Eastern Mediterranean Health Journal [2019; Vol.25, Issue 8]

La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Volume 25 / No. 8 August/Août 8 ددع / نوشرعلاو سمالخا دلجلما بآ/سطسغأ2019 Eastern M editerranean H ealth Journal Vol. 25 N o. 8 – 2019 The Easter Mediterranean Region suffers from the greatest number of natural and man-made disasters. In response, the World Health Organization (WHO) has strongly advocated for health systems preparedness in order to mitigate the effects of displaced populations, ensure family access to adequate health facilities, and support the maintenance of child health and welfare measures as part of WHO’s commitment to Sustainable Development Goal 3: “Ensure healthy lives and promote well-being for all ages.” 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 . Yémen Subscriptions and Permissions Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: emrgoksp@who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: emrgoegp@who.int. EMHJ 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) 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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ISSN 1020-3397 Cover 25-03.indd 4-6 4/25/2019 11:15:19 AM Editorial ...................................................................................................................................................................................................................525 Research articles Dental environment and war-related stress among dental students, Yemen Esam Halboub, Mohammad Nasser Alhajj, Mohammed Ali Al-Wesabi, Saba Al-Sanaani and Abdulbaset Mufadhal .......................... 529 Relationship between domestic violence and infertility Seyede Marziye Rahebi, Mona Rahnavardi, Sedighe Rezaie-Chamani, Mojgan Nazari and Shadi Sabetghadam ................................ 537 Prevalence and risk factors of anaemia among ever-married women in Jordan Rasha Arabyat, Ghaith Arabyat and Ghaith Al-Taani ................................................................................................................................................... 543 Health system preparedness in Pakistan for crisis management: a cross-sectional evaluation study Zia Ul-Haq, Basharat Hussain Shah, Mohammad Ardakani, Saeed Akbar Khan,Saleem Muhammad, Saeed Farooq, Sardar Hayat Khan and Qudsia Huda ................................................................................................................................................... 553 Perspectives of medical students and teaching faculty on teaching medicine in their native language Ziyad Alrajhi, Ali Alhamdan, Musab Alshareef, Osama Almubaireek, Mohamud Mohamud, Aamir Omair, Emad Masuadi and Bashir Hamad .................................................................................................................................................................................... 562 Cognitive factors associated with Brucellosis preventive behaviours among diagnosed patients: an application of Empowerment Model Towhid Babazadeh, Haidar Nadrian, Soheila Ranjbaran, Hamed Rezakhani-Moghaddam and Mehran Aghemiri ............................. 567 The effect of a maternal training programme on early childhood development in Egypt Heba Mohammed, Omaima El-Gibaly, Eman Monazea, Medhat Saleh and Hanaa Mohammed ............................................................... 575 Influenza pandemic preparedness in the World Health Organization Eastern Mediterranean Region Wasiq Khan, Amira El Rifay, Mamunur Malik and Ghazi Kayali ........................................................................................................................... 583 WHO events addressing public health priorities Steering committee for Eastern Mediterranean Region drug regulatory authorities............................................................ 591 Vol. 25.08 – 2019 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, Manar El Sheikh Abdelrahman (Statistics editors) Administration Iman Fawzy, Marwa Madi 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 527 Editorial EMHJ – Vol. 25 No. 8 – 2019 Citation: Editorial. East Mediterr Health J. 2019;25(8):527–528. https://doi.org/10.26719/2019.25.8.527 Copyright © World Health Organization (WHO) 2019. 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). More than 1.5 billion people have been affected by crises over the last decade, especially the vulnerable groups including children and women (1), incurring economic losses in excess of US$ 1.3 trillion (2). The Easter Medi- terranean Region suffers from the greatest number of natural and man-made disasters and is especially prone to such events because of its geo-climactic characteristics with significant increase in the risk of disasters projected over the next two decades (3). In addition, it is home to many tenacious conflicts including insurgencies, ethnic tensions, and sectarian clashes with potential for further escalation (4). Such calamities not only lead to displaced populations and infrastructure damage, but also lead to breakdowns in health systems that permit disease out- breaks. The World Health Organization (WHO) has strong- ly advocated health systems’ preparedness for effective management of crisis situations, which forms the basis for the study “Health system preparedness in Pakistan for crisis management: a cross-sectional evaluation study” (5). Pakistan has been beset with environmental and po- litical degradation for a number of years, and adequate urgent response to human catastrophe incidents, due to political turmoil or extreme weather events, continues to be challenge for humanitarian organizations when inad- equate country-wide crises response mechanisms hinder effective health systems. Moreover, preparedness for disease pandemics need not always be linked to the presence of health systems degradation, but can also highlight the need to anticipate potential disasters before they even materialize. Although the last influenza H1N1 pandemic in 2009 was relatively mild, fear prevails that the next one might not be (6,7). Due to frequent mutations and re-assortment in its ge- nome, influenza is a continuously evolving virus; poten- tial source of epidemics / pandemics, accordingly (8). Pre- dicting when or where an influenza pandemic may arise, or even which strain will be the culprit is a difficult task (9). Thus, WHO has urged every country to develop and maintain an up-to-date national influenza preparedness plan, and provided guidance on plan content (10), as dis- cussed in the article “Influenza pandemic preparedness in the WHO Eastern Mediterranean Region (11). Empowerment of patients to self-manage the com- mon zoonotic disease brucellosis in the article “Cognitive factors associated with Brucellosis preventive behav- iours among diagnosed patients: an application of Em- powerment Model” (12) highlights how relatively com- mon diseases still require a country-wide approach to their containment. However, one aspect of the effect of internal politi- cal conflict on populations has received little attention, namely how the health care professionals of tomorrow struggle to qualify in such adverse environments. Re- gional political upheaval that started in 2011 extended to Yemen, resulting in civic instability and eventually ended up with a war that is still ongoing. The effects of war on dental students in Yemen have not been widely studied, although political conflicts would be expected to have direct / indirect negative consequences on soci- ety, including university students (13). This topic was the focus of research in the article “Dental environment and war-related stress among dental students, Yemen” (14). In addition to the political turmoil that can affect students’ performance, the article “Perspectives of medical stu- dents and teaching faculty on teaching medicine in their native language” (15) looks at how the choice of using the native language for instruction in medicine has a signifi- cant impact on the students who sit for such studies, as it facilitates the process of acquiring knowledge and utiliz- es the optimum potential of the students. Of course, environmental stress can have a multitude of sources including domestic, as examined in the article “Relationship between domestic violence and infertility” (16), when the anxiety of infertility is compounded by so- cial expectations and fear that can manifest in aggressive behaviour and even injury, where usually it is the woman suffering assault, both psychological and physical. Sup- porting women’s health continues to be of great impor- tance when considering the more traditional roles that women as mothers and caregivers undertake in the Re- gion, and maternal support in the relation with effective child development is the focus of research in the article “The effect of a maternal training programme on early childhood development in Egypt” (17), which examines positive correlations with effective maternal training and improved cognitive and behavioural development in children. Yet diet and maternal and reproductive health is an issue that can have consequences for family harmo- ny, particularly among high-risk subgroups, and is the focus of the article “Prevalence and risk factors of anae- mia among ever-married women in Jordan” (18), where the importance of nutrient fortification of essential food- stuffs, especially for women during their reproductive age, is examined. Looking forward, September issue of the EMHJ cov- ers a wide range of topical public health issues, including the prevalence of female genital mutilation in regions of Iraq, the issue of bullying in schools and if diet can play a role in its prevention, the importance of partner noti- fication for HIV awareness and diagnosis in Lebanon, and attention to public health risks associated with mass gatherings. 528 EMHJ – Vol. 25 No. 8 – 2019Editorial References 1. United Nations. United Nations Plan of Action on Disaster Risk Reduction for Resilience: Towards a Risk-informed and Inte- grated Approach to Sustainable Development. New York: United Nations; 2016. (http://www.preventionweb.net/files/49076_un- planofaction.pdf). 2. United Nations. Sendai Framework for Disaster Risk Reduction 2015-2030. New York: United Nations; 2015. (http://www.wcdrr. org/). 3. The World Bank. Disaster Risk Management in South Asia: A Regional Overview. Washington, DC: The World Bank; 2012 (http:// documents.worldbank.org/curated/en/648281468170977802/Disaster-risk-management-in-South-Asia-regional-overview). 4. Muni SD. Conflicts in South Asia: Causes, consequences, prospects. Institute of South Asian Studies; 2013 Mar 26. Report No.: 170–26 March 2013. (https://www.files.ethz.ch/isn/162720/ISAS_Working_Paper_170_-_Conflicts_in_South_Asia_26032013170324. pdf). 5. Ul-Haq Z; Shah BH; Ardakani M; Akbar Khan SA; Muhammad S; Farooq S; et al. Health system preparedness in Pakistan for cri- sis management: a cross-sectional evaluation study. East Mediterr Health J. 2019;25(8):xxx. https://doi.org/10.26719/emhj.18.072. 6. Centers for Disease Control and Prevention. Influenza epidemiology and prevention of vaccine-preventable disease. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington DC: Public Health Foundation, 2015. 7. Taubenberger JK, Morens DM. Influenza: the once and future pandemic. Public Health Rep. 2010;125(3_suppl) Suppl 3:15–26. http://dx.doi.org/10.1177/00333549101250S305. 8. Stöhr K. Influenza–WHO cares. Lancet Infect Dis. 2002;2(9):517. http://dx.doi.org/10.1016/S1473-3099(02)00366-3. 9. Hussein I. Will Egypt unleash another flu pandemic? Nature Middle East. 2015; Published online 12 March 2015. 10. Leventhal A, Ramlawi A, Belbiesi A, Sheikh S, Haddadin A, Husseini S, et al. Enhanced surveillance for detection and manage- ment of infectious diseases: regional collaboration in the middle East. Emerg Health Threats J. 2013;6. http://dx.doi.org/10.3402/ ehtj.v6i0.19955. 11. Khan W; El Rifay A; Malik M; Kayali G. Influenza pandemic preparedness in the WHO Eastern Mediterranean Region. East Mediterr Health J. 2019;25(8):xxx. https://doi.org/10.26719/emhj.18.070. 12. Babazadeh T; Nadrian H; Ranjbaran S; Rezakhani-Moghaddam H; Aghemiri M. Cognitive factors associated with Brucellosis pre- ventive behaviours among diagnosed patients: an application of Empowerment Model. East Mediterr Health J. 2019;25(8):xxx. https://doi.org/10.26719/emhj.18.062. 13. Cardall WR, Rowan RC, Bay C. Dental education from the students’ perspective: curriculum and climate. J Dent Educ. 2008;72:600–9. 14. Halboub E; Alhajj MN; Al-Wesabi MA; Al-Sanaani S; Mufadhal A. Dental environment and war-related stress among dental stu- dents, Yemen. East Mediterr Health J. 2019;25(8):xxx. https://doi.org/10.26719/emhj.19.002. 15. Alrajhi Z; Alhamdan A; Alshareef M; Almubaireek O; Mohamud M; Omair A; et al. Perspectives of medical students and teach- ing faculty on teaching medicine in their native language. East Mediterr Health J. 2019;25(8):xxx. https://doi.org/10.26719/ emhj.18.073 16. Rahebi SM; Rahnavardi M; Rezaie-Chamani S; Nazari M; Sabetghadam S. Relationship between domestic violence and infertili- ty. East Mediterr Health J. 2019;25(8):xxx. https://doi.org/10.26719/emhj.19.001. 17. Mohammed H; El-Gibaly O; Monazea E; Saleh M; Mohammed H. The effect of a maternal training programme on early child- hood development in Egypt. East Mediterr Health J. 2019;25(8):xxx. https://doi.org/10.26719/emhj.18.065. 18. Arabyat R; Arabyat G; Al-Taani G. Prevalence and risk factors of anaemia among ever-married women in Jordan. East Mediterr Health J. 2018;24(8):xxx. https://doi.org/10.26719/emhj.18.074. 529 Research article EMHJ – Vol. 25 No. 8 – 2019 Dental environment and war-related stress among dental students, Yemen Esam Halboub,1,2 Mohammad Nasser Alhajj,3 Mohammed Ali Al-Wesabi,4 Saba Al-Sanaani 5 and Abdulbaset Mufadhal 6 1Department of Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, Jazan University, Saudi Arabia. 2Department of Oral Medicine, Oral Pathology and Oral Radiology, Faculty of Dentistry, Sana’a University, Sana’a, Yemen. 3Department of Prosthodontics, Faculty of Dentistry, Thamar University, Dhamar, Yemen. 4Department of Oral Medicine and Periodontology, Faculty of Dentistry, University of Science and Technology, Sana’a, Yemen. 5Faculty of Dentistry, University of Science and Technology, Sana’a, Yemen. 6Department of Conservative Dentistry and Endodontics, Faculty of Dentistry, Sana’a University, Sana’a, Yemen. (Correspondence to: Mohammed Nasser Alhajj: m.n.alhajj@hotmail.com). Abstract Background: Education related to health sciences appears to be the most stressful. Aims: The aim of this study was to evaluate the perceived stress among Yemeni dental students and to explore the effect of the war circumstances on the perceived stress. Methods: This cross-sectional study targeted all dental students at the two main dental faculties in Yemen. Dental envi- ronmental stress questionnaire was used. An extra 12 items (as one domain) were developed to reflect the stress resulting from the current war circumstances. Results: A total of 1051 dental students participated in this study. The overall dental environmental stress was 1.63±0.45. The most significant stressor domain was “workload”, followed by “war-related” along with “performance pressure”. In general, females, married, and clinical students, and those with lower GPA scored significantly higher stress levels than their counterparts. Regression analysis revealed that the university, sex, and study level as the most significant determi- nants for most domains. Conclusions: The level of stress among Yemeni dental students can be considered as moderate to high. This stress was further exacerbated by the war circumstances present. Keywords: Stress; war-related stress; DES; dental students; Yemen Citation: Halboub E; Alhajj MN; Al-Wesabi MA; Al-Sanaani S; Mufadhal A. Dental environment and war-related stress among dental students, Yemen. East Mediterr Health J. 2019;25(8):529–536. https://doi.org/10.26719/emhj.19.002 Received: 17/10/17; accepted: 25/09/18 Copyright © World Health Organization (WHO) 2019. 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). Introduction Stress is defined as the body’s reaction to a change that entails a physical, mental or emotional response. Such a response may be positive, stimulating and motivating for individuals to do their best, or negative, depressing and reducing an individual’s performance (1,2). Perception of stress is not the same among different people; it can be affected by beliefs, attitudes and occupation. In gen- eral, education – specifically higher education – poses a substantial amount of stress for enrolled students (3–5). Education related to the health sciences seems to be the most stressful. In this context, dental schools are consid- ered highly stressful learning environments, and stress among dental students has been revealed to be higher than among the general student population (6–8). Dental students’ performance can be greatly affected when com- mencing clinical training, since they become exposed to the same patient-related stressors faced by dental practi- tioners (9–12). Dental environment-induced stress can negatively affect students’ well-being unless dealt with appropriately. Ultimately, the academic performance of these students will deteriorate (8,13). Stress can be very much expected among dental students not only because of their academic environment, but also because of their social and cultural background, which can provoke or modify stress among such students (14). With no doubt, war and political conflicts have direct and indirect negative consequences on society, including university students (15). In February 2011 the so-called “Arab Spring” extended to Yemen, resulting in political instability and eventually ended up with a war that is still ongoing. The effects of war on dental students have not been widely studied. Apart from one recent study that investigated stress among Libyan dental students during the conflict (16), further studies have not been investigated. The result of this study regarding the stress perception was comparable to conducted studies in other countries. In addition to the Dental Environment Stress (DES) questionnaire, we included an extra domain (12 items) related to the ongoing war In comparison with the Libyan study. Hence, determining the stress-provoking factors is very important; it will give policy-makers, academic staff and administrators a comprehensive knowledge to modify teaching curricula and/or environment in such a way to be more conducive to students’ learning. The aims of this study, therefore, were to evaluate the perceived dental environment-induced stress and sources of such stress among undergraduate dental students in Yemen, 530 EMHJ – Vol. 25 No. 8 – 2019Research article and to explore whether the current war circumstances add to perceived stress. Methods This descriptive questionnaire-based, cross-sectional study was conducted during the 2106/2017 academic year. It targeted all dental students at two main dental faculties in Sana’a, Yemen: one public, Sana’a University, and one private, University of Science and Technology (UST). Ethical approvals were obtained from the Research Committees at both faculties. The questionnaire was ac- companied by a covering letter describing the study and its aims, stressing the confidentiality of the data and the voluntary participation, and asking the participants to sign to confirm his/her inclusion. For better understanding, a bilingual (Arabic and English) modified version of the DES questionnaire was used. Apart from the demographic data, it comprised 41 items grouped under seven stress-provoking domains as follows: self-efficacy beliefs (nine items), faculty and administration (ten items), workload (six items), patient treatment (four items), clinical training (four items), performance pressure (three items), and social stressors (five items) (17,18). An extra 12 items were developed to reflect what extent students were affected by in the current war circumstances in Yemen; it was referred to as the “War-related stress” domain. However, these domains were not displayed to the students in the distributed questionnaires. Responses to each item in the questionnaire were modified into a three-point Likert scale with 1 = no stress, 2 = moderate stress, and 3 = severe stress. A fourth possible response (0 = not applicable) was added where the stress situation under question is not applicable to the participant. Completed questionnaires were input into SPSS software version 21 (IBM Corp., Armonk, NY, USA). The study data were presented as frequencies with proportions or means with standard deviations (SDs), as appropriate. The summary scores of the individual domains and of the overall DES, presented as means and SDs, were considered as the dependent variables. Sex, marital status, Grade Point Average (GPA) and level of study were considered as independent variables. Differences in stress by the independent variables were analysed using non-parametric tests (Mann–Whitney U test and Kruskal–Wallis test). Multiple linear regression analyses were then conducted to determine the independent determinants. A P-value less than 0.05 was considered significant. Results A total number of 1507 dental students from both facul- ties were invited (Sana’a = 875 with 74% females and UST = 632 with 60% females). Finally, 1052 students participat- ed, representing an overall response rate of 70%. The mean age estimated at 21.11 ± 1.76 years (range = 17–29 years). Almost 72% (n = 752) of the participants were females and 9% (n = 92) were married. The highest proportion of participation was from the first year (approximately 28%, n = 291) while the lowest was from fifth year (15%, n= 160). Most of the students (74%, n = 713) had a GPA higher than 80% (Table 1). For all participants, the overall DES score was 1.63 ± 0.45 out of three. The highest fraction of this stress was attributed to “Workload” (2.07 ± 0.54) and “War-related Table 1 Demographic characteristics of dental students of Sana’a and UST university dental schools All (N= 1052) Sana’a (N= 638) UST (N= 414) N (%) N (%) N (%) Sex (N= 1048) Male 296 (28.2) 150 (23.6) 146 (35.4) Female 752 (71.8) 485 (76.4) 267 (64.6) Marital Status (N= 1039) Single 947 (91.1) 578 (92.2) 369 (89.6) Married 92 (8.9) 49 (7.8) 43 (10.4) Study level (N= 1050) First 291 (27.7) 199 (31.2) 92 (22.3) Second 186 (17.7) 109 (17.1) 77 (18.7) Third 224 (21.3) 117 (18.3) 107 (26.0) Fourth 189 (18.0) 101 (15.8) 88 (21.4) Fifth 160 (15.2) 112 (17.6) 48 (11.7) Mark of previous year (N= 967) ≤ 70% 47 (4.9) 30 (4.9) 17 (4.8) > 70%–80% 207 (21.4) 120 (19.6) 87 (24.5) > 80%–90% 436 (45.1) 285 (46.6) 151 (42.5) > 90% 277 (28.6) 177 (28.9) 100 (28.2) 531 Research article EMHJ – Vol. 25 No. 8 – 2019 stress” along with “Performance pressure” (1.84 ± 0.61 and 1.83 ± 0.63, respectively). For each dental school, Students in Sana’a University scored higher level of stress in all domains except for “patient treatment”, “clinical training” and “social stressor”, where they scored lower than UST students (Table 2). Table 3a presents the five highest scored items for all participants and Table 3b by university. There were two items related to war situation: “Frequent or permanent power outage due to the current war circumstances” and “Your family’s worries about you, due to the current war circumstances, when you go to college”, which had scores of 2.25 ± 0.97 and 2.24 ± 0.89, respectively. Comparisons of domain scores by different grouping factors are presented in Table 4. Students from Sana’a University had significantly more stress in all domains except for “clinical training”, “patient treatment”, and “social stressor” where the stress level was lower than that of UST students; however, the latter two were not significant (P = 0.087 and P = 0.245, respectively). In addition, although students from Sana’a University had a higher score in performance pressure, the difference was not significant (P = 0.84). Females scored significantly higher than males, except for “social stressors” where Table 2 Mean scores of stress among study participants according to DES domains All Sana’a UST mean±SD mean±SD mean±SD Self-efficacy beliefs (N= 1020) 1.76±0.56 1.85±0.54 1.63±0.57 Faculty and administration (N= 962) 1.60±0.58 1.64±0.58 1.55±0.57 Workload (N= 1017) 2.07±0.54 2.12±0.49 1.99±0.60 Patient treatment (N= 1010) 1.49±0.97 1.45±0.98 1.56±0.95 Clinical training (N= 994) 1.23±0.95 1.16±0.96 1.32±0.92 Performance pressure (N= 1011) 1.83±0.63 1.87±0.59 1.77±0.69 Social stressors (N= 987) 0.97±0.56 0.95±0.54 1.00±0.58 War-related stress (N= 1008) 1.84±0.61 1.94±0.56 1.70±0.65 Table 3a Mean scores of stress related to selected items of DES questionnaire for all participants N Mean±SD Lack of time to do assigned school work 1046 2.33±0.80 Lack of time for relaxation 1040 2.26±0.86 Frequent or permanent power outage due to the current war circumstances 1045 2.25±0.97 Your family’s worries about you when you go to college due to the current war circumstances 1045 2.24±0.89 Overloaded feeling due to huge study syllabus 1047 2.23±0.83 Table 3b Mean scores of stress related to selected items of DES questionnaire for Sana’a and UST universities Sana’a Frequent or permanent power outage due to the current war circumstances 631 2.42±0.82 Lack of time to do assigned school work 632 2.40±0.73 Overloaded feeling due to huge study syllabus 633 2.35±0.74 Fear of failing a course or the year 634 2.33±0.90 Competition for grades 632 2.32±0.78 UST Lack of time to do assigned school work 414 2.22±0.88 Lack of time for relaxation 414 2.21±0.95 Your family’s worries about you when you go to college due to the current war circumstances 414 2.16±0.96 Examinations and quizzes 414 2.06±0.82 Fear of being unable to catch up if falling behind 414 2.05±0.94 532 EMHJ – Vol. 25 No. 8 – 2019Research article the opposite was indicated. Married students scored higher for stress compared to single students; however, these scores were significantly higher in four of the eight domains (“patient treatment”, P = 0.008; “clinical training”, P < 0.001; “performance pressure”, P = 0.015; and “social stressors”, P < 0.001). Regarding study levels, it has been shown that stress increased significantly (P < 0.001) with progressive study levels except for “Self-efficacy beliefs.” Students who had a higher GPA scored significantly (P < 0.001) lower levels of stress than their peers, except for “Self-efficacy beliefs.” Multivariate analyses revealed that “clinical training”, “faculty and administration”, and “patient treatment” were the domains for which the multivariate models explained substantial fractions of their variability: R2= 0.527, 0.446 and 0.386, respectively. The university, sex and study levels were the most significant independent determinants for most of the domains. Marital status and GPA were less significant determinants (Table 5). Discussion To the best of our knowledge, this study was the first to assess the per- ceived DES and stress-provoking fac- tors among dental students in Yem- en. In addition, it explored whether war circumstances increased such stress. Since March 2015, Yemen has been under an unstable situation due to the war and political conflict. Sa- na’a city is the capital of Yemen and is one of the most affected governo- rates countrywide. This study aimed to know to what extent such circum- stances may affect dental students’ learning performance. The results of the present study showed that war-related stress ranked the second highest source of perceived stress among dental students in Yemen. The workload- related stress ranked the first. This reflects the extent to which these students are determined to handle their study obligations, even under harsh circumstances such as conflict. Nevertheless, these war-related Ta bl e 4 Co m pa ri so n by D ES d om ai ns b y U ni ve rs it y, G en de r, M ar it al S ta tu s, S tu dy L ev el , a nd G PA Se lf- ef fi ca cy be lie fs Fa cu lty a nd ad m in is tr at io n W or kl oa d Pa ti en t tr ea tm en t Cl in ic al tr ai ni ng Pe rf or m an ce pr es su re So ci al st re ss or s W ar -R el at ed st re ss M ea n± SD P M ea n± SD P M ea n± SD P M ea n± SD P M ea n± SD P M ea n± SD P M ea n± SD P M ea n± SD P U ni ve rs ity † Sa na 'a 1.8 5± 0. 54 <0 .0 01 1.6 4± 0. 58 0. 02 0 2. 12 ±0 .4 9 0. 00 2 1.4 5± 0. 98 0. 08 7 1.1 6± 0. 96 0. 01 5 1.8 7± 05 9 0. 08 4 0. 95 ±0 .5 4 0. 24 5 1.9 4± 0. 56 <0 .0 01 U ST 1.6 3± 0. 57 1.5 5± 0. 57 1.9 9± 0. 60 1.5 6± 0. 95 1.3 2± 0. 92 1.7 7± 0. 69 1.0 0± 0. 58 1.7 0± 0. 65 G en de r † M al e 1.5 8± 0. 56 <0 .0 01 1.3 9± 0. 53 <0 .0 01 1.7 9± 0. 55 <0 .0 01 1.3 9± 0. 87 0. 00 9 1.1 1± 0. 84 0. 01 5 1.6 4± 0. 64 <0 .0 01 1.1 3± 0. 55 <0 .0 01 1.7 7± 0. 63 0. 01 3 Fe m al e 1.8 4± 0. 55 1.6 9± 0. 57 2. 18 ±0 .4 9 1.5 3± 1.0 1 1.2 7± 0. 98 1.9 0± 0. 61 0. 90 ±0 .5 4 1.8 7± 0. 60 M ar ita l S ta tu s † Si ng le 1.7 7± 0. 56 0. 97 3 1.6 0± 0. 57 0. 25 4 2. 06 ±0 .5 3 0. 18 7 1.4 7± 0. 98 0. 00 8 1.1 9± 0. 95 <0 .0 01 1.8 2± 0. 63 0. 01 0 0. 93 ±0 .5 4 <0 .0 01 1.8 4± 0. 61 0. 35 6 M ar ri ed 1.7 6± 0. 57 1.6 6± 0. 57 2. 13 ±0 .5 5 1.7 6± 0. 91 1.6 1± 0. 90 1.9 9± 0. 63 1.3 6± 0. 61 1.9 1± 0. 54 St ud y Le ve l ‡ Fi rs t 1.7 4± 0. 57 0. 28 0 1.1 3± 0. 44 <0 .0 01 1.8 4± 0. 55 <0 .0 01 0. 78 ±0 .7 9 <0 .0 01 0. 36 ±0 .5 7 <0 .0 01 1.5 0± 0. 56 <0 .0 01 0. 87 ±0 .5 1 0. 00 1 1.6 9± 0. 61 <0 .0 01 Se co nd 1.7 4± 0. 57 1.3 5± 0. 48 2. 03 ±0 .5 4 1.0 5± 0. 91 0. 61 ±0 .6 6 1.5 0± 0. 45 0. 91 ±0 .5 4 1.7 2± 0. 63 Th ir d 1.7 5± 0. 55 1.7 2± 0. 42 2. 10 ±0 .4 9 1.5 3± 0. 88 1.5 1± 0. 75 1.8 1± 0. 55 1.0 1± 0. 54 1.9 1± 0. 56 Fo ur th 1.7 7± 0. 57 1.9 7± 0. 45 2. 24 ±0 .5 1 2. 32 ±0 .5 1 2. 07 ±0 .5 8 2. 26 ±0 .5 9 1.0 7± 0. 66 2. 02 ±0 .5 8 Fi ft h 1.8 6± 0. 55 2. 10 ±0 .4 0 2. 26 ±0 .4 2 2. 23 ±0 .4 6 2. 00 ±0 .5 1 2. 31 ±0 .4 6 1.0 4± 0. 49 1.9 6± 0. 59 G PA L as t se m es te r ‡ _ 7 0% 1.8 2± 0. 52 0. 16 7 1.7 6± 0. 55 <0 .0 01 2. 07 ±0 .5 8 0. 00 1 2. 02 ±0 .8 0 <0 .0 01 1.7 2± 0. 88 <0 .0 01 2. 07 ±0 .5 9 <0 .0 01 1.1 4± 0. 54 <0 .0 01 1.9 1± 0. 58 <0 .0 01 > 70 % - 8 0% 1.7 9± 0. 51 1.8 4± 0. 55 2. 18 ±0 .4 7 1.9 1± 0. 77 1.7 3± 0. 75 2. 02 ±0 .5 9 1.0 9± 0. 55 1.9 5± 0. 62 > 80 % - 9 0% 1.7 9± 0. 58 1.6 2± 0. 58 2. 06 ±0 .5 4 1.5 0± 0. 98 1.2 3± 0. 96 1.8 4± 0. 64 0. 99 ±0 .5 7 1.8 9± 0. 61 > 90 % 1.7 1± 0. 56 1.3 7± 0. 50 1.9 8± 0. 54 1.0 3± 0. 93 0. 73 ±0 .8 2 1.6 1± 0. 55 0. 82 ±0 .5 2 1.6 9± 0. 57 †: M an n– W hi tn ey U te st ; ‡ : K ru sk al –W al lis te st 533 Research article EMHJ – Vol. 25 No. 8 – 2019 circumstances had obvious effects on these students and causing substantial levels of stress. The results of this study are in the line with existing studies, indicating that dental students are exposed to a heavy workload and academic requirements, which act as sources of stress that affect the psychological and physical health of the students (19–24). In the present study, the majority of the respondents reported that they had either moderate to severe stress, which was in agreement with other published studies (25,26). ‘Workload’ was the highest stressor perceived by dental students, and this is consistent with previous studies (16,19,21,22,27). It is known that the dental curriculum is composed of many subjects entailing lectures, laboratory work, and clinical work that consume students’ time and energy. Comparing the two universities, the mean score of stress due to workload in Sana’a University was slightly higher than that of UST dental students (2.12 ± 0.49 vs. 1.99 ± 0.60). This might be due to the facilities in the private dental school, which ease the accomplishment of clinical and laboratorial requirements, as well as the fact that the staff-to-student ratio is better in the private dental schools. Surprisingly, the war-related stress score was lower than that of workload stress. This can be explained by the determination of these students to succeed whatever the prevailing circumstances. However, the workload domain is revealed as an important stressor for students and suggests urgent modifications in the dental curricula are required in order to prioritize quality rather than quantity. Within the “workload” domain, the most stressful items were “lack of time for relaxation” among all students (mean score = 2.33 ± 0.80) and among UST dental students (mean score = 2.22 ± 0.88), and “Frequent Table 5 Regression analysis between the domains of DES and the independent variables Independent variable B 95% CI Adjusted R2 P-value Self-efficacy beliefs University -0.217 -0.289 -0.145 0.080 <0.001 Sex 0.228 0.150 0.305 <0.001 GPA Last semester -0.056 -0.097 -0.014 0.009 Faculty and administration Study Level 0.250 0.230 0.270 0.446 <0.001 Sex 0.199 0.135 0.263 <0.001 University -0.065 -0.123 -0.007 0.029 Workload Sex 0.325 0.255 0.395 0.179 <0.001 Study Level 0.099 0.077 0.121 <0.001 University -0.109 -0.173 -0.044 0.001 Patient treatment Study Level 0.399 0.360 0.437 0.386 <0.001 GPA Last semester -0.075 0-.141 -0.008 0.029 Clinical training Study Level 0.471 0.441 0.501 0.527 <0.001 University 0.127 0.039 0.214 0.005 Marital Status 0.184 0.033 0.335 0.017 Performance pressure Study Level 0.223 0.199 0.247 0.298 <0.001 Sex 0.174 0.097 0.251 <0.001 University -0.074 -0.144 -0.003 0.041 Social stressors Marital Status 0.379 0.256 0.501 0.114 <0.001 Sex -0.261 -0.339 -0.184 <0.001 GPA Last semester -0.067 -0.115 -0.020 0.006 Study Level 0.036 0.008 0.064 0.013 War-Related Stress University -0.262 -0.339 -0.184 0.084 <0.001 Study Level 0.072 0.042 0.102 <0.001 GPA Last semester -0.052 -0.103 -0.001 0.046 534 EMHJ – Vol. 25 No. 8 – 2019Research article or permanent power outage due to the current war circumstances” among Sana’a University (mean score = 2.42 ± 0.82). The timetable of dental students is full of lectures, laboratory work, and clinical sessions, meaning students find little time to relax. Additionally, permanent power outage substantially adds to war-related stress. Students in clinical years of study (4th and 5th) scored higher levels of stress in comparison to students in the preclinical years (1st, 2nd and 3rd). This result is similar to that obtained by many previous studies (20,26,28–31). Students at clinical levels of study are increasingly exposed to clinical duties toward their patients, besides theory. Participants with a high GPA (more than 90%) showed lower levels of stress in all domains. In general, students with a high GPA are well organized, more confident and more productive, and demonstrate the ability to manage their time effectively (32). This study is one of very few studies that compared the issue of stress among private and public school dental students (17,33). “University” factor along with “study level” and “Marital status” factors were revealed to be significant independent determinants of most of the stress domains. They together explained more than half (53%) of the variability in the stress score of “clinical training” domain. Public and private universities have different administration systems, different facilities, different educational environment, and different socioeconomic backgrounds of enrolled students. In accordance with a study among Malaysian dental students, students in public universities had higher levels of stress than their counterparts in private universities (33). Furthermore, “Marital status” appeared to be an independent factor for stress. Family responsibilities and duties of married dental students, as well as having children, increase psychological pressure and affecting the overall amount of stress. As revealed by other studies, married students are expected to reside in their own homes and live away from parents’ home (34–36). In our study, female students had higher levels of stress than male counterparts in all stress domains except for “social stressors” domain. Many studies reported gender-related differences regarding DES (17,20,37–39). Female students were more open to express stress issues than their male counterparts, and their response to stressors also differed. Some studies suggested that gender differences could be explained by the fact that males are simply less emotionally expressive (17,40). Conclusion DES perceived by dental students in Yemen is generally moderate to high and it is exacerbated by the war circum- stances. The study showed the effects of external factors on stress perception among dental students. Funding: None. Competing interests: None declared. L’environnement dentaire et le stress lié à la guerre chez les étudiants yéménites en médecine dentaire Résumé Contexte : Les études en sciences de la santé semblent être celles qui génèrent le plus de stress. Objectifs : La présente étude avait pour objet d’évaluer le stress perçu par les étudiants en médecine dentaire yéménites et d’analyser l’impact des situations de guerre sur ce ressenti. Méthodes : La présente étude transversale ciblait tous les étudiants en médecine dentaire des deux principales facultés dentaires du Yémen. Un questionnaire sur le stress en environnement dentaire a été utilisé aux fins de cette étude. Plus de 12 items (constituant un seul domaine) ont été définis pour rendre compte du stress dû à la situation de guerre que connaît actuellement ce pays. Résultats : Un total de 1051 étudiants en médecine dentaire ont participé à cette étude. Globalement, le stress en environnement dentaire était de 1,63±0,45. La charge de travail constituait le facteur de stress le plus important, suivie par le facteur lié à la guerre ainsi que la pression en termes de performance. En général, les femmes mariées et les étudiants en médecine clinique ainsi que ceux dont la moyenne pondérée était plus faible présentaient un niveau de stress significativement plus élevé que leurs camarades. L’analyse de régression a montré que l’université, le sexe et le niveau d’étude constituaient les déterminants les plus importants dans la plupart des domaines. Conclusions : Le niveau de stress parmi les étudiants en médecine dentaire yéménites est considéré comme étant modéré à élevé. Ce stress était encore aggravé par la situation de guerre que connaît ce pays. 535 Research article EMHJ – Vol. 25 No. 8 – 2019 References 1. Cohen S, Kessler RC, Gordon LU. Strategies for measuring stress in studies of psychiatric and physical disorders. In: Cohen S, Kessler R, Gordon U, editors. Measuring stress: A guide for health and social scientists. NewYork: Oxford University Press; 1995. 2. Folkman S. Stress: Appraisal and Coping. In: Gellman MD, Turner JR, editors. Encyclopedia of Behavioral Medicine. New York (NY): Springer New York; 2013. http://dx.doi.org/10.1007/978-1-4419-1005-9_215 3. Almeida DM, Kessler RC. Everyday stressors and gender differences in daily distress. J Pers Soc Psychol. 1998;75(3):670–80. http://dx.doi.org/10.1037/0022-3514.75.3.670 4. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354–73. http://dx.doi.org/10.1097/00001888-200604000-00009 5. Li C, Liu JC, Xiao X, Chen X, Yue S, Yu H, et al. Psychological distress and type 2 diabetes mellitus: a 4-year policemen cohort study in China. BMJ Open. 2017;7(1):e014235. http://dx.doi.org/10.1136/bmjopen-2016-014235 6. Tosevski DL, Milovancevic MP, Gajic SD. Personality and psychopathology of university students. Curr Opin Psychiatry. 2010;23(1):48–52. http://dx.doi.org/10.1097/YCO.0b013e328333d625 7. Lloyd C, Musser LA. Psychiatric symptoms in dental students. J Nerv Ment Dis. 1989;177(2):61–9. http://dx.doi. org/10.1097/00005053-198902000-00001 8. Schmitter M, Liedl M, Beck J, Rammelsberg P. Chronic stress in medical and dental education. Med Teach. 2008;30(1):97–9. http://dx.doi.org/10.1080/01421590701769571 9. Fredericks MA, Mundy P. Dental students: relationship between social class, stress, achievement, and attitudes. J Am Coll Dent. 1967;34:218–28. 10. Davis EL, Tedesco LA, Meier ST. Dental student stress, burnout, and memory. J Dent Educ. 1989;53:193–5. 11. Stewart DW, de Vries J, Singer DL, Degen GG, Wener P. Canadian dental students’ perceptions of their learning environment and psychological functioning over time. J Dent Educ. 2006;70:972–81. 12. Cardall WR, Rowan RC, Bay C. Dental education from the students’ perspective: curriculum and climate. J Dent Educ. 2008;72:600–9. 13. Uraz A, Tocak YS, Yozgatligil C, Cetiner S, Bal B. Psychological well-being, health, and stress sources in Turkish dental students. J Dent Educ. 2013;77:1345–55. 14. Manstead ASR. The psychology of social class: How socioeconomic status impacts thought, feelings, and behaviour. Br J Soc Psychol. 2018;57(2):267–91. http://dx.doi.org/10.1111/bjso.12251 15. Al-Jbarat M. Yemen Crises; Historical Roots and Solution Spheres. GJHSS. 2017;16:1–8. 16. Arheiam A, El Tantawi M, Al-Omami M, Peeran S, Elmisalati W. Perception of Stress among Dental Students Living in A War-Af- fected Zone. J Dent Educ. 2019;83:48–55. 17. Alhajj MN, Khader Y, Murad AH, Celebic A, Halboub E, Marquez JR, et al. Perceived sources of stress amongst dental students: A multicountry study. Eur J Dent Educ 2018;22:258–71. 18. Al-Sowygh ZH, Alfadley AA, Al-Saif MI, Al-Wadei SH. Perceived causes of stress among Saudi dental students. King Saud Univ J Dent Sci. 2013;4:7–15. نميلا ،نانسلأا بط بلاط ينب برلحاب قلعتلما داهجلإاو نانسلأا بط ةئيب لضفم طسابلا دبع ،نياعنصلا أبس ،بياصولا ليع دممح ،جالحا صران دممح ،بوبلح ماصع ةصلالخا .اًداهجإ رثكلأا وه ةيحصلا مولعلاب طبترلما ميلعتلا نأ ودبي :ةيفللخا .روصتلما داهجلإا لىع برلحا فورظ رثأ ةفرعمو ،ينينميلا نانسلأا بط بلاط ينب روصتلما داهجلإا مييقت لىإ ةساردلا هذه تفده :فادهلأا في داهجلإا نايبتسا مدخُتساو .نميلا في نانسلأا بطل ينتسيئر ينتيلك في نانسلأا بط بلاط عيجم ةيعطقلما ةساردلا هذه تفدهتسا :ثحبلا قرط .ةيرالجا برلحا فورظ نع ئشانلا داهجلإا سكعتل )دحاو لامج ةباثمب( اًيفاضإ اًدنب 12 َعِضُوو .نانسلأا بط ةئيب تلااجلما رثكأ تناكو .1.63±0.45 نانسلأا بط ةئيب في داهجلإا لدعم لياجمإ غلبو .ةساردلا هذه في نانسأ بلاط 1051 كراش :جئاتنلا في ينبردتلما بلاطلاو تاجوزتلما تابلاطلا ،ةماع ةفصبو .ءادلأا طغض بناج لىإ برلحاب طبترلما لاجلما هيليو ،لمعلا ءبع لامج يه ةدهجلما سنلجا عونو ةعمالجا نأ دادترلاا ليلتح فشكو .مهئارظن نم يرثكب لىعأ داهجإ نم نوناعي لقأ يمكارت لدعم لىع ينلصالحا بلاطلاو تادايعلا .داهجلإل ةببسُلما تلااجلما مظعلم ةبسنلاب ةزرابلا ةددحلما لماوعلا رثكأ يه سياردلا ىوتسلماو .كانه برلحا فورظ ببسب داهجلإا اذه مقافتو .اًعفترم لىإ اًطسوتم ينينميلا نانسلأا بلاط ينب داهجلإا ىوتسم رابتعا نكمي :تاجاتنتسلاا 536 EMHJ – Vol. 25 No. 8 – 2019Research article 19. Rosli TI, Abdul RR, Abdul RS, Ramli R. A survey of perceived stress among undergraduate dental students in Universiti Kebang- saan Malaysia. Singapore Dent J. 2005;27:17–22. 20. Al-Saleh SA, Al-Madi EM, Al-Angari NS, Al-Shehri HA, Shukri MM. Survey of perceived stress-inducing problems among dental students, Saudi Arabia. Saudi Dent J. 2010;22:83–8. http://dx.doi.org/10.1016/j.sdentj.2010.02.007 21. Montero-Marín J, Demarzo MMP, Stapinski L, Gili M, García-Campayo J. Perceived stress latent factors and the burnout sub- types: a structural model in dental students. PLoS One. 2014;9(6):e99765. http://dx.doi.org/10.1371/journal.pone.0099765 22. Al-Sowygh ZH. Academic distress, perceived stress and coping strategies among dental students in Saudi Arabia. Saudi Dent J. 2013;25:97–105. http://dx.doi.org/10.1016/j.sdentj.2013.05.002 23. Jain M, Sharma A, Singh S, Jain V, Miglani S. The stress of clinical dental training: A cross-sectional survey among dental students and dentists of a dental college in India. J Indian Assoc Public Health. 2016;14:434. http://dx.doi.org/10.4103/2319- 5932.195827 24. Murad AH, Alhajj MN. Evaluation of stress among undergraduate dental students in Al-Qadisiyah University-Iraq. J Stoma. 2017;70:171–82. 25. Elani HW, Allison PJ, Kumar RA, Mancini L, Lambrou A, Bedos C. A systematic review of stress in dental students. J Dent Educ. 2014;78:226–42. 26. Bhayat A, Madiba TK. The self-perceived sources of stress among dental students at a South African Dental School and their methods of coping. SADJ. 2017;72:6–10. 27. Elani HW, Bedos C, Allison PJ. Sources of stress in Canadian dental students: a prospective mixed methods study. J Dent Educ. 2013;77:1488–97. 28. Abu-Ghazaleh SB, Rajab LD, Sonbol HN. Psychological stress among dental students at the University of Jordan. J Dent Educ. 2011;75:1107–14. 29. Peker I, Alkurt MT, Usta MG, Turkbay T. The evaluation of perceived sources of stress and stress levels among Turkish dental students. Int Dent J. 2009;59:103–11. 30. Wilson V, Rayner C, Gordon N, Shaikh A, Crombie K, Yasin-Harnekar S. Perceived stress among dental students at the Universi- ty of the Western Cape. SADJ. 2015;70:255–9. 31. Aboalshamat K, Hou X-Y, Strodl E. Psychological well-being status among medical and dental students in Makkah, Saudi Arabia: A cross-sectional study. Med Teach. 2015;37:S75–81. 32. Halboub E, Alhajj MN, AlKhairat AM, Sahaqi A-AM, Quadri MFA. Perceived Stress among Undergraduate Dental Students in Relation to Gender, Clinical Training and Academic Performance. Acta Stomatol Croat. 2018;52:37–45. http://dx.doi.org/10.15644/ asc52/1/6 33. Babar MG, Hasan SS, Ooi YJ, Ahmed SI, Wong PS, Ahmad SF, et al. Perceived sources of stress among Malaysian dental students. Int J Med Educ. 2015;6:56–61. http://dx.doi.org/10.5116/ijme.5521.3b2d 34. Naidu RS, Adams JS, Simeon D, Persad S. Sources of stress and psychological disturbance among dental students in the West Indies. J Dent Educ. 2002;66:1021–30. 35. Humphris G, Blinkhorn A, Freeman R, Gorter R, Hoad Reddick G, Murtomaa H, et al. Psychological stress in undergraduate den- tal students: baseline results from seven European dental schools. Eur J Dent Educ. 2002;6:22–9. http://dx.doi.org/10.1034/j.1600- 0579.2002.060105.x 36. Murphy RJ, Gray SA, Sterling G, Reeves K, DuCette J. A comparative study of professional student stress. J Dent Educ. 2009;73:328–37. 37. Menck Sangiorgio JP, Medeiros Araujo P, Hirata Navarro C, Renan Zen I, da Costa SC, Vivan Ribeiro PH, et al. Dental Environ- ment Stress: Findings among Lusophone Dental Students. Pesqui Bras Pediatric Dentistry Clin. 2016;16:411–24. 38. Uraz A, Tocak YS, Yozgatlıgil C, Cetiner S, Bal B. Psychological well-being, health, and stress sources in Turkish dental students. J Dent Educ. 2013;77:1345–55. 39. Crego A, Carrillo-Diaz M, Armfield JM, Romero M. Stress and academic performance in dental students: the role of coping strat- egies and examination-related self-efficacy. J Dent Educ. 2016;80:165–72. 40. Sanders A, Lushington K. Sources of stress for Australian dental students. J Dent Educ. 1999;63:688–97. 537 Research article EMHJ – Vol. 25 No. 8 – 2019 Relationship between domestic violence and infertility Seyede Marziye Rahebi,1 Mona Rahnavardi,1 Sedighe Rezaie-Chamani,1 Mojgan Nazari 2 and Shadi Sabetghadam 3 1School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Islamic Republic of Iran. 2Social Determinants of Health Research Center (SDHRC), Guilan University of Medical Sciences, Rasht, Islamic Republic of Iran. 3Alzahra Hospital, Guilan University of Medical Sciences, Rasht, Islamic Republic of Iran. (Correspondence to: Mona Rahnavard: mona.rahnavardi@yahoo.com). Abstract Background: Infertility is a significant psychological stressor among infertile couples. Aggressive behaviour such as domestic violence may be the consequence of this situation. Aims: To determine the relationship between domestic violence and infertility and its associated factors. Methods: This unmatched case-control study was conducted on 400 women who were referred to Al-Zahra teaching Hos- pital in Rasht, Islamic Republic of Iran, from May to December 2015. The data were collected by WHO Domestic violence questionnaire, which was validated in the Islamic Republic of Iran. Data were analyzed by using descriptive and analytical statistic (Chi square, t test, and logistic regression). Results: Out of the 200 infertile women 136 (68%) reported a history of physical violence, 120 (60%) had experienced sexu- al violence and 140 (70%) had psychological violence. There was a significant relationship between infertility and physical, sexual and psychological violence (P < 0.05). Logistic regression analysis revealed that the education level of women [OR= 0.176, 95% CI (0.070-0.446)], unemployment husband [OR=15.83, 95% CI (1.307-191.977)] and infertility [OR= 0.133, 95% CI (0.057-0.31)] were associated with domestic violence (P < 0.05). Conclusions: In this study there was a relationship between infertility and physical, sexual and psychological violence and infertile women were more likely to encounter domestic violence. Screening for domestic violence is necessary for infertile couples. Keywords: domestic violence, infertility, women, Risk factors, sexual violence Citation: Rahebi SM; Rahnavardi M; Rezaie-Chamani S; Nazari M; Sabetghadam S. Relationship between domestic violence and infertility. East Medi- terr Health J. 2019;25(8):537–542. https://doi.org/10.26719/emhj.19.001 Received: 22/01/17; accepted: 29/11/17 Copyright © World Health Organization (WHO) 2019. 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). Introduction Infertility in a couple is usually defined as the failure to become pregnant after 1 year of regular, unprotected sex- ual intercourse (1). Worldwide many couples suffer from infertility; it is a global health problem, with an estimat- ed 8–12% sufferers (2), while the prevalence of primary infertility in the Islamic Republic of Iran was reported as 24.9% in 2004 (3). Worldwide violence is a vital commu- nity health distress commonly observed among all cul- tures, regardless of geographical limitation, educational level or economic development (4). Domestic violence is defined as exerting any violent behaviour against an- other person and within an intimate relationship, and includes physical, psychological and sexual violence (5). Domestic violence may cause physical, psychological or sexual harm to those involved (6,7). The prevalence of domestic violence among ever partnered women was re- ported to be from 15.4% in Japan to 70.9% in Ethiopia by a World Health Organization (WHO) multi-country study report (8). The prevalence of domestic violence in the Is- lamic Republic of Iran was reported to be from 47.3% up to 80% (3,9–11). Marital conflict and divorce may be associated with infertility (1) and could be a formerly unrecognized risk factor for domestic violence (12). Infertility is a significant psychological stressor among infertile couples. Aggressive behaviour may be the consequences of difficulty of dealing with this situation (13). Some researchers reported that infertile women who experience domestic violence were 33.6% in Turkey (1), 31.2% to 35.9% in Nigeria (14,15) and 34.7% in the Islamic Republic of Iran (3). Childbearing is considered highly desirable in many cultures (16), yet it is women alone who are constantly held responsible for a couple’s infertility and is often punished socially and economically as a consequence (17). Globally, regardless of socioeconomic or educational levels of couples, domestic violence affects the quality of life among millions infertile women (1). There are a limited number of studies in the Islamic Republic of Iran about the relationship between domestic violence and infertility. Most studies have no control group with which to compare results. The present study was conducted with the aim of assessing the relationship between domestic violence (psychological, physical and sexual) and infertility among women who suffered from infertility at a reproductive health referral centre in Rasht, Islamic Republic of Iran. Methods Subjects and settings This unmatched case-control study was conducted on 538 EMHJ – Vol. 25 No. 8 – 2019Research article 400 women who were referred to Al-Zahra teaching Hos- pital in Rasht, Islamic Republic of Iran, from May 2015 to December 2015. The sample size was determined by us- ing the prevalence of domestic violence in infertile and fertile women as at least 176 for each group based on pre- vious studies by Ardabili et al. and Ahmadi et al. (16,18). n ≥ P= (P1+P2)/2 α = 0.05 Z1- α /2 = 1.96 β = 0.20 Z1- β /2 = 0.84 P1 = 0.6, P2 = 0.44 In an infertility clinic 200 infertile women who met the inclusion criteria of the study were selected as cases. Two hundred women who had at least one child were selected by simple random sampling from other clinics in Al-Zahra Hospital as a control group. In order to evaluate the factors affecting domestic violence among women, they were divided into two groups – abused and non-abused women – by using WHO domestic violence questionnaire and calculating the relationship between characteristics and socio-demographic data with domestic violence. The inclusion criteria of this study were Iranian nationality and duration of marriage at least one year. Exclusion criteria were any chronic disease which has an effect on fertility. The ethical committee of Guilan University of Medical Sciences approved this study (93121120, 2 March 2015). Written consent was obtained from the participants in a private setting. WHO ethical and safety recommendations for research on domestic violence against women were considered in this study. The participants were assured that all their information would remain confidential. Instruments The data were collected by using the WHO domestic vi- olence questionnaire (19), which contains 34 items. The field of physical violence has 10 items, sexual violence has 5 items and psychological violence has 11 items, while other questions concerned demographic variables. The number of cases of violence is calculated based on a Lik- ert scale 1–5 (never, one time, two times, 3–5 times, more than 5 times). In this study a participant who has at least one positive answer to each question related to physical, sexual or psychological violence were considered to have been abused. The validity of the questionnaire in Iran was investigated by other researchers (17,18). The total CVI of the questionnaire was calculated 0.74 and Cron- bach’s alpha coefficient of the questionnaire on three are- as physical, sexual and psychological violence were 0.99, 0.89 and 0.88, respectively. Ten researchers and faculty members evaluate the questionnaire. The CVR for each item was calculated above 0.8. The questionnaires were filed by participant in order to prevent shame and em- barrassment. Data analysis The data were analyzed by using SPSS software for de- scriptive and analytical statistical tests (chi square test, t-test, and multiple logistic regressions) and the signifi- cance level was 0.05. The confounding factors were con- trolled with logistic regression. Results The mean age of the respondents in the infertile and fer- tile groups was 32.96 and 32.44 respectively. Nearly 45% of participants in both fertile and infertile groups had average incomes. In this study the majority of women in infertile (n=163, 81.5%) and fertile (n=150, 75%) groups were housewives. The education level of more than 50% of participants was secondary school in infertile group (n=101, 50.5%) and fertile group (n= 104, 52%) respective- ly. Within each group there was no significant differ- ence in age, education level of women, education level of husband, wife’s or husband’s occupation (Table 1). The duration of marriage among participants was 2–22 years (median 8.45± 4.37). Out of the 200 infertile women that participate in this study 167 (83.5%) reported a history of domestic violence, 136 (68%) physical violence, 120 (60%) sexual violence and 140 (70%) psychological (emotional) violence. There was a significant relationship between infertility and physical, sexual and psychological vio- lence (Table 2). In the control group the duration of marriage was 1–28 years (median 10/44 ± 6.42). Fifty-three (26.5%) infertile women and 34 (17%) fertile women also experienced physical and psychological violence; there was a statistically significant difference between the two groups, with the infertile group demonstrating higher levels of abuse than the fertile group. Logistic regression showed significant associations between the women’s education level and domestic violence [OR= 0.176, CI 95% (0.070–0.446)]. The chance of violence among women with high school education was 80% less than women with university education. There was significant association between an unemployed husband and domestic violence [OR=15.83, CI 95% (1.307–191.977)]; women with an unemployed husband were 16 times more exposed to domestic violence. As the number of children [OR=0.379, CI 95% (0.189–0.762)] increased in the family, the chance of domestic violence decreased by approximately 60%. There was significant relationship between infertility and domestic violence [OR= 0.133, CI 95% (0.057–0.31)]. The chances of violence against women with infertility were 87% more than fertile women (Table 3). Discussion Violence affects the lives of millions of women world- wide and in all socioeconomic and educational classes (20). In this study the prevalence of physical, psychologi- cal and sexual violence in infertile women was 68%, 70% and 60%, respectively. Similarly, other studies showed 2 21 221112/1 )1()1()1(2(         − −+−+− −− pp ppppzppz βα 539 Research article EMHJ – Vol. 25 No. 8 – 2019 a high prevalence of psychological violence (1,3,14,15), which may be related to different perceptions of violence in women compare to men. Also women demonstrate a greater sense of responsibility for infertility, which may cause personal psychological distress. The prevalence of sexual violence varied from 7% in Turkey to 57% in Pakistan (1,3,15,16). Reasons for the difference between our study findings with other studies could relate to different cultures, different perceptions of violence or different instruments used. Women may hide sexual violence in many cultures. These women are more likely to suffer depression, which also has an adverse effect on fertility. The prevalence of physical violence reported from studies showed abuse varied from 14% in the Islamic Republic of Iran to 83% in Nigeria (1,15,16). Again, the variation may be related to different cultures or different instruments used. Psychological violence was the most type of violence in all studies. In the present study the chance of domestic violence against women with infertility was about 80% more than for fertile women. Infertility is a significant psychological stressor among infertile couples. Aggressive behaviour may be as a result of inability to deal with this situation (13). Infertile women may display greater sensitivity, so may have different perceptions about domestic violence compared to fertile women. There is great variability in the definitions for domestic violence worldwide and the prevalence of domestic violence among infertile women is difficult to compare across studies (12). In this study infertile women also reported violence from their family (26.5%). In other studies, perpetrators were also female relatives or members of the husband’s family (1,21). There Table 1 Characteristics and socio-demographic data for infertile and fertile women and their spouses variable Infertile women (n=200) Fertile women (n=200) P-value Age a 32.96 ± 7.25 32.44 ± 6.45 0.44b Husband’s age a 36.63± 7.97 36.02 ± 7.24 0.42b Duration of marriage a 8.45± 4.37 10.44 ± 6.40 0.0001b* Education level of the woman c Primary school Secondary school University 46 (23%) 101 (50.5%) 53 (26.5%) 49 (24.5%) 104 (52%) 47 (23.5%) 0.9d Education level of the husband c Illiterate Less than secondary Secondary school University 3 (1.5%) 66 (33%) 88 (44%) 43 (21.5%) 5 (2.5%) 54 (27%) 93(46.5%) 48 (24%) 0.7d Occupation of woman c Housewife Employed Worker Independent job Expertise 163 (81.5%) 15 (7.5%) 14 (7%) 8 (4) 0 (0%) 150 (75%) 30 (15%) 13 (6.5%) 6 (3%) 1 (0.5%) 0.1d Husband’s status c Unemployed Employed Worker Independent job Expertise 20 (10%) 50 (25%) 58 (29%) 72 (36%) 0 (0%) 17 (8.5%) 56 (28%) 54 (27%) 66 (33%) 7 (3.5%) 0.09d aValues are given as mean ± SD bBy t-test cValues are given as number (percentage) dBy x2 test Table2 Prevalence of the type of domestic violence in fertile and infertile groups a Group Infertile women (n=200) Fertile women (n=200) P- value b Type of violence Total domestic violence 167 (83.5%) 102 (51%) 0.0001 Psychological 140 (70%) 90 (45%) 0.0001 Sexual 120 (60%) 71 (35.5%) 0.0001 Physical 136 (68%) 84 (42%) 0.0001 aValues are given as number (percentage) bBy x2 test 540 EMHJ – Vol. 25 No. 8 – 2019Research article was no relationship between wife’s age and husband’s age with regard to violence in this study, which was similarly to other studies (1,16). In contrast, Kaur et al. (2014) reported a correlation between wife’s age and husband’s age with regard to domestic violence (22). In the present study there was no association between duration of marriage and domestic violence, which was similar to one study in Turkey (1). However, age at marriage was associated with domestic violence; women who married younger were more exposed to domestic violence (3), and unemployment significantly influenced the experience of violence. Similar studies reported a significant relationship between the husband’s employment and domestic violence (3,22). In this study, the level of women’s education was associated with domestic violence, and is similar to studies in Nigeria and Punjab, India (14,22). The number of children and infertility were associated with domestic violence in this study, with increased number of children decreasing the chance of violence by 60%, which was similar to a study in Turkey (23). Thus, studies showed that age, education level and income status did not protect women from violence. The prevalence of depression was high among infertile couples in the Islamic Republic of Iran (24). In Iranian culture the chances of divorce among infertile women are high and the probability of remarriage will decrease after divorce (25); thus, infertile women live in anxiety and fear (1,25). Decreased self-steem, poor sexual satisfaction and conflict between couples are consequences of infertility. Quality and satisfaction of marital life may decrease with these factors and domestic violence could be a consequence (25,26). Moreover, Infertile women fear losing family support because of a weak system of social support in many countries (27). Limitations Participant reticence to share experiences may be a limi- tation in this study. Conclusion Infertile women were more exposed to an increased risk of domestic violence compared to fertile woman in this study. Domestic violence is a risk factor for stress, anxi- ety and fear among women and this factor may have an adverse effect on fertility. Thus, it is necessary to provide a domestic violence programme within infertility care. Table 3 Adjusted odds ratios (OR) for predicting factor for total domestic violence Variables B SE Adjusted OR df 95% Confidence interval P-value lower upper Number of pregnancy 0.813 0.670 2.254 1 0.606 8.385 0.225 Number of delivery -0.250 0.931 0.779 1 0.126 4.835 0.789 Number of abortion -0.442 0.631 0.643 1 0.187 2.216 0.484 Number of live child -0.970 0.356 0.379 1 0.189 0.762 0.006* Women education level 4 0.005 Illiterate -0.373 0.683 0.689 1 0.181 2.629 0.585 Primary school -0.485 0.517 0.616 1 0.223 1.697 0.348 Secondary school -1.736 0.474 0.176 1 0.070 0.446 0.0001* University** -0.525 0.371 0.592 1 0.286 1.226 0.158 Education level of the men 5 0.335 Illiterate -0.183 1.110 0.832 1 0.094 7.337 0.869 Primary school 0.901 0.725 2.463 1 0.595 10.201 0.214 Secondary school -0.185 0.556 0.831 1 0.280 2.472 0.739 University** 0.514 0.408 0.980 1 0.751 3.723 0.208 Husband job 1.672 4 0.057 Unemployed 2.762 1.273 15.839 1 1.307 191.977 0.030* Employed 0.277 0.950 1.319 1 0.205 8.485 0.771 Worker 0.544 1.016 1.723 1 0.235 12.615 0.592 Expertise** 0.205 0.980 1.228 1 0.180 8.377 0.834 Housing 3 0.513 Owner ** 0.063 0.653 1.065 1 0.296 3.830 0.923 Tenant 0.479 0.608 1.615 1 0.491 5.314 0.430 Infertility -2.015 0.431 .133 1 0.057 0.310 0.0001* *P value less than 0.05 is significant **Reference group 541 Research article EMHJ – Vol. 25 No. 8 – 2019 Domestic violence victims may need primary care and special attention during her visits, and infertile women need to be educated by health care providers on how to prevent domestic violence. Increasing couples’ knowl- edge about infertility and empowering women about their rights may decrease domestic violence. Acknowledgments The authors thank Guilan University of Medical Sciences for financial support, and the staff of the infertility clinics in Alzahra hospital for their sincere cooperation with this project. We also thank all the women who participated in this study. Funding: Guilan University of Medical Sciences. Competing interests: None declared. مقعلاو ليزنلما فنعلا ينب ةقلاعلا مدق تباث يداش ،يرظن ناكرم ،ينجم يياضر ةقيدص ،يدرونهر ىنم ،يبهار ةيضرم ةديس ةصلالخا .ليزنلما فنعلاك نياودع كولس هنع مجني دقو ،ينميقعلا ينجوزلا ينب اًديدش اًيسفن اًطغض لثمي مقعلا :ةيفللخا .عوضولماب ةقلعتلما لماوعلاو مقعلاو ليزنلما فنعلا ينب ةقلاعلا ديدتح :فادهلأا ءارهزلا ىفشتسم لىإ نهتلاحإ تتم ةأرما 400 لىع هذه اهعون نم ةديرف ةطباض تلااحب ةنترقلما ةيدارفلإا تلاالحا ةسارد تيرجُأ :ثحبلا قرط ليلتح متو .ناريإ في هنم ققحتلا مت يذلاو ،ةيلماعلا ةحصلا ةمظنلم ليزنلما فنعلا نايبتسا مادختساب تانايبلا عجم متو .ناريإ ،تشر ةنيدم في ةيميلعتلا .)يقطنلما طابترلااو ،T رابتخاو ،ياك عبرم( ةيليلحتلاو ةيفصولا تاءاصحلإا مادختساب تانايبلا 140و سينلجا فنعلا نم ةأرما )%60( 120 تناع مانيب ،نيدبلا فنعلل خيرات دوجو ةأرما )%68( 136 تركذ ،مقعلاب ةباصم ةأرما 200 ينب نم :جئاتنلا نأ يقطنلما طابترلاا ليلتح فشكو .)50.0 < )ةيلماتحلاا( P( سيفنلاو سينلجاو نيدبلا فنعلاو مقعلا ينب ةمهم ةقلاع دجوتو .سيفنلا فنعلا نم ةأرما )%70( مقعلاو ،]OR= 15.83; %95 CI=1.307-191.977[ ينلطاعلا جاوزلأاو ،]OR= 0.176;%95 CI= 0.07-0.446[ ءاسنلل يميلعتلا ىوتسلما .)50.0 <P( ليزنلما فنعلاب طبتري ]OR= 0.133; %95 CI= 0.057-0.31[ .حجرلأا لىع ليزنلما فنعلل تمايقعلا ءاسنلا تضرعتو .سيفنلاو سينلجاو نيدبلا فنعلاو مقعلا ينب ةقلاع ةساردلا هذه في دجوت :تاجاتنتسلاا .مقعلاب ينباصلما جاوزلأا ينب ليزنلما فنعلا يّرتح بيج كلذل Relation entre violence domestique et stérilité Résumé Contexte : La stérilité est un facteur de stress psychologique important pour les couples concernés. Les comportements agressifs tels que la violence domestique peuvent être la conséquence de cette situation. Objectifs : Déterminer la relation entre la violence domestique et la stérilité et les facteurs qui y sont associés. Méthodes : La présente étude cas-témoins sans appariement a été menée auprès de 400 femmes adressées au Centre hospitalier universitaire Al-Zahra de Rasht (République islamique d’Iran) de mai à décembre 2015. Les données ont été recueillies à l’aide du questionnaire de l’OMS sur la violence domestique, validé par la République islamique d’Iran. Les données ont été analysées à l’aide de statistiques descriptives et analytiques (test du chi-carré, test T et régression logistique). Résultats : Sur les 200 femmes stériles, 136 (68 %) ont fait état d’antécédents de violence physique, 120 (60 %) ont été victimes de violence sexuelle et 140 (70 %) de violence psychologique. Nous avons observé une relation significative entre la stérilité et la violence physique, sexuelle et psychologique (p < 0,05). L’analyse de régression logistique a montré que le niveau d’éducation des femmes [OR = 0,176, IC à 95 % (0,070-0,446], le chômage du mari [OR = 15,83, IC à 95 % (1,307- 191,977)] et la stérilité [OR = 0,133, IC à 95 % (0,057-0,31)] étaient associés à la violence domestique (p < 0,05). Conclusions : La présente étude a mis en lumière une relation entre stérilité et violence physique, sexuelle et psychologique. Les femmes stériles étaient plus susceptibles d’être victimes de violence domestique. Il est donc nécessaire de détecter la violence domestique chez les couples stériles. 542 EMHJ – Vol. 25 No. 8 – 2019Research article References 1. Yildizhan R, Adali E, Kolusari A, Kurdoglu M, Yildizhan B, Sahin G. Domestic violence against infertile women in a Turkish setting. Int J Gynaecol Obstet. 2009;104(2):110–2. http://dx.doi.org/10.1016/j.ijgo.2008.10.007 2. Boivin J, Bunting L, Collins JA, Nygren KG. A.Collins J, G.Nygren3 K. International estimates of infertility prevalence and treat- ment-seeking: potential need and demand for infertility medical care. Hum Reprod. 2007;22(6):1506–12. http://dx.doi.org/10.1093/ humrep/dem046 3. Sheikhan Z, Ozgoli G, Azar M. Alavimajd4 H. Domestic violence in Iranian infertile women. Med J Islam Repub Iran. 2014;28:152. 4. Akyuz A, Seven M, Şahiner G, Bakır B. Studying the effect of infertility on marital violence in turkish women. Int J Fertil Steril. 2013;6(4):286–93. 5. Johnson R, Humera A, Kukreja S, Found M, Lindow S. The prevalence of emotional abuse in gynecology patients and its associa- tion with gynecological symptoms. Euro J Obst Gyne Rep Bio. 2007;133:95–9. 6. World Health Organization. World report on violence and health. Geneva: World Health Organization; 2002. 7. Semahegn A, Mengistie B. Domestic violence against women and associated factors in Ethiopia; systematic review. Semahegn and Mengistie Reproductive Health. 2015;12:78. 8. Devries K, Watts C, Yoshihama M, Kiss L, Schraiber LB, Deyessa N, et al. Violence against women is strongly associated with suicide attempts: Evidence from the WHO multi-country study on women’s health and domestic violence against women. Soc Sci Med. 2011;73(1):79–86. http://dx.doi.org/10.1016/j.socscimed.2011.05.006 9. Nohjah S, Latifi S, Haghighi M, Eatesam H, Fathollahifar A, Zaman N, et al. The prevalence of domestic violence against women and its related factors in Khuzestan province, in 2007-2008. Behbood. Res J Med Sci, Kermanshah. 2011;15:278–86. 10. Taherkhani S. MirmohammadAli M, Kazemnezhad A, Arbabi M, Amelvalizadeh M. Investigation of domestic violence against women and its relationship with the couple’s profile. J For Med. 2009;15:123–9. 11. Hassan M, Kashanian M, Roohi M, Vizheh M, Hassan M. Domestic violence against pregnant women: prevalence and associat- ed factors. Journal of Research Women and Society. 2010;1:77–96. 12. Stellar C. GarciaMoreno C, Temmerman M, Poel Svd. A systematic review and narrative report of the relationship between infer- tility, subfertility, and intimate partner violence. J Gynecol Obstet; 2015., http://dx.doi.org/10.1016/j.ijgo.2015.08.012Int 13. Etesami pour R, Banihashemi K. Comparison sexual disorders and violence in fertile and infertile women. Journal of birjand university of medical sciences 2011; 18(1): 10-17. 14. Aduloju PO, Olagbuji NB, Olofinbiyi AB, Awoleke JO. Prevalence and predictors of intimate partner violence among women attending infertility clinic in south-western Nigeria. Eur J Obstet Gynecol Reprod Biol. 2015;188:66–9. http://dx.doi.org/10.1016/j. ejogrb.2015.02.027 15. Iliyasu Z, Galadanci HS, Abubakar S, Auwal MS, Odoh C, Salihu HM, et al. Phenotypes of intimate partner violence among wom- en experiencing infertility in Kano, Northwest Nigeria. Int J Gynecol Obstet; 2015., http://dx.doi.org/10.1016/j.ijgo.2015.08.010 16. Ardabily HE, Moghadam ZB, Salsali M, Ramezanzadeh F, Nedjat S. Prevalence and risk factors for domestic violence against infertile women in an Iranian setting. Int J Gynaecol Obstet. 2011;112(1):15–7. http://dx.doi.org/10.1016/j.ijgo.2010.07.030 17. Dyer S, Abrahams N, Mokoena N, Lombard C, van der Spuy ZM. Spuy Zvd. Psychological distress among women suffering from couple infertility in South Africa: a quantitative assessment. Hum Reprod. 2005;20(7):1938–43. http://dx.doi.org/10.1093/humrep/ deh845 18. Ahmadi M. rahnavardi M, kiyani M, poor hoseyn gholi A. Relationship between Domestic Violence and Suicidal Thoughts on Women Referred to Rasht City Health-Medical Center and the Family Courts in 2013. Scientific Journal of Forensic Medicine. 2014;20(4):201–10. 19. Hajian S, Vakilian K, Mirzaii Najm-abadi K, Hajian P, Jalalian M. Violence against Women by Their Intimate Partners in Shahroud in Northeastern Region of Iran. Glob J Health Sci. 2014;6(3):117–30. http://dx.doi.org/10.5539/gjhs.v6n3p117 20. Ali TS, Bustamante Gavino I. Gavino lB. Prevalence of and reasons for domestic violence among women from low socioeconom- ic communities of Karachi. East Mediterr Health J. 2007;13(6):1417–26. http://dx.doi.org/10.26719/2007.13.6.1417 21. Ameh N, Kene T, Onuh S, Okohue J, Umeora O, Anozie O. Burden of domestic violence amongst infertile women attending infer- tility clinics in Nigeria. Niger J Med. 2007;16(4):375–7. 22. Kaur S, Patidar AB. Meenakshi, Sharma S, Navneet. Domestic Violence and Its Contributory Factors among Married Women in selected slums of Ludhiana, Punjab. Nursing and Midwifery Research Journal. 2014;10(1):30–5. 23. Kocacik F, Dogan O. Domestic violence against women in Sivas, Turkey: survey study. Croat Med J. 2007;742:9–47. 24. Abedinia V, Ramezanzadeh F, Noorbala A. Effects of a psychological intervention on quality of life in infertile couples. J Fam Rep Hea. 2009;3:87–93. 25. Hasanpoor–Azghdy SB, Simbar M, Vedadhir A. The social consequences of infertility among Iranian women: a qualitative study. Int J Fertil Steril. 2015;8(4):409–20. 26. Dhont N, van de Wijgert J, Coene G, Gasarabwe A, Temmerman M. ‘Mama and papa nothing’: living with infertility among an urban population in Kigali, Rwanda. Hum Reprod. 2011;26(3):623–9. http://dx.doi.org/10.1093/humrep/deq373 27. Wiersema NJ, Drukker AJ, Dung M, Nhu G, Nhu N, Lambalk CB. Consequences of infertility in developing countries: results of a questionnaire and interview survey in the South of Vietnam. J Transl Med. 2006;4(1):54. http://dx.doi.org/10.1186/1479-5876-4-54 543 Research article EMHJ – Vol. 25 No. 8 – 2019 Prevalence and risk factors of anaemia among ever-married women in Jordan Rasha Arabyat,1 Ghaith Arabyat 2 and Ghaith Al-Taani 1 1Department of Pharmacy Practice, Faculty of Pharmacy, Yarmouk University, Irbid, Jordan. 2Jordanian Royal Medical Services, Amman, Jordan. (Corre- spondence to: Rasha Arabyat: rasha.arabyat@yu.edu.jo). Abstract Background: Anaemia is associated with poor health outcomes and is considered a serious public health problem par- ticularly in low- and middle-income countries. Specific subgroups are at higher risk of anaemia, such as women of repro- ductive age. Aims: This study examined the prevalence and risk factors of anaemia among ever-married women in Jordan using a secondary analysis of the Jordan Population and Family Health Survey. Methods: This is a secondary analysis of data from a nationally representative sample of ever-married women aged 15–49 years that were tested for haemoglobin levels in the 2012 JPFHS. Anaemia was categorized according to the WHO criteria. Univariate and multivariate logistic regression analyses were used to investigate risk factors associated with anaemia. Results: The prevalence of any anaemia was 37.3%; specifically, 20% had mild anaemia (haemoglobin 11.0–11.9 g/dl), 16.3% had moderate anaemia (hemoglobin 8.0–10.9 g/dl) and 1% had severe anaemia (haemoglobin < 8.0 g/dl). Factors that were associated with anaemia in the multivariate regression included urban women (P = 0.01), living in the north (P = 0.014) or south regions (P = 0.013) of Jordan, having multiple children (P < 0.001), being pregnant (P < 0.01), and using IUD as a contraceptive method (P < 0.001). Conclusions: A high prevalence of anaemia among ever-married women of reproductive age in Jordan was noticed. The results emphasize the importance of urgent public health interventions to prevent anaemia in Jordan, particularly among high-risk subgroups. Keywords: anaemia, Jordan Population and Family Health Survey (JPFHS), risk factors, public health, Jordan. Citation: Arabyat R; Arabyat G; Al-Taani G. Prevalence and risk factors of anaemia among ever-married women in Jordan. East Mediterr Health J. 2019;25(8):543–552. https://doi.org/10.26719/emhj.18.074 Received: 05/03/18; accepted: 03/07/18 Copyright © World Health Organization (WHO) 2019. 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). Introduction Anaemia among ever-married women has been identified as a major public health problem, particularly in low and middle-income countries (1). Anaemia is associated with poor immunity, cognitive dysfunction, decreased ability to work and reduced overall quality of life (2). In Jordan, the prevalence of anaemia has increased steadily over the past decade (3) despite the reduced global prevalence of anaemia worldwide (4). Jordan implemented various pro- grammes for prevention and treatment of anaemia and other micronutrient deficiencies. These programmes in- cluded the national wheat flour fortification programmes with iron along with multiple other micronutrients. The Ministry of Health (MoH) in Jordan also initiated routine screening programmes for pregnant women attending neonatal, prenatal, or postnatal care clinics for anaemia. Anaemic women are given a supplement that contains iron, zinc, and folic acid (5). Despite these interventions, the prevalence of iron-deficiency anaemia was not signif- icantly improved during 2002–2010. Apart from national and international reports, limited scientific research exists in Jordan on the determinants and prevalence of anaemia among ever-married women. Moreover, most of the studies conducted in Jordan to assess anaemia prevalence were either descriptive, based on a small sample size, or covered only limited geographical regions (6–8). The 2012 Jordan Population and Family Health Survey is the most recent population- based survey that assesses anaemia and nutritional status in women of childbearing age using a nationally representative sample. However, the published findings of the 2012 JPFHS only included descriptive analysis and applied criteria for diagnosis of anaemia among women that is slightly different from the World Health Organization (WHO) cutoffs (9). The objective of this study is to examine the prevalence and risk factors of anaemia among ever-married women (15–49 years) in Jordan based on data from the 2012 JPFHS by using multivariate regression analysis and applying the most recent WHO cutoffs to categorize anaemia. Methods Data source This is a secondary analysis of data from the 2012 Jordan Population and Family Health Survey, a nationally repre- sentative sample of 15 190 households of the 12 governo- rates of Jordan. JPFHS data are collected in collaboration 544 EMHJ – Vol. 25 No. 8 – 2019Research article with the United States Agency for International Devel- opment (USAID; lead contributor), WHO and United Na- tions International Children’s Emergency Fund (UNICEF) and other agencies (3). The survey was designed to collect information on ever-married women of reproductive age (15–49 years). The survey employed a two-stage cluster sampling procedure. In the first stage, 806 primary sam- pling units (PSUs) or clusters were selected with a proba- bility proportional to the size of the cluster. In the second stage, a fixed number of 20 households were selected in each PSU. The sample was stratified into urban and rural areas, Badia and refugee camps domains. Participation in the survey was completely voluntarily as explained in the informed consent form obtained prior to data collection. The response rate was estimated to be 97%. More infor- mation about sample design, sampling frame, method- ology and organization of the survey is available in JPF- HS/2012 final report (10). Authorization to use the dataset was gained from the DHS program in the United States of America. Measurement of haemoglobin level The JPFHS includes data on 11 352 ever-married women aged 15–49 years. Haemoglobin level, as an estimate of the prevalence of anaemia, was measured in a subsample of two-thirds (6953 ever-married women) of the selected households in each PSU. A drop of capillary blood was taken in the field from the women to measure their hae- moglobin level using the hemoCue instrument. In this method, the blood is drawn from the finger directly into a reagent-coated microcuvette, which is then inserted into a portable-battery operated photometer. Haemoglo- bin level is then displayed numerically in grams per dec- iliter (10).The hemoCue instrument is a valid and highly precise method to estimate the prevalence of anaemia at the population level and the results obtained by this in- strument are similar to the standard laboratory methods for measurement of haemoglobin concentration (11,12). Anaemia levels among women have been adjusted for the influence of altitude because higher altitude of the household location is associated with higher levels of haemoglobin to compensate for lower concentrations of oxygen. Smoking also increases haemoglobin level sub- stantially. Therefore, haemoglobin level was also adjust- ed for smoking status for proper diagnosis of anaemia in smokers (10). Study variables Selection of variables included in the analysis was speci- fied based on a review of the published literature pertain- ing to predictors/risk factors of anaemia among women in low-income countries. Variables included in the anal- ysis were limited to those collected by the JPFHS. The primary outcome of interest for this study was anaemia level. Anaemia was categorized according to the WHO criteria (9). Anaemia in non-pregnant women was clas- sified based on the measured haemoglobin level as: no anaemia (haemoglobin ≥ 12.0 g/dL), mild (haemoglobin = 11.0–11.9 g/dL), moderate (haemoglobin = 8.0–10.9) g/ dL), and severe (haemoglobin < 8.0 g/dL) and in pregnant women was classified as: no anaemia (haemoglobin ≥ 11.0 g/dL), mild (haemoglobin = 10.0 –10.9 g/dL), moder- ate (haemoglobin = 7.0–9.9 g/dL) or severe (haemoglobin < 7.0 g/dL) (9). Several factors that might put women at risk of anaemia were assessed as risk factors for anaemia. These factors included demographic, socio-economic, and health-related factors. Household economic status was measured via the wealth index estimated from information on household assets. This index was used to reflect the relative wealth of the surveyed household and was stratified into five wealth quintiles (poorest, poor, middle, rich, and richest) (10). Body mass index (BMI) was used to reflect the overall nutritional status of women participating in the survey. BMI is a simple weight-to-height ratio calculated by dividing weight in kilogrammes by the height in metre square (kg/ m2). Women were classified according to their BMI as underweight (< 18.5kg/m2), normal (18.5–24.9 kg/m2) and overweight (≥ 25kg/m2). Facing problems in accessing health care was hypothesized to be a risk factor for anaemia. In the 2012 JPFHS, women were asked about barriers that they might face in accessing health care. Women were considered to have problems in accessing health care if they had concerns about at least one of the following factors: not knowing where to go, not getting permission to go, not being able to get money needed for treatment, distance to the health facility, having to take transportation, not wanting to go alone and concern that there may not be a female health provider. Additional independent variables incorporated in this analysis were age (15–19, 20–29, 30–39, or 40–49 years); residence (rural, urban); region (central, north or south); Badia (Badia, non-Badia); camps (camp, non- camp); education (no education, elementary, preparatory, secondary, or higher education); number of children (0, 1, 2–3, 4–5, or 6+); maternity status (pregnant, breastfeeding, neither); using intrauterine device (IUD) (yes, no); and tobacco smoking (yes, no) (Table 1). Statistical analysis The effects of the different independent variables on women anaemia were estimated using multivariate logistic regression method using STATA statistical pack- age, version 14.0 (11). Survey commands in STATA were used to apply sampling weights to get the prevalence of anaemia by severity level. In the bivariate analysis, possi- ble significant predictors of anaemia were examined us- ing chi-squared test (χ2). Second, a multiple logistic mod- el was built in which the anaemia level was analysed as a binary variable comparing no anaemia with having any level of anaemia (mild, moderate, or severe). Results from the multiple logistic regression are presented as adjusted odds ratios (AORs) with 95% confidence intervals (CI) and P-values. Observations with missing data were excluded. The alpha significance level was set at 0.05. 545 Research article EMHJ – Vol. 25 No. 8 – 2019 Ethical approval This is a secondary analysis of existing dataset with all identifying information of study participants removed. Before asking any question and before performing he- moglobin testing, informed consent was acquired from respondents, explaining the purpose of the study and the voluntary nature of participation. Results Prevalence of anaemia among ever-married women of the 7440 ever-married women that were eligible for haemoglobin testing, 6953 (93.5%) were measured. The remaining eligible women were excluded from the anal- ysis because they either refused to be measured (n = 478, 6.4%) or were not present in the household (n = 9, 0.12%) at the time of measurement (Figure 1). The overall prevalence of anaemia among ever-married women in Jordan was 37.3%. The prevalence of mild, moderate, and severe anaemia was 20%, 16.3%, and 1% respectively. Ta- ble 1 demonstrates the weighted prevalence of anaemia by severity level as a function of selected characteristics. Prevalence of anaemia did not vary by education, wealth quintiles, BMI, tobacco smoking, difficulties in accessing health care, living in Badia or camps. The highest preva- lence of anaemia was noticed among women who were having six or more children (43.4%, n = 1,569), using IUD (42.6%, n = 1,313), or pregnant (40.2%, n = 690) (Table 1). The results of multivariate regression analysis of the significant factors associated with anaemia are summarized in Table 2. Having six or more children was significantly associated with anaemia (AOR = 1.54, 95% CI = 1.22-1.93, P < 0.001, n =1,569). Being pregnant (n = 690) significantly increases the likelihood of anaemia (AOR = 1.26, 95% CI = 1.06–1.51, P = 0.009). Ever-married women who were using IUD (n = 1313) had higher odds of anaemia compared to those who were not using IUD (AOR = 1.38, 95% CI = 1.21–1.57, P < 0.001). Those residing in urban areas (n = 4940) were more likely to suffer from anaemia (AOR = 1.17, 95% CI = 1.05–1.31, P = 0.01) compared to those residing in rural areas (n = 2013). Lastly, women living in north (n = 2,516) and south regions (n = 1990) of Jordan had significantly greater odds of anaemia compared to those living in central regions (n = 2447) of Jordan (AOR = 1.18, 95% CI = 1.05–1.31, P = 0.01 and AOR = 1.26, 95% CI = 1.06–1.37, P = 0.013) Discussion In the current study, prevalence of anaemia and its as- sociated risk factors among a representative sample of ever-married women aged 15 to 49 years in Jordan are in- vestigated. The study, based on the 2012 JPFHS, revealed that anaemia is common among Jordanian women of reproductive age. The estimated prevalence rate of anae- mia among ever-married women in Jordan (37%) is only 3% lower than the 40% threshold determined by WHO for Figure 1 Flow diagram of ever-married women aged 15-49 years who were measured for haemoglobin, 2012 JPFHS 11 673 ever-married women age 15–49 were identified for the JPFHS 321 were excluded because they were either unavailable or refused to be interviewed 3912 ever-married women were not eligbile for Hgb 11 352 ever-married women age 15–49 completed interviews for the JPFHS 7440 ever-married women age 15–49 were eligible for Hgb testing 9 ever-married women were not available at time of Hgb test 478 ever-married women aged 15–49 re- fused to be measured 6953 ever-married women age 15–49 were measured for Hgb level 546 EMHJ – Vol. 25 No. 8 – 2019Research article Table 1 Prevalence of anaemia among ever-married women aged 15–49 years by background characteristics, maternity status, and other selected characteristics, JPFHS 2012 Anaemia status by haemoglobin level Any anaemia (%) Mild anaemia (%) Moderate anaemia (%) Severe anaemia (%) P-value Non-pregnant <12.0 g/dl 11.0 - 11.9 g/dl 8.0 - 10.9 g/dl < 8.0 g/dl Pregnant <11.0 g/dl 10.0 - 10.9 g/dl 7.0 - 9.9 g/dl < 7.0 g/dl Characteristic Number of Women (n) Total 6953 37.3 20.0 16.3 1 Age (years) <0.001 15–19 152 31.7 20.1 11.3 0.2 20–29 2034 35.8 21.8 13.9 0.1 30–39 2665 38.8 21 17 0.8 40–49 2102 37.0 17.2 17.8 2.0 Residence 0.013 Rural 2013 36.9 18.2 17.1 1.6 Urban 4940 37.4 20.4 16.1 0.9 Region 0.215 Central 2447 36.2 20.1 15.1 1.0 North 2516 38.8 19.7 18.1 1.1 South 1990 39.4 20.3 18.0 1.1 Badia 0.618 Badia 773 37.3 18.5 17.8 1.0 Non-Badia 6180 37.4 20.2 16.2 1.0 Camps 0.671 Camp 584 35.9 19.0 15.9 1.0 Non-camp 6369 37.4 20.1 16.3 1.0 Education 0.384 No education 251 31.9 14.5 17.0 0.4 Elementary 617 39.6 22.8 15.9 1.0 Preparatory 995 41.1 21.6 18.3 1.2 Secondary 2969 38.6 20.7 17.0 0.9 Higher 2121 32.9 17.8 14.1 1.0 Wealth quintiles 0.774 poorest 1672 38.6 19.3 18.6 0.8 poor 1813 39.0 21.7 15.9 1.5 Middle 1599 40.8 21.4 18.5 0.9 rich 1212 33.6 17.8 14.8 1.0 richest 657 33.1 19.6 12.7 0.8 Number of children <0.001 0 641 30.4 16.7 13.3 0.4 1 725 34.5 18.6 14.6 1.3 2–3 2079 35.4 21.3 13.3 0.7 4–5 1939 38.3 20.4 16.9 1.0 6+ 1569 43.4 19.7 22.2 1.5 Maternity status <0.001 Pregnant 690 40.2 26.1 14.0 0.1 Breastfeeding 1211 33.7 22.0 11.4 0.3 Neither 5052 37.7 18.8 17.6 1.3 547 Research article EMHJ – Vol. 25 No. 8 – 2019 classifying anaemia as a “severe public health problem” (12). For specific subgroups (pregnant women, those who use IUD, and high-parity women), the estimated anaemia rates are above the threshold of identifying anaemia as a severe public health problem. This prevalence has in- creased over the past decade from 29% of ever-married women in 2002 to 37.3% in 2012 (13). Despite the national wheat fortification programme, which was initiated in 2002 in Jordan, no significant improvement in the prev- alence of iron-deficiency anaemia was noticed among a nationally representative sample of women aged 15–49 years between 2002 and 2012 (5). Accordingly, the govern- ment has to reconsider the cost-effectiveness of the na- tional wheat fortification programme. One possible ex- planation for such disappointing results is the decreased access to foods that are rich in iron, such as red meat, be- cause of economic crises that led to significant increases in food price index (5). Results from our study show no significant association between anaemia and women’s education and wealth, which are inconsistent with overall trends in non-industrialized and some industrialized countries (4). Anaemia is usually associated with disadvantaged populations where people of lower education and income are at increased risk for anaemia. Previous studies conducted in Tanzania (14), Mali (15), and India (16) showed higher risk of anaemia among non-educated and poor women. It is possible that non-educated and poor women have lower access to health information and healthcare facilities compared to educated and wealthy women. However, our analysis based on JPFHS show that there are no differences in access to health care between anaemic and non-anaemic women. The highest prevalence of anaemia is found in pregnant women. Anaemia during pregnancy elevates the risk of maternal and neonatal morbidity and mortality, which are major causes of death in low and middle-income countries including Jordan (4). Causes for anaemia during pregnancy include nutritional deficiencies, bacterial and parasitic infections, and genetic disorders of the red blood cells such as thalassaemia (17). In Jordan, thalassaemia is one of the most common haemoglobinopathies, which may partly justify the high prevalence of anaemia among Jordanian pregnant women (18). The World Health Organization recommended the prenatal use of iron supplements in low and middle-income countries to overcome the high burden of anaemia among pregnant women (19). A comprehensive meta-analysis of randomized controlled trials suggested that iron use during pregnancy is associated with a significant reduction in the risk of low birth weight (19). To comply with WHO recommendations, and due to the high prevalence of anaemia among pregnant women, the ministry of health (MoH) in Jordan initiated routine anaemia screening and treatment programmes for pregnant women attending antenatal clinics. Women who are found to have anaemia are given a combination of iron, zinc, and folic acid supplements. Given the high prevalence of anaemia among pregnant women in Jordan, routine supplementation programmes for all pregnant women (not only the anaemic ones) maybe more appropriate option as recommended by Table 1 Prevalence of anaemia among ever-married women aged 15 – 49 years by background characteristics, maternity status, and other selected characteristics, JPFHS 2012 (concluded) Anaemia status by haemoglobin level Any anaemia (%) Mild anaemia (%) Moderate anaemia (%) Severe anaemia (%) P-value Non-pregnant <12.0 g/dl 11.0–11.9 g/dl 8.0–10.9 g/dl < 8.0 g/dl Pregnant <11.0 g/dl 10.0–10.9 g/dl 7.0–9.9 g/dl < 7.0 g/dl Characteristic Number of Women (n) Using IUD <0.001 Yes 1313 42.6 19.5 21.8 1.3 No 5626 36.0 20.2 14.9 0.9 BMI 0.939 <18.5 (thin) 112 28.4 16.2 12.0 0.2 18.5–24.9 (normal) 1765 39.5 20.3 18.5 0.7 ≥ 25 ( overweight and obese) 5076 36.6 20.0 15.5 1.1 Tobacco smoking 0.998 Yes 967 36.2 19.3 15.9 1.1 No 5986 37.5 20.2 16.3 1.0 Problems in accessing healthcare 0.989 Yes 4194 37.4 20.7 15.9 0.8 No 2759 37.0 18.8 16.9 1.3 548 EMHJ – Vol. 25 No. 8 – 2019Research article Table 2 Results from the multivariate logistic regression of factors associated with anaemia among ever-married women aged 15–49 years, Jordan 2012 Variable β coefficient Standard error AOR* 95% CI P-value Age (years) 15–19 1.00 0.71–1.48 0.924 20–29 0.02 0.187 1.01 0.68–1.44 0.894 30–39 -0.03 0.193 0.98 0.78–1.70 0.512 40–49 0.13 0.199 1.14 Residence Rural 1.00 Urban 0.157 0.061 1.17 1.05–1.31 0.01 Region Central 1.00 North 0.150 0.061 1.18 1.05–1.32 0.014 South 0.163 0.066 1.20 1.06–1.37 0.013 Badia Non-Badia 1.00 Badia -0.076 0.088 0.93 0.78–1.1 0.39 Camps Non-camp 1.00 Camp -0.139 0.097 0.87 0.72–1.1 0.155 Education No education 1.00 Elementary 0.137 0.159 1.15 0.84–1.57 0.39 Preparatory 0.193 0.153 1.21 0.90–1.64 0.21 Secondary 0.120 0.147 1.13 0.85–1.5 0.41 Higher 0.051 0.152 1.1 0.78–1.42 0.74 Wealth quintiles poorest 1.00 poor 0.087 0.072 1.1 0.95–1.26 0.228 Middle 0.127 0.077 1.14 0.98–1.3 0.097 rich -0.035 0.086 0.97 0.82–1.14 0.685 richest -0.022 0.107 0.98 0.79–1.21 0.840 Number of children 0 1.00 1 0.04 0.119 1.04 0.82–1.31 0.74 2–3 0.25 0.102 1.29 1.05–1.58 0.013 4–5 0.33 0.110 1.39 1.12–1.72 0.003 6+ 0.44 0.117 1.54 1.22–1.93 <0.001 Maternity status Neither pregnant/breastfeeding 1.0 Pregnant 0.23 0.089 1.26 1.06–1.51 0.009 Breastfeeding -0.035 0.072 0.97 0.84–1.11 0.643 Using IUD No 1.00 Yes 0.322 0.066 1.38 1.21–1.57 <0.001 BMI <18.5 (thin) 1.00 18.5–24.9 (normal) 0.116 0.207 1.12 0.75–1.68 0.573 ≥ 25 ( overweight and obese) -0.03 0.204 0.97 0.65–1.44 0.883 Tobacco smoking No 1.00 Yes -0.002 0.074 0.99 0.86–1.15 0.978 Problems in accessing healthcare No 1.00 Yes -0.006 0.052 0.99 0.90–1.100 0.909 * AOR = Adjusted odds ratio. 549 Research article EMHJ – Vol. 25 No. 8 – 2019 WHO and as practiced in other countries of the Region. These programmes, among others, would have the potential to improve the iron-status of pregnant women and subsequently reduce the overall prevalence of anaemia. However, not enough information exists on the exact number of pregnant women enrolled in these programmes, and therefore their full potential cannot be estimated accurately (5). In this analysis, it was found that the prevalence of anaemia among women of reproductive age in Jordan also varied according to the geographical region. We found that living in north or south regions of Jordan is associated with a higher prevalence of anaemia compared to living in central regions. A previous study conducted among women over 15 years old in southern regions of Jordan estimated that more than half of the surveyed women reported having anaemia (haemoglobin < 12 g/dL) (7). Similar to our results, an analysis of the Haitian Demographic and Health Survey found that women living in urban areas are at greater risk for anaemia compared to living in rural areas (20). The authors of the Haitian study attributed this variation to the different types of food consumed by the urban and rural populations. People living in rural areas have more access to low-cost micronutrient-rich fruits and vegetables compared to those living in urban areas (20). Additionally, the food system in the urban areas changed over the past decade with more access to fast food that is poor in micronutrients (21). A previous study conducted among Bedouin schoolchildren in Jordan concluded that urbanization negatively impacted their micronutrient status and led to under-nutrition (8). Future research may investigate the impact of urbanization on the prevalence of anaemia among ever-married women in Jordan. According to our analysis, increased age was found to be a significant predictor for anaemia in the bivariate but not in the multivariate analysis. Previous studies showed that ever-married women of older age have a higher risk of anaemia compared to younger women. Poor diet and the presence of other comorbidities may make older adults more susceptible to anaemia (22). Consistent with our findings, several other studies have confirmed that anaemia is common in older populations and its prevalence increases with advancing age (23–25). Earlier, anaemia was merely seen as a manifestation of underlying diseases, but recent evidence suggests that its presence alone is associated with an increased risk for death, coronary and cerebrovascular complications and reduced quality of life (26–28). Recent data from clinical practice suggest that anaemia is frequently under- diagnosed and treated in elderly populations. Under- diagnosis of anaemia in older persons may be due to misperceptions that anaemia is a natural phase of aging. Furthermore, symptoms of anaemia may be overlooked by the presence of comorbidities with similar clinical presentation (26). The presence of anaemia requires a thorough investigation to identify the underlying cause and treat the condition appropriately according to published guidelines for evaluation and management of anaemia in the elderly (29,30). Our analysis showed that the use of Intrauterine Device (IUD) increases the risk of anaemia independent from other factors. However, there is no question in the JPFHS to specify the exact type of IUD used. The use of copper–IUD as a contraceptive method may increase the risk of iron-deficiency anaemia by increasing menstrual loss. There is inconsistent data regarding the risk of anaemia with IUD use. For example, a hospital-based study conducted in Egypt found that IUD users had significantly lower levels of haemoglobin compared to non-users or users of other contraceptive methods (31). In contrast, a longitudinal prospective study conducted among Iranian women found that there was no significant increase in anaemia cases among copper–IUD users (32). A recent meta-analysis of studies that measured haemoglobin changes among copper–IUD users found significant decreases of haemoglobin level after one year of use, but these changes were not sufficient to induce anaemia in women with no history of anaemia (33). Another systematic review found no significant changes of haemoglobin level among anaemic women who used copper–IUD for up to one year (34). Given the increase use of IUD devices in low and middle-income countries including Jordan, and the possible increase in the risk of iron-deficiency anaemia, it is recommended that iron supplements should be provided for copper–IUD users in family planning clinics. Lastly, results from our study indicated that having six or more children (high-parity) significantly increases the risk of anaemia. A retrospective cohort study conducted in Oman among pregnant women found that high parity women have three times greater risk for developing anaemia compared to low-parity women (less than five pregnancies with gestational age ≥ 20 weeks) and the risk increases in a dose-response mode with increasing level of parity (35). Another cross-sectional study conducted in Indonesia showed that multiparous (having two or more live birth) women had 58% greater risk of becoming anaemic compared to nulliparous (has never given birth) women (P < 0.001) (36). One possible explanation for such an increased risk of anaemia is that high parity exposes women to more frequent episodes of haemorrhage which may occur before, during or after each delivery (35). Additionally, repeated pregnancy, delivery and breastfeeding reduce the level of several micronutrients in the body, including iron (37). Inadequate replacement of the lost iron with each pregnancy may increase the risk of anaemia in high parity women (36). The main strengths of this study included using a nationally representative sample of ever-married women in Jordan aged 15–49 years, which allows for generalization of results and measuring haemoglobin level directly without relying on medical records or self- reported information. Additionally, this study applied the most recent WHO cutoffs of haemoglobin level for defining anaemia and used a multivariate regression analysis to study risk factors of anaemia. However, our study has some limitations. First, due to the cross- 550 EMHJ – Vol. 25 No. 8 – 2019Research article sectional nature of the study it is not possible to establish causality between the different risk factors and anaemia. Second, the Jordan JPFHS included questions about micronutrients intake and types of food and liquid consumed by children only but not women. BMI was used as an indication of women’s nutritional status but no significant association was found with anaemia. Using BMI as a proxy for nutritional status is not accurate since it does not differentiate between lean muscle and fat tissue (38). Third, most of variables measured in the study were self-reported, which make the results of study subject to recall and social desirability biases. Fourth, measuring serum haemoglobin concentration at the population level as an indicator of anaemia is considered the most reliable method as compared to other clinical measures (39,40). However, anaemia is a multifaceted condition that requires obtaining medical and family histories as well as physical examination for accurate diagnosis. A small number of healthy people may fall below the reference range and some individuals with an underlying condition may fall within the normal reference range for haemoglobin concentration. Lastly, data used for analysis were collected more than five years ago. Nevertheless, at the time of writing, the most recent data available for Jordan from the Demographic and Health Survey website was for 2012. Conclusion Anaemia is common among ever-married women aged 15–49 years in Jordan. We identified several important risk factors associated with anaemia. Results from our study enhance the current knowledge about the preva- lence, distribution, and risk factors of anaemia among women in Jordan and raised anaemia as a public health concern that requires urgent and expanded countrywide intervention. Funding: None. Conflict of interests: None declared. Prévalence et facteurs de risque d’anémie chez les femmes mariées ou l’ayant été en Jordanie Résumé Contexte : L’anémie est associée à des conséquences néfastes sur la santé et constitue un grave problème de santé publique, en particulier dans les pays à revenu faible ou intermédiaire. Des sous-groupes spécifiques présentent un risque d’anémie plus élevé, comme par exemple les femmes en âge de procréer. Objectifs : La présente étude a examiné la prévalence et les facteurs de risque de l’anémie chez les femmes mariées ou l’ayant été en Jordanie au moyen d’une analyse secondaire de l’enquête de santé familiale de la population jordanienne. Méthodes : Il s’agit d’une analyse secondaire des données obtenues à partir d’un échantillon national représentatif de femmes mariées ou l’ayant été, âgées entre 15 et 49 ans, dont le taux d’hémoglobine a été mesuré dans le cadre de l’enquête de santé familiale de la population jordanienne réalisée en 2012. L’anémie a été classée selon les critères fixés par l’OMS. Des analyses de régression logistique univariée et multivariée ont été conduites afin d’analyser les facteurs de risque associés à l’anémie. Résultats : La prévalence de l’anémie était de 37,3 % ; plus précisément, 20 % présentaient une légère anémie (taux d’hémoglobine compris entre 11,0 et 11,9 g/dl), 16,3 % une anémie modérée (taux d’hémoglobine compris entre 8,0 et 10,9 g/dl) et 1 % une anémie sévère (taux d’hémoglobine < 8,0 g/dl). Les facteurs associés à l’anémie dans la régression multivariée étaient les suivants : femmes vivant en milieu urbain (p = 0,01), dans les régions du nord (p = 0,014) ou du sud (p = 0,013) de la Jordanie, ayant plusieurs enfants (p < 0,001), étant enceintes (p < 0,01), et ayant recours au dispositif intra-utérin comme méthode contraceptive (p < 0,001). Conclusions : Une prévalence élevée de l’anémie a été constatée chez les femmes en âge de procréer mariées ou l’ayant été en Jordanie. Les résultats soulignent l’importance des interventions urgentes de santé publique visant à prévenir l’anémie en Jordanie, en particulier parmi les sous-groupes à risque élevé. ندرلأا في لبق نم نجوزت تيلالا وأ اًيلاح تاجوزتلما ءاسنلا ينب هب ةصالخا رطلخا لماوعو مدلا رقف راشتنا لدعم نياعطلا ثيغ ،تايبرع ثيغ ،تايبرع اشر ةصلالخا .لخدلا ةطسوتمو ةضفخنم نادلبلا في ماّيس لا ،ةماعلا ةحصلل ةبسنلاب ةيرطخ ةلكشم دعيو ةفيعضلا ةيحصلا تاجرخلماب مدلا رقف طبتري :ةيفللخا .باجنلإا نس في ءاسنلا لثم ،بركأ لكشب مدلا رقفب ةباصلإا رطلخ ةضرعم ةددحلما ةيعرفلا تائفلا دعتو ،ندرلأا في لبق نم نجوزت تيلالا وأ اًيلاح تاجوزتلما ءاسنلا ينب هب ةطبترلما رطلخا لماوعو مدلا رقف راشتنا لدعم ةساردلا هذه تصحف :فادهلأا .ندرلأا في ةيسرلأا ةحصلاو ناكسلا حسلم يوناث ليلتح مادختساب تحوارت تيلالاو لبق نم نجوزت تيلالا وأ اًيلاح تاجوزتلما ءاسنلل ةينطو ةلثمم ةنيع نم ةذوخألما تانايبلل اًيوناث ًلايلتح اذه دعي :ثحبلا قرط 551 Research article EMHJ – Vol. 25 No. 8 – 2019 References 1. Balarajan Y, Ramakrishnan U, Özaltin E, Shankar AH, Subramanian S. Anaemia in low-income and middle-income countries. Lancet. 2011;378(9809):2123–35. http://dx.doi.org/10.1016/S0140-6736(10)62304-5 2. Haas JD, Brownlie T 4th. Iron deficiency and reduced work capacity: a critical review of the research to determine a causal rela- tionship. J Nutr. 2001;131(2):676S–90S. http://dx.doi.org/10.1093/jn/131.2.676S 3. The DHS Program - Jordan. Standard DHS, 2012 [Internet]. [cited 2017 Jun 30]. Available from: http://dhsprogram.com/what-we- do/survey/survey-display-403.cfm 4. Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca F, et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995–2011: a systematic analysis of population-representative data. Lancet Glob Health. 2013;1(1):e16–25. http://dx.doi.org/10.1016/ S2214-109X(13)70001-9 5. Serdula M, Nichols E, Aburto N, Masa’d H, Obaid B, Wirth J, et al. Micronutrient status in Jordan: 2002 and 2010. Eur J Clin Nutr. 2014;68(10):1124–8. http://dx.doi.org/10.1038/ejcn.2014.100 6. Al-Mehaisen L, Khader Y, Al-Kuran O, Abu Issa F, Amarin Z. Maternal anemia in rural Jordan: room for improvement. Anemia. 2011;2011:381812. http://dx.doi.org/10.1155/2011/381812 7. Abu-Moghli FA, Khalaf IA, Tokiko S, Atsuko I, Nabolsi MM, Al-Sharairi BA. Reproductive and non-reproductive health status of women aged 15 years and above in southern Jordan. East Mediterr Health J. 2012 May;18(5):417–25. 8. Khatib IMD, Elmadfa I. High prevalence rates of anemia, vitamin A deficiency and stunting imperil the health status of Bedouin schoolchildren in North Badia, Jordan. Ann Nutr Metab. 2009;55(4):358–67. http://dx.doi.org/10.1159/000258632 9. World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Geneva: World Health Organization; 2011 (http://www.who.int/vmnis/indicators/haemoglobin/en/). 10. Department of Statistics. Jordan population and family health survey 2012. Calverton, MD: ICF International; 2013 (https:// dhsprogram.com/pubs/pdf/FR282/FR282.pdf). 11. StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP. 12. World Health Organization. Iron deficiency anaemia: assessment, prevention and control: a guide for programme managers. Geneva: World Health Organization; 2001 (https://www.who.int/nutrition/publications/micronutrients/anaemia_iron_deficien- cy/WHO_NHD_01.3/en/). 13. Macro. Jordan population and family health survey 2002. Calverton, Maryland, MD: Department of Statistics/Jordan and ORC Macro; 2003 (http://www.dhsprogram.com/publications/publication-FR138-DHS-Final-Reports.cfm). 14. Wilunda C, Massawe S, Jackson C. Determinants of moderate to severe anaemia among women of reproductive age in Tanzania: analysis of data from the 2010 Tanzania demographic and health survey. Trop Med Int Health. 2013;18(12):1488–97. http://dx.doi. org/10.1111/tmi.12199 15. Ngnie-Teta I, Kuate-Defo B, Receveur O. Multilevel modelling of sociodemographic predictors of various levels of anaemia among women in Mali. Public Health Nutr. 2009;12(09):1462–9. http://dx.doi.org/10.1017/S1368980008004400 16. Ghosh S. Exploring socioeconomic vulnerability of anaemia among women in eastern Indian States. J Biosoc Sci. 2009;41(06):763–87. http://dx.doi.org/10.1017/S0021932009990149 17. Breymann C. Iron deficiency anemia in pregnancy. In Elsevier; 2015. p. 339–47. 18. Hamamy HA, Al-Allawi NA. Epidemiological profile of common haemoglobinopathies in Arab countries. J Community Genet. 2013;4(2):147–67. http://dx.doi.org/10.1007/s12687-012-0127-8 19. Haider BA, Olofin I, Wang M, Spiegelman D, Ezzati M, Fawzi WW. Anaemia, prenatal iron use, and risk of adverse pregnancy رقف فينصت متو .2012 ماعل ندرلأا في ةيسرلأا ةحصلاو ناكسلا حسم في نيهدل ينبولجوميلها تايوتسم صحف متو اًماع 49و 15 ينب نهرماعأ ةطبترلما رطلخا لماوع ءاصقتسلا تايرغتلما ةددعتمو يرغتلما ةديحو يقطنلما طابترلاا تلايلتح تمدخُتساو .ةيلماعلا ةحصلا ةمظنم يرياعلم اًقفو مدلا .مدلا رقفب ،)ترليسيد/مارج 11.0–11.9 ينبولجوميلها( فيفلخا مدلا رقف نم نوناعي %20 ديدحتلابو ؛%37.3 مدلا رقف راشتنا لدعم غلب :جئاتنلا 8.0 < ينبولجوميلها( ديدشلا مدلا رقف نم نوناعي %1و ،)ترليسيد/مارغ 8.0–10.9 ينبولجوميلها( لدتعلما مدلا رقف نم نوناعي %16.3و قطانلما في نشعي تيلالاو ،)P =0.01 )ةيلماتحلاا(( ضرلحا ءاسن تايرغتلما ددعتم طابترلاا في مدلا رقفب ةطبترلما لماوعلا تلمشو .)ترليسيد/مارج تيلالاو ،)P < 0.01( لماولحاو ،)P < 0.001( لافطأ ةدع نيهدل تيلالاو ،ندرلأا في )P = 0.013( ةيبونلجا قطانلما وأ )P = 0.014( ةيلماشلا .)P < 0.001( لملحا عنلم ةليسو ةباثمب بلوللا نمدختسي تدكأو .ندرلأا في لبق نم نجوزت تيلالا وأ اًيلاح تاجوزتلما باجنلإا نس في ءاسنلا ينب مدلا رقفل عفترم راشتنا لدعم َظِحوُل :تاجاتنتسلاا .عفترم رطلخ ةضرعلما ةيعرفلا تائفلا ينب ماّيس لا ،ندرلأا في مدلا رقف نم ةياقولل ةماعلا ةحصلا في ةلجاعلا تلاخدتلا ةيهمأ جئاتنلا 552 EMHJ – Vol. 25 No. 8 – 2019Research article outcomes: systematic review and meta-analysis. BMJ. 2013;346 jun21 3:f3443. http://dx.doi.org/10.1136/bmj.f3443 20. Heidkamp RA, Ngnie-Teta I, Ayoya MAA, Stoltzfus RJ, Mamadoultaibou A, Durandisse EB, et al. Predictors of anemia among haitian children aged 6 to 59 months and women of childbearing age and their implications for programming. Food Nutr Bull. 2013 Dec;34(4):462–79. http://dx.doi.org/10.1177/156482651303400411 21. Konstantyner T, Roma Oliveira TC, de Aguiar Carrazedo Taddei JA. Risk Factors for Anemia among Brazilian Infants from the 2006 National Demographic Health Survey. Anemia. 2012;2012:850681. http://dx.doi.org/10.1155/2012/850681 22. Fairweather-Tait SJ, Wawer AA, Gillings R, Jennings A, Myint PK. Iron status in the elderly. Mech Ageing Dev. 2014;136–137:22– 8. http://dx.doi.org/10.1016/j.mad.2013.11.005 23. Patel KV. Epidemiology of anemia in older adults. Semin Hematol. 2008 Oct;45(4):210-7 http://dx.doi.org/10.1053/j.seminhema- tol.2008.06.006 24. Berliner N. Anemia in the elderly. Trans Am Clin Climatol Assoc. 2013;124:230. 25. Zakai NA, Katz R, Hirsch C, Shlipak MG, Chaves PH, Newman AB, et al. A prospective study of anemia status, hemoglobin con- centration, and mortality in an elderly cohort: the Cardiovascular Health Study. Arch Intern Med. 2005;165(19):2214–20. http:// dx.doi.org/10.1001/archinte.165.19.2214 26. Balducci L, Ershler W, Krantz S. Anemia in the elderly—clinical findings and impact on health. Crit Rev Oncol Hematol. 2006;58(2):156–65. http://dx.doi.org/10.1016/j.critrevonc.2005.09.003 27. Eisenstaedt R, Penninx BW, Woodman RC. Anemia in the elderly: current understanding and emerging concepts. Blood Rev. 2006;20(4):213–26. http://dx.doi.org/10.1016/j.blre.2005.12.002 28. Woodman R, Ferrucci L, Guralnik J. Anemia in older adults. Curr Opin Hematol. 2005;12(2):123–8. 29. Goodnough LT, Schrier SL. Evaluation and management of anemia in the elderly. Am J Hematol. 2014;89(1):88–96. 30. Andrès E, Serraj K, Federici L, Vogel T, Kaltenbach G. Anemia in elderly patients: new insight into an old disorder. Geriatr Geron- tol Int. 2013;13(3):519–27. 31. Hassan EO, El-Hussinie M, El-Nahal N. The prevalence of anemia among clients of family planning clinics in Egypt. Contracep- tion. 1999;60(2):93–9. http://dx.doi.org/10.1016/S0010-7824(99)00066-9 32. Behboudi-Gandevani S, Imani S, Moghaddam-Banaem L, Roudbar-Mohammadi S. Can intrauterine contraceptive devices lead to VulvoVaginal Candidiasis (VVC) andanemia in Iranian new users? Sex Reprod Healthc. 2015;6(1):40–3. http://dx.doi. org/10.1016/j.srhc.2014.09.003 33. Lowe RF, Prata N. Hemoglobin and serum ferritin levels in women using copper-releasing or levonorgestrel-releasing intrauter- ine devices: a systematic review. Contraception. 2013;87(4):486–96. http://dx.doi.org/10.1016/j.contraception.2012.09.025 34. Tepper NK, Steenland MW, Marchbanks PA, Curtis KM. Hemoglobin measurement prior to initiating copper intrauterine devic- es: a systematic review. Contraception. 2013;87(5):639–44. http://dx.doi.org/10.1016/j.contraception.2012.08.008 35. Al-Farsi YM, Brooks DR, Werler MM, Cabral HJ, Al-Shafei MA, Wallenburg HC. Effect of high parity on occurrence of anemia in pregnancy: a cohort study. BMC Pregnancy Childbirth. 2011;11(1):7. http://dx.doi.org/10.1186/1471-2393-11-7 36. Opitasari C, Andayasari L. Young mothers, parity and the risks of anemia in the third trimester of pregnancy. Health Sci J In- dones. 2015;6(1):7–11. 37. Farooq A, Rauf S, Hassan U, Sadiq N. Impact of multi parity on iron content in multiparous women. J Ayub Med Coll Abbottabad. 2011;23(2):12–9. 38. Gurunathan U, Myles P. Limitations of body mass index as an obesity measure of perioperative risk. Br J Anaesth. 2016 Mar;116(3):319-21. http://dx.doi.org/10.1093/bja/aev541 39. Neufeld L, García-Guerra A, Sánchez-Francia D, Newton-Sánchez O, Ramírez-Villalobos MD, Rivera-Dommarco J. Hemoglo- bin measured by Hemocue and a reference method in venous and capillary blood: a validation study. Salud Publica Mex. 2002 Jun;44(3):219–27. http://dx.doi.org/10.1590/S0036-36342002000300005 40. Gwetu TP, Chhagan MK. Evaluation of the diagnostic accuracy of the HemoCue device for detecting anaemia in healthy school- aged children in KwaZulu-Natal, South Africa. South Afr Med J. 2015 Jul;105(7):596–9. http://dx.doi.org/10.7196/SAMJnew.7919 553 Research article EMHJ – Vol. 25 No. 8 – 2019 Health system preparedness in Pakistan for crisis management: a cross-sectional evaluation study Zia Ul-Haq,1,2 Basharat Hussain Shah,1 Mohammad Ardakani,3 Saeed Akbar Khan,3 Saleem Muhammad,5 Saeed Farooq,4 Sardar Hayat Khan 3 and Qudsia Huda 6 1Institute of Public Health and Social Sciences, Khyber Medical University, Peshawar, Pakistan. 2Institute of Health and Wellbeing, University of Glas- gow, Glasgow, United Kingdom. 3World Health Organization, Islamabad, Pakistan. 4Primary Care and Health Sciences, University of Keel, Keel, United Kingdom. 5Gomal Medical College, Dera Ismail Khan, Pakistan. 6World Health Organization, Geneva, Switzerland. (Correspondence to: Zia Ul-Haq: drzia@kmu.edu.pk; zia.ulhaq@glasgow.ac.uk). Abstract Background: The World Health Organization (WHO) has strongly advocated health systems’ preparedness for effective management of crisis situations globally for more than two decades. Pakistan is known for its high vulnerability to haz- ards and lack of coping and adaptive capabilities. Health systems’ preparedness for locales with such high-risk profile is essential, yet there is a dearth of studies addressing the status of such preparedness in the country. Aims: This study aimed to assess the status of preparedness of health-system components for crisis management in the most disaster prone districts of Pakistan. Methods: A purposive sample of 12 of the most disaster prone districts in two provinces of Pakistan was evaluated for preparedness using the WHO’s toolkit for assessing health-system capacity for crisis management. Six core functions of the Health Systems Framework, with a total of 229 indicators, were evaluated at the district management as well as sec- ondary and tertiary health care facilities level. Proportions of indicators prepared were calculated and preparedness was classified as Acceptable (≥ 66%), Partial (36–65%) or Inadequate (≤ 35%). Results: Seventy-two percent, 95% Confidence Interval [46.0, 90.0] of indicators in these most vulnerable districts were evaluated as partially or inadequately prepared for appropriate management of crises. Even the highest scoring core func- tion, Leadership and Governance was partially prepared with a score of 53.6% (52.4, 54.9). Process elements were found to be less prepared compared with structure components. Conclusions: Federal level strategic planning, implementation, management and follow-up aimed at ensuring health-sys- tems’ preparedness need to be reviewed and strengthened. Keywords: Disaster preparedness, crisis management, health system, health risk, hazard, Pakistan Citation: Ul-Haq Z; Shah BH; Ardakani M; Akbar Khan SA; Muhammad S; Farooq S; et al. Health system preparedness in Pakistan for crisis manage- ment: a cross-sectional evaluation study. East Mediterr Health J. 2019;25(8):553–561. https://doi.org/10.26719/emhj.18.072 Received: 24/12/17; accepted: 12/07/18 Copyright © World Health Organization (WHO) 2019. 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). Introduction Health crisis is a blanket term referring to any event with a potentially momentous impact on human health in a population, including disastrous situations resulting from natural, technological, societal, and other sources (1). In spite of different causal dynamics, all such even- tualities present similar challenges to health systems, a fact reflected in the World Health Organization’s (WHO) ‘all-hazards’ approach towards preparedness for respond- ing to them, enabling a unified mechanism for their ef- fective management (2). More than 1.5 billion people have been affected by crises over the last decade, especially the vulnerable groups including children and women (3), in- curring economic losses in excess of US$ 1.3 trillion (4). Globally, an average of 110 000 people died annually from natural or technological disasters during 2004–2013, not to mention the burden of injuries, illnesses, and psycho- logical trauma (5,6). South Asia, harbouring more than a fifth of the world’s population, ranks second lowest among the world regions (after Sub-Saharan Africa) in the human development index, life expectancy at birth, expected and mean years of schooling, and gross national income per capita (7). The region is especially prone to disasters because of its geo-climactic characteristics, having the fastest exposure growth rate in the world, 3.5% per year, with significant increase in the risk of disasters projected over the next two decades. More than 600 million people live along the 2200 kilometre-long geological fault line across the Himalayan belt where, in addition to earthquakes, the threats include avalanches and glacial lake outburst floods, while droughts, floods and cyclones originating in the Bay of Bengal and the Arabian Sea affect the lowlands (8). Moreover, the region is home to many tenacious conflicts including insurgencies, ethnic tensions, and sectarian clashes with potential for further escalation (9). Pakistan, comprising 156 districts in five provinces and a population of 207 million in 2017 (10), expected to reach more than 295 million by 2050 (11), has been in the midst of a vicious cycle of violence with the resulting mass casualties for more than two decades, added to the natural disasters taking their toll (12–14). The country is 554 EMHJ – Vol. 25 No. 8 – 2019Research article known to be in the very high to high risk category in its lack of coping and adaptive capabilities as well as in its vulnerability to hazardous situations (1,15). Conservative estimates put the violence-related death toll for the country at more than 62 000 since 2003 (16), while natural disasters over the last decade have affected more than 50 million people, causing more than 80 000 deaths and economic losses estimated at US$ 25.5 billion (17). The December 2005 earthquake alone cost more than the collective development aid of the previous three years put together (18). Disasters result from a combination of exposure, vulnerability and the systems’ lack of capacity to cope (19). The need for multisectoral coordination for effective management of relief as well as for reduction of disaster risk has been felt for a long time. The United Nations General Assembly designated the 1990s as International Decade for Natural Disaster Reduction (IDNDR) (20). In order to continue the implementation of International Strategy for Disaster Reduction (ISDR) in the new century, the United Nations Office for Disaster Risk Reduction (UNISDR) was created in December 1999 (21). UNISDR defines its goal as “reducing disaster risks through systematic efforts to analyze and reduce the causal factors of disasters”, emphasizing the role of preemptive readiness for managing natural hazards (22). Preparedness (1) is vitally important for all emergency response systems (23) and for locales characterized by high levels of insecurity and uncertainty, efforts aimed at ensuring preparedness should be proportionately robust. In spite of the country’s marked vulnerability to potential disasters, there is a dearth of studies aimed at assessment of preparedness for handling crises in Pakistan. On 21 June, 2018, PubMed search for preparedness and (evaluation or assessment) and (health system) and Pakistan in title did not return any results. Pakistan’s health system consists of primary, secondary, and tertiary care levels. Basic health units and rural health centres are the major primary care facilities caring for 10 000–15 000 and 25 000–50 000 population respectively. Secondary care facilities include Tehsil and District headquarter hospitals catering for 100 000– 300 000 and 1–2 million individuals respectively. There are tertiary care health facilities at provincial level, some of which are teaching hospitals as well (24). National Disaster Management Authority, National Health Emergency Preparedness & Response Network and the Ministry of National Health Services, Regulations & Coordination are some of the organizations involved in disaster management in Pakistan. The 2017 National Action Plan for Disaster Risk Management details the national, provincial, and district levels of disaster management infrastructure in the country, advocating progress monitoring, review and follow up (25). Study aim The objective of this study was to address the lack of pub- lished information regarding the state of health system preparedness for crisis management in the most vulner- able areas of Pakistan. Methods A purposive sample of 12 of the most disaster prone dis- tricts from Khyber Pakhtunkhwa and six from Punjab was selected by the WHO Pakistan office, and public health professionals from Khyber Medical University, Pesha- war, based on risk stratification by the National Disaster Management Authority (26), the relevant Departments of Health, and field experience of the core team members in Pakistan. Khyber Pakhtunkhwa, with an area of 74 521 square kilometres and population density of 259 per square kilometre, carries a very high risk profile. Punjab covers an area of 205 344 square kilometres and is the most densely populated of the five provinces of Pakistan, with a population density of 536 per square kilometres. Preparedness for natural or manmade, predictable or un- predictable disasters (24) at district management as well secondary and tertiary health care delivery facilities was assessed using indicators documented in the toolkit pub- lished by the WHO Regional Office for Europe (EURO) in 2012 (27). Benchmark cutoffs were adopted from previous such assessments in the European Union using the same instrument (28). Analysis of published studies regarding disastrous situations from locales as diverse as the Carib- bean, Africa, North America, Europe, Pakistan and Japan has shown that actual experience “supports the content and value of the WHO toolkit” (29). The toolkit, pilot tested in several countries, covers the six core functions of WHO Health Systems Framework: Leadership and Governance; Health Workforce; Medical Products, Vaccines, and Technology; Health Information; Health Financing; and Service Delivery. The content is organized in a hierarchical fashion with different number of key components within each core function, with a total of 16 key components, several essential attributes within each key component, a total of 51 essential attributes and multiple Indicators within each essential attribute, a total of 229 indicators. Documentation (30) consists of coding an indicator at one of three levels of preparedness: Not prepared (0); Partially Prepared (1); and Fully Prepared (2). A perfect score of 2 on each indicator would render a total score of 458 for each of the 18 districts. Conformity scores are calculated as proportions of achieved scores out of the maximum achievable at different levels of health system hierarchy as well as that of the evaluation structure of the toolkit, i.e. two times the number of indicators assessing the relevant level; conformity scores are then categorized based on cutoffs described below. Assessment of preparedness was done at district health management level, responsible for primary healthcare, and at secondary and tertiary healthcare facilities. Three tertiary care and nine secondary care hospitals from Khyber Pakhtunkhwa and six secondary care hospitals from Punjab were included in the study. As the country was not in a crisis situation at the time of the study, the evaluation covers inter-disaster and health sector preparedness phases (25). After approval by the Ethical Review Board of Khyber Medical University, the Coordination Group, 555 Research article EMHJ – Vol. 25 No. 8 – 2019 consisting of members from WHO, the two provincial ministries of health, and Khyber Medical University, formed assessment teams consisting of personnel with experience in the relevant domains. The assessment teams were trained in the evaluation of each component of the toolkit by the relevant resource persons, according to the user manual for the toolkit (2). In order to ensure a unified evaluation process, evaluators were observed by the resource persons during mock interviews and advised till process consistency was ascertained. The teams met and interviewed district health officers, hospital medical superintendents, and heads of emergency departments of selected hospitals for the relevant information from September 2016 to February 2017. Assessment forms were filled by evaluators while the key person was being interviewed, having signed written informed consent. Data were entered in Microsoft Excel® 2010 Spreadsheet, exported to Stata version 14 for analysis (31). Means and Standard Deviations (SD) are reported as summary measures for interval-ratio scale variables. Proportions for categorical variables are reported as percentages. Two group comparisons of scores are done using t-tests while multiple group comparisons are done using Kruskal-Wallis test. Conformity scores are categorized as inadequately prepared (score ≤ 35%), partially prepared (36–65%), or acceptable (66–100%) (28). Ninety-five percent confidence intervals are reported for estimation of parameters and all tests of significance are two-tailed at an alpha of 0.05. Results Less than 4% of data were missing. Punjab had signifi- cantly higher conformity scores in all core-functions (Figure 2 and Figure 3, Table 1), key components, and essential attributes (Figure 1) overall, and at district lev- el, with t-tests t(4120, 0.05) values ranging from –22.4 to –36.58, all P values < 0.001, and Cohen’s d values ranging from 1.2 (District level) to 0.7 (Essential Attribute level). Overall, only 27.8%, 95% Confidence Interval [26.4, 29.2] of indicators were classifiable as acceptably prepared to manage a crisis situation, 50% (48.5, 51.5) as partially, and 22.2% (20.9, 23.5) as inadequately prepared at districts level. Among the five districts with overall conformity scores in the acceptable category of preparedness, two were from Khyber Pakhtunkhwa, with scores of 86.0 and 85.0% while three were from Punjab, with scores 80.0, 78.0, and 72%. One third of the KP districts had conformity scores evaluated as inadequately prepared, ranging from 18 to 22%; none of the Punjab districts fell in this category. Only one district out of the least prepared 60% was from Punjab. In Khyber Pakhtunkhwa 16.7% (15.3, 18.1) of indicators at district level were in the acceptable category, 50% (48.1, 51.9) in partially, while 33.3% (31.5, 35.1) were in the inadequately prepared range while in Punjab, 50% (47.3, 52.7) fell in acceptably and the other 50% in partially prepared categories. None of the six Core Functions of the WHO Health Systems Framework achieved a score more than 54% while for half of these (Health Workforce, Health Financing, and Service Delivery) it was less than 50%. The highest scores were observed in the Leadership and Governance: 53.6% (52.4, 54.9), and Health Information: 52.5% (50.7, 54.4) functions, while the lowest were in Service Delivery: 46.9% (45.7, 48.1) and Health Workforce: 46.7% (43.1, 50.3). None of the 16 Key Components achieved a score at acceptable level of preparedness, while two were in the inadequate preparedness category: Emergency Medical Services and Mass-casualty Management, 34.4% (27.6, 41.20), and National and subnational strategies for financing health-sector emergency management, 30.9% (26.5, 35.3). The key component Medical supplies and equipment for emergency response operations had an overall conformity score of 51.7%, with 61% (56, 66) of indicators assessed as partially or inadequately prepared. Four Essential Attributes, out of a total of 51 (27), achieved scores at acceptable level of preparedness: National structure for multisectoral emergency management and coordination, 72.2% (64.5, 79.9), Prevention and control of communicable diseases and immunization, 69.4% (57.5, 81.3), National committee Table 1 Comparison of conformity scores in the core functions of WHO Health Systems Frameworks between the two provinces Function Overall Mean(SD) [95% CI] Khyber Pakhtunkhwa Mean(SD) [95% CI] Punjab Mean(SD) [95% CI] P-value 1. Leadership and Governance 53.6 (23.8) [52.4, 54.9] 44.3 (23.4) [42.8, 45.8] 72.3 (9.0) [71.4, 73.1] < 0.001 2. Health Workforce 46.7 (25.5) [43.1, 50.3] 37.5 (19.4) [34.2, 40.8] 65.2 (26.5) [58.6, 71.7] < 0.001 3. Medical Products, Vaccines and Technology 51.8 (30.8) [48.7, 54.8] 38.4 (28.1) [35.0, 41.8] 78.4 (13.9) [76.0, 80.8] < 0.001 4. Health Information 52.5 (23.8) [50.7, 54.4] 48.2 (24.2) [45.9, 50.5] 61.2 (20.5) [58.4, 64.0] < 0.001 5. Health Financing 31.0 (25.2) [26.5, 35.4] 25.6 (21.8) [20.8, 30.3] 41.7 (28.1) [32.9, 50.4] < 0.001 6. Service Delivery 46.9 (23.1) [45.7, 48.1] 40.3 (23.0) [38.8, 41.7] 60.1 (16.8) [58.6, 61.6] < 0.001 556 EMHJ – Vol. 25 No. 8 – 2019Research article 60 50 40 30 20 10 0 % Overall (4122) KP (2748) Punjab (1374) Acceptable Partial Inadequate 1456 1167 1499 707 793 1248 749 374 251 Proportions of essential attributes of Healthcare Systems Framework Core functions at different levels of preparedness Figure 1 Overall health system preparedness for crisis management in two provinces of Pakistan Means and 95% confidence intervals for Conformity scores in the six core functions of WHO Health Systems Framework 8 6 4 2 Mean 95% Cls: Punb KP 1 Leadership 2 Workforce 3 Products 4 Information 5 Financing 6 Service Core functions Figure 2 Comparison of the levels of preparedness between the two provinces in the six core functions of WHO Health Systems Frameworks 557 Research article EMHJ – Vol. 25 No. 8 – 2019 for multisectoral emergency management, 67.1% (61.0, 73.2), and Mother-and-child health-care and reproductive health, 66.7% (53.6, 79.8). All of the attributes with scores in acceptable category either predominantly evaluated structure (three out of four), or were equivocal in assessment stance. Six Essential Attributes had scores in inadequately prepared category: Research and evidence base, 18.5% (10.6, 26.4), Health-sector financing mechanisms, 24.3% (17.3, 31.3), Management of situations involving mass fatality and missing persons, 27.8% (23.1, 32.5), Emergency telecommunications, 32.6% (25.2, 40.0), Capacity for mass-casualty management, 34.4% (27.5, 41.3), and Nutrition and food safety, 34.7% (23.6, 45.8). All of the attributes in the inadequately prepared category either predominantly evaluated process (five out of six), or were equivocal in evaluation stance. The difference of scores achieved in the six core functions of the WHO Health Systems Framework was statistically significant (Kruskal-Wallis χ2 (5) = 140.61, P < 0.001, ε2 = 0.1). Post hoc tests revealed all the 15 pairwise comparisons to be significant except two: Health Workforce versus Service Delivery (Difference: –0.423, P = 0.336), and Medical Products versus Health Information (Difference: –0.645, P = 0.260). Difference of conformity scores between primary healthcare and other system components was not significant (t (4120) = 0.044, P = 0.965). Discussion The use of a validated instrument administered by trained personnel from the relevant areas of expertise lends credibility to this evaluation. With less than 30% of district-level indicators classifiable as acceptably pre- pared, the level of preparedness in these most vulnerable areas of a disaster prone country is almost half of that reported for locales (28) at very low levels of vulnerabil- ity (15). Development of human resources, training and education was second only to health system financing mechanisms in lack of preparedness. Health workforce ultimately channels all invested resources to the end recipient and any deficiency in this area will have sys- tem-wide implications. Among the 13 Essential Attributes belonging to the Leadership and Governance function, which scored the highest among the six components while still being less than 54% compliant, the most prominently deficient attribute was Research and Evidence base, followed by Programmes on Emergency Preparedness and Risk Reduction. These components can be construed as predominantly process indicators. This is in stark contrast with the fact that the highest scoring attributes in this function were National Structures and Committees for Emergency Management and Coordination – both indicators of elements of structure. An entity scoring the highest in the domain of structure and the lowest Figure 3 Comparison of scores out of the total possible in main components of WHO Health Systems Framework between the studied districts Maximum possible score Bannu Kohat Muzaffar Garh Mianwali Sialkot Rajan Pur Jhang Lower Dir Haripur Nowshehra Mardan Charsadda Gujart Peshawar Chitral D.I.Khan Tank Swat 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Leadership Health workforce Products, Vaccines, Technology Health information Health financing Service delivery District wise status of preparedness in the six Core Functions of the WHO Health Systems Framework 32.3% 4.8% 9.6% 15.3% 3.1% 34.9% 558 EMHJ – Vol. 25 No. 8 – 2019Research article in the functionality of that same structure may reflect management issues. As the study did not include any covariates of preparedness, no light can be shed on the possible causal mechanisms behind this structure- function divide. In the core function with the second highest preparedness, Health Information, the most deficient were the attributes of strategies for risk communication with the public and the staff during operations, other than information sharing at national and international levels. The three attributes of this function scoring the highest were Surveillance System, Emergency Reporting System, and Multisectoral Initial Rapid Assessment, all predominantly structure-related or equivocal indicators. For the third place holding core function, Medical Products, Vaccines, and Technology the highest scores were for the Supply, while the lowest ones were in Services. For the fourth next highest scoring function, Service Delivery, the highest scores were again in the indicators construable as predominantly structure-related: Communicable Disease and Immunization, Maternal and Child Health, and Health Services for displaced persons, while the lowest were in the capacity for mass- casualty management, emergency telecommunications, and management of situations involving mass fatality and missing persons; all of which indicators assess aspects of process and function. The fifth highest scoring core function, Health Workforce, had both attributes, Development of Human Resources and Training and Education, almost at par (48 & 46% respectively) regarding lack of preparedness, both indicators of process. The least prepared function, Health Financing, has two components, Multi-sectorial Mechanisms of Financing & Health-sector Financing, both concerning function rather than structure. Conclusions The study detected, in addition to a poor overall prepar- edness of health system for crisis management, a con- sistent pattern of poorer performance in the process, coordination, and operational aspects compared to the structural elements. Limitations The findings cannot be generalized to the whole country as the evaluation was limited to high-risk districts. Lack of information on covariates precludes elucidation of causal mechanisms. Recommendations Leadership and Governance function: Research and ev- idence base being the least compliant attribute of this function, strengthening collaboration regarding applied research between academic and the disaster manage- ment institutions is called for. Health Workforce Function: Development of human resources, training & education attributes were found to be partially prepared. Health workforce development, preferably though skilled partnerships like that with the WHO, should be strengthened. Medical Products, Vaccines, and Technology Function: All four attributes of this function were partially prepared. Up to 61% of indicators in the medical supplies key component showed inadequate or partial availability of emergency provisions. The finding needs confirmation through further studies as such supplies are usually among the first items on any aid initiative. Ensuring ongoing provision of locale-specific requirements must be prioritized appropriately. Health Information Function: The most deficient attributes were strategies for risk communication to the public and to the field staff. This Achilles’ heel of the whole disaster management system needs urgent attention of decision makers and researchers. Health Financing Function: Health sector financing mechanisms was the least compliant attribute in this function. Agencies managing federal and provincial budgetary and contingency fund allocation must take notice. Service Delivery Function: Preparedness for mass fatality and missing persons’ management, emergency telecommunications, capacity for mass casualty management, and nutrition and food safety were all among the least compliant attributes within this function. NDMA and other relevant agencies should address this issue on priority basis. Protocol development for implementation of crisis management plans and ongoing periodic assessment of preparedness status with dissemination of results to the relevant quarters must be made part of the disaster management mechanisms in the country. System barri- ers must be identified and leverage for fundamental solu- tions to this structure-function schism must be sought. Further studies based on random selection of areas and including data on covariate profiles are required to elu- cidate determinants of preparedness. Moreover, stud- ies for assessment at district management and primary healthcare levels are recommended, especially regarding area-specific emergency reserves. Funding: WHO Pakistan office funded the study with- out any role in data collection or analysis. Competing interests: None declared. 559 Research article EMHJ – Vol. 25 No. 8 – 2019 Préparation du système de santé pakistanais à la gestion de crise : étude transversale Résumé Contexte : Depuis plus de deux décennies, l’Organisation mondiale de la Santé (OMS) recommande vivement que les systèmes de santé soient prêts à gérer efficacement les situations de crise à l’échelle mondiale. Le Pakistan est connu pour son importante vulnérabilité face aux risques et pour son manque de capacités de réaction et d’adaptation. La préparation des systèmes de santé dans les zones présentant un profil de risque élevé est essentielle. On observe cependant que très peu d’études sont consacrées à l’état de cette préparation dans le pays. Objectifs : La présente étude avait pour objet d’évaluer l’état de préparation des composantes du système de santé pour la gestion de crise dans les districts du Pakistan les plus exposés aux catastrophes. Méthodes : Un échantillon choisi à dessein de 12 des districts les plus exposés aux catastrophes dans deux provinces du Pakistan a été évalué pour ce qui concerne la préparation, à l’aide des outils de l’OMS destinés à évaluer la capacité du système de santé en matière de gestion de crise. Six fonctions essentielles du cadre des systèmes de santé, comprenant un total de 229 indicateurs, ont été évaluées, au niveau de la gestion par les districts ainsi que par les établissements de soins de santé secondaires et tertiaires. Les indicateurs pris en compte exprimés en proportions ont été calculés afin d’évaluer le niveau de préparation considéré comme étant acceptable (≥ 66 %), partiel (36–65 %) ou insuffisant (≤ 35 %). Résultats : Soixante-douze pour cent (intervalle de confiance à 95 % = 46,0, 90,0) des indicateurs dans ces districts les plus vulnérables présentaient un niveau de préparation partiel ou insuffisant pour assurer une gestion appropriée des crises. Même la fonction essentielle, Leadership et Gouvernance, dont le score était le plus élevé, présentait un niveau de préparation partielle, avec un résultat de 53,6 % [52,4, 54,9]. L’étude a montré que le niveau de préparation des éléments de processus était moindre que celui des composantes de structure. Conclusions : Au niveau fédéral, la planification stratégique, la mise en œuvre, la gestion et le suivi visant à assurer la préparation des systèmes de santé doivent être révisés et renforcés. ةيعطقم ةيمييقت ةسارد :تامزلأا ةرادلإ ناتسكاب في يحصلا ماظنلا بهأت ىده ةيسدق ،ناخ تايح رادراس ،قوراف ديعس ،دممح ميلس ،ناخ بركأ ديعس ،نياكادرأ دممح ،هاش ينسح تاراشب ،قلحا ءايض ةصلالخا فرعُتو .نمزلا نم نيدقع نع ديزي الم لماعلا ىوتسم لىع ةيلعافب تامزلأا ةرادلإ ةيحصلا مُظُنلا بهأت ةدشب ةيلماعلا ةحصلا ةمظنم تديأ :ةيفللخا عفترم مسترلما تاذ نكاملأا في ةيحصلا مُظُنلا بهأت دعيو .فيكتلاو اله يدصتلا لىع ةردقلا رفاوت مدعو رطاخملل ةعفترلما اهضرعت ةيلباقب ناتسكاب .دلبلا في بهأتلا اذه ةلاح لوانتت يتلا تاساردلا ردنت كلذ عمو ،اًيروضر رطاخلما .ناتسكاب في ثراوكلل ةضرعلما قطانلما رثكأ في تامزلأا ةرادلإ يحصلا ماظنلا صرانع بهأت ةلاح مييقت لىإ ةساردلا هذه تفده :فادهلأا ةعوممج مادختساب ،بهأتلا ثيح نم ناتسكابب ينتظفامح في ثراوكلل ةضرعلما قطانلما رثكأ نم 12 تمض ةدوصقم ةنيع مييقت مت :ثحبلا قرط ،ةيحصلا مُظُنلا لمع راطلإ ةتسلا ةيساسلأا فئاظولا مييقت ىرج ماك .تامزلأا ةرادإ لىع يحصلا ماظنلا ةردق مييقتل ةيلماعلا ةحصلا ةمظنم تاودأ بسن باسح متو .ةيثلاثلاو ةيوناثلا ةيحصلا ةياعرلا قفارم ىوتسم لىعو ةددحلما قطانلماب تامزلأا ةرادإ ىوتسم لىع ،اًشرؤم 229 لىع لمتشي ماب .)%35 ≥( ٍفاك يرغ وأ )%65-36( يئزج وأ )%66 ≤( لوبقم هنأ لىع بهأتلا فينصت متو ،بهأتلا ثيح نم تاشرؤلما عتمتت انهأ لىع رطخلل ةضرع رثكلأا قطانلما هذه في تاشرؤلما نم (CI=٤6٫٠9٠٫٠) = %95 ةقثلا لصاف ،ةئالماب ينعبسو يننثا مييقت مت :جئاتنلا ددعب اًيئزج ةبهأتم ةمكولحاو ةدايقلا دعت ،اًطاقن لىعلأا ةيساسلأا ةفيظولا في ىتح .بسانم لكشب تامزلأا ةرادلإ فياكلا يرغ وأ يئزلجا بهأتلاب .لكيلها صرانعب ةنراقم اًبهأت لقأ ةيلمعلا صرانع نأ َدِجُوو .53،6% ]52٫٤٫5٤٫9[ طاقن مُظُنلا بهأت نماض لىإ فدته يتلا ةعباتلماو ،ةرادلإاو ،ذيفنتلاو ،يداتحلاا ىوتسلما لىع يجيتاترسلاا طيطختلا زيزعتو ضارعتسا بيج :تاجاتنتسلاا .ةيحصلا 560 EMHJ – Vol. 25 No. 8 – 2019Research article References 1. United Nations Office for Disaster Risk Reduction. Terminology on Disaster Risk Reduction. International Strategy for Disaster Reduction (ISDR) 2009 (http://www.unisdr.org/files/7817_UNISDRTerminologyEnglish.pdf). 2. World Health Organization Regional Office for Europe. Strengthening health-system emergency preparedness: Toolkit for assessing health-system capacity for crisis management. Copenhagen: WHO Regional Office for Europe; 2012 (http://www.euro. who.int/en/publications/abstracts/strengthening-health-system-emergency-preparedness.-toolkit-for-assessing-health-sys- tem-capacity-for-crisis-management.-part-1.-user-manual-2012). 3. United Nations. United Nations Plan of Action on Disaster Risk Reduction for Resilience: Towards a Risk-informed and Inte- grated Approach to Sustainable Development. New York: United Nations; 2016. (http://www.preventionweb.net/files/49076_un- planofaction.pdf). 4. United Nations. Sendai Framework for Disaster Risk Reduction 2015 - 2030. New York: United Nations; 2015. (http://www.wcdrr. org/). 5. CRED. Center for Research on Epidemiology of Disasters. School of Public Health, Université Catholique de Louvain. Ottignies- Louvain-la-Neuve: Université Catholique de Louvain; 2017 (http://www.cred.be)./) 6. World Health Organization. WHO’s Work in Emergency Risk and Crisis Management. Geneva: World Health Organization; 2016. (http://apps.who.int/iris/bitstream/10665/251551/1/WHO-WHE-ERM-EXT-2016.4-eng.pdf?ua=1). 7. United Nations Development Program. Human Development Report 2016: Human Development for Everyone. New York: UNDP; 2016. (http://hdr.undp.org/sites/default/files/2016_human_development_report.pdf). 8. The World Bank. Disaster Risk Management in South Asia: A Regional Overview. Washington, DC: The World Bank; 2012 (http:// documents.worldbank.org/curated/en/648281468170977802/Disaster-risk-management-in-South-Asia-regional-overview). 9. Muni SD. Conflicts in South Asia: Causes, consequences, prospects. Institute of South Asian Studies; 2013 Mar 26. Report No.: 170–26 March 2013. (https://www.files.ethz.ch/isn/162720/ISAS_Working_Paper_170_-_Conflicts_in_South_Asia_26032013170324. pdf). 10. Pakistan Bureau of Statistics. Provincial Summary Results of 6TH Population and Housing Census-2017. Islamabad: Pakistan Bureau of Statistics; 2018. (http://www.pbs.gov.pk/content/provisional-summary-results-6th-population-and-housing-cen- sus-2017-0). 11. Asian Development Bank. Islamic Republic of Pakistan: Country Environment Analysis. 2008. (https://www.adb.org/sites/de- fault/files/institutional-document/32193/country-environment-analysis.pdf). 12. Khan H, Khan A. Natural hazards and disaster management in Pakistan. Munich Personal RePEc Archive 2008 (https://mpra. ub.uni-muenchen.de/11052/1/NATURAL). 13. World Health Organization. Pakistan Health Situation Report # 1. Geneva: World Health Organization; 2015 (http://www.who. int/hac/crises/afg/afghanistan_earhquake_26october2015.pdf?ua=1). 14. National Disaster Management Authority. Multi-sector Initial Rapid Assessment Report. 2014 Sep 20. (http://www.ndma.gov.pk/ publications/Smira_2014.pdf). 15. Birkmann J, Welle T. The WorldRiskIndex 2016: Reveals the Necessity for Regional Cooperation in Vulnerability Reduction. J of Extr Even. 2016;3(1). https://doi.org/10.1142/S2345737616500056 16. South Asian Intelligence Report. Fatalities in Terrorist Violence in Pakistan 2003-2017. South Asia Terrorism Portal 2017 (http:// www.satp.org/satporgtp/countries/pakistan/database/casualties.htm). 17. United Nations Development Programme. Disaster Risk Reduction in Pakistan. New York: UNDP; 2017 (http://www.pk.undp. org/content/dam/pakistan/docs/CPRU/Disaster%20Risk%20Management/Project%20brief%20-%20Disaster%20Risk%20Reduc- tion%20in%20Pakistan.pdf). 18. Gaiha R. Natural Disasters in South Asia. 2010. Report No.: ASARC Working Paper 2010/06. (https://crawford.anu.edu.au/acde/ asarc/pdf/papers/2010/WP2010_06.pdf). 19. United Nations General Assembly. Report of the open-ended intergovernmental expert working group on indicators and termi- nology relating to disaster risk reduction. New York: United Nations; 2017. https://www.preventionweb.net/files/50683_oiewgre- portenglish.pdf). 20. United Nations General Assembly. Session 44 Resolution 236. 989 Dec 22. Report No.: A/RES/44/236. (http://www.un.org/ga/ search/view_doc.asp?symbol=A/RES/44/236). 21. UNISDR. The United Nations Office for Disaster Risk Reduction. (https://www.unisdr.org/who-we-are/mandate). 22. United Nations Office for Disaster Risk Reduction. What is Disaster Risk Reduction. New York: United Nations; 2017 (https:// www.unisdr.org/who-we-are/what-is-drr). 23. CARER. Center for Advanced Research in Emergency Response. Emergency Response Systems: Concepts, features, evaluation and design. 2011 (http://liu.diva-portal.org/smash/get/diva2:507142/FULLTEXT01.pdf). 24. World Health Organization Regional Office for the Eatern Mediterranean (WHO/EMRO). Health System Profile: Pakistan. Cai- ro: WHO/EMRO; 2007. (http://apps.who.int/medicinedocs/documents/s17305e/s17305e.pdf). 561 Research article EMHJ – Vol. 25 No. 8 – 2019 25. National Action Plan for the Implementaon of Bangkok Principles on Health Aspects of the Sendai Framework for Disaster Risk Reduction. 2017. (http://www.nheprn.gov.pk/userfiles1/file/policies/20171215NationalActionPlan.pdf). 26. National Disaster Management Authority. National Disaster Management Plan: Main Volume. 2012. (http://www.ndma.gov.pk/ plans/NDMP-Main%20Vol.pdf). 27. World Health Organization Regional Office for Europe. Toolkit for assessing health-system capacity for crisis management: Part I; User Manual. Copenhagen: World Health Organization Regional Office for Europe; 2012 (http://www.euro.who.int/__data/ assets/pdf_file/0008/157886/e96187.pdf). 28. Djalali A, Della CF, Foletti M, Ragazzoni L, Ripoll GA, Lupescu O, et al. Art of disaster preparedness in European union: a survey on the health systems. PLoS Curr. 2014 Dec 17;6. https://doi.org/10.1371/currents.dis.56cf1c5c1b0deae1595a48e294685d2f 29. Bayntun C, Rockenschaub G, Murray V. Developing a health system approach to disaster management: A qualitative analysis of the core literature to complement the WHO Toolkit for assessing health-system capacity for crisis management. PLoS Curr 2012 Aug 22;4:e5028b6037259a. https://doi.org/10.1371/5028b6037259a 30. World Health Organization Regional Office for Europe. Toolkit for assessing health-system capacity for crisis management: Part II; Assessment form. Copenhagen: World Health Organization Regional Office for Europe; 2012 (http://www.euro.who. int/__data/assets/pdf_file/0010/157888/e96188.pdf). 31. Stata Statistical Software. Release 14 [computer program]. College Station, TX: StataCorp LP.; 2015. 562 EMHJ – Vol. 25 No. 8 – 2019Research article Perspectives of medical students and teaching faculty on teaching medicine in their native language Ziyad Alrajhi,1 Ali Alhamdan,1 Musab Alshareef,1 Osama Almubaireek,1 Mahmoud Mahmoud,2 Aamir Omair,2 Emad Masuadi 2 and Bashir Hamad 3 1College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. 2Department of Medical Education, College of Medicine, King Saudi bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. 3Sudan Medical Specialization Board, Sudan Khartoum. International University of Africa, Khartoum, Sudan. (Correspondence to: Ziyad Alrajhi: alrajhiziyad@gmail.com). Abstract Background: One of the basic policy questions to be decided at the inception of medical education institutes is the lan- guage of instruction. Aims: This study explored the perspectives of medical faculty and students at a college in Saudi Arabia on the language of instruction in medical education. Methods: A cross-sectional survey of undergraduate medical students and full-time faculty members at a medical college in Riyadh, Saudi Arabia, was conducted in 2016. Each participant completed a self-administered, validated 28-item ques- tionnaire. Results: The total number of students and faculty who responded were 468 (76%) and 37 (93%) respectively. Most stu- dents and faculty members agreed that studying in English enables a better access to medical information (n=457, 91%) and more job opportunities (n=419, 83%). Less than 15% of the students preferred to be taught in Arabic in most of the cur- riculum aspects except for communication skills (n=131, 28%) and the Objective Structured Clinical Examination (OSCE) (n=119, 26%). Conclusions: Most medical students and faculty members preferred English as the language of instruction for medical education and did not believe that teaching medicine in Arabic should be sought as a future goal. Keywords: medical education, native language, English, Arabic, Saudi Arabia. Citation: Alrajhi Z; Alhamdan A; Alshareef M; Almubaireek O; Mohamud M; Omair A; et al. Perspectives of medical students and teaching faculty on teaching medicine in their native language. East Mediterr Health J. 2019;25(8):562–566. https://doi.org/10.26719/emhj.18.073 Received: 30/08/17; accepted: 30/01/18 Copyright © World Health Organization (WHO) 2019. 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). Introduction Nearly every year, new medical colleges are established throughout the world in response to the shortages that exist in health care personnel. One of the basic policy questions to be decided at the inception of these medical education institutes is the language of instruction. There is currently no global standard in this regard: different medical colleges around the world use different languag- es of instruction. About 37% of medical colleges outside the United States of America and Canada use English as the medium of instruction, while only 22% of the coun- tries in which these medical colleges are located have English as an official language (1). About 15% of medical colleges around the world use two or three languages for instruction (1). In the Arab world, with a population of more than 400 million people distributed across 22 countries speaking mainly Arabic, only the Syrian Arab Republic uses Arabic as the language of instruction in all its medical colleges (2). Arabic has been used in the country since 1918 when the first medical college was established (3). English, on the other hand, constitutes the primary language of instruction in most of the medical colleges in Arab countries, apart from four countries that use French: Tunisia, Morocco, Algeria, and Mauritania. The choice of using the native language for instruction in medicine has a significant impact on the students who study it, as it facilitates the process of acquiring knowledge and utilizes the optimum potential of the students. If the language of instruction is not their native language, students begin their college journey with a challenge, encountering a curriculum in a language that is unfamiliar and different, which leaves the student with the burden of trying to keep their grades up and understand new terminology (4). The English language barrier has been shown to be associated with poor student performance (5–7), and a poor ability to communicate with patients (8,9). In the British Council report “English as a medium of instruction: a growing global phenomenon”, teaching medicine in English when it is not the native language may lead to difficulties when those students or graduates start their clinical practice and interact with patients who might not know any English at all (10). On the other hand, opponents of the native language choice associate instruction in English with better job opportunities, social status, and self-esteem (11,12). Furthermore, students in Egypt have overwhelmingly expressed concern over Arabization, as it would add a new burden to their academic careers (9). Linguistic policies and slow Arabization processes have also been blamed for the inadequacy of specialized 563 Research article EMHJ – Vol. 25 No. 8 – 2019 scientific materials in Arabic (12). Previous studies have considered the attitudes of medical faculty and students towards the language of instruction (9,12). It was recommended that these studies be repeated periodically to assess the emergence of new trends and to help guide new linguistic policies (12). In response to this recommendation, the present study explored the perspectives of medical faculty and students regarding the use of Arabic as the language of instruction in medical colleges in Saudi Arabia. It also investigated their perspectives on the obstacles to adopting Arabic for teaching medicine, and on the scientific, economic, and social impact of language choice in medical education. Methods Settings and participants This study was conducted at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) in Riyadh, Saudi Arabia. The institution was established in Septem- ber 2004 to offer health sciences programmes and uses English as the medium of instruction and assessment. The college of medicine adopted the medical curriculum from the University of Sydney in Australia. The college of medicine at KSAU-HS has two different branches, one for females and the other for males. They both use the same curriculum but the full-time teaching faculty is different in each college. Almost all the students had Arabic as the language of instruction during high school. Before enter- ing the college of medicine, students complete two years of English and basic sciences (taught in English) study at the College of Science and Health Professions. This study approached all 613 male and female medical undergradu- ate students and 55 full time teaching faculty. Instrument development and data collection methods The research team developed a questionnaire that con- sisted of questions regarding demographic character- istics, awareness of the languages used to teach med- icine worldwide, perceived language superiority, and language practice preference. Face and content validity were checked by four medical educators before a pilot study was conducted on 100 students and the internal consistency was assessed using Cronbach’s alpha. An ex- ploratory factor analysis was used to assess the construct validity of the questionnaire. Timings of the questionnaire distribution were carefully selected to maximize the response rate. Student participants were approached at break times, after lectures, and at the end of the academic day. The faculty was approached during their office hours to hand them the questionnaires, which were collected the next day. Survey instruments for the students and faculty were identical except for a question about the year-of-study (students) and the respondent’s position at the college (faculty). Participation in this study was voluntary and a consent form was attached to the questionnaire. The confidentiality of the study participants was ensured and all questionnaires were kept in a safe and secure place that could only accessed by the research team. Statistical analysis SPSS software (IBM Corp. Released 2013. IBM SPSS Sta- tistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) was used for data entry and analysis. Categorical data were presented as frequencies and percentages. A Chi-square test was used to assess the association be- tween knowledge about language use in medical teach- ing worldwide and language practice preference with the baseline characteristics of the faculty and students. The test was considered to show a significant difference if the P-value was less than 0.05. Results The questionnaire was completed by 468 (76%) out of 613 students and 37 (93%) out of 40 available faculty mem- bers. The overall Cronbach’s alpha was 0.81 for the 21 Likert-type scale items; further analysis showed high re- liability of the domains as well (participants’ awareness about language use in medical teaching worldwide [0.89], perceived language superiority [0.71], and language prac- tice preference [0.74]). To test the construct validity of the instrument, an exploratory factor analysis (EFA) was used that confirmed the five factors the instrument con- tained thereby explaining 66% of the total variance. The extraction method used was principal component analy- sis and varimax rotation with Kaiser normalization. Only two items, the Objective Structured Clinical Examination (OSCE) and communication skills, were misclassified by loading higher on “preference for teaching medicine in Arabic in the future” rather than “language use”. The Bartlett’s tests of sphericity was used to ascertain wheth- er factor analysis can be carried out (P-value < 0.001) with a Kaiser-Meyer-Olkin measure of sampling adequacy of 0.76. The majority of the respondents were males for both students (n=279, 60%) and faculty (n=26, 70%), which is similar to the general distribution of the study population. The mean age of the student respondents was 22.0 + 1.8 years, while the mean age of the faculty member respondents was 40 + 10.9 years. The distribution of the proportion of students who responded had a greater proportion from first and second year, this is similar to the general distribution of the study population. Of the faculty respondents, half (n=19, 51%) were assistant professors and above, while the remaining (n=18, 49%) were lecturers or teaching assistants. Table 1 shows the respondents’ opinions about the advantages of studying medicine in English. The overall response showed high agreement for the statements that medical graduates from programmes instructed in English have better access to medical information (n=457, 91%) and more job opportunities (n=419, 83%). Around half of the participants agreed that medical graduates who studied in English are more competent (n=260, 51%) 564 EMHJ – Vol. 25 No. 8 – 2019Research article and have a higher social status (n=239, 47%). There was no significant difference between the students and the faculty for any of the four statements. Preferred language for teaching and testing Table 2 shows that the general selection of the preferred language was languages other than Arabic. The high- est preference for the Arabic language was for commu- nication skills by the students (n=129, 28%) and faculty (n=2, 5%). There were significant differences between students and faculty for three items: communication skills (P = 0.003), community doctor theme / personal and professional development sessions (P = 0.04), and OSCE (P = 0.002), which were all higher for students. Should Arabic be used as a language of instruction for medicine in the future? Only 159 (36%) students and 11 (31%) faculty members thought that teaching medicine in Arabic should be a goal that must be sought in the future, with no significant dif- ference between the students and the faculty. The language used by lecturers in teaching The majority of students (n=408, 88%) and faculty (n=35, 95%) stated that English is currently the language used by lecturers in teaching. Knowledge about language of instruction for medicine worldwide Seven randomly selected countries were provided in the questionnaire asking the participants about the language of medical instruction for these countries. Most of the respondents (n=394, 78%) did not know the language of instruction for medicine in various countries presented in the questionnaire. Favouring English as the language of instruction Participants who favoured English as the language of medical instruction gave a variety of reasons for their preference. The most notable reason was access to the best and most updated medical resources. Furthermore, they mentioned the English language as being the main language of medicine and that it must be used to be able to communicate with the medical scientific community. Moreover, many students mentioned that using English provides more job opportunities and makes it easier to pursue further training. Other notable reasons for fa- vouring English were the availability of teaching faculty, availability of medical terminology, less learning effort, higher social status, and more competence upon gradu- ation. Favouring Arabic as the language of instruction The most frequently cited reason among those who fa- voured Arabic as the language of instruction in medicine was that Arabic is the spoken language of their popula- tion, so using Arabic as the language of instruction would improve the quality of care by better understanding pa- tients’ complaints, helping to explain the condition to the patients, and spreading awareness to the community. An- other reason cited was that Arabic, being the native lan- Table 1 Students’ and faculty’s perceptions about advantages of medical graduates who studied in English Students [n=468] Faculty [n=37] P-value n (%) n (%) Have better access to medical information 423 (91) 34 (92) 0.79 a Are more competent 241 (52) 19 (53) 0.99 Have more job opportunities 389 (84) 30 (81) 0.75 a Have a higher social status 219 (47) 20 (56) 0.39 aFishers Exact test was used for small-expected amount Table 2 Students’ and faculty’s Arabic language preference in teaching and assessment Students [n=468] Faculty [n=37] P-value n (%) n (%) Lectures 27 (6) 0 (0) 0.245 Problem-based learning tutorials 37 (8) 1 (3) 0.345 Procedural skills 62 (13) 1 (3) 0.069 Communication skills 129 (28) 2 (5) 0.003 Laboratory sessions 27 (6) 1 (3) 0.712 Written examination 21 (4) 0 (0) 0.388a Community and doctor theme / personal and professional development 71 (15) 1 (3) 0.044 Objective structured clinical examination 118 (25) 1 (3) 0.002 aFishers Exact test was used for small-expected amount 565 Research article EMHJ – Vol. 25 No. 8 – 2019 guage of the students, would enable better understand- ing of the content and spare the time and effort required for translation. Other reasons mentioned were the need to strengthen the sense of identity and independence and the need to support the Arabic language. Discussion The purpose of this study was to explore the perspectives of medical students and faculty at KSAU-HS in Riyadh, Saudi Arabia on the possibility of using the Arabic lan- guage as the medium of instruction in undergraduate medical education. Approximately one-third of the stu- dents and the faculty thought that teaching medicine in Arabic was a goal that must be sought in the future; this suggests that majority of those who participated fa- voured English as the language of instruction. The over- whelming preference for English in this study is consist- ent with the published literature. A study conducted in Egypt showed that only 9% of the students thought that teaching medicine in a foreign language was a major ob- stacle (9). Approximately 70% of the students surveyed by Sabbour et al. in Egypt indicated a preference for using Arabic to learn communication skills (9). This contrasts with the findings of the present study, where only 28% of the participants reported such a preference. Another study conducted in Saudi Arabia found similar results and showed that 96% of the study participants considered English to be superior to Arabic, and that 82% of them thought that English was more appropriate for medical instruction and other scientific specialties (11). This can be explained by the fact that, for students and faculty members alike, the usage of Arabic as a language of instruction brings a sizable academic burden and fear of having to adapt to an unfamiliar educational system. Moreover, Al Jarf (2008) study also showed that most participants thought that English was the language of instruction for medical education programmes worldwide (11). However, this study found that 78% of the participants indicated that they did not know which language of instruction was used to teach medicine in other parts of the world. A study that was conducted in Libya showed that 63% of the medical students preferred to be taught in a mixture of Arabic and English (10). Ahmed et al. (2015) study showed far more acceptance of using Arabic as the language of instruction in their medical and dental education programmes compared to only 28% of participants in the present study, who indicated that Arabic could be used to teach communication skills (10). Both the medical students and faculty members who participated in the present study preferred English as the language of instruction for medical education. Furthermore, the majority believed that using Arabic as the language of instruction should not be sought as a future goal. One of the main strengths of the present study is that the tool used was validated, and showed high internal consistency and reliability. Moreover, it included all students and full-time faculty members of both genders at a recently established medical college in Riyadh, Saudi Arabia. A limitation of the present study is that the students and teaching faculty who were surveyed were all from one institution. Future studies should include a larger sample from different institutions. Further research is needed to better understand the applicability and the practicality of teaching medicine in Arabic. We recommend conducting a similar study at a university where the medium of in- struction is a native language other than English. Funding: This work was supported by the King Abdul- lah International Medical Research Center, Riyadh, Saudi Arabia. Competing interests: None declared. Points de vue des étudiants en médecine et du corps professoral concernant l’enseignement de la médecine dans leur langue maternelle Résumé Contexte : L’une des questions de politique essentielles qui se pose au moment de la création d’instituts d’enseignement de la médecine concerne la langue dans laquelle la formation sera dispensée. Objectifs : La présente étude analyse les points de vue du corps professoral et des étudiants d’une faculté d’Arabie saoudite concernant la langue utilisée dans l’enseignement de la médecine. Méthodes : Une étude transversale a été réalisée en 2016 auprès d’étudiants en médecine de premier cycle et de membres du corps professoral à temps plein d’une faculté de médecine de Riyad (Arabie saoudite). Chaque participant a rempli un questionnaire auto-administré et validé comportant 28 items. Résultats : Le nombre total d’étudiants et d’enseignants ayant répondu au questionnaire était respectivement de 468 (76 %) et de 37 (93 %). La majorité des étudiants et des membres du corps professoral reconnaissait que l’enseignement dispensé en anglais permet un meilleur accès à l’information médicale (n = 457, 91 %) et offre davantage de possibilités d’emploi (n = 419, 83 %). Moins de 15 % des étudiants préféraient l’enseignement dispensé en arabe dans la plupart des matières du programme, à l’exception des compétences en communication (n = 131, 28 %) et de l’Examen Clinique Objectif Structuré (ECOS) (n = 119, 26 %). Conclusions : La majorité des étudiants en médecine et des membres du corps professoral privilégiaient l’anglais comme langue d’enseignement de la médecine et estimaient que l’enseignement en arabe ne devait pas constituer un objectif pour l’avenir. 566 EMHJ – Vol. 25 No. 8 – 2019Research article ملأا مهتغلب بطلا سيردت نأشب سيردتلا ةئيه ءاضعأو بطلا بلاط رظن تاهجو دحم يرشب ،يدوسم دماع ،يرمع رماع ،دوممح دوممح ،كييربلما ةماسأ ،فيشرلا بعصم ،نادملحا ليع ،يحجارلا دايز ةصلالخا .سيردتلا ةغل يه يبطلا ميلعتلل تاسسؤم ءاشنإ دنع انهأشب رارق ذاتخا بيج يتلا تاسايسلاب ةقلعتلما ةيساسلأا لئاسلما نم :ةيفللخا ةغل نأشب ةيدوعسلا ةيبرعلا ةكلملماب بطلا تايلك ىدحإ في بطلا بلاطو سيردتلا ةئيه ءاضعأ رظن تاهجو ةساردلا هذه تثحب :فادهلأا .يبطلا ميلعتلا في سيردتلا بطلا تايلك ىدحإ في لماك ماودب ينلماعلا سيردتلا ةئيه ءاضعأو بطلا تايلك بلاط لىع ةيعطقم ةيئاصقتسا ةسارد تيرجُأ :ثحبلا قرط .اًدنب 28 مضي هنم ققحتم ةباجلإا تياذ اًنايبتسا كراشم لك لمكأو .2016 ماع في ،ةيدوعسلا ةيبرعلا ةكلملما ،ضايرلا ةنيدمب بلاطلا مظعم قفتاو .لياوتلا لىع )%37 )93و )%468 )76 نايبتسلاا لىع اوباجأ نيذلا سيردتلا ةئيه ءاضعأو بلاطلا ددع لياجمإ غلب :جئاتنلا لمع صرفو )%n=457، 91( لضفأ لكشب ةيبطلا تامولعلما لىع لوصلحا نم نّكُت ةيزيلجنلإا ةغللاب ةساردلا نأ لىع سيردتلا ةئيه ءاضعأو لصاوتلا تاراهم ءانثتساب ،ةيساردلا جهانلما بناوج مظعم في ةيبرعلا ةغللاب سيردتلا بلاطلا نم %15 نم لقأ لضفُيو .)%n=419، 83( لضفأ .)%OSCE( )n=119، 26( فادهلأا مظنم يريسرلا صحفلاو )%n=131، 28( ةغللاب بطلا سيردت عضو بيج لا هنأ نودقتعيو ،يبطلا ميلعتلا في ةيزيلجنلإا ةغللا سيردتلا ةئيه ءاضعأو بلاطلا مظعم لضفُي :تاجاتنتسلاا .ليبقتسم فدهك ةيبرعلا References 1. Boulet J, Bede C, Mckinley D, Norcini J. An overview of the world’s medical schools. Med Teach. 2007;29(1):20–6. http://dx.doi. org/10.1080/01421590601131823 2. Cote R. Choosing one dialect for the Arabic speaking world: a status planning dilemma. 75 Arizona working papers in SLA & Teaching. 2009;16:75–22. 3. Al khatib B. Review of the history of the teaching of medicine in Arabic. East Mediterr Health J. 1995;1(2):284–9. 4. Anand A, Bammidi S. Medical education and training: implications for India. Ann Neurosci. 2013;20(4):133. http://dx.doi. org/10.5214/ans.0972.7531.200402 5. McLean M, Murdoch-Eaton D, Shaban S. Poor English language proficiency hinders generic skills development: a qualitative study of the perspectives of first-year medical students. J Furth High Educ. 2013;37(4):462–481. http://dx.doi.org/10.1080/030987 7X.2011.645461 6. Mandal A, Ghosh A, Sengupta G, Bera T, Das N, Mukherjee S, et al. Factors affecting the performance of undergraduate medical students: a perspective. Indian J Community Med. 2012;37(2):126–129. http://dx.doi.org/10.4103/0970-0218.96104 7. Kaliyadan F, Thalamkandathil N, Parupalli SR, Amin TT, Balaha MH, Al Bu Ali WH. English language proficiency and academic performance: a study of a medical preparatory year program in Saudi Arabia. Avicenna J Med. 2015;5(4):140–4. http://dx.doi. org/10.4103/2231-0770.165126 8. Mirza DM, Hashim MJ. Communication skills training in English alone can leave Arab medical students unconfident with patient communication in their native language. Educ Health (Abingdon). 2010 Aug;23(2):450 PMID: 20853245 9. Sabbour SM, Dewedar SA, Kandil SK. Language barriers in medical education and attitudes towards Arabization of medicine: student and staff perspectives. East Mediterr Health J. 2010;16(12):1263–1271. http://dx.doi.org/10.26719/2010.16.12.1263 10. Dearden J. English as a medium of instruction: a growing global phenomenon. Oxford: British Council / OUP; 2014. (https:// www.britishcouncil.org/sites/default/files/e484_emi_-_cover_option_3_final_web.pdf). 11. Ahmed KM, Peeran SW, Qasem Ahmed MA. Attitudes of Libyan dental and medical students toward the use of English language as a medium of instruction. Dent Med Res. 2015;3(2):53–5. http://dx.doi.org/10.4103/2348-1471.159188 12. Al Jarf R. The impact of English as an international language (EIL) upon Arabic in Saudi Arabia. Asian EFL J. 2008;10(4):193–210. 567 Research article EMHJ – Vol. 25 No. 8 – 2019 Cognitive factors associated with brucellosis preventive behaviours among diagnosed patients: an application of Empowerment Model Towhid Babazadeh,1 Haidar Nadrian,2 Soheila Ranjbaran,3 Hamed Rezakhani-Moghaddam 4 and Mehran Aghemiri 5 1Department of Public Health, Sarab Faculty of Medical Sciences, Sarab, Islamic Republic of Iran. 2Social Determinants of Health Research Center, Tabriz University of Medical Sciences, Tabriz, Islamic Republic of Iran. 3Department of Health Education and Promotion, School of Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 4Department of Public Health, Khalkhal University of Medical Sciences, Khalkhal, Islamic Republic of Iran. 5Department of Medicine, Tarbiat Modares University, Tehran, Islamic Republic of Iran. (Correspondence to: Haidar Nadrian: haidarnadrian@gmail.com). Abstract Background: Brucellosis is an endemic disease in many countries, especially in the Mediterranean region, as well as countries such as the Islamic Republic of Iran. Despite the preventive measures against brucellosis adopted in different countries throughout the world, the disease is still a public health concern. Aims: Our aim in the present study was to examine the cognitive factors associated with Brucellosis Preventive Behav- iours (BPBs) among diagnosed patients utilizing Empowerment Model. Methods: In 2013, applying a cross-sectional study, all 238 patients with brucellosis in Chaldoran County, Islamic Repub- lic of Iran, were recruited to answer a researcher-made EM-based questionnaire and BPBs Scale through interview. Results: Hierarchical multiple linear regressions were performed with BPBs as the outcome variable. Predictors for this variable, according to their natures, were classified in two different blocks. In the first block, significant effect was found on BPBs by demographic variables (∆R2 = 0.301). In the second block, the level of education, knowledge, and self-efficacy were significant predictors (P < 0.001) of BPBs (∆R2 = 0.808). Conclusions: The Empowerment Model was found as a helpful framework in predicting the risk factors of BPBs. Health care providers in low- and middle-income countries should consider the patients’ knowledge on the disease and their level of self-efficacy to perform BPBs as the core categories of empowerment while designing brucellosis prevention programmes. Keywords: Brucellosis, preventive behaviours, knowledge, self-efficacy, Empowerment Model Citation: Babazadeh T; Nadrian H; Ranjbaran S; Rezakhani-Moghaddam H; Aghemiri M. Cognitive factors associated with Brucellosis preventive behaviours among diagnosed patients: an application of Empowerment Model. East Mediterr Health J. 2019;25(8):567–574. https://doi.org/10.26719/ emhj.18.062 Received: 04/10/16; accepted: 28/11/17 Introduction Brucellosis is the most common zoonosis disease world- wide and causes infection in domestic animals, wildlife and humans (1). Human brucellosis is a bacteraemia process that presents an undulating period, with a high tendency towards relapses which evolves into a chron- ic state with frequent reinfection (2). Brucella infection causes abortion, preterm delivery and intra-uterine in- fection among animals (3). Symptoms of brucellosis such as intermittent fever, chills, malaise, arthralgia, diapho- resis, myalgia, headache, anorexia, and fatigue-like influ- enza are generally non-specific to humans (4). Brucellosis is an endemic disease in many countries, especially in the Mediterranean region, including Kuwait, Saudi Arabia and some parts of Africa (1,3,5,6). The World Health Organization (WHO) has reported about 500 000 cases of brucellosis worldwide, and 10 000–20 000 cases per year in Europe (7). Based on the world’s map of brucellosis (2006), the brucellosis incidence in the Islamic Republic of Iran was 50 to 500 per 100 000 people (8). In a previous study, the prevalence of brucellosis in the Islamic Republic of Iran was reported as high in several provinces including Hamedan, Kurdistan, Lorestan, and West and East Azerbaijan (5). Despite the preventive measures against brucellosis adopted in different countries throughout the world, particularly the Mediterranean and the Islamic Republic of Iran, the disease is still a public health concern (9). Brucellosis is transmitted through different ways, including inhalation of contaminated air, dust soaked in urine and faeces of infected animals, direct contact with infected animals, and consumption of dairy products (2–5). All of these transmission routes can be mitigated by performing preventive behaviours, which have been emphasized in several previous studies (3,10,11). Theory-based interventions may be more effective in influencing brucellosis preventive behaviours (BPBs) in comparison to other approaches, as they provide a framework to develop health promotion interventions and guide the evaluation of these interventions (12). To our knowledge, few studies have used a framework to promote BPBs in rural areas (10,13). In a study, Oruogi et al. applied the PRECEDE–PROCEED model as a framework to reduce the brucellosis incidence in rural areas of Khomain County, Islamic Republic of Iran. The results of 568 EMHJ – Vol. 25 No. 8 – 2019Research article their intervention showed a remarkable decrease in the incidence of brucellosis from 147 to 43 cases per 100 000 after a nine months’ follow-up (10). In a study conducted by Babaei et al., cognitive factors such as self-efficacy and perceived susceptibility were associated with BPBs (11). Several earlier studies (10,11,14–17), as well as the Ottawa Charter on Health Promotion (14), have emphasized the effectiveness of empowerment as a strategy to prevent diseases and promote health. Moreover, Sausa et al. (15), concluded that knowledge raising alone is not enough to change behaviour and, therefore, emphasized on empowerment as a strategy to promote health-related behaviours. Empowering patients begins with the provision of information and training, and ends with the active participation of patients in the decision-making process about their disease and performing health promoting behaviours (16). Empowerment may happen effectively through education, but participation plays a vital role in empowering members to deal with the nature of their illness and to improve the capacity of their self-care for health promotion (17). Masoodi et al. evaluated the effects of a family-centered empowerment model on skill, attitude and knowledge of multiple sclerosis (MS) patients’ caregivers and found that empowering the caregivers promoted their knowledge, attitude and skills on giving more efficient care to their patients (18). In the present study, the Empowerment Model was used as a framework to determine the factors associated with empowering the brucellosis patients to perform BPBs. This model provides a framework to empower patients and their families in the areas where patients need intervention (19). EM was developed by Elhani (2002) and since then has been applied as a framework to intervene in health-related behaviours (20,21). The EM constructs includes: 1) knowledge (including facts, information and skills that are acquired by a person through experience or education); 2) Attitude (positive or negative evaluation of the behaviour by individuals) (2), and self-efficacy (a personal belief of ability to carry out the recommended plan of action successfully); and 3) self-esteem (feeling valued) (21). Identifying brucellosis influential factors in the present study may be useful in designing empowerment- based interventional efforts aiming at brucellosis prevention. The questions that guided the study were as follows: 1) May the cognitive factors be associated with BPBs among the diagnosed patients? 2) To what extent might the cognitive factors of Empowerment Model be associated with BPBs among diagnosed patients?; and 3) Might EM be applied as a framework for designing empowerment-based interventional programmes aimed at brucellosis recurrence prevention among diagnosed patients? Therefore, our aim in the present study was to examine the cognitive factors associated with BPBs among patients diagnosed with brucellosis utilizing the Empowerment Model model. Methods Participants and procedure This cross-sectional study was carried out from April to November 2013. Through census, all the 238 patients with brucellosis in Chaldoran were recruited to participate in the study. All those who were satisfied with participation in the study and were also diagnosed with brucellosis were included in the study. Ethical approval for the study was provided from the Ethics Committee in Tehran University of Medical Sciences (Ethical Code was 98382). Before the implementation of the study, the purpose was explained to the participants and all signed consent forms. Data were collected using face-to-face interviews conducted in a consultation room at Health Houses by two trained healthcare providers. Each interview lasted for 35 to 40 minutes. Measures The instruments used for data collection were research- er-prepared questionnaires. In order to confirm the content validity of the instruments, a panel of experts involving four scholars in the areas of health education and a physician with specialty in infectious diseases, re- viewed and assessed the questions orally by evaluating the appropriateness and relevance of the items to brucel- losis patients, response format and confirmed them to be representative of the constructs. The responses from the panel of experts were used to revise and modify the tools, which were then pilot tested by a sample of bru- cellosis patients to examine their utility. The pilot study was conducted to examine the utility of the instruments and to identify the problems/benefits associated with the design. The first draft was prepared following consultation with the research team. The questionnaire was pilot tested with 20 brucellosis patients. The data were used to esti- mate the internal consistency of the scales, using Cron- bach’s coefficient alpha. The content validity of the scales was also established. This pilot sample was not included in the final sample. For data collection, a questionnaire consisting of demographic characteristics (age, gender, level of education, residency and occupation), Empower- ment Model constructs (Knowledge, Attitude, Self-effica- cy and Self-esteem) and BPBs were prepared. The Brucellosis Knowledge Questionnaire (BKQ) was prepared by the researchers to measure knowledge towards the brucellosis disease. BKQ included 19 items. An item example is as follows: “boiling milk for at least five minutes destroys the brucellosis microbes”. The respondents should select ‘Yes’, ‘No’ or ‘don’t know’ for each item. For a correct answer a score of 3 was assigned and for incorrect answer and “I don’t know”, the scores of 1 and 2 were considered, respectively. The possible score ranged from 19 to 57 (Cronbach α = 0.82). The Brucellosis Attitude Questionnaire (BAQ) was a ten-item scale developed to measure the attitudes of 569 Research article EMHJ – Vol. 25 No. 8 – 2019 patients towards BPBs. The response format was based on a five-point Likert-type scaling (five = totally agree, four = agree, three = no idea, two = disagree and one = totally disagree). Examples of BAQ items are: animals with brucellosis should be separated from other animals; boiling milk is a suitable method to destroy brucellosis germs. The theoretical range was 10–50, in which higher scores indicated more positive attitude toward BPBs (Cronbach α = 0.78). The Brucellosis Self-Efficacy scale (BSES) was also a researcher-prepared seven-item scale developed to measure the self-efficacy towards BPBs. Again, a five- point Likert-type scaling ranged from 1 = very low to 5 = very high, was used. Examples of items are: I believe that I can wear a mask while working in the barn; I believe that I can wear gloves while working in the barn. The theoretical range for this instrument was 7–35. The higher score showed more self-efficacy toward BPBs (Cronbach α = 0.83). The General Self-Esteem Scale (GSES) was a nine- item scale developed by the researchers to measure the general self-esteem of brucellosis patients. The response format was based on a two-point scaling (agree = 2 and disagree = 1). Examples of the items were as follow: I feel that I am a valuable person; I can do my jobs as good as other people. The theoretical range for this scale was 9–18, within which higher scores indicated higher self- esteem among the patients (Cronbach α = 0.81). The Brucellosis Preventive Behaviours Scale (BPBS) was also a nine-item instrument with a two-point scaling (yes= 2 and no= 1). The items comprised activities that should be conducted to prevent brucellosis. The list of the items is provided in Table 1. Statistics Data were coded numerically and entered into Statistical Package for Social Sciences (SPSS) software, version 20.0 for Windows. The level of significance was considered to be < 0.05, a priori. Summary statistics and frequency dis- tributions were used to describe and interpret the mean- ing of data. An additional calculation was performed on the mean score of the variables. The differences between the Empowerment Model constructs by demographic variables were analyzed using one-way ANOVA and t-test or their non-parametric equivalents (Kruskal-Wallis and Man-Whitney U tests). Pearson correlation coefficient was applied to indicate the associations between the Empowerment Model structures and BPBs. Moreover, hierarchical linear regression analysis (HLRA) with enter method was applied to illustrate the variations in BPBs on the basis of the Empowerment Model constructs. HLRA was performed in two blocks to evaluate the efficiency of Empowerment Model constructs over the influence of the other factors. Predictors for the BPBs were classified in two different blocks according to their natures: (Block 1) Demographic characteristics: age, gender, level of ed- ucation, residency; (Block 2) Empowerment Model con- structs: including knowledge, attitude, self-efficacy and self-esteem. Results Demographic characteristics and brucellosis preventive behaviours The age of the participants ranged from 17 to 50 years (mean age = 35.13 ± 9.51). 38% of the patients were illiter- ate or with elementary education. 37% were ranchers and 61% were rural residents (Table 2). Statistically significant differences were found in the BPBs by all the character- istics, except for gender (P < 0.001). Applying a series of Kruskal-Wallis and Man-Whitney U tests, the level of performing BPBs was found to be less prevalent among those with lower level of education, ranchers and rural residents. Brucellosis preventive behaviours among patients The most prevalent BPBs among patients were “Fresh cheese usage” (87.3%),” “time vaccinating of livestock” (51.2%), “washing hands with soap and water after every contact with cattle secretions” (47.3%) and “wearing a mask while working in the barn” (44.9%), respectively (Table 1). Table 1 Frequency of brucellosis preventive behaviours among patients (n= 238), Chaldoran County, Islamic Republic of Iran, 2013 Brucellosis preventive behaviors YES NO N % N % Pasteurized milk usage 16 5.7 267 94.3 Raw milk usage 85 30 198 70 Fresh cheese usage 247 87.3 36 12.7 On time vaccinating of the livestock 145 51.2 138 48.8 Wearing gloves while working in the barn 84 29.7 199 70.3 Wearing mask while working in the barn 127 44.9 156 55.2 Disinfecting the obstetric secretions of the livestock in the barn 12 4.2 271 95.8 Washing the udder of cattle before milking 4 1.4 279 98.6 Eating raw or partially cooked meat 103 36.4 180 63.6 Washing hands with soap and water after every contact with the cattle’s secretions 134 47.3 149 52.7 570 EMHJ – Vol. 25 No. 8 – 2019Research article Empowerment Model constructs and brucellosis preventive behaviours Pearson’s correlation coefficient test revealed statistical- ly significant associations between the BPBs and knowl- edge (P < 0.01, r = 0.571), attitude (P < 0.01, r = 0.172) and self-efficacy (P < 0.01, r = 0.214) (Table 3). Prediction of brucellosis preventive behaviours by Empowerment Model constructs Demographic characteristics of the respondents ex- plained approximately 30% of the observed variance in BPBs, which was statistically significant (P < 0.001) (Table 4). Also, the EM constructs were responsible for, approximately, 51.0% of change in the observed variance (P< 0.001). In the first block, the level of education was the only significant predictor for BPBs (∆R2 = 0.301); and, in the second block, knowledge, self-efficacy and the level of education were significant predictors of BPBs (∆R2 = 0.507). Patients’ knowledge on brucellosis was the strongest predictor for performing BPBs. Discussion The current study investigated the factors associated with BPBs among patients with brucellosis applying the EM. Our findings indicated significant differences in BPBs by the patient’s level of education, occupation and residency. The mean score of BPBs was higher among those with a university education compared to the illit- erate and people with low level of education. In the hi- erarchical regression analysis, the level of education was the only significant predictor of BPBs in the first step of the analysis. In line with these findings, Babaei et al., (11) found significant difference in BPBs by the education lev- el of the ranchers. These findings show that the level of disease prevention literacy among literate people is high- er compared to their illiterate counterparts. In addition, Sun et al., (22) reported that education has positive and direct effect on prior knowledge and health literacy. Also, Sohng et al. (23) reported that the mean score of health promoting behaviours was higher among people with a higher level of education. In comparison with the illiter- ate and those with low level of education in the present study, the patients with the higher levels of education may have had the ability to seek health information from various sources, which, consequently, have led them to a better level of knowledge on the disease and thus per- form a higher level of BPBs. In the present study, when applying Pearson Correlation Coefficient test a significant positive association was found between the knowledge on brucellosis disease and BPBs. Moreover, in the regression analysis, we found that the patients’ knowledge on the disease and its prevention was the strongest predictor for BPBs. As Tebug et al. noted, having low knowledge on zoonotic diseases may lead to its prevalence and causes problems in controlling them (24). They also reported that only 15% of the stockbreeders knew brucellosis as a zoonotic disease (24). Mostafaei et al., (25) reported the students’ level of awareness about brucellosis as undesirable. These findings urge the need for designing and implementing educational programmes to raise people’s awareness about brucellosis and its prevention. Table 2 Association between demographic characteristics and brucellosis preventive behaviours among patients (n= 238), Chaldoran County, Islamic Republic of Iran, 2013 Characteristics N (%) Mean SD P Age (years) 238 (100) 35.1 9.5 Sex* Male 197 (69.6%) 2.73 1.95 P = 0.540 Female 86 (30.4%) 2.51 1.29 Level of education** Illiterate/elementary 108 (38.2%) 2.08 0.88 P < 0.001 High school/diploma 104 (37.7%) 2.30 1.10 College 71 (25.1%) 3.91 1.81 Employment** Rancher 95 (33.6%) 2.04 1.06 Farmer 41 (14.5%) 2.48 1.07 P < 0.001 Worker 26 (9.2%) 2.65 1.67 Housewife 62 (21.9%) 2.40 1.05 Employee 59 (20.8%) 3.82 1.74 Residency* Urban 110 (38.9%) 2.94 1.72 P = 0.003 Rural 173 (61.1%) 2.42 1.21 *Differences in the means were measured using Man-Whitney U test. **Differences in the means were measured using Kruskal-Wallis test. 571 Research article EMHJ – Vol. 25 No. 8 – 2019 Therefore, knowledge on the disease is still a major risk factor for brucellosis morbidity, which should be considered as a core category while designing brucellosis prevention programmes. In the regions with a high prevalence of the disease, a brucellosis prevention campaign may be considered as a strategy in prevention programmes. Similar with our findings, Tebug et al. in Malawi (24) found that working at a stockyard is a risk factor for brucellosis. However, in the study conducted by Orouji et al., in the rural areas of Khomain County, no significant association was found between occupation and BPBs (10). This difference in the results may be related to the target groups of the studies. In our study, the target group was people with brucellosis with a high risk for not performing the BPBs compared to healthy people in the study of Orouji et al. (10). The most common high risk behaviours among patients in the present study were consumption of unpasteurized milk and fresh cheese, not wearing a mask while working in the barn, and not washing the cows’ udders before milking. Clearly, 69.6% of the participants reported eating fresh cheese. Similar with this finding, Sufian et al., (9), Earhart et al., (6) and Makita et al., (26) reported the consumption of unpasteurized dairy products as a prevalent risk factor for brucellosis. In the study in Malawi (24), 34% of the respondents consumed unpasteurized milk. Moreover, Minas et al., (27) in Greece, attributed 8.49% of the brucellosis infection to dairy products. In addition, the findings of the present study showed that the majority of the brucellosis patients did not wear gloves and mask while working in the barn, and had direct contact with the obstetric secretions. In fact, in this study 48.8% of the patients did not use gloves and 70.3% did not wear a mask while working in the barn. Moreover, 49.9% reported not disinfecting the obstetrics secretions in the barn and 63.3% reported not washing their hands after touching faeces and other secretions of livestock. All of these factors may have an important role in brucellosis infection. Earhart et al. (6) reported a significant association between brucellosis infection and having contact with the secretions of aborted animals. The findings of the analysis conducted by Bikas et al. (28) and Cooper et al (29) showed that trauma during animal delivery is an important risk factor for being infected with brucellosis. These findings, again, suggest that patients may not be aware of the ways of brucellosis transmission and they, also, may not consider themselves susceptible to brucellosis. The mean score for self-efficacy among the brucellosis patients was relatively low, which is similar to those found by Hung et al., on malaria prevention (30). Moreover, a significant association was found between self-efficacy and BPBs in the present study. Further analysis and applying hierarchical regression presented self-efficacy as a significant predictor for BPBs. The association between self-efficacy and high-risk behaviours was confirmed in previous studies (31–33). Self-efficacy is an important precondition for self-management in promoting health behaviours (34,35). These findings suggest that self-efficacy improvement should be a core strategy in planning brucellosis prevention interventions by healthcare providers. According to the findings of hierarchical regression analysis in the present study, Empowerment Model was able to explain and describe 50.7% of the behavioural changes in patients afflicted with brucellosis. Moreover, Table 3 Associations between the Empowerment Model constructs and brucellosis preventive behaviours among patients (n= 238), Chaldoran County, Islamic Republic of Iran, 2013 1 2 3 4 5 M ± SD Possible range 1 = Knowledge 1 5.3±1.74 0–10 2 = Attitude 0.172** 1 24.17±2.3 10–50 3 = Self-efficacy 0.214* 0.296** 1 14.85±3.71 7–35 4 = Self-esteem -0.043 0.217** 0.276** 1 13.68±1.97 9–18 5 = BPBs*** 0.571** 0.131** 0.261** -0.018 1 2.62±1.45 0–10 * Correlate is significant at the 0.05 level (2-tailed); ** Correlate is significant at the 0.01 level (2-tailed); ***Brucellosis Preventive Behaviours Table 4 Hierarchical regression analysis for prediction of brucellosis preventive behaviours by demographic and the Empowerment Model constructs among patients (n= 238), Chaldoran County, Islamic Republic of Iran, 2013 Step/Variable B (Step 2) B (Step 1) Block 1 Age -0.029 -0.047 Level of Education 0.538* 0.407* Gender 0.048 0.057 job 0.023 0.015 Residence 0.041 0.029 Block 2 Knowledge 0.426* Attitude 0.018 Self-efficacy 0.167* Self-esteem -0.037 ∆R2 0.301 0.507 Cumulative ∆R2 0.301 0.808 P value 0.001 0.001 *Significant at the 0.05 level 572 EMHJ – Vol. 25 No. 8 – 2019Research article among the constructs of the Empowerment Model, knowledge and self-efficacy were the significant predictors of BPBs. In the study conducted by Babaei et al., among the ranchers, self-efficacy was the strongest predictor of BPBs (11). Moreover, several previous studies (36,37) have reported knowledge and self-efficacy as the most powerful predictors of preventive behaviours among different populations. Considering the applicability of Empowerment Model in predicting BPBs in the present study, it can be concluded that Empowerment Model may be considered as an alternate methodological choice while designing educational interventions aiming at BPBs promotion in the high risk areas. Limitations Considering that the method of data collection in our study was based on self-reporting by patients with bru- cellosis, there is a possibility for recall bias. Also, as the nature of study was cross-sectional, the generalizability of the findings is warranted. Another limitation may be the lack of information on economic status of patients. Level of income may be a predictor for the level of BPBs among these patients, which could be considered in the present study. Finally, considering the significant asso- ciation between the level of education and BPBs, further research is suggested with more focus on health literacy among patients with brucellosis. Conclusion The results of the present study showed the Empower- ment Model as a helpful framework in identifying and predicting the risk factors of BPBs. Promoting knowl- edge, self-efficacy and disease – specific health literacy may be the core strategies while designing intervention- al programmes to promote BPBs among the patients in low- and middle-income countries. Moreover, among the constructs of the Empowerment Model, knowledge and self-efficacy were the significant predictors of BPBs. Considering the strength of the Empowerment Model in predicting the cognitive factors associated with BPBs and also the lack of socio-environmental factors in this model, it is suggested to be integrated with other models such as the ecological model or the PRECEDE–PROCEED model, and used as a comprehensive framework while designing health promotion interventions for brucellosis prevention and control. Funding: None. Competing interests: None declared. Facteurs cognitifs associés aux comportements de prévention de la brucellose chez les patients diagnostiqués : application du modèle d’autonomisation Résumé Contexte : Dans de nombreux pays, la brucellose est une maladie endémique, en particulier dans la Région de la Méditerranée, ainsi que dans des pays tels que la République islamique d’Iran. En dépit des mesures de prévention de la brucellose adoptées dans différents pays à travers le monde, cette maladie reste un problème de santé publique. Objectifs : La présente étude avait pour objectif d’examiner les facteurs cognitifs associés aux comportements de prévention de la brucellose chez les patients diagnostiqués à partir du modèle d’autonomisation. Méthodes : Dans le cadre d’une étude transversale réalisée en 2013, l’ensemble des 238 patients atteints de brucellose dans la circonscription de Chaldoran, en République islamique d’Iran, ont été recrutés. Lors d’un entretien, il a été demandé aux patients de remplir un questionnaire basé sur le modèle d’autonomisation ainsi que sur une échelle des comportements de prévention de la brucellose élaborés par les chercheurs. Résultats : Des régressions linéaires hiérarchiques multiples ont été réalisées, les comportements de prévention de la brucellose constituant la variable de jugement. En fonction de leur nature, les facteurs prédictifs de cette variable ont été classés en deux groupes distincts. Dans le premier groupe, on a constaté un effet significatif sur les comportements de prévention de la brucellose en fonction des variables démographiques (∆R2 = 0,301). Dans le second groupe, les niveaux d’éducation, de connaissances et d’efficacité personnelle constituaient des facteurs prédictifs significatifs (p < 0,001) des comportements préventifs de la brucellose (∆R2 = 0,808). Conclusions : Le modèle d’autonomisation a constitué un cadre utile pour prévoir les facteurs de risque associés aux comportements de prévention de la brucellose. Dans les pays à revenu faible et intermédiaire, il est recommandé aux prestataires de soins de santé de prendre en compte les connaissances des patients sur la maladie ainsi que leur niveau d’efficacité personnelle concernant les comportements de prévention de la brucellose comme catégories de base de l’autonomisation dans le processus d’élaboration de programmes de prévention de cette maladie. 573 Research article EMHJ – Vol. 25 No. 8 – 2019 جذومن قيبطت :مهصيخشت مت نيذلا ضىرلما ينب تلايسوبرلا ءاد نم ةيئاقولا تايكولسلاب ةطبترلما ةيكاردلإا لماوعلا ينكمتلا ييرم هغأ نارهم ،مدقم نياخاضر دماح ،نابرجنر لايهس ،نايردن رديح ،ةداز اباب ديحوت ةصلالخا ينبت مغرو .ةيملاسلإا ناريإ ةيروهجم كلذ في ماب ،طسوتلما قشر ميلقإ في ماّيس لا ،نادلبلا نم ديدعلا في اًنطوتم اًضرم تلايسوبرلا ءاد دعي :ةيفللخا .ةماعلا ةحصلل ةبسنلاب اًقلق لِّثمُي ضرلما لازي لا ،لماعلا نادلب فلتمخ في تلايسوبرلا ءاد ةحفاكلم ةيئاقولا يربادتلا مهصيخشت مت نيذلا ضىرلما ينب تلايسوبرلا ءاد نم ةيئاقولا تايكولسلاب ةطبترلما ةيكاردلإا لماوعلا صحف في ةساردلا هذه في انفده لَّثتم :فادهلأا .ينكمتلا جذومن مادختساب ضرلماب ناريإ ةيروهجم ،ناردلاشت ةعطاقم في تلايسوبرلا ءادب اًباصم اًضيرم 238 رايتخا مت ثيح ،ةيعطقم ةسارد قيبطت مت ،2013 ماع في :ثحبلا قرط ةلباقم ءارجإ للاخ نم تلايسوبرلا ءاد نم ةيئاقولا تايكولسلا سايقمو نوثحاب هعضو ينكتم جذومن لىع مئاق نايبتسا لىع ةباجلإل ،ةيملاسلإا .مهعم فينصت متو .تاجرخلما يرغتم ةباثمب تلايسوبرلا ءاد نم ةيئاقولا تايكولسلا مادختساب ةيمرلها ةددعتلما ةيطلخا تادادترلاا تيرجُأ :جئاتنلا تلايسوبرلا ءاد نم ةيئاقولا تايكولسلا لىع يربك رثأ كانه ناك ،لىولأا ةعومجلما في .ينتفلتمخ ينتعوممج في ،اهتعيبطل اًقفو ،يرغتلما اذله تاشرؤلما ةمهم تاشرؤم ةيتاذلا ةءافكلاو ةفرعلما ىوتسمو يميلعتلا ىوتسلما ناك ،ةيناثلا ةعومجلما فيو .)2R∆ = 0.301( ةيناكسلا تايرغتلما قفو .)2R∆ = 0.808( تلايسوبرلا ءاد نم ةيئاقولا تايكولسلل )P < 0.001( لىع بيجو .تلايسوبرلا ءاد نم ةيئاقولا تايكولسلاب ةصالخا رطلخا لماوعب ؤبنتلا في اًديفم اًراطإ دعي ينكمتلا جذومن نأ َدِجُو :تاجاتنتسلاا عابتا في ةيتاذلا متهءافك ىوتسمو ضرلماب ضىرلما ةفرعم ىدم رابتعلاا في ذخلأا لخدلا ةطسوتمو ةضفخنم نادلبلا في ةيحصلا ةياعرلا يمدقم .هتاذ تقولا في تلايسوبرلا ءاد نم ةياقولل جمارب عضوو ،ينكمتلل ةيساسلأا تائفلا ةباثمب تلايسوبرلا ءاد نم ةيئاقولا تايكولسلا References 1. Jafari S, Ashrafizadeh SG, Zeinoddini A, Rasoulinejad M, Entezari P, Seddighi S, et al. Celecoxib for the treatment of mild-to-mod- erate depression due to acute brucellosis: a double-blind, placebo-controlled, randomized trial. J Clin Pharm Ther. 2015;40(4):441– 6. http://dx.doi.org/10.1111/jcpt.12287 2. de los Ángeles Mantecón M, Gutiérrez MP, del Pilar Zarzosa M, Fernández-Lago L, de Dios Colmenero J, Vizcaíno N, et al. Influ- ence of brucellosis history on serological diagnosis and evolution of patients with acute brucellosis. J Infect. 2008;57(5):397–403. http://dx.doi.org/10.1016/j.jinf.2008.08.005 3. Roushan MRH, Baiani M, Asnafi N, Saedi F. Outcomes of 19 pregnant women with brucellosis in Babol, northern Iran. Trans R Soc Trop Med Hyg. 2011;105(9):540–2. http://dx.doi.org/10.1016/j.trstmh.2011.06.003 4. Olsen S. Brucellosis in the United States: role and significance of wildlife reservoirs. Vaccine. 2010;28:F73–6. http://dx.doi. org/10.1016/j.vaccine.2010.03.059 5. Almasi-Hashiani A, Khodayari M, Eshrati B, Shamsi M. Factors affecting the interval between the onset and diagnosis of brucel- losis in Markazi Province, Iran (2010-11). Arak Medical University Journal. 2012;14(7):21–30. 6. Earhart K, Vafakolov S, Yarmohamedova N, Michael A, Tjaden J, Soliman A. Risk factors for brucellosis in Samarqand Oblast, Uzbekistan. Int J Infect Dis. 2009;13(6):749–53. http://dx.doi.org/10.1016/j.ijid.2009.02.014 7. World Health Organization Regional Office for South-East Asia (WHO/SEARO). A brief guide to emerging infectious diseases and zoonoses. New Delhi: WHO/SEARO; 2014 (http://apps.who.int/iris/bitstream/10665/204722/1/B5123.pdf?ua=1) 8. Farahani S, Shah Mohamadi S, Navidi I, Sofian M. An investigation of the epidemiology of brucellosis in Arak City, Iran,(2001- 2010). Arak Medical University Journal. 2012;14(7):49–54. 9. Sofian M, Aghakhani A, Velayati AA, Banifazl M, Eslamifar A, Ramezani A. Risk factors for human brucellosis in Iran: a case–con- trol study. Int J Infect Dis. 2008;12(2):157–61. http://dx.doi.org/10.1016/j.ijid.2007.04.019 10. Orouji M, Hashemi S, Hazavehei S, Charkazi A, Jvaheri J, Moazeni M. The positive impact of educational intervention program based on precede model on preventive behaviors to reduce Brucellosis in the rural people of Khomein. Research Development in Nursing and Midwifery. 2012;1:51–60. 11. Babaei V, Babazadeh T, Kiani A, Garmaroodi G, Batebi A. Investigating the Effective Factors in Preventive Behaviors of Brucello- sis in Stockbreeder of Charaoymaq County: A Health Belief Model. Journal of Fasa University of Medical Sciences 2015;5(4):4-9. 12. Plotnikoff RC, Trinh L, Courneya KS, Karunamuni N, Sigal RJ. Predictors of aerobic physical activity and resistance train- ing among Canadian adults with type 2 diabetes: An application of the Protection Motivation Theory. Psychol Sport Exerc. 2009;10(3):320–8. http://dx.doi.org/10.1016/j.psychsport.2008.10.002 574 EMHJ – Vol. 25 No. 8 – 2019Research article 13. Jahangiry L, Nadrian H, Mahdavi B, Allahvrdipour H, Kousha A. Primary development and psychometric properties of PRECEDE Model based scales for Brucellosis prevention among an Iranian Rural Population. Arch Clin Infect Dis. In Press(In Press):e62957. http://dx.doi.org/10.5812/archcid.62957. 14. Kickbusch I, Nutbeam D. Health promotion glossary. Geneva: World Health Organization; 1998. 15. Sousa P, Antunes A, Carvalho J, Casey A. Parental perspectives on negotiation of their child’s care in hospital. Nurs Child Young People. 2013;25(2):24–8. http://dx.doi.org/10.7748/ncyp2013.03.25.2.24.e142 16. Mehri A, Solhi M, Garmaroudi G, Nadrian H, Sighaldeh SS. Health promoting lifestyle and its determinants among university students in Sabzevar, Iran. Int J Pre Med. 2016; 7: 65. http://dx.doi.org/10.4103/2008-7802.180411 17. Heidari M, Alhani F, Kazemnejad A, Moezzi F. The effect of empowerment model on quality of life of Diabetic adolescents. Iran J Pediatr. 2007;17 Suppl 1:87–94. 18. Masoodi R, Allhani F, Moghadassi J, Ghorbani M. The effect of family-centered empowerment model on skiii, atittude, and knowledge of mutiple sclerosis caregivers. Journal of Birjand University of Medical Sciences. 2010;17(2):87–97. 19. Kargar Najafi M, Borhani F, Dortaj R, Sabzevari S. The Effect of Family-Centered Empowerment Model on the Mothers’ Knowl- edge and Attitudes about Thalassemia Disorder. Iran J Ped Hematol Oncol. 2011;1(3):98–103. 20. Rajabi R, Sabzevari S, Borhani F, Haghdoost A, Bazargan N. The effect of family-centered Empowerment Model on quality of life school age children with asthma. J Health Prot Manage. 2013;2(4):7–15. 21. Teymouri F, Alhani F, Kazemnejad A. The effect of family-centered empowerment model on the Quality of life of school-age asthma children. 2011. 22. Sun X, Shi Y, Zeng Q, Wang Y, Du W, Wei N, et al. Determinants of health literacy and health behavior regarding infectious respiratory diseases: a pathway model. BMC Public Health. 2013;13(1):1. 23. Sohng KY, Sohng S, Yeom HA. Health-Promoting Behaviors of Elderly Korean Immigrants in the United States. Public Health Nurs. 2002;19(4):294–300. http://dx.doi.org/10.1046/j.1525-1446.2002.19409.x 24. Tebug S, Njunga GR, Chagunda MG, Mapemba JP, Awah-Ndukum J, Wiedemann S. Risk, knowledge and preventive measures of smallholder dairy farmers in northern Malawi with regard to zoonotic brucellosis and bovine tuberculosis. Onderstepoort Journal of Veterinary Research. 2014;81(1):01-6. 25. Mostafei G, Eskandari E, Ghazizadeh S, Nasrollahzadeh Z, Hosseindoost GR, Gilasi HR, et al. Determining the Students’ Knowl- edge of Kashan University of Medical Sciences about Brucellosis. Scientific Journal of Ilam University of Medical Sciences. 2013;21(4):30–6. 26. Makita K, Desissa F, Teklu A, Zewde G, Grace D. Risk assessment of staphylococcal poisoning due to consumption of infor- mally-marketed milk and home-made yoghurt in Debre Zeit, Ethiopia. Int J Food Microbiol. 2012;153(1):135–41. http://dx.doi. org/10.1016/j.ijfoodmicro.2011.10.028 27. Minas M, Minas A, Gourgulianis K, Stournara A. Epidemiological and clinical aspects of human brucellosis in Central Greece. Jpn J Infect Dis. 2007;60(6):362. 28. Bikas C, Jelastopulu E, Leotsinidis M, Kondakis X. Epidemiology of human brucellosis in a rural area of north-western Pelopon- nese in Greece. Eur J Epidemiol. 2002;18(3):267–74. http://dx.doi.org/10.1023/A:1023368420840 29. Cooper CW. Risk factors in transmission of brucellosis from animals to humans in Saudi Arabia. Trans R Soc Trop Med Hyg. 1992;86(2):206–9. http://dx.doi.org/10.1016/0035-9203(92)90575-W 30. Hung W-S, Hu SC, Hsu Y-C, Chen K-L, Chen K-H, Yu M-C, et al. Factors affecting the use of anti-malaria preventive meas- ures among Taiwan immigrants returning to malaria-endemic regions. Travel Med Infect Dis. 2014;12(4):370–7. http://dx.doi. org/10.1016/j.tmaid.2013.07.001 31. Kanera IM, Bolman CA, Mesters I, Willems RA, Beaulen AA, Lechner L. Prevalence and correlates of healthy lifestyle behaviors among early cancer survivors. BMC Cancer. 2016;16(1):4. http://dx.doi.org/10.1186/s12885-015-2019-x 32. Vakili M, Rahaei Z, Nadrian H, YarMohammadi P. Determinants of oral health behaviors among high school students in Shahre- kord, Iran based on Health Promotion Model. . American Dental Hygienists Association. 2011 85(1):39-48. 33. Morowatisharifabad MA, Fallahi A, Nadrian H, Haerian A, Babaki BN. Interdental Cleaning Behaviour and Its Relationship with Psychological Constructs Based on the Transtheoretical Model. Oral Health Prev Dent. 2011;9(3):211–20. 34. Sarkar U, Fisher L, Schillinger D. Is self-efficacy associated with diabetes self-management across race/ethnicity and health literacy? Diabetes Care. 2006;29(4):823–9. http://dx.doi.org/10.2337/diacare.29.04.06.dc05-1615 35. Ali M, Haidar N, Ali MM, Maryam A. Determinants of seat belt use among drivers in Sabzevar, Iran: a comparison of theory of planned behavior and health belief model. Traffic Inj Prev. 2011;12(1):104–9. http://dx.doi.org/10.1080/15389588.2010.535227 36. Shirzadi S, Nadrian H, Asghari Jafarabadi M, Allahverdipour H, Hassankhani H. Determinants of mammography adoption among Iranian women: What are the differences in the cognitive factors by the stages of test adoption?. Health care women int. 2017;38(9):956-70. http://dx.doi.org/10.1080/07399332.2017.1338705 37. Taymoori P, Lubans D, Berry TR. Evaluation of the health promotion model to predict physical activity in Iranian adolescent boys. Health Educat Behav. 2010;37(1):84-96. 575 Research article EMHJ – Vol. 25 No. 8 – 2019 The effect of a maternal training programme on early childhood development in Egypt Heba Mohammed,1 Omaima El-Gibaly,1 Eman Monazea,1 Medhat Saleh 1 and Hanaa Mohammed 2 1Public Health and Community Medicine, Faculty of Medicine, Assiut University, Egypt. 2Faculty of Medicine, Assiut University, Egypt. (Correspond- ence to: Heba Mohammed: dr.heba.mahmoud@hotmail.com). Abstract Background: The initial years of life, particularly the first two years, are considered the most important for brain devel- opment and timely interventions profoundly affect the health of the child and families. Aims: This study aimed to determine the effect of maternal health education on motor, social and cognitive development in infants less than two years old, and to identify the factors that could affect normal development. Methods: Two hundred and ten mothers and their infants (109 interventions, 101 controls) were recruited from mater- nal and child health centres in Assiut Governorate, Egypt, in 2017. The maternal training programme has been taught to mothers of infants in intervention groups twice per month and up to five months’ duration; however, routine services are provided to control groups only. Bivariate and multivariable analyses were performed to identify the most important predictors of normal development. Results: There were significant improvements in early childhood developmental domains for the intervention groups after five months comparable to the base line assessment. Percent of normal development among intervention groups in communication subscale increased from 46.8% to 76% to 97.9% compared to 50.5% to 46.8% to 57.4% in the control groups (baseline, after two month and after five months assessment respectively). The intervention was a significant predictor in normal development. Conclusions: There was an improvement in early childhood developmental domains for the intervention groups after applying maternal training programme. Designing educational interventions for routine health care services that reach all children will provide mothers with the opportunity for improvement in early childhood developmental. Keywords: early childhood development; maternal training; intervention; ASQ-3, Egypt Citation: Mohammed H; El-Gibaly O; Monazea E; Saleh M; Mohammed H. The effect of a maternal training programme on early childhood develop- ment in Egypt. East Mediterr Health J. 2019;25(8):575–582. https://doi.org/10.26719/emhj.18.065 Received: 04/02/18; accepted: 30/07/18 Copyright © World Health Organization (WHO) 2019. 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). Introduction Child development is defined as those aspects of growth that involve physical, mental, emotional and social changes (1). Developmental delay is a condition in which the child is not developing and/or does not reach skills in accordance with the sequence of predetermined stag- es (2). Approximately 5–15% of all children in the gener- al population show developmental disorders (3) and are classified into different categories (gross motor, fine motor, social skill, speech and mental skill) (4). A study undertaken in the United States of America reported that nearly one in six children had developmental delays (5). Systematic reviews of the scientific literature demon- strate effectiveness of early childhood development pro- grammes in preventing developmental delay (6). Following the emphasis on home environment and the importance of the role of parents in educating children using toys appropriate to their age, Nagar and Sharma (2009) found that there was a statistically significant relationship between developmental age and psychomotor development concerning home environment (7). In an intervention on the importance of the role of playing in improving developmental skills in infants between 13 and 17 months of age, a significant relationship was revealed in improving mental and motor developmental skills in the intervention group rather than in the control group (8). Increasing detection of developmental disorders at an earlier age through intervention services are cost effective and improve the developmental prognosis, resulting in short and long- term benefits (9). Currently, there is little awareness about the problem of delayed development and there is no strategy to improve development of disadvantaged children or how to provide mothers with relevant skills in early childhood developmental. This study assessed the impact of early childhood developmental support services on caregivers (mothers) with regard to motor, social and cognitive development of children and to identify those factors that could affect normal child development. Methods Study design and setting A pre-test / post-test control group study was conducted in Assiut Governorate, Egypt at two urban and two rural maternal and child health centres. Data were collected from July 2016 to March 2017. 576 EMHJ – Vol. 25 No. 8 – 2019Research article Sampling technique The sites were chosen based on data and approvals from the Ministry of Health, since these sites have sufficient numbers of patients, availability of well-trained nursing staff, equipped for the conduct of health education class- es, proper assessment of growth and development, and practical distance from Assiut University. Mothers and their children were recruited from immunization clin- ics of urban and rural maternal and child health centres (two urban and two rural), randomly assigned into inter- vention and control groups, and excluding children with congenital and neurological diseases. Sample size Two hundred and ten participants were interviewed at the baseline survey (109 interventions, 101 controls); 190 (90.5%) successfully completed the study after two months (96 interventions, 94 controls), and 188 (89.5%) successfully completed the study after four months (94 intervention, 94 control). Twenty-two (10.5%) women dropped out during the study period after baseline as- sessment due to refusal to complete to the end line as- sessment, especially those in urban settings and those travelling outside their countries. Rural areas had lower dropout rate because rural outreach workers (Raedat Rifi- yat) had communication with most mothers and there- fore reminded them before each class. Study design Data were collected using two questionnaires (one for the mothers and the other for children). For mothers the questionnaire was semi–structured and administered through personal interview. Information collected in- cluded: · Background information of the child and mother (age of the mother, marital status, education, occupation, father’s age, education, occupation, child age, sex and birth weight). · Evidence of maternal social support (help from hus- band, as well from immediate family and others). · Pattern of breast feeding, time of start breast feeding, exclusive breast feeding, and foods given to the baby after six months. · Child morbidity and exposure to any health problems in the previous two months. Children were interviewed using the Ages and Stages Questionnaires, 3rd edition ASQ-3. ASQ-3, which is a screening tool that assesses a child’s development from 2 to 60 months of age; it evaluates five domains of development: 1. Communication: this refers to a child’s language, lis- tening and comprehension skills. 2. Gross motor: this refers to a child’s use and coordina- tion of arm and legs. 3. Fine motor: this refers to a child’s movements and co- ordination of hands and fingers. 4. Problem solving: this refers to a child’s problem-solv- ing, learning and play skills. 5. Personal–social: this refers to a child’s self-learning skills and interaction skills with others. Each domain has a set of six items and parents rate the most appropriate answer for each skill: “Yes,” “Sometimes,” “Not yet,” with point values of 10, 5, or 0, respectively. The total score for each skill is obtained by adding the scores of the six items and comparing with the cut-off points, which vary for all skills and ages (3). The ASQ-3 English version was translated into Arabic and back translated to ensure accuracy. For each domain results are reported as “normal” or “suspect developmental delay”, indicating that a particular milestone attainment was not evident and further evaluation is recommended. Cut-off points for each subscale are provided to indicate whether the score falls within a normal developmental range based on chronological age, or if it represents “at risk” or delayed development. ASQ-3 has established reliability and validity for practical use in a written questionnaire and has widespread use in clinical and research settings (10,11); Cronbach’s alpha for total score was 0.86. Children in intervention groups were entered into maternal health education programmes; routine services were provided to control groups only. Description of intervention The period of intervention was five months and was de- livered by the researchers and assisted by two trained nurses. Approximately 10–15 mothers and their chil- dren were present per class, creating 3 groups in each intervention site. The groups were classified according to child age (2 – <6 months, 6 – <9 months and 9 – <12 months) to allow mothers to receive age-related informa- tion and absorb the information received. Every mother in the intervention groups received twice monthly health education classes, resulting in a total of 60 classes for the intervention. Education classes included PowerPoint presentations and literature prepared by the researchers based on the book “Ages and Stages Learning Activities 0–5 years” (12), which contains pictures illustrating various aspects of development; for example pictures of children in activities that would promote motor development (crawling, pushing, holding, etc.) and cognitive development (naming objects, looking at a book, playing matching games, etc.). Each session lasted approximately two to three hours. For one hour trainers explained the different aspects of child development for each age group and demonstrated how these could be promoted through play and interaction. Mothers also learned how to use everyday activities (e.g. bathing, dressing the child) and everyday household tasks (e.g. laundry, meal preparation) to promote interaction and development. For the remaining two hours the trainers and mother played with the child in ways that would promote development. All children 577 Research article EMHJ – Vol. 25 No. 8 – 2019 at the intervention and control sites were assessed by ASQ-3 according to their age after two months and after five months from the baseline assessment. Statistical analysis SPSS software version 20 was used for analyses. Bivariate analysis and t-test were used for comparison of the mean; Chi-square test was used for comparison of proportions between intervention and control groups; McNemar test was used for comparisons of proportion within the same group before and after intervention; and multivariable logistic regression analysis was performed to identify the most important predictors of normal childhood de- velopment. P value < 0.05 was considered statistically significant. Ethical approval Informed and written consent was obtained from the mothers of all the children enrolled in the study. Ethical approval was taken for conducting this study from the Ethics Review Committee, Faculty of Medicine, Assiut University, Egypt. Approval from the Ministry of Health and Population from each study site was also taken. For ethical considerations, the end-line survey was followed by health education for mothers in the control groups. The original copy of the English version of ages and stag- es questionnaire was purchased. Results A total of 210 infants and their mothers were included in the study (109 interventions and 101 controls). There was no statistically significant difference in child’s age, gender, residence, mother’s age, education, occupation, father age and education (P ≥ 0.05) between interven- tion and control groups at the base line assessment. The mean age of children was 5.7 ± 3.4 months in interven- tion groups and 6.1 ± 3.3 months in control groups; 50.5% and 49.5% were males in intervention and control group respectively; mean age of the mother was 28.8 ± 4.4 years and 25.5 ± 3.7 years in intervention and control group respectively. Mean birth weight was 3018.23 ± 383.96 g and 2975.36 ± 394.132 g among intervention and control groups respectively, and there was no statistical signif- icance. 95.5% of mothers in interventions group had breast fed their infant compared to 96% in the control groups; 33.7% of mothers in the interventions group started breast feeding in the first 30 minutes after birth compared to 33% in the controls; and 69.7% of mothers in the intervention groups were exclusively breast feeding compared to 69.3% in the control groups. The food given to the infant after 6 months from birth were milk products followed by vegetables and bread categories. Nearly 60% of the intervention groups were exposed to health problems in the previous two months compared to 55.5% in the control groups; there was no statistical significance. The most common health problems were gastroenteritis, common cold and fever. There was no statistically significant difference between the intervention and control groups at the baseline assessment regarding communication, gross motor, fine motor, problem solving and personal social skills. After two months and after five months from the base line, there were significant differences between interventions and controls regarding the five developmental subscales. In intervention groups, percent of normal child development in communication subscale increased from 46.8% to 76% to 97.9% compared to 50.5% to 46.8% to 57.4% in the control groups (baseline, after two month and after five months assessment respectively) (Table 1). There was a significant improvement in child development in the intervention groups in all domains after five months comparable to the base line assessment (P < 0.001). Percent of suspect developmental delay was 52%, 63.8%, 54.3%, 52% and 50% regarding communication, gross motor, fine motor skills, problem-solving personal social skills, respectively, at the baseline in interventions groups, compared to 2.2%, 23.4%, 14.9%, 3.2% and 5.3% after applying the maternal health education program (Table 2). Logistic regression analysis for early childhood developmental domains at the end line assessment (after five months) found that intervention was a significant predictor in normal child development in communication, growth motor, fine motor, problem solving and personal social (OR = 3.42, 3,15, 4.23, 4.21, 4.59 respectively). In addition, maternal social support in child raising (husband, relatives, neighbours and friends) was a significant predictor in communication, personal social domains (Table 3). Discussion Child development is difficult to measure because of its nature and influence by continuous biomedical and/or sociocultural factors. Most well conducted studies on psychosocial stimulation programmes have resulted in immediate benefits to children’s development and some have shown long-term benefits in social behaviour and school achievement (8). We believe that our intervention also benefited mothers, since health education brought mothers together and facilitated a sharing of experiences, ideas and general interaction. Mothers gained knowledge of better care for their children and they valued their new skills in dealing with different items of early childhood developmental. The intervention effect showed that children in intervention groups had a marked significant increase in the achievement of normal developmental milestones compared to children in the control groups, which was shown to be highly significant in the multiple regression analysis. Consistent with our results, a study done in northeast Brazil to improve cognitive and motor development in a community-based intervention (the intervention comprised ten weekly visits and three workshops over 578 EMHJ – Vol. 25 No. 8 – 2019Research article a four-month period) was associated with significant improvements in cognitive and motor development (8). Our study found significant percent increases in communication, fine and gross motor, problem solving and personal social skills for the intervention groups compared to control groups two months and five months after the intervention. This was compatible with results of the study by Rezaeian et al. (1), which investigated the effect of implementation of evidence-based care package on the gross motor development on 1–12 months old infants, and the study was also conducted in the Islamic Republic of Iran among 12-month-old infants on motor skills (13). Our study supports the role of playing and learning to improve early childhood developmental domains, consistent with a study by Miquelote et al. (14) on the effect of the home environment on motor and cognitive behaviour of infants aged three to 18 months in Brazil. A quasi-experimental study by Sajedi and Barati (15) investigated the effect of perceptual motor training on motor skills of preschool children. After 15 one- hour training sessions over two months, a significant statistical improvement was observed in motor skills. In our study, the percentage of suspected development delay at the baseline in interventions groups was consistent with a study carried out by Kyerematen et al. (16) on the application of the ASQ in child development in a low-income Peruvian shantytown population. Of the 129 children in the study (average age 22 ± 6.8 months), Table 1 Assessment of the early childhood developmental domains at the baseline, after 2 months and after 5 months Subscale Baseline After 2 months After 5 months Intervention (N=109, %) Control (N=101, %) Intervention (N=96, %) Control (N=94, %) Intervention (N=94, %) Control (N=94, %) Communication Normal development 51 (46.8) 51(50.5) 73 (76.0) 44 (46.8) 92 (97.9) 54 (57.4) At risk of disorder 46 (42.2) 39(38.6) 22 (22.9) 42 (44.7) 2 (2.1) 39 (41.5) Delayed development 12 (11.0) 11(10.9) 1 (1.1) 8 (8.5) 0 (0.0) 1 (1.1) P-value* 0.85 0.001 <0.001 Gross motor Normal development 39 (35.8) 37 (36.6) 55 (57.3) 37 (39.4) 72 (76.6) 51 (54.3) At risk of disorder 41(37.6) 37 (36.6) 28 (29.2) 38 (40.4) 17 (18.1) 31 (33.0) Delayed development 29(26.6) 27 (26.7) 13 (13.5) 19 (20.2) 5 (5.3) 12 (12.8) P-value* 0.99 0.04 0.005 Fine motor Normal development 51 (46.8) 40 (39.6) 68 (70.8) 38 (40.4) 80 (85.1) 60 (63.8) At risk of disorder 48 (44.0) 51 (50.5) 22 (22.9) 51 (54.3) 13 (13.8) 31 (33.0) Delayed development 10 (9.2) 10 (9.9) 6 (6.2) 5 (5.3) 1 (1.1) 3 (3.2) P-value* 0.57 0.001 0.004 Problem solving Normal development 51 (46.8) 46 (45.5) 77 (80.2) 47 (50.0) 91 (96.8) 42 (44.7) At risk of disorder 53 (48.6) 46 (45.5) 19 (19.8) 41 (43.6) 3 (3.2) 49 (52.1) Delayed development 5 (4.6) 9 (8.9) 0 (0.0) 6 (6.4) 0 (0.0) 3 (3.2) P-value* 0.45 0.001 <0.001 Personal social Normal development 56 (51.4) 50 (49.5) 77 (80.2) 43 (45.7) 89 (94.7) 49 (52.1) At risk of disorder 38 (34.9) 37 (36.6) 17 (17.7) 39 (41.5 5 (5.3) 40 (42.6) Delayed development 15 (13.8) 14 (13.9) 2 (2.1) 12 (12.8) 0 (0.0) 5 (5.3) P-value* 0.96 0.001 <0.001 579 Research article EMHJ – Vol. 25 No. 8 – 2019 38.7% had suspect results for at least one of the five scales, namely communication scale (15.5%), gross motor (3.8%), fine motor (10%), problem solving (13.9%) and the personal-social scale (5.4%). A study in the Islamic Republic of Iran by Sajedi et al. (17) using the ASQ showed Iranian children delayed in the communication, gross motor, fine motor, problem-solving and social-personal domains (3.87%, 4.04%, 4.31%, 4.15% and 3.69%, respectively). Alptekin (18) reported that the prevalence of developmental delay by using the ASQ– transforming rehabilitation (ASQ-TR) during childhood in Turkey was 6.4% in a community-based sample consisting of children aged 3–60 months. Another study, using the Norwegian ASQ cut-off points among infant aged 4-12 months, suggested that between 5.7% and 7.0% of young children had suspect developmental delay (19). In addition, a cross-sectional study of 510 kindergartens (age group 24–60 months) in the east of Menuofia Governorate, Egypt, found that the prevalence of suspect developmental delay among the studied children was 2.9%, 0%, 1.7%, 2.2%, and 0.6% regarding communication, gross motor, fine motor, problem-solving, skills, personal social skills, respectively (20). Differences between the above studies may be due to variations in age groups, study design and other factors such as the nutritional status of children. Moreover, beside the intervention, maternal social support was found to be another predictor for child development in the communication and personal Table 2 Comparison of early childhood developmental domains among intervention and contrl sites before and after intervention. Subscale Intervention P-value* Control P-value* Baseline (N, %) End line (N, %) Baseline (N, %) End line (N, %) Communication Normal 45 (47.9) 92 (97.8) <0.001 48 (51.1) 54 (57.4) 0.33 Suspect 49 (52.1) 2 (2.2) 46 (48.9) 40 (42.6) Gross motor Normal 34 (36.2) 72 (76.6) <0.001 35 (37.2) 51 (54.3) 0.01 Suspect 60 (63.8) 22 (23.4) 59 (62.8) 43 (45.7) Fine motor Normal 43 (45.7) 80 (85.1) <0.001 35 (37.2) 60 (63.8) 0.001 Suspect 51 (54.3) 14 (14.9) 59 (62.8) 34 (36.2) Problem solving Normal 45 (47.9) 91 (96.8) <0.001 43 (45.7) 42 (44.7) 1.0 Suspect 49 (52.1) 3 (3.2) 51 (45.3) 52 (55.3) Personal social Normal 47 (50.0) 89 (94.7) <0.001 47 (50.0) 49 (52.1) 0.86 Suspect 47 (50.0) 5 (5.3) 47 (50.0) 45 (47.9) Analysis conducted on the children who complete the study in the end line survey (94 in intervention and 94 in control groups) Table 3 Logistic regression analysis of factors predicting normal developmental milestone at the end line assessment predictors Communication Growth motor Fine motor Problem solving Personal-social OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Groups (ref: intervention) 3.42 (2.02–7.66)** 3.15 (1.51–6.59)* 4.23 (2.39–8.46)** 4.21 (2.66–8.48)** 4.59 (2.79–8.54)** Maternal social support (ref: support) 3.30 (1.56–5.98)* 1.58 (0.7–3.56) 2.25 (1.09–4.6) 1.36 (0.65–2.88) 2.1 (0.96–4.5)* Logistic regression models OR=odds ratios; 95% CI=95% confidence intervals. Other variables included in the model are: mother’s age, mother’s education, residence, family type (nuclear or extended), parity and sex of child. *P<0.01 **P<0.001 580 EMHJ – Vol. 25 No. 8 – 2019Research article social scale, which was consistent with other results that previously identified maternal social support as a protective factor for child development outcomes (21,22). Primary care, public health, prenatal and parenting programmes could inform parents about the importance of establishing a social support network. Parents, caregivers and families need to be supported in providing care and protection for young children in order help them achieve their developmental potential. The intervention packages should be applied at developmentally appropriate times during the life course, target multiple risks, and build on existing delivery platforms for feasibility of scale-up (23). If children with developmental delays or disabilities and their families are not provided with timely and appropriate early intervention, support and protection, their difficulties can become more severe, often leading to lifetime consequences, increased poverty and profound exclusion (24). Limitations Our study has a number of limitations, including miss- ing mothers and their children in the end line survey, and subjective nature of questions in ASQ-3. However, this last problem was mitigated by explanations offered by the researcher. Conclusions This study’s results revealed the impact of maternal health education in improvement of early childhood de- velopmental domains. Designing educational interven- tions in routine healthcare services that reach all children, and provide policy mechanisms for sustainability of the programme, will provide mothers with the opportunity for improvement of early childhood developmental and allow for early diagnosis of child development disorders. Funding: None. Competing interests: None declared. Impact d’un programme de formation des mères sur le développement du jeune enfant en Égypte Résumé Contexte : Les premières années de vie, en particulier les deux premières années, sont considérées comme les plus importantes pour le développement du cerveau et les interventions en temps opportun affectent profondément la santé de l’enfant et des familles. Objectifs : La présente étude visait à déterminer l’impact de l’éducation sanitaire des mères sur le développement moteur, social et cognitif des nourrissons de moins de deux ans, et à identifier les facteurs susceptibles d’affecter leur développement normal. Méthodes : 210 mères et leurs nourrissons (109 interventions, 101 témoins) ont été recrutés dans les centres de santé maternelle et infantile (SMI) du gouvernorat d’Assiout (Égypte) en 2017. Le programme de formation des mères a été dispensé aux mères de nourrissons dans les groupes d’intervention deux fois par mois et pour une durée maximale de cinq mois ; cependant, les services systématiques sont fournis uniquement aux groupes témoins. Des analyses bivariées et multivariées ont été réalisées pour identifier les facteurs prédictifs du développement normal les plus importants. Résultats : Il y a eu des améliorations significatives dans les domaines du développement du jeune enfant pour les groupes d’intervention après cinq mois, comparables à celles de l’évaluation initiale. Le pourcentage de développement normal parmi les groupes d’intervention dans la sous-échelle de communication est passé de 46,8 % à 76 % puis à 97,9 %, comparativement à 50,5 % à 46,8 % puis à 57,4 % dans les groupes témoins (évaluation initiale après deux mois et après cinq mois respectivement). L’intervention était un facteur prédictif significatif du développement normal. Conclusions : Il y a eu une amélioration dans les domaines du développement du jeune enfant pour les groupes d’intervention après l’application du programme de formation des mères. La conception d’interventions éducatives concernant les services de soins de santé généraux qui atteignent tous les enfants offre aux mères l’opportunité d’améliorer le développement du jeune enfant. 581 Research article EMHJ – Vol. 25 No. 8 – 2019 صرم في ةركبلما ةلوفطلا ةلحرم في روطتلا لىع تاهملأا بيردت جمانرب يرثأت دممح ءانه ،حلاص تحدم ،عزانم نمايإ ،ليابلجا ةميمأ ،دممح ةبه ةصلالخا .ةسرلأاو لفطلا ةحص في ةدشب ةبسانلما تلاخدتلا رثؤت ماك ،غامدلا روطتل ةيهمأ رثكلأا ،ينتنس لوأ ماّيس لا ،رمعلا نم لىولأا تاونسلا دعت :ةيفللخا ،ينتنسلا نود عضرلا في يكاردلإاو يعماتجلااو يكرلحا روطتلا نأشب تاهملأل يحصلا فيقثتلا يرثأت ديدتح لىإ ةساردلا هذه تفده :فادهلأا .يعيبطلا روطتلا لىع رثؤت نأ نكمي يتلا لماوعلا ديدتحو ةظفامح في لافطلأاو تاهملأا ةحص زكارم نم )ًاطباض 101و ،لخدتلل اوضرعت 109( نلهافطأو تاهملأا نم 210 رايتخا مت :ثحبلا قرط عمو ؛رهشأ ةسخم رادم لىع اًيرهش ينترم تلاخدتلا تاعوممج في تاهملأا بيردت جمانرب لىع لافطلأا تاهمأ بيردت متو .2017 ،صرم ،طويسأ رثكلأا تاشرؤلما ديدحتل تايرغتلما ةددعتمو تايرغتلما ةيئانث تلايلتح تيرجُأو .طقف ةطباضلا تاعومجملل ةينيتورلا تامدلخا ميدقت مت ،كلذ .يعيبطلا روطتلل ةيهمأ مييقتلاب ةنراقم رهشأ ةسخم رورم دعب تلاخدتلا تاعومجلم ةبسنلاب ةركبلما ةلوفطلا ةلحرم في روطتلا تلاامج في ىبرك تانستح تدجو :جئاتنلا ةبسنلاب ةنراقم %97.9 لىإ %76 لىإ %46.8 نم لصاوتلا سايقم ثيح نم تلاخدتلا تاعوممج ينب يعيبطلا روطتلا ةبسن تدادزا .سياسلأا اًشرؤم لخدتلا ناكو .)لياوتلا لىع رهشأ ةسخم دعبو نيرهش دعب مييقتلا ،ساسلأا طخ( ةطباضلا تاعومجلما في %57.4 لىإ %46.8 لىإ %50.5 .يعيبطلا روطتلا في ًماهم .تاهملأا بيردت جمانرب ذيفنت دعب تلاخدتلا تاعومجلم ةبسنلاب ةركبلما ةلوفطلا ةلحرم في روطتلا تلاامج في نستح كانه ناك :تاجاتنتسلاا نسحتب تاهملأل ةصرفلا يرفوت لىإ لافطلأا عيجم لىإ لوصولا لىإ فدته يتلا ةينيتورلا ةيحصلا ةياعرلا تامدلخ ةيفيقثت تلاخدت عضو يدؤيسو .ةركبلما ةلوفطلا ةلحرم في نلهافطأ روطت References 1. Rezaeian A, Niknejad Jalali A, Mazlom S. An investigation of the effect of implementation of evidence-based care package on the gross motor development of the foster care infants. Evidence Based Care Journal. 2013;3(3):69-80 http://dx.doi.org/10.22038/ EBCJ.2013.1800 2. Shevell MI. Present conceptualization of early childhood neurodevelopmental disabilities. J Child Neurol. 2010 Jan;25(1):120-6 http://dx.doi.org/10.1177/0883073809336122 3. Kerstjens JM, Bos AF, ten Vergert EMJ, de Meer G, Butcher PR, Reijneveld SA. Support for the global feasibility of the Ages and Stages Questionnaire as developmental screener. Early Hum Dev. 2009 Jul;85(7):443-7 http://dx.doi.org/10.1016/j.earlhum- dev.2009.03.001 4. Nouhjah S, Mokhveli Khazaei F, Mahdavi Zadeh N. Assessment of motor development of children attending health centers of Dezful City using World Health Organization standard indexes. Journal of Paramedical Sciences & Rehabilitation. 2014;3(1):16– 26. 5. Boyle CA, Boulet S, Schieve LA, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, et al. Trends in the prevalence of developmental disabilities in US children, 1997–2008. Pediatrics. 2011:peds. 2010-989 http://dx.doi.org/10.1542/peds.2010-2989 6. Anderson LM, Shinn C, Fullilove MT, Scrimshaw SC, Fielding JE, Normand J, et al. The effectiveness of early childhood develop- ment programs: A systematic review. Am J Prev Med. 2003 Apr;24(3 Suppl):32-46 http://dx.doi.org/10.1016/S0749-3797(02)00655-4 7. Shipra N, Shubhangna S. Influence of intervention on temperament and developmental outcomes of infants. J Hum Ecol. 2009 28(2):121-126 http://dx.doi 10.1080/09709274.2009.11906227 8. Eickmann SH, Lima ACV, Guerra MQ, Lima MC, Lira PIC, Huttly SRA, et al. Improved cognitive and motor development in a community-based intervention of psychosocial stimulation in northeast Brazil. Dev Med Child Neurol. 2003. Aug;45(8):536-41: http://dx.doi/10.1017/s0012162203000987 9. Kynø NM, Ravn IH, Lindemann R, Fagerland MW, Smeby NA, Torgersen AM. Effect of an early intervention programme on development of moderate and late preterm infants at 36 months: a randomized controlled study. Infant Behav Dev. 2012 Dec;35(4):916-26 http://dx.doi/10.1016/j.infbeh.2012.09.004 10. Limbos MM, Joyce DP. Comparison of the ASQ and PEDS in screening for developmental delay in children presenting for pri- mary care. J Dev Behav Pediatr. 2011 Sep;32(7):499-511 http://dx.doi/10.1097/dbp.0b013e31822552e9 11. Hornman J, Kerstjens JM, de Winter AF, Bos AF, Reijneveld SA. Validity and internal consistency of the Ages and Stages Ques- tionnaire 60-month version and the effect of three scoring methods. Early Hum Dev. 2013 Dec;89(12):1011-5 http://dx.doi/10.1016/j. earlhumdev.2013.08.016 12. Twombly E, Fink G. Ages and Stages learning activities: Baltimore, MD: PH Brookes Publishing; 2004. 13. Ahmadi J, Ahmadi Doulabi M, Sajedi F, Nasiri M. The Effect of Care Package on Motor Development among 12-Month-Old In- 582 EMHJ – Vol. 25 No. 8 – 2019Research article fants in Saqqez-Iran: A Randomized Clinical Trial Study. Int J Pediatr 2017 5(8):5571-82 http://dx.doi/10.22038/IJP.2017.23461.1974 14. Miquelote AF, Santos DC, Caçola PM, Montebelo MIdL, Gabbard C. Effect of the home environment on motor and cognitive behavior of infants. Infant Behavior and Development. 2012;35(3):329-34 http://dx.doi/10.1016/j.infbeh.2012.02.002 15. Kosari S, Hemayat-Talab R, Arab-Ameri E, Keyhani F. The effect of physical exercise on the development of gross motor skills in children with attention deficit/hyperactivity disorder. Zahedan Journal of Research in Medical Sciences. 2013;15(2):74–8. 16. Kyerematen V, Hamb A, Oberhelman RA, Cabrera L, Bernabe-Ortiz A, Berry SJ. Exploratory application of the Ages and Stages (ASQ) child development screening test in a low-income Peruvian shantytown population. BMJ open. 2014;4(1):e004132 http:// dx.doi/10.1136/bmjopen-2013-004132 17. Sajedi F, Vameghi R, Kraskian Mujembari A. Prevalence of undetected developmental delays in Iranian children. Child Care Health Dev. 2014 May;40(3):379-88 http://dx.doi/10.1111/cch.12042 18. Alptekin K, Ulas H, Akdede BB, Tümüklü M, Akvardar Y. Prevalence and risk factors of psychotic symptoms: in the city of Izmir, Turkey. Soc Psychiatry Psychiatr Epidemiol. 2009 Nov;44(11):905-10 http://dx.doi/10.1007/s00127-009-0012-x 19. Alvik A, Grøholt B. Examination of the cut-off scores determined by the Ages and Stages Questionnaire in a population-based sample of 6 month-old Norwegian infants. BMC pediatrics. 2011;11(1):117 http://dx.doi/10.1186/1471-2431-11-117 20. EL-Ella SSA, Tawfik MAM, Barseem NF, Elatabany AMAM. Assessment of intellectual development in preschool children in the East of Menoufia Governorate, Egypt. Menoufia Medical Journal. 2017;30(3):741 http://dx.doi/10.4103/1110-2098.218257 21. Cabaj JL, McDonald SW, Tough SC. Early childhood risk and resilience factors for behavioural and emotional problems in mid- dle childhood. BMC pediatrics. 2014;14(1):166 http://dx.doi/10.1186/1471-2431-14-166 22. McDonald SW, Kehler HL, Tough SC. Protective factors for child development at age 2 in the presence of poor maternal mental health: results from the All Our Babies (AOB) pregnancy cohort. BMJ open. 2016;6(11):e 012096 http://dx.doi/10.1136/bmjop- en-2016-012096 23. Britto PR, Lye SJ, Proulx K, Yousafzai AK, Matthews SG, Vaivada T, et al. Nurturing care: promoting early childhood develop- ment. Lancet. 2016;389(10064):91–102. http://dx.doi.org/10.1016/S0140-6736(16)31390-3 24. World Health Organization, UNICEF. Early childhood development and disability: discussion paper. Geneva & New York: WHO & UNICEF; 2012. 583 Research article EMHJ – Vol. 25 No. 8 – 2019 Influenza pandemic preparedness in the World Health Organization Eastern Mediterranean Region Wasiq Khan,1 Amira El Rifay,2 Mamunur Malik 3 and Ghazi Kayali 4,5 1Department of Health, University of Bath, United Kingdom. 2Center of Excellence for Influenza Viruses, Child Health department National Research Centre, Giza, Egypt. 3World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt. 4Department of Epidemiology, Univer- sity of Texas Health Sciences Center, Houston, Texas, United States of America. 5Human Link, Hazmieh, Lebanon. (Correspondence to: Ghazi Kayali: ghazi@human-link.org). Abstract Background: Preparedness is key to controlling influenza pandemics and epidemics. Aims: A comprehensive literature review was conducted to analyse the response and preparedness to influenza pandem- ics in the World Health Organization Eastern Mediterranean Region (WHO/EMR). Methods: Published and grey literatures were searched in PubMed, Scopus, and Google scholar, and the WHO/EMR online databases. International and national plans were searched via official websites of the relevant ministries of the countries. Results: We found that the response from EMR countries was minimal and scientific papers published were limited. Moreover, most of those papers studied the preparedness plan partially by focusing on one or more elements such as in- fection control measures and vaccines, or were directed to certain populations such as health workers. Continuous active surveillance is ignored in most of the countries although it was the most important lesson learned from the pandemic. Conclusions: The national preparedness plans should be updated, taking guidance from the findings in the present re- port, to address any emerging pandemic virus as well as attending to surges of seasonal influenza cases. Keywords: influenza, preparedness plans, Middle East, research and pandemic, Eastern Mediterranean Region Received: 14/06/17; accepted: 06/12/17 Citation: Khan W; El Rifay A; Malik M; Kayali G. Influenza pandemic preparedness in the World Health Organization Eastern Mediterranean Region. East Mediterr Health J. 2019;25(8):583–590. https://doi.org/10.26719/emhj.18.070 Received: 14/06/17; accepted: 06/12/17 Copyright © World Health Organization (WHO) 2019. 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). Introduction Although the last influenza H1N1 pandemic in 2009 was mild, fear prevails that the next one might not be (1,2). Due to frequent mutations and reassortment in its genome, influenza is a continuously evolving virus (3). Predicting when or where an influenza pandemic may arise, or even which strain will be the culprit is a difficult task (4). Following the emergence of avian influenza H5N1 and the fear of its pandemic potential, having an adequate preparedness plan became a priority as the World Health Organization (WHO) urged every country to develop and maintain an up-to-date national influenza preparedness plan, and provided guidance on plan content (5). Comprehensive research on the epidemiology, medical anthropology, and pandemic management policies was conducted and resulted in the production of international and national plans (6). However, the pandemic did not turn out as expected, leading to re-evaluation of preparedness mechanisms (6). Two years after the 2009 H1N1 pandemic, the published data around this issue exceeded 2500 articles around the world in an attempt to understand the pandemic dynamics (7). The location of the WHO Eastern Mediterranean Region (EMR) makes it important for influenza A virus circulation, as EMR countries lie under four of the eight global migratory bird flyways: Central Asia–India, West Asia–Africa, Mediterranean–Black Sea, and East Atlantic (8). The pandemic burden became recently more significant in the EMR with the sudden surge in human cases of H5N1 in Egypt. Earlier reviews of pandemic preparedness plans in the region reveal that WHO EMR’s response to pandemic (H1N1) 2009 was successful in many ways, yet lacking in others. Overall, the response to the H1N1 pandemic was a learning experience on which capacity to face future events in the Region can be built and strengthened. In order to understand the preparedness and response to influenza outbreaks and pandemics in the WHO EMR, with particular reference to challenges and constraints specific to the Region, we reviewed peer-reviewed scientific literature, non- peer-reviewed literature, and international and national plans. We then issued guidance for updating the current preparedness plans for the countries of the EMR. Methods Search strategy Searching the literature and preparedness plans for the Region was performed using the search terms in three languages (Arabic, English and French) for all the availa- ble published data up to 2016. The relevant records only 584 EMHJ – Vol. 25 No. 8 – 2019Research article were maintained after reviewing the full text of each. Most of the deleted records were due to irrelevant sub- ject matter. First, the peer-reviewed and the non-peer-reviewed scientific literature published on influenza pandemic preparedness was searched in the following databases: PubMed, Scopus and Google scholar (all fields). The search terms were “pandemic influenza”, “preparedness” AND “country name” (Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, South Sudan, Sudan, Syria, Tunisia, United Arab Emirates (UAE), and Yemen). An additional search term “Middle East” was also used to avoid excluding any multinational publication. An alternative country name of certain countries was also used to avoid excluding publications when, for instance, if the French name of the country was commonly used. These alternative names were: Liban, Maroc, Gaza and West Bank, Syrie, Tunisie, and Emirats. Then the search was expanded by amendment of the search terms into “pandemic influenza” AND “country name” and this in turn yielded more documents. Finally, search terms “epidemic influenza” AND “country name’ were used resulting in more publications from the Region. Second, the WHO EMR databases, Index Medicus for the Eastern Mediterranean Region (IMEMR), WHO EMR Publications (EMRPUB), and WHO EMR Institutional Digital Repository (IDRNET), were searched for published articles using search term “influenza preparedness”. Third, international pandemic preparedness plans and checklists were searched via official websites that compile such documents (e.g., http://www.who.int, http://www.cdc.gov, http://ecdc.europa.eu/en/Pages/ home.aspx, and http://www.flu.gov/). National preparedness plans in the EMR were searched in the official ministry of health websites for the different countries using the same search terms but in different languages (Arabic and English), since some national plans are available only in Arabic. Google was used first to follow the links to the published plans or to access the official ministry of health website for each country. Published peer-reviewed and non-peer- reviewed scientific literature Publications related to pandemic and/or epidemic pre- paredness and response were limited to seven countries (Bahrain, Egypt, Islamic Republic of Iran, Palestine, Pa- kistan, Saudi Arabia and United Arab Emirates). A total of 72 articles were analysed out of which 22 (30.5%) were non-peer-reviewed publications. Few articles were pub- lished before 2009, after which the field gained more at- tention after the pandemic, when 65 articles (90%) were published from 2009 onwards. Saudi Arabia led the other countries by 41 (56.9%) records and was followed by Is- lamic Republic of Iran by 18 (25%) records and Egypt by 6 (8.3%) records. Other EMR countries had less than five records. Out of a total of 72 records from seven countries, 21 (29.1%) records fell under the Knowledge, Attitude, and Practice (KAP) type of study. Infection control measures was the top priority for researchers in Saudi Arabia re- sulting in several articles related to awareness, public be- haviour during mass gatherings, and vaccination policy. Only a few records covered thoroughly issues related to preparedness plans. A few Iranian articles focused on the lessons learned from the pandemic, mostly through conducting literature reviews or reviews of official reports from WHO and the Iranian disease control center (9). Assessing public health information about the pandemic showed that the mass media is the most effective way in disseminating emergency notifications (10). Egyptian researchers had six publications, out of which two non-peer-reviewed publications were found. One criticized the policy adopted by local authorities in response to the 2009 H1N1 pandemic (11). The other assessed the knowledge level of medical students regarding preventive measures of H1N1 (12). Another three published articles from Egypt were KAP type (13,14). Only one review discussed the epidemic control measures in Egypt and concluded that unless a global collaboration exists, HPAI H5N1 virus in Egypt will continue to compromise the poultry industry, endanger public health, and pose a serious pandemic threat (15). Bahrain publications were limited to KAP type (16,17), while Pakistan published one article in which authors suggested a model for multiple control strategies for prevention of pandemics (18). One non-peer-reviewed publication from the United Arab Emirates tried to estimate the required vaccine in case of influenza epidemic by using mathematical models (19). Only two articles were generated from collaboration between three countries (Palestine, Jordan, and Israel) and both were produced by members of the Middle East Consortium on Infectious Disease Surveillance (MECIDS) in 2006 and 2013 respectively (5,20). Following the avian influenza incidents in 2005–2006, MECIDS conducted a series of national pandemic influenza tabletop exercises to identify gaps in preparedness and cross-sectoral cooperation and to develop a list of priority actions to improve preparedness and response in 2007 and 2008. Non-peer-reviewed literature publications from EMR databases The WHO Regional Office for the Eastern Mediterranean had organized preparedness sub-regional meetings up to 2016. Reports generated from these meetings were pub- lished and available on IDRNET database (21–24). Moreo- ver, a regional strategy on preparedness and response was issued and contained steps for protection of the interna- tional community against pandemic influenza according to International Health Regulations (IHR) (2005). As for the IMEMR database, eight articles were available, four of which were KAP type evaluating the knowledge lev- 585 Research article EMHJ – Vol. 25 No. 8 – 2019 el and preventive measures of influenza adopted by the general population, school students, medical students, and pilgrims. One publication illustrated the early out- comes of pandemic H1N1 surveillance in the United Arab Emirates providing the incidence of confirmed H1N1 cas- es (21). Another two publications described the pandemic history and the characteristics of the virus (22,23). Pandemic preparedness plans in EMR Search for national preparedness plans in the Region re- sulted in eight plans for the following countries (Egypt, Islamic Republic of Iran, Lebanon, Jordan, Palestine, Sau- di Arabia, Oman and Yemen) out of the 23 EMR countries, and were published between 2006 and 2016. All the pub- lished plans were produced by the ministry of health of the country using checklists and/or tools from interna- tional bodies such as WHO and CDC. All the examined plans followed the international guidelines but failed to cover the basic elements comprehensively. The priority of most of the plans was human infections and included infection- control measures, pharmacological issues, and crises management algorithms. Only the Egyptian and Saudi Arabian plans discussed both animal and human influenza control and sector integration was planned in case of crises. Ethical and legal issues, special country circumstances, border screening, integration of international bodies were almost ignored. Continuous active surveillance was ignored in most of the countries after the post-pandemic phase although it was the most important lesson learned from the pandemic (24). Communication and collaboration of assigned authorities in almost all plans were taken into consideration, but risk communication was not always clearly defined. Improving future planning This review revealed several common themes that re- quired improvement in the influenza preparedness plans of the WHO EMR Member States. Those themes were: epidemiologic surveillance, virologic surveillance, risk communication, infection control, vaccines, antivirals, hospitalization and critical care, inter-country coordina- tion, regional and international coordination, plan revi- sion and evaluation, and lack of focus on epidemic influ- enza. Epidemiologic surveillance Very few plans and publications discussed epidemiologic surveillance in the Region. Surveillance is a key function of monitoring seasonal influenza, pandemic prepared- ness planning, and IHR compliance. Surveillance has been highlighted as an area that requires improvement in several regions (25,26). All country plans should describe their current epidemiologic surveillance system and countries lacking systematic, sustainable surveillance should implement that immediately. Plans should then describe how epidemiologic surveillance would expand during pandemic response. Attention should be directed at the frequency of generating reports and how region- al surveillance would be tied up to central surveillance units. Frequency of reporting during a pandemic needs to be quicker to enable the decision makers nationally and globally to monitor the pandemic and respond ac- cordingly. Virologic surveillance Capacity for laboratory surveillance has been highlighted as a key to success in the WHO European Region (EURO), while it was an area that needed improvement in the WHO African Region (AFRO) (25,27,28). Countries with no virologic surveillance should implement that imme- diately. Surge capacity for virologic surveillance should be clearly identified especially that during a pandemic, sampling and testing would be dramatically increased to cover diagnosis of disease as well as virus character- ization. Little evidence was found on reports analyzing virologic surveillance data, hence indicating that there is not enough virologic surveillance occurring in the Re- gion. Virologic surveillance, especially at initial phases of a pandemic, is essential for understanding the viral char- acteristics which is important for vaccine preparation. At later stages, virologic surveillance is key to understanding whether any genetic and antigenic drift is occurring. In the plan, countries must clearly state which laboratories will be utilized in the surge and they are encouraged to include not only public health laboratories but also research and private laboratories with influenza capacity. The related logistics must be clearly detailed in the plan including but not limited to logistics of sample collection, sample transportation, availability of lab kits and reagents, and result reporting mechanisms. Risk communication During a pandemic, risk communication is key to dis- perse information to all stakeholders. The analysis in this report indicated that pandemic risk communication is sparse in the EMR as is the case in African and Asia–Pa- cific regions (26–28). The countries’ pandemic plans must clearly detail all the risk communication methods to be utilized during a pandemic. This should include mecha- nisms of communication with the public, care providers, and other stakeholders. Infection control The primary role of pandemic preparedness is to limit or stop viral transmission. If disease requires hospitaliza- tion, then nosocomial transmission must be minimized. Sparse evidence was found on how infection control would be enhanced in hospitals dealing with infected patients. Plans should clearly define infection control policies to be enacted, how infection control supplies would be stockpiled and dispersed, which hospitals to be designated to primarily receive patients, and other neces- sary measures for infection control. Furthermore, plans for border screening should be in place including setting up proper quarantine facilities dedicated for receiving incoming cases of disease in conjunction with other in- fection control measures. Finally, plans should include 586 EMHJ – Vol. 25 No. 8 – 2019Research article insight on transmission and infection control in the com- munity settings and how this would be communicated with key community players (26,30). Vaccines Having plans for stockpiling and distribution of vaccines is key to proper response (27,30). In the event of a pandem- ic, it is highly likely that the current vaccines would not be effective and hence there would be a delay between virus detection and availability of vaccines. Even when a vaccine is prepared, quantities will not be sufficient to cover the entire population. Little was found in relation to vaccine and antiviral policies in this search. Countries should include pandemic vaccination policies that deter- mine the target populations that should receive the vac- cine, the number of dozes required, vaccine storage units, vaccine dispersal facilities, and vaccine uptake monitor- ing. Furthermore, seasonal influenza vaccination policies should be revised and enforced. Antivirals For antivirals, countries should work under the assump- tion that current antivirals would be effective against an upcoming pandemic virus. It is highly unlikely that a novel antiviral drug would be available swiftly if the pandemic strain is resistant to the current ones. Hence, pandemic preparedness must include plans for stockpil- ing currently available antiviral drugs as this is a key to a successful response, only vaccines and antiviral drugs are clearly efficacious in preventing infection or treat- ing illness (26,29,30). This should also include where the stocks would be stored, how they will be dispersed, and the guidelines for clinical use. Other drugs such as anti- biotics to fight secondary bacterial infections and pneu- monia, antipyretics, and anti-inflammatory drugs should be also included in planning (29). Hospitalization and critical care It is highly likely that in case of a pandemic, a surge in utilization of healthcare resources and personnel would occur (26,29). This would include a surge in hospital bed use as well as intensive care beds. Evidence of such plan- ning in the EMR was negligible. Plans should carefully consider what to do in case of such surge taking into ac- count other sectors that could assist in healthcare such as the private and military sectors. Inter-country coordination In several countries, non-governmental, academic, and private institutions play a significant role in public health, hence coordination and utilization of such in- stitutions is necessary. All this mandates having clearly defined channels of communication and coordination, as well as pre-defining how decision-making and lead- ership would be structured. A pandemic preparedness evaluation exercise in Thailand revealed the importance of planning at all administrative levels (31). Very few of the reviewed plans had elements describing how coor- dination will take place with sectors other than health. In countries that are under a federal law, that are geo- graphically large, that are heavily populated, or that are religiously or ethnically diverse, sub-national plans must be included and then incorporated and linked to the na- tional plan. Ethical and legal frameworks During a pandemic, situations necessitating restricting people movement, mandating quarantines, mandating certain infection control measures, mandating certain clinical interventions, among others may arise. Such is- sues require having provisions to obtain the necessary ethical and legal frameworks for implementations. Fur- thermore, having a clear legal framework is essential to determine leadership and proper channels of communi- cation and coordination. Lack of clear legal frameworks was highlighted as a weakness in influenza preparedness in Africa (25). Regional and international coordination Little evidence of regional collaboration was found. Fur- thermore, influenza pandemic response is a global effort coordinated by WHO with significant contributions from other global influenza authorities. Regional plans must indicate how coordination with WHO collabo- rating centers, and WHO reference laboratories will be handled. Plans must be compatible with IHR and other globally recognized health treaties. Plan revision and evaluation None of the reviewed plans clearly stated when and how the plan would be evaluated and revised. Furthermore, none of the plans made provisions for mock-exercises or simulations. Plans should clearly mention this and make use of epidemic and outbreak situations that occur fre- quently in the Region to activate all or parts of the plan. Lessons learned from such exercises would help improve pandemic preparedness plans. Furthermore, data col- lected from outbreak, epidemic, or pandemic response should be readily available to researchers who can pro- vide analysis, expert opinion, and design specifically-tai- lored research aimed at improving various aspects of pandemic preparedness. Lack of focus on epidemic influenza Our analysis showed that preparedness and response efforts were largely focused on pandemic influenza. All findings were related to either the 2009 H1N1 pandemic or the arrival of H5N1 to the region in 2005–2006. Prepar- edness and response to outbreaks of seasonal influenza are largely lacking. Focus of the plan should not be on a single virus as this might lead to confusion if a different virus emerged. This is what happened during the 2009 H1N1 pandemic as focus was on H5N1 for a long time while the H1N1 pandemic virus did not have the same ep- idemiology of H5N1 (29). The findings described in the above themes are recommended to be used as a guidance to assist EMR countries in updating or preparing their national 587 Research article EMHJ – Vol. 25 No. 8 – 2019 influenza pandemic preparedness plans. These are summarized as an influenza preparedness planning guidance document in Table 1. Conclusion This review of the published peer-reviewed literature, non-peer-reviewed literature, and countries’ influenza preparedness plans revealed that influenza preparedness and response remain weak in the EMR. An essential first step would be updating the national influenza prepared- ness plans guided by the findings of this report. Funding: This work was supported under the Pandemic Influenza Preparedness Partnership Contributions for implementation activities in the WHO Eastern Mediter- ranean Region. The funder had no role in study design and collection, analysis, and interpretation of data and in writing the manuscript. Competing interests: None declared. Table 1 Influenza preparedness planning guidance document ContentGoalItem The plan introduction should cover the essential information focusing on the local and regional situation of the disease. • Informative introduction. • Objectives. Introduction and objectives The plan should identify the preparedness goals and provide a formal risk assessment. Clearly indicate when the plan would be activated. The risk assessment should be based on the WHO Tool for Influenza Pandemic Risk Assessment (TIPRA) (http://apps.who.int/iris/bitstream/10665/250130/1/WHO-OHE-PED-GIP- 2016.2-eng.pdf?ua=1). Risk assessment trigger should be based on TIPRA’s epidemiological and virological triggers (TIPRA document, page 10). Conduct a risk assessment exercise based on TIPRA. List names and contact information of primary and secondary experts to assist in conducting TIPRA exercises. • Identify risk factors for pandemics/ epidemics and plans for mitigation. • Identify a panel of experts (epidemiologists, veterinarians, virologists, clinicians, immunologists, pharmacologists, molecular virologists). Risk assessment ContentGoalItem Describe the current epidemiological surveillance system. Explain how epidemiological surveillance would expand during pandemic response. • A functional surveillance system is an integral aspect of the national influenza plan to provide early detection of emerging viruses and to monitor seasonal influenza. Epidemiological surveillance Describe the current epidemiological surveillance system. State which laboratories will be utilized in a surge. The related logistics must be clearly detailed including, but not limited to, logistics of sample collection, sample transportation, availability of laboratory kits and reagents, and result reporting mechanisms. • Essential for understanding the viral characteristics which is important for vaccine preparation and antiviral sensitivity. Virological surveillance Describe the surveillance systems at the sub-national level.• Sub-national surveillance systems are crucial for complete surveillance data Sub-national surveillance system Pandemic planning committee comprising stakeholders from both private and public sectors. The plan should identify means of communications, what should be the role of each member of the committee during a pandemic or an epidemic. • Strong communication strategy is a key to a coordinated response. Communication command strategy 588 EMHJ – Vol. 25 No. 8 – 2019Research article Table 1 Influenza preparedness planning guidance document (concluded) ContentGoalItem Detail all the risk communication methods to be utilized during a pandemic. It is not enough to rely on the media or publish awareness pamphlets. This should include mechanisms of communication with the public, care providers, and other stakeholders. Algorithm with available contact data (rapid response). • Provide and exchange relevant information to the public, partners, and stakeholders in order to allow them to make informed decisions. Risk communication Engagement of decision-makers and assigned authorities and include non-governmental, academic, and private institutions. Sub-national plans must be included and then incorporated and linked to the national plan. • Coordination across sectors. using a one health approach. • Maintenance of essential services. Collaboration and inter- country coordination Indicate how coordination with WHO/EMRO, WHO collaborating centres, and WHO reference laboratories will be handled. Plans must be compatible with IHR and other globally recognized health treaties. State how findings will be shared with WHO. • To integrate the plan with regional and international efforts Regional and international coordination Include provisions for vulnerable groups in countries suffering from political circumstances (refugees ) or mass gathering (Hajj). • To protect vulnerable groups. Special/vulnerable population Describe legal and ethical frameworks that will take effect if, for example, restricting people movement, mandating quarantines, mandating certain infection control measures, and mandating certain clinical interventions will be implemented. • Clear legal framework is essential to determine leadership and proper channels of communication and coordination. Ethical and legal frameworks ContentGoalItem Estimate health capacities to be utilized with consideration of NGOs and private sector together with governmental hospitals. Describe alternative health sectors that can assist to cover the surge of health care services needed. Trained personnel (medical staff, health care workers, laboratory staff, volunteers). • To provide health care services. • Maintenance of health services. during pandemic/ epidemic. Health care response Definition of confirmed or suspected cases. Diagnostic tools and checklists. Case management algorithm. • Accurate and early diagnosis of cases. Case identification and management Define infection control policies to be enacted, how infection control supplies would be stockpiled and dispersed, which hospitals to be designated to primarily receive patients, patient triaging, and other necessary measures for infection control. Plans for border screening should be in place including setting up proper quarantine facilities dedicated for receiving incoming cases of disease. Stockpiled personal protective equipment. Plans for non-pharmacological community-based interventions. • Prevent transmission. Infection control Describe the current policy for seasonal influenza vaccination. Estimate the number of doses required if a novel vaccine is introduced in response to a pandemic and define the populations to receive it. Describe the logistics of vaccine dispersal. Describe how drugs are stockpiled and how distribution will occur during a pandemic/ epidemic. • Vaccine stockpiles of current vaccines. • Vaccine requirements if a new vaccine is needed. • Provide and maintain stockpiled antivirals, anti- biotics, and other relevant medications Pharmacological intervention Identify the current network of national and sub-national laboratories where influenza diagnostics are performed. Identify the network of laboratories, including private or academic laboratories, that can assist in case of a surge. Provide clear instructions for sample collection, storage, diagnostics algorithms, and result reporting. • Laboratory capacity is key for pandemic preparedness. Laboratory capacity Provide frequencies of plan simulations and exercises, evaluation, and revision.• Evaluation to address any gaps. Revision of the plan Provide pre-designed checklist and tools. Include TIPRA tools. • Checklists and tools, as applicable, needed to aid plan execution. Checklist and tools 589 Research article EMHJ – Vol. 25 No. 8 – 2019 ةيلماعلا ةحصلا ةمظنلم طسوتلما قشر ميلقإ في ازنولفنلإا ةحئالج بهأتلا ليايك يزاغ ،كلام نومأم ،يعافرلا ةيرمأ ،ناخ قثاو ةصلالخا .ازنولفنلإا ةئبوأ ةحفاكم في اًيسيئر اًرمأ بهأتلا دعي :ةيفللخا .ةيلماعلا ةحصلا ةمظنلم طسوتلما قشر ميلقإ في ازنولفنلإا ةئبولأ بهأتلاو ةباجتسلاا ليلحتل ةروشنلما داوملل لماش ضارعتسا يرجُأ :فادهلأا ةصالخاو Google-scholarو Scopusو PubMed تانايبلا دعاوق في ةيمسرلا يرغ تاروشنلماو ةروشنلما داولما نع ثحبلا مت :ثحبلا قرط ةينوتركللإا عقاولما للاخ نم ةينطولاو ةيلودلا ططلخا نع ثحبلا مت ماك .تنترنلإا برع ةيلماعلا ةحصلا ةمظنلم طسوتلما قشرل يميلقلإا بتكلماب .عوضولماب ةلصلا تاذ نادلبلا تارازول ةيمسرلا هذه مظعم تماق ،كلذ لىإ ةفاضإ .ةدودمح ةروشنلما ةيملعلا قارولأاو ةليئض تناك طسوتلما قشر ميلقإ نادلب نم ةباجتسلاا نأ اندجو :جئاتنلا ةيناكس تائف لىإ اههيجوت مت وأ ،تاحاقللاو ىودعلا ةحفاكم يربادت لثم ،رثكأ وأ صرنع لىع زيكترلا للاخ نم اًيئزج بهأتلا ةطخ ةساردب قارولأا .ةحئالجا نم ةيهمأ ةدافتسلما سوردلا رثكأ هنوك مغر نادلبلا مظعم في لصاوتلما طشنلا دصترلا لافغإ متو .ينيحصلا ينلماعلا لثم ةددمح ةلجاعمو ةدجتسم سويرف ةحئاج يلأ يدصتلا فدبه ،ليالحا ريرقتلا في جئاتنلاب داشترسلااو ،ةينطولا بهأتلا ططخ ثيدتح بيج :تاجاتنتسلاا .ةيمسولما ازنولفنلإا تلااح ديازت References 1. Centers for Disease Control and Prevention. Influenza epidemiology and prevention of vaccine-preventable disease. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington DC: Public Health Foundation, 2015. 2. Taubenberger JK, Morens DM. Influenza: the once and future pandemic. Public Health Rep. 2010;125(3_suppl) Suppl 3:15–26. http://dx.doi.org/10.1177/00333549101250S305 3. Stöhr K. Influenza–WHO cares. Lancet Infect Dis. 2002;2(9):517. http://dx.doi.org/10.1016/S1473-3099(02)00366-3 4. Hussein I. Will Egypt unleash another flu pandemic? Nature Middle East. 2015; Published online 12 March 2015. 5. Leventhal A, Ramlawi A, Belbiesi A, Sheikh S, Haddadin A, Husseini S, et al. Enhanced surveillance for detection and manage- ment of infectious diseases: regional collaboration in the middle East. Emerg Health Threats J. 2013;6. http://dx.doi.org/10.3402/ ehtj.v6i0.19955 6. Holmberg M, Lundgren B. Framing post-pandemic preparedness: Comparing eight European plans. Glob Public Health. 2018 Jan;13(1):99-114. http://dx.doi.org/10.1080/17441692.2016.1149202 7. Cheng VC, To KK, Tse H, Hung IF, Yuen KY. Two years after pandemic influenza A/2009/H1N1: what have we learned? Clin Microbiol Rev. 2012;25(2):223–63. Préparation à la pandémie de grippe dans la Région de l’OMS pour la Méditerranée orientale Résumé Contexte : La préparation est essentielle pour lutter contre les épidémies et les pandémies de grippe. Objectifs : Une étude exhaustive de la littérature a été menée afin d’analyser la riposte et la préparation aux pandémies de grippe dans la Région de l’OMS pour la Méditerranée orientale. Méthodes : Des recherches ont été effectuées dans la littérature publiée et grise dans PubMed, Scopus et Google Scholar ainsi que dans les bases de données en ligne qui concernent la Région de l’OMS pour la Méditerranée orientale. Les plans internationaux et nationaux ont également fait l’objet de recherches via les sites Web officiels des ministères concernés des pays. Résultats : Nous avons constaté que la riposte des pays de la Région de la Méditerranée orientale était minimale et que le nombre d’articles scientifiques publiés était limité. De surcroît, la majorité des articles présentait une analyse partielle du plan de préparation en mettant l’accent sur un ou plusieurs aspects tels que les mesures de lutte contre les infections et les vaccins, ou visait certaines populations comme les agents de santé. La plupart des pays ne tiennent pas compte de la nécessité de mettre en place une surveillance active et continue, bien que ce soit l’enseignement le plus important à retenir de la pandémie. Conclusions : Les plans de préparation nationaux doivent être mis à jour sur la base des conclusions du présent article, afin de traiter l’apparition de tout virus pandémique et de faire face aux fortes augmentations de cas de grippe saisonnière. 590 EMHJ – Vol. 25 No. 8 – 2019Research article 8. Kayali G, Webby RJ, Samhouri D, Mafi AR, Bassili A. Influenza research in the Eastern Mediterranean Region: The current state and the way forward. Influenza Other Respi Viruses. 2013;7(6):914–21. http://dx.doi.org/10.1111/irv.12136 9. Tavana A. Pandemic influenza A H1N1 in Iran and lessons learnt. Ann Trop Med Public Health. 2012;5(4):295–7. http://dx.doi. org/10.4103/1755-6783.102023 10. Gholami J, Hosseini SH, Ashoorkhani M, Majdzadeh SR. Lessons learned from H1N1 epidemic: The role of mass media in in- forming physicians. Int J Prev Med. 2011;2(1):32–7. 11. Seef S, Jeppsson A. Is it a policy crisis or it is a health crisis? The Egyptian context–analysis of the Egyptian health policy for the H1N1 flu pandemic control. Pan Afr Med J. 2013;14:59. 12. Kamal NN, Seedhom AE. Knowledge, attitude and practice of El-Minia university students towards pandemic H1N1, Egypt, 2009. J Public Health (Bangkok). 2011;19(6):505–10. http://dx.doi.org/10.1007/s10389-011-0427-1 13. El-Bahnasawy MM, Elmeniawy NZ, Morsy TA. An interventional program for nursing staff on selected mass gathering infec- tious diseases at Hajj. J Egypt Soc Parasitol. 2014;44(2):405–24. http://dx.doi.org/10.12816/0006480 14. El Gaafary MM, Abd Elaziz KM, Abdel-Rahman AG, Allam MF. Concerns, perceived impacts and preparedness of health care workers in a referral hospital in Egypt in facing influenza (H1N1) epidemic. J Prev Med Hyg. 2010;51(3):105–9. 15. Abdelwhab EM, Hafez HM. An overview of the epidemic of highly pathogenic H5N1 avian influenza virus in Egypt: epidemiolo- gy and control challenges. Epidemiol Infect. 2011;139(5):647–57. http://dx.doi.org/10.1017/S0950268810003122 16. Shahid M. On the roads to H1N1 pandemic era: drive safe and fearless using colour-coded masks. Asian Pac J Trop Med. 2012;5(4):333–4. http://dx.doi.org/10.1016/S1995-7645(12)60052-2 17. Janahi E, Awadh M, Awadh S. Public knowledge, risk perception, attitudes and practices in relation to the swine flu pandemic: A cross sectional questionnaire-based survey in Bahrain. Int J Collab Res Intern Med Public Health. 2011;3(6):451–64. 18. Ullah R, Zaman G, Islam S. Multiple control strategies for prevention of avian influenza pandemic. Scientific World Journal. 2014; 2014: 949718. 19. Rihan FA, Anwar MN, Sheek-Hussein M, Denic S. (2012). SIR model of swine influenza epidemic in Abu Dhabi: Estimation of vaccination requirement. Journal of Public Health Frontier 1; 85-89. 20. Leventhal A, Ramlawi A, Belbiesi A, Balicer RD. Regional collaboration in the Middle East to deal with H5N1 avian flu. BMJ. 2006;333(7573):856–8. http://dx.doi.org/10.1136/bmj.38994.420926.80 21. Ahmed F, Al Hosani F, Al Mannaie A, Harrison O. Early outcomes of pandemic influenza (H1N1) 2009 surveillance in Abu Dhabi Emirate, May-August 2009. East Mediterr Health J. 2012;18(1):31–6. http://dx.doi.org/10.26719/2012.18.1.31 22. Al Hajjar S, McIntosh K. The first influenza pandemic of the 21st century. Ann Saudi Med. 2010;30(1):1–10. http://dx.doi. org/10.5144/0256-4947.59365 23. Al-Muharrmi Z. Understanding the Influenza A H1N1 2009 Pandemic. Sultan Qaboos Univ Med J. 2010;10(2):187–95. 24. Ungchusak K, Sawanpanyalert P, Hanchoworakul W, Sawanpanyalert N, Maloney SA, Brown RC, et al. Lessons learned from influenza A(H1N1)pdm09 pandemic response in Thailand. Emerg Infect Dis. 2012;18(7):1058–64. http://dx.doi.org/10.3201/ eid1807.110976 25. Breiman RF, Nasidi A, Katz MA, Kariuki Njenga M, Vertefeuille J. Preparedness for highly pathogenic avian influenza pandemic in Africa. Emerg Infect Dis. 2007;13(10):1453–8. http://dx.doi.org/10.3201/eid1310.070400 26. Ortu G, Mounier-Jack S, Coker R. Pandemic influenza preparedness in Africa is a profound challenge for an already distressed region: analysis of national preparedness plans. Health Policy Plan. 2008;23(3):161–9. http://dx.doi.org/10.1093/heapol/czn004 27. Al-Muharrmi Z. Understanding the Influenza A H1N1 2009 Pandemic. Sultan Qaboos Univ Med J. 2010;10(2):187–95. 28. Nikolay B, Salje H, Sturm-Ramirez K, Azziz-Baumgartner E, Homaira N, Ahmed M. Evaluating Hospital-Based Surveillance for Outbreak Detection in Bangladesh. Analysis of Healthcare Utilization Data. 2017;14(1):e1002218. 29. Coker R, Mounier-Jack S. Pandemic influenza preparedness in the Asia-Pacific region. Lancet. 2006;368(9538):886–9. http://dx- .doi.org/10.1016/S0140-6736(06)69209-X 30. Monto AS. Vaccines and antiviral drugs in pandemic preparedness. Emerg Infect Dis. 2006;12(1):55–60. http://dx.doi.org/10.3201/ eid1201.051068 31. Putthasri W, Lertiendumrong J, Chompook P, Tangcharoensathien V, Coker R. Capacity of Thailand to contain an emerging influenza pandemic. Emerg Infect Dis. 2009;15(3):423–32. http://dx.doi.org/10.3201/eid1503.080872 EMHJ – Vol. 25 No. 8 – 2019WHO events addressing public health priorities 591 Steering committee for Eastern Mediterranean Region drug regulatory authorities1 1 This report is extracted from the Summary report on the meeting of the Steering Committee for Eastern Mediterranean drug regulatory authorities, Amman, Jordan, 9–10 April 2019 (http://applications.emro.who.int/docs/IC_Meet_Rep_2019_EN_23814.PDF?ua=1). Citation: Steering committee for Eastern Mediterranean Region drug regulatory authorities. East Mediterr Health J. 2019;25(8):591–592 https://doi. org/10.26719/2019.25.8.591 Copyright © World Health Organization (WHO) 2019. 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). Introduction Effective regulation of medicines and medical products promotes and protects public health. Regulation aims to ensure the quality, safety and efficacy of medical prod- ucts (medicines, vaccines, diagnostics, medical devices, etc.) through enforcement of legislations, norms and standards. National regulatory authorities (NRAs) for medical products, with adequate capacity, can efficiently play this role. The World Health Organization (WHO) Regional Office for the Eastern Mediterranean organized the first Eastern Mediterranean Drug Regulatory Authorities Conference (EMDRAC) in 1993 (1), to serve as a biennial event bringing together NRAs from the Region as well as regulatory leaders from regional and international organizations to exchange experience and share cutting- edge professional approaches and techniques spanning all core regulatory functions. At the 2018 Eastern Mediterranean Drug Regulatory Authorities Conference (EMDRAC 2018) held in Salalah, Oman, in July 2018 (2), it was agreed by NRAs to establish a steering committee to meet annually for capacity-building, collaboration, harmonization and monitoring of the EMDRAC recommendations. The steering committee would be composed of selected directors of NRAs in the Region in order to enhance cooperation between regulatory authorities in the Region; identify and plan capacity- building activities related to the regulation of medical products; exchange relevant information on safety and quality of medical products; promote effective regulation and regulatory mechanisms of medical products; review progress made towards implementation of EMDRAC and International Conference of Drug Regulatory Authorities (ICDRA) recommendations; andpromote research on the regulation of production, distribution and use of medicines, vaccines and medical products. Subsequently, the WHO Regional Office for the Eastern Mediterranean organized the first meeting of the Steering Committee for Eastern Mediterranean Drug Regulatory Authorities from 9 to 10 April 2019, in Amman, Jordan (3). The meeting was attended by representatives from 11 Member States of the Region (Afghanistan, Bahrain, Egypt, Iraq, Jordan, Kuwait, Morocco, Oman, Palestine, Saudi Arabia and Syrian Arab Republic). The WHO Secretariat comprised staff members from headquarters, the regional and country offices. The objectives of the meeting were to: • develop and agree on terms of reference for the Steer- ing Committee; • discuss regional and national challenges encountered by NRAs in the regulation of medical products; and • facilitate further collaboration between NRAs and promote regulatory harmonization initiatives. Summary of discussions Challenges in the regulation of medical products in the Region were discussed in group work sessions. Identified challenges included: lack of coordination between NRAs at regional level; absence of well-trained human resources; weak registration systems (especially for medical devices, vaccines and other biologicals); weak pharmacovigilance systems; poor implementation of good manufacturing practices; weak post-marketing surveillance and inspection; poor quality control laboratories; and lack of proper pricing control systems. The terms of reference of the Steering Committee were discussed. It was agreed that the Committee will act as an advisory body to enhance capacity-building, collaboration, harmonization and networking among NRAs in Member States of the Region, and to prepare and monitor implementation of EMDRAC recommendations. Membership of the Committee will be voluntary for designated representatives from Member States (head of the NRA or his/her alternative) which wish to be represented. The Steering Committee will be composed of nine members, serving for a period of two years and for a maximum of two terms. The chair and vice-chair will serve on a rotational basis among countries, and will be selected upon mutual agreement by members of the Steering Committee. Other Member States of the Region can attend Steering Committee meetings as observers. Guests and experts can be invited to Steering Committee meetings, as needed. The WHO Regional Office for the Eastern Mediterranean will serve as secretariat to the Steering Committee. WHO events addressing public health priorities 592 EMHJ – Vol. 25 No. 8 – 2019 Recommendations To the Steering Committee • Serving as a platform for information sharing, con- vergence and cooperation in the Region. • Working towards obtaining and building commit- ment from Member States in the area of regulatory systems strengthening. • Consulting with NRAs on topics of interest for the EMDRAC, and subsequently approving the agenda. • Promoting collaboration between Member States, including exchange of information and expertise on existing requirements and regulations. • Promoting harmonization of the regulatory guide- lines among Member States. • Facilitating the implementation of EMDRAC recom- mendations by NRAs. • Facilitating signing memoranda of understanding (MoUs) between NRAs for exchange of information and technical assistance for needed services for strengthening regulatory systems. • Holding face-to-face meetings at least twice a year, and virtual meetings (via teleconference) every four months, or as the need arises. To WHO • Providing technical and administrative support to the Steering Committee. • Facilitating and organizing face-to-face and virtual meetings of the Steering Committee • Developing, managing and updating advocacy and information materials. • Ensuring reporting on activities of the Steering Com- mittee and disseminating the information to all Member States. • Developing a networking tool (EZcollab or Share- Point) for the heads of NRAs in the Region to share all information related to the regulation of medical products. References 1. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Drug regulatory authorities of the Eastern Mediterranean Region – report on the joint WHO/DSE regional meeting, Tunis, Tunisia, 2-8 November 1993. Alexan- dria: WHO/EMRO; 1995 (https://apps.who.int/iris/bitstream/handle/10665/258633/who_em_pts_165_e_l_en.pdf?sequence=1&isAl- lowed=y). 2. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Summary report on the Eastern Med- iterranean drug regulatory authorities conference (EMDRAC). Cairo: WHO/EMRO; 2019 (http://applications.emro.who.int/docs/ IC_Meet_Rep_2019_EN_22324.pdf?ua=1). 3. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Summary report on the meeting of the Steering Committee for Eastern Mediterranean drug regulatory authorities. Cairo: WHO/EMRO; 2019 (http://applications. emro.who.int/docs/IC_Meet_Rep_2019_EN_23814.PDF?ua=1). 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) 2020. Open Access. 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 26-02.indd 4-6 2/23/2020 10:30:31 AM