, none of the students had had any indigenous language training. Thus, the Yorùbá language that they use for clinical clerkship was learned informally and this may not be adequate for effective communication in a clinical setting. Most of the students expressed interest in improving their knowledge of the indigenous language. Thus, there is the need for language tuition for medical students with a view to improving their competence in clinical communication. Some (16.0%) of Table 1 Students’ views on the benefits of, support for and barriers to the use of indigenous languages in clinical practice, Nigeria, 2019 Item No. (%) (n = 312) Strongly agree Agree Undecided Disagree Strongly disagree Knowledge of indigenous language among medical students could promote language concordance between patients and students 142 (45.5) 124 (39.7) 40 (12.8) 4 (1.3) 2 (0.6) Clinical clerkship in the native language could enhance diagnostic accuracy and help patients and their families to understand diagnosis and treatment 185 (59.3) 32 (10.3) 65 (20.8) 11 (3.5) 19 (6.1) Use of indigenous language could save physicians from unnecessary litigation 72 (23.1) 103 (33.0) 87 (27.9) 41 (13.1) 9 (2.9) Use of indigenous language instead of an interpreter for clinical clerkship during MBBS examination could save time 104 (33.3) 140 (44.9) 38 (12.2) 20 (6.4) 10 (3.2) I support the incorporation of a year course in indigenous language into the pre-basic MBBS programme for effective clinical communication 69 (22.1) 161 (51.6) 59 (18.9) 10 (3.2) 13 (4.2) Multilingualism is a potential barrier to the inclusion of indigenous language into the medical school curriculum 81 (26) 207 (66.3) 0 (0) 20 (6.4) 4 (1.3) MBBS= Bachelor of Medicine, Bachelor of Surgery. EMHJ 28-2 Book.indb 159 21/03/2022 5:05 PM 160 Short research communication EMHJ – Vol. 28 No. 2 – 2022 the participants depended on interpreters for their clinical clerkship and such practice was considered contrary to good-quality health care by most of our participants. Patients who communicated through an interpreter rated their provider as less friendly, less respectful, less concerned for the patient as a person, and less likely to make the patient comfortable (13). These findings support the need for language tuition to ensure consistency of communication between patients and students. Our participants considered there were several values of language tuition for medical students. They agreed that it could enhance health care delivery. Some 56.1% of the participants thought that the use of the indigenous language in clinical communication could protect physicians from litigation. They thought speaking directly with patients instead of through an interpreter could save time during the MBBS examination. Other researchers have reported on the benefits of clinical communication in the language that the patient understands (14,15). In a study of medical students’ perception of the usefulness of additional language tuition in the University Cape Town medical school programme, the vast majority of the students believed that learning Xhosa and/or Afrikaans was valuable (9). These values underscore the need for the incorporation of language training in the curriculum of medical schools where such training does not exist. The training may be introduced during the pre-basic year of the students’ medical education. It has been suggested that students should consider learning other languages before the demands of medical school make additional learning more challenging (14). A recent paper stated: “While learning a new language may be the last thing you want to add to your plate as a medical student, the fact is that doing so can help you not only learn better, but also to apply that learning in the most effective way. The old doctor spoke Latin, the new doctor speaks English, the good doctor speaks to the patient and the more directly you’re able to communicate with patients, the more successful you’ll be from a patient care perspective” (1). The vast majority of our respondents considered that multilingual nature of Nigeria was a potential barrier to nationwide incorporation of the indigenous language into the medical school curriculum. This finding contrasts sharply with the opinion of others who argue that the important thing is for health care professionals to learn a set of communication skills so they can work effectively in the communities they serve (3). In a multilingual South Africa with 11 official languages, all health sciences students learn Afrikaans and Xhosa at the University of Cape Town (3). This attests to the feasibility of learning medicine in a foreign language while learning communication in an indigenous language in a multilingual society. All that is required is a modification of the curriculum. Thus, prospective candidates seeking admission to study medicine should be made to understand the need to study the indigenous language of the area where the medical school they wish to attend is situated. Funding: None. Competing interests: None declared. Figure 1 Students’ views on the benefits of the use of indigenous languages in clinical practice, Nigeria, 2019 0 20 40 60 80 100 Saves time of clerkship during MBBS examination Avoids the need for an interpreter Protects against litigation Enables optimization of health care by relating diseases with cultures and beliefs Enhances diagnostic accuracy Improves students' knowledge of diseases Fosters patient- student language concordance Pe rc en ta ge o f r es po nd en ts EMHJ 28-2 Book.indb 160 21/03/2022 5:05 PM 161 Short research communication EMHJ – Vol. 28 No. 2 – 2022 ةيعطقم ةسارد :اييرجين ،يريسرلا بيردتلا في ةيلصلأا بوعشلا ةغل مادختسا ايداولوأ يدنيهيك ،ويوبنوجوأ يميف ،ينيوجلاوأ لاوبيدأ ،ينيوجلاوأ لاوميدأ ،يديجلاوأ يوت ،اينوتلاوأ ليدلاوأ ،ينيوجلاوأ يجنابيوأ ةصلالخا .ةيلاعفب مهعم لصاوتلا لجأ نم مهاضرلم ملأا ةغللا ءابطلأا فرعي نأ مهلما نم :ةيفللخا في )ةيلصلأا بوعشلا ةغل( ابورويلا ةغل مادختسا نأشب اييرجين في بطلا بلاط تاسراممو ءارآ فاشكتسا لىإ ةساردلا هذه تفده :فادهلأا .يريسرلا مهبيردت .مهسفنأب نوبيجتسلما اهؤلمي تانايبتسا للاخ نم تانايبلا تعُجو .يتيكيإ ةيلاو في بطلل ينتيلك بلاط لىع ةيعطقم ةسارد تيرجُأ :ثحبلا قرط في ابورويلا ةغل )%70.8( بلاطلا مظعم مدختساو .ثانلإا نم 136و روكذلا نم 176 مهنم ،بطلا ةيلك في اًبلاط 312 ةساردلا تلمش :جئاتنلا بلاطلا نم يأ لصيح لمو .ينيوفشلا ينجترلما لىع بلاطلا نم %16.0 ىوس دمتعي لمو .ةيزيلجنلإا ةغللاب بطلا مهملعت مغر يريسرلا مهبيردت ةيلكل ةيساردلا جهانلما في ةيلصلأا بوعشلا ةغل لىع يوغللا بيردتلا جاردإ )%73.7( بلاطلا مظعم ديأو .يبطلا مهميلعت ءانثأ ةيوغل تارود لىع .لصاوتلا تاراهم ززعي نأ هنأش نم بطلا ةيلك في ةيلصلأا بوعشلا تاغل سيردت نأ لىع اوقفتاو ،بطلا زجاوح يأ لىع بلغتلا في ةدعاسملل اييرجين في بطلا ةيلكل ةيساردلا جهانلما في ةيلصلأا بوعشلا ةغل لىع بيردتلا جاردإب صىوُي :تاجاتنتسلاا .ةيريسرلا ةسرمالما في ةيوغل References 1. Hughes J. Why medical students should learn languages [internet]. Oslo: Keystone Academic Solutions; 2018 (https://www. healthcarestudies.com/article/why-medical-students-should-learn-languages/, accessed 12 May 2019). 2. Powell J. Overcoming language, cultural barriers in health care [internet]. Boston: Tufts Medical Center; 2016 (https://hhma.org/ blog/overcoming-language-cultural-barriers-in-health-care/, accessed 18 May 2019). 3. Burch V. Cultural competence or speaking the patient’s language? Afr J Health Prof Educ. 2016;8(1):3. https://doi.org/10.7196/ AJHPE.2016.v8i1.802 4. Federal Ministry of Health; Consumer Protection Council. Patients’ bill of rights. Abuja: Federal Ministry of Health; 2018 (http:// fccpc.gov.ng/uploads/files/patients-bill-of-rights-full-version.pdf, accessed 17 November 2019). 5. Harmsen JA, Bernsen RM, Bruijnzeels MA, Meeuwesen L. Patients’ evaluation of quality of care in general practice: what are the cultural and linguistic barriers? Patient Educ Couns. 2008;72(1):155–62. https://doi.org/10.1016/j.pec.2008.03.018 6. Benson OV, Anyalebechi LI, Ariole IA. Promoting indigenous language in Nigeria: issues and challenges for the library and infor- mation professionals. Libr Philos Pract. 2017 (http://digitalcommons.unl.edu/libphilprac/1472, accessed 17 November 2019). 7. Schmuter G. Learning a second language: diversifying medical school from within. Acad Med. 2020;95(2);172. https://doi. org/10.1097/ACM.0000000000003070 Utilisation de la langue autochtone dans le cadre des stages cliniques : une enquête transversale au Nigéria Résumé Contexte : Il est important que les médecins maîtrisent la langue maternelle de leurs patients pour pouvoir communiquer avec eux de manière efficace. Objectifs : Le présent article visait à examiner les opinions et les pratiques des étudiants en médecine au Nigéria concernant l'utilisation du Yoruba (la langue autochtone) dans le cadre de leur stage clinique. Méthodes : Il s'agissait d'une enquête transversale auprès d'étudiants de deux facultés de médecine de l'État d'Ekiti (Nigéria). Les données ont été recueillies au moyen de questionnaires auto-administrés. Résultats : L'étude a porté sur 312 étudiants en médecine, dont 176 hommes et 136 femmes. La plupart des étudiants (70,8 %) utilisaient le Yoruba durant leur stage clinique, alors que la médecine leur était enseignée en anglais. Seuls 16,0 % des étudiants avaient recours à des interprètes. Aucun des étudiants n'avait bénéficié de cours de langue durant son cursus médical. La plupart des étudiants (73,7 %) étaient favorables à l'intégration d'une formation en langue autochtone dans le programme des études de médecine. Ils ont convenu que l'enseignement des langues autochtones dans les facultés de médecine permettrait d'améliorer les compétences de communication. Conclusions : L'intégration d'une formation en langue autochtone dans le programme d'études des facultés de médecine au Nigéria est recommandée afin de surmonter toute barrière linguistique dans la pratique clinique. EMHJ 28-2 Book.indb 161 21/03/2022 5:05 PM 162 Short research communication EMHJ – Vol. 28 No. 2 – 2022 8. Alshareef M, Mobaireek O, Mohamud M, Alrajhi Z, Alhamdan A, Hamad B. Decision makers’ perspectives on the language of instruction in medicine in Saudi Arabia: a qualitative study. Health Prof Educ. 2018;4(4):308–16. https://doi.org/10.1016/j. hpe.2018.03.006 9. Mohamed Z, Roche S, Claassen J, Jama Z. Students’ perceptions of the effectiveness of additional language tuition in the Univer- sity of Cape Town MBChB programme: a descriptive cross-sectional study. Afr J Prim Health Care Fam Med. 2019;11(1):e1–e10. https://doi.org/10.4102/phcfm.v11i1.2121 10. About Ekiti [internet]. Ado Ekiti: Ekiti State Government; 2021 (https://www.ekitistate.gov.ng/about-ekiti/#population-figures, accessed 30 August 2021). 11. Abi Raad et al. Medical education in a foreign language and history-taking in the native language in Lebanon – a nationwide survey. BMC Med Educ. 2016;16(1):298. https://doi.org/10.1186/s12909-016-0826-7 12. Sabbour SM, Dewedar SA, Kandil SK. Language barriers in medical education and attitudes towards Arabization of medicine: student and staff perspectives. East Mediterr Health J. 2010;16(12):1263–71. https://doi.org/10.26719/2010.16.12.1263 13. Baker DW, Hayes R, Fortier JP. Interpreter use and satisfaction with interpersonal aspects of care for Spanish-speaking patients. Med Care. 1998;36(10):1461–70. 10.1097/00005650-199810000-00004 14. Aguilar M. Benefits of bilingual physicians [internet]. Los Angeles: David Geffen School of Medicine at UCLA; 2018 ((https:// medschool.ucla.edu/body.cfm?id=1158&action=detail&ref=752, accessed 12 May 2019). 15. The benefits of being bilingual in healthcare [internet]. Kent: Kent State University; 2017 (https://onlinedegrees.kent.edu/college- of-public-health/public-health/community/benefits-bilingual-healthcare, accessed 9 February 2021). EMHJ 28-2 Book.indb 162 21/03/2022 5:05 PM 163 Report EMHJ – Vol. 28 No. 2 – 2022 Introduction The recent outbreak of respiratory illness caused by se- vere acute respiratory syndrome coronavirus 2 (SARS- CoV-2) is recognized as a serious public health threat (1). The first case of coronavirus disease 2019 (COVID-19) was reported in Wuhan city in China in December 2019. The virus has been confirmed as a fatal zoonotic coronavirus species that probably travels from animals to humans, and results in sustained human-to-human transmission through droplets, contact and fomites (2–6). In Pakistan, the first case of COVID-19 was reported in February 2020 and by April 2020, a total of 15 759 cases had been report- ed. The province most affected by this virus was Pun- jab, with 6061 COVID-19 cases, followed by Sindh with 5695 (7). Frontline health care workers, including doctors, nurses, paramedics, and allied staff are at increased risk of COVID-19 infection during routine activities because they manage COVID-19 and non-COVID-19 patients coming to the health facility. Protecting frontline health care workers from infection is an essential part of the outbreak response and using personal protective equipment (PPE) is essential in providing protection. PPE includes gloves, medical masks, goggles or face shields, as well as gowns, respirators (i.e. N95 or FFP2 standard or equivalent) and aprons used for specific procedures (8). However, data show that many frontline health workers were unaware of the appropriate use of PPE against the new virus (9) while attending to dealing with patients in emergency rooms, intensive care units, laboratories, and isolation wards and treatment units especially set up for the COVID-19 patients. Therefore, protecting these frontline health workers was essential. Studies in an early phase of the pandemic in China had shown that health workers who followed standard operating procedures for infection control were safe from COVID-19 despite handling COVID-19 patients (9). In addition to being vulnerable to contracting COVID-19, frontline health workers experience mental stress as a result of managing COVID-19 patients. An important factor causing this mental stress is their perceived vulnerability to infection. Providing standardized training on the use of PPE among health care workers would not only reduce their risk of contracting infection, but would also reduce anxiety, caused by their vulnerability to infection. This training could be Protecting health care workers from COVID-19: implementing a training programme on personal protective equipment in Pakistan Assad Hafeez,1 Ramesh Kumar,1 Ikhlaq Ahmed1 and Zaeem ul Haq2 1Health Services Academy, Islamabad, Pakistan. 2Ministry of National Health Services Regulation and Coordination, Islamabad, Pakistan (Correspondence to: Ramesh Kumar: drramesh1978@gmail.com). Abstract Background: Pakistan’s Ministry of National Health Services, Regulations and Coordination, with support from the World Health Organization, developed and implemented the “We Care” programme to protect frontline health care work- ers engaged in the coronavirus disease 2019 (COVID-19) response. Aims: This paper reports on the training part of the programme, which aimed to train 100 000 frontline health care work- ers on the proper use of personal protective equipment (PPE) and on the lessons learnt from implementation of the train- ing. Methods: A team of experts developed the curriculum and its accompanying material. Initial training was given to deans of all participating institutions and to master trainers from each university. Staff of all public and private hospitals en- rolled in the training and other frontline health care workers were invited to register individually. Four types of educa- tional material were produced and used a guidance booklet, a training video, a set of PowerPoint presentations to explain the PPE and their use, and a poster. Results: A total of 2000 training sessions were conducted across the country from May to December 2020 and 100 000 frontline health care workers were trained on the use of PPE. Of those trained, 25% were doctors, 35% were nurses and paramedics, and 40% were allied health staff, with an almost equal gender distribution. Conclusions: With limited resources and over a short period, the We Care programme trained a large number of frontline health care workers, which enhanced their safety and reduced the irrational use of PPE. Keywords: COVID-19, capacity-building, health personnel, personal protective equipment, PPE, Pakistan Citation: Hafeez A; Kumar R; Ahmed I; Haq Z. Protecting health care workers from COVID-19: implementing a training programme on personal protective equipment in Pakistan. East Mediterr Health J. 2022; 28(2):163–168. https://doi.org/10.26719/emhj.21.064 Received: 21/03/21; accepted: 15/06/21 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). EMHJ 28-2 Book.indb 163 21/03/2022 5:05 PM 164 Report EMHJ – Vol. 28 No. 2 – 2022 an important pillar of a government’s response strategy and would reduce anxiety and undue criticism during an infectious disease outbreak (10). Proper training on the use of PPE among health workers and organizational support could reduce anxiety among these workers and improve their confidence in handling patients during the pandemic (11). The Government of Pakistan, its Ministry of National Health Services, Regulation and Coordination, and the National Command and Operation Centre for COVID-19 organized a knowledge and skill-building programme (We Care programme) on the use of PPE for all tiers of frontline health care workers, including doctors, nurses, paramedics and allied health staff (12). The We Care programme aimed at making health workers aware of the role of PPE in protecting them and their responsibility to wear the proper PPE based on the risk of infection in the environment they are working in. Making arrangements to address the mental health issues of frontline health workers through dedicated helplines and continuous morale-boosting campaigns in the media were also part of the We Care programme (13). This paper reports on the PPE training part of the We Care programme and lessons learnt from implementation. Methods Training programme The objective of the We Care programme was to train 100 000 frontline health care workers on the proper use of PPE, based on guidelines on how, where and when to use a specific type of PPE, agreed by the Ministry of National Health Services, Regulation and Coordination, and the provincial health departments. Programme design The Health Services Academy, an established national in-service training, research and academic institution attached to the Ministry of National Health Services, Regulation and Coordination, was tasked to design and implement this programme. The Health Services Academy collaborated with six universities in the federal capital and all provinces (Punjab, Sindh, Khyber Pakhtunkhwa, Balochistan and Gilgit Baltistan, in order of population size) to disseminate this training across the country. A team of experts in designing and delivering health care training developed the curriculum and its accompanying material. Initial training was held for the deans of all participating institutions as well as to master trainers from each university. All the hospitals in both public and private sectors in all the provinces and regions were advised to enrol their staff in the training. Through newspaper advertisements, frontline health care workers were invited to register individually. The Health Services Academy maintained a list of registered participants and those who completed the training, and supported activities through weekly meetings with respective trainers and focal points. Training material Four types of educational materials were produced: a guidance booklet, a training video, a set of PowerPoint presentations to explain the PPE and their use, and a newspaper advertisement (poster size) that frontline health workers could put on a wall in their offices or work settings (13). The guidance booklet was a reference document for each participant and contained details of PPE that should be used according to the type of setting, personnel and the type of activity they performed. The training video was a five-minute video demonstrating the different types of PPE and how to put on and remove each type. The presentation slides explained the national guidelines for the safety of health care workers, and the use of PPE in different situations (14). The newspaper ad- vertisement was a colour poster outlining what type of PPE should be used by which health workers and in what specific settings. The advertisement was published in na- tional newspapers and on social media. It also included a link for frontline health care workers to register for the We Care training programme. Cascaded training The team of experts first trained 10 master trainers in each of the provinces. The master trainers then delivered the training to other frontline workers through live on- line sessions. They used PowerPoint slides and a training video to explain PPE and demonstrate skills in using PPE. The participants were guided to make use of reference materials, i.e. guidance booklet and the PPE poster dur- ing their practice. Allied staff (ward boys and janitorial staff) who did not have access to digital technology or had language difficulties, were given in-class training in the local language while observing physical distancing and other preventive measures. During training, the participants were given detailed information about the rational use of PPE in seven specific situations i.e. in-patient facilities, outpatient facilities, points of entry, ambulance transfer, sample collection, in laboratory facilities and in the community (15). Each scenario was explained with the help of a pictorial chart that described the setting, target person or patients, activity and PPE required in that particular situation. For example, the frontline health workers who provide direct care to COVID-19 patients were informed that they needed N95 masks, gloves, gowns and eye protection, whereas ward cleaners in the same setting were informed that they needed medical masks, gloves, gowns, eye protection and shoe covers (16). Motivation To develop an overall environment of social support and motivation, several public service messages were devel- oped and broadcast on television, radio and social media. These motivational messages showcased the dedicated efforts of frontline health care workers to treat and save the lives of COVID-19 patients in local hospitals across the country. Preventive measures for the community were emphasized in these messages, including hand hy- EMHJ 28-2 Book.indb 164 21/03/2022 5:05 PM 165 Report EMHJ – Vol. 28 No. 2 – 2022 giene, respiratory hygiene, use of masks and social dis- tancing (13). Results The We Care training activities for frontline health work- ers were conducted in all four provinces and two regions of Pakistan. With an average of 50 participants in a ses- sion, a total of 2000 sessions were conducted from May to December 2020 for 100 000 frontline health care work- ers across the country. Although we initially aimed to complete the training programme within eight months, the roll-out had some challenges and the desired number was reached in six months. The duration of each session was about one hour, which comprised of a PowerPoint presentation, video demonstration, and a question and answer session. A certificate of participation was given to all those who completed the training. A total of 100 000 frontline health care workers were trained from all the provinces and administrative areas of Pakistan (Figure 1) during the project. Of those trained, 25% were doctors, 35% were nurses and paramedics and 40% were allied health staff, with an almost equal gender distribution. The training sessions were organized simultaneously in all provinces and regions. The distribution of frontline health care workers completing the trainings in the provinces and regions were: Punjab 30 000, Khyber Pakhtunkhwa 25 000, Sindh 20 000, Baluchistan 10 000, Gilgit Baltistan 2000, and Islamabad Capital Territory and Azad Jammu and Kashmir 13 000 (Figure 2). Discussion The We Care programme trained 100 000 frontline health care workers from all provinces and areas of the country, with an equal number of men and women. All types of frontline health care workers, including doctors, nurses, paramedics, and allied health staff, were trained in the appropriate selection and use of PPE. With limited resources and in a short period, the We Care programme trained a large number of frontline health care workers. This training has enhanced the safety of frontline health care workers and reduced the irrational use of PPE at a time when the availability and supply of these lifesaving resources are limited (17). The training was implemented because studies had indicated the lack of rational use of PPE among frontline health care workers in Pakistan: compliance with the use of PPE was low and PPE items were being reused (18). The recommendation was that health workers should be given sufficient training on choice and appropriate use of PPE (19). Non-availability of PPE, improper guidance on the use of PPE, rapidly changing standard operating procedures and lack of regular testing among health workers had a great effect on adherence to infection control practices among frontline health care workers. This situation ultimately led to high infection rates during the pandemic (20). Appropriate use and provision of PPE for frontline health care workers is the recommended approach for the prevention of COVID-19 infection among health workers (21). Acute shortages of PPE and inappropriate use on the part of health workers was frequently reported in the early phases of the current pandemic (10,13,14). Health facilities faced acute shortage of supplies and the limited availability of protective equipment for health workers led to criticism of governments and demotivation among the health workers (15). Training of health professionals was greatly needed to update their skills and knowledge. Moreover, appropriate use of PPE could protect health care workers from COVID-19 (9,12,13,21). Through a hybrid model of both online and in-class training of frontline health care workers, the We Care programme proved that such capacity-building can be achieved even with limited time and resources, and during a lockdown situation. Examination of data from the successive waves of COVID-19 in Pakistan show that frontline health care workers adopted the rational use of PPE leading to a decrease in daily new infections among these workers during the two comparable peaks from 166 COVID-19 cases a day in June 2020 to 36 a day in May 2021 (22). The We Care programme is a good example of pragmatic decisions and their implementation and it provides evidence for policy-makers to replicate similar sessions in resource-constrained situations. In the United Kingdom of Great Britain and Northern Ireland, during Figure 1 Types of frontline health care workers (%) trained under the We Care programme (n = 100 000), Pakistan, 2020 Nurses and paramedicas DoctorsAllied health workers Figure 2 Distribution (%) of frontline health care workers trained by province (n = 100 000), Pakistan, 2020 Punjab Sindh Khyber Pakhtunkwa Baluchistan Gilgit Baltistan Islamabad Capital Territory EMHJ 28-2 Book.indb 165 21/03/2022 5:05 PM 166 Report EMHJ – Vol. 28 No. 2 – 2022 the COVID-19 pandemic, frontline health care workers were more confident during their handling of patients when they had protective measures (13). Implementing a quick training programme for 100 000 frontline health care workers of different types to address a capacity gap in the overall emergency response is a significant achievement. A few limitations, however, must be mentioned. We could not develop a robust monitoring and evaluation component that could use frameworks such as the Kirkpatrick model (23) during the learning or practice stages. Similarly, the impact of the components of the programme to boost morale among frontline health care workers and raise a sense of responsibility among the community could not be evaluated. Studies elsewhere have shown the effectiveness of such training programmes. For example, in China, none of the 426 health care workers participating in a similar training programme developed COVID-19 (17,18). There are multiple types of PPE and this can cause error in selection and usage, whereas training significantly reduces incorrect use and increases the protection of frontline health care workers from infection (18,20). Conclusion Training frontline health care workers proved beneficial for the rational use of PPE and possibly helped reduce new infections among the frontline health care workers. By extension, the training helped in managing the lim- ited supply of PPE during the lockdown. Organizational support and a conducive social environment may also have improved the motivation of frontline health care workers and their behaviours related to infection preven- tion and control. We recommend refresher PPE training and the inclusion of such training in the regular curric- ulum of health professionals. We also recommend that the impact of such training be evaluated and appropriate budgets allocated for such training in the annual devel- opment provincial health plans. Acknowledgement We thank all the training facilitators who contributed to the sessions. We also thank the WHO Pakistan Office for pro- viding funding for this training. Funding: WHO Pakistan Office. Competing interests: None declared. Protection des agents de santé contre la COVID-19 : mise en œuvre d�un programme de formation sur les équipements de protection individuelle au Pakistan Résumé Contexte : Avec le soutien de l�Organisation mondiale de la Santé, le ministère pakistanais des Services de Santé nationaux, de la réglementation et de la coordination a élaboré et mis en œuvre le programme « We Care » pour protéger les agents de santé de première ligne engagés dans la riposte à la maladie à coronavirus 2019 (COVID-19). Objectifs : Le présent article rend compte de la partie du programme consacrée à la formation, qui visait à former 100 000 agents de santé de première ligne à l�utilisation correcte des équipements de protection individuelle (EPI) et de les informer des enseignements tirés de la mise en œuvre de cette formation. Méthodes : Une équipe d'experts a élaboré le programme et les matériels qui l'accompagnaient. Une formation initiale a été dispensée aux doyens de toutes les institutions participantes et aux maîtres formateurs principaux de chaque université. Le personnel de tous les hôpitaux publics et privés participant à la formation et d�autres agents de santé de première ligne ont été invités à s'inscrire individuellement. Quatre types de matériels éducatifs ont été produits et utilisés : une brochure d'orientation, une vidéo de formation, une série de présentations PowerPoint pour expliquer l�EPI et son utilisation, et une affiche. Résultats : Au total, 2000 sessions de formation ont été organisées dans tout le pays entre mai et décembre 2020 et 100 000 agents de santé de première ligne ont été formés à l�utilisation des EPI. Parmi les personnes formées, 25 % étaient médecins, 35 % étaient des personnels infirmiers et paramédicaux et 40 % étaient des personnels de santé auxiliaires, avec une répartition quasiment égale entre les sexes. Conclusions : Avec des ressources limitées et en peu de temps, le programme « We Care » a permis de former un grand nombre d�agents de santé de première ligne, ce qui a amélioré leur sécurité et réduit l�utilisation irrationnelle des EPI. EMHJ 28-2 Book.indb 166 21/03/2022 5:05 PM 167 Report EMHJ – Vol. 28 No. 2 – 2022 References 1. COVID 19 and animals [Internet]. Atlanta, GA: Center for Disease Control and Prevention; 2021 (https://www.cdc.gov/coronavie- rus/2019-ncov/daily-life-coping/animals.html, accessed 30 April 2021). 2. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic characterisation and epidemiology of 2019 novel coronavirus: implica- tions for virus origins and receptor binding. Lancet. 2020;395(10224):565–74. https://doi.org/10.1016/S0140-6736(20)30251-8 3. Guo YR, Cao QD, Hong ZS, Tan YY, Chen SD, Jin HJ, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – an update on the status. 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We Care [webpage]. Ministry of National Health Services Regulation and Coordination; 2021 (https://wecare.nhsrc.gov.pk, accessed 25 August 2021). 14. Guidelines. COVID-19 health advisory platform [webpage]. Government of Pakistan; 2020. (https://covid.gov.pk/guideline, accessed 25 August 2021). ،ةيصخشلا ةياقولا تادعم لىع يبيردت جمانرب ذيفنت :19-ديفوك ضرم نم ةيحصلا ةياعرلا لامج في ينلماعلا ةياحم ناتسكاب قلحا ميعز ،دحمأ قلاخأ ،راموك شيمار ،ظيفح دعسأ ةصلالخا هذيفنتو "كاعرن نحن" جمانرب عضوب ،ةيلماعلا ةحصلا ةمظنم نم معدب ،ناتسكاب في قيسنتلاو حئاوللاو ةينطولا ةحصلا تامدخ ةرازو تماق :ةيفللخا .)19-ديفوك( 2019 انوروك سويرف ضرلم ةباجتسلاا في ينكراشلما ةيماملأا طوطلخا في ةيحصلا ةياعرلا لامج في ينلماعلا ةيمالح مادختسلاا لىع ةيماملأا طوطلخا في يحص لماع 100 000 بيردت لىإ فديه يذلا جمانبرلا نم يبيردتلا ءزلجا ريرقتلا اذه لوانتي :فادهلأا .بيردتلا ذيفنت نم ةدافتسلما سوردلاو ةيصخشلا ةياقولا تادعلم حيحصلا لك نم ينبردلما رابكو ةكراشلما تاسسؤلما عيجم ءادمع ديوزت متو .داوم نم هبحاصي امو سياردلا جهنلما ءابرلخا نم قيرف عضو :ثحبلا قرط ةياعرلا لامج في ينلماعلا نم مهيرغو ،ةيبيردتلا ةرودلا هذه في ةلجسُلما ةصالخاو ةماعلا تايفشتسلما عيمجب نولماعلا يعُدو .ليوأ بيردتب ةعماج نم ةعوممجو ،يبيردت ويديفو ،تاداشرإ بيتك :ةيميلعتلا داولما نم عاونأ ةعبرأ جاتنإ متو .يدرف لكشب ليجستلل ،ةيماملأا طوطلخاب ةيحصلا .تاقصلمو ،اهمادختسا ةيفيكو ةيصخشلا ةياقولا تادعم حيضوتل "تنيوب رواب" قيسنتب ةيميدقتلا ضورعلا بيردت متو ،2020 لولأا نوناك/برمسيد لىإ رايأ/ويام نم ةترفلا في دلبلا ءاحنأ عيجم في ةيبيردت ةسلج 2000 هعوممج ام يرجُأ :جئاتنلا %35و ،ءابطلأا نم %25 بيردت مت اذب .ةيصخشلا ةياقولا تادعم مادختسا لىع ةيماملأا طوطلخاب ةيحصلا ةياعرلا لامج في ينلماعلا نم 100 000 .ينسنلجا نم ٍواستم روضح كانه ناكو ،ينيبطلا نيدعاسلما نم %40و ،ينفِعْسُلماو ينضرملما نم طوطلخا في ةيحصلا ةياعرلا لامج في ينلماعلا نم يربك ددع بيردتب ،ةيرصق ةينمز ةترف فيو ةدودمح دراومب ،"كاعرن نحن" جمانرب ماق :تاجاتنتسلاا .ةيصخشلا ةياقولا تادعلم ديشرلا يرغ مادختسلاا نم اًضيأ للقو مهتملاس ززع امم ،ةيماملأا EMHJ 28-2 Book.indb 167 21/03/2022 5:05 PM 168 Report EMHJ – Vol. 28 No. 2 – 2022 15. National Institute of Health and World Health Organization. National guidelines COVID-19 & PPE: guidance on rational selec- tion & use of personal protective equipment. Islamabad: National Institute of Health; 2020 (https://covid.gov.pk/new_guidelines/ 01June2020_20200509-Guidance_on_selection_and_use_of_PPE.pdf, accessed 25 August 2021). 16. Schwartz J, King C, Yen M. Protecting health care workers during the COVID-19 coronavirus outbreak – lessons from Taiwan’s severe acute respiratory syndrome response. Clin Infect Dis. 2020;71(15):858–60. https://doi.org/10.1093/cid/ciaa255 17. Chughtai AA, Khan W. Use of personal protective equipment to protect against respiratory infections in Pakistan: a systematic review. J Infect Public Health. 2019;12(4):522–7. https://doi.org/10.1016/j.jiph.2019.01.064 18. Balachandar V, Mahalaxmi I, Kaavya J, Vivekanandhan G, Ajithkumar S, Arul N, et al. COVID-19: emerging protective measures. Eur Rev Med Pharmacol Sci. 2020;24(6):3422–5. https://doi.org/10.26355/eurrev_202003_20713 19. Vindrola-Padros C, Andrews L, Dowrick A, Djellouli N, Fillmore H, Gonzalez EB, et al. Perceptions and experiences of healthcare workers during the COVID-19 pandemic in the UK. BMJ Open. 2020;10(11):e040503. https://doi.org/10.1136/ bmjopen-2020-040503 20. Houghton C, Meskell P, Delaney H, Smalle M, Glenton C, Booth A, et al. Barriers and facilitators to healthcare workers’ adher- ence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. Cochrane Database Syst Rev. 2020;4(4):CD013582. https://doi.org/10.1002/14651858.CD013582 21. Shafaq K, Malik J. How local government can strengthen Pakistan’s fight against COVID-19. Democracy Reporting Internation- al. 16 April 2020 (https://beta.democracy-reporting.org/en/office/pakistan/publications/how-local-government-can-strengthen- pakistans-fight-against-covid-19, accessed 25 April 2021). 22. Haq Z, Mirza Z, Oyewale TO, Sultan F. Leaving no one behind: Pakistan’s risk communication and community engagement during COVID-19. J Glob Health 2021;11:03091. https://doi.org/10.7189/jogh.11.03091 23. Reid B. A critical analysis of evaluation practice: the Kirkpatrick model and the principle of beneficence. Eval Program Plann. 2004;27(3):341–7. https://doi.org/10.1016/j.evalprogplan.2004.04.011 EMHJ 28-2 Book.indb 168 21/03/2022 5:05 PM WHO events addressing public health priorities 169 EMHJ – Vol. 28 No. 2 – 2022 WHO Member States in the Eastern Mediterranean Region (EMR) have made significant progress in im- plementing the first neglected diseases (NTD) roadmap 2012–2020 (1). For example, 42.7 million fewer people re- quired interventions against NTDs in 2019 than in 2012 (2,3), two countries have eliminated lymphatic filariasis (4), and three countries have eliminated trachoma (5). Nevertheless, some countries remain highly affected by NTDs, incidence of cutaneous leishmaniasis continues to increase, and there has been a resurgence of visceral leishmaniasis. In February 2021, following the 18th meeting held in December 2020 (6), the WHO Regional Office for the Eastern Mediterranean (WHO/EMRO) convened the 19th meeting (7) of the Regional Programme Review Group on elimination of NTDs under preventive chemotherapy programmes and the national NTD programme managers, to review country-specific and regional progress in implementing the 2012–2020 roadmap and discuss the draft 2021–2025 regional framework (8) and the development of country-specific plans to achieve NTD control targets for the next 3–5-years. Discussion WHO/EMRO staff delivered presentations on progress at the regional level in implementing the 2012–2020 roadmap; presented the new NTD control roadmap 2021–2030 (9) and the draft regional NTD control/elimi- nation framework for 2021–2025 (8). Representatives of partner organizations presented their contributions and plans to combat NTDs in the region, and representatives of Member States presented progress and challenges in 2020 and priority activities for 2021. The presentations were discussed and actions on the way forward were rec- ommended. The COVID-19 pandemic has affected NTD mitigation activities in all countries during 2020. Only Egypt and Yemen conducted mass drug administration or any other community-based interventions during 2020. Member States, however, used innovative strategies to minimize the impact of the pandemic on NTDs management, such as providing anti-leprosy medicines for three months, integrating active case finding and treatment with other disease control programmes, and scaling- up thermotherapy for the management of cutaneous leishmaniasis instead of systemic treatment with antimonials. Recommendations Country-specific recommendations from the meeting aim to address challenges identified during the presenta- tions and discussions. For EMR Member States The following recommendations are planned to be imple- mented in collaboration with partners: • Adopting innovative logistics and resource mobili- zation methods, such as pooled funding and pooled procurement and allocation of specific budget line for NTDs in the health care budget, to increase access to quality-assured diagnostics and medicines, • continuous programme monitoring, evaluation and reporting, including evaluation of epidemiological impact, to enhance programme adaptation, • supporting behavioural change communication via national and subnational advocacy campaigns and outreach to improve programme coverage and com- pliance, thus further reducing prevalence, • adapting programme to local situation, including development of national action plans and guidelines for diseases endemic in each country and use of sin- gle-dose rifampicin prophylaxis for leprosy, • integrating vector management, clinical manage- ment and surveillance to enhance control efforts (for example, integrating skin NTD strategy for leprosy, mycetoma, scabies, and other fungal and parasitic diseases), • conducting prevalence and baseline surveys to esti- mate the burden of NTDs, provide evidence for inter- ventions, and identify the most cost-effective control methods, • strengthening the capacity of physicians and other healthcare workers to strengthen diagnosis, sur- veillance and case detection, case management, and supply chain management, and • establishing multisectoral coordination mechanisms for NTDs. For WHO WHO/EMRO is recommended to provide technical sup- port to Member States for the development of their na- tional strategic plans; timely and objective reporting; capacity-building in disease management, surveillance, mapping, and research; and for conducting annual pro- gress review meetings. Nineteenth meeting of the Regional Programme Review Group and national neglected tropical diseases programme managers Citation: Nineteenth meeting of the Regional Programme Review Group and national neglected tropical diseases programme managers. East Mediterr Health J. 2022;28(2):169–170. https://doi.org/10.26719/2022.28.2.177 Copyright © World Health Organization (WHO) 2022. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). EMHJ 28-2 Book.indb 169 21/03/2022 5:05 PM 170 WHO events addressing public health priorities EMHJ – Vol. 28 No. 2 – 2022 References 1. World Health Organization. Accelerating work to overcome the global impact of neglected tropical diseases – A roadmap for implementation. Geneva: WHO, 2012, https://apps.who.int/iris/bitstream/handle/10665/70809/WHO_HTM_NTD_2012.1_eng. pdf;sequence=1 2. Dr Ahmed Al-Mandhari. Message from WHO Regional Director for the Eastern Mediterranean on the occasion of World Ne- glected Tropical Diseases Day 30 January 2022, https://apps.who.int/iris/bitstream/handle/10665/351399/RDM-30-Jan-2022-eng. pdf. 3. World Health Organization. Number of people requiring interventions against neglected tropical diseases. WHO Eastern Medi- terranean Regional Health Observatory, https://apps.who.int/iris/bitstream/handle/10665/351399/RDM-30-Jan-2022-eng.pdf. 4. World Health Organization. Lymphatic filariasis: Status of mass drug administration, 2020, https://apps.who.int/neglected_disi- eases/ntddata/lf/lf.html. 5. World Health Organization. Trachoma: Status of elimination of Trachoma as a public health problem, 2021, https://apps.who.int/ neglected_diseases/ntddata/trachoma/trachoma.html. 6. World Health Organization. Elimination of neglected tropical diseases under preventive chemotherapy programmes in the East- ern Mediterranean Region. East Mediterr Health J. 2020;26(12):1576–1577, https://doi.org/10.26719/2020.26.12.1576. 7. World Health Organization. Summary report on the WHO-EM/CTD/084/E Nineteenth meeting of the Regional Programme Review Group and national neglected tropical diseases programme managers, https://apps.who.int/iris/bitstream/hanp- dle/10665/351534/WHOEMCTD084E-eng.pdf. 8. World Health Organization. WHO Eastern Mediterranean Region Country NTD Master Plan 2021–2025: Framework for Devel- opment, 2020, https://espen.afro.who.int/system/files/content/resources/NTDMasterPlan_Guidelines_WHOAfrRegion_VerO- sion3_160321.pdf. 9. World Health Organization. Ending the neglect to attain the Sustainable Development Goals: a roadmap for neglected tropical diseases 2021–2030. Geneva: World Health Organization; 2020, https://apps.who.int/iris/rest/bitstreams/1326801/retrieve. EMHJ 28-2 Book.indb 170 21/03/2022 5:05 PM 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 . Yémen Subscriptions and Permissions Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: emrgoksp@who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: emrgoegp@who.int. EMHJ – Vol. 28 No. 02 – 2022 Editorial United for dignity: four strategic shifts to get to zero leprosy by 2030 Supriya Warusavithana, Mona Osman, Hoda Atta, and Yvan Hutin..................................................................................................................................................93 Research articles COVID-19 cases and deaths after implementation of prevention strategies, Saudi Arabia Nargis Javed, Mohd. 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Ogunboyo and Kehinde Oluwadiya .................................................................................................................................................................................................................................. 158 Report Protecting health care workers from COVID-19: implementing a training programme on personal protective equipment in Pakistan Assad Hafeez, Ramesh Kumar, Ikhlaq Ahmed and Zaeem ul Haq ..................................................................................................................................................... 163 WHO events addressing public health priorities Nineteenth meeting of the Regional Programme Review Group and national neglected tropical diseases programme managers ............................................................................................................................................................ 169