Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 21 / No. 1 January/Janvier ¼Ø{L ëíP_UÐíïØn"Ð{dCÐ ©nUÐëinT }xnfx2015 V l m 2 1 N m b r 1 J n r 2 0 1 5 WHO carries out its vital work as the directing and coordinating authority on international health within the UN system with the guidance and support of its governing bodies, the World Health Assembly and the Executive Board. As the executive body of the Health Assembly, the Board meets in January to give effect to decisions of the Health Assembly, discuss pressing public health problems and submit advice or proposals to the Health Assembly. EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. 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ISSN 1020‑3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا .هجراخو ميلقلإا فى ةحصلاب ينمتهلما طسوتلما قشرل ةيحصلا ةلجلما 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. Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen Cover 21-1.indd 4-6 2/17/2015 2:43:58 PM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 21 No. 1 ¼Ø{LëíP_UÐíïØn"Ð{dCÐrr Editorial Winter chill of Geneva warmed by the WHO Executive Board Ala Alwan.............................................................................................................................................................................................................................................................................................................3 Research articles *ODJEFODFPGBDVUFNZPDBSEJBMJOGBSDUJPOJO*TMBNJD3FQVCMJDPG*SBOBTUVEZVTJOHOBUJPOBMSFHJTUSZEBUBJO A. Ahmadi, H. Soori, Y. Mehrabi, K. Etemad, T. Samavat and A. Khaledifar.............................................................................................................................................................................. &QJEFNJPMPHJDBMBOEDISPOPMPHJDBMQSPėMFPGQSFUFSNCJSUIJOUIFSFHJPOPG.POBTUJS 5VOJTJB CFUXFFOBOE S. El Mhamdi, M. El Ghardallou, A. Ben Salah, I. Bouanene, A. Sriha,1 K. Ben Salem, R . Falah and M.S. Soltani ....................................................................................................13 Problems of providing services to people affected by HIV/AIDS: service providers and recipients perspectives G. Moradi, M. Mohraz, M.M. Gouya, M. Dejman, S.S. Alinaghi, K. Rahmani and H. Malekafzali-Ardakani .......................................................................................................... Psychometric properties of the Persian version of the Sexual and Reproductive Health Needs Assessment Questionnaire S. Khani, L. Moghaddam-Banaem, E. Mohamadi, A.A. Vedadhir and E.Hajizadeh.............................................................................................................................................................29 Herbal and nutritional supplement use among college students in Qatar R. Mamtani, S. Cheema, B. MacRae, H. Alrouh, T. Lopez, M. ElHajj and Z. Mahfoud.......................................................................................................................................................39 Medical faculty members’ perspectives on the components of cross-cultural competence in the Islamic Republic of Iran: a qualitative study M. Mousavi Bazaz, A. Zabihi Zazoly and H. Karimi Moonaghi ................................................................................................................................................................................................. Risk factors influencing dentists’ hepatitis B-related knowledge and attitudes and their willingness to treat hepatitis B positive patients B. Khosravanifard, V. Rakhshan, S. Sherafat and L. Najafi-Salehi ................................................................................................................................................................................................ Short communication Development, implementation and evaluation of a medication safety programme for schoolchildren in Qatar K.J. Wilby, H.M. Hazi and M.A. Ashour...............................................................................................................................................................................................................................................62 WHO events addressing public health priorities Accelerating progress towards universal health coverage by engaging the private sector.....................................................................................................................67 Eastern Mediterranean Health Journal reviewers’ list 2014 .................................................................................................................................................................................... Guidelines for authors...................................................................................................................................................................................................................................................................................72 Ala Alwan, Editor-in-chief Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Zuhair Hallaj Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editors Fiona Curlet, Guy Penet (French) Freelance: Alison Bichard, Marie-France Roux Graphics Suhaib Al Asbahi, Diana Tawadros Administration Nadia Abu-Saleh, Yasmeen Sedky, Iman Fawzy HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 3 Editorial Winter chill of Geneva warmed by the WHO Executive Board Ala Alwan1 The winter chill of Geneva is warmed in the last week of January every year by the meeting of the WHO Execu- tive Board, which gathers to follow up on decisions of the World Health Assembly and provide guidance and direction to the WHO Secretariat. This year, the Board was faced with a record number of agenda items. Some of these were crucial to the current global public health situation and oth- ers to the future of global health and to WHO itself. The Executive Board held a special session on the Ebola emergency. The discussions took place against the back- drop of the most recent data showing a reduction in new cases. This good news was welcomed, but it also highlighted the impact of the surge in resources put in place to respond to the outbreak, re- sources that are not ordinarily available, as has been highlighted by recent arti- cles in the global press. The Board urged WHO to maintain the positive impact of the current response, including the assignment of a Special Representa- tive for coordination and response. It requested an interim assessment of WHO’s outbreak response and drew attention to areas where it felt WHO ca- pacity needed strengthening. The Board was concerned also to recognize the selfless contribution of health workers, and the need for support for survivors, their families and children orphaned by the outbreak. In its discussion on progress in implementation of the International )FBMUI 3FHVMBUJPOT *)3 B number of Board Members from our Region noted the discrepancies shown up by the recent country assessments for Ebola readiness conducted in the Region, and the self-assessments con- ducted by Member States of readiness to implement the IHR. The MERS- CoV outbreaks in our Region, as well as the Ebola outbreaks, underscore the insufficiency of current capacities to deal with global outbreak emergencies and highlight further the need for coun- tries to make IHR implementation a national priority. With the good news that no new cases of polio had been reported in Africa for the past 6 months, the con- tinuing presence of polio in our Re- gion was brought under the spotlight. Through the regional members of the Board, Member States of the Region reiterated their commitment to stop- ping transmission and to supporting the national efforts being made in Af- ghanistan and Pakistan. Pakistan, in particular, is affected by intense trans- mission of the virus, accounting for PGBMMOFXDBTFT JO BOEUIF virus continues to spread beyond its borders. The Board was informed that Pakistan is implementing an emer- gency plan. This remains a regional and global challenge that requires continu- ing political, civil society and religious leadership. Noncommunicable diseases were brought into the spotlight again as Board Members discussed how to take the work forward on implementing the QPMJUJDBMEFDMBSBUJPOPGUIF6OJUFE Nations General Assembly on preven- tion and control of noncommunicable diseases. The regional Board mem- bers, following up on the request of the Regional Committee in October XFSFLFFO UPQVTI GPSQSPDFTT indicators by which Member States could measure their progress towards implementation and against which WHO could report to the General Assembly. Other members were less eager to add to existing agreements. After much lively debate, compromise was reached and the Board requested the Director-General to publish a tech- nical note, in the next few months, on IPX TIFXJMM SFQPSU JO UP UIF 6/(FOFSBM"TTFNCMZPOUIFOBUJPOBM DPNNJUNFOUTNBEFJOBOE using existing survey tools and taking into account existing indicators at global and regional levels. The Board also considered the fu- ture of WHO itself and the drive for re- form. One of the key strategic directions for our work in the Region over the past three years has been to strengthen and streamline management, including moving more resources to country level, and thus provide more efficient and effective support to Member States. I was able to assure members of the Board that in the Region we have put in place managerial measures to improve transparency, improve compliance with standard procedures and mitigate risks to operations. Many of the meas- ures put in place have already brought positive results. Board members urged WHO to implement similar measures across all regions, and we will continue to improve and expand our efforts in this important area. 1Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 4 Also in the context of reform, the Board discussed several issues that will have impact on the work of WHO in general and its programmes at country level in the years to come. Of particular note were the items on rotation and mobility of WHO staff, the distribution of funds across the three levels of WHO (termed ‘strategic budget space allo- cation’), and the programme budget GPS 8IJMF SPUBUJPO BOE mobility of the WHO workforce was welcomed by the Board, the other two items were extensively debated. The Board requested the Working Group on Strategic Budget Space Allocation to continue its work and to report back at its next session on the specific issue of technical cooperation at country level. It entrusted WHO with additional work on the proposed programme budget CFGPSFQSFTFOUJOH JU UP UIF World Health Assembly for endorse- NFOUJO.BZ*UJTNZWJFXUIBUUIF success of reform will depend, to a great extent, on how WHO can reinforce its country presence and strengthen technical support to countries. The WHO Executive Board has 34 members, who serve 3 year terms, and represent the six regions. Member States who are not currently members of the Board may participate in the meeting without vote. It has been heartening in recent years to see ever more interest and active participation from Member States of the Region who are not Board members. In addition to the five cur- rent Board Members from the Region, .FNCFS 4UBUFT TFOU EFMFHBUJPOT this year, as well as Palestine which has Observer status. Regional participants were vocal in the discussions and in sup- porting crucial decisions that will affect WHO’s work in the Region. One of the most interesting aspects of governance forums such as the WHO Executive Board and the World Health Assembly is the interaction and col- laboration between ministry of health experts and diplomats, as Member States engage in health diplomacy and negotiation. This year, we were able to demonstrate the value of this to a new generation of regional health leaders who were attending the first Leadership for Health Programme and who had the chance to attend the Executive Board meeting and observe one of WHO’s governing bodies in action. I hope we will see some of them representing Member States on the Board in future years. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 5 Incidence of acute myocardial infarction in Islamic Republic of Iran: a study using national registry data in 2012 A. Ahmadi, 1 H. Soori,2 Y. Mehrabi,2 K. Etemad 2, T. Samavat 3 and A. Khaledifar 4 ABSTRACT Population-based data on myocardial infarction rates in the Islamic Republic of Iran have not been reported on a national or provincial scale. In a cross-sectional study, data were collected on 20 750 new cases of myocardial infarction (ICD10 codes I21–22) admitted to hospitals and registered by the Iranian Myocardial Infarction Registry in 2012. The crude and age-adjusted incidence for the 31 provinces and the whole country were directly calculated per 100 000 people using the WHO standard population. Overall, males comprised 72.4% of cases and had a significantly lower mean age at incidence than women [59.6 (SD 13.3) years versus 65.4 (SD 12.6) years]. The male:female incidence ratio was 2.63. The age-standardized myocardial infarction incidence rate was 73.3 per 100 000 in the whole country (95% CI: 72.3%–74.3%) and varied significantly from 24.5 to 152.5 per 100 000 across the 31 provinces. The study provides baseline data for monitoring and managing cardiovascular diseases in the country. 1Department of Epidemiology & Biostatistics, School of Public Health; 2Safety Promotion & Injury Prevention Research Center, Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to H. Soori: hsoori@yahoo.com). 3Ministry of Health & Medical Education, Center for Non-Communicable Disease Control, Cardiovascular Office, Tehran, Islamic Republic of Iran. 4Department of Cardiology, School of Medicine & Hajar Hospital, Shahrekord University of Medical Sciences, Shahrekord, Islamic Republic of Iran. Received: 22/03/14; accepted: 08/09/14 2012êmK9eITÐTÐÓmhmg<êÐzGm<oGÐÚØogX°GüÐëÐ|wÎowÚf+9Øm"ÐncaTÐ[KÊmY@ÐâRíé öz^X Únax{UnBëĆHÚ̺ÓÐí5HÒ}wnJºØ5LÐÝíÚTº-Ð}gYøíØnxºïÚH{YnAºï{1ÌML çnåå]fUÐDååLphYĆååHüÐëÐ}ååxÎpååxÚg+:oåådbUÐåå\LÊnååZAÐÓø ö{åå_YéååAphincååHÓnååinh=ååL}ååxÚnb>ØÐ{ååLÎååx3oååÉ°#Ð ÓønåAåYÒ{åx{@påUnA20 750åLÓnåinh= åe= p}_åYpåHÐÚØ: ëåAnUÐênåSåU|Uí Ónå^RnCÐçnå]iDåLíÌåfJUÐ håUÐoåcYå óõSåYqdå ôHíÓnhaåZCÐOÎqå ód õBØÌ22-121~å hYÐí}UÐ10ßÐ}åY±U<í{åUÐåhf[UÐoådbUÐå\LÊnåZAÐ åI100 000cå UåUÐoåAyåå [CÐíênå#ÐâåSUÐé ö{å_YÑnåAå >í 2012ênåL:oådbUÐå\LÊnåZAø©Ð}ååxüÐ ÚåT|UÐcåI{åSí ëncåUÐØ{å_UpåhCn_UÐpå[UÐpåe^fYÚnåh_YêÐ{åHn=cT{ådUÐ:í31ååUÐÓnå^RnCÐåYT: nåYcåZ= 65.4åå=nbYpfååHSD 13.359.6ÊnååfUÐååYEååc=ååSÌâååSUÐ{ååfLåå0{U]ååHUÐ}ååe_UÐënTíºÓønåå"ÐååY·72.4ênååLåå@= 73.3åUÐoåA Eå_CÐoådbUÐå\LÊnåZAÐâåSíé {å_YënTí 2.63ÔnåiüÐOÎÚåT|UÐÓnåLSípåiqåinTí pfåHSD 12.6 cåU152.5OÎ24.5åYEåTcåZ=Nå?ĆUÐíî{åAüÐÓnå^RnCÐNå=åxn>íº·74.3 ·72.3 :CI·95cT{ådUÐ:100 000cåU {dUÐ:phýnLUÐphdbUÐßÐ}YúÐÒÚÐØÎí{É}UphUíÌÓninh=ê{b>pHÐÚ{UÐì|wí 100 000 Incidence de l'infarctus aigu du myocarde en République islamique d'Iran : étude à partir des données du registre national en 2012 RÉSUMÉ Les données en population sur les taux d'infarctus du myocarde en République islamique d'Iran n'ont pas été rapportées à l'échelle régionale ou nationale. Dans une étude transversale, des données ont été recueillies sur 20 750 nouveaux cas d'infarctus du myocarde (CIM-10 codes I21–22) admis dans des établissements hospitaliers et enregistrés dans le Registre iranien des infarctus du myocarde en 2012. L'incidence brute et l'incidence ajustée pour l'âge dans les 31 provinces et l'ensemble du pays ont été directement calculées pour 100 000 personnes à l'aide de la population type de l'OMS. Globalement, les hommes représentaient 72,4 % des cas et étaient nettement moins âgés en moyenne à l'incidence que les femmes (59,6 ans [ET 13,3 ans] contre 65,4 ans [ET 12,6 ans]). Le rapport d'incidence homme-femme était de 2,63. Le taux d'incidence standardisé en fonction de l'âge pour l'infarctus du myocarde était de 73,3 pour 100 000 dans l'ensemble du pays (IC à 95 % : 72,3 %–74,3 %) et variait significativement, de 24,5 à 152,5 pour 100 000, entre les 31 provinces. L'étude fournit des données initiales pour le suivi et la prise en charge des maladies cardio-vasculaires dans le pays. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 6 Introduction Despite decreases in mortality rates due to cardiovascular diseases in most de- veloped countries, these diseases have become the most important health problem and cause of mortality in many developing countries worldwide, including the Islamic Republic of Iran (1,2). Although cardiovascular diseases were previously of greatest concern to high-income countries (3), the age- adjusted incidence of these diseases has recently declined in these countries. Coronary heart disease is also on the rise in low- and moderate income countries (4) due to increases in life expectancy and changes in urbaniza- tion and lifestyle that have increased the prevalence of cardiovascular disease risk factors (5–7). C a r d i o v a s c u l a r d i s e a s e s a r e generally manifested by myocardial infarction, and the World Health Or- ganization (WHO) has suggested that myocardial infarction rates can be used as a proxy for cardiovascular disease rates in epidemiological studies (8). Comparison of rates of myocardial infarction in different geographical ar- eas and communities within a country reveal important information that can be applied in evidence-based decision- making, research, prioritization and health systems planning in order to better identify myocardial infarction etiology and risk factors and to assess cardiovascular disease prevention ap- proaches (9–11). Reliable data to determine myo- cardial infarction rates are rare in de- veloping countries. In the Islamic Republic of Iran, for example, the data required to assess myocardial infarc- tion incidence have been mainly based on a limited number of hospitals and limited studies on small populations (12–14). According to a report by the Iranian Ministry of Health and Medi- DBM&EVDBUJPO JO DBSEJPWBTDVMBS EJTFBTFTPWFSBMMDPNQSJTFEPG UIF causes of death, and the mortality rate EVF UPNZPDBSEJBM JOGBSDUJPOXBT QFS 6). To date, no adequate estimate of myocardial infarction inci- dence has been reported for the whole country or in all the regions. In view of this, and reports of the varying distri- bution of cardiovascular disease risk factors across the different provinces (15,16), the present study was con- ducted to determine the incidence rate of myocardial infarction at the national and provincial level in the Islamic Re- public of Iran. Methods Study setting The Iranian Myocardial Infarction Reg- JTUSZXBTTFUVQJOCZUIF0đDFPG Cardiovascular Diseases of the Iranian Ministry of Health and Medical Educa- UJPO"U UIFFOEPG UIFDPWFSBHF of the Registry was complete and was usable across the whole country (6,17). The Registry covers all hospitals that are equipped with a coronary care unit in 31 provinces of the country. Data collection In a cross-sectional study, data were DPMMFDUFEPOOFXDBTFTPGNZP- cardial infarction recorded by the Reg- JTUSZ JO *ODMVTJPODSJUFSJBXFSF based on the WHO and World Heart Federation definition of myocardial infarction diagnosis as per the Interna- tional Classification of Diseases (ICD10) codes I21 and I22 (8). Patients with myocardial infarction history or no definite diagnosis by the cardiologist were excluded from the study. The data collected included patients’ age, sex and province of residence. The ethics DPNNJĨFF PG 4IBIJE#FIFTIUJ6OJ- versity of Medical Sciences approved this study. Data analysis Crude incidence rates were calculated for each province and the whole coun- USZQFSQFPQMF for different age groups. To estimate the population denominator for the incidence, the data of the population census from the Sta- UJTUJDBM$FOUFSPG*SBOJOXFSFVTFE To adjust the rates, we used the direct standardization method and the WHO standard population (18). All continu- ous values were reported as means and standard deviation (SD) and categori- cal variables as percentages. The t-test and analysis of variance were employed to compare differences in means of con- tinuous variables between 2 groups and among more than 2 groups. The data were analysed by Stata software, version 12. PWBMVFT XFSFDPOTJEFSFEBT significant. Results 0GOFXDBTFTPGNZPDBSEJBM JO- GBSDUJPO XFSFJONBMFT BOE JO GFNBMFT ĉF male:female incidence ratio was 2.63. Age at myocardial infarction The mean age at myocardial infarction was 61.2 (SD 13.4) years in the whole QPQVMBUJPOĉFNFBOBHFJONFO< (SD 13.3) years] was significantly lower DPNQBSFEXJUIXPNFO< 4% years] (P The mean age in different prov- inces by sex is shown in Table 1. The mean age at myocardial infarction varied significantly across different provinces (P ĉF MPXFTU mean age was recorded in patients SFTJEJOH JO 4FNOBO QSPWJODF < (SD 21.9) years], followed by Tehran < 4% ZFBST>BOE-PSFTUBO < 4% ZFBST> BOE UIFTF mean ages were significantly different GSPNUIPTFJO"SEBCJM< 4% years] (P ĉFIJHIFTUNFBO age was in Zanjan province [64.4 (SD 12.8) years] and this was higher than JO4JTUBOBOE#BMVDIJTUBO < 4% 13.9) years] (P ĉFNFBOBHF of men was not significantly different across the provinces. For women, the HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 7 $*m "ěFS standardization, the highest myocardial infarction incidence was in North Kho- SBTBO QFS GPMMPXFECZ Kerman, Khouzestan, Yazd, Semnan and West Azarbaijan (149.2, 143.7, BOE QFS respectively), and the lowest incidence XBT JO2PN<QFS $*m > Figure 1 illustrates the geographical distribution of myocardial infarction highest mean age was in Ardabil [68.4 4% ZFBST>BOE UIJTXBTTJHOJė- cantly different from the lowest age, in Hamadan [62.1 (SD 12.9) years] (P Myocardial infarction incidence rate Crude and age-standardized myocar- dial infarction incidence rates in the country’s provinces are shown in Ta- ble 2. The crude myocardial infarction JODJEFODFSBUFXBTQFSJO the whole country. The highest crude myocardial infarction incidence rate was in North Khorasan at 126.7 per QFPQMF GPMMPXFE CZ :B[E Semnan, Kerman, West Azarbaijan, BOE,IPV[FTUBO BOEQFS SFTQFD- tively). After adjustment, the crude myo- cardial infarction incidence rate in the whole country increased to 73.3 per Table 1 Mean age at incidence of myocardial infarction by sex in provinces of the Islamic Republic of Iran, 2012 Province Mean (SD) age (years) P-value Total Males Females Alborz 60.4 (13.3) 58.6 (13.1 65.6 (12.5) 0.001 Ardabil 63.2 (15.1) 60.8 (14.6) 68.4 (15.0) 0.001 West Azerbaijan 61.5 (13.6) 60.4 (13.5) 64.3 (13.3) 0.001 East Azerbaijan 61.0 (12.7) 59.0 (12.6) 64.9 (11.8) 0.001 Bushehr 61.3 (13.4) 60.9 (12.9) 62.5 (14.6) 0.462 Chaharmahal & Bakhtiari 62.4 (13.3) 60.2 (13.3) 68.9 (11.0) 0.001 Iilam 62.4 (11.9) 59.2 (11.8) 67.4 (10.3) 0.001 Esfahan 61.7 (13.6) 59.7 (13.5) 66.9 (12.7) 0.001 Fars 61.0 (13.6) 59.4 (13.7) 65.3 (12.3) 0.001 Ghazvin 61.4 (12.8) 59.6 (12.6) 66.4 (11.9) 0.001 Gilan 60.6 (13.2) 58.9 (13.3) 65.7 (11.7) 0.001 Golestan 60.4 (12.5) 58.7 (12.2) 64.4 (12.1) 0.001 Hamadan 60.0 (13.8) 59.3 (14.0) 62.1 (12.9) 0.068 Hormozgan 62.1 (13.8) 60.0 (14.0) 67.9 (11.4) 0.001 Kerman 61.4 (12.9) 59.5 (12.7) 66.5 (12.0) 0.001 Kermnanshah 62.0 (13.7) 60.1 (13.3) 66.2 (13.8) 0.001 South Khorasan 61.6 (13.5) 60.1 (13.9) 65.3 (11.8) 0.009 Razavi Khorasan 61.8 (12.9) 60.6 (13.0) 65.3 (12.1) 0.001 North Khorasan 61.7 (13.0) 59.6 (13.1) 66.3 (11.5) 0.001 Khuzestan 60.8 (13.2) 59.4 (13.3) 64.6 (12.1) 0.001 Kohgiluyeh & Boyer-Ahmad 61.0 (11.8) 58.5 (11.1) 66.8 (11.5) 0.001 Kurdistan 62.6 (13.6) 60.4 (14.2) 67.7 (10.8) 0.001 Lorestan 60.1 (14.5) 59.0 (14.0) 63.0 (15.4) 0.001 Markazi 61.0 (13.2) 59.7 (13.5) 64.9 (11.5) 0.001 Mazandaran 61.9 (13.2) 60.0 (13.3) 66.6 (11.6) 0.001 Qom 58.6 (12.7) 57.2 (12.0) 66.6 (13.7) 0.008 Semnan 59.1 (12.9) 58.1 (12.7 62.0 (13.0) 0.012 Sistan & Baluchestan 60.3 (13.9) 58.0 (13.0) 66.0 (14.5) 0.001 Tehran 60.4 (13.5) 59.0 (13.3) 64.2 (13.3) 0.001 Yazd 60.8 (13.3) 59.7 (13.4) 63.9 (12.6) 0.001 Zanjan 64.4 (12.8) 63.6 (12.7) 66.8 (12.9) 0.18 Total 61.2 (13.4) 59.6 (13.3) 65.4 (12.6) 0.001 SD = standard deviation. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 8 incidence in the different provinces of the country. Discussion This is the first report on the hospital- based age-standardized incidence of myocardial infarction in the Islamic Republic of Iran. Our study showed that the incidence rate of myocardial infarction was higher than the mean national rate in more than half of the provinces. These provincial disparities in myocardial infarction incidence rates mirror a national study on noncom- municable diseases risk factors in the Islamic Republic of Iran that mapped the differences in the prevalence of cardiovascular disease risk factors across the country’s provinces (19,20). The wide difference in myocardial infarction incidence rates—ranging GSPNQFSJO2PNUP QFS JO/PSUI ,IPSBTBOã could be due to different genetic or environmental factors, disparities in disease risk factors and different socio- economic status distribution across the provinces as well as to varying coverage in local myocardial infarction registries (8,12,20). This needs further investiga- tion in future studies. The especially Table 2 Crude and adjusted myocardial infarction incidence rates per 100 000 population in provinces of the Islamic Republic of Iran, 2012 Province No. of cases Incidence (per 100 000 population) Crude rate Adjusted rate 95% CI Alborz 852 73.2 97.8 91.0–104.5 Ardabil 506 91.0 108.4 98.8–117.9 West Azerbaijan 1 455 108.2 130.8 124.0–137.7 East Azerbaijan 636 35.4 39.9 36.7–43.0 Bushehr 173 39.9 58.6 49.6–67.7 Chaharmahal & Bakhtiari 321 85.5 105.0 93.3–116.7 Iilam 103 43.3 61.6 49.3–73.9 Esfahan 1 079 45.5 52.3 49.1–55.5 Fars 1 019 49.0 58.7 55.0–62.3 Ghazvin 432 78.8 97.8 88.5–107.2 Gilan 1 226 92.0 96.6 91.2–102.1 Golestan 526 69.1 89.2 81.4–97.0 Hamadan 419 51.5 57.6 52.0–63.2 Hormozgan 203 34.5 49.3 42.2–56.5 Kerman 1 396 118.5 149.2 141.2–157.2 Kermnanshah 604 67.7 79.4 72.9–85.9 South Khorasan 212 76.5 81.3 70.1–92.6 Razavi Khorasan 1 161 44.9 53.5 50.3–56.5 North Khorasan 452 126.7 152.5 138.2–166.7 Khuzestan 1 957 108.1 143.7 137.2–150.3 Kohgiluyeh & Boyer-Ahmad 125 61.5 62.9 51.5–74.3 Kurdistan 259 39.1 47.2 41.4–53.1 Lorestan 670 87.9 106.4 98.1–114.7 Markazi 522 76.7 86.5 79.0–94.1 Mazandaran 1 333 85.9 97.3 92.0–102.6 Qom 99 19.8 24.5 19.6–29.5 Semnan 347 119.0 132.5 118.4–146.6 Sistan & Baluchestan 253 32.7 44.1 38.5–49.7 Tehran 1 684 49.9 51.4 47.6–55.1 Yazd 571 121.7 141.3 129.5–153.0 Zanjan 155 34.0 40.1 33.7–46.5 Total 20 750 64.9 73.3 72.3–74.3 CI = confidence interval. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 9 low incidence in Qom could also be explained by inadequate registration of myocardial infarctions, and this too should be addressed in subsequent studies to obtain a more accurate estimate of myocardial infarction in this province. In literature searches we found no studies using similar data on myocar- dial infarction incidence rates from the Islamic Republic of Iran. The mor- tality rate due to myocardial infarction IBTCFFOSFQPSUFEBTQFS in the Islamic Republic of Iran (6). In our study, the age-adjusted incidence of recorded cases of myocardial in- GBSDUJPOXBTMPXFSBUQFS Potential reasons for this inconsist- ency are differences in measures, defective registration of the causes of death and cardiac arrest and/or registration of myocardial infarction instead of the correct cause of death (21,22). It should also be noted that myocardial infarction cases who died at home or outside hospital were not included in the records of myocardial infarction in our study. In the Islamic Republic of Iran the mortality rate due to acute myocardial infarction before arrival at hospital has been reported to CF 23 "CPVUPGėSTUNZP- cardial infarctions were detected only on death certificates (24) and, in view of this, the estimated incidence rate of myocardial infarction in our study DBOCFSFWJTFEVQUPQFS people. In other words, approximately NZPDBSEJBM JOGBSDUJPO DBTFT were estimated to die before arriving in hospital. This indicates that, despite the failure to register some cases of myocardial infarction outside hos- pital, a low number of deaths due to myocardial infarction are estimated to be registered in the Islamic Repub- lic of Iran and therefore our findings based on myocardial infarction cases registered in hospital seem reason- able. The standardized incidence rate of myocardial infarction in this study is IJHIDPNQBSFEXJUIBZFBS TUVEZ in Japan that reported myocardial infarction incidence rates of 7.4 and QFS JO BOE respectively (25). Our results are also higher compared with age-adjusted, standardized mortality rates due to myocardial infarction in Korea in BOEBUBOEQFS SFTQFDUJWFMZ 26). However, the incidence rate was lower com- pared with a study in Finland report- ing myocardial infarction incidence rates in men and women of 738.8 BOE QFS JOEJWJEVBMT SFTQFDUJWFMZ JOBQPQVMBUJPOPG UP 84-year-olds (9). The rate was also lower compared with other parts of the WHO Eastern Mediterranean Re- gion; in Kuwait the myocardial infarc- tion incidence rate was reported to be QFSQBUJFOUTBENJĨFE to hospitals (27). The Gulf Registry of Acute Coronary Events reported that the highest acute coronary syndrome incidence rate in Arab countries was in Oman, where the crude and stand- ardized incidences of myocardial infarction with ST-elevation myocar- dial infarction were 92.8 and 184.9 per SFTQFDUJWFMZ 28). The rate of myocardial infarction we found in the Islamic Republic of Iran is lower than in Oman. Since a population-based myocardial infarction incidence rate has not been yet reported from Arab countries, and in view of the mortality rate due to acute coronary syndrome JO:FNFO 0NBO BOE PUIFS"SBCDPVOUSJFT UIFNZP- cardial infarction incidence rate seems to be higher in the Islamic Republic of Iran than in Arab countries (except for Oman, Kuwait and Yemen) (27–29). The incidence rate of coronary heart disease in developed countries has been reported to range from m QFS JONFO BOE mQFSJOXPNFO 30). *OPOFTUVEZJOUIF6OJUFE,JOHEPN Figure 1 Incidence-adjusted rates of myocardial infarction in provinces of the Islamic Republic of Iran, 2012 MI rate per 100 000 Metres EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 10 the incidence rate of acute myocardial JOGBSDUJPOXBTQFSBOE the rate of all coronary events was 91 QFS0VS SBUFPGNZPDBSEJBM infarction was higher compared with that study, but lower in comparison with all coronary events (30). The age of male and female patients BOEZFBSTSFTQFDUJWFMZ BOE the total population (61.2 years) in our study in the Islamic Republic of Iran was lower compared with stud- ies in Japan (25), Puerto Rico (31) and The Netherlands (10), which reported the mean ages of myocardial JOGBSDUJPOQBUJFOUT BT BOE years respectively. On the other hand, the mean age of incidence in our study was higher compared with a study in *OEJB ZFBST 7 *O,VXBJU of myocardial infarction patients were male and the mean age was reported UPCFZFBST 27), which is lower than in our study. According to reg- JTUSJFTPGBDVUFDPSPOBSZFWFOUT JO hospitals in 6 Arab countries (Yemen, Oman, Bahrain, Kuwait, Qatar and UIF6OJUFE"SBC&NJSBUFT UIFNFBO BHF BU JODJEFODFXBTZFBST 29). Our study indicates that mean age at incidence of myocardial infarction is higher in the Islamic Republic of Iran than in these Arab countries (except for Yemen, with a mean age at inci- dence of 61 years). The difference in mean age across different studies could be attributed to different popu- lation age distributions, differences in life expectancies and lifestyles and variations in distribution of and cop- ing with cardiovascular disease risk factors. In the present study, the major- ity of the patients were male and the male:female incidence ratio was 2.63. This ratio is similar to studies in other countries (9,27–29,32); for example, in Finland the male:female ratio was SFQPSUFEUPCF 9). The sex ratio in the Islamic Republic of Iran was similar to that reported by the Gulf Registry of Acute Coronary Events, in XIJDIPGUIFQBUJFOUTXFSFNBMF (29). Although the quality of hospital registry of myocardial infarction data in the Islamic Republic of Iran has been reported as acceptable (33), failure to register myocardial infarc- tion cases who die outside hospital and/or at home was one of the limita- tions of the present study. We recom- mend that this is addressed in future research, accompanied by periodical assessments of the myocardial infarc- tions registry in order to determine the accuracy of the registered cases until the registry of data of myocardial infarctions becomes consistent in the country. Among the strengths of this study were that it was hospital-based, it included all the provinces of the country (based on formal provincial borders), it estimated the incidence using population denominators from the Statistical Center of Iran, as per WHO standards, it used a definite diagnosis by a cardiologist, and it was the first study on the incidence of myocardial infarction in the whole country. Conclusion Reports of age-adjusted incidence rates of myocardial infarction in developing countries, particularly by province or state, are rare. Without such an index, planners of health sys- tems inevitably use alternative indices such as mortality. We report for the first time the myocardial infarction incidence rates of hospitalized pa- tients at provincial level in the Islamic Republic of Iran. The standardized incidence rate of myocardial infarc- tion in the whole country (73.3 per XBTIJHIFS UIBO JO TPNF Arab countries of the Eastern Medi- terranean Region (except for Oman, Kuwait and Yemen). The mean age of myocardial infarction in men was significantly lower than in women. As myocardial infarction is the principal cause of death in the community, es- timates of myocardial infarction inci- dence rate by province are valuable in health policy-making, resource alloca- tion and prioritization and prevention and control of cardiovascular diseases. This study has paved the way for planning for and reducing disparities among the provinces, and monitoring and managing myocardial infarctions at the micro- and macro level in the Islamic Republic of Iran. The myocar- dial infarction cases who died at home or outside hospital were not included in our estimates of myocardial infarc- tion incidence. It is recommended that the Iranian Myocardial Infarction Registry officials put in place a system for registering outside-hospital deaths in order to derive the actual myocar- dial infarction incidence rate in our country. Acknowledgements We gratefully thank the personnel of the Cardiology Office (Dr Hozhabri and Mr Babrian), the personnel of the treatment deputies of the universi- ties of medical sciences, the nurses and cardiologists in hospital coronary care units across the Islamic Republic of Iran and the officials and advisors of the Iranian Myocardial Infarction Registry Programme, particularly Dr Seyyed-Saeed Hashemi-Nazari. Funding: This work was approved by the Management Centre of Non- Communicable Diseases and Office of Cardiovascular Diseases Preven- tion of the Iranian Ministry of Health and Medical Education (approval no. BOEXBTQBSUPGB1I%UIF- sis in Epidemiology by Ali Ahmadi at 4IBIJE#FIFTIUJ6OJWFSTJUZPG.FEJ- cal Sciences. Competing interests: None declared. 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El Ghardallou,1 A. Ben Salah,1 I. Bouanene,1 A. Sriha,1 K. Ben Salem,1 R. Falah2 and M.S. Soltani1 ABSTRACT Data about the profile and risk factors of premature births in Tunisia are scarce. The objective of this study was to describe the epidemiological profile of preterm births in Monastir, Tunisia, and to study the chronological trends of associated factors over the years 1994–2012. A population-based study was conducted using data from the regional births database on all deliveries in public maternity units. The overall prevalence of preterm births among the 161 116 deliveries in the 19-year period was 5.60% (95% CI: 5.13%–6.07%). The rate of preterm births and of adequate prenatal care increased significantly over the study period. Extremes of maternal age (≤ 19 and ≥ 35 years), having a twin pregnancy and the occurrence of complications during pregnancy were significant predictors of prematurity in the final regression model. Efforts should be made to improve the quality of health care in the region, especially for high-risk pregnancies. 1Department of Preventive Medicine and Epidemiology; 2Department of Gynaecology and Obstetrics, University Hospital of Monastir, Monastir, Tunisia (Correspondence to S. El Mhamdi: sanaelmhamdi@yahoo.fr). Received: 16/04/14; accepted: 02/10/14 2012í1994XmKM<~h=DGmhXgcRÎ9ÒBÐÒØøcTeX}TÐíým<TÐgQíETÐ ©n]dHH{e7ºÖĆRÊn@Úº3nH=YnTºn²Ê5H̺NfhL=ÜnfxκyUnÉ=îíÚ̺öUØ}`UÐx}Yºï{eCÐÊnfH ì|åwåYæ{å4ÐënTí åi>:nå)på]>}CÐÚnå]BøÐåYÐLíÒåCÐÒØøå UÐå hRíF=pååbd_CÐÓnååinhUÐ:ÒÚ{å ôiènå fwoåÉ°#Ð éĆååBnåå)påå]>}CÐååYÐ_dUpååhfY~UÐÓnååwn9øÐpååHÐÚØíºååi=EååHniY:ÒååCÐÓÐØøåådUååýn=UÐååhRíFUÐååÉípååHÐÚ{UÐ ÓÐØøåUÐ åh+DåL åhdSüÐÓÐØøíÓnåinh=Ò{åLnSåYÓ|åBÌÓnåinh=êÐ{åHn= phincåHpåHÐÚØqå óx}@jR 2012-1994ÓÐfåUÐ ðnååYnL19ååUÐÒGååR:ÒØøí161 116ååUÐNåå=ÒååCÐÒØøååUÐÓønåå"McååUÐÚnååZiøÐëncååR pååhYe_UÐpååYYúÐÓÐ{ååAí:qåå/ååUÐ éĆåBáådYcåZ=ÒØøådUpb=nåUÐpåhRncUÐpåxnL}UÐé {å_YíÒåCÐÓÐØøåUÐé {å_YØÐØÛÐ{åSí ·6.07 ·5.13 :CI·95·5.60 Ónååþ¬fYqååinTºååe"ÐÊnååf?ÌÓnååaLn\YÔí{ååAíºååYÌ>åå1Øåå@ííºðnååYnL35 ≤ í19 ≥ê±ååUï ¬{åå"Ð}ååe_UÐëÎí pååHÐÚ{UÐÒGååR :påh[UÐpåxnL}UÐÒØå@NåUØåg@é|å=å`fxåiÌOÎpåHÐÚ{UÐqå[dBí åýngfUÐæ´åUÐÕÙåei:ÕÐ{å#ÐÚnå=øn=på öegY påhUn_UÐÒÚå]#ÐÓÐÙåe"ÐÓønåA:5håHøºåhdSüÐ Caractéristiques épidémiologiques et chronologiques des naissances prématurées dans la région de Monastir (Tunisie) entre 1994 et 2012 RÉSUMÉ Les données sur les caractéristiques des naissances prématurées et leurs facteurs de risque sont rares en Tunisie. La présente étude avait pour objectif de décrire les caractéristiques épidémiologiques des naissances prématurées à Monastir (Tunisie), et d'étudier les tendances chronologiques des facteurs associés entre 1994 et 2012. Une étude en population a été menée à l'aide de données issues de la base de données des naissances régionale incluant tous les accouchements ayant eu lieu dans des maternités publiques. La prévalence globale des naissances prématurées pour 161 116 accouchements sur cette période de 19 ans était de 5,60 % (IC à 95 % : 5,13 %–6,07 %). Le taux de naissances prématurées et de soins prénatals adéquats a augmenté de manière significative au cours de la période de l'étude. L'âge extrême de la mère (d 19 ans ou t 35 ans), une grossesse gémellaire et la survenue de complications pendant la grossesse étaient des facteurs prédictifs importants de prématurité dans le modèle de régression final. Des actions devraient être menées pour améliorer la qualité des soins de santé dans la région, notamment pour les grossesses à haut risque. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 14 Introduction Preterm labour—defined as delivery occurring before 37 weeks of gestation EBZT ãJTBNBKPSEFUFSNJOBOU of neonatal mortality and has long- term adverse health outcomes (1–4). Compared with term infants, preterm infants have higher rates of cerebral palsy, mental retardation, sensory im- pairments, dysfunction in cognitive areas (e.g. attention, visual processing, academic progress) and respiratory illnesses in later life (5,6). Causal vari- ables include medical conditions of the mother and of the fetus, environmental exposure and socioeconomic and cul- tural factors (1). In developed countries the rate of QSFNBUVSJUZ SBOHFT GSPNUPPG live births. However, these rates are estimated to be substantially higher in developing countries (1). In Tunisia, despite the activities of the national perinatology programme, data about the profile and risk factors of prema- ture births are scarce (7). The aim of this study was to describe the epide- miological profile of preterm births in the region of Monastir and to study the chronological trends of associ- ated factors over a period of 19 years m Methods Study design and sample A retrospective population study was conducted using data from the period +BOVBSZ UP%FDFNCFSDPO- cerning births at the public maternity facilities of the region of Monastir. Ac- cording to data from the Moroccan National Statistics Institute, the gov- FSOPSBUF PG.POBTUJS JO IBE B QPQVMBUJPOPG JOIBCJUBOUT 8). 8PNFOPG DIJMECFBSJOH BHF m ZFBST BDDPVOUFE GPS BCPVU PG this population. The study included all newborns aged from 24 to 43 gestation weeks. Data collection Data for this study were collected from the births register which was established by the Department of Preventive Medi- DJOFBOE&QJEFNJPMPHZBUUIF6OJWFSTJUZ Hospital of Monastir. This register was JNQMFNFOUFEJOBOEBMMEFMJWFSJFT that occur in the different public health facilities of the region are recorded in the database. The facilities include a university maternity unit (tertiary-care level), 2 regional ones (secondary-care level) and 7 peripheral maternity units (primary-care level). Midwives in each maternity unit record information in the register about: woman’s obstetric history (maternal age, parity, interpregnancy interval, pregnancy complications); current pregnancy and prenatal care (gestational age, twin pregnan- cies, prenatal visits); and newborn characteristics (prematurity, weight, malformations). To avoid missing data, midwives receive periodic train- ing on the quality of data collection. Members of the Department of Pre- ventive Medicine and Epidemiology make regular visits to maternity units to supervise midwives and ensure the quality of data collection. Definitions For this study preterm delivery was defined as birth before 37 weeks ges- UBUJPOBM BHF EBZT PG HFTUBUJPO Gestational age was estimated based on the last menstrual period and/or ultra- sound assessment prior to 12 weeks of pregnancy. We considered the age of viability to be 24 weeks (7,8). Preterm births were also subdivided according to gestational age (9) into: extreme prematurity (< 28 weeks); severe pre- maturity (28–31 weeks); moderate prematurity (32–33 weeks); and near term (34–36 weeks). Low birthweight was defined as BCJSUIXFJHIUPG LH 10). Preg- nancy complications, especially those following complications that require special care, were premature rupture of membranes and eclampsia. New- born malformations were visible new- born malformations detected during delivery. Advanced maternal age was defined BTBHFɓZFBSTBUEFMJWFSZ 11); young maternal age was defined as age ≤ 19 years at delivery (12). Prenatal care was considered as adequate if the minimum of number of antenatal visits was 4 and the 7 quality criteria were fulfilled (13,14). We defined interpregnancy interval as the interval from the first birth until the estimated date of the last menstrual period before the second pregnancy, expressed in completed months (15). Parity was the number of pregnancies carried to 28 weeks (16) and multiparity was defined as parity > 4 (17). Data analysis Statistical analyses were performed using SPSS WFSTJPO6OJWBSJBUF analyses were used to identify factors associated with preterm delivery. The chi-squared test was used to assess significance for categorical variables. The risks of preterm birth were ex- QSFTTFEBTPEETSBUJP 03 XJUI confidence intervals (CI). A P-value ≤ XBTDPOTJEFSFEUPCFTUBUJTUJDBMMZ significant. Multivariate stepwise logistic regression was performed to identify the determinants of preterm birth. In this model, variables with a univariate UFTU WBMVF ɒ XFSF JODMVEFEĉF final returned variables were those sig- OJėDBOUBU UIF MFWFMPG5PEFTDSJCF the chronological profile, we used the Spearman (r) correlation test. Results Prevalence of preterm births Data were analysed from 161 116 deliveries in the public maternity facilities of Monastir over the study QFSJPE m 0WFS UIF year period, the overall prevalence of HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 15 Regression analysis of risk factors for premature birth Table 3 shows that the risk factors for premature birth in the final regression model were extremes of maternal ages (P UXJOQSFHOBODZ BEKVTUFE 03 $* m BOE QSFUFSNCJSUITXBT $* m EFMJWFSJFT XJUI PGEFMJWFSJFTPDDVSSJOHQSJPS UP 33 weeks. The distribution of overall deliveries included in the study ac- cording to gestational age is presented in Table 1. The preterm birth rate increased sig- OJėDBOUMZGSPNJOUPJO P 'JHVSF )PXFWFS the proportion of births from pregnan- cies with short interpregnancy interval EFDSFBTFE TJHOJėDBOUMZ GSPN JO UP JO P (Figure 2). Similarly, the proportion of births in women with adequate prenatal DBSFJODSFBTFETJHOJėDBOUMZGSPN JO UP JO P (Figure 3). Characteristics of preterm birth The mean maternal age of preterm ba- CJFTXBT 4% ZFBSTBOE PGXPNFOIBEBOBEWBODFEBHF ɓ years) age. The mean parity was 2.4 (SD BOEPGXPNFOXFSFQSJNJQB- SBT"MNPTUBMMUIFXPNFO IBE NBEFBUMFBTUQSFOBUBMWJTJUBOE on average had received adequate pre- natal care. Among preterm deliveries, 6776 XFSF WBHJOBM EFMJWFSJFT BOE XFSF DBFTBSFBO TFD- tion deliveries; 4692 preterm infants IBEB MPXCJSUIXFJHIU kg). The results of the univariate analyses of factors associated with preterm birth are displayed in Table 2. Maternal factors significantly associ- ated with increased risk of preterm birth were: extremes of maternal age ɒPSɓZFBST QSJNJQBSJUZPS multiparity; and short interpregnancy interval (< 24 months). Women with inadequate prenatal care were more exposed to the risk of preterm delivery DSVEF03 $*m A male fetus was also at higher risk PG QSFUFSN CJSUI 03D $*m .PUIFSTXIPIBEB twin pregnancy were more likely to IBWFFBSMJFS MBCPVS 03D $*m %BUBPOOFXCPSO malformations and pregnancy com- plications identified from the register were also significantly associated with preterm birth. Table 1 Distribution of deliveries in the Monastir region of Tunisia according to infant’s gestational age, 1994–2012 Variable No. % Extreme prematurity (< 28 weeks) 644 0.4 Severe prematurity (29–31 weeks) 806 0.5 Moderate prematurity (32–33 weeks) 1 128 0.7 Near term (34–36 weeks) 6 445 4.0 Term 152 093 94.4 Total 161 116 100.0 8 7 6 5 4 3 2 1 0 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 4.8 4.5 4.3 4.3 4.8 5.6 5.8 5.3 5.4 5.7 5.7 6.2 6.2 5.8 6.9 6.9 7.27 7 % Figure 1 Trends of premature births in the region of Monastir, Tunisia, 1994–2012 40 35 30 25 20 15 10 5 0 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 % 37.7 31.7 31 26.5 20.9 19.6 19.9 21.420 20.5 21.8 21 22.6 22.3 22.1 22 21.8 21.6 25 Figure 2 Trends of births in which mother had short interpregnancy interval (< 24 months) in the region of Monastir, Tunisia, 1994–2012 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 16 occurrence of complications during QSFHOBODZ 03B $*m 1.96). Discussion This study aimed to provide an estimate of the preterm birth rate in the region of Monastir in Tunisia. We also identified the determinants of preterm births and their trends in the region over a period of 19 years. The data were derived from the births register of the Department of Preventive Medicine and Epide- NJPMPHZBU UIF6OJWFSTJUZ)PTQJUBMPG Monastir. The database had a number of benefits, as it provided data for this population study without the selection bias of hospital studies. It also had some limitations, such as collecting data only on deliveries in public sector facilities and the lack of data on subsequent pregnancies. However, the proportion of deliveries outside the public sector BSFMFTTUIBOGPSQSJWBUFDMJOJDTBOE MFTTUIBOGPSIPNFCJSUIEFMJWFSJFTJO the region (18,19). Although we used a large database our results cannot be extrapolated to the whole country. They may be used as guidance for our country and for other North African popula- tions with the same ethnic origin (Arab Berber) and cultural features. Another limitation of the database was the lack of data on the women’s socioeconomic and behavioural factors (smoking, al- cohol, drug abuse) and these are also factors that may influence the risk of premature births. According to the World Health Organization, preterm birth is a ma- jor determinant of neonatal mortality and morbidity and has long-term ad- verse consequences for health (20). It represents one of the most significant problems in perinatology and is of con- cern in both developed and developing countries. Preterm birth rates have been SFQPSUFEUPSBOHFGSPNUPPGMJWF births in some developed communities but are estimated to be substantially higher in developing countries (1,21). The prevalence of preterm birth varies widely by country all over the world. In this study, the prematurity rate was FTUJNBUFEBUĉJT SFTVMU JOPOF region of Tunisia is lower in comparison with other north African countries; for FYBNQMF JO.PSPDDPBOE JO Libya (22,23). Preterm birth rates, as an indicator of maternal and perinatal health, reflect health disparities between regions. In Tunisia, the preterm birth rate increased TJHOJėDBOUMZ GSPN UPĉJT increase could be explained by the great changes that have taken place in the lifestyles of Tunisian women over this period (such as working outside the home and marriage at older ages), but also to improvements in the quality of prenatal care and the success of na- tional prevention programmes (such as screening for fetal and maternal conditions requiring early induction of delivery) (16). Indeed, during the last decade, we noticed that the rate of ad- equate prenatal care also increased. As a result, risk factors for prematurity are being identified earlier. This trend was also highlighted in high-income coun- USJFTTVDIUIF6OJUFE4UBUFTPG"NFSJDB and Japan. According to the vital sta- tistics of Japan, the preterm birth rate IBTJODSFBTFETJHOJėDBOUMZGSPNJO UPJOĉJTėOEJOHXBT explained differently and improvements in reproductive health technology were believed to be the major contributor to this trend (24). The determinants for preterm de- livery in our population that were iden- tified in univariate analysis were twin pregnancy, extremes of maternal age, interpregnancy interval, sex of newborn and newborn malformations. Twin pregnancy remained significantly asso- ciated with preterm delivery even after adjustment in the multivariate model. In fact, according to international sta- UJTUJDT OFBSMZPG UXJOTBSFQSFUFSN CJSUITBOEBCPVUPGUXJOCJSUITXJMM lead to spontaneous labour before 37 weeks of gestation (3). This observation underlines the importance of follow up for high-risk, multiple-gestation preg- nancies. Extremes of maternal age (≤ 19 ZFBSTBOEɓZFBST XFSFBMTPJEFOUJ- fied as risk factors of prematurity in the final model, a finding which is in concordance with several other studies (25–27). Silveira et al., using the data of a birth cohort study which included all hospitals births in Pelotas, Brazil, found that young maternal age was an important risk factor, probably due to biological immaturity of the mother 90 80 70 60 50 40 30 20 10 0 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 % 49.2 55.1 52.1 57.6 58.4 59.4 65.1 60.3 64.3 69.2 69.9 72 73.2 73.9 75.2 77.6 72.5 78 79.8 Figure 3 Trends of births in which mother received adequate prenatal care (minimum 4 antenatal visits plus 7 quality criteria met) in the region of Monastir, Tunisia, 1994–2012 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 17 (25). Delbeare et al., using data ob- tained from a regional population- based perinatal database in Brussels, reported that older maternal age was an independent risk factor for adverse pregnancy outcomes including very preterm birth (26). According to the literature, women with a short interpregnancy interval are at increased risk of preterm delivery (28). During the study period the proportion of pregnancies with short interpregnancy interval decreased, pre- sumably as a consequence of the high educational level of Tunisian women and the promotion of contraception use as part of family planning strate- gies. However, interpregnancy interval was not identified as a determinant of preterm birth. Giving birth to a male fetus was as- sociated with preterm birth in the uni- variate analysis but not in the multiple regression analysis. Lao et al. has con- firmed this result in their study of Chi- nese women with singleton pregnancies and concluded that carrying a male fetus is an independent risk factor for sponta- neous preterm labour and preterm birth at 34–36 weeks of gestation (29). Table 2 Factors associated with prematurity: results of the univariate logistic regression analysis Variable Total Preterm births Crude OR 95% CI P-value No. No. % Maternal age (years) < 0.001 20–34 129 460 7 188 79.7 1 ≤ 19 3 413 256 2.8 1.24 1.17–1.54 ≥ 35 28 243 1 579 17.5 1.78 1.17–1.98 Parity < 0.001 2–3 75 878 4 284 47.5 1 1 52 223 2 914 32.3 1.29 1.23–1.35 > 3 33 015 1 825 20.2 3.48 1.33–8.63 Interpregnancy interval (months) 0.003 ≥ 24 123 483 6 731 74.6 1 < 24 37 512 2 292 25.4 1.12 1.03–1.21 Prenatal care < 0.001 Adequate 105 949 5 775 64 1 Inadequate 55 068 3 248 36 1.10 1.06–1.16 Sex 0.04 Female 78 786 4 232 46.9 1 Male 82 330 4 791 53.1 1.07 1.03–1.13 Twin pregnancy < 0.001 No 143 900 7 453 82.6 1 Yes 17 216 1 570 17.4 1.68 1.59–1.78 Malformations < 0.001 No 160 882 8 930 98.9 1 Yes 234 93 1.1 2.17 1.49–3.16 Complications < 0.001 No 160 819 8 992 99.6 1 Yes 297 31 0.4 2.3 1.58–3.34 Birthweight < 0.001 Normal weight 133 243 4 136 45.8 1 Low birth weight 19 334 4 692 52 3.46 2.88–4.17 Macrosomia 8 539 195 2.2 1.76 0.61–2.92 Type of delivery < 0.001 Vaginal delivery 137 593 6 588 73 1 Forceps delivery 4 189 152 1.7 3.49 1.58–4.57 Caesarean section 19 334 2 283 25.3 9.19 7.55–10.9 OR = odds ratio; CI = confidence interval. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 18 A higher risk of preterm birth among newborns with congenital anomalies was observed in the crude analyses, but was no longer significant after adjustment for other factors. In fact, previous stud- ies reported that infants with congenital anomalies such as neural-tube defects are more likely to be delivered preterm (3). In our study, maternal complica- tions during labour (premature rupture References 1. Beck S, Wojdyla D, Say L, Betran AP, Merialdi M, Requejo JH, et al. The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity. Bull World Health Organ. 2010 Jan;88(1):31–8. PMID:20428351 2. Nguyen N, Savitz DA, Throp JM. Risk factors for preterm birth in Vietnam. Int J Gynaecol Obstet. 2004 Jul;86(1):70–8. PMID: 15207686 3. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet. 2008 Jan 5;371(9606):75– 84. 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However, other studies doubted the effectiveness of prenatal care for preventing prematurity (24). In our study, we noticed a significant increase of the proportion of women receiving adequate prenatal care over the 19-year study period, which probably reflects improved knowledge about and inter- est in prenatal care among pregnant women. Conclusions Early induced deliveries may be una- voidable for some conditions. However, the results of our study show that we need to enhance the management of multiple pregnancies and pregnancies at the extremes of maternal ages to reduce the rate of spontaneous prematurity in this region. Competing interests: None declared. 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Silveira MF, Victora CG, Barros AJD, Santos IS, Matijasevich A, Barros FC. Determinantes de nascimento pré-termo na coorte de nascimentos de 2004, Pelotas, Rio Grande do Sul, Brasil. [Determinants of preterm birth: Pelotas Rio Grande do Sul State, Brazil, 2004 birth cohort.] Cad Saúde Pública. 2010;26:185–94. 26. Delbaere I, Verstraelen H, Goetgeluk S, Martens G, De Backer G, Temmerman M. Pregnancy outcome in primiparae of ad- vanced maternal age. Eur J Obstet Gynecol Reprod Biol. 2007 Nov;135(1):41–6. PMID:17118520 27. Shrim A, Ates S, Mallozzi A, Brown R, Ponette V, Levin I, et al. Is young maternal age really a risk factor for adverse pregnancy outcome in a Canadian tertiary referral hospital? J Pediatr Ado- lesc Gynecol. 2011 Aug;24(4):218–22. PMID:21620742 28. Smith GC, Pell JP, Dobbie R. Interpregnancy interval and risk of preterm birth and neonatal death: retrospective cohort study. BMJ. 2003 Aug 9;327(7410):313. PMID:12907483 29. Lao TT, Sahota DS, Suen SS, Law LW. The impact of fetal gender on preterm birth in a southern Chinese population. J Matern Fetal Neonatal Med. 2011 Dec;24(12):1440–3. PMID:22023147 30. Boivin A1, Luo ZC, Audibert F, Mâsse B, Lefebvre F, Tessier R, et al. Pregnancy complications among women born preterm. CMAJ. 2012 Nov 6;184(16):1777–84. PMID:23008489 31. Debiec KE, Paul KJ, Mitchell CM, Hitti JE. Inadequate pre- natal care and risk of preterm delivery among adolescents: a retrospective study over 10 years. Am J Obstet Gynecol. 2010;203:122.e1–6. PMID:20471628 32. Shrestha S, Dangol SS, Shrestha M, Shrestha RP. Outcome of preterm babies and associated risk factors in a hospital. JNMA J Nepal Med Assoc. 2010 Oct–Dec;50(180):286–90. PMID:22049892 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 20 Problems of providing services to people affected by HIV/AIDS: service providers and recipients perspectives G. Moradi,1 M. Mohraz,2 M.M. Gouya,3 M. Dejman,4 S.S. Alinaghi,2 K. Rahmani 5 and H. Malekafzali-Ardakani 6 ABSTRACT This qualitative study aimed to identify the health-care problems of people living with HIV (PLHIV) in 2 large cities: Tehran and Kermanshah. Two main groups of stakeholders — service providers (policy-makers, managers, physicians and counsellors) and service recipients (PLHIV and their relatives) — participated in focus group discussions and in-depth interviews. We identified 24 themes covering the major health problems of PLHIV, including: incomplete and inadequate coverage of health-care services; patients’ substance abuse; patients’ fear of stigma; occupational burnout of certain service providers; patients’ dissatisfaction with some of the services provided by counselling centres/clinics; medical staff’s failure to observe confidentiality; and patients’ lack of access to required specialized services. The problems and needs identified can inform the design and implementation of health programmes in our country and elsewhere in the Eastern Mediterranean Region. 1Kurdistan Research Centre for Social Determinants of Health, Kurdistan University of Medical Sciences, Sanandaj, Islamic Republic of Iran. 2Iranian Research Centre for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviours; 6Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to H. Malekafzali-Ardakani: malek179@ gmail.com). 3Department of Infectious and Tropical Diseases, Centre for Communicable Diseases Control, Ministry of Health and Medical Education, Tehran, Islamic Republic of Iran. 4Social Determinants of Health Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran. 5Department of Epidemiology, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. Received: 18/02/14; accepted: 11/03/14 wz`BÐíÓmXz#ÐXzaX|]hof?íXÛzwüÐ ïOTÐKmeBÐÛ ó ó^ TÐÜíD`<M<mZBÐÞmH±TÓmXz#Ðwza=SmYX ©nTØÚÌM\RÌdYNAº©n1Ú{UnBºbhfdL{hH{1Ì{hHºën+ØpY[_Yºn= óTï{gY{e7ºÛ}7fhYºïØÐ}YØnS Nfx{Y:ïPåUÐåLnfCÐÛ óå ó_UÐÜíEåa=Nå=n[CÐÞnåI±UpåY {bCÐpåh[UÐpåxnL}UÐTnåZYDåLæ}´å_UÐOÎpåHÐÚ{UÐì|åwqåR{woåÉ°#Ð ÓnåY{#ÐåY ¬{bYnåª på hf_CÐæÐ}åJúÐÓnåLe6åYënhåhýÚënå Le6qTÚnåIºpå hahTç}åJêÐ{åHnR ìnåZfY}TíëÐ}ågJNå>ET åå)ÚnSÌíïPååUÐååLnfCÐÛ óåå ó_UÐÜíEååa=ëåå=n[CÐÞnååIúÐÓnååY{#ÐååbdYíëíÚnååZYíÊnååJÌíëí}ååx{YíÓnååHnhHåå_Ðí Nå=n[CÐÞnåI±Uphåhý}UÐpåh[UÐTnåZCÐå]`>ðnåLY24ëåAnUÐØ ö{åA{åSí påb ¬e_YÓĆå=nbYíÒ~å öT}YpåhLn+ÓnåZSnfY:ÐTÚnåI æåBíºÓÐÚ{åedU}åCÐåJn_>íºnågYÊĆYê{åLípåh[UÐpåxnL}UÐÓnåY{Bpåh]`>åbiåUÙ:5å=ÅïPåUÐåLnfCÐÛ óå ó_UÐÜíEåa= ºØnåIÚüÐÓÐØnåhL ~TÐ}YåóõSåYpåY {bCÐÓnåY{#Ðå_=åL}åCÐnåÚê{åLíºÓnåY{#ÐåY ¬{bCåfgCÐçnåwÚüÐíºpåeÉUÐåY}åCÐ Ón@nhAøÐíTnåZCÐëÌOÎëåAnUÐådBí på=d]CÐpåh[[UÐÓnåY{#ÐDåL ó}åCÐéå[Aê{åLíºpåx ödUå]UÐåSn]UÐÒnåLÐ}Yê{åLí åHCÐç åhdSÎåYî}åBÌåTnYÌ:í{ådUÐÐ|åw:påh[UÐsåYÐFUÐ|åhaf>íåhe[>ï}å>ëÌåcexnåghdLæ}´å_UÐå>åUÐ Difficultés dans l'offre de services aux personnes touchées par le VIH/sida : point de vue des prestataires et des bénéficiaires de services RÉSUMÉ La présente étude qualitative visait à identifier les problèmes de soins de santé pour les personnes vivant avec le VIH dans deux grandes villes : Téhéran et Kermanshah. Deux grands groupes de parties intéressées — des prestataires de services (responsables politiques, administrateurs, médecins et conseillers) et des bénéficiaires de services (les personnes vivant avec le VIH et leur famille) — ont participé à des groupes de discussions thématiques et à des entretiens approfondis. Nous avons identifié 24 thèmes couvrant les principaux problèmes de santé des personnes vivant avec le VIH et notamment la couverture incomplète et insuffisante des services de soins de santé, l'abus de substances psychoactives des patients, la crainte de la stigmatisation ressentie par les patients, l'épuisement professionnel chez certains prestataires de services, l'insatisfaction des patients au sujet de certains services proposés par des centres de conseil/des dispensaires, l'échec du personnel médical à respecter la confidentialité, et le manque d'accès des patients aux services spécialisés nécessaires. Les difficultés et les besoins identifiés peuvent servir de base à l'élaboration et la mise en œuvre de programmes de santé dans notre pays et ailleurs dans la Région de la Méditerranée orientale. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 21 Introduction Although the overall prevalence of HIV in the World Health Organiza- tion (WHO) Eastern Mediterranean Region (EMR) is still low, the Region is at high risk regarding the spread of HIV/AIDS (1,2). In the Islamic Re- public of Iran, one of the most populous countries in the EMR, government data SFDPSEFE)*7QPTJUJWFJOEJWJEV- BMT UP UIFFOEPG4FQUFNCFS 1), XIJMF UIF6OJUFE/BUJPOT FTUJNBUFE BTNBOZBT m individuals were living with HIV in 2). The country’s HIV epidemic is concentrated among injecting drug VTFST *%6T PG DBTFT BSFEVF UP OFFEMFTIBSJOH WFSTVT UP TFYVBM USBOTNJTTJPO UP JOGFDUFE CMPPEBOECMPPEQSPEVDUTBOEUP mother-to-child transmission (3). Many diagnostic, treatment and counselling services for people living with HIV/AIDS (PLHIV) are provid- ed free of charge in the Islamic Republic of Iran. These include counselling ser- vices, harm reduction, CD4 count tests, antiretroviral therapy, regular visits by general physicians, infectious disease specialists and psychiatrists, family plan- ning services, and treatment of tuber- culosis. The majority of these services are offered in special centres known as counselling centres for behavioural diseases. There is one centre in cities with a population of less than 1 million, while in other cities with over 1 million residents, there are up to 4 centres de- pending on the population (4). In addi- tion, in all provinces “triangular clinics” provide specialized services for high-risk individuals and PLHIV, which include counselling for behavioural disorders, centres for vulnerable women, clubs for HIV-positive people, voluntary counselling and testing centres, shelters for homeless drug users, and clinics in prisons (5,6). Although interventions such as antiretroviral therapy have increased patients’ lifespan, PLHIV still face many social and psychological problems and difficulties in accessing health services. Compared with uninfected individu- als, PLHIV suffer from stigma, anxiety, depression, job loss, poorer access to health-care services and lower quality of life. Several studies have shown that the nature of the epidemic and the culture and environment of a particular country or city are the most important factors which affect the services received by patients (7–9). In a study in Western Cape, South Africa, HIV-positive wom- en perceived stigma from health pro- viders which negatively affected their access to services, their visits to health service centres and their engagement in social interactions (10). Despite the many services available and attempts to provided care and treat- ment of PLHIV in Islamic Republic of Iran, there are still many challenges for diagnosed individuals. To the best of our knowledge, there has been no pub- lished qualitative study in this or other countries of the EMR to investigate the problems of providing rehabilita- tion and supportive services for PLHIV. The available quantitative studies do not provide a deep understanding of the existing problems (11), whereas qualitative studies are more able to shed light on deeper layers of care- and treat- ment-related problems of PLHIV (12). Determining the problems in offering services can be an appropriate guide for future planning of health and treatment services. A study was therefore con- EVDUFEJOUPJOWFTUJHBUFUIFIFBMUI care problems of PLHIV in the Islamic Republic of Iran from the perspective of 2 main groups of stakeholders: service providers (i.e. policy-makers, managers, experts, physicians and counsellors) and service recipients (i.e. PLHIV and their relatives). Methods In this qualitative research, participants’ views about the problems of PLHIV with regard to health-care services and supportive measures were collected using a number of FGDs and in-depth interviews. Sampling We selected participants from 2 cit- ies: Tehran, the capital city, and Ker- manshah, another major city where many people with HIV/AIDS are living. We used purposive sampling to select the most informed and knowl- edgeable participants (13). Different criteria were used for selecting the participants depending on the stake- holder group. PLHIV were those who had been HIV-positive for more than 2 years; had a minimum experience of 6 months in visiting one of the centres providing services for PLHIV; and were aged over 18 years and literate. The relatives of these PLHIV were those who had a continuous life with the PLHIV as his/her spouse, parent, sibling, child or caretaker; and were aged over 18 years and literate. Physi- cians and counsellors were selected from among those who had at least 1 year of experience working in one of the centres providing services for 1-)*7 " UPUBM PG 1-)*7T 1-)*7 SFMBUJWFT QIZTJDJBOT BOE DPVOTFMMPSTXFSFJOWJUFEGPS'(%T QFPQMFBDDFQUFEUIFJOWJUBUJPOBOE participated in the discussions. We also selected 6 key persons among policy-makers and managers who had considerable experience of providing health services for PLHIV. All 6 invited to the FGDs accepted and partici- pated in the discussions. In addition, 6 individual interviews were conducted with the managers and policy-makers. Data collection A total of 4 FGDs were conducted with the HIV-positive people, 2 FGDs with the relatives and 2 FGDs with physicians/counsellors, with a mini- mum of 6 people per focus group. It was hoped that participants would be more comfortable sharing ideas in an EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 22 categorized into 24 themes. Further analysis of these themes indicated that they could be clustered into various groups based on stakeholders’ ideas; JF UIFNFTCFMPOHFE UP UIFQPMJDZ makers and managers, 6 to the physi- cians and counsellors, 7 themes to the PLHIV and 6 to PLHIV’s relatives. Tables 1 and 2 show the identified cat- egories (themes) in each stakeholder group, illustrated by examples of quotes from participants, and the macro-cat- egories which were formed by cluster- ing themes with similar content. The findings have been ordered based on their frequency, i.e. the findings with the highest frequency of responses have been placed higher than those with lower frequencies. The following macro-categories were determine based on the views of the different groups of stakeholders: PLHIV’s lack of complete access to the service centres; incomplete coverage of PLHIV health services in these centres; lack of access to the required special- ized care services; lack of awareness and training in the community; substance abuse by PLHIV; problems associated with methadone maintenance therapy (MMT) for PLHIV; stigma perceived by patients; burnout of personnel that provide care for PLHIV; employment problems of PLHIV; excessive bu- reaucratic processes; inconsistency of services provided across the country; dissatisfaction with some of the ser- vices provided in counselling centres; and dissatisfaction with hospital care. Similar themes were identified by the different groups of stakeholders. From the perspectives of managers, policy-makers, physicians and counsel- lors, there were a number of problems in common: difficulties for PLHIV in accessing the centres that provide services; inadequate and incomplete coverage of PLHIV treatment services; lack of awareness in the community; substance abuse by PLHIV; PLHIV’s fear of stigma; and burnout by medical personnel (Table 1). homogenous group. Two research- ers participated in each FGD; one of them managed the FGD and the other recorded the nonverbal interactions of participants. Following the partici- pants’ agreement, some of these ses- sions were recorded and transcribed. To conduct the FGDs the facilitators, who were trained in qualitative meth- ods, started by presenting the aim of the FGD and then proceeded with a set of questions and follow-up probe questions to investigate the problems of providing health-care services for PLHIV (for example, barriers to accessing services, family problems and problems related to health-care delivery systems). Every FGD took CFUXFFOUPIPVST To conduct the in-depth interviews with managers a similar question guide was used, with probe questions to gain a deeper understanding of the responses. The FGDs were conducted in a si- lent room and the individual interviews took place in the managers’ offices. Ethical considerations Participants’ discussions were record- ed only with their agreement (hence, not all the interviews and FGDs were recorded). During the sessions, the researchers stopped recording when- ever participants asked not to record their voice. When it was not possible to record, notes were taken and the conversations were summarized on paper. Moreover, the participants were assured that the collected data would remain strictly confidential and would be used only for research purposes. Participants had complete freedom to leave the study at any stage they wished and to protect their identity a code was used instead of their actual names. Data handling and analysis 6TJOHOpenCode software for qualita- tive data analysis, the transcripts were first reviewed and initial themes were extracted. Care was taken to use the participants’ own responses for the wording of the initial themes, which were subsequently categorized ac- cording to their content; that is, those extracts which had similar thematic content were grouped together. In order to reduce the number of catego- ries, these were further clustered to form a number of macro-categories. During the process of theme extrac- tion and categorization, each newly extracted theme was carefully com- pared with the previous ones in order to further enhance the reliability of the study. The researchers utilized various bias reduction techniques in order to mini- mize the factors that threaten the inter- nal and external validity of the analysis (14). To secure the trustworthiness of the analysed data, the 4 indices of credibility, dependency, conformabil- ity and transferability were checked. In order to enhance credibility the par- ticipants were selected from among those who had experience of contact with HIV care services. Dependency was improved by taking the ideas of the research team into account with regard to the review, theme extraction and analysis of transcripts and so the research reports were given to various researchers and experts who provided feedback. To increase the conform- ability of the research members of the research team discussed any conflicting findings and came to an agreement. The transferability of the findings was improved by providing a rich descrip- tion of the data and by ensuring that individuals with different responsibili- ties and educational backgrounds par- ticipated in the study. Results The themes of the study were analysed within the 4 stakeholder groups: policy- makers and managers; physicians and counsellors; PLHIV; and relatives of PLHIV. In general, the findings were HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 23 Table 1 Views of managers, policy-makers, physicians and counsellors about the problems of providing services for people living with HIV/AIDS (PLHIV) in the Islamic Republic of Iran Macro-category Category Example quotes Views of managers and policy-makers Difficulties for PLHIV in accessing service centres Long traveling distances for PLHIV to receive health-care services “Some of the PLHIV do not go to these centres due to the long distances.” PLHIV cannot cover cost of commuting to the centres due to financial problems “Some people do not have the fare for transport to these centres.” Small number of service centres (counselling centres), especially in mega-cities “There are a limited number of counselling centres.” Incomplete coverage of services for PLHIV in counselling centres (specialized services and care) Lack of specialized services for PLHIV and care in counselling centres “Counselling centres do not have the capacity to provide specialized services.” PLHIV not receiving required health services provided by other centres, e.g. hospitals or health centres, due to patients’ financial problems “Other centres do not provide the required services due to patients’ lack of financial ability.” Inappropriate coverage by insurance services Inappropriate coverage of insurance services and lack of insurance for health needs “Given that most of the infected people do not have health insurance, they face financial problems if they want to use health-care services.” Lack of awareness and training in the community Insufficient awareness about HIV/ AIDS in the community “Still the community has little information in this regard. People suppose that the patients will certainly die.” Insufficient awareness about HIV/ AIDS among PLHIV “Patients do not have enough information about the disease and its treatment.” Lack of awareness about HIV/AIDS among medical staff Insufficient awareness about HIV/ AIDS among medical staff “Unfortunately, medical staff, especially in other centres, do not have enough knowledge about patients’ treatment and care. They do not admit patients appropriately.” Substance abuse by PLHIV Insufficient substance abuse treatment centres willing to provide services for PLHIV “Substance abuse is itself a problem among many patients. There are still no effective substance abuse treatment services for these individuals.” Stigma of HIV Patients’ fear of stigma from the community and health personnel hinders their utilization of services and needs more elucidation to be understood “Because of the stigma and the fear of being recognized as HIV patients in the community, PLHIV are not willing to refer to counselling centres.” Views of physicians and counsellors Difficulties for PLHIV in accessing service centres Long traveling distances for PLHIV to receive health-care services “There is a long travel distance [between home and the centres] for the patients.” “Long travelling distances, poverty and substance abuse prevent patients getting to the centres.” PLHIV cannot cover cost of commuting to the centres due to financial problems “These patients do not have money even for food, let alone for commuting to the centres.” Lack of timely referral of PLHIV to services Lack of awareness and training in the community Lack of awareness about HIV/AIDS in the community “There is insufficient training [about HIV/AIDS] in the community.” Lack of awareness about HIV/AIDS among medical staff “Hospital personnel still do not have suitable knowledge about HIV.” Incomplete coverage of services for PLHIV in these centres Lack of/inappropriate insurance coverage for PLHIV “Most of the patients do not have an insurance card/book or do not even have the financial ability to get insurance.” EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 24 PLHIV and their relatives also identified a number of problems in common: patient’s fear of stigma; dis- satisfaction with some of the services provided by counselling or medical centres; violation of confidentiality by medical staff; difficulties in accessing specialized services; inequity in services provided in different centres across the country; financial difficulties of PLHIV and their families; lack of employment for PLHIV; and substance abuse by PLHIV (Table 2). According to participants’ re- sponses, while some of these problems were mentioned by all groups of stake- holders, others were pinpointed only by specific groups. For instance, all 4 groups believed that fear of stigma was one of the major problems for PLHIV in receiving care services. However, closer inspection of the 4 groups’ views showed that from the perspec- tive of managers, policy-makers and relatives, the stigma originated only from the community, whereas physi- cians and counsellors also believed that it could originate from medical staff. On the other hand, patients themselves claimed that the strongest stigma came from their family, fol- lowed by the community and medical personnel. Discussion Even without a vaccine against HIV, the effectiveness of antiretroviral therapy in treating and preventing HIV infec- tion, and the increased availability of resources for HIV programmes in low- and middle-income nations, are reasons for optimism (15). Neverthe- less, this study has drawn attention to a number of health-care problems for PLHIV in the Islamic Republic of Iran, in terms of service provision is- sues (incomplete coverage of services, especially specialized services, patient dissatisfaction); access problems (patients’ inability to pay for transport or for services); staffing problems (burnout, confidentiality violations); low community awareness; patients’ fear of stigma; patients’ financial/em- ployment problems; and patients’ drug use. These problems may be common to other countries of the EMR, due to these countries’ cultural and social similarities, and the study may provide evidence which can also be applied in other parts of the world. Table 1 Views of managers, policy-makers, physicians and counsellors about the problems of providing services for people living with HIV/AIDS (PLHIV) in the Islamic Republic of Iran (concluded) Macro-category Category Example quotes Incomplete coverage of services for PLHIV in these centres (continued) PLHIV are not receiving more specialized services due to financial constraints (Only general services and some limited specialized services, e.g. visits by infection- and antiretroviral-therapy- specialists, are free in PLHIV service centres; other services, e.g. surgery, are not free) “Patients do not have any money for more specialized services.” Simultaneous infection with hepatitis C virus “A lot of patients are also infected by hepatitis C, but they cannot provide the cost of its treatment. On the other hand, this situation has not been predicted in the system that provides services for them.” Lack of additional tests required for PLHIV, e.g. viral load, in the centres “Not all parts of the country yet have the facilities to do more specialized tests like viral load.” Stigma of HIV PLHIV’s fear of stigma from the community “Patients still suffer from the fear caused by stigma. It is always one of the stressful factors for patients.” PLHIV’s fear of stigma from medical staff “At the moment, the system that provides services for these patients has a stigmatizing attitude toward them.” Injecting drug use (IDU) by PLHIV Insufficient IDU treatment centres which are willing to admit PLHIV “Patients’ substance abuse and lack of effective substance abuse treatment services for them have caused a lot of problems.” Burnout of personnel who provide care for PLHIV Fatigue and burnout among service providers due to working with PLHIV “For years, staff in counselling centres have provided services for these patients. They suffer from work-related fatigue and burnout. In other words, their patience for work has been minimized.” HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 25 Table 2 Views of people living with HIV/AIDS (PLHIV) and their relatives about the problems of providing services for PLHIV in the Islamic Republic of Iran Macro-category Category Example quotes Views of PLHIV Stigma of HIV PLHIV fear the stigma that is attached to them by their family “Our own families have a negative attitude toward us. This is worse than any other thing, including the disease itself.” PLHIV fear the stigma that is attached to them by the community “People in the community will reject us if they know that we are HIV-positive individuals.” PLHIV fear the stigma that is attached to them by medical staff “Even the medical staff look down on us.” “When hospital staff found that my brother is HIV infected, they put a tag on his room door saying that the room is isolated due to the risk of HIV. It prevented personnel from providing proper services. Additionally, other patients and visitors looked down at us. It really annoyed us.” Dissatisfaction with some of the services provided in counselling centres Counsellors’ weakness in conducting counselling sessions for PLHIV “Despite the fact that we need further counselling, after one or two sessions we do not experience any good quality counselling.” Medical staff’s lack of respect for PLHIV in counselling centres “Unfortunately, a large number of medical personnel do not have an appropriate behaviour toward us, especially when the centres are busy.” Medical staff’s inattention and lack of motivation (e.g. causing long waiting times for PLHIV to receive drugs and services) “Some of the patients are employed and their employers give them only a short time off in order to go to the counselling centre. However, they wait too long in the centres due to personnel’s negligence.” “In most cases, when we refer to services, we face staff inattention. They will treat us in way that makes us feel embarrassed.” Frequent changes of medications and problems with side-effects for PLHIV “Our medicines have side-effects and change frequently.” Lack of awareness and training in the community and special groups Lack of awareness in the community about HIV/AIDS (e.g. the training programmes provided for the public and high-risk groups are sporadic and cross- sectional) “The community and the people around us are not yet sufficiently familiar with this disease.” Lack of an organized and continuous training programme about HIV/AIDS for PLHIV In each stage, patients need some information about the disease, self-care, and other issues. Such trainings are not provided and most trainings for patients are limited to primary ones.) “We need permanent and ongoing training; however, after diagnosis, we do not receive a lot of training.” Violation of patients’ confidentiality Violation of patients’ confidentiality by medical staff “Some of the medical personnel, especially in hospitals, inform other staff and our family about our disease as soon as we are admitted to the medical centre.” Lack of access to required specialized care services Lack of access to infectious disease specialists and psychiatrists for PLHIV during all weekdays “Unfortunately, we do not have access to specialists, particularly infectious disease specialists on all weekdays.” Employment problems of PLHIV Lack of jobs for PLHIV who are unemployed “We have problems with finding jobs. But the policy-makers to do not take any action [to solve this problem] in this regard.” Excessive bureaucracya Excessive bureaucratic processes for receiving services (e.g. although there are some pre-defined support services such as loans, job, insurance, and health and hospital services, the bureaucratic complications deter patients from using them) “I was in jail some years ago. I was promised an employment loan of 100 million rials when I left prison. But I never received this loan due to administrative bureaucracy.” EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 26 In general, the views of manag- ers/policy-makers and physicians/ counsellors were similar. Both groups believed that the main obstacles to providing services for PLHIV were access difficulties for patients; the incomplete coverage of health-care services, particularly special services for PLHIV; insufficient awareness and training in the community; and substance abuse by PLHIV. The most important common factors in this regard are patients’ financial prob- lems, including inadequate insurance coverage, and substance abuse. Fur- thermore, in most parts of the world HIV/AIDS-infected people are co- infected with hepatitis B and/or C virus (16) and this increases the costs of their treatment. As a result, financial problems and inadequate insurance coverage are the main obstacles to pa- tients’ continuing treatment. In addi- tion, physicians and counsellors at the counselling centres for behavioural disorders believed that staff burnout was one of the problems in offering adequate services. The same point was raised by PLHIV themselves, who were not satisfied with some of the services provided by the personnel at the centres. These findings are echoed in studies in Zambia (17) and in Ma- lawi (18). The views of PLHIV and their relatives were also somewhat similar. Aside from the fear of stigma, both groups claimed that the main prob- lem was with some of the services provided in counselling centres and they expressed dissatisfaction with counselling sessions and frequent changes of medication and medica- tion side-effects. Furthermore, PLHIV believed that some of the medical staff, especially hospital nurses, did not respect them and had violated their confidentiality. The same issue (i.e. patient confidentiality and its violation by physicians and nurses) was men- tioned in other HIV-related studies (19–21). All 4 groups of stakeholders men- tioned that stigmatization of PLHIV Table 2 Views of people living with HIV/AIDS (PLHIV) and their relatives about the problems of providing services for PLHIV in the Islamic Republic of Iran (concluded) Macro-category Category Example quotes Views of relatives of PLHIV Stigma of HIV Relatives fear the stigma attached to them by the community “In fact, in the community, both the patient and his/her family members are stigmatized.” Disparities in services provided across the country Disparities in services provided in different counselling centres across the country “We moved to another city, where the provided services were better than those offered here. For example, dental services were also provided there.” “Good services are only offered in provincial capitals.” Problems associated with methadone maintenance therapy (MMT) for PLHIV Lack of a comprehensive plan for the unification of patients’ MMT in service centres across the country “The excessive costs of methadone and lack of a unified procedure for receiving it have caused a lot of problems for us. Our patient is an addict who requires methadone along with other medications; however, there are many problems in providing MMT.” Dissatisfaction with some of the services provided in counselling centres Counsellors’ weakness in conducting counselling sessions “Given the large number of patients covered by counselling centres, the counselling sessions are often short and incomplete.” Frequent change in patients’ medications, and the subsequent side- effects (e.g. when ART is not available it leads to discontinuity of treatment or to one of the drugs in a regime being replaced with other drugs) “Frequent change of patients’ medications causes side-effects. Also, sometimes their medicines are not provided on time.” Dissatisfaction with hospital care Inadequate provision of health services, particularly at the time of patients’ admission to hospital “Unfortunately, when these patients are admitted for a particular problem, many of the physicians and medical staff avoid accepting them or offering their services.” Substance abuse by PLHIV Problems in health care caused by patients’ substance abuse “The problem of their [patients’] substance abuse causes great problems in treatment and other social services that are provided for them.” aProposed only by one of the PLHIV. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 27 was a major problem in providing services for patients. As indicated in a number of other studies such stigma has clearly existed from the very early days when HIV/AIDS was diagnosed in various parts of the world (7,22,23). The results further indicate that lack of sufficient awareness within the community and among the medi- cal staff was another major problem from the perspective of PLHIV. They felt not only that members of the public were unwilling to be in contact with them, but also that many of the medical staff were not interested in providing health services for them. This is a bitter reality, despite the fact that in recent years physicians and nurses in the Islamic Republic of Iran have become accustomed to provid- ing health care for PLHIV. Although nowadays, people with HIV receive more free care and health services from the public sector, they still suf- fer from lack of adequate specialized services. There are 3 main reasons for this: financial problems of patients; stigma attached to PLHIV especially by medical staff; and inadequate cov- erage of insurance services (many of the PLHIV either do not have any insurance, or if they have it, the insurance cannot cover specialized services such as dental services or certain types of surgery). Another major category of prob- lem for PLHIV was their inability to access the counselling centres for behavioural disorders due to the small number of centres; the long travelling distances; and their inability to cover the commuting costs. It is inferred from the present study that patients’ financial difficulties were the key fac- tor in this problem. A study in Los "OHFMFT JO UIF6OJUFE4UBUFT DBNF to the same conclusion regarding the costs of services and transport for PLHIV (24). Moreover, in research in suburban and rural areas of Califor- nia, it was suggested that physical and transport issues were the main prob- lems in accessing health services for PLHIV. They proposed that setting up transportation systems or mobile clinics can be helpful for individu- als with physical disabilities (25). In another study, it was indicated that solving patients’ transport problems would simplify access to HIV services and other peripheral services, which in turn can have a positive influence on the health of PLHIV (26). Patients’ financial difficulties were also one of the main obstacles to their receiving some services. This is due to structural defects in the Iranian health system, so that in spite of the presence of insur- ance organizations, the costs of health care and hospital services are generally high both for the general population and PLHIV (27). Another problem identified in this study, and one which was mentioned in another study, is the issue of rela- tionships between service providers and clients. It seems necessary that all the staff who provide services for PL- HIV should be trained about effective communication with patients (28). A major problem of people with HIV/AIDS in the Islamic Republic of Iran is substance abuse, a subject that was mentioned by all groups of participants except the PLHIV them- selves. Since most of the individuals who have been diagnosed with HIV in this country are substance abusers (3), the lack of effective planning and services for substance abuse treat- ment will cause problems for patients in receiving other health and treat- ment services, an issue that has also been highlighted in some other stud- ies (29,30). Conclusions and recommendations This research adopted a qualitative methodology to collect the ideas of various groups of stakeholders (both service providers and recipients). The results highlight the need to pay at- tention to the problems that hinder service provision for PLHIV and to consider possible solutions. We suggest that there is a need to promote advocacy among policy- makers to make necessary changes in the health system to provide services effectively to PLHIV. The advocacy must be initiated by the relevant international and national organiza- UJPOTBđMJBUFEXJUI UIF +PJOU6OJUFE Nations Programme on HIV/AIDS and WHO. Since a major obstacle to receiving appropriate services was the stigma perceived by PLHIV and their relatives, training strategies are needed to reduce stigma originating within the community. The Iranian Ministry of Health also needs to take action to tackle stigmatization of PLHIV by therapists. Another major obstacle to providing services was the difficulty for PLHIV in access- ing services. Patients’ access must become geographically and economi- cally feasible. Because most PLHIV JO*TMBNJD3FQVCMJDPG*SBOBSF*%6T appropriate measures are needed to provide them with access to harm reduction services. Considering the increasing burden of HIV/AIDS in the Islamic Republic of Iran and other countries, we suggest that integrat- ing HIV-related services into primary health services could be a beneficial way to improve services to patients. Acknowledgements We also extend our appreciation to the staff of the universities of medical sciences and the participants of our study. Funding:8FBSFHSBUFGVM UP UIF6/- AIDS/Iran for providing a grant for this study. Competing interests: None declared. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 28 1. Global report. UNAIDS report on the global AIDS epidemic 2013. 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Outcomes associated with a cognitive-behavioral chronic pain management program implemented in three public HIV primary care clinics. J Behav Health Serv Res. 2012 Apr;39(2):158–73. PMID:21947662 References HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 29 Psychometric properties of the Persian version of the Sexual and Reproductive Health Needs Assessment Questionnaire S. Khani,1 L. Moghaddam-Banaem,1 E. Mohamadi,2 A.A. Vedadhir3 and E.Hajizadeh4 ABSTRACT No tools to assess women’s general sexual and reproductive health needs have been validated in the Iranian context. This study in Sari in Mazandaran province of the Islamic Republic of Iran was conducted to evaluate the psychometric properties of a Persian version of the Sexual and Reproductive Health Needs Assessment Questionnaire (first developed for the International Organization for Migration and United Nations Population Fund). The Persian version of the questionnaire was found to have adequate face and content validity (quantitative and qualitative) for assessing sexual and reproductive health needs among women (content validity index = 0.88). The test–retest reliability showed that, except for the domain of sexually transmitted infections, all domains of the questionnaire had an acceptable reliability (intra-class correlation coefficients > 0.5). This questionnaire is a valid tool for assessing the sexual and reproductive health needs of Iranian women and planning/designing strategies to meet them. 1Department of Midwifery and Reproductive Health; 2Department of Nursing; 4Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Islamic Republic of Iran (Correspondence to L. Moghaddam-Banaem: moghaddamb@modares.ac.ir). 3Department of Anthropology, Social Sciences Faculty, University of Tehran, Tehran, Islamic Republic of Iran. Received: 27/04/14; accepted: 31/08/14 ogåe!ÐoåZTÐÓmå?mg@Ðågga=ëmgåGøogåGÚm`TÐoåecTowFXbgåTÐåýmZ#Ðogå`eTÐogåGmgaTÐåýmZ#Ð og<mhüÐí ìØÐÛ@nAhwÐ}=κEwØÐØíML=̺ï{e7hLºýnf=ê{bYÐ{hUº©nBî}`É çnhåUÐ:ÒÌ}åedUpåh=niüÐíphåf!Ðpå[UÐénå6:påYn_UÐÓnå@nhAøÐå¬hb>åUÐÓÐíØúÐåYïÌpåÉåYåb´UÐåx3oåÉ°#Ð påfdU¢åafUÐÜnåhbUÐåýn[BåhhbUphYĆåHüÐëÐ}åxÎpåxÚge=ëÐÚ{åiÛnYpå^Rn7:ïÚnåH:påHÐÚ{UÐì|åwqåóx}@Ì{åSí ©Ð}åxüÐ Ò{åCÐåYúÐçí{åfÉíÒ}ågdUpåhUí{UÐpåe^fedUðøíÌ åíï|åUÐpåh=niüÐíphåf!Ðpå[UÐÓnå@nhAÐåhhb>ënhåHøphåHÚnaUÐ phåf!Ðpå[UÐÓnå@nhAÐåhhbUðnåahTí ð5åTyåhÉîå7íåýĆYå@íÓÐÙënhåHĆUphåHÚnaUÐpåfUÐëÌ{å@í{åSí ëncådU ÓÐÙënhåHøÐåxØnhY åh+ëÌÚnåBøÐÒØnåLÎ ÚnBøÐpåhS?YÓ}ågKÌí 0.88îåCÐpåÉ kåYÊnåfUÐî{åUpåh=niüÐí ënhåHøÐÐ|åwFå_xåU|=í ðnhåf@påUbfCÐpåx{_ôCÐßÐ}åYúÐëÐ{åhYÊnfåHn=0.5 <åf[UÐåBÐØå=ÐGUÐÓĆå õYn_ ôYpåUbYpåhS?Y någhdUÓnhh>ÐGåHÐåhe[> UípåhiÐ}xüÐÒÌ}åedUpåh=niüÐíphåf!Ðpå[UÐÓnå@nhAÐåhhbUpå"nÉÒÐØÌ Propriétés psychométriques de la version en langue perse du Sexual and Reproductive Health Needs Assessment Questionnaire évaluant les besoins en santé sexuelle et génésique RÉSUMÉ Dans le contexte iranien, aucun outil évaluant les besoins généraux en santé sexuelle et génésique des femmes n'a été validé. La présente étude à Sari, dans la province de Mazandaran (République islamique d'Iran), a été menée afin d'évaluer les propriétés psychométriques de la version en langue perse du Sexual and Reproductive Health Needs Assessment Questionnaire (initialement élaboré pour l'Organisation internationale pour les migrations et le Fonds des Nations Unies pour la population). Il a été estimé que la version en langue perse du questionnaire avait une validité apparente et de contenu adéquate (quantitative et qualitative) pour évaluer les besoins en santé sexuelle et génésique des femmes (indice de validité de contenu = 0,88). La fiabilité d'un test-retest a démontré qu'à l'exception du domaine des infections sexuellement transmissibles, tous les domaines du questionnaire avaient une fiabilité acceptable (coefficients de corrélation intra-classe > 0,5). Le questionnaire est un outil valable pour évaluer les besoins en santé sexuelle et génésique des femmes iraniennes et pour prévoir/élaborer des stratégies qui y répondent. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 30 Introduction Each person has the right to have satisfying reproductive and sexual activities, free of violence or coercion (1,2). Women’s health directly affects long-term development programmes in any country (3) and meeting wom- en’s sexual and reproductive health (SRH) needs plays an important role in social health provision and pro- motion (4). Despite the outstanding progress in health care in the Islamic Republic of Iran, some deficiencies in the provision of sexual health ser- vices in health-care centres have been noted, which might be attributed to sociocultural barriers (5). Accurate determination of unmet needs is necessary to address these deficien- cies and plan for better reproductive services for women (6). In order to properly assess any aspect of health needs in the community a culturally appropriate tool is required in the lan- guage of that community (7). It is hoped that use of appropriate tools to determine women’s SRH needs, and meeting those needs, will lead to reduced mortality and morbidity in women and children (8). Health needs assessment is a sys- tematic method for reviewing health challenges in a society, leading to the identification of priorities and better allocation of resources to promote health and reduce health inequities (9). Our review of studies conducted in the Islamic Republic of Iran revealed that many of the tools used to define SRH needs were specific to particular groups—such as pre-marriage couples (10), students (11,12), people living with HIV/AIDS (12) and adolescents (13)—and there were no general SRH needs assessment tools that had been validated in the Iranian context. We therefore decided to adapt and test an international standard questionnaire for assessing women’s SRH needs in a northern area of the Islamic Republic of Iran. For this study we selected the SRH Needs Assessment Questionnaire, which was designed by New Dimen- sion Consulting (NEDICO) for the International Organization for Migra- UJPOBOEUIF6OJUFE/BUJPOT1PQVMBUJPO Fund to be used among mobile and vulnerable populations in Zimbabwe (14,15). It covers needs in various do- mains of reproductive health includ- ing safe motherhood, family planning, sexual behaviours, sexually transmitted infections (STIs), HIV/AIDS and physical and sexual violence. The ques- tionnaire is similar to the Reproductive Health Assessment Questionnaire for Conflict-Affected Women developed CZUIF6OJUFE4UBUFT$FOUFSTGPS%JTFBTF Control and Prevention (CDC) (16). The SRH Needs Assessment Question- naire, however, is slightly shorter and easier than the CDC questionnaire in terms of understanding and completion by participants, coding, data entry and data analysis. This study in Mazandaran province of the Islamic Republic of Iran was conducted to evaluate the psycho- metric properties of a Persian version of the questionnaire, with a focus on the assessment of face and content validity and reliability of the instrument. Methods Study setting This psychometric study was carried PVU GSPN+VMZ UP.BZĉF study was conducted in Sari, the larg- est city of Mazandaran province in the north of Islamic Republic of Iran. This is a region which has higher scores on favourable reproductive health indices compared with the whole country, e.g. percentage of pregnant women with BU MFBTUQSFOBUBMDBSFWJTJUT JO *TMBNJD3FQVCMJDPG*SBOWFSTVTJO Mazandaran), contraception methods VTFJOSFQSPEVDUJWFBHFT WFSTVT SFTQFDUJWFMZ BOEQFSDFOUBHFPG women who receive at least one post- OBUBM DBSF WJTJU WFSTVT respectively) (17). Sari, in the centre of Mazandaran, was selected for the study, so that the final Persian version of the tool would meet higher than average Iranian standards. Questionnaire Consent to create and test a Persian version of the SRH Needs Assessment Questionnaire (14) was obtained from the deviser of the questionnaire (NED- ICO). The questionnaire is a 114-item English-language instrument consisting PGCBDLHSPVOEJOGPSNBUJPO JUFNT TBGFNPUIFSIPPE JUFNT GBNJMZ planning (16 items), sexual history and GVODUJPO JUFNT 45*T JUFNT HIV/AIDS (14 items) and violence against women (16 items). Translation 5SBOTMBUJPOXBTBTUBHFQSPDFTT4UBHF 1 was to translate the English question- naire into Persian, using the decentred or symmetric method of translation (18,19). In this method, the researcher avoided verbatim translation to be able to implement cultural and social considerations and modifications in the original version. The process of cultural adaptation was supervised by the researchers throughout all phases of the study. The forward–backward procedure was applied for translation (20). Two competent English language translators translated the questionnaire from English to Persian. Stage 2 was back-translation. The 2 Persian versions were translated back into English by 2 other translators who had no access to the original version. Stage 3 was synthesis into one version of the translated questionnaire. The research group compared and revised these 2 versions of the questionnaire and their items, in order to generate an appropriate version. Stage 4 was a review by an expert committee. The final English version and original question- naire were compared item-by-item and in general by 2 other English language and SRH experts, and they confirmed HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 31 totally relevant. The experts evaluated 3 aspects of the questionnaire—each single item, each domain of SRH and the overall questionnaire—checking for the grammar, wording, item alloca- tion, scaling and any needed modifica- tions, eliminations or additions to the questionnaire. Every point made by the experts was applied and made available to the research group. After discussing these views, they would decide which modifications to implement. In order to confirm whether the questionnaire still needed modifications in content, 2 focus group discussions were held with 17 women attending health centres as main beneficiaries and 2 panels of SRH experts. The question- naire modified by the previous stages— translation, adaptation, face and content validations—was made available to them. Each item was read and members expressed their opinions. After reaching a consensus of all members present, that particular item was registered in the questionnaire. Reliability The reliability of the questionnaire was assessed using the test–retest method. This was conducted to assess the ques- tionnaire’s stability by estimating and interpreting the intra-class correlation coefficient (ICC) (24 " UPUBMPG women completed the questionnaire twice in 2-week intervals. Then, scores of these 2 stages were compared and *$$WBMVFTPGɓXFSFDPOTJEFSFE satisfactory (24). Ethical considerations An informed written consent consisting of the general conditions of the study and its applications was obtained from all participants, they were all assured about the preservation of the privacy and confidentiality of their information and comments, and the questionnaires were completed anonymously (without asking the name of the participants or knowing the participant beforehand). The World Health Organization’s UIFTJNJMBSJUZPG UIFWFSTJPOT4UBHF was testing of the tool, in which the va- lidity (face and content) and reliability were assessed. Participants A total of 21 SRH experts and 17 female clients participated in 4 focus group discussions to assess the qualitative con- tent validity of the questionnaire. " TBNQMF PG XPNFO BĨFOE- ing health-care and behavioural diseases consultation centres of Sari, Mazandaran, Islamic Republic of Iran participated in the test–retest phase to assess reliability. Women eligible for the TUVEZXFSFPGSFQSPEVDUJWFBHF m years) and married at least once. All women were selected through a con- venience sampling method and were interviewed face-to-face after a brief explanation about the aims of the study and obtaining their written consent to participate in the study. The interview was performed by one midwife in each centre who read each item from her copy and let the participant chose the appropriate response in her own copy of the questionnaire. For illiterate women, the questionnaire was filled in by the interviewer. Analysis of validity and reliability All statistical procedures were conduct- ed using SPSS, version 19. Face validity, content validity and reliability of the questionnaire were assessed as follows: Face validity Both qualitative and quantitative meth- ods were used for assessing the face va- lidity of the questionnaire. To examine qualitative face validity, 11 reproductive health experts assessed the question- naire, including the head of the family IFBMUIEFQBSUNFOUPG.B[BOEBSBO6OJ- versity of Medical Sciences, an expert from behavioural diseases consultation centres, a social medicine physician, 2 reproductive health experts, a health education expert, a maternal and child health physician, a medical sociologist, an expert with a nursing PhD and 2 midwives. A total of 24 women attending health centres of Sari were interviewed to express their opinions about the ap- pearance of the questionnaire. Then, in the quantitative approach to face validity, impact scores (frequency × importance) were determined by the percentage of participants who identi- fied each item of the questionnaire as extremely important, very important, important, little importance or not JNQPSUBOU BU BMM 4DPSFT PG mXFSF allocated to these levels respectively. Data were entered into the com- puter and the impact scores given by all subjects were totalled. Impact scores > XFSFDPOTJEFSFEBDDFQUBCMF 21). Content validity Two methods (qualitative and quan- titative) were used to assess content validity. In the quantitative phase, 2 indicators of content validity assess- ment were measured: content validity ratio (CVR) and content validity index (CVI). First, to assess content validity by $73 FYQFSUT XIPXFSFOPU GSPN the previous group) were asked to evaluate each item of the questionnaire according to a 3-point scale (necessary, useful but not necessary or not neces- sary) and the CVR was calculated for each item. According to Lawsche, items XJUI$73 CBTFEPOFYQFSUT evaluation) were kept and considered significant (22). To assess content validity by CVI the method of Waltz and Bausell was used (23). The main researcher presented the Persian version of the RVFTUJPOOBJSF UP 43) TQFDJBMJTUT (who were not the experts in previous stages) and requested them to assess the relevancy of each item or statement in the questionnaire. The relevancy criteria were assessed in the format of a 4-point Likert scale for each item: irrelevant, nearly relevant, relevant and EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 32 (WHO) ethical and safety recommen- dations for research on domestic vio- lence against women were also applied (25). The research design of this study was approved by the ethics commit- UFFPG5BSCJBU.PEBSFT6OJWFSTJUZ'PS any stages of the study that required contacting participants, an introductory letter was obtained from the research EFQVUZPG5BSCJBU.PEBSFT6OJWFSTJUZ and the health deputy of Mazandaran 6OJWFSTJUZPG.FEJDBM4DJFODFT Results Translation and adaptation of the questionnaire Several changes were made in this phase with regard to items about educa- tion, religion, childbirth, health care and pregnancy services provided, abortion sites and HIV/AIDS services; these were modified in accordance with the rules of the Iranian Ministry of Educa- tion, as well as the religious beliefs and culture of Iranians, and the existing regulations of the health-care system of the country. Marital status and age of partici- pants at first marriage were asked before enquiring about pregnancy, childbirth and number of children. Due to the confidential and private nature of the questions about sexual violence, as well as to gain the confidence of partici- pants, the order of questions related to QIZTJDBMWJPMFODF OPTm XBT swapped with questions about sexual WJPMFODF OPTm In questions nos. 62–66 “female condom” was changed to “condom”, given that this type of condom is not usually used in Islamic Republic of Iran. Also, question no. 72, “What type of condom have you used so far?”, was omitted (Table 1). Validity assessment In qualitative face validity, the length of the questionnaire and its tabulated form were assessed by 11 reproductive health experts and 24 participants, and the table format of the questionnaire was converted to common numbered format. Question no. 26 (“Who assisted you to deliver at the health centre?”) and question no. 27 (“Who assisted you to deliver at home?”) were merged into one question: “Delivery agent (in your last delivery)”. In qualitative face validity, 21 ques- tions were reworded or modified (Table 2) and 4 questions about the demo- graphic characteristics of the woman’s husband were added: husband’s age, education level, job and household’s monthly income. In quantitative face validity, the total mean impact score was 4.24. The im- QBDUTDPSFXBT GPSRVFTUJPOT BMM of which were omitted. Lack of availabil- ity of female condoms, lack of diversity in religion in the people of this part of Islamic Republic of Iran, application of this tool for fixed populations rather than mobile/refugee camp populations and the fact that there are very few cases of adoption in the country were the reasons for omitting the questions with JNQBDUTDPSF 5BCMF The overall CVR score of the ques- UJPOOBJSFXBT" UPUBMPGRVFT- UJPOTXJUI$73 XFSFPNJĨFE (Table 1). The overall CVI of the question- OBJSFXBTĉF$7*TPCUBJOFEGPS all the constructs of the questionnaire were as follows: background variables TBGFNPUIFSIPPE GBNJMZ QMBOOJOH TFYVBMCFIBWJPVSBOE IJTUPSZ TFYVBMMZ USBOTNJĨFE EJTFBTFT )*7"*%4 BOEWJPMFODFBHBJOTUXPNFO "MM RVFTUJPOT IBE$7* ɓ BOE thus no questions were omitted in this stage. In qualitative content validity the following modifications were imple- mented at this phase of assessment of content analysis: The “no response” option was omitted from all answer items. In the section on background characteristics, 2 questions (nos. 11 and 12) were merged into one question, and 2 open-ended questions about job were replaced by a close-ended question XJUI SFTQPOTF JUFNT 5BCMF *O the 2nd construct, in 4 questions (nos. m iBCPSUJPOuXBTFYDMVEFE GSPN the contraception methods in line with WHO guidelines (26), and 7 questions on unwanted pregnancy were added (Table 2). In the focus group discussions and expert panels the following modifica- tions were implemented. In the sec- tion on background characteristics, spouse’s sociodemographic character- istics were added (i.e. age, education and occupation) and some general information (i.e. family income per month and total expenditure of the household per month). In the 1st construct, a question was reworded according to the experts’ opinions. In the 2nd construct, one more question XBTBMTPFEJUFE *O UIFUIDPOTUSVDU UIFPQUJPOTPGRVFTUJPOT OPT BOE XFSF FEJUFE BOE 2 questions (nos. 91 and 92) were changed into options in one question OP BCPVUNPEFTPG)*7"*%4 transmission (in which only the cor- rect modes were included and the rest were omitted, because when there are both correct and incorrect transmis- sion routes of HIV as options in one question, participants may assume all of them are correct). In the 6th con- TUSVDU RVFTUJPOT OPT BOE XFSF SFXPSEFEBT well. Table 1 shows the questions omit- ted from the tool in various phases and the reasons for their omission. The reworded or modified items of the tool are presented in Table 2. Reliability assessment "UPUBMPGXPNFOQBSUJDJQBUFEJOUIF test–retest phase. The mean age of the participants was 31 (standard devia- tion 7.8) years. A majority of them were IPVTFXJWFT BOE UIFIJHIFTU MFWFMPGFEVDBUJPOBMBĨBJONFOUJO HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 33 of participants was high-school diploma (Table 3). Table 4 shows the ICCs for all domains separately as well as for the whole questionnaire. The overall ICC XBT"MM EPNBJOTPG UIF1FSTJBO version of the questionnaire showed TBUJTGBDUPSZ SFMJBCJMJUZ *$$ FY- cept for the domain of STIs, which was CPSEFSMJOF *$$ Discussion This psychometric study showed that, with slight modifications to the original questionnaire, the Persian version of the SRH Needs Assessment Questionnaire is a valid instrument to assess women’s SRH needs, except in the domain of STIs, which had reliability coefficient close to but slightly below the threshold *$$ *O UIF TUVEZPG.VTBWJ et al. which used behavioural change theories to design a domestic tool for the evaluation of reproductive health in Iranian young people, it was shown that the reliability of the questionnaire was moderate in some domains such as HIV, STIs and use of condoms (27). The low reliability coefficient in the STI domain in our study may be due to spontaneous remission of STI symp- toms in the 2-week interval between test and retest. Some questions in the Persian ver- sion of SRH Needs Assessment Ques- tionnaire were omitted because the target population of the Persian version of the tool are a fixed population and not the mobile/refugee camp population of the original questionnaire; for example, question no. 3 [“How long have you been staying here (camp)?”], was omit- ted. Furthermore, mobile (not fixed) populations and refugees often live in unstable circumstances that expose them to higher risk for SRH problems such as pregnancy complications, STIs, HIV/AIDS or gender-based violence. Thus, such questions were omitted (28,29). In this study, all “no response” options were omitted from the ques- tionnaire because these options could increase the likelihood of the partici- pants choosing them over other items. In a study examining the effect of an educational programme on the aware- ness of women attending hospitals in Bangalore about some aspects of safe motherhood, Tamrakar excluded all “none” options from the instrument in the content validity assessment. That study also provided evidence for high reliability of the instrument using Spearman correlation coefficient (r BOEUIFTQMJUIBMGNFUIPE GPS assessing reliability of the instrument (30). Since women’s awareness about some aspects of safe motherhood had been evaluated, and usually knowl- edge-related questionnaire items have good integrity and homogeneity, it was possible to halve the questions in that study. However, the split-half method of reliability assessment was not appropriate in our study as the Table 1 Items omitted from the Persian version of the Sexual and Reproductive Health Needs Assessment Questionnaire and reasons for omission Order Item no. Item Stage Indexa Score Reasons for omission 1 72 Which type of condom did you use? Adaption – – Female condoms are not available in Islamic Republic of Iran 2 3 What is your religion? Quantitative face validity Impact score 1.47 Most people in this part of I.R. Iran are Muslims 3 4 How long have you been staying here? (camp) Quantitative face validity Impact score 1.45 Women in this study were a fixed population and were not mobile/ living in refugee camps 4 10 How many children are you staying with who are not your own? Quantitative face validity Impact score 1.35 There are very few cases of adoption in Islamic Republic of Iran 5 70 (a,b) How many different sexual partners have you had in the past 1 month, 6 months, 1 year (including husband or live-in partner) Quantitative face validity Impact score 1.35 A 3–6 month period could be too short for determining the number of sexual partners 6 37 Did you start breastfeeding soon after birth? Quantitative content validity CVR 0.60 The question is unclear and participants may have different perceptions of “soon” 7 49 Where do you obtain your sanitary wear from? Quantitative content validity CVR 0.30 Women in this study were a fixed population and usually obtain their sanitary hygiene products from drug stores or supermarkets aImpact scores < 1.5 and CVR < 0.62 for each item were considered as inadequate. CVR = content validity ratio. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 34 Table 2 Items modified or added in different phases of testing the Persian version of the Sexual and Reproductive Health Needs Assessment Questionnaire Row Item no. Stage/ Phase Original version Persian version 1 17 Quantitative face validity Have you ever been pregnant? Number of pregnancies: 2 26,27 Qualitative face validity Who assisted you to deliver at the health centre? Who assisted you to deliver at home? Delivery agent (in your last delivery): 3 68 Qualitative face validity As far as you know, does it happen in this community that women or girls trade sex in order to get food, protection or other things they need? In your neighbourhood, are there any women or girls who are paid for sex? 4 75 Qualitative face validity Are you currently married or living with a sexual partner? Your marital status or living with sexual partner: 5 11 Qualitative face validity Do you earn money from any form of work? Occupation: housewife, office employee, skilled worker (factory, technician), ordinary non-professional worker, professional job (medical, engineering etc.), farming, livestock, fishery industry, city and inter-city driver, service worker, shopkeeper, retiree, other (please state) 6 12 Qualitative face validity If yes, what kind of work do you do? 7 51 Qualitative face validity What family planning methods have you ever heard of? Abortion was omitted from contraceptive methods 8 52 Qualitative face validity Which family planning methods have you ever used? As above 9 53 Qualitative face validity Which family planning methods are you using now? As above 10 54 Qualitative face validity Which family planning methods would you prefer to use? As above 11 – Qualitative face validity (new item) Spouse’s age was added 12 – Qualitative face validity (new item) Educational level of spouse was added 13 – Qualitative face validity (new item) Occupation of spouse was added 14 -– Qualitative face validity (new item) Household monthly income was added 15 86 Qualitative face validity As far as you know, can you get AIDS from: mosquitoes, sex, blood transfusion, hugging a person with AIDS, sharing needles/injection, sharing a meal with someone who is infected? Incorrect options such as mosquitoes, hugging and sharing a meal were eliminated since participants may learn wrong ideas. Item nos. 91 and 92 were eliminated and added to this item as options. The modified question was: As far as you know, through which of the following routs can you get AIDS? (you can choose several options): vaginal intercourse; anal intercourse; oral sex; mother to fetus; breastfeeding; syringe share; blood transfusion; blood products; transplantation of infected tissue; shared tattooing tools, circumcision, ear piercing, phlebotomy, shared barber’s razor; other (please state). 91(a) Can a pregnant woman infected with HIV or AIDS transmit the virus to her unborn child? 91(b) Can a woman with HIV or AIDS transmit the virus to her newborn child through breastfeeding? nature of items in each domain was different from that in the others and therefore ICC was used for assessing reliability. Pourmarzi et al. conducted a study aiming to compare SRH education needs of youth in Tehran before and after marriage. To assess the validity of the tool, the face and content valid- ity methods were used. In their study, the split-half method (odd-even) was used for reliability assessment and HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 35 Table 2 Items modified or added in different phases of testing the Persian version of the Sexual and Reproductive Health Needs Assessment Questionnaire (continued) Row Item no. Stage/ Phase Original version Persian version 16 88 Qualitative content validity Do you worry that you could get HIV? What is the likelihood of your being infected with HIV/AIDS by next year?: not at all; very little; little; moderate; high; very high; I am HIV positive; I don’t know (new item) What are your reasons for not being at risk? (you can select more than one option): I have not had any sexual contact; I have had only one sexual partner; I regularly use condom; my partner is faithful; I do not share needles; I am not in contact with infected blood, or have not received infected blood; I am careful in choosing a partner; I have had HIV testing (new item) What are your reasons for being at risk of getting AIDS? (you can select more than one option): I have multiple sexual partners; I am not faithful to my partner; I am suffering from sexually transmitted diseases; my husband or sexual partner is HIV/AIDS infected; I have had unprotected sexual contact; I used drugs; I have been raped; other (please specify) 17 90 Qualitative face validity As far as you know, what can a person do to avoid getting AIDS? These questions were turned into one question (no. 86) 18 91 Qualitative face validity Can a pregnant woman infected with HIV or AIDS transmit the virus to her unborn child? 20 99 Qualitative face validity As far as you know, does it happen in this community (camp) that women or girls are forced to have sex against their will? Has any women or girls around you been forced into having sex? 21 103 Qualitative face validity Have you ever been forced to have sex? Have you ever been forced into having sex by people other than your spouse or partner? 22 104 Qualitative face validity During the past 12 months, did any of your sexual partner(s) force you to have sex with them even though you did not want to have sex? Have you ever been forced into having sex by your spouse or partner? 23 108 Qualitative face validity Are there things that you think might be helpful to you in coping with your experiences of forced sex? What do you think might help prevent violent/ forced sex against women? 24 109 Qualitative face validity Since arriving in this community, has anyone ever hit you? Have you been battered in the past 12 months? 25 114 Qualitative face validity Are there things that you think might be helpful to you in coping with your experiences of physical violence? What can be done to prevent physical violence against women? 9 63 Quantitative content validity Have you ever used a female condom? Have you ever used a condom? 10 64 Quantitative content validity If “no”, why have you not used a female condom? If “no”, why have you not used a condom? 11 65 Quantitative content validity Do you know any place or person where you can obtain female condom? Do you know any place or person where you can obtain condom? 66 Quantitative content validity Which places or persons do you know where you can obtain female condom? Which places or persons do you know where you can obtain condom? EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 36 Table 2 Items modified or added in different phases of testing the Persian version of the Sexual and Reproductive Health Needs Assessment Questionnaire (concluded) Row Item no. Stage/ Phase Original version Persian version 13 – Quantitative content validity (new item) Have you ever had unwanted pregnancy? 14 – Quantitative content validity (new item) If yes, how many times? 14 – Quantitative content validity (new item) Have you ever had termination(s) of pregnancy? 15 – Quantitative content validity (new item) If yes, how many times? 16 – Quantitative content validity (new item) Did you use contraception, before your unwanted pregnancy? Quantitative content validity (new item) If yes, what method of contraception did you use? Quantitative content validity (new item) If no, what was your reason for not using any contraception method? the Spearman correlation coefficient XBT 31). Researchers compared youths’ views on 11 general topics in the form of educational needs for SRH before and after marriage, while the SRH needs were not investigated in detail in their study. Meanwhile, in the present study, SRH needs were separately assessed using a standard questionnaire in 6 domains, and each domain included a number of ques- tions about women’s needs. It seems that, although the subjects of these 2 studies are generally similar, different tools were used in each study in view of the aims of the two studies. It ap- pears the use of psychometric tools in our study was more suitable for assessing SRH needs. In a study by Haddad et al. to de- sign the Arabic version of a question- naire about violence against women in Jordan, the standard NorVold Domestic Abuse Questionnaire (NORAQ) was used. This instru- ment includes multiple aspects of violence, such as emotional, physical and sexual violence. They concluded that the questionnaire was valid and reliable for use in the Eastern Medi- terranean Region (32). In the present study, violence against women was presented and psychometrically eval- uated as one of the SRH domains, and this could be useful in the assess- ment of this dimension of SRH. One of the limitations of our study was that the SRH questionnaire which we used did not cover all potential dimensions or domains of SRH, such as the sexual performance and satisfac- tion of women, infertility and so forth. However, if all possible dimensions were included in the questionnaire, it might be too long and difficult for participants to complete. In addition its validity and reliability would have decreased. In this psychometric study, the criterion validity assessment of the Persian version of SRH Needs Assessment Questionnaire was not performed, because there is no stand- ard, well-known tool in this field. A criterion is a standard of judgement or an established standard which the other measure is compared to (33). Table 3 Demographic characteristics of women participants in the test–retest of the Persian version of the Sexual and Reproductive Health Needs Assessment Questionnaire in Sari, Islamic Republic of Iran (n = 60) Variable Value Age (years) [mean (SD)] 31.0 (7.8) Age at marriage (years) [mean (SD)] 34.2 (9.6) Husband’s age (years) [mean (SD)] 20.6 (5.5) Educational level [no. (%)] Less than high school 20 (33.3) High school diploma 23 (38.4) College education 17 (28.3) Occupational status [no. (%)] Housewife 45 (76.3) Employed 15 (23.7) Husband’s educational level [no. (%)] Less than high school 19 (31.7) High school diploma 25 (41.7) College education 16 (26.6) HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 37 References 1. Witkin BRAJ. Planning and conducting needs assessments: a practical guide. Thousand Oaks (CA): Sage Publications, Inc; 1995. 2. 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Other limitations of this study stem from the given setting and population of the study, as in our study the SRH needs of women in rural areas, of men or of young people in Mazandaran were not assessed. We suggest that special and contextualized tools be developed and used for these groups or communities in Persian-speaking regions. Conclusion The results of this study indicate that the Persian version of the SRH Needs Assessment Questionnaire has adequate face and content validity (quantitative and qualitative) for assessing SRH needs among Iranian women. The test–retest reliability showed that, except for the domain of STIs, all other domains of the questionnaire have an acceptable Table 4 Reliability assessment for each domain of the Persian version of the Sexual and Reproductive Health Needs Assessment Questionnaire Domain Intra-class correlation coefficient 95% CI P-value Safe motherhood 0.81 0.68–0.88 < 0.001 Family planning 0.71 0.52–0.83 < 0.001 Sexual history 0.99 0.98–0.99 < 0.001 Sexually transmitted infections 0.49 0.13–0.70 0.007 HIV/AIDS 0.67 0.45–0.80 < 0.001 Violence 0.60 0.33–0.76 < 0.001 Total 0.66 0.43–0.80 < 0.001 CI = confidence interval. reliability. This questionnaire can be used by policy-makers, managers, researchers and health-care providers to assess the SRH needs of Iranian women and plan and design strategies to meet them. Acknowledgements This article is derived from the thesis of Soghra Khani for fulfilment of a PhD degree in Reproductive Health at Tar- CJBU.PEBSFT6OJWFSTJUZ 'BDVMUZPG4DJ- ences), Tehran, Islamic Republic of Iran. We also wish to express our grati- tude to the team members of New Dimension Consulting–Zimbabwe, including Dr Victoria James, for giving us permission to make the Persian ver- sion of the questionnaire. Funding: This study was approved and funded by the research council of 5BSCJBU.PEBSFT6OJWFSTJUZ 'BDVMUZ of Medical Sciences), Tehran, Islamic Republic of Iran. Competing interests: None declared. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 38 datedSeptember2011_FINAL_Tag508.pdf, accessed 1 October 2014). 17. Rashidian A. Health observatory: first report. I.R. Iran multiple- indicator demographic and health survey 2010. Tehran: Minis- try of Health; 2012. 18. Process of translation and adaptation of instruments [Internet]. 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Screening for domestic violence in Jordan: validation of an Arabic version of a domestic violence against women ques- tionnaire. Int J Womens Health. 2011;3:79–86. PMID:21445377 33. Oluwatayo JA. Validity and reliability issues in education- al research. Journal of Educational and Social Research. 2012;2(2):391–400. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 39 Herbal and nutritional supplement use among college students in Qatar R. Mamtani,1 S. Cheema,1 B. MacRae,2 H. Alrouh,1 T. Lopez,2 M. ElHajj 3 and Z. Mahfoud 1 ABSTRACT There is increasing demand for herbal and nutritional supplements in the Middle East. This study aimed to examine the use of supplements by college students in Qatar and to elucidate users’ views about them. A total of 419 college students completed a self-administered questionnaire. Almost half of the respondents (49.6%) had used supplements (ever users), with 32.7% reporting using them in the previous 6 months (current users). Of the latter, 27.7% had used herbal supplements, 56.2% vitamins and minerals and 56.9% non-vitamin, non-mineral, non-herbal supplements. Many participants considered supplements to be safer and more effective than conventional medicines. Supplements were preferred over conventional medicines for the treatment of digestive conditions and common respiratory ailments and for weight management. Educating health-care providers about the benefits and risks of supplements is imperative and will enable health-care practitioners to guide patients in making informed decisions about supplement use. 1Weill Cornell Medical College in Qatar, Doha, Qatar (Correspondence to S. Cheema: soc2005@qatar-med.cornell.edu). 2College of the North Atlantic in Qatar, Doha, Qatar. 3Qatar University, Doha, Qatar Received: 06/01/14; accepted: 11/03/14 |ó\ óR9Óm^Xm!ÐÑ°IîzTowí{_TÐíogY^TÐÓ° «dbBÐêÐzGÐ ßa7ßnxÚØnxÛºÕn"ÐQnYº~h=Unhin>ºÖí}UÐqecAºï}TnYÜí}=º5hIpdhgHº©nYnYÚ{fhRÐÚ êÐ{ååHÐpååHÐÚØOÎrååUÐÐ|ååw óæ ó{åå ów{ååSí ååHíúÐçPååUÐ:pååxí|`UÐíphååZ_UÐÓĆåå ¬ecCÐDååL{ååxÐ~YoåådJènååfwoååÉ°#Ð ÑĆåJåYðnåUnJ419åLe6nåYênåSí n¹jåZ=NY õ{åCÐ}å^iÓnåg@íÊĆåHÐOÎí}å ó]óS:Ónå_Yn!ÐÑĆåJåSåYÓĆå ¬ecCÐ ºmYqåSíïÌ:NY õ{åYÓĆå ¬ecYÐY{åHÐ{åS·49.6N_ód]åCÐå[iåYÑ ô}åbxnåYëncåR .ÐÙënhåHÐÊåe=Ónå_Yn!Ð ÓĆå ¬ecYÐY{åHÐ{åSÒEåBúÐpåLeCÐåY·27.7ënTí NåhUnANY õ{åYpb=nåUÐpåUÐ}gåIúÐéĆåBnwY{åHз32.7 åY ëÌNTÚnååZCÐååY{ååx{_UÐFååLÐí phååZLEååQípååhi{_YEååQípååhfhYnhREååQÓĆåå ¬ecY·56.9íºëØnåå_YíÓnååfhYnhR·56.2íºphååZL påhe\4ÐÓønå"Ðpå!n_Cpåx{hdbUÐpåxíØúÐDåLpåd \aYÓĆå ¬ecCÐqåinTí påx{hdbUÐpåxíØúÐåYpåhUn_R}åTÌíðnåinYÌ}åTÌÓĆå ¬ecCÐ ÓĆå ¬ecCÐ}åJn8í{åýÐRëjåZ=påh[UÐpåxnL}UÐåY ¬{bYåhb>ëÌOÎpåHÐÚ{UÐqå[dBí ëÛåUÐ:åc´dUíp_ýnåZUÐphåafUÐåd_UÐí ÓĆå ¬ecCÐêÐ{åHÐëjåZ=ÒEfåYÓÐÚÐ}åSÙnåĺÐ: ó}åCÐåh@>åYpåh[UÐpåxnL}UÐÚnå,å ¬cexëÌijåIåYíºåfY{å=ø ñ}åYÌ Consommation de compléments nutritionnels et à base de plantes par des étudiants de l'enseignement supérieur au Qatar RÉSUMÉ La demande en compléments nutritionnels et à base de plantes est croissante au Moyen-Orient. La présente étude visait à examiner la consommation de compléments par des étudiants de l'enseignement supérieur au Qatar et à élucider le point de vue des utilisateurs en la matière. Au total, 419 étudiants ont rempli un autoquestionnaire. Près de la moitié des répondants (49,6 %) avaient déjà consommé des compléments au moins une fois dans leur vie, et 32,7 % indiquaient en avoir consommés au cours des six derniers mois. Parmi ceux-ci, 27,7 % avaient déjà consommé des compléments à base de plantes, 56,2 % avaient choisi des vitamines et des minéraux et 56,9 % des compléments ne contenant ni vitamines, ni minéraux, ni plantes. De nombreux participants considéraient les compléments comme plus sûrs et plus efficaces que les médicaments conventionnels. Les compléments étaient préférés aux médicaments conventionnels pour le traitement des affections digestives, des maladies respiratoires courantes et pour le contrôle du poids. L'éducation d les prestataires de soins de santé aux risques et aux avantages des compléments est impérative et permettra aux praticiens de conseiller les patients pour qu'ils prennent des décisions éclairées en la matière. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 40 Introduction The demand for herbal and nutritional supplements is high. Presently, around PG UIF XPSMET QPQVMBUJPO VTF herbal medicines (1–4), and nutritional supplement use is also common (5,6). Evidence regarding the benefits and risks of supplements is becoming appar- ent (7). They are increasingly gaining acceptance and their sales have soared JOSFDFOUZFBST JOUIFHMPCBMNBS- LFUXBTWBMVFEBUîmCJMMJPO 8). An increased demand has been reported in the Middle East, particularly in the Gulf Cooperation Council (GCC) nations (9–12). There have been some reports about supplement use among the general population and particularly by diabetic patients in Kuwait, Bahrain and Saudi Arabia (10,13). Population-based data on supplement use among students, however, are scarce. A recent study from Palestine reported that herbal self-therapy was common among uni- versity students, but the study did not report on nutritional supplement use (14). Another study of athletes in Qatar SFQPSUFE UIBU PWFS PG SFTQPOE- ents used vitamin supplements (15). Clearly further data on the effectiveness and safety of supplements is needed (7,16,17). Such data could be instruc- tive to help us develop evidence-based recommendations governing the use of supplements. To contribute to this knowledge, we conducted a survey directed at college students in Doha, Qatar. The purpose of our study was to determine the extent of use of supplements among college students and to elucidate the views of students towards their use. Methods Sampling " TBNQMF PG TUVEFOUTXFSF FTUJ- mated to be sufficient to assess the prevalence of ever use of supplements UPXJUIJOBNBSHJOPGFSSPSPGXJUI BDPOėEFODFJOUFSWBMĉJTTBNQMF size was estimated to be sufficient to detect differences between ever use and OFWFSVTFPGBU MFBTU DPSSFTQPOE- JOH UP BO PEET SBUJP PG XJUI QPXFS BOE B TJHOJėDBODF MFWFM PG using the chi-squared test. The study was carried out from "QSJM UP +VOF3FQSFTFOUBUJWF samples of students from 2 colleg- es—Weill Cornell Medical College in Qatar and the College of the North Atlantic in Qatar—were obtained using stratified sampling. The students were stratified according to their year of study and nationality. Random samples proportional to the size of each stratum were drawn. Approval for this study was obtained from the institutional review boards of the col- leges. From the total student population (n TUVEFOUTXFSFTFMFDUFE UPQBSUJDJQBUF JO UIF TUVEZ0G UIF students, 419 completed the question- naire, representing a response rate of Data collection We developed a self-administered questionnaire to obtain students’ demographic information, details of supplements used and users’ views regarding supplements versus conven- UJPOBMNFEJDJOFTĉFJUFNRVFTUJPO- naire was adapted from a survey utilized in a previous study (18). We piloted the questionnaire on 6 students and circu- lated the feedback among the authors. Thereafter, minor language adjustments were made to the questionnaire to add clarity. The questionnaire was distributed by the research staff and was complet- ed voluntarily by the students in the classrooms of the respective colleges. Participants were asked if they had taken (yes/no) at least 1 nutritional or herbal supplement at some point in their life (defined as ever users) and then to list any supplements taken in the last 6 months (defined as current/ recent users). They were asked to re- spond by agreeing, disagreeing or stat- ing that they had no opinion regarding statements related to the safety and effectiveness of supplements when compared with conventional prescrip- tion and non-prescription medicines. Students were also asked to select their preference between supplements and prescription/non-prescription medicines for treating various medical conditions. The following definitions of herbal and nutritional supplements were in- cluded in the questionnaire to aid re- spondents in answering the questions (19,20). No guidance or assistance was provided to the students as they completed the questionnaire. “Herbal and nutritional supplements are sub- stances you eat or drink. They can be vitamins, minerals and herbs, or parts of these substances.” “Herbal supple- ments are plants or plant parts used for their scent, flavour or therapeutic properties. Examples include Echinacea, ginseng and aloe.” “Nutritional supple- ments refers to vitamins, minerals and other nutrients that are used to sup- port health and treat illness. Examples include vitamins, fish oil and omega-3 fatty acids.” Data analysis The respondents’ demographic char- acteristics were summarized using frequency distributions. Associations between the students’ ever use of supplements and their demographic and behavioural characteristics were assessed using the chi-squared test or Fisher exact test. The student’s views about supplements versus prescrip- tion and non-prescription medica- tions and their preferences towards each in treating various illnesses were summarized using frequency distribu- tions. Analyses were performed using IBM SPSS software, version 21. The TJHOJėDBODFMFWFMXBTTFUBU HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 41 non-herbal, non-vitamin, non-mineral supplements (the most commonly used were proteins, fish oil and omega WJUBNJOTBOENJOFSBMT NPTU commonly multivitamins, vitamin %BOE WJUBNJO$ BOEIFSCBM supplements (most commonly ginger, mint and olive oil). Several respondents reported using more than one type of supplement. Respondents’ perceived views on supplements Participants expressed confidence in the effectiveness and safety of supple- NFOUT*OUFSNTPGTBGFUZ BHSFFE that supplements were safer than NFEJDJOFT XIJMFEJTBHSFFE$PO- DFSOJOHFĎFDUJWFOFTTBHSFFEUIBU supplements were more effective than NFEJDJOFT XIFSFBTEJTBHSFFE Results Demographic characteristics Table 1 shows the demographic char- acteristics of the respondents (n = 419); XFSFBHFEZFBSTPSZPVOHFS XFSF GFNBMF XFSF PG 2BUBSJOBUJPOBMJUZ BOEXFSF JO a college programme related to health DBSF0G BMM SFTQPOEFOUT SBUFE their health as excellent or good. Supplement use Of the 419 students who completed UIF RVFTUJPOOBJSF IBE used at least 1 nutritional or herbal supplement at some point in their MJGF $*m 4FYXBT the only variable that correlated sig- nificantly with students’ ever use of sup- plements; the proportion of students ever using supplements was higher in GFNBMFT UIBOJONBMFT (P /POFPG UIFPUIFS MJTUFE variables (age, marital status, national- ity, year of college, health-related field of study or self-rated health) were sig- nificantly associated with supplement use. The top 2 reasons for using sup- plements reported by the respondents were that they were safe to use and they prevented sickness. Types of supplements A total of 137 students out of 419 XFSFDVSSFOUSFDFOUVTFSTPG supplements. For analysis the responses were divided into 3 main categories: herbal supplements; vitamins and minerals; and non-herbal, non-vitamin, non-mineral supplements. Of all cur- SFOUSFDFOU VTFST IBE UBLFO Table 1 Proportion of students ever using supplements and the association of supplement use with respondents’ demographic characteristics Characteristic Totala Ever-users Never-users P-valueb No. No. % No. % All 419 208 49.6 211 50.4 Age (years) ≤ 24 329 171 52.0 158 48.0 0.095 ≥ 25 86 36 41.9 50 58.0 Sex Female 168 95 56.5 73 43.5 0.023 Male 248 112 45.2 136 54.8 Marital status Never married 345 172 49.9 173 50.1 0.845 Ever married 70 34 48.6 36 51.4 Nationality Qatari 192 91 47.4 101 52.6 0.372 Non-Qatari 224 116 51.8 108 48.2 Health-related field of study Yes 169 81 47.9 88 52.1 0.620 No 246 124 50.4 122 49.6 Year in college First year 120 61 50.8 59 49.2 0.962 Second year 140 69 49.3 71 50.7 Third or more 156 77 49.4 79 50.6 Self-rated health Excellent or good 346 168 48.6 178 51.4 0.302 Fair or below 72 40 55.6 32 44.4 aNumber of students may not always add up to the total as some did not answer all the questions; bChi-squared or Fisher exact test, as appropriate. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 42 Medicines were the most com- mon first choice for treating most conditions (Figure 1). However, sup- plements were the preferred option for the treatment of conditions related to weight problems and common digestive and respiratory ailments. Preference for their use in treating conditions such as cancer and diabe- tes was notably lower. Discussion In this study in Qatar the proportion of college students who had ever used TVQQMFNFOUTXBTIJHI 8IJMF supplements have beneficial health ef- fects, their inappropriate use can result in adverse effects (7). Consulting a licensed health-care practitioner before using supplements is important. Among the supplement users, mul- tivitamins and proteins were commonly reported supplements. The finding about the use of protein supplements is of concern since they can cause adverse gastrointestinal effects such as stomach cramps and diarrhoea (21). Addition- ally, they have not been shown to have any beneficial effect on athletic perfor- mance and strength training (22,23). Excessive use of multivitamins has also been reported to have negative health consequences (7). Sex was the only demographic characteristic significantly associated with supplement use; females were more likely to have ever used herbal or nutritional supplements. This as- sociation with respondents’ sex was observed in other studies on the gen- eral population in Saudi Arabia and UIF6OJUFE4UBUFT 10,24), in addition to college students in Palestine (14). However, another study from the 6OJUFE4UBUFTGPVOEOPTJHOJėDBOUTFY differences in use of non-herbal, non- vitamin, non-mineral supplements (25). Most respondents had a favourable stance towards supplements; they had higher confidence in them and viewed them as both safer and more effective than prescription and non-prescrip- tion medicines. Most respondents favoured supplements over medicines for minor health concerns such as weight loss/gain and gastrointestinal disturbances. Whilst the majority of respondents favoured prescription and non-prescription medicines for the treatment of serious and potentially life-threatening conditions, a portion still favoured supplements for treating cancer, diabetes and high blood pres- sure. This is a highly concerning finding since these individuals might not seek conventional treatments of scientifi- cally proven value. In the WHO Eastern Mediterra- nean Region, particularly in the GCC nations where there has been a rapid industrial and economic growth, the demand for supplements is strong and likely to grow (9–12), due to increasing wealth, level of education, health aware- ness, prevalence of chronic conditions 100 90 80 70 60 50 40 30 20 10 0 C an ce r A st hm a an d/ or lu ng d is or de rs In fe rt ili ty Br ul se s a nd /o r I ng ur ie s D ia be te s H ea da ch e an d/ or m ig ra in e A th rit its jo in t p ai n Se xu al d is or de r Im m un ity a nd n ut rie nt s d is or de rs In so m ni a H ig h bl oo d pr es su re H ig h ch ol es te ro l A nx ie ty a nd /o r d ep re ss io n Sk in d is or de rs Fa tig ue Ba ck p ai n an d/ or n ec k pa in C ol d an d flu St om ac h an d/ or d ig es tiv e di so rd er s W ei gh t g ai n G en er al w el l-b ei ng fo r h ea lth & b od y W ei gh t l os s Medicine Both/No answer Supplement % Figure 1 Students’ choice of supplements versus medicines for treating various medical conditions and for promoting health (n = 208) HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 43 and associated use of alternative medi- cines (2,24), media publicity and the availability of supplements through the Internet (26). Health practition- ers in the region who do not possess the knowledge and skills to counsel patients on appropriate use of supple- ments (27,28) could benefit from the findings of this study as well as training in this area. Our study has several limitations. The estimates of supplement use were based on self-reported information and we were unable to validate the subjects’ responses. Our study sample was lim- ited to 2 colleges and therefore may not be representative of the nation’s college population. Additionally, some examples of supplements (e.g. multi- vitamins and fish oil) were mentioned as examples in the survey questions and this may have had a suggestion bias effect on the responses. Conclusions As the evidence regarding the benefits and risks of supplements continues to emerge, it is imperative to develop evidence-based national guidelines on how best to incorporate this aspect of medical care into the health-care delivery systems in Qatar. Additionally, all health- care practitioners and students should be educated in this discipline so that they are prepared to engage in meaningful discussions with patients to help them make informed decisions about the use of supplements. Furthermore, creating public awareness regarding the appropri- ate use of supplements is essential. Acknowledgements We would like to acknowledge Albert Lowenfels for his guidance on prepara- tion of the manuscript, and to Paul Rut- ter for sharing the original survey from his study. Additionally, we acknowledge Norman Wong and Wisal Salih, for their contribution in administering the survey, Sura Al-Samraye, Nneka On- wuachu and Mariyam Mohammed and Basma Tawfiq for data collection and data input. Funding: This work was funded by both the Qatar Foundation through the Weill Cornell Medical College in Qatar Biomedical Research Program and by the SEED Program at the Col- lege of the North Atlantic – Qatar (CNA-Q). Competing interests: None declared. 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PMID:20799552 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 45 Medical faculty members’ perspectives on the components of cross-cultural competence in the Islamic Republic of Iran: a qualitative study M. Mousavi Bazaz,1 A. Zabihi Zazoly 2 and H. Karimi Moonaghi 2 ABSTRACT Despite the importance of cultural competence in health care, there has been no research to develop a framework for cultural competence in the Iranian context. This qualitative study at Mashhad University of Medical Sciences aimed to elucidate the views of medical faculty staff on the components of cross-cultural competence and compare these with similar studies published in English. Using a combination of archival studies, semi-structured interviews and focus group discussions among faculty members 3 major domains (knowledge, attitude and behaviour) and 21 components were identified to describe the cross-cultural competence of faculty members in medical schools. Participants expressed the importance of knowledge as a precursor to changing attitudes and the 6 knowledge components related to knowledge and awareness of values, beliefs and norms of different ethnic, racial and cultural groups. Experts mostly emphasized the importance of interaction between faculty members and clients (students and patients). 1Department of Community Medicine; 2Department of Medical Education, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran (Correspondence to A. Zabihi Zazoly: zabihia901@mums.ac.ir; arshad9067@yahoo.com). Received: 01/02/14; accepted: 04/08/14 og`gSoGÐÚØogX°GüÐëÐ|wÎowÚf+9ÓmQmaTÐM<~QmeTÐÓmhbXK\TÐ~wÚzTÐoþgvÊm[KÌ|]hÓmf?í bóiYex}TNAº<íÛÛh=ÙpaJnLºÛÐ~=ïHY6 :nåbUÐåRnfdUÚnåJÎ åUrå=ïÌènåfwåcx3å ilRpå h[UÐpå xnL}UÐénå6::nåbUÐåRnfUÐpå hªÌåYåQ}UÐDåLoåÉ°#Ð å]UÐåxÚ{UÐpåþhwÊnå\LÌÊÐÚËÊĆåHÐOÎpåh]UÐêåd_dU{gåZYpå_Yn@:påhahcUÐpåHÐÚ{UÐì|åwqå óR{w{åSí ©Ð}åxüÐçnhåUÐ: åYsåx~YêÐ{åHÐî{åUí påx~hdiüÐpå`dUn=Ó ó õPåôip)nåZYÓnåHÐÚØ åYpåHÐÚ{UÐì|åwpåiÚnbYíÓnåRnbUÐNå=åRnfUÐÓnåicYåL påR}_CÐphåhýÚÓønå63{åx{Ļå>ºåxÚ{UÐpåþhwÊnå\LÌNå=Ò~å öT}YpåhLn+ÓnåZSnfYípåe^fYå õIÓĆå=nbYíphahåIÚÌÓnåHÐÚØ pååhªÌååLëTÚnååZCÐ FååLí oåå]UÐÓnååhdT:ååxÚ{UÐpååþhwÊnåå\LÌÓnååRnb?Nåå=ååRnfUÐååÉUðnååi ¬cY21íèdååUÐíååSÐCÐí påhf?üÐÓnåL5!ÐæÐ}åLÌíÓÐ{åb_YíåóhõSèÐÚØÎípåR}_e=påbd_CÐpåUÐpåR}_CÐÓnåicYíåSÐCÐEåh`>: påx{hg/Òå]T påR}_CÐ }åCÐíÑĆå]UÐNå_ õ@Ð}CÐNå=íåxÚ{UÐpåþhwÊnå\LÌNå=åLnaUÐpåhªÌDåLÊÐFå#Ðå^_Y{å öTÌí påadCÐpåhRnbUÐípåhS}_UÐí Points de vue des membres du personnel enseignant médical sur les composantes de la compétence interculturelle en République islamique d'Iran : étude qualitative RÉSUMÉ En dépit de l'importance de la compétence culturelle dans les soins de santé, aucune recherche n'a été menée visant à établir un cadre pour la compétence culturelle dans le contexte iranien. La présente étude qualitative à l'Université des Sciences médicales de Mashhad visait à élucider les points de vue des membres du personnel enseignant médical sur les composantes de la compétence interculturelle et à les comparer avec des études similaires publiées en langue anglaise. À l'aide d'une association d'études d'archives, d'entretiens semi-structurés et de groupes de discussions thématiques impliquant des membres du corps enseignant, trois domaines principaux (les connaissances, les attitudes et les comportements) ont été dégagés et 21 composantes ont été identifiées pour décrire la compétence interculturelle des membres du personnel enseignant des écoles de médecine. Les participants ont insisté sur l'importance des connaissances comme élément précurseur permettant une modification des attitudes et sur les six composantes de ce domaine liées à la connaissance des valeurs, des croyances et des normes sociales des différents groupes ethniques, raciaux et culturels et à la sensibilisation en la matière. Les experts ont surtout souligné l'importance de l'interaction entre les membres du corps enseignant et les clients (les étudiants et les patients). EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 46 Introduction The cultural competence movement CFHBOBMNPTUZFBSTBHP 1). Although there is currently no standardized defi- nition of cultural competence, Cross et al.’s definition is the most commonly cited (2). This defines cultural compe- tence as “a set of congruent behaviours, attitudes, and policies that come to- gether in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations” (3). Three major areas of health research provide a context that addresses the im- portance of culturally competent care: health disparities; access to health care; and quality of care (4). In the context of health care, the components of cultural competence bridge the cultural gap that exists between providers and patients (5) and play a critical role in reducing health disparities and improving health outcomes for patients (6). When care is provided that takes patients’ values and beliefs into account, it is likely to result, for example, in better access to health care and increased compliance with medication by patients (7). Conversely, a lack of cultural competence among health-care providers may lead to pa- tient dissatisfaction (8). The Islamic Republic of Iran has many ethnic and religious groups which have a variety of subcultures, languages, lifestyles, customs, traditions and differ- ent modes of livelihood (9–11). Nowa- days, foreign migrants too constitute a large part of the country’s population (12) and providing education for the increasing number of foreign students in the country has become an important issue in higher education (13). The cul- tural diversity of Iranian society raises challenges for the health-care system in trying to serve patients of diverse languages and cultures. Research in the Islamic Republic of Iran shows that be- liefs about health care and people’s per- ceptions of illness and health vary across ethnic and religious groups (9,14). Despite its long tradition in disciplines such as psychology, it is only within the past decades that cultural competence has been studied in the context of health and become integrated into the medi- cal education curriculum (15). In the educational realm, cultural competence has been defined as “the ability to suc- cessfully teach students who come from different cultures other than your own” (16). In their book, Diller and Moule stated that it entails developing certain personal and interpersonal awareness and sensitivities, developing certain bodies of cultural knowledge and mastering a set of skills that, taken to- gether, underlie effective cross-cultural teaching (17). The available evidence on multicultural education addressing ethnic and religious diversity highlights the importance of providing cultural competence education and assessment of faculty staff members in the Islamic Republic of Iran. Faculty members act as role models and prepare their stu- dents to deliver culturally competent care (6). Yet cultural diversity poses a pedagogical and social challenge to educators (18); at all levels, they must develop cultural knowledge, awareness and sensitivity to help diverse learners (19). Despite the clear importance of cul- tural competence in health care, there has been no research to develop a framework to specify the components of cultural competence in the Iranian context. The purpose of this study was to elucidate medical faculty members’ perspectives on the components of cul- tural competence applicable to medical schools and how these compare with those found in the English language literature. Methods Study design and participants #FUXFFO0DUPCFSBOE4FQUFNCFS UIFBVUIPSTDPOEVDUFEBRVBMJUB- UJWF TUVEZ JO.BTIIBE6OJWFSTJUZ PG Medical Sciences. Since there was no existing framework for cultural compe- tence of faculty members in the Islamic Republic of Iran, we used an inductive and exploratory approach to understand the dimensions of cultural competence. We therefore chose a combination of methods, including archive study, semi-structured interviews and focus group discussions (FGD) to combine evidence and the collective perspec- tive of experts. In the archive study, we reviewed the current evidence to iden- tify the existing components of cultural competence and then we completed these components by semi-structured interviews and FGDs. To obtain a range of perspectives on cultural competence, we recruited participants who were faculty mem- bers and educational experts at Mash- IBE6OJWFSTJUZPG.FEJDBM4DJFODFT XIPIBEIBENPSF UIBOZFBSTPG experience in teaching, research and service and who were considered as role models in the university. The participants were selected through purposeful sampling (unique cases) and later on by snowball sampling. The inclusion criteria for the partici- pants were having expertise in medical science, teaching and being active in medical education and ethics. Par- ticipants unwilling to participate were excluded. We invited 21 faculty mem- bers who had valuable educational ex- periences to participate in this study; PG UIFNFYQSFTTFE UIFJS SFBEJOFTT to participate in FGDs and the re- maining 6 faculty members were given individual interviews to accommodate their busy schedules,. Data collection Table 1 summarizes the study steps and the participants at each stage. Step 1: archive study We reviewed the published literature and frameworks to identify the existing components of cultural competency. #FUXFFO0DUPCFSBOE"QSJM HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 47 Afterwards, 112 components were extracted by reviewing the obtained data, extracting key phrases and organ- izing concepts and meaning through 28 discussion session lasting on average 3 hours. Components that had similar meanings were combined and duplicate DPNQPOFOUTXFSFSFNPWFE'JOBMMZ components in 3 domains—knowl- edge, attitude and practice—were iden- tified as suitable for defining the cultural competence of faculty members in the medical school. The components were developed in Persian language and translated into English for reporting purposes. Step 2: interviews The semi-structured interviews were conducted with 6 faculty members. For consistency we used a single interviewer (A.Z.), although all the researchers par- ticipated in developing the interview guide. Interviews were tape-recorded if the respondent agreed. If the respond- ent did not agree the interviewer took notes and dictated the responses as close to verbatim as possible immediately we searched the databases of Google Scholar, ScienceDirect, PubMed, Pro- Quest, OvidMD, Education Resources Information Center (ERIC), WhereIsDoc, OhioLINK electronic theses and disser- tation centre, the Iranian databases Ma- giran and Scientific Information Database (SID), and the website of the Iranian Council of Cultural Revolution, with no specific timespan to limit the search. The keywords used were: cultural competence, multicultural education, framework AND cultural competence, components of cultural competence, cultural competence AND faculty members, cultural competence AND medical science. We also consulted the databases of colleges and associations and publications from government and nongovernmental organizations including the Association of Ameri- can Medical Colleges; the National Center for Cultural Competence (an initiative based at the Georgetown 6OJWFSTJUZ$FOUFS GPS$IJMEBOE)V- man Development); and the Liaison Committee on Medical Education (an accrediting body for educational programmes at schools of medicine in America and Canada). The publi- cations and documents were mostly in English language. Articles were included if they were available as full texts; were written in English; reflected the components, elements or domains of cross-cultural competence; and were applicable to faculty members of a medical school. The identified articles were then screened and assessed for eligibility according to the inclusion criteria. The included articles were criti- cally appraised with an assessment tool for descriptive and qualitative articles by 2 of researchers (M.M. and A.Z.). Another researcher (H.K.) moderated in the case of disagreement. Based on their content and purpose, the aggregated results were classified into 3 categories related to the impor- tance of cultural competence, education about cultural competence and assess- ment of cultural competence. This was done by the researchers in 12 discus- sion sessions lasting on average 2 hours. Table 1 Outline of the study steps and participants Sequence of steps Aim of step Participants Activities conducted Results Step 1: archive study To identify the existing components of cultural competence Researchers Searching databases, surveying articles and documents, identifying existing components during 40 discussion sessions 20 components in 3 domains were identified relating to cultural competence of faculty members in medical schools Step 2: interviews To identify the new components of cultural competence Researchers & 6 faculty members Conducting 6 interviews, analysing data and eliciting new components After deleting duplicate components, 5 new components were added Step 3: first FGD To identify the new components of cultural competence Researchers & 14 faculty members Conducting FGDs, brain-storming and summarizing findings After deleting duplicate components, 3 new components were added Step 4: questionnaire To determine the importance of each component (scoring round) Researchers & 21 faculty members Scoring the components Mean score of all the components was > 5 Step 5: second FGD To finalize the components Researchers & 8 faculty members Preparing the final framework 21 components in 3 domains were agreed to define the cultural competence of faculty members in medical schools FGD = focus group discussion. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 48 following the interview. Each interview MBTUFE BQQSPYJNBUFMZNJOVUFT BOE was scheduled at a time and place that was convenient for the interviewee. We continued data collection until theoreti- cal saturation was reached. We used the archive study to design the interview questions, which included items cover- ing the domains and components of cultural competence. Step 3: first FGD We conducted 2 FGDs. We invited NFEJDBM TDIPPM GBDVMUZNFNCFST by e-mail and letter to participate in our sessions. FGDs were audio- recorded with the agreement of the participants. During each session, re- searchers took notes of the important points and gave the opportunity to all the members to express their com- ments and ideas. The first FGD consisted of 7 fac- ulty members from clinical science and 7 members from basic science. We provided copies of the questions and the needed information for the faculty members. Afterwards, one of the researchers (M.M.) presented relevant explanations and asked ques- tions and then in a brain-storming session participants discussed the is- sues together. Step 4: questionnaire The main goal of Step 4 was validation of the components. The 28 compo- nents obtained from the previous steps were used to construct a questionnaire. Participants were asked to score the importance of each component from MPXFTUTDPSF UP IJHIFTUTDPSF They were also requested to add addi- tional components that they considered important and to provide comments about deleting or modifying the free text at the end of the questionnaire. This step was conducted face to face. Step 5: second FGD The second FGD included 4 faculty members from clinical science and 4 from basic science. After providing a report containing the results of Step 4 participants discussed the issues to- gether. Some of the components were integrated or revised. Then general discussions took place for each compo- nent. When we believed we had reached saturation we finalized the components in this step. Data analysis Qualitative data were analysed using qualitative analysis and the inductive approach. The recorded interviews and FGDs were transcribed verbatim by 2 of researchers (M.M. and A.Z.). The same 2 researchers independently read each transcript, extracted im- portant statements and phrases and formulated meanings for these state- ments. Statements and phrases from all participants that were similar were grouped together or clustered into one list of themes. The researchers (M.M. and A.Z.) sent the other researcher (H.K.) a copy of their results along with original descriptions for valida- tion and confirmation of the consist- ency between these clusters and the original descriptions. Similar results were obtained. Then all the research- ers (M.M., A.Z. and H.K.) combined the results and wrote an exhaustive description. We returned these finding to the participants to validate the find- ings. No new data were revealed from the participants. Quantitative data were analysed using SPSS WFSTJPO 8F VTFE descriptive statistics, including mean and standard deviation (SD) to ana- lyse quantitative data from the scoring steps. Results Table 2 shows selected demographic characteristics of the participants, in- cluding age, sex, subject and academic SBOL.PTUPG UIFQBSUJDJQBOUT were men and the largest proportion PGQBSUJDJQBOUTXFSFBHFEmZFBST Archive study #PY MJTUT UIFDPNQPOFOUT JO UIF 3 domains of knowledge, attitude and practice, based on the results of the archive study. Knowledge was defined as “Having awareness of the values, beliefs and norms of different ethnic, racial and cultural groups”; attitude Table 2 Selected demographic characteristics of the study participants (n = 21) Characteristic No. % Age (years) ≤ 45 4 19 46–50 8 38 51–60 5 24 ≥ 61 4 19 Sex Female 4 19 Male 17 81 Subject Clinic science 10 48 Basic science 11 52 Academic rank Professor 6 29 Associate professor 6 29 Assistant professor 6 29 Lecturer 3 14 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 49 was “Having the values, beliefs and un- derstandings that are the foundation of professional norms”; and practice was “Demonstrating knowledge and attitude in behaviours and encoun- ters”. Interviews and FGDs The 8 new components, includ- ing 1 component in the domain of knowledge and 7 components in the domain of practice, were added to the previous components after analysing the interviews and the first FGD and eliminating the duplicate components. The following components were added. In the domain of knowledge we added: “Having awareness of one’s limitations regarding cultural context and issues”. In the domain of practice the following were added: “Maintain- ing equity in professional behaviour in encounters with people from dif- ferent cultures”; “Having appropriate behaviour in cultural encounters”, “Having appropriate appearance (e.g. clothing) considering the beliefs of the local culture”; “Being open to criticism and tactful about giving criti- cism to others”; “Having modesty in expression”; “Cultural production (e.g. faculty members should make their own experiences and ideas viable and lasting)”; and “Having tolerance in encounters with different cultures in the area of professional activities”. Box 1 Initial list of components of cross-cultural competence of faculty members in medical school based on the archive study Knowledge r Having awareness of relevant sources to obtain cultural information r Having awareness of the risk of discrimination among people from different cultural backgrounds r Having awareness of the different needs of people from different cultures r Having awareness of non-verbal communication symbols in different cultures r Having awareness of beliefs in various cultural communities Attitude r Accepting cultural diversity (customs, different ways of communication, beliefs, different traditions and perspectives) r Having an altruistic viewpoint r 6OEFSTUBOEJOHUIFSJTLPGTFMFDUJOHPOFTPXODVMUVSF IFSIJTOPSNTBOEQSPGFTTJPOBMWBMVFT BTUIFDPSSFDUDVMUVSF TFMG centred) r Believing in the need to be careful of one’s behaviour regarding reactions to people from different cultural backgrounds Practice r Demonstrating a desire to respond to the client’s cultural needs (e.g. patients, patient’s family, students, colleagues and other clients) r Having the ability to create a trustworthy relationship r Expressing empathy r Demonstrating a respectful attitude towards differences between people from different cultural backgrounds r Being flexible in choosing the appropriate approach with clients from different cultures r Allocating sufficient and appropriate time for clients r Practising active listening r Having good verbal communication skills r Having the ability to use non-verbal communication skills and body language r Having consideration for education about cultural competence for students in the area of professional activities r Practising self-development in fields related to cultural competence (e.g. attending educational programmes, cultural trips, etc.) EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 50 In the validation step the mean scores ranged from 6.9 to 9.3 and the mean of all the components was greater UIBO PVUPG JOEJDBUJOHUIBUBMMPG them were considered important. The IJHIFTU TDPSF <NFBO 4% > was given to the component “Accept- ing cultural diversity (customs, differ- ent ways of communication, beliefs, different traditions and perspectives)” from the attitude domain. The lowest TDPSF <NFBO 4% >XBTHJWFO to “Having awareness of non-verbal communication symbols in different cultures” from the knowledge domain. No new components were added by the participants. In the second FGD, we changed the name of the “practice” domain to “behaviour”. Six components were combined—“Having the ability to use non-verbal communication skills and body language”, “Having good verbal communication skills”, “Practising active listening”, “Expressing empa- thy”, “Having modesty in expression” and “Having appropriate behaviour in cultural encounters”—and the component “Having good verbal and non-verbal communication skills” was created. Two components were eliminated—“Allocating sufficient and appropriate time for clients”; “Having tolerance in encounters with differ- ent cultures in the area of professional activities”—since other components already covered their concept. The components of “Having appropriate appearance (e.g. clothing, etc.) con- sidering the beliefs of the local culture” and “Cultural production (faculty members should make their own ex- periences and ideas viable and last- ing)” were transformed into “Having appearance appropriate to accepted norms of society” and “Making one’s own experiences and ideas viable and lasting (cultural production)”. Other components were modified in terms of their word structure and the final list of components were prepared and ac- cepted by all the participants (Box 2). Discussion A major portion of the cultural competence literature can be found in the fields of health care and social work (20). Most of the frameworks we identified originated from North America (21–23), although some had CFFOEFWFMPQFE JO UIF6OJUFE,JOH- dom (24) and New Zealand (25). Despite some differences, the existing frameworks for cultural competence have much in common (25). The components of cultural competence, however, need to be determined for each country, based on its specific goals, vision and population charac- teristics. These components are also likely to reflect a country’s political, historical and sociocultural features. There are now many examples of frameworks, standards and models for cultural competence—e.g. the Accreditation Readiness Standards for Culturally Competent Healthcare Practitioners under the Joint Com- mission’s 21 standards and the Cul- turally and Linguistically Appropriate Services (CLAS) standards—but they have not been exclusively de- veloped to relate to medical faculty members (26–28). Existing frame- works are used to assess the compe- tence both of students and faculty members as well as other health-care personnel, and these place less em- phasis on the interaction between faculty members and students of culturally diverse backgrounds and more emphasis on the faculty mem- bers being role models and training providers of cultural competence for students. In our study in the Islamic Republic of Iran, both of these situ- ations were considered. Participants in the current study identified ethnic and religious diversity as important factors and emphasized the devel- opment of knowledge, attitude and behaviour based on this. Participants did not identify racism and discrimi- nation as significant issues. In current study, the 21 compo- nents of cultural competence identi- fied were categorized into 3 major domains: knowledge (6 compo- nents), attitude (4 components) and behaviour (11 components). Many standards and guidelines that are cur- rently used to define cultural com- petence—e.g. the standards of the Medical Council of New Zealand and frameworks of cultural competence from North America—are based on these same domains (25,29). Our participants expressed the importance of knowledge as a precur- sor to changing an attitude; there- fore, knowledge was placed before attitude in this study and included 6 components related to knowledge and awareness of values, beliefs and norms of different ethnic, racial and cultural groups. In some of the exist- ing frameworks, e.g. that of Jirwe et al. (25), cultural sensitivity is seen as a precursor to culturally appropriate care. The 4 components of attitude in our study are similar to their study regarding cultural sensitivity. In our study, behaviour included 11 compo- nents related to demonstrating knowl- edge and to attitude in behaviour and encounters. More specifically, key aspects of cross-cultural compe- tence include the ability to manage language barriers, communication styles, mistrust and prejudice, family dynamics, customs and spirituality, and sexual and gender issues. Cross- cultural competence depends also on demonstrating empathy, curiosity and respect, which are key factors for effective patient care in a multicultural context (30). In the current study, the identified components of behaviour also included these aspects. Many studies and frameworks, e.g. the Tool for Assessing Cultural Competence Training (TACCT), and the models of Campinha-Bacote and Jirwe et al., have emphasized the importance of establishing effective communication skills in cross-cultural HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 51 encounters (23,25,31). In the current study, the following components em- phasized this issue: “Having the ability to build trustworthy relationships with clients from different cultures” and “Having good verbal and non-verbal communication skills”. Many exist- ing frameworks and components, e.g. TACCT, have emphasized health dis- parities. In our study, the component of “Maintaining equity and fairness in professional behaviour in encounters with people from different cultures” focuses on disparities. Some of the components in the current study highlight the interaction between faculty members and students, e.g. “Making one’s own experiences and ideas viable and lasting (cultural pro- duction)”, “Having consideration for education about cultural competence for students in the area of professional activities” and “Being open to criticism and tactful about giving criticism to others”. Furthermore, these 3 compo- nents are also relevant to interactions with other clients. There are some limitations to this study that could be addressed and used to guide future research in this Box 2 Final list of components of cross-cultural competence of faculty members in medical schools Knowledge r Having awareness of information resources about different ethnic and religious cultures r Having awareness of the risk of discrimination towards people from different cultural backgrounds r Having awareness of the diversity of needs of people from different cultures r Having awareness of non-verbal communication symbols in different cultures r Having awareness of beliefs in various cultural communities r Having awareness of one’s own limitations (knowledge, communication, practical) concerning different ethnic and reli- gious cultures Attitude r Accepting cultural diversity (e.g. customs, different ways of communication, beliefs, different traditions and perspectives) r Having an altruistic point of view r 6OEFSTUBOEJOHUIFSJTLPGTFMFDUJOHPOFTPXODVMUVSF PXOOPSNTBOEWBMVFTJOQSPGFTTJPO BTUIFDPSSFDUDVMUVSFJOQSP- fessional behaviour (culturally self-centred) r Believing in the need to care about professional behaviour in interactions with people from different cultures Behaviour r Demonstrating the desire to respond to the needs of clients from different cultures (e.g. patients, patient’s family, students, colleagues and other clients) r Having the ability to build trustworthy relationships with clients from different cultures r Demonstrating a respectful manner towards cultural differences among people in the area of professional activities (e.g. being respectful to different experiences and perspectives) r Being flexible in choosing the appropriate approach with clients from different cultures r Having good verbal and non-verbal communication skills r Considering education in cultural competence for students in the area of professional activities r Practising self-development in fields of cultural competence (e.g. attending educational programmes, cultural trips, etc.) r Maintaining equity and fairness in professional behaviour in encounters with people from different cultures r Having appearance appropriate to accepted norms of society r Being open to criticism and tactful about giving criticism to others r Making one’s own experiences and ideas viable and lasting (cultural production) EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 52 References 1. 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Purnell L. The Purnell model for cultural competence. J Transcult Nurs. 2002 Jul;13(3):193–6. PMID:12113149 23. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: a model of care. J Transcult Nurs. 2002 Jul;13(3):181–4. PMID:12113146 24. Papadopoulos I, Tilki M, Taylor G. Transcultural care: a guide for health care professionals. Slough, United Kingdom: Quay Books; 1998. 25. Jirwe M, Gerrish K, Keeney S, Emami A. Identifying the core components of cultural competence: findings from a Delphi study. J Clin Nurs. 2009 Sep;18 (18):2622–34. PMID:19538568 area. Although we invited faculty mem- bers who had had educational experi- ence at universities of different areas in Islamic Republic of Iran, the number of experts was limited. Secondly, the study was only conducted at one institution. Further research is needed to among a wider group of faculty members. Conclusions Available evidence from multicul- tural education addressing ethnic and religious diversity highlights the importance of education and the assessment of cultural competence in faculty members and students of medical science. A comprehensive educational strategy must be devel- oped for assessment among faculty members and students in the Islamic Republic of Iran. The components developed in this study will provide guidance for developing a tool to as- sess the cross-cultural competence of faculty members in Iranian medical schools. Acknowledgements We wish to thank the Vice Chancellor GPS3FTFBSDIPG.BTIIBE6OJWFSTJUZPG Medical Science. We would also like to thank the faculty members who par- ticipated in this study for providing their time and thoughtful comments. Funding: This research was financially supported by the Vice Chancellor for 3FTFBSDI PG.BTIIBE6OJWFSTJUZ PG .FEJDBM4DJFODF DPEF Competing interests: None declared. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 53 26. Hines D. Cultural competence: assessment and education re- sources for home care and hospice clinicians. Home Healthc Nurse. 2012 Jan;30(1):38–45. PMID:22173617 27. Naughton J, Adayana Healthcare Group. Cultural competency in healthcare. Indianapolis (IN): Adayana Government Group; 2009 (http://www.adayana.com/sites/default/files/docs/ Cultural%20Competency%20in%20Healthcare%20Whitepa- per_1.pdf, accessed 16 September 2014). 28. Grote E. Principles and practices of cultural competency: a review of the literature. Canberra, Australian Capital Terri- tory: Indigenous Higher Education Advisory Council; 2008 (http://www.deewr.gov.au/Indigenous/HigherEducation/ Programs/IHEAC/Documents/PrinciplePracCulturalComp. pdf, accessed 16 September 2014). 29. Statement on cultural competence. August 06. Auckland: Medical Council of New Zealand; 2006 (http://www.mcnz. org.nz/assets/News-and-Publications/Statements/State- ment-on-cultural-competence.pdf, accessed 16 September 2014).. 30. Bardet A, Green AR, Paroz S, Singy P, Vaucher P, Bodenmann P. Medical residents' feedback on needs and acquired skills following a short course on cross-cultural competence. Int J Med Educ. 2012;3:107–14. 31. Lie D. A framework for enhancing and assessing cultural com- petency training. Kaohsiung J Med Sci. 2009 Sep;25(9):486– 92. PMID:19717367 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 54 Risk factors influencing dentists’ hepatitis B-related knowledge and attitudes and their willingness to treat hepatitis B positive patients B. Khosravanifard,1 V. Rakhshan,2,3 S. Sherafat 4 and L. Najafi-Salehi 4 ABSTRACT This study assessed factors that could predict dentists’ knowledge, attitudes and behaviour towards hepatitis B virus (HBV). A total of 300 dentists in Tehran, Islamic Republic of Iran were surveyed and their demographic, educational and office characteristics were analysed in relation to their scores on knowledge about HBV, self-reported attitudes towards treating people infected with HBV and actual behaviour towards treating simulated HBV-positive patients. Having a Master’s degree, faculty membership, taking ≥ 3 continuing education courses, wearing eye- shields, spending more time on preparing dental units and higher self-confidence about knowledge predicted better knowledge. A positive attitude was associated with having attended more courses and working in group practice. The number of courses and a shorter dental unit preparation time positively affected dentists’ behaviour. 1Department of Orthodontics; 3Department of Dental Anatomy and Morphology, Dental Branch, Islamic Azad University, Tehran, Islamic Republic of Iran (Correspondence to V. Rakhshan: vahid.rakhshan@gmail.com). 2Iranian Tissue Bank and Research Centre, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Private Dental Practice, Tehran, Islamic Republic of Iran. Received: 29/10/13; accepted: 21/08/14 Mg<mªüÐ|BÐo!m^BvØÐz^GÐíf`RÐXCKí"-"zbTÐÑmfTm<ocZTÐÓÐÙëmeGúÐÊmIÌæÚm^XCK|«>j=TÐXÐ^TÐ "-"zbTÐÑmfTø "nÉaiDhUºqRÐ ÐEeHºënZBÚ{hAíºØ}R©ÐíBênf) ÜíEååRìnåå9gTdååHíåågaSÐYíënfååHúÐÊnååJÌæÚnåå_YååLÿåå¬f>ëÌååcexååUÐååYÐ_UÐååhhb>OÎpååHÐÚ{UÐì|ååwqååóR{woååÉ°#Ð påhRÐ}Qex{UÐå*Ð~h,åhdĻå>íºphYĆåHüÐëÐ}åxÎpåxÚge=ëÐ}ågJ:ënfåHÌoåhJ300åLe6nåYyåYå>{åbR "-"{åcUÐÑnågUÐ ðnåh>ÐÙnågfLådCÐågaSÐYíº"-"{åcUÐÑnågUÐÜíEåRåLågRÚn_YÞå[=nåwíÛ}AÌåUÐÓnå@Ú{Un=påd[UÐÓÐÙpåhcCÐípåhehd_UÐí ÑnågUn=på=nÉüÐëå_f[x}åYpå!n_YåiMå_aUÐgTdåHíº"-"{åcUÐÑnågUÐÜíEåa=îí{å_=Nå=n[CÐÞnåIúÐpå!n_Yìnå9 âíÚØÊÐ{å>ÚÐíº}eåCÐåhd_UÐåY}åTjRÓÐÚíØÔĆå?|åBÌíºåxÚ{UÐpåþhwpåx\LíºEå@nCÐpå@ÚØDåLéå["ÐëncåR "-"{åcUÐ ÙnåĺÐënTí å\RÌpåR}_e=ÿåfxºpåR}_CÐéåAåafUn=påbUÐîåYânåa>ÚÐíºphöfåUÐÒ~åg@úÐEå\UéåJÌqåSíåh[ĺíºNåfh_dU qåSUÐ óWå õSíÓÐÚí{åUÐØ{åLëÎå? påhLn+påHÚn,:åe_UÐåY{åx~e=ípåhxÚ{UÐÓÐÚí{åUÐåY{åx~YÚå\=ðnå]>}Y-nå«ÎåSY ënfåHúÐÊnåJÌèdåHDåL-nå«Î}å?ÌåUënTphöfåUÐÒ~åg@úÐEå\Uå[CÐ Facteurs de risque influant sur les connaissances des dentistes en matière d'hépatite B et leurs attitudes et volonté de soigner des patients positifs pour l'hépatite B RÉSUMÉ La présente étude visait à évaluer les facteurs permettant de prédire les connaissances, les attitudes et le comportement des dentistes vis-à-vis du virus d'hépatite B. Au total, 300 dentistes à Téhéran (République islamique d'Iran) ont participé à une enquête tandis que leurs caractéristiques démographiques, académiques et professionnelles ont été analysées en lien avec leurs scores pour les connaissances sur le virus de l'hépatite B, pour leurs attitudes autodéclarées concernant les soins accordés aux personnes infectées par ce virus et pour leur comportement réel de soignant envers les patients ayant prétendu être infectés. Être titulaire d'un diplôme de Master, être membre d'une faculté, avoir suivi au moins trois cours de formation continue, porter des lunettes de sécurité, passer plus de temps à préparer les unités dentaires et avoir davantage d'assurance sur ses connaissances étaient des facteurs prédictifs d'un niveau de connaissances supérieur. Une attitude positive était associée à une participation à davantage de formations et à une activité exercée au sein d'un groupement médical. Le nombre de formations et un temps de préparation de l'unité dentaire plus court influaient positivement sur le comportement des dentistes. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 55 Introduction Hepatitis B is a serious global public health threat and is estimated to kill about 1 million people annually (1–5). The hepatitis B virus (HBV) is about UP UJNFTNPSF JOGFDUJPVT UIBO HIV (6). This might deter clinicians from treating HBV-positive patients (7), even though it is unethical and in some countries illegal to refuse treat- ment to HBV patients (1,8). Clinicians’ reluctance to treat infected patients could also have serious implications for public health (9); for example, there is a greater risk of cross-contamination if patients conceal their disease status (1,3,9,10). Despite these issues, many dentists still refuse to treat patients suffering from bloodborne diseases (8) due to dentists’ higher exposure risks than the general public and even other health- care professionals (1,2,4,5,7,9,11–14). Dentists’ unwillingness cannot be tackled by legal penalties (8) but by improvements in attitude (9,15,16), which might be a reflection of im- proved knowledge and confidence (9,10,15,16). Factors influencing clini- cians’ attitude and willingness to treat HBV-positive patients and their knowl- edge about hepatitis B can be used to improve the quality and ethics of dental practice, to improve patients’ lives and to reduce cross-contamination risks. Such information is of value to clini- cians, academics and policy-makers worldwide. However, to the best of our knowledge, research into these factors has not been reported before in the English language literature. In a previous report of the same re- search, we described Tehran dentists’ knowledge about hepatitis and HBV, their self-reported attitudes towards people with HBV and their actual behaviour towards treating simulated HBV-positive patients (7). In this paper, we report the demographic, educational and office factors influencing dentists’ knowledge, attitudes and behaviour. Methods Sampling This 2-phase cross-sectional study was QFSGPSNFEPOEFOUJTUT JODMVEJOH 189 general practitioners with a general dentist qualification [Doctor of Dental Medicine (DDM)/Doctor of Dental Surgery (DDS)/Doctor of Medicine in Dentistry (DMD)] and 111 spe- cialists with a Master of Science in Dentistry (MSD), who were randomly TFMFDUFEGSPNUIFNPSFUIBOEFO- tists practising in Tehran. A total of 392 dentists were selected and visited and/ or called until the desired sample size was reached. The inclusion criterion was practising dentistry in Tehran. The exclusion criteria were not being avail- able at the scheduled session or refusal to participate in the second session (92 dentists were excluded). Each included dentist (n QBSUJDJQBUFE JOCPUI phases of the study. More details about the sampling are given in our earlier report (7). Dentists could state their refusal to participate at any time and they would be excluded. No personal identifiers or occupational data were collected. Ethi- cal approval for the study was obtained from the internal review board of the institution. Data collection First phase: evaluation by simulated patients In the first phase, dentists’ behaviour in terms of their actual willingness to treat patients infected with HBV was directly observed by 2 final-year undergraduate female dental students (aged about 23 years old) who acted as simulated patients. Each observer WJTJUFEBOEFWBMVBUFEEFOUJTUT"U the time of registration and before the dental examination, the observers declared that they were bloodborne HBV-positive. Afterwards the den- tists’ reactions were recorded (9) and their willingness to treat the simulated patient was scored on a 4-point scale GSPN BCTPMVUFMZ SFGVTFE UP (absolutely agreed). Further details of the methods have been described elsewhere (7). Second phase: interviews using knowl- edge and attitude questionnaires About 1 week later, each observer visited the dentists who had been surveyed by the other observer, and interviewed them face-to-face regarding their knowledge and attitudes using a structured questionnaire which also collected demographic data and office characteristics. The knowledge-oriented ques- tionnaire was designed by a panel of experts and included 18 questions regarding diagnostic criteria and management of HBV infection. The maximum obtainable score was 44. Some questions had a score of 1 and some had higher scores (different weights) (7). The attitude-oriented questionnaire included 13 questions with 4 Likert-scale answers, (scored GSPNUPGPSFBDIRVFTUJPO XIJDI represented the extent of dentists’ at- titudes towards and willingness to participate in treating HBV-positive patients (7,9). The following data about the den- tists were also recorded: r demographic profile: age; sex; office district (Tehran south, west, east, cen- tre and north, as a proxy for economic status). r office characteristics: type of office (solo practice usually charging high- er fees, or group practice in a clinic with different departments, usually charging patients lower fees, or both); number of personnel working at the office. r the dentists’ self-reported infection control practices, namely: wearing dental masks, latex gloves, dental glasses/eye-shields; estimated time to prepare the dental unit for the next patient; and available steriliza- tion units (autoclave, oven or both) (7). EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 56 self-confidence concerning knowledge of hepatitis B; using eye-shield/glasses; and time taken to prepare the dental unit for each patient. A new model was tested with fac- tors that might theoretically affect knowledge: sex; age; degree; place of graduation; experience; faculty mem- bership; number of courses attended; time elapsed since the last course; con- fidence about knowledge; and sources of information. The model was then manually optimized (adjusted R2 = F P *UJEFOUJėFE 3 significant variables: faculty mem- bership; number of courses attended; and self-confidence about knowledge (Table 3). Attitude Overall, the mean attitude score of den- UJTUTXBT 4% PGUIFIJHIFTU possible score. All the variables includ- ing knowledge and behaviour were entered into the backward-selection multiple regression analysis as potential predictors. The final model which had the greatest adjusted R2 value (R2 = F P JEFOUJėFE significant predictors for attitude (Table 2): working in group practice; and num- ber of courses attended. When all the variables (including knowledge and behaviour) were en- tered into a single regression model, only working in group practice with other dentists was a significant predictor of attitude (β P Behaviour Overall, the mean behaviour score of EFOUJTUTXBT 4% PG UIF highest possible score. All the variables including knowledge and attitude were modelled in a series of backward-se- lection multiple binary logistic regres- sions. Dentists who had not received hepatitis B vaccination (compared with UIPTFXIPXFSFWBDDJOBUFE 03 $* m UIPTFXIP IBE IBE UIFJS UJUSFT UFTUFE 03 $*m BOEDMJOJDJBOTXIPhad r education and experience: qualifi- cations [general dentist (DDM)/ (DDS)/(DMD) versus specialist (MSD)]; work experience (< 6 years versus ≥ 6 years); university teaching experience (faculty membership); location of graduation (Iranian or foreign university); number of con- tinuing education courses attended PSɓ UJNFFMBQTFEGSPNMBTU continuing education course (8,9). r self-confidence: self-rated knowledge of hepatitis B (rated on a 4-point Likert scale from very poor to very good). r major source of information regard- ing hepatitis B (books, articles, media, classes). r vaccination status: completed 3-course HBV vaccination; checked hepatitis B surface antigen antibody (antiHBs) status. Statistical analysis For the risk-factor analyses, bivariate and multivariate analyses were per- formed. Data were missing regarding the country of education in MSD pro- grammes as most dentists only had a general dentistry degree; thus this vari- able was excluded from the multivari- ate models in order to avoid decreasing the sample size to 111 cases; its effect was assessed (along with the effects of other variables) only using Spearman correlation coefficient. Predictors of knowledge and attitude (their total scores entered as continuous variables) were analysed using stepwise and single-model linear regression analysis. Behaviour predictors were modelled in an ordinal logistic regression. The behaviour score was also dichotomized into agreeing to treat and not agreeing to treat the simulated patient (7) and the association of the independent vari- ables with the binary behaviour scores were assessed using binary logistic regression. The statistical software used was SPSS WFSTJPOĉF MFWFMPG TJHOJė- cance was set at Pɒ Results The mean age of participants was 43.9 4% ZFBST BOE PG them were males. The educational and occupational characteristics of the sam- ple are reported in our earlier paper (7). #SJFĚZ IBEHSBEVBUFE GSPNGPS- eign universities with a general dentistry RVBMJėDBUJPO BOE XFSF GPSFJHO graduates with a specialist (Master’s) EFHSFF IBE ZFBSTPGDMJOJDBM FYQFSJFODF IBEBDBEFNJDUFBDI- JOH FYQFSJFODF IBE BĨFOEFE continuing education courses > 3 times BOEIBEBĨFOEFETVDIDPVSTFT within the previous 2 years. Of the par- UJDJQBOUT IBECFFOWBDDJOBUFE BHBJOTUIFQBUJUJT#CVUPOMZIBE had their antibody titre tested. No significant correlations were found between the dentists’ place of graduate education and any of the dependent variables (Spearman coef- ficient, all P WBMVFT 5BCMF The Spearman correlation coefficient indicated significant associations be- tween dentists’ knowledge and the fol- lowing variables: MS degree; number of continuing education courses attended; duration since last course; faculty mem- bership; time assigned to prepare the dental chair/unit for patients; using eye-shields; and vaccination status. The only variable that significantly corre- lated with attitude was the number of courses attended. Behaviour was cor- related (negatively) only with being vaccinated (Table 1). Knowledge Overall, the mean knowledge score PGEFOUJTUTXBT 4% PG the highest possible score. All the vari- ables including attitude and knowledge were modelled in a backward-selection multiple regression analysis. The final SFHSFTTJPONPEFMJEFOUJėFEQSFEJDUPST for knowledge (adjusted R2 F = 8.739, P 5BCMF IBWJOHBO MSD degree; attended ≥ 3 continuing education courses; having very good HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 57 attended ≥ 3 continuing education courses (compared with dentists who IBEBĨFOEFE DPVSTFT 03 $*m XFSF TJHOJėDBOUMZ more willing to deliver dental treatment to the HBV-positive simulated patient. Graduates from Iranian universities were significantly more likely to agree to treat patients (compared with dentists XIPIBEHSBEVBUFEBCSPBE 03 $*m 5BCMF All the variables (including knowl- edge and attitude) were entered into a multiple ordinal logistic regression. Afterwards, the model was optimized 5BCMF ĉF SFTVMUT TIPXFE UIBU clinicians with general dentist qualifica- tions were more likely to treat HBV- positive patients than were specialist EFOUJTUTXJUIBO.4%EFHSFF 03 $*m ĉFQPTJUJWF BT- sociations of the number of courses 03 $*m BOEUIF negative association of vaccination were Table 1 Bivariate correlations (Spearman coefficient ρ) between dentists’ risk factors and scores on knowledge about hepatitis B, self-reported attitudes towards people with hepatitis B and actual behaviour in agreeing to treat hepatitis B virus (HBV) positive patients (n = 300) Independent variable Knowledge a Attitudes b Behaviour c ρ P-value ρ P-value ρ P-value Demographic data Sex: male –0.044 0.443 0.023 0.694 0.037 0.526 Age: older 0.022 0.704 0.105 0.070 0.062 0.283 Practice location –0.048 0.407 –0.048 0.410 –0.041 0.481 Educational characteristics Degree: MSD 0.169 0.003 0.068 0.241 –0.105 0.069 Study origin: abroad –0.111 0.056 –0.025 0.671 0.060 0.301 No. of continuing education courses: ≥ 3 0.185 0.001 0.151 0.009 0.105 0.069 Last course date: ≥ 2 yr –0.163 0.005 –0.103 0.076 –0.029 0.621 Specialty origin: abroad 0.036 0.708 0.005 0.958 –0.051 0.593 Experience: ≥ 6 yr –0.014 0.815 0.055 0.348 0.002 0.975 Faculty membership: yes 0.185 0.001 0.008 0.886 0.007 0.904 Source of HBV knowledge Classes: yes 0.034 0.558 –0.029 0.620 –0.052 0.371 Books: yes –0.002 0.974 –0.050 0.385 0.030 0.600 Articles: yes 0.007 0.898 0.083 0.149 0.044 0.443 TV: yes –0.067 0.248 –0.039 0.506 0.021 0.720 HBV vaccination history Vaccinated: yes 0.122 0.034 –0.047 0.416 –0.123 0.032 Titre check: yes 0.082 0.165 0.023 0.700 0.093 0.117 Office characteristics Solo practice: yes 0.112 0.054 –0.025 0.671 –0.019 0.742 Group practice: yes –0.059 0.307 0.106 0.066 –0.073 0.205 No. of personnel: higher –0.002 0.969 –0.047 0.432 0.087 0.144 Office practices Preparation time for next patient: longer 0.120 0.042 0.016 0.787 –0.136 0.021 Use mask: yes 0.032 0.577 0.022 0.708 0.045 0.438 Use gloves: yes 0.011 0.853 0.092 0.111 –0.021 0.717 Use eye-shield: yes 0.183 0.002 –0.039 0.498 0.039 0.499 Have oven: yes –0.029 0.618 0.059 0.311 0.009 0.880 Have autoclave: yes 0.029 0.614 –0.025 0.672 –0.041 0.484 Self-confidence Self-rated knowledge about HBV: higher 0.171 0.003 0.032 0.584 –0.044 0.450 aBased on 18 items, higher score indicated better knowledge; bBased on 13 items, higher score indicated better attitudes; cBased on 1 item, dichotomized into willing or unwilling to treat a simulated HBV-positive patient. MSD = Master of science in dentistry. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 58 BHBJO DPOėSNFE 03 $* m #FĨFSCFIBWJPVSXBT BT- sociated with dentists working at dental offices that had unit preparation times NJO 03 $*m 5BCMF Discussion The multivariable analyses of the study findings indicated that knowledge about hepatitis B was better among dentist who were MSD degree holders, academic faculty members, had taken more continuing education courses, used dental eye-shields, would put more time into preparing their dental units for each patient and had higher self- confidence about their knowledge. A positive attitude towards people with HBV was more frequent in dentists at- tending more courses and those work- ing in group practice clinics along with other dentists. The number of courses taken positively affected dentists’ behav- iour as well. Foreign-graduated dentists were more likely to reject HBV-positive patients. A higher rate of willingness to accept HBV-positive patients was found in dentists practising at offices that prepared the unit for the next pa- tient faster (< 3 min). Surprisingly, dentists who were immunized against HBV were about UJNFTNPSF MJLFMZ UP SFKFDU USFBU- ment for HBV-positive patients. On the other hand, a confirmed antibody titre improved dentists’ willingness to treat patients about 2.3-fold. In view of the lack of any similar studies on risk factors for dentists’ knowledge, attitude, and behaviour towards hepatitis B, we can only speculate about the explanation GPSUIJT6OWBDDJOBUFEEFOUJTUTNJHIUCF less knowledgeable about the hazards of HBV and its cross-contamination or they might be risk-takers who care less about their own and their patients’ safe- ty. Dentists who are vaccinated might be more knowledgeable or more cau- tious and this might discourage them from delivering dental care to HBV- positive patients unless they are certain of their titre elevation after immuniza- tion. Hepatitis B vaccination can fail to produce proper levels of immunization and antibody titres need to be assessed (3,17). Dentists should be taught that it is their antibody titre that matters, not Table 2 Risk factors for dentists’ knowledge about hepatitis B and self-reported attitudes towards people with hepatitis B, determined using stepwise multiple linear regression Predictors B SE Beta P-value 95% CI for B Predictors of knowledge Degree: MSD 2.126 0.784 0.149 0.007 0.583 to 3.670 No. of courses: ≥ 3 1.154 0.454 0.140 0.012 0.260 to 2.048 Use eye-shield: yes 1.936 0.821 0.130 0.019 0.320 to 3.552 Preparation time for next patient: longer 1.974 0.937 0.115 0.036 0.130 to 3.819 Self-confidence: very good 1.868 0.559 0.183 0.001 0.769 to 2.967 Predictors of attitudes Group practice: yes 0.859 0.425 0.115 0.044 0.021 to 1.696 No. of courses: ≥ 3 0.639 0.240 0.151 0.008 0.166 to 1.112 Use gloves: yes 5.782 3.485 0.094 0.098 –1.077 to 12.64 All variables were initially modelled. Any variables not shown in the table were non-significant. B = regression coefficient; SE = standard error; CI = confidence interval for the regression coefficient. MSD = Master of science in dentistry. Table 3 Predictors of dentists’ knowledge about hepatitis B virus Predictors of knowledge B SE Beta P-value 95% CI for B Sex: male –0.765 0.862 –0.051 0.376 –2.461 to 0.931 Age: older 0.013 0.061 0.014 0.830 –0.108 to 0.134 Degree: MSD 1.579 0.877 0.110 0.073 –0.147 to 3.305 Study origin: homeland –1.678 0.970 –0.096 0.085 –3.586 to 0.231 Experience: : ≥ 6 yr –1.245 1.169 –0.067 0.288 –3.547 to 1.056 Faculty membership: yes 2.137 1.070 0.123 0.047 0.031 to 4.244 No. of courses: ≥ 3 1.266 0.469 0.153 0.007 0.344 to 2.189 Self-confidence: very good 1.849 0.564 0.181 0.001 0.739 to 2.959 B = regression coefficient; SE = standard error; CI = confidence interval for the regression coefficient. MSD = Master of science in dentistry. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 59 only their vaccination status. Checking antibody status could be made manda- tory, as it deals not only with dentists’ health but also with prevention of cross- infection to patients (3). Dentists’ willingness to treat the simulated HBV-positive patients also increased with clinical experience (14). Attendance at postgraduate courses has been shown to improve dentists’ willingness to treat AIDS patients (18), similar to our results for HBV. The number of continuing education courses attended by dentists was the only factor in our study that boosted all domains: knowledge, attitudes and behaviour. Taking continuing educa- tion courses is one of the major ways to remain licensed to practise dentistry in the Islamic Republic of Iran. However, there are other ways to remain licensed to work, such as attending conferences or taking part in certain journals’ tests. "ěFSZFBSTIBTFMBQTFE TJODFHSBEV- ation, every dentist needs to do such activities annually to keep their licence. Dentists graduated in other countries (mostly Eastern Europe or Asia) had a tendency to reject HBV-positive pa- tients. It seems that dentists who work or graduate in countries with higher risks of bloodborne or sexually trans- mitted infections need to be educated better through extra courses. This is confirmed by the positive effect of such courses on acceptance of HBV-positive patients, when other factors were held constant. Interestingly, knowledge had no as- sociation with dentists’ willingness to deliver dental care to a simulated HBV- positive patient. This is similar to studies on patients with HCV (19) and HIV (9), but contrasts with other research on HIV (20) and HCV (16). In line with the findings of another study on willingness to treat patients with AIDS (8), but in contrast to our own findings on AIDS patients (9), we found that working in a clinic with other dentists encouraged dentists to show more posi- tive behaviour and attitudes towards HBV-positive patients. A longer period of work experience negatively affected 6OJUFE,JOHEPNEFOUJTUTBĨJUVEFT 8) and Iranian dentists’ attitudes and be- haviour concerning AIDS patients (9). Nevertheless, it did not affect attitudes and behaviours related to treating HBV patients in this study. No other studies have assessed these factors in order for us to compare the results. Limitations and strengths Some constraints limited the current study. It is interesting that the variation Table 4 Results of stepwise backward-selection multiple binary logistic regression analysis for dentists’ actual behaviour in agreeing to treat simulated hepatitis B positive patients (only the final model is illustrated) Predictors of behaviour B P-value OR (95% CI) Study origin: homeland 0.73 0.032 2.08 (1.06 to 4.07) No. of courses: ≥ 3 0.76 0.005 2.15 (1.26 to 3.67) Vaccinated: yes –0.96 0.028 0.38 (0.16 to 0.90) Titre check: yes 0.84 0.002 2.31 (1.35 to 3.96) All variables were initially modelled. Any variables not shown in the table were non-significant. B = regression coefficient; OR = odds ratio; CI = confidence interval for the odds ratio. Table 5 Results of multiple ordinal logistic regression analysis for dentists’ actual behaviour in agreeing to treat simulated hepatitis B positive patients Predictors of behaviour B P-value OR (95% CI) Degree: MSD –0.508 0.042 0.60 (0.37 to 0.98) Office: solo practice 0.518 0.070 1.68 (0.96 to 2.94) Office: group practice 0.420 0.275 1.52 (0.72 to 3.23) Faculty membership: yes 0.337 0.274 1.40 (0.77 to 2.56) No. of courses: ≥ 3 0.620 0.012 1.86 (1.14 to 3.02) Last course: < 2 yr –0.792 0.087 0.45 (0.18 to 1.12) Last course: ≥ 2 yr –0.796 0.076 0.45 (0.19 to 1.09) Unit preparation time: t 3 min –0.583 0.039 0.56 (0.32 to 0.97) Vaccinated: yes –0.776 0.045 0.46 (0.22 to 0.98) Titre check: yes 0.369 0.132 1.45 (0.90 to 2.34) Self-confidence: higher –0.158 0.327 0.85 (0.62 to 1.17) All variables were initially modelled. Any variables not shown in the table were non-significant. B = regression coefficient; SE = standard error; CI = confidence interval for the odds ratio. MSD = Master of science in dentistry. EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 60 of self-reported attitudes towards HBV was much narrower than the variability of behaviour towards actual patients. This implies that dentists’ behaviour is affected by many uncontrollable fac- tors, rather than merely reflecting their attitudes and beliefs. This indicates the need for direct observations instead of relying on self-declared attitudes in interviews. An advantage of this study was that the multivariable models benefited from the inclusion of numerous differ- ent variables which allowed us to con- trol for many confounders. Thus, the results are more reliable compared with the bivariate statistics used in previous studies on knowledge, attitudes and behaviour. However, the study design would be improved if some variables were assessed in more detail. For exam- ple, future studies should record den- tists’ work experience or the duration since last education course in years and not as dichotomized variables, as the latter discards useful details. It should be noted that the adjusted R2 values were small, indicating that better models with larger samples and more controls are still needed. The strengths and limitations of our simulated patient methods have been discussed in more detail in a previous article (9) and in the earlier paper on this same research (7). Another limi- tation of the survey methods was the method of assessing attitudes, since the interviews were face-to-face and dentists might have been biased to- wards giving more favourable answers, even though they had been told that their personal information would not be recorded. However, this limitation would not have affected responses to the knowledge or behaviour parts of the study. To our knowledge this is the first study of knowledge, attitudes and be- haviour towards HBV which did not rely on mass-survey methods. The generalizability of the findings might be limited by different practice require- ments and public health policies of dif- ferent countries regarding universal precautions and obligatory vaccination policies. For example, vaccination of dentists is obligatory in many coun- tries but not in the Islamic Republic of Iran, although vaccination of dentists (and the general public) is encouraged because the vaccine is available free of charge. On the other hand, policies on universal precautions in Islamic Repub- lic of Iran follow similar standards to many other countries and this favours the generalizability of the findings. Conclusions As expected, better knowledge was found among Master’s degree holders, faculty members and dentists who had taken more courses, as well as those who used dental eye-shields and who put more time into preparing dental units, as well as dentists with higher self-confidence about their knowledge. Working in teams and attending more courses was associated with a better attitude towards patients with HBV. The number of courses also seemed to positively affect dentists’ behaviour. Dentists graduated from the Islamic Republic of Iran were more willing to treat HBV-positive patients than were foreign-graduated dentists. Clinicians who worked in offices that needed a longer time for preparing the dental unit for the next patient were less likely to welcome patients. Inter- estingly, vaccination status alone did not facilitate the acceptance of HBV- positive patients (and in fact worsened the case). Thus, emphasis should be placed on antibody titre assessment, which was a factor contributing posi- tively to dentists’ acceptance of HBV- positive patients. Since the results of this and our previous study show that attending postgraduate courses can improve dentists’ behaviour and at- titudes, obligatory courses regarding hepatitis, AIDS and infection control for dentists can be recommended in the Islamic Republic of Iran, and as far as our results could be generalized to other countries, in other regions as well. Acknowledgements The authors sincerely thank colleagues who helped in different phases of this study, which was based on two DDS theses, the protocols of which were ap- QSPWFEBOE SFHJTUFSFEBT BOE CZUIFJOUFSOBMSFWJFXCPBSEPG UIF6OJWFSTJUZ Authors' contributions: Behnam Khosravanifard conceived, designed, and supervised the study. Vahid Rakh- shan was consulted regarding the study design, searched the literature, digitized the questionnaires, conceived the analysis of risk factors using multivari- ate statistics, designed and performed the statistical analyses, optimized the regression models, interpreted and discussed the findings, and drafted/ revised the article. Samira Sherafat and Leili Najafi-Salehi each interviewed the dentists, acted as a standardized patient, and calculated/digitized the scores. Funding: The study was self-funded by the authors. Competing interests: None declared References 1. Mahboobi N, Agha-Hosseini F, Mahboobi N, Safari S, Lavanchy D, Alavian SM. Hepatitis B virus infection in den- tistry: a forgotten topic. J Viral Hepat. 2010 May;17(5):307–16. PMID:20196802 2. Resende VL, Abreu MH, Paiva SM, Teixeira R, Pordeus IA. Concerns regarding hepatitis B vaccination and post-vac- cination test among Brazilian dentists. Virol J. 2010;7:154. 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J Dent Educ. 2011 Mar;75(3):421–7. PMID:21368266 12. Song KB, Choi KS, Lang WP, Jacobson JJ. Hepatitis B prevalence and infection control among dental health care workers in a community in South Korea. J Public Health Dent. 1999 Win- ter;59(1):39–43. PMID:11396043 13. Veronesi L, Bonanini M, Dall’Aglio P, Pizzi S, Manfiedi M, Tanzi ML. Health hazard evaluation in private dental practices: a survey in a province of northen Italy. Acta Biomed. 2004 Apr;75(1):50–5. PMID:15315087 14. Brailo V, Pelivan I, Škaricić J, Vuletić M, Dulcić N, Cerjan-Letica G. Treating patients with HIV and Hepatitis B and C infections: Croatian dental students’ knowledge, attitudes, and risk per- ceptions. J Dent Educ. 2011 Aug;75(8):1115–26. PMID:21828306 15. Sears B. HIV discrimination in health care services in Los Ange- les county: the results of three testing studies. Williams Institute study. Los Angeles (CA): The Williams Institute; 2006 (http:// www.bc.edu/content/dam/files/schools/law_sites/library/ pdf/content/tremblay_schulman/2006-12-00.Sears_Ho.pdf, accessed 19 October 2014). 16. Richmond JA, Dunning TL, Desmond PV. Health profession- als’ attitudes toward caring for people with hepatitis C. J Viral Hepat. 2007 Sep;14(9):624–32. PMID:17697014 17. Lasemi E, Haddadpour N, Navi F, Rakhshan A, Rakhshan V. Rate of acquired immunity in dental students after hepatitis B vaccination. Dent Res J (Isfahan). 2011 Summer;8(3):128–31. PMID:22013475 18. Wilson NH, Burke FJ, Cheung SW. Factors associated with den- tists’ willingness to treat high-risk patients. Br Dent J. 1995 Feb 25;178(4):145–8. PMID:7893547 19. van de Mortel TF. Health care workers’ knowledge of hepatitis C and attitudes towards patients with hepatitis C: a pilot study. Aust J Adv Nurs. 2002 Sep-Nov;20(1):13–9. PMID:12405278 20. Kitaura H, Adachi N, Kobayashi K, Yamada T. Knowledge and attitudes of Japanese dental health care workers towards HIV-related disease. J Dent. 1997 May-Jul;25(3-4):279–83. PMID:9175358 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 62 Short communication Development, implementation and evaluation of a medication safety programme for schoolchildren in Qatar K.J. Wilby,1 H.M. Hazi 1 and M.A. Ashour 2 ABSTRACT The objectives of this study were to assess the needs of schoolchildren relating to medication safety and to develop and implement a health promotion programme in Qatar. Semi-structured interviews were completed with teachers, nurses and school administrators at 2 primary schools in Doha. Two main themes were identified from these interviews, namely medication basics and medication safety. Subsequently, a 25-minute health promotion programme was developed and delivered to 11 groups of schoolchildren aged 6–10 years. The student groups contained both expatriate and local Qatari students. The programme was evaluated based on perceptions of site representatives, investigators and peer reviewers using a standardized evaluation form. All the evaluators agreed that the programme was beneficial and should be recommended to other schools in Qatar. This study can serve as a prototype for future programmes in the Eastern Mediterranean Region and elsewhere. 1Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar (Correspondence to K.J. Wilby: kjw@qu.edu.qa). 2National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar. Received: 30/01/14; accepted: 03/11/14 |ó\ óR9ÜÚÐzBÐ{gX°TogýÐízTÐoX°TÐKrXmh|<gga=í{g`e=íØÐzKÎ ÚInLph]LÒí}Yºï~wa][Yî{wºdxíë@xnT p[UÐ~åx~_UsåYni}=|haf>íØÐ{åLÎípåhýÐí{UÐpYĆåUn=påbd_CÐÜÚÐ{åCÐ|åhYĆ>Ónå@nhAÐåhhb>påHÐÚ{UÐì|åwæÐ{åwÌqåinToåÉ°#Ð æ}´å_UÐå>í påAí{UÐ: ÷NåóhýÐ{=ÐNåHÚ{Y:ÜÚÐ{åYï}åx{YíNå ¬},íNåed_Y åYpåeö^ fYå õIÓĆå=nbYÛnåiÎå>{åSí }åó]óS: såYni}=ØÐ{åLÎ åUÙ{å_=– å>í på hýÐí{UÐpYĆåUÐíÒÐíÐ{åCÐÓnhåHnHÌnåªíºÓĆå=nbCÐì|åwéĆåBåYNhåhýÚNåLYDåL ÓnåLe6qdeåIÐ{åSí ÓÐfåH10í6Nå=åwÚ5LÌÖÐíÐGå>ÜÚÐ{åCÐ|åhYĆ>åYpåLe611OÎê ¬{å ôSíºpåbhSØ25å> {Ypå[UÐ~åx~_U ÊÐ}å^iNå_@Ð}YíNåAnUÐí åSCÐMåö,ÓÐÚå[>OÎðÐØnfåHÐsåYniFUÐåhhb>å>í Nåhd7Nåx}ó]óSÑĆåJíåx{RÐíÑĆåJDåLÑĆå]UÐ :î}åBÌÜÚÐ{åYåóõSåYìØ5åLn= ó¥åxëÌå`fxíðÐ{åhaYënTsåYniFUÐëÌDåLNåe¬hbCÐ åh+åa>Ðí Ò{å AYåhhb>ÒÚ5åHÐêÐ{åHn= î}åBÌåJnfYíåHCÐç åhdSÎ:phdbåYsåYÐFUÕÙåeiÌpå=ne=ëåc>ëÌpåHÐÚ{UÐì|å4åcexí }åó]óS Développement, mise en œuvre et évaluation d’un programme de sûreté des médicaments pour les écoliers au Qatar RÉSUMÉ Les objectifs de la présente étude étaient d'évaluer les besoins des écoliers en matière de sûreté des médicaments et d’élaborer puis de mettre en œuvre un programme de promotion de la santé au Qatar. Des entretiens semi-structurés ont été menés auprès des enseignants, du personnel infirmier et des administrateurs de deux écoles primaires à Doha. Ces entretiens ont permis de dégager deux thèmes principaux, à savoir les informations de base sur les médicaments et la sûreté des médicaments. Ensuite, un programme de promotion de la santé de 25 minutes a été élaboré puis présenté à 11 groupes d'écoliers âgés de 6 à 10 ans. Les groupes d’écoliers étaient composés à la fois d’expatriés et de Qataris. Le programme a été évalué à partir des points de vue des représentants des établissements scolaires, des chercheurs et des pairs évaluateurs à l'aide d'un formulaire d'évaluation standardisé. Tous les évaluateurs ont reconnu que le programme était bénéfique et devait être recommandé à d'autres écoles au Qatar. La présente étude peut servir de modèle aux futurs programmes dans la Région de la Méditerranée orientale et dans d'autres régions. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 63 Introduction Medication safety is a high priority for health-care institutions, governments and international health organiza- tions. The World Health Organization (WHO) states that the majority of adverse drug reactions (ADRs) are pre- ventable, yet, despite this, unintended reactions to medications are among the leading causes of death in many countries (1). This is especially alarming as the use of medication is constantly increasing in countries worldwide (2). Other government bodies, such as the Canadian Institute for Health Research, have listed medication safety initiatives as high priority for funding and research (3). One vulnerable population that is particularly prone to the harmful effects of medications, vitamins and supple- ments is children. Children commonly display highly sensitive reactions to medications, including ADRs (4). They are also at greater risk of the harmful effects of medications due to accidental ingestion or unintended overdose (5). Therefore, preventative medication safety initiatives are very important for reducing the harmful effects of medica- tions in children. Health promotion programmes aim to educate individuals regarding health-related matters in the hope of promoting better health practices. Health promotion targets are broad and include initiatives such as diet and exercise programmes, disease preven- tion and specialty topics such as oral health and hygiene (6–8). Programmes targeting medications and medication safety, however, are rare. In fact, we were unable to identify any published reports describing a health promotion programme targeting medication safety in children. With medications account- ing for many undesirable and harmful effects (including death) (1), we believe medication safety should be targeted as an important health promotion ini- tiative. Due to the heightened risks of medication use by children, medication safety programmes could be designed to fit the health curricula of primary schools worldwide. The objectives of this project were to assess the needs of primary-school children relating to medication safety and to develop, implement and evaluate a health promotion programme tar- geting medication safety principles for schoolchildren in Qatar. Methods Study setting The study was carried out from March UP.BZ5XP TDIPPM TJUFTXFSF selected to participate in this project. To enhance the generalizability of the study to the population in Qatar the schools were selected to have diverse student populations. One school consisted largely of expatriate students from North America and the second school had primarily Qatari nationals with a small proportion of Arab expa- triate students. Children aged 6–11 years (grades 1–6) were selected for inclusion. Their primary language of instruction was English with Arabic as a core curriculum component. Ethical approval for this project was obtained from the institutional review CPBSE BU2BUBS 6OJWFSTJUZ JO%PIB Qatar. Needs assessment A needs assessment was first done to develop themes that would be used to develop the programme. Six semi- structured interviews were completed with school staff (1 administrator, 1 teacher and 1 nurse at the first site, and 1 administrator and 2 teachers at the second site). Semi-structured inter- views are a flexible way of interviewing which rely on pre-established interview guides but allow for subjects to discuss important considerations that were not identified by the investigators (9). Informed consent was obtained prior to each interview and a predefined script was used as a guide. Interview questions were developed by the investigators and peer-reviewed by an expert in the field. The expert was a pharmacist by training and had extensive experience in qualitative research, development of health promotion programmes and paediatric populations. The interview questions were as follows: “What types of health promotion programmes are offered at your institution?”; “Do you currently have any health promotion activities relating to medications and medication safety offered at your in- stitution?”; “How would you describe your students’ knowledge regarding medications and medication safety?”; “Do you believe a health promotion programme targeting medications and medication safety would be beneficial for your students?”; “If yes, what con- cepts do you feel your students would benefit learning from with respect to medications?” The number of interviews was not pre-defined but instead they were car- ried out until saturation was reached. Saturation was established when all investigators agreed that no new in- formation or themes were being dis- cussed. Interviews were recorded and transcripts prepared upon completion. Three investigators independently re- viewed the interviews and transcripts and identified major themes. All investi- gators agreed upon the final themes and any disagreement was resolved through discussion. Health promotion programme The themes identified were used to develop a health promotion pro- gramme regarding medication safety for children. A variety of verbal, visual and interactive activities were used to communicate the core messages of medication basics and medication safety. The programme was developed in English and, while the major content remained similar, presentations were adapted for different age groups and for EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 64 of schoolchildren aged 6–11 at the 2 school sites. An evaluation was obtained from a school representa- tive (teacher or administrator) at the completion of each presenta- tion. A summary of the evaluations is presented in Table 2. Overall, the programme was received positively XJUIPGFWBMVBUPSTBHSFFJOHPS strongly agreeing that the programme should be available for other schools in Qatar. Positive qualitative com- ments described the programme as “very worthwhile and informative”, “novel and important” and “effective through a variety of teaching meth- ods”. Suggestions for improvement included more practice to increase the confidence of presenters; clearer communication for native-English students; and modification of interac- tive activities to be more suitable for older students. Peer evaluations were also positive with all of the reviewers agreeing or the different sites. For example, Arabic language was used to clarify points at the school that comprised children whose primary language was Arabic. Each health promotion presentation XBT EFTJHOFE UP CF NJOVUFT JO length. The health promotion presenta- tions were evaluated by schoolteachers and administrators using an evaluation rubric. Additionally, each presentation XBT FWBMVBUFECZQFFS SFWJFXFS reviewers in total) in the final year of study at the College of Pharmacy at 2BUBS6OJWFSTJUZ-BTUMZ UIF JOWFTUJ- gators reflected on the strengths and weaknesses at the conclusion of each presentation and brainstormed ways to improve and enhance the content for subsequent presentations. Analysis Descriptive statistics were used to sum- marize evaluations from site representa- tives and peer reviewers. Investigators’ suggestions for improvement were summarized qualitatively. Results Themes identified from the needs assessment After completion of 6 semi-structured interviews (3 from each site), it was determined that saturation had been reached and no further interviews were planned. The major themes identified from the interviews and the transcripts, namely medication basics and medica- tion safety, are summarized in Table 1, along with the programme’s objectives and major activities. Evaluation of the health promotion programme The health promotion presenta- tion that was subsequently de- signed—entitled “Medications and you”—was delivered to 11 groups Table 1 Themes emerging from semi-structured interviews with school staff, and the objectives and associated activities designed for the “Medications and you” health promotion programme for schoolchildren Major themes identified Health promotion programme Objectives Activities Medication basics To define medications and describe at least 4 common dosage forms Visual presentation and question-and-answer session using projected slides: description of pharmacist, variety of dosage forms (tablets, capsules, liquids, creams, injections) and symptoms that may require the use of medications To list at least 3 symptoms or times when a child would seek medications Word search activity about trustworthy adults, to illustrate from where medications can be obtained To describe trustworthy adults from whom a child could seek medications and medication advice Interactive activity where students opened small containers and needed to determine if the label inside related to someone trustworthy from whom medications or medication advice can be obtained Medication safety To create a safe plan for a child faced with the prospect of sharing medications or taking medications without parental or trustworthy adult guidance Interactive videos using Talking Tom Cat and Talking Gingera to ask situational questions regarding sharing self-administered medications To compare and contrast medications and candy in terms of appearance and familiarity Wise Owl video to illustrate the importance of seeking parental (or trustworthy adult) guidance prior to taking medications To describe safe procedures for a child encountering unknown substances Interactive game where children guessed if sealed samples contained medication or candy, with all samples actually containing medications aFree online application available for download. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 65 strongly agreeing with every category on the rubric presented in Table 2. Sug- gestions for improvement obtained from the peer reviewers included in- corporating more interactive activities; louder and clearer communication from presenters; and greater efforts to keep the younger children focused. Discussion To our knowledge, this is the first published report of a medication safety health promotion programme for primary-school students in the Eastern Mediterranean Region and possibly worldwide. With the increas- ing use of medications to treat both acute and chronic diseases, education is needed to ensure children avoid both preventable and incidental harmful effects of medications. This programme may serve as a platform for future programmes aiming to ac- complish similar objectives through promotion of safe medication prac- tices. Raising awareness of medication safety with children may have many beneficial effects. Throughout the pres- entations, we found that the children had common misconceptions about medications, especially when trying to distinguish between medications and candy. With the pharmaceuti- cal industry developing novel dosage forms for medications and supplements (gummies, dissolvable flakes, flavoured chewables), it is important for children to be educated regarding the similari- ties between medications and candy in order to avoid harmful effects from incidental exposure. Additionally, it is important for children to recognize trustworthy adults to ask for advice re- garding medications as well as for them to know from whom they should re- ceive medications. As with other health promotion initiatives, the children may further disseminate the information through discussions with parents, rela- tives, and friends. This project allowed us to identify a target population for widespread roll- out of this programme. It was found that children aged 7–9 years were the most interactive, demonstrated the value of learning, and were more fa- miliar with the activities and videos chosen for the presentations. Future presentation will be tailored to this population, considering all types of teaching methods. Additionally, it was found that adapting the programme based on language, culture and religion was positively received and this will be encouraged for future sites. While this project provides a platform for a health promotion pro- gramme regarding medication safety to children, some limitations should be discussed. Firstly, the programme was piloted in only 2 sites in one coun- try. This limitation was recognized and we attempted to overcome it by selecting sites with diverse popula- tions and inclusion of children with varying ages. Secondly, it was not pos- sible to assess changes in children’s knowledge after the presentations and it is not known if any change would be sustainable. If this programme or simi- lar programmes were implemented on a wider municipal or national level, researchers should be encouraged to assess hard outcomes, such as inci- dence of adverse drug reactions and/ or hospital or doctor visits. Thirdly, parents were not involved, and learn- ing may be enhanced by providing information resources to parents for reinforcement at home. Finally, the age range of the students was not IPNPHFOPVT m ZFBST CVU BT discussed, this was a pilot study to determine the most appropriate age range for this type of intervention. Despite the limitations mentioned above, this project serves as a novel prototype for teaching medication safety principles to children. The methods are adaptable to most popu- lations and can be replicated to fit the needs of many regions. As such, the results from this project may be used to further develop health promotion regarding medication safety. Future research should attempt to refine health promotion initiatives and as- sess sustainable effects, in order to ensure the best possible outcomes are being achieved. Competing interests: None declared. Table 2 Results of on-site evaluations of the “Medications and you” health promotion programme by a representative in schools (n = 12) Assessment item (statement about the programme) Level of agreement Strongly agree Agree Neutral Disagree Strongly disagree Met my objectives and expectations 7 5 0 0 0 Was clearly and effectively communicated 3 9 0 0 0 Used appropriate audio-visual aids and interactive activities 11 1 0 0 0 Benefited the students participating 8 4 0 0 0 Should be recommended to other schools in Qatar 9 3 0 0 0 EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 66 References 1. Fact sheet. Medicines: safety of medicine—adverse drug reac- tions. Geneva: World Health Organization; 2008. 2. The global use of medicines: outlook through 2015. Danbury (CT): IMS Institute for Healthcare Informatics; 2011. (http:// www.imshealth.com/ims/Global/Content/Insights/IMS%20 Institute%20for%20Healthcare%20Informatics/Documents/ The_Global_Use_of_Medicines_Report.pdf, accessed 24 November 2014). 3. (Drug safety and effectiveness network. Ottawa (ON): Cana- dian Institutes of Health Research; 2012 (http://www.cihr-irsc. gc.ca/e/40269.html, accessed 24 November 2014). 4. Smyth RM, Gargon E, Kirkham J, Cresswell L, Golder S, Smyth R, et al. Adverse drug reactions in children—a systematic re- view. PLoS One. 2012;7(3):e24061. PMID:22403604 5. Cohen AL, Budnitz DS, Weidenbach KN, Jernigan DB, Schroeder TJ, Shehab N, et al. National surveillance of emer- gency department visits for outpatient adverse drug events in children and adolescents. J Pediatr. 2008 Mar;152(3):416–21. PMID:18280852 6. Parcel GS, Simons-Morton B, O’Hara NM, Baranowski T, Wil- son B. School promotion of healthful diet and physical activ- ity: impact on learning outcomes and self-reported behavior. Health Educ Q. 1989 Summer;16(2):181–99. PMID:2732062 7. Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Faucette N, Hov- ell MF. The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Sports, Play and Active Recreation for Kids. Am J Public Health. 1997 Aug;87(8):1328–34. PMID:9279269 8. Kay E, Locker D. A systematic review of the effectiveness of health promotion aimed at improving oral health. Community Dent Health. 1998 Sep;15(3):132–44. PMID:10645682 9. Mason J. Semistructured Interview. In: Lewis-Beck MS, Bryman A, Liao TF, editors. The SAGE encyclopedia of social science research methods. Thousand Oaks (CA): Sage Publications; 2004. HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 67 WHO events addressing public health priorities Private sector role in achieving universal health coverage Most countries of the Eastern Mediterranean Region (EMR) have witnessed a rapid expansion of the private health sector over past decades. According to information available in some countries of the Region, an estimated PGUIF&.3QPQVMBUJPOTFFLTIFBMUIDBSFGSPNQSJWBUF providers and the percentage of health-care services from the private sector used by the poorest quintile ranges be- UXFFOBOE*UJTJODSFBTJOHMZSFDPHOJ[FEUIBUUIF private sector has an important role to play in contributing to countries’ health system goals, notably in the achieve- NFOUPGVOJWFSTBMIFBMUIDPWFSBHF 6)$ XIJDIFOTVSFT that everyone who needs health services is able to get them, without undue financial hardship. Yet many challenges remain. The range of services provided by the private sector is variable, standards are questionable, regulation is poor and there is insufficient information about the financial burden to the users of these services. Enforcement of service delivery quality standards in the private sector is among the biggest challenges faced by governments and ministries of health in the Region. Ways are needed to partner effectively with the private sector, by strengthening public–private partnerships (PPPs) for health-care provi- sion, so that its contribution can be better harnessed. "U UIF8PSME)FBMUI"TTFNCMZ JO.BZ BOE the Regional Committee for the Eastern Mediterranean NFFUJOH JO0DUPCFS.FNCFS4UBUFTBHSFFEPOUIF need to engage with the private health sector as part of FĎPSUT UPXBSET6)$ BOEBQSFMJNJOBSZBOBMZTJTPG UIF private health sector in the Region was presented at the UI TFTTJPO PG UIF3FHJPOBM$PNNJĨFF JO0DUPCFS 5PESBXPO JOUFSOBUJPOBMBOESFHJPOBMFYQFSJFODF of involving the private health sector in EMR countries a Regional Consultation on engaging the private health TFDUPSGPSBDDFMFSBUJOHQSPHSFTTUPXBSET6)$UPPLQMBDF JO$BJSP &HZQU JO+VOFĉFBJNTPGUIFXPSLTIPQ were to: raise awareness among policy-makers and key stakeholders on the role and contribution of the private IFBMUITFDUPSJOQSPHSFTTJOHUPXBSET6)$ TIBSFFYQFSJ- ences and results of analytical studies in selected countries of the Region on regulation of the private sector and its role in health service provision; and develop a roadmap GPSQSJWBUFTFDUPSJOWPMWFNFOUJONPWJOHUPXBSET6)$JO the EMR countries. The consultation involved representatives from min- istries of health, academia and the private sector from 14 countries of the Region along with selected health system focal points from WHO country offices in collaboration with the International Development Research Centre, a Canadian government agency that works with developing countries. The workshop was facilitated by WHO staff from the Regional Office as well as international experts in PPPs. Challenges in developing the private sector role in service provision A rapid assessment of the private health sector in 12 countries has shown that one-quarter of total health expenditure goes to the private health sector in group 1 countries (high income), half in group 2 countries (mid- dle income) and as much as three-quarters of total health expenditure in group 3 (low income/conflict zones); most of this expenditure is direct out-of-pocket payments. Yet private health insurance has limited scope in all three groups of countries. EMR has a diversity of private sector service provision; in some countries health-care services are mostly provided by the public sector, while in other countries the private sector has a much larger role. Service utilization also varies across different income groups within countries. The key priority areas to consider with regard to involvement of the private sector in service provi- sion are: the regulatory capacity of ministries of health; partnerships with the private health sector; reducing out-of-pocket payments incurred in the private sector; and improving quality. The discussions raised several issues. It was high- lighted that the public perception in the Region is that the private sector provides better quality health-care services, despite a lack of evidence for this. The issue of quality of care needed to be addressed and linked not only to the system of governance in general but also to the public’s perception of services. Even within the same income bands there is great variability among countries in the development and status of the private health sector; for example, in some countries the private health sector has sufficient political power to influence regulation. Fur- thermore, in some countries public sector physicians also work in the private sector and this could be a barrier to developing an appropriate regulatory framework. It was noted that public sector officials may fail to understand Accelerating progress towards universal health coverage by engaging the private sector EMHJ r 7PM /P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 68 the potential contribution of the private health sector, and at the same time private sector providers may not be aware PG UIFJS SPMF JO6)$0ěFODPNQMFY DMJOJDBM DBTFT BSF managed by the public health sector and the less complex ones by the private health sector. Countries needs to plan for the future role of the private health sector to ensure 6)$BOEQSJWBUFIFBMUIQSPWJEFSTOFFEUPCFFOHBHFEJO these discussions. There is also a need to better understand how the private health sector can benefit from the public health sector. Countries’ experiences and success stories Universal health coverage The first technical session considered how to leverage the QSJWBUFIFBMUITFDUPS UPBDDFMFSBUF6)$&YQFSJFODF GSPN ĉBJMBOEãXIJDIBDIJFWFE6)$BěFSãTIPXTIPX UIFQSJWBUFTFDUPS BMCFJUQSPWJEJOHPOMZPGUPUBMIFBMUIGB- cilities) plays an important role in filling government gaps in 6)$JNQMFNFOUBUJPO*O-FCBOPOFĎPSUTBSFCFJOHNBEF to expand the primary health-care network with a prepaid benefit pack of services, tariff unification, links between key providers and payers through an e-health system and the strengthening of public hospitals. Regulatory assessment The second technical session looked at the challenges for governments in regulating the private sector particularly in low- and middle-income countries. Regulation in the health sector is a contextually evolving process, not a one-time radical shift, and is not an alternative to better governance. Presentations were also given on experiences of private sector regulatory assessment from Egypt and Yemen, and on regulation of the pharmaceutical sector and medical products. It was noted that regulatory agencies spend more time in enforcement of the private than the public health sector and a paradigm shift is required so that the focus of regulation is on outputs like quality, efficiency and acces- TJCJMJUZ6OJėFE3FHJPOBMSFHVMBUJPOTTIPVMECFEFWFMPQFE for medical devices and pharmaceuticals as they have for vaccines. Assessment tools The third technical session looked at methodologies avail- able to assess the private health sector. Participants were shown a presentation of the new web-based private sector assessment (PSA) tool which helps to centralize data and inform strategic recommendations. Experiences of rapid assessment of the role and contribution of the private sec- tor in health care delivery were shared from four countries of the Region: Lebanon, Jordan, Saudi Arabia and Pakistan. It was pointed out that regulation of the private sector should be seen as facilitating rather than controlling, with the private sector as equal partners. Participants agreed that health information systems that pool information Participants at the Regional Consultation on engaging the private health sector for accelerating progress towards universal health coverage, June 2014 HCÐçPUph[UÐpdCÐëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 69 Box 1 Recommendations r ensure political commitment from policy-makers in EMR countries to engage with private health sector part- ners; r document the physical and financial size and scope of the range of services provided by the private sector; r strengthen the institutional capacity of ministries of health to engage with the private health sector; r transform perception regarding regulation from being a “coercive” to a “facilitating” instrument for increased private health sector engagement; r inform the population at large of the potential role of the private health sector in realizing public health goals; r develop national health plans that respond to the needs and priorities of the public and private health sectors, particularly the human resources plans; and r build stronger interaction with the private health sector associations and syndicates in terms of sharing mutual interests, mandates, capacities and activities. would protect confidentiality and be less threatening to the private sector. Public–private partnerships The fourth technical session looked at PPPs and included experiences of medical syndicates from Lebanon, Egypt and Pakistan. The presentations showed how different contract- ing arrangements in health care have led to the development of different PPP arrangements. It was noted that implement- JOH6)$DBO JODSFBTF UIFCVSEFOPG DBSFEFMJWFSZCZ UIF private sector. Experience from India shows that despite the vast network of health facilities, systemic deficiencies have steadily eroded the ability of the public health system to meet the burgeoning demand for health services effectively. Many provincial governments across India are exploring PPPs to address the challenge of equitable access to affordable health- care services for the poor. The way forward The meeting reviewed the Regional framework of action for engaging the private sector which includes seven commit- ments: building platforms for dialogue; policy and steward- ship; mapping private sectors; regulation and governance; purchasing and financing private sector services; leveraging quality and access; and patient information, engagement and satisfaction. Participants agreed on a set of recommendations organized around these seven areas of work (Box 1) and identified those for priority action within their own country. The meeting emphasized the essential role WHO plays to advocate and guide countries in engaging with the private TFDUPSBOEUIFJNQPSUBODFPGMJOLJOH111TXJUI6)$UPLFFQ in mind the reason for engaging the private health sector. The challenge is how to leverage the private sector to ensure health coverage for vulnerable groups of the population. EMHJ r 7PM/P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 70 Eastern Mediterranean Health Journal reviewers’ panel, 2014 The Eastern Mediterranean Health Journal extends sincere thanks the following experts for their generous and invaluable assistance in the review of papers considered for publication during the year 2014. Hilmy Abaza Ahmed Abdalla Mohamed Abdel Aziz Sarab Abdelalrahman Mohammad Abdel-Sabour Sayed Abdelwahab Yousef Abdulrazzaq Maya Abou Saad Laith Jamal Abu Raddad Niveen Abu-Rmeileh Ahmed Adeel Salim Adib Rima Afifi Waqar Ahmed Suhail Ahmed Yaser Ahmed George Aislaitner Kamel Ajlouni Tasleem Akhtar Shala Al-Alaf Asim Al-Ansari Deena Alasfoor Gary Albrecht Mohamed Al-Ghobain Mohamed Ali Yagoub Al-Kandari Hamid Allahverdipour Mansour Al-Nozha Omnia Al-Rashidy Najeeb Al-Shorbaji Ahmad Al-Yousfi Suhail Amad Avni Amin Nada A-Rahman George Araj Said Arnaout Mazen Asayreh Mohamed Assai Fazal Ather Ali Azin Fereidoun Azizi Hanan Badr Kunal Bagchi Robert Bain Brian Barber Peter Barss Pierre Bartsch Hyam Bashour Amen Bawazir Shahrzad Bazargan-Hejazi Abdulbari Bener Venkatraman Chandra-Mouli Maria Chun Leonard Cohen Antonella Daniele Jocelyn DeJong Aparajit Dey Laila Dorgham Bassel Doughan Dolina Dowling Maha El Tantawi Mohamed El-Barrawy Wafaa Eldin Abdel-Hady El-Gilany Dalal Elkaffash Mohamed El-Kalioby Ahmed-Refat El-Kashmery Eman Ellabany Dawlat El-Miligy Abdel Rahman El-Naggar Farouk El-Sabban Gamal El-Samra Ihab El-Sawy Nuha El-Sharif Fawzi El-Shobaki Fatma El-Zanaty Mohammad Eslami Marthe Everard Massimo Fabiani Farshad Farzadfar Mahmoud Fathalla Matthew Ferrari Alfredo Fort Heba Fouad Mohsen Gadallah Ahmed Gado Salma Galal Frederico Garcia Margaret Gerbasi Abdul Ghaffar Rita Giacaman Laura Gillini Mahdieh Golzarand David Gordon David Greenfield Scott Grosse Leonor Guariguata Jagadish Guria Wafa Habbal Sevil Hakimi Samia Halileh Shaher Hamaideh Saeed Hamid Hideki Hashimoto Abdulla Hattab Joumana Hermez Claus Heuck Tamer Hifnawy Seif Hussein Abdullatif Husseini Nahla Hwalla Samer Jabbour Sahar Jamal Matthew Jowett Ibrahim Kabbash Barbara Kahl Mohamed Kamel Laila Kamel Kristian M. Kamstrup Maria Kantzanou Zohreh Keshavarz Haris Khan Ibrahim Kharboush Rana Khatib Mohamed Khayyal Tawfik Khoja John Koutelekos Nabil Kronfol Wesam Kurdi Faris Lami Iciar Larizgoitia Meryem Lemrani Joel Lexchin Anna-Leena Lohiniva Ondrej Mach David MacLean Haifa Madi Ramez Mahaini Osama Maher Soad Mahfouzpoor El-Sheikh Mahgoub Manal Mahmoud Sawsan Majali Jacques Malchaire Mamunur Rahman Malik Adel Mansour Azhar Maqbool Seyed Marandi Silvio Mariotti Helen Mason Mohamed Massoud Awad Mataria Inke Mathauer Jeanne Maugein Mary-Louise Mclaws Afaf Meleis HCÐçPUph[UÐpdCÐ ëíP_UÐíïØn"Ð{dCÐ éíúÐØ{_UÐ 71 Arranged in alphabetical order according to the family name. Anthony Miller Tahir Mir Mohamed Izham Mohamed Ibrahim Amira Mohsen Iliana Mourad Haider Mousa Fawaz Mzayek Amr Nadim Boubker Naouri Eyerusalem Negussie Barbara Nichols Nuha Nuwayri-Salti Lotta Nybergh Omar Obeid Stephen Odusanya Hiroshi Ogawa Tarek Okasha Jennifer Olmsted Ann Olsson Peter Olumese Adelheid Onyango Abdalla Osman Juliet Otieno Alvisa Palese Yojana Patil Debra Patterson James Paturas Philippe Pirnay Michal Pirozynski Giorgi Pkhakadze Jose Postigo Maqbool Qadir Abid Qazi Farouk Qureshi Naseem Qureshi Adil Qureshi Mervat Rady Ahmed Ragab Alaa Ramzy Abd-Elsayed Nibedita Ray-Bennett Penny Rhodes Walter Riesen Tonia Rifaey Gojka Roglic Bassem Saab Cornelia Sack Ritu Sadana Ali Sadek Khalid Saeed Leyla Sağlam Pascale Salameh Amir Sayem Stephen Schmaltz Salaam Semaan Amira Shaheen Rizwana Shaikh Sherine Shawky Asem Shehabi Olla Shideed Shahram Solaymani-Mohammadi Rachida Soulaymani-Bencheikh Kwok-Cho Tang Kholoud Tayel Nadia Teleb Maphefo Thekiso Krisha Thiagarajah +JOBO6TUB Raman Velayudhan Mohamud Verjee Krisantha Weerasuriya Hiam Wehbe Ruth Williams Bahareh Yazdizadeh Mohamed Yehia Mustafa Younis Randa Youssef Taoufik Zeribi Fabio Zicker EMHJ r 7PM/P r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF 72 1. Papers submitted for publication to the Eastern Mediterranean Health Journal (EMHJ) must not have been published, accepted for publication or currently be under consideration for publication elsewhere. The World Health Organization (WHO) Regional Office for the Eastern Mediterranean reserves all rights of reproduction and republication of material that appears in the EMHJ. 2. Papers submitted for publication to the EMHJ should conform XJUIUIF6OJGPSN3FRVJSFNFOUTGPS.BOVTDSJQUT4VCNJĨFEUP #JPNFEJDBM+PVSOBMT 63. PGUIF*OUFSOBUJPOBM$PNNJĨFFPG Medical Journal Editors (ICMJE). 3. Ethical considerations: Where applicable, a statement must be included indicating approval for the study was granted by the ethics committee/institutional review board of the relevant institution. 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Les instructions relatives à la soumission d’un manuscrit en utilisant le système en ligne sont disponibles en anglais sur notre site Web accessibles à l’adresse suivante : http://www.emro.who.int/emh-journal/authors/, et en cliquant sur « Editorial Manager ». 7. Les résumés des articles acceptés pour publication seront traduits dans les trois langues. Pour assurer que les noms des auteurs soient correctement écrits dans les résumés en arabe, les auteurs rédigeant en anglais ou en français mais dont la langue maternelle s’écrit en caractères arabes doivent fournir leur nom complet en écriture arabe avec une translittération de leur nom en anglais ou en français. 8. Les manuscrits doivent être préparés en format traitement de texte (Microsoft Word, de préférence), avec double interlignage, mise en page d’une seule colonne, police Times New Roman, taille de caractère 12. 9. Tous les articles dont la publication est envisagée seront revus par des pairs. Le Comité de rédaction se réserve le droit d’accepter ou de refuser tout article, sur la base des commentaires des réviseurs, de la rigueur scientifique et de la pertinence de l’article pour La Revue. Les articles sont acceptés sous réserve de la révision statistique et rédactionnelle dont ils feront l’objet, comme jugé nécessaire, ce qui peut amener à abréger le texte et à supprimer certaines données présentées sous forme de tableaux ou de graphiques. Sujets : Le sujet de l’article doit concerner la santé publique ou un autre sujet biomédical ou technique connexe faisant partie du champ d’intérêt de l’OMS, et se rapporter plus particulièrement à la Région de la Méditerranée orientale ou revêtir une importance particulière pour celle-ci. 11. 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Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int GBÐçOTogBm^TÐoZTÐod]eBogdgcRüÐoecTÐÊm[KÌëÐzcTÐ phYĆHüÐëÐ}xÎpxÚg+ nhhU i> x}UÐ ënTn= Ò{CÐph=}_UÐÓÐÚnYüÐ ënin`RÌ ëØÚúÐ WY ënfU qxcUÐ }]S N]dR ë5 ôL çÐ}_UÐ énY[UÐ ëÐØUÐ .h@ ehUÐ pxÚUÐph=}_UÐpxÚge!Ð pxØ_UÐph=}_UÐpcdeCÐ Ñ}`CÐ Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 21 / No. 1 January/Janvier 1 ددع / نوشرعلاو يدالحا دلجلما نياثلا نوناك/رياني2015 Contents V o lu m e 2 1 N u m b er 1 Jan u ary 2 0 1 5 WHO carries out its vital work as the directing and coordinating authority on international health within the UN system with the guidance and support of its governing bodies, the World Health Assembly and the Executive Board. As the executive body of the Health Assembly, the Board meets in January to give effect to decisions of the Health Assembly, discuss pressing public health problems and submit advice or proposals to the Health Assembly. Editorial Winter chill of Geneva warmed by the WHO Executive Board .................................................................................. 3 Research articles Incidence of acute myocardial infarction in Islamic Republic of Iran: a study using national registry data in 2012 ....................................................................................................................................................... 5 Epidemiological and chronological profile of preterm birth in the region of Monastir (Tunisia) between 1994 and 2012 ...............................................................................................................................................13 Problems of providing services to people affected by HIV/AIDS: service providers and recipients perspectives ...............................................................................................................................................20 Psychometric properties of the Persian version of the Sexual and Reproductive Health Needs Assessment Questionnaire ..............................................................................................................................29 Herbal and nutritional supplement use among college students in Qatar .............................................................. 39 Medical faculty members’ perspectives on the components of cross-cultural competence in the Islamic Republic of Iran: a qualitative study .................................................................................................... 45 Risk factors influencing dentists’ hepatitis B-related knowledge and attitudes and their willingness to treat hepatitis B positive patients ........................................................................................................ 54 Short communication Development, implementation and evaluation of a medication safety programme for schoolchildren in Qatar ..............................................................................................................................................62 WHO events addressing public health priorities Accelerating progress towards universal health coverage by engaging the private sector .....................................67 Eastern Mediterranean Health Journal reviewers’ list 2014 .............................................................................................70 Guidelines for authors ........................................................................................................................................................ 72 Cover 21-1.indd 1-3 2/17/2015 2:43:57 PM
Всемирная организация здравоохранения (ВОЗ / WHO) · Journal articles
Eastern Mediterranean Health Journal [2015; Vol.21, Issue 1]
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