Eastern Mediterranean Health Journal [2018; Vol.24, Issue 7]

Test for hepatitis B and C. It could save your life. In the Eastern Mediterranean Region, 8 out of 9 people with hepatitis are unaware of their infection. #Test4Hepatitis La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal EMHJ – Vol. 24 No. 7 – 2018 Volume 24 / No. 7 July/Juillet 7 ددع / نوشرعلاو عبارلا دلجلما زوتم/ويلوي2018 Eastern M editerranean H ealth Journal Vol. 24 N o. 7 – 2018 Editorial Towards a hepatitis-free Egypt: is this achievable? Wahid Doss, Joumana Hermez, Hoda Atta and Jean Jabbour ................................................................................................................................................................609 Research articles Payment system of urban family physician programme in the Islamic Republic of Iran: is it appropriate? Leila Doshmangir, Arash Rashidian, Amirhossein Takian, Parinaz Doshmangir and Hakimeh Mostafavi .......................................................................... 611 Association between coronary artery disease and hepatitis C virus seropositivity Osama Shoeib, Medhat Ashmawy, Seham Badr and Mahmoud El Amroosy .................................................................................................................................. 618 Social, psychological and demographic variables related to breastfeeding among Kuwaiti mothers Yagoub Al-Kandari and Ramadan A. Ahmed ...............................................................................................................................................................................................624 Associations between red reflex abnormality, consanguinity and intensive care hospitalization of newborns in Turkey Zeynep Gursel Ozkurt, Selahattin Balsak, Yusuf Yildirim, Harun Yuksel and Ihsan Caca ..........................................................................................................631 Women’s sexual and reproductive health care needs assessment: an Iranian perspective Soghra Khani, Lida Moghaddam-Banaem, Eesa Mohamadi, Abu Ali Vedadhir and Ebrahim Hajizadeh .............................................................................. 637 Use of induced abortion for birth control by mothers in Iraq Hajir Al-Ridhwany, Asma Aljawadi and Muthanna Abduljawad ..........................................................................................................................................................644 Fruit and vegetable intake among Emirati adolescents: a mixed methods study Nora Makansi, Paul Allison, Manal Awad and Christophe Bedos ....................................................................................................................................................... 653 Geographical inequality in cataract surgery among Iranians between 2006 and 2011 Cyrus Alinia, Seyed-Farzad Mohammadi, Mahmoud Jabbarvand and Hasan Hashemi .............................................................................................................664 Engagement of health research institutions in knowledge translation in the Eastern Mediterranean Region Fadi El-Jardali, Ahmed Mandil, Diana Jamal, Lama BouKarroum, Samar El-Feky, Mohamed Nour and Mazen Al-Abbar ..............................................672 Reviews Health challenges and access to health care among Syrian refugees in Jordan: a review Wireen Dator, Hamzeh Abunab and Norenia Dao-ayen .........................................................................................................................................................................680 Cancer care for adolescents and young adults in Jordan Hikmat Abdel-Razeq, Maha Barbar, Taher Abu Hejleh and Asem Mansour ....................................................................................................................................687 Commentary Reducing maternal mortality: the case for availability and safety of blood supply Yetmgeta Abdella, Rana Hajjeh and Cees Th. Smit Sibinga....................................................................................................................................................................696 WHO events addressing public health priorities Twenty-third meeting of the Eastern Mediterranean Regional Working Group on GAVI, the Vaccine Alliance ..........698 Cover 24-07.indd 1-3 03/09/2018 09:03:59 Eastern Mediterranean Health Journal IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and individuals within and outside the Region. طسوتلما قشرل ةيحصلا ةلجلما ةماعلا ةحصلا في ةديدلجا تاردابلماو تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخاو ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا La Revue de Santé de la Méditerranée Orientale EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa- tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes concernés au sein et hors de la Région. Correspondence Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic Tunisia . United Arab Emirates . Yemen طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا برغلما . صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةيروسلا ةيبرعلا ةيروهملجا نميلا . ةيدوعسلا ةيبرعلا ةكلملما Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . 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EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. If authors are staff members of the World Health Organization, the authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions, policy or views of the World Health Organization. ISSN 1020-3397 Cover 24-07.indd 4-6 03/09/2018 09:03:59 Editorial Towards a hepatitis-free Egypt: is this achievable? Wahid Doss, Joumana Hermez, Hoda Atta and Jean Jabbour ...................................................................................................................................609 Research articles Payment system of urban family physician programme in the Islamic Republic of Iran: is it appropriate? Leila Doshmangir, Arash Rashidian, Amirhossein Takian, Parinaz Doshmangir and Hakimeh Mostafavi ............................................. 611 Association between coronary artery disease and hepatitis C virus seropositivity Osama Shoeib, Medhat Ashmawy, Seham Badr and Mahmoud El Amroosy ......................................................................................................618 Social, psychological and demographic variables related to breastfeeding among Kuwaiti mothers Yagoub Al-Kandari and Ramadan A. Ahmed ..................................................................................................................................................................624 Associations between red reflex abnormality, consanguinity and intensive care hospitalization of newborns in Turkey Zeynep Gursel Ozkurt, Selahattin Balsak, Yusuf Yildirim, Harun Yuksel and Ihsan Caca .............................................................................631 Women’s sexual and reproductive health care needs assessment: an Iranian perspective Soghra Khani, Lida Moghaddam-Banaem, Eesa Mohamadi, Abu Ali Vedadhir and Ebrahim Hajizadeh ................................................. 637 Use of induced abortion for birth control by mothers in Iraq Hajir Al-Ridhwany, Asma Aljawadi and Muthanna Abduljawad .............................................................................................................................644 Fruit and vegetable intake among Emirati adolescents: a mixed methods study Nora Makansi, Paul Allison, Manal Awad and Christophe Bedos ........................................................................................................................... 653 Geographical inequality in cataract surgery among Iranians between 2006 and 2011 Cyrus Alinia, Seyed-Farzad Mohammadi, Mahmoud Jabbarvand and Hasan Hashemi ................................................................................664 Engagement of health research institutions in knowledge translation in the Eastern Mediterranean Region Fadi El-Jardali, Ahmed Mandil, Diana Jamal, Lama BouKarroum, Samar El-Feky, Mohamed Nour and Mazen Al-Abbar ................. 672 Reviews Health challenges and access to health care among Syrian refugees in Jordan: a review Wireen Dator, Hamzeh Abunab and Norenia Dao-ayen ............................................................................................................................................680 Cancer care for adolescents and young adults in Jordan Hikmat Abdel-Razeq, Maha Barbar, Taher Abu Hejleh and Asem Mansour .......................................................................................................687 Commentary Reducing maternal mortality: the case for availability and safety of blood supply Yetmgeta Abdella, Rana Hajjeh and Cees Th. Smit Sibinga .......................................................................................................................................696 WHO events addressing public health priorities Twenty-third meeting of the Eastern Mediterranean Regional Working Group on GAVI, the Vaccine Alliance ........ 698 Vol. 24.07 – 2018 La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Ahmed Al-Mandhari Editor-in-Chief Arash Rashidian Executive Editor Ahmed Mandil Deputy Executive Editor Phillip Dingwall Managing Editor Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editorial assistants Nadia Abu-Saleh, Suhaib Al Asbahi (graphics), Diana Tawadros (graphics) Editorial support Guy Penet (French editor) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Technical editors) Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics editors) Administration Iman Fawzy Web publishing Nahed El Shazly, Ihab Fouad, Hazem Sakr Library and printing support Hatem Nour El Din, Metry Al Ashkar, John Badawi, Ahmed Magdy, Amin El Sayed Cover and internal layout designed by Diana Tawadros and Suhaib Al Asbahi Printed by WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt Editorial 609 EMHJ – Vol. 24 No. 7 – 2018 Towards a hepatitis-free Egypt: is this achievable? Wahid Doss,1 Jean Jabbour,2 Hoda Atta,3 Joumana Hermez 4 and Alaa Hashish 5 1Chairman, National Committee for Control of Viral Hepatitis, Ministry of Health and Population, Cairo, Egypt. 2World Health Organization Representative, Cairo, Egypt. 3Coordinator, Department for Communicable Diseases, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 4Regional Advisor, Department for Communicable Diseases, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 5Technical Officer, Communicable Diseases Cluster, World Health Organization Representative Office, Cairo, Egypt. Citation: Doss W; Jabbour J; Atta H; Hermez J; Hashish A. Towards a hepatitis-free Egypt: is this achievable? East Mediterr Health J. 2018;24(7):609–610. https://doi.org/10.26719/2018.24.7.609 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Over the past few years, we have seen remarkable developments in the global commitment to address viral hepatitis. In May 2016, 194 countries of the World Health Assembly unanimously adopted the first‐ever Global Health Sector Strategy on viral hepatitis, 2016–2021 (1). Through these high‐level strategies, countries made a commitment to eliminate viral hepatitis as a public health threat by 2030. Unfortunately, Egypt has one of the highest global burdens of hepatitis C virus (HCV) infections; it is estimated that prevalence of HCV is around 4.5% to 6.7% (2). Egypt had recognized the enormous health, social and economic burden of hepatitis infection, which was the driver to establish national response to fight the disease. It has become clearer that the root causes, as well as catalysts of transmission of HCV and hepatitis B (HBV), are strongly associated with healthcare- related malpractices. There was an ever-growing need to establish a comprehensive Infection Prevention and Control programme in the Egyptian Ministry of Health and Population (MoHP). Such a programme was successfully launched in 2001 and has succeeded in improving adherence to infection prevention and control practices and developing the national infection control guidelines. This was followed by the establishment of the Egyptian National Committee for Control of Viral Hepatitis (NCCVH) (3) in 2006, which started to treat patients using interferon regimen. By October 2014, the NCCVH introduced the first approved highly effective direct antiviral agent (DAAs) for nationwide treatment of HCV infection at 1% of its international price at that time; this medication has been shown to cure over 90% of those receiving such treatment. Subsequently, the MoHP introduced other approved DAAs consecutively during 2015 and 2016, in addition to encouraging the local manufacturers to produce highly effective generic medicines to effectively implement the elimination programme in the shortest possible time. In 2014, the MoHP in Egypt launched the “Plan of Action for the Prevention, Care and Treatment of Viral Hepatitis” (4), which focuses on seven main components for viral hepatitis prevention and control, namely surveillance, infection prevention and control, blood safety, hepatitis B vaccination, care and treatment, communication, and research. This large national programme to treat patients with HCV infection was found to be feasible and manageable. Scaling up of the treatment programme was possible with the availability of more medications, with greater affordability through allocating more resources and decreasing costs, along with the decision to treat all stages of fibrosis and removing the requirement of a strict fibrosis assessment. Although the MoHP has announced more than one date to achieve HCV elimination, we can still see that HCV elimination in Egypt is achievable ahead of the 2030 target for the following reasons: the high political support from the Egyptian president as well as the government has made all needed resources possible; commitment from MoHP to accomplish this task in collaboration with all other stakeholders; and presence of coordinated health civil society organizations working hand in hand with health authorities to identify cases from different geographical areas, thereby adding more hope to treat more people living with HCV. Since 2014, when the Egyptian programme started using DAAs, around 1.8 million cases have been successfully treated, mainly using locally produced effective generic medicines. The national financing scheme covered the cost of treatment for all cases and supported the enrollment of more patients. Hence, despite the high prevalence of hepatitis as an old and long- standing disease in Egypt, the resultant health workforce is well trained to manage such illnesses, utilizing those skilled healthcare workers dealing with liver diseases for decades and building upon their capacities. Egypt has an ambitious goal of eliminating hepatitis; this goal is guided by a clear political vision from the Egyptian president. The country is planning to screen 45 million citizens in one year starting 1 October 2018, respecting the WHO core testing principles of providing consent, confidentiality, counseling, correct results and connection to treatment for all people who will be discovered positive. The aim is to treat all identified cases from the screening. Meanwhile, international partners such as the World Health Organization (WHO), USAID, Centers for Disease Control and Prevention (CDC) and the World Bank (5) are working closely with the Government of Egypt to technically and financially support the optimistic goal of eliminating HCV. Building national capacities in EMHJ – Vol. 24 No. 7 – 2018Editorial 610 References . 1 World Health Organization. Global health sector strategy on viral hepatitis 2021–2016. Geneva: World Health Organization; 2016 (http://apps.who.int/iris/bitstream/handle/246177/10665/WHO-HIV-2016.06-eng.pdf;jsessionid=10F21056DC7293B9C437F10FF746 5E60?sequence=1). . 2 World Health Organization. Key facts on hepatitis C treatment. Geneva: World Health Oganization; 2016 (http://www.who.int/ medicines/areas/access/hepCtreat_key_facts/en/). . 3 National Committee for Control of Viral Hepatitis (http://www.nccvh.org.eg/). . 4 Ministry of Health and Population (MoHP). Plan of action for the prevention, care & treatmjent of viral hepatitis, Egypt, –2014 2018. Cairo: MoHP; 2014 (http://www.emro.who.int/images/stories/egypt/VH_Plan_of_Action_FINAL_PRINT1.pdf). . 5 World Bank. Eliminating hepatitis C from Egypt: 2017 update on current trends and policy recommendations. Washington DC: The World Bank; 2017 (http://documents.worldbank.org/curated/en/164381517333701631/pdf/-123068WP-P-157533PUBLIC- Eliminating-Hepatitis-C-from-Egypt-2017-Update.pdf). . 6 World Health Organization. WHO director-general addresses the executive board. Geneva: World Health Organization; 22 January 2018 (http://www.who.int/dg/speeches/-142/2018executive-board/en/). managing huge data influx is very crucial to achieve such a target. In 2016, the World health Assembly approved the first global health sector strategy on viral hepatitis; a strategy that contributes to the achievement of the 2030 Agenda for Sustainable Development (1). Egypt is working towards achieving elimination, as a pioneering country, through real political leadership, and there are ongoing activities to implement the needed strategic directions to achieve global targets, such as eliminating hepatitis by 2023. Thus, WHO is working closely with the Government of Egypt to support this goal. As Dr Tedros Adhanom Ghebreyesus, WHO Director-General, stated: “We have a historic opportunity to make transformational improvement in world health. Let us make universal health coverage a reality for many more people” (6). Research article 611 EMHJ – Vol. 24 No. 7 – 2018 Payment system of urban family physician programme in the Islamic Republic of Iran: is it appropriate? Leila Doshmangir,1,2 Arash Rashidian,3,4 Amirhossein Takian,3,5 Parinaz Doshmangir 1 and Hakimeh Mostafavi 6 1Tabriz Health Services Management Research Center, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 2Social Determinants of Health Research Center, Management and Safety PRomotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 3Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Department of Information, Evidence and Research, World Health Organization Regional Office for the Eastern Mediteranean, Cairo, Egypt. 5Health Equity Research Centre (HERC), Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 6Health Economy, Standard and Health Technology Department, Vice-Chancellor’s Office in Treatment Affairs , Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: Hakimeh Mostafavi: hakimeh_mostafavi@yahoo.com). Introduction Establishment of the family medicine programme (FMP) on the basis of an appropriate referral system is one of the main strategies to increase access and improve efficien- cy of healthcare systems globally (1,2). Payment mecha- nisms and financial incentives to reimburse family phy- sicians (FPs) play a major role in improving the quality of healthcare services. Hence, well-designed applications are required to measure and allocate such incentives for improving practices (3). Moreover, the financial incen- tives have a major role in the specialty that medical stu- dents choose in the future (4). Current payment methods worldwide include fee for service (FFS), salary, capitation, pay for performance (PFP), and some other mixed methods; each with its strengths and weaknesses. Payment methods affect both provider and purchaser of the services (5). Capitation means that the number of people who refer to health centres is the main factor for payment. In other words, just visiting the patients is a measure for payment without any attention to results of treatment (6). Capitation may foster effectiveness of healthcare services through proper mechanisms to select patients. FFS may increase the quality of provided services, while increasing the cost (7). FFS is the main mechanism for payment in public hospitals. Some believe that FFS prevents low-quality services, and patients may access optimal treatments (8). This method is applied in the United States of America (USA) but it has not been successful and has resulted in high costs (9). Salary is a continuous way to reimburse health workers and professionals. It is known to decrease the level of relationship between the physician’s income and type of services offered to patients, which could affect service quality. PFP is a common method in primary health care (PHC) network, by which practitioners are paid on the basis of their achievements. There is a lack of evidence for the relationship between payment methods and the quality of health services (10). Hence, mixing and matching and switching among payment methods in health systems are common to meet health policy goals (11), and many health systems prefer to apply a mix of payment methods to avoid extra costs (12). Abstract Background: The payment system is pivotal in implementing policies in the health sector. Equitable access to healthcare is the main principle of the payment system. Aims: This study aimed to investigate aspects of the payment system in the urban family physician programme (FPP) in the Islamic Republic of Iran. Methods: This was a qualitative study. We obtained data from key informants and both formal and grey literature. We used content analysis for data analysis. Results: A range of concepts was explored related to the payment system of the FPP. By merging similar expressions, we categorized the findings into four main themes including: payment method, payment criteria and incentives, payment process and amount of payment. Conclusions: FPP is required to follow convenient implementation methods. The mechanisms of payment in the health sector are weak and have no transparency. A blurred combination of criteria makes an unclear process for determining the payment mechanisms. It is recommended that the opinions of key stakeholders be taken into consideration prior to developing payment mechanisms and financial incentives. Keywords: family physicians, healthcare access, Iran, payment system, urban area Citation: Doshmangir L; Rashidian A; Takian A; Doshmangir P; Mostafavi H. Payment system of urban family physician programme in the Islamic Republic of Iran: is it appropriate? East Mediterr Health J. 2018;24(7):611–617. https://doi.org/10.26719/2018.24.7.611 Received: 21/04/16; accepted: 22/05/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). EMHJ – Vol. 24 No. 7 – 2018Research article 612 There is little information about payment systems for FMP in the Islamic Republic of Iran. Therefore, this study aimed to identify an appropriate payment system for the urban family physician programme (FPP) in the Islamic Republic of Iran. Payment mechanisms involve some methods to transfer funds from a buyer, that is, the government, insurance company, or patient, to healthcare providers, namely, individual physicians or institutes (13). The health systems in different countries have applied diverse payment methods. For instance, while FFS is the dominant method in Australia, PFP has been used to improve the quality and outcome of health services since 1998 (14). Similarly, FFS is often used for reimbursement of 90% of PHC physicians in the USA (15). FFS as well as the state fee schedules are applied In Canada (16). Similarly, FFS was executed in 2008 in Ghana, where no standard fee schedules were in place (17). In contrast, France has a national social insurance system that pays a fixed fee per each registered patient to doctors (18). In Turkey, all physicians receive salaries and bonuses, while physicians who work in deprived areas may receive an additional reward (19). These experiences suggest that there are different approaches in health payment systems globally. The most common payment methods are outlined by Quinn (12). The aim to enhance universal access to health care services led to establishment of the PHC network in the Islamic Republic of Iran in 1984 (20). Community health workers and general practitioners are the main members of PHC system. Especially in rural areas, the PHC has a critical role in delivering services to people (21,22). PHC has contributed to significant improvement of many health indicators: child and maternal mortality, life expectancy and control of infectious diseases in the Islamic Republic of Iran (23,24). Some of the most important health index improvements are shown in Table 1. Similar to health systems in many developing countries, the Iranian system has faced several emerging problems, with major causes of death being noncommunicable diseases and traffic accidents (23). In addition, the quality and efficiency of healthcare services have been questioned for not meeting the requirements of demographic transition, public expectations and changes in disease patterns (13). To increase equitable access to health services of people residing in villages and small towns of < 20 000 inhabitants, the Iranian Ministry of Health and Medical Education (MOHME) seized the opportunity of launching the FMP (13). The FMP was endorsed by the 4th and 5th National Development Plans, and assigned a general practitioner to a population of 2000–4000 (20) as the manager of the health team. Ten years into its implementation, the FMP has expanded to larger cities, and all urban settings of two pilot provinces since 2011. This study aimed to investigate aspects of the payment system in the urban FPP of the health system in the Islamic Republic of Iran. Methods Study design This was a qualitative study using three main data sources: interviewing nine key informants, reviewing literature and searching national documents, and national web sites. The study was conducted from December 2012 to November 2013, when national expansion of the FPP in the Islamic Republic of Iran was announced. Sampling and data collection We selected key informants that had direct participation in PHC management and development of the FPP payment system. We conducted face-to-face interviews with nine key informants from MoHME, two medical universities, insurance companies, and three FPs. All interviews were conducted in the interviewees’ offices by L.D. using a semistructured guide. We asked questions about current payment mechanisms and the views of the interviewees about these mechanisms. All interviews were recorded and transcribed. The average time of the interviews was 50 minutes. Because of the limited number of managers who were informed about the FPP payment system, we only interviewed nine people. In other words, purposive sampling was applied to identify the key informants, who had valuable experiences about the FMP. We searched several websites to select relevant documents (http://www.salamatnews.com, http://www. salamatiran.com, http://rc.majlis.ir/fa/parliament,http:// irimc.net /default.aspx, http://www.irna.ir, http:// tebyannews.comhttp://www.webda.ir, http://www.tums. ac.ir, http://www.dolat.ir). We considered the following criteria for selecting the websites: national websites well known for health policy issues; websites of institutes involved in FPPs; and websites of the three pioneer medical universities in the country. We also purposefully selected some comprehensive and appropriate news, which was directly or indirectly related to FPPs. The main data collection tool was a researcher-made form that functioned as our document analysis worksheet. In addition, we used other document-based data sources including: legislative laws, administrative/executive regulations, payment procedures, guidelines, reviews, reports, policy statements, and minutes of meetings Table 1 Selected health indices in Islamic Republic of Iran before the beginning of primary health care in 1981 and 2013 Health index 1981 2013 General life expectancy, years 46/7 74 Infant mortality rate, deaths/1000 live births 94 17 Population growth rate, % 3/9 1/4 Overall vaccination coverage (%) 40 > 90 Research article 613 EMHJ – Vol. 24 No. 7 – 2018 and documents related to focus groups and round table discussions from organizations, such as MoHME, Iranian Parliament, Iranian Medical Association and health insurance corporations. Urban FPP was the subject of major national debate at the time of data collection, which led to collection of a large volume of data. After removing the duplicates, we gathered 728 documents, which were classified based on their type. We designed some tables and then inserted the related news and statements in the tables. In this phase two authors (L.D. and P.D.) extracted the appropriate date from documents and H.M. checked and controlled the extracted data. Data analysis All the documents and transcribed interviews were imported to MAXQDA version 10 and were coded. The data were analysed through qualitative content analysis (25). The analysis included reading the documents and transcripts several times and then coding them inductively and deductively. Two authors (L.D. and H.M.) coded the data, and discussed them in continuous sessions and A.R. rechecked the themes. Finally, the themes and concepts were finalized according to the suggestions of the research team members. Ethical consideration We obtained verbal consent from interviewees and ensured confidential and anonymous data collection, analysis and reporting. The researchers tried their best to be neutral during all phases of the study. The study was approved by the Ethics Committee of Tehran University of Medical Sciences and registered in the Knowledge Utilization Research Center (Registration Code: 19704). Results We identified four main themes that are considered as pillars in developing an appropriate payment system for the FPP in the Islamic Republic of Iran: payment method, payment criteria and incentives, payment process and amount of payment. Payment method We revealed lack of consensus among various stakehold- ers on the current FPP payment methods in rural Islamic Republic of Iran. Some participants suggested that pay- ment should be based on capitation, while others stated that FFS and PFP are appropriate ways to pay service providers. Some interviewees preferred salary and bonus as the most appropriate payment methods in the imple- mentation of the FPP. Some participants stated that sala- ries guaranteed a monthly income for doctors and other health team members. Others pointed out that it was im- perative to have additional payments per capita for some special tasks, such as diagnosis, treatment and surveil- lance of target diseases. Several interviewees highlight- ed the importance of designing a payment system based on mixed payment methods, including a combination of capitation, FFS and bonus. According to participants, 40% of the payment to FPs was based on their performance. This led to 80–120% variation in payment to FPs according to their assessment scores. Some participants mentioned the benefits of the mixed payment and considered it the best type of payment system worldwide. Participants who endorsed mixed payment methods expressed their concern about physicians who worked in day clinics and were paid a salary or capitation, while those who worked in night clinics were paid based on FFS. Payment criteria and incentives Development of measures to determine the payment cri- teria was an important factor to avoid unhealthy compe- tition among physicians. Various criteria are used for re- imbursement of FPs, such as size of population covered, career, length of residence in a city, and age and sex of the patients referred. Moreover, payments were higher for covering elderly patients and pregnant women, as well as working in poor and deprived regions. Another issue was FPs being penalized; for instance, if they were unable to register 2500 people, their income would be reduced. This led some participants to criticize the existing criteria for paying FPs in some regions and to call for more realistic payment models. Midwives are part of the family medicine team. The FPP has failed to employ midwives, as they were forced to conduct activities such as pharmaceutical services, injections, dressings and other inappropriate services. In addition, insufficient income was another major barrier to attracting midwives to join the FPP. Amount of payment Amount of payment was regarded as a critical factor for developing an appropriate culture and increasing public interest in FPPs. Some interviewees stated that FPs were important in developing a referral culture in the Islamic Republic of Iran. Some participants believed that meas- ures should be taken to avoid the significant income dif- ference between the members of the health team (e.g., general physicians and specialists), while PFP could be implemented to incentivize good practice. The current payment system considered an annual increase of 1% for up to 20 years of experience. Also, in the first 5 years of implementing the FPP, 1–3% will be added to the payment of physicians. For practices that have registered critical populations, that is, people aged > 60 years, children aged < 5 years, pregnant women, and patients with chronic diseases, the payment for FPPs will increase by 20% per capita. Some participants expressed major concerns about the amount of per capita payment to FPs, branding it low as well as unfair. In addition to direct costs of running their practices, such as living accommodation, human resources, equipment and administration, FPs were also responsible for other costs that were not included in their compensation, such as differential cost of premises in the city, as well as hidden costs (due to the nature of the FPP), EMHJ – Vol. 24 No. 7 – 2018Research article 614 such as travel for personnel to meetings, and follow-up through telephone contact. Some participants claimed that implementation of the FPP was a means to generate income for FPs. In other words, discrimination in the salary payment system or inequitable payment to various groups of physicians, resulted in planning for the FPP, as a new way to increasing the income of some physicians. However, this claim requires more evaluation. Process of payment To motivate the health team members to deliver health services, the FPP has scheduled PFP. This means that 80% of the salary is fixed, while the remaining 20% is based on evaluation score. In addition, an extra 20% incentive is considered for each physician who covers a high pro- portion of children aged < 5 years or pregnant women, as well as patients > 60 years. Some participants were concerned about the payment inconsistency among various levels of the FPP. In other words, they believed that physicians received different payments at each level and in the private and public sectors. Discussion In 2013, MoHME created the opportunity for launching the FMP in the Islamic Republic of Iran to increase equitable access to health services. Undoubtedly, the payment system has an important role in providing the appropriate health services. The experiences of FPP in other countries show a wide range of parallel reforms to bring the cost of health services down considerably (26,27). Payment systems have to adapt to a hierarchy of policy priorities and practical financial considerations to meet the goals of equitable access and affordable health services. In other words, selected payment systems and applied incentives should be coordinated with the major goals of the health system and also improve the clinical knowledge of the population and their cultural level, and implementation of ethical principles (28). This study shed light on the perceptions of some key decision makers in the Islamic Republic of Iran about payment arrangements in the FPP. Our findings suggest four major concepts about the payment system: payment method, payment criteria and incentives, payment process and amount of payment. We found no definite consensus about the suitable methods of payment to FPs. Hence, attention needs to be given to the impact of various payment techniques on physicians’ performance. Although most participants pointed out the emphasis on capitation, others mentioned the use of FFS as well as performance-based methods. It seems that the lack of a clear definition on how to pay FPs was the main reason for such incompatibility. While salary payment was highlighted by the FPP policy, the real payment was, as few interviewees envisaged, based on the number of delivered healthcare services; namely, an FFS system. Some participants identified the capitation method as the main payment system in the FPP, and bonuses were paid to enhance quality and reduce physicians’ reluctance to provide services. Nevertheless, some pointed out that none of the payment systems could actually compensate the complicated and important functions of FPs (29). This is why many countries that have implemented FPP have consequently used mixed payment methods that include salary, capitation, bonuses and FFS. Some advantages of this mixed payment system are motivating physicians, preventing unnecessary visits, and improving the quality of care and diagnosis (13). Determining the payment criteria is another major concept. For example, measures such as the possibility of studying in a specialty field and receiving more bonuses are considered motivational for the physicians. Therefore, the payment may decrease if the physicians cannot preserve and maintain the assigned population, which may result in physicians’ dissatisfaction (30). Delayed payments and low levels of bonuses are also regarded as reasons for physicians’ dissatisfaction (31). One of the strengths of targeted payments is to encourage physicians to meet the desired standards of care and population health. Otherwise, it is likely targeted payments may act as a disincentive (11). Some participants identified that the payment rates of the FPP were inappropriate regardless of appropriate methods of payment. They believed that payments were too low in relation to the physicians’ workload, which resulted in physicians’ dissatisfaction. In addition, midwives as important members of the health team had to carry many inappropriate tasks, which led to their dissatisfaction, along with their unsatisfactory pay levels (24). Lack of guidelines was one of the main problems in determining the payment rate among various service providers. For example, while accurate criteria were available to determine pay level for FPs who received higher payments, other members of the health teams often received low wages that were not appropriate for their workload and responsibilities. Continuous and successful implementation of the FPP may therefore require a fair approach financially and nonfinancially to all healthcare providers in the team. Our findings also indicated that the payments did not occur in a single consolidated step, but in several stages and after evaluating the performance of the health team members. The staging of payments was seen as an instrument to motivate health team members. Some studies have suggested that it is better to apply a value- based system to compensate the physicians. Such an approach can improve the long-term performance of physicians (32). The generalization of our results is subject to certain limitations. Although we tried to conduct a comprehensive search of the subject in relevant public electronic media, it is likely that some information was Research article 615 EMHJ – Vol. 24 No. 7 – 2018 overlooked. The interpretations of the research team may be different from what was intended by the participants. The researchers could not discuss the issues with some participants who were interviewed by the media; this was addressed by interviewing other participants in the field. Nonetheless, our study was validated in three ways. First, different data sources were used, including documents, literature, media news and interviews, which allowed for a high triangulation (33). Second, respondents from different organizations were interviewed. Third, codes and themes were developed and reviewed by all members of the research team as a check on bias. Conclusion Although implementing an FPP is a major step to improve public health and equal access to health services in urban areas, our study shows that the Iranian health system has started on the road of a difficult journey. Moreover, it seems that the mechanisms of payment in the health sector are weak and have no transparency. A blurred combination of criteria makes unclear the process for determining payment in the health system. Hence, it is recommended that the political and professional opinions of key stakeholders should be taken into consideration prior to developing appropriate payment mechanisms and financial incentives for the FPP. Le système de paiements du programme de médecins de famille en zone urbaine en République islamique d’Iran : est-il adapté ? Résumé Contexte : Le système de paiements joue un rôle central en vue de la mise en œuvre de politiques dans le secteur de la santé. Un accès équitable aux soins de santé est le principe fondamental qui sous-tend ce système. Objectifs : La présente étude avait pour objet d’examiner certains aspects du système de paiements du Programme de médecins de famille en zone urbaine dans le cadre du système de santé de la République islamique d’Iran. Méthodes : Il s’agissait d’une étude qualitative. Nous avons obtenu les données par l’intermédiaire d’informateurs clés ainsi que dans la littérature, à la fois officielle et grise. L’analyse des données a été effectuée à l’aide de méthodes d’analyse de contenu. Résultats : Nous avons étudié une série de concepts liés au système de paiements du Programme de médecins de famille. En fusionnant les expressions semblables, nous avons réparti les résultats selon quatre thèmes principaux : les modes de paiement, les critères de paiement et les incitations, les processus de paiement et le montant des paiements. Conclusions : Les Programmes de médecins de famille ont l’obligation de suivre des méthodes de mise en œuvre accessibles. Il semble que les mécanismes de paiement dans le secteur de la santé soient peu performants et manquent de transparence. Un mélange confus de critères donne lieu à un processus imprécis qui ne permet pas de déterminer le modèle de paiement. Il est recommandé de prendre en compte les avis des principaux intervenants avant d’élaborer des mécanismes de paiement et des incitations financières. Acknowledgements We are grateful to all individuals who gave their time and made this work possible. Funding: The study was funded by departmental resources. Competing interests: None declared. ؟بسانم وه له :ةيملاسلإا ناريإ ةيروهجم في ةيضرلحا ةسرلأا بيبط جمانرب في فيلاكتلا عفد ماظن يوفطصم ةميكح ،يركنُمشد زانيرب ،نايكت ينسحيرمأ ،نايديشر شرآ ،يركنُمشد لايل ةصلالخا لداعلا لوصولا وه فيلاكتلا عفد ماظن في سييئرلا أدبلماو .يحصلا عاطقلا في تاسايسلا ذيفنت لجأ نم ًايروضر فيلاكتلا عفد ماظن برتعي :ةيفللخا .ةيحصلا ةياعرلا تامدلخ .ةيملاسلإا ناريإ ةيروهجم في يحصلا ماظنلا في ةيضرلحا ةسرلأا بيبط جمانرب في فيلاكتلا عفد ماظن بناوج ةسارد :فدلها لىع ع َّزوت لم يتلا ةيمسرلا تاروشنلما نمو اهنع ينغلبلما ينيسيئرلا صاخشلأا نم تانايبلا لىع اهيف انلصح ،ةيفصو ةسارد هذه :ثحبلا قرط .ىوتحلما ليلتح مادختساب تانايبلا انللحف .سانلا نمض جئاتنلا فينصتل ةبهاشم يرباعت انمجدو ،ةيضرلحا ةسرلأا بيبط جمانرب في فيلاكتلا عفد ماظنب قلعتت يتلا ميهافلما نم ًلاامج انيصقتسا :جئاتنلا .ةعوفدلما غلابلما ،عفدلا ةيلمع ،عفدلا تاز ِّف َُم ،عفدلا يرياعم ،عفدلا ةقيرط :نمضتت عيضاولما نم ةيسيئر تائف 4 EMHJ – Vol. 24 No. 7 – 2018Research article 616 References 1. van Weel C, Rosser WW. 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BMC Health Serv Res. 2015 05 6;15(1):191. http://dx.doi.org/10.1186/s12913-015-0847-7 PMID:25943469 33. Denzin NK, Lincoln YS (editors). Collecting and interpreting qualitative materials. Thousand Oaks, CA: SAGE Publications; 2008. EMHJ – Vol. 24 No. 7 – 2018Research article 618 Association between coronary artery disease and hepatitis C virus seropositivity Osama Shoeib,1 Medhat Ashmawy,1 Seham Badr1 and Mahmoud El Amroosy 1 1Cardiology Department, Faculty of Medicine, Tanta University, Tanta, Egypt (Correspondence to: Osama Shoeib: oshouip@gmail.com). Introduction Ischaemic heart disease, became one of the major killers worldwide during 2012 (1). Recently, it has become the leading cause of death in Egypt and has started to affect younger age groups (2). Many epidemiological studies found an association between several infectious etiologies and coronary artery disease (CAD) mainly due to alterations in blood lipids (3–5). The inflammation hypothesis of atherosclerosis postulates that the key events involved in the initiation and progression of the lesion are represented mainly by inflammatory and fibro-proliferative processes triggered by cytokines and growth factors. However, one of the most interesting recent developments has been the idea that infective agents may provoke a pro-inflammatory effect and have a significant role in atherothrombosis (6). In the early 1970s, the monoclonal hypothesis was first proposed. This suggested a potential role for viral infection in the atherosclerotic process. Specifically, this theory proposed that a mutation or a viral agent may represent events able to transform a single smooth muscle cell into the progenitor of a proliferative clone (7). Hepatitis C virus (HCV) causes chronic liver disease and adds to the disease burden globally, The World Health Organization has declared HCV a global health problem, with approximately 3% of the world’s population (roughly 170–200 million people) infected with HCV. In the United States of America, approximately 3 million people are chronically infected (4). Egypt has the highest prevalence of HCV in the world, with a national prevalence of 10–13% (8,9). Generally, HCV causes hepatic manifestations but extra-hepatic manifestations have also been documented (10). Common extra-hepatic manifestations include thyroid disorder and type II Diabetes Mellitus. Some studies have found an association between HCV infection and dilated cardiomyopathy and myocarditis (11,12) and alterations in lipid metabolism (3,5,6). This association with alteration in the lipid metabolism has led some researchers to suspect HCV infection as a risk factor for CAD, with some studies reporting an increased risk or an increase in measures of subclinical atherosclerosis (13–16). Scanty data on the relationship between HCV infection and atherosclerosis are available with some studies showing an association between HCV seropositivity and carotid artery plaque and carotid intima–media thickening, independent from other risk factors for atherosclerosis (13,17). The present study was undertaken to study the relationship or association of Abstract Background: Coronary artery disease (CAD) is one of the leading causes of death worldwide. Predisposing factors include some infectious aetiologies that have a systemic effect like hepatitis C virus. Aims: The aim of this study was to explore the association between hepatitis C viral infection and coronary artery disease. Methods: This case–control study was designed to include 100 patients attending the Cardiology Department in Tanta University Hospital, Gharbia Governorate, Egypt, for diagnostic angiography. A consecutive sample of 50 patients with abnormal angiographic findings was matched with another 50 consecutive patients with normal angiographic findings regarding age, sex, and major risk factors for coronary artery disease (diabetes mellitus, hypertension and smoking). Pa- tients were investigated for hepatitis C virus (HCV) infection. Results: We found that 46% of abnormal angiography were HCV-positive compared to 28% of patients with normal angi- ography; this difference was not statistically significant. On studying the number of vessels affected among patients with abnormal angiography it was noted that one vessel affection was found mainly among HCV-negative patients (59.3% com- pared to 17.4% among HCV-negative and -positive patients). Multi-vessel affection was found mainly among HCV-positive patient (47.8% compared to 22.2% among HCV-positive and -negative respectively). Conclusions: The possible association between HCV positivity and extension of coronary artery disease may refer to the role of HCV in coronary artery disease pathology. Further studies on a large scale to investigate this association are recommended. Keywords: coronary disease, stenosis, atherosclerosis, hepatitis C Citation: Shoeib O; Ashmawy M; Badr S; El Amroosy M. Association between coronary artery disease and hepatitis C virus seropositivity. East Mediterr Health J. 2018;24(7):618–623. https://doi.org/10.26719/2018.24.7.618 Received: 25/06/15; accepted: 18/06/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Research article 619 EMHJ – Vol. 24 No. 7 – 2018 active viral replication [polymerase chain reaction (PCR) positive] with number of cardiac vessels blocked. Methods Study design This was a case–control study in which the presence of HCV infection was compared in patients having known CAD with controls who did not have CAD; without adjusting for CAD risk factors. Study setting The study was carried out in the Cardiology Department, Tanta University Hospital, a teaching hospital in Tanta City, Gharbia Governorate in the middle of the Nile Delta, northern Egypt. The hospital also serves the surrounding governorates. The cardiology department has 40 beds. Data were collected from 1 June 2011 to end of December 2011 from patients attending the cardiology department for diagnostic catheterization (coronary angiography) Sampling We selected 50 consecutive patients with abnormal findings in coronary angiography sufficient to diagnose CAD (defined as > 50% stenosis of one of the proximal coronary arteries). These were matched for age, sex and major risk factors (diabetes mellitus, hypertension and smoking status). Another 50 consecutive patients with normal coronary angiography were also tested for viral markers and they served as controls. Patients having ≥ 1 of the following conditions were not included in the study: those having other viral hepatitis, especially hepatitis B; those with impaired liver or kidney function; and those with uncontrolled diabetes, acute or chronic inflammatory disease or history/ presence of neoplastic disease. At our centre, all patients undergoing coronary angiography undergo full medical history taking and general and local clinical examination, 12-leads surface ECG, echocardiography and routine laboratory investigations, including prothrombin time, partial thromboplastin time, kidney function test, liver function test and random blood sugar test. Testing for HBsAg and anti-HCV was also done using the ELISA (enzyme-linked immunosorbent assay) technique to exclude these infections. Positive cases were tested further using the qualitative PCR technique to confirm the viral replication. Coronary angiography was done using the femoral approach (18) and standard imaging technique (19). Ethical considerations The protocol of the study was approved by the ethical committee of Tanta University Faculty of Medicine and verbal consent was taken from patients while maintaining patient confidentiality. Statistical analysis Data were analysed using SPSS, version 11. The chi- squared test was used for a qualitative data and student t-test for quantitative data. Results were considered statistically significant at the 5% level. Results A total of 100 patients were included in this study, 57 males and 43 females (Table 1). There was no significant difference between cases, i.e. those having abnormal an- giography, and controls, i.e. those with normal angiogra- phy, in regard to age, sex and residence. Overall 27% of the study participants had diabetes mellitus, 57% had hypertension and 34% were smokers (Table 2). There was no significant difference between Characteristic Angiography findings Total (n = 100) χ2 P-value Normal (n = 50) Abnormal (n = 50) No. % No. % No. % Age (years) 20– 4 8 4 8 8 8 0 1 40– 22 44 22 44 44 44 60– 24 48 24 48 48 48 Sex Male 28 56 29 58 57 57 0.0408 0.84 Female 22 44 21 42 43 43 Residence Urban 17 34 15 30 32 32 0.1838 0.668 Rural 33 66 35 70 68 68 Table 1 Sociodemographic characteristics of study participants in relation to angiography results EMHJ – Vol. 24 No. 7 – 2018Research article 620 cases (abnormal angiography) and controls (normal angiography) regarding these risk factors for CAD. Although 46% of the patients who had CAD were HCV- positive compared with only 28% of those who had no CAD, the difference was not statistically significant (P = 0.062) (Table 3). In 47.8% of the HCV-positive patients, more than 2 vessels were affected compared with 22.2% of the HCV- negative patients. Among the HCV-negative patients, 59.3% showed affection of one vessel only compared with 17.4% who were HCV-positive and this difference was statistically significant (P = 0.0105) (Table 4). Patients who were HCV-seropositive had more vessels affected than those who were HCV-seronegative. Discussion Our study showed that patients with multiple vessel coronary artery disease were more likely to suffer from concomitant active hepatitis C infection than those who had single vessel disease. Several studies have investigated the extra-hepatic manifestation of HCV, but there has been little research investigating the relationship between HCV and cardiovascular disease (18). The association between HCV infection and CAD is less clear. A small number of studies have shown conflicting results; some have reported no association between HCV infection and CAD (19–21), while other research has reported an increased risk or an increase in measures of subclinical atherosclerosis (17). Tsui et al. analysed data from a cohort of patients with stable coronary heart disease and found that HCV-seropositive patients had higher rates of death, cardiovascular events and hospitalization because of heart failure during the follow-up despite lower cholesterol and C-reactive protein levels (22). After adjustment for age and cardiovascular risk factors together with the inflammatory markers level the cardiovascular events remained 50% greater in the HCV-positive group, but the difference was not significant. Despite having a greater number of patients (981) in their study, they were broader in regard to CAD diagnosis as they included all patients with a history of myocardial infarction, coronary angiographic stenosis > 50%, and patients with positive treadmill test, which may introduce some inaccuracies. In contrast, our study included only patients diagnosed using the gold standard method, which is diagnostic coronary angiography showing > 50% stenosis. Since HCV virus is endemic in Egypt, many researchers are also studying the association of heart disease primary risk factors that may be specific to our country. Egyptian researchers have studied the metabolic and cardiovascular risk profiles and hepatitis C virus infection in rural Egypt and found a positive relationship between HCV infection and some cardiovascular risk factors such as elevated triglycerides (23). Okasha and Fayez studied 202 patients who were referred for coronary artery disease. All patients were investigated for HCV infection. The results of coronary angiography were compared between HCV-positive and negative patients and they found that HCV infection had no impact on development of CAD. Coronary angiographic findings are not different between HCV- positive and negative patients with more left descending coronary artery affection in positive cases (24). Vassalle et al. investigated 491 patients with CAD and a control group of 195 patients and found that HCV seropositivity was 2.0% in control subjects and 6.3% in the CAD group; HCV seropositivity also increased with the number of vessels affected. Univariate logistic regression analysis showed that, in addition to other Table 2 SRisk factors among patients with normal angiography (control) and patients with abnormal angiography (study group) Risk factor Angiography findings Total (n = 100) χ2 P-value Normal (n = 50) Abnormal (n = 50) No. % No. % No. % Diabetes mellitus Present 12 24 15 30 27 27 0.4566 0.499 Absent 38 76 35 70 73 73 Hypertension Present 32 64 25 50 57 57 1.9992 0.157 Absent 18 36 25 50 43 43 Smoking status Smoker 16 32 18 36 34 34 0.1783 0.673 Non-smokera 34 68 32 64 66 66 Research article 621 EMHJ – Vol. 24 No. 7 – 2018 conventional atherogenic risk factors such as age, sex, smoking, hypertension, diabetes and dyslipidaemia, HCV seropositivity was associated with CAD (odds ratio 3.2). Multivariate logistic regression analysis showed that HCV seropositivity still represented an independent predictor for CAD (odds ratio 4.2; P < 0.05) (15). These results are concordant with our results as our study showed that two-thirds of our patients with more than 2 vessels affected were HCV seropositive. It has been reported that HCV infection accelerates atherosclerosis (23,25); this may be a result of the inflammatory process due to the infection itself; moreover, the prevalence of HCV increases with age and increasing age is also a risk factor for CAD. This may explain the increased number of vessels affected in HCV- positive patients as has been reported in our study. Butt et al. reported that, despite having a better risk profile of being younger and with a better lipid profile, HCV-infected subjects were at a significantly higher risk of developing CAD compared with HCV-uninfected subjects, even after adjustment for other risk factors for cardiovascular disease (18). This is also concordant with our results that showed that HCV seropositivity was higher among patients with CAD compared with patients with normal coronary arteries; however, the difference was not statistically significant, possibly due to the limited number of our study population compared to the study of Butt et al. In contrast, other studies (19–21) discount such a relationship, either in stable CAD patients or those with acute myocardial infarction (21,24). It is possible that the disparate findings might be due to differences in the populations examined, outcomes evaluated, and confounding variables used in the multivariate analyses. As HCV infection is endemic and highly prevalent in Egypt, a considerable proportion of patients with abnormal angiography were HCV-positive and a significant relationship was found between HCV infection and the number of vessels affected, this may call for other studies that include a larger number of cases and longer duration of follow-up to document the associations. The current study had the following limitations: the results were from a single medical centre (Tanta University Hospital) and the sample size was small. Also, some risk factors, such as dyslipidaemia, were not matched while others, such as diabetes mellitus and hypertension, were not matched according to disease severity or control, which may affect the coronary arteries. Nevertheless, from the results of this study the following actions may be considered: enforcement of preventive measures for HCV infection, especially among risk groups; screening of the apparently normal population for early detection and management of HCV infection to reduce its effect on coronary arteries; and routine HCV infection testing for every cardiac patient not only for those undergoing catheterization but also for those under medical treatment. Funding: None. Competing interests: None declared. HCV status Angiography findings Total (n = 100) χ2 P-value Normal (n = 50) Abnormal (n = 50) No. % No. % No. % Positive 14 28 23 46 37 37 3.4749 0.062 Negative 36 72 27 54 63 63 Total 50 50 50 50 100 100 Table 4. Association between numbers of vessels affected among patients with abnormal angiography and HCV infection: No. of vessels affected Angiography findings Total (n = 100) χ2 P-value Normal (n = 50) Abnormal (n = 50) No. % No. % No. % 1 4 17.4 16 59.3 20 40.0 9.1011 0.0105 2 8 34.8 5 18.5 13 26.0 ≥ 3 11 47.8 6 22.2 17 34.0 Total 23 46.0 27 54.0 50 100.0 EMHJ – Vol. 24 No. 7 – 2018Research article 622 Association entre coronaropathie et séropositivité au virus de l’hépatite C Résumé Contexte : La coronaropathie constitue l’une des principales causes de mortalité dans le monde. Ses facteurs prédisposants comprennent certaines étiologies infectieuses ayant un effet systémique à l’instar du virus de l’hépatite C. . Objectif : L’objectif de cette étude était d’examiner la possibilité d’une association entre l’infection par le virus de l’hépatite C et la coronaropathie. Méthodes : La présente étude cas-témoins a été conçue pour inclure 100 patients venant en consultation au département de cardiologie du Centre hospitalier universitaire de Tanta, dans le gouvernorat de Gharbeya (Égypte), pour une angiographie à visée diagnostique. On a comparé un échantillon consécutif de 50 patients présentant des résultats angiographiques anormaux à un autre groupe de 50 patients consécutifs pour lesquels les résultats angiographiques étaient normaux en prenant en compte l’âge, le sexe et les principaux facteurs de risque de coronaropathie (diabète sucré, hypertension et tabagisme). Les patients ont été soumis à un test de dépistage de l’infection par le virus de l’hépatite C (VHC). Résultats : 46 % des patients présentant des résultats angiographiques anormaux étaient positifs au VHC, contre 28 % chez ceux pour lesquels les résultats angiographiques étaient normaux ; cette différence n’était pas statistiquement significative. Après examen du nombre de vaisseaux concernés chez les patients dont les résultats angiographiques étaient anormaux, une seule atteinte vasculaire a été observée, principalement chez les patients négatifs au VHC (59,3 % parmi les patients négatifs au VHC contre 17,4 % chez les patients positifs au VHC). On a observé, principalement chez les patients positifs au VHC, que plusieurs vaisseaux étaient atteints (respectivement 47,8 % et 22,2 % parmi les patients positifs au VHC et négatifs au VHC). Conclusion : Une association éventuelle entre la séropositivité au VHC et l’étendue de la coronaropathie pourrait être liée au rôle joué par le VHC dans la pathologie de cette maladie. Des recherches plus poussées et de grande ampleur sont recommandées afin d’étudier plus en détail cette association. C دبكلا باهتلا سويرفل ةيلصلما ةيبايجلإاو يجاتلا نايشرلا ضرم ينب طابترلاا سيورمعلا دوممح ،ردب ماهس ،يوماشع تحدم ،بيعش ةماسأ ةصلالخا لقتنت يتلا ضارملأا بابسأ ضعبل ةبِّبسلما لماوعلا لمشتو .لماعلا ءاحنأ عيجم في ةافولا بابسأ ةعيلط في يجاتلا نايشرلا ضرم تيأي :ةيفللخا .C سويرفلاب دبكلا باهتلا سويرف لثم مسلجا ةزهجأ لىع يرثأت اله يتلاو ىودعلاب .يجاتلا نايشرلا ضرمو C سيويرفلا دبكلا باهتلاب ىودعلا ينب ةقلاعلا فاشكتسا وه ةساردلا هذه نم فدلها ناك :فدلها ،اطنط في يعمالجا ىفشتسلما في بلقلا ضارمأ مسق اوعجار نيذلا ضىرلما نم 100 لمشتل هذه دهاوشلاو تلاالحا ةسارد ْتَم ِّمُص :ثحبلا قرط ميهدل ًاضيرم 50 ت َّمضو لياتتلاب اهوذخأ ةنيع ينب ةنراقم نوثحابلا ىرجأو .ةيعولأل صييخشتلا ريوصتلا ءارجإ دصقب ،صرم ،ةيبرغلا ةظفامح في رمعلا ةنراقلما تلمشو ،ةيومدلا ةيعولأا ريوصتل ةيعيبط جئاتن ميهدلو ًاضيأ لياتتلاب مهوذخأ رخآ ًاضيرم 50و ،ةيعيبط يرغ ةيعولأا ريوصت جئاتن فشكل تارابتخا ضىرملل نوثحابلا ىرجأو .)ينخدتلاو مدلا طغض عافتراو يركسلا( يجاتلا نايشرلا ضرلم ةيسيئرلا رطلخا لماوعو سنلجاو .C سويرفلاب دبكلا باهتلا سويرفب ىودعلا عم ةنراقلماب ،يعيبط يرغ ميهدل ةيعولأا ريوصت جئاتن نيذلا ضىرلما نم ٪46 ىدل ًايبايجإ ناك C دبكلا باهتلا سويرف نأ نوثحابلا دجو :جئاتنلا ميهدل نيذلا ضىرلما ىدل ةباصلما ةيعولأا ددع ةسارد دنعو .ًايئاصحإ ةيهمأ هل سيل قرفلا اذه نكلو .ًايعيبط ةيعولأا ريوصت ميهدل نيذلا نم ٪28 ،C دبكلا باهتلا سويرفل ينيبلسلا ضىرلما ينب سييئر لكشب دوجوم دحاو ءاعو لىع ةباصلإا راصتقا نأ ظحول ،ةيعولأا ريوصتل ةيعيبط يرغ جئاتن لكشب تناك دقف ةددعتلما ةيعولأا تاباصإ امأ .)سويرفلل ينيبايجلإا ضىرلما ينب ٪17.4و C دبكلا باهتلا سويرفل ينيبلسلا ضىرلما ينب ٪59.3( .)٪ 22.2( سويرفلل ينيبلسلا عم ةنراقلماب )٪ 47.8( C دبكلا باهتلا سويرفل ينيبايجلإا ضىرلما ىدل سييئر سويرف رود لىإ يجاتلا نايشرلا ضرمب ةباصلإا لدعم دايدزاو C دبكلا باهتلا سويرف ةيبايجإ ينب لمتحلما طابترلاا دوجو يرشي دق :تاجاتنتسلاا .طابترلاا اذه ةساردل عساو قاطن لىع تاساردلا نم ديزلما ءارجإب نوثحابلا صيويو .يجاتلا نايشرلا ضارمأ في C دبكلا باهتلا Research article 623 EMHJ – Vol. 24 No. 7 – 2018 References 1. 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Chronic hepatitis C virus infection and atherosclero- sis: clinical impact and mechanisms. World J Gastroenterol. 2014;20(13):3410–7. PMID:24707124 EMHJ – Vol. 24 No. 7 – 2018Research article 624 Social, psychological and demographic variables related to breast- feeding among Kuwaiti mothers Yagoub Al-Kandari 1 and Ramadan A. Ahmed 2 1Department of Sociology and Social Work and Anthropology, Kuwait University, Kuwait (Correspondence to: Y.Y. Al-Kandari: alkandari66@hotmail. com). 2Department of Psychology, Munofiya University, Egypt. Introduction Few studies have dealt with breastfeeding behaviour in Kuwait. Al-Enezi et al. concluded that there is a range of economic, social and educational factors associated with reproductive behaviour, breastfeeding and child nutrition (1). One study from the 1970s compared children’s feeding and parental attitudes towards children’s food in Kuwait, Egypt and Bahrain, with a focus on the transition from breastfeeding to regular food (2). Variables examined included maternal nutrition and education, parental age, monthly income, and age of the children when they were weaned. There was a significant relationship between these variables and children’s feeding behaviour. Another study concentrated on breastfeeding versus artificial feeding and weaning behaviour of 2833 Kuwaiti mothers with children aged ≤ 1 year (3). The researchers found that > 60% of mothers breastfed their children on an average of 5.8 months. Differences in breastfeeding duration were found between old and young mothers. They also found that most infants in families without nursemaids were breastfed by their mothers. Al-Bustan and Kohli found a relationship between some socioeconomic variables and breastfeeding, including a lower rate of breastfeeding among working mothers (4). Fluoride was found more often in the teeth of children who were breastfed compared with those who were not. Studies about breastfeeding behaviour conducted in the last two or three decades of the last century in Kuwait have revealed significant changes due to the effects of modern life. For example, the increase in the number of women obtaining a higher education and being involved in the workplace changed the role and status of women in contemporary Kuwaiti society (5). In 2006, the numbers of women participating in the Kuwaiti labour force reached the highest rate in the Arab world, increasing from 37% in 2003 to 42% (6). These statistics leave no doubt about the significant impact of a woman’s career on the length of time she chooses to breastfeed and on her behavior toward her child in general because of the impact of her absence from home when compared to the traditional stay-at-home mothers. These studies did not consider the relationship between some of the social and psychological variables and maternal breastfeeding behaviour, such as the cultural differences between social groups within a community. Abstract Background: Many studies have discussed the relationship between breastfeeding and certain social, psychological and demographic variables. Aims: The aim of this study was to determine the effect of social, psychological and demographic variables on breastfeed- ing among Kuwaiti mothers. Methods: The total of 712 married women were selected who answered a questionnaire. Questions were asked about duration of breastfeeding and bottle feeding, degree of spousal relationship, religious sect and background. Religiosity, family stability and general health self-rating scales were used. Results: Women who came from urban roots and consanguineous marriages had a higher mean duration of breastfeed- ing than those who came from Bedouin roots and nonconsanguineous marriages. There was a significant difference among the three maternal age groups in the duration of breastfeeding. A significant relationship was found between the duration of breastfeeding and all social, psychological and demographic variables except general health. Correlations were found between the duration of breastfeeding and maternal and paternal education, maternal occupation, years of marriage, age at marriage, family stability scale, self-esteem scale, and socioeconomic variables. The duration of artificial feeding, number of abortions, degree of religiosity, family stability scale, age, and socioeconomic scale related to the du- ration of the mother’s breastfeeding. Conclusions: Education plays an important role in affecting women’s health in general and breastfeeding practice in particular. Keywords: breastfeeding, artificial feeding, social factors, psychological factors, demographic factors. Citation: Al-Kandari Y; Ahmed RA. Social, psychological and demographic variables related to breastfeeding among Kuwaiti mothers East Mediterr Health J. 2018;24(7):624–630. https://doi.org/10.26719/2018.24.7.624 Received:12/11/15; accepted: 26/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo).. Research article 625 EMHJ – Vol. 24 No. 7 – 2018 The aim of the current study was to determine the effect of social, physiological and demographic variables on breastfeeding among Kuwaiti mothers. The study was based on the following hypotheses: 1) there are significant differences between Sunni and Shiite, urban and Bedouin, and consanguineous and nonconsanguineous marriages in breastfeeding and artificial-feeding behaviour; 2) there are significant differences among women’s age and breastfeeding duration for the first four children that women bear; and 3) there is a significant relationship between some sociocultural, demographic and psychological factors and breast- or bottle-feeding behaviour. Methods Study sample A total of 712 married Kuwaiti women, aged 17–61 years, were selected from the six governorates in Kuwait using a nonrandom opportunistic voluntary sampling method during 2013. Research assistants helped to collect data by direct contact with the participants and the response rate was high. Only a few questionnaires were omitted, due to the fact that they were not completed in full. The respondents answered the questionnaire voluntarily after an explanation of the study aims. The method of sample selection and some of the study tools and variables were used in similar studies conducted elsewhere (7–10). Respondents were informed that the researchers would respect their confidentiality and anonymity. They were also informed that participation in this study was voluntarily. Informed consent was obtained. Variables and measurements The questionnaire included demographic information about paternal education, maternal occupation, maternal age, governorates and family income. Other family and social variables included: years of marriage, age at marriage, number of children, number of abortions, and average year of discontinuing breastfeeding. Education was divided into eight categories, from 1 “read and write or below” to 8 “PhD”. Annual family income was also divided into eight categories, from 1 “≤ 500 Kuwaiti dinars” to 8 “≥ 2100 Kuwaiti dinars”. Occupation was divided into six categories, from 1 “not working (housewife)” to 6 “professional”. Socioeconomic status was measured by using three variables: annual income, educational level, and occupational position coded according to the Social Science Research Council. Respondents were asked about the duration of breastfeeding and using artificial feeding. Respondents were asked for how long they breastfed their infants and when they started artificial feeding. There were also questions about consanguineous/nonconsanguineous marriage, Sunni or Shiite religious sect, and tribal or urban origins. The self-rating scale of religiosity was measured by the following question: “What is your level of religiosity in general?” and the self-rating scale of general health question was, “What is your estimation of your health in general?” A scale from 0 to 10 was used. The respondents were asked to circle the number to describe their feelings concerning their religiosity and health. For religiosity, the lowest score (0) was “not religious at all,” and the highest score was “very religious.” For health, the lowest score (0) was “feeling poorly,” and the highest score was “feeling excellent”. These 2 single item self-reports have been used previously for research in Kuwait (11,12). Both scales show reliability and validity. For example, the self-report scale for religiosity shows temporal stability and both concurrent and factorial validity (13). Abel- Khalek reported, “Although there are Western-developed inventories to measure religiosity, they are based on the Christian concept of God. It is not yet known whether these inventories are valid for Islamic conceptions” (12). A 1-week test–retest of reliability for these 2 scales was completed, which showed a correlation of 0.77 and 0.89 for the 2 scales, respectively. Some social and psychological scales were also used. The family stability scale developed by Muktar contained 31 sentences, to which the participants responded using a 5-point scale: from strongly agree (5) to strongly disagree (1) (6). The Self-Esteem scale developed by Rosenberg was used in this study (14). The scale contained 10 sentences, with a 5-point scale from strongly agree (5) to strongly disagree (1). The emotional scale developed by Darweesh and Shaker, which was used in a Jordanian study, was used with some modifications to fit the sample in the current study (15). The overall scale contained 35 sentences, to which the participants responded using a 5-point scale: from strongly agree (5) to strongly disagree (1). Six faculty members from the College of Social Sciences reviewed the scales to obtain content validity. For reliability, these scales have been shown to have high internal consistency overall (α coefficient of 0.94, 0.77 and 0.95, respectively). Statistical analysis SPSS version 19.0 was used for data analysis. Both descriptive and inferential statistics were used to examine the research hypotheses. The t-test was used to examine differences between Sunni and Shiite, urban and Bedouin, and consanguineous and nonconsanguineous marriages with regard to breastfeeding and artificial feeding. Analysis of variance was used to examine differences among three age groups of mothers in relation to breastfeeding. Correlation coefficients between breastfeeding and artificial feeding with some sociocultural, demographic and physiological factors were used. For the purpose of predicting breastfeeding and artificial feeding times, a multiple linear regression model was used. Results There was no significant difference between Sunnis and Shiites concerning duration of breastfeeding or artificial feeding (Table 1). There was no significant difference between urban and Bedouin mothers concerning duration of breastfeeding. However, women of urban origin had a significantly higher mean duration of EMHJ – Vol. 24 No. 7 – 2018Research article 626 artificial feeding than those of Bedouin origin. Women in a consanguineous marriage had a significantly higher mean duration of breastfeeding than women in a nonconsanguineous marriage. Maternal age is an important determinant of breastfeeding. We investigated the differences among age groups in breastfeeding the first four children (Table 2). For the first child, there was a significant difference among the three age groups in the duration of breastfeeding. The highest mean duration was found among women aged ≥ 41 years, while the lowest duration was in women aged 31–40 years. Women aged ≥ 41 years had a higher mean duration of breastfeeding for their second, third and fourth children, while those aged ≤ 30 years had a lower mean duration of breastfeeding. In general, older women breastfeed their children for a longer time than younger women do. Table 2 shows that the longest mean durations were found among women aged ≥ 41 years for breastfeeding their children compared with the other age categories. A t-test showed that there was a significant difference between the overall mean of breastfeeding the fourth child versus the first child (P < 0.001). There were significant relationships between the duration of breastfeeding and all social, psychological and demographic variables, except average year of stopping breastfeeding and general health (Table 3). Negative significant correlations were found between the duration of breastfeeding and maternal and paternal education, maternal occupation, maternal years of marriage, maternal age at marriage, family stability scale, self-esteem scale and socioeconomics. In contrast, positive correlations were found between duration of breastfeeding and number of children, number of abortions, age, and religiosity and emotional scales. There was a positive relationship between duration of artificial feeding and maternal occupation, years of marriage, family stability and self-esteem scales, and socioeconomics. In contrast, negative correlations were found between artificial feeding duration and number of abortions, maternal age and religiosity. To predict the effect of social, psychological and demographic variables on the duration of breastfeeding, a multivariate regression model was used (Table 4). Duration of artificial feeding, number of abortions, degree of religiosity, family stability scale, maternal age and socioeconomics exerted a negative effect on the duration of breastfeeding. The higher the mean of these variables, the shorter the breastfeeding duration. A positive association was found between the duration of breastfeeding and artificial feeding and family stability, and negative associations were found with other variables. Discussion Our results showed that women of urban origin had a significantly higher mean duration of artificial feeding than those of Bedouin origin. Significant differences among women’s age and breastfeeding duration for their Table 1 Infant feeding among social groups, religious sects and spousal relationships Variables Breastfeedinga Artificial feedinga n M SD t P n M SD t P Sect Sunni Shiite 462 136 6.55 6.0 6.69 6.62 0.847 NS 447 141 20.65 19.35 10.04 11.79 1.29 NS Roots Urban Bedouin 167 422 6.29 6.52 7.14 6.54 −0.385 NS 171 406 21.43 19.61 9.67 10.81 2.43 < 0.05 Spousal relationship Consanguineous Nonconsanguineous 246 344 7.46 5.76 7.39 6.09 3.04 < 0.01 239 343 20.36 20.49 10.29 10.56 0.156 NS aSome mothers used both artificial feeding and breastfeeding. M = mean; SD = standard deviation; NS = not significant. Table 2 Differences in breastfeeding first 4 children among 3 age groups of women Breastfeeding Maternal age (years) n Mean SD P Child 1 ≤ 30 31–40 ≥ 41 Total 256 181 152 589 6.14 5.55 7.84 6.40 6.79 5.67 7.20 6.63 < 0.005 Child 2 ≤ 30 31–40 ≥ 41 Total 160 179 152 491 5.52 5.68 7.92 6.32 5.47 6.05 7.54 6.46 < 0.001 Child 3 ≤ 30 31–40 ≥ 41 Total 64 144 137 345 5.16 6.01 8.82 6.97 5.71 5.76 8.15 6.96 < 0.001 Child 4 ≤ 30 31–40 ≥ 41 Total 35 108 116 259 4.94 6.17 9.29 7.40 5.97 6.82 8.28 7.59 < 0.001 Results measured by analysis of variance. SD = standard deviation.. Research article 627 EMHJ – Vol. 24 No. 7 – 2018 first four children were found. There was also a significant relationship between some sociocultural, demographic and psychological factors and breast- or bottle-feeding behaviour. Our data show how modernization plays an important role affecting women’s health in general and breastfeeding practice in particular. The mean duration of breastfeeding among Kuwaiti mothers did not exceed six months. In contrast, artificial feeding lasted for around 20 months. Although the World Health Organization (WHO) strongly recommends exclusive breastfeeding up to six months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond, there has been a decline in the duration of breastfeeding over time in Kuwait (16). Kuwaiti mothers, like 65% of those in Europe and the United States of America, do not follow the WHO recommendation (17). A new study in Kuwait showed that 30% of all infants received breast milk for up to 6 months (18). This affects women’s general health (19). The proportion of children breastfeeding at six months in Kuwait is below international targets and ranges from 35 to 44%. Changes in women’s roles in Kuwait constitute the strongest factor for explaining the decline in duration of breastfeeding. The number of women involved in the labour force has been increasing, especially in the last two decades, and has reached 42% of the total local labour force (20), with a greater percentage in higher education compared with men (21). Traditionally, women spent most of their time at home taking care of their children. With few responsibilities for women outside the home, the fertility rate was higher compared with that in modern society. Modernization has resulted in a clear decline in fertility rates in Kuwait (22). Work stress and time spent at work may be the main reasons for the reduction in duration of breastfeeding in Kuwait. Grummer-Strawn has shown that there is a universally downward trend in the duration of breastfeeding (23). Our results show that older women have a longer duration of breastfeeding. This also may explain why the educational level of women is negatively related to the duration of breastfeeding. Other important elements related to modern life and women’s age that may affect the duration of breastfeeding are years of marriage, age at marriage, number of children, socioeconomic status, and husband’s educational level. These results are supported by previous studies (24). Our data did not show a clear difference between Sunnis and Shiites for duration of breastfeeding and artificial feeding. Lack of any difference in breastfeeding behaviour among a population may indicate the effect of acculturation. Some studies have concentrated on acculturation among different ethnic groups and duration of breastfeeding (25). In modern Kuwait, all subgroups have become more connected to one other, as they are involved in the same social and economic activities. Acculturation in Kuwait has been facilitated by the small land mass, availability of communication technology, and equal opportunities for work and education for all Kuwaiti citizens. We showed that women in a consanguineous marriage had a longer mean duration of breastfeeding than women in a nonconsanguineous marriage. Although there has been a decline in consanguinity (26) and the tendency for women to live in a nuclear family in Kuwait (5,27,28), many still practice consanguinity. Kin provide family members and women with a high level of social support. One aspect of this is taking care of each other’s children. A woman who marries her relative always lives in the extended family with support and help from family members. Relatives can offer a great deal of help with social life duties and responsibilities. Table 4 Prediction of effect of social, psychological and demographic variables on duration of breastfeeding, a multivariate regression model Variables B β t Artificial feeding 3.43 0.88 19.11*** Abortion −6.19 −0.14 −2.84** Religiosity −4.75 −0.12 −2.21* Family stability 0.357 0.18 2.69* Maternal age −0.721 −0.12 −1.98* Socioeconomics −4.06 −0.15 −1.95* R2 0.24 F = 3.55*** Adjusted R2 0.18 *P < 0.05 **P < 0.01 ***P < 0.001 Table 3 Correlation coefficients between breastfeeding and artificial feeding and health, sociocultural, demographic and psychological factors Variables Breastfeeding Artificial feeding Maternal education −0.13** 0.081 Paternal Education −0.11* −0.054 Maternal occupation −0.22** 0.18** Years of marriage −0.17** 0.20** Age at marriage −0.011* −0.04 Number of children 0.12** 0.06 Number of abortions 0.25** −0.18* Average year stopping breastfeeding −0.03 0.16* General health scale −0.02 0.10* Religiosity scale 0.10** −0.26** Family stability scale −0.13** 0.12** Self-esteem scale −0.19** 0.10* Emotional scale 0.17** 0.07 Age 0.10* −0.33** Socioeconomics −0.24** 0.14** *P < 0.05 **P < 0.01 EMHJ – Vol. 24 No. 7 – 2018Research article 628 Variables sociales, psychologiques et démographiques associées à l’allaitement chez les mères koweïtiennes Résumé Contexte : De nombreuses études ont déjà examiné les rapports entre l’allaitement au sein et certaines variables sociales, psychologiques et démographiques. Objectifs : L’objectif de la présente étude était de déterminer l’impact des variables sociales, psychologiques et démographiques sur l’allaitement chez les mères koweïtiennes. Méthodes : On a sélectionné 712 femmes mariées au total qui ont été priées de répondre à un questionnaire. Les questions portaient sur la durée de l’allaitement et de l’alimentation au biberon, le lien de parenté entre les époux, l’appartenance religieuse et le milieu. On a utilisé des échelles autorapportées de religiosité, de stabilité familiale et de santé générale. Résultats : Les femmes issues de milieux urbains et vivant au sein d’un mariage consanguin ont fait état de durées d’allaitement moyennes plus longues que celles issues de racines bédouines et vivant dans un mariage non consanguin. Des différences significatives sur le plan de la durée d’allaitement entre les trois groupes d’âge maternels ont été notées. Un lien significatif a été constaté entre la durée de l’allaitement et toutes les variables sociales, psychologiques et démographiques, à l’exception de la santé générale. Des corrélations ont été établies entre la durée d’allaitement au sein et les niveaux d’éducation de la mère et du père, la profession de la mère, l’année du mariage, l’âge au moment du mariage, l’échelle de stabilité de la famille, l’échelle d’estime personnelle et les variables socio-économiques. La durée d’alimentation au biberon, le nombre d’avortements, le degré de religiosité, l’échelle de stabilité de la famille, l’âge et l’échelle socio-économique étaient liés à la durée de l’allaitement au sein par la mère. Conclusions : L’éducation affecte de façon importante la santé des femmes en général et la pratique de l’allaitement au sein en particulier.. Women in a consanguineous marriage have more time to take care of their children, especially when new born, compared with others who marry outside their families. This, in general, has a positive effect on women’s health (29). Women from a Bedouin background used artificial feeding more than women of urban origin did. A possible explanation is that they have become involved in modern social life only recently, compared with others. Education is the main factor in this involvement. There was a boom of Kuwaiti women in higher education in recent decades and most of these women were of Bedouin origin (5,21). The number of women attending university increased because of changes in traditional and tribal values concerning women’s education and work. As a result, artificial feeding became an alternative method for them during this period of transition. Other factors related to the duration of breastfeeding include religiosity and self-esteem. Some have stated that religiosity is the major factor that affects the duration of breastfeeding (30,31). Self-esteem was a major psychological factor related to breastfeeding, which was also supported in previous studies (32). Religiosity and self-esteem are related to women’s mental health. Mothers who are happy are healthier than others who are not, and this can affect breastfeeding (29,33). This study was primarily limited by its sample size and selection. It could be said that this was a primary study that examined too many variables related to breastfeeding. For this reason, further studies are needed with a larger sample of Kuwaiti women and examining different variables. Some social, demographic and psychological factors that affect breastfeeding practices also need to be studied independently. We also need some research using qualitative methods to support the purely quantitative techniques used in this study, especially for such a behavioural research aim. Factors such as education, nature of work, religiosity, and social family life need to be researched further in future studies. Biocultural studies are rare in Kuwait and more are needed. Conclusion Our data show that some social, psychological and demographic variables influence breastfeeding practice among mothers in Kuwait. Although there is no information in the literature to allow trend analysis of breastfeeding over time, our data clearly show the decline in breastfeeding duration. There is a trend toward western lifestyle. The reduced duration of breastfeeding is related to increased numbers of women going out to work, as in western countries. That was one of the major changes in the role of women that had an effect on health. Health promotion programmes for mothers are needed before and after birth. There is a need to limit inappropriate marketing of breast-milk substitutes, empower mothers to breastfeed during work time, and establish nurseries for mothers at work and prepare health awareness campaigns. Funding: This research is funded by Research Depart- ment at Kuwait University (Project no. OS01/11). Authors would like to thank Kuwait University for their support. Competing interests: None declared. Research article 629 EMHJ – Vol. 24 No. 7 – 2018 تيوكلا ةلود في تاهملأا ينب ةيعيبطلا ةعاضرلاب ةقلعتلما ةيناكسلاو ةيسفنلاو ةيعماتجلاا تايرغتلما دحمأ راتسلا دبع ناضمر ،يردنكلا بوقعي ةصلالخا .ةيناكسلاو ةيسفنلاو ةيعماتجلاا تايرغتلما ضعبو ةيعيبطلا ةعاضرلا ينب ةقلاعلا تاساردلا نم يرثكلا شقان :ةيفللخا .تيوكلا ةلود في تاهملأا ينب ةيعيبطلا ةعاضرلا لىع ةيناكسلاو ةيسفنلاو ةيعماتجلاا تايرغتلما رثأ ديدتح وه ةساردلا هذه نم فدلها :فدلها ةعاضرلا ةدم لوح ةلئسأ نايبتسلاا نمضتو .ةساردلا نايبتسا لىع ةباجلإل تاجوزتلما ءاسنلا نم ةأرما 712 لياجمإ رايتخا مت :ثحبلا قرط نم لكل تياذلا سايقلل سيياقم مادختسا عم ،ةيساسلأا تامولعلماو ةينيدلا ةفئاطلاو ،ينجوزلا ينب ةبارقلا ةجردو ،ةجاجزلاب ماعطلإاو ،ةيعيبطلا .ةماعلا ةيحصلا ةلالحاو ليئاعلا رارقتسلااو ينيدلا مازتللاا نردحنا تياوللا ىدل امم لوطأ نبهراقأ نم تاجوزتمو ةيضرلحا روذلجا نم تاردحنلما ءاسنلا ىدل ةيعيبطلا ةعاضرلا ةدم طسوتم ناك :جئاتنلا ماك .تاهملأل ثلاثلا ةيرمعلا تاعومجلما ينب ةيعيبطلا ةعاضرلا ةترف في هب ّدَتْعُي قرف كانه ناكو .نبهراقأ نم تاجوزتم ّنكي لمو ةيودب روذج نم مت .ةماعلا ةيحصلا ةلالحا ءانثتساب ةيناكسلاو ةيسفنلاو ةيعماتجلاا تايرغتلما عيجم ينبو ةيعيبطلا ةعاضرلا ةدم ينب ًايئاصحإ هب ّدَتْعُي طابترا كانه ناك ،ةسرلأا رارقتسا سايقمو ،جاوزلا خيراتو ،جاوزلا نسو ،ملأا لمعو ،ءابلآاو تاهملأا ميلعتو ةيعيبطلا ةعاضرلا ةدم ينب تاطابترلاا لىع روثعلا ،ضاهجلإا تارم ددعو ،ةيعانطصلاا تاضرحتسلماب ةيذغتلا ةدم نم لك طبتريو .ةيداصتقلااو ةيعماتجلاا تايرغتلماو ،تاذلا ماترحا سايقمو .ةيعيبطلا ةعاضرلا ةدمب يداصتقلاا يعماتجلاا سايقلا ملسو ،رمعلاو ،ةسرلأا رارقتسا سايقمو ،ينيدلا مازتللاا ةجردو .صوصلخا هجو لىع ةيعيبطلا ةعاضرلا ةسرامم لىعو ماع لكشب ةأرلما ةحص لىع يرثأتلا في ًاماه ًارود ميلعتلا يدؤي :جاتنتسلاا References 1. 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Health Psychol. 2002 Mar;21(2):187–93. https://doi.org/10.1037/0278-6133.21.2.187 PMID:11950109 Research article 631 EMHJ – Vol. 24 No. 7 – 2018 Associations between red reflex abnormality, consanguinity and intensive care hospitalization of newborns in Turkey Zeynep Ozkurt,1 Selahattin Balsak,2 Yusuf Yildirim,1 Harun Yuksel 1 and Ihsan Caca 1 1Department of Ophthalmology, Dicle University of Medicine, Diyarbakir, Turkey (Correspondence to: Z. Gursel Ozkurt: drzeynepgursel@gmail.com). 2Department of Ophthalmology, Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey. Introduction The red reflex test was first described by Bruckner in 1962 and has proven to be effective for detecting vision- and life-threatening ocular conditions of children and adults (1). The American Academy of Pediatrics published a policy statement in 2016 and recommended red reflex screening in infants aged 0–6 months on every visit to their general practitioner (GP) and once at age 6–12 months, 1–3 years, 4–5 years and ≥ 6 years (2). This test is simple, noninvasive and can be performed quickly by GPs and paediatricians. It depends on transmission of light through the eye, and reflection of light from the ocular fundus back to the examiner’s eye. Besides the red colour, the red reflex can also be yellow, orange or any combination (3). A normal red reflex requires transparency of the tear film, cornea, aqueous humour, crystalline lens and vitreous humour. Any transmission block at any part of the optical pathway results in reflex abnormality that includes its absence, asymmetry, leukocoria, or nonhomogeneous reflex (1,4). Consanguineous marriage is a widely preferred custom from ancient times in the Middle East, Central and Southern Asia, and Northern Africa (5). Consanguineous marriage is also common in Turkey with an overall prevalence of 21.2%; however, the rate varies significantly according to geographical regions (6). Recent studies from the Middle East have shown potential recessive genetic causes of common paediatric ocular conditions (7). Up to one third of cataracts are inherited and they may be autosomal dominant, autosomal recessive or X linked (8–10). These data highlight the additional importance of performing red reflex screening test in Turkey. Previously, only one study about red reflex screening results was reported from Turkey; however, the associations of consanguinity, hospitalization in neonatal intensive care service (NICS) and red reflex abnormality were not reported (11). Israel is the only country in the Middle East that has reported red reflex screening results, although association with consanguinity has not been reported (3). It is important to document red reflex abnormality rates and their association with risk factors in Turkey and the Middle East to attract the attention of GPs and paediatricians. Also, indicating the association of consanguinity and ocular diseases will be helpful in informing the public about risks of intermarriages. In this study, we evaluated the red reflex of newborns hospitalized in the NICS and in the rooming-in unit (RIU) at Dicle University, Faculty of Medicine Hospital and Diyarbakir Maternity and Child Health Hospital, Turkey. We estimated the percentage of ocular disorders that could be detected by red reflex screening test and investigated a possible relation between ocular disorders and consanguinity. Abstract Background: Red reflex screening is the primary but unheeded test for the detection of vision- and life-threatening eye conditions. Aims: To evaluate the red reflex of newborns, percentage of ocular diseases resulting in red reflex abnormality, and their relation with consanguinity in Southeast Turkey. Methods: Newborns (n = 1358) were examined with pencil light and direct ophthalmoscopy. Results: Eight hundred of these newborns were hospitalized in a rooming-in unit. (RIU) and 558 were in the neonatal intensive care service (NICS). In the RIU there were 7 (0.88%) newborns with abnormal red reflex and in the NICS there were 14 (2.51%). Sensitivity of pencil light examination was 71.4%. Studies from the Middle East have shown potential re- cessive genetic causes of common paediatric ocular conditions. In our study, consanguineous marriage was found to have a significant association with red reflex abnormality (P = 0.017). Conclusions: Red reflex screening test is important in the early diagnosis of vision- and life-threatening eye disorders in Southeast Turkey where consanguinity is common. Keywords: congenital cataract, consanguinity, intensive care, newborn screening, red reflex test Citation: Gursel Ozkurt Z; Balsak S; Yildirim Y; Yuksel H; Caca I. Associations between red reflex abnormality, consanguinity and intensive care hospitalization of newborns in Turkey. East Mediterr Health J. 2018;24(7):631–636. https://doi.org/10.26719/2018.24.7.631 Received: 13/05/16; accepted: 20/06/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). EMHJ – Vol. 24 No. 7 – 2018Research article 632 Methods In this prospective study, between June 2013 and August 2014, we examined by the red reflex screening test results of 1358 newborns hospitalized in the RIU or NICS of Dicle University, Faculty of Medicine Hospital and Diyarbakir Maternity and Child Health Hospital. The study protocol was approved by the Institutional Review Board of the hospital and the study was conducted in accordance with the principles of the Declaration of Helsinki. Informed consent was obtained from each parent. Ophthalmological examination was performed by an ophthalmologist (ZGO and SB) and included an external examination of the globe with pencil light and visualization of the red reflex with direct ophthalmoscopy without dilating the pupils. The eyelids of the newborns were opened gently by the examiner’s fingers, and an eyelid speculum was not used. The test was performed with a direct ophthalmoscope, set at 0 lens power, held close to the newborn’s eye and focused on each pupil individually at ~30 cm from the eye. Lack of a red reflex or presence of a white or dim red reflex or dark spots in the red reflex was an indication for further evaluation with pupillary dilation. We prospectively recorded data of each newborn, including sex, number of children that the parents had, and the degree of consanguinity between the parents and concomitant systemic or genetic diseases of the newborns, if they were hospitalized in the NICS. Statistical analysis was performed with SPSS version 15 (SPSS, Chicago, IL, USA). The statistical calculations included descriptive statistics, χ2 test, Fisher’s exact test and independent samples t test. Data were presented as mean (standard deviation). P < 0.05 was considered significant. Results Eight hundred (58.9%) newborns were hospitalized in the RIU and 558 (41.1%) in the NICS. We found suspicious red reflex abnormality in 30 (2.2%) patients. After further evaluation with pupillary dilation, we diagnosed ocular pathology causing red reflex abnormality in 21 (1.5%) of these newborns. Therefore, the red reflex test without pupillary dilation had a positive predictive value of 70%, which is expected to be higher with clinical experience. The pathological distribution at both locations is shown in Table 1. Red reflex abnormality was found in seven of 800 newborns in the RIU and 14 of 558 in the NICS. The abnormal red reflex rate was 0.88% in the RIU and 2.51% in the NICS and 1.55% overall. The red reflex abnormality rate was ~3-fold higher in newborns hospitalized in the NICS compared with the RIU. Sex did not have a significant effect on red reflex abnormality (P = 0.58). The rate of systemic anomalies in the newborns with abnormal red reflex was 33.3%. We analysed consanguineous marriage rates of the parents of newborns in the RUI and NICS. Overall, 27.9% of the consanguineous marriages were first- cousin and 14.3% were second-cousin marriages. There were 2 newborns for whom both maternal and paternal grandmothers and grandfathers were siblings (double first-cousin marriages). Parental consanguineous marriage rate among the newborns with confirmed abnormal red reflex was 71.4% compared with 29.4% in newborns with normal red reflex (Table 2). Consanguineous marriage and confirmed red reflex abnormality were significantly associated (odds ratio: 6.0, 95% confidence interval: 2.31–15.59, P = 0.017). We also investigated the number of children that the parents had. The mean number of children in the families with parental consanguinity was 3.5 (2.1), compared with 2.9 (1.9) in the families without parental consanguinity, which was a significant difference (P < 0.01). In the external examination of the globes with pencil light illumination, no pathology was observed in six of the 21 newborns with red reflex abnormality. In 15 (71.4%) of them, suspicious abnormalities could be realized with pencil light illumination. We selected six cases of congenital cataract. In the RUI, there were two (0.25%) cases of congenital cataract and four (0.71%) in the NICS, although this difference was not significant (P = 0.20). Among these six cases, only two were visible with pencil light illumination. Discussion The red reflex screening test is an essential part of paediatric examination. It can provide early diagnosis of important treatable vision- and life-threatening conditions, such as congenital cataract and retinoblastoma (12). In several developed countries, eye-screening protocols have been applied already. In Sweden, a study conducted between 2007 and 2009 reported that, at ~90% of all paediatric and neonatal units, eye-screening protocols were used and screening with red reflex examination in maternity wards increased the detection 3-fold (19 vs 64%), which emphasizes the importance of the red reflex test (13). Congenital cataract is a potential vision-threatening disease and has been reported as a priority of the Global Vision 2020 initiative of the World Health Organization (14). It is still the most common treatable cause of visual disability in infancy and childhood, accounting for nearly 10% of childhood blindness worldwide (15,16). In 2007 and 2008 Eventov-Friedman et al. screened 11 500 newborns in the Middle East with red reflex examination and reported an incidence of congenital cataract of 4.3 per 10 000 (3). In the United States of America (USA) and Europe, based on the routine notification systems for monitoring congenital anomalies, congenital or infantile cataracts were estimated to be ~1 per 10 000 births in 1996. Also, the British Congenital Cataract Interest Group reported a cumulative incidence of congenital and infantile cataract of 2.29 per 10 000 by age 1 year in 1995– 1996 (17). In other studies between 2006 and 2011, the incidence was estimated between 1 and 6 per 10 000 live births (8,9). Screening of 2718 newborns between 2007 and 2010 at a hospital in Istanbul was reported. There were two (0.07%) cases of congenital cataract; however, Research article 633 EMHJ – Vol. 24 No. 7 – 2018 it was not clear whether they included newborns in the NICS (11). In our study, in the RUI, there were two (0.25%) cases of congenital cataract and 4 (0.71%) in the NICS. According to the two previous studies from Turkey, it seems that the incidence of congenital cataracts is higher in Turkey than developed countries. The high rates of consanguineous marriages may be associated with this higher incidence. We calculated consanguinity ratios among the families of the newborns. Related spouses had 3.5 (2.1) children and unrelated spouses had 2.9 (1.9), which was a significant difference (P < 0.01). This means the calculated consanguinity ratios among families and among newborns will be different. The real rate of intermarriage in Turkey may be lower than our results suggest, but the demand of consanguineous spouses to have more offspring can increase the incidence of congenital cataracts. Newborns with congenital cataracts should be operated upon within 6 weeks after birth to prevent visual deprivation (18). In the United Kingdom of Great Britain and Northern Ireland, less than half of the cases in the 1995–1996 cohort of infants with congenital and infantile cataract were detected by screening examinations at age ≤ 8 weeks. Also, a study conducted in the USA between 1968 and 1998 reported that 38% of infantile cataracts were diagnosed after 6 weeks of age (19). In the study of Sotomi et al., 27 infants with congenital cataracts were evaluated between 1991 and 2001 and the authors concluded that none of them was detected by newborn screening examination (20). A retrospective study of retinoblastoma from 1914 to 2000 reported that, among 1831 children with leukocoria, only 123 (8%) were detected by a paediatrician (21). These findings suggest that most clinicians are still unaware of the importance of the red reflex screening test, or examinations are not sensitive enough and additional training is needed. A recent study from New Zealand in 2016 suggested that development of an online resource or practical refresher sessions would help to improve current practices (22). Educational posters sent to GPs and neonatologists also increase referrals of abnormal red reflexes to ophthalmology departments (12). Screening with pencil light illumination can be incorrectly accepted as sufficient by GPs and paediatricians. In Denmark, a study was performed with pencil light screening of 5-week-old infants between 2008 and 2012; however, the screening did not change the age at detection compared with no screening (23). In our study, six of 21 newborns with abnormal red reflex were not detectable with pencil light illumination. Among 6 cases of congenital cataract, only 2 were visible with pencil light. GPs and paediatricians should be informed that pencil light screening can never replace red reflex examination with an ophthalmoscope. In Asia and Northern Africa, consanguinity is a widely held custom with a rate varying between 20 and 55% (3,24). Conversely, in North America and Western Europe, the rate of first-cousin marriage is 0.5% and continues to decline (25). In Turkey, consanguinity is also common, with an overall rate of 21.2%, but the rate changes according to geographical region (26,27). In our study, the rate of parental consanguineous marriage among newborns with red reflex abnormality was 70.6%, compared with 29.4% among newborns with normal red reflex. Consanguinity increases the probability of union of two identical recessive gene mutations that are both inherited from a common ancestor (28,29). A review from the Middle East shows potential recessive genetic causes of common paediatric ocular conditions (6). Furthermore, it is known that up to one third of cataracts are inherited (7–9). Therefore, higher rates of consanguinity make the red reflex screening test even more important in Turkey, the Middle East, Asia and Africa. First cousins marry at younger ages and they tend to have a higher mean number of pregnancies than Table 1. Distribution of ocular diseases diagnosed in newborns with abnormal red reflex Ocular diseases RIU NICS Corneal opacity 1 bilateral, 2 unilateral (0.38%) 2 bilateral, 2 unilateral (0.71%) Cataract 2 bilateral (0.25%) 3 bilateral (0.53%) Coloboma 1 unilateral (0.13%) 1 bilateral (0.17%) Cataract and coloboma — 1 unilateral (0.17%) Corneal opacity and microphthalmia — 1 bilateral (0.17%) Corneal opacity and buphthalmos — 1 bilateral (0.17%) Retinal detachment — 1 bilateral (0.17%) Retinitis and microphthalmia — 1 bilateral (0.17%) Intravitreal haemorrhage 1 unilateral (0.13%) — Anophthalmia — 1 bilateral (0.17%) Table 2 Association between red reflex results and marriage type Marriage type Abnormal red reflex test Normal red reflex test Consanguineous marriage 15 393 Unrelated marriage 6 944 EMHJ – Vol. 24 No. 7 – 2018Research article 634 Associations entre anomalies du reflet rétinien, consanguinité et hospitalisation en soins intensifs des nouveau-nés en Turquie Résumé Contexte : Le reflet rétinien est l’examen principal permettant de détecter les affections oculaires dangereuses pour la vue et potentiellement mortelles ; pourtant, il ne reçoit pas l’attention voulue. Objectif : Évaluer le reflet rétinien chez les nourrissons, le pourcentage de pathologies oculaires conduisant à des anomalies du reflet rétinien et leur relation avec la consanguinité dans la région du sud-est de la Turquie. Méthodes : Des nouveau-nés (n = 1358) ont été examinés à la lampe-stylo et par ophtalmoscopie directe. Résultats : Parmi eux, huit cents étaient hospitalisés en pouponnière et 558 se trouvaient en unité de soins intensifs néonatals. Sept (0,88 %) nouveau-nés en pouponnière avaient une anomalie du reflet rétinien contre 14 (2,51 %) à l’unité de soins intensifs néonatals. La sensibilité à l’examen par lampe-stylo était de 71,4 %. Des études issues du Moyen-Orient ont démontré l’existence potentielle de causes génétiques récessives à l’origine de pathologies oculaires pédiatriques courantes. Notre étude a révélé que le mariage consanguin était associé de façon significative à des anomalies du reflet rétinien (p = 0,017). Conclusion : L’examen du reflet rétinien est important dans le cadre du diagnostic précoce de troubles oculaires dangereux pour la vue et potentiellement mortels dans le sud-est de la Turquie, où la consanguinité est courante. في ىفشتسلما في ةزكرلما ةياعرلا في ةدلاولا يثيدح لاخدإو براقلأا جاوزو يعيبطلا يرغ رحملأا سكعنلما ينب طابترلاا ايكرت اكاك ناسحإ ،ليسكوي نوراه ،ميردلي فسوي ،كاسلاب ينتاهلس ،تروكزوأ بنيز ةصلالخا ىقلي لا رابتخا هنكلو ،ةايلحا ددتهو ةيؤرلا ةملاس ددته دق نويعلاب تلااح نع فشكلل ليولأا رابتخلاا وه رحملأا سكعنلما نع يرحتلا نإ :ةيفللخا .مماتهلاا جاوزب كلذ ةقلاعو ،يعيبطلا يرغ رحملأا سكعنلما لىإ يدؤت يتلا ينعلا ضارملأ ةيوئلما ةبسنلاو ،ةدلاولا يثيدح ىدل رحملأا سكعنلما مييقت :فدلها .ايكرت قشر بونج في براقلأا .شرابلما ينعلا يرظنتبو يعبصأ حابصم نم ثعبنلما ءوضلا مادختساب ةدلاولا ثيدح 1358 نوثحابلا صحف :ثحبلا قرط ةياعرلا ةدحو في ةدلاولا ثيدح 558و ىفشتسلما في )ّمُلأا َعَم ةدلاولا ثيدح ُءاقِْبإ( ةَنَكاَسُلما ةدحو لىإ ةدلاولا ثيدح 800 لاخدإ مت :جئاتنلا ةزكرلما ةياعرلا ةدحو فيو ،يعيبط يرغ رحملأا سكعنلما ميهدل )٪0.88( ةدلاولا ثيدح 7 كانه ناك ةَنَكاَسُلما ةدحو فيو ،ةدلاولا يثيدلح ةزكرلما نم تاساردلا ترهظأ دقو .٪71.4 يعبصلأا حابصلماب ءوضلا صحف ةيساسح تناك )٪2.51( ةدلاولا ثيدح 14 كانه ناك ةدلاولا يثيدلح ًايئاصحإ هب ُّدَتْعُي طابترا دوجو حضتا ةساردلا هذه فيو .لافطلأا ىدل ةعئاش نويعلاب تلاالح ةلمتحلما ةيحنتلما ةيثارولا بابسلأا طسولأا قشرلا .)0.017 = P( ناكو يعيبطلا يرغ رحملأا سكعنلما ينبو براقلأا جاوز ينب عيشي ثيح ايكرت قشر بونج في ةايلحاو صربلا د ِّدته يتلا ينعلا تابارطضلا ركبلما صيخشتلا في مهم رحملأا سكعنلما صحف رابتخا :جاتنتسلاا .براقلأا جاوز unrelated spouses have (30). In our study, related spouses had a significantly higher mean number of children than unrelated spouses had, which carries an extra risk of ocular genetic diseases. Such cultural features in Turkey contribute to the added importance of the red reflex screening test. The main limitation of our study was the small number of newborns examined for calculating the incidence of common ocular disorders resulting in red reflex abnormality. In Turkey, consanguinity rate changes widely according to geographical region, so screening newborns in only 1 region of the country limits the generalization of our results to the rest of the country. Conclusion In conclusion, the red reflex screening test is important in the early diagnosis of vision- and life-threatening eye disorders. Congenital cataracts and retinoblastomas are not detected by GPs and paediatricians. 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Hum Hered. 2014;77(1-4):16–25. https://doi.org/10.1159/000358403 PMID:25060266 Research article 637 EMHJ – Vol. 24 No. 7 – 2018 Women’s sexual and reproductive health care needs assessment: an Iranian perspective Soghra Khani,1 Lida Moghaddam-Banaem,1 Eesa Mohamadi,2 Abu Ali Vedadhir 3 and Ebrahim Hajizadeh 4 1Department of Midwifery and Reproductive Health; 2Department of Nursing; 4Department of Statistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Islamic Republic of Iran (Correspondence to: Lida Moghaddam-Banaem: moghaddamb@modares.ac.ir). 3Department of Anthropology, Faculty of Social Sciences, University of Tehran, Tehran, Islamic Republic of Iran. Introduction According to article 25 of the Universal Declaration of Human Rights (1948), health is considered a right of humans (1). All people have the right to have access to adequate information and services regarding sexual and reproductive health (SRH) care (2). The provision of SRH care for all has been repeatedly identified as a requirement to achieve the Millennium Development Goals (3). Improving SRH in society contributes to a reduction in poverty and the achievement of other development goals (4). Sexual and reproductive health comprises a wide variety of dimensions such as safe motherhood, family planning, HIV/AIDS and other sexually transmitted infections (STIs) as well as domestic violence (5). If there is any problem in providing or receiving health care services in each of the above-mentioned dimensions, women’s SRH needs will be endangered (6). Access to reproductive health care services influences global welfare and security through the acceleration of demographic transition and the shift from short life expectancy and large families to long life expectancy and small families (1). In 2010, 287 000 women worldwide died owing to complications of pregnancy (7). It’s worth noting that from 1990 to 2015, less than 50% of deliveries in low-income countries were attended by a skilled health care provider (8). Also, 12% of women aged 15–49 years who were married or in a sexual relationship wanted to avoid pregnancy, but had no access to, or could not use, effective contraception methods (9). Only about 56% of pregnant women received the recommended minimum 4 sessions of antenatal care (10). According to international law, SRH is a human right and plays an important role in morbidity, mortality and life expectancy, however, reproductive health problems are a leading cause of women’s ill health and mortality worldwide (11), therefore, it is necessary to meet women’s SRH care needs. Despite the impressive success in health care promotion in the Iranian health care system, Iranian women are still in need of receiving sexual health care and appropriate HIV/AIDS services (12). The main aspects of SRH, including gender, sexuality, reproduction and sexual relationships, should be investigated. given the cultural diversity in human societies (13). There is a lack of studies on the SRH needs of Iranian women; existing studies are limited to a few surveys conducted in specific or convenience groups such Abstract Background: Reproductive health problems are a leading cause of women’s ill health and mortality worldwide. There is a need to investigate sexual and reproductive health care needs in different societies and cultural contexts. Despite the success in health care promotion in the Iranian health care system, women still need to receive sexual health care and appropriate HIV/AIDS services. However, studies on the sexual and reproductive health care needs of Iranian women are lacking. Aims: This study aimed to investigate the sexual and reproductive health care needs of women referred to health care centres in an urban area of the Islamic Republic of Iran. Methods: We carried out a cross-sectional study in 2013 on 514 women living in an urban area in the north of the Islamic Republic of Iran. Taking into consideration ethical principles, data were collected using the Sexual and Reproductive Health Care Needs Assessment Questionnaire. Results: The findings showed a greater need for the provision of care by practitioners in the sexual history and activities domain (73%) compared with other domains. Also, the woman’s age and the location where she sought treatment and care for sexually transmitted infections were predictors of sexual activities needs. Conclusions: Owing to the high prevalence of women’s referral to health care centres seeking treatment of sexual disorders, there is a need for the provision of sexual counseling centres and services promoting women’s reproductive health care. Keywords: Iran, reproductive health, sexual health, needs assessment Citation: Khani S; Moghaddam-Banaem L; Mohamadi E; Vedadhir AA; Hajizadeh E. Women’s sexual and reproductive health care needs assessment: an Iranian perspective. East Mediterr Health J. 2018;24(7):637–643. https://doi.org/10.26719/2018.24.7.637 Received: 08/11/15; accepted: 28/05/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). EMHJ – Vol. 24 No. 7 – 2018Research article 638 as adolescents (14), students (15), HIV-positive patients (16) and couples (17). To the best of our knowledge, there are no studies regarding SRH needs assessment of women referred to health care centres in the Islamic Republic of Iran. Therefore, the aim of this study was to investigate the sexual and reproductive health care needs of women referred to health care centres in an urban area of the Islamic Republic of Iran. Our findings will help health care professionals understand women’s health care needs and devise strategies for meeting these needs. Methods This cross-sectional study was conducted from February to July 2013. The sample included 514 women referred to health care centres in an urban area located in the north of the Islamic Republic of Iran. The following inclusion criteria were used: being a native Iranian, speaking Farsi and being in the reproductive age (15–49 years). Before the initiation of this study, an associate midwife provided the participants with all necessary information about their rights, the study method and data collection. Those who agreed to participate were asked to sign an informed consent form. In cases where the participant was illiterate, verbal informed consent was obtained. The study research proposal was approved by the ethics committee affiliated with Tarbiat Modares University. To determine the sample size, a pilot study was conducted in which a sample of 50 women referred to health care centres in the study zone were asked to complete a questionnaire. It was found that 70% (P = 0.7) of the samples declared the need for SHR care. Accordingly, the sample size was calculated using the following formula: n = [Z21–α/2 × p (1–p)]/d2 n = [(1.96)2 × (0.70 × 0.30)]/(0.04)2 = 504 Taking into consideration possible losses, the number of participants was determined as 514. A multistage sampling method was used. A list of 20 health care centres was provided from three municipality districts in Sari, in the north of the country. Next, 12 centres were randomly selected using a random numbers table, four from each district. The number of women referred to each health care centre was identified. Taking into account the estimated sample size, 514 women were selected using the random numbers table. After obtaining written informed consent, those who met the inclusion criteria were interviewed by the centre midwife staff who were trusted by the participants. To gather the data, the Sexual and Reproductive Health (SRH) Needs Assessment Questionnaire was used (18). This special tool, devised by the UNFPA, was selected because it covers the needs in various domains of reproductive health. The self-administered questionnaire comprised 114 items in seven domains: background data, safe motherhood morbidity profile and hygiene practices, family planning, sexual history and activities, STIs, HIV/ AIDS, and sexual- and gender-based violence. The Farsi version of the questionnaire was validated previously by Iranian researchers (19). To choose the most common SRH needs, 2 panels of experts comprising the research team members, a health education specialist and a reproductive health specialist were invited to discuss women’s needs in each domain and in total by assigning a score of 1 or 2 to each item. For instance, if a woman had inappropriate health care, she was considered to have a need for care and was given a score of 2, and if the woman had ideal health care status, a score of 1 was given. Where an item had multiple options, it was decided that if the woman chose > 2 options, a score of 2 was given and if the woman selected ≤ 2 options, a score of 1 was allocated. Therefore, according to the scores, a dichotomous option was created: “having the need” and “having no need” (20). The sum of the scores for each domain was computed. The 50th percentiles (cut- off point) of the sum of the scores were calculated and women who scored more than the cut-off points were recognized as having a need. Lastly, the frequency of the women’s responses for each domain was calculated. Regarding an item in the Iranian version of the questionnaire, it should be noted that in Iranian society, temporary marriage is defined and approved according to Article 1075, 1936, of the Iranian civil law. In the case of divorce or expiration of the marriage contract, the woman is allowed to marry again after three menstrual periods to ensure she is not pregnant by the previous partner. We used SPSS, version 21, to analyse data. Frequency measures, independent sample t-test, chi-squared and logistic regression were the main statistical tests used for data analysis. P-values < 0.05 were considered statistically significant. Results Demographic characteristics The mean age of the participants was 31.6 [standard deviation (SD) = 7] years. The mean age at marriage of the women and their husbands was 19.8 (SD = 5) years and 34.8 (SD = 8) years, respectively. The education level of 41.7% of the women and 39.9% of their husbands was secondary high school and diploma, respectively. More details regarding demographic characteristics are provided in Table 1. Sexual and reproductive health needs According to the scores given to the women, the majority were recognized as having needs in all SRH domains (Table 2). Women’s needs in the sexual history and activities domain (375 women, 73%) were greater than in other SRH domains. Seventy-two women (14.3%) began their sexual activities before age 18 years (Table 3). Additionally, 13 women (2.6%) had the experience of temporary marriage with more than 1 sexual partner in a year, and the majority (11 women) did not consistently use condoms in their sexual relationships. Nine women (1.8%) suspected their husbands were having a sexual relationship with others. Research article 639 EMHJ – Vol. 24 No. 7 – 2018 The t-test and chi-squared tests showed that age (P = 0.03), place where STI treatment was sought (P = 0.001), current pregnancy (P = 0.005), history of unwanted pregnancy (P = 0.002), and history of sexual coercion (P = 0.005) were associated with women’s need in the sexual activities’ domain. The variables with 0.05 < P < 0.2 were history of beating (P = 0.1), marriage age (P = 0.1), education level (P = 0.1) and employment status (P = 0.1). All these variables (P < 0.2) were entered in the logistic regression analysis. Factors related to the women’s sexual activities needs were: age (P = 0.002), place where STI treatment was sought (P = 0.014) and sexual coercion (P = 0.003) (Table 4). Discussion The majority of the participants asserted a need for SRH care in all domains. The women’s needs in the domain of sexual history and activities were greater than in other domains. In a study in Sari, the most common SRH need of women who were referred to the health care centres was caesarean surgery (21). According to that study, the definition of the most common SRH need was based on the frequency of the item regardless of SRH domain. However, in our study we defined SRH needs based on the score given by the women and the 50th percentile of the dichotomous need items in each domain. The high prevalence for women’s needs in the sexual activities domain indicated that the women were comfortable in expressing their sexual needs. Another reason was that women sought equality with men, especially in terms of sexual rights (22). Age, education level and marriage age had a significant statistical relationship with the women’s sexual activities needs. According to a report to the Sixty-Fifth World Health Assembly, the latest international estimates indicated that more than 60 million women aged 20–24 years worldwide were married before age 18 years (23). Older age and higher education level are the protective factors for marriage and pregnancy in early adolescence (24). Although the prevalence of having Table 1 Sociodemographic characteristics of participants (n = 514) Characteristic Value Mean SD Age (years) 31.6 7.5 Age at marriage (years) 20.9 4.0 Husband’s age (years) 34.8 8.0 No. % Education level Below high school 124 24.3 High school diploma 213 41.7 Academic degree 174 34.1 Education level of the husband Below high school 140 28.4 High school diploma 205 41.6 Academic degree 148 30.0 Family breadwinner Participant 14 2.8 Husband 461 91.5 Other 29 5.8 SD = standard deviation. Table 2 Distribution of women with sexual and reproductive health needs in six domains (n = 514) Domain More than 50th percentile Less than 50th percentile No. % No. % Safe motherhood 268 52.1 246 47.9 Family planning 310 60.3 59 68.6 Sexual history and activities 375 73.0 139 27.0 Sexually transmitted infections 282 54.9 232 45.1 HIV/AIDs 274 53.3 240 46.7 Violence 263 51.2 251 48.8 Total 254 49.4 260 50.6 Table 3 Distribution of participants’ characteristics in the sexual history and activities domain (n = 514) Variable No. % Age of starting sexual relationship (years) < 18 72 14.3 ≥ 18 442 85.7 Suspicion of husband sexual relationship with others No 439 85.4 Yes 9 1.8 Don’t know 66 12.8 Temporary marriage No 489 95.2 Yes 13 2.5 Missing 12 2.3 Continuous use of condoms (n = 13) No 11 78.6 Yes 2 21.4 Table 4 The factors influencing the women’s needs in the sexual history and activities domain (n = 514)) Factor OR 95% CI P-value Age 1.21 1.4–1.07 0.002 Location where STI treatment was sought 2.50 1.7–8.11 0.014 Sexual coercion 3.50 1.05–11.8 0.03 OR = odds ratio; CI = confidence interval; STI = sexually transmitted infection. EMHJ – Vol. 24 No. 7 – 2018Research article 640 multiple sexual partners was very low [13 women (2.6%) experienced temporary marriage], the majority did not consistently use condoms in their sexual relationships. This behaviour influences the prevalence of STIs and may increase the prevalence of HIV/AIDS. Many of these women stated that their husbands preferred not to use condoms. In a study in South Africa, it was demonstrated that practical issues, such as financial constraints, were barriers to condom use (25); sex workers avoided condom use due to negative symbolism. Thus, the more they were exposed to risk of STIs and AIDS, the less they used condoms. A recent systematic review found a high prevalence of HIV among female sex workers (26). Fritz et al. showed that interventions focused on men and couples were necessary along with incentives to encourage men to participate in STI prevention programmes (27). Expanding condom use promotion programmes among couples may be an effective strategy for couples wishing to practice contraception (28). Our results indicate there is a relationship between a woman’s age and sexual activities needs domains. With older age, the need for sexual activities is lower. In a Canadian study, 34.4% of Inuit people used condoms in their sexual relationships, and this was more common in younger people (15–19 years) compared with those aged ≥ 30 years (29). There is a considerable diversity in the results of different studies, because sexual behaviours vary with age, marital or cohabiting status, education and ethnicity (30). In our study, 134 women (26%) experienced sexual coercion and 94.8% of perpetrators were their husbands/ partners. The reported prevalence is lower than the prevalence of sexual violence, partner or non-partner, in the Eastern Mediterranean Region (36.4%) and globally (35%) (31). The relatively high prevalence of this type of violence could be due to the cultural differences in various communities, so between 0.3 and 11.5% of women experience sexual violence by a non-partner after age 15 years (32). Although, it seems that our definition of SRH needs (above the 50th percentile) is likely to overestimate needs, the results are sufficient to illustrate that women referred to the health care centres do not have much access to appropriate SRH services. Our instrument was too lengthy to assess the women’s SRH needs. Therefore, the researchers tried to incorporate the interviewer method, establish and promote a friendly atmosphere during the interviews, and provide a break with some refreshments in the middle of the sessions to prevent the participants from getting tired. The research-based findings can assist policy- makers and health care managers of SRH programmes in distributing the required resources and providing facilities and planning for educational and counselling programmes based on the most common SRH needs of women. Further studies are suggested to assess each domain of SRH needs separately. Although men are usually ignored in SRH research, their role is critical in women’s general and sexual health. Thus, future studies need to assess the SRH needs of men. One of the main limitations of this study was its descriptive design so that the relationships between the variables could not represent the causal relationships. Using logistic regression, the effects of confounder variables on the outcome variables were minimized. The sensitivity of some questions and an increased risk of nonresponse or false response by the women could be considered a limitation of this study. In this respect, we assured the women of the confidentiality of the collected data. In addition, before asking the participants to answer sensitive questions, to break the ice, they were asked some introductory questions, e.g. before asking about number of sexual partners (temporary marriage) in a year, they were asked, “Do women or girls with more than one temporary marriage in a year live in your neighbourhood?” Acknowledgements We would like to thank Dr Victoria James and the NEDICO team who kindly allowed us to translate and use the SRH questionnaire. Funding: This study was part of the first author’s PhD research project in reproductive health, supported financially by the Faculty of Medical Sciences, Tarbiat Modares University, Tehran. Competing interests: None declared. Research article 641 EMHJ – Vol. 24 No. 7 – 2018 Évaluation des besoins des femmes en matière de soins de santé sexuelle et génésique : perspective iranienne Résumé Contexte : Les problèmes de santé génésique comptent parmi les principales causes de mauvaise santé et de mortalité féminine dans le monde. Une évaluation des besoins en matière de soins de santé sexuelle et génésique doit être effectuée dans différentes sociétés et divers contextes culturels. Malgré les succès obtenus dans la promotion des soins de santé au sein du système de santé iranien, les femmes ont encore besoin de bénéficier de soins de santé sexuelle et de traitement du VIH/sida appropriés. Cependant, les études portant sur les besoins des femmes iraniennes en matière de soins de santé sexuelle et génésique sont insuffisantes. Objectif : La présente étude avait pour objet d’examiner les besoins en soins de santé sexuelle et génésique chez des femmes ayant été orientées vers des centres de soins dans une zone urbaine de République islamique d’Iran. Méthodes : En 2013, nous avons réalisé une étude transversale portant sur 514 femmes demeurant dans une zone urbaine située dans le nord de la République islamique d’Iran. Les données ont été recueillies dans le respect des principes éthiques et à l’aide du Questionnaire d’évaluation des besoins en soins de santé sexuelle et génésique. Résultats : Les résultats ont démontré que les médecins devaient prodiguer davantage de soins et de conseils dans le domaine des antécédents sexuels et des activités sexuelles (73 %) que dans d’autres domaines. En outre, l’âge de la femme et le lieu où elle avait demandé à recevoir un traitement et des soins suite à une infection sexuellement transmissible constituaient des facteurs prédictifs des besoins de traitement associés aux activités sexuelles. Conclusion : La forte prévalence de femmes dirigées vers des centres de soins en vue d’obtenir des traitements contre des affections sexuelles indique la nécessité de mettre en place des centres et des services de conseil en santé sexuelle pour promouvoir les soins de santé génésique de la femme. ةيملاسلإا ناريإ ةيروهجم نم رظن ةهجو :ةأرملل ةيباجنلإاو ةيسنلجا ةحصلا ةياعر تاجايتحا مييقت هدازيجاح ميهاربإ ،يرهظاديف ليع وبأ ،يدممح ىسيع ،مئانب-مدقم اديل ،نياخ ىرغص ةصلالخا ةياعرلا تاجايتحا ةساردل ةجالحا ّستمو .لماعلا ءاحنأ عيجم في اتهومو ةأرلما ةحص للاتعا بابسأ ةعيلط في ةيباجنلإا ةحصلا لكاشم تيأت :ةيفللخا ةياعرلا ماظن في ةيحصلا ةياعرلا زيزعت في زَرْحُلما حاجنلا نم مغرلا لىعو .ةيفاقثلا تاقايسلاو تاعمتجلما فلتمخ في ةيباجنلإاو ةيسنلجا ةيحصلا كلذل ّستمو .زديلإا/ةيشربلا ةعانلما صقن سويرفل ةمئلالما تامدلخاو ةيسنلجا ةيحصلا ةياعرلا يقلت لىإ ةجاحب ءاسنلا لازت لا ،نياريلإا ةيحصلا .تايناريلإا ءاسنلل ةيباجنلإاو ةيسنلجا ةيحصلا ةياعرلا تاجايتحا لوح تاسارد لىإ ةجالحا ناريإ ةيروهجم في ةيضرح ةقطنم في ةيحصلا ةياعرلا زكارم لىإ تلااحلما ءاسنلل ةيباجنلإاو ةيسنلجا ةيحصلا ةياعرلا تاجايتحا ةسارد :فادهلأا .ةيملاسلإا تانايبلا انعمجف ،ةيملاسلإا ناريإ ةيروهجم لماش في ةيضرح ةقطنم في شيعت ةأرما 514 لىع 2013 ماع في ةيعطقم ةسارد انيرجأ :ثحبلا قرط .ةيقلاخلأا ئدابلما رابتعلاا في ذخلأا عم ةيباجنلإاو ةيسنلجا ةياعرلا تاجايتحا مييقت نايبتسا مادختساب نهنم عم ةنراقم )٪73( ةيسنلجا ةطشنلأاو ضيرلما خيراتلا ذخأ تلاامج في ةياعرلل ينسرمالما ءابطلأا ميدقتل بركأ ةجاح دوجو جئاتنلا ترهظأ :جئاتنلا تاجايتحا نع تائبنلما نم تناك ًايسنج ةلوقنلما ضارملأاب ةصالخا ةياعرلاو جلاعلا هيف تبلط يذلا عقولماو ةأرلما رمع نأ ماك .ىرخلأا تلااجلما .ةيسنلجا ةطشنلأا لىإ ةسام ةجالحا نإف ،ةيحصلا ةياعرلا زكارم لىإ ةيسنلجا تابارطضلال جلاع نع نثحبي تيلالا ءاسنلا ةلاحإ راشتنا لدعم عافترلا ًارظن :جاتنتسلاا .ةأرملل ةيباجنلإا ةيحصلا ةياعرلا زيزعتل ةيسنلجا ةروشلما ميدقتل تامدخو زكارم يرفوت References 1. 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Introduction Women can face many challenges in relation to their reproductive health, including abortion, maternal mortality, poor availability of information and family planning services, and sexually transmitted infections (1). Induced abortion is one of the traditional methods of birth control and its prevalence can be used as an indicator for unmet maternal reproductive needs (2,3). Even where family planning methods are available, a woman may not use them because of financial constraints, personal beliefs, opposition from family members, or concerns about the perceived adverse effects on health or future fertility (4). Induced abortion is defined as the intentional termination of a pregnancy before the fetus can live independently. It may be elective (based on a woman’s personal choice) or therapeutic (to preserve the health or save the life of a pregnant woman). It may also be unsafe. The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating a pregnancy that is performed by an individual lacking the necessary skills, or in an environment that does not conform to minimal medical standards, or both (5). Little is known about the use of induced abortion by married women in Iraq. The present study therefore aimed to determine whether induced abortion is used as a method of birth control among mothers in Mosul, northern Iraq and the sociodemographic and family factors associated with such behaviour. Methods Study design A cross-sectional design was used. Sample size and selection The required sample size (n) was estimated by the Daniel equation (6): n = [{Z(1–α)2 × pq/d2}×2] + 5%, where: α = 0.05, Z =1.96, p (proportion of married women of child- bearing age) = 14% (7), q = 0.86; d = 0.03; design effect = 2 (8) and contingency error = 5% (6). Therefore, the minimum sample size required for the study with 95% confidence interval and 0.03 width, was 1231 married women of child-bearing age (15–49 years). We interviewed 1302 women. Distribution of the estimated sample was weighted taking into consideration the population size and proportion of married women of child-bearing age in each catchment area (14% of the total population) (see Appendix available online). A multistage stratified sampling method was used. Abstract Background: Induced abortion is a traditional method of birth control and it can indicate unmet maternal reproductive needs. Little is known about the use of induced abortion by married women in Iraq. Aims: This cross-sectional study aimed to explore whether induced abortion is used for birth control by married women in Mosul, and to determine the sociodemographic and family characteristics associated with its use. Methods: Multistage stratified sampling was used to recruit 1302 married women of child-bearing age (15–49 years) attending primary health care centres in Mosul. Women were interviewed using a validated questionnaire between April 2011 and 31 January 2012. Data collected included: use of induced abortion and method, social and family background, and contraceptive use. The χ2-test was used to assess the association of sociodemographic and cultural factors with the induced abortion. Results: Of the 1302 women, 13.5% had tried to induce an abortion at some time, by undertaking heavy physical activities (66.2%) or using of herbal remedies (22.2%) or pharmacological preparations (17.6%). The prevalence of reported induced abortion was significantly lower among women using contraceptives, older women, those with a higher education, working women, suburban and rural residents, those living in extended families, and women in consanguineous marriages and non-polygynous marriages (P < 0.05). Conclusions: Over 10% of the married women had induced abortion to control births. Health education is recommended to encourage contraceptive use. Keywords: Abortion, induced; prevalence, birth control, Iraq Citation: Al-Ridhwany H; Aljawadi A; Abduljawad M. Use of induced abortion for birth control by mothers in Iraq. East Mediterr Health J. 2018;24(7):644–652. https://doi.org/10.26719/2018.24.7.644 Received: 15/08/16; accepted: 11/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Research article 645 EMHJ – Vol. 24 No. 7 – 2018 For the purposes of this research, Mosul was divided into four areas: north-east, north-west, south-east and south-west. Each area was stratified into 3 social strata (urban, suburban and rural) according to their closeness to the city centre of Mosul. Then, 20 primary health care centres (PHCCs)—70% of all health centres in Mosul— were non-randomly selected according to population size and proportion of women of child-bearing age (15– 49 years) in each catchment area (7) (Figure 1). Finally, a convenience sample of eligible women was selected. Women were approached on entry to the examination room, and eligible mothers who consented to be included in the study were interviewed. The inclusion criteria were: currently married, woman of child-bearing age (15– 49 years) and attending one of the selected health centres. A specially designed interview questionnaire was developed which enquired about: experience of induced abortion as a means of birth control, and sociodemographic and family characteristics. The questionnaire was validated using the Angoff method (9). We recruited 11 experts to judge the coverage, clarity and reality of the questionnaire. They assessed its validity in the 3 areas as 85.0%, 85.5% and 80.9% respectively. To assess the questionnaire reliability, a pilot study was conducted in Al-Arabi health centre, one of the selected centres, among 20 women who met the inclusion criteria; they were chosen consecutively during their visits to the antenatal care unit within the centre: reliability was 87.2%, and intra-observer and inter-observer variation were 86.8% and 82.9% respectively. Data collection It took 10 months (1 April 2011 — 31 January 2012) to collect all the required data. The biggest problem in collecting the data was asking the women about their sociodemographic characteristics, especially the young women, mainly because of the volatile security situation in Mosul. People in Mosul have witnessed many criminal events since 2003 (killings, kidnappings and blackmail) which were still occurring during the study period. Thus, people are very apprehensive about talking with strangers, particualrly about address, husband’s occupation, economic status, children, and many other personal details. Revealing such information is considered risky and might threaten the whole family. Wives, who have the weakest position in the family, are more likely to be blamed for any leaked information. As a result, the mothers were very cautious at the beginning of the interview. However, this problem was solved by good communication and explaining the aim of the study. Mothers were allowed first to talk freely about their pregnancies and children. Then, they answered the open-ended questions on the questionnaire and lastly, when they felt safe, they started to discuss their sociodemographic backgrounds. All the required data, including husband’s characteristics, were obtained by interviewing the eligible mothers. Husband’s occupation was considered an important item because it can determine the social class of the family according to the general occupational classification in England and Wales, as described by Al-Youzbaki (10). Statistical analysis The study aimed to determine the prevalence of induced abortion as a means of birth control within the studied sample. The association of some sociodemographic and cultural factors with the induced abortion was examined using the chi-squared test. A P-value ≤ 0.05 was considered statistically significant. Odds ratios (OR) and 95% confidence intervals (CI) were calculated (6). Ethical considerations The study received ethical approval from the Nineveh Health Directorate in Mosul. The purpose of the study Figure 1 Map of Mosul city, northern Iraq, showing the geographical division of the city by the Tigris River and Nineveh Street into 4 quarters and the distribution of the 20 primary health care centres (red stars) included EMHJ – Vol. 24 No. 7 – 2018Research article 646 was explained to the women and their verbal consent was obtained before the interviews. It was made clear to them that they did not have to participate and they could withdraw at any time, and that this would not affect their care at the health centre. Results A total of 1 302 mothers who met the inclusion criteria were interviewed; only 2 women declined to participate. The mean age and standard deviation (SD) of the sample was 30.0 (SD 7.7) years; 7.4% were teenagers. The majority of the women (70.3%) were 20–39 years old and 12.3% were older. More than half of the women (52.4%) were urban residents. Most of the women (93.9%) were Muslims, and 83.7% were Arabs, 7.3% Kurds, 4.8% Turkmen and 4.1% Shabaks. Almost half of the women (48.8%) were illiterate. Of the 1302 women, 176 (13.5%) had induced an abortion at some time in their reproductive life: 106 (60.2%) had done so by undertaking heavy physical activities, 39 (22.2%) had used herbal remedies and 31 (17.6%) had used pharmacological preparations. The association of different sociodemographic characteristics with induced abortion is shown in Table 1. The reported prevalence of induced abortion was significantly lower in Muslim women than Christian (12.6% versus 27.8%) (OR 0.4, 95% CI: 0.2–0.6, P < 0.001). The prevalence of induced abortion was about 2 to 3 times higher in Arab women (15.0%) than Kurds and Turkmen (4.2% and 7.9% respectively) (OR 0.3, 95% CI: 0.1– 0.8, P = 0.006 and OR 0.4, 95% CI: 0.1–0.9, P = 0.02). More urban women (19.6%) had tried inducing an abortion than suburban and rural women (6.8%) (OR 3.4, 95% CI: 2.3–4.8, P < 0.001), but fewer urbanized mothers (those who had moved from rural areas to urban settings in the past 10 years) had tried to induce an abortion (OR 0.5, 95% CI: 0.3–0.9, P = 0.02). Significantly more mothers with unemployed husbands had tried to induce abortion (20.5%) than mothers with employed husbands (OR 1.8, 95% CI: 1.0–2.9, P = 0.02). Among the latter, the lowest prevalence (10.9%) was reported by mothers whose husbands had partly skilled/unskilled occupations (OR 0.7, 95% CI: 0.5–0.9, P = 0.02). Table 2 shows prevalence of induced abortion according to family characteristics. The reported prevalence of induced abortion was significantly higher among women living in a nuclear family (18.7%) than those living in an extended family (9.9%) (OR 2.1, 95% CI: 1.5–2.9, P < 0.001), and in women living in polygynous families (marriage of a man to more than one woman at a time) Table 1 Association of induced abortion with sociodemographic characteristics Sociodemographic characteristics Induced abortion Total (n = 1302) OR (95% CI)a P-value Yes (n = 176) No (n = 1126) No. (%) No. (%) No. (%) Religion Muslim 154 (12.6) 1069 (87.4) 1223 (93.9) 0.4 (0.2–0.6) < 0.001 Christian 22 (27.8) 57 (72.2) 79 (6.1) Ethnicity Arab 163 (15.0) 927 (85.0) 1090 (83.7) 2.7 (1.5–5.1) 0.001 Kurd 4 (4.2) 91 (95.8) 95 (7.3) 0.3 (0.1–0.8) 0.006 Turkmen 5 (7.9) 58 (92.1) 63 (4.9) 0.4 (0.1–0.9) 0.02 Shabak 4 (7.4) 50 (92.6) 54 (4.1) 0.5 (0.2–1.5) 0.2 Residence Urban 134 (19.6) 548 (80.4) 682 (52.4) 3.4 (2.3–4.8) < 0.001 Suburban and rural 42 (6.8) 578 (93.2) 620 (47.6) Urbanizationb Present 16 (8.2) 179 (91.8) 195 (15.0) 0.5 (0.3–0.9) 0.02 Absent 160 (14.5) 947 (85.5) 1107 (85.5) Social classc 1st and 2nd 6 (12.5) 42 (87.5) 48 (3.7) 0.9 (0.3–2.3) 0.8 3rd 91 (14.5) 537 (85.5) 628 (48.2) 1.2 (0.8–1.6) 0.3 4th and 5th 56 (10.9) 458 (89.1) 514 (39.5) 0.7 (0.5–0.9) 0.02 Unemployed 23 (20.5) 89 (79.5) 112 (8.6) 1.8 (1.0–2.9) 0.02 aFor ethnicity and social class ORs (95% CIs), each group was compared with the sum of the other 3 groups. bMoved from rural areas to an urban area in the past 10 years. cBased on husband’s occupation: 1st and 2nd = professional/semi-professional occupations; 3rd = non-manual skilled occupations; 4th and 5th = partly skilled/unskilled occupations. OR = odds ratio, CI = confidence interval. Research article 647 EMHJ – Vol. 24 No. 7 – 2018 (28.4% versus 12.6%) (OR 2.8, 95% CI: 1.7–4.4, P < 0.001). The prevalence of induced abortion was significantly lower in women in a consanguineous marriage (10.3% versus 19.6%) (OR 0.5, 95% CI: 0.3–0.7, P < 0.001). Table 3 shows the prevalence of induced abortion according to the woman’s and her husband’s characteristics. Mothers under 30 years of age were significantly more likely to have tried to induce an abortion (16.3%) than older women (10.8%0 (OR 1.6, 95% CI: 1.1–2.2, P = 0.004). Induced abortion was significantly less likely to be reported by mothers with less than 12 years of schooling (12.6% versus 27.7% of higher educated women) (OR 0.4, 95% CI: 0.2–0.6, P < 0.001) and housewives (12.1% versus 30.3% of working women) (OR 0.3, 95% CI: 0.2–0.5, P < 0.001). Moreover, contraceptives use significantly reduced the prevalence of induced abortion (6.9% versus 20.7% of non-users) (OR 0.3, 95% CI: 0.2–0.4, P < 0.001). Women whose husbands were under 30 years of age were significantly less likely to have tried to induce an abortion (5.6% versus 16.1% with older husbands) (OR 0.3, 95% CI: 0.2–0.4, P < 0.001). The age of the woman and her husband at marriage, the age of the woman at first pregnancy, and the husband’s education were not significantly associated with induced abortion. Discussion Obtaining information about the practice of induced abortion is challenging because of the culture of silence that surrounds the topic. According to the finding of our study, 13.5% of the mothers in Mosul had tried to induce abortion intentionally to control their births at some point in their reproductive life. The real prevalence of induced abortion in the community may be higher. The possibility of underestimation may be due to recall bias, which usually accompanies a cross-sectional study design. It may also be a result of non-differential misclassification which might be expected when researching such a sensitive issue in our setting: mothers might have answered the question about inducing an abortion by giving a socially acceptable but inaccurate reply. This type of bias tends towards the null hypothesis which can result in an underestimation of the true situation (11). Although induced abortion has been legal in the United States of America since 1973, it is not generally considered permissible by many religions and societies (12). Under the Iraqi general principles of criminal law, as stated in article 63 of the Penal Code (13), the abortion law explicitly prohibits the performance of abortions, but implies several exceptions in cases of necessity. Induced abortion is allowed in Iraq to preserve the life and health of the pregnant woman and for reasons of fetal abnormality. Iraqi law also allows abortion in cases of incest and rape. Islamic teachings encourage Muslims to reproduce and forbids fetal killing except when the pregnancy is proved to be a high risk to the pregnant woman. In such cases, induced abortion may be allowed (14). This may be the first time such a sensitive topic had been addressed in a study setting. As a result, there are no available data on the practice of induced abortion as a method birth control in Iraq. However, the estimated prevalence is almost 3 times that reported by a nationally representative survey in Syria in 2006 (15) which reported that 4% of married women ages 15–49 years had had at least one abortion; the authors noted that the figure was likely to be an underestimation because abortion is also banned in the country. Most of the induced abortions in the present study were attempted by heavy physical efforts and to a lesser extent by the use of some herbal and pharmaceutical substances. None of the women reported surgical intervention for terminating the pregnancy. However, this does not mean that surgical intervention did not occur and that unsafe abortion did not happen. However, this is against the law and the religion so it is unlikely any women would admit to this. Table 2 Association of induced abortion with family characteristics Family characteristic Induced abortion Total (n = 1302) OR (95% CI)a P-value Yes (n = 176) No (n = 1126) No. (%) No. (%) No. (%) Family structure Nuclear 101 (18.7) 440 (81.3) 541 (41.6) 2.1 (1.5–2.9) < 0.001 Extended 75 (9.9) 686 (90.1) 761 (58.4) Consanguineous marriage Yes 88 (10.3) 764 (89.7) 852 (65.4) 0.5 (0.3–0.7) < 0.001 No 88 (19.6) 362 (80.4) 450 (34.6) Polygyny Yes 27 (28.4) 68 (71.6) 95 (7.3) 2.8 (1.7–4.4) < 0.001 No 152 (12.6) 1055 (87.4) 1207 (92.7) OR = odds ratio, CI = confidence interval. EMHJ – Vol. 24 No. 7 – 2018Research article 648 According to the data published by the Population Reference Bureau (16), 1 in 4 pregnancies in the Middle East and North Africa region are unintended; they were either wanting to have a child later or not wanting any more children. Many women with unintended pregnancies resort to clandestine abortions that are not safe. The annual worldwide abortion rate in 2010–2014 was 35 per 1 000 women aged 15–44 years; 27 per 1 000 women in the developed regions and 37 per 1 000 women in the developing world (17). During 2010–2014, 45% of abortions were considered to be unsafe, with the Africa and Latin America having the higheset prevalence of insafe abortions (about 76% each) (18). Our study clearly shows that the lower the prevalence of contraceptive use, the higher the prevalence of induced abortion (P < 0.001). The prevalence of induced abortion as a birth control method was 20.7% among women who did not use contraceptives versus 6.9% among women who did. However, only just over half of the women were using a contraceptive method at the time of data collection. A cross-sectional study in Mosul in 2008 found that only 40.2% of mothers had their family planning needs met (women are said to have met their need for family planning when they use any method of contraception to delay or stop their next birth) (19). Yet, the same study reported that 20.2% of mothers were prohibited from using contraceptives and were described as having unmet needs. A later study in 2010 in Mosul Table 3 Association of induced abortion with personal characteristics of the woman and her husband Personal characteristics Induced abortion Total (n = 1302) OR (95% CI)a P-value Yes (n = 176 No (n = 1126) No. (%) No. (%) No. (%) Woman’s age (years) < 30 105 (16.3) 540 (83.7) 645 (49.5) 1.6 (1.1–2.2) 0.004 ≥ 30 71 (10.8) 586 (89.2) 657 (50.5) Woman’s education (years of schooling) < 12 153 (12.6) 1066 (87.4) 1219 (93.6) 0.4 (0.2–0.6) < 0.001 ≥ 12 23 (27.7) 60 (72.3) 83 (6.4) Woman’s occupation Housewife 146 (12.1) 1057 (87.9) 1203 (92.4) 0.3 (0.2–0.5) < 0.001 Working 30 (30.3) 69 (69.7) 99 (7.6) Woman’s age at marriage (years) < 20 103 (12.6) 713 (87.4) 816 (62.7) 0.8 (0.6–1.1) 0.2 ≥ 20 73 (15.0) 413 (85.0) 486 (37.3) Woman’s age at first pregnancy (years) < 20 100 (13.6) 635 (86.4) 735 (56.5) 1.0 (0.7–1.4) 0.9 ≥ 20 76 (13.4) 491 (86.6) 567 (43.5) Contraceptive use Yes 47 (6.9) 631 (93.1) 678 (52.1) 0.3 (0.2–0.4) < 0.001 No 129 (20.7) 495 (79.3) 624 (47.9) Husband’s age (years) < 30 18 (5.6) 302 (94.4) 320 (24.6) 0.3 (0.2–0.5) < 0.001 ≥ 30 158 (16.1) 824 (83.9) 982 (75.4) Husband’s age at marriage (years) < 25 73 (13.6) 464 (86.4) 537 (41.2) 1.0 (0.7–1.4) 0.9 ≥ 25 103 (13.5) 662 (86.5) 765 (58.8) Husband’s education (years of schooling) < 12 150 (14.4) 895 (85.6) 1045 (80.3) 1.3 (0.9–2.0) 0.2 ≥ 12 26 (10.1) 231 (89.9) 257 (19.7) OR = odds ratio; CI = confidence interval. Research article 649 EMHJ – Vol. 24 No. 7 – 2018 found a higher prevalence of contraceptive use (50.4%) among mothers of child-bearing age (20). However, both studies were based on health institutions. A community- based survey in Iraq in 2006 reported that 33% of married women at the national level were using a family planning method, but the percentage was lower in Nineveh governorate (21.8%) (21). In the Islamic Republic of Iran in 2008 the abortion rate was reported to be 0.26 abortions per married woman (22), but it varied between provinces. The authors stated that the Islamic Republic of Iran, as other areas all over the world, showed a negative correlation between the use of contraceptives and the abortion rate: a lower rate of abortion was reported in areas that had higher rates of contraceptive use. Similarly, data from Tunisia and Turkey (14,17) suggest that abortion rates have declined as family planning programmes have expanded. In Turkey, the rate of abortion dropped from 18% of pregnancies in 1993 to 11% in 2003. At the same time, the percentage of married women using modern contraception increased from 34% to 42% during that period (16). Limitations In order to achieve the aims of the present study, a cross-sectional study design was used. Among the many advantage of this design is that it is relatively quick, easy to perform and comparatively less expensive. It also useful for measuring a current event and so can be helpful in the planning required health services (11). Furthermore, a cross-sectional study design has a long tradition in sociology and forms the general methodology of sociological researches (10). However, no cross-sectional study is free of recall biases which may alter the conclusions of a study (11). In our study, the questionnaire used was constructed to minimize such bias. The other important problem with cross-sectional studies is selection bias. Nonetheless, we selected our sample from women attending health institutions; such participants are not only more accessible but also more cooperative with investigators than persons in the community, particularly in discussing such an issue. In addition, a similar sample is more often associated with selection bias (23). However, in our study, efforts were made to select a representative sample by using a multistage stratified sampling technique so as to include all social strata distributed in urban, periurban and rural settings. Conclusion Induced abortion is still used for controlling birth by 13.5% of mothers in Mosul. This was significantly negatively associated with contraceptive use; women who used contraceptives were less likely to have reported an induced abortion. Health education is recommended to highlight the risks of induced abortion and to encourage contraceptive use. Health information can be introduced within high-school curricula in line with the customs and religious teachings of the local community. In addition, appropriate human resources are needed to make family planning programmes more acceptable and accessible. Acknowledgements We would like to thank the Nineveh Health Directorate for allowing us to conduct this study. We also thank Mosul University, College of Medicine, Department of Family and Community Medicine for their support and advice. Finally, we especially thank the study participants for their willingness to take part in this study Funding: None. Competing interests: None declared. L’avortement provoqué en tant que méthode contraceptive des mères en Iraq Résumé Contexte : L’avortement provoqué est une pratique traditionnellement adoptée comme méthode contraceptive et il peut indiquer des besoins non satisfaits en matière de reproduction chez les mères. Le recours à l’avortement provoqué chez les femmes mariées en Iraq reste un sujet méconnu. Objectifs : La présente étude transversale avait pour objectif de rechercher si les femmes mariées résidant à Mossoul avaient recours à l’avortement provoqué en tant que méthode contraceptive et de déterminer les caractéristiques sociodémographiques et familiales liées à son utilisation. Méthodes : L’échantillonnage stratifié à plusieurs degrés a été utilisé pour recruter 1302 femmes mariées en âge de procréer (15-49 ans) qui consultaient dans des établissements de soins de santé primaires à Mossoul. Les femmes ont été interrogées entre le mois d’avril 2011 et le 31 janvier 2012 à l’aide d’un questionnaire validé. Les données recueillies comprenaient le recours à l’avortement provoqué et la méthode utilisée, le contexte social et familial et l’utilisation de contraceptifs. Le test du χ2 a été utilisé pour évaluer l’association entre les facteurs sociodémographiques et culturels et l’avortement provoqué. Résultats : Sur les 1302 femmes, 13,5 % avaient tenté de déclencher un avortement provoqué au moins une fois via des activités physiques lourdes (66,2 %), l’administration de remèdes à base de plantes (22,2 %) ou des préparations pharmacologiques (17,6 %). La prévalence des avortements provoqués déclarés était significativement moindre parmi EMHJ – Vol. 24 No. 7 – 2018Research article 650 قارعلا في لسنلا ميظنت دصقب تاهملأا ىدل د َّمعتلما ضاهجلإا داولجا دبع ىنثم ،يداولجا ءماسأ ،نياوضرلا رجاه ةصلالخا ةليلق تامولعلماو .ةابللما يرغ ةيباجنلإا تاجايتحلاا رادقم لىإ يرشي نأ نكميو ،لسنلا ميظنتل ةيديلقتلا قرطلا نم د َّمعتلما ضاهجلإا برتعي :ةيفللخا .ضرغلا اذله د َّمعتلما ضاهجلإل قارعلا في تاجوزتلما ءاسنلا مادختسا نع ميظنت ضارغلأ د َّمعتلما ضاهجلإا نمدختسي لصولما في تاجوزتلما ءاسنلا تناك اذإ ام فاشكتسا لىإ ةيعطقلما ةساردلا هذه تفده :فادهلأا .هل نهمادختساب ةطبترلما ةيناكسلاو ةيعماتجلاا صئاصلخا ديدحتلو ،لسنلا -15( باجنلإا نس في ةجوزتم ةأرما 1302 ةساردلا هذه في اولخدي يكل تاقبطلا ةددعتلما تانيعلا ذخأ ةقيرط نوثحابلا مدختسا :ثحبلا قرط نياثلا نوناك/رياني 31و 2011 ناسين/ليربأ ينب ةترفلا في نوثحابلا ىرجأو .لصولما في ةيلولأا ةيحصلا ةياعرلا زكارم نعجاري نمم )ةنس 49 ةقيرطو ،د َّمعتلما ضاهجلإا مادختسا :نوثحابلا اهعجم يتلا تانايبلا تلمشو .هتحص نم ققحتلا مت نايبتسا مادختساب ءاسنلا عم تلاباقم 2012 ةيعماتجلاا لماوعلا ينب طباترلا مييقتل عَّبرم ياك رابتخا نوثحابلا مدختساو .لملحا عنم لئاسو مادختساو ،ةيسرلأاو ةيعماتجلاا ةيفللخاو ،هب مايقلا .د َّمعتلما ضاهجلإاو ةيفاقثلاو ةيناكسلاو )٪66.2( ةفينع ةيندب تاطاشنب مايقلاب ،ام تقو في د َّمعتلما ضاهجلإا نلواح نهنم ٪13.5 نأ ينبتو ،ةأرما 1302 ةساردلا تلمش :جئاتنلا لقأ هنع غ َّلَبُلما د َّمعتلما ضاهجلإا راشتنا لدعم ناكو .)٪17.6( ةيئاود تاضرحتسم وأ )٪22.2( ةيبشع تاجلاعل نهمادختسا للاخ نم وأ ناكسو ،تلاماعلا ءاسنلاو ،لياعلا ميلعتلا لىع نلصح تيلالا ءاسنلاو ،ا ًّنس بركلأا ءاسنلاو ،لملحا عنم لئاسو نمدختسي تياوللا ءاسنلا ينب يرثكب .)0.05 < P( رئاضر نيهدل سيل تيلالاو ،نبهراقلأ تاجوزتلما ءاسنلا فيو ،ةدتمم سرأ في نشعي تياوللا ءاسنلاو ،فايرلأاو يحاوضلا يحصلا فيقثتلاب نوثحابلا صيويو .لسنلا ميظنت دصقب د َّمعتلما ضاهجلإا نمدختسا دق تاجوزتلما ءاسنلا نم ٪10 نم رثكأ نإ :تاجاتنتسلاا .لملحا عنم لئاسو مادختسا عيجشتل References 1. 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EMHJ – Vol. 24 No. 7 – 2018Research article 652 Appendix Distribution of the studied sample Stratification Population size No. of married women (15–49) years Weighted size 1st 2nd 3rd Proportional sample size No. of studied mothers North-west Urban Al-Yarmook 56 596 7923 5.8% 76 Al-Hadbaa 45 900 6426 4.7% 62 Peri-urban Nablus 68 000 9520 6.9% 89 Tamooz 37 707 5279 3.9% 50 Rural Al-Mawali 8400 1176 0.9% 12 Sub-total 216 603 30 324 22.2% 289 South-west Urban Babel-Baidh 255 505 35 771 26.1% 340 Al-Qarbi 32 276 4519 3.3% 43 Peri-urban Al- Rafedeen 40 590 5683 4.1% 53 Al-Ma'moon 23 924 3349 2.4% 31 Rural Albu-Seef 8000 1120 0.8% 10 Sub-total 360 295 50 442 36.7% 477 North-east Urban Al-Arabi 15 015 2102 1.5% 20 Al-Sukkar 35 035 4905 3.6% 47 Peri-urban Al-Rasheedia 62 563 8759 6.4% 83 Al-Qahera 29 229 4092 3% 39 Rural Sad-Badoosh 1 500 210 0.2% 3 Sub-total 143 342 20 068 14.7% 191 South-east Urban Al-Noor 60 860 8520 6.2% 81 Al-Wahda 8 412 1178 0.9% 12 Peri-urban Al-Zahraa 44 067 6169 4.5% 59 Al-Karama 122 325 17 126 12.5% 163 Rural Al-Khadhraa 23 000 3220 2.3% 30 Sub-total 258 664 36 213 26.4% 345 Grand total 978 904 137 047 100.0% 1302 Research article 653 EMHJ – Vol. 24 No. 7 – 2018 Fruit and vegetable intake among Emirati adolescents: a mixed methods study Nora Makansi,1 Paul Allison,2 Manal Awad3 and Christophe Bedos2 1Center for Research on Children and Families, McGill University, Montreal, Quebec, Canada (Correspondence to: Nora Makansi: nora.makansi@ mail.mcgill.ca). 2Faculty of Dentistry, McGill University, Montreal, Quebec, Canada. 3Department of Preventative and Restorative Dentistry, College of Dental Medicine, University of Sharjah, Sharjah, United Arab Emirates. Introduction Eating behaviours of adolescents in the Middle East have evolved and now tend to resemble those reported in Western Europe and North America, especially in terms of snacking and fast food consumption (1,2). Such behaviours have been associated with several diseases, including obesity and type 2 diabetes (3,4). This phenomenon is particularly evident in Gulf countries, such as the United Arab Emirates (UAE) (5), where oil wealth relative to the small population size has prompted rapid socioenvironmental and nutritional shifts. In the UAE, significant associations were found in adolescent females between obesity, missing breakfast and fast food consumption (6). Combined figures of overweight and obesity in the Gulf region are now as high as 42.2% in Kuwaiti adolescent males and 42.4% among Bahraini adolescent females (7). The European Society of Cardiology warns that the Gulf region is facing an epidemic of cardiovascular diseases, describing the situation as a “time bomb set to explode in 10–15 years” (8). Increased intake of fruits and vegetables has a protective effect against chronic diseases (9). Interventions to promote healthy eating among adolescents are particularly relevant in countries like the UAE. In order to design targeted interventions, we need to understand these behaviours within their socioenvironmental context. Therefore, the aim of this study was: 1) to describe and understand the eating behaviours of Emirati adolescents in the UAE, and 2) to explore behavioural and contextual factors associated with their fruit and vegetable intake. Such findings can inform future interventions and may also be transferable to neighbouring Gulf countries that share similar social, economic and environmental characteristics. Methods Study design A sequential explanatory study using a mixed methods approach was selected for its potential to capture the multidimensional nature and complexity of eating behaviour. Quantitative data were first collected followed by qualitative data. Abstract Background: Interventions to promote healthy eating in adolescents are needed in the United Arab Emirates. To design effective interventions, adolescent eating behaviours need to be understood. Aims: This study aimed to describe eating behaviours of adolescents in Dubai and the factors associated with fruit and vegetable intake. Methods: This was a sequential explanatory study using a mixed methods approach. Ten of the 34 Arabic high schools in Dubai were randomly selected and students in grades 10–12 were included. Data were collected on self-reported fruit and vegetables intake, eating behaviours, food availability and sociodemographic variables. In the qualitative phase, 14 students were interviewed about their eating behaviour. Results: A total of 620 students were included: 57% were boys and most reported medium/high family affluence. Only 28% of the participants met the recommended daily fruit and vegetable intake, with significantly more males than females meeting it (P < 0.01). Lunch was the most frequently eaten meal, breakfast was frequently skipped, and there were high levels of fast food and soft drink consumption. Adequate fruit and vegetable intake was positively associated with increased lunch frequency, being male, parental support for healthy eating, and positive perception of family meals. Conclusions: There are significant differences in eating habits between Emirati male and female adolescents. Lunch, as the main family meal, faces threats because of modern working hours. The gender-specific social context may require targeted interventions to achieve optimal outcomes in each group. Keywords: Eating behaviour; adolescent; diet, obesity, United Arab Emirates Citation: Makansi N; Allison P; Awad M; Bedos C. Fruit and vegetable intake among Emirati adolescents: a mixed methods study. East Mediterr Health J. 2018;24(7):653–663. https://doi.org/10.26719/2018.24.7.653 Received: 08/08/16; accepted: 12/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). EMHJ – Vol. 24 No. 7 – 2018Research article 654 Study population and sampling At the time of recruitment for the study, there were 24 public and 48 private high schools in Dubai. The majority of Emirati students (64%) attend public high schools (10). The study was carried out in Arabic, hence, our sampling frame included Arabic high schools only. A total of 34 high schools (24 public and 10 private) were retained in the sampling frame. We randomly selected 4 out of 10 male public schools, 4 out of 14 female public schools, and 2 out of 10 private schools. Two of the public schools we initially contacted declined because of “lack of time”, and another 2 were randomly selected. Quantitative phase Sample size Based on previous research (11,12), it was estimated that the proportion of adolescents who meet the daily recommended intake of fruits and vegetables was 32%. Using the appropriate formula for proportions (13), and assuming a design effect of 2 (given the cluster design of the study), a sample size of 668 was calculated. The final sample size was 700. Classes were recruited within the schools based on the availabilities in the academic schedules. All students in a selected class were invited to participate. Data collection The survey was administered during school hours to students who had returned the signed parental consent forms and agreed to participate. We used the validated EAT (Eating Among Teens) survey (14). We also included a standard set of questions to assess fruit and vegetable intake based on the YRBS (Youth Risk Behavior Surveillance) survey (15). The tool was translated from English into Arabic using a multistage process of back translation (translation, synthesis, back translation, expert review and pretesting) and was adapted to cultural values of the UAE (16). We pilot-tested the translated questionnaire on a convenience sample of grade 10 students in a girls’ public school (n = 29). One of the authors (NM) was present throughout the session to answer and clarify any questions and collect the written feedback. Based on the pilot survey, and after consultation with the research team members and a professor from the faculty of dietetic and human nutrition at McGill University, the final modifications of the survey included the omission of items measuring self-efficacy. This was done to reduce the length of the survey and to focus on practical findings that can be directly addressed by an intervention. Questionnaire items We assessed self-reported intake of fruit and vegetables, meal frequency, snacking patterns, fast food intake, and soft drink consumption. Sociodemographic variables included: age, sex, grade and family affluence (based on number of cars owned by the family, family holidays in the past year and family computers, and having own bedroom). Socioenvironmental factors included: frequency of family meals, parental presence at meals, priority of family meals, parental support for healthy eating, and atmosphere of family meals. Finally, we assessed the availability of fruit and vegetables, and some common unhealthy snacks (crisps, chocolate, candy and soft drinks) at home and at school. Details of the variables are given in the supplemental table (available on line). Data analysis Analysis was performed using SPSS, version 20. Descriptive statistics were used to describe the demographic characteristics of the sample. The association between eating behaviours and sex was explored using the chi- squared test. A single level multivariate analysis was done using the generalized linear mixed model (17). The dependent variable was dichotomized as: 0 = not meeting the recommended daily intake of fruit and vegetables and 1 = meeting the recommended daily intake (18). The cut-off score for adequate fruit and vegetable intake combined (in relation to recommended daily intake) was ≥ 5 portions per day. Qualitative phase Sample selection Since our goal was to inform future nutritional interventions for this target population, the sampling frame included students who did not meet the recommended daily intake of fruit and/or vegetables. We used stratified purposeful sampling based on sex and frequency of reported intake (students reporting zero intake of fruit and/or vegetables and students reporting less than the recommended intake). Participants were then purposefully selected from these strata. The rationale for stratifying was to capture various profiles within the sampling frame. Sample size The sample size was determined during data collection based on reaching thematic saturation. The decision to stop at 14 interviews followed a sense of saturation on main themes of interest, as well as the time limitation as students were approaching the examination period. Data collection A semi-structured interview guide was developed from the findings of the quantitative phase. The goal was to give context to and further our understanding of the quantitative findings (19). All students invited agreed to participate. The first author (NM) conducted all interviews, accompanied by a research assistant. Interviews lasted about 25–30 minutes and were audio recorded for transcription and analysis. Data analysis We analysed interview data using qualitative content analysis with an unconstrained deductive coding approach (20). We developed a list of categories and preliminary codes based on the survey items, such as “meal skipping” and “parental influence”. We also coded emerging themes such as “social norms” and “parental control”. NM and the research assistant independently coded two interview transcripts for cross-comparison. Results were regularly discussed with the research team. Research article 655 EMHJ – Vol. 24 No. 7 – 2018 Ethical considerations Ethical approval was obtained from the Research Ethics Committee at the University of Sharjah, UAE, and from the Institutional Review Board at McGill University in Montreal, Canada. Permission to access schools was obtained from the Knowledge and Human Development Authority of Dubai. Results Out of the 700 questionnaires handed out, 80 were completed by non-Emirati students and hence were excluded from the analysis. Table 1 shows the demographic characteristics of the overall sample (n = 620). Most participants reported high (47.1%) to medium (39.7%) family affluence. About half of them (48.9%) reported that neither parent had attended college/university. In the qualitative phase, the sample consisted of seven females and seven males. At the time of the interviews, nine participants were in grade 12 and 5 were in grade 11. Seven participants reported high family affluence and nine indicated that neither of their parents had attended college/university. The sections below report the integrated quantitative and qualitative findings. Eating behaviours Less than a third of the participants met the recommendations for intake of fruit and vegetables combined, however, males were significantly more likely than females to meet the recommendations (33.2% males versus 21.3% females, P < 0.01) (Table 2). Breakfast was the most frequently skipped meal with a significant difference between girls and boys (P < 0.001). On school mornings, participants explained that they lack appetite. On weekends, however, most participants eat a breakfast meal because they are “more relaxed” and “not pressed for time”. During school hours, food choices were limited. The school canteen sold prepackaged croissant, za’tar bread, crisps, chocolate, juices and occasional cooked foods like pasta or French fries. The schools in our sample had no assigned dining areas and students typically ate in the schoolyard. Most participants said they would not bring food from home explaining, as two girls said; “no one does that!” and “(Only) girls who are on a diet.” When probed on school food choices, participants criticized the quality and presentation of food. Some suggested adding traditional hot meals while others described the available selection as “boring”, “Cold and not appetizing”. Participants always ate “lunch” at home after returning from school. All participants described lunch as the most significant meal of the day, hence confirming the quantitative results (Table 2). This significance stemmed from factors including location, timing, quality and social context of the lunch meal. Lunch consisted of traditional meat or vegetable stews with rice as a staple side dish. Salads were often served as well. In terms of context, lunch was the time for family gathering. However, some participants explained that it had become difficult for some family members to attend lunch because of longer working hours; lunch would therefore be set up at a certain time and family members ate at different times upon their arrival from school or work. More students skipped dinner than lunch (Table 2). Like breakfast there was a significant difference between boys and girls (P < 0.01). Participants described dinner as a “light” meal eaten later in the evening. They also appeared to have more control over food choices in the evening citing choices like fast food meals, instant noodles and sandwiches. Socioenvironmental factors Table 3 shows the prevalence of family meals, parental presence at meals, and availability of fruit and vegetables at home. Participants reported high availability of fruit and vegetables at home only but at school they were rarely available; on the other hand, potato crisps, chocolate and candy were reportedly “always” available at school. More than a third of the students recognized time barriers as a threat to family meals (Table 4). This finding was supported during the interviews as students described the conflict between long working hours and having lunch with the family. Table 1 Sociodemographic characteristics of high-school students (n = 620) Variable No. % Sex Male 351 56.6 Female 269 43.4 Age (years) ≤ 15 104 16.8 16 218 35.2 17 177 28.5 ≥ 18 121 19.5 Grade 10 164 26.5 11 218 35.2 12 238 38.4 Family affluence scale Low 81 13.1 Medium 246 39.7 High 292 47.1 Parental education Neither attended college/ university 303 48.9 At least one parent attended college/university 236 38.1 Don’t know 81 13.1 EMHJ – Vol. 24 No. 7 – 2018Research article 656 Factors associated with fruit and vegetable intake Table 5 shows the factors associated with meeting the recommended daily fruit and vegetable intake. Being male, eating frequent lunches, consuming soft drinks and snacking were significantly associated with meeting the recommendations for fruit and vegetable intake across the models. In the final adjusted model (model 3), parental support for healthy eating and family meal Table 2 Distribution of the high-school students by eating behaviour and gender Eating behaviour Males (n = 351) Females (n = 269) P-valuea No. (%) No. (%) Meal frequency (past 7 days) Breakfast (days) < 0.001 Never 46 (13.2) 53 (19.8) 1–2 67 (19.2) 75 (28.0) 3–4 43 (12.3) 44 (16.4) 5–6 37 (10.6) 21 (7.8) Daily 156 (44.7) 75 (28.0) Lunch (days) Never 8 (2.3) 5 (1.9) 1–2 22 (6.3) 21 (7.8) 3–4 62 (17.7) 62 (23.1) 5–6 43 (12.3) 40 (14.9) Daily 216 (61.5) 140 (52.2) Dinner (days) < 0.01 Never 15 (4.3) 6 (2.2) 1–2 42 (12.0) 42 (15.6) 3–4 45 (12.8) 66 (24.5) 5–6 71 (20.2) 43 (16.0) Daily 178 (50.7) 112 (41.6) Frequency of foods/drinks consumed Soft drinks intake (past 7 days)b None 57 (16.4) 51(19.0) Less than once a day 148 (42.5) 126 (47.0) At least once a day 143 (41.1) 91(34.0) Frequency of eating fast food (past 7 days) Never 79 (22.6) 50 (18.6) 1–2 times 175 (50.1) 137 (50.9) ≥3 times 95 (27.2) 82 (30.5) Snacking frequency (previous day) Never 77 (22.1) 53 (19.7) Once 128 (36.7) 89 (33.1) 2–3 times 101 (28.9) 86 (32.0) ≥ 4 times 43 (12.3) 41 (15.2) Fruit and 100% fruit juice intake < 0.01 ≥ 2 portions per day 132 (37.7) 70 (26.1) Vegetable intakec < 0.01 ≥ 3 portions per day 111 (31.8) 56 (20.9) Fruit and vegetable intake < 0.01 ≥ 5 portions per day 116 (33.2) 57 (21.3) aChi-squared test. bA can, bottle or glass. cGreen salad, potatoes (excluding French fries), carrots or other vegetables Research article 657 EMHJ – Vol. 24 No. 7 – 2018 atmosphere were also significantly positively correlated with adequate fruit and vegetable intake. Qualitative factors that emerged Accessibility. Qualitative analysis led us to replace our initial deductive theme of food “availability” with “acces- sibility”, as participants talked about choosing food that was in front of them or prepared for them: “I wouldn’t get up to make a salad for me. If they make it, I eat it.” The interviews also reflected that respondents did not participate in food-related tasks and simply received food. References were made to the “nanny”, “housemaid”, or the mother as the individuals responsible for food preparation at home. Food presentation. Appeal of food also emerged as an influencing factor on the students’ food choices; they expressed willingness to try food that “looked good” such as packaged salads with special toppings or vegetables in familiar stews Parental control. Some participants described their parents’ support in the form of control over what they can or cannot eat. Some parents were said to prohibit certain foods. Students perceived the strategies their parents use to control their food intake as positive and helpful: “Since a young age (my parents) don’t let us eat too much chocolate and stuff and I feel they do a good job”, “My parents don’t pay attention to what I eat but I feel that parents should…they should say eat this, don’t eat too much of that”. Social and peer norms. Girls, in particular, described the eating habits of their school friends as a main influence on their food choices. They expressed sensitivity towards their friends’ perception of what they ate: “my friends believe it would look funny (to eat an apple at school) so they discourage me to eat healthy food at school. I would feel more comfortable if everyone was eating it”. Boys, on the other hand, did not seem affected by a certain context. They all made references to several environmental settings (besides school) where influential interactions with peers may occur including sports venues and during evening outings. Discussion Our results showed low rates of fruit and vegetable intake in Emirati adolescents, with significantly lower intake frequency among girls. These results are consistent with previous reports from the Gulf region. In Bahrain, only 25.3% and 26.3% of adolescents reported daily consumption of fruit and vegetables respectively. Girls were also less likely than boys to report adequate intake (21). In Saudi Arabia, more than 50% of adolescents reported they “never” or “rarely” consumed fruit and vegetables (2). In 2013, a study among Kuwaiti adolescents similarly reported significantly lower intake of fruit and vegetables among girls than boys (22). In Western Europe and North America, low rates of fruit and vegetable intake are also common among adolescents, but they tend to be more pronounced among low-income families and certain ethnic groups (such as African Americans) (12,23). In contrast to our findings, girls in North America and Europe tend to report higher intake of fruit and vegetable than boys (24,25). This said, our observed gender differences should to be interpreted in context. Our qualitative data suggest that the eating habits of boys may be influenced by a wider range of socioenvironmental factors than girls because they typically lead a more active and socially varied lifestyle, which may lead to higher energy needs and food intake. Our analysis showed no correlation between skipping breakfast and adequate fruit and vegetable intake. This could be because, traditionally, fruit and vegetables are not eaten at breakfast in the region. Breakfast was the most commonly skipped meal in our study especially among girls. Similarly, in Bahrain, 62.8% of females versus 37.2% of males reported irregular breakfast consumption (21). Also, reports from Kuwait and Jeddah, Saudi Arabic showed that over half of the adolescent participants skipped the morning meal (2,22). Family meal frequency has been shown to positively influence the quality of adolescents’ diet (26). Family lunches are a long-standing tradition in the Middle East (27). Culturally, this is different from European and North American societies, where dinner (the evening meal) is considered the main family meal. Yet our data indicate that the tension between lunch timing and modern Table 3 Frequency of family meals, parental presence at meals, and availability of fruits and vegetables at home Variable No. % Family meal frequencya 1–2 times 168 27.2 3–6 times 155 25.1 7 or more times 295 47.7 Parental presence at mealb Never 77 12.5 1–2 times 85 13.8 3–6 times 126 20.4 Every day 330 53.4 Fruit and vegetable availability at home Never 10 1.6 Sometimes (irregularly) 48 7.8 Usually 123 19.9 Always 436 70.7 Fruit and vegetable availability at school Never 386 62.3 Sometimes (irregularly) 132 21.3 Usually 51 8.2 Always 49 7.9 aNumber of times in the past 7 days all or most of the family living in the house ate a meal together. bNumber of times in the past 7 days when at least one of the parents was with the adolescent when they ate their main meal EMHJ – Vol. 24 No. 7 – 2018Research article 658 working hours might be affecting the family lunch and eating patterns of Emirati adolescents. More research is needed to assess the impact of this tension and possible means to preserve this family meal. Contrary to previous reports (24,28), we did not find an association between family affluence and intake of fruit and vegetables. This could be due to the fact that the vast majority of students in this sample were from families of moderate to high affluence. Fast food consumption among Emirati adolescents in our sample was as high as reports from neighbouring countries such as Saudi Arabia where 55.7% of adolescents eat outside the house (mainly in fast food restaurants) up to three times per week (2). In contrast with Kuwaiti adolescents, more girls (30.5%) than boys (27.2%) in our study reported eating fast food on 3 days or more in the past week (22). Qualitative themes that emerged added important information that helped refine our interpretations. For example, the distinction we made between ‘availability’, and ‘accessibility’ has been previously highlighted in research on children’s (rather than adolescents’) dietary habits in the US, where accessibility was used to refer to “prepared fruits and vegetables within reach or in a visible place, in the fridge or on a table” (29). Adolescents in our study expressed a similar dependence on their social support system. This can be attributed to the strong cultural emphasis on children’s dependence on family in this region, even during adolescence. Yet, in order to involve Emirati parents in future interventions, it is important to recognize potential challenges. For example, half of the parents in our study reportedly did not have higher education. These parents may lack the knowledge needed to guide the eating habits of their adolescent children (30). Our results also indicated that subgroups of the adolescent population, defined by demographic and lifestyle factors, may require different intervention approaches. As an example, given the social restrictions on female lifestyle, schools become an important setting for socializing among Emirati girls. This may lead to a stronger influence of school social norms among females (30). On the other hand, social norms in boys’ schools might be diluted, as they tend to have more opportunities to socialize outside school. It is also possible that girls are generally more responsive to peer influence than boys (31). We recommend further investigation of social and peer norms among Emirati adolescents. Finally, our findings emphasize the need for supportive food environments in schools. In October of Table 4 Adolescents’ home environment with regard to healthy eating and family meals Home environment variable Response categories (n = 620) No. (%) No. (%) No. (%) No. (%) Parental support for healthy eatinga Rate the following statements Not at all A little bit Somewhat Very much My mother cares about eating healthy food 19 (3.1) 95 (15.3) 173 (27.9) 324 (52.3) My father cares about eating healthy food 59 (9.5) 80 (12.9) 172 (27.7) 284 (45.8) My mother encourages me to eat healthy food 24 (3.9) 58 (9.4) 134 (21.6) 395 (63.7) My father encourages me to eat healthy food 59 (9.5) 95 (15.3) 134 (21.6) 305 (49.2) Atmosphere at the family mealb How strongly do you agree with the following statement? Strongly disagree Disagree Agree Strongly agree In my family, mealtime is a time for talking with other family members 27 (4.4) 51 (8.2) 142 (22.9) 393 (63.4) In my family, meal time is about more than just getting food; we talk with each other 43 (6.9) 78 (12.6) 150 (24.2) 342 (55.2) In my family, eating brings people together in an enjoyable way 22 (3.5) 64 (10.3) 208 (33.5) 319 (51.5) I enjoy eating meals with my family 21 (3.4) 56 (9.0) 154 (24.8) 377 (60.8) Importance of the family mealc How strongly do you agree with the following statement? Strongly disagree Disagree Agree Strongly agree In my family, it is important that the family eat at least one meal a day together 80 (12.9) 78 (12.6) 182 (29.4) 274 (44.2) In my family we are expected to be home for the main meal 33 (5.3) 78 (12.6) 205 (33.1) 291 (46.9) In my family, it is often difficult to find a time when family members can sit down to eat a meal together 84 (13.5) 160 (25.8) 139 (22.4) 227 (36.6) In my family, different schedules make it hard for us to eat meals together 155(25.0) 217 (35.0) 116 (18.7) 125 (20.2) an = 590, range: 0–12, mean = 9.1 (SD 2.8). bn = 608, range: 0–12, mean = 9.6 (SD 2.7). cn = 600, range: 0–15, mean = 8.4 (SD 2.8). Research article 659 EMHJ – Vol. 24 No. 7 – 2018 2012, after finalizing the data collection for this study, and independent of our research project, the Ministry of Education of the UAE made a significant move towards improving the quality of school food across the country. A 15-page guide for school caterers was issued (32). The guide reportedly bans the selling of fried potatoes, crisps, ice creams and chocolate in schools. Such initiatives could be re-examined to assess their effect on eating habits and attitudes of adolescents. Future school-based interventions could use creative ways to introduce fruits and vegetables, such as fresh cocktails and attractive salads. Another idea is to install a salad bar in the school cafeteria, offering a colourful selection of fresh products and allowing students to build their own plates. Salad bars have been shown to entice adolescents to try new vegetables and fruits (33,34). Limitations The cross-sectional design of this study and exclusion of Emirati students attending private high schools where Arabic is taught as a second language may limit the generalizability of the results. However, we argue that language is an important component of the cultural homogeneity in our target population for future interventions. We did not formally validate the adapted questionnaire used in this study; however, it was formally back translated to Arabic and was successfully piloted for face and construct validity. Finally, the qualitative sample size was partly determined by thematic saturation. True data saturation is difficult to achieve; however we argue that the purposeful sampling within the larger sample and the homogeneity of the qualitative sample helped achieve the supplemental purpose of our qualitative interviews and enhance thematic saturation. Conclusion Despite the similarities between eating behaviours of Emirati adolescents and those reported in Western Europe and North America, there are unique socioenvironmental and lifestyle influences that affect male versus female Emirati adolescents differently. Future interventions may benefit from gender-specific strategies as well as creative school-based programmes. Funding: None. Competing interests: None declared Table 5 Dietary and home environment factors associated with consumption of the recommended daily intake of fruits and vegetablesa (n = 619): multivariate analysis Variable Odds ratio (95% confidence interval)b Model 1 Model 2 Model 3 Dietary behaviour Breakfast 1.1 (0.9–1.2) 1.0 (0.9–1.2) 0.9 (0.8–1.1) Lunch 1.3 (1.1–1.6) 1.3 (1.1–1.6) 1.3 (1.0–1.6) Dinner 0.9 (0.8–1.1) 0.9 (0.8–1.1) 0.9 (0.8–1.1) Soft drinks 1.7 (1.2–2.6) 2.4 (1.6–3.5) 2.5 (1.6–3.9) Snacking 1.1 (0.9–1.3) 1.2 (0.96–1.4) 1.3 (1.0–1.6) Fast-food meals 0.8 (0.6–1.1) 0.8 (0.6–1.1) 0.9 (0.7–1.3) Sex (male) ____ 1.6 (1.1–2.4) 1.7 (1.1–2.7) Age ____ 1.1 (0.9–1.3) 1.2 (0.9–1.4) Home environment Family affluence ____ ____ 1.0 (0.8–1.4) Parental support for healthy eating ____ ____ 1.1 (0.99–1.2) Family meal frequency ____ ____ 0.9 (0.7–1.2) Family meal priority ____ ____ 0.9 (0.8–1.00) Family meal atmosphere ____ ____ 1.1 (0.99–1.2) Home availability of fruits and vegetables ____ ____ 0.97 (0.7–1.4) aEating fruit and vegetables 5 or more times a day. bGeneralized linear mixed model – model 1: unadjusted model [AIC (Akaike information criterion) = 547.2]; model 2: adjusted for age and sex (AIC = 667.4); model 3: adjusted for dietary behaviour, age, sex EMHJ – Vol. 24 No. 7 – 2018Research article 660 Table 5 Description of variables Variable Description of survey item Fruit and vegetable intake Six questions assessed self-reported intake of fruit (two questions for fruits and 100% fruit juice) and vegetables (four questions for green salad, potatoes-other than french-fries, carrots, and other vegetables) in the past 7 days. The response scale ranged from 0 = none in the past 7 days to 6 = 4 or more times per day. The scale was later dichotomized into 0 = does not meet recommended daily intake and 1= meets recommended daily intake for fruit and vegetables combined. The cut-off score was “≥ 5 portions per day” for fruit and vegetables combined (ftp://ftp.cdc.gov/pub/data/yrbs/2009/yrbs_2009_national_user_ guide.pdf). Meal patterns Frequency of intake of main meals was assessed with the question “During the past week, how many days did you eat breakfast/lunch/dinner?” Response categories were “never, 1–2 days, 3–4 days, 5–6 days and every day” Fast food Frequency of fast food intake was assessed with the question “In the past week, how often did you eat something from a fast food restaurant (like McDonalds, Burger King, Hardees, etc.)?” Response categories were “never, 1–2 times and 3 times or more” Snacking Frequency of snacking was assessed with the question “How many times did you snack (eat between meals) yesterday?” Range: 0 = none; 4 = more than 5 times; recoded into 0 = none; 3 = 4 times or more Soft drinks Soft drinks consumption was measured with the question “During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite?” Response categories were “none, less than once a day, at least once a day”. Family affluence We calculated a composite score for family affluence scale by summing the responses to 4 items including number of cars owned by family, having own bedroom, family holidays in the past year and number of family computers. Then, we recoded the sum into a 3-point ordinal scale (low, medium and high family affluence) (Richter M, Moor I, van Lenthe FJ. Explaining socioeconomic differences in adolescent self-rated health: the contribution of material, psychosocial and behavioural factors. J Epidemiol Community Health. 2012 Aug;66(8):691–7. https://doi.org/10.1136/jech.2010.125500 PMID:21543387). Family meals Frequency of family meals was assessed with the question “During the past 7 days, how many times did all, or most, of your family living in your house, eat a meal together?” Response categories were “1–2 times, 3–6 times, and 7 or more times” Parental presence at meal “On how many of the past 7 days was at least one of your parents in the room with you when you ate your main meal?” Responses ranged from “never” to “every day” Priority of family meals Five statements, rated on a 4-point Likert-scale: “In my family, it is important that the family eat at least one meal a day together”, “In my family we are expected to be home for dinner”, “I am often just too busy to eat dinner with my family”, “In my family, different schedules make it make it hard to eat meals together on a regular basis”, “In my family, it is often difficult to find a time when family members can sit down to a meal together”. Coding reversed for the last 3 items, range: 0 = strongly disagree; 3 = strongly agree Parental support for healthy eating Four statements, rated on a 4-point Likert scale: “My mother cares about eating healthy food”, “My mother encourages me to eat healthy foods”. Same questions for the father. Range: 0 = not at all; 3 = very much Atmosphere at family meal Four statements, rated on a 4-point Likert scale : “I enjoy eating meals with my family”, “In my family, eating brings people together in an enjoyable way”, “In my family, mealtime is a time for talking with other family members”, “In my family, dinner time is about more than just getting food; we talk with each other”. Range: 0 = strongly disagree; 3 = strongly agree Availability of fruits and vegetables at home/school Two statements, rated on a 4-point Likert scale on availability of fruits and vegetables at home. One statement for availability of fruits and vegetables at school. Range 0 = never; 3 = always Availability of unhealthy snacks Six statements, rated on a 4-point Likert scale on availability of chips and salty snacks; chocolate and candy, and soft drinks at home and school. Range: 0 = never; 3 = always Research article 661 EMHJ – Vol. 24 No. 7 – 2018 L’apport en fruits et légumes chez les adolescents émiratis : une étude à méthodologie mixte Résumé Contexte : Les adolescents des Émirats arabes unis doivent être encouragés à adopter une alimentation saine. Afin de mettre en place des interventions efficaces à cet effet, il faut tout d’abord bien comprendre les comportements alimentaires des adolescents. Objectif : La présente étude avait pour objectif de décrire les comportements alimentaires des adolescents à Dubaï ainsi que les différents facteurs liés à leur apport en fruits et légumes. Méthodes : Il s’agissait d’une étude séquentielle à visée explicative qui s’appuyait sur une approche méthodologique mixte. Dix des 34 lycées arabes de Dubaï ont été choisis au hasard et on y a recruté des élèves du secondaire (15-18 ans). Les données recueillies concernaient l’apport en fruits et légumes autodéclaré par les élèves, les comportements alimentaires, la disponibilité de la nourriture et les variables sociodémographiques. Lors de la phase qualitative, 14 élèves ont été questionnés au regard de leur comportement alimentaire. Résultats : Au total, 620 élèves ont été inclus, dont 57 % de garçons, et la plupart ont déclaré un niveau d’aisance familiale moyen à aisé. Seuls 28 % des participants atteignaient le niveau recommandé en matière d’apport quotidien en fruits et légumes, dont une part significativement plus élevée de garçons que de filles (p < 0,01). Le repas le plus fréquemment consommé était le déjeuner, le petit-déjeuner était souvent négligé et le taux de consommation de fast-food et de boissons gazeuses était élevé. Un bon apport en fruits et légumes a été corrélé de façon positive avec une prise de déjeuner plus fréquente, une appartenance au sexe masculin, un soutien parental en faveur d’une alimentation saine et une perception favorable des repas de famille. Conclusion : Des différences significatives sur le plan des habitudes alimentaires ont été notées entre les adolescents et les adolescentes émiratis. Les horaires de travail actuels constituent une menace pour le traditionnel déjeuner familial. Le contexte social étant propre à chaque sexe, il pourrait s’avérer nécessaire de cibler les interventions afin d’optimiser les résultats au sein de chaque groupe. ةطلتمخ قرط مادختساب ةسارد :ةدحتلما ةيبرعلا تاراملإا في ينقهارلما ىدل تاواضرلخاو ةهكافلا لوانت سوديب فوتسيرك ،ضوع لانم ،نوسيلأ لواب ،سيناكم ارون ةصلالخا ّدب لا ،ةلاعفلا تلاخدتلا ميمصت لجأ نمو .ةدحتلما ةيبرعلا تاراملإا في ينقهارلما ىدل يحصلا لكلأا زيزعتل تلاخدت لىإ ةجاح كانه :ةيفللخا .ماعطلا لوانت في ينقهارلما تايكولس مهف نم .تاواضرلخاو هكاوفلا لوانتب ةطبترلما لماوعلاو بيد في ماعطلا لوانت في ينقهارلما تايكولس فصو لىإ ةساردلا هذه تفده :فادهلأا ًارايتخا بيد في ةيوناث ةسردم 34 ينب نم سرادم 10 رايتخا مت .ةطلتخلما قرطلا ةبراقم مادختساب ةيعباتت ةيحيضوت ةسارد هذه :ثحبلا قرط نعو تاوضرلخاو هكاوفلا كلاهتسا نع ًايتاذ اهنع غلبلما تانايبلا تَعُِجو .ةساردلا في 12-10 ةيساردلا فوفصلا نم بلاط جاردلإ ًايئاوشع مهكولس لوح ًابلاط 14 عم تلاباقم تيرجأ ،ةيفيكلا ةساردلا ةلحرم فيو .ةيناكسلاو ةيعماتجلاا تايرغتلماو ءاذغلا رفاوتو ماعطلا لوانت تايكولس .ماعطلا لوانت في ِفوتسي لمو .عيفرلا/طسوتلما ليئاعلا ءارثلا يوذ نم هنأ نع غلبأ مهمظعمو دلاولأا نم مهنم ٪57 ناك ،ًابلاط 620 لياجإ ةساردلا تلمش :جئاتنلا نيذلا ثانلإا ددع نم بركأ مهنيب روكذلا ددع ناكو ،ةساردلا في ينكراشلما نم طقف ٪28 لاإ تاواضرلخاو هكاوفلا نم هب صىولما يمويلا لوخدلما طاقسإ بلاغلا نم ناكو ،الهوانت متي نأ بلغي يتلا تابجولا رثكأ وه ءادغلا ناكو .)0.01 < P( ،ًايئاصحإ هب ّدَتعي رادقمب يمويلا لوخدلما اوفوتسا ينبو ةهج نم ةهكافلا لوخدم ينب بيايجإ طابترا كانه ناكو .ةوللحا تابوشرلماو ةعيسرلا تابجولا كلاهتسا نم ةيلاع ةبسن تلجسو ،راطفلإا ةبجو .ةيلئاعلا تابجولل بيايجلإا كاردلإاو ،يحصلا ماعطلا لوانتل نيدلاولا معدو ،روكذلا نم بلاطلا نوكو ،ءادغلا لوانت راركت نم لك ةيلئاعلا ةبجولا انهوك ثيح نم ءادغلا ةبجو هجاوتو .ينقهارلما نم ثانلإاو روكذلا ينب لكلأا تاداع في ابه ّدتعي تافلاتخا كانه :تاجاتنتسلاا في لىثلما جئاتنلا قيقتح فدهتست تلاخدت ينسنلجاب صالخا يعماتجلاا قايسلا بلطتي دقو .ةثيدلحا لمعلا تاعاس ببسب الهاوزب تاديدته ةيسيئرلا .ةعوممج لك References 1. 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Public Health Nutr. 2007 Dec;10(12):1490–6. https://doi. org/10.1017/S1368980007000444 PMID:1761075 EMHJ – Vol. 24 No. 7 – 2018Research article 664 Geographical inequality in cataract surgery among Iranians between 2006 and 2011 Cyrus Alinia,1 Seyed-Farzad Mohammadi,2 Mahmoud Jabbarvand 2 and Hasan Hashemi 3 1Department of Public Health, School of Public Health, Urmia University of Medical Sciences, Urmia, Islamic Republic of Iran. 2Translational Ophthalmology Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to: Seyed-Farzad Mohammadi: sfmohammadi@tums.ac.ir). 3Noor Ophthalmology Research Center, Tehran, Islamic Republic of Iran. Introduction Cataract is the second leading cause of visual impairment after uncorrected refractive errors, and is responsible for 33% of visual impairment and half of the cases of blindness worldwide (1,2). The epidemiological burden of cataract has increased by 12% in the past two decades (3). Patients with cataract lose about 40% of their total health- related quality of life that can be recovered by cataract surgery (4), which is a highly cost-effective intervention with excellent prognosis for sight restoration (5). VISION 2020: the Right to Sight is an international drive to increase cataract surgical services in order to reduce the cataract “backlog” of people needing cataract surgery (6). One of the landmark indicators in the assessment of eye care programmes, particularly in developing countries, is the cataract surgical rate, which is the number of cataract surgeries performed per million population per year. Cataract surgery utilization varies between populations of different socioeconomic status, and is generally lower among the poor, which is attributed to unequal availability and affordability of cataract surgery. This study aimed to investigate the avoidable total inequality and income-related inequality in the use of cataract surgery and the change in inequality between 2006 and 2011 in the Islamic Republic of Iran. We used a comprehensive spectrum of metrics, such as ranges and Lorenz curves based on subnational data. To our knowledge, this has not been done before in the field of ophthalmology. The Lorenz curve is a tool for describing resource distribution. It indicates which proportion of the total cataract surgical number is in the hands of a given percentage of the population by relating the cumulative proportion of cataract surgical number to the cumulative proportion of various income groups (7). The curve was originally used to represent the size distribution of income and wealth (8) but in recent years it has been used to monitor policies for allocation of health care resources (9–11). Methods Data sources The cataract surgical numbers for 2006 and 2011 were obtained from a province-based cross-sectional survey in the Islamic Republic of Iran. The sampling and data collection method are reported elsewhere (12). The Statistics Centre of Iran provided the national 2006 and 2011 census data for other required information such as population socioeconomic data, in particular the gross annual household per capita income and household Abstract Background: Cataract surgery is a highly cost-effective intervention for sight restoration but inequalities exist in its use which health care systems should aim to reduce. Aims: This study aimed to measure the level of inequality in cataract surgery use and the changes in inequality between 2006 and 2011 in the Islamic Republic of Iran. Methods: A number of metrics, including ranges and indexes based on Lorenz curves (Gini, concentration and dissimilarity indexes), were used to measure the inequality in cataract surgery use among Iranians in 2006 and 2011. Cataract surgical numbers and socioeconomic data were obtained from a province-based survey and the national census database. Results: Significant inter-provincial and inter-regional differences were found in cataract surgical proportions. South Khorasan province had the lowest cataract surgical rate in 2006 and 2011, while Tehran province had the highest rate in both years. Inequality in the distribution of cataract surgery services decreased between 2006 and 2011: the Gini, concentration and dissimilarity indexes decreased by 0.028, 0.03 and 0.037, respectively. However, cataract surgery delivery remained in favour of the better-off provinces. Conclusions: To reduce this inequality, policy-makers should improve financial and physical access to cataract surgery, especially in the relatively deprived provinces, and tackle physician-induced demand. Keywords: Cataract surgery, inequality, Gini index, socioeconomic factors, Iran. Received: 05/04/16; accepted: 16/07/17 Citation: Alinia C; Mohammadi S-F; Jabbarvand M; Hashemi H. Geographical inequality in cataract surgery among Iranians between 2006 and 2011. East Mediterr Health J. 2018;24(7):664–671. https://doi.org/10.26719/2018.24.7.664 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Research article 665 EMHJ – Vol. 24 No. 7 – 2018 dimensions. We prepared a data profile containing the subnational (province and region) cataract surgical numbers and their related population factors to measure the inequality in the cataract surgical rate. Data analysis To describe the national distribution of the population adjusted for cataract surgical number, we applied range indicators such as absolute range, range ratio, coefficient of variation and the Mcloone index to determine the income-related unequal distribution of cataract surgery use among Iranians. For the time-trend, we used the Gini concentration and dissimilarity indicators. Range indicators Range is simply the difference between the highest and lowest adjusted cataract surgical number. Range ratio is calculated by dividing the adjusted cataract surgical number at the 95th centile by the value at the 5th centile. Range is skewed by outliers, while this issue is solved with the range ratio (13). The Mcloone index, which takes a much larger proportion of the data into account than the range ratio index, is the sum of all adjusted cataract surgical numbers at or below the median divided by the median multiplied by the number of observations at or below the median. Values range between zero and one (14). The coefficient of variation (15) considers the dispersion of all data points around the mean (14). Indicators based on Lorenz curves The Gini coefficient is equal to 1 minus twice the area under the Lorenz curve, and the output ranges between zero (no inequality) and 1 (maximum inequality). The concentration index quantifies the degree of socioeconomic-related inequality in a health variable (16). The concentration curve is the cumulative proportion of the cataract surgical number shown against the cumulative population proportion when the population is arranged in order of adjusted income by household dimension (socioeconomic variable) (17). The concentration index ranges between –1 and +1; it is negative when the curve lies above the line of equality (disproportionate concentration among the poor), positive when it lies below the line of equality, and zero when there is no socioeconomic-related inequality (9). For a favourable variable such as cataract surgical number, a positive concentration index value means the cataract surgical number is higher among the rich (18). The index of dissimilarity allows us to observe intra-population variations and analyses how much of a change is needed to achieve perfect equality (19). The lower the value of the index of dissimilarity the less the inequality (20). Methodological adjustments to the model The Islamic Republic of Iran has 31 provinces; these boundaries are not a barrier to receiving health care because everyone can obtain services in any province. Thus, we measured inequality indicators by province and region. To minimize information bias with region- based indices, the following were taken into account for grouping: the neighbouring provinces, having physical access (ophthalmologist per capita and geographical distance between patient and provider), existence of an ophthalmology residency training centre, existence of ophthalmology centres and a referral system, and the results of an interview with university authorities to determine where cataract patients were referred. Based on these factors, Iranian provinces were grouped into 9 regions (Table 1). Data on cataract surgical number for 3 provinces (Ilam, Kohgiluyeh & Boyer-Ahmad and Zanjan) were not available and they were excluded from the analysis. Kerman was divided in regions 2 and 5 with a coefficient of 0.5 because of its large area and being next to the two Table 1 Grouping of Iranian provinces into 9 regions Region No. Province Population 2006 2011 1 North Khorasan, South Khorasan, Razavi Khorasan 7 423 660 7 524 663 2 Sistan & Baluchestan, Hormozgan, Kermana 5 487 572 5 582 004 3 Tehran, Golestan, Mazandaran, Gilan, Markazi, Qom, Qazvin, Semnan 25 943 822 26 326 152 4 Esfahan, Kohgiluyeh & Boyer Ahmad, Chaharmahal & Bakhtiari 5 700 029 5 774 575 5 Yazd, Kermana 2 495 990 2 543 922 6 Fars, Bushehr 5 543 701 5 629 607 7 Khuzestan, Ilam, Lorestan 6 225 223 6 285 963 8 Kurdistan, Kermanshah, Hamedan 5 161 561 5 197 140 9 West Azerbaijan, East Azerbaijan, Zanjan, Ardabil 6 995 853 7 053 684 aBecause of its large area, Kerman province is divided into 2 parts; the northern part is included in region 2 and its southern part is included in region 5 EMHJ – Vol. 24 No. 7 – 2018Research article 666 referral centres of Sistan & Baluchistan in the south and Yazd in the north. All data were analysed with Microsoft Excel and the distribution plotted with geographic information system (GIS) software. Ethical considerations The protocol for this survey was approved by the Tehran University of Medical Sciences, and ethics approval was granted by the Human Research Ethics Committee at the university. The tenets of the Declaration of Helsinki were followed throughout. Results Overall, we found significant differences in the cataract surgical rates between the provinces and regions. In 2006 and 2011, South Khorasan had the lowest cataract surgical rate while Tehran had the highest. The province-based absolute range over the studied time period increased by 12 261 surgeries. In addition, the province range ratio of cataract surgical number showed a 1.38 times increase while the region-based ratio had a 2.6 times decline. Other range indicators confirm the decreasing trend of both provincial and regional inequality in cataract surgery utilization, although related inequality values are still high. The coefficient of variation index decreased by 0.24 and 0.19 in province and region-based analyses respectively, indicating decreased service utilization within the population. As shown in Figure 1, concentration of cataract surgical rate was mainly in the western half of the country and there was little change in its distribution from 2006 to 2011. If we accept the median value of national cataract surgical rate as a reasonable benchmark, the Mcloone index shows that a larger proportion of provinces are reaching this median over time, so that the higher Mcloone index in both provincial and regional divisions over the two time periods supports increased equality in access to cataract surgery services. However, there are still large gaps, especially between provinces (Table 2). The Gini coefficient decreased by 13.8% in 5 years, similarly the concentration index and dissimilarity index decreased by 15.0% and 16% over this time period respectively (Table 3). High-income provinces have the largest proportion of the Iranian population and use cataract surgery services the most, while provinces with a predominantly middle- income population have the lowest population proportion and cataract surgery use; rates are disproportionate in both groups (Table 3). Stratifying the provinces by household per capita income into five income quintiles showed that the Gini index was highest in the middle per capita income category (highest inequality) and lowest in the fourth quintile in both years, and there was a decreasing trend in all quintiles and hence in the total. Nevertheless, substantial cross-province differences were observed in the level of equality in the cataract surgical rate. The regional-based Gini index decreased by 66.4% and the concentration index declined by 29.6%. The 29.8% decrease in the dissimilarity index indicates that the decrease in inequality has reduced the need for relocation of resources for cataract surgery services from more affluent provinces to relatively deprived provinces by 29.8% (Table 4). Discussion Key findings Our findings show substantial avoidable income-related inequality in cataract surgery delivery between provinces, although we identified a trend towards some decreased inequality in the distribution of cataract surgery services from 2006 to 2011. Region-based inequality analysis showed the same trend but considerably lower inequality for both years and all measures. The inequality in cataract surgery delivery in favour of the better-off means that there is an unequal distribution of cataract surgery providers across the country which favours the higher income provinces. The three main reasons for this are: existing differences in socioeconomic and health status, the health care referral system, and financial incentives for providers. Socioeconomic and health status The more developed the province, the higher the pur- chasing power and education level of the population, and thus the better the financial and informational access to health care services it has, such as cataract surgery, and the higher the utilization rates (21). Given that life expec- tancy in the more prosperous provinces is higher than the poorer provinces and cataract is an age-related disease, a higher incidence of cataract disorders is expected in the Table 2 Range indicators of inequality in cataract surgery utilization in the Islamic Republic of Iran, 2006 and 2011 Year Absolute range Range ratio Coefficient of variation Mcloone index Provincial inequality 2006 139 122 54.48 1.85 0.450 2011 151 383 75.22 1.61 0.518 Regional inequality 2006 179 911 24.94 1.26 0.621 2011 198 212 9.600 1.07 0.735 Research article 667 EMHJ – Vol. 24 No. 7 – 2018 prosperous provinces and so its higher cataract surgical rate is not attributed to inequality. These results should be interpreted with caution because it seems likely that this relationship results from an ecological fallacy. All we know is that there is a positive and significant relationship between higher income provinces and rate of cataract surgery. But, this does not necessarily mean a positive causal relationship between income level and the number of cataract surgeries. Since the individual-level data are not available, we cannot evaluate the ecological fallacy related to the findings. During the 2 time periods of the study, inter-provincial socioeconomic inequalities in cataract surgery utilization fell from 0.2 to 0.17. This confirms the existence of avoidable inequalities favouring the rich. Changes in income-related inequalities were not the same across all five income quintiles; resource allocation, whether intentional or unintentional, has changed the winners and losers over time. In 2006, concentration indexes were negative for the 3rd and 4th income quintiles, meaning a pro-poor inequality in cataract surgery use. In 2011, the concentration index for the first (poorest) quintile became negative and the fourth remained negative, while the concentration index in the middle-class provinces (3rd quintile) shifted from below the equality line to above, therefore suggesting the richest utilized cataract surgery more than the poorest. In income categories with a positive concentration index, in order to remove income-related inequality, cataract surgery services need to be transferred from higher to lower income provinces, which would lead to a bivariate concentration index close to zero. The dissimilarity index, on the one hand confirms the Gini coefficient index and concentration index results, and on the other hand indicates that in order to disperse cataract surgery services evenly or equally across the country, 75.1% of these deliveries should have moved from high-income provinces to low-income ones in 2011. This need for resource reallocation was lower (64.8%) in 2006. Given the different inequality figures in the income quintiles, the need for a shift in resources to achieve equality in cataract surgery utilization varies between them as well. This need was highest for the middle-income group in 2006 and 2011, and lowest for the second income quintile in 2006 (8.7%) and richest provinces in 2011 (6.8%). Table 4 Regional inequality in cataract surgery utilization in the Islamic Republic of Iran in 2006 and 2011 Year No. of cataract surgeries Population size Gini index Concentration index Dissimilarity index 2006 390 869 70 977 413 0.113 0.054 0.168 2011 502 495 71 917 710 0.038 0.038 0.118 Table 3 Provincial inequality in cataract surgery numbers in the Islamic Republic of Iran in 2006 and 2011 Income group Year No. of CS Rel. % CS Cumul. % CS Rel. % Pop. Cumul. % Pop. Gini index Concentration index Dissimilarity index Poorest 2006 36 276 9.3 9.3 13.3 13.3 0.143 0.026 0.246 2011 50 849 10.1 10.1 13.2 13.2 0.024 –0.14 0.188 2nd 2006 45 731 11.7 21 16.8 30.1 0.086 0.025 0.087 2011 58 564 11.7 21.8 16.8 30.0 0.02 0 0.099 3rd 2006 23 907 6.1 27.1 11.5 41.6 0.21 –0.137 0.274 2011 35 627 7.1 28.9 11.5 41.5 0.164 0.051 0.273 4th 2006 66 044 16.9 44 17.9 59.5 0.024 –0.045 0.146 2011 71 828 14.3 43.2 17.9 59.4 0.012 –0.078 0.186 Richest 2006 218 911 56.0 100 40.5 100 0.14 0.148 0.169 2011 285 627 56.8 100 40.6 100 0.054 0.041 0.068 Total/ average 2006 13 934 100 – 100 – 0.203 0.2 0.232 2011 502 495 100 – 100 – 0.175 0.17 0.195 EMHJ – Vol. 24 No. 7 – 2018Research article 668 Iranian health care referral system Specialty and subspecialty care are in the second and third levels of the health care referral system in the Islamic Republic of Iran. Cataract surgery is often done by general ophthalmologists who work within the second level in all provinces. Complicated cases are referred to anterior segment ophthalmologists in the third level in the few subspecialty ophthalmology centres and hospitals and these are concentrated in the more developed provinces. This referral system has two macro effects on inequality in the cataract surgical rate. By establishing modern ophthalmic care centres in more developed provinces, particularly in the capital, Tehran, physical access, as measured by ophthalmologist per capita and geographical distance between patient and provider, has been increasing for adjacent cities and provinces and decreasing for remoter regions. The concentration of resources, including ophthalmic specialists and technologies, increases cataract surgery supply in high-income provinces; at the same time it attracts more ophthalmologists to those areas. Overall, this results in inequality in cataract surgery utilization which favours the richest. Provider incentives According to the microeconomic profit-maximization theory, all firms or providers, such as ophthalmologists, behave in a manner that returns the greatest profit by determining the price and number of cataract surgery. The opportunity to work in the private sector, where fees are higher, attracts ophthalmologists to more developed provinces. Another notable incentive-related issue with cataract surgery is the ophthalmologist-induced demand that may be higher in high-supply areas such as more developed provinces. Performing early cataract surgery to maximize surgeon profit regardless of patient need can artificially increase utilization inequality (22). Policy implications and the future Some of the reasons mentioned earlier for the inequality in cataract surgery utilization, including differences in the socioeconomic and health status of patients, a weak referral system, and physician-induced demand, are not justifiable and must be resolved. Other reasons, such as differences in cataract surgery need, are understandable but should be considered in order to achieve equity in cataract surgery utilization. To eliminate inequality between provinces, all factors related to access (physical, financial and informational) and supplier-induced demand should be removed and the distribution of ophthalmologists adjusted. As a way to decrease access inequality, the Ministry of Health and Medical Education policy requires that newly graduated ophthalmologists are assigned to facilities across the country as part of their mandatory service on graduation. However, our results indicate that this scheme has had very little success. We recommend the following policies in order to eliminate the inequality in access to cataract surgery services. 1. Resource redistribution: Avoidable cataract surgery inequality can be decreased significantly by redistributing and improving the infrastructure through provision of necessary resources – budgetary Figure 1 Distribution of population-adjusted cataract surgery in 2006 and 2011 in the Islamic Republic of Iran (CSR = cataract surgical rate) Research article 669 EMHJ – Vol. 24 No. 7 – 2018 resources, trained and skilled human resources, and technology resources – in favour of the poorer provinces. However, decreased inequality does not necessarily imply service adequacy, but rather reduced differences in resource allocation between different groups. 2. Access improvement: Since utilization is a manifestation of factors related to access (financial, physical and informational), policy-makers should ensure that all these access factors are tackled using appropriate measures. Resource redistribution to bring providers closer to those with cataracts may solve the physical access problem, but does not guarantee cataract surgery utilization by patients who need it. Many cases of untreated cataract are due to financial barriers or even lack of sufficient information about the availability and effectiveness of cataract surgery. Therefore, insurance coverage for cataract surgery and increasing health literacy, particularly in deprived and remote areas, using social media should improve financial and informational access respectively (23). A further study with more focus on evaluating physician- induced cataract surgery and also the level of need for cataract surgery among different strata of the population is therefore recommended. A decomposition study can determine the contribution of each significant socioeconomic variable and help policy-makers control the determinants of inequality in cataract surgery utilization. Limitations Inequality measures greatly depend on the data types (individual or group levels), ranking types (based on, for example, income, wealth, expenditure, education), and the degree of freedom of the data. In our study, data selection was based on availability, possibility, and adequacy. In this regard, lack of data limited our ability to define socioeconomic determinants or differences within provinces or on an individual level. Another limitation was the lack of data on disposable household income so we had to use data on gross household income. Funding: This study was partially supported by Hormoz Chams Research Chair in Public Health Ophthalmology, Allama Tabatabaei Award, National Elite Foundation (http://bmn.ir/). Competing interests: None declared. Opération de la cataracte parmi les Iraniens en 2006 et 2011 : inégalités géographiques Résumé Contexte : L’opération de la cataracte est une intervention de restauration de la vue ayant un très bon rapport coût- efficacité, mais des inégalités existent quant à la possibilité d’en bénéficier, et il est du ressort des systèmes de soins de santé de s’efforcer de les réduire. Objectif : La présente étude avait pour objectif de mesurer le niveau d’inégalité en matière de recours à l’opération de la cataracte, ainsi que les changements en termes d’inégalités entre 2006 et 2011 en République islamique d’Iran. Méthodes : Un certain nombre de mesures, dont des étendues et des indices reposant sur la courbe de Lorenz (coefficient de Gini, indices de concentration et de dissimilarité) ont été utilisés afin de mesurer les inégalités en matière d’opération de la cataracte parmi les Iraniens en 2006 et en 2011. Le nombre d’opérations de la cataracte et des données socio- économiques ont été obtenus au moyen d’une étude réalisée dans les provinces et à partir de la base de données de recensement national. Résultats : Des différences interprovinciales et interrégionales ont été trouvées concernant le taux de recours à la chirurgie de la cataracte. Le Khorasan méridional affichait le taux d’opération de la cataracte le plus bas en 2006 et 2011, tandis que la province de Téhéran avait le taux le plus élevé pour les deux années. Les inégalités en matière de distribution des services d’opération de la cataracte ont diminué entre 2006 et 2011, le coefficient de Gini et les indices de concentration et de dissimilarité ayant respectivement baissé de 0,028, 0,03 et 0,037. Néanmoins, l’opération de la cataracte reste davantage pratiquée dans les provinces plus riches. Conclusion : Afin de réduire ces inégalités, les responsables politiques devraient améliorer l’accès à l’opération de la cataracte, tant au niveau financier qu’en termes de disponibilité d’infrastructures pratiquant ce type d’opération, notamment dans les provinces relativement pauvres. Pour ce faire, il convient également de s’attaquer au problème de la demande induite par les médecins. 2011و 2006 يَماع في ينيناريلإا ينب ينعلا ةسدع ةمتع ةحارج في فيارغلجا توافتلا يمشاه نسح ،دنورابج دوممح ،يدممح دازرف ديس ،اين ليع سويرس ةصلالخا هذه نم ةدافتسلاا في ةاواسلما مدعل هجوأ كانه نكلو ،صربلا ةداعتسلا ةفلكتلا ثيح نم ةياغلل ٌلاعف ٌلخدت ينعلا ةسدع ةمتع ةحارج نإ :ةيفللخا EMHJ – Vol. 24 No. 7 – 2018Research article 670 .كلذ نم دلحا لىإ فدته نأ ةيحصلا ةياعرلا مظنل يغبنيو ،ةحارلجا يَماع ينب ىوتسلما اذه في تايريغتلاو ينعلا ةسدع ةمتع ةحارج نم ةدافتسلاا في ةاواسلما مدع ىوتسم سايق لىإ ةساردلا هذه تفده :فادهلأا .ةيملاسلإا ناريإ ةيروهجم في 2011و 2006 تاشرؤمو زيكرتو ينيج لماعم( زنرول تاينحنم لىإ ةدنتسلما تاشرؤلماو تاقاطنلا لىع تلمتشا ،تاسايقلا نم ددع مِدْخُتسا :ثحبلا قرط تاحارج دادعأ تَعُِجمو .2011و 2006 يَماع في ينيناريلإا ينب ينعلا ةسدع ةمتع ةحارج نم ةدافتسلاا في ةاواسلما مدع سايقل كلذو )فلاتخلاا .ناكسلل ينطولا دادعتلا تانايب ةدعاقو تاعطاقلما ىوتسم لىع تاحوسم نم ةيداصتقلاا ةيعماتجلاا تانايبلاو ينعلا ةسدع ةمتع لدعم ىندأ ناسارخ بونج ةعطاقم تلجسو .ينعلا ةسدع ةمتع تاحارج بسن في ميلاقلأا ينبو تاعطاقلما ينب ةيربك تافلاتخا تَدِجو :جئاتنلا في ةاواسلما مدع ىوتسم ضفخناو .ينماعلا لاك في لدعم لىعأ نارهط ةعطاقم تلجس ينح في ،2011و 2006 في ينعلا ةسدع ةمتع تاحارلج 0.028 رادقمب فلاتخلاا تاشرؤمو زيكترلاو ينيج لماعم ضفخناف :2011و 2006 يماع ينب ينعلا ةسدع ةمتع ةحارج تامدخ عيزوت .ًءارث رفولأا تاعطاقملل ًةابامح رثكأ ينعلا ةسدع ةمتع تاحارج لىع لوصلحا في ةردقلا تلظ نكل .لياوتلا لىع 0.037و 0.03و لجأ نم ةيدالماو ةيلالما ةردقلا اونسيح نأ ،ينعلا ةسدع ةمتع ةحارج لامج في ةاواسلما مدع نم دلحا ةيغب ،تاسايسلا يعناصل يغبني :تاجاتنتسلاا .ءابطلأل ةجالحا نع مجانلا بلطلا ةلجاعمو ،اًيبسن ةمورحلما ميلاقلأا في ماّيس لا ،ةحارلجا هذه لىع لوصلحا References 1. 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Eye Contact Lens. 2018 Jan 15. https://doi.org/10.1097/ICL.0000000000000443 PMID:29369233 EMHJ – Vol. 24 No. 7 – 2018Research article 672 Engagement of health research institutions in knowledge translation in the Eastern Mediterranean Region Fadi El-Jardali,1 Ahmed Mandil,2 Diana Jamal,1 Lama BouKarroum,1 Samar El-Feky,2 Mohamed Nour 2 and Mazen Al-Abbar 1 1Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon 2WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. (Correspondence to: Fadi El-Jardali: fe08@aub.edu.lb). Introduction The role of evidence-informed health policies in improv- ing health systems, and reducing inequity is increasing- ly recognized. There is a need support the translation of evidence to action across decision-making interfaces and embedding research within policy-making processes and practice (1,2). The World Health Report 2013 empha- sized the crucial role of translating evidence into policies in supporting health in general and attaining Universal Health Care coverage in particular (3). One of the strat- egies that emerged from the report was to support the knowledge translation (KT) of evidence to policies and actions. KT is defined as “a dynamic and iterative pro- cess that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and prod- ucts, and strengthen the health care system” (4). Despite global calls, the work on KT and utilization of research in policy-making is still limited in the Eastern Mediterranean Region (EMR). A recent survey of researchers in the EMR showed that only 15% produced policy briefs, disseminated messages that specified possible actions (24%), interacted with policy-makers and stakeholders in priority-setting (16%), and involved them in their research (20%) (5). Another survey of policy- makers revealed that less than 43.1% collaborated with researchers and less than half reported that research is not delivered at the right time, lacks actionable messages (35.5%), and lacks information about research quality and local applicability (40.1%) (6). Health research institutions in the EMR can play an integral role in promoting and supporting KT. Assessing institutions’ engagement in KT and in bridging the “research-policy” gap is important in designing context- specific strategies to promote KT and informing funding efforts in the Region. There are scarce, if any, previous regional surveys that document engagement of institutions undertaking health research in the EMR in KT. Previous studies focusing on knowledge translation were country specific and not regional in nature (7). The objective of this study was to explore engagement of EMR institutions undertaking health research in KT with emphasis on institutional planning for research, national planning of health research and knowledge management, translation and dissemination. Abstract Background: Health research institutions in the Eastern Mediterranean Region (EMR) can play an integral role in pro- moting and supporting Knowledge Translation (KT). Assessing institutions’ engagement in KT and bridging the “re- search-policy” gap is important in designing context-specific strategies to promote KT and informing funding efforts in the region. Aims: The objective of this study was to explore the engagement of EMR institutions in KT activities. Methods: A cross-sectional survey of institutions undertaking health research in the 22 EMR countries was undertaken. The survey covered institutional characteristics, institutional planning for research, national planning for health research, and knowledge management, translation and dissemination. Results: 575 institutions were contacted of which 223 (38.3%) responded. Half the sampled institutions reported conduct- ing priority-setting exercises, with 60.2% not following a standardized approach. Less than half institutions reported fre- quently/always (40.5%) involving policymakers and stakeholders in setting priorities for research on health. Only 26.5% of respondent institutions reported that they examine the extent to which health policymakers utilize their research results. Moreover, only 23.3% reported measuring the impact of their health research. Conclusions: There is still misalignment between national health research priorities and actual research production, and KT activities are still rarely undertaken by institutions in the EMR. National governments and international funding agencies are called to support research production and translation in the EMR. Institutions and researchers are also called to produce policy-relevant research and be responsive to the needs and priorities of policy-makers. Keywords: knowledge translation, Eastern Mediterranean Region, research institutions, health research, health policy Citation: El-Jardali F; Mandil A; Jamal D; BouKarroum L; El-Feky S; Nour M; et al. Engagement of health research institutions in knowledge translation in the Eastern Mediterranean Region. East Mediterr Health J. 2018;24(7):672–679. https://doi.org/10.26719/2018.24.7.672 Received: 12/01/18; accepted: 08/08/18 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Research article 673 EMHJ – Vol. 24 No. 7 – 2018 Methods A cross-sectional survey of institutions undertaking health research in all 22 EMR Member States was con- ducted from August 2015 to July 2016. The survey was developed based on various sources (1,8–15). The survey included 10 sections, of which four are discussed in this paper, and are: institutional characteristics; institutional planning for research (adapted from El-Jardali et al. [4–5] and Kennedy et al. [10]); national planning of health re- search (adapted from Tugwell et al. [8], Kennedy et al. [10], World Health Organization [11], and Ismail et al. [9]); and knowledge management, translation and dissemination (adapted from Lavis et al. [13], Campbell et al. [15] and Gholami et al. [14]). The survey was pilot-tested to ensure validity and reliability and the time of completion was es- timated using a guiding protocol for pilot testing. Data were collected through trained focal people identified by the World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO) in each of the study countries. The surveys were administered in English electronically through email. Data were analysed using Statistical Package for the Social Sciences (SPSS) version 24. Questions were analysed based on country income level, facility type and sector. Thematic analysis was used for the open-ended questions whereby data was coded and then categorized by most recurrent themes. Results A total of 575 institutions were contacted across 22 coun- tries in the EMR of which 223 (38.8%) from 22 countries responded to the survey. Institutional characteristics The majority of sampled institutions were academic re- search centres / institutes (44.7%). Organizational sectors were mostly public (64.2%) while only 10.6% were private. Most organizations were public of which 68% had less than 20 years of experience. A total of 40% of non-aca- demic research centres/institutes were non-governmen- tal organizations (NGOs). Institutional planning for research for health Funding types and sources The majority of institutions submitted less than 10 pro- posals to national, regional or international sources, and mainly in response to calls for proposals. Institutions re- ceived less than 10 grants regardless of funding source. Institutions within low–middle income countries were most likely to receive funding for less than 10 proposals (83.1%). Moreover, non-academic research centres were least likely to receive funding from regional sources (80%). Priority setting Half of the sampled institutions reported conducting priority setting exercises. Even when conducting priori- ty-setting exercises, 60.2% reported not following a stand- ardized priority setting methodology. When asked about methodologies, responses were diverse and not reported descriptively by many institutions in this survey. Some reported conducting literature reviews, focus groups, or surveys without elaborating on the exact methodology. Less than half of the institutions reported frequently / always (40.5%) involving policy-makers and stakeholders when setting priorities for research on health (Table 1). Moreover, 43.1% frequently/always translate high-priori- ty policy concerns into priority research on health themes and/or questions. It was not clear how often institutions made an up-to-date list of the country’s research on health priorities to be available to researchers/scientists. It was also unclear how often institutions involved poli- cy-makers and stakeholders in research projects (Table 1). National planning for health research Similar numbers of institutions reported knowing (49.1%) and not knowing (43.8%) whether their countries have national health research priorities. The overwhelming majority of proposals did not address national health re- search priorities (70.2%). Topics mainly included noncom- municable diseases (NCDs), maternal and child health, cancer, reproductive healthcare and mental health. Up- per–middle income countries were most likely to report Table 1 Trends in priority setting exercises Never/rarely Occasionally Frequently/always n (%) n (%) n (%) How often does your institution involve policymakers and stakeholders in setting priorities for the institution’s research on health? 53 (27.2) 63 (32.3) 79 (40.5) How often does your institution translate high priority policy concerns into priority research on health themes and/or questions? 41 (21) 70 (35.9) 84 (43.1) How often does your institution make available an up-to-date list of the country’s research on health priorities to the institution’s researchers / scientists? 62 (31.8) 63 (32.3) 70 (35.9) How often does your institution involve policymakers and stakeholders in its research projects (in the development of joint proposals/ research methodology and tools/ analysis & write-up/ publications?) 56 (28.8) 72 (36.9) 67 (34.3) EMHJ – Vol. 24 No. 7 – 2018Research article 674 not having national health research priorities, whereas low–middle income countries were most likely to report not knowing whether their countries had national health research priorities. Recognition and coordination of national health priorities Institutions indicated that funders occasionally (35.4%), or frequently (23.9%) formulate their priorities and calls for proposals for research for health in response to na- tional / regional needs. Half the respondents (48.2%) did not know whether their countries had a national health council that regulates funding priorities. Only 29.2% of institutions were involved in a national priority setting exercise between 2010 and 2014, held either by the insti- tution itself, or in collaboration with WHO, ministries of health or national research councils. A little over half of responding institutions reported that their country’s ministry of health has a department that coordinates health research (55.8%) and less than half reported having a national health sector strategy (46.9%). Around half of responding institutions did not know whether their countries had legislation that deals with health research (55.4%). However, 57% reported that their countries had a national ethical review committee (Table 2). Knowledge management, translation and dissemination Dissemination of research findings Institutions reported mostly disseminating their re- search findings through seminars and conferences (64.1%), peer-reviewed scientific journals (58.8%), and in- stitutional websites (58.7%). Those methods reported to be never or rarely used included policy briefs (48.4%), policy dialogues (48.4%), letters/briefs/tailored messages to pol- icy-makers/stakeholders (39.9%), and institution-owned, peer-reviewed scientific journals (40.4%) (Table 3). Other means of dissemination included media briefings, pres- entations to stakeholders, and lectures among others. The majority of institutions (72.2%) reported disseminat- ing health research findings within their institutions, sometimes referred to as “permeability of information”. Methods for dissemination included seminars, confer- ences, dissemination on website, newsletters, journal ar- ticles, and journal clubs, among others. Knowledge transfer and translation Institutions reported that they most frequently transfer/ translate knowledge to the following categories: other academic faculties / schools / institutes / departments (39.9%); policy-makers in the government (36.3%); health- care providers (36.3%); and directors in health care insti- tutions (34.1%). Knowledge transfer and translation was reported to be never or rarely conducted with directors in NGOs (53.8%); directors in international agencies (55.2%); directors in donor agencies (64.1%); and general public or healthcare recipients (43.9%) (Table 3). Knowledge trans- fer and translation was least reported by high-income countries to policy-makers (26.7%) and directors in NGOs (10%). Low–middle income countries were likely to never or rarely report transferring and translating knowledge to directors in donor agencies (52.3%) and directors in a health professional association or group (21.5%). Approx- imately two-thirds of respondent institutions reported that their researchers had the skills to disseminate re- search findings to policy-makers in government (62.8%), and directors of NGOs (74.9%) (Table 4). Table 2 Coordination of national health research N % Does the Ministry of Health have a department that deals with and coordinates health research in your country? Yes 116 55.8 No 31 14.9 Don’t know 61 29.3 Does your country have a National Health or Health Sector strategy? Yes 97 46.9 No 16 7.7 Don’t know 94 45.4 Is there any legislation in your country that deals specifically with health research? Yes 63 30.9 No 28 13.7 Don’t know 113 55.4 Does your country have a National Ethics Review Committee? Yes 127 57.0 No 23 10.3 Don’t know 73 32.7 Research article 675 EMHJ – Vol. 24 No. 7 – 2018 Research impact Only 26.5% of respondent institutions reported that they frequently/always examine the extent to which health policy-makers utilize the institution’s health research re- sults. Moreover, only 23.3% measure the impact of their health research outcomes (Table 5). More than half of responding institutions (55.3%) reported believing that health research produced by their institution has im- pacted health policymaking. Some reported methods for impact assessment included feedback from stakeholders, article citation, implementation of research recommen- dations, and changes in health policy, among others. Discussion This mapping exercise provides an overview of the en- gagement of institutions undertaking health research in the EMR in KT activities. The study showed that many EMR countries might be lacking a national strategy for health research, since almost half of respondents report- ed not having or not knowing whether their countries have national health research priorities. This finding concurs with another mapping exercise conducted in the Region, which showed that three out of 10 countries sur- veyed reported setting national health research priorities, while only two countries had a dedicated national health research policy (10). Findings highlight misalignment between national health research priorities and actual research production, since the majority of respondents indicated submitting proposals not addressing national health research priorities. This corroborates findings of previous studies conducted in the Region that highlighted a gap in the production of policy-relevant research (5,16,17). This can be explained by the fact that only 31.7% of the surveyed institutions reported being involved in a national priority setting exercise over the past five years. A survey of researchers in the EMR has also found that less than half of researchers (16%) interacted with policy- makers and stakeholders in priority setting (5). Even when institutions reported conducting priority-setting exercises, 60.2% reported not following a standardized Table 3 Means of disseminating health research findings and frequency of knowledge transfer and translation Never/ rarely Occasionally Frequently/ always n (%) n (%) n (%) Means of dissemination of health research findings Institution own peer-reviewed scientific journal 90 (40.4) 34 (15.2) 99 (44.4) Other peer-reviewed scientific journals 50 (22.4) 42 (18.8) 131 (58.7) Seminars/conferences 28 (12.6) 52 (23.3) 143 (64.1) Press releases to the media 75 (33.6) 72 (32.3) 76 (34.1) Institution/researcher’s social media 88 (39.5) 61 (27.4) 74 (33.2) Institution’s website 41 (18.4) 64 (28.7) 118 (52.9) Newsletters/emails/printed reports to research networks within the institution 57 (25.6) 68 (30.5) 98 (43.9) Newsletters/emails/printed reports to research networks outside the institution 76 (34.1) 75 (33.6) 72 (32.3) Letters/briefs/tailored messages to policy-makers/stakeholders 89 (39.9) 72 (32.3) 62 (27.8) Policy briefs 108 (48.4) 64 (28.7) 51 (22.9) Policy dialogues 108 (48.4) 72 (32.3) 43 (19.3) Frequency of knowledge transfer and translation Policy-makers in the government (e.g., Ministry of Health, Ministry of Social Affairs, Ministry of Education, etc.) 57 (25.6) 85 (38.1) 81 (36.3) Directors in nongovernmental organizations (NGOs) 120 (53.8) 57 (25.6) 46 (20.6) Directors in international agencies (e.g., United States Agency for International Development [USAID], World Bank, WHO, etc.) 123 (55.2) 54 (24.2) 46 (20.6) Directors in donor agencies 143 (64.1) 46 (20.6) 34 (15.2) Directors in health care institutions (e.g. PHCCs, hospitals, etc.) 71 (31.8) 76 (34.1) 76 (34.1) Directors in a health professional association or group (e.g., Syndicate of Hospitals, Order of Physicians, Order of Nurses, etc.) 79 (35.4) 79 (35.4) 65 (29.1) Healthcare providers (e.g., clinicians, nurses, pharmacists, etc.) 64 (28.7) 78 (35) 81 (36.3) Other academic faculties/schools/institutes/departments 55 (24.7) 79 (35.4) 89 (39.9) General public or healthcare recipients (e.g., citizens, patients, clients, etc.) 98 (43.9) 80 (35.9) 45 (20.2) EMHJ – Vol. 24 No. 7 – 2018Research article 676 methodology, while the remainder provided no details on the exact methodology. There was no significant difference according to organization type, sector or country income level with regard to whether or not such an exercise was conducted. However, involving policy- makers and stakeholders in setting priorities for research on health was highest among NGOs. Conducting priority setting is only the first step in KT and should be followed by evidence synthesis, development of KT products and impact assessment (18). Around half of respondents did not know whether a national health council that regulates funding priorities exists in their country. Findings also suggest that funders occasionally and rarely formulate their priorities and calls for proposals in response to national/regional needs, which can partially explain the misalignment. Respondents mostly reported NCDs as their top priority, which corresponds to regional and global priorities as declared by stakeholders, policy-makers and regional and international organizations (17,19–21). Our findings suggest that KT activities including policy briefs, policy dialogues and letters/briefs tailored to policy-makers are still rarely undertaken by institutions in the EMR. This supports findings of a previous survey of researchers in the EMR (5). Another survey conducted in 2008 in 10 countries in the EMR also found that none of those countries reported systematic efforts to feed research results into decision-making (10). Indeed, only 26.5% of the institutions surveyed in this study reported frequently/always examining the extent to which health policy-makers utilize their health research results, and only 23.3% measure the impact of their health research outcomes. Policy briefs and similar KT products are important tools for topics that are highly politicized and where the nature of the problem is contentious and lacks clarity (22). As such, there is a need for capacity development to create such tools and evaluation of their effectiveness in the context of the EMR. It was interesting to observe that institutions in high-income EMR countries were least likely to transfer/ translate knowledge to policy-makers and directors in NGOs. In addition, they were most likely to report submitting proposals not addressing national health research priorities and not knowing whether a national health council that regulates funding priorities existed in their countries, compared to other income level countries. These findings can be interpreted by the minimal representation of major research institutions from high-income EMR countries. Implications for research and policy National governments and international funding agen- cies are called to support research production and trans- lation through increasing the funding allocated to health research and knowledge translation, and through invest- ing and supporting capacity building activities in KT in the Region. Recently, WHO/EMRO has supported capac- ity building activities in this regard, including holding a regional training of trainers policy briefs development workshop carried out during Sept 2016 (23), followed by national exercises carried out in the Islamic Republic of Iran, which are also planned for Egypt, Saudi Arabia and Sudan. In addition, the Knowledge to Policy (K2P) Center at the American University of Beirut, Lebanon, has been designated as a WHO-Collaborating Center for Evidence Informed Policy and Practice during the period 2016–2019 to support this agenda (24). K2P is supporting WHO/EMRO through conducting priority-setting exer- cises to identify policy relevant priorities. The Center is also building capacity in evidence synthesis, producing knowledge translation documents, and guidance docu- ments. Institutions and researchers can also work to produce policy-relevant research and engage policy-makers in regular national priority-setting exercises. There is also a need for a standardized methodology for a priority- setting and impact assessment. A measure of the impact of research on policy can motivate institutions and researchers to engage in KT and for funders to support such KT activities. Table 4 Skills for disseminating health research Do researchers in your institution have skills on how to disseminate research results to: No N (%) Yes N (%) Policy-makers in the government (e.g., Ministry of Health, Ministry of Social Affairs, Ministry of Education, etc.) 83 (37.2) 140 (62.8) Directors in nongovernmental organizations 56 (25.1) 167 (74.9) Table 5 Utilization of research results and impact Never/rarely Occasionally Frequently/always N (%) N (%) N (%) How often do you examine the extent to which health policy-makers utilize your institution’s health research results? 86 (38.6%) 78 (35) 59 (26.5) How often do you measure the impact of your health research outcomes (did it influence policymaking)? 93 (41.7%) 78 (35) 52 (23.3) Research article 677 EMHJ – Vol. 24 No. 7 – 2018 Engagement des établissements de recherche en santé en faveur de l’application du savoir dans la Région de la Méditerranée orientale Résumé Contexte : Les établissements de recherche en santé de la Région de la Méditerranée orientale peuvent jouer un rôle prépondérant dans la promotion de l’application du savoir et le soutien apporté à cet égard. Il importe d’évaluer l’engagement des établissements en faveur de l’application du savoir et de combler le décalage entre les recherches et les politiques pour l’élaboration de stratégies adaptées au contexte qui permettent de faire la promotion de l’application du savoir, ainsi que pour l’orientation des efforts de financement dans la Région. Objectifs : L’objectif de la présente étude était d’examiner l’engagement des établissements de la Région de la Méditerranée orientale dans les activités liées à l’application du savoir. Méthodes : Une étude transversale a été réalisée auprès d’établissements faisant de la recherche en santé dans les 22 pays de la Région de la Méditerranée orientale. L’étude couvrait les aspects institutionnels, la planification institutionnelle de la recherche, la planification nationale de la recherche en santé, ainsi que la gestion des connaissances, leur application et leur diffusion. Résultats : Sur 575 établissements contactés, 223 (38,3 %) ont répondu. La moitié des établissements étudiés ont rapporté avoir réalisé des exercices d’établissement des priorités, 60,2 % de ces établissements ne suivant pas une approche standardisée. Moins de la moitié des établissements ont indiqué qu’ils impliquaient fréquemment/toujours (40,5 %) les responsables politiques et les parties prenantes dans l’établissement des priorités en matière de recherche en santé. Seulement 26,5 % des établissements ayant répondu ont mentionné qu’ils cherchaient à savoir dans quelle mesure les responsables politiques en santé utilisaient leurs résultats de recherche. De plus, seulement 23,3 % ont déclaré mesurer l’impact de leur recherche en santé. Conclusion : Il existe toujours un décalage entre les priorités de recherche en santé nationales et les travaux de recherche produits concrètement, et les établissements de la Région de la Méditerranée orientale continuent de ne mener des activités liées à l’application du savoir qu’en de rares occasions. Les gouvernements des pays et les bailleurs de fonds internationaux sont appelés à soutenir la production et l’application de la recherche dans la Région. Les établissements et les chercheurs sont également incités à générer une recherche utile à la politique, ainsi qu’à répondre aux besoins et aux priorités des responsables de l’élaboration des politiques. طسوتلما قشر ميلقإ في فراعملل ةيقيبطتلا ةجمترلا في ةيحصلا ثوحبلا تاسسؤم ةكراشم رابعلا نزام ،رون دممح ،يقفلا رمس ،موركوب الم ،لاجم انايد ،ليدنم دحمأ ،ليدرلجا يداف ةصلالخا يأ( فراعملل ةيقيبطتلا ةجمترلا معدو زيزعت في ًايساسأ ًارود بعلت نأ طسوتلما قشر ميلقإ في ةيحصلا ثوحبلاب ةينعلما تاسسؤملل نكمي :ةيفللخا »تاسايسلاو - ثوحبلا« ينب ةوجفلا دسو فراعملل ةيقيبطتلا ةجمترلا في تاسسؤلما ةكراشم مييقت ُّدَعُيو .)قيبطتلا عضوم ةيثحبلا ةفرعلما عضو .ميلقلإا في ةلوذبلما ليومتلا دوهج هيجوتو قيبطتلا عضوم فراعلما عضو زيزعتل قايسلا ةددمح تايجيتاترسا ميمصت في ًاماه ًارمأ .فراعملل ةيقيبطتلا ةجمترلا ةطشنأ في طسوتلما قشر ميلقإ تاسسؤم ةكراشم فاشكتسا وه ةساردلا هذه نم فدلها :فادهلأا صئاصلخا حسلما ىّطغ دقو .طسوتلما قشر ميلقإ نادلب نم ًادلب 22 في ةيحص ًاثوحب يرتج يتلا تاسسؤملل ضرعتسم حسم :ثحبلا قرط Acknowledgements This survey and related research work was supported by the WHO Regional Office for the Eastern Mediterranean. Com- pletion of this project would not have been possible without the continuous support and encouragement of Dr Ala Alwan, former Regional Director; Dr Mahmoud Fikri, late Regional Director; Dr Jaouad Mahjour, Former Director of Programme Management, and Dr Arash Rashidian, Director, Information, Evidence and Research Department. The following experts supported country-specific databases and encouraged response of participating health research institutions: Dr Najibul- lah Safi, Afghanistan; Dr Randah Hamadeh, Bahrain; Dr Sherine Shawky, Egypt; Dr Reza Majdzadeh, Islamic Republic of Iran; Dr Nada Alwan, Iraq; Dr Raeda Abu Al Rub, Jordan; Dr Hanan Badr, Kuwait; Dr Salim Adib, Lebanon; Dr Azza Greiw, Libya; Dr Asma El Alami Felousse, Morocco; Dr Adhra Al Mawali, Oman; Dr Assad Hafeez and Dr Saima Hamid, Pakistan; Dr Niveen Abu Rmeileh, Palestine; Dr Ziad Mahfoud, Qatar; Dr Haifa Wahabi, Saudi Arabia; Dr Samira Abdel Rahman, Sudan; Dr Hyam Bashour, Syrian Arab Republic; Dr Chokri Arafa, Tunisia; Dr Ghada Al Tajir, United Arab Emirates, and Dr Ali Assabri, Yemen. Funding: None. Competing interests: None declared. EMHJ – Vol. 24 No. 7 – 2018Research article 678 References 1. Gonzalez Block MA, Mills A. Assessing capacity for health policy and systems research in low and middle income countries. 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Health Res Policy Syst. 2017 09 4;15(1):77. https:// .شرنلاو ةجمترلاو ،فراعلما ةرادإو ،ةيحصلا ثوحبلل ينطولا طيطختلاو ،ثوحبلل سيسؤلما طيطختلاو ،ةيسسؤلما يرتج انهأب ةنيعلا اهتلمش يتلا تاسسؤلما فصن تدافأو .)%38.3( اهنم ةسسؤم 233 تباجتساو ةسسؤم 575 لىع لاصتلاا ىرج :جئاتنلا تاسايسلا عانص كشرت انهأب )%40.5( تاسسؤلما فصن نم لقأ دافأو .اًيرايعم ًاجهنم اهنم %60.2 عبتي لم ثيح ،تايولولأا ديدحتل تايلمع سردت انهأ ةبيجتسلما تاسسؤلما نم طقف %26.5 تدافأو .ةيحصلا اهثوحب تايولوأ ديدتح في ًمائاد وأ نايحلأا نم يرثك في ةحلصلما باحصأو مهثوحب يرثأت نوسيقي منهأب ينكراشلما نم طقف %23.3 دافأ ،كلذ لىع ةولاع .مهثوحب جئاتن نم ةيحصلا تاسايسلا يعناص ةدافتسا ىدم .ةيحصلا طسوتلما قشر ميلقإ في ةيثحبلا تاسسؤلما علطضت ام ًاردانو ،ةينطولا ةيحصلا ةيثحبلا تايولولأا ينب تلالاتخا كانه لازت لا :تاجاتنتسلاا ثوحبلا جاتنإ معدل ةوعدم ةيلودلا ليومتلا تلااكوو ةينطولا تاموكلحا نإو .فراعملل ةيقيبطتلا ةجمترلا ةطشنأو ثوحبلل ليعفلا جاتنلإاب ةباجتسلااو تاسايسلاب ةلص تاذ ثوحب جاتنإ لىإ نووعدم نوثحابلاو تاسسؤلما كلذكو .طسوتلما قشر ميلقإ في اله ةيقيبطتلا ةجمترلاو .متهايولوأو تاسايسلا يعضاو تاجايتحلا Research article 679 EMHJ – Vol. 24 No. 7 – 2018 doi.org/10.1186/s12961-017-0242-4 PMID:28870215 19. Alwan A. Responding to priority health challenges in the Arab world. Lancet. 2014 Jan 25;383(9914):284–6. https://doi.org/10.1016/ S0140-6736(13)62572-6 PMID:24452039 20. General Assembly of the United Nations. High-level meeting on Non-Communicable diseases. United Nations: New York; 2011 (http://www.un.org/en/ga/president/65/issues/ncdiseases.shtml). 21. World Health Organization WHO (2013). Global action plan for the prevention and control of noncommunicable diseases 2013- 2020. Geneva: World Health Organization; 2013. 22. Lavis JN, Permanand G, Oxman AD, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 13: Preparing and using policy briefs to support evidence-informed policymaking. Health Res Policy Syst. 2009 12 16;7 Suppl 1:S13. https://doi.org/10.1186/1478-4505-7-S1-S13 PMID:20018103 23. World Health Organization Regional Office for the Eastern Mediterranean WHO EMRO. Training of trainers workshop on capacity-building in development of policy briefs (http://www.emro.who.int/rpc/rpc-news/training-of-trainers-workshop-on-ca- pacity-building-in-development-of-policy-briefs.html). 24. Knowledge to Policy (K2P) Center. Beirut: American University of Beirut; 2017 (http://website.aub.edu.lb/k2p/Pages/index.aspx, accessed 24 November 2017). EMHJ – Vol. 24 No. 7 – 2018Review 680 Health challenges and access to health care among Syrian refugees in Jordan: a review Wireen Dator,1 Hamzeh Abunab2 and Norenia Dao-ayen3 1Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia. 2Isra University, Amman, Jordan. 3Saint Louis University, Baguio City, Philippines. (Correspondence to: Hamzeh Y. Abunab: Habunab2015@gmail.com). Introduction The 21st century has witnessed a growing number of conflicts in different parts of the world. As a result, the number of refugees seeking sanctuary in other countries is constantly increasing. The influx of refugees affects the political, socioeconomic and health circumstances of both the refugees and the host countries. The World Health Organization (WHO) and other United Nations (UN) and international aid agencies allocate resources and develop programmes to protect and sustain the security and welfare of refugees (1). Conflicts remain the greatest threat to human development (2), and at the present time, the Middle East one of the regions most affected by conflicts (3). As a result, the region has experienced and continues to experience high levels of human displacement. Iraq, Syria and Yemen collectively represent more than 30% of the global displacement of people, including 2.7 million refugees, 13.9 million internally displaced people and an estimated 374 200 stateless individuals. From Palestine alone, there are 5.1 million refugees registered in the UN Relief and Works Agency for Palestine Refugees in the Near East (3). Syria has faced an unprecedented level of displacement since 2011. At the end of 2015, more than 6.5 million Syrians were internally displaced and 4.6 million had sought refuge in different countries, including Jordan (4). Refugees in Jordan In the Middle East, Jordan is known for its modernized health care system, and Jordan’s expenditure on health represents 7.2% of its gross domestic product. The Jordanian health care system includes the public sector, private sector and non-profit organizations (5). Jordan has remained one of the few stable countries in the Middle East despite the conflicts in the surrounding countries. Its geographical location makes Jordan an important gateway for many refugees from neighbouring countries. Jordan has a long history of dealing with refugee crises since the Arab–Israeli wars which started in 1948, the Gulf wars in 1991 and 2003 and the recent Syrian conflict since 2011 (6). According to UNHCR (Office of the UN High Commissioner for Refugees), the number of Syrian refugees who fled the country because of armed conflict exceeds the 655 404 who are registered by the Jordanian Ministry of Interior and the 750 000 who entered Jordan before the crisis, making the number of Syrians living in Jordan over 1.4 million (4). In addition to that, there are about 13 0911 Iraqi and 634 182 Palestinian refugees (7,8) who also sought shelter in Jordan. Abstract Background: Syrian refugees in Jordan are currently facing difficulties in accessing adequate healthcare. Aims: This study looked at the health conditions and barriers to accessing healthcare in Syrian refugees settled in Jordan. Methods: Pubmed, CINAHL and Google Scholar were searched for published cross-sectional studies on the health status of Syrian refugees, specifically the prevalence of chronic diseases, communicable diseases, physical impairments, emotional and mental health problems, and barriers to health care. The terms searched were: Syrian refugee, health access barriers, health access, chronic diseases, communicable diseases/infectious diseases, physical impairment and mental health. The prevalence and 95% confidence intervals (CI) were calculated. Results: The literature search yielded 265 articles, of which 8 were eligible for inclusion. The prevalence of the conditions assessed were: chronic diseases, 29% (95% CI: 0.190–0.429); communicable diseases, 42.9% (95% CI: 0.184–0.713); emotional and mental health problems, 32.9% (95% CI: 0.191–0.504); physical impairment, 14.4% (95% CI: 0.056–0.322). Financial issues were the greatest barrier to accessing health care for 66% (95% CI: 0.449–0.823%). Conclusions: The health challenges of Syrian refugees are not just about chronic and acute diseases, injuries, or shortage of health resources or health disparities. It is a health burden that has become an economic, political and social crisis for the Jordanian government and its people, and measures and support to help Jordan continue to provide for refugees are needed. Keywords: Refugees, Health resources, Health services accessibility, Health status, Syria, Jordan Citation: Dator W; Abunab H; Dao-ayen N. Health challenges and access to health care among Syrian refugees in Jordan: a review. East Mediterr Health J. 2018;24(7):680–686. https://doi.org/10.26719/2018.24.7.680 Received: 03/10/16; accepted: 04/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Review 681 EMHJ – Vol. 24 No. 7 – 2018 In 2014, Jordan’s Ministry of Planning and International Cooperation reported that meeting the needs of Syrian refugees had severely affected Jordan’s public finances and government expenditure on subsidies, public services and security. Refugees began to leave the camps to live in cities and towns within Jordan, and this has placed an extra burden on the basic services and infrastructure, and the resources the local communities (9,10). Jordanian communities have borne the brunt of the influx of refugee with increased vulnerability to communicable diseases, compromised health services, and access to them, and increasing levels of morbidity, environmental issues, social problems. Aims of the study Refugees need various kinds of support including health care, education, infrastructure and resettlement resources and funding (11,12). Because of their circumstances, refugees may have poor health and face difficulties accessing health care. Lack of health insurance, and language and cultural differences are additional factors that contribute to their poorer health. This aim of this study was to evaluate the health condition of Syrian refugees in Jordan to identify their health challenges, specifically the prevalence of chronic diseases, communicable diseases, physical impairments, emotional and mental health problems, and barriers to health care, by a review of the available studies and reports. Methods Study design Searches were carried out using MEDLINE (PubMed), CINAHL, Google Scholar databases with no restriction on the date of publication. The following terms, alone or in combination, were searched: Syrian refugees, health access barriers, health access, chronic diseases, communicable diseases/infectious diseases, physical impairment and mental health. Medical subject headings (MeSH) descriptors were used to index the content of the databases. The prevalence of the outcome measures was computed based on the findings reported in the selected study using the prevalence ratio and its confidence interval levels (CI) at 95% CI. Study selection criteria Studies included in this review met the following criteria: 1) Externally displaced Syrian citizens in Jordan; 2) Outcomes – prevalence of communicable and noncommunicable diseases, physical impairment, emotional, mental health problems, and barriers to health care access; and 3) Study design – cross-sectional studies. Selected studies were evaluated using the quality assessment tool for cross-sectional studies of the Joanna Briggs Institute (13). The tool includes 8 questions assessing the following: clarity of inclusion criteria in the selected studies; detailed description of study subjects and setting; reliability and validity of measurements; objective, standard criteria used for measurement of the condition, identification of confounding factors; strategies used to deal with confounding factors; valid and reliable measurement of outcomes; and appropriateness of the statistical analyses used. Every item should be rated “Yes”, “No”, “Unclear”, or “Not applicable” (13). The result of the appraisal is rated as “include”, exclude” or “seek further information”. Review articles, editorials and other publications that were not original research articles were excluded. Synthesis of main findings Data were abstracted using a standardized abstraction tool developed by the authors to include the following information: author’s name, year of publication, study design, sample size and outcome measures obtained. The outcomes considered were: prevalence of communicable and noncommunicable diseases, physical impairment, emotional and mental health problems and barriers to accessing health care. Results The literature search yielded 265 articles (Figure 1) but only 8 studies were eligible for inclusion in the review (14–21). The general characteristics of the studies included are shown in Table 1. The total number of respondents from the 8 studies included in this review is 2 779. The result of the quality assessment is shown in Table 2. Outcomes measured A critical review done of the articles evaluated the health status of the refugees in terms of the prevalence of chronic diseases, infectious or communicable diseases, emotional and mental health problems, and physical im- pairments as outcomes that were statistically measured. Refugees were located in different parts of the country in both urban and rural areas of various governorates as designated by the Jordan government. As well as Amman, which hosts the largest urban refugee population, Irbid, Karak and Maan also have Syrian refugee populations (14,17,18). The prevalence of chronic diseases among Syrian refugees, was 29% (95% CI: 0.190–0.429). There were varying chronic conditions reported, however, the most frequently reported were hypertension, diabetes, musculoskeletal conditions, cardiovascular diseases, metabolism conditions, arthritis and respiratory diseases. Acute illnesses were also prevalent to a certain extent (14–18,20,21). The prevalence of communicable or infectious disease was 42.9% (95% CI: 0.184–0.713). The communicable diseases reported among the refugees included influenza and infectious diarrhoea. Influenza was the most prevalent communicable disease among the refugees and skin diseases were one of the less prevalent noncommunicable diseases (14,16,17). Emotional or mental health problems had a prevalence of 32.9% (95% CI: 0.191–0.504%). Different signs of psychological distress were observed in the refugees from the different camps. These signs included: stress, EMHJ – Vol. 24 No. 7 – 2018Review 682 anxiety, fear, anger, fatigue, lethargy, lack of motivation, feelings of hopelessness, depression, difficulty falling asleep or staying asleep, and having periods of terror or panic. Emotional or mental problems among the Syrian refugees were drawn from a psychological assessment conducted which revealed high a proportion of respondents suffering from one or more signs of distress. About a third of the refugees assessed suffered all 6 distresses. The majority of the refugees reported that psychological treatment and support were not needed despite the high prevalence of emotional or mental health problems (14,15,19,20). The prevalence of physical impairments was 14.4% (95% CI: 0.056–0.322%). This included functional limitations such as physical mobility, vision and hearing problems, and injuries of which 80% were sustained as a direct result of the war in Syria. Most of the injured Table 1 Characteristics of 8 included studies in the meta-analysis, Jordan No. Author (reference number) Design Sample size Measured outcomes 1 Ay et al., 2016 (14) Cross-sectional 196 - Need for health care services - Accessibility of health services - Barriers to health services access 2 Al-Fahoum et al., 2015 (15) Cross-sectional 120 - Adequacy of health care services - Satisfaction with the provided services 3 Basheti et al., 2015 (16) Cross-sectional 73 - Prevalence of psychological distress - Perspectives of the provided health care services 4 Doocy et al., 2016 (17) Cross-sectional 1550 - Access and utilization of health services among Syrian refugees 5 Doocy et al., 2015 (18) Cross-sectional 1550 - Prevalence of noncommunicable diseases - Understanding of issues related to care-seeking for noncommunicable diseases 6 Gammouh et al., 2015 (19) Cross-sectional 765 - Prevalence of chronic disease - Depression prevalence and comorbidity - Medication shortages 7 Handicap International and HelpAge International, 2014 (20) Cross-sectional 429 - The number and needs of Syrian refugees living with impairment, injury and chronic disease 8 UNHCR, 2015 (21) Cross-sectional 411 - Access to and utilization of key health services Table 2 Critical appraisal checklist for analytical cross sectional studies Item Ay et al., 2016 (14) Al-Fahoum et al., 2015 (15) Basheti et al., 2015 (16) Doocy et al., 2016 (17) Doocy et al., 2015 (18) Gammouh et al., 2015 (19) Handicap & HelpAge II, 2014 (20) UNHCR, 2015 (21) Were the criteria for inclusion in the sample clearly defined? Y Y Y Y Y Y Y Y Were the study subjects and the setting described in detail? Y Y Y Y Y Y Y Y Was the exposure measured in a valid and reliable way? Y UN Y Y Y Y Y Y Were objective, standard criteria used for measurement of the condition? Y Y Y Y Y Y Y Y Were confounding factors identified? Y Y Y Y Y Y Y Y Were strategies to deal with confounding factors stated? Y Y Y Y Y Y Y Y Were the outcomes measured in a valid and reliable way? Y Y Y Y Y Y Y Y Was appropriate statistical analysis used? Y Y Y Y Y Y Y Y Overall appraisal: Include(√), Exclude (X), or seek further info(?) √ √ √ √ √ √ √ √ Legends: Y=Yes; N= No; UN= Unclear; NA= Not applicable. Review 683 EMHJ – Vol. 24 No. 7 – 2018 people were male, around 25% were female; and a small percentage of children had also been injured. A number of disabled household members had received treatment or support—surgical treatment, rehabilitation, psychological support or assistive devices (16,20,21). Financial issues as a barrier to accessing health care was reported with a prevalence of 66% (95% CI: 0.449–0.823%). These included cost of the medical services, medicines and transportation. Refugees in the camps have free access to health care services which are subsidized by the government and other international agencies collaborating on the welfare of refugees. On the other hand, the refugees who live outside the camps are treated like non-insured Jordanians. Both refugees in the camps and those outside the camps are reported to experience financial barriers. Refugees are burdened by out-of-pocket payments to cover the high costs of services, consultations and medications in private centres. The cost of transportation is one of the highest expenses for refugees seeking health services from health centres outside the refugee camps because the majority are located far from the camps (14,17,19,20). The total prevalence of the transportation problems for refugees was 26.7% (95% CI: 0.057–0.686%) (14,17,21). The unavailability of medicines and medical equipment was reported as a barrier to obtaining the health care needed with prevalence of 26.7% (95% CI: 0.070–0.638%). Refugees seeking consultations receive prescriptions but in most cases the prescribed medications were not obtained because the medicine was out of stock at the public facility or the family could not afford the cost of the medicine. Refugees also reported other structural barriers, such as a lack of specialist doctors in health centres, and the refusal of the health facilities or personnel to provide services. The lack of medical equipment was the least reported barrier (14,17,21). The level of awareness about the available health care services also was assessed in 4 studies. The assessment included the refugees’ knowledge of the available health services such as UNHCR-supported facilities, free access to vaccination, and subsidized access to government primary health care. Lack of knowledge of the health services available to them was reported as barrier by 20.6% (95% CI: 0.115–0.342%) of refugees (14,15,17,21). Discussion Because of Jordan’s long experience of hosting refugees, it has mechanisms in place to sustain the welfare of refugees in the country. Despite the enormous sociopolitical, environmental and economic burdens of handling refugees, Jordan has remained steadfast in its humanitarian commitment to refugees despite depletion of its resources and, to some extent, deprivation of its local population of government allocations (8,9,14,15). The movement of Syrian refugees from their country began in 2011 and has continued unabated up to now. By the end of 2015, Syrians made up nearly 15% of the population in Jordan (8). Two main programmes were developed to respond to the Syrian crisis in Jordan—the Sixth Regional Response Plan (RRP6) of UNCHR and the National Resilience Plan (NRP) of the government of Jordan (9). Health condition of Syrian refugees Despite access to health care, refugees are still burdened by diseases (17). The health challenges faced by refugees reflect in general the health conditions and trends in both Syria and Jordan, and, to some extent, across the world. The epidemiology of diseases in Syrian refugees mirrors that of many countries worldwide. The findings of this review show that Syrian refugees suffer from chronic diseases, communicable diseases, injuries, and mental and emotional problems (14–21). Chronic diseases like diabetes, hypertension, cardiovascular diseases and cancer are among the leading causes of mortality and morbidity globally (2). The high burden of these noncommunicable diseases are more complex and they often require specialist care (18). Syrian refugees suffer from the same chronic illnesses, and in most cases they were diagnosed while still in Syria. Even before the outbreak of war, Syria was known to have a high burden of noncommunicable diseases (18). Displacement of refugees from their own homes and their loss of resources have worsened their health conditions. Although the risk factors for these chronic diseases are mostly modifiable, refugees are more concerned with and focused on their survival than managing their chronic conditions. At the same time, their living conditions as refugees make them more vulnerable to different kinds of diseases, both chronic and acute, communicable and noncommunicable. Therefore, health services for health promotion and illness prevention should be intensified and provision of hospital and health centre services for acute care should be improved and widened. Promotion programmes improve health-seeking behaviour and increase knowledge about home treatments for minor illnesses such as upper respiratory infections. According to UNCHR partners, one of the most unmet gaps in the response to refugees is for noncommunicable diseases (21). The ability of refugees to manage simple illnesses by themselves can help improve their health status. Improvement in their health status will reduce the number of visits to health centres and hence decrease the financial expenditure of the health services. This, to some extent, should ease the financial problems of the refugees and the burden on the health care system in Jordan. Experiencing war causes emotional and psychological stress. A number of nonpolitical organizations in Jordan, together with other groups and nongovernmental organizations, have programmes to help refugees with mental problems (15). Psychological problems when left unresolved can have dangerous consequences, and can escalate to anxiety, depression, violence, and suicide. The Jordanian government, and local nongovernmental and international organizations have included the mental health of the refugees in their recovery programmes. Programmes like the mental health and psychological support sub-working group manage clinical psychiatric care, and other groups are responsible for psychological support. EMHJ – Vol. 24 No. 7 – 2018Review 684 The Jordanian government and UNCHR have laid out comprehensive programmes to tackle the health needs of refugees, but some refugees have failed to access these services because of their lack of knowledge about them. In 2013, the Community Health Task Group was created to raise community awareness of their rights to access health care, and what and where care services are available (22). The coverage of the community health programme, which targets both refugees and Jordanians, was initially implemented in the north of Jordan and has not been expanded across the country where thousands of other refugees are living (22). Health services and state policies Health services and access to them by refugees in Jordan are fairly well established. Jordan has one of the most advanced and well-resourced health care systems in the region, with both public and private sector services that can be used by Syrian refugees (5). Jordan has integrated refugees into their health system so they can use the public services in a similar way as Jordanians. Refugees who are registered under the Ministry of Interior in Jordan are provided with health care access and benefits in the governorate where they are settled in the same way as uninsured Jordanians (16). International organizations like UNCHR also provide help for the refugees. Free health services and resources are available in the camps to help alleviate the financial burden on Jordan in meeting the health needs of the refugees. However, these are still not enough to cope with the health needs of the refugees and improve their health status, particularly as their numbers keep increasing (9). The Sixth Regional Response Plan of UNHCR involves intersectoral working groups in an organized, systematic and specialized delivery of services, which includes: cash assistance; education; food security; health, reproductive health and mental health services; nutrition; noncommunicable diseases; community health; non-food items; protection; child protection; sexual and gender- based violence; shelter; and WASH, which is responsible for water, sanitation and hygiene services. Health is one of the main components of both the UNCHR and Host Community Support Platform responses to the refugee crisis (9). The Host Community Support Platform/National Resilience Plan was established in September 2013 to prevent the deterioration of development achievements in Jordan while tackling the refugee crisis. The effect of the Syrian refugee crisis has extended across communities all over Jordan but the Host Community Support Platform initially covered only northern Jordan, mainly Irbid, Mafraq, and Zarqa governorates; it will gradually expand geographically as the crisis in the northern area is resolved (9). The programme is a government initiative parallel to the Sixth Regional Response Plan of UNHCR. In 2014, changes in the health care policies of the Ministry of Health on the access of health services by refugees required refugees to cover the costs of medicines and consultations, and this has greatly affected them (14). It has been reported that money is one of the main barriers for refugees to access health services, as well as the distance of clinics from their camps (17,19,20). Although, the programmes of the Sixth Regional Response Plan of UNHCR provide cash assistance to Syrian refugees both in and out of the camps and to vulnerable Jordanian nationals, the financial burden is still reported as a barrier to health access despite the cash assistance. Conclusions The burden of the health challenges of the Syrian refugees in Jordan is not confined to the Syrians themselves. It is not just about chronic and acute diseases, injuries, shortages of health resources, or health disparities. It is a health burden that has become an economic, political and social crisis for the Jordanian government and its people Although the health conditions of the Syrian refugees are not the best, Jordan appears to have responded adequately to the burden of the Syrian refugee crisis and provided for the needs of the large number of refugees, while at the same time maintaining service standards for Jordanians and mitigating the effect of the influx of refugees into the country. The commitment of Jordan to the responsibility of hosting the refugees, particularly given that Jordan is not an economic power in the world, is admirable and worthy of reward. Yet, some of this burden should be assumed by the international community, at least with resources that will help support the initiatives of Jordan if the financial burden is too great to allow them to maintain these initiatives and continue to take in refugees. It may also be beneficial to mobilize the refugees themselves to tackle health issues. The community organizing participatory action research model is a long- term strategy for implementing primary health care delivery in depressed and underserved communities; this could be used by the Jordanian government to empower refugees (23,24). Using this model, refugee communities would be trained and organized to participate in their health care as a part of a larger effort. It would be a long-term process but, in view of the large number of the refugees, it could be a powerful, self-serving and empowering mechanism for the refugees that at the same time could augment the Jordanian government’s refugee response programme. Finally, it is recommended to undertake a future systematic review alongside meta- analysis to capture the rising needs of Syrian refugees in Jordan. Funding: None. Competing interests: None declared. Review 685 EMHJ – Vol. 24 No. 7 – 2018 Défis en matière de santé et d’accès aux soins pour les réfugiés syriens en Jordanie : analyse Résumé Contexte : Les réfugiés syriens en Jordanie connaissent actuellement des difficultés pour accéder à des soins de santé adéquats. Objectif : La présente étude a examiné les conditions sanitaires et les obstacles qui empêchent les réfugiés syriens établis en Jordanie d’accéder aux soins de santé. Méthodes : Des recherches ont été effectuées dans les bases de données Pubmed, CINAHL et Google Scholar afin d’identifier des études transversales portant sur l’état de santé des réfugiés syriens, et plus particulièrement sur la prévalence des pathologies chroniques et des maladies transmissibles, des handicaps physiques, des problèmes émotionnels et de santé mentale, et les obstacles aux soins de santé. Les termes recherchés étaient les suivants : réfugié syrien, obstacles relatifs à l’accès à la santé, accès à la santé, pathologies chroniques, maladies transmissibles/ infectieuses, handicaps physiques et santé mentale. On a calculé les taux de prévalence et les intervalles de confiance (IC) à 95 %. Résultats : La recherche dans la littérature a produit 265 articles, dont 8 admissibles à l’inclusion. Les taux de prévalence des affections évaluées étaient : 29 % pour les maladies chroniques (IC à 95 % : 0,190-0,429) ; 42,9 % pour les maladies transmissibles (IC à 95 % : 0,184-0,713) ; 32,9 % pour les problèmes émotionnels et de santé mentale (IC à 95 % : de 0,191 à 0,504) ; 14,4 % pour les handicaps physiques (IC à 95 % : 0,056-0,322). Les problèmes financiers constituaient le principal obstacle à l’accès aux soins de santé dans 66 % des cas (IC à 95 % : 0,449-0,823). Conclusion : Les défis de santé auxquels sont confrontés les réfugiés syriens ne sont pas seulement liés aux pathologies chroniques et aiguës, aux traumatismes, à un manque de ressources en santé ou à des disparités en matière de santé. Il s’agit d’un fardeau de santé publique qui s’est transformé en crise économique, politique et sociale pour le gouvernement jordanien et sa population ; aussi des mesures et une aide sont-elles nécessaires afin de permettre à la Jordanie de continuer à pourvoir aux besoins des réfugiés. ةعجارم :ندرلأا في ينيروسلا ينئجلالا ينب ةيحصلا ةياعرلا لىع لوصلحاو ةيحصلا تايدحتلا ينياواد اينيرون ،بان وبأ ةزحم ،روتاد نيريو ةصلالخا .ةيفاكلا ةيحصلا ةياعرلا لىع لوصلحا في تابوعص ًايلاح ندرلأا في نويروسلا نوئجلالا هجاوي :ةيفللخا .ةيحصلا ةياعرلا لىإ ندرلأا في نيدوجولما ينيروسلا ينئجلالا لوصو قيعت يتلا زجاولحاو ةيحصلا تلاالحا ةساردلا هذه تضرعتسا :فدلها ينئجّلال يحصلا عضولا لوح ةروشنم ةيعطقم تاسارد نع Google Scholarو CINAHLو Pubmed تاحفص في ثحبلا مت :ثحبلا قرط زجاولحاو ،ةيسفنلاو ةيفطاعلا ةيحصلا لكاشلماو ،ةيدسلجا تاقاعلإاو ،ةيدعلما ضارملأاو ،ةنمزلما ضارملأا راشتنا تلادعم ًاديدتحو ،ينيروسلا لىإ لوصولا ،ةحصلا لىإ لوصولا تاقيعم ،نويروسلا نوئجلالا :ةيلاتلا تاحلطصلما مادختساب ثحبلا انيرجأ دقو .ةيحصلا ةياعرلا قيعت يتلا ةقث لصاوفب راشتنلاا لدعم باسح مت ماك .ةيسفنلا ةحصلاو ةيدسلجا تاقاعلإا ،ةيدعلما ضارملأا/ةيراسلا ضارملأا ،ةنمزلما ضارملأا ،ةحصلا .٪95 راشتنا لدعم ناكو .ةساردلا في جاردلإل ةلهؤم اهنم تلااقم 8 تناك ،ًلااقم 265 ثحبلا اهنع رفسأ يتلا ةروشنلما تلااقلما ددع غلب :جئاتنلا ؛)0.713–0.184 :CI %95( %42.9 ةيراسلا ضارملأاو ؛)0.429–0.190 :CI %95( %29 ةنمزلما ضارملأا :اهمييقت مت يتلا تلاالحا اياضقلا تناكو .)0.322–0.056 :CI %95( %14.4 ةيدسج ةلع ؛)0.504–0.191 :CI %95( %32.9 ةيفطاعلاو ةيسفنلا ةحصلا لكاشم .)%0.823–0.449 :CI %95( مهنم %66 ىدل ةيحصلا ةياعرلا لىإ لوصولا مامأ فقي قئاع بركأ ةيلالما ةيحصلا دراولما صقن وأ ،تاباصلإا وأ ،ةدالحاو ةنمزلما ضارملأا لىع صرتقت لا ينيروسلا ينئجلالا هجاوت يتلا ةيحصلا تايدحتلا نإ :جاتنتسلاا يربادتلا ذاتخا لىإ وعدت ةجالحاو ،اهبعشو ةيندرلأا ةموكلحا هجاوت ةيعماتجاو ةيسايسو ةيداصتقا ةمزأ لىإ لوتح يحص ءبع هنإ .ةيحصلا قراوفلا وأ .ينئجلال ةدعاسلما ميدقت ةلصاوم لىع ندرلأا ةدعاسلم معدلا ميدقتو References 1. 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San Francis- co: John Wiley & Sons; 2011. Review 687 EMHJ – Vol. 24 No. 7 – 2018 Cancer care for adolescents and young adults in Jordan Hikmat Abdel-Razeq,1 Maha Barbar,2 Taher Abu Hejleh 1 and Asem Mansour 3 1Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan (Correspondence to: H. Abdel-Razeq: habdelrazeq@khcc.jo). 2Department of Pediatrics, Hashemite University, Zarka, Jordan. 3Department of Radiology, King Hussein Cancer Center, Amman, Jordan. Introduction Cancer is one of the leading causes of morbidity and mortality in Jordan. Latest national mortality data showed that cancer accounts for 16.5% of all deaths, next only to cardiovascular disease, which claims more than one third (38.4%) of the total national mortality (1). Adult oncologists usually deal with older patients who tend to have the highest incidence of cancer, and paediatric oncologists tend to focus on younger age groups. Thus, many of the issues related to older paediatric patients and younger adults are lost in between. Ferrari et al. described this situation as: “Adolescent patients with cancer reside in a ‘no-man’s land’ between the world of paediatric oncology and that of ‘adult’ medical oncology” (2). Additionally, adolescent and young adult (AYA) patients are underrepresented in clinical trials and that might explain the lack of progress in treatment outcomes in this age group (2,3). The field of AYA oncology is evolving rapidly and has become a focused subspecialty. In Jordan and many neighbouring countries, the definition of paediatric patients is inconsistent. We use 18 years of age as the cutoff at our centre, however, many hospitals and healthcare facilities, including the Ministry of Health and military and university-based hospitals in the country treat patients above the age of 13 years as adults. There is significant variation in the definition used to describe the age of the AYA cancer population. The National Comprehensive Cancer Network (NCCN) (4) and National Cancer Institute (NCI) (5) define AYAs as 15–39 years, and as such, reported that ~70 000 young patients are diagnosed with cancer each year in the United States of America (USA), which accounts for ~5% of all cancers diagnosed. Other researches and health organizations, including the World Health Organization (WHO) (6) and the Surveillance, Epidemiology and End Results (SEER) programme (7), use different definitions of 15–25 and 15–29 years, respectively. Tumour biology and treatment outcomes vary among different age groups. Thus, an age-specific approach is needed when dealing with these cancers; acute leukaemia is a good example (8–10). Fortunately, treatment outcomes in childhood and adolescent cancer tend to be significantly better compared to those in older adults. Many younger patients survive, which highlights the need for a structured survivorship programme that takes into account the many specific issues related to their cancer and its treatment-related late complications; both physical and psychosocial (11,12). This retrospective study and literature review aimed to address such specific issues. It is hoped that this work may stimulate more research in this important field, especially given that most of our population is within this younger age group. Methods We utilized the latest edition of the Jordan Cancer Abstract Background: Adolescents and young adults with cancer have special characteristics and needs. Aims: This study highlighted psychosocial challenges, fertility issues and secondary diseases encountered in adolescents and young adults with cancer. This work is meant to be a platform for future interventions for cancer in this demographic. Methods: We investigated the latest edition of the Jordan Cancer Registry (JCR) and our more comprehensive institutional database during 2000–2012. Smoking, obesity and fertility preservation were addressed briefly as important issues among AYA patients. Results: Cancer among adolescents and young adults represents 16.3% of all new cancer cases and has increased by 25% over the past 12 years. Women are more likely to be involved (female: male ratio of 1.44: 1) because of thyroid and breast cancers. Five-year survival rate for the AYA group was 72.4%, which was significantly better than for adults aged ≥ 40 years (59.8%) but worse than for paediatric patients aged < 15 years (79.2%) (P < 0.0001). Conclusions: Cancer in adolescents and young adults represents a substantial and growing proportion of oncological diagnoses. Due to their special needs and treatment complications, a dedicated service is urgently needed. Keywords: Cancer; Jordan; adolescents, survival, registry Citation: Abdel-Razeq H; Barbar M; Abu Hejleh T; Mansour A. Cancer care for adolescents and young adults in Jordan. East Mediterr Health J. 2018;24(7):687–695. https://doi.org/10.26719/2018.24.7.687 Received: 23/01/17; accepted: 15/06/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). EMHJ – Vol. 24 No. 7 – 2018Review 688 Registry (JCR) report published in 2012 (13). The JCR report stems from an annual population-based registry that was established in 1996 under the jurisdiction of the Ministry of Health. We identified all cancers reported by the JCR in the 15–39-year age group for the period 2000–2012. The national registry does not report treatment outcomes or survival data, so these data were collected using our own institutional cancer registry that was started in 2006. This represents > 60% of the total national cancer patients and is matched to the dataset used to generate the JCR report. The cases registered within our cancer centre had their diagnosis confirmed and all their treatment and follow- up in our institution. Pubmed/Medline was searched for all published literature using the key words: Cancer; Jordan; Adolescents, Survival and Registry. Abstracts presented at major international conferences were also reviewed. Descriptive statistics were performed for all variables. Results for continuous variables were expressed as median (interquartile range). Categorical variables were expressed as numbers (percentages). The Kaplan–Meier method was adopted to estimate overall survival (OS) curves, and a log-rank test was used to compare patients’ survival times between age groups. OS was calculated from the time of primary diagnosis to death from any cause or to the last contact based on the patients’ status (dead or alive). A significance level of P ≤ 0.05 was used in the analysis. All curves were created using GraphPad Prism version 6 (La Jolla, CA, USA), and all analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC, USA). Results A total of 5013 new cancer cases were recorded in Jordan in 2012. Median age at diagnosis was 56 years, with considerable variation according to the cancer site and sex (60 years for men and 53 years for women) (13). In 2012, the crude incidence rate of all cancers among Jordanians was 78.5 per 100 000 (71.2 for men and 86.2 for women). The age-standardized rate (ASR) adjusted to the World Standard Population was 133.4 per 100 000 population (126.1 for men and 141.4 for women) (13). There were 815 AYAs, aged 15–39 years, diagnosed with cancer throughout Jordan in 2012. This represents 16.3% of the total number of cancer cases diagnosed during this period (Table 1). The female: male ratio was 1.44: 1. This female predominance was evident across all age subgroups and was mostly due to the high percentage of breast and thyroid cancers in women in the AYA age group. Breast cancer, thyroid cancer and Hodgkin’s lymphoma were the most common cancers in women in the AYA group, while testicular cancer, leukaemia and lymphoma were the most commonly encountered tumours among men (Figure 1). Since the introduction of the population-based national cancer registry in 1996, the total number of reported cases of cancer has increased from 3362 in 2000 to 5013 in 2012; a 49% increase. A similar increase was also noted in the AYA group, albeit at a slower rate. Cancer cases have increased from 654 in 2000 to 815 in 2012; a 25% increase. Much of this increase was in the older age groups of 30–34 and 35–39 years (Figure 2). The number of cases did not increase as much in the younger age Table 1 AYA (male and female) versus all cancer cases (2012) Primary cancer AYA cases (n) All cases (n) % Breast 149 1008 14.8 Thyroid 97 203 47.8 HD 68 109 62.4 Leukaemia 71 243 29.2 Colorectal 58 567 10.2 Testis 50 59 84.7 NHL 49 218 22.5 Brain and CNS 34 167 20.4 Bone 33 47 70.2 Total 815 5013 16.3 HD = Hodgkin’s disease; NHL = non-Hodgkin’s lymphoma, CNS = central nervous system Source: Jordan Cancer Registry, Ministry of Health, 2012. Figure 1 Common cancer sites in male and female AYAs. Percentages from total number of female (n=491) or male (n=324) AYA cancers. 15.9 29.9 8.1% 5.7% 5.4% Breast Thyroid HD Leukemia Colon/ Rectum 160 140 120 100 80 60 40 20 0 N um be r o f C as es (F em al es ) 8.6% 6.2% Breast Thyroid HD Leukemia Colon/ Rectum 160 140 120 100 80 60 40 20 0 N um be r o f C as es (M al es ) 8.6% 13.3% 15.4% Review 689 EMHJ – Vol. 24 No. 7 – 2018 groups (15–29 years). Survival data were available for 10 328 patients; 2194 (21.2%) of them among the AYA group (Figure 3A). All were diagnosed, treated and followed up at our institution. Five-year OS for the AYA group was 72.37%, which was significantly better than for adults aged ≥ 40 years (59.75%) but worse than for paediatric patients aged < 15 years (79.18%) (log-rank test < 0.0001). To address further the importance of age, we grouped AYA patients into two groups (15–30 and 31–39 years). Five-year OS for the younger group was 75.48%, compared to 69.93% for the older group (P = 0.0295) (Figure 3B). Discussion Survival of AYA patients with cancer is significantly better than in older age groups. Even among the AYA age group itself, patients aged ≤ 30 years have better survival than those aged > 30 years. Such findings can be explained by the types of cancer encountered and absence of comorbidity in this age group. A total of 4.1 million (43%) Jordanians are within the AYA age group, which means that Jordan, like many other countries in the Eastern Mediterranean Region, can be considered to have a young population. Although the incidence of cancer in this age group is lower than in older people, many special issues are encountered in routine clinical practice that are worth highlighting. Women are more affected than men because of breast and thyroid cancer. This highlights the importance of issues like fertility preservation among young women, and many are exposed to therapies that can negatively affect their fertility. In the following paragraphs we address issues related to breast cancer as the commonest cancer in this age group, followed by a brief discussion of late effects of childhood cancers, smoking, obesity and fertility preservation. Breast cancer Breast cancer remains the most common cancer among women, even in the AYA group. In Jordan and many neighbouring countries, breast cancer tends to be diagnosed at an earlier age. As reported by the JCR, the median age at diagnosis had not changed over the last 12 Figure 3 (A) Overall survival among AYA patients (n = 10 328). Figure 2 Cancer cases among different age groups over the past 12 years 300 275 250 225 200 175 150 125 100 75 50 25 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 15-19 F+M 20-24 F+M 25-29 F+M 30-34 F+M 35-39 F+M Age group (years) <15 15-39 >39 Age (years) Subjects Events Censored 5-year survival rate <15 1125 216 909 79.18% 15-39 2194 559 1635 72.37% >39 7009 2643 4366 59.75% 0 2 4 6 8 10 100 80 60 40 20 0 Log rank <0.0001 % Survival (years) Source: King Hussein Cancer Center Registry data (July 2006–December 2013). EMHJ – Vol. 24 No. 7 – 2018Review 690 years and remains at 50–51 years (13). In 2012, 149 breast cancer cases were reported among AYAs, representing 18.3% of all cancers in this age group and 14.8% of all breast cancer cases. In western societies, only 7.0% of all female breast cancer is diagnosed in women aged < 40 years (14). Breast cancer in younger patients tends to be associated with more aggressive features (15–17), leading to poorer prognosis and a need for more aggressive treatment, which results in a higher likelihood of long- term treatment-related toxicity, and unique psychosocial concerns (18). Additionally, familial breast cancer is more common in this age group. Over 10–15% of breast cancer patients carry high-risk mutation genes like BRCA-1 and BRCA-2 (19). Given the high penetrance rates among such mutation carriers (20,21), it is important to identify patients for whom many additional risk-reduction interventions, like bilateral mastectomy and oophorectomy can be considered. Breast reconstruction following surgery in the diseased breast or prophylactic mastectomy is important, especially in young patients. Such surgery cannot be performed without the appropriate setup that includes a multidisciplinary team approach with full psychosocial support that should also address financial cost. Most reconstructive procedures and prophylactic surgery are usually denied by almost all local private and governmental health insurance plans. Late effects of childhood cancer Late effects of childhood cancer treatment are well recognized and defined as adverse effects with onset ≥ 5 years after completion of therapy. However, this problem is not sufficiently addressed in cancer care in developing countries. The Childhood Cancer Survivor Study initiated in 1994 is the main source for understanding these late effects (22). Large cohorts of survivors were collected and followed longitudinally. In its initial phase, the study included > 14 000 survivors who were treated between 1970 and 1986. More recently, the study has expanded to include 10 000 more survivors diagnosed between 1987 and 1999 (23). Premature menopause, stroke, and second cancers were among the common potential late effects. Childhood cancer survivors should receive close, long- term follow-up, which is not routinely available. Smoking The association between tobacco smoking and cancer is well established. In a study reported in 2012, approximately half (45%) of the Jordanian population had smoked a cigarette in the past month, 40% in the past week, and 36% in past 24 hours (24). Waterpipe tobacco smoking is becoming popular in Jordan and neighbouring countries, especially among AYAs. In another study reported in 2014, Figure 3 (B) Overall survival by age group among AYAs (n = 2194). Source: King Hussein Cancer Center Registry data (July 2006–December 2013). Age group (years) 15-30 30-39 Age (years) Subjects Events Censored 5-year survival rate 15-30 951 220 731 75.48% 30-39 1243 339 904 69.93% 0 2 4 6 8 10 100 80 60 40 20 0 Log rank p=0.0295 % Survival (years) Review 691 EMHJ – Vol. 24 No. 7 – 2018 1845 students from 4 local universities were randomly recruited. Waterpipe tobacco smoking rates were 30% in the past 30 days and 56% ever, while cigarette smoking rates were 29% in the past 30 days and 57% ever. Past 30-day waterpipe tobacco smoking rates were 59% for men and 13% for women (25). In a third study conducted among 547 students in local dental schools, 54.3% of men and 11.1% of women reported current tobacco use. The majority had used both cigarettes and waterpipe tobacco. Nearly half of the women reported that they smoked at home in the presence of their parents (26). These findings underscore the extent of the smoking problem in our population, especially among the younger age groups, and the urgent need for effective smoking cessation interventions. A national cancer control programme does not exist in Jordan. However, a tobacco control programme was recently established to help increase public awareness of the hazards of smoking and to introduce new legislation that prohibits smoking in public places. However, compliance with such programmes is still poor. Although no official data exist on the smoking rates among AYA cancer survivors, it is expected to be high. The physical and psychosocial complications that result from cancer treatment places stress on patients, especially younger ones, that may encourage them to smoke, especially within a society that views smoking as a common cultural habit. This is an important issue to recognize as the late complications of AYA cancer treatment, such as coronary artery disease and stroke, are likely be higher with smoking. Obesity Obesity continues to represent a significant public health problem and has recently grown into a major global health epidemic (27). In the USA, more than two thirds of adults are now overweight and one third is obese. It is also estimated that one third of children and adolescents in the USA are either obese or overweight (28). In a more recent report, the prevalence of obesity among children and adolescents aged 2–19 years was 17.0% and extreme obesity was 5.8% (29). Obesity in Jordan and many neighbouring countries is also common. In a study that included 2836 subjects aged ≥ 25 years conducted in 4 Jordanian towns, the overall prevalence of obesity, defined as body mass index ≥ 30 kg/m2, was 49.7%. Obesity was more common in women (59.8 vs 32.7% in men) (30). More recent studies have reached similar conclusions (31,32). Cancer treatment, directly or indirectly, can lead to overweight and obesity. Steroids are active components of many chemotherapeutic regimens and are widely prescribed as antiemetic therapy. Cranial irradiation for childhood cancer appears to have the greatest influence on obesity in adult life. In a study reported in 2015, 47% of those who received this form of treatment became obese compared with 29.4% who did not (33). A retrospective study in 2003 compared 1765 adult survivors of childhood acute lymphoblastic leukaemia, whose treatment protocol included cranial irradiation, to 2565 adult siblings of childhood cancer survivors (34). The odds ratio for being obese in survivors in comparison with siblings was 2.59 for women and 1.86 for men. The risk of obesity was greatest among women diagnosed at 0–4 years of age and treated with radiation doses ≥ 20 Gy. Even in children and adolescents, obesity is associated with many comorbidities including gastrointestinal, endocrine, cardiovascular, orthopaedic, pulmonary, neurological, dermatological and psychosocial problems (35). In addition to these serious medical problems, direct medical cost and economic impact related to obesity and its associated problems put a lot of pressure on healthcare budgets (36). Many large epidemiological studies have clearly shown that obesity is a major modifiable risk factor for many cancers including, but not limited to, cancer of the endometrium, colorectum, kidney, oesophagus, breast and pancreas (37–40). Moreover, obesity can be a poor prognostic factor and contributes to the unfavourable survival rates in obese patients with cancer (38,41–43). Higher likelihood of comorbidity and unfavourable tumour characteristics and a tendency to underdose chemotherapy in obese patients may contribute to such poorer survival rates, particularly among breast cancer patients (44,45). With the earlier onset of overweight and obesity, often occurring during childhood, there is a concern that the effects of obesity on cancer outcomes are even worse. Although we do not have strong evidence that weight loss is associated with better cancer survival, improved diet and greater physical activity associated with weight loss do have clear health advantages. Given the above problems, there is an urgent need to implement health programmes to prevent and control overweight and obesity at a national level (46). Counselling with a dietician and establishment of an exercise programme should be routine components of the multidisciplinary approach to cancer. Oncologists should devote enough time to discuss weight loss with their overweight patients with cancer (47). Fertility preservation Over recent decades, survival rates for most cancers have significantly improved and more younger patients survive their disease. Many of the cancer treatment methods, especially chemotherapy, can have a negative impact on fertility both in men and women. There are established means of preserving fertility prior to cancer therapy. Sperm cryopreservation is routinely practiced in young men and in vitro fertilization and embryo cryopreservation are widely available for young women. Several innovative techniques, including ovarian tissue cryopreservation, are being actively investigated. Current techniques are limited by the patient’s sexual immaturity, and all available approaches for children are experimental (48,49). Several studies have shown that gonadotropin-releasing hormone agonists when used with chemotherapy protect against ovarian failure, reducing the risk of early menopause and improving prospects for fertility (50). EMHJ – Vol. 24 No. 7 – 2018Review 692 Several factors may contribute to low compliance rates. Impaired future fertility is difficult for children to understand although outcomes are potentially traumatic to them as adults (51). Additionally, patients may not be aware of the potential fertility loss and such problems may not be communicated well by the treating physicians (51, 52). Patients and families are usually overwhelmed and focus exclusively on the cancer diagnosis and treatment and may be concerned that pursuing fertility preservation will delay their treatment, thus negatively affecting their cure rates (53–55). In a web-based survey from the Dana– Farber Cancer Institute, Boston, USA, in 2010, only 29% of 657 breast cancer patients with a mean age at diagnosis of 32.9 years reported that infertility concerns influenced their treatment decisions (56). In 2013, the American Society of Clinical Oncology (ASCO) issued updated guidelines recommending that providers discuss fertility preservation with all patients of reproductive age who will be receiving cancer treatment with a possible risk of iatrogenic infertility. However, compliance with such recommendations is still poor, even in western societies (57). In another study, 201 patients aged 13–50 years who received a new cancer diagnosis and planned to initiate curative chemotherapy at the University of North Carolina were reviewed (58). Only 59 (29%) received fertility counselling and 23 (11%) attempted sperm banking. Younger patients were significantly more likely to be counselled, with mean ages of 27.4 and 40.4 years for counselled and noncounselled patients, respectively. Among counselled patients, those with a lower median income or who had Medicaid or no insurance were less likely to bank sperm. The present study and many others (59–61) clearly demonstrate the low referral rates for fertility counselling and fertility preservation. Improved education for providers, system-wide interventions, implementing standardized processes for sperm and ova preservation, and the institution of fertility preservation programmes will hopefully increase referral for such services. Conclusion More than 40% of the Jordanian population are within the AYA age group. Fortunately, the cancer incidence in this age group is lower and their survival is better than in older adults. Smoking, obesity and fertility preservation are among many other important issues in this age group. Specialized ancillary services addressing these issues need to be incorporated into multidisciplinary teams treating such patients, leading to the establishment of comprehensive AYA cancer programmes. Funding: None. Competing interests: None declared. Soins du cancer chez l’adolescent et le jeune adulte en Jordanie Résumé Contexte : Les caractéristiques et les besoins particuliers des adolescents et des jeunes adultes atteints de cancer sont spécifiques. Objectif : La présente étude a mis en évidence les difficultés psychosociales, les questions liées à fécondité et les pathologies secondaires auxquelles font face les adolescents et les jeunes adultes atteints de cancer. Ce travail a été conçu pour servir de tremplin à de futures interventions en faveur d’un traitement anticancéreux destiné à cette tranche de population. Méthodes : De 2000 à 2012, nous avons basé notre étude sur la dernière édition du Registre national du cancer de Jordanie, ainsi que sur notre base de données institutionnelle, plus complète. Les questions liées au tabagisme, à l’obésité et à la préservation de la fécondité chez les patients appartenant au groupe des adolescents et des jeunes adultes ont été brièvement traitées et considérées comme des problèmes importants. Résultats : Le cancer des adolescents et des jeunes adultes représente 16,3 % de tous les nouveaux cas de cancer et cette proportion a augmenté de 25 % ces 12 dernières années. Le risque d’atteinte est plus élevé chez les femmes (le ratio femmes- hommes étant de 1,44 : 1) en raison des cancers de la thyroïde et du sein. Le taux de survie à cinq ans pour le groupe des adolescents et des jeunes adultes était de 72,4 %, taux significativement plus élevé que celui présenté par les adultes de 40 ans et plus (59,8 %), mais moins favorable que celui des patients pédiatriques de moins de 15 ans (79,2 %) (p < 0,0001). Conclusion : Le cancer des adolescents et des jeunes adultes représente une part notable et croissante des diagnostics oncologiques. Étant donné qu’il implique des besoins et des complications de traitement particuliers, il est urgent de créer un service consacré à cette tranche de population. Review 693 EMHJ – Vol. 24 No. 7 – 2018 ندرلأا في بابشلاو ينقهارلما ناطسرلا ضىرم ةياعر روصنم مصاع ،ةلجح وبأ رهاط ،ربرب اهم ،قازرلا دبع تمكح ةصلالخا .ةصاخ تاجايتحاو ةزيمتم صئاصخ ناطسرلاب ينباصلما بابشلاو ينقهارملل :ةيفللخا نوباصلما بابشلاو نوقهارلما اههجاوي يتلا ةيوناثلا ضارملأاو ةبوصلخا اياضقو ةيعماتجلااو ةيسفنلا تايدحتلا ةساردلا هذه تزربأ :فدلها .ةيناكسلا ةعومجلما هذه في ناطسرلل ةيلبقتسلما تلاخدتلا اهنم قلطنت ةصنم ءاسرلإ ةساردلا هذه فدتهو .ناطسرلاب .2012-2000 ةترفلا للاخ انيدل ةيلومش رثكلأا ةيسسؤلما تانايبلا ةدعاقو ناطسرلل نيدرلأا لجسلا نم رادصإ ثدحأ انسرد :ثحبلا قرط .بابشلاو ينقهارلما ناطسرلا ضىرم ينب ةمهم اياضق اهرابتعاب ةبوصلخا لىع ةظفاحلماو ةنمسلاو ينخدتلا اياضق زايجإب انسردو يتنثلاا تاونسلا للاخ ٪25 ةبسنب داز دقو ،ةديدلجا ناطسرلا تلااح عوممج نم ٪16.3 بابشلاو ينقهارلما بيصي يذلا ناطسرلا لثمي :جئاتنلا ناطسر ببسب كلذو ،)1 لىإ 1.44 روكذلا لىإ ثانلإا ةبسن( روكذلا ةباصإ نم ًلاماتحا رثكأ ثانلإا ةباصإ نأ ةساردلا نم حضتاو .ةيضالما ةشرع رادقمب لضفأ وهو ،٪72.4 بابشلاو ينقهارلما ةعوممج ىدل تاونس 5 ةدلم ةايلحا ديق لىع ءاقبلا لدعم ناكو .يدثلا ناطسرو ةيقردلا ةدغلا < P( ناكو )٪79.2( ًاماع 15 نع مهرماعأ لقت نيذلا لافطلأا ىدل أوسأ هنكلو ،)٪ 59.8( رثكأ وأ ًاماع 40 رمع في ينغلابلا ىدل امم هب ّدتعي .)0.0001 ببسب مله ةصصمخ ةدحو ءاشنإ لىإ ةجالحا ّستمو .مارولأا تاصيخشت نم ةيمانتمو ةيربك ةبسن بابشلاو ينقهارلما في ناطسرلا لثمي :جاتنتسلاا .ميهدل جلاعلا تافعاضمو ةصالخا متهاجايتحا References 1. 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J Pediatr Hematol Oncol. 2012 Nov;34(8):e315–9. https://doi.org/10.1097/MPH.0b013e3182678e3a PMID:22983421 EMHJ – Vol. 24 No. 7 – 2018Commentary 696 Reducing maternal mortality: the case for availability and safety of blood supply Yetmgeta Abdella,1 Rana Hajjeh 1 and Cees Th. Smit Sibinga 2 1World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: Y.E. Abdella: abdellay@who.int). 2International Quality Management (IQM) Consulting, Zuidhorn, Netherlands. Citation:Abdella Y; Hajjeh R; Smit Sibinga C. Reducing maternal mortality: the case for availability and safety of blood supply. East Mediterr Health J. 2018;24(7):696–697. https://doi.org/10.26719/2018.24.7.696 Received: 16/02/17; accepted: 30/08/17 Copyright Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Maternal health is one of the main public health concerns globally and in the World Health Organization (WHO) Eastern Mediterranean Region. An estimated 303 000 maternal deaths occurred worldwide in 2015; most of which were avoidable (1). Three quarters of the countries with maternal mortality ratios (MMRs) > 300 per 100 000 live births are fragile states. Some countries in the Region, including those with humanitarian emergencies, such as Afghanistan, Somalia and Yemen, are among those with the highest MMRs in the world (2). As a result of sustained efforts of governments and partners, including WHO, United Nations Children’s Fund, United Nations Population Fund, and World Bank Group, the global MMR decreased by 43.9% from 385 deaths per 100 000 live births in 1990 to 216 in 2015 (1). By the end of 2015, much progress had been made towards achieving Millennium Development Goal 5 in the Region. Between 1990 and 2015, MMR decreased by 54% although the decline has been uneven between and within countries (3). Haemorrhage remains the leading direct cause of maternal death worldwide, representing 27% of maternal deaths; of which, more than two thirds are due to postpartum haemorrhage (4). The prevention and treatment of postpartum haemorrhage requires a multiplicity of interventions, including rapid recognition of warning signs of blood loss, vigorous resuscitation with fluids, and timely blood transfusion (5,6). At least one quarter of all maternal deaths due to haemorrhage could be prevented by rapid access to safe blood transfusion (7). However, data collected from countries in the Region indicate that rapid availability and access to safe blood transfusion for patients in need remain a challenge. In 2013, ~7 million units of whole blood were collected. Blood donation rates vary among countries, ranging from 0.7 (Yemen) to 29.0 (Lebanon) units per 1000 population. Six countries, including those with a high burden of maternal mortality, have inadequate blood supplies, with donation rates < 10 units per 1000 population (8). Despite the vital role of blood transfusion in the implementation of essential interventions for maternal health, such as management of postpartum haemorrhage, and delivery of universal health coverage, inadequate attention is given to blood transfusion services and their linkage to maternal health programmes. In January 2016, the global development community committed to the 2030 agenda for Sustainable Development Goals (SDGs), with new targets including 1 that focuses on reducing maternal mortality (9). SDG Target 3 challenges governments and partners to reduce the global maternal mortality ratio to < 70 per 100 000 live births by 2030, with no country having a maternal mortality rate of more than twice the global average (9). The increasing global attention on the SDGs and the set targets provide much needed impetus to focus on proven interventions in reducing MMR, which cannot be ensured without significant investment to ensure the availability and safety of blood transfusion (7). This requires identifying gaps through an in-depth analysis of factors affecting access to safe blood and implementing interventions, in line with the Regional Strategic Framework for Blood Safety and Availability 2016–2025 (10). In view of this, it is critical to encourage ministries of health, particularly in countries with high rates of maternal mortality to take concrete steps towards improving timely availability and access to safe blood transfusion as part of a comprehensive approach to reduce maternal mortality. This will require strengthening partnerships between maternal health programmes and blood transfusion services to improve access to and ensure safety of blood in order to contribute to achieving SDG targets and deliver universal health coverage. References . 1 Alkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, et al.; United Nations Maternal Mortality Estimation Inter-Agency Group collaborators and technical advisory group. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter- Agency Group. Lancet. 2016 Jan 74–462:(10017)387;30. https://doi.org/10.1016/S7-00838(15)6736-0140 PMID:26584737 Commentary 697 EMHJ – Vol. 24 No. 7 – 2018 . 2 Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015 (http://apps.who.int/iris/bitstream/hand le/9789241565141/194254/10665_eng.pdf?sequence=1, accessed 28 March 2018). . 3 Shaping the future of health in the WHO Eastern Mediterranean Region. Reinforcing the role of WHO 2016–2012. Progress report May 2016. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2016 (http://applications. emro.who.int/dsaf/EMROPUB_2016_EN_18776.pdf?ua=1, accessed 28 March 2018) . 4 Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014 Jun;6)2):e33–323. https://doi.org/10.1016/S109-2214X(-70227(14X PMID:25103301 . 5 Campbell OM, Graham WJ; Lancet Maternal Survival Series Steering Group. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006 Oct 99–1284:(9543)368;7. https://doi.org/10.1016/S1-69381(06)6736-0140 PMID:17027735 . 6 WHO recommendations for the prevention of postpartum haemorrhage. Geneva: World Health Organization; 2012 (http://apps. who.int/iris/bitstream/handle/9789241548502/75411/10665_eng.pdf?sequence=1, accessed 28 March 2018). . 7 Bates I, Chapotera GK, McKew S, van den Broek N. Maternal mortality in sub-Saharan Africa: the contribution of ineffective blood transfusion services. BJOG. 2008 Oct;9–1331:(11)115. https://doi.org/10.1111/j.0528.2008.01866-1471.x PMID:18823485 . 8 The 2016 regional status report on blood safety and availability. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2017 (http://applications.emro.who.int/docs/EMROPub_2017_EN_18907.pdf?ua=1, accessed 28 March 2018). . 9 Sustainable Development Goals. New York: United Nations; 2015 (https://sustainabledevelopment.un.org/?menu=1300, accessed 28 March 2018) . 10 Strategic framework for blood safety and availability 2025–2016. World Health Organization Regional Office for the Eastern Mediterranean; 2016 (http://applications.emro.who.int/dsaf/EMROPub_2017_EN_19608.pdf?ua=1, accessed 28 March 2018). EMHJ – Vol. 24 No. 7 – 2018WHO events addressing public health priorities 698 1 This report is extracted from the Summary report on the twenty-third meeting of the Eastern Mediterranean Regional Working Group on GAVI, the Vaccine Alliance, Muscat, Oman, 15–16 December 2017 (http://applications.emro.who.int/docs/IC_Meet_Rep_2018_EN_17001.pdf?ua=1). Twenty-third meeting of the Eastern Mediterranean Regional Working Group on GAVI, the Vaccine Alliance Citation: Twenty-third meeting of the Eastern Mediterranean Regional Working Group on GAVI, the Vaccine Alliance. East Mediterr Health J. 2018;24(7):698-699 https://doi.org/10.26719/2018.24.7.698 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). The Global Alliance for Vaccines and Immunization (GAVI) is an international organization created in 2000, which brings together public and private sectors with the shared goal of creating equal access to new and underused vaccines for children living in the world’s poorest countries (1). The twenty-third meeting of the Eastern Mediterranean Regional Working Group on GAVI, the Vaccine Alliance, was held during 15–16 December 2017, Muscat, Oman. It was organized by the World Health Organization (WHO) as Chair of the Regional Working Group and attended by ministry of health staff from both immunization and health system departments in GAVI- supported countries of the WHO Eastern Mediterranean Region, as well as representatives from GAVI Secretariat, the Bill & Melinda Gates Foundation, Centers for Disease Control and Prevention (CDC), United Nations Children’s Fund (UNICEF) and WHO staff from headquarters, the Regional Office and country offices (2). The objectives of the meeting were to: • review progress in implementing Expanded Pro- gramme on Immunization (EPI) activities supported by GAVI; • identify weaknesses, gaps and recommend corrective measures; • brief and update participants on new GAVI policies and new GAVI window of support ; • review progress on the implementation of GAVI part- ners’ engagement framework (PEF) activities; and • review implementation of the health system strength- ening-agreed activities that should improve EPI ac- cess and coverage in GAVI-eligible countries. The meeting was the first to be held with the updated terms of reference agreed upon at the twenty-second meeting of the Regional Working Group on GAVI (3). The regional working groups are the primary regional forums for GAVI partner and programme coordination, consensus building, and monitoring the implementation of GAVI resources and support, in the context of GAVI’s PEF. The meeting was inaugurated by Dr Akjemal Magtymova, WHO Representative in Oman, who highlighted the sincere efforts of GAVI in supporting countries to achieve the goals of Global Vaccine Action Plan (4) and the Eastern Mediterranean Vaccine Action Plan 2016–2020 (5). Dr Nadia Teleb, WHO Regional Advisor for Vaccine Preventable Diseases and Immunization, noting WHO’s role in chairing the Regional Working Group since the inception of GAVI, welcomed UNICEF as the new Chair and stressed the importance of the Group for successful utilization of GAVI support. Ms Nicolette Selman, GAVI Regional Head of Country Support, acknowledged the progress achieved in some countries, and encouraged all countries to achieve the global immunization goals. Summary of discussions It was noted that the GAVI 2016–2020 strategy necessitates new ways of working. The GAVI Alliance needs to renew the focus of its investments to improve coverage and equity in the Region. Participants were briefed on the fragility, emergencies and refugee policy that was approved by the GAVI Board in June 2017, in response to a changing global context. Afghanistan, Somalia, Sudan and Yemen are the countries affected by the policy in the Region. The key principles for PEF were outlined as being country focus, differentiation, transparency and accountability. It was agreed that for 2018, PEF targeted country assistance planning will be done through the One targeted assistance (TA) Plan (6). GAVI’s approach was welcomed by participants, who requested greater clarity on flexibility regarding yellow fever and meningitis, as well as specific plans for refugee and cross-border activities. The need to simplify processes was also highlighted by participants. Moreover, participants were briefed that the average Penta3 coverage for 2016, as per WHO/UNICEF estimates, for the six GAVI support-receiving countries in the Region was 73%, compared with 91% for the remaining 16 countries. An estimated 3.7 million infants in the Region did not receive their third dose of diptheria-tetanus- pertussis (DTP) vaccine during 2016, with 98% of them living in countries facing difficult situations (7). Recommendations To Member States • Analyse coverage and equity, and determine why cov- erage is low and unequitable in specific populations and where the unimmunized children are. WHO events addressing public health priorities 699 EMHJ – Vol. 24 No. 7 – 2018 References 1. Gavi. About Gavi, the Vaccine Alliance. Geneva: Gavi; 2017 (https://www.gavi.org/about/). 2. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Summary report on the Twenty-third meeting of the Eastern Mediterranean Regional Working Group on Gavi, the Vaccine Alliance. Cairo: WHO/EMRO; 2018 (http:// applications.emro.who.int/docs/IC_Meet_Rep_2018_EN_17001.pdf?ua=1). 3. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Summary report on the Twenty-sec- ond meeting of the Eastern Mediterranean Regional Working Group on Gavi, the Vaccine Alliance. Cairo: WHO/EMRO; 2017 (http://apps.who.int/iris/bitstream/handle/10665/255796/IC_Meet_Rep_2017_EN_19886.pdf?sequence=1&isAllowed=y). 4. World Health Assembly. Global Vaccine Action Plan. Geneva: World Health Assembly; 2012 (http://www.who.int/immunization/ global_vaccine_action_plan/GVAP_doc_2011_2020/en/). 5. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). The Global Vaccine Action Plan. Cai- ro: WHO/EMRO; 2015 (http://applications.emro.who.int/docs/RC62_presentation_technical_papers_2015_6_16470_EN.pdf). 6. Gavi. Partners’ engagement framework. Geneva: Gavi; 2017 (https://www.gavi.org/about/governance/.../06---partners--engage- ment-framework). 7. World Health Organization. Global Vaccine Action Plan: regional reports on progress towards GVAP–RVAP goals. Geneva: World Health Organization; 2017 (http://www.who.int/immunization/global_vaccine_action_plan/web_regional_gvap_reports_2017. pdf?ua=1). • Review implementation progress regularly, identify bottlenecks and take remedial actions in consultation with in-country partners. • Target and tailor strategies to address coverage and equity constraints and enhance immunization out- comes. • Conduct the application development process in a coordinated and comprehensive manner following a specific timeline. • Ensure long term planning in a holistic manner to identify the need for technical assistance. • Provide a plan for the continuation/expansion of sur- veillance activities, so that WHO can develop a pro- posal to secure the required funding from partners. • Put more effort into improved data quality, analysis and availability, to allow evidence-based discussions during the Joint Appraisal. • Identify missed children, and prepare strategies and activities to reach them. To partners and GAVI Secretariat • Support countries in the above mentioned activities. • Ensure the quality and timeliness of technical assis- tance is identified. • Modify the technical assistance planning template to capture staff and activity costs separately in a sepa- rate worksheet. • Extend the duration of the grant beyond two years for better planning. • Issue standard guidance to senior country managers on the number and formulation of milestones for mid and end of year. • Allow the leverage of existing resources for continua- tion of important surveillance activities. • Request UNICEF to share their experience of urban immunization, for instance at EPI manager/regional working group meetings. To WHO • expedite the streamlining of administrative process- es to support countries in implementing planned activities in a timely manner. • ensure greater engagement in supporting country teams in the application development process to en- sure quality. • Support better documentation in countries of the relevant information required for the application process. • Develop a proposal based on country needs for con- tinuation/expansion of surveillance activities. Eastern Mediterranean Health Journal IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and individuals within and outside the Region. طسوتلما قشرل ةيحصلا ةلجلما ةماعلا ةحصلا في ةديدلجا تاردابلماو تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخاو ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا La Revue de Santé de la Méditerranée Orientale EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa- tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes concernés au sein et hors de la Région. Correspondence Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic Tunisia . United Arab Emirates . Yemen طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا برغلما . صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةيروسلا ةيبرعلا ةيروهملجا نميلا . ةيدوعسلا ةيبرعلا ةكلملما Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . 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EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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In the Eastern Mediterranean Region, 8 out of 9 people with hepatitis are unaware of their infection. #Test4Hepatitis La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal EMHJ – Vol. 24 No. 7 – 2018 Volume 24 / No. 7 July/Juillet 7 ددع / نوشرعلاو عبارلا دلجلما زوتم/ويلوي2018 Eastern M editerranean H ealth Journal Vol. 24 N o. 7 – 2018 Editorial Towards a hepatitis-free Egypt: is this achievable? Wahid Doss, Joumana Hermez, Hoda Atta and Jean Jabbour ................................................................................................................................................................609 Research articles Payment system of urban family physician programme in the Islamic Republic of Iran: is it appropriate? 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Smit Sibinga....................................................................................................................................................................696 WHO events addressing public health priorities Twenty-third meeting of the Eastern Mediterranean Regional Working Group on GAVI, the Vaccine Alliance ..........698 Cover 24-07.indd 1-3 03/09/2018 09:03:59