Eastern Mediterranean Health Journal [2018; Vol.24, Issue 10]

La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal EMHJ – Vol. 24 No. 10 – 2018 Volume 24 / No. 10 October/Octobre 10 ددع / نوشرعلاو عبارلا دلجلما لولأا نيشرت/ربوتكأ2018 Eastern M editerranean H ealth Journal Vol. 24 N o. 10 – 2018 The World Health Organization and the United Nations International Children’s Emergency Fund (UNICEF) have revisited current operational strategies to control cholera in Yemen, following a recent upsurge in reported cases, in order to accelerate efforts to curtail the epidemic. Editorial Cholera in Yemen: concerns remain over recent spike but control efforts show promise Ahmed Al-Mandhari, Altaf Musani, Abdinasir Abubakar and Mamunur Malik ............................................................................................................................. 971 Letter to the editor Global recommendations to prevent tooth decay must be evidence-based Christopher Holmgren and Habib Benzian ..................................................................................................................................................................................................973 Research articles Assessment of overweight and obesity in Iranian adolescents: optimal cut-off values of anthropometric indices Mohammad Motlagh, Seiyed Shirvani, Zahra Hassanzadeh-Rostami, Majzobeh Taheri and Reza Ghadimi ......................................................................975 Estimation du coût de la prise en charge du cancer broncho‐pulmonaire en Tunisie Chahida Harizi, Hedia Bellali, Aicha Hchaichi, Agnès Hamzaoui et Mohamed Kouni Chahed ................................................................................................ 988 Customary practices, domestic violence, and psychosomatic pain among adolescent mothers in Turkey Yasin Bez, Cem Uysal, Mahmut Bulut, Mehmet Kaya, Neval Goruk, Suleyman Demir and Aytekin Sir .............................................................................. 994 Effect of postpartum depression on women’s mental and physical health four years after childbirth Fatemeh Abdollahi and Mehran Zarghami ................................................................................................................................................................................................1002 Trends in occupational injuries and diseases among Saudi and non-Saudi insured workers Mohsin Abbas, Muhammad Kashif, Mansour Balkhyour, Ijaz Ahmad, Zaki-ul-Zaman Asam and Rashid Saeed ............................................................. 1010 Use of complementary and alternative medicine among paediatric patients with hepatogastrointestinal diseases Seyed Mosavat, Mojtaba Heydari, Mohammad Hashempur and Seyed Dehghani ..................................................................................................................... 1018 Commentary Challenges for pregnant Syrian refugees in Lebanon Lena Abdin .............................................................................................................................................................................................................................................................1026 WHO events addressing public health priorities Improving access to assistive technology in the Eastern Mediterranean Region .............................................................. 1030 Cover 24-10.indd 1-3 17/12/2018 13:57:40 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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ISSN 1020-3397 Cover 24-10.indd 4-6 17/12/2018 13:57:40 Editorial Cholera in Yemen: concerns remain over recent spike but control efforts show promise Ahmed Al-Mandhari, Altaf Musani, Abdinasir Abubakar and Mamunur Malik ................................................................................................ 971 Letter to the editor Global recommendations to prevent tooth decay must be evidence-based Christopher Holmgren and Habib Benzian .....................................................................................................................................................................973 Research articles Assessment of overweight and obesity in Iranian adolescents: optimal cut-off values of anthropometric indices Mohammad Motlagh, Seiyed Shirvani, Zahra Hassanzadeh-Rostami, Majzobeh Taheri and Reza Ghadimi .........................................975 Estimation du coût de la prise en charge du cancer broncho‐pulmonaire en Tunisie Chahida Harizi, Hedia Bellali, Aicha Hchaichi, Agnès Hamzaoui et Mohamed Kouni Chahed ................................................................... 988 Customary practices, domestic violence, and psychosomatic pain among adolescent mothers in Turkey Yasin Bez, Cem Uysal, Mahmut Bulut, Mehmet Kaya, Neval Goruk, Suleyman Demir and Aytekin Sir .................................................. 994 Effect of postpartum depression on women’s mental and physical health four years after childbirth Fatemeh Abdollahi and Mehran Zarghami ....................................................................................................................................................................1002 Trends in occupational injuries and diseases among Saudi and non-Saudi insured workers Mohsin Abbas, Muhammad Kashif, Mansour Balkhyour, Ijaz Ahmad, Zaki-ul-Zaman Asam and Rashid Saeed ................................ 1010 Use of complementary and alternative medicine among paediatric patients with hepatogastrointestinal diseases Seyed Mosavat, Mojtaba Heydari, Mohammad Hashempur and Seyed Dehghani ........................................................................................ 1018 Commentary Challenges for pregnant Syrian refugees in Lebanon Lena Abdin .................................................................................................................................................................................................................................1026 WHO events addressing public health priorities Improving access to assistive technology in the Eastern Mediterranean Region ................................................................. 1030 Vol. 24.10 – 2018 La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Book 24-10.indb 969 12/17/2018 2:22:05 PM Ahmed Al-Mandhari Editor-in-Chief Arash Rashidian Executive Editor Ahmed Mandil Deputy Executive Editor Phillip Dingwall Managing Editor Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editorial assistants Nadia Abu-Saleh, Suhaib Al Asbahi (graphics), Diana Tawadros (graphics) Editorial support Guy Penet (French editor) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Technical editors) Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics editors) Administration Iman Fawzy, 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 Book 24-10.indb 970 12/17/2018 2:22:05 PM Editorial 971 EMHJ – Vol. 24 No. 10 – 2018 Cholera in Yemen: concerns remain over recent spike but control efforts show promise Ahmed Al-Mandhari,1 Altaf Musani,2 Abdinasir Abubakar 3 and Mamunur Malik 4 1Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2WHO Country Representative, Sana’a, Yemen. 3Infectious Hazard Management, Department of Health Emergency, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 4Infectious Hazard Management, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. (Correspondence to: Mamunur Malik: malikm@who.int). Citation: Al-Mandhari A; Musani A; Abubakar A; Malik MR. Cholera in Yemen: concerns remain over recent spike but control efforts show promise. East Mediterr Health J. 2018;24(10):971–972. https://doi.org/26719/2018.24.10.971 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). October 2018 would be two years since the world came to know of the first case of cholera in war-torn Yemen. Soon after, the outbreak developed at an unprecedented scale and turned into one of the worst historical cholera events in terms of cases reported (1). By the end of September 2018, more than one million suspected cases had been reported across the country in all but one governorate (2), where approximately 60% of these cases remained concentrated in roughly half of the 330 districts in the country (3). How many of these million cases are “true” cholera could not be ascertained due to inadequate laboratory testing capacity in Yemen. Despite this uncertainty, such high number of cases with rapid geographic spread, raging over such a long period and showing little signs of waning, has already raised alarm. Although the outbreak started in October 2016, the major upsurge of the new cases was seen after May 2017 and the country continued to report a high case load until early 2018. Recently, the surveillance data shows a declining trend when compared to the same period last year. The number of suspected cases has ranged from about 1500 to 5000 per week—a drop from 2017, when approximately 5000 new cases were reported every day during the same period in 2017 (4). Not only have fewer cases been reported in recent months, but also fewer districts have reported suspected cholera cases compared to the same period in 2018. However, the recent spike in reported cholera case numbers continues to be worrisome. Cholera is one of the oldest foes to humanity. Humanitarian crisis resulting from war or any other protracted and complex emergencies resulting in collapse or near collapse of health systems provide an ideal environment for emergence and re-emergence of cholera epidemics, as witnessed in Haiti, Zimbabwe and now in Yemen (3). Despite being one of the oldest killer diseases the world continues to face, the technical solutions to control and even eliminate the risk of cholera are easily available, affordable and feasible to implement. The disease can be easily treated; for over 80% of cases, simple rehydration therapy means in just a few hours the patient can walk home from health facilities after receiving treatment, provided the access to healthcare early is unimpeded. A recent meeting organized by the World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) in Amman, Jordan, revisited the current operational strategies to control cholera in Yemen. Following a recent upsurge in reported cholera cases, a set of potentially high-value and high- impact strategies were considered to accelerate control efforts for an immediate halt to the progression of the epidemic, after showing signs that transmission is likely slowing down. First, the current evolution of cholera surveillance data would be studied more in-depth in order to identify 1) districts with active transmission; 2) districts where transmission shows signs of waning; and 3) districts where the transmission probably has stopped. The control efforts would be scaled up to target districts with active transmission with the goal of achieving “zero transmission” within the next three to six months. Second, currently over 600 000 people living in the disease hotspot districts have been protected from cholera through a mass immunization campaign with two-dose inactivated oral cholera vaccines (OCVs) between May and September 2018. The country received 1.3 million doses of OCVs from the Global task Force on Cholera Control (GTFCC) for conducting pre-emptive vaccination campaign in high-risk districts. The remaining doses currently available in the country would have to be used to judiciously target districts where active transmission is ongoing in order to achieve “zero” transmission. Despite earlier apprehension that mass immunization campaign with a two-dose OCV (administered 10–14 days apart) would be logistically difficult in the context of Yemen due to security issues and mobile populations, the success of protecting over half a million people pre- emptively against a rapidly spreading outbreak will go a long way in halting the epidemic. Experience has already demonstrated that deployment of OCV, reactively, in epidemics can also be effective (4–6). Third, since cholera is a water-borne disease that thrives in poor water and sanitation situations and transmission is fecal–oral, the only way we can interrupt the transmission is to improve access to clean water. It is plausible that the water and sanitation situation in Book 24-10.indb 971 12/17/2018 2:22:05 PM EMHJ – Vol. 24 No. 10 – 2018Editorial 972 References . 1 Von Seidlein L, Sack D, Azman AS, Ivers LC, Lopez AL, Deen JL. Cholera outbreak in Yemen. Lancet Gastroenterol Hepatol. 2017 Nov;777:(11)2. https://doi.org/10.1016/S-30287(17)1253-2468X PMID: 29017710 . 2 Al-Mekhlafi HM. Yemen in a Time of Cholera: Current situation and challenges. Am J Trop Med Hyg. 2018 Jun;1562-1558:(6)98. https://doi.org/10.4269/ajtmh.0811-17 PMID: 29557331 . 3 Camacho A, Bouhenia M, Alyusfi R, Alkohlani A, Naji MAM, de Radigues X, et al. Cholera epidemic in Yemen, 18-2016: an analysis of surveillance data. Lancet Glob Health. 2018 Jun;6)6):e-680e690 https://doi.org/10.1016/S109-2214X(4-30230(18 PMID: 29731398 . 4 Qadri F, Islam T, Clemens JD. Cholera in Yemen - An old foe rearing its ugly head. N Engl J Med. 7-2005:(21)377;2017. https://doi. org/10.1056/NEJMp1712099 PMID: 29091747 . 5 Ciglenecki I, Azman AS, Jamet C, Serafini M, Luquero FJ, Cabrol J-C. Progress and challenges in using oral cholera vaccines to control outbreaks: The Médecins Sans Frontières experience. J Infect Dis. 2018 Oct 218;15(suppl_3):S-165S166. https://doi. org/10.1093/infdis/jiy487 PMID: 30239901 . 6 Azman AS, Parker LA, Rumunu J, Tadesse F, Grandesso F, Deng LL, et al. Effectiveness of one dose of oral cholera vaccine in response to an outbreak: a case-cohort study. Lancet Glob Health. 2016 Nov;11)4):e-856e863 https://doi.org/10.1016/S-2214 109X(-30211(16X . 7 Cholera, 2011. Weekly epidemiological record / Releve epidemiologique hebdomadaire. 304-289:(32/31)87;2012. (http://www.who. int/wer/2012/wer32_8731.pdf?ua=1). Yemen has near collapsed owing to the protracted crisis and long-term investment would be needed to restore the water and sanitation infrastructure. Providing clean water to nearly 16 million Yemenis who currently lack access to safe water would be a daunting task (4). As transmission needs to be stopped at the household level, it is here that efforts should now be targeted in those disease hotspots showing continued transmission. A variety of interventions should be considered to scale up mass distribution of chlorinated water or chlorination/ water purification tablets, provide hygiene kits with soap for hand washing, and provide training on making water safe for drinking and safe disposal of human waste at the household level. An active collaboration and engagement between the health and water and sanitation / hygiene (WASH) sector will be critical to achieve this at the household level. The cholera surveillance data should guide these interventions and prioritize areas to target. Fourth, all cases, including those mild cases not seeking healthcare owing to lack of access or health- seeking behaviour, should be brought under the cover of treatment through community-based outreach services or establishing oral rehydration therapy (ORT) centres at community level. Cholera transmission can only be interrupted if we can interrupt its transmission through treating all dehydrated cases, since this would minimize repeated purging of Vibrio bacterium in the environment and limit its propagation. The meeting also underscored the need to understand better the transmission pathways of such a large scale epidemic with a low fatality case rate. However, it is unclear what have been the drivers of the noted cholera spike as well as the prolonged and sustained cholera transmission in Yemen, including the epidemiological and environmental determinants. A number of other knowledge gaps were also identified in the meeting that require active collaboration between Yemeni health authorities, WHO, UNICEF, international organizations and academia. Understanding the full genome sequence of the Vibrio bacterium to detect if the circulating strain has mutated into a more virulent or toxigenic strain, along with better predictive models and real-time analysis of risk factors for deaths, were some of the key knowledge gaps that require more evidence in order to accelerate cholera response. The meeting also looked at the current strategy for identifying and reporting suspected cases, adherence of healthcare workers to case definition, and current strategy for laboratory testing. Records indicate that the last outbreak of cholera was officially reported from Yemen in 2011 (7). The unprecedented scale of this current outbreak has exceeded all our previous understandings of the disease’s duration and transmission patterns. However, after two years of continued efforts to halt the interruption, we clearly see positive signs of ending cholera. International agencies including WHO and UNICEF need to combine and consolidate ongoing efforts in order to overcome remaining obstacles. Recent gains need to be sustained and integrated into a comprehensive long-term plan in line with the “End Cholera – A Road Map for 2030”, which WHO Member States endorsed during the Seventy-First World Health Assembly in 2018, and vowed to reduce by 90% the magnitude of cholera outbreaks with the support of Global Task Force on Cholera Control (GTFCC) partners. It is hoped that this collective experience, knowledge and partnership in controlling cholera in one of the worst humanitarian crisis settings ever seen, also be used to control other infectious disease threats in the country, and help recover and improve the public health system in Yemen. Book 24-10.indb 972 12/17/2018 2:22:05 PM Letter to the editor 973 EMHJ – Vol. 24 No. 10 – 2018 Global recommendations to prevent tooth decay must be evidence- based Christopher Holmgren 1 and Habib Benzian 2 1Aide Odontologique Interantionale, Montrouge, France. 2Department for Epidemiology and Health Promotion, New York University College of Dentistry, New York United States of America. (Correspondence to: Habib Benzian: habib.benzian@nyu.edu) Citation: Holmgren C; Benzian H. Global recommendations to prevent tooth decay must be evidence-based. East Mediterr Health J. 2018;24(10):973-974. https://doi.org/10.26719/2018.24.10.973 Received: 15/06/18; accepted: 15/10/18 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Sir, We commend Drs Doumit and Al Sayah on their short communication entitled "The trends in consumption patterns of toothbrushes and toothpastes in Lebanon" (1). Toothbrushing twice-daily with fluoride toothpaste (FT) is an essential caries-preventive measure that cannot be highlighted enough. The research also provides interesting insights in consumption of oral hygiene products in Lebanon. We are, however, concerned that certain aspects in the communication require clarification and correction. For instance, the use of the term "fluoride intake" is misleading, since toothpaste should not be swallowed. "Fluoride exposure" would be the preferred term to reflect the topical effect of FT. Our main concern relates to the repeated reference to "WHO consumption recommendations" that, according to our knowledge, do not exist in this form. The recommendation of "yearly consumption of four toothbrushes and 6 tubes of toothpastes per individual", referenced to WHO TC846 (1994) (2) cannot be found in the report, nor on the WHO website. We are unsure of the source of these recommendations since they are not evidence-based. Should such recommendations appear in unidentified WHO documents then they ought to be reviewed with urgency. Examining the cited recommendation for toothpaste consumption, the authors' estimation of 170 grams net of toothpaste/tube amounts to 1.02 kilograms/ person/year. Translated to brushing twice daily with FT, this recommendation equals 1.4 grams toothpaste per brushing. This is in stark contrast to the often- recommended pea-sized toothpaste amount weighing about 0.25 grams, resulting in an annual use of 182.5 grams FT/person (3). Evidence shows that the quantity of toothpaste used per brushing is not as important as the concentration of available fluoride in the dentifrice (4). However, using large amounts of toothpaste has cost implications for poorer communities who are already challenged to afford FT even when based on an annual consumption of 182.5 grams (3). From a public health perspective, it is unwise to promote unjustified recommendations for using more toothpaste per brushing (5). Oral health professionals and toothbrush manufacturers often advise to replace toothbrushes every three months, claiming harmful bacterial contamination after longer use and reduced efficacy of plaque removal due to wear of bristles. While there is no evidence of harmful effects of bacterial growth on older toothbrushes if used and stored properly (6), research on the effects of toothbrush wear on plaque removal is inconclusive, though most studies do not find a significant reduction in cleaning capacities of older brushes (7–9). Future emerging evidence may help to define more solid recommendations for replacement of toothbrushes, keeping in mind that the cost of frequent toothbrush replacement might be prohibitive for poor communities (10). Contrary to the author’s conclusions, this study on the trends in consumption patterns of toothbrushes and toothpastes in Lebanon suggests that consumption patterns appear to be appropriate. Preventive efforts in Lebanon would be better targeted to promoting toothbrushing with an adequate and safe amount of effective FT, and towards stepping-up efforts to ensure universal affordability of FT for all population groups. Letter in response to article: The trends in consumption patterns of toothbrushes and toothpastes in Lebanon Doumit M; Al Sayah F. The trends in consumption patterns of toothbrushes and toothpastes in Lebanon. East Mediterr Health J. 2018;24(2):216-220. https://doi.org/10.26719/2018.24.2.216. Book 24-10.indb 973 12/17/2018 2:22:06 PM EMHJ – Vol. 24 No. 10 – 2018Letter to the editor 974 References . 1 Doumit M, Al Sayah F. The trends in consumption patterns of toothbrushes and toothpastes in Lebanon. East Mediterr Health J. 20–216:(2)24;2018. http://dx.doi.org/2018.24.2.216/10.26719 . 2 World Health Organization (WHO). Fluorides and oral health. Report No. 846 WHO Technical Report Series. Geneva: WHO; 1994. . 3 Goldman A, Yee R, Holmgren C, Benzian H. Global affordability of fluoride toothpaste. Global Health. 7:(1)4;2008. http://dx.doi. org/7-4-8603-1744/10.1186 . 4 Zero DT. Dentifrices, mouthwashes, and remineralization/caries arrestment strategies. BMC Oral Health. 6;2006 Suppl 1:S9. http://dx.doi.org/-6-6831-1472/10.1186S-1S9 . 5 Creeth J, Bosma ML, Govier K. How much is a ‘pea-sized amount’? A study of dentifrice dosing by parents in three countries. Int Dent J. 63;2013 Suppl 30–2:25. http://dx.doi.org/10.1111/idj.12074 . 6 Frazelle MR, Munro CL. Toothbrush contamination: a review of the literature. Nurs Res Pract. 2012:420630;2012. http://dx.doi. org/420630/2012/10.1155 . 7 van Palenstein Helderman WH, Kyaing MM, Aung MT, Soe W, Rosema NA, van der Weijden GA, et al. Plaque removal by young children using old and new toothbrushes. J Dent Res. 42–1138:(12)85;2006. http://dx.doi.org/154405910608501214/10.1177 . 8 Tan E, Daly C. Comparison of new and -3month-old toothbrushes in plaque removal. J Clin Periodontol. 50–645:(7)29;2002. http:// dx.doi.org/10.1034/j.051-1600X.2002.290709.x . 9 Rosema NA, Hennequin-Hoenderdos NL, Versteeg PA, van Palenstein Helderman WH, van der Velden U, van der Weijden GA. Plaque-removing efficacy of new and used manual toothbrushes - a professional brushing study. Int J Dent Hyg. –237:(4)11;2013 43. http://dx.doi.org/10.1111/idh.12021 . 10 Malekafzali B, Biria M, Tadayon N, Abbasi H. Comparison of plaque removal efficacy of new and -3month-old toothbrushes in children. East Mediterr Health J. 20–115:(2)17;2011. http://dx.doi.org/2011.17.2.115/10.26719 Response by Dr Mounir Doumit: For further clarification, fluoride toothpaste (FT) is delivered now with different concentrations ranging between 450 to 1500 ppm, the said concentration varies in connection with the age of the patient. Since we have a risk of fluorosis and the FT may be swallowed by the children it is preferable in our view to mention “fluoride intake” (1). “Fluoride exposure” should be used when we are referring to water fluoridation, salt, tablets or drops. The WHO reference provided might have a typographical error when noting the reference. However, the ADA and the PDA (2) always recommend what we provided under our article. As to the calculation regarding the quantity of FT used by an individual, we are of the view that it is around 680 g per year, not more, and this is an average noted worldwide (1). In Lebanon the DMFT is considerably high (3) and our recommendation in all our articles is to use correctly the oral personal hygiene and follow a healthy lifestyle by reducing sugar (4–7). References . 1 Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochran Database Syst Rev. 2010 Jan 1);20):CD007868. http://dx.doi.org/14651858/10.1002.CD007868.pub2 . 2 American Dental Association. (https://www.ada.org/en/member-center/oral-health-topics/toothbrushes); (https://www.ada.org/ en/science-research/ada-seal-of-acceptance/ada-seal-products/product-category?supercategory=Toothpastes); (https://www.ada. org/en/member-center/oral-health-topics/toothpastes). . 3 Doumit M, Doughan B. Dental caries and fluorosis among children in Lebanon. Indian J Dent Res. 2018 May-Jun;22–317:(3)29. http://dx.doi.org/10.4103/ijdr.IJDR_17_475 . 4 Ciancio S, Morgano SM, Doumit M, Shammari KFA, Al-Suwayed A, Al-Suwaidi A, et al. Improving oral health in the Middle East - recommendations from the first Middle East Oral Hygiene Advisory Board meeting. Int Dent J. 2010 Jun;3)60S209-204:(1. . 5 Morgano SM, Doumit M, Shammari KFA, Al-Suwayed A, Al-Suwaidi A, Debaybo D, et al. Burden of oral disease in the Middle East: Opportunities for dental public health. Int Dent J. 2010 Jun;3)60S199-197:(1. . 6 Doumit M, Doughan B. Oral health in school children in Lebanon. Sante. 2002 Apr-Jun;8–223:(2)12. . 7 Ali Hussein S, Doumit M, Doughan B, El Nadeef M. Oral health in Lebanon: a pilot pathfinder survey. East Mediterr Health J. 1996 Jun 303-299:(2)2;15. Book 24-10.indb 974 12/17/2018 2:22:06 PM Research article 975 EMHJ – Vol. 24 No. 10 – 2018 Assessment of overweight and obesity in Iranian adolescents: optimal cut-off values of anthropometric indices Mohammad Motlagh,1 Seiyed Shirvani,2 Zahra Hassanzadeh-Rostami,3 Majzobeh Taheri 4 and Reza Ghadimi 2 1Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Islamic Republic of Iran (Correspondence to: Mohammad E. Motlagh: motlagh@health. gov.ir). 2Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Islamic Republic of Iran. 3Department of Community Nutrition, Nutrition and Food Sciences Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran. 4Department of Health, Ministry of Health and Medical Education, Tehran, Islamic Republic of Iran. Introduction The increasing trend of overweight and obesity is a critical public health problem worldwide (1). Obesity in children and adolescents increases the risk of metabolic syndrome conditions. Furthermore, it can cause chronic disease in adulthood, such as hyperlipidaemia, diabetes, metabolic syndrome, muscle-skeletal disorders, asthma and apnoea (2). Fat distribution and type of obesity are the main predictors of metabolic disorders (3). Despite the se- rious health risks of obesity in all age groups, no exact in- dex to determine body fat percentage is available (4). Var- ious indices have been used to estimate overweight and obesity with varying limitations and strengths. However, body mass index (BMI) is the most appropriate method for screening of weight status in all age groups (5). Two popular indices for abdominal obesity are waist circumference (WC) and waist-to-hip ratio (WHpR) (6). Waist-to-height ratio (WHtR) is another index to estimate waist girth. WHtR adjusted for height is a new predictor of obesity and cardio/metabolic risks (7). In addition, neck circumference (NC) has recently been used as a new measure of fat deposition and cardio/metabolic disease (8–10). Studies have shown that abdominal obesity better predicts major causes of death—cancer and cardiovascular disease—compared with BMI (11,12). Similarly, NC can accurately predict metabolic syndrome and blood pressure differences as it measures upper body adiposity (13). Therefore, the limitations of BMI in detecting fat distribution and differentiating between fat and muscle deposition can be overcome using WC and NC. Anthropometric indices are affected by demographic factors such as age, sex, race or ethnicity, and geographical location because of different characteristics of populations in body size and composition (14). Thus, the cut-off points of these indices differ in various regions. Consequently, the levels of obesity and obesity- related health risks may differ by ethnicity at the same level of BMI. For instance, health risks at lower levels of BMI among Asian populations have been reported (15). This study aimed to evaluate the use of WC, WHpR, WHtR and NC as a reliable alternative to BMI and determine the optimal cut-off values for identification of overweight and obesity. Abstract Background: Various indices have been used to estimate overweight and obesity; all have limitations and strengths. The prevalence of overweight and obesity may differ by ethnicity. Aims: This study evaluated waist circumference (WC), waist-to-hip ratio (WHpR), waist-to-height ratio (WHtR) and neck circumference (NC) as reliable alternatives to body mass index for screening for overweight and obesity, and determined their optimum cut-off values in different ethnic groups. Methods: The study was conducted from November 2015 to February 2016 among adolescents aged 12–14 years from five ethnicities in the Islamic Republic of Iran: Arab, Kurdish, Sistani and Baluchi, Turkish and Turkman. Stratified multistage sampling was used to select 2444 students. Receiver operating characteristic curves were constructed to evaluate WC, WHpR, WHtR and NC as screening indices for overweight and obesity as categorized by body mass index centiles. Results: The prevalence of overweight and obesity in the total sample were 15.3% and 9.2% respectively, with higher rates in students of Arab, Kurdish and Turkish ethnicity. The areas under curve ranged from 0.8 to 0.9 for WC, WHtR and NC. The mean optimum values with the highest sensitivity and specificity to identify overweight were: 72.3 cm (sensitivity 0.80, specificity 0.75) for WC, 0.46 (0.85, 0.70) for WHtR and 31 cm (0.76, 0.76) for NC. For obesity mean optimum values were: 77 cm (0.84, 0.81) for WC, 0.50 (0.84, 0.84) for WHtR and 31.5 cm (0.88, 0.71) for NC. Conclusions: WC, WHtR and NC may be useful tools to screen for adiposity using their optimum values for sex and ethnicity. Keywords: overweight, obesity, anthropometric indices, adolescent, ethnicity, Iran Citation: Motlagh ME; Shirvani SDN; Hassanzadeh-Rostami Z; Taheri M; Ghadimi R. Assessment of overweight and obesity in Iranian adolescents: optimal cut-off values of anthropometric indices. East Mediterr Health J. 2018;24(10):975–987. https://doi.org/10.26719/2018.24.10.975 Received: 09/01/17; accepted: 03/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Book 24-10.indb 975 12/17/2018 2:22:06 PM EMHJ – Vol. 24 No. 10 – 2018Research article 976 Methods Study design and sample This community-based cross-sectional survey was car- ried out from November 2015 to February 2016. The sam- ple included adolescents aged 12–14 years from 5 differ- ent ethnic groups in 5 geographical regions of the Islamic Republic of Iran where each ethnic group is concentrat- ed. The study participants were categorized into the fol- lowing 5 ethnic groups according to both their parents’ ethnicity and their place of residence. · Arab ethnicity: inhabitants in some parts of Khoz- estan province · Kurdish: mostly from western Islamic Republic of Iran (Kurdistan province) · Sistani and Baluchi: ethnic group in Sistan and Bluch- estan province in the east of the country · Turkish ethnicity: mostly living in the north-east of the country, especially in Azerbaijan, Ardabil and Zanjan provinces · Turkman: a branch of Turkmen in northern and north-eastern Islamic Republic of Iran (Golestan and Khorasan provinces). The sample size was estimated as 504 for each ethnic group based on 30% predicted prevalence of obesity (16), 95% confidence interval and a precision level of 5% (total of 2 520). The participants were selected using stratified multistage sampling according to socioeconomic status and geographical location. In the first stage, 125 junior high schools (25 schools from each ethnic region) were selected by random sampling, out of a total of 674 schools in all 5 provinces. Then, 20 adolescents were selected in each school by simple random sampling (Figure 1). After drop-outs, the final sample was 2 444 students. Inclusion criteria were students between 12 and 14 years of age from the selected ethnicities. Exclusion criteria were other ethnic origins and students with developmental and intellectual disabilities, which was assessed by asking the student’s teacher. Verbal consent was obtained from all participants and their parents or legal caregivers after explaining the aim of the study. Data collection Demographic variables and anthropometric measures were obtained for all participants, including age, sex, ethnicity, residence area, weight, height, waist circumfer- ence, hip circumference and neck circumference. Weight and height measures were taken by trained health staff. Weight was recorded in light clothing by a digital weighing scale (Beurer, Germany) to the nearest 0.1 kg. Weight scale accuracy was checked against standard scales, twice a day. Height was measured barefoot using a non-stretch tape measure (Seca, Japan) to the nearest 0.5 cm. WC was measured at the midway between the lowest rib margin and the iliac crest while the student was standing, and hip circumference was measured at the maximum extension of the buttock using a non-stretch measuring tape, to the nearest 0.1 cm. NC was measured at the midway of the neck, between mid-cervical spine and mid anterior neck using a non- stretch measuring tape, to the nearest 0.1 cm. WHpR was the ratio of the waist to hip circumferences and WHtR was calculated by dividing the waist circumference by height. BMI was calculated as weight divided by height squared (kg/m2). The students were categorized as underweight (BMI lower than 5th age- and sex- specific centiles), normal weight (BMI between 5th and 85th age- and sex-specific centiles), overweight (BMI between 85th and 95th age- and sex-specific centiles), and obese (BMI greater than 95th age- and sex-specific centiles) based on NCHS/CDC cut-off points (17). Data analysis Statistical analyses were performed using SPSS, version 18. Anthropometric indices and demographic characteris- tics of the participants were reported as mean and stand- ard deviation (SD) and frequency. Normal distribution of the data was checked using histogram and Q-Q plots. We assessed between-group comparisons using the in- dependent samples t-test and one-way ANOVA; post-hoc tests were used for further analysis. Receiver operating characteristic (ROC) curves were used to determine the usefulness of WC, WHpR, WHtR and NC as screening tools of overweight and obesity, and to estimate appropriate cut-off values by the Youden index. The area under the curve (AUC) and 95% confidence interval (CI) were calculated from the ROC analysis to determine the overall accuracy of the anthropometric indices in screening for overweight and obesity. Sensitivity and specificity values, and true-positive and true-negative rates were calculated to construct the ROC curves. Sensitivity was defined as the probability that obesity or overweight would correctly classify subjects who were test-positive for each method (WC, WHpR, WHtR and NC). Specificity was defined as the probability of correctly classifying the subjects who were test-negative for each method (WC, WHpR, WHtR and NC). A P-values less than 0.05 was considered statistically significant. Ethical considerations The study was approved by the Ethics Committee of Ah- vaz Jundishapur University of Medical Science, Ahvaz, Islamic Republic of Iran. Results A total of 2 444 students, aged 12–14 years, participated in the study, 48% of whom were boys. Demographic charac- teristics and anthropometric data of the students accord- ing to sex and ethnic group are summarized in Table 1. Girls had a significantly higher mean BMI than boys (P < 0.001). There were significant differences between the ethnic groups in relation to all anthropometric indices (P < 0.001). Mean BMI was significantly higher in stu- Book 24-10.indb 976 12/17/2018 2:22:06 PM Research article 977 EMHJ – Vol. 24 No. 10 – 2018 Si st an i a nd B al uc hi et hn ic ity 50 4 st ud en ts 25 sc ho ol s i n ea ch e th ni c gr ou p an d 20 -2 1 st ud en ts in e ac h sc ho ol w er e ra nd om ly se le ct ed Fi na l s am pl e (4 86 ) 25 6 M al e, 23 0 Fe m al e Tu rk is h et hn ic ity 50 4 st ud en ts 25 sc ho ol s i n ea ch e th ni c gr ou p an d 20 -2 1 st ud en ts in e ac h sc ho ol w er e ra nd om ly se le ct ed Fi na l s am pl e (4 68 ) 24 3 M al e, 25 4 Fe m al e Tu rk m an e th ni ci ty 50 4 st ud en ts 25 sc ho ol s i n ea ch e th ni c gr ou p an d 20 -2 1 st ud en ts in e ac h sc ho ol w er e ra nd om ly se le ct ed Fi na l s am pl e (5 03 ) 24 9 M al e, 25 4 Fe m al e A ra b et hn ic ity 50 4 st ud en ts 25 sc ho ol s i n ea ch e th ni c gr ou p an d 20 -2 1 st ud en ts in e ac h sc ho ol w er e ra nd om ly se le ct ed Fi na l s am pl e (4 90 ) 25 0 M al e, 24 0 Fe m al e K ur di sh e th ni ci ty 50 4 st ud en ts 25 sc ho ol s i n ea ch e th ni c gr ou p an d 20 -2 1 st ud en ts in e ac h sc ho ol w er e ra nd om ly se le ct ed Fi na l s am pl e (4 80 ) 25 9 M al e, 22 1 Fe m al e In iti al s tu dy p op ul at io n 25 20 sc ho ol st ud en ts fr om fi ve e th ni c gr ou ps D ro p- ou ts n= 14 D ro p- ou ts n= 24 D ro p- ou ts n= 18 D ro p- ou ts n= 36 D ro p- ou ts n= 1 Fi gu re 1 Fl ow ch ar t o f t he p ar ti ci pa nt s i n th e st ud y Book 24-10.indb 977 12/17/2018 2:22:06 PM EMHJ – Vol. 24 No. 10 – 2018Research article 978 dents of Arab ethnicity and lower in Sistani and Baluchi students compared to other groups. Students of Kurdish ethnicity had significantly higher WC, WHpR and WHtR values compared to other ethnic groups. NC was signifi- cantly higher in Kurdish and Turkish students, and lower in Arab, and Sistani and Baluchi students. The prevalence of underweight, overweight and obesity in the total sample was 6.7%, 15.3% and 9.2% respectively using BMI centiles. Table 2 shows the prevalence of underweight, overweight and obesity according to sex and ethnicity. The lowest prevalence of both overweight (8.8%) and obesity (3.1%) was seen in Sistani and Baluchi students. The highest prevalence of overweight was seen in female Kurdish students (21.6%) and male Turkish students (21.8%). The highest prevalence of obesity was seen in both girls and boys of Arab ethnicity. Table 3 shows the relationship between anthropomet- ric indices and underweight, overweight and obesity (as categorized by BMI). A significant increasing trend was seen in all anthropometric indices with increasing BMI score. The AUC of anthropometric indices assuming BMI overweight and obesity categories as standard criteria are shown in Table 4. The AUC of WC, WHtR and NC showed very good accuracy to identify overweight and obesity, as indicated by AUCs greater than 0.8. The AUC of WHpR showed sufficient accuracy, as indicated by AUCs greater than 0.6 (Table 4 and Figure 2). Tables 5 and 6 show the optimal cut-off points to identify overweight and obesity, as determined by the highest sensitivity and specificity, according to sex and ethnic group. In the total male population, the optimal cut-off values of WC to identify overweight and obesity were respectively 72.75 cm and 77.55 cm; WHpR were 0.88 and 0.88; WHtR were 0.46 and 0.49, and NC were 30.95 cm and 31.55 cm. These values in females to identify overweight and obesity were respectively: WC: 72.75 cm and 77.70 cm; WHpR: 0.84 and 0.84; WHtR: 0.47 and 0.50; and NC: 30.9 cm and 31.60 cm. Discussion Our findings indicate that 15.3% of the participants were overweight and 9.2% were obese. The anthropometric indices WC, WHtR and NC identified overweight and obesity accurately, as categorized by BMI centiles. Fur- thermore, the optimum values of WC, WHtR and NC were 72.3 cm, 0.46 and 31 cm respectively to identify overweight, and 77 cm, 0.50 and 31.5 cm respectively to identify obesity, based on the maximum sensitivities and specificities. Recent studies have reported similar though slightly lower rates of overweight and obesity in Iranian school- aged children (18–23). This may be a consequence of the nutrition transition that is occurring in developing countries (24). In our study, students of Arab ethnicity had the highest BMI values and those of Sistani and Baluchi ethnicity had the lowest. Moreover, we observed a higher prevalence of obesity in students of Arab ethnicity compared with other ethnic groups. The main causes of higher obesity in Arab ethnicity may be different dietary habits, inactivity due to the hotter and more humid climate conditions in Khozestan and genetic factors (25). On the other hand, the prevalence of overweight and obesity were lowest in the Sistani and Baluchi ethnic group and a high prevalence of underweight was observed in this group. In this regard, Mirmohammadi et al. also reported low prevalence rates of overweight and obesity in Baluchi ethnic groups (20). The lower socioeconomic development in this region and lower availability of food might be the reason. Our study found that girls had Table 1 Age and anthropometric measurements of the students by sex and ethnic group Characteristic Age (years) BMI (kg/m2) WC WHpR WHtR NC Ethnicity Arab 13.05 (0.7) 20.91 (4.57)a 70.98 (10.22) 0.82 (0.06) 0.45 (0.06) 29.87 (2.93)d Kurdish 12.94 (0.69) 19.95 (3.86) 78.02 (10.38) 0.89 (0.04)c 0.49 (0.06)c 31.51 (2.41)e Sistani & Baluchi 13.07 (0.69) 17.98 (3.46)b 68.64 (8.47) 0.83 (0.07) 0.44 (0.04) 29.89 (2.59)f Turkish 12.89 (0.72) 20.03 (3.56) 69.99 (12.26) 0.82 (0.07) 0.44 (0.07) 31.56 (2.80)g Turkman 13.06 (0.69) 19.85 (3.59) 71.98 (10.09) 0.83 (0.06) 0.45 (0.06) 30.89 (2.52) P-value (one-way ANOVA) < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 Sex Male 12.99 (0.68) 19.22 (3.84) 71.24 (10.29) 0.85 (0.60) 0.45 (0.06) 30.71 (2.79) Female 13.01 (0.72) 20.23 (3.98) 71.77 (11.41) 0.83 (0.07) 0.46 (0.07) 30.85 (2.73) P-value (independent samples t-test) 0.39 < 0.001 0.23 < 0.001 0.24 0.75 Data are presented as mean (standard deviation). Multiple comparisons were done using post-hoc tests which showed statistically significant differences between the ethnic groups: aArab ethnicity compared to other ethnic groups; bSistani & Baluchi ethnicity compared to other ethnic groups; cKurdish ethnicity compared to other ethnic groups; dArab ethnicity compared to other ethnic groups except Sistani & Baluchi ethnicity; eKurdish ethnicity compared to other ethnic groups except Turkish ethnicity; fSistani & Baluchi ethnicity compared to other ethnic groups except Arab ethnicity; gTurkish ethnicity compared to other ethnic groups except Kurdish ethnicity. BMI = body mass index; WC = waist circumference; WHpR = waist-to-hip ratio; WHtR = waist-to-height ratio; NC = neck circumference. Book 24-10.indb 978 12/17/2018 2:22:06 PM Research article 979 EMHJ – Vol. 24 No. 10 – 2018 significantly higher BMI values than boys. The higher BMI in girls may be due to less physical activity, as was shown in the CASPIAN study conducted in the Iranian population (23). In addition, we found boys had a higher prevalence of obesity and lower prevalence of overweight than girls. Other studies have reported similar results (18,26,27). However, different results have been reported by other studies. For instance, 2 studies in Iranian children and/or adolescents reported a higher prevalence of both overweight and obesity in boys (19,28). These differences may be due to differences in mean age of the participants and residence. The second part of our study demonstrated the suitability of WC, WHpR, WHtR and NC to screen for overweight and obesity, as an alternative to BMI centiles. The BMI index does not determine fat content and distribution in overweight individuals which is a limitation, particularly as central fat and upper adiposity are reliable indicators of cardio/metabolic disorders (13,14). A higher AUC for WHtR was found compared to WC, NC, and WHpR. This concurs with previous studies that showed a higher AUC for WHtR compared to WC to screen for obesity (29–31). Moreover, WHtR was a good predictor of body fat percentage and, in particular, it was more sensitive than BMI in identifying body fat, measured by skinfold methods (32,33). Furthermore, a systematic review and meta-analysis reported WHtR was a stronger predictor of cardiovascular disease risk factors compared with WC in different age and ethnic groups (34). The greater AUC for WHtR in different population groups supports its use as a reliable screening tool for adiposity. Furthermore, the WHtR index overcomes some of the limitations of WC as it is adjusted for height. Because WHtR removes the height variation effect, it can be a determinant of body fat distribution. Moreover, WHtR does not need age- and sex-specific references and so it is easier to interpret. In our study, the optimal cut-off points of WHtR to define overweight and obesity were respectively 0.46 and 0.49 in male students and 0.47 and 0.50 in female students. Similar studies used WHtR thresholds to identify adiposity in children, also showing nearly consistent results (30,32,33). We found a suitable area under the ROC curve for WC. The optimal accuracy of WC to detect overweight and excess fat was consistent with recent findings (30,33,35–37). WC is known to be a practical tool for screening of over- nutrition. Because of the appropriate accuracy and ease of measuring and interpreting WC, it can be used alone or with BMI to satisfactorily screen for overweight and obesity, and could overcome the BMI limitations. Fujita et al., using a DEXA technique, showed a direct relationship between body fat and BMI, WC and WHtR (30). WC has also been reported to be a more sensitive index for detecting body fat percentage compared with BMI (38), and can predict cardio/metabolic disorders and metabolic syndrome conditions (39,40). We estimated that the optimal cut-off points of WC were 73 cm to identify overweight and 77 cm for Ta bl e 2 Pr ev al en ce o f u nd er w ei gh t, no rm al w ei gh t, ov er w ei gh t a nd o be si ty b as ed o n bo dy m as s i nd ex b y se x an d et hn ic it y in 12 –1 4- ye ar -o ld st ud en ts Et hn ic it y U nd er w ei gh t N or m al w ei gh t O ve rw ei gh t O be si ty P- va lu ea M al es Fe m al es M al es Fe m al es M al es Fe m al es M al es Fe m al es Ar ab 11 4. 6 4 1.6 16 8 70 .0 15 5 62 .0 26 10 .8 47 18 .8 35 14 .5 44 17 .6 0. 01 Ku rd is h 12 5. 4 8 3. 1 15 3 69 .2 17 4 67 .2 34 15 .4 56 21 .6 22 10 .0 21 8. 1 0. 20 Si st an i & B al uc hi 59 25 .7 34 13 .3 15 4 67 .0 18 1 70 .7 11 4. 8 32 12 .5 6 2. 6 9 3. 5 < 0. 00 1 Tu rk is h 6 2.7 9 3.7 14 0 62 .2 17 8 73 .3 49 21 .8 43 17 .7 30 13 .3 13 5. 3 0. 00 9 Tu rk m an 14 5. 5 7 2. 8 18 8 74 .0 17 7 71 .1 25 9. 8 47 18 .9 27 10 .6 18 7.2 0. 01 To ta l 10 2 8.7 62 4. 9 80 3 68 .6 86 5 68 .8 14 5 12 .4 22 5 17 .9 12 0 10 .3 10 5 8. 4 < 0. 00 1 Da ta ar e p re se nt ed as n um be r a nd p er ce nt ag e. a P ea rs on ch i-s qu ar ed te st co m pa rin g s ex an d bo dy m as s i nd ex ca te go ry in ea ch et hn ic gr ou p. Book 24-10.indb 979 12/17/2018 2:22:06 PM EMHJ – Vol. 24 No. 10 – 2018Research article 980 obesity, in both sexes. These values concur with recent studies which used BMI centiles as the reference (29,35). Mazıcıoğlu et al. determined overweight in 13-year-old Turkish children and reported WC cut-off points of 72.5 in males and 67.5 in females (35). On the other hand, based on percentage of body fat, WC cut-off points in other studies showed lower values; this might be because of the younger age groups and also different socioeconomic status of the sample which affected the health status of children (31,33). The Kurdish ethnic group in our study had significantly higher WC, WHtR and WHpR values compared with other ethnic groups. The high prevalence of abdominal obesity in Kurdish adolescents supports the use of WC and/or WHtR in screening for over-nutrition. Although the BMI values were significantly higher in students of Arab ethnicity, the central obesity measures in the Arab group were similar to other ethnicities. Therefore, the use of BMI centiles may be more appropriate in those of Arab ethnicity together with WC. The area under the ROC curve for WHpR was not in a suitable range. WHpR is a less accurate anthropometric measurement tool, especially in obese subjects, as it will underestimate the obesity and central body fat because both waist and hip circumferences increase similarly in overweight or obese people. Therefore, it may not be a useful predictive index of metabolic disease. In other studies, WHpR was also reported to be a less accurate index than WC and WHtR (41,42). In our study, NC showed an adequate accuracy to identify overweight and obesity. The AUC of NC was lower than WHtR and WC but higher than WHpR. In this regard, Coutinho et al. reported a direct relationship between NC and BMI, WC, and body fat%. Hatipoglu et al. also reported NC to be an easy and accurate method to diagnose children with higher BMI levels (41,43); however they concluded WC was superior to NC for identifying overweight and obesity (41). The optimal cut-off points for NC in our study were 30.9 cm and 31.6 cm for overweight and obesity respectively in both sexes. Hatipoglu et al. reported similar NC values of 32.5 cm (males) and 31 cm (females) in post-pubertal subjects (41). We observed significantly higher NC values in Kurdish and Turkish ethnic groups and significantly lower values in Arab and Sistani and Baluchi participants. This is in line with our results for the central adiposity indices that showed higher upper fat content in the Kurdish adolescents and relatively lower fat content in students of Arab ethnicity. The main limitation of our study was the lack of body composition analysis and skinfold thickness values to measure adiposity. Furthermore, because we sampled just 5 ethnic groups, the overall prevalence of overweight and obesity and also the optimal cut-off points cannot be generalized to the Iranian student population. Therefore, in accordance with our objective, the results are presented separately by ethnic groups. Moreover, Fars ethnicity, which is a major ethnic group of the Islamic Republic of Iran, was not included in our study, although it would be an appropriate comparison group. Table 4 Area under the receiver operating characteristic curve of anthropometric indices to determine overweight and obesity, based on body mass index level, in Iranian students aged 12–14 years Anthropometric indices Overweight Obesity Girls Boys Total Girls Boys Total Waist circumference AUC 0.83 0.87 0.85 0.85 0.91 0.88 95% CI 0.80–0.86 0.84–0.89 0.83–0.87 0.81–0.90 0.87–0.95 0.86–0.91 Waist-to-hip ratio AUC 0.62 0.67 0.64 0.63 0.74 0.69 95% CI 0.59–0.66 0.63–0.71 0.61–0.66 0.57–0.69 0.69–0.79 0.65–0.73 Waist-to-height ratio AUC 0.85 0.87 0.86 0.87 0.91 0.89 95% CI 0.82–0.88 0.85–0.90 0.84–0.88 0.83–0.91 0.88–0.95 0.87–0.92 Neck circumference AUC 0.84 0.82 0.83 0.87 0.87 0.87 95% CI 0.82–0.86 0.80–0.85 0.81–0.85 0.84–0.90 0.83–0.90 0.85–0.89 AUC = area under curve; CI = confidence interval. Table 3 Relationship between anthropometric parameters and nutritional status based on to body mass index centiles Anthropometric parameter Underweight Normal weight Overweight Obesity P-value Waist circumference (cm) 61.91 (6.72) 68.72 (8.95) 78.38 (10.27) 87.90 (11.51) < 0.001a Waist-to-hip ratio 0.83 (0.07) 0.83 (0.07) 0.85 (0.07) 0.88 (0.07) < 0.001b Waist-to-height ratio 0.40 (0.04) 0.44 (0.05) 0.45 (0.06) 0.55 (0.06) < 0.001a Neck circumference (cm) 28.07 (1.84) 30.14 (2.25) 32.42 (2.49) 34.27 (2.57) < 0.001a Data are presented as mean (standard deviation). P-values were calculated by one way ANOVA. aStatistically significant differences between all nutritional status subgroups (post-hoc test). bStatistically significant differences between all nutritional status subgroups except underweight and normal subgroups (post-hoc test). Book 24-10.indb 980 12/17/2018 2:22:06 PM Research article 981 EMHJ – Vol. 24 No. 10 – 2018 Figure 2 Area under the receiver operating characteristic curves for waist circumference (WC), waist-to-hip ratio (WHpR), waist-to-height ratio (WHtR) and neck circumference (NC) to define overweight in females (A1) and males (A2), and obesity in females (B1) and males (B2) Book 24-10.indb 981 12/17/2018 2:22:06 PM EMHJ – Vol. 24 No. 10 – 2018Research article 982 Ta bl e 5 Pr op os ed cu t- of f p oi nt s b as ed o n th e hi gh es t s en si ti vi ty a nd sp ec ifi ci ty v al ue s o f a nt hr op om et ri c i nd ic es to cl as si fy o ve rw ei gh t a nd o be si ty , b as ed o n bo dy m as s i nd ex le ve l, in m al e st ud en ts a ge d 12 –1 4 ye ar s Et hn ic it y W C W H pR W H tR N C O pt im al th re sh ol d Se ns it iv it y Sp ec ifi ci ty O pt im al th re sh ol d Se ns it iv it y Sp ec ifi ci ty O pt im al th re sh ol d Se ns it iv it y Sp ec ifi ci ty O pt im al th re sh ol d Se ns it iv it y Sp ec ifi ci ty Ar ab O ve rw ei gh t 69 .8 5 0. 81 0. 80 0. 83 0.7 5 0. 64 0. 46 0. 9. 0. 87 30 .75 0. 61 0. 80 O be si ty 77 .3 0 0. 94 0. 95 0. 86 0.7 1 0.7 4 0. 49 0. 94 0. 93 31 .75 0. 83 0. 88 Ku rd ish O ve rw ei gh t 75 .2 0 0. 98 0. 80 0. 91 0.7 5 0.7 4 0. 49 0. 91 0. 92 31 .75 0. 89 0.7 0 O be si ty 85 .5 0 0. 96 0. 91 0. 92 0. 86 0. 81 0. 53 0. 96 0. 91 32 .75 1.0 0 0.7 7 Si st an i a nd B al uc hi O ve rw ei gh t 72 .5 0. 82 0. 80 0. 87 0.7 1 0. 65 0. 48 0. 88 0. 89 31 .75 0. 88 0. 83 O be si ty 78 .5 0 0. 83 0. 91 0. 84 0. 67 0. 50 0. 50 0. 83 0. 93 32 .8 0 1.0 0 0. 91 Tu rk ish O ve rw ei gh t 72 .5 0 0. 63 0. 59 0. 81 0. 61 0. 32 0. 46 0. 65 0. 66 31 .5 0 0. 65 0. 60 O be si ty 72 .5 0 0. 80 0. 56 0. 84 0.7 7 0. 50 0. 46 0. 80 0. 63 31 .5 0 0.7 3 0. 55 Tu rk m an O ve rw ei gh t 75 .5 5 0. 94 0. 89 0. 87 0.7 9 0.7 5 0. 47 0. 90 0. 88 30 .9 5 0. 98 0. 57 O be si ty 82 .5 0 1.0 0 0. 94 0. 88 0. 82 0.7 6 0. 50 0. 96 0. 89 31 .4 0. 96 0. 65 To ta l s am pl e O ve rw ei gh t 72 .75 0. 82 0.7 6 0. 88 0. 60 0. 69 0. 46 0. 84 0. 81 30 .9 5 0. 85 0. 61 O be si ty 77 .5 5 0. 88 0. 85 0. 88 0.7 0 0. 69 0. 49 0. 88 0. 87 31 .5 5 0. 87 0.7 1 W C = w ai st ci rc um fer en ce ; W H pR = w ai st- to -h eig ht ra tio ; W H tR = w ai st- to -h ip ra tio ; N C = ne ck ci rc um fer en ce . Book 24-10.indb 982 12/17/2018 2:22:06 PM Research article 983 EMHJ – Vol. 24 No. 10 – 2018 Ta bl e 6 Pr op os ed cu t- of f p oi nt s b as ed o n th e hi gh es t s en si ti vi ty a nd sp ec ifi ci ty v al ue s o f a nt hr op om et ri c i nd ic es to cl as si fy o ve rw ei gh t a nd o be si ty , b as ed o n bo dy m as s i nd ex le ve l, in fe m al e st ud en ts a ge d 12 –1 4 ye ar s Et hn ic it y W C W H pR W H tR N C O pt im al th re sh ol d Se ns it iv it y Sp ec ifi ci ty O pt im al th re sh ol d Se ns it iv it y Sp ec ifi ci ty O pt im al th re sh ol d Se ns it iv it y Sp ec ifi ci ty O pt im al th re sh ol d Se ns it iv it y Sp ec ifi ci ty Ar ab O ve rw ei gh t 69 .6 0 0. 81 0. 80 0.7 9 0. 64 0. 46 0. 44 0. 86 0.7 9 30 .3 0 0. 84 0. 82 O be si ty 73 .5 0 0. 84 0. 86 0. 80 0. 64 0. 52 0. 47 0. 89 0. 84 30 .75 0. 91 0.7 2 Ku rd ish O ve rw ei gh t 81 .5 0 0. 94 0. 83 0. 88 0.7 8 0. 50 0. 50 0. 95 0. 88 31 .4 0 0. 92 0. 67 O be si ty 86 .75 0. 91 0. 89 0. 91 0. 86 0. 68 0. 53 0. 91 0.7 7 32 .75 0. 86 0. 90 Si st an i a nd B al uc hi O ve rw ei gh t 73 .5 0 0. 83 0. 87 0.7 9 0.7 3 0. 42 0. 47 0. 88 0. 83 30 .8 0. 81 0. 83 O be si ty 81 .75 0. 89 0. 94 0. 83 0.7 8 0. 64 0. 53 0. 89 0. 96 32 .3 0 1.0 0 0. 92 Tu rk ish O ve rw ei gh t 72 .5 0 0.7 1 0. 69 0. 82 0. 61 0. 54 0. 46 0.7 0 0.7 3 31 .5 0 0.7 0 0. 56 O be si ty 78 .5 0 0.7 7 0. 86 0. 83 0. 62 0. 58 0. 50 0.7 7 0. 83 31 .5 0 0. 85 0. 52 Tu rk m an O ve rw ei gh t 74 .5 0 0. 82 0.7 9 0. 84 0. 68 0. 64 0. 47 0. 83 0. 83 31 .35 0. 83 0. 83 O be si ty 79 .5 0 0. 89 0. 84 0. 86 0. 67 0.7 4 0. 49 0. 94 0. 84 32 .2 5 0. 94 0. 85 To ta l s am pl e O ve rw ei gh t 72 .75 0. 82 0. 69 0. 84 0. 61 0. 59 0. 47 0. 82 0.7 4 30 .9 0 0. 88 0. 66 O be si ty 77 .70 0. 82 0.7 8 0. 84 0. 60 0. 59 0. 50 0. 80 0. 84 31 .6 0 0. 90 0.7 2 W C = w ai st cir cu m fer en ce ; W H pR = w ai st- to -h eig ht ra tio ; W H tR = w ai st- to -h ip ra tio ; N C = ne ck ci rc um fer en ce . Book 24-10.indb 983 12/17/2018 2:22:07 PM EMHJ – Vol. 24 No. 10 – 2018Research article 984 Conclusion The prevalence of overweight and obesity is of concern and needs to be considered in health programmes. The rates were different in various ethnic groups. WC, WHtR and NC successfully identified overweight and obesity in Iranian adolescents. Ethnic differences need to be consid- ered to estimate optimal cut-off points of anthropometric indices. Acknowledgements We thank the health services staff in all 5 provinces for conducting the interviews and collecting the data. We are also grateful to the parents and caregivers for consenting to their children’s participation in the study. Funding: This study was financially supported by Ahvaz Jundishapur University of Medical Science, Ahvaz, Islamic Re- public of Iran (Registration no. AJUMS.REC.1393.119). Competing interests: None declared. Évaluation de la surcharge pondérale et de l’obésité chez les adolescents iraniens : valeurs seuils optimales pour les indices anthropométriques Résumé Contexte : Divers indices sont utilisés pour estimer la surcharge pondérale et l’obésité ; ils présentent tous des avantages et des inconvénients. La prévalence de la surcharge pondérale et de l’obésité peut varier en fonction de l’origine ethnique. Objectifs : La présente étude a évalué le tour de taille, le rapport tour de taille/tour de hanches, le rapport tour de taille/ taille et la circonférence du cou en les considérant comme des alternatives fiables à l’indice de masse corporelle pour dépister la surcharge pondérale et l’obésité. Elle a ensuite déterminé leurs valeurs seuils optimales pour différents groupes ethniques. Méthodes : L’étude a été réalisée en République islamique d’Iran entre novembre 2015 et février 2016 auprès d’adolescents âgés de 12 à 14 ans et issus de 5 groupes ethniques différents : arabe ; kurde ; sistani et baloutche ; turc et turkmène. Une méthode d’échantillonnage stratifié à plusieurs degrés a été utilisée pour sélectionner 2444 étudiants. Des courbes ROC (fonction d’efficacité du récepteur) ont été tracées pour évaluer le tour de taille, le rapport tour de taille/tour de hanches, le rapport tour de taille/taille et la circonférence du cou en tant qu’indices de dépistage de la surcharge pondérale et de l’obésité telles que catégorisées par les percentiles d’indice de masse corporelle. Résultats : La prévalence de la surcharge pondérale et de l’obésité dans l’échantillon total était, respectivement, de 15,3 % et 9,2 %. Des taux plus élevés ont été observés chez les étudiants d’origine arabe, kurde et turque. Les aires sous la courbe oscillaient entre 0,8 et 0,9 pour le tour de taille, le rapport tour de taille/taille et la circonférence du cou. Les valeurs optimales moyennes ayant la sensibilité et la spécificité la plus élevée pour dépister la surcharge pondérale étaient : 72,3 cm (sensibilité 0,80 ; spécificité 0,75) pour le tour de taille, 0,46 (0,85 ; 0,70) pour le rapport tour de taille/taille et 31 cm (0,76 ; 0,76) pour la circonférence du cou. Pour l’obésité, les valeurs optimales moyennes étaient : 77 cm (0,84 ; 0,81) pour le tour de taille, 0,50 (0,84 ; 0,84) pour le rapport tour de taille/taille et 31,5 cm (0,88 ; 0,71) pour la circonférence du cou. Conclusions : Les valeurs optimales du tour de taille, du rapport tour de taille/taille et de la circonférence du cou selon le sexe et le groupe ethnique peuvent s’avérer utiles pour dépister l’adiposité. ةيترموبورثنلأا تاشرؤم عطقل لىثلما ميقلا :ينيناريلإا ينقهارلما ىدل ةنمسلاو نزولا ةدايزل مييقت يميدق اضر ،يرهاط ةبوذمج ،يمتسر هداز نسح ءارهز ،نياويرش ديسلا ،قلطم دممح ةصلالخا ةنمسلاو نزولا ةدايز راشتنا لدعم فلتيخو .فعضو ةوق نطاوم اهعيملج ناكو ؛ةنمسلاو نزولا ةدايز ريدقتل بسانلما فلتمخ تمدختسا :ةيفللخا .قرعلا فلاتخاب ةلتك بَسِْنلم ةقوثوم لئادبك ةبقرلا طيمحو لوطلا لىإ صرلخا ةبسنو كرولا لىإ صرلخا ةبسنو صرلخا طيمح مادختسا ةساردلا هذه تميق :فادهلأا .ةفلتخلما ةيقرعلا تاعومجلما في َلثُلما لْصَفلا مَيِق لع فرعتلا مت ماك ،ةنمسلاو نزولا ةدايز ي ِّرحتل مسلجا مهرماعأ حواترت نيذلا ينقهارلما تلوانتو 2016 طابش/ريابرف لىإ 2015 ماع نياثلا نيشرت/برمفون نم ةساردلا تيرجأ دقو :ثحبلا قرط كترلاو ينيشولبلاو ينيناتسيسلاو دركلاو برعلا نم مهف :ةيملاسلإا ناريإ ةيروهجم في )ةينثإ( ةيقرع تاعوممج 5 لىإ نومتنيو ةنس 14-12 ينب ينقلتلما في ةلماعلا صئاصخلل تاينحنم مسر متو .اًبلاط 2444 رايتخلا لحارلما ةددعتلما ةيقبطلا تانيعلا ذخأ ةساردلا تمدختساو .نماكترلاو بسح تائف لىإ اهميسقتب ةنمسلاو نزولا ةدايزل بِسانم اهرابتعاب ةبقرلا طيمحو لوطلا لىإ صرلخا ةبسنو كرولا لىإ صرلخا ةبسنو صرلخا طيمح مييقتل Book 24-10.indb 984 12/17/2018 2:22:07 PM Research article 985 EMHJ – Vol. 24 No. 10 – 2018 References 1. 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J Sci Med Sport. 2009 Jul;12(4):449–51. https://doi.org/10.1016/j.jsams.2008.05.002 PMID:18768363 34. Ashwell M, Gunn P, Gibson S. Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis. Obes Rev. 2012 Mar;13(3):275–86. https://doi.org/10.1111/j.1467- 789X.2011.00952.x PMID:22106927 35. Mazıcıoğlu MM, Hatipoğlu N, Oztürk A, Ciçek B, Ustünbaş HB, Kurtoğlu S. Waist circumference and mid-upper arm circumfer- ence in evaluation of obesity in children aged between 6 and 17 years. J Clin Res Pediatr Endocrinol. 2010;2(4):144–50. https://doi. org/10.4274/jcrpe.v2i4.144 PMID:21274313 36. Reilly JJ, Dorosty AR, Ghomizadeh NM, Sherriff A, Wells JC, Ness AR. Comparison of waist circumference percentiles versus body mass index percentiles for diagnosis of obesity in a large cohort of children. Int J Pediatr Obes. 2010 Apr;5(2):151–6. https:// doi.org/10.3109/17477160903159440 PMID:19657861. 37. Glässer N, Zellner K, Kromeyer-Hauschild K. Validity of body mass index and waist circumference to detect excess fat mass in children aged 7-14 years. Eur J Clin Nutr. 2011 Feb;65(2):151–9. https://doi.org/10.1038/ejcn.2010.245 PMID:21048772 38. Hosseini M, Amirkhani MA, Mansourian M, Ziaoddini H, Ardalan G, Poursafa P, et al. Risk scoring system for prediction of abdominal obesity in a national sample of youths: CASPIAN Study. ARYA Atherosclerosis J. 2009;5(2):85–8. 39. Maffeis C, Banzato C, Talamini G; Obesity Study Group of the Italian Society of Pediatric Endocrinology and Diabetology. Waist- to-height ratio, a useful index to identify high metabolic risk in overweight children. J Pediatr. 2008 Feb;152(2):207–13. https://doi. org/10.1016/j.jpeds.2007.09.021 PMID:18206690 40. Chen B, Li HF. Waist circumference as an indicator of high blood pressure in preschool obese children. Asia Pac J Clin Nutr. 2011;20(4):557–62. PMID:22094841 Book 24-10.indb 986 12/17/2018 2:22:07 PM Research article 987 EMHJ – Vol. 24 No. 10 – 2018 41. Hatipoglu N, Mazicioglu MM, Kurtoglu S, Kendirci M. Neck circumference: an additional tool of screening overweight and obesity in childhood. Eur J Pediatr. 2010 Jun;169(6):733–9. https://doi.org/10.1007/s00431-009-1104-z PMID:19936785 42. Mushtaq MUGS, Gull S, Abdullah HM, Shahid U, Shad MA, Akram J. Waist circumference, waist-hip ratio and waist-height ratio percentiles and central obesity among Pakistani children aged five to twelve years. BMC Pediatr. 2011 11 21;11(1):105. https://doi. org/10.1186/1471-2431-11-105 PMID:22104025 43. Coutinho CA, Longui CA, Monte O, Conde W, Kochi C. Measurement of neck circumference and its correlation with body composition in a sample of students in São Paulo, Brazil. Horm Res Paediatr. 2014;82(3):179–86. https://doi.org/10.1159/000364823 PMID:25138376 Book 24-10.indb 987 12/17/2018 2:22:07 PM EMHJ – Vol. 24 No. 10 – 2018Research article 988 Estimation du coût de la prise en charge du cancer broncho‐pulmonaire en Tunisie Chahida Harizi,1,2 Hedia Bellali,1,2 Aicha Hchaichi,1 Agnès Hamzaoui 3 et Mohamed Kouni Chahed 1,2 1Service d’Épidémiologie et de Statistique, Hôpital Mami, Ariana (Tunisie) (Correspondance à : adresser à C. Harizi : chahidaharizi@hotmail. fr). 2Département d’Épidémiologie et de Médecine préventive, Faculté de Médecine de Tunis, Université de Tunis El Manar (Tunisie). 3Service de pneumologie, Pavillon B, Hôpital Mami, Ariana (Tunisie). Introduction Selon les données du registre des cancers du Nord de la Tunisie, le cancer broncho‐pulmonaire (CBP) est le premier cancer de l’homme. Il représente 25 % des cancers chez l'homme, et le nombre annuel de nouveaux cas de cancer broncho‐pulmonaire pendant la période 2009‐2013 a été estimé à 2000 en moyenne. Ce chiffre correspond à un taux d’incidence standardisé de 38 cas pour 100 000 habitants. Selon les projections du registre des cancers du Nord de la Tunisie, ce nombre passerait à 3800 et l’incidence standardisée serait de 46 pour 100 000 habitants durant la période 2019‐2024 (1). Le tabagisme, principal facteur de risque du CBP, reste encore très fréquent en Tunisie avec une prévalence de 50 % chez les hommes de plus de 25 ans (2), ce qui indique que l’épidémie nous menace avec une augmentation sans cesse croissante du nombre de cancers bronchiques dans les prochaines décennies. De par sa fréquence, le CBP est considéré comme grave, avec une proportion d’extension à distance de l’ordre de 40 % et un taux de survie à 1 an estimé à 15 % (3). Le diagnostic et la prise en charge précoces constituent les principales méthodes pour améliorer la qualité de vie et allonger la durée de survie des patients, d’autant plus qu’aucun moyen de dépistage efficace et spécifique n’est disponible. Les évolutions thérapeutiques du CBP, et notamment la place prépondérante de la chimiothérapie, ont eu un impact majeur sur l’évolution rapide des coûts de prise en charge, et la maîtrise des dépenses engendrées par le CBP devient un enjeu majeur pour les systèmes de santé. Ainsi, l’évaluation médico‐économique des thérapeutiques et des stratégies médicales devient indispensable dans les maladies chroniques nécessitant des prises en charge coûteuses pour une efficacité modeste, comme les cancers broncho‐pulmonaires (4). Très peu d’études sur le coût de la prise en charge du CBP ont été menées dans les pays en développement et au Moyen‐Orient. En Tunisie, en raison des contraintes budgétaires auxquelles fait face notre système de soins, l’analyse de la charge économique de la prise en charge du CBP s’avère indispensable. L’ objectif de notre étude était d’estimer les coûts directs de la prise en charge du CBP et d’identifier les postes de dépenses les plus importants. Méthodes Type d’étude Il s’agit d’une étude descriptive rétrospective, réalisée au niveau de l’hôpital Abderrahmane Mami de l’Ariana durant l’année 2012 et couvrant la période hospitalière comprise entre juin 2008 et juin 2010. Résumé Contexte : le cancer broncho‐pulmonaire (CBP) constitue un fardeau en termes de dépenses de santé. Objectifs : L’objectif de ce travail était d’estimer les coûts directs de la prise en charge du CBP en Tunisie et d’identifier les postes des dépenses les plus importants. Méthodes : Une étude descriptive rétrospective couvrant une période de deux ans (juin 2008 à juin 2010) a été réalisée en 2012. La méthode de tarification hospitalière a été utilisée pour estimer le coût direct de la prise en charge du CBP. Résultats : Parmi les 549 patients colligés, 60 % étaient diagnostiqués au stade T4 et 59 % au stade M1. La chirurgie était appliquée dans 26,3 % des cas et la chimiothérapie dans 44,1 % des cas. Le coût direct moyen de la prise en charge du CBP était estimé à TND 3900 (USD 1980) par patient. Conclusion : La chimiothérapie représentait le poste de dépense le plus important avec 46 %, suivie du coût du séjour hospitalier. Une prévention primaire, s’appuyant sur l’application des politiques de lutte antitabac, constitue la meilleure stratégie pour réduire cette morbidité. Mots clés : prise en charge, cancer, broncho‐pulmonaire, Tunisie, prévention, dépenses, santé, tarification, hospitalière Citation : Harizi C; Bellali H; Hchaichi A; Hamzaoui A; Chahed K. Estimation du coût de la prise en charge du cancer broncho‐pulmonaire en Tunisie. East Mediterr Health J. 2018;24(10):988-993. https://doi.org/10.26719/2018.24.10.988 Reçu : 10/09/15 ; accepté : 20/11/17 © Organisation mondiale de la Santé 2018. Certains droits réservés. La présente publication est disponible sous la licence Creative Commons Attribution – Pas d’utilisation commerciale – Partage dans les mêmes conditions 3.0 IGO (CC BY-NC–SA 3.0 IGO ; (https://creativecommons.org/ licenses/by–nc–sa/3.0/igo). Book 24-10.indb 988 12/17/2018 2:22:07 PM Research article 989 EMHJ – Vol. 24 No. 10 – 2018 Patients étudiés Tous les patients admis pour cancer broncho‐pulmonaire dans l’un des services hospitaliers de l’hôpital Abderrahmane Mami de l’Ariana durant la période de l’étude ont été inclus. Données recueillies Un canevas de collecte des données a été utilisé pour relever, à partir des dossiers médicaux, des informations concernant les caractéristiques socio‐démographiques des patients, les facteurs de risque, les circonstances ayant conduit à l’hospitalisation, la symptomatologie et les données de l’examen clinique, les explorations diagnostiques, les indications thérapeutiques de prise en charge, l’évolution et l’issue finale. Ce canevas a également permis de collecter des données concernant les aspects relatifs aux coûts de la prise en charge en mentionnant la nature et le nombre de tous les actes et examens complémentaires (biologie, imagerie, autres techniques) qui ont servi pour établir le diagnostic, le bilan préopératoire, le suivi postopératoire, le protocole de chimiothérapie, les séances de radiothérapie qui figurent dans le dossier, même si ces examens ont été pratiqués dans un autre hôpital. Calcul des coûts Le coût direct médical est égal à la somme des frais des différents postes de consommation (hôtellerie, examens biologiques, imagerie, chimiothérapie, chirurgie et radiothérapie). En ce qui concerne les frais hôteliers d’hospitalisation, une journée d’hospitalisation coûte 40 dinars tunisiens (USD 28,47) dans les services de chirurgie et 30 dinars (USD 21,35) dans les services de médecine, en prenant un taux de change moyen d’un dollar US (USD) pour 1,4 dinar pendant la période de l’étude. Le coût de cette journée d’hospitalisation est un coût macroéconomique qui englobe les frais hôteliers proprement dits, ainsi que ceux du personnel et des médicaments non spécifiques. Le calcul des coûts était basé sur la nomenclature des actes professionnels du ministère de la Santé publique et sur les tarifs fixés par les ministères des finances et de la santé publique pour la prise en charge des malades dans les structures sanitaires publiques (5-7). Ainsi, le coût de prise en charge du CBP a été estimé pour chaque patient en multipliant le volume de consommation de soins de chaque composante de prise en charge par les coûts unitaires correspondants. Un taux d’actualisation annuel de 3 % (8) a été considéré pour actualiser les coûts en utilisant la formule citée ci‐dessous : V(n) = V(0) x (1 + i)^n où · V(0) est la valeur actuelle du flux · V(n) est la valeur du flux à l’année n · i est le taux d’actualisation · n est le temps, exprimé en nombre d’années, de la date de V(0) à la date de V(n). Analyse des données La saisie des données ainsi que leur exploitation statistique ont été effectuées avec le logiciel SPSS (version 17.0). L’analyse descriptive comporte le calcul des fréquences pour les variables qualitatives ainsi que le calcul des moyennes et écarts types pour les variables quantitatives. Résultats Caractéristiques socio-démographiques Au total, 549 patients ont été inclus. L’âge moyen était de 61,45 ans (écart type [ET] 10) avec des extrêmes compris entre 21 et 91 ans. Le sexe masculin était dominant avec un sex ratio de 8,46. Près de la moitié des patients admis (65,8 %) étaient originaires du Nord‐ Est du pays. La quasi‐totalité des patients étaient des fumeurs (91,6 %) (Tableau 1). Type histologique et modalités thérapeutiques Le cancer du poumon non à petites cellules (CPNAPC) représentait le type histologique le plus fréquent avec 79,9 %, composé essentiellement par l’adénocarcinome dans 41,4 % des cas suivi du cancer épidermoïde et du cancer à grandes cellules dans 23,5 % et 14,9 % des cas, respectivement. Le cancer à petites cellules (CPAPC) ne représentait que 15,7 % des cas. La classification TNM a montré que 60 % d'entre eux étaient au stade T4 lors du diagnostic et que 59 % étaient au stade de métastase à distance (M1). Près de la moitié (47,1 %) des patients étaient traités par chimiothérapie, tandis que 26,3 % seulement étaient traités chirurgicalement et 12,8 % étaient traités par radiothérapie. Le traitement antidouleur était prescrit chez 42,6 % des patients (Tableau 2). Pour la chimiothérapie, 82 % des patients ont reçu une chimiothérapie de première ligne seulement (Figure 1). Analyse de coûts de la prise en charge Le tableau 3 résume les coûts médicaux moyens directs de la prise en charge du cancer broncho‐ pulmonaire. Le coût total de la prise en charge s'élevait à 2 141 639,5 dinars (USD 1 524 483,24) ‒ soit un coût moyen par patient de l’ordre de 3900 dinars (USD 2776,14). Quarante‐six pour cent de ce coût a été alloué à la chimiothérapie. Le total du coût pour la chimiothérapie de première ligne s'élevait à 6 0 0 1 0 5 , 6 d i n a r s ( U S D 4 2 7 1 7 3 , 1 7 ) ‒ s o i t 2372 dinars (USD 1688,46) par patient ; 42 patients ont été traités par une chimiothérapiede deuxième ligne qui a coûté 378 614,4 dinars (USD 269 509,09) ‒ soit 9015 dinars (USD 6417,15) par patient ‒ et les trois patients traités par chimiothérapie de troisième ligne ont coûté 5878 dinars (USD 4184,14) ‒ soit 1959,3 dinars (USD 1394,69) par patient. Le séjour hospitalier représente le deuxième poste de dépense avec 407 130 dinars (USD 289 807,35) ‒ soit 741,6 dinars par patient (USD 527,89/patient), suivi de Book 24-10.indb 989 12/17/2018 2:22:07 PM EMHJ – Vol. 24 No. 10 – 2018Research article 990 l’imagerie avec 352 038,5 dinars (USD 250 591,56) ‒ soit 641,2 dinars par patient (USD 456,42/patient). Discussion Cette étude est la première en Tunisie à avoir estimé le coût direct médical du cancer broncho‐pulmonaire. Elle a mis en évidence que le coût direct médical de la prise en charge était de 2 141 639,5 dinars (USD 1 524 483,24) ‒ soit un coût moyen par patient de l’ordre de 3900 dinars (USD 2776,14). Ce coût est considéré comme élevé pour notre système de santé qui présente plusieurs défis dans un contexte de transitions socio-économique, démographique et épidémiologique ; en effet, ce coût excède celui de la prise en charge du cancer du col de l’utérus en Tunisie en 2003 estimé, après actualisation des coûts, à 3797 [ET 1661] dinars (USD 2711 [ET 1186]) (9) et celui de la prise en charge de l’infarctus du myocarde en phase aiguë estimé, après actualisation des coûts, à 2670 dinars (USD 1906,4) (10). Ce coût relativement élevé de la prise en charge du cancer broncho‐pulmonaire pourrait être expliqué par le diagnostic tardif effectué. En effet, 60 % de nos patients étaient diagnostiqués au stade T4 et 59 % au stade de métastase M1 ; seulement 26,3 % parmi eux avaient subi un traitement chirurgical. Et ceci à l’échelle nationale, tandis qu’à l’échelle internationale les choses sont un peu différentes. En effet, la variabilité des méthodes utilisées par les différentes études internationales menées à ce sujet, la diversité des modes d’évaluation économique selon les pays et la différence des prix rendent la comparaison des coûts de prise en charge de cette maladie difficile. Tableau 2 Répartition des patients selon le type histologique et les modalités thérapeutiques n % Type histologique Adénocarcinome 206 41,4 Épidermoïde 117 23,5 Autre 175 35,1 Métastase Oui 251 52,3 Non 172 40,7 Traitement chirurgical Oui 127 26,3 Non 355 73,7 Chimiothérapie Oui 253 47,1 Non 284 52,9 Radiothérapie Oui 61 12,8 Non 414 87,2 Traitement antidouleur Oui 202 42,6 Non 273 57,4 Tableau 1 Caractéristiques socio-démographiques de la population d’étude (n = 549) Caractéristiques n % Âge < 60 ans 259 47,7 ≥ 60 ans 284 52,3 Sexe Hommes 489 89,4 Femmes 58 10,6 Origine Nord-Est 345 65,8 Nord-Ouest 99 18,9 Centre 24 4,6 Sud 56 10,7 Situation de travail En activité / en formation 36 10,9 Au chômage 295 89,1 Sécurité sociale Oui 444 92 ,9 Non 34 7,1 Tabac Oui 500 91,6 Non 46 8,4 Figure 1 Lignes de chimiothérapie administrées à la population d’étude Chimiothérapie de 1re ligne Chimiothérapie de 2e ligne Chimiothérapie de 3e ligne Book 24-10.indb 990 12/17/2018 2:22:07 PM Research article 991 EMHJ – Vol. 24 No. 10 – 2018 En Espagne, Corral et al. (11) ont estimé le coût global à EUR 13 218 (28 550 dinars) pour le CBNPC stade III et à EUR 16 120 (34 819 dinars) pour le CBNPC stade II, alors que Kang et al. ont estimé le coût total de prise en charge du CBNPC à Sydney (Australie) à AUD 10 975 (21 654 dinars) et celui du CBPC à AUD 14 799 (29 198 dinars) (12). Aux Pays‐Bas, le coût total du traitement par patient par an était de EUR 33 143 (71 588 dinars) (13), et en Chine, il était de USD 11 566 (22 819 dinars) (14). Ainsi, on remarque que le coût de la prise en charge du cancer bronchique était plus important que les chiffres tunisiens. Ceci peut être expliqué par la comptabilisation dans les études internationales des dépenses indirectes qui augmentent le coût de façon importante, contrairement à ce qui a été fait dans notre étude, où on s’est limité à l’utilisation de la méthode des coûts directs compte tenu des contraintes méthodologiques liées à l’utilisation du coût indirect. En fait, les coûts calculés ne concernent que les dépenses liées aux actes diagnostiques et thérapeutiques. Or les composantes du coût de la prise en charge du cancer sont multiples et comprennent plus largement l’impact de la maladie sur la vie des personnes (années potentielles de vie perdues), le coût des soins en établissement de santé et en ambulatoire, la perte de productivité du fait de l’arrêt de travail pour maladie et/ou de la mortalité, le coût de la politique de prévention primaire participant à la lutte contre le cancer, le coût du dépistage organisé et enfin le coût de la recherche scientifique (15). D’autre part, la plupart des études internationales ont inclus le coût relatif au personnel médical, paramédical et aux soins infirmiers des patients. C’est ainsi que Billingham et al. (16) et van der Linden (13) ont inclus le coût du personnel médical et des visites médicales à domicile dans le calcul du coût de la prise en charge du cancer bronchique, contrairement à notre étude où on a adopté la méthodologie de la tarification hospitalière qui ne donne qu’une estimation approximative des coûts réels souvent très difficiles à reconstituer (17), ce qui a sous‐estimé le coût de la prise en charge, notamment par comparaison avec le secteur privé où la comptabilisation des coûts se fait de façon plus détaillée et en comptabilisant le coût du personnel médical et paramédical à part. Ce coût de prise en charge du CBP qu’on a calculé était aussi relativement plus faible par rapport à celui calculé dans quelques pays en développement tels que le Maroc, où une étude similaire faite en 2010 a estimé le coût direct médical d’un patient atteint du cancer du poumon durant la première année suivant son diagnostic à 35 364 dirhams marocains par an (7064 dinars) (18). Ceci peut être dû à l’approche adoptée par notre hôpital concernant la prise en charge du CBP, où au moins un quart de nos patients passe par un personnel multidisciplinaire d’oncologie assurant une prise en charge rationnelle avec une réduction des coûts. Cette étude marocaine a montré aussi que les traitements occupent 88 % des dépenses, suivis du coût de la surveillance (8 %) et du coût du diagnostic (4 %). La répartition du coût en fonction des moyens thérapeutiques montre que, contrairement à notre étude, la radiothérapie à elle seule représente 68 % de l’ensemble du coût des traitements alors que la chimiothérapie ne représente que 20 % du coût thérapeutique. Notre étude a quelques limites qui méritent d’être mentionnées. D’abord, il se peut que certaines explorations ne soient pas prises en compte dans notre étude, ce qui pourrait sous‐estimer le coût de prise en charge du CBP puisque la collecte des données a été faite de façon rétrospective à partir des dossiers des malades. Cependant, cela n’affecte pas nos conclusions de façon remarquable du moment où on utilise ces dossiers médicaux dans notre système de tarification. Ainsi, tous les explorations complémentaires sont gardées dans le dossier pour être comptabilisées par la suite à la sortie du malade afin d’effectuer une facture de sortie. Ensuite, le calcul des coûts des séjours souffre de certaines insuffisances liées essentiellement à la détermination des frais fixes (tarifs hôteliers). Il est évident que ces tarifs fixes ne constituent qu’une estimation moyenne et que des différences flagrantes doivent exister selon les différents services d’hospitalisation. En effet, ces tarifs hôteliers d’hospitalisation qui ont été fixés par la nomenclature hospitalière n’ont pas été révisés depuis longtemps, alors que l’inflation a touché tous les autres secteurs de l’économie ; ils seraient alors sous-estimés. Cependant, il n’a pas été possible dans ce travail de calculer les coûts en utilisant la comptabilité analytique à cause du type rétrospectif de l’étude. Ainsi, les informations indispensables pour utiliser cette méthode, telle que la charge du travail du personnel, ne figurent pas dans les dossiers des patients. Pour ce qui est du coût des actes médico‐chirurgicaux et des médicaments, cela ne nous a pas posé de problème puisque nous avons utilisé les tarifs unitaires actualisés pour chaque catégorie. Tableau 3 Coût direct de la prise en charge du cancer broncho‐pulmonaire par poste de dépense Poste de dépense Coût (TND) % Séjour hospitalier 407 130,0 19,0 Chimiothérapie 984 598,0 46,0 de 1re ligne 600 105,6 60,9 de 2e ligne 378 614,4 38,5 de 3e ligne 5878,0 0,6 Explorations biologiques 220 756,0 10,3 Imagerie 352 038,5 16,4 Chirurgie 52 215,0 2,4 Radiothérapie 79 200,0 3,8 Autres explorations 45 702,0 2,1 Total 2 141 639,5 100 TND : dinar tunisien. Book 24-10.indb 991 12/17/2018 2:22:07 PM EMHJ – Vol. 24 No. 10 – 2018Research article 992 Conclusion Cette étude a eu le mérite de fournir des données objectives actualisées sur le coût direct de la prise en charge du CBP à l’hôpital de l’Ariana dans un contexte d’explosion des coûts liée à une indication de plus en plus large de la chimiothérapie dans le traitement du CBP. Ce travail constituerait une bonne base pour insérer dorénavant les considérations économiques dans le débat sur la stratégie de prévention du CBP, qui doit se faire dans le cadre d’une réflexion approfondie sur les perspectives de prévention et d’amélioration de la prise en charge d’une morbidité appelée à devenir de plus en plus fréquente dans notre pays à l’avenir. Financement : Aucun. Conflit d’intérêt : Les auteurs déclarent ne pas avoir de conflit d’intérêt en relation avec cet article. Cost estimation of medical care management of lung cancer in Tunisia Abstract Background: Lung cancer management is very expensive for the Tunisian healthcare system. Aim: The aim of this study was to evaluate the direct costs of treating lung cancer in Tunisia, and to identify the main treatment of high expenditure. Methods: A retrospective study was conducted in 2012 including all patients admitted between 2008 and 2010 for lung cancer management. The hospital payment system was used to estimate the direct costs of the medical care management of lung cancer. Results: We collected 549 patients and the majority of patients were diagnosed with advanced stages of the disease: 60 % in stage T4 and 59 % in stage M1. 26 % of patients underwent surgery and 44.1 % chemotherapy. The total direct costs of lung cancer management were estimated to be TND 3900 (US$ 1980) per patient. Conclusions: Chemotherapy accounted for the largest percentage of direct costs (46 %) followed by the cost of the hospital stay. Primary prevention, based on the application of policies to control tobacco, is the best strategy to reduce this morbidity. سنوت في ةئرلا ناطسرل ةيبطلا ةياعرلا فيلاكت ريدقت دهاشلا دممح ،يوازحم ساينا ،شيياشح ةشئاع ،ليلاب ةيده ،يزيرح ةدهاش ةصلالخا .سنوت في ةيحصلا ةياعرلا ماظنل ًادج فلكم ةئرلا ناطسر جلاع نإ :ةيفللخا .تاقفنلا عفترلما سييئرلا جلاعلا ديدتحو ،سنوت في ةئرلا ناطسر جلاعل ةشرابلما فيلاكتلا مييقت ةساردلا هذه نم فدلها ناك :فدلها جلاع لجأ نم 2010و 2008 يماع ينب ىفشتسملل ملهاخدإ مت نيذلا ضىرلما عيجم تلمش ،2012 ماع في ةيداعتسا ةسارد تيرجأ :ثحبلا قرط .ةئرلا ناطسرل ةيبطلا ةياعرلاو جلاعلل ةشرابلما فيلاكتلا ريدقتل ىفشتسلما في عفدلا ماظن مادختسا مت .ةئرلا ناطسر في %59 ،)T4( ةلحرلما في مهنم %60 :ضرلما نم ةمدقتم لحارمب مهتباصإ صيخشت مت دق مهمظعم ناك ،اًضيرم 549 ةساردلا تمض :جئاتنلا 3900 ـب ةئرلا ناطسر جلاعل ةشرابلما فيلاكتلا عوممج ر ِّدُق دقو .ةيئايميك ةلجاعم 44.15 ىقلتو ،ةحارجلل مهنم %26 عضخ ماك .)M1( ةلحرلما .دحاولا ضيرملل )اًيكيرمأ اًرلاود 1980 لداعي امم( سينوت رانيد ةيلولأا ةياقولا برتعتو .ىفشتسلما في ةماقلإا فيلاكت هولتي )%46( ةشرابلما فيلاكتلا نم ةيوئم ةبسن بركأ لثمي يئايميكلا جلاعلا نإ :تاجاتنتسلاا .ضرلما اذه ةأطو نم فيفختلل ةيجيتاترسا لضفأ غبتلا ةحفاكم تاسايس قيبطت لىإ دنتست يتلا Références 1. Registre des cancers Nord-Tunisie : données 1999-2003, évolution 1994-2003, Projections à l’horizon 2024. Tunis : Ministère de la Santé Publique, Institut Salah Azaiez, Institut National de la Santé Publique, Ministère de l’Enseignement Supérieur, de la Recherche Scientifique et de la Technologie, 2003. 2. Fakhfakh R, Hsairi M, Maalej M, Achour N, Nacef T. Tobacco use in Tunisia: behaviour and awareness. Bull. World Health Organ. 2002;80(5):350-6. PMID:12077609 3. McWilliams A, Lam B, Sutedja T. Early proximal lung cancer diagnosis and treatment. Eur Respir J. 2009 Mar;33(3):656-65. https://doi.org/ 10.1183/09031936.00124608 PMID:19251801 Book 24-10.indb 992 12/17/2018 2:22:07 PM Research article 993 EMHJ – Vol. 24 No. 10 – 2018 4. Vergnenègre A, Chouaïd C, Lafuma A. L’évaluation médico-économique des cancers bronchiques. Approche théorique et applications pratiques. Rev Mal Respir. 1998 Sep;15(4):469-78. PMID:9805757 5. Arrêté des Ministres des Finances et de la Santé publique du 19 décembre 1996, fixant les tarifs de la prise en charge des malades payants dans les structures sanitaires publiques relevant du ministère de la santé publique. Journal Officiel de la République Tunisienne. 1996;104:2253-5 (http://www.cnudst.rnrt.tn/jortsrc/1996/1996f/jo10496.pdf, consulté le 14 avril 2018) 6. Ministère de la Santé publique, Pharmacie Centrale de Tunisie. Tarif des spécialités. Prix hôpitaux. Tunis, 2010 (données non publiables). 7. Arrêté du Ministre de la Santé publique du 1er juin 2006, fixant la nomenclature générale des actes professionnels des médecins, biologistes, médecins dentistes, psychologues cliniciens, sages–femmes et auxiliaires médicaux. Journal Officiel de la République Tunisienne. 2006;46:1514-7 (http://www.legislation.tn/sites/default/files/fraction-journal-officiel/2006/2006F/046/ TF20062734.pdf, consulté le 7 mai 2018). 8. Fireman BH, Quesenberry CP, Somkin CP, Jacobson AS, Baer D, West D, et al. Cost of Care for Cancer in a Health Maintenance Organization. Health Care Financ Rev. 1997 Summer;18(4):51–76. PMID:10175613 9. Ben Gobrane H, Aounallah–Skhiri H, Oueslati F, Frikha H, Achour N, Hsairi M. Estimation du coût de la prise en charge du cancer invasif du col de l’utérus en Tunisie. Santé Publique. 2009; 6(21): 561–9. https:/doi.org/10.3917/spub.096.0561 10. Aounallah–Skhiri H, Ben Abdelkrim I, Ouldezein H, Arfa C, Ben Romdhane H, Kafsi MN, et al. Coût direct médical de la prise en charge de l’infarctus du myocarde en phase aiguë. Tunis Med. 2005; 83 Suppl 5: 24–9 11. Corral J, Alfons Espinàs J, Cots F, Pareja L, Solà J, Font R, et al. Estimation of lung cancer diagnosis and treatment costs based on a patient–level analysis in Catalonia (Spain). BMC Health Serv Res. 2015; 15:70. https://doi.org/10.1186/s12913–015–0725–3 PMID:25889153 12. Kang S, Koh E–S,Vinod SK, Jalaludin B. Cost analysis of lung cancer management in South Western Sydney. J Med Imaging Radiat Oncol. 2012; 56(2):235–41 . https://doi.org/10.1111/j.1754–9485.2012.02354.x 13. van der Linden N, Bongers ML, Coupé VMH, Smit EF, Groen HJM, Welling A, et al. Costs of non–small cell lung cancer in the Netherlands. Lung Cancer. 2016; 91:79–88. https://doi.org/10.1016/j.lungcan.2015.10.015 14. Zeng X, Karnon J, Wang S, Wu B, Wan X, Peng L. The Cost of Treating Advanced Non–Small Cell Lung Cancer: Estimates from the Chinese Experience. PLoS ONE. 2012;7(10) :e48323. https://doi.org/10.1371/journal.pone.0048323 PMID:23118985 15. Amalric F. Analyse économique des coûts du cancer en France. Impact sur la qualité de vie, prévention, dépistage, soins, recherche. Boulogne–Bilancourt : Institut National du Cancer, 2007. 142 p. (Collection « ÉTUDES ET EXPERTISES »). 16. Billingham LJ, Bathers S, Burton A, Bryan S, Cullen MH. Patterns, costs and cost–effectiveness of care in a trial of chemotherapy for advanced non–small cell lung cancer. Lung cancer. 2002 Aug;37(2):219–25. https://doi.org/10.1016/S0169– 5002(02)00042–9 PMID:12140146 17. Vergnenègre A, Atsou K, Chouaïd C. Pharmacoéconomie pour le pneumologue. EMC – Pneumologie. 2010;1–15 [Article 6–000– P–36]. https://doi.org/10.1016/S1155–195X(10)52382–X 18. Amadou MD. Étude économique des cancers au Maroc : Estimation à partir des référentiels internationaux [thèse]. Fès, Université Sidi Mohammed Ben Abdellah, Faculté de Médecine et de Pharmacie, 2010. Book 24-10.indb 993 12/17/2018 2:22:07 PM EMHJ – Vol. 24 No. 10 – 2018Research article 994 Customary practices, domestic violence, and psychosomatic pain among adolescent mothers in Turkey Yasin Bez,1 Cem Uysal,2 Mahmut Bulut,3 Mehmet Kaya,3 Neval Goruk,4 Suleyman Demir 3 and Aytekin Sir 3 1Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, United States of America (Correspond- ence to: Y. Bez: yasinbez@gmail.com). 2Department of Forensic Medicine. 3Department of Psychiatry, Dicle University School of Medicine, Diyarbakır, Turkey. 4Department of Obstetrics and Gynecology, Memorial Diyarbakır Hospital, Diyarbakır, Turkey. Introduction The World Health Organization (WHO) estimates that 10% of all births worldwide each year are by adolescents aged 15–19 years (1,2). In recent years there has been a growing scientific interest in adolescent pregnancy, which can be defined as pregnancy in girls aged 10–19 years (1,3). Some factors like declining age at menarche, growing independence from parents, premarital sexual relations, and customs that promote marriage in adoles- cence have led to an increase in adolescent pregnancy in many countries (1,4). Furthermore, it is known that fertil- ity in adolescents rapidly increases with age and reaches up to 13% by 19 years (3,5). Since many adolescents are sexually active, voluntary or involuntary pregnancies may occur. Compared to other age groups, adolescent pregnancy and delivery may carry a high risk for mothers and their children, including increased miscarriage, low birth weight, and maternal and infant morbidity and mortality rates (1,2,6–11). Besides health problems, many social problems like lower levels of education, unemployment, financial dependence, domestic violence and child abuse may be seen among women married in adolescence (6,12–15). Moreover, the majority of these factors are known to be associated with psychological problems, including psychosomatic symptoms that are characterized with by unexplained bodily pains (16). Therefore, one may expect higher rates of psychosomatic pain. In the present study, we aimed to determine the demographic characteristics of adolescent mothers; social, cultural and personal factors that were related to their marriages; history of domestic violence before and after their marriages; age at first pregnancy; number of miscarriages; and whether they suffered from any kind of psychosomatic pain. Methods Study design This was a case–control study. Approximately 700 wom- en gave their first birth in a 3-month period in the city of Diyarbakir, Turkey in 2010. The rate of adolescent moth- erhood was reported to be 32% among married women in the same geographical area (17). By using the formula at http://www.raosoft.com/samplesize.html, the sample size calculation yielded a sample of 227 study cases with a 5% error margin and 95% confidence level. After obtain- ing the necessary approvals from the Dicle University Ethics Committee the study was conducted between Feb- Abstract Background: Adolescent motherhood is present in many societies worldwide, including Turkey. Aims: We aimed to determine the demographical and cultural characteristics of adolescent mothers, lifetime domestic violence and history of miscarriage, and whether they suffer from any kind of medically unexplained (psychosomatic) pain in a study in south-eastern Turkey. Methods: We included 501 mothers in this case–control study. The study group comprised 228 mothers who gave their first deliveries at or before 19 years of age, and the control group consisted of 273 mothers who first delivered after 19 years of age. The case–control study was conducted between February and April 2013 in Diyarbakir, Turkey. Results: Adolescent mothers marry more frequently with their relatives. They have a higher prevalence of culture-bound customary applications such as bride price. They are less likely to be asked for their consent to marry and tend to have more children. They are more frequently victims of domestic violence and more often report medically unexplained psy- chosomatic pain. Conclusions: Adolescent motherhood is still a public health problem that seems to be related to certain culture-bound customary practices, continuing domestic violence across generations, increased number of children, and more prevalent psychosomatic pain. Keywords: adolescent motherhood, cultural customs, cultural factors, domestic violence, psychosomatic pain Citation: Bez Y; Uysal C; Bulut M; Kaya M; Goruk N; Demir S; Sir A. Customary practices, domestic violence, and psychosomatic pain among adoles- cent mothers in Turkey. East Mediterr Health J. 2018;24(10):994–1001. https://doi.org/10.26719/2018.24.10.994 Received: 03/01/16; accepted: 03/08/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Book 24-10.indb 994 12/17/2018 2:22:07 PM Research article 995 EMHJ – Vol. 24 No. 10 – 2018 ruary and April 2013 in Diyarbakir. A total of 501 women were enrolled from two sources: (1) women who attended the obstetrics and gynaecology hospital for their preg- nancy and had had their first delivery at ≤ 19 years of age and agreed to participate in the study; and (2) women who were enrolled in an epidemiological study recently conducted by the authors. The case group comprised 228 women who gave their first birth at age ≤ 19 years (adoles- cent mothers) and the control group comprised 273 wom- en who delivered their first baby after 19 years of age. Interview All participants were interviewed face-to-face using a semistructured interview form prepared by the authors. To determine the topics to be assessed in this form, Y.B., C.U. and M.C.K. thoroughly searched the available liter- ature using the following keywords “domestic violence”, “customary practice, “psychosomatic pain”, “bodily pain”, “culture”, “abuse”, “bride price”, “berdel”, and “miscar- riage” in combination with “adolescent motherhood”, “adolescent mother”, “early age marriage”, “adolescent marriage”, and “childhood marriage”. Available literature published in English and Turkish languages by the end of November 2012 were selected by their relevance. An expert panel, including two adult psychiatrists (Y.B. and M.C.K.), a forensic medicine physician (C.U.), and an ob- stetrics and gynaecology physician (N.Y.G.), reviewed the selected literature in an 8-hour meeting and created 65 questions in the light of it. Fifty nonleading, nonchal- lenging and noncriticizing questions (24 open ended, 17 yes or no, and 9 multiple choice) that intended to obtain answers to the study questions were selected by the ex- pert panel in a second meeting. A second group of experts (A.S., M.B., S.D., Y.B., C.U. and M.C.K) critically reviewed the questions in terms of their structure and created the final versions. All questions were simple, clear, free of jar- gon, easy to ask, and time framed. A standardized form was created and tested on 30 individuals to assess appli- cability. The question with the lowest response rate was the one that assessed medically unexplained (psychoso- matic) pain (83%). The overall response rate was 91.2%. All questions were asked in the same order to all participants and their answers were recorded immediately on the standardized forms. The interview form collected information about demographic variables: age at first pregnancy; number of siblings; kinship with the spouse; whether consent to marry was obtained; history of domestic violence before and after marriage (WHO operational definition of domestic violence included acts of physical, sexual and psychological abuse, and control by an intimate partner) (18); whether official and religious weddings were performed; existence of some culture-bound customary practices such as bride price and its amount, berdel (2 men from different families marry each other’s sisters without dowry or any bonnet payment), and cradle engagement; history of miscarriage; any type of current domestic violence towards children; whether she was co- wife; and existence of medically unexplained bodily pain or psychosomatic pain (pain lasting for ≥ 6 months that was sufficiently severe to cause significant distress or to interfere with normal activities in the previous year, and that could not be explained by a medical condition or substance use/abuse) (19). Statistical analysis Statistical analysis was performed using SPSS version 18.0 (Chicago, IL, USA). Descriptive variables are present- ed as frequency and within group percentage, and mean (standard deviation). Categorical variables were com- pared by χ2 test. Normality of distribution of continuous variables was tested by Kolmogorov–Smirnov test. Con- tinuous variables were compared using Student’s t test or its nonparametric equivalent (Mann–Whitney U test). Logistic regression models were tested to understand better the predictors of the current domestic violence of the participants towards their children. All descriptive data, comparisons and the best logistic regression model are presented. Ethics The study was approved by the local Ethics Committee and was conducted in accordance with the ethical stand- ards laid down in the 1964 Declaration of Helsinki and its later amendments. Results There were 501 women with a mean age of 29.9 (13.0) years (range 14–59 years). Mean age of the participants and their spouses at marriage were 18.6 (4.1) and 23.7 (5.0) years. Four hundred and ninety-three (98.4%) were reli- giously married while 8 (1.6%) were not. Among those re- ligiously married, 439 (89%) were legally married, while 54 (11%) were not. Three hundred and seventy-four par- ticipants (74.7%) reported that they had given consent for their marriage. Two hundred and fifty-one (50.1%) partic- ipants were persuaded to have an arranged marriage; 69 (13.8%) were forced into an arranged marriage; 111 (22.2%) were married voluntarily; and 36 (6.8%) were abducted for marriage. Thirty-six participants (7.2%) did not describe any of these types of marriage. Fifteen (3.0%) participants were co-wives. Mean age at giving first birth was 19.8 (4.3) years among the whole study participants. Among all participants, 219 (43.7%) had at least 1 lifetime miscar- riage. One hundred and twenty-nine (25.7%) participants reported that they had any kind of bodily pain that was considered to be nonorganic in etiology (medically unex- plained bodily pain or psychosomatic pain). Most marriages were based on culture-bound customary practices. Bride price was given for 120 (24%) participants and cradle engagement or berdel was performed in marriages of 26 (5.2%) participants. One hundred and twenty-three (24.5%) participants reported that they were third-degree relatives (first cousins) with their husbands. To understand better the trends in culture-bound customary marriages, similar information was collected for the parents of all participants. Among all participants, 115 women (23%) reported that their Book 24-10.indb 995 12/17/2018 2:22:07 PM EMHJ – Vol. 24 No. 10 – 2018Research article 996 parents were third-degree relatives of each other. The percentage of parents who were cousins was also high among women who were married to their cousins (40.6%, 50 out of 123). One hundred and thirteen (22.6%) participants reported domestic violence, either physical or verbal in nature, before their marriages, whereas 79 (15.8%) reported it only after marriage. Participants with domestic violence before marriage had a significantly higher frequency of domestic violence even after marriage than those who did not report violence before marriage (37.2 and 10.4%, respectively; χ2 = 40.18, P < 0.001). Three hundred and forty (67.9%) participants reported domestic violence neither before nor after marriage; 104 (20.7%) reported it either before or after marriage; and 40 (8%) reported it both before and after marriage. These three groups were asked whether they currently inflicted domestic violence on their children. The latter group reported the highest rate [35.3, 48.1 and 52.5% in order; χ2 = 8.54, degrees of freedom (df) = 2, P = 0.014]. Logistic regression models were tested to show predictors of current domestic violence against children. The best model included the following independent variables: age at marriage and first pregnancy; number of children; kinship with spouse; history of domestic violence before and after marriage; whether she was a co-wife; adolescent pregnancy; and medically unexplained bodily pain (Nagelkerke R2 = 0.13, df = 9, P < 0.001) (Table 1). According to this model having a history of domestic violence before marriage, number of children, and medically unexplained bodily pain were significant predictors of domestic violence against children. Two hundred and twenty-eight (45.5%) participants who gave their first birth at ≤ 19 years of age and those who delivered at > 19 years of age (n = 273, 54.5%) were compared in terms of study variables. Comparisons are shown in Table 2 and Table 3. Discussion Women who became mothers during adolescence face some problems in their later life. According to our results, they marry at an earlier age and more frequently with their relatives; culture-bound customary practices like bride price are more prevalent; they have more children; they are more frequently victims of domestic violence; they may live as a co-wife; and they are less likely to be asked for their consent to marry. It is important to note that they more often report medically unexplained bodily pain that may have undesired personal or familial conse- quences and increased healthcare utilization. In our study, the mean age of adolescent mothers at their first delivery was 16.3 (1.3) years, which is earlier than the age reported in previous studies (3,14). One of them reported a mean age of 17.8 (0.7) years and another 18 (1.1) years. The mean age of husbands of adolescent mothers in our study was 22.5 (4.9) years, which is also earlier than the age reported in the previous studies [26.0 (0.3) and 29.2 (4.6) years]. Therefore, our study sample may be considered as a younger population. These differences may be attributed to different geographical and cultural characteristics of the study populations, as the previous studies enrolled participants from a different geographical region of Turkey and Uganda. In a previous study, most of the women completed both religious and civil marriage rites, while only a few of them were married through either one alone, and only < 1% were out of religious or civil wedlock (20). In another study conducted in Turkey, 28.1% of the women who practiced both legal and religious marriage were under age, while underage marriage rose to 44.7% among those who were only religiously married (21). Consistent with previous studies, civil marriage was less common among adolescent mothers compared to adult mothers in our study, which may be expected since there are also legal limitations for marriage under 18 years of age in Turkey (22,23). Most mothers in our study were asked for their consent to marriage, however the ratio of consenting individuals was lower among adolescent mothers. This might have happened because parents usually do not seek the consent of their adolescent daughters before their marriages, or to the difficulties these adolescents face in making their own decision independently and expressing it to their parents. In the study by Keskinoglu et al., 945 of 8034 pregnant Table 1 Logistic regression analysis of variables associated with current domestic violence of mothers against their children B P Oddsratio 95% confidence interval Age at marriage 0.131 0.146 1.140 0.956–1.360 Age at first pregnancy −0.112 0.238 0.894 0.742–0.1.077 Number of children currently owned 0.179 0.005 1.196 1.057–1.353 Existence of kinship with the spouse 0.070 0.794 1.073 0.653–1.812 Childhood history of domestic violence 0.685 0.015 0.504 0.291–0.873 Domestic violence after marriage 0.104 0.758 1.109 0.574–2.141 Being co-wife 0.803 0.278 2.231 0.524–9.507 Adolescent pregnancy 0.590 0.149 1.804 0.810–4.018 Medically unexplained bodily pain 0.747 0.008 0.474 0.273–0.823 Book 24-10.indb 996 12/17/2018 2:22:07 PM Research article 997 EMHJ – Vol. 24 No. 10 – 2018 women who were admitted to their hospital for delivery in 2004 were adolescent mothers aged ≤ 19 years. Also, the rate of adolescent pregnancy was ~11.8% and the mean age was 18.1 years (11). In the study conducted by Sir et al., 37% of the married women reported that they married before 18 years of age and 32% had their first pregnancy before that age (17). According to our study, the age at first pregnancy was similar to that reported by Sir et al., while the mean age of marriage correlated with the study of Keskinoglu et al. Adolescent marriages in Middle Eastern countries are largely based on culture-bound practices and traditions. Examples of such marriages include bride exchange (exchange of girls between 2 families), betrothal in the cradle, and bride price paid by groom’s family to the bride’s family (5,24). In the study by Sir et al., the families of 21% of the women were reported to receive a bride price to give consent for marriage. In the same study, 7.8% of the marriages below the age of 18 years and 1.5% of those over that age were found to be made through betrothal in the Table 2 Comparison of categorical variables between mothers who have first delivery at age ≤19 years and > 19 years Mothers first delivery at age ≤ 19 years (n=228)a N (%) Mothers first delivery at age > 19 years (n=273)b N (%) χ2 P Parents are relatives Yes 90 (39.5%) 91 (33.5%) 1.94 0.163 No 138 (60.5%) 181 (66.5) Domestic violence before marriage Present 67 (35.1%) 46 (20.9%) 10.29 0.001 Not present 124 (64.9%) 174 79.1%) Religiously married Yes 223 (97.8%) 270 (99.6%) 3.46 0.098 No 5 (2.2%) 1 (0.4%) Legally married Yes 176 (77.2%) 265 (97.4%) 47.78 < 0.001 No 52 (22.8%) 7 (2.6%) Bride price Yes 79 (35%) 41 (15.2%) 26.21 < 0.001 No 147 (65%) 229 (84.8%) Consent to marry Present 150 (67%) 224 (84.5%) 20.82 < 0.001 Not present 74 (33%) 41 (15.5% Kinship with the spouse Yes 105 (46.1%) 88 (32.2%) 10.01 0.002 No 123 (54.9%) 185 (67.8%) Existence of any co-wife Yes 12 (5.7%) 3 (1.2%) 7.57 0.006 No 200 (94.3%) 254 (98.8%) History of miscarriage Yes 105 (47.7%) 114 (44.7%) 0.43 0.51 No 115 (52.3%) 141 (56.3%) Current domestic violence towards children Yes 90 (39.8%) 101 (39.1%) 0.023 0.926 No 136 (60.2%) 157 (60.9%) Medically unexplained (psychosomatic) pain Present 83 (48.3%) 46 (26.4%) 17.61 < 0.001 Not present 89 (51.7%) 128 (73.6%) aSummation of cases for each variable may be different from the total number of cases in this column (N = 228) due to missing data in some cases. Categorical comparisons were made using available data. Percentages were calculated within groups. bSummation of cases for each variable may be different from the total number of cases in this column (N = 273) due to missing data in some cases. Categorical comparisons made using available data. Percentages were calculated within groups. Book 24-10.indb 997 12/17/2018 2:22:07 PM EMHJ – Vol. 24 No. 10 – 2018Research article 998 cradle or bride exchange, and the ratio of these marriages to the total female population was 3.5% (17), which is in line with our results. Also, our results about bride price demonstrate that adolescent mothers are worth greater amounts and they more frequently become junior wives in a polygamous household. In some societies, consanguineous marriages are preferred for economic and cultural reasons (25), and they are even observed between uncles and nieces or aunts and nephews (26). In Turkey, consanguineous marriages usually occur between third-degree relatives because of legal and religious restrictions. In a study in Turkey, marriages between blood relatives were mostly observed between paternal cousins (21). In our study, 123 (24.5%) participants reported that they were third-degree relatives (first cousins) with their husbands. Thus, our study has demonstrated that the rate of consanguineous marriages is more frequent among adolescent mothers. In the study by Atuyambe et al., 24% of the adolescent mothers and 13.5% of the adult mothers were found to have experienced domestic violence from their birth families (14). Another study has pointed out that adolescent mothers are more likely to suffer from domestic violence due to significantly younger age compared to their husbands (21,27–29). Being the junior wife in a polygamous household is also one of the factors associated with facing domestic violence (21). In another study, adolescent mothers were observed to suffer mostly from domestic violence of a physical and sexual nature (30). In our study, adolescent mothers were found to be subject to greater violence both before and after their marriages. We found that history of domestic violence before marriage, increased number of children owned, and existence of medically unexplained bodily pain were significant predictors of domestic violence towards offspring. Parents who have suffered from domestic violence more frequently show violence to their offspring, which may be considered as inheritance of violence across generations. We observed greater parental violence towards children in families with a larger number of children. A negative correlation between the number of children and the socioeconomic and educational status of the family has been observed previously (29). Families with lower socioeconomic and educational status might resort to violence to set ground rules for their children or might spend less time with their children. Also, families may be overwhelmed with the higher number of children and use violence since they run out of tolerance and patience. One study found that 14.6% of the multiparous women started giving birth during adolescence, and 3.9% of these had > 3 children (11). Marriage during adolescence means early fertility and greater number of children. The number of miscarriages also increases with the number of births (17,23,25). Our study emphasizes that women who start giving birth during adolescence become more fertile in the long term. In our study, 43.7% of women had miscarriage at least once in their lives, and it reached 47.7% among adolescent mothers, which is higher than the rare miscarriage rate in the general population in Turkey (~21%). A quarter of the participants reported any kind of bodily pain that was considered nonorganic in etiology by their physicians. Although determining the type and cause of this kind of pain deserves thorough evaluation by a psychiatrist, it may be an indication of the impaired psychological well-being. The related literature reports higher levels of anxiety disorder and depression in women who became mothers during adolescence (31– 34). In our study, adolescent mothers were subjected to greater domestic violence, forced marriages, and marriages without the performance of the legal rites. These factors may explain why psychiatric disorders are more common among individuals who become mothers during adolescence. We demonstrated that mothers who complained of psychosomatic pain were more often using violence towards their children. This finding is in accordance with the literature and indicates that psychiatric disorders in one or both parents increase the risk of physical abuse (35). Despite efforts to improve legal regulations against adolescent marriage, it is still an important worldwide problem, especially in developing countries. Perhaps, Table 3 Comparison of continuous variables between mothers who have first delivery at age ≤ 19 years and > 19 years Mothers first delivery at ≤ 19 years of age (n = 228) Mean ± SD Mothers first delivery at age > 19 years (n = 273 ) Mean ± SD t or z value P Number of siblings 8.4 ± 2.8 8.13 ± 2.3 1.3 0.16 Age at marriage (years) 15.6 ± 1.6 21.1 ± 3.9 −21.1 < 0.001 Age of husband at marriage (years) 22.5 ± 4.9 24.7 ± 4.8 4.82 < 0.001 Amount of bride pricea 10.772 ± 22.69 10.346 ± 16.21 0.09 0.92 Age at first delivery (years) 16.3 ± 1.3 22.8 ± 3.6 −26.3 < 0.001 Number of childrenb 4 (2–5)c 3 (2–4)c 4.328d < 0.001 aAmount is in Turkish Lira. bMann–Whitney U test performed after Kolmogorov–Smirnov test did not prove normality of distribution. cShows median (25th–75th percentiles). dShows z value. Book 24-10.indb 998 12/17/2018 2:22:07 PM Research article 999 EMHJ – Vol. 24 No. 10 – 2018 instead of condemning or trying to forbid this tradition or suggesting punishment for those who engage in adolescent marriage, the right course of action would be to adopt socially appropriate and acceptable approaches to decrease adolescent marriages and consequent pregnancies, while providing support to individuals who have already engaged in it. This study had some limitations: (1) some of the collected data may have been affected by recall bias as they were based on interviews rather than documentation; (2) the psychological problems and their severity were not assessed using any standardized measurements; and (3) there was inadequate information about the children of the study participants. The strengths of our study included: (1) the study population was in Southeast Turkey (also known as Mesopotamia) where consanguineous and underage marriages below the age of 19 years are prevalent; and (2) the large sample size. Conclusion Our results demonstrate that adolescent marriage and motherhood continue to be serious public health prob- lems. This seems to be related to some culture-bound cus- tomary practices, continuing domestic violence across generations, increased number of children, and negative health consequences including medically unexplained bodily pain that potentially can cause increased health- care utilization. Funding: None. Competing interests: None declared Pratiques coutumières, violence domestique et douleur psychosomatique chez les mères adolescentes en Turquie Résumé Contexte : Le phénomène de la maternité adolescente existe dans de nombreuses sociétés du monde, y compris en Turquie. Objectifs : La présente étude, menée dans le sud-est de la Turquie, avait pour objectif d’identifier les caractéristiques démographiques et culturelles des mères adolescentes, d’examiner les antécédents de fausses couches et de violence domestique tout au long de la vie et de déterminer si ces mères ont souffert d’une forme quelconque de douleur (psychosomatique) médicalement inexpliquée. Méthodes : Nous avons inclus 501 mères dans cette étude cas-témoin. Le groupe d’étude comprenait 228 mères qui avaient eu leur premier accouchement à 19 ans ou avant et le groupe de contrôle comptait 273 mères qui avaient eu leur premier accouchement après 19 ans. L’étude cas-témoin a été réalisée entre février et avril 2013 à Diyarbakir en Turquie. Résultats : Les mères adolescentes se marient plus souvent avec des membres de leur parenté. Elles présentent une plus forte prévalence d’applications coutumières liées à la culture, comme la pratique du « prix de la fiancée ». Elles sont moins susceptibles de se voir demander leur consentement pour le mariage et ont tendance à avoir davantage d’enfants. Elles sont plus fréquemment victimes de violence domestique et rapportent plus souvent des douleurs psychosomatiques médicalement inexpliquées. Conclusions : La maternité adolescente représente encore un problème de santé publique. Elle semble associée à certaines pratiques coutumières liées à la culture, à une violence domestique qui se perpétue d’une génération à l’autre, à un nombre élevé d’enfants ainsi qu’à une plus forte prévalence de douleurs psychosomatiques. ايكرت في تاقهارلما تاهملأا ينب ةيدسلجا ةيسفنلا ملالآاو ،ليزنلما فنعلاو ،ةيفاقثلا تايرثأتلا يرس نكيتيا ،يرمد نمايلس ،كروج لافين ،اياك لماك دممح ،تولوب دوممح ،لاسوي ميس ،زب ينساي ةصلالخا .ايكرت كلذ في ماب ،لماعلا ءاحنأ عيجم في تاعمتجلما نم ديدعلا في تاقهارلما ينب ةموملأا دجوت :ةيفللخا ناك اذإ امو ،ضاهجلإل يبطلا خيراتلاو ،ةايلحا ىدم ليزنلما فنعلاو ،تاقهارلما تاهملأل ةيفاقثلاو ةيناكسلا صئاصلخا ديدتح لىإ انفده :فادهلأا .ايكرت قشر بونج في اهانيرجأ ةسارد في )يدسلجا سيفنلا لملأا( اًيبط هيرسفت رذعتي يذلا لملأا عاونأ نم عون يأ نم ينناعي تاقهارلما تاهملأا لبق وأ نس في ةرم لولأ ندلو نمم اًمأ 228 نم ةساردلا ةعوممج تفلأت .دهاوشلاو تلااحلل ةسارد في اًمأ 501 انتسارد تلمش :ثحبلا قرط طابش/ريابرف ينب دهاوشلاو تلاالحا ةسارد تيرجأ دقو .اًماع 19 رمع دعب ةرم لولأ ندلو اًمأ 273 نم دهاوشلا ةعوممج تفلأتو ،اًماع 19 رمع .ايكرت ،ركب رايد في 2013 ماع ناسين/ليربأو تلاماتحلاا نمو .روهلما لثم اًيفاقث ةطبترلما ةيفرعلا تاقيبطتلا راشتنا تلادعم ديزتو .نبهراقأ نم تاقهارلما تاهملأا جوزتت نأ بلغي :جئاتنلا نايحلأا نم يرثك في ّنه تاقهارلما تاهملأاو .لافطلأا نم ديزلما باجنإ لىإ ليتم يهو ،جاوزلا لع ةقهارلما سورعلا ةقفاوم بلط ثودلحا ةليلقلا .اًيبط اهريبرت رذعتي يتلا ةيسنلجا ةيسفنلا ملالآا نم نايحلأا نم يرثك في ينكتشي نأ بلغيو ليزنلما فنعلا اياحض Book 24-10.indb 999 12/17/2018 2:22:07 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1000 References 1. 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J Sociol Res. 2012;15(2):128–61. 22. Coban AI. Adolescent marriages. Fam Soc. 2009;4(16):37–50. 23. Duvan CI, Turhan NO, Onaran Y, Gumus YH, Gozdemir E. Adolescent pregnancies: maternal and fetal outcomes. N J Med. 2010;27:113–6. 24. Altinay AG, Arat Y. Violence against women in Turkey: a nationwide survey. Istanbul: Punto Publishing Solutions; 2009. http:// research.sabanciuniv.edu/11418/1/Violence_Against_Women_in_Turkey.pdf رارمتسابو ،ةيفرع ةفاقثب ةطبترلما تاسرمالما ضعبب ةلص اله نأ ودبي يتلا ةماعلا ةحصلا تلاكشم نم تاقهارلما تاهملأا لازت لا :تاجاتنتسلاا .اراشتنا رثكلأا ةيدسلجا ةيسفنلا ملالآاو ،لافطلأا ددع ةدايزو ،لايجلأا برع ىسرلأا فنعلا Book 24-10.indb 1000 12/17/2018 2:22:07 PM Research article 1001 EMHJ – Vol. 24 No. 10 – 2018 25. Hamamy H. Consanguineous marriages: preconception consultation in primary health care settings. J Community Genet. 2012 Jul;3(3):185–92. https://doi.org/10.1007/s12687-011-0072-y PMID:22109912 26. 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Child psychiatry perspectives on child abuse and neglect. In: Polat O, editor. All aspects of child abuse. Volume 2. Anka- ra: Seçkin Publishing; 2007. pp. 139–50. Book 24-10.indb 1001 12/17/2018 2:22:07 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1002 Effect of postpartum depression on women’s mental and physical health four years after childbirth Fatemeh Abdollahi 1 and Mehran Zarghami 2 1Department of Public Health, Faculty of Health and Health Sciences Research Centers, Addiction Institute; Mazandaran University of Medical Scienc- es, Sari, Islamic Republic of Iran. 2Department of Psychiatry, Faculty of Medicine; and Psychiatry and Behavioral Sciences Research Center, Addiction Institute; Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran. (Correspondence to: Mehran Zarghami: mzarghami@mazums. ac.ir or mehran.zarghami@gmail.com) Introduction Depression is a significant public health concern with a worldwide prevalence of 4.7% (1,2). A study published in 2010 among the Iranian population reported a prevalence of depression of 4.1% (95% CI: 3.1–5.1) with women being 1.95 times more likely to be depressed than men (3). Postpartum depression, with a reported prevalence of 19.8–82.1% in some developing countries (4,5), can affect a mother’s relationship with her child (4,6). In the Islamic Republic of Iran, the prevalence of postpartum depression has been reported to be 25.3% (95% CI: 22.7– 27.9%) (6). Longitudinal studies have shown that this condition can have long-term effects on a child’s growth and development and attachment to his/her mother (7,8). It also affects women’s mental health in the long term (9,10). Because of postpartum depression episodes, these women may not be willing to get pregnant again (11). Suicide from psychiatric illness is the main cause of maternal death in the first postpartum year and may be a consequence of untreated postpartum depression (12,13). Maternal expectations and outlook were found to be a risk factor for the occurrence of subsequent problems for both mother and child (10,14), and women with a history of postpartum depression have developed more depressive symptoms later (14,15). The prevalence of depression has been examined in follow-up studies of women with postpartum depression (14,16). The prevalence of recurrent depressive symptoms has been estimated to be range between 23% and 49% in different samples with different risk factors reported (17,18). However, social differences between the samples could have affected these results. Few studies have followed up depressive symptoms in the long term in different populations (10) and no such studies have been done in Iranian women. From January to June 2009, we conducted a longitudinal study among women during pregnancy and after delivery in Mazandaran Province (19). A high rate of postpartum depression (14.1%) was identified (19). The current study aimed to follow up those women to investigate the prevalence of subsequent depression and other physical and mental illnesses 4 years later. Abstract Background: Postpartum depression has been shown to affect women’s health in the long term but no studies have as- sessed this in the Islamic Republic of Iran. Aims: This study determined the prevalence of current depression and illness in women who had experienced postpar- tum depression four years after childbirth, and evaluated the factors associated with current depression. Methods: In a cohort study in 2009, 1801 pregnant women without depression at 32–42 weeks of pregnancy attending Mazandaran primary healthcare centres were examined for postpartum depression using the Edinburgh Postnatal De- pression Scale (EPDS). After four years, 204 women of the original cohort with postpartum depression and 467 without postpartum depression were again evaluated using the EPDS, and other questionnaires to determine the prevalence of current depression and other health problems. Multivariable logistic regression analysis was used to evaluate the factors associated with current depression and other health problems. Results: The mean age of the women was 30.13 (SD 5.21) years. Women with postpartum depression were two times more likely to experience depression four years after childbirth (OR = 2.16, 95% CI: 1.38–3.36). They were also significantly more likely to experience chronic diseases (OR = 2.49, 95% CI: 1.38–4.50) and score higher on the General Health Questionnaire (OR = 2.50, 95% CI: 1.38–4.50). Conclusions: Postpartum depression predisposes women to later depression and other mental and physical health prob- lems. Women with postpartum depression need to be identified and provided with support and appropriate interventions to avoid later health problems. Keywords: Mental health, depression, postpartum, pregnancy, Iran Citation: Abdollahi F; Zarghami M. Effect of postpartum depression on women’s mental and physical health four years after childbirth. East Mediterr Health J. 2018;24(10):1002–1009. https://doi.org/10.26719/2018.24.10.1002 Received: 20/02/16; accepted: 12/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo) Book 24-10.indb 1002 12/17/2018 2:22:07 PM Research article 1003 EMHJ – Vol. 24 No. 10 – 2018 Methods Study design and setting This was a longitudinal study conducted in Mazandaran primary health care centres (PHCCs) in northern Islamic Republic of Iran. These PHCCs are public centres pro- viding preventive care and health education services for women, and are data surveillance centres for pregnancy and birth. Study sample In the original study (January to June 2009), a sample of women was followed from between 32 and 42 weeks of pregnancy to 12 weeks postpartum to determine the incidence and predictors of postpartum depression (19). In total, 2279 women participated in the original study, of whom 1801 had no symptoms of depression at 32–42 weeks of pregnancy, as assessed by the Edinburgh postna- tal depression scale (EPDS). Women on pharmacological treatment for psychiatric disorders were excluded from the original study. Of the 1801 women, 1546 were followed until 12 weeks postpartum. For the present study, four years later, the PHCC records of the 1546 women were re- viewed to identify eligible participants. Three groups of women were excluded from the present study: those who reported experiencing chronic diseases during the origi- nal study (women using daily medication), those with po- tential depression based on EPDS who were referred to a physician for treatment, and those who became pregnant during the four years. From 1546 women, all depressed women scoring above the EPDS threshold (> 12) during 12 postpartum weeks (n = 254) who met the eligibility criteria for this study were considered for inclusion after four years. Of the 254 women, 216 eligible women who attended the PHCCs for infant care and completed the consent form were recruited as the case group. The wom- en were followed again from February to October 2013. In addition, 475 eligible women of the 1 292 women without postpartum depression were randomly chosen as a con- trol group. First, the sample size was determined for each city and PHCC. Then, a list was made of all eligible wom- en without postpartum depression in each PHCC and each was assigned a unique number. Then, the required sample in each PHCC was selected by drawing numbers randomly. These women were asked to participant in the study when they were attending the PHCC (Figure 1). Because of some difficulties in reaching and recruiting women in urban areas—some had changed address and some declined to participate—most women taking part in this study came from rural areas (59.9%). Data collection Data were collected using four questionnaires: · Iranian EPDS version (20) · Life event rating scale (LERS) (21) · 28-item general health questionnaire (GHQ-28) (22) · A questionnaire asking about: chronic diseases (e.g. diabetes mellitus, hypertension, heart disease, and use of daily medication); acute diseases (e.g. infec- tious diseases, pain); other mental health problems (e.g. depression, anxiety), use of daily medication for chronic diseases in the past four years; PHCC location (rural, urban). · A checklist including maternal/child characteristics (education, parity, child’s age and sex). The researchers and trained health care practitioners distributed the questionnaires to the eligible women. All the women were literate and completed the questionnaire in Farsi at the PHCC. All standardized questionnaires were already validated for the Iranian population (23–25). Data on the socioeconomic background, pregnancy course, medical history, birth weight and infant characteristics at the time of delivery were recorded in the original study (19). According to the GHQ scores, participants were divided into 2 groups: unhealthy (score > 21) and healthy (score ≤ 21). Statistical analysis Data were analysed using SPSS, version 20. Continuous variables are presented as mean and standard deviation (SD), and categorical variables as number and percent- age. The differences between the groups with and with- out postpartum depression were analysed according to sociodemographic characteristics (age, PHCC location, education and parity), GHQ scores, LERS events, daily medication use and acute and chronic diseases using chi-squared and t-tests. Backward multivariable logistic regression analysis was used to determine which vari- ables were significant predictors of current depression. The dependent variable was current depression and data are presented as odds ratios and 95% confidence intervals (CI). Maternal depression was also categorized into four groups: · No depression (women without depression over 12 weeks postpartum and at the time of the current study four years later); · Postpartum depression only (women with depres- sion over 12 weeks postpartum but who were not depressed four years later at the time of the current study); · Current depression only (women without depression over 12 weeks postpartum but who were depressed four years later at the time of the current study); and · Both postpartum depression and current depression (women who were depressed both over 12 weeks postpartum and four years later at the time of the current study) A P-value less than 0.05 was considered statistically significant. Book 24-10.indb 1003 12/17/2018 2:22:07 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1004 Ethical considerations Ethical approval for the study was obtained from the Medical Ethics Committee of Mazandaran Medical Sciences University. Written consent was received from all participants and they were assured that the informa- tion in the questionnaires would be kept confidential. Results A total of 691 women agreed to take part in this study. Of these, 12 women with a history of postpartum depression dropped out (5.6%), and 8 (1.7%) women without depres- sion were also excluded from the analysis because they did not complete the questionnaires. Thus, 671 (98.8%) women completed the four-year follow-up: 204 with postpartum depression (case group) and 467 without postpartum depression (control group). There were no so- ciodemographic differences between the 2 groups of the participants in terms of age, PHCC location, education, parity and baby’s sex (Table 1). The mean ages of all the women and their infants in this study were 30.13 (SD 5.21) years and 47.79 (SD 1.28) months respectively. The mean EPDS and median GHQ-28 scores were 8.89 (SD 4.59) and 21.00 (SD 9.74) respectively and the mean life events number was 3.76 (SD 2.93). Of the 671 women in the study, 78 (11.6%) suffered from both postpartum depression and current depression and 406 (60.5%) had not experienced any depression (Table 2). Table 1 Background of the participants Variable With postpartum depression (n = 204) Without postpartum depression (n = 467) P-value Age (years) [mean (SD)] 30.10 (5.13) 30.14 (5.25) 0.43 Education (upper secondary, grades 10-12) [no. (%)] 114 (55.9%) 226 (48.4%) 0.14 Primipara [no. (%)] 121 (59.3%) 297 (63.6%) 0.55 Infant’s age (months) [mean (SD)] 47.87 (0.73) 47.89 (0.79) 0.06 Child sex (female) [No. (%)] 103 (50.5%) 241 (51.6%) 0.43 Figure 1 Flow chart of sampling procedure of the study during 32–42 weeks pregnancy to four years after birth (EPDS = Edinburgh postnatal depression scale) Total number of mother s who completed first EPDS questionnaire during pregnancy (n = 2 279) Mothers with EPDS ≤ 12 during 32 weeks pregnancy to term n = 1 801 (71%) EPDS > 12 254 (14.1%) Mothers who dropped out 255 (14.2%) EPDS ≤ 12 1 292 (85.9%) Mothers included in the cohort and followed up for 12 weeks after delivery and cases analysed n = 1 546 (85.8%) EPDS ≤ 12 126 (61.8%) EPDS > 12 78 (38.2 % ) Dropped out 8 (1.7% ) EPDS ≤ 12 406 (86.9%) EPDS > 12 61 (13.1%) Followed up 4 years after birth (n = 475) Followed up 4 years after birth (n = 216) Dropped out 12 (5.6 %) Book 24-10.indb 1004 12/17/2018 2:22:08 PM Research article 1005 EMHJ – Vol. 24 No. 10 – 2018 Four years after delivery, current depression was 3 times more prevalent in the women who had experienced postpartum depression than the women who had not had postpartum depression (38.2% versus 13.1%, P < 0.001). According to GHQ-28 scores, psychological distress was significantly more common in women who had had postpartum depression than the women who had not (61.8% versus 26.6%, P < 0.001). There were also significant differences between the two groups in experiencing physical illnesses (chronic diseases: 19.6% versus 5.4%; acute diseases: 37.3% versus 15.2%, P < 0.001 for both) and other mental health problems (15.7% versus 2.8%, P < 0.001) as well as daily medication use (21.6% versus 6.0%, P < 0.001) (Table 3). In the multivariable logistic regression analysis, the factors significantly associated with current depression were; higher scores in the GHQ-28, having acute and chronic diseases, and experiencing postpartum depression (Cox Snell R2 = 0.138) (Table 4). Women who had experienced postpartum depression had twice the risk of depression 4 years later (odds ratio = 2.16; 95% CI: 1.38–3.36). Discussion We evaluated subsequent depression four years after childbirth in the women from northern Islamic Republic of Iran. To our knowledge, this is the first study from the developing world exploring depression recurrence and long-term consequences of postpartum depression. The majority of the women were of poor and middle socioec- onomic status. The main finding was that women who had experienced postpartum depression were twotimes more likely to suffer from depression four years after childbirth than women who had not experienced post- partum depression. In similar studies from developed countries, women experiencing postpartum depression were predicted to be at a higher risk of subsequent de- Table 2 Proportion of women with depression (n = 671) Depression No. % Both postpartum and current 78 11.6 Postpartum only 126 18.8 Current only 61 9.1 None 406 60.5 Table 3 Reported health problems in women experiencing postpartum depression four years after childbirth compared with non- depressed women Variable With postpartum depression (n = 204) Without -postpartum depression (n = 467) P-valuea No. (%) No. (%) Current depression based on EPDS < 0.001 Yes (> 12) 78 (38.2) 61 (13.1) No (≤ 12) 126 (61.8) 406 (86.9) GHQ-28 scores < 0.001 Unhealthy (> 21) 126 (61.8) 124 (26.6) Healthy (≤ 21) 78 (38.2) 343 (73.4) Chronic diseases < 0.001 Yes 40 (19.6) 25 (5.4) No 164 (80.4) 442 (94.6) Acute diseases < 0.001 Yes 76 (37.3) 71 (15.2) No 128 (62.7) 396 (84.1) Other mental health problems < 0.001 Yes 32 (15.7) 13 (2.8) No 172 (84.3) 454 (97.2) Daily medication use < 0.001 Yes 44 (21.6) 28 (6.0) No 160 (78.4) 439 (94.0) Life events from LERS 0.825 ≥ 4 95 (46.6) 207 (44.3) 2-3 64 (31.4) 148 (31.7) ≤ 1 45 (22.1) 112 (24) aChi-squared test. EPDS = Edinburgh postnatal depression scale; GHQ = general health questionnaire; LERS = life event rating scale. Book 24-10.indb 1005 12/17/2018 2:22:08 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1006 pression (10,15). Other longitudinal studies also reported that postpartum depression could affect women’s mental health in the long term (9,14); however, earlier longitudi- nal studies had not found a higher prevalence of subse- quent depression in women with a history of postpartum depression (26,27). Socioeconomic differences between the samples could explain the different results of these studies. Moreover, different methods and tools were used in these studies, follow-up duration varied and they had fairly small sample sizes which may have been resulted in the different findings. For example, in the study by Luoma et al., 147 women were included and maternal de- pression was assessed immediately after birth and when the children were 8–9 years old (27). Cooper and Murray assessed recurrent depression using a structured clinical interview in 40 women 5 years after giving birth (26). There was a significant difference between the women with a history of postpartum depression and those without in terms of physical illness, daily medication use and psychiatric distress related to general medical illness (measured by GHQ-28). In a study in Sweden, history of postpartum depression was shown to be a risk factor for negative health outcomes in the sample of women (10). The authors reported that women with a history of postpartum depression were more vulnerable to illnesses and likely to be on treatment with daily medication than those with no history of postpartum depression (10). A consequence of postpartum depression is reduced quality of life and increased likelihood of risky behaviour that may eventually lead to high morbidity in women (11,28,29). In our study, 19.6% of the women with postpartum depression suffered from chronic diseases, which required further interventions. Although psychosocial stressors may have affect the development of postpartum depression (30), there was no significant difference between the 2 groups in our study in terms of life events. A recent review concluded that the majority of these psychosocial factors are largely social in nature (3). A limitation of our study was using the EPDS – and not a structured clinical interview – to detect depression. EPDS was developed to identify depression in the postpartum period, although there are many similarities between this scale and other depression scales, and some studies have concluded that the EPDS is suitable for screening major depressive episode among men, in antepartum and postpartum women, and in the community (31–33). Indeed, items from EPDS are derived from other depression scales. Moreover, we used a self- reported questionnaire with retrospective data which may lead to recall bias. Another limitation of our study was failing to contact all depressed women in the case group, especially in urban areas, which led to selection bias. We also did not have any data on the women who dropped out. Moreover, other demographic characteristics and depression predictors were not evaluated, which may have acted as confounders. Conclusion Our results suggest that postpartum depression predis- posed women to subsequent depression and other phys- ical and mental illnesses later on. Our study was carried out in one area of the Islamic Republic of Iran and there- fore generalization of the results should be considered with caution. Replication of our study in other Iranian so- cieties is recommended. Our results indicate the need to identify and follow up women with postpartum depres- sion early after delivery or during their perinatal health clinic visits. Early identification of women who are at risk of subsequent depression and giving them more support and appropriate psychosocial and medical interventions can improve their mental and physical health. Acknowledgements We would like to thank the women who participated in this study and also the health workers in PHCCs for their assis- tance in data collection. Funding: This study was supported by a grant from the Mazandaran University of Medical Sciences (No: 139265). Competing interests: None declared. Effet de la dépression postpartum sur la santé mentale et physique des femmes quatre ans après la naissance Résumé Contexte : Il a été démontré que la dépression postpartum a un impact sur la santé des femmes à long terme, mais aucune étude n’avait encore cherché à évaluer cet impact en République islamique d’Iran. Objectifs : La présente étude a déterminé la prévalence de la maladie et de la dépression courante quatre ans après la naissance chez les femmes ayant souffert d’une dépression postpartum et évalué les facteurs associés à la dépression courante. Méthodes : Dans une étude de cohorte réalisée en 2009, 1 801 femmes enceintes sans dépression à 32-42 semaines de grossesse qui consultaient dans les centres de soins de santé primaires de Mazandaran ont été examinées à la recherche de dépression postpartum à l’aide de l’échelle de dépression postnatale d’Édimbourg (Edinburgh Postnatal Depression Scale, EPDS). Quatre ans plus tard, 204 femmes de la cohorte initiale ayant souffert de dépression postpartum et 467 femmes Book 24-10.indb 1006 12/17/2018 2:22:08 PM Research article 1007 EMHJ – Vol. 24 No. 10 – 2018 de la cohorte sans dépression postpartum ont été évaluées de nouveau à l’aide de l’EPDS et d’autres questionnaires pour déterminer la prévalence de la dépression courante et d’autres problèmes de santé. Une analyse de régression logistique multivariable a été utilisée pour évaluer les facteurs associés à la dépression courante et aux autres problèmes de santé. Résultats : L’âge moyen des femmes était de 30,13 ans (ET 5,21). Les femmes ayant vécu une dépression postpartum étaient deux fois plus susceptibles de souffrir de dépression quatre ans après avoir donné naissance (OR = 2,16 et IC à 95 % : 1,38-3,36). Elles étaient aussi beaucoup plus susceptibles de souffrir de maladies chroniques (OR = 2,49 et IC à 95 % : 1,38-4,50) et d’obtenir un score plus élevé au Questionnaire général de santé (OR = 2,50 et IC 95 % : 1,38-4,50). Conclusions : La dépression postpartum prédispose les femmes à une dépression ultérieure et à d’autres problèmes de santé mentale et physique. Les femmes souffrant de dépression postpartum doivent être identifiées et bénéficier de soutien et d’interventions appropriées afin d’éviter les problèmes de santé ultérieurs. ةدلاولا لىع تاونس عبرأ دعب ةأرملل ةيدسلجاو ةيسفنلا ةحصلا لىع ةدلاولل لياتلا بائتكلاا يرثأت يماغضر نارهم ،يهللا دبع ةمطاف ةصلالخا ناريإ ةيروهجم في يرثأتلا اذه مييقتل تاسارد دجوت لا نكلو ،ليوطلا ىدلما لع ةأرلما ةحص لع رثؤي بائتكلاا نأ تباثلا نم حبصأ :ةيفللخا .ةيملاسلإا تاونس 4 رورم دعب ةدلاولل لياتلا بائتكلاا نم ينناع تياوللا ءاسنلا ىدل ضرمللو بائتكلال ليالحا راشتنلاا لدعم ةساردلا هذه تددح :فادهلأا .ليالحا بائتكلااب ةطبترلما لماوعلا مييقت عم ،ةدلاولا لع عيباسلأا في بائتكلااب تاباصم َّنكي لم تيلالا لماولحا ءاسنلا نم 1801 تلمشو ،2009 ماع في تيرجأ يتلا بارتلأا ةسارد في :ثحبلا قرط بائتكلال ةبرندأ سايقم مادختساب ةدلاولا دعب بائتكلا نهصحفل نارادنازام في ةيلولأا ةيحصلا ةياعرلا زكارم نعجار مث نهلحم نم 42 – 32 نم 467 عم ةدلاولا ولت بائتكلاا تلوانت يتلا ةيلصلأا بارتلأا ةسارد لىإ ينمتني تياوللا ءاسنلا نم 204 مييقت ديعأ تاونس 4 دعبف .ةدلاولا ولت راشتنلا ةيلالحا تلادعلما ديدحتل ىرخأ تانايبتسا عم ،ةدلاولا ولت بائتكلال ةبرندأ سايقم مادختساب ةدلاولا ولت بائتكلااب تاباصلما يرغ ءاسنلا نم اهيرغو ليالحا بائتكلااب ةطبترلما لماوعلا مييقتل تايرغتلما ددعتلما يتسجوللا ف ُّوَحَّتلا ليلتح مادختسا مت .ىرخلأا ةيحصلا لكاشلماو بائتكلاا .ةيحصلا لكاشلما نم ةاناعم لماتحا ّنيهدل بائتكلااب تاباصلما ءاسنلا نأ حضتاو .ةنس )5.21 يرايعلما فارحنلاا( 30.13 ءاسنلا رمع طسوتم ناك :جئاتنلا يربك رادقمب بركأ لماتحا كانه ناك ماك .)3.36-1.38=CI%95 ;2.16 =OR( نهيرغ ْيَفعض رادقمب ةدلاولا لع تاونس 4 رورم دعب بائتكلاا %95 ;2.5 =OR( ةـــــــماعلا ةــحصلا نايبتسا في ةعفترم اًزارحأ اوققحو ،)1.384.5 =CI %95 ;2.49 =OR( ةنمزم ضارمأ نم ةاناعلم .)4.5-1.38 =CI ةيسفنلا ةيحصلا لكاشلما نم هيرغبو بائتكلااب قحلا تقو في ةباصلإل تاض َّرعم ةدلاولا ولت بائتكلااب نبصي تياوللا تاديسلا :تاجاتنتسلاا لكاشلماب نهتباصإ بنجتل ّنله ةمئلالما تلاخدتلاو معدلا يرفوتو ةدلاولا ولت بائتكلااب نبصي تياوللا تاديسلا لع فرعتلا يغبني .ةيمسلجاو .قحلا تقو في ةيحصلا References 1. 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Introduction The incidence of occupational injuries among migrant workers is reported as high as compared to that of the native working population (1–5). In a recent review of migrant workers of 16 countries, the percentage of oc- cupational injuries was twice that of native workers (6). Migrant workers are also less aware of workplace safety and have little knowledge about their occupational rights (injury compensation or other financial benefits) (7). Sau- di Arabia has > 9 million migrant workers according to a recent Labor Force Survey (2016_Q2) (8). The Population Division of the United Nations ranked Saudi Arabia in fourth position regarding number of migrant workers. Previously, a 4 times higher incidence of occupational injuries/diseases was found among migrant workers as compared to native Saudi workers in Saudi Arabia. The present study analysed and compared the trends in occupational injuries/diseases between non-Saudi insured workers (NSIWs) and Saudi insured workers (SIWs) between 2004 and 2014 in Saudi Arabia. Methods We used an open data source in the form of published annual statistical reports between 2004 and 2014 avail- able on the website of General Organization for Social Insurance (GOSI) (http://www.gosi.gov.sa/). The original data for occupational injuries from Arabic statistical re- ports were translated into English and transformed into MS Excel format for analysis. The index value calculation method was used to determine the trends in occupational injuries/diseases in NSIWs and SIWs between 2004 and 2014. The index values calculation method had 2 different types of implications: (1) the occupational injuries/diseas- es trends based on the reference year 2004; and (2) occu- pational injuries/diseases trends for NSIWs based on the occupational injuries/diseases of SIWs for each variable. Index value yearly trends in occupational injuries/dis- eases of both SIWs and NSIWs were calculated for each type of economic activity and major occupation in 2004 and 2014 by considering the respective occupational in- juries/diseases value of the year 2004, and calculation of the slope value (S) displayed the upward and downward trends in occupational injuries/diseases. S was used to de- scribe both direction and steepness of the data (9). A nega- tive value of S showed a decline in occupational injuries/ diseases, and a positive value of S showed an increase. According to GOSI, occupational (employment) injuries are: (1) any accident incurred by the worker during per- formance or because of work; (2) any accident incurred by the worker on their way from their dwelling to their workplace and return, or on their way from their work- Abstract Background: The ongoing industrial and infrastructural development in Saudi Arabia carries a high risk of occupation- al injuries/diseases. Aims: To compare trends in occupational injuries and diseases among Saudi and non-Saudi insured workers. Methods: We used the index values method and slope (S) calculation to analyse the occupational injuries/diseases trends from data in the annual statistical reports published by the General Organization for Social Insurance between 2004 and 2014. Data for 10 565 993 (18.5%) Saudi insured workers (SIWs) and 46 402 079 (81.5%) non-Saudi insured work- ers (NSIWs) and 896 627 occupational injuries/diseases were analysed. Results: The distribution of incidences of occupational injuries/diseases among NSIWs (93.5%) was 14 times higher than that of SIWs (6.5%). Occupational injuries/diseases were more likely to increase among NSIWs than SIWs, particularly in the construction, trade, financing and real estate economic activities, and engineering, technicians and service workers occupations. There was a general decreasing trend in occupational injuries/diseases until 2013. Conclusions: Non-Saudi insured workers were at high risk of occupational injuries/diseases, therefore, implementation of an effective injury prevention programme is required. Keywords: occupational injuries, occupational diseases, insured workers, Saudi Arabia, migrant workers Citation: Abbas M; Kashif M; Balkhyour M; Ahmad I; Asam Z; Saeed R. Trends in occupational injuries and diseases among Saudi and non-Saudi insured workers. East Mediterr Health J. 2018;24(10):1010–1017. https://doi.org/10.26719/2018.24.10.1010 Received: 18/07/17; accepted: 21/11/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Book 24-10.indb 1010 12/17/2018 2:22:08 PM Research article 1011 EMHJ – Vol. 24 No. 10 – 2018 place to the place where they usually take their meal or attend prayer, and return; (3) any accident incurred by the worker during movements they make for the purpose of doing an assignment required by their employer; and (4) any disease established to be caused by work, as well as any occupational disease diagnosed in accordance with the Schedule of Occupational Diseases (10). Results Data analysis showed the higher percentages of NSIWs in terms of employment (80.9%) and suffering of occu- pational injuries/diseases (93.5%) as compared to SIWs’ employment (19.1%) and occupational injuries/diseases (6.5%). Figure 1 shows the overall decreasing trend of oc- cupational injuries/diseases between 2004 and 2013, but the decrease was greater in SIWs. Index value trends of insured workers increased due to their higher share in employment and occupational injuries/diseases. Index value trends in occupational injuries/diseases in SIWs and NSIWs according to economic activities, based on 2004 as a reference, are shown in Table 1. Trends in occupational injuries/diseases in SIWs and NSIWs decreased for all types of economic activities except financing and real estate. Index value trends in occupational injuries/diseases in NSIWs based on SIWs according to economic activities are shown in Table 2. When we took values of occupational injuries/ diseases in SIWs as a reference, occupational injuries/ diseases among NSIWs increased in construction, followed by trade, financing and real estate, post and communications, and manufacturing, but decreased in agriculture and fishing, and social services. Index value trends in occupational injuries/diseases in SIWs and NSIWs according to occupation, based on 2004 as a reference, are shown in Table 3. Trends in occupational injuries/diseases in NSIWs increased in engineering, followed by services workers, sales workers and industrial, chemical and food workers. In SIWs, there were increases in industrial, chemical and food workers followed by other occupations and technicians. Index value trends in occupational injuries/diseases in NSIWs based on SIWs according to major occupations are shown in Table 4. When we took values of occupational injuries/diseases in SIWs as a reference, occupational injuries/diseases among NSIWs increased most for engineering, followed by technicians, administrative and managerial workers, services workers and specialists. Discussion This is believed to be the first national level comparison of occupational injuries/diseases between SIWs and NSI- Ws. The index value calculation method has already been used in different studies conducted in Turkey, Republic of Korea and Pakistan to determine trends in occupation- al injuries (9,11,12). Overall, this study found a clear higher percentage share of NSIW with SIW by employment (4 times) and occupational injuries/diseases (14 times). In- volvement of NSIWs in more hazardous jobs and higher employment share could explain the higher number of oc- cupational injuries/diseases as higher rates of accidents/ disability have been observed among migrant workers in Qatar and the United Arab Emirates (UAE) (13,14). A higher share of employment and occupational injuries have also been found in other Gulf countries such as Qatar (15) and UAE (16). Figure 1. Index value trends in occupational injuries among Saudi and Non-Saudi insured workers. 120.0 110.0 100.0 90.0 80.0 70.0 60.0 50.0 40.0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Total workers injuries Saudi workers injuries Non-Saudi workers injuries Book 24-10.indb 1011 12/17/2018 2:22:08 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1012 The greater decrease in occupational injuries/diseases among SIWs as compared to NSIWs is consistent with another study (17). The downward trend in index values of occupational injuries could also have been due to the steps taken by GOSI such as: awarding occupational health and safety (OHS) prizes to establishments, pro- viding technical and regulatory assistance, training pro- grammes, OHS workshops, field studies about OHS and strict inspection of premises. The outcomes of this study illustrate that, as compared to SIWs, the increased index value trends in occupational injuries/diseases of NSIWs show the related suffering from work conditions or unsafe practices. The global construction sector is the most hazardous for occupational accidents/injuries, with extensive involvement of migrant workers. It has been shown that migrant workers in the construction sector have a significantly high proportion (42%) of severe occupational injuries, which is consistent with our study (18). After construction, trade and manufacturing economic activities were the second and third most problematic groups, respectively, regarding incidence of occupational injuries/diseases among NSIWs. This could be associated with the growing industrial activities in Saudi Arabia. Between 2004 and 2014 occupational injuries/diseases increased in mining and quarrying in SIWs and NSIWs, which could be associated with the hazardous nature of oil exploration activities. Increased trends in occupational injuries/diseases in NSIWs in trade, financing and real estate, manufacturing, and agriculture and fishing may have been due to the high level of NSIW involvement in blue collar jobs and lack of interest in these jobs from SIWs. The distribution of occupational injuries/diseases among migrant workers varied with the nature of the occupation. The most hazardous occupations regarding injuries/diseases were engineering and services among SIWs and NSIWs. The increased trend in occupational injuries for SIWs and NSIWs among industrial, chemical and food workers could have been due to inadequate preventive measures. A recent study reported that occupational injuries among migrant workers were due to stress and depression, which may have been due to job choice and being away from their home country (18). Trends in occupational injuries/diseases increased in Saudi and non-Saudi technicians. Our study had some limitations regarding types of occupational injuries, age of the working population, and gender and nationality distribution of the migrant workers. A major strength of our study was that the findings are of national importance concerning occupational injury/disease burden among SIWs and NSIWs. Table 1 Index value trends in occupational injuries/diseases of NSIWs and SIWs by types of economic activity Economic activities 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Slope NSIWs’ injuries Index value by time, 2004 = 100 Post and communications 100.0 111.8 97.3 110.9 90.4 78.0 66.6 67.6 54.9 50.6 76.9 -5.4 Trade 100.0 114.5 104.9 101.9 84.4 68.7 65.4 80.6 72.2 42.6 53.6 -6.2 Construction 100.0 107.2 94.6 98.4 113.1 110.8 96.1 93.2 79.6 68.4 91.3 -2.5 Mining and quarrying 100.0 103.8 101.6 120.9 123.2 130.7 113.0 87.2 95.5 88.4 123.2 -0.4 Social services 100.0 107.0 70.7 63.5 65.3 64.5 43.5 36.9 34.4 30.7 37.1 -7.3 Agriculture and fishing 100.0 118.2 106.5 101.7 102.1 100.5 90.2 71.3 55.1 46.9 63.1 -6.3 Manufacturing 100.0 104.2 90.6 88.7 90.4 79.1 64.9 61.0 51.7 47.9 60.6 -5.6 Electricity and water 100.0 108.1 112.7 93.8 116.0 131.0 97.3 91.9 68.8 55.4 65.7 -4.9 Finance and real estate 100.0 117.6 153.0 301.7 369.6 472.8 611.1 489.2 461.2 388.0 713.7 51.7 SIWs’ injuries Index value by time, 2004 = 100 Post and communications 100.0 136.2 101.0 139.8 102.6 98.5 85.2 81.6 71.9 51.5 66.8 -6.6 Trade 100.0 118.6 108.8 95.4 79.8 67.0 57.4 47.9 37.8 30.3 35.0 -9.2 Construction 100.0 127.9 121.8 126.7 110.4 84.2 70.3 64.1 53.8 47.0 55.4 -8.3 Mining and quarrying 100.0 131.0 126.4 134.4 144.7 120.2 90.2 99.0 72.9 76.5 128.2 -3.3 Social services 100.0 134.7 131.6 129.3 115.5 101.3 98.3 104.7 101.3 94.6 125.6 -1.7 Agriculture and fishing 100.0 96.7 101.7 126.7 125.0 111.7 105.0 113.3 138.3 105.0 101.7 1.0 Manufacturing 100.0 110.6 106.8 106.1 101.7 86.2 72.0 66.8 56.3 43.9 49.1 -7.1 Electricity and water 100.0 95.4 92.6 88.1 86.4 91.2 59.2 54.2 46.3 33.3 46.7 -6.8 Finance and real estate 100.0 114.7 185.3 379.4 376.5 305.9 367.6 438.2 352.9 276.5 441.2 27.0 NSIWs = non-Saudi insured workers; SIWs = Saudi insured workers. Book 24-10.indb 1012 12/17/2018 2:22:09 PM Research article 1013 EMHJ – Vol. 24 No. 10 – 2018 Conclusions We found a high level of occupational injuries/diseases among NSIWs, which needs to be addressed through an effective injury prevention programme, especially for the construction sector, and engineering and services work- ers. The decline in overall occupational injuries/diseas- es burden could be associated with positive steps taken by GOSI. The burden of occupational injuries/diseases among NSIWs could be reduced over time through gov- ernment and private sector partnerships, occupational safety education, and minimizing language barriers. Fu- ture studies could be designed to investigate the severity of occupational injuries/diseases among SIWs and NSI- Ws. Funding: None. Competing interests: None declared. Table 2 Index value trends of occupational injuries/diseases of NSIWs based on SIWs values by types of economic activity Economic activities 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Slope Index value by nationality, occupational injuries/diseases value of SIWs = 100 Post and communications SIWs 196.0 267.0 198.0 274.0 201.0 193.0 167.0 160.0 141.0 101.0 131.0 NSIWs 2006.0 2243.0 1952.0 2225.0 1813.0 1564.0 1335.0 1357.0 1102.0 1016.0 1542.0 Index value 1023.5 840.1 985.9 812.0 902.0 810.4 799.4 848.1 781.6 1005.9 1177.1 7.2 Trade SIWs 1555.0 1845.0 1692.0 1483.0 1241.0 1042.0 893.0 745.0 588.0 471.0 544.0 NSIWs 23125.0 26470.0 24254.0 23559.0 19525.0 15897.0 15135.0 18640.0 16687.0 9841.0 12404.0 Index value 1487.1 1434.7 1433.5 1588.6 1573.3 1525.6 1694.8 2502.0 2837.9 2089.4 2280.1 115.9 Construction SIWs 868.0 1110.0 1057.0 1100.0 958.0 731.0 610.0 556.0 467.0 408.0 481.0 NSIWs 38431.0 41216.0 36370.0 37829.0 43472.0 42577.0 36917.0 35811.0 30581.0 26292.0 35071.0 Index value 4427.5 3713.2 3440.9 3439.0 4537.8 5824.5 6052.0 6440.8 6548.4 6444.1 7291.3 382.6 Mining and quarrying SIWs 387.0 507.0 489.0 520.0 560.0 465.0 349.0 383.0 282.0 296.0 496.0 NSIWs 690.0 716.0 701.0 834.0 850.0 902.0 780.0 602.0 659.0 610.0 850.0 Index value 178.3 141.2 143.4 160.4 151.8 194.0 223.5 157.2 233.7 206.1 171.4 5.1 Social services SIWs 297.0 400.0 391.0 384.0 343.0 301.0 292.0 311.0 301.0 281.0 373.0 NSIWs 4005.0 4286.0 2832.0 2543.0 2617.0 2584.0 1741.0 1478.0 1376.0 1230.0 1487.0 Index value 1348.5 1071.5 724.3 662.2 763.0 858.5 596.2 475.2 457.1 437.7 398.7 -78.4 Agriculture and fishing SIWs 60.0 58.0 61.0 76.0 75.0 67.0 63.0 68.0 83.0 63.0 61.0 NSIWs 757.0 895.0 806.0 770.0 773.0 761.0 683.0 540.0 417.0 355.0 478.0 Index value 1261.7 1543.1 1321.3 1013.2 1030.7 1135.8 1084.1 794.1 502.4 563.5 783.6 -83.2 Manufacturing SIWs 2529.0 2798.0 2701.0 2684.0 2572.0 2180.0 1820.0 1690.0 1425.0 1110.0 1242.0 NSIWs 16774.0 17485.0 15191.0 14886.0 15169.0 13274.0 10894.0 10231.0 8678.0 8038.0 10158.0 Index value 663.3 624.9 562.4 554.6 589.8 608.9 598.6 605.4 609.0 724.1 817.9 12.9 Electricity and water SIWs 544.0 519.0 504.0 479.0 470.0 496.0 322.0 295.0 252.0 181.0 254.0 NSIWs 848.0 917.0 956.0 795.0 984.0 1111.0 825.0 779.0 583.0 470.0 557.0 Index value 155.9 176.7 189.7 166.0 209.4 224.0 256.2 264.1 231.3 259.7 219.3 9.2 Finance and real estate SIWs 34.0 39.0 63.0 129.0 128.0 104.0 125.0 149.0 120.0 94.0 150.0 NSIWs 415.0 488.0 635.0 1252.0 1534.0 1962.0 2536.0 2030.0 1914.0 1610.0 2962.0 Index value 1220.6 1251.3 1007.9 970.5 1198.4 1886.5 2028.8 1362.4 1595.0 1712.8 1974.7 81.7 NSIWs = non-Saudi insured workers; SIWs = Saudi insured workers. Book 24-10.indb 1013 12/17/2018 2:22:09 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1014 Table 3 Index values trends of occupational injuries/diseases of NSIWs and SIWs by major types of occupation Major occupations 2004 2005 2006 2007 2008 2009 2010 2011 2013 2014 Slope NSIWs’ injuries Index value by time, 2004 = 100 Administrative and managerial 100.0 6.0 5.1 7.1 12.0 18.6 21.7 19.9 21.1 21.8 -2.9 Specialists 100.0 181.5 157.3 157.8 157.3 146.2 133.8 126.9 99.9 130.4 -3.2 Technicians 100.0 105.9 115.6 162.0 238.5 278.6 290.2 339.9 260.6 335.6 28.8 Clerical and related 100.0 4.6 3.7 3.2 2.7 2.0 1.7 1.3 0.9 1.0 -5.7 Sales 100.0 1357.4 1127.8 1088.9 972.2 864.8 674.1 609.3 557.4 844.4 -17.2 Services 100.0 8448.0 7127.4 6880.0 5898.1 4742.2 3773.2 3523.2 2413.7 3613.1 -237.1 Agriculture 100.0 0.6 0.5 0.5 0.6 0.6 0.5 0.5 0.4 0.7 -5.4 Industrial, chemical and food 100.0 343.5 341.5 414.9 599.2 726.6 689.5 721.0 654.4 685.5 62.4 Engineering 100.0 5214.5 4941.4 5269.4 6459.6 6635.3 6141.5 6428.5 4309.3 5343.0 309.6 Other occupations 100.0 65.7 61.2 62.4 23.0 14.6 9.6 18.0 39.3 66.3 -5.3 SIWs’ injuries Index value by time, 2004 = 100 Administrative and managerial 100.0 83.7 67.3 85.7 136.7 202.0 144.9 163.3 134.7 140.8 8.8 Specialists 100.0 96.6 88.1 91.5 93.2 86.4 61.0 63.6 53.4 86.4 -3.9 Technicians 100.0 270.7 345.5 479.8 521.2 491.9 487.9 514.1 348.5 448.5 27.4 Clerical and related 100.0 105.2 83.7 81.5 65.3 53.8 45.2 38.7 31.8 45.8 -8.2 Sales 100.0 134.4 100.8 133.6 141.8 108.2 86.1 75.4 59.8 72.1 -6.5 Services 100.0 113.5 107.8 103.5 87.5 69.9 54.3 49.1 31.4 37.9 -9.6 Agriculture 100.0 46.2 84.6 69.2 61.5 107.7 100.0 138.5 130.8 184.6 10.7 Industrial, chemical and food 100.0 269.1 238.2 309.1 356.4 518.2 450.9 525.5 478.2 525.5 44.3 Engineering 100.0 116.3 114.5 106.1 104.8 86.1 76.9 69.1 44.7 50.6 -7.8 Other occupations 100.0 106.3 165.6 362.5 387.5 390.6 225.0 262.5 168.8 459.4 22.7 NSIWs = non-Saudi insured workers; SIWs = Saudi insured workers. Book 24-10.indb 1014 12/17/2018 2:22:09 PM Research article 1015 EMHJ – Vol. 24 No. 10 – 2018 Table 4 Index value trends in occupational injuries/diseases of NSIWs based on SIWs values by major occupations Major occupations (Index value by nationality, occupational injuries/diseases value of SIWs = 100) 2004 2005 2006 2007 2008 2009 2010 2011 2013 2014 Slope Administrative and managerial SIWs 49.0 41.0 33.0 42.0 67.0 99.0 71.0 80.0 66.0 69.0 NSIWs 54.0 70.0 59.0 83.0 140.0 217.0 253.0 232.0 246.0 254.0 Index value 110.2 170.7 178.8 197.6 209.0 219.2 356.3 290.0 372.7 368.1 29.0 Specialists SIWs 118.0 114.0 104.0 108.0 110.0 102.0 72.0 75.0 63.0 102.0 NSIWs 1164.0 1229.0 1065.0 1068.0 1065.0 990.0 906.0 859.0 676.0 883.0 Index value 986.4 1078.1 1024.0 988.9 968.2 970.6 1258.3 1145.3 1073.0 865.7 1.8 Technicians SIWs 99.0 268.0 342.0 475.0 516.0 487.0 483.0 509.0 345.0 444.0 NSIWs 677.0 1385.0 1512.0 2119.0 3120.0 3644.0 3796.0 4446.0 3408.0 4389.0 Index value 683.8 516.8 442.1 446.1 604.7 748.3 785.9 873.5 987.8 988.5 56.7 Clerical and related SIWs 877.0 923.0 734.0 715.0 573.0 472.0 396.0 339.0 279.0 402.0 NSIWs 1308.0 1311.0 1053.0 920.0 788.0 589.0 481.0 382.0 256.0 284.0 Index value 149.1 142.0 143.5 128.7 137.5 124.8 121.5 112.7 91.8 70.6 –7.6 Sales SIWs 122.0 164.0 123.0 163.0 173.0 132.0 105.0 92.0 73.0 88.0 NSIWs 671.0 733.0 609.0 588.0 525.0 467.0 364.0 329.0 301.0 456.0 Index value 550.0 447.0 495.1 360.7 303.5 353.8 346.7 357.6 412.3 518.2 –7.3 Services SIWs 3288.0 3731.0 3544.0 3404.0 2877.0 2298.0 1784.0 1616.0 1033.0 1247.0 NSIWs 53339.0 56686.0 47825.0 46165.0 39576.0 31820.0 25318.0 23641.0 16196.0 24244.0 Index value 1622.2 1519.3 1349.5 1356.2 1375.6 1384.7 1419.2 1462.9 1567.9 1944.2 24.3 Agriculture SIWs 13.0 6.0 11.0 9.0 8.0 14.0 13.0 18.0 17.0 24.0 NSIWs 248.0 316.0 278.0 256.0 334.0 336.0 292.0 288.0 227.0 375.0 Index value 1907.7 5266.7 2527.3 2844.4 4175.0 2400.0 2246.2 1600.0 1335.3 1562.5 Industrial, chemical and food SIWs 55.0 148.0 131.0 170.0 196.0 285.0 248.0 289.0 263.0 289.0 NSIWs 614.0 852.0 847.0 1029.0 1486.0 1802.0 1710.0 1788.0 1623.0 1700.0 Index value 1116.4 575.7 646.6 605.3 758.2 632.3 689.5 618.7 617.1 588.2 –27.1 Engineering SIWs 1817.0 2114.0 2081.0 1927.0 1904.0 1565.0 1397.0 1255.0 812.0 920.0 NSIWs 28798.0 32017.0 30340.0 32354.0 39662.0 40741.0 37709.0 39471.0 26459.0 32806.0 Index value 1584.9 1514.5 1458.0 1679.0 2083.1 2603.3 2699.3 3145.1 3258.5 3565.9 254.9 Other occupations SIWs 32.0 34.0 53.0 116.0 124.0 125.0 72.0 84.0 54.0 147.0 NSIWs 178.0 117.0 109.0 111.0 41.0 26.0 17.0 32.0 70.0 118.0 Index value 556.3 344.1 205.7 95.7 33.1 20.8 23.6 38.1 129.6 80.3 –41.5 Book 24-10.indb 1015 12/17/2018 2:22:09 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1016 Tendances des accidents du travail et des maladies professionnelles chez les travailleurs assurés saoudiens et non saoudiens Résumé Contexte : Le développement actuel des industries et des infrastructures en Arabie saoudite est associé à un risque élevé d’accidents du travail et de maladies professionnelles. Objectif : La présente étude avait pour objectif de comparer les tendances des accidents du travail et des maladies professionnelles chez les travailleurs assurés saoudiens et non saoudiens. Méthodes : Nous avons utilisé la méthode des valeurs d’indice et le calcul de la pente pour analyser les tendances des accidents du travail et des maladies professionnelles à partir des données des rapports statistiques annuels publiés par l’Organisation générale de l’assurance sociale entre 2004 et 2014. Nous avons analysé les données portant sur 10 565 993 travailleurs assurés saoudiens (18,5 %) et 46 402 079 travailleurs assurés non saoudiens (81,5 %) ainsi que sur 896 627 accidents du travail et maladies professionnelles. Résultats : La distribution des incidences des accidents du travail et des maladies professionnelles chez les travailleurs assurés non saoudiens (93,5 %) était 14 fois plus importante que chez les travailleurs assurés saoudiens (6,5 %). Les accidents du travail et les maladies professionnelles étaient plus susceptibles d’augmenter chez les travailleurs assurés non saoudiens que chez les travailleurs assurés saoudiens, en particulier dans les secteurs économiques de la construction, du commerce, de la finance et de l’immobilier, dans les professions d’ingénieur et de technicien et dans le secteur des services. Jusqu’en 2013, on observait une tendance globale à la baisse des accidents du travail et des maladies professionnelles. Conclusions : La mise en place d’un programme de prévention efficace s’impose donc pour réduire le risque élevé d’accidents du travail et de maladies professionnelles auquel sont exposés les travailleurs assurés non saoudiens. مهيلع نمؤلما ينلماعلا ينيدوعسلا يرغو ينيدوعسلا ينب ةينهلما ضارملأاو تاباصلإا ديعس دشار ،ماصع نامزلا يكز ،دحمأ زاجعإ ،رويلخاب روصنم ،فشاك دممح ،سابع نسمح ةصلالخا .ةينهلما ضارملأاو تاباصلإل ةيلاع رطامخ لمتح ةيدوعسلا ةيبرعلا ةكلملما في ةلصاوتلما ةيتحتلا ةينبلاو ةيعانصلا ةيمنتلا نإ :ةيفللخا مهيلع نمؤلما ينلماعلا ينيدوعسلا يرغو ينيدوعسلا ينب ةينهلما ضارملأاو تاباصلإا تاهاتجا ةنراقم لىإ ةساردلا تفده :فدلها تدرو يتلا تانايبلا نم اًقلاطنا ةينهلما ضارملأا/تاباصلإا تاهاتجإ ليلحتل )S( لمالماو ةيعجرلما ميقلا باسح بولسأ انمدختسا :ثحبلا قرط تانايب هب انمق يذلا ليلحتلا لمش دقو .2014 و 2004 يماع ينب ةيعماتجلاا تانيمأتلل ةماعلا ةسسؤلما اهشرنت يتلا ةيونسلا ةيئاصحلإا ريراقتلا في .ةينهم اًضارمأ/تاباصإ 896627 و هيلع اًنمؤم يدوعس يرغ ًلاماع 46402079 و )%18.5( هيلع اًنمؤم اًيدوعس ًلاماع 10565993 نع ينلماعلا نم ةرم 14 لعأ وهو )%93.5( مهيلع نمؤلما ينيدوعسلا يرغ ينلماعلا ينب ةينهلما ضارملأا/تاباصلإا عوقو لدعم ناك :جئاتنلا لماعلا نم رثكأ مهيلع نمؤلما ينيدوعسلا يرغ ينلماعلا ينب اتهدايزب حجرت ةينهلما ضارملأا/تاباصلإا تناكو .)%6.5(مهيلع نمؤلما ينيدوعسلا ناك .تامدلخا لماع نهمو ،ةسدنلهاو ،ةيداصتقلاا ةطشنلأا نم تاراقعلاو ليومتلاو ،ةراجتلاو ءانبلا لماعأ في مايسلا ،مهيلع نمؤلما ينيدوعسلا .2013 ماع ىتح ةينهلما ضارملأا/تاباصلإا في ماع ضافخنا هاتجا كانه ذيفنت وه بولطلما نإف كلذلو ،ةينهلما ضارملأا/تاباصلإل ةعفترم رطاخلم ةضرع اوناك ينيدوعسلا يرغ نم مهيلع نمؤلما لماعلا :تاجاتنتسلاا .ةباصلإا نم ةلاعفلا ةياقولل جمانرب References 1. Salvatore MA, Baglio G, Cacciani L, Spagnolo A, Rosano A. Work-related injuries among immigrant workers in Italy. J Immigr Minor Health. 2013 Feb;15(1):182–7. https://doi.org/10.1007/s10903-012-9673-8 PMID:22752688 2. Marín AJ, Grzywacz JG, Arcury TA, Carrillo L, Coates ML, Quandt SA. Evidence of organizational injustice in poultry process- ing plants: Possible effects on occupational health and safety among Latino workers in North Carolina. Am J Ind Med. 2009 Jan;52(1):37–48. https://doi.org/10.1002/ajim.20643 PMID:18942666 3. Dong X, Ringen K, Men Y, Fujimoto A. Medical costs and sources of payment for work-related injuries among Hispanic con- struction workers. J Occup Environ Med. 2007 Dec;49(12):1367–75. https://doi.org/10.1097/JOM.0b013e31815796a8 PMID:18231083 4. Grzywacz JG, Arcury TA, Marín A, Carrillo L, Coates ML, Burke B, et al. The organization of work: implications for injury and illness among immigrant Latino poultry-processing workers. Arch Environ Occup Health. 2007 Spring;62(1):19–26. https://doi. org/10.3200/AEOH.62.1.19-26 PMID:18171643 5. Ahonen EQ, Benavides FG. Risk of fatal and non-fatal occupational injury in foreign workers in Spain. J Epidemiol Community Health. 2006 May;60(5):424–6. https://doi.org/10.1136/jech.2005.044099 PMID:16614333 Book 24-10.indb 1016 12/17/2018 2:22:09 PM Research article 1017 EMHJ – Vol. 24 No. 10 – 2018 6. Salminen S. Are immigrants at increased risk of occupational injury? A literature review. Ergon Open J. 2011;4(1):125–30. https:// doi.org/10.2174/1875934301104010125 7. López-Jacob MJ, Safont EC, García AM, Garí A, Agudelo-Suárez A, Gil A, et al. Participation and influence of migrant workers on working conditions: a qualitative approach. New Solut. 2010;20(2):225–38. https://doi.org/10.2190/NS.20.2.g PMID:20621886 8. General Authority for Statistics [website] (https://www.stats.gov.sa/sites/default/files/mwshrt_lqw_lml_1999-2016-lmwq_llktr- wny.pdf, accessed 19 June 2018). 9. Abbas M. Trend of occupational injuries/diseases in Pakistan: index value analysis of injured employed persons from 2001-02 to 2012-13. Saf Health Work. 2015 Sep;6(3):218–26. https://doi.org/10.1016/j.shaw.2015.05.004 PMID:26929831 10. Insurance terms [website]. Riyadh: General Organization for Social Insurance; 2017 (http://www.gosi.gov.sa/portal/web/guest/ policy/terminology,date accessed 29 May 2018) 11. Unsar S, Sut N. General assessment of the occupational accidents that occurred in Turkey between the years 2000 and 2005. Saf Sci 2009; 47:614e9. https://doi.org/10.1016/j.ssci.2008.08.001. 12. Rhee KY, Choe SW, Kim YS, Koo KH. The trend of occupational injuries in Korea from 2001 to 2010. Saf Health Work 2013; 4:63e70. https://doi.org/10.5491/SHAW.2013.4.1.63. 13. Byler CG. Hispanic/Latino fatal occupational injury rates. Mon Labor Rev. 2013;136:14–23. 14. Premji S, Messing K, Lippel K. Broken English, broken bones? Mechanisms linking language proficiency and occupational health in a Montreal garment factory. Int J Health Serv. 2008;38(1):1–19. https://doi.org/10.2190/HS.38.1.a PMID:18341120 15. Al-Thani H, El-Menyar A, Consunji R, Mekkodathil A, Peralta R, Allen KA, et al. Epidemiology of occupational injuries by na- tionality in Qatar: evidence for focused occupational safety programmes. Injury. 2015 Sep;46(9):1806–13. https://doi.org/10.1016/j. injury.2015.04.023 PMID:25943291 16. Barss P, Addley K, Grivna M, Stanculescu C, Abu-Zidan F. Occupational injury in the United Arab Emirates: epidemiology and prevention. Occup Med (Lond). 2009 Oct;59(7):493–8. https://doi.org/10.1093/occmed/kqp101 PMID:19640929 17. Hämäläinen P, Leena Saarela K, Takala J. Global trend according to estimated number of occupational accidents and fatal work-related diseases at region and country level. J Safety Res. 2009;40(2):125–39. https://doi.org/10.1016/j.jsr.2008.12.010 PMID:19433205 18. Al-Thani H, El-Menyar A, Abdelrahman H, Zarour A, Consunji R, Peralta R, et al. Workplace-related traumatic injuries: insights from a rapidly developing Middle Eastern country. J Environ Public Health. 2014;2014:430832. https://doi.org/10.1155/2014/430832 PMID:24734049 Book 24-10.indb 1017 12/17/2018 2:22:09 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1018 Use of complementary and alternative medicine among paediatric patients with hepatogastrointestinal diseases Seyed Hamdollah Mosavat, 1 Mojtaba Heydari, 1,2 Mohammad Hashem Hashempur 3 and Seyed Mohsen Dehghani 4 1Pharmaceutical Sciences Research Center, 2Research Center for Psychiatry and Behaviour Science, 4Department of Paediatric Gastroenterology, Nama- zi Hospital, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to: Seyed M. Dehghani: dehghanism@sums.ac.ir; Mohammad Hashem Hashempur: hashempur@gmail.com). 3Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Islamic Republic of Iran. Introduction Complementary and alternative medicine (CAM) covers a broad range of therapies that are outside convention- al medicine (1). It is defined as “a group of diverse medi- cal and health care systems, practices, and products that are not presently considered to be a part of conventional medicine “according to National Center for Complemen- tary and Alternative Medicine in the United States of America (2). Recently, there has been a tendency toward using CAM (3). Several studies have evaluated the prev- alence of CAM use and its associated factors in recent decades. Many have shown the noticeably prevalent use of CAM associated with factors such as age, race, socio- economic status, education level, severity of disease and availability (4,5). Several specific considerations are discussed on CAM use in paediatric patients. Ethical considerations due to inability of informed selection of therapeutic modality along with the narrow gap between therapeutic and toxic doses in paediatric patients make CAM use more challenging in this group. The prevalence of CAM use in children has been reported as a wide range, from 10% to more than 80% of the study population (5–8), mainly due to different CAM definitions and study populations or different sample size (9). As an instance, among children with cancer, juvenile rheumatoid arthritis and cystic fibrosis, utilization of CAM is more prevalent (10). Some studies examined the use of CAM, comparing groups of children presenting with different diseases which leads to different results (5). Among paediatric medical conditions, chronic gastrointestinal complaints and diseases such as chronic constipation, chronic abdominal pain and failure to thrive, along with patients with chronic hepatic diseases such as cirrhosis and hepatic transplant patients, are also disposed to high prevalence of CAM use (11). Use of CAM in these patients has specific considerations such as potential lower toxic doses and different herb and drug interactions in the absence of normal liver metabolism. These facts emphasize the need for more information on CAM use and associated factors in children with hepatic and gastrointestinal diseases. This study aimed to evaluate the prevalence and type of CAM use in patients attending a paediatric Abstract Background: The use of complementary and alternative medicine (CAM) is becoming increasingly popular in Middle Eastern countries; it is often used for paediatric medical conditions such as chronic gastrointestinal complaints and fail- ure to thrive. It is also commonly used in patients with chronic hepatic conditions such as cirrhosis and in hepatic trans- plant patients. Aims: This study aimed to evaluate the prevalence, types and associated factors of CAM use in children with hepatogas- trointestinal disease in Shiraz, Islamic Republic of Iran. Methods: In a cross-sectional study carried out during September 2013–January 2014, 238 parents of children attending a paediatric gastroenterology and hepatology clinic at Shiraz University of Medical Sciences received a self-administered questionnaire covering associated factors of complementary and alternative medicine use; 210 questionnaires were com- pleted and returned. Results: Complementary and alternative medicine was used by 103 patients (49%); 74 (71.8%) of these used herbal reme- dies. Older age of the child significantly increased CAM use. Those with previous positive experience of CAM (62.1% of users, 40.2% of non-users) and those who had received recommendation for CAM by health care providers (24.3% of users, 6.6% of non-users) were significantly more likely to use CAM. Conclusions: This survey demonstrated the high prevalence of CAM use (especially herbal remedies) in paediatric pa- tients with hepatogastrointestinal diseases. Keywords: hepatogastrointestinal disease; children; Iran; complementary and alternative medicine (CAM) Citation: Mosavat SH; Heydari MH; Hashempur M; Dehghani SM. Use of complementary and alternative medicine among paediatric patients with hepatogastrointestinal diseases. East Mediterr Health J. 2018;24(10):1018–1025. https://doi.org/10.26719/2018.24.10.1018 Received: 04/07/15; accepted: 23/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Book 24-10.indb 1018 12/17/2018 2:22:09 PM Research article 1019 EMHJ – Vol. 24 No. 10 – 2018 hepatogastrointestinal clinic at Shiraz University of Medical Sciences. In addition, we attempt to describe child- and parent-related factors associated with the use of CAM. Methods Study design and sampling We conducted a cross-sectional study on a convenience sample of 238 parents of paediatric patients presenting for health care visits at Shiraz University of Medical Sciences paediatric gastroenterology and hepatic referral clinic from September 2013 to January 2014. The study population was limited to parents of children with any gastrointestinal disease that were referred to the paediat- ric gastroenterology and hepatic clinic. The study protocol was approved by the Medical Ethics Committee of Shiraz University of Medical Sciences (approval number: 90-5765). Data collection The researchers developed and piloted a survey on 20 parents (separate from the study group) to determine the information necessary to address the aims of the study. Parents who were referred for their child to be visited by the paediatric gastroenterologist were invited to participate in this study. After signing the informed consent form, they filled out a self-administered questionnaire which took about 15–20 minutes to complete. Parents who for any reason were not able to express their ideas or filled out the questionnaires incompletely were excluded from the study. We designed the semi-structured questionnaire based on the current literature and our study goals. The questionnaire consisted of 16 questions including both open- and closed-ended questions, which were categorized into 2 domains. The first domain consisted of 9 questions regarding sociodemographic data such as child’s and parents’ age, parents’ education status, type of child’s disease and residence. The second domain consisted of 7 questions about the use of CAM within the last year, the type of CAM used, positive previous experiences about the beneficial effects of CAM, local access to CAM, the patient’s view about possible interactions of CAM with chemical drugs. It was necessary for us to mention popular types of CAM that are practised among Iranian people to better define CAM for participants. Also, the patients’ parents determined the type of disease for which CAM is used (e.g. abdominal pain, constipation, jaundice, diarrhoea, reflux and inflammatory bowel disease), type of CAM used, previous recommendations or prohibition by their health care providers, previous positive or negative experience with CAM and their access to CAM providers Statistical analysis Descriptive statistics were used to characterize the study participants overall and within subgroups. Bivariate comparisons of the user and non-user groups were made using the Chi-squared test for categorical variables and the t-test for continuous variables. P values < 0.05 were considered statistically significant. Multiple logistic regression analysis was undertaken to determine the independent association between CAM use and the multivariate predictors. Selected variables in the logistic regression model were based on the analysis of each variable using Chi-squared and the independent t-test. If the P value was ≤ 0.25, the variable was then examined using logistic regression. Results From 238 questionnaires distributed, a total of 210 (88.23%) were completed. Twenty eight patients (11.76%) were excluded from the study because they refused to complete the questionnaires or filled out the question- naires incompletely. The mean age of the paediatric patients was 6.2 [standard deviation (SD) 4.9] years (range 1 month–19 years) and the mean age of the mothers and fathers was 31.6 (SD 6.35) years (range 23–68 years) and 36.3 (SD 7.58) years (range 18–51 years) respectively. Patients presented with a variety of diseases, including gastrointestinal diseases (46.6%), hepatic diseases (31.1%) and failure to thrive (6.8%) (Table 1). Details of sociodemographic characteristics of the participants and associated factors in CAM users versus non-users are shown in Table 1.The use of CAM was not influenced by the parents’ attitude about side-effects (P = 0.063) nor their attitude about the results of the combination of CAM with routine drugs (P = 0.195). One hundred and three patients (49%) used CAM in the course of their hepatogastrointestinal disease; 74 (71.8%) used herbal remedies and 46 (44.6%) used other types of CAM (Table 2). Spiritual therapy was sued by 35.9%. It should be noted that the patients were allowed to choose more than one option, so the summation of values may total more than 100%. Among the herbal remedies, the most common ones used in hepatogastrointestinal diseases by the study population are shown in Table 3. Descurainia sophia (33%) and Thymus vulgaris (16%) were the 2 most commonly mentioned. No significant difference in the rate of CAM use was observed among patients with different parents’ ages (P = 0.35 and P = 0.09 for mothers and fathers respectively) (Table 2), but logistic regression analysis showed that older age of the child significantly increased CAM use (OR 0.08; P = 0.036) (Table 4). Patients with previous positive experience of CAM (62.1% of users vs 40.2% of non-users, P = 0.046) and patients who had received recommendation for CAM use by health care providers (24.3% of users vs 6.6% of non-users, P = 0.001) were significantly more likely to use CAM than others according to logistic regression analysis (Tables1,4). But prohibition of CAM use by health care providers did not significantly affect the prevalence of CAM use (20.4% of users vs 20.6% of non-users, P = 0.97). Book 24-10.indb 1019 12/17/2018 2:22:09 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1020 Discussion Our findings demonstrated the prevalence and associat- ed factors of CAM use in paediatric patients referred to Shiraz University of Medical Sciences paediatric hepato- gastroenterology clinic. This study showed that 49% of the patients used at least 1 type of CAM. Herbal remedies were the most common type used. Older child age was as- sociated with the use of CAM. Additionally, the patients who were advised by their health care provider to use CAM and those who had previous positive experience with CAM were more likely to use it. Complementary and alternative medicine is commonly used in the Iranian population, especially herbal medicine (12,13). Several studies have been done on the pattern and associated factors of CAM use in different diseases, and prevalence ranged from 10% to 67%. This wide range was influenced by differences in the population samples and types of CAM (14–18). To the best of our knowledge, although there has been no study that evaluated the prevalence and type of CAM used in paediatric patients with hepatogastrointestinal diseases in Iran, the prevalence rate of CAM use in our study was similar to the findings of Tonekaboni et al. for epileptic children in Tehran (17). They reported a 44% prevalence of CAM use. Additionally, our result on the use of CAM is similar to those of 2 studies conducted in Turkey and Switzerland. Arýkan et al. in their survey on Table 1 Sociodemographic characteristics of users and non-users of complementary and alternative medicine (CAM) among paediatric patients (n = 210) with hepatogastrointestinal diseases, Shiraz, 2013–2014 Characteristic CAM users CAM non-users P-value Bivariate analysis Logistic regression Mean (SD) Mean (SD) Age (years) Mother 31.26 (5.67) 32.08 (6.96) 0.35 0.037 Father 35.46 (6.27) 37.21 (8.61) 0.09 Child 5.63 (4.39) 6.83 (5.44) 0.08 No. of children in family 1.9 (1.0) 2.0 (1.0) 0.39 % % Residence Urban 47.6 47.7 0.98 Rural 52.4 52.3 Availability of CAM Available 70.9 58.0 0.051 0.090 Unavailable 29.1 42.0 Previous positive experience with CAM Yes 62.1 40.2 0.001 0.040 No 37.9 58.8 Parents' attitude about side-effects of CAM Mild 57.3 54.3 0.063 Moderate 29.1 38.3 Severe 13.6 7.4 Parents' attitude about CAM combination with children’s conventional drugs Synergic effects with drugs 37.8 23.4 0.195 Interaction with drugs 43,7 50.5 None 18.5 26.1 Health care provider recommended CAM Yes 24.3% 6.6 < 0.0001 0.001 No 75.7% 93.4 Health care provider prohibited CAM Yes 20.4 20.6 0.97 No 79.6 79.4 Disease type Hepatic 31.1 28.0 0.29 Gastrointestinal 46.6 33.6 Failure to thrive 6.8 7.5 Other 15.5 30.9 SD = standard deviation. Book 24-10.indb 1020 12/17/2018 2:22:09 PM Research article 1021 EMHJ – Vol. 24 No. 10 – 2018 children with type I diabetes demonstrated CAM use by 52% of them (19). Moreover, Zuzak et al. reported 58% CAM use in a population of paediatric patients presenting to an emergency department (20). However, our results are in contrast with those of several other studies on paediatric patients. For example, 19% of parents of children with type I diabetes at an American urban paediatric clinic reported CAM use for their children (21). Another study in a primary paediatric care centre in Washington DC reported CAM use in 21% of children (22). Also, a survey in a general paediatric clinic reported a lower CAM use (30%), in contrast to our findings (23). As in previous Iranian research on prevalence of CAM use (24), herbal remedies were the most common form, (71.8%) of CAM use in our study. However, some investigations on CAM use for paediatric patients reported herbal medicine use by 40–60% of CAM users (19,21–23). Spiritual therapy was another common type of CAM reported in our study. This is probably due to the religious beliefs which are very common in Iranian culture. Live raw fish swallowing was a traditional remedy in Iranian folklore medicine for treatment of paediatric jaundice (25). This folk habit was also reported to be used in other countries (26) and is associated with the risk of parasitic infections (27). Among the herbal remedies used, Descurainia sophia is one of the most common herbs used in Traditional Persian Medicine as a neonatal jaundice remedy (28–30). Although we did not find any study about the relationship between D. sophia and jaundice, some research that showed anti-inflammatory and laxative effects of D. sophia (31,32). Thymus vulgaris is another plant used frequently by patients, especially for abdominal pain. The antispasmodic and gastrotonic effects of this plant are supported by previous studies (33,34). Taranjabin, or Persian manna, and Cotoneaster are traditional laxatives used commonly in paediatric patients (35), and are traditionally used in the management of neonatal jaundice. Some clinical studies support the efficacy of these herbs in the treatment of neonatal jaundice (36– 38). However, according to the most famous resources of Traditional Persian Medicine, such as the Canon of medicine by Avicenna (980–1037 AD) (39), and the Liber continens of Rhazes (865–925 AD) (40), there is no scientific support for some of these uses. The reasons for the use of medicinal herbs by the Iranian population are clear. Briefly, several investigations indicate their relative efficacy in some traditional uses. Also, Traditional Persian Medicine has a long history and there are inextricable relationships with the daily life of Table 2 Distribution of types of complementary and alternative medicine (CAM) used by paediatric patients (n = 103) with hepatogastrointestinal diseases, Shiraz, 2013–2014 Type of CAM Users (%)a Natural products Herbal remedies 71.8 Swallowing raw fish 5.8 Other 5.2 Mind and body practices Spiritual therapy 35.9 Energy healing therapy 3.8 Wet cupping 2.9 Gem therapy 1.9 Other 2.9 aPatients may use more than one type of CAM. Table 3 Herbs commonly used for paediatric patients (n = 103) with hepatogastrointestinal diseases, Shiraz, 2013–2014 Herb species % Descurainia sophia 33 Thymus vulgaris 16 Cotoneaster sp. 13 Alhagi maurorum 11 Fumaria officinalis 5 Mentha piperita 4 Ziziphus jujube 4 Borago officinalis 4 Olea europaea 4 Other 18 Table 4 Logistic regression analysis: independent association between use of complementary and alternative medicine and selected external predictors Variable Odds ratio 95 % confidence interval Lower bound Upper bound (Constant) 0.354 –0.075 0.782 Availability of CAM 0.117 –0.024 0.257 Previous positive experience with CAM 0.139 0.002 0.275 Parents' attitude about CAM combination 0.067 –0.024 0.157 Health care providers' recommendation 0.311 0.125 0.498 Mean child age 0.014 0.001 0.027 Only variables with P < 0.25 in statistical comparison between users and non-users were entered into the analysis. Book 24-10.indb 1021 12/17/2018 2:22:09 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1022 Iranian people (41). Accessibility and the relatively low cost of medicinal herbs are among the other reasons for their use (42). This study showed a slight but statistically significant positive association between the child’s age and use of CAM. Previous studies also showed a higher prevalence of CAM use in adult populations than paediatric populations (43–45). Also, according to a study by Ottolini et al., older children were treated with CAM more than younger ones (22). This lower frequency of CAM use in children, especially the younger ones, may be due to parental considerations about the potential adverse events of herbs on smaller children. Our study had some limitations. It was not a population- based survey and our results are not generalizable to the entire population. Moreover the sample size was not large enough to be really representative of the population variations. Lack of a validated questionnaire is a common methodological problem in the most surveys like ours (9). Another consideration in interpreting our results is that supplements (vitamins, probiotics and fish oil) were not considered as CAM in our study. As a conclusion, this study demonstrated a high prevalence of CAM use, particularly herbal remedies, in paediatric patients with hepatogastrointestinal diseases, which was independently and significantly associated with previous positive experience, healthcare providers’ recommendation and older age of the child. Acknowledgements The authors would like to thank the Research Centre for Traditional Medicine and History of Medicine and the Vice Chan- cellery of Technology and Research of Shiraz University, all of the study participants for their participation, and Dr Nasrin Shokrpour at the University's Research Consultation Centre for editing the final manuscript. Funding: This study was supported by Shiraz University of Medical Sciences (grant number: 92-6709) and Fasa Universi- ty of Medical Sciences (grant number: 96078). Utilisation des médicaments complémentaires et alternatifs chez les patients pédiatriques atteints de maladies hépato-gastro-intestinales Résumé Contexte : L’utilisation des médicaments complémentaires et alternatifs (MCA) est de plus en plus populaire dans les pays du Moyen-Orient. Ils sont souvent employés pour traiter les problèmes médicaux pédiatriques tels que les troubles gastro-intestinaux chroniques et les retards staturo-pondéraux. Elles sont aussi couramment utilisées chez les patients atteints de maladies hépatiques chroniques telles que la cirrhose et chez les patients ayant reçu une greffe de foie. Objectifs : La présente étude avait pour objectif d’évaluer la prévalence de l’utilisation des médicaments complémentaires et alternatifs ainsi que les types de médicaments et les facteurs associés chez les enfants souffrants de maladies hépato- gastro-intestinales à Chiraz, en République islamique d’Iran. Méthodes : Dans une étude transversale réalisée entre septembre 2013 et janvier 2014, 238 parents d’enfants consultant dans une clinique d’hépatologie et de gastro-entérologie pédiatrique à l’Université des Sciences médicales de Chiraz ont reçu un questionnaire auto-administré couvrant les facteurs associés à l’utilisation des médicaments complémentaires et alternatifs ; 210 questionnaires ont été remplis et renvoyés. Résultats : Des médicaments complémentaires et alternatifs étaient utilisés pour le traitement de 103 patients (49 %) ; 74 (71,8 %) d’entre eux utilisaient des remèdes à base de plantes. Ces médicaments étaient beaucoup plus utilisés chez les enfants plus âgés. Les répondants ayant eu des expériences précédentes positives avec des médicaments complémentaires et alternatifs (62,1 % d’utilisateurs, 40,2 % de non-utilisateurs) et ceux à qui des prestataires de soins de santé avaient recommandé ces médicaments (24,3 % d’utilisateurs, 6,6 % de non-utilisateurs) étaient beaucoup plus susceptibles d’utiliser les médicaments complémentaires et alternatifs. Conclusions : La présente étude a montré la forte prévalence de l’utilisation des médicaments complémentaires et alternatifs (en particulier les remèdes à base de plantes) chez les patients pédiatriques atteints de maladies gastro- intestinales. Book 24-10.indb 1022 12/17/2018 2:22:10 PM Research article 1023 EMHJ – Vol. 24 No. 10 – 2018 References 1. Harris PE, Cooper KL, Relton C, Thomas KJ. Prevalence of complementary and alternative medicine (CAM) use by the general population: a systematic review and update. 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Use of complementary medicine in pediatric patients with inflammatory bowel disease: results from a multicenter survey. J Pediatr Gastroenterol Nutr. 2009 Jan;48(1):55–60. https://doi. org/10.1097/MPG.0b013e318169330f PMID:19172124 6. Davis MP, Darden PM. Use of complementary and alternative medicine by children in the United States. Arch Pediatr Adolesc Med. 2003 Apr;157(4):393–6. https://doi.org/10.1001/archpedi.157.4.393 PMID:12695237 7. Adams D, Schiffgen M, Kundu A, Dagenais S, Clifford T, Baydala L, et al. Patterns of utilization of complementary and alterna- tive medicine in 2 pediatric gastroenterology clinics. J Pediatr Gastroenterol Nutr. 2014 Sep;59(3):334–9. https://doi.org/10.1097/ MPG.0000000000000439 PMID:24854897 8. Ozturk C, Karayagiz G. Exploration of the use of complementary and alternative medicine among Turkish children. J Clin Nurs. 2008 Oct;17(19):2558–64. https://doi.org/10.1111/j.1365-2702.2008.02329.x PMID:18808623 9. Posadzki P, Watson L, Alotaibi A, Ernst E. Prevalence of complementary and alternative medicine (CAM)-use in UK paediatric patients: a systematic review of surveys. Complement Ther Med. 2013 Jun;21(3):224–31. https://doi.org/10.1016/j.ctim.2012.11.006 PMID:23642955 10. Lin YC, Lee AC, Kemper KJ, Berde CB. Use of complementary and alternative medicine in pediatric pain management service: a survey. Pain Med. 2005 Nov-Dec;6(6):452–8. https://doi.org/10.1111/j.1526-4637.2005.00071.x PMID:16336482 11. Haas L, McClain C, Varilek G. Complementary and alternative medicine and gastrointestinal diseases. Current opinion in gastro- enterology. 2000;Mar;16(2):188–96. PMID:17024040 12. Hashempur MH, Ghasemi MS, Daneshfard B, Ghoreishi PS, Lari ZN, Homayouni K, et al. Efficacy of topical chamomile oil for mild and moderate carpal tunnel syndrome: A randomized double-blind placebo-controlled clinical trial. Complement Ther Clin Pract. 2017 Feb;26:61–7. https://doi.org/10.1016/j.ctcp.2016.11.010 PMID:28107852 ءاعملأاو ةدعلماو دبكلا ضارمأب ضىرلما لافطلأل لييمكتلاو ليدبلا بطلا مادختسا نياقهد نسمح ديس ،روب مشاه مشاه دممح ،يرديح ىبتمج ،تاواسم هلادحم ديس ةصلالخا لثم ةينطابلا لافطلأا بط تلااح في مدختسي نأ بلغيو ؛طسولأا قشرلا نادلب في لييمكتلاو ليدبلا بطلا مادختساو ةيبعش دادزت :ةيفللخا .دبكلا عرزو دبكلا ع ُّمَشَت لثم ةنمزم ةيدبك تلااح نم نوناعي نيذلا ضىرملل همادختسا عيشي ماك .ومنلا لشفو ءاعملأاو ةدعلما في ةنمزلما ىواكشلا ةدعلماو ءاعملأاو دبكلا في ضارملأ ليدبلاو لييمكتلا بطلاب ةطبترلما لماوعلاو طمانلأاو راشتنلاا ىدم مييقت لىإ ةساردلا هذه تفده :فادهلأا .ةيملاسلإا ناريإ ةيروهجم في زايرش في ،لافطلأل نيذلا لافطلأا تاهمأو ءابآ نم 238 تلمشو ،2014 ماع نياثلا نوناك/رياني – 2013 لوليأ/برمتبس للاخ تذفن ةيعطقم ةسارد في :ةقيرطلا لماوعلا يطغي اًيتاذ لمكتسي ًانايبتسإ اوقلت ،زايرش في ةيبطلا مولعلا ةعماج في دبكلاو ءاعملأاو ةدعلما ضارملأ لافطلأا بط ةدايع لع نوددتري .ًانايبتسا 210 اولمكتساف ؛ليدبلاو لييمكتلا بطلاب ةطبترلما لفطلا نس مدقت عمو .ةيبشعلا تاجلاعلا )%71.8( مهنم 74 مدختساو ؛)%49( اًضيرم 103 ىدل مدختسي لييمكتلاو ليدبلا بطلا ناك :جئاتنلا نم %62.1( لييمكتلاو ليدبلا بطلا في ةقباس ةيبايجإ ةبرخ نوكلمي نيذلا نأ َدِجُو دقلو .ةيربك ةدايز لييمكتلاو ليدبلا بطلا مادختسا دادزي لييمكتلاو ليدبلا بطلا لوح ةيحصلا ةياعرلا تامدخ يمدقم نم تايصوت اوقلت نيذلا كئلوأو )ينمدختسلما يرغ نم %40.2و ،هل ينمدختسلما .بركأ لييمكتلاو ليدبلا بطلل مهمادختسا لماتحا ناك )ينمدختسلما يرغ نم %6.6و ،هل ينمدختسلما نم %24.3( نيذلا ضىرلما لافطلأل )ةيبشعلا تالجاعلماا مايس لاو( لييمكتلاو ليدبلا بطلا مادختسا راشتنا لدعم عافترا ةساردلا هذه ترهظأ :تاجاتنتسلاا .ءاعملأاو ةدعلماو دبكلا في ضارمأ نم نوناعي Book 24-10.indb 1023 12/17/2018 2:22:10 PM EMHJ – Vol. 24 No. 10 – 2018Research article 1024 13. Qasemzadeh MJ, Sharifi H, Hamedanian M, Gharehbeglou M, Heydari M, Sardari M, et al. The effect of Viola odorata flower syrup on the cough of children with asthma: a double-blind, randomized controlled trial. J Evid Based Complementary Altern Med. 2015 Oct;20(4):287–91. https://doi.org/10.1177/2156587215584862 PMID:25954025 14. Pasalar M, Lankarani KB. Herbal medicines, a prominent component in complementary and alternative medicine use in gastro- intestinal field. Am J Gastroenterol. 2015 Jun;110(6):935. https://doi.org/10.1038/ajg.2015.108 PMID:26052773 15. Roozbeh J, Hashempur MH, Heydari M. Use of herbal remedies among patients undergoing hemodialysis. Iran J Kidney Dis. 2013 Nov;7(6):492–5. PMID:24241097 16. Yekta Z, Zamani A, Mehdizade M, Farajzadegan Z. Pattern of complementary and alternative medicine use in urban population. J Res Health Sci. 2007 07 28;7(1):24–31. PMID:23343868 17. Tonekaboni SH, Jafari Naeini S, Khajeh A, Yaghini O, Ghazavi A, Abdollah Gorji F. Use of complementary and alternative medicine for epileptic children in Tehran: a cross-sectional study (2009-2011). Iran J Child Neurol. 2014 Winter;8(1):26–31. PMID:24665324 18. Asadi-Pooya AA, Emami M. Perception and use of complementary and alternative medicine among children and adults with epilepsy: the importance of the decision makers. Acta Med Iran. 2014;52(2):153–7. PMID:24659074 19. Arýkan D, Sívríkaya SK, Olgun N. Complementary alternative medicine use in children with type 1 diabetes mellitus in Erzurum, Turkey. J Clin Nurs. 2009 Aug;18(15):2136–44. https://doi.org/10.1111/j.1365-2702.2008.02464.x PMID:19077023 20. Zuzak TJ, Zuzak-Siegrist I, Simões-Wüst AP, Rist L, Staubli G. Use of complementary and alternative medicine by patients presenting to a paediatric emergency department. Eur J Pediatr. 2009 Apr;168(4):431–7. https://doi.org/10.1007/s00431-008-0765-3 PMID:18597113 21. Miller JL, Binns HJ, Brickman WJ. Complementary and alternative medicine use in children with type 1 diabetes: a pilot survey of parents. Explore (NY). 2008 Sep-Oct;4(5):311–4. https://doi.org/10.1016/j.explore.2008.06.002 PMID:18775401 22. Ottolini MC, Hamburger EK, Loprieato JO, Coleman RH, Sachs HC, Madden R, et al. Complementary and alterna- tive medicine use among children in the Washington, DC area. Ambul Pediatr. 2001 Mar-Apr;1(2):122–5. https://doi. org/10.1367/1539-4409(2001)001<0122:CAAMUA>2.0.CO;2 PMID:11888385 23. Vlieger AM, van de Putte EM, Hoeksma H. [The use of complementary and alternative medicine in children at a general paediat- ric clinic and parental reasons for use]. Ned Tijdschr Geneeskd. 2006 Mar 18;150(11):625–30. PMID:16610506 24. Hashempur MH, Heydari M, Mosavat SH, Heydari ST, Shams M. Complementary and alternative medicine use in Iranian pa- tients with diabetes mellitus. J Integr Med. 2015 Sep;13(5):319–25. https://doi.org/10.1016/S2095-4964(15)60196-0 PMID:26343103 25. Abramson SB. Nitric oxide in inflammation and pain associated with osteoarthritis. Arthritis Res Ther. 2008;10 Suppl 2:S2. https://doi.org/10.1186/ar2463 PMID:19007427 26. Lim JU, Joo KR, Shin HP, Cha JM, Lee JI, Lim SJ. Obstructive jaundice caused by Clonorchiasis-associated duodenal papillitis: a case report. J Korean Med Sci. 2011 Jan;26(1):135–7. https://doi.org/10.3346/jkms.2011.26.1.135 PMID:21218042 27. Hafeez M. Helminth parasites of public health importance-Trematodes. J Parasit Dis. 2003;27:69–75. 28. Yazdi EG, Minaei MB, Dabaghian FH, Ardakani MEZ, Ranjbar AM, Rastegari M, et al. Efficacy of Myrtus communis L. and Descurainia sophia L. versus salicylic acid for wart treatment. Iran Red Crescent Med J. 2014 10 5;16(10):e16386. https://doi. org/10.5812/ircmj.16386 PMID:25558385 29. Amiri MS, Joharchi MR, Taghavizadehyazdi ME. Ethno-medicinal plants used to cure jaundice by traditional healers of Mash- had, Iran. Iran J Pharm Res. 2014 Winter;13(1):157–62. PMID:24734067 30. Boskabadi H, Maamouri G, Ebrahimi M, Ghayour-Mobarhan M, Esmaeily H, Sahebkar A, et al. Neonatal hypernatremia and dehydration in infants receiving inadequate breastfeeding. Asia Pac J Clin Nutr. 2010;19(3):301–7. PMID:20805072 31. Lee YJ, Kim NS, Kim H, Yi J-M, Oh S-M, Bang O-S, et al. Cytotoxic and anti-inflammatory constituents from the seeds of Des- curainia sophia. Arch Pharm Res. 2013 May;36(5):536–41. https://doi.org/10.1007/s12272-013-0066-x PMID:23435946 32. Nimrouzi M, Sadeghpour O, Imanieh MH, Shams Ardekani M, Salehi A, Minaei MB, et al. Flixweed vs Polyethylene Gly- col in the Treatment of Childhood Functional Constipation: A Randomized Clinical Trial. Iran J Pediatr. 2015 Apr;25(2):e425. PMID:26196006 33. Esmaeili D, Mobarez AM, Tohidpour A. Anti-helicobacter pylori activities of shoya powder and essential oils of thymus vulgaris and eucalyptus globulus. Open Microbiol J. 2012;6(1):65–9. https://doi.org/10.2174/1874285801206010065 PMID:22927892 34. Nikolić M, Glamočlija J, Ferreira IC, Calhelha RC, Fernandes Â, Marković T, et al. Chemical composition, antimicrobial, antioxi- dant and antitumor activity of Thymus serpyllum L., Thymus algeriensis Boiss. and Reut and Thymus vulgaris L. essential oils. Ind Crops Prod. 2014;52:183–90. https://doi.org/10.1016/j.indcrop.2013.10.006 35. Ramezany F, Kiyani N, Khademizadeh M. Persian manna in the past and the present: an overview. Am J Pharmacol Sci. 2013;1(3):35–7. https://doi.org/10.12691/ajps-1-3-1 36. Farhat AS, Mohammadzadeh A, Amir M, Ramezani M. Effect of Cotoneaster tricolor pojark manna on serum bilirubin levels in neonates. Int J Pharmacol. 2006;2(4):455–8. https://doi.org/10.3923/ijp.2006.455.458 37. Azadbakht M, Pishva N, Mohammadi Samani S, Alinejad F. The effect of purgative manna on the infant jaundice. Iran J Pharm Sci. 2005;1(2):95–100. Book 24-10.indb 1024 12/17/2018 2:22:10 PM Research article 1025 EMHJ – Vol. 24 No. 10 – 2018 38. Ghotbi F, Nahidi S, Zangi M. Surveying the effect of Cotoneaster spp. (shir khesht) on neonatal jaundice. Res Med. 2006;30(4):353–61. 39. Dalfardi B, Heydari M, Golzari SE, Mahmoudi Nezhad GS, Hashempur MH. Al-Baghdadi’s description of venous blood circula- tion. Int J Cardiol. 2014 Jun 1;174(1):209–10. https://doi.org/10.1016/j.ijcard.2014.03.199 PMID:24746501 40. Mosavat SH, Ghahramani L, Haghighi ER, Chaijan MR, Hashempur MH, Heydari M. Anorectal Diseases in Avicenna’s “Canon of Medicine”. Acta Med Hist Adriat. 2015;13 Suppl 2:103–14. PMID:26959635 41. Heyadri M, Hashempur MH, Ayati MH, Quintern D, Nimrouzi M, Heyadri M. The use of Chinese herbal drugs in Islamic medi- cine. J Integr Med. 2015 Nov;13(6):363–7. https://doi.org/10.1016/S2095-4964(15)60205-9 PMID:26559361 42. WHO traditional medicine strategy 2002–2005. Geneva: World Health Organization; 2002 (WHO/EDM/TRM/2002.1; http:// www.wpro.who.int/health_technology/book_who_traditional_medicine_strategy_2002_2005.pdf, accessed 18 March 2018). 43. Ernst E. Prevalence of complementary/alternative medicine for children: a systematic review. Eur J Pediatr. 1999 Jan;158(1):7–11. https://doi.org/10.1007/s004310051000 PMID:9950300 44. Barnes PM, Powell-Griner E, McFann K, Nahin RL, editors. Complementary and alternative medicine use among adults: United States, 2002. Bethesda, Maryland: Centers for Disease Control and Prevention; 2004 (Advance Data No. 343). 45. Wheaton AG, Blanck HM, Gizlice Z, Reyes M. Medicinal herb use in a population-based survey of adults: prevalence and fre- quency of use, reasons for use, and use among their children. Annals of epidemiology. 2005;15(9):678-85. Book 24-10.indb 1025 12/17/2018 2:22:10 PM EMHJ – Vol. 24 No. 10 – 2018Commentary 1026 Challenges for pregnant Syrian refugees in Lebanon Lena Abdin 1 1School of Advanced International Studies, Johns Hopkins University, Washington, United States of America. (Correspondence to: lenaabdin@gmail. com). Introduction During the summer of 2015 this study conducted research on various nongovernmental organizations (NGOs) and clinics operating on the ground that dealt with antenatal care for Syrian refugees. The main aim was to determine the challenges facing Syrian refugees who were pregnant and spending their term in a refugee environment. Antenatal care is defined as “the branch of medicine that deals with the care of women during pregnancy, childbirth, and the recuperative period following delivery” (1). The main focus of this exploration is antenatal care, but in order to understand what it takes to treat a woman while she is pregnant, it is important to understand the circumstances of her pregnancy in the refugee setting context. The process was begun by conducting a literature review on what was already documented for this topic. Only one study had been published and another, conducted at Johns Hopkins, was in the process of publication (2,3). The head of the first study was contacted and insight gained on where to do interviews on the ground and which NGOs were most responsive. Due to inaccessibility to makeshift camps or rural areas to conduct interviews, it was decided to focus on three different clinics around Beirut: the UNHCR designated maternal clinic, Caritas’s designated maternal clinic, and a local Lebanese non-profit clinic. The directors of health departments were interviewed at UNHCR, Caritas, and Première Urgence-Aide Médicale Internationale and requesting access to their respective clinics to speak with patients. At the clinics the patients were informed about the study in order to gauge their willingness to be interviewed. The women were given the option of remaining anonymous as some were afraid to give their full names for fear of repercussion back in the Syrian Arab Republic, where many refugees are viewed as “traitors” for leaving the country. Only the women who felt comfortable doing so wrote their names on the survey forms. The survey covered basic questions about the woman’s living situation (where she lived and with how many people) and demographic information. It also covered the medical aspects of pregnancy such as how many visits she had had with the doctor and what vitamins/procedures she had had during her pregnancy. The survey also asked if she had used birth control in the past and what her birth plan was. Fifty-three women were invited for interview and seven refused, giving a total of 42 women who were interviewed. For those who could not read, the questions were read aloud and answers recorded on the survey form. A limitation of this survey was the location of interviews, which only took place in clinics. Another limitation was the size of the sample. With only 42 women interviewed, the results cannot be generalized to all Syrian refugee women in Lebanon – many do not have access to clinics. Furthermore, because this is an ongoing conflict and the number of Syrian refugees is growing daily, newly arrived refugees may have different characteristics and needs. Setting Awareness is one of the pertinent issues faced by or- ganizations on the ground in Lebanon when it comes to contraception and antenatal care. Many of the women interviewed had either barely finished secondary educa- tion or had only primary education. Almost 100% of those interviewed had absolutely no knowledge of reproduc- tive health prior to marriage. Even after marriage, most reproductive health information is taught through reli- gious and cultural mechanisms (e.g. religion classes and women’s social gatherings) rather than educational or scientific mechanisms. One case stood out in this regard. A woman entered the doctor’s office at the Caritas clinic with her mother and mother-in-law, and was complaining of pain and cramps. When asked if she was on any medication the response was ovary stimulants, which had been prescribed since she still was not pregnant after eight months of marriage. Ovary stimulants are dangerous and can harm the reproductive future of a woman (4), yet speed of conception was considered more important by the family than the health of the woman and her future child. The health risks involved in giving this type of medication to a most likely healthy woman were explained and that there were less invasive ways of trying to determine if there was infertility (like testing the male sperm). The three women listened andthen left, with the mother-in-law returning later to ask if the doctor could Keywords: refugees, pregnancy, contraception, costs, healthcare Citation: Abdin L. Challenges for pregnant Syrian refugees in Lebanon. East Mediterr Health J. 2018;24(10):1026–1029. https://doi. org/10.26719/2018.24.10.1026 Received: 02/06/16; accepted: 23/07/17 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Book 24-10.indb 1026 12/17/2018 2:22:10 PM Commentary 1027 EMHJ – Vol. 24 No. 10 – 2018 refill the prescription for the ovary stimulants because the previous doctor had refused out of concern for the daughter. The lack of reproductive awareness and education is a major issue for many Middle Eastern countries. Cultural norms like delivering a son as the first child immediately after marriage to ensure the family’s continued lineage and honour are still prevalent, even among desperate refugee populations. These norms do not disappear simply because these populations have been uprooted. This is why education and awareness are key when considering how to empower and teach refugees about reproduction, especially in a country with a population crisis as found in Lebanon. Contraception Cost barriers A 2013 study found that the main barriers to contracep- tive use in Lebanon for Syrian refugees were high cost, distance from services and absence of their desired method of contraception (5). The United Nations High Commissioner for Refugees (UNHCR) provides free ac- cess to family planning and contraception methods for registered refugees. Before the start of the conflict, the Syrian Arab Republic had an efficient health care system for middle- and lower-income families. Family planning methods and contraceptives were free and used by 58% of women (5). However, in Lebanon these numbers seem to have dropped. According to a United Nations Population Fund (UNFPA) report, among Syrian refugee women in Lebanon in 2012 only 37% of non-pregnant married wom- en were using contraception (6). During the interviews conducted in Lebanon for this research, many Christian women claimed they had never used contraceptives for religious reasons. However, Muslim women claimed that the cost of contraceptives in Lebanon was too high. Fur- thermore, they were used to certain brands and to receiv- ing the contraceptives for free. Lebanon as host country is barely able to meet the demand for basic healthcare for Lebanese citizens, let alone for Syrian refugees, according to UNHCR (7). The Lebanese public–private healthcare system makes it all the more difficult to address the needs of refugees. Most clinics in Beirut are privately owned and operated and are very expensive for Syrian refugees. The women interviewed verified this on multiple occasions, citing the high costs of private healthcare. Uninsured Lebanese citizens obtain care through the Ministry of Health via public hospitals that cover up to 85% of the cost of hospital visits (8). The influx of Syrian refugees also exacerbates the challenges faced by Lebanese citizens seeking access to public healthcare (9). Other issues are simply those of immediate need, whereby funds and services provided by organizations are usually directed at more life-threatening medical problems for Syrian refugees rather than issues such as contraception. Awareness and knowledge Contraception can help alleviate the already evident population crisis in Lebanon due to the immense in- flux of refugees. However, many Syrian refugees are simply uneducated about contraception. There is still a widely held belief that birth control prevents a woman from getting pregnant later on in life. However, field workers from the International Medical Corps in Bei- rut revealed that awareness sessions have helped in in- creasing knowledge of the positive outcomes of birth control as well as reducing pregnancy rates in refugee populations in rural areas. These sessions have been most effective when led by a religious leader in the community. Moreover, targeting men in their aware- ness sessions on contraception was important since it is usually the husband who decides whether or not his wife should utilize some form of birth control. Pregnancy Cost barriers The cost of antenatal care itself is a huge burden for refugees, despite the subsidy paid by UNHCR. Antena- tal care for registered Syrian women is covered for up to four antenatal care visits, 85% of laboratory costs and 75% of delivery costs. Pregnancy supplements and two ultrasound scans are provided free of charge. However, unregistered Syrian refugee women are only eligible for one visit to a primary healthcare centre supported by UNHCR. This is problematic for the following rea- sons. First, there are many refugees illegally working and living in Lebanon that are not registered with UNHCR. There is no reliable data on the number of unregistered Syrian refugees currently in Lebanon. General estimates and media reports citing unnamed Lebanese officials put the number of Syrians living in Lebanon and not registered with UNHCR between 200 000 and 400 000, although the reliability of and sources for these estimates, which do not distinguish between those in need of protection and/or assistance and those not in need, are unknown (10). The reasons for them being unregistered are numerous, but they most likely fear reprisal from the Syrian regime or reprisal against their family members still living in the Syrian Arab Republic due to their association with perceived “anti- regime” institutions like the United Nations (UN) (11). Second, even those registered could be living in a decentralized living situation such as makeshift camps where they do not have the ability to reach areas in which UNHCR operates, or just do not have information on where to access clinics or services. Antenatal care in the Syrian Arab Republic was not expensive and often free, while the cost of Lebanese antenatal care services is more expensive. A woman in Lebanon will have to spend the equivalent of US$ 20 just to see a doctor and pay for supplements and transport, which is often more than half of a worker’s weekly wage (12). Book 24-10.indb 1027 12/17/2018 2:22:10 PM EMHJ – Vol. 24 No. 10 – 2018Commentary 1028 Awareness and knowledge Syrian women interviewed had difficulties knowing what kind of antenatal care was available, who was pro- viding it, and how best to access it. The NGOs try to ad- vertise discounted antenatal care and contraception to Syrian women utilizing mobile clinics to reach rural ar- eas and camps. They distribute easy-to-read pamphlets and contact local religious leaders to encourage women to seek care. Women interviewed had other reasons for not seeking antenatal care or taking essential pregnancy vitamins. In a region with a high prevalence of iron deficiency anaemia among reproductive age women, only 59.9% of women took iron tablets during their pregnancy. Even fewer (41.2%) had an adequate diet of vitamins, minerals, and folic acid (13). Many of the women also had a distrust of the doctors and nurses in Lebanon. They were used to their family doctor in the Syrian Arab Republic and were simply unaccustomed to the facilities and practices of their new surroundings. Others did not think antenatal care was important to their baby’s health and only visited the doctor when they thought there was something wrong. Delivery Cost barriers High costs for antenatal care have Syrian refugee women going back to the Syrian Arab Republic for delivery, which is dangerous for both mother and child. Of the women interviewed, about 30% said they could see themselves returning to their country to deliver their child, solely on the basis of cost efficiency. According to a study conduct- ed by Johns Hopkins University, 93.6% of Syrian refugee households observed incurred an out-of-pocket payment for the delivery of their child in Lebanon (14); the average payment was L£ 234 294 (US$ 155). Of the Syrian refugee households that reported out-of-pocket costs, 93.6% were serviced at private clinics or hospitals. No significant differences in the cost of delivery were noted between refugee households with all members registered with UNHCR and those with some or none of the members registered (14). However, it should be noted that a “great- er proportion of refugees with all household members registered reported having a portion of the delivery cost paid on their behalf by an organization such as a human- itarian organization compared to households with some or none of the members registered, and these differences were marginally significant” (14). Conclusion Countries like Lebanon that host Syrian refugees have started to shift from emergency, short-term solutions to more long-term, integrative solutions. One such solution is mobile clinics. Refugees are spread over 1700 locations in Lebanon, making access challenging, even though the geographic spread of public health facilities is relatively good. Mobile clinics are used to alleviate the suffering of women in more hard-to-reach areas. They have also been sources of success when it comes to awareness and ac- cess to contraceptives. Humanitarian agencies conduct visits to remote areas with mobile clinics to reach the more vulnerable Syrian refugee populations. There are 23 mobile clinics operating throughout Lebanon through 12 agencies (IMC, AMEL, Caritas Liban, Makhzoumi Foun- dation, MSF-Ch, Humedica, Layan, MSF-Belgium, IMA, RI, LRC and Beyond) in 250 locations (as of July 2014). A mobile clinic team includes at least one medical doctor, one nurse, and/or one health educator or counsellor (15). Safe and affordable healthcare for pregnant women demands a concerted effort on the part of the host government and NGOs on the ground to provide these services at no cost to these women, yet there is a funding gap (16). While it is too early to see the repercussions, there have been reports of Syrian women resorting to prostitution in Beirut and elsewhere, either by force or willingly (17). In the absence of more funding, there should be active ways to encourage non-registered refugees to register with UNHCR in order to have access to family planning and lower-cost antenatal care. Incentives and communication strategies that foster UNHCR registration would help reduce the costs associated with antenatal care and delivery. More importantly, it is vital to give these women more education when it comes to family planning and pregnancy. As already mentioned, many of the women do not have adequate sexual or reproductive education and rely heavily on family members. The NGOs should commit to conducting more awareness sessions with incentives to attend such as a free service or receiving donated items. This way, aid workers would have the opportunity to educate women and men on reproductive health. Pamphlets and other means of communication could also help raise awareness. There have been case studies on sending SMS text messages to rural populations with awareness campaign slogans that have proven successful (18). The same could be done in this context; NGOs have the contact information of men and women registered with UNHCR and in clinics. In the absence of a physical meeting due to distance or lack of access to transportation, an SMS could be sent out with messages related to reproductive health or antenatal care. Improving access to the UNHCR web of healthcare providers by reducing fees and improving access to free vital medication would help build trust within the community and allow refugees to have more options. Moreover, most generic medications in the Syrian Arab Republic are labelled in Arabic, while in Lebanon they are mostly labelled in English or French. It would be worthwhile having pharmacies associated with UNHCR or healthcare providers explain the medications to Syrian refugees who needed to take them and make them feel comfortable about using them. The Syrian refugee crisis is not ending soon. Host countries like Lebanon and the NGOs operating within them need to shift from emergency short-term solutions to more long-term solutions and sustainability. This study was able to reach those women with access to a Book 24-10.indb 1028 12/17/2018 2:22:10 PM Commentary 1029 EMHJ – Vol. 24 No. 10 – 2018 healthcare facility, but there are women who do not have the capabilities to ensure healthcare for their new-born and themselves. The Lebanese healthcare system is not readily accessible for refugees due to costs, while public hospitals are overwhelmed and international resources are limited. The only way to ensure the safety of pregnant refugees in Lebanon is to focus on Syrian households registering with UNHCR in order to allow them access to affordable antenatal care. Funding: None. Competing interests: None declared. References 1. American Heritage Dictionary of the English Language. Boston: Houghton Mifflin; 2011. 2. Benage M, Greenough PG, Vinck P, Omeira N, Pham P. An assessment of antenatal care among Syrian refugees in Lebanon. Confl Health. 2015 Feb;9:8. PMID: 2574138 3. Maternal health care utilization among Syrian refugees in Lebanon and Jordan. Matern Child Health J. 2017 Sep;21(9):1798–807. PMID: 2870709 4. Institute of Medicine and National Research Council. Assessing the medical risks of human oocyte donation for stem cell re- search. Washington DC: The National Academies Press; 2007. 5. UN Population Fund. Response to the Syrian humanitarian crisis, Jan–April 2013. Geneva: UNHCR; 2013 (http://data.unhcr.org/ syrianrefugees/country.php?id=122, accessed 1 April 2016). 6. The number of Syrian refugees in Lebanon passes the 1 million mark. Geneva: UNHCR; 2014 (http://www.unhcr.org/en-us/news/ latest/2014/4/533c1d5b9/number-syrian-refugees-lebanon-passes-1-million-mark.html, accessed 1 May 2018). 7. Syrian Arab Republic: WHO statistical profile. Geneva: World Health Organization; 2013. 8. Response to the Syrian humanitarian crisis in Lebanon. Geneva: UNFPA; 2016 (https://data2.unhcr.org/en/situations/syria/loca- tion/71, accessed 1 May 2016). 9. Samari G, The response to Syrian refugee women’s health needs in Lebanon, Turkey and Jordan and recommendations for im- proved practice. New York: Humanity in Action Inc.; 2015. 10. Background paper on unregistered Syrian refugees in Lebanon. Beirut: Lebanon Humanitarian INGO Forum; 2014 (http://lhif. org/uploaded/News/d92fe3a1b1dd46f2a281254fa551bd09LHIF%20Background%20Paper%20on%20Unregistered%20Syrian%20 Refugees%20(FINAL).pdf, accessed 5 May 2018). 11. Misery beyond the war zone: Life for Syrian refugees and displaced populations in Lebanon. Geneva: Médecins Sans Frontières; 2013 (http://www.doctorswithoutborders.org/sites/usa/files/Syria-Lebanon-Report-2013.pdf, accessed 5 May 2018). 12. Syrian refugees in Lebanon, “Pregnant women often have no idea where to go”. News and stories 6 August 2013. Geneva: Mé- decins Sans Frontières; 2013 (http://www.doctorswithoutborders.org/news-stories/field-news/syrian-refugees-lebanon-pregnant- women-often-have-no-idea-where-go, accessed 5 May 2018). 13. Benage M, Greenough PG, VinckP, Omeira N, Pham P. An assessment of antenatal care among Syrian refugees in Lebanon. Con- flict and Health. 2015;9:8. https://doi.org/10.1186/s13031-015-0035-8 14. Syrian refugee and affected host population health access survey in Lebanon. Baltimore: Johns Hopkins University Bloomberg School of Public Health and Médicins du Monde; 2015 (https://data.unhcr.org/syrianrefugees/download.php?id=9550, accessed 5 May 2018). 15. Syria regional refugee response: health within the Lebanon refugee context. Geneva: UNHCR; 2014 (http://data.unhcr.org/syrian- refugees/country.php?id=122, accessed April 2016). 16. Funding requirements for 2016. Geneva: UNHCR; 2016 (http://data.unhcr.org/syrianrefugees/country.php?id=122, accessed 1 March 2016). 17. Mroue, B, Lebanon shocked over sex trafficking of young Syrian women. Associated Press; 13 April 2016. (http://bigstory.ap.org/ article/72253307caef4863858d659ce6686808/lebanon-shocked-over-sex-trafficking-young-syrian-women, accessed 5 May 2018). 18. Déglise C, Suggs LS, Odermatt P. Short message service (SMS) applications for disease prevention in developing countries. J Med Internet Res. 2012;14(1):e3. http://doi.org/10.2196/jmir.1823. Book 24-10.indb 1029 12/17/2018 2:22:10 PM EMHJ – Vol. 24 No. 10 – 2018WHO events addressing public health priorities 1030 Improving access to assistive technology in the Eastern Mediterranean Region Citation: Improving access to assistive technology in the Eastern Mediterranean Region. East Mediterr Health J. 2018;24(10):1030-1031 https://doi. org/10.26719/2018.24.10.1030 Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Introduction Enabling the disabled to participate fully in society and contribute to its economic development is enshrined in the United Nations’ Convention of the Rights of Persons with Disabilities (1). To support this commitment to the rights of the disabled, the World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO) organized a consultative meeting on improving access to assistive technology in the Eastern Mediterranean Region (EMR) in Islamabad, Pakistan, from 8 to 10 May 2018 (2). The objectives of the meeting were to: • update participants on the progress made to improve access to assistive technology, and to operationalize the Global Cooperation on Assistive Technology (GATE), resolution EM/RC63/R.3 (3) and the Islama- bad Declaration; and • finalize the draft strategic action framework on im- proving access to assistive technology in the Eastern Mediterranean Region (distributed to all WHO Mem- ber States during the Seventy-first World Health Assembly in May 2018). The meeting brought together representatives of 13 EMR countries as well as experts, members of civil society and representatives from national and state-level governments of Pakistan. The President of Pakistan, His Excellency Mamnoon Hussain, officially opened the meeting by welcoming the participants to Pakistan and stating that the meeting’s objective was to enable people with disabilities to realize their full potential in society. The President also described the activities of the Government of Pakistan to improve access to assistive devices at the national level, and acknowledged the leadership of the Government and the Minister of National Health Services, Regulation and Coordination in pursuing the initiative and achieving success at the international level. He prompted the meeting’s to work together to change the destiny of people with disabilities in the Eastern Mediterranean Region. The President also officially appointed Dr Sana Hafeez as the WHO Global Ambassador of GATE. Her Excellency Saira Afzal Tarar, Federal Minister of National Health Services, Regulation and Coordination, Pakistan, stated in her address that while there is collective resolve among countries of the Region to stand up for the rights of those in need of assistive technology, lack of information, national policies and programmes, as well as financial and human resources, presented challenges for assistive technology provision. Dr Zafar Mirza, Director, Health Systems Development, WHO/EMRO, delivered a message from Dr Jaouad Mahjour, then Director, Programme Management, in which Dr Mahjour emphasized that access to assistive technology was an essential element of both the continuum of healthcare and universal health coverage, and that it needed to be integrated into efforts to attain target 3.8 of the Sustainable Development Goals (SDGs) (4). Summary of discussions Considerable interest was shown regarding the Norwegian model of assistive technology provision, particularly in relation to the provision of more significant assistive technology items such as cars and the coverage/exclusion of items such as washing machines, cellular telephones, computers and smart home technology. It was noted that the Norwegian model may not be applicable in many low-income countries, which may have little budget for assistive technology programmes. Nevertheless, it was agreed that the Norwegian model may be drawn upon when pursuing national efforts to improve access to assistive technology, taking into account local contexts and resources. As a model of successful cooperation and collaboration between ministries and agencies, Norway’s experience indicates that through cooperation and construction of a national system, countries can bring about cost reductions and enable improved access for those who need assistive devices. Participants appealed to WHO to develop assistive product specifications. It was pointed out that while the Priority Assistive Products List of 50 products (5), developed by WHO, does have minimum specifications, WHO cannot impose those specifications on manufacturers or enforce them in countries. Thus, WHO can help individual countries develop standards, but cannot impose a specific set of standards or specifications. The working groups’ discussions on the strategic action framework resulted in a high degree of consistency in the actions suggested by each group. All groups recognized that it was the responsibility of countries to implement the framework and improve access, with WHO’s technical 1 This report is extracted from the Summary report on the consultative meeting on improving access to assistive technology in the Eastern Mediter- ranean Region, Islamabad, Pakistan, 8–10 May 2018 (http://applications.emro.who.int/docs/EMROPub_2018_EN_20766.pdf?ua=1). Book 24-10.indb 1030 12/17/2018 2:22:10 PM WHO events addressing public health priorities 1031 EMHJ – Vol. 24 No. 10 – 2018 References 1. United Nations. Convention on the rights of persons with disabilities. New York: United Nations; (http://www.un.org/disabili- ties/documents/convention/convoptprot-e.pdf). 2. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Summary report on the consultative meeting on improving access to assistive technology in the Eastern Mediterranean Region. Cairo: WHO/EMRO; 2018 (http://ap- plications.emro.who.int/docs/EMROPub_2018_EN_20766.pdf?ua=1). 3. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Improving access to assistive technol- ogy; Regional Committee for the Eastern Mediterranean, Sixty-third Session Agenda item 5(a). Cairo: WHO/EMRO; 2016 (http:// applications.emro.who.int/docs/RC63_Resolutions_2016_R3_19120_EN.pdf?ua=1). 4. World Health Organization. Sustainable development goals (ýSDGs)ý : Goal 3. Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. Geneva: World Health Organization; 2016 (http://apps.who.int/iris/han- dle/10665/208286). 5. World Health Organization. Priority assistive products list. Geneva: World Health Organization; 2016 (https://www.who.int/phi/ implementation/assistive_technology/low_res_english.pdf). support as needed. WHO could develop standards or models for countries to adapt to their national contexts. Civil society and nongovernmental organizations also have a role to play in funding, awareness-raising and educational initiatives. Manufacturers and private sector providers need to be aware of any minimum standards and specifications regarding products and provisions that were developed or adopted by countries. The groups identified the potential challenges of implementing the framework in development and emergency contexts. These were divided into three categories: alacrity, resources and capacity. In terms of alacrity, lack of political will and poor oversight were noted. Lack of awareness and understanding among the general public, decision- makers and within the healthcare system itself, could lead to lack of political will. Thus, broad and sustained campaigns are required to educate, inform and inspire relevant audiences. Robust and thorough monitoring and evaluation schemes and practices are needed, as is political ownership. A memorandum of understanding between concerned ministries and leading public figures could be drawn up in each country. There is also a lack of collaboration between relevant stakeholders, including between ministries and other organizations in the provision of assistive technology. The lack of resources is a significant barrier to implementing the framework. Not having appropriate, or even minimal, financial resources to support assistive technology programmes is compounded by the lack of political will to secure national resources for them. Insufficient human resources further impedes implementation. There is also a lack of capacity, including products and production ability to make products to meet identified needs. Inadequate training and education limits implementation. There is a particular dearth of capacity for providing assistive technology in emergency contexts. Improved data collection and analysis would allow a better understanding of needs and support the monitoring and evaluation of national programmes. The way forward The final framework will be piloted in three countries of the Region and assessed for its efficacy. Book 24-10.indb 1031 12/17/2018 2:22:10 PM Eastern Mediterranean Health Journal IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in public health and health services; and for the exchange of ideas, concepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Collaborating Centres and individuals within and outside the Region. طسوتلما قشرل ةيحصلا ةلجلما ةماعلا ةحصلا في ةديدلجا تاردابلماو تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخاو ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا La Revue de Santé de la Méditerranée Orientale EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine de la santé publique et des services de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informa- tions, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collaborateurs de l’OMS et personnes concernés au sein et hors de la Région. Correspondence Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic Tunisia . United Arab Emirates . Yemen طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا برغلما . صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةيروسلا ةيبرعلا ةيروهملجا نميلا . ةيدوعسلا ةيبرعلا ةكلملما Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . 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EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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ISSN 1020-3397 Cover 24-10.indd 4-6 17/12/2018 13:57:40 La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal EMHJ – Vol. 24 No. 10 – 2018 Volume 24 / No. 10 October/Octobre 10 ددع / نوشرعلاو عبارلا دلجلما لولأا نيشرت/ربوتكأ2018 Eastern M editerranean H ealth Journal Vol. 24 N o. 10 – 2018 The World Health Organization and the United Nations International Children’s Emergency Fund (UNICEF) have revisited current operational strategies to control cholera in Yemen, following a recent upsurge in reported cases, in order to accelerate efforts to curtail the epidemic. Editorial Cholera in Yemen: concerns remain over recent spike but control efforts show promise Ahmed Al-Mandhari, Altaf Musani, Abdinasir Abubakar and Mamunur Malik ............................................................................................................................. 971 Letter to the editor Global recommendations to prevent tooth decay must be evidence-based Christopher Holmgren and Habib Benzian ..................................................................................................................................................................................................973 Research articles Assessment of overweight and obesity in Iranian adolescents: optimal cut-off values of anthropometric indices Mohammad Motlagh, Seiyed Shirvani, Zahra Hassanzadeh-Rostami, Majzobeh Taheri and Reza Ghadimi ......................................................................975 Estimation du coût de la prise en charge du cancer broncho‐pulmonaire en Tunisie Chahida Harizi, Hedia Bellali, Aicha Hchaichi, Agnès Hamzaoui et Mohamed Kouni Chahed ................................................................................................ 988 Customary practices, domestic violence, and psychosomatic pain among adolescent mothers in Turkey Yasin Bez, Cem Uysal, Mahmut Bulut, Mehmet Kaya, Neval Goruk, Suleyman Demir and Aytekin Sir .............................................................................. 994 Effect of postpartum depression on women’s mental and physical health four years after childbirth Fatemeh Abdollahi and Mehran Zarghami ................................................................................................................................................................................................1002 Trends in occupational injuries and diseases among Saudi and non-Saudi insured workers Mohsin Abbas, Muhammad Kashif, Mansour Balkhyour, Ijaz Ahmad, Zaki-ul-Zaman Asam and Rashid Saeed ............................................................. 1010 Use of complementary and alternative medicine among paediatric patients with hepatogastrointestinal diseases Seyed Mosavat, Mojtaba Heydari, Mohammad Hashempur and Seyed Dehghani ..................................................................................................................... 1018 Commentary Challenges for pregnant Syrian refugees in Lebanon Lena Abdin .............................................................................................................................................................................................................................................................1026 WHO events addressing public health priorities Improving access to assistive technology in the Eastern Mediterranean Region .............................................................. 1030 Cover 24-10.indd 1-3 17/12/2018 13:57:40