Eastern Mediterranean Health Journal [2014; Vol.20, Issue 9]

Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 20 / No. 9 September/Septembre 9 ددع / نوشرعلا دلجلما برمتبس / لوليأ2014 EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. 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 collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2014 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. ISSN 1020-3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emhj@emro.who.int طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen Cover 20-10 (69 Cyan - 37 Yellow).indd 4-6 14/10/2014 10:20 Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 20 No. 9 9 ددع نوشرعلا دلجلما•  2014  • Editorial Benefits and pitfalls of social health insurance in pursuit of universal health coverage: lessons for the Eastern Mediterranean Sameen Siddiqi, Awad Mataria and Eduardo Banzon ................................................................................................................................................................................................................. 527 Research articles Pattern of cigarette and waterpipe smoking in the adult population of Jordan M. Jaghbir, S. Shreif and M. Ahram .................................................................................................................................................................................................................................................................. 529 Quitting smoking and utilization of smoking cessation services in Jordan: a population-based survey M. Jaghbir, S. Shareif and M. Ahram ................................................................................................................................................................................................................................................... 538 Household storage of medicines and self-medication practices in south-east Islamic Republic of Iran B. Foroutan and R . Foroutan ..................................................................................................................................................................................................................................................................547 Use of complementary and alternative medicine among midlife Arab women living in Qatar L.M. Gerber, R . Mamtani, Y.-L.Chiu, A. Bener, M. Murphy, S. Cheema and M. Verjee .....................................................................................................................................................554 Knowledge of periconceptional folic acid use among pregnant women at Ain Shams University Hospital, Cairo, Egypt W. Al-Darzi, F. Al-Mudares, A. Farah, A. Ali and D. Marzouk ..................................................................................................................................................................................................561 Factors affecting the process of obtaining informed consent to surgery among patients and relatives in a developing country: results from Pakistan F. Jahan, R . Roshan, K. Nanji, U. Sajwani, S. Warsani and S. Jaffer .......................................................................................................................................................................................... 569 Interobserver variations in reporting of prostatic adeno carcinoma using core biopsy specimens: a retrospective study from a tertiary referral hospital in Saudi Arabia A.C. Al-Rikabi and H. Alkhalidi ........................................................................................................................................................................................................................................................... 578 Dr Ala Alwan, Editor-in-chief Editorial Board Professor Zulfiqar Bhutta Professor Mahmoud Fahmy Fathalla Professor Rita Giacaman Dr Ziad Memish Dr Sameen Siddiqi Professor Huda Zurayk International Advisory Panel Dr Mansour M. Al-Nozha Professor Fereidoun Azizi Professor Rafik Boukhris Professor Majid Ezzati Dr Zuhair Hallaj Professor Hans V. Hogerzeil Professor Mohamed A. Ghoneim Professor Alan Lopez Dr Hossein Malekafzali Professor El-Sheikh Mahgoub Professor Ahmed Mandil Dr Hooman Momen Dr Sania Nishtar Dr Hikmat Shaarbaf Dr Salman Rawaf Editors Fiona Curlet, Guy Penet (French) Freelance: Alison Bichard, Marie-France Roux Graphics Suhaib Al Asbahi, Diana Tawadros Administration Nadia Abu-Saleh, Yasmeen Sedky طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 527 Editorial Benefits and pitfalls of social health insurance in pursuit of universal health coverage: lessons for the Eastern Mediterranean Sameen Siddiqi,1 Awad Mataria 1 and Eduardo Banzon 1 Countries of the Eastern Mediterranean Region (EMR) of the World Health Organization have never been as com- mitted as they are today to ensure that all people have access to needed health services without the risk of financial hardship – the message of universal health coverage (UHC) (1). The aver- age share of out-of-pocket payments for EMR countries stands at around 40% and in some countries is close to 70% of total health expenditure (2). This con- stitutes a major hindrance to pursue the goal of UHC and calls for establishing prepayment and pooling arrangements that guarantee financial protection to all population groups. In their quest for equitable, efficient and sustainable forms of prepayment, countries can choose from multiple arrangements that include allocations from general government revenues, obligatory health insurance, and modalities such as vol- untary health insurance and medical saving accounts. Traditionally, obligatory health insurance financed through premium contributions (from employers and/ or employees) was called social health insurance (SHI), but these days SHI describes a variety of ways of raising and pooling money that involves a mix between obligatory insurance contributions and general government revenues. This change has come about in high-income countries as popula- tions have aged and the ratio of those who pay contributions to those who do not has fallen, so general government revenues have been mixed with obliga- tory contributions. Similarly, in low- and middle-income countries – with their large informal sector1 and vulnerable populations, the concept of SHI has evolved into a prepayment arrangement that is not only funded by premium contributions but also financed from government allocations to subsidize contributions on behalf of the poor and vulnerable populations, including those in the informal sector. Many elements of this new definition of SHI make it an attractive arrangement that countries worldwide are employing or consider- ing implementing. This is also the case with most EMR countries. In EMR, countries have been dis- tributed into three groups2 that are at different stages of introducing or ex- panding this new vision of raising and pooling funds for health, frequently called SHI. Many countries in Group 2, which are mostly middle income, have a long tradition of obligatory health insurance contributions and have man- aged to expand coverage to the poor and part of the informal sector using government subsidies; for example, the Islamic Republic of Iran. As an alter- nate approach, Morocco and Tunisia implement a separate subsidized SHI scheme to cover the poor and vulner- able population. As for Jordan and Palestine, SHI is managed by the Min- istry of Health. Despite the multitude of SHI arrangements, the share of out-of- pocket spending remains unacceptably high in many Group 2 countries due to a relatively small benefit package, substantial co-payments, and vulner- able population groups who are not covered. Group 1 or the Gulf Coopera- tion Council countries rely mainly on general government revenues gener- ated primarily from natural resources to cover a generous package of health services for their citizens. In recent years, Qatar and the United Arab Emirates – in particular in Abu Dhabi and Dubai – have shifted from general government revenue to SHI to cover nationals for all or selected services. The large expatriate populations in these countries are either covered by private health insurance or are granted access to a limited pack- age against nominal payment and in 1Department of Health System Development, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 1 The informal sector covers a wide range of employment categories including the self-employed and those with casual, temporary and unpaid jobs, etc. Source: World Bank http://lnweb90.worldbank.org/eca/eca.nsf/1f3aa35cab9dea4f85256a77004e4ef2/4e4ede543787a0c085256a9 40073f4e4). 2 EMR countries are commonly categorized into three health system groups based on population health outcomes, health system performance and the level of health expenditure. Group 1 (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates); Group 2 (Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libya, Morocco, occupied Palestinian territory, Syrian Arab Republic and Tunisia); Group 3 (Afghanistan, Djibouti, Pakistan, Somalia, South Sudan, Sudan and Yemen). EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 528 many cases are left without cover. As for Group 3 countries, Sudan is more advanced in terms of implementing SHI, where the poor and those in the in- formal sector are partially covered using government subsidies and zakat funds. In these countries, the overall level of financing is inadequate, large segments of the population are not covered and the share of out-of-pocket spending hovers at around 60% of total health expenditure. Several features make SHI a power- ful instrument for financing the health system and enhancing the move to- wards UHC. The obligatory nature of SHI results in no opt-outs and ensures social solidarity where the rich, healthy, young and employed subsidize the poor, sick, elderly and unemployed. The clear linkage between contributions and benefits empowers the individuals to demand “paid-for” benefits rather than seek “free” care. Indeed, having an insur- ance membership card is an enabling tool. Members of SHI are more willing to pay premium contributions as they perceive their payment as a “benefit tax”. SHI can improve efficiency by facilitat- ing strategic purchasing. The presence of an independent or quasi-independ- ent fund that enjoys autonomy from the government enables mobilizing money that remains flexible and protected from budgetary negotiations. If not properly designed or imple- mented, however, SHI can suffer from several pitfalls. For example, the benefit package may be limited to curative care without emphasis on health promotion and prevention. When implemented in its classical form, SHI may leave out the poorest segments of the population and those in the informal sector. In addi- tion, if fragmented with too many funds, SHI may become inefficient with high administrative costs and delayed reim- bursements. High levels of co-payments and low tariffs to attract private providers may perpetuate financial hardship (3). It is important to recognize the dif- ferences between the types of SHI ar- rangements and the way pooled funds are used to pay for services. When designing obligatory health insurance, it is necessary to consider the package and provider payment methods in ways that ensure efficiency and quality and utilization of services. Countries that attend to these potential pitfalls manage to progress “quickly and surely” towards UHC. The experience of Turkey in merging its five SHI schemes into a single-payer system in less than 10 years, while also integrating its “Green Card” scheme for the poor into the same pool, allowed the country to move closer to UHC (4). Similarly, Thailand, backed by a high level of political commitment, managed to achieve UHC by adding a Universal Coverage scheme for the poor and informal sector, paid entirely from general government revenues. This scheme avoided fee-for-service payments, thereby covering a large population with a wide range of quality services at an affordable cost (5). While designing or expanding SHI, policy-makers need to ensure that: it re- mains obligatory and not voluntary for people who can pay, with general gov- ernment revenues covering those who cannot; it is inclusive and seeks non-risk- related contributions; the benefit package has a promotive and preventive compo- nent; it fosters a single-payer arrangement as far as possible; and it enjoys a degree of autonomy in its implementation to ensure efficiency. SHI means covering not only those who are in the formal sec- tor or those who contribute to payroll taxes but all population groups through government subsidies and other innova- tive financing mechanisms. Ultimately it is the responsibility of governments to ensure that all people in their countries are protected from the risk of financial ca- tastrophe and impoverishment. SHI is an effective instrument to achieve this goal. References 1. The World Health Report 2010. Health systems financing: the path to universal coverage. Geneva: World Health Organiza- tion; 2012. 2. Towards universal health coverage: challenges, opportunities and roadmap. Cairo: World Health Organization Regional Office for the Eastern Mediterranean; 2013 (EM/RC60/Tech. Disc.2 Rev.1). 3. Liu X, Tang S, Yu B, Phuong NK, Yan F, Thien DD, et al. Can rural health insurance improve equity in health care utilization? A comparison between China and Vietnam. Int J Equity Health. 2012 (doi: 10.1186/1475-9276-11-10). 4. Atun R, Aydın S, Chakraborty S, Sümer S, Aran M, Gürol I, et al. Universal health coverage in Turkey: enhancement of equity. The Lancet. 2013;382(9886):65–99. 5. Maeda A, Cashin C, Harris J, Ikegami N, Reich M. Universal health coverage for inclusive and sustainable development: a synthesis of 11 country case studies. Washington DC: World Bank Publications; 2014:2–14. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 529 Pattern of cigarette and waterpipe smoking in the adult population of Jordan M. Jaghbir,1 S. Shreif 1 and M. Ahram 2 1Department of Family and Community Medicine; 2Department of Physiology and Biochemistry, Faculty of Medicine. University of Jordan, Amman, Jordan (Correspondence to M. Jaghbir: jaghbirm@yahoo.com; mjaghbir@ju.edu.jo). Received: 30/12/13; accepted: 14/04/14 ABSTRACT An increasing prevalence of smoking in Jordan has been noted and this necessitates understanding the social behaviours that have lead to this habit. This cross-sectional, descriptive study determined the prevalence of smoking among Jordanians in relation to demographics with a focus on 4 types of tobacco products—cigarettes, waterpipes, cigars and pipes. A population sample of 3196 adults aged 18+ years answered an interview questionnaire about their smoking habit and types and amounts of tobacco consumed. Overall 32.3% of the respondents reported being current smokers (54.9% of males and 8.3% of females) and 2.9% were ex-smokers. Cigarette smoking was the most frequent type of tobacco smoking (93.0%) and one-third of cigarette smokers consumed more than 20 cigarettes per day. Waterpipe smoking was the second most common habit (8.6%) and was significantly associated with lower age in both males and females. Reducing the high rate of smoking in Jordan must be a priority. ندرلأا في ينغلابلا ناكسلا ىدل ةليجرنلاو رئاجسلا ينخدت زارط مارهأ دحمأ نومأم ،فيشرلا يفطل رمس ،يربغلجا قيفوت ضيام دـ قو .ةداـ علا هذـ ه لىإ يدؤـ ت يـ تلا ةـ يعماتجلاا تايكولـ سلا مـ هف بـ لطتي اذــ هو ،ندرلأا في نـ خدتلا راـ شتنا دــ يازت ظـ حول دـ قل :ةـ صلالخا طماـنأ ةـعبرأ ىـع زـيكترلا عـم ،ةيناكـسلا ةـبيكترلاب قـلعتي ماـيف نـيندرلأا نـب نـخدتلا راـشتنا ةضرعتـسلما ةـيفصولا ةـساردلا هذـه تد َّدـح مـهرماعأ دـيزت ًاـغلاب 3196 تـمض ناكـسلا نـم ةـنيع تـباجأ دـقو .نوـيلغلاو راجيـسلاو ةـليجرنلاو رئاجـسلا :يـه - غـبتلا تاـجتنم نـم نـم % 32.3 هـ ُّيلاجمإ اـم رـكذف .انهوكلهتـسي يـتلا غـبتلا تاـيمكو طماـنأو ،مـيهدل نـخدتلا ةداـع لوـح ةـلباقم نايبتـسا ىـع ،ةنـس 18 ىـع رئاجـسلا نـخدت ناكو .نقباـس نـنخدم مـهنم % 2.9 ناكو ،)ثاـنلإا نـم % 8.3و روـكذلا نـم % 54.9( نوـُّيلاح نوـنخدم مـنهأ نعَلطتـسلما ناكو .موـيلا في ةراجيـس 20 نـم رـثكأ نوكلهتـسي رئاجـسلا يـنخدم ثـلث ناكو ،)% 93.0( غـبتلا نـخدت طماـنأ نـم ًاعويـش رـثكلأا طـمنلا .ثاــ نلإاو روــ كذلا نــ م لك ىدــ ل لــ قأ رماــ عأب - ظوــ حلم لكــ شب -ًاــ نترقم ناكو ،)% 8.6( ًاعويــ ش تاداــ علا رــ ثكأ نياــ ث ةــ ليجرنلا نــ خدت .تاـيولولأا نـم نوـكي نأ بـيج ندرلأا في نـخدتلل عـفترلما لدـعلما ضـْفَخ نأ لىإ نوـثحابلا صـلخو Caractéristiques de la consommation de cigarettes et du narguilé dans la population adulte de Jordanie RÉSUMÉ Une prévalence accrue de la consommation de tabac a été observée en Jordanie et cette augmentation nécessite une compréhension des comportements sociaux qui conduisent à cette habitude. La présente étude transversale descriptive a déterminé la prévalence de la consommation de tabac chez les Jordaniens axée sur quatre types de produit —les cigarettes, les narguilés, les cigares et les pipes, en tenant compte des données démographiques. Un échantillon de population de 3196 adultes âgés de 18 ans et plus a répondu à un questionnaire administré pendant un entretien sur les habitudes de consommation de tabac et les types et quantités de tabac consommés. Dans l'ensemble, 32,3 % des répondants ont déclaré être des fumeurs actifs (54,9 % d'hommes et 8,3 % de femmes) et 2,9 % étaient d'anciens consommateurs de tabac. Fumer des cigarettes était la forme de consommation de tabac la plus fréquente (93,0 %) et un tiers d’entre eux fumaient plus de 20 cigarettes par jour. Fumer le narguilé arrivait en deuxième position dans les habitudes de consommation (8,6 %) et était significativement associé à un âge plus jeune chez les hommes comme chez les femmes. Réduire le fort taux de consommation de tabac en Jordanie doit être une priorité. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 530 Introduction The World Health Organization (WHO) has described tobacco smoking as an epidemic (1). Strong evidence links tobacco smoking to mortality and numerous diseases, primarily cardiovascular diseases and cancer (2,3). The estimated number of smoking-related annual deaths from smoking-attributable diseases are ex- pected to increase to 10 million within the next 30 years or so, of which 70% will occur in developing countries (4). In Jordan, an Eastern Mediterranean Region (EMR) country, cardiovas- cular disease is the leading cause of mortality (36.1%), followed by cancer (15.6%) (5). In fact, cancer cases in Jordan are steadily increasing. For ex- ample, according to the Jordan Cancer Registry, there has been a 4% increase in cancer cases between 2008 and 2009 (6). Lung cancer ranked second among males (11.2%), closely follow- ing colorectal cancer (12.7%) (6). It is well accepted that at least one-third of all the new cases of cancer every year can be prevented and that tobacco is one of the most preventable causes of cancer. Hence, tobacco control should be established as the top priority in public health programmes for disease prevention, including cancer. Rates of smoking and tobacco consumption are variable across the EMR, with a high smoking prevalence in some countries, such as Lebanon, Jor- dan, Egypt, Tunisia and the Syrian Arab Republic (7). A review of 36 studies related to the prevalence of smoking in Saudi Arabia has indicated rates of up to 52.3% (8). Among EMR countries, Jor- dan had the highest age-standardized rate of smoking (36.5%) followed by Tunisia (25.7%) (9). Significantly, the rate of smoking has been on the increase in the EMR countries (9,10). The same trend is expected to be occurring in Jor- dan, which suggests that the number of Jordanians who will die or be disabled as a result of tobacco-related diseases will increase. Due to the relatively low age of the population, the rate of smoking- related disease is expected to increase. In order to learn more about public smoking habits including the rates and types of products smoked, a question- naire was conducted as part of a national survey of knowledge, attitudes and prac- tices (KAP) towards cancer prevention and care in Jordan that included ques- tions about smoking habits. Overall, the focus of the study was to help identify the current smoking practices among the population of Jordan in an effort to better control this life-threatening habit. This was the first study of its kind at the national level in Jordan. Methods Study design This was a quantitative, cross-sectional, descriptive survey. Data collection spanned 2 months from 24 January to 19 March 2011. The survey consisted of 10 sections starting with a section about demographic characteristics. One section enquired about the lifestyle of participants and included questions about smoking habits. The results of this part of the survey form the focus of this paper. Participants The KAP survey sample was based on the 2004 Jordan Population and Housing Census as the sampling frame. The sampling frame was stratified by governorate, major cities (each city with a population of more than 100 000 was considered a stratum, i.e. 6 cities) and other urban and other rural areas. A 3-stage sampling procedure was em- ployed. First, blocks were selected sys- tematically as primary sampling units (PSUs) with a probability proportional to the size of the PSU. In the second stage, a fixed number of 15 households were selected as final sampling units in each PSU, resulting in a sample size of about 4500 households. In the third stage, random selection of individual interviewees from each household was carried out using Kish tables (11). The final sample size in this survey was 3196 participants (a response rate of 93%). Overall, the characteristics of survey participants correlated well with na- tional estimates, as published earlier (12). Instrument A structured questionnaire was de- signed by a national advisory committee that consisted of research experts from different research, clinical and academic institutions in Jordan. The design of the survey was based on international references/tools that were used as a guide to the development of the ques- tionnaire and to ensure appropriate themes and adaptation to the local context. Face-to-face interviews were conducted in interviewees’ households and took an average of 30 minutes to complete. Verbal informed consent was obtained; agreement to host interviews in the participants’ house is a culturally appropriate method to obtain consent in Jordan. A pilot study was conducted to test the survey tool, sampling technique, survey methods and interviewers’ level of work. The pilot study spanned a day and was carried out in one area in the capital city, Amman. The pilot sample consisted of 56 randomly selected sub- jects. Following the pilot, a 2-day review session was conducted and resulted in implementation of minor modifica- tions. Measures Respondents were first asked if they considered themselves as non-smokers, current smokers or ex-smokers. Those who described themselves as current smokers were asked about the types of tobacco they used and 4 options were provided: cigarettes, cigars, pipes and waterpipes (nargile). In addition, respondents were asked about the amount of tobacco consumed (i.e. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 531 number of times each type of tobacco product was smoked daily). Data collection Data collection was carried out in the 3 regions of Jordan (North, Middle and South). The face-to-face inter- views were conducted by 18 trained teams. Each team consisted of 3 data collectors, 1 controller, 1 field supervi- sor and 1 driver. The controllers and supervisors conducted spot checks by randomly visiting some sampled households. In order to facilitate data collection, each interviewing team was assigned a number of blocks in the sample area. Interviewers made repeated attempts to obtain the re- sponses of eligible respondents by calling back to interview respondents who were not home at the time of the first visit or by attempting to persuade respondents who were reluctant to be interviewed. Data processing and analysis Data entry using Oracle software started 1 week after the initiation of data collection. After editing and cleaning, the data were exported to SPSS, version 17.0. SPSS was used to run univariate and bivariate analyses to describe all the survey variables. As most of the variables in the study were measured on a nominal and/or ordinal level, descriptive statistics were used to describe the basic features of the data. The chi-squared test was used to correlate demographic data with smoking habits. Results Demographic characteristics A total of 3196 respondents participat- ed in the survey. Their demographic characteristics are summarized in Table 1. There was an approximately equal distribution of males and fe- males. The respondents’ mean age was 39 years, with about 78% of the participants being between 18 and 49 years of age. The highest percentage of participants had attained prepara- tory to high-school education (51.3%), with the remainder having a diploma degree and above (29.5%) or elemen- tary education and below (19.2%). Approximately half of respondents had a monthly household income below 300 Jordanian dinar (JD) (US $430). Individuals with the medium income (300–599 JD) represented 38.7% and those with high income (above 600 JD) represented 14.2%. The majority of respondents were married (73.1%), and most of the rest were single (19.9%); the “other” category (7.0%) included those who were widowed, divorced or separated. Pattern of smoking habits When participants were asked about their smoking habits, 64.8% of them reported that they had never smoked, whereas 32.3% were current smokers and 2.9% were ex-smokers (Table 1). The prevalence of current smok- ing varied greatly according to sex, whereby 54.9% of male respondents reported being current smokers com- pared with only 8.3% of females (P < 0.001). A significant difference in smoking habits was also noted with age, with the highest prevalence being in the 40–49 years age group (40.0%) and the lowest among those aged 60+ years (16.3%) (P < 0.001). Intermedi- ate educational status had a significant association with smoking habits, with more than one-third of them (36.9%) being current smokers versus approxi- mately 27% of the groups of lower and higher educational status (P < 0.001). No significant relationship was found between smoking habits and income (P = 0.379). A significant effect of marital status on smoking habits was found; those who were divorced, Table 1 Demographic characteristics of the participants (n = 3196) Characteristic No. % Sex Male 1647 51.5 Female 1549 49.5 Age (years) 18–29 964 30.1 30–39 915 28.6 40–49 627 19.6 50–59 271 8.5 60+ 419 13.1 Education Elementary or less 614 19.2 Preparatory to high school 1638 51.3 Diploma and above 944 29.5 Monthly income (JD) a < 300 1495 47.1 300–599 1227 38.7 600+ 452 14.2 Marital status b Single 636 19.9 Married 2338 73.1 Othera 222 7.0 a22 respondents refused to declare their income; bThis category included divorced, widowed and separated. JD = Jordanian dinar. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 532 widowed or separated were more likely to be non- or ex-smokers than were single and married individuals (P < 0.001). The latter 2 groups, single and married respondents, appeared to have similar smoking habits; 61.9% versus 63.9% respectively were non- smokers, while 36.5% versus 33.0% respectively were current smokers. Pattern of smoking according to sex When analysing the data in more de- tail to look at differences in smoking habits between males and females some interesting associations were noted (Table 2). Whereas the per- centage of males smoking was low only among those 60+ years old (P < 0.001), the lowest percentage of female smokers was among the youngest (18–29 years) and oldest (60+ years) age groups (P < 0.001). Similarly, the prevalence of smoking by single and married male smokers was higher than among those who were divorced, widowed or separated (P < 0.001). On the other hand, more married females smoked than the single or other categories (P = 0.01). When looking at the aforementioned overall smoking habits, there was no association between smoking and income among females. However, males with lower income were more likely to be smokers than those with higher income (P < 0.001). Income did not show any significant effect on the prevalence of smoking among females (P = 0.894). It is noteworthy that more males with intermediate education smoked than those with lower and higher educational status (P < 0.001). The prevalence of smok- ing was significantly different among females according to level of educa- tion (P = 0.046). Type of smoking Current smokers (n = 1032) were asked about the type of tobacco products they smoked daily (Table 3). The majority indicated that they smoked cigarettes (93.0%). There Table 2 Smoking habits of the study group in relation to socioeconomic characteristics How would you describe your smoking habits of any tobacco products? Non-smoker Current smoker Ex-smoker No. % No. % No. % Total 2072 64.8 1032 32.3 93 2.9 Sex Male 669 40.6 904 54.9 75 4.6 Female 1403 90.6 128 8.3 18 1.2 χ2 = 876.2; P < 0.001 Age (years) 18–29 652 67.7 295 30.6 16 1.7 30–39 555 60.6 336 36.7 25 2.7 40–49 362 57.7 251 40.0 14 2.2 50–59 179 66.3 82 30.4 9 3.3 60+ 322 77.0 68 16.3 28 6.7 χ2 = 97.1; P < 0.001 Education Elementary or less 411 66.8 167 27.2 37 6.0 Preparatory to high school 996 60.8 604 36.9 38 2.3 Diploma and above 664 70.3 262 27.8 18 1.9 χ2 = 56.2; P < 0.001 Monthly income (JD) a < 300 946 63.3 502 33.6 47 3.1 300–599 804 65.5 390 31.8 33 2.7 600+ 307 67.9 135 29.9 10 2.2 χ2 = 4.2; P = 0.379 Marital status Single 394 61.9 232 36.5 10 1.6 Married 1495 63.9 772 33.0 71 3.0 Other 182 82.0 28 12.6 12 5.4 χ2 = 50.4; P < 0.001 a22 respondents refused to declare their income. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 533 was a significant difference in the prevalence of cigarette smoking by sex, in which 93.7% of males smoked cigarettes in comparison with 88.3% of females (P = 0.025). A significant difference was also found across the different age groups (P = 0.042). The rate of cigarette smoking was high- est among age groups 40–49 years (96.4%), 50–59 years (95.2%) and 60+ years (95.6%), and lowest among the age groups 18–29 years (90.5%) and 30–39 years (91.4%). On the other hand, income, level of education and marital status were not associated with cigarette smoking (P = 0.361, P = 0.167 and P = 0.267 respectively). Approximately half of smokers con- sumed 11–20 cigarettes a day and almost one-third consumed more than 20 cigarettes a day (Table 4). Smoking waterpipes daily rated second among the 4 types of tobacco products; 89 respondents (8.6%) in- dicated that they smoked this type of tobacco product. Waterpipe smoking had a significant negative association with age, with the highest percentage (13.3%) among the age group 18–29 years and the lowest among those aged 60+ years (1.5%) (P < 0.001) (Table 5). No significant difference, however, was found between waterpipe smok- ing and sex, level of education, income or marital status (P = 0.072, P = 0.254, P = 0.514 and P = 0.065 respectively). Smoking cigars and pipes were the least common habits, with a rate of 0.5% (n = 5) and 0.2% (n = 2) respec- tively. Only 23 (2.4%) respondents indicated that they smoked both ciga- rettes and waterpipes daily. Type of smoking habit according to sex We examined the types of smoking (cigarettes and waterpipes) accord- ing to sex (Table 6). Whereas there was no significant difference among females in the percentage smoking cigarettes by age (P = 0.062), the per- centage of males smoking cigarettes tended to be lowest in the youngest age group (18–29 years) and peaked at the middle age group (40–49 years) (P = 0.024). In contrast, the prevalence of waterpipe smoking was significantly higher at lower ages among both males and females (P = 0.014 and 0.004 respectively). There was a significant difference in water- pipe smoking by females according to marital status, whereby single females were more likely to smoke Table 3 Smoking habits of males and females in relation to socioeconomic characteristics How would you describe your smoking habits of any tobacco products? Males Females Non-smoker Current smoker Ex-smoker Non-smoker Current smoker Ex-smoker No. % No. % No. % No. % No. % No. % Age (years) 18–29 199 40.8 276 56.6 13 2.7 453 95.4 19 4.0 3 0.6 30–39 163 34.1 293 61.3 22 4.6 392 89.7 43 9.8 2 0.5 40–49 123 35.4 213 61.4 11 3.2 239 85.7 37 13.3 3 1.1 50–59 36 34.0 66 62.3 4 3.8 143 86.7 17 10.3 5 3.0 60+ 147 65.0 56 24.8 23 10.2 175 91.1 12 6.2 5 2.6 χ2 = 108.1; P < 0.001 χ2 = 35.65; P < 0.001 Education Elementary or less 93 36.2 137 53.3 27 10.5 318 88.6 30 8.4 10 2.8 Preparatory to high school 317 35.5 544 60.9 32 3.6 680 91.2 60 8.0 6 0.8 Diploma and above 259 52.0 223 44.8 16 3.2 405 90.6 39 8.7 3 0.7 χ2 = 62.06; P < 0.001 χ2 = 9.69; P = 0.046 Monthly income (JD) a < 300 255 34.7 442 60.1 38 5.2 691 90.8 60 7.9 10 1.3 300–599 288 44.0 338 51.7 28 4.3 516 89.9 52 9.1 6 1.0 600+ 123 49.2 120 48.0 7 2.8 185 91.1 15 7.4 3 1.5 χ2 = 22.26; P < 0.001 χ2 = 1.10; P = 0.894 Marital status Single 190 44.8 224 52.8 10 2.4 204 44.8 8 3.8 0 0.0 Married 457 38.6 669 56.5 58 4.9 457 38.6 669 56.5 58 4.9 Other 22 56.4 10 25.6 7 17.9 160 87.9 17 9.3 5 2.7 χ2 = 32.56 ; P < 0.001 χ2 = 16.02; P = 0.003 a22 respondents refused to declare their income. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 534 this type of tobacco product than married women or other categories (P = 0.031), a trend that was not observed among males (P = 0.175). However, we need to be cautious in interpreting these data due to the low number of females admitting to smoking waterpipes. No significant differences were noted in smoking either cigarettes or waterpipes be- tween males and females according to education or income. Table 4 Number of cigarettes consumed daily by cigarette smokers (n = 960) No. of cigarettes No. % Cumulative % 1–10 165 17.2 17.2 11–20 461 48.0 65.2 21–30 114 11.9 77.1 31–40 176 18.3 95.4 41–50 8 0.8 96.2 51–100 36 3.8 100.0 Table 5 Types of tobacco consumed by the study group in relation to socioeconomic characteristics What kind of tobacco do you smoke? a Cigarettes Waterpipes Cigars Pipes No. % No. % No. % No. % Total 960 93.0 89 8.6 5 0.5 2 0.2 Sex Male 846 93.7 73 8.1 3 0.3 2 0.2 Female 113 88.3 16 12.5 2 0.6 0 0.0 χ2 = 5.0; P = 0.025 χ2 = 2.8; P =0.072 χ2 = 3.5; P = 0.120 χ2 = 0.28; P =0.767 Age (years) 18–29 267 90.5 39 13.2 0 0 0 0.0 30–39 307 91.4 33 9.8 2 0.6 0 0.0 40–49 242 96.4 14 5.6 1 0.4 0 0.0 50–59 79 95.2 3 3.6 1 1.2 1 1.2 60+ 65 95.6 1 1.5 1 1.5 1 1.5 χ2 = 9.9; P = 0.04 χ2 = 18.2; P = 0.001 χ2 = 3.8; P = 0.430 χ2 = 11.8; P = 0.02 Education Elementary or less 155 92.8 13 7.8 0 0.0 1 0.6 Preparatory to high school 568 94.0 47 7.8 3 0.5 1 0.2 Diploma and above 237 90.5 29 11.1 2 0.8 0 0.0 χ2 = 3.6; P = 0.17 χ2 = 2.7; P = 0.25 χ2 = 1.2; P = 0.53 χ2 = 2.0; P = 0.38 Monthly income (JD) b < 300 472 94.0 40 8.0 1 0.2 1 0.2 300–599 359 92.1 34 8.7 2 0.5 1 0.3 600+ 123 91.1 15 11.1 1 0.7 0 0.0 χ2 = 2.0; P = 0.361 χ2 = 1.3; P = 0.51 χ2 = 1.1; P = 0.592 χ2 = 0.34; P = 0.84 Marital status Single 213 91.8 27 11.6 0 0.0 0 0.0 Married 719 93.1 63 8.2 5 0.6 2 0.3 Other 28 100.0 0 0.0 0 0.0 0 0.0 χ2 = 2.6; P = 0.27 χ2 = 1.69; P = 0.43 χ2 = 0.68; P = 0.71 χ2 = 5.46; P = 0.07 a23 respondents indicated they smoked both cigarettes and waterpipes daily; b7 respondents refused to declare their income. Discussion This study offers 3 important find- ings. First of all, the overall preva- lence of current smoking in Jordan was 32.3% and this reached 54.9% among males above 18 years old. These figures are higher than previ- ous reports from the country as will be discussed below. Second, a major concern was the degree of consump- tion as almost 80% of the smokers consumed more than 10 cigarettes a day. The third important finding is that the rate of waterpipe smoking was the highest among the young females and males. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 535 The prevalence of smoking for both sexes was higher than previously reported figures. For example, in Jordan a survey 30 years ago reported that the rate of smoking was 29% (7). This is in contrast to data published in the United States of America (USA), where smok- ing rates among adults halved from 42% to 20.8% between 1965 and 2011, with 23.9% of men smoking compared with 18.1% of women (13). Rates of smoking are generally 5 times higher among men than women as described in our study as well as in other reports from the region (10). However, the gap between the sexes declines with younger ages (14). In developed countries, smoking rates for men have peaked and have begun to de- cline; on the other hand, the rate of smok- ing among women continues to increase (15). In our study, the prevalence of current smoking varied greatly between the sexes with the gap being highest at the youngest age group (14-fold) and lowest at the age groups 40–49 years (4.6-fold) and 60+ years (4-fold), in contrast to the aforementioned reports. The low prevalence of smoking among Jordanian women probably reflects cultural norms that dissuade women from starting to smoke. Therefore, awareness campaigns and stricter policies should be considered in Jordan to decrease the rate of smoking, as is the case in most developed coun- tries. In addition, the creation of primary prevention programmes that promote non-smoking among Jordanian women might be useful in maintaining this low prevalence in the future. The prevalence of current smoking among adults in the USA was 24.4% among those aged 18–24 years and 24.1% at ages 25–44 years, both of which were the highest rates across all age groups (13). The prevalence of smok- ing in our study varied significantly with age, reaching a peak at age 40–49 years. However, a major concern is the finding that both male and female youngsters were more likely to smoke waterpipes compared with older age groups. Such a trend has been consistently reported in Jordan and neighbouring countries, where both cigarette and waterpipe smoking was common among young college students (16–19). Cafes that facilitate smoking of waterpipes are be- coming widespread especially in areas surrounding colleges and universities. These observations have recently led to the implementation of strict regula- tions by the Ministry of Health and the municipality of Amman. Table 6 Types of tobacco consumed by males and females in relation to socioeconomic characteristics What king of tobacco do you smoke?a Cigarettes Waterpipes Males Females Males Females No. % No. % No. % No. % Age (years) 18–29 253 91.7 14 70.0 31 11.2 8 42.1 30–39 268 91.8 39 90.7 29 9.9 4 9.3 40–49 209 98.1 33 89.2 11 5.2 3 8.1 50–59 63 95.5 16 94.1 2 3.0 1 5.9 60+ 53 94.6 12 100.0 1 1.8 0 0.0 χ2 = 11.22; P = 0.024 χ2 = 8.95; P = 0.062 χ2 = 12.5; P =0.01 χ2 = 15.5; P = 0.004 Education Elementary or less 126 92.0 29 96.7 12 8.8 1 3.3 Preparatory to high school 517 95.0 51 85.0 39 7.2 9 15.0 Diploma and above 203 91.4 34 87.2 23 10.3 7 17.9 χ2 = 4.25; P = 0.119 χ2 = 2.73; P =0.256 χ2 = 2.15; P =0.34 χ2 = 3.49; P = 0.175 Monthly income (JD) b < 300 418 94.8 54 90.0 34 7.7 7 11.7 300–599 315 93.2 44 84.6 26 7.7 8 15.4 600+ 109 90.8 15 93.8 13 10.8 1 6.7 χ2 = 2.68; P = 0.262 χ2 = 1.31; P = 0.520 χ2 = 1.37; P = 0.51 χ2 = 0.893; P = 0.640 Marital status Single 206 92.0 6 85.7 24 10.7 3 37.5 Married 630 94.2 89 86.4 49 7.3 13 12.7 Other 10 100.0 17 100.0 0 0.0 0 0.0 χ2 = 2.06; P = 0.357 χ2 = 2.63; P = 0.268 χ2 = 3.49; P = 0.175 χ2 = 6.96; P = 0.031 a23 respondents indicated they smoked both cigarettes and waterpipes daily; b7 respondents refused to declare their income. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 536 References 1. Controlling the smoking epidemic. Geneva: World Health Organization; 1979 (Technical Report Series No 636). 2. Jacobs DR Jr, Adachi H, Mulder I, Kromhout D, Menotti A, Nissinen A, et al. Cigarette smoking and mortality risk: twenty- five-year follow-up of the Seven Countries Study. Arch Intern Med. 1999 Apr 12;159(7):733–40. PMID:10218754 3. Martinet Y, Wirth N. Smoking-related diseases. In: Palange P, Simonds AK, editors. ERS handbook of respiratory medicine. Lausanne: European Respiratory Society; 2013. 4. Guidelines for controlling and monitoring the tobacco epi- demic. Geneva: World Health Organization; 1998. 5. Information and research for better health. Issue 1. July 2013. Amman, Jordan: Ministry of Health; 2013 (in Arabic) (http:// www.moh.gov.jo/AR/Documents/rep2012.pdf, accessed 12 May 2014). 6. Jordan Cancer Registry. 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Atlanta (GA): Centers for Disease Control and Pre- vention; 2011 (http://www.cdc.gov/tobacco/data_statistics/ tables/trends/cig_smoking/, accessed 12 May 2014). 14. Women and the tobacco epidemic: challenges for the 21st century. Geneva: World Health Organization; 2011. 15. Peto R, Lopez AD, Boreham Ji, Thun M, Heath C Jr, editors. Mortality from smoking in developed countries 1950–2000: indirect estimates from national vital statistics. New York (NY): Oxford University Press; 1994. 16. Azab M, Khabour OF, Alkaraki AK, Eissenberg T, Alzoubi KH, Primack BA. Water pipe tobacco smoking among university students in Jordan. Nicotine Tob Res. 2010 Jun;12(6):606–12. PMID:20418383 17. Chaaya M, El-Roueiheb Z, Chemaitelly H, Azar G, Nasr J, Al- Sahab B. Argileh smoking among university students: a new tobacco epidemic. Nicotine Tob Res. 2004 Jun;6(3):457–63. PMID:15203779 18. Khabour OF, Alzoubi KH, Eissenberg T, Mehrotra P, Azab M, Carroll MV, et al. Waterpipe tobacco and cigarette smoking among university students in Jordan. Int J Tuberc Lung Dis. 2012 Jul;16(7):986–92. PMID:22525279 19. Mzayek F, Khader Y, Eissenberg T, Al Ali R, Ward KD, Maziak W. Patterns of water-pipe and cigarette smoking initiation in schoolchildren: Irbid longitudinal smoking study. Nicotine Tob Res. 2012 Apr;14(4):448–54. PMID:22140149 In this study, smoking habits also showed significant differences according to educational status, with a trend towards higher prevalence of smoking among those with intermediate educational level. Our findings are not in line with the overall trend of declining prevalence of smoking with increasing education in the USA, in which smoking prevalence was found to be high among adults who had earned a general educational development diploma (43.2%) and those with 9–11 years of edu- cation (32.6%) (20). In the USA, Finland and Australia smoking rates correlated inversely with educational level (20–22). Initially we did not find a significant association between income status and smoking prevalence in Jordan. However, we found that males with lower income were more likely to smoke than those with higher incomes. This accords with has been reported in the USA and Finland, where a higher prevalence of smoking was associated with lower income (20,21). With regards to marital status, smoking prevalence among single and married in- dividuals was very similar (36.5% versus 33.0% respectively), whether analysing males, females or both sexes. This is in con- trast to a Swedish study showing a higher prevalence of smoking among single than married people (23). It is important to note that, consist- ent with other self-reporting interview methods, individuals may be reluctant to explicitly state their smoking practices and may rather provide answers that are socially acceptable. However, a significant strength of our study was the involvement of a representative sample of the Jordanian population. Conclusion and Recommendations Reducing the prevalence of smoking in Jordan must be set as a priority. Reducing the prevalence of smoking can be approached through education, particularly among the youth. In ad- dition, creation of smoking cessation programmes and primary prevention programmes that promote non- smoking can be useful. Official action through activating current laws and regulations and imposing new ones is of vital importance. Acknowledgements Funding: This work was supported by the Arab Fund for Economic and Social Development (AFESD). The KAP sur- vey was implemented by King Hussein Institute for Biotechnology and Cancer (KHIBC) under the National Life Science Research and Biotechnology Promotion (LSR/BTP) Initiative in Jordan. Competing interests: None declared طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 537 20. Tobacco use among adults: United States, 2005. MMWR Morb Mortal Wkly Rep. 2006 Oct 27;55(42):1145–8. (http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5542a1.htm, accessed 14 May 2014). 21. Laaksonen M, Rahkonen O, Karvonen S, Lahelma E. Socio- economic status and smoking: analysing inequalities with multiple indicators. Eur J Public Health. 2005 Jun;15(3):262–9. PMID:15755781 22. Australian social trends 2000. Canberra: Australian Bureau of Statistics; 2000 (http://www.ausstats.abs.gov.au/ausstats/ subscriber.nsf/0/0061403922BF6F55CA2569110080BA2C/$F ile/41020_2000.pdf, accessed 12 May 2014). 23. Lindström M. Social capital, economic conditions, marital status and daily smoking: a population-based study. Public Health. 2010 Feb;124(2):71–7. PMID:20181369 EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 538 Quitting smoking and utilization of smoking cessation services in Jordan: a population-based survey M. Jaghbir,1 S. Shareif 1 and M. Ahram 2 1Department of Family and Community Medicine; 2Department of Physiology and Biochemistry, Faculty of Medicine, University of Jordan, Amman, Jordan (Correspondence to M. Jaghbir: jaghbirm@yahoo.com; mjaghbir@ju.edu.jo). Received: 16/01/14; accepted: 14/04/14 ABSTRACT Increasing rates of smoking in Jordan have been documented. It is therefore important to understand the trends and factors associated with attempts to quit smoking, such as the utilization of smoking cessation clinics and hotlines. A population sample of 3196 adults aged 18+ years were interviewed about their smoking habits; 1032 (32.3%) were current smokers and 93 (2.9%) had successfully quit smoking (8.7% of ever-smokers). A high percentage of current smokers (62.8%) had tried, unsuccessfully, to quit smoking. Almost half of them had heard of smoking cessation clinics and hotlines, but only 2.4% had ever utilized them. After being informed about these services, 53.0% of current smokers agreed that they were likely to utilize them. Only 19.9% of current smokers had ever received advice from a health-care practitioner about contacting these services. The study should guide decision-makers on strategies to reduce the high smoking rates in Jordan. نياكس حسم :ندرلأا في ينخدتلا نع علاقلإا تامدخ نم ةدافتسلااو ينخدتلا نع علاقلإا مارهأ دحمأ نومأم ،فيشرلا يفطل رمس ،يربغلجا قيفوت ضيام تلاواـحمب ةـطبترلما لـماوعلاو تاـهاتجلاا مـهفن نأ مـهلما نـم هـنإف اذـلو ،ندرلأا في نـخدتلا تلادـعم عاـفترا قـيثوت مـت دـقل :ةـصلالخا تاـباقم تـَيرجأ دـقو .كـلذب ةـصالخا ةنخاـسلا طوـطلخا نـمو نـخدتلا نـع عاـقلإا تاداـيع نـم ةدافتـسلاا لـثم ؛نـخدتلا نـع عاـقلإا )% 32.3( 1032 ناكـف ؛مـيهدل نـخدتلا تاداـع نأـشب ًاـماع 18 نـع مـهرماعأ دـيزت نـمم نـغلابلا ناكـسلا نـم 3196 نـم ةـفلؤم ةـنيع عـم ةيرـبك ةـيوئم ةبـسن نإو .)ًاقباـس اـم تـقو في نـنخدلما نـم % 8.7( حاـجنب نـخدتلا نـع اوـعلقأ دـق )% 2.9( 93و ،نـيلاح نـنخدم مـهنم عاـقلإا تاداـيعب اوعمـس دـق ًاـبيرقت مـهفصن ناكو .اوـحجني لمو نـخدتلا نـع عاـقلإا اوـلواح دـق اوـناك )% 62.8( نـيلالحا نـنخدلما نـم ىـع مـهعاطإ مـت نأ دـعبو .ًاقباـس اـم تـقو في اـهنم اودافتـسا طـقف مـهنم % 2.4 نـكل ،كـلذب ةـصالخا ةنخاـسلا طوـطلخاو نـخدتلا نـع اوـقلت دـق نـيلالحا نـنخدلما نـم طـقف % 19.9 ناكو .مـهديفت نأ لـمتحلما نـم تـناك اـنهأب نـيلالحا نـنخدلما نـم % 53 َّرـقأ تاـمدلخا هذـه عاـنص هـجوت نأ ةـساردلا هذـله يـغبنيف .تاـمدلخا هذـبه لاـصتلااب قـلعتت ةـيحصلا ةـياعرلا لاـمج في سراـمم نـم ةـحيصن ًاقباـس اـم تـقو في .ندرلأا في ةـعفترلما نـخدتلا تلادـعم نـم دـلحا لىإ يـمرت تايجيتارـسا عـضو لىإ رارـقلا Arrêt de la consommation du tabac et recours aux services de sevrage tabagique en Jordanie : enquête en population RÉSUMÉ L'augmentation des taux de tabagisme en Jordanie est avérée. Il est par conséquent important de comprendre les tendances et les facteurs associés aux tentatives d'arrêt de la consommation de tabac, tels que le recours à des cliniques de sevrage tabagique et aux services d’écoute téléphonique. Un échantillon de population de 3196 adultes âgés de 18 ans et plus a été interrogé sur les habitudes de consommation de tabac ; 1032 (32,3 %) étaient des consommateurs actifs et 93 (2,9 %) avaient réussi à arrêter de fumer (8,7 % d'adultes ayant déjà fumé). Un fort pourcentage de fumeurs actifs (62,8 %) avait essayé, sans succès, d'arrêter. Près de la moitié d'entre eux avait entendu parler des cliniques de sevrage tabagique et des services d'écoute téléphonique, mais seuls 2,4 % les avaient déjà utilisés. Après avoir été informés à propos de ces services, 53,0 % des fumeurs actifs convenaient qu'il était probable qu'ils les utilisent. Seuls 19,9 % des fumeurs actifs avaient déjà reçu des conseils d'un professionnel de santé les incitant à contacter ces services. La présente étude devrait orienter les décisionnaires sur les stratégies visant à réduire les taux élevés de consommation de tabac en Jordanie. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 539 Introduction Numerous studies have reported a sub- stantial health benefit of quitting smok- ing. For example, similar mortality rates have been documented between those who quit cigarette smoking and those who have never smoked (1,2). The benefits of quitting reach beyond im- provements in individuals’ own health and quality of life; Parrott and Godfrey have shown that there are major reduc- tions in the cost of health care, with consequent savings for the national gross domestic product of countries (3). As a result, a growing number of countries have campaigned to reduce the number of smokers and are report- ing higher proportions of ex-smokers than smokers (4). The United States of America (USA), as an example, has successfully reduced the prevalence of cigarette smoking among adults from 42.4% to 19.3% between 1965 and 2010, in part due to an increase in the number of those who have quit smoking (5). Both older and more recent sur- veys have indicated a high prevalence of smoking among Jordanians, in particular among males, who have a smoking rate as high as 55% (6–8). This correlates well with the rate of lung cancer in Jordan, which ranks second among all cancers in males (9). In the current study, we utilized data from a national survey of knowledge, attitudes and practices (KAP) towards cancer prevention and care in Jordan based on a sample representing the Jordanian population. Our analyses attempted to offer a deeper understanding of at- tempts to quit smoking by Jordanians, their knowledge of cessation clinics and hotlines and their previous and poten- tial utilization of these services. The role of health-care providers is critical for advising patients and persuading smok- ers to quit. We therefore investigated whether smokers had ever been advised by a health-care provider to quit smok- ing. It was hoped that the data generated would inform efforts to promote smok- ing cessation in Jordan. Methods Study design This was a quantitative, cross- sectional, descriptive survey. Data collection spanned 2 months from 24 January to 19 March 2011. The survey consisted of 10 sections start- ing with a section about demographic characteristics. One section enquired about the lifestyle of participants in- cluding smoking habits and quitting patterns among smokers as well as their knowledge, attitude and practice towards smoking cessation clinics and hotlines, which was the focus of this study. Participants The KAP survey sample was based on the 2004 Jordan Population and Housing Census as the sampling frame. The sampling frame was strati- fied by governorate, major cities (each city with a population of more than 100 000 was considered a stratum, i.e. 6 cities) and other urban and other rural areas. A 3-stage sampling pro- cedure was employed. First, blocks were selected systematically as pri- mary sampling units (PSUs) with a probability proportional to the size of the PSU. In the second stage, a fixed number of 15 households were selected as final sampling units in each PSU, resulting in a sample size of about 4500 households. In the third stage, random selection of individual interviewees from each household was carried out using Kish tables (10). The final sample size in the KAP survey was 3196 participants (a response rate of 93%): 1647 males and 1549 females. The demographic distribution of the whole interviewed sample are shown in our earlier paper (8). The number of current smokers on which this report is based was 1032. Instrument A structured questionnaire was de- signed by a national advisory committee that consisted of research experts from different research, clinical and academic institutions in Jordan. The design of the survey was based on international references/tools that were used as a guide to the development of the ques- tionnaire and to ensure appropriate themes and adaptation to the local context. Face-to-face interviews were conducted in interviewees’ households and took an average of 30 minutes to complete. Verbal informed consent was obtained; agreement to host interviews in the participants’ house is a culturally appropriate method to obtain consent in Jordan. A pilot study was conducted to test the survey tool, sampling technique, survey methods and interviewers’ level of work. The pilot study spanned a day and was carried out in one area in the capital city, Amman. The pilot sample consisted of 56 randomly selected sub- jects. Following the pilot, a 2-day review session was conducted and resulted in implementation of minor modifica- tions. Measures Respondents were first asked if they considered themselves as non-smokers, current smokers or ex-smokers. Those who described themselves as smok- ers were then asked whether they had tried to quit smoking or not, whether they had heard about smoking cessa- tion clinics and whether they had ever utilized them. After the smokers had been informed about the availability of smoking cessation clinics they were asked about the possibility of their con- sulting one in the future. The latter were measured on a 4-point Likert scale, with scores ranging from very likely to very unlikely. Then they were asked whether any physician or health-care provider had ever suggested these services to them in the previous 12 months to help them to quit smoking. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 540 Data collection Data collection was carried out in the 3 regions of Jordan (North, Middle and South). The face-to-face interviews were conducted by 18 trained teams. Each team consisted of 3 data collec- tors, 1 controller, 1 field supervisor and 1 driver. The controllers and supervisors conducted spot checks by randomly visiting some sampled households. In order to facilitate data collection, each interviewing team was assigned a number of blocks in the sample area. Interviewers made repeated attempts to obtain the responses of eligible re- spondents by calling back to interview respondents who were not home at the time of the first visit or by attempt- ing to persuade respondents who were reluctant to be interviewed. Data processing and analysis Data entry using Oracle software started 1 week after the initiation of data collec- tion. After editing and cleaning, the data were exported to SPSS, version 17.0. SPSS was used to run univariate and bi- variate analyses to describe all the survey variables. As most of the variables in the study were measured on a nominal and/ or ordinal level, descriptive statistics were used to describe the basic features of the data. Responses to questions were analysed using the chi-squared and/or Pearson correlation coefficients when comparing sociodemographic groups or ranked data respectively. Results Of the 3196 participants interviewed about their smoking habits in the main KAP survey 2071 (64.8%) reported that they had never smoked, 1032 (32.3%) were current smokers and only 93 (2.9%) were ex-smokers. The ex-smokers there- fore represented 8.7% of ever-smokers. Demographic characteristics The demographic characteristics of the 1032 current smokers are shown on Table 1. Current smokers were mainly males (87.6%) and the majority were young and middle-aged adults (28.6%, 32.6% and 24.2% respectively). Indi- viduals with intermediate education (58.5%) constituted the majority of cur- rent smokers compared with those with lower (16.2%) and higher (25.4%) edu- cational levels. Current smokers were also mainly within the low (48.5%) and intermediate (37.8%) income groups rather than the higher income group (13.1%). Attempts to quit smoking Self-reported current smokers were asked if they had ever attempted to quit smoking. A considerable proportion of them (62.8%) had attempted to quit but had failed to do so. This compares with 384 individuals (37.2%) who had never tried to quit. There were no sig- nificant associations between attempt- ing to quit smoking and sex, age or income. However, a significantly higher proportion of those with intermediate educational level had never tried to quit smoking (41.6%) in contrast to those with lower (31.7%) and higher (30.9%) educational status (P = 0.003) (Table 2). Potential utilization of smoking cessation clinics and hotlines Current smokers were asked about their knowledge of smoking cessation clinics or hotlines before this survey. Approxi- mately half of them (50.6%) had never heard of such services. Males (50.6%) had significantly better knowledge of smoking cessation clinics or hotlines than did females (41.4%) (P = 0.044) (Table 3). As for age, although there was no significant difference among the age groups (P = 0.065), a significant trend towards increasing knowledge with increasing age (r = 0.09; P = 0.006) was found. In addition, there was a sig- nificant association of knowledge with better levels of education (P < 0.001) and income (P < 0.001). Only 25 cur- rent smokers (2.4%) had ever called a smoking cessation clinic or hotline, with no significant associations by sex, education, age or income (Table 3). Interestingly, a significant association was found between attempting to quit Table 1 Participants’ demographic characteristics (n = 1032) Characteristic No. % Sex Male 904 87.6 Female 128 12.4 Age (years) 18–29 295 28.6 30–39 336 32.6 40–49 250 24.2 50–59 83 8.0 60+ 68 6.6 Education Elementary or less 167 16.2 Preparatory to high school 604 58.5 Diploma and above 262 25.4 Monthly income (JD) a < 300 501 48.5 300–599 390 37.8 600+ 135 13.1 a6 respondents refused to declare their income. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 541 smoking and knowledge of smoking cessation clinics or hotlines (χ2 = 7.035; P = 0.005), but not the actual practice of utilizing them (χ2 = 3.268; P = 0.051) (detailed data not shown). In addition, the practice of calling a smoking cessa- tion clinic or hotline did not show any trend with age (r = 0.001; P = 0.980), education (r = 0.03; P = 0.392) or in- come (r = –0.007; P = 0.815). After informing them about the existence of smoking cessation clinics and hotlines, we assessed the intention of smokers to utilize these services in the future; 53.0% of current smokers agreed that they were likely or very likely to do so. There was no significant difference by sex in intention to use services (P = 0.499). However, young- er individuals were more likely than older smokers to agree that they would seek help from a cessation clinic (P < 0.001) (Table 4). A significant trend was also observed between decreas- ing age and the likelihood of calling a cessation clinic (r = 0.13; P < 0.001). Significant differences across the 3 income groups were noted, whereby the likelihood of calling a smoking cessation clinic was lowest at the high- est income (43.0%) in comparison with 52.8% and 56.4% for the low- and middle-income levels, respectively (P < 0.001). Despite the lack of a signifi- cant trend between increasing educa- tion and the likelihood to call these services (P = 0.076), individuals with the highest educational level (43.1%) were significantly less likely to utilize such services than those in the low (53.9%) and intermediate (56.9%) educational levels (P = 0.011). A correlation was found between attempting to quit smoking and the likelihood of calling a smoking cessation clinic or hotline (r = –0.207; P < 0.001) (Table 4). Role of health-care providers We asked current smokers whether they had ever been advised by a health- care provider to quit smoking by calling a cessation clinic or hotline. Only 19.9% of current smokers had ever received any advice to quit smoking (Table 5). There were significant disparities in receiving advice from health-care providers among individuals accord- ing to income, educational level and age. More specifically, individuals in the higher income and education catego- ries were more likely to be advised by their physicians to quit smoking than Table 2 Attempts to quit smoking in relation to socioeconomic characteristics among current smokers Variable Ever tried to quit smoking No Yes, but failed No. % No. % Total 384 37.2 648 62.8 Sex Male 329 36.4 575 63.6 Female 55 43.0 73 57.0 χ2 = 2.08; P = 0.090 Age (years) 18–29 110 37.2 186 62.8 30–39 108 32.1 228 67.9 40–49 106 42.4 144 57.6 50–59 35 42.2 48 57.8 60+ 25 36.8 43 63.2 χ2 = 7.46; P = 0.114 (r = –0.04; P = 0.265) Education Elementary or less 53 31.7 114 68.3 Preparatory to high school 251 41.6 352 58.4 Diploma and above 81 30.9 181 69.1 χ2 = 11.46; P = 0.003 (r = 0.02; P = 0.455) Monthly income (JD) a < 300 177 35.3 324 64.7 300–599 147 37.3 243 62.3 600+ 58 43.0 77 57.0 χ2 = 2.71; P = 0.258 (r = –0.05; P = 0.112) a6 respondents refused to declare their income. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 542 were individuals with lower income and educational level (P = 0.003 and P < 0.001 respectively). As for age, younger individuals were less likely to receive ad- vice from their physicians (P < 0.001). Discussion We found a high number of current smokers in our survey who had at- tempted to quit smoking but had failed. Although knowledge of smoking cessa- tion clinics and hotlines existed among half of respondents, it did not translate into action, as less than 3% had ever utilized them. However, the potential use of these services was indicated by around half of respondents. Further- more, the role of health-care providers in advising smokers to utilize smoking cessation clinics or hotlines was not only minimal but was also biased to- wards certain subsets of the population. The quit rate in the Jordanian population on which this study was based (2.9% of the total sample were ex-smokers) was close to the estimated figures in Britain of 1–2% in the last 40 years and 2–3% in 2005 (11), but lower those in the USA, which had a success rate of 6.2% in 2009 (12). However, more of the current smokers (62.8%) interviewed in Jordan had attempted to quit smoking than those in the USA, where 52.4% of smokers had made a quit attempt in 2009 (12). Overall, nu- merous different factors are likely to play important roles in quitting tobacco. Health concerns were reported to be a common motivational factor to quit smoking in different studies including those in Saudi Arabia and Lebanon (13–15). Another study illustrated the importance of setting a model for children as the primary reason for quit- ting smoking, rather than the cost or family pressure (13). It would therefore be interesting to investigate further the reasons for attempts to quit smoking or the lack of such attempts. Initially, it seems that cost was unlikely to be a mo- tivational factor to quit smoking among Jordanians, as income level was not as- sociated with attempting to quit smok- ing. However, this observation could be due to the low price of cigarettes not only in Jordan but also in other Table 3 Knowledge and utilization of smoking cessation clinics and hotlines among current smokers in relation to sociodemographic characteristics Variable Ever heard of a smoking cessation clinic or hotline Ever called a smoking cessation clinic or hotline No Yes No Yes No. % No. % No. % No. % Total 522 50.6 510 49.4 1007 97.6 25 2.4 Sex Male 447 49.4 457 50.6 883 97.7 21 2.3 Female 75 58.6 53 41.4 125 96.9 4 3.1 χ2 = 4.048; P = 0.044 χ2 = 0.289; P = 0.382 Age (years) 18–29 168 56.9 127 43.1 291 98.3 5 1.7 30–39 169 50.3 167 49.7 326 97.0 10 3.0 40–49 117 46.8 133 53.2 243 96.8 8 3.2 50–59 40 48.2 43 51.8 82 98.8 1 1.2 60+ 28 41.2 40 58.8 67 98.5 1 1.5 χ2 = 8.84; P = 0.065 (r = 0.09; P = 0.006) χ2 = 2.52; P = 0.642 (r = 0.001; P = 0.980) Education Elementary or less 96 57.5 71 42.5 164 98.2 3 1.8 Preparatory to high school 323 53.6 280 46.4 589 97.7 14 2.3 Diploma and above 103 39.3 159 60.7 254 96.9 8 3.1 χ2 = 18.76; P < 0.001 (r = 0.13; P < 0.001) χ2 = 0.75; P = 0.688 (r = 0.03; P = 0.392) Monthly income (JD) a < 300 280 55.9 221 44.1 490 97.8 11 2.2 300–599 183 46.9 207 53.1 380 97.4 10 2.6 600+ 56 41.5 79 58.5 133 95.5 2 1.5 χ2 = 12.40; P = 0.002 (r = 0.11; P < 0.001) χ2 = 0.55; P = 0.761 (r = –0.007; P = 0.815) a6 respondents refused to declare their income. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 543 countries in the Eastern Mediterranean Region (16). We agree with the sug- gestions of Abdullah and Husten that increasing the cost of cigarette smoking in developing countries by increasing taxes would have an impact on reducing smoking and increasing the readiness to quit (17). It is worth mentioning that an important barrier to utilizing smoking cessation intervention is the higher cost of tobacco quitting services compared with the price of cigarettes (16). The role of education seems perplexing, as those with intermediate education in our study were less likely to attempt to quit smoking. In a study in the USA, attempting to quit smoking was associ- ated with a higher level of education (12). We also found no significant dif- ference according to sex. This is con- trary to what has been shown earlier that females are less likely to quit smoking than males due to higher behavioural dependence (18). Importantly, we found strong corre- lations of between attempts to quit and knowledge about smoking cessation clinics/hotlines and the probability of seeking help. . In addition, the likelihood of utilizing these services was higher among those who had made unsuc- cessful attempts to quit smoking. The importance of such services is illustrated by a study conducted among Jorda- nian university students, who reported that lack of knowledge on how to quit was a reason for not quitting smoking (19). Two studies, one from the USA and another from Hong Kong, found positive results from smoking cessation support (20,21). Similarly, a multina- tional cohort study found that lack of assistance to quit was predictive of re- lapses (22). The success rate of smoking cessation clinics has been variable (23). It is likely that the modest success of these clinics is due to their low recogni- tion by the public. This is exactly the Table 4 Likelihood of calling smoking cessation clinics and hotlines among current smokers in relation to sociodemographic characteristics Variable Likelihood of calling a smoking cessation clinic or hotline Very likely Likely Unlikely Very unlikely No. % No. % No. % No. % Total 132 12.8 415 40.2 249 24.1 236 22.9 Sex Male 113 12.5 370 40.9 219 24.3 202 22.4 Female 19 15.0 45 35.4 30 22.8 34 26.8 χ2 = 2.37; P = 0.499 Age (years) 18–29 47 15.9 119 40.3 81 27.5 48 16.3 30–39 53 15.8 140 41.7 62 18.5 81 24.1 40–49 26 10.4 93 37.2 67 26.8 64 25.6 50–59 2 2.4 38 45.8 18 21.7 25 30.1 60+ 4 5.9 25 36.8 21 30.9 18 26.5 χ2 = 34.40; P < 0.001 (r = 0.13; P < 0.001) Education Elementary or less 17 10.2 73 43.7 36 21.6 41 24.6 Preparatory to high school 83 13.5 261 42.6 137 22.3 132 21.5 Diploma and above 32 12.2 81 30.9 76 29.0 73 27.9 χ2 = 16.64; P = 0.011 (r = 0.06; P = 0.076) Monthly income (JD) a < 300 56 11.2 208 41.5 140 27.9 97 19.4 300–599 71 18.2 149 38.2 74 19.0 96 24.6 600+ 5 3.7 53 39.3 35 25.9 42 31.1 χ2 = 33.94; P < 0.001 (r = 0.07; P = 0.038) Ever tried to quit smoking No 31 23.3 117 28.3 122 49.2 115 48.5 Yes, but failed 102 76.7 297 71.7 126 50.8 122 51.5 χ2 = 53.36; P < 0.001 (r = –0.21; P < 0.001) a6 respondents refused to declare their income. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 544 trend we found, whereby more than half of our survey respondents had not heard about these facilities and only 2.4% of smokers had ever utilized them. A reason for lack of knowledge could be the existence of only 2 such clinics in the capital, Amman, one of which is government-run and lacks sufficient funding. One solution is to strengthen, integrate and/or increase public knowl- edge of these services. Other solutions include the integration of counselling into clinical practice including follow- up and medications, as suggested previ- ously (17,24). In addition, the provision of multiple forms of smoking cessation assistance is needed (25). Previous studies have highlighted the role of health-care providers in at- tempts to quit smoking. Recent studies revealed that the role of physicians is vital when it comes to smoking cessa- tion (26,27). According to a Centers for Disease Control report, over 50% of smokers received advice from their health-care provider to quit smoking (28). In a sample of mostly long-term cancer survivors drawn from the 2000 National Health Interview Survey, 42.3% of individuals who visited a health-care provider in the previous year reported being asked about their smoking status (29). In addition, two- thirds of individuals smoking at the time of diagnosis reported being advised to quit smoking by a health-care pro- vider (30). Unfortunately, in our study, only one-fifth of smokers who had visited any health-care providers had been advised to call a smoking cessation clinic or hotline. It is also unfortunate that younger individuals were less likely to be targeted for advice by health-care providers as this group were more likely to report that they would seek assistance from smoking cessation clin- ics or hotlines. In a recently published study, 46.7% of Jordanian physicians were current smokers (31) and, based on a previous study, a high percentage (81%) of them smoked in front of their patients (32). Shishani et al. found that Jordanian physicians and nurses lacked knowledge about the addictive effects of smoking (33). Collectively, these data suggest a limited involvement of physicians in advising patients to quit smoking in Jordan. It is interesting to note that Jordanian (33) and Egyptian (34) health-care providers requested Table 5 Role of health-care providers in advising smokers to use smoking cessation clinics or hotline services in relation to sociodemographic characteristics Variable Referred to cessation clinic or hotline by health-care provider No Yes Have not visited health-care provider recently No. % No. % No. % Total 680 65.9 205 19.9 147 14.2 Sex Male 600 66.4 176 19.5 128 14.2 Female 80 62.5 29 22.7 19 14.8 χ2 = 0.865; P = 0.649 Age (years) 18–29 207 69.6 45 15.2 44 14.9 30–39 229 68.2 61 18.2 46 13.7 40–49 150 59.8 60 23.9 41 16.3 50–59 56 67.5 19 22.9 8 9.6 60+ 39 57.4 21 30.9 8 11.8 χ2 = 15.97; P = 0.043 Education Elementary or less 111 66.9 19 11.4 36 21.7 Preparatory to high school 388 64.2 124 20.5 92 15.2 Diploma and above 181 69.3 61 23.4 19 7.3 χ2 = 24.19; P < 0.001 Monthly income (JD) a < 300 339 67.4 84 16.7 80 15.9 300–599 262 67.2 77 19.7 51 13.1 600+ 78 57.4 43 31.6 15 11.0 χ2 = 16.13; P = 0.003 a6 respondents refused to declare their income. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 545 education and training to increase their knowledge and counselling capabilities in smoking cessation. Previous studies conducted in Saudi Arabia and Jordan found that health education is an ef- fective means of smoking cessation (15,19). This enforces the need to establish educational programmes to promote smoking cessation efforts. It is important to note that, con- sistent with other self-report interview methods, individuals may be reluctant to state their views objectively and may provide biased answers that are socially acceptable. However, a major strength of our study was the involvement of a representative sample of the Jordanian population. Conclusion and Recommendations There was a large difference in our study between the proportion of current smokers who wished to quit smoking and those who had suc- cessfully quit. It is also important to highlight the missed opportunities for health-care providers to advise smok- ers to quit. Concerted efforts need to be initiated among the various social and health groups in Jordan, along with government policies to increase knowledge about smoking cessation services among the public and health- care providers and to support smok- ing cessation programmes. Income was not associated with desire to quit smoking, which suggests that an in- crease in the price of tobacco products is warranted. Acknowledgements Funding: This work was supported by the Arab Fund for Economic and Social Development (AFESD). The KAP sur- vey was implemented by King Hussein Institute for Biotechnology and Cancer (KHIBC) under The National Life Science Research and Biotechnology Promotion (LSR/BTP) Initiative in Jordan. Competing interests: None declared. References 1. A Report of the Surgeon General: how tobacco smoke causes disease: the biology and behavioral basis for smoking-attribut- able disease, 2010. 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J Family Med Prim Care. 2013 Apr;2(2):159–63. PMID:24479071 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 547 Household storage of medicines and self-medication practices in south-east Islamic Republic of Iran B. Foroutan 1 and R. Foroutan 2 1Department of Pharmacology, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Islamic Republic of Iran (Correspondence to B. Foroutan: behzad_foroutan@hotmail.com). 2School of Medicine, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran. Received: 10/06/13; accepted: 16/04/14 ABSTRACT Self-medication and inappropriate storage of medicines at home are potential health risks. This cross- sectional study in south-east Islamic Republic of Iran in 2010 aimed to determine where householders kept their medicines and to assess the frequency and determinants of self-medication. Householders from different parts of Birjand city (n = 500) were visited and completed a semi-structured questionnaire. Analgesics were the most common medicines stored at home, followed by adult cold remedies and antibiotics. The refrigerator was the most common place for storing medicines (50.6%). Most householders did not consult the package inserts. Many householders (53.6%) reported that they practised self-medication, and the frequency of reuse of physician- prescribed antibiotics was high. There was a significant association between self-medication and educational level but not with age, sex, martial status, occupation and type of insurance. Better public knowledge and information about storage and risks of reuse of prescription medications is needed. ةيملاسلإا ناريإ ةيروهجم قشر بونج في تياذلا بيبطتلا تاسراممو ةيودلأل ليزنلما نيزختلا ناتوروف اضر ،ناتوروف دازبه بوـنج في تـيرجأ ةـسارد تـفده دـقو .ةـلمتمح ةـيحص رـطامخ نلاكـشي لزـنلما في ةـيودلأل مـئلالما رـغ نـيزختلاو تياذـلا بـيبطتلا نإ :ةـصلالخا حــ سم يــ فف .هــ تاد ِّدمحو تياذــ لا بــ يبطتلا ةرــ تو مــ ييقت لىإو ،اــ هتيودأ سرلأا اــ به ظــ فتح يــ تلا نــ كاملأا دــ يدتح لىإ ةيملاــ سلإا نارــ يإ ةــ يروهجم قشر تـناكف .مـظنم هبـش نايبتـسا ءلـم مـتو )500 = ددـعلا( دـنجرب ةـنيدم نـم ةـفلتمخ قـطانم نـم سرأ ةراـيز تـتم 2010 ماـع يرـجأ ضرعتـسم ةـجلاثلا تـناكو .ةـ يويلحا تاداـضلماو نـغلابلا ىدـل درـلا تلازـن جلاـع ةـ يودأ اـهتلت ،ًاعويـش لزـنلما في نزـتخ يـتلا ةـ يودلأا رـ ثكأ تانكـسلما ةرــ ثك سرأ ترــ كذو .تاوــ بعلا في ةــ جردلما تارــ نلا ىــ ع عــ لطت لم سرلأا مــ ظعم نأ َّنــ بتو .)% 50.6( ةــ يودلأا نــ يزختل ًاعويــ ش رــ ثكلأا ناكــ لما طـُبارت كاـنه ناكو .ةـيلاع ءاـبطلأا لـبق نـم ةـفوصولما ةـيويلحا تاداـضلما مادختـسا ةداـعإ ةرـتو تـناكو ،تياذـلا بـيبطتلا سراـتم اـنهأ )% 53.6( تـصلخو .يـئاعلا عـضولا كـلذكو نـمأتلا عوـنو ةـنهلماو سـنلجاو نـسلا عـم طـبارت كاـنه نـكي لم .يـميلعتلا ىوتـسلماو تياذـلا بـيبطتلا نـب رـبك .ةـيبطلا تاـفصولا ةـيودأ مادختـسا ةداـعإ رـطامخو ةـيودلأا نـيزتخ نأـشب مـتهامولعمو روـهملجا ةـفرعم نـستح لىإ ةـجاح كاـنه نأ لىإ ةـساردلا Conservation de médicaments à domicile et pratiques d'automédication dans le sud-est de la République islamique d'Iran RÉSUMÉ L'automédication et la conservation inappropriée de médicaments à domicile représentent des risques potentiels pour la santé. La présente enquête transversale réalisée en 2010 dans le sud-est de la République islamique d'Iran visait à déterminer où les ménages conservaient leurs médicaments et à évaluer la fréquence de l'automédication et ses déterminants. Des ménages dans différents quartiers de la ville de Birjand (n = 500) ont fait l'objet d'une visite et ont rempli un questionnaire semi-structuré. Les analgésiques étaient les médicaments les plus couramment conservés à domicile, suivis par les médicaments contre le rhume chez l'adulte et les antibiotiques. Le réfrigérateur était l'endroit le plus fréquent pour la conservation des médicaments (50,6 %). La plupart des ménages ne consultaient pas les notices des médicaments. De nombreux ménages (53,6 %) ont affirmé qu'ils pratiquaient l'automédication, et la fréquence de réutilisation des antibiotiques prescrits par un médecin était élevée. Il existait une forte association entre l'automédication et le niveau d'études, contrairement à l'âge, au sexe, à la situation matrimoniale, au métier et au type d'assurance. La population a besoin d'accroître ses connaissances et son niveau d'information sur la conservation des médicaments et sur les risques liés à la réutilisation des médicaments prescrits. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 548 Introduction Self-medication is a global concern, in both developed and developing coun- tries (1–9) including those of the Mid- dle East (10–12). It has been estimated that about 60–80% of health problems are treated by self-medication (13). This is a practice in which individuals utilize any types and dosages of medication for treating themselves, without profes- sional supervision, to control an illness or an abnormal condition (14,15). Based on the official figures, annual sales of non-prescription products in the United States of America exceed US$ 31 billion, although these sales represent less than 20% of total spend- ing on prescription pharmaceuticals (16). Concerns about self-medication include sharing prescription medicines with other members of the family, using leftovers from previous prescriptions or disrespecting the medical prescrip- tion by prolonging or interrupting the dosage and the administration period prescribed (1). Inappropriate storage and use of medicines at home could have a direct influence on public health, the environ- ment and the health-care services and it increases the risk of self-medication (17). Previous studies have identified a link between medicine storage and self-medication practices (18). This in- cludes medications stored intentionally while they remain in use or medications that are incompletely used. Storing medicines at home might increase the risk of self-medication, and some au- thors have reported a high frequency of exchange of self-medication between family members (11). Self-medication is influenced by many factors, such as local legislation and accessibility of medicines; advertisements by pharma- ceutical companies; individuals’ level of education, number of family members and income; and local societal and cul- tural norms. One of the main reasons for self-medication is often the finan- cial burden of consulting a doctor. In economically deprived communities, most episodes of illnesses are treated by self-medication (19), which provides a low-cost alternative for people who cannot afford the high cost of clinical services and also as many medicines in developing countries are dispensed over-the-counter. The present study in a city in the south-east of the Islamic Republic of Iran aimed to find out where medicines were kept at home, to investigate the frequency and determinants of self- medication among family members and to explore whether or not the medication package inserts were used. The study would inform strategies such as educational programmes aiming to promote public knowledge about medicines. These strategies would help householders to pay more attention to storing medicines at home and raise awareness of self-medication practices. Methods Sampling The study was conducted in March 2010 in the city of Birjand, south-east of Islamic Republic of Iran. A sample of 500 householders were recruited by stratifying the local regions of the city (north, south, east, west and central) into different sections to cover fami- lies of different socioeconomic status. Householders from each section were selected through a systematic, random sampling technique to cover all parts of the city. Local authorities were contact- ed to obtain formal permission to con- duct the study and householders were informed in advance about the study to ensure their agreement to participate in the study. Selected households were visited and the data collection super- visors explained the objectives of the study. Heads of households were asked to consent for their home to be included in the study and for them to participate in filling the questionnaires. They were told that their names and those of their families would not be recorded. Each household was given a code and con- sidered as a unit. When a householder was not willing to participate the next household in the sampling frame was taken until the sample size was reached (n = 500). Data collection The survey was conducted by 2 students who were trained by the researcher by conducting several household visits in the presence of the researcher before the actual start of the study. Householders completed a pre- tested, researcher-designed question- naire which collected data about their demographic characteristics (age, sex, marital status, education, occupation and insurance coverage/organization) and asked about use of medicines at home. They were asked: whether they kept medicines in the house; whether they read the package inserts; where they kept the medicines (refrigerator, kitchen cabinet, bedroom, bathroom, elsewhere); whether they stored pre- scription medicines for re-use; what kinds of medicines were reused (pain, fever, antibiotics, cold cures, herbal med- icines); whether they returned unused medicine to the pharmacy; whether they knew about self-medication; what formulations of medicines they kept (tablets, drops, syrup capsules injec- tions suppositories, creams/ointment); how many times in the past 3 months they self-medicated without consulting the doctor (once, twice, three times, more than three times); and whether they paid attention to the expiry date of the medicines. The questionnaire contained both open-ended questions and questions with a list of possible an- swers. We defined leftover medicines as medications prescribed by the doctor over the previous 3 months and kept by the householder. Medicine names, strength, dosage form, expiry date and quantity were recorded. We did not record householders’ income because most of participants were employed طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 549 within a similar range of annual in- come and there were few unemployed householders. Educational status was analysed in 2 categories: no formal education or primary school only; and secondary school or higher. Data analysis The data were reviewed, organized, tabulated and analysed using Microsoft Excel, 2010 version. Descriptive analysis was conducted by calculating means and standard deviation (SD) and pro- portions for continuous and discrete data respectively. The chi-squared and t-tests were used to analyse statistical significance. The cut-off for statistical significance was P < 0.05. Results A total of 500 householders completed the questionnaires: 231 (46.2%) fe- males and 269 (53.8%) males. Table 1 shows their demographic character- istics. Of the householders, 62.8% had completed secondary school or higher levels and 37.2% had no schooling or only primary school level. Most of the participants (73.6%) were married and living with their families, while 26.4% were single. One-third (34.4%) of householders had no insurance cover- age/organization to support and cover medication costs and 5.0% of partici- pants were unemployed. All the households reported that they kept medicines at home. Table 2 shows the places where medicines were kept at home. The most common place was the refrigerator (50.6%) or a kitchen cupboard (42.6%); the remain- der kept medicines in the bedroom. None of the households kept medi- cines in the bathroom. Only 6.8% of the householders said that they had read the instructions in the manufacturers’ patient information leaflets (package inserts) and 93.2% did not (some par- ticipants admitted that they threw away the leaflets). Overall, 268 (53.6%) householders reported that they practised self-med- ication for self-diagnosed disorders or symptoms. Table 2 also shows the most commonly reported therapeutic categories used for self-medication. Analgesics (e.g. non-steroidal anti- inflammatories, paracetamol and its related compounds or combinations such as paracetamol plus codeine) were the main therapeutic group, used by 59.6% of respondents for self-medi- cation. The number of times within the last 3 months that householders had self-medicated themselves and their families with analgesics were as fol- lows: 1 time (19.4%); 2 times (22.4%); 3 times (16.8%) and ≥ 3 times (41.4%). Adult cold remedies were used for self- medication by 11.6% of respondents, antibiotics (left-overs from doctors’ prescriptions) by 9.8%, herbal rem- edies by 9.2% and corticosteroids by 7.0% (Table 2). In answer to the question related to reuse of antibiotics prescribed by the doctor, one-third reported that they reused them. Of those who reused antibiotics, 70.7% reported that they did not know this type of use was self-medication. The results also showed that tablets were the most commonly used formulation for self-medication (35.6%), followed by capsules (24.4%); syrup (21.4%), ointments (10.8%); ampoules (4.0%) and suppositories (3.8%). Table 3 shows self-medication practices by age, sex, occupation and insurance coverage/organiza- tion name. There was a significant association between self-medication practices and educational level (P = 0.007). Respondents with secondary/ higher education were less likely to use self-medication than those who had none/primary education only. There was no significant association between self-medication and age, sex, marital status, occupation or type of insurance. Table 1 Demographic characteristics of participants (n = 500) Variable No. % Sex Female 231 46.2 Male 269 53.8 Mean (SD) age (years) 29.4 (1.32) Marital status Married 368 73.6 Single 132 26.4 Occupation Government employee 260 52.0 NGO employee 101 20.2 Housewife 60 12.0 Retired 54 10.8 Unemployed 25 5.0 Insurance cover/organization Social security insurance 196 39.2 Iran health insurance 122 24.4 Other health insurance 10 2.0 No insurance 172 34.4 Education Secondary school/higher 314 62.8 None/primary school only 186 37.2 NGO = nongovernmental organization. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 550 Discussion Our study revealed that nearly half of households stored medicines in the refrigerator, whether this was the cor- rect place or not. The correct place for storage depends on the medicine; for example, after preparation of antibiotic suspensions they must be kept cool but not frozen, whereas adult cold remedies should be kept at room temperature in a kitchen or bedroom cupboard. The kitchen cupboard was the second most common storage place. This finding contrasts with that of other countries. In a study in Qatar, for example, most medicines were kept in the bedroom (20,21). Our findings raise concerns about how medications are stored and disposed of in the community. None of the participants said that they returned unused medicines to a local pharmacy and keeping them in their home could be a risk of potential harm. The refrigerator is not a suitable place for all medicines, and even if, based on the recommendations of the package inserts, those medicines should be kept in a refrigerator, freezing must be avoided. Also it is necessary to ensure that children are not able to get access to medicines that are kept in a refrigerator. Most medicines are sensitive to light and heat, and may need to be destroyed earlier than the expiry date, or even be- come toxic, especially antibiotics. Places such as cabinets and kitchen cupboards might be suitable although humidity should also be considered. Pharmaceutical companies in the Islamic Republic of Iran are required to include a leaflet with medication pack- ages which briefly explains about the drug, its indications and side-effects. This covers most outpatient prescrip- tion and some non-prescription medi- cines and medical supplies. Only 6.8% of householders said that they had read the package inserts. Even if medicines are stored cor- rectly, it does not mean that these medicines would be suitable for a fam- ily member to start self-medication and reuse them. None of the householders in our study reported routinely returned unwanted medications to a pharmacy for proper disposal. Furthermore, a high prevalence of self-medication was noted among householders (53.6%). Muras et al. reported that antibiotic self-medica- tion for respiratory tract infection was common in Poland (22). Previous studies have documented the link between medicine storage plac- es at home and frequency of self-med- ication (23,24). Medicines prescribed for one symptom/disease may be used both as self-medication for (repeated) episodes of the same symptom/dis- ease or for a member of the family with the same symptom/disease but not by consultation with a physician. Find- ing unused prescription medicines in homes in the Islamic Republic of Iran is not surprising because self-medication practices are common among people of all educational levels (11,12,25–27). Other research has found that the majority of householders keep unused medicines at home either to use them in the future or to give them to someone else who has similar symptoms (28). Furthermore, leftover medications may be a result of non-completion to treat- ment regimens (29). Table 2 Storage of medicines at home and self-medication practices of participants (n = 500) Variable No. % Storage place of medications Refrigerator 253 50.6 Kitchen cupboard 213 42.6 Other 34 6.8 Consulted package inserts 34 6.8 Practises self-medication Yes 268 53.6 No 232 46.4 Frequency of self-medication in last 3 months (n = 268) 1 52 19.4 2 60 22.4 3 45 16.8 ≥ 3 111 41.4 Therapeutic class used for self-medication (n = 268) Analgesics 159 59.3 Adult cold remedies 31 11.6 Antibiotics 26 9.7 Herbal remedies 25 9.3 Corticosteroids 18 6.7 Other 9 3.4 Formulation used for self-medication (n = 268) Tablets 95 35.4 Capsules 65 24.3 Syrup 57 21.3 Ointments 29 10.8 Ampoules 11 4.1 Suppositories 11 4.1 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 551 There was a significant asso- ciation between self-medication and educational level. Lower educated householders were more likely to self- medicate. Self-medication provides a lower cost alternative for people who cannot afford the cost of clinical servic- es (30,31). Based on a study in India, the prevalence of self-medication was 37% in urban and 17% in rural popula- tions (32). The results showed that stored medicines belonged mostly to 3 cat- egories: analgesics, adult cold remedies and antibiotics. In the Islamic Republic of Iran, analgesics are the most com- monly procured over-the-counter medicines and self-medication with them is frequent. They are usually the first-line of medicines used by com- munity members in event of illness (33). Adult cold formulations (a com- bination of phenylephrine, chlorphe- niramine maleate and paracetamol) are also widely consumed products in the Islamic Republic of Iran. Nearly 10% of households in the present study reported that they used antibiotics for self-medication and one-third reported that reused them. It should be noted that this study refers to antibiotics origi- nally prescribed by the doctor and then kept and reused, as antibiotics are not sold over-the counter in the Islamic Republic of Iran. This may be in order to save money because antibiotics are expensive to buy. In Saudi Arabian households Abou-Auda found that res- piratory medicines, followed closely by central nervous system (CNS) agents and antibiotics, were the most common reused medicines (16.8%, 16.4% and 14.3% respectively) (34). In contrast, a British study revealed that among medicines returned to pharmacies, 28.0% were cardiovascular medicines, 19.1% were CNS agents, 14.8% were respiratory agents, 11.4% were gastro- intestinal agents and only 4.0% were antibiotics (35). Tablets were the formulations most commonly used for self-medication (35.6%). However, it should be em- phasized that tablets might be the most frequently used dosage form in self-medication simply because most medicines for self-medication come in tablet form. It is not surprising that nearly 10% of households kept herbal remedies. Self- medication with herbal preparations is likely to be frequent in south-east Islam- ic Republic of Iran because people in Table 3 Participants’ self-medication practices by demographic data and type of insurance Variable Practises self-medication P-value (χ2 test) Yes No No. % No. % Sex 0.704 Male 142 54.4 119 45.6 Female 126 52.7 113 47.3 Age (years) 0.832 20–29 58 50.4 57 49.6 30–39 69 53.5 60 46.5 40–49 71 53.8 61 46.2 ≥ 50 70 56.4 54 43.6 Marital status 0.613 Married 199 54.1 169 45.9 Single 68 51.5 64 48.5 Occupation 0.544 Employed 253 53.3 222 46.7 Unemployed 15 60.0 10 40.0 Insurance coverage/organization 0.728 Social security insurance 103 52.6 93 47.4 Iran health insurance 62 50.8 60 49.2 Other health insurance 5 50.0 5 50.0 None 98 57.0 74 43.0 Educational level 0.007a Secondary/higher 153 48.7 161 51.3 None/primary 115 61.2 73 38.8 aSignificant at P < 0.05. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 552 References 1. Stosic R, Dunagan F, Palmer H, Fowler T, Adams I. Responsible self-medication: perceived risks and benefits of over-the- counter analgesic use. Int J Pharm Pract. 2011 Aug;19(4):236– 45. PMID:21733011 2. Hughes CM, McElnay JC, Fleming GF. Benefits and risks of self medication. Drug Saf. 2001;24(14):1027–37. PMID:11735659 3. Hayran O, Karavus M, Aksayan S. Help-seeking behavior and self-medication of a population in an urban area in Turkey: cross sectional study. Croat Med J. 2000 Sep;41(3):327–32. PMID:10962055 4. Beitz R, Dören M, Knopf H, Melchert HU. Selbstmedikation mit Over-the-Counter-(OTC-)Praparaten in Deutschland. [Self-medication with over-the-counter (OTC) prepara- tions in Germany]. Bundesgesundheitsblatt Gesundheits- forschung Gesundheitsschutz. 2004 Nov;47(11):1043–50. PMID:15549197 5. 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PMID:9548207 this area are proud of their background related to traditional medicine. Previous studies in the Islamic Republic of Iran show that people take herbs as supple- ments to promote health, prevent illness (especially the common cold), boost the immune system, prevent stress and to supplement regular nutrition and they believe that use of herbs is part of a healthy lifestyle (36,37). One of the strengths of the present study was that it was carried out in the community and was not based on a specific target group. However, an ab- sence of a standard definition of self- medication and the study design which did not include a comparison group mean the results should be interpreted with caution. Conclusions Keeping medicines at home and self- medication are important health is- sues. Very few householders in our study consulted the package inserts or stored their medicines according to the manufacturers’ instructions. It is important for patients to be aware of information about manufacturers’ recommended storage conditions for medicines. There is a need for more pa- tient awareness about the safe handling and storage of medicines at home. A high prevalence of self-medication was also noted among householders, especially those who were less well- educated. Doctors have to take into account that their patients are likely to keep several prescription medicines in their homes. These patients are po- tential providers to their friends and relatives of medicines that are poten- tially unsafe for self-medication. Better public knowledge and information about the risks of reuse of prescription medications is needed. Acknowledgements The authors would like to express their gratitude towards all the respondents for showing concern towards this issue and also to thank Mr Javadinia for his contribution to data collection. Funding: None. Competing interests: None declared. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 553 20. Kheir N, Hajj ME, Wilbur K, Kaissi R, Yousif A. An exploratory study on medications in Qatar homes. Drug Healthc Patient Saf. 2011;3:99–106. PMID:22279414 21. Jassim AM. In-home Drug Storage and Self-medication with Antimicrobial Drugs in Basrah, Iraq. Oman Med J. 2010 Apr;25(2):79–87. PMID:22125705 22. Muras M, Krajewski J, Nocun M, Godycki-Cwirko M. A survey of patient behaviours and beliefs regarding antibiotic self- medication for respiratory tract infections in Poland. Arch Med Sci. 2013 Oct 31;9(5):854–7. 23. Poirier S, Barbeau G. An in-home medication inventory among elderly receiving home care services. J Geriatr Drug Ther. 1999;12(3):43–54. 24. Thompson S, Stewart K. Prescription medication use practices among non-institutionalised older persons. Int J Pharm Pract. 2001;9(3):141–51. 25. Habibzadeh A, Alizadeh M, Malek A, Maghbooli L, Shoja MM, Ghabili K. Illicit methylphenidate use among Iranian medical students: prevalence and knowledge. Drug Des Devel Ther. 2011;5:71–6. PMID:21340040 26. Amidi S, Ajamee G, Sadeghi HR, Yourshalmi P, Gharehjeh AM. Dispensing drugs without prescription and treating patients by pharmacy attendants in Shiraz, Iran. Am J Public Health. 1978 May;68(5):495–7. PMID:646001 27. Bijani A, Hasanjani Roshan AR, Yazdanpour S, Hosseini SR. Are older women likely to use medicines than older men? Results from AHAP study. Caspian J Intern Med. 2014 Spring;5(2):77–81. PMID:24778781 28. Zargarzadeh AH, Tavakoli N, Hassanzadeh A. A survey on the extent of medication storage and wastage in ur- ban Iranian households. Clin Ther. 2005 Jun;27(6):970–8. PMID:16117997 29. Asefzadeh S, Nassiri-asl M. Drugs at home in Qazvin, Iran: community based participatory research. Eur J Sci Res. 2009;32(1):42–6. 30. Yousef AM, Al-Bakri AG, Bustanji Y, Wazaify M. Self-medi- cation patterns in Amman, Jordan. Pharm World Sci. 2008 Jan;30(1):24–30. PMID:17562220 31. Nunes de Melo M, Madureira B, Nunes Ferreira AP, Mendes Z, Miranda Ada C, Martins AP. Prevalence of self-medication in rural areas of Portugal. Pharm World Sci. 2006 Feb;28(1):19–25. PMID:16703269 32. Dineshkumar B, Raghuram TC, Radhaiah G, Krishnaswamy K. Profile of drug use in urban and rural India. Pharmacoeconom- ics. 1995 Apr;7(4):332–46. PMID:10155322 33. Sepehri G, Khazaelli P, Dahooie FA, Sepehri E, Dehghani MR. Prevalence of potential drug interactions in an Iranian general hospital. Indian J Pharm Sci. 2012 Jan;74(1):75–9. PMID:23204627 34. Abou-Auda HS. An economic assessment of the extent of medication use and wastage among families in Saudi Arabia and Arabian Gulf countries. Clin Ther. 2003 Apr;25(4):1276–92. PMID:12809973 35. Daniszewsi, R., et al., An investigation of medicines returned to general practitioners and community pharmacies. Int J Pharm Pract. 2002;10 SuppI:R42. 36. Hasani-Ranjbar S, Nayebi N, Larijani B, Abdollahi M. A systema- tic review of the efficacy and safety of herbal medicines used in the treatment of obesity. World J Gastroenterol. 2009 Jul 7;15(25):3073-85. PMID:19575486 37. Hasani-Ranjbar S, Larijani B, Abdollahi M. A systematic review of the potential herbal sources of future drugs effective in oxidant-related diseases. Inflamm Allergy Drug Targets. 2009 Mar;8(1):2-10. PMID:19275687 EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 554 Use of complementary and alternative medicine among midlife Arab women living in Qatar L.M. Gerber,1 R. Mamtani,2 Y.-L.Chiu,1 A. Bener,3 M. Murphy,4 S. Cheema 2 and M. Verjee 2 1Weill Cornell Medical College, New York, United States of America (Correspondence to L.M. Gerber: LIG2002@med.cornell.edu). 2Weill Cornell Medical College in Qatar, Doha, Qatar. 3Hamad Medical Corporation, Doha, Qatar. 4The University of the West Indies, St. Michael, Barbados. Received: 25/09/13; accepted: 22/04/14 ABSTRACT The prevalence of use of complementary and alternative medicine (CAM) is widespread and is growing worldwide. This cross-sectional study in Qatar examined the use of CAM and its correlates among Arab women in their midlife years. Women aged 40–60 years (n = 814) were recruited at primary care centres in Qatar and completed a specially designed, pre-tested questionnaire. Overall, 38.2% of midlife women in Qatar had used CAM in the previous 12 months. Nutritional remedies and herbal remedies were the most commonly used CAM therapies, followed by physical methods. Qatari nationality and higher level of education were independently associated with CAM use. Menopause transition status was not independently associated with use of CAM. The prevalence of CAM use by women in Qatar was high, consistent with other reports worldwide. It is essential to educate and inform patients and health-care providers about the benefits and limitations associated with CAM. رَطَق في َنشعي تياوللا رمعلا فصتنم في تايبرعلا ءاسنلا ىدل ليدبلاو ممتلما بطلا مادختسا يجيرف دوممح ،مايش ةليهس ،فيرام يتنافودام ،رنب يرابلا دبع ،وشت ينلاي ،نياتمم ردنيفار ،ربرغ ادنيل ةـساردلا هذـه تـماق دـقو .لماـعلا ءاـحنأ عـيجم في دـيازت في وـهو ،عـساو قاـطن ىـع رـتنم لـيدبلاو مـمتلما بـطلا مادختـسا نإ :ةـصلالخا تـعوطت دـقف .نـهرماعأ فـصتنم تاونـس في تاـيبرع ءاـسن ىدـل هـتاطابتراو لـيدبلاو مـمتلما بـطلا مادختـسا ةـساردب رـَطَق في ةضرعتـسلما هراـبتخا مـت ًاـصيصخ مـ َّمصم نايبتـسا ءلـمب َنـمقو ،رـَطَق في ةـيلولأا ةـيحصلا ةـياعرلا زـكارم في )814 = ددـعلا( ةنـس 60-40 رماـعأب ءاـسن .ةقباـ سلا ًارهـ ش 12 ــلا في لـ يدبلاو مـ متلما بـ طلا نمدختـ سا دـ ق رـ َطَق في رـ معلا فـ صتنم في ءاـ سنلا نـ م % 38.2 هـ يلاجمإ اـ م ناكـ ف .ًاقبـ سم .ةـيئايزيفلا قرـطلا اـهتلت ،مادختـسلاا في ًاعويـش لـيدبلاو مـمتلما بـطلا تاـلجاعم رـثكأ ةيبـشعلا تاـجلاعلاو ةـيئاذغلا تاـجلاعلا تـناكو نـس ةـلاح نـكت لمو .لـيدبلاو مـمتلما بـطلا مادختـسا عـم - لقتـسم لكـشب - ةـطبترم ىـعلأا مـيلعتلا ىوتـسمو ةـيرطقلا ةيـسنلجا تـناكو نـم لـيدبلاو مـمتلما بـطلا مادختـسا راـشتنا ناكو .لـيدبلاو مـمتلما بـطلا مادختـسا عـم - لقتـسم لكـشب - ةـطبترم ةـيلاقتنلاا ساـيلإا ضىرـلما فـيقثت يرورـلا نـم نأ لىإ ةـساردلا تـصلخو .لماـعلا ءاـحنأ عـيجم نـم ىرـخأ رـيراقت عـم قـفتي ماـب ،ًاـعفترم رـَطَق في ءاـسنلا لـَبِق .لـيدبلاو مـمتلما بـطلاب ةـطبترلما دوـيقلاو دـئاوفلا ىـع مـهعلاطإو ةـيحصلا ةـياعرلا يـم ِّدقمو Recours aux médecines complémentaires et parallèles chez des femmes arabes en milieu de vie au Qatar RÉSUMÉ L’utilisation des médecines complémentaires et parallèles est largement prévalente et en augmentation dans le monde. La présente étude transversale au Qatar a examiné le recours aux médecines complémentaires et parallèles et ses corrélats chez des femmes arabes en milieu de vie. Des femmes âgées de 40 à 60 ans (n = 814) ont été recrutées dans des centres de soins de santé primaires au Qatar et ont rempli un questionnaire spécialement conçu ayant été testé au préalable. Au total, 38,2 % des femmes en milieu de vie interrogées vivant au Qatar avaient eu recours aux médecines complémentaires et parallèles durant les 12 mois précédents. Des remèdes nutritionnels et à base de plantes étaient les traitements complémentaires et parallèles les plus fréquemment utilisés, suivis par des méthodes physiques. La nationalité qatarie et un niveau d'études plus élevé étaient indépendamment associés à l'utilisation de médecines complémentaires et parallèles. Le statut de transition ménopausique n'était pas indépendamment associé à l'utilisation de ces médecines. La prévalence de leur utilisation chez les femmes au Qatar était élevée et concordait avec les études menées sur le sujet dans d'autre pays du monde. Il est essentiel d'éduquer et d'informer les patientes et les prestataires de soins de santé sur les bénéfices et les limites associés aux médecines complémentaires et parallèles. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 555 Introduction The demand for complementary and alternative medicine (CAM) is strong and growing worldwide. The reported prevalence of CAM use spans a wide range (40–70%), possibly due to vary- ing definitions of CAM (1,2). The Na- tional Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health defines CAM as “a group of diverse medical and health care systems, practices and prod- ucts that are not presently considered part of conventional medicine” (3,4), although it has been noted that there may be cultural differences in terms of what is considered complementary or alternative (5). In general, women use CAM more often than men do (6). The use of CAM by women during midlife has been found to be higher than during other stages of the lifespan (7). In the United States of America (USA), CAM use during midlife by women is in keeping with the global trend (8). A cross-sectional study by Upchurch et al. which utilized data from the Nation- al Health Interview Survey found that 46% of women ages 40–59 years used CAM in the previous year, with bio- logical therapies being used the most and prayer being frequently reported (9). That study also found ethnic dif- ferences in CAM use in the USA, con- sistent with reports that analysed data from the Study of Women’s Health Across the Nation (SWAN) over mul- tiple collection points (10). In the 5 ethnic groups studied in the SWAN (white, black, Hispanic, Japanese and Chinese), white and Japanese women between the ages of 42 and 52 years were more likely to use CAM than the other ethnic groups, with white women using psychological remedies and Japanese women using herbal and physical remedies the most. In Middle Eastern countries such as Qatar, CAM has been gaining popular- ity. A number of studies have examined CAM use by cancer patients in Arab countries (11). A 2008 household study in Saudi Arabia found that the majority of participants using CAM were women (60.9%) and that of the persons sampled aged 50 years and over (n = 238) 72% used alternative medicine; the most frequently used CAM by Saudi Arabians included prayer and nutritional/herbal remedies such as honey and black seed (12). In another study in Turkey, research- ers found that 76% and 24% of the study sample reported using prayer and herbal remedies respectively (13). CAM use was also found to be preva- lent in Palestine; in one study, 77% of women and 67% of men reported using CAM in the previous year (14). Lit- tle is known, however, about the use of CAM by Middle Eastern women specifically during midlife, and a search of the literature found no studies on this subject focusing on Qatari women. Qatar is a rapidly developing nation and a member of the Gulf Cooperation Council (GCC). The purpose of this study was to investigate the use of CAM and the correlates of its use among women in their midlife years who were attending primary care centres in Qatar. Specifically, this report compared the use of CAM between Qatari and non- Qatari Arab women and among women reporting vasomotor, somatic and psychological symptoms. In addition, this report evaluated the independent associations of nationality, educational level and menopause status to CAM use. The findings from this study could be instructive in guiding public health policy and health professional educa- tion programmes in this region. Methods Study design and sampling The Study of Women’s Health in Qatar (SWIQ) aimed to examine the physi- cal, biological, psychological and social changes in women in their middle years. It was a 2-phase, mixed-methods study conducted in Doha, Qatar. A report on the qualitative phase of the study has previously been reported (15). Data for this study were derived from a cross-sectional study conducted from July 2011 to May 2012. Women were recruited from 9 primary care centres. The health centres were se- lected to represent geographically, east, west, north, south and central locations of the population in Qatar. Participants were eligible for inclusion if they were between 40 and 60 years of age, were of Qatari nationality or a national of another Arab country, and were Ara- bic or English speaking. Participants were excluded if they had a history of bilateral oophorectomy. A total of 951 women were approached to participate in the study. Of these, 64 were found to be ineligible and 46 women (4.8% of a total of 887 eligible) declined to participate in the study. Interviewer- administered, structured surveys were then conducted at the health centres and a total of 841 women completed the evaluation. The protocol and consent form were approved by the institutional review committees at Weill Cornell Medical College–Qatar and at Hamad Medical Corporation, Qatar. Survey instrument During the qualitative phase of this study, 6 focus group discussions were conducted as a precursor to the quanti- tative survey data collection to guide the development of the survey instrument. The focus groups examined the experi- ences of midlife transition in Qatari and Arabic women and explored whether any nationality differences needed to be considered in the development of the quantitative measures. A total of 41 Arabic-speaking women between the ages of 40 and 60 years (a mix of pre-, peri-, and postmenopausal women) participated, with 3 Qatari and 3 non- Qatari groups (15). EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 556 The survey instrument, which was developed using the existing SWAN survey as a foundation, was piloted by a trained moderator and assistant mod- erator, who were both culturally and lin- guistically matched to the focus group participants. The survey instrument was first developed in English, translated into Arabic and then back-translated into Arabic to confirm the quality of the translation. Themes and issues perti- nent to survey development were iden- tified during the focus groups through discussions held with participants immediately after piloting the survey, and appropriate revisions were made to the instrument (i.e. length, cultural and social acceptability of questions, ease of understanding questions, etc.) before it was used in the field. Measures Menopause status Questions about menopause status included: the time of the last menstrual cycle, whether the woman had men- struated in the last 12 months, regular- ity of menstruation and whether cycles changed in length. Menopause status was categorized into premenopausal, perimenopausal and postmenopausal. Women having a hysterectomy but at least 1 ovary were categorized sepa- rately. Use of CAM The SWIQ included questions about CAM use that were derived from the SWAN (10). Participants were asked whether, in the previous 12 months, they had used any of 5 types of self-care therapies: special diets or nutritional remedies, such as macrobiotic or veg- etarian diets, or vitamin supplements or therapy; herbs or herbal remedies, such as homeopathy or Chinese herbs or teas; psychological methods, such as meditation and mental imagery and relaxation techniques; physical methods such as massage, acupres- sure, acupuncture; or folk medicine or traditional Chinese medicine. CAM use was analysed as any CAM use if respondents reported use of any of the 5 CAM types or as the specific type reported. Symptom experience To assess the presence or absence of 22 health-related symptoms, women were asked “Thinking back over the past 2 weeks, how often have you been bothered by any of the following?” (16,17). Each symptom was treated as a binary categorical variable (scored yes or no), and symptoms were analysed in 3 categories: vasomotor symptoms (hot flashes or night sweats); somatic symptoms (aches/stiffness in joints or headaches); psychological symp- toms (feeling blue or depressed, mood changes, irritability or nervous tension) (10). Participants were categorized as being symptomatic in any of the 3 symptom categories if they reported having at least 1 of the symptoms in the category. Statistical methods The chi-squared test was used to test for the difference in the distribution of categorical variables (any CAM use and use of specific CAM types) between Qatari and non-Qatari Arab women and between women reporting recent experience of symptoms and those who did not. Multivariable logistic regres- sion analyses were used to evaluate the independent associations between nationality, education level, menopause status and CAM use. The odds ratios (OR), 95% confidence intervals (CI) and P-values of the covariates were re- ported. All statistical tests were 2-sided, and P < 0.05 was considered statistically significant. Analyses were performed using SAS, version 9.2 software. Results The characteristics of the sample are presented in Table 1. Close to half (51.7%) of the participants were aged 40–49 years, and the remainder were aged 50–59 years. Qataris comprised 45.2% of the sample while non-Qatari Arab women originated from many neighbouring countries. Overall, 321 (38.2%) of midlife women in Qatar had used CAM in the previous 12 months. CAM use was sig- nificantly associated with educational status; significantly more CAM users were university graduates and profes- sionals (55.1%) than were non-users (39.7%) (P < 0.001). Women reporting CAM use did not differ by age group or by menopause status from women who did not report CAM use. More CAM users than non-users were of Qatari nationality (50.5% versus 41.9% respec- tively) (P = 0.02). There was no differ- ence in CAM use among non-Qatari Arabs by nationality. For those who reported CAM use, nutritional remedies and herbal remedies were the most frequently used types of CAM, followed by physical methods (Table 2). Non- Qataris more often used nutritional remedies (P = 0.01), while Qataris more often used physical methods (P < 0.001) and folk medicine (P = 0.02). More Qatari women than non- Qataris reported use of more than 1 CAM therapy (15.8% versus 8.5%) (P = 0.003) (Figure 1). Vasomotor symptoms were report- ed by 348 women, somatic symptoms by 739 and psychological symptoms by 716. Overall, women who reported vasomotor symptoms were more likely to use CAM than women who did not (41.7% versus 35.7%), although this difference did not reach statistical sig- nificance (P = 0.08) (Table 3). There was also a trend towards greater CAM use among women reporting somatic symptoms compared with women not reporting those symptoms (P = 0.08). A description of symptom reporting by CAM use category is presented in Table 4. Women reporting vasomotor, somatic and psychological symptoms reported use of nutritional remedies طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 557 Table 1 Selected characteristics of the study population, by complementary/alternative medicine (CAM) use status Characteristic Total sample (n = 841) Any CAM use (n = 321) No CAM use (n = 520) P-value No. % No. % No. % Age (years) 40–49 435 51.7 169 52.7 266 51.2 0.67 50–59 406 48.3 152 47.3 254 48.8 Nationality Qatari 380 45.2 162 50.5 218 41.9 0.02 Non-Qatari 461 54.8 159 49.5 302 58.1 Egyptian 144 17.1 55 34.6 89 29.5 0.12 Jordanian 76 9.0 30 18.9 46 15.2 Palestinian 56 6.7 14 8.8 42 13.9 Sudanese 42 5.0 9 5.7 33 10.9 Lebanese 34 4.0 16 10.1 18 6.0 Syrian 33 3.9 12 7.6 21 7.0 Other 76 9.0 23 14.5 53 17.6 Education Illiterate 57 6.8 12 3.7 45 8.7 < 0.001 Primary 66 7.9 16 5.0 50 9.6 Elementary 99 11.8 33 10.3 66 12.7 Secondary 235 28.0 83 25.9 152 29.3 University graduate & above 383 45.6 177 55.1 206 39.7 Menopause status Premenopausal 197 23.4 79 24.6 118 22.7 0.80 Perimenopausal 353 42.0 135 42.1 218 41.9 Postmenopausal 265 31.5 99 30.8 166 31.9 Hysterectomy 26 3.1 8 2.5 18 3.5 Table 2 Prevalence of use of any type and specific types of complementary/alternative medicine (CAM), by nationality Use of CAM Total sample Qatari Non-Qatari P-value (n = 841) (n = 380) (n = 461) No. % No. % No. % Any type 321 38.2 162 42.6 159 34.5 0.02 Nutritional remedies Yes 158 18.8 68 17.9 90 19.5 0.01 No 163 19.4 94 24.7 69 15.0 Herbal remedies Yes 134 15.9 67 17.6 67 14.5 0.89 No 187 22.2 95 25.0 92 20.0 Psychological methods Yes 25 3.0 14 3.7 11 2.4 0.56 No 296 35.2 148 38.9 148 32.1 Physical methods Yes 97 11.5 69 18.2 28 6.1 < 0.001 No 224 26.6 93 24.5 131 28.4 Folk medicine Yes 38 4.5 26 6.8 12 2.6 0.02 No 283 33.7 136 35.8 147 31.9 EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 558 and herbal remedies most frequently, and then physical methods. It should be noted that these categories were not mutually exclusive and women often used more than one type of CAM. A multivariable logistic regression model predicting CAM use is shown in Table 5. Qatari nationality was a significant predictor of CAM use (OR = 1.75; 95% CI: 1.29–2.37), after controlling for age, education level, menopause status and vasomotor, so- matic and psychological symptoms. Level of education was an additional independent significant predictor of CAM use, whereby increasing level of education was associated with increas- ing use of CAM; university graduates and above were 3.75 times more likely to use CAM. Age, menopause transi- tion status and symptom experience were not independently associated with use of CAM. Discussion This study found that, overall, 38.2% of midlife women in Qatar used CAM in the previous year, which was in the range (20–64%) reported from the SWAN using the same survey about CAM use (10). The use of CAM by women in Qa- tar follows the global trend, with 42.6% of Qatari women in our study reporting CAM use, compared with 34.5% of other Arab women in Qatar. Also in line with previous research findings (6), this study found that CAM use was more prevalent in women of higher educational status. Similar to findings of the SWAN, nu- tritional and herbal remedies were the CAM therapies most commonly used by midlife women in Qatar (10). Based on our study findings and observations made in other studies, it is evident that CAM use is quite prevalent in Qatar and other Arab states in the Middle East (11–14). While our study did not focus on reasons for their use, it has been reported that people use CAM remedies for a variety of reasons. These include the availability of CAM in local communities, the lower cost of CAM compared with conventional treatments and the perceived effec- tiveness and safety of CAM therapies (18). The perceptions of the public and more specifically of patients about the effectiveness and safety of CAM are of concern, since there are questions about the benefits and side-effects associated with commonly used CAM treatments (19–21). In our study sample, it should be noted that non-Qatari women repre- sented a diverse and heterogeneous group of women from 18 different nationalities, the most frequent being those from Egypt, Jordan, Palestine, Sudan, Lebanon and Syrian Arab Re- public. Thus, they represented women of many backgrounds, who may vary in their use of particular types of self-care therapies. This study had several limitations. First, since the survey ascertained CAM use among patients who were attending primary care centres, we cannot general- ize these findings to all women of similar ages. Second, the CAM classification and questions used in this study were derived from the SWAN study questionnaire, 57.4 26.8 15.8 65.5 26.0 8.5 0 10 20 30 40 50 60 70 0 (n = 520) 1 (n =222) > 1 (n = 99) % o f r es po nd en ts Qatari Non-Qatari No. of types of CAM used Figure 1 Number of types of complementary/alternative medicine (CAM) used, by nationality (P = 0.003, chi-squared test) Table 3 Prevalence of use of any type of complementary/alternative medicine (CAM), by menopause symptom category Use of any type of CAM Vasomotor symptoms Somatic symptoms Psychological symptoms Yes No Yes No Yes No (n = 348) (n = 493) (n = 739) (n = 102) (n = 716) (n = 125) No. % No. % No. % No. % No. % No. % Yes 145 41.7 176 35.7 290 39.2 31 30.4 273 38.1 48 38.4 No 203 58.3 317 64.3 449 60.8 71 69.6 443 61.9 77 61.6 P = 0.08 P = 0.08 P = 0.95 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 559 which has some idiosyncrasies, as previ- ously reported (22). For example, it clas- sifies homeopathic treatments as herbal remedies. Additionally, it is recognized that there is not one standard definition of CAM. However, these particularities do not affect our estimate of the overall use of CAM in this study population. Third, this study did not enquire about the reasons for use of CAM. Table 4 Prevalence of use of any type and specific types of complementary/alternative medicine (CAM), by menopause symptom category Use of CAM Vasomotor symptoms Yes (n = 348) Somatic symptoms Yes (n = 739) Psychological symptoms Yes (n = 716) No. % No. % No. % Any type 145 41.7 290 39.2 273 38.1 Nutritional remedies 69 19.8 138 18.7 132 18.4 Herbal remedies 69 19.8 127 17.2 118 16.5 Psychological methods 10 2.9 22 3.0 20 2.8 Physical methods 44 12.6 86 11.6 84 11.7 Folk medicine 15 4.3 35 4.7 34 4.8 Table 5 Multivariable logistic regression analysis of any type of complementary/ alternative medicine (CAM) use Predictor variable Adjusted OR (95% CI) P-value Age (years) 50–59 0.97 (0.68–1.39) 0.89 40–49 Ref. Nationality Qatari 1.75 (1.29–2.37) < 0.001 Non-Qatari Ref. Education level University graduate & above 3.75 (2.28–6.16) < 0.001 Secondary 2.35 (1.39–3.99) 0.002 Elementary 1.90 (1.03–3.49) 0.04 Illiterate/primary Ref. Menopause status Postmenopausal 1.01 (0.63–1.61) 0.98 Perimenopausal 0.91 (0.62–1.34) 0.63 Premenopausal Ref. Vasomotor symptoms Yes 1.30 (0.96–1.76) 0.09 Somatic symptoms Yes 1.48 (0.93–2.36) 0.10 Psychological symptoms Yes 1.07 (0.70–1.62) 0.77 Ref. = reference group; OR = odds ratio; CI = confidence interval. There is no doubt that some CAM treatments are beneficial. Examples of these include use of acupuncture for nausea and chronic musculoskeletal pain, massage therapy for anxiety, and mind–body techniques such as medi- tation for pain and anxiety (19–21). There are many CAM therapies, however, which are either ineffective or might even be harmful to patients. Coffee enemas, ozone therapy, mega- doses of vitamins, certain herbs and shark cartilage are examples of such therapies (19,21). It is therefore imper- ative to educate and inform patients about the benefits and limitations as- sociated with CAM. It is also neces- sary to educate medical doctors about CAM (23) so that they can become better informed to help patients differ- entiate between safe, beneficial treat- ments and those that are harmful and ineffective. Our recommendations are consistent with the views of NCCAM, as well as other organizations whose mission is to define and disseminate the safety and efficacy of these prac- tices (24,25). Acknowledgements The authors would like to thank the re- search team in Qatar: Darine Dimassi, Nadia Omar and Hala Al-Ali, for their assistance with this project, and to all the women who generously gave their time to participate in the Study of Women’s Health in Qatar. Funding: This research was supported by the Qatar National Research Fund, National Priorities Research Program. Support was also provided by the Clinical Translational Science Center (CTSC), National Center for Advanc- ing Translational Sciences (NCATS) grant #UL1-TR000457-06. Competing interests: None declared. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 560 References 1. Turner L, Galipeau J, Garritty C, Manheimer E, Wieland LS, Yazdi F, et al. An evaluation of epidemiological and reporting characteristics of complementary and alternative medicine (CAM) systematic reviews (SRs). PLoS One. 2013;8(1):e53536. PMID:23341949 2. Wieland LS, Manheimer E, Berman BM. Development and clas- sification of an operational definition of complementary and alternative medicine for the Cochrane collaboration. Altern Ther Health Med. 2011 Mar-Apr;17(2):50–9. PMID:21717826 3. Complementary, alternative, or integrative health: what’s in a name? [Internet]. National Center for Complementary and Alternative Medicine. (http://nccam.nih.gov/health/ whatiscam, accessed 24 May 2014). 4. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Com- plementary and alternative medicine use among adults: United States, 2002. 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Unconventional therapies for can- cer and cancer-related symptoms. Lancet Oncol. 2001 Apr;2(4):226–32. PMID:11905768 21. Edzard E, Pittler MH, Wider B, Boddy K. Oxford handbook of complementary medicine. Oxford: Oxford University Press; 2008. 22. Fugh-Berman A. CAM: asking the right questions. Menopause. 2008 Jan–Feb;15(1):7–8. PMID:18182937 23. Sampson W. The need for educational reform in teaching about alternative therapies. Acad Med. 2001 Mar;76(3):248– 50. PMID:11242574 24. Ernst E. Assessments of complementary and alternative medi- cine: the clinical guidelines from NICE. Int J Clin Pract. 2010 Sep;64(10):1350–8. PMID:20716143 25. Guidelines on developing consumer information on proper use of traditional, complementary, and alternative medicine. Geneva: World Health Organization; 2004. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 561 Knowledge of periconceptional folic acid use among pregnant women at Ain Shams University Hospital, Cairo, Egypt W. Al-Darzi,1 F. Al-Mudares,1 A. Farah,1 A. Ali 1 and D. Marzouk 2 1Faculty of Medicine; 2Department of Public Health, Ain Shams University, Cairo, Egypt (Correspondence to W. Al-Darzi: waleed.aldarzi@gmail.com). Received: 03/01/13; accepted: 23/06/13 ABSTRACT Egypt has a high incidence of neural tube defects. Folic acid supplementation in the periconceptional period is known to lower the risk of such defects. This cross-sectional study aimed to measure the level of knowledge about periconceptional folic acid use among pregnant women attending for antenatal care at Ain Shams University Hospital, Cairo, Egypt in 2012. Questionnaires were filled through personal interviews with 660 pregnant women. Of the respondents, 62.4% had heard of folic acid and 39.2% knew about the role of folic acid supplementation in prevention of congenital anomalies. Knowledge about using folic acid before and in the first trimester of pregnancy was highest among university-educated women and those working in professional occupations. Only 18.8% of women reported taking folic acid, and 8.8% had used it before conception. Awareness campaigns are suggested to improve knowledge about folic acid among women in the childbearing period in Egypt. صرم ،ةرهاقلا ،سمش ينع ةعماج ىفشتسم في لماولحا ءاسنلا ىدل لملحاب ةطيحلما ةترفلا في كيلوفلا ضحم مادختساب ةفرعلما قوزرم ءايض ،ليع نحمرلا دبع ،حرف ورمع ،سردلما قئاف ،يزردلا ديلو ةـطيحلما ةرـفلا في كـيلوفلا ضـمحب ةـيليمكتلا ةـلجاعلما نأ فورـعلما نـمو .يـبصعلا بوـبنلأا بوـيعل عـفترم عوـقو رـم في ظـحول :ةـصلالخا ضـ حم مادختـ سا لوـ ح ةـ فرعلما ىوتـ سم ساـ يق لىإ ةضرعتـ سلما ةـ ساردلا هذـ ه تـ فده دـ قو .بوـ يعلا هذـ ه لـ ثم رـ طامخ نـ م لـ لقت لـ ملحاب سمـش نـع ةـعماج ىفـشتسم في ةدلاوـلل ةقباـسلا ةـياعرلا ىـع نددرـي يـئلالا لـماولحا ءاـسنلا ىدـل لـملحاب ةـطيحلما ةرـفلا في كـيلوفلا تاعَلطتـسلما نـم % 62.4 نأ َّنـبتف .لـماح ةأرـما 660 عـم ةيصخـش تلاـباقم للاـخ نـم تانايبتـسا ءلـم مـتف .2012 ماـع في رـم في ةرـهاقلاب .ةـ يقللخا تاذوذـ شلا نـ م ةـ ياقولا في كـ يلوفلا ضـ محب ةـ يليمكتلا ةـ لجاعلما رودـ ب مـ لع ىـ ع نـ هنم % 39.2و ،كـ يلوفلا ضـ محب َنعمـ س دـ ق ًاـيعماج ًاـيلعت نـقلت تياوـللا ءاـسنلا نـب ىـعأ هـنم لىولأا ةـثلاثلا رهـشلأا فيو لـملحا لـبق كـيلوفلا ضـحم مادختـسا نـع ةـفرعلما تـناكو هنمدختـسا دـق َّنـك نـهنم % 8.8و ،كـيلوفلا ضـحم لواـنتب ءاـسنلا نـم طـقف % 18.8 تداـفأ دـقو .ةـ ّيفَرِح نـهم في نـلمعي تياوـللا ءاـسنلاو .رـم في باـجنلإا ةرـف في ّنـه تياوـللا ءاـسنلا ىدـل كـيلوفلا ضـحم نـع ةـفرعلما نـسحتل ةـيعوت تلاـمحب ماـيقلا حارـقا مـتو .لـملحا لـبق Connaissances sur l'utilisation périconceptionnelle de l'acide folique chez des femmes enceintes à l'hôpital universitaire Ain Shams, au Caire (Égypte) RÉSUMÉ En Égypte, l'incidence des malformations du tube neural est élevée. La supplémentation en acide folique durant la période périconceptionnelle est connue pour réduire le risque de telles malformations. La présente étude transversale visait à mesurer le niveau de connaissances sur l'utilisation périconceptionnelle de l'acide folique chez des femmes enceintes consultant à l'hôpital universitaire Ain Shams au Caire (Égypte) pour des soins prénatals en 2012. Des questionnaires ont été remplis pendant des entretiens individuels avec 660 femmes enceintes. Parmi les répondantes, 62,4 % avaient entendu parler de l'acide folique et 39,2 % connaissaient le rôle de la supplémentation en acide folique dans la prévention des anomalies congénitales. Les femmes ayant fait des études universitaires et celles exerçant une activité professionnelle possédaient les connaissances les plus élevées sur l'utilisation de l'acide folique avant et pendant le premier trimestre de grossesse. Seules 18,8 % des femmes ont déclaré prendre de l'acide folique, et 8,8 % y avaient eu recours avant la conception. Des campagnes de sensibilisation sont suggérées pour améliorer les connaissances sur l'acide folique chez les femmes en âge de procréer en Égypte. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 562 Introduction Neural tube defects (NTDs) are birth defects of the brain and spinal cord that can cause death, or permanent damage to the nervous system (1). The most frequent forms of NTDs are spina bifida and anencephaly (2). Such defects are among the most common birth defects worldwide (3), occurring in an estimat- ed 300 000 newborns each year (2,4). Evidence of the relationship between insufficient intake of maternal folic acid and the risk of NTDs led to the United States Public Health Service recom- mendation in 1992 that women with the capacity to become pregnant need to consume 400 µg folic acid on a daily basis (5). The incidence of NTDs falls by 50%–80% when women consume folic acid supplements daily, and there is now a consensus that supplementation should begin not only during the first trimester but also earlier, before concep- tion (6–8); this was supported by a cohort study in 1999 by Berry et al. (9). In view of the benefits of consuming folic acid for women in the childbearing years, several studies have been con- ducted in different parts of the world to assess women’s awareness of the role of folic acid in fetal development. In the United States of America (USA), there has been an increasing trend in the percentage of women who are aware of the benefits of folic acid, up to 85% (10), whereas in Qatar 53.7% of women had heard about folic acid and only 15% of them knew its role in preventing birth defects (11). With regard to preconcep- tional use of folic acid, a study conduct- ed in Taipei among pregnant women showed that only 15.6% of them had taken folic acid before conception (12). In Egypt, neurological disorders are the most common birth defects, with NTDs forming 10.2% of neurological disorders (13). One study found the incidence of NTDs in Egypt to be 1.38% (14), which is high compared with other parts of the world, where the reported incidence ranges from 0.05% to 0.36% (2,15). To date, there had been very little evidence in the literature about knowledge and prac- tice of folic acid use among pregnant women in Egypt. The aim of this study was to measure the level of knowledge about periconceptional use of folic acid among pregnant women at Ain Shams University hospital, Cairo, Egypt. The current study will provide a baseline description about folic acid knowledge which can be used to assess the need for awareness campaigns. Methods Study design and sample This cross-sectional, observational study was conducted in the antenatal care (ANC) clinic at Ain Shams Uni- versity Hospital, Cairo, Egypt. This is considered one of the main hospitals in north-east Cairo, receiving a variety of patients from different regions of Cairo and even from other governorates. Any pregnant women aged 18–45 years who sought medical consultation at the ANC clinic were included. The diagnosis of pregnancy was confirmed by viewing patients’ files, previous his- tory, examination and investigations [previous urine beta-human chorionic gonadotropin (βHCG), blood βHCG or ultrasound]. Pregnant woman who were younger than 18 or older than 45 years were excluded. Data were collect- ed by questionnaires from 670 pregnant women during the period from June to August 2012; 10 pregnant women did not give consent for participation in the study, giving a response rate of 98.2%. Data collection An anonymous, standardized question- naire was filled through an interpersonal interview. This included 15 questions about the following: sociodemographic data (age, residency, occupation, educa- tional level); obstetric history (gravid- ity, previous ANC; number of ANC visits; gestational age); and folic acid knowledge and use (ever heard about folic acid before, from where she heard about it, recommended period of intake according to her knowledge, whether she took folic acid in the current preg- nancy and if so when, benefits of folic acid intake, and different food sources of folic acid). The number of ANC visits in the current pregnancy was classified as sufficient or insufficient, according the recommendations of the Royal Col- lege of Obstetricians and Gynaecolo- gists (16). The validity of the questionnaire was tested by translating a pre-existing questionnaire (17) to Arabic language and comparing the findings of both questionnaires. The reliability of the questionnaire was evaluated by inter- viewing 20 patients from the inpatient clinic twice with different interviewers and separated by 5 days. The findings of both interviews were compared. Af- ter the pilot study, the questions were rearranged, modified by adding more choices or substituting open questions. The questionnaire was written in the common Egyptian Arabic dialect and each interviewer followed the ques- tion structure strictly with agreed-upon alternative explanations. Each interview was conducted by one of the trained authors. The pregnant women were interviewed while they were waiting for their ANC visit, in a separate area from the other participants to ensure privacy and confidentiality. Participants who agreed to participate were interviewed regardless of whether if was their first or follow-up visit. The interviewers visited the ANC clinic 4 times per week for a 9-week period. Verbal consent was taken from each participant (n = 660) before filling the questionnaire. The study protocol has been approved by the ethics committee of Ain Shams University. The question- naire was developed by the authors of this study in consultation with the com- munity department at Ain Shams Uni- versity. Then it received ethical approval from 2 different faculty staff members. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 563 Data analysis The collected data were revised, coded and tabulated using SPSS, version 15.0.1 for Windows. Quantitative continuous variables are expressed as mean and standard deviation (SD). Qualitative variables are expressed as frequencies and percentages. Student t-test was used to compare continuous vari- ables between the 2 study groups. Chi- squared and Fisher exact tests were used to examine the relationship between categorical variables. Both univariate and multivariate logistic regression analyses were done to examine the as- sociation of awareness and intake of folic acid supplements with selected sociodemographic and obstetric char- acteristics of the studied women. P < 0.05 was considered as the cut-off value for significance. Results Sociodemographic characteristics and folic acid knowledge Table 1 shows the sociodemographic characteristics of all the pregnant women in the study and of the women who had heard about folic acid before. From the total sample of 660 women, 412 (62.4%) had heard about folic acid. Only 79 (12.0%) women knew it was important to take folic acid before pregnancy and 53 (8.2%) knew about taking it in both the preconception and 1st trimester periods. Out of the whole sample of women, 259 (39.2%) mentioned its role in prevention of birth defects. Out of the total sample of respond- ents, 124 (18.8%) reported taking folic acid in the current pregnancy; 58 (8.8%) had taken it before pregnancy and 80 (12.1%) took it in the 1st trimester. For the women who had heard about folic acid their main source of knowledge was the physician, reported by 92.0%; other sources of knowledge were the family, nurses, pharmacists, media, books and the Internet (8.0%). The highest knowledge rates about folic acid were found among women working in professional jobs (90.9%). Women with university education (88.3%) and of women with history of ≥ 6 pregnancies (84.4%) were the most aware about folic acid. The lowest knowledge rates were among illiterate women and those with only primary school educational (25.0% and 35.6% respectively). When the participants who reported knowing about folic acid were asked about sources of folic acid, 92.0% reported folic acid supplements, 2.9% fish, 1.1% liver and 4.0% green vegetables The relationship between the so- ciodemographic characteristics of the pregnant women and their knowledge about the use of folic acid was analysed for 3 groups: those who knew about preconceptional use of folic acid (n = 79), those who knew about 1st trimes- ter use of folic acid (n = 324) and those who knew the recommended period of intake of folic acid, i.e. knew about folic acid intake during both the preconcep- tional and 1st trimester periods (n = 54) (Table 2). Highly significant relation- ships between the educational level of pregnant women and their knowledge about folic acid intake were seen in all 3 groups (P < 0.01). Occupational status and number of previous pregnancies were significantly related to women’s awareness of folic acid utilization pre- conception (P = 0.011 and P = 0.0001 respectively) and in both recommend- ed intake periods (P = 0.004 and P = 0.046 respectively). Having a sufficient number of ANC visits for the current Table 1 Sociodemographic characteristics and obstetric history of the study women in relation to their general awareness of folic acid Variable All women Heard about folic acid No. % No. % Total 660 100.0 412 62.4 Age group (years) 18–24 209 31.7 111 53.1 25–29 359 54.4 238 66.3 30–34 74 11.2 51 68.9 35–45 18 2.7 12 66.7 Education Illiterate 116 17.6 29 25.0 Primary school 45 6.8 16 35.6 Preparatory school 106 16.1 56 52.8 Secondary school 299 45.3 228 76.3 University 94 14.2 83 88.3 Job Not working 600 90.9 360 60.0 Skilled work 27 4.1 22 81.5 Professional 33 5.0 30 90.9 Gravidity (no.) ≤ 2 432 65.5 266 61.6 3–5 196 29.7 119 60.7 ≥ 6 32 4.8 27 84.4 ANC visits in current pregnancy Insufficient 99 15.0 43 43.4 Sufficient 561 85.0 369 65.8 n/a = not applicable; ANC = antenatal care. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 564 pregnancy was significantly related to knowledge of folic acid intake during the 1st trimester (P = 0.029). Univariate analysis Table 3 shows the univariate analysis of sociodemographic characteristics of the study women and their knowl- edge about folic acid intake. Knowl- edge about folic acid intake during the preconceptional period showed significant relationships with age group (25–29 years), university education level, professional occupation and his- tory of ≥ 2 pregnancies. Women with university education level were about 13-fold more aware about folic acid than illiterate women (OR = 12.8, 95% CI: 1.65–99.0), while specialist working women were 3-fold more aware about folic acid than non-working women (OR = 3.14, 95% CI: 1.44–6.85). Women who had a pregnancy history of ≥ 3 were 1.8–4.6 times more aware than women with history of ≤ 2 pregnancies. Secondary school/diploma and university levels of education were high- ly significantly associated with knowl- edge about folic acid intake during the 1st trimester. Women with secondary school and university educational level were more than 4-fold (OR = 4.52, 95% CI: 2.02–10.1) and 6-fold (OR = 6.11, 95% CI: 2.33–16.1) more aware than illiterate women respectively. Suf- ficient ANC visits during the current pregnancy was significantly related to knowledge about folic acid, as women who had sufficient ANC visits during their current pregnancy were twice as aware about folic acid than those who had insufficient ANC visits (OR = 2.09, 95% CI: 1.07–4.10). The relationship of sociodemo- graphic characteristics of the women with their knowledge about the both periods of folic acid intake showed very similar results as for knowledge about folic acid during the preconceptional period. Multivariate analysis The multivariate analysis of sociode- mographic characteristics is shown in Table 4. The relationships between the women’s knowledge of folic acid and their sociodemographic characteristics Table 2 Relationship between women’s sociodemographic and obstetric characteristics and their knowledge about folic acid supplementation in different stages of pregnancy Variable Knew about folic acid supplementation during: Preconception (n = 79) 1st trimester (n = 324) Both periods (n = 54) No. %a P-value No. %a P-value No. %a P-value Age (years) 18–24 15 13.5 0.098 87 78.4 0.694 9 8.1 0.190 25–29 53 22.3 187 78.6 38 16.0 30–34 7 13.7 42 82.4 5 9.8 35–45 4 33.3 8 66.7 2 16.7 Education Illiterate 1 3.4 0.002 15 51.7 < 0.001 0 0.0 < 0.001 Primary school 1 6.3 12 75.0 1 6.3 Preparatory school 6 10.7 36 64.3 1 1.8 Secondary school 45 19.7 189 82.9 29 12.7 University 26 31.3 72 86.7 23 27.7 Occupation Not working 63 17.5 0.011 280 77.8 0.486 40 11.1 0.004 Skilled work 4 18.2 18 81.8 4 18.2 Professional 12 40.0 26 86.7 10 33.3 Gravidity (no.) ≤ 2 39 14.7 < 0.001 206 77.4 0.101 27 10.2 0.046 3–5 28 23.5 100 84.0 21 17.6 ≥ 6 12 44.4 18 66.7 6 22.2 ANC visits in current pregnancy Insufficient 5 11.4 0.164 29 65.9 0.029 3 6.8 0.191 Sufficient 74 20.1 295 80.2 51 13.9 aPercentage of women in each sociodemographic and obstetric category who had heard about folic acid. ANC = antenatal care. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 565 in the multivariate analysis were similar to those in the univariate analysis, ex- cept for occupational status which was not significant in multivariate analysis. Discussion The impact of NTDs is considered a global health-care issue affecting huge number of newborns each year (4). Fortunately, the risks of NTDs can be reduced by using folic acid before and during the 1st trimester of pregnancy (6,8,9). In Egypt, the high incidence of NTDs (14) points to a need for preven- tion by increasing women’s awareness of periconceptional use of folic acid. The present study at a tertiary care clinic in Cairo, Egypt showed that 62.4% of the pregnant women surveyed knew about folic acid in pregnancy. Looking at differ- ent studies conducted in the Middle East, the level of awareness ranged from 46.6% to 85% (11,18,19). In Taiwan the aware- ness rate among pregnant women was 89.1% (12). In a study in Kansas, USA, the level of general awareness about folic acid was 88% among women of child- bearing ages (20). A small percentage of women in the present study had some university education (14.2%) whereas in the Kansas study 65.6% of women had some college education or were college graduates (20), which might explain their higher general awareness level. The present study demonstrated that the proportion of all participants who knew about the benefits of folic acid in prevention of birth defects was 39.2%. This percentage is higher than in other nearby countries in the Middle East (8.7%–14%) (11,18,21), but lower than in Israel and Abu Dhabi, United Arab Emirates (UAE) (46.6%–77.7%) (19,22), which shows that there is room for improvement. When compared with Israel our women’s knowledge about taking folic acid both preconception and in the 1st trimester was considerably lower (Egypt: 8.2%, Israel: 77.7%) (19). Although in the present study the nature of the women’s occupation af- fected their knowledge about use of folic acid before conception, it was sig- nificant in univariate analysis but not in multivariate analysis, which suggests Table 3 Univariate analysis of association of women’s sociodemographic and obstetric characteristics with their knowledge about folic acid supplementation in different stages of pregnancy Variable Knew about folic acid supplementation during: Preconception 1st trimester Both periods Crude OR (95% CI) P-value Crude OR (95% CI) P-value Crude OR (95% CI) P-value Age (years) 18–24 (Ref.) 25–29 1.83 (0.98–3.42) 0.057 1.01 (0.59–1.75) 0.967 2.15 (1.00–4.63) 0.049 30–34 1.02 (0.39–2.67) 0.971 1.29 (0.55–3.01) 0.560 1.51 (0.51–4.50) 0.458 35–45 3.20 (0.86–12.0) 0.084 0.55 (0.15–1.99) 0.363 2.27 (0.43–12.0) 0.335 Education Illiterate (Ref.) Primary school 1.87 (0.11–32.0) 0.667 2.80 (0.73–10.8) 0.134 1.87 (0.11–32.0) 0.667 Preparatory school 3.36 (0.39–29.3) 0.273 1.68 (0.68–4.18) 0.264 0.51 (0.03–8.45) 0.638 Secondary school 6.89 (0.91–52.0) 0.061 4.52 (2.02–10.1) < 0.001 4.08 (0.54–31.1) 0.175 University 12.8 (1.65–99.0) 0.015 6.11 (2.33–16.1) < 0.001 10.7 (1.38–83.5) 0.023 Occupation Not working (Ref.) Skilled work 1.05 (0.34–3.20) 0.935 1.29 (0.42–3.91) 0.658 1.73 (0.56–5.36) 0.343 Professional 3.14 (1.44–6.85) 0.004 1.86 (0.63–5.48) 0.262 3.89 (1.70–8.88) < 0.001 Gravidity (no.) ≤ 2 (Ref.) 3–5 1.79 (1.04–3.08) 0.035 1.53 (0.87–2.71) 0.141 1.90 (1.02–3.52) 0.042 ≥ 6 4.66 (2.03–10.7) < 0.001 0.59 (0.25–1.37) 0.213 3.10 (1.20–8.00) 0.019 ANC visits in current pregnancy Insufficient (Ref.) Sufficient 1.96 (0.75–5.16) 0.171 2.09 (1.07–4.10) 0.032 2.25 (0.67–7.53) 0.189 OR = odds ratio; CI = confidence interval; ANC = antenatal care; (Ref.) = reference category. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 566 that as a variable it has less influence than educational level or number of pregnancies. Knowledge about the use of folic acid during both the preconcep- tional and 1st trimester periods was very high among women with university education, and increased significantly with the number of pregnancies. In the present study 18.8% of the pregnant women reported consuming folic acid during the current pregnancy. In the UAE the percentage was much higher, at 68% (18,22), which may be due to the fact that the UAE govern- ment ANC facilities provided folic acid free of charge. Supplying folic acid supplements for all visitors to ANC clinics is likely to raise the percent- age of females using them and hence decrease the incidence of NTDs. This is an important consideration for policy-makers. Besides the emotional, psychological and physical effects of spina bifida, the total cost of lifetime management of the cases who survive is high and causes a huge burden on the community (23). Further studies should be done to study the cost–ben- efit of providing folic acid free of charge in Egypt. A study in Qatar demonstrated that the physician was the main source of women’s knowledge about folic acid (63.4%) (11), although in Taipei the percentage was 44.4% (12). Other sources of knowledge in those studies included newspapers, books, nurses, pharmacists and the family. Our study revealed that 92.0% of women knew about folic acid from the physician. This finding should be considered in folic acid promotion campaigns. Amtai et al. suggested that every family planning consultation and every child vaccina- tion should be used as an opportunity to promote folic acid use (19). This is also applicable in Egypt, especially during visits for obligatory childhood immuni- zations. Another method of spreading folic acid awareness is through aware- ness campaigns, which could include posters, announcements in the media and sessions for high-school or even university students. These campaigns should educate women about foods that are rich in folic acid, in addition to encouraging the consumption of the Table 4 Multivariate analysis of association of women’s sociodemographic and obstetric characteristics and their knowledge about folic acid supplementation in different stages of pregnancy Variable Knew about folic acid supplementation during: Preconception 1st trimester Both periods Adjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value Age (years) 18–24 (Ref.) 25–29. 1.42 (0.72–2.81) 0.313 1.04 (0.57–1.88) 0.906 1.69 (0.73–3.87) 0.218 30–34 0.71 (0.24–2.11) 0.536 1.44 (0.55–3.77) 0.461 0.99 (0.28–3.45) 0.983 35–45 2.07 (0.46–9.38) 0.343 0.68 (0.17–2.77) 0.589 1.58 (0.25–9.96) 0.628 Education Illiterate (Ref.) Primary school 1.94 (0.11–35.0) 0.653 2.66 (0.66–10.8) 0.171 1.85 (0.10–33.4) 0.676 Preparatory school 3.00 (0.33–27.2) 0.329 2.11 (0.82–5.44) 0.124 0.47 (0.03–8.12) 0.605 Secondary school 7.65 (1.00–58.7) 0.050 5.67 (2.44–13.2) < 0.001 4.62 (0.60–35.8) 0.143 University 15.33 (1.88–124) 0.011 7.23 (2.52–20.7) < 0.001 13.1 (1.59–108) 0.017 Occupation Not working (Ref.) Skilled work 0.77 (0.23–2.54) 0.666 1.07 (0.33–3.48) 0.906 1.11 (0.33–3.75) 0.865 Professional 1.53 (0.61–3.84) 0.370 1.03 (0.31–3.47) 0.959 1.40 (0.53–3.74) 0.499 Gravidity (no.) ≤ 2 (Ref.) 3–5 2.17 (1.18–4.00) 0.013 1.73 (0.93–3.23) 0.083 2.30 (1.13–4.67) 0.021 ≥ 6 6.23 (2.37–16.4) < 0.001 0.61 (0.24–1.57) 0.307 4.83 (1.59–14.7) 0.006 ANC visits in current pregnancy Insufficient (Ref.) Sufficient 1.90 (0.68–5.29) 0.220 2.21 (1.08–4.52) 0.030 2.01 (0.57–7.10) 0.281 OR = odds ratio; CI = confidence interval; ANC = antenatal care; (Ref.) = reference category. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 567 recommended daily dose of folic acid supplements or as part of multivitamin tablets. Fortification of foods with folic acid is another strategy for decreasing NTDs. Data has revealed an association between folic acid fortification and a decrease in the risk of NTDs (24). It is noteworthy that the fortification of some foods, including enriching cereals and grains with folic acid, was mandated in the USA since 1998 (25). After folic acid fortification was implemented the reduction in the prevalence of NTDs in the country was 23% (26). There were some limitations that may have affected the study findings. First, the study may have been subjected to population bias, as the data were collected from only one health-care centre in Cairo, Egypt. Secondly, the study women were attending a tertiary health-care facility and they may not have had the same level of knowledge as women attending for ANC in pri- mary or secondary health-care facilities. Thirdly, women below age 18 years and older than 45 years were not included in our sample and therefore our results might not accurately reflect the level of knowledge about folic acid in all women of childbearing ages. Finally, women were included regardless their previous number of ANC visits. In conclusion, there is room for im- provement regarding the knowledge about folic acid among women in the childbearing years in Egypt. The present study revealed that a small propor- tion of women were aware about the importance of preconceptional folic acid, and even fewer had consumed fo- lic acid in the preconceptional period. Knowledge about folic acid intake was significantly higher among women with university education and high gravid- ity. 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MMWR Morb Mortal Wkly Rep. 2002 Sep 13;51(36):808-10. PMID:12269469 26. Mathews TJ, Honein MA, Erickson JD. Spina bifida and an- encephaly prevalence–United States, 1991–2001. MMWR Recomm Rep. 2002 Sep 13;51 RR-13:9–11. PMID:12353510 طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 569 Factors affecting the process of obtaining informed consent to surgery among patients and relatives in a developing country: results from Pakistan F. Jahan,1 R. Roshan,2 K. Nanji,3 U. Sajwani,4 S. Warsani 5 and S. Jaffer 6 1Department of Family Medicine, Oman Medical College, Sohar, Oman (Correspondence to F. Jahan: firdous@omc.edu.om). 2Division of Nursing Services; 3Department of Family Medicine; 4B1-Surgical Unit; 5Neurosurgery Unit; 6Office of the Chief Operating Officer, Aga Khan University Hospital, Karachi, Pakistan. Received: 24/12/12; accepted: 25/09/13 ABSTRACT Efforts have been made in Pakistan to create ethical guidelines for research and medical practice. This study explored the perceptions of and factors affecting the process of obtaining informed consent to surgery among inpatients and families at a tertiary-care hospital in Karachi. A random sample of 400 post-surgery adult patients answered a pre-tested, structured questionnaire. Overall, 233 patients (58.3%) had signed the surgery consent form themselves, while 167 relatives (41.7%) had signed on behalf of the patient. Perceived factors significantly associated with patients not signing the consent form themselves were: language used (adjusted OR = 4.6), medical terminology used (aOR = 2.7), insufficient time allocation (aOR = 3.8), cultural/traditional reasons (aOR = 1.5) and low education (aOR = 2.4). Inappropriate timing for taking consent and not being informed/asked about consent were not statistically significant factors. Health-care practitioners should encourage patients to sign the consent form themselves. ناتسكاب نم جئاتن :ةيمانلا نادلبلا في مبهراقأو ضىرلما ىدل ةيحارج ةيلمع لىع ةقبسم ةقفاوم لىع لوصلحا ةيلمع لىع رثؤت يتلا لماوعلا رفعج ىملس ،نياسْرَو ينهاش ،نياوجس ىَمْظُع ،يجنان ةيرمشك ،ناشور انيزور ،ناهج سودرف هذـه تفـشكتسا دـقو .ةـيبطلا ةـسرمالماو ثوـحبلل ةـيقلاخأ ةيداـشرإ لـئلاد عـضو لـجأ نـم ناتـسكاب في ًارـخؤم دوـهج تـلذب دـقل :ةـصلالخا ضىرـم ىدـل ةـيلمعلا هذـه ىـع رـثؤت يـتلا َلـماوعلاو ،ةـيحارج ةـيلمع ىـع ةقبـسم ةـقفاوم ىـع لوـصلحا ةـيلمع نـع تاروـصتلا ةـساردلا 400 نـم ةـنوكم ةيئاوـشع ةـنيع تـباجأ 2010 ماـع تـيرجأ ةضرعتـسم ةـسارد يـفف .يـتارك في ةـيثلاثلا ةـياعرلل ىفـشتسم في مـتهلائاعو ينـيلخاد ىـع ةـقفاولما ةرماتـسا ىـع اوـعَّقو دـق )% 58.3( ًاـضيرم 233 هـيلاجمإ اـم ناكـف .ًاقبـسم هراـبتخا مـت مـَّظنم نايبتـسا ىـع ةـحارلجا دـعب غـلاب ضـيرم ظوـحلم لكـشب - تـطبترا يـتلا ةر َّوـصتلما لـماوعلا تـناكو .ضـيرلما نـع ةـباين )% 41.7( براـقلأا نـم 167 عـ َّقو ينـح في ،مهـسفنأب ةـحارلجا ةـلدعلما OR( ةمدختـسلما ةـ يبطلا تاـحلطصلماو ،)4.6= ةـلدعلما OR( ةمدختـسلما ةـغللا :مهـسفنأب ةـقفاولما ةرماتـسا ىـع ضىرـلما عـيقوت مدـعب - =ةـلدعلما OR( ضـفخنلما مـيلعتلاو ،)1.5 = ةـلدعلما OR( ةـيديلقت/ةيفاقث بابـسأو ،)3.8 = ةـلدعلما OR( صـصخلما تـقولا ةـيافك مدـعو ،)2.7= وـسرامم نوـكي نأ يـغبنيف .ًاـيئاصحإ ينـ َّمهم يرـغ ينـَلماع ةـقفاولما نـع لاؤـسلا/غلابلإا مدـعو ،ةـقفاولما ذـخلأ بـسانلما يرـغ تـيقوتلا ناكو .)2.4 .مهـسفنأب ةـقفاولما ةرماتـسا ىـع عـيقوتلا ىـع ضىرـلما اوعجـشي نأو ،ةقبـسلما ةـقفاولما ةـيلمع في رـثؤت يـتلا لـماوعلاب مـلع ىـع ةـيحصلا ةـياعرلا Facteurs influant sur le processus d'obtention d'un consentement éclairé pour une intervention chirurgicale chez des patients et des parents dans un pays en développement : résultats du Pakistan RÉSUMÉ Des efforts récents ont été réalisés au Pakistan en vue de créer des lignes directrices pour l'éthique en recherche et pratique médicales. La présente étude a évalué les perceptions relatives au processus d'obtention d'un consentement éclairé pour une intervention chirurgicale et les facteurs d’influence chez des patients hospitalisés et leur famille dans un hôpital de soins tertiaires à Karachi. Un échantillon aléatoire de 400 patients adultes postopératoires a répondu à un questionnaire prétesté et structuré. Au total, 233 patients (58,3 %) avaient signé eux-mêmes le formulaire de consentement à une intervention chirurgicale, tandis que 167 parents (41,7 %) avaient signé pour le patient. Les facteurs perçus comme fortement associés aux patients qui n'avaient pas signé eux-mêmes le formulaire de consentement étaient les suivants : la langue utilisée (OR ajusté = 4,6), la terminologie médicale utilisée (OR ajusté = 2,7), l'insuffisance du temps alloué (OR ajusté = 3,8), des raisons culturelles/traditionnelles (OR ajusté = 1,5) et un faible niveau d'études (OR ajusté = 2,4). Un moment inopportun pour demander le consentement et l’absence d’information/d’interrogation à ce sujet n'étaient pas des facteurs statistiquement significatifs. Les professionnels de santé doivent encourager les patients à signer eux-mêmes le formulaire. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 570 Introduction The most important goal of informed consent is that patients have an oppor- tunity to be informed participants in decisions about their health care (1). It is generally accepted that complete informed consent includes a discussion of the following elements: the nature of the decision/procedure; reasonable alternatives to the proposed interven- tion; the relevant risks, benefits and uncertainties related to each alternative (2); assessment of the patient’s under- standing; and the patient’s acceptance of the intervention. It originates from the legal and ethical right the patient has to direct what happens to his/her body and from the ethical duty of the physi- cian to involve the patient in health-care decisions. Informed consent recognizes not only patients’ autonomy in decision- making but also their right to complete information. The informed consent process requires the physician to ex- plain in sufficient detail the diagnostic, therapeutic and prognostic reasoning that leads to his/her expert decision on what is in the best interest of the patient (3). In most cases, it is clear whether or not patients are competent to make their own decisions (4). However, if patients are judged to be incapacitated /incompetent to make health care deci- sions, a surrogate decision-maker must speak for them (5). Most developed countries have enshrined these concepts of informed consent, privacy and confidentiality in federal or state laws and codes of eth- ics. In Pakistan there have been some recent efforts to create ethical guide- lines for research and medical practice. Significantly, the Pakistan Medical and Dental Council, the regulatory body of medical practitioners, has formulated a code of ethics for all doctors, although no concrete steps have been taken to ensure its application. At the same time, cultural values in Pakistan offer a challenge to the practice of medical ethics in Pakistan (6). This is because crucial decisions are often made by fam- ily members or are left entirely up to the physician, and there seems to be a general acceptance of this practise among the public. Patients’ awareness of their rights to informed consent and privacy is often low (7). Previous quali- tative research has shown that many physicians do not think it is necessary to obtain a formal consent after providing the patients with thorough information (8,9). In view of these observations, this study was conducted to identify the perceptions of and factors affecting the process of obtaining informed consent to surgery among inpatients and fami- lies attending a tertiary care hospital in Karachi, Pakistan. Methods Study setting This hospital-based, cross-sectional study was conducted between July and October 2010 in Aga Khan University Hospital, Karachi, Pakistan. Karachi is the largest city of Pakistan and is the capital city of Sind Province. The Aga Khan University is a 563-bed not-for- profit, private institution in Pakistan providing high-quality health care. The hospital has also been awarded the prestigious Joint Commission International accreditation and ISO 9001:2008 certification. The study patients were selected from the surgi- cal ward of the hospital. This ward has 56 beds and provides comprehensive inpatient services for general surgery, urology, otolaryngology and head and neck surgery, ophthalmology, cardio- thoracic and dental surgery. Sample selection Post-surgery patients, over the age of 18 years, admitted to the surgical ward and giving consent to participate were in- cluded in the study. Those patients who required special care, intensive care unit or coronary care unit admission were excluded. The sample size was calcu- lated using Epi-Info, version 6, and based on a prevalence of 50% with 5% error bound and 5% level of significance; the required sample size was estimated as at least 385 subjects. The patients were selected through simple random sampling. The study statistician used computer-generated random numbers to identify patients from the daily list of patients requiring surgery. Patients were identified on the day of the surgery and were recruited and interviewed on the 2nd day of the surgery. Written informed consent for participation in this survey was obtained from each participant (verbally with thumb impression from those who could not read or write). The study was reviewed and approved by the ethics review committee of the Aga Khan Uni- versity and Hospital. Data collection Data were collected while ensuring strict confidentiality for the participants. The patients were interviewed in an environment where their privacy could be ensured (attendants were asked to leave the area and ambulant patients were interviewed in a separate room adjacent to the ward). Two nursing graduates were trained for screening the eligible patients and administration of the questionnaire. Questionnaire development The questionnaire was formulated after an extensive literature search (Medline) and consensus by the study investiga- tors, who are involved in the hospital quality management committee. The questionnaire comprised 3 sections: section A dealt with the descriptive characteristics of the study participants; section B consisted of 12 questions about to the consent process and 9 questions about the important clauses of the surgical informed consent form; and section C was about the factors as- sociated with not signing of the consent form by patients themselves, and future طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 571 recommendations. To enhance its comprehensibility the English version of the questionnaire was translated into the local Urdu language and was back- translated into English to check for consistency; any discrepancies found were removed. Pre-testing of the Urdu version was done on 5% of the sample size (n = 25). The final questionnaire was shared with experts in the field of family medicine and the quality control department to obtain their suggestions for improvement. Data analysis Statistical analysis was carried out using SPSS software, version 17. Proportions were reported for all the variables such as age, sex and occupation. Univariate and multivariate logistic regression was done to identify the perceived factors associated with the consent process. The results are reported in form of odds ratio (OR) and 95% confidence interval (CI). P-values < 0.05 were considered statistically significant throughout the study. Results A total of 490 eligible patients were ap- proached, out of whom 400 consented to participate and were included in the final analysis, yielding a response rate of 81.6% (400/490). Missing in- formation was handled through mean imputation. Table 1 shows the sociodemo- graphic characteristics of the study sam- ple. Out of the total 400 participants a majority were males (53.5%). The median age was 37 years, range 14–78 years. Most of the participants were sin- gle, divorced or widowed (75.0%) and one-quarter were married. Less than half of the participants (42.8%) were in paid employment, while 7.8% were students and 4.0% were retired. Of the participants 41.8% had education to secondary level, 35.0% had education to intermediate level and above, while 9.3% participants were unable to read or write. Table 2 presents the perceptions of patients regarding the informed con- sent process. Although in most cases information about surgery was given in the clinic (70.0%), the consent for sur- gery was signed in the ward (76.8%) and 14.8% of respondents stated that con- sent was only signed in the operating theatre. Just over half of the respondents (57.3%) agreed that informed consent was important to obtain before any sur- gery. About one-third of the patients (32.9%) said they were influenced by family and friends to proceed to surgery. In this study 233 (58.3%) of the pa- tients signed the surgery consent form themselves, while for 167 (42.8%) of patients the form was signed on their behalf by a relative (spouse, parent, sibling or child). There was no statisti- cally significant difference in the pro- portion of males and females whose relatives signed on their behalf [data not shown]. Table 2 compares the perceptions of patients who signed for themselves and relatives who signed on their be- half regarding the informed consent process. When asked about the impor- tance of obtaining consent before any surgery 63.8% of patients who signed the consent form themselves agree that consent before any surgery was impor- tant, whereas only 48.2% of the relatives signing agreed that it was important (P < 0.01). A majority of patients (84.3%) and relatives (79.6%) agreed that the consent form has a medico-legal mean- ing and wanted detailed information (86.5% and 78.4% respectively). Of Table 1 Sociodemographic characteristics of the study respondents (n = 400) Variable No. % Sex Male 214 53.5 Female 186 46.5 Age [median (IQR) years] 37 (14–78) Marital status Married 100 25.0 Single 300 75.0 Occupation Earning 171 42.8 Housewife 165 41.3 Retired 16 4.0 Student 31 7.8 Unemployed 17 4.3 Educational status Cannot read or write 37 9.3 Primary (1–5 years) 56 14.0 Secondary (6–10 years) 167 41.8 Intermediate and above (> 10 years) 140 35.0 Consent form signed by: Self 233 58.3 Parent 36 9.0 Spouse 56 14.0 Child 51 12.8 Sibling 24 6.0 IQR = interquartile range. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 572 Table 2 Perceptions of patients and relatives who signed the surgery consent form regarding the informed consent process Statement/ characteristics of consent Total (n = 400) Self-signed (n = 233) Relative signeda (n = 167) P-value No. % No. % No. % Who explained the information Doctor 271 67.8 168 72.1 103 61.7 0.01 Resident 129 32.3 65 27.9 64 38.3 Where information was given Operating theatre 32 8.0 14 6.0 18 10.8 0.04 Ward 88 22.0 45 19.3 43 25.7 Clinic 280 70.0 174 74.7 106 63.5 Where consent was taken Operating theatre 59 14.8 28 12.0 31 18.6 > 0.05 Ward 307 76.8 183 78.5 124 74.3 Clinic 34 8.5 22 9.4 12 7.2 Informed consent influenced your decision to proceed with surgery Yes 135 33.8 72 31.9 63 37.7 < 0.01 No 265 66.3 161 69.1 104 62.3 Influenced by anyone to proceed with surgery No 67 17.0 40 17.7 27 16.2 0.04 Yes, family/friends 74 32.9 51 22.6 23 13.8 Yes, doctor 252 64.1 135 59.7 117 70.1 Informed consent is important before any surgery Yes 225 57.3 146 63.8 79 48.2 < 0.01 No 168 42.7 83 36.2 85 51.8 Know about medico-legal significance of informed consent Yes 326 82.3 193 84.3 133 79.6 < 0.01 No 70 17.7 36 15.7 34 20.4 Amount of information preferred Detailed 329 83.1 198 86.5 131 78.4 0.02 Limited 67 16.9 31 13.5 36 21.6 Amount of information preferred if going for same surgery Detailed 303 77.1 164 71.6 139 84.8 < 0.01 Limited 90 22.9 65 28.4 25 15.2 Received educational materials about pre- & post-operative management Yes 78 19.6 49 21.3 29 17.4 > 0.05 No 319 80.4 181 78.7 138 82.6 Materials were helpful (n = 81) Yes 62 76.5 39 79.6 23 71.9 < 0.01 No 19 23.5 10 20.4 9 28.1 Satisfied with information provided Yes 367 91.8 227 97.4 140 83.8 < 0.001 No 33 8.3 6 2.6 27 16.2 aRelatives: parent, spouse, sibling, other relative. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 573 the patients who signed the consent form themselves 89.7% said they were given the opportunity to ask ques- tions compared with 76.6% of relatives who signed for them. Many patients and relatives reported that they were not informed about the complica- tions (51.1% and 56.9% respectively), length of stay in the hospital (21.2% and 16.8% respectively), alterna- tives to surgery (44.7% and 44.3% respectively) and type of anaesthesia (28.8% and 20.4% respectively). Few patients (21.3%) or relatives (17.4%) had received any educational materi- als regarding pre- and post-operative management and care/information guidance, but those who received them found the information very help- ful (79.6% and 71.9% respectively). Almost all the patients signing for themselves (97.4%) were satisfied with the information they had been given, compared with 83.8% of rela- tives who were satisfied (P < 0.001). Table 3 presents responses to the important clauses of the surgery informed consent form. All the pa- tients who signed the consent form reported they were informed about the indications for surgery, whereas 7.8% of the relatives who signed the consent said they were not informed about the indications (P < 0.001). Of the patients 83.8% said that they were informed about possible complica- tions if surgery were not done, com- pared with only 69.5% of the relatives (P < 0.001). Overall, in only 14.8% of cases were respondents informed about the alternatives to surgery and 59.8% were informed about the type of anaesthesia to be used in the sur- gery. Most of the patients who signed the consent form themselves (82.4%) were informed about the nature of the surgery as compared with only 59.9% of the relatives who signed on their behalf, whereas 89.3% versus 73.1% of the patients and relatives respectively were informed about the expected benefits of the surgery. Most of the patients who signed for themselves (89.7%) were given the opportunity to ask questions whereas 76.6% of the relatives were given the opportunity. Table 4 shows the univariate and multivariate regression analysis of the factors associated with not signing of the surgical consent form by patients themselves. When adjusted for other confounders in multivariate logistic regression analysis the statistically significant factors associated with pa- tients not signing the consent form themselves were: language, medical terminology, insufficient time, cul- ture/traditions and educational status. When there were language barriers the patient was 4.6 times more likely to not sign the form themselves, whereas when there were cultural barriers the patients were 1.5 times more likely to not sign the form. Those patients who had lower educational status were 2.4 times more likely not to sign the consent form themselves. Moreover, when inappropriate medical termi- nologies were used patients were 2.7 times more likely to not sign the consent form. If patients were given insufficient time to understand the contents of the consent form, they were 3.8 times more likely to not sign the consent form themselves. Factors that were not significant in the regres- sion analysis were: inappropriate tim- ing for taking consent and not being informed about or asked for consent. Discussion Informed consent is more than simply getting a patient to sign a writ- ten consent form. It is a process of communication between a patient and the physician that results in the patient’s authorization or agreement to undergo a specific medical inter- vention (10). An important part of such a clinical, ethical judgement is the patient’s capacity to participate in the informed consent process, which includes understanding that one is being asked to authorize surgical management and understanding the nature of that surgery as well as its clinical benefits and risks. Just over half of the patients (58.3%) signed the consent form themselves and for the rest consent was given by a relative. The literature supports our finding that signing con- sent forms by relatives and not only by patients is also common practice in other countries (11). In practice, surgeons and physicians in Pakistan prefer to fill out the consent form in the outpatient clinic where they can explain the procedure and ask the pa- tients to sign the relevant forms (12). However, this may not allow adequate time for deliberation and reflection, as outlined by the United Kingdom General Medical Council guidelines (2). In our study, although a major- ity of patients (70.0%) had received information from the consultant in the outpatient clinic, in fact signature was taken on the ward for 76.8%, while 14.8% claimed that signature was taken in the operating theatre. In clinical situations it is important to have informed consent to make important decisions; however con- sent practices vary in different institu- tions and countries. There is a lack of awareness about consent even among educated patients in Pakistan (13,14). Previous studies have also looked at the consent practices in surgery pa- tients (15). In a study in Pakistan and the United Kingdom written consent was routinely obtained for surgical treatment by the staff (16). This prac- tice has previously been pointed out in another study in Pakistan, in which only 29% patients signed their own consent (8). A great majority of patients and relatives agreed that the consent form has a medico-legal meaning and want- ed detailed information. Few patients (21.3%) or relatives (17.4%) had received any educational materials EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 574 Table 3 Attitudes of patients and relatives who signed the surgery consent form towards the important clauses of the consent form Statement Total (n = 400) Self-signed (n = 233) Relative signeda (n = 167) P-value No. % No. % No. % Informed about nature of surgery Yes 292 73.0 192 82.4 100 59.9 < 0.001 No 75 18.8 32 13.7 43 25.7 Don’t know 33 8.3 9 3.9 24 14.4 Informed about indications for surgery Yes 383 95.8 233 100.0 150 89.8 < 0.001 No 13 3.3 0 0.0 13 7.8 Don’t know 4 1.0 0 0.0 4 2.4 Informed about possible complications of surgery Yes 177 44.3 105 45.1 72 43.1 > 0.05 No 214 53.5 119 51.1 95 56.9 Don’t know 9 2.3 9 3.9 0 0.0 Informed about length of hospital stay after surgery Yes 291 74.0 169 74.8 122 73.1 0.037 No 76 19.3 48 21.2 28 16.8 Don’t know 26 6.6 9 4.0 17 10.2 Informed about alternatives to surgery Yes 58 14.8 35 15.5 23 13.8 > 0.05 No 175 44.5 101 44.7 74 44.3 Don’t know 160 40.7 90 39.8 70 41.9 Informed about possible complications if surgery was not done Yes 306 77.9 192 83.8 114 69.5 < 0.001 No 58 14.8 27 11.8 31 18.9 Don’t know 29 7.4 10 4.4 19 11.6 Informed about expected benefits of surgery Yes 330 82.5 208 89.3 122 73.1 < 0.001 No 27 6.8 9 3.9 18 10.8 Don’t know 43 10.8 16 6.9 27 16.2 Informed about type of anaesthesia Yes 239 59.8 144 61.8 95 56.9 0.01 No 101 25.3 67 28.8 34 20.4 Don’t know 60 15.0 22 9.4 38 22.8 Given opportunity to ask questions Yes 337 84.3 209 89.7 128 76.6 < 0.001 No 28 7.0 12 5.2 16 9.6 Don’t know 35 8.8 12 5.2 23 13.8 aRelatives: parent, spouse, sibling, other relative. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 575 regarding pre- and post-operative management and care/information guidance. However, satisfaction with the information provided was high among both patients (97.4%) and relatives (83.8%). Regarding perceptions and knowl- edge about the important clauses of informed consent for surgery there were significant differences between the patients and relatives. In the cur- rent study 82.4% of patients who signed the consent form themselves were informed about the nature of the surgery as compared with only 59.9% of the relatives who signed on the patient’s behalf. Slightly higher proportions of patients and relatives reported that they were informed about the expected benefits of the surgery (89.3% versus 73.1% respec- tively). Not all the patients or relatives were given the opportunity to ask questions. Other research has shown that knowledge regarding consent is deficient not only in patients, but also among health-care professionals, who are often unaware of some of the im- portant aspect of consent (17). Many of our patients and relatives reported that they were not informed about the complications, length of stay in the hospital, alternatives to surgery and type of anaesthesia. In this study the multiple regres- sion analysis shows that the significant factors associated with not signing of the consent form by patient them- selves were language problems, medi- cal terms used during explanation, insufficient time allocated, cultural/ traditional reasons and low educa- tional status. The literature has shown before that a low level of literacy influences patients’ understanding about the information given regarding procedures (18). In Pakistan the high rates of illiteracy among the popula- tion obstructs patients’ ability to read the informed consent forms. People with regional dialects sometimes do not understand either the national (Urdu) or official (English) languages, and this makes communication dif- ficult (8). Another factor identified in the study was cultural/traditional rea- sons. In this part of the world women are commonly not given autonomy to take decisions. Usually a male or the head of the family takes impor- tant decisions and, since the consent form is seen as a legal document, it is mostly men who sign it on behalf of their wives. However, in this study there was no significant difference in the proportion of males and females Table 4 Factors associated with patients not signing the surgery informed consent form for themselves (n = 400) Variable Self-signed Relative signed OR (95% CI) AOR (95% CI) P-value No. % No. % Language factors No 33 44.6 41 55.4 1 1 Yes 200 61.3 126 38.7 2.3 (1.6–3.3) 4.6 (1.9–5.2) < 0.01 Better educational statusa Yes 177 57.7 130 42.3 1 No 56 62.2 34 37.8 2.6 (1.8–3.9) 2.4 (1.8–5.0) 0.01 Insufficient time allocated No 41 45.1 50 54.9 1 1 Yes 192 62.1 117 37.9 1.9 (1.4–2.6) 3.8 (2.8–4.7) 0.02 Medical terminology used No 59 56.7 45 43.3 1 1 Yes 174 58.8 122 41.2 1.8 (1.3–2.5) 2.7 (1.1–6.7) 0.03 Cultural/traditional reasons No 133 71.5 53 28.5 1 1 Yes 100 46.7 114 53.3 1.6 (1.2–2.3) 1.5 (1.1–3.5) 0.04 Inappropriate timing No 184 57.1 138 42.9 1 Yes 49 62.8 29 37.2 1.3 (1.0–1.8) – – Not informed/asked No 208 63.0 122 37.0 1 Yes 25 35.7 45 64.3 1.2 (1.0–1.7) – – aYes: > 6 years of education. OR = odds ratio; CI = confidence interval; AOR = adjusted odds ratio;. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 576 References 1. McCullough LB, Chervenak FA. Informed consent. Clin Perina- tol. 2007 Jun;34(2):275–85, vi. PMID:17572234 2. Consent: patients and doctors making decisions together. London: General Medical Council; 2008 (http://www.gmc- uk.org/static/documents/content/Consent_-_English_0911. pdf, accessed 12 June 2014). 3. Moskop JC, Marco CA, Larkin GL, Geiderman JM, Derse AR. From Hippocrates to HIPAA: privacy and confidential- ity in emergency medicine–Part I: conceptual, moral, and legal foundations. Ann Emerg Med. 2005 Jan;45(1):53–9. PMID:15635311 4. Courtney MJ. Information about surgery: what does the public want to know? ANZ J Surg. 2001 Jan;71(1):24–6. PMID:11167593 5. Del Carmen MG, Joffe S. Informed consent for medical treat- ment and research: a review. Oncologist. 2005 Sep;10(8):636– 41. PMID:16177288 6. Jafarey A. Informed consent: views from Karachi. East Mediterr Health J. 2006;12 Suppl 1:S50–5. PMID:17037689 7. Bhurgri H, Qidwai W. Awareness of the process of informed consent among family practice patients in Karachi. J Pak Med Assoc. 2004 Jul;54(7):398–401. PMID:15449928 8. Khan RI. Informed consent and some of its problems in Paki- stan. J Pak Med Assoc. 2008 Feb;58(2):82–4. PMID:18333527 9. Paterick TJ, Carson GV, Allen MC, Paterick TE. Medical in- formed consent: general considerations for physicians. Mayo Clin Proc. 2008 Mar;83(3):313–9. PMID:18315998 10. Ruhnke GW, Wilson SR, Akamatsu T, Kinoue T, Takashima Y, Goldstein MK, et al. Ethical decision making and patient autonomy: a comparison of physicians and patients in Ja- pan and the United States. Chest. 2000 Oct;118(4):1172–82. PMID:11035693 11. Sypher B, Hall RT, Rosencrance G. Autonomy, informed con- sent and advance directives: a study of physician attitudes. W V Med J. 2005 May-Jun;101(3):131–3. PMID:16161532 12. Moazam F. Families, patients, and physicians in medical de- cision nmaking: a Pakistani perspective. Hastings Cent Rep. 2000 Nov-Dec;30(6):28–37. PMID:11475993 13. Shiraz B, Shamim MS, Shamim MS, Ahmed A. Medical ethics in surgical wards: knowledge, attitude and practice of surgi- cal team members in Karachi. Indian J Med Ethics. 2005 Jul- Sep;2(3):94–6. PMID:16276659 14. Mahmood K. Informed consent and medical ethics. Ann King Edward Med Coll. 2005;11:247–9. 15. Qidwai W, Qureshi H, Azam SI, Ali SS, Ayub S. Perception of bioethics among general practitioners in Karachi. Pak J Med Sci. 2002;18:221–6. 16. Samad A, Khanzada TW, Kumar B, Rajput A. Perception of consent among house surgeons: differences between Pakistan and United Kingdom hospitals. J Coll Physicians Surg Pak. 2008 Dec;18(12):789–90. PMID:19032899 17. Shamsa Z, Rizwan HM, Ahmed NS, Ayesha RA, Ahsan A, Fatima NM. The awareness of 'informed consent', among medical whose relatives signed on their behalf. This could be because the study pri- vate hospital mainly serves an urban population, who tend to be better edu- cated (only 9.3% of our patients were illiterate) and therefore more likely to understand and acknowledge wom- en’s autonomy. It would be interesting to note the practice in government and rural hospitals, where patients may have lower literacy levels. There is evidence that if the consent process is communicated properly patient satisfaction levels during and after surgery are higher (19,20). Taking consent at the ap- propriate time and in the correct manner can resolve many issues after surgery (21,22). This was evident from the results of our study, in which a majority of the patients (86.5%) and their relatives (78.4%) wanted to have detailed information about the surgery. Moreover, the patients (63.8%) and relatives (48.2%) who signed the consent form knew that obtaining consent before any surgery is important. Making patients’ aware about their right to informed consent and privacy is essential in health care (23). Previous qualitative research has shown that a significant number of physicians do not think it is necessary to obtain a proper consent and that signing a document is sufficient, but the literature has shown that shared decision-making and proper com- munication will lead to better out- comes in terms of patient satisfaction, smooth recovery from procedures and surgery as well as better compli- ance with doctors’ advice (9, 24). This study had some limitations. It was a quantitative study and the results could have been more meaningful if patients’ perceptions had been as- sessed qualitatively to determine the subjective perceptions of the patients regarding the barriers faced during signing of the consent form. In addi- tion, this study was conducted in a private hospital, so extrapolation of the results to government and semi- private hospitals should be done with caution as there could be differences in practices. Conclusions This study showed the perceptions of patients and their relatives to sign- ing a surgery consent form. Health care practitioners need to be aware and knowledgeable about the various factors affecting informed consent in order to improve the informed con- sent process. In this study language was identified as the greatest bar- rier to informed consent. Therefore translation of the informed consent form into various regional languages and providing translators is recom- mended. Health-care practitioners also need to be aware of particular items in the consent form (such as medical terminology) that may be problematic and to ask potential subjects direct questions about their understanding of those items. Further comparative studies regarding the informed consent process should be carried out between government and private hospitals to improve the process. Competing interests: None declared. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 577 students and the current consent practices at a tertiary care hospital objective: our study aims to document. Ann Pak Inst Med Sci. 2011;7(4):176–9. 18. Rothman RL, DeWalt DA, Malone R, Bryant B, Shintani A, Crigler B, et al. Influence of patient literacy on the effective- ness of a primary care-based diabetes disease management program. JAMA. 2004 Oct 13;292(14):1711–6. PMID:15479936 19. Yousuf RM, Fauzi ARM, How SH, Rasool AG, Rehana K. Aware- ness, knowledge and attitude toward informed consent among doctors in two different cultures in Asia: a cross-sectional com- parative study in Malaysia and Kashmir, India. Singapore Med J. 2007 Jun;48(6):559–65. PMID:17538757 20. Boisaubin EV. Observations of physician, patient and fam- ily perceptions of informed consent in Houston, Texas. J Med Philos. 2004 Apr;29(2):225–36. PMID:15371189 21. Amin FM, Jawaid M, Rehman S. An audit of information pro- vided during Preoperative informed consent. Pak J Med Sci. 2006;22:10–3. 22. Imam SZ, Syed KS, Ali SA, Ali SU, Fatima K, Gill M, et al. Patients’ satisfaction and opinions of their experiences during admis- sion in a tertiary care hospital in Pakistan—a cross sectional study. BMC Health Serv Res. 2007;7:161. PMID:17915023 23. Schildmann J, Cushing A, Doyal L, Vollmann J. Informed con- sent in clinical practice: pre-registration house officers’ knowl- edge, difficulties and the need for postgraduate training. Med Teach. 2005 Nov;27(7):649–51. PMID:16332561 24. Whitney SN, McGuire AL, McCullough LB. A typology of shared decision making, informed consent, and sim- ple consent. Ann Intern Med. 2004 Jan 6;140(1):54–9. PMID:14706973 EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 578 Interobserver variations in reporting of prostatic adeno­ carcinoma using core biopsy specimens: a retrospective study from a tertiary referral hospital in Saudi Arabia A.C. Al-Rikabi 1 and H. Alkhalidi 1 1Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia (Correspondence to A.C. Al-Rikabi: ammar_rikabi12@ yahoo.com). Received: 20/06/12; accepted: 08/07/12 ABSTRACT In recent years, greater numbers of prostate biopsy cores are being submitted for histopathological assessment, with a concomitant increase in workload for the pathologist. This retrospective study aimed to assess the concordance and interobserver variation between histopathologists in reporting prostatic adenocarcinoma using material obtained from prostatic core biopsy specimens. A total of 810 prostatic needle core biopsy specimens obtained from 100 patients with suspected prostatic adenocarcinoma were retrieved from the archival material at King Khalid University Hospital, Riyadh, and classified independently by 3 experienced histopathologists who were blinded to the original diagnosis. There was considerable interobserver agreement between the pathologists, with unweighted kappa scores ranging from 0.69–0.85. We would encourage other hospital pathologists to review periodically the uniformity of diagnoses in an attempt to improve their practices in prostate gland pathology. :ةـيبل تاـعزخ تاـنيع مادختـساب تاتـسوبرلا في ةـيدغلا ةـناطسرلا نـع غاـبلإا في نـصحافلا نـب تاـفاتخلاا مـييقت ةيدوعـسلا ةـيبرعلا ةـكلملما في يـعماج ةـلاحإ ىفـشتسم نـم ةيداعتـسا ةـسارد يدلالخا ماشه ،بياكرلا رّمع اـم عـم ،يجولوثابوتـسيلها مـ ييقتلا لـجأ نـم تاتـسوبرلل ةـ يبللا تاـعزلخا نـم برـكأ دادـعأ لاـسرإ ةرـخلأا تاونـسلا في مـتي :ةـصالخا قـفاوتلا مـ ييقت لىإ ةيداعتـسلاا ةـساردلا هذـه تـفده دـقو .اـ يجولوثابلا صياـصتخلا ةبـسنلاب لـمعلا ءبـع في ةداـ يز نـم كـلذ بـحاصي مــ ت داوــ م مادختــ ساب تاتــ سوبرلا في ةــ يدغلا ةــ ناطسرلا نــ ع غاــ بلإا في ايجولوثابوتــ سيلها يــ يصاصتخا نــ م نــ صحافلا نــ ب فاــ تخلااو تاتـسوبرلا نـم ةرـبلإاب ةـيبل تاـعزلخ تاـنيع 810 هـعوممج اـم بـلج مـت دـقف .تاتـسوبرلا نـم ةـيبل تاـعزخ تاـنيع نـم اـهيلع لوـصلحا كللما ةـعماج ىفـشتسم في ةيفيـشرلأا داوـلما نـم كـلذو ،تاتـسوبرلا في ةـيدغ ةـناطسرب مـهتباصإب هبتـشي ضـيرم 100 نـم اـهيلع لوـصلحا مـت مـهيلع يـ ِّمُع نـيذلاو ،ةبرـلخا يوذ ايجولوثابوتـسيلها يـيصاصتخا نـم ةـثاث لـَبِق نـم - لقتـسم لكـشب - اـهفينصت مـتو ،ضاـيرلاب دـلاخ اـم حوارـت ةـح ِّجرم رـغ اـباك زارـحأ عـم َقـَفارت ،اـيجولوثابلا يـيصاصتخا نـم نـصحافلا نـب رـبك قاـفتا كاـنه ناكـف .يـصلأا صيخـشتلا قـُفاَوَت - يرود لكـشب - اوـعجاري نأ ىـع ىرـخأ تايفـشتسم في اـيجولوثابلا يـيصاصتخا عيجـشت لىإ ناـثحابلا صـلخو .0.85و 0.69 نـب .تاتـسوبرلا ةدـغ اـيجولوثاب لاـمج في متهاـسرامم نـسحتل ةـلوامح في تاصيخـشتلا Évaluation des variations inter­observateurs dans la notification des adénocarcinomes prostatiques à partir d'échantillons de microbiopsie : étude rétrospective dans un hôpital de soins tertiaires en Arabie saoudite RÉSUMÉ Ces dernières années, le nombre d'échantillons de microbiopsie de la prostate soumis à une analyse histopathologique a augmenté, ainsi que la charge de travail concomitante du pathologiste. La présente étude rétrospective visait à évaluer la concordance et la variation inter-observateurs parmi les histopathologistes dans la notification de l'adénocarcinome prostatique à partir d'échantillons de microbiopsie prostatiques. Au total, 810 échantillons prostatiques de microbiopsie au trocart de 100 patients chez qui un adénocarcinome prostatique était suspecté, ont été extraits des archives de l'hôpital universitaire King Khalid à Riyad, puis classifiés indépendamment par trois histopathologistes expérimentés qui ignoraient le diagnostic initial. La concordance entre les observateurs pathologistes était élevée, avec des scores kappa non pondérés compris entre 0,69 et 0,85. Nous encourageons d'autres pathologistes hospitaliers à examiner périodiquement l'uniformité des diagnostics afin d'améliorer leurs pratiques dans la pathologie de la prostate. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 579 Introduction Apart from skin cancer, carcinoma of the prostate is the most common internal malignancy among men in Western countries. It is responsible for 10% of cancer deaths (1) and is on the increase in most countries (2). The rate of prostate cancer in Saudi Arabia ranked sixth among male patients with a crude annual incidence of 5.7 per 100 000 (3). The diagnosis of prostate cancer re- quires the estimation of prostate-specif- ic antigen and multiple cores obtained by thin-bore needle biopsies. Increasing the number of needle cores analysed to between 6 to 12 has been shown to im- prove prostate cancer detection by 29% (4,5). For this reason, a greater number of prostate biopsies are obtained nowa- days and more biopsy cores are being submitted than ever before and this has created a huge interpretive burden for the diagnostic histopathologist (6), a burden that is exacerbated by the diffi- culties of prostate biopsy interpretation (6,7). The subject of interobserver varia- tion in cytological and histological diag- noses of cancer and its epidemiological implications has become increasingly relevant in the last 20 years. Various studies have shown highly reproducible diagnoses of uterine cervical neoplasia (8), while there was considerable inter- observer variation in the reporting of anal intraepithelial neoplasia (9) and in certain types of breast carcinomas (10). With this in mind, this study in Saudi Arabia aimed to assess the diag- nostic reproducibility and interobserver variation in histopathological reporting of prostatic adenocarcinoma among 3 histopathology consultants. Methods Sample In this retrospective study a total of 810 prostatic needle biopsies obtained from 100 patients from 2005 until the end of 2011 were retrieved from the archives of the histopathology unit at King Khalid University Hospital, Riyadh. The number of needle cores obtained from each patient varied from 6 to 12 cores. This was due to an evidence-based change in the policy (in the last 10 years) regarding the number of needle cores that should be obtained per patient. Data collection All biopsies were processed and stained using haematoxylin and eosin stain in our laboratory. We routinely obtain 6 cuts (2 adjacent sections from 3 sepa- rate levels) from the paraffin block for routine staining. Three experienced general histo- pathologists were asked to examine each of the 810 stained needle biopsies without their knowledge of the previous clinical, radiological or histopathological findings of the 100 patients from whom those biopsies were obtained. The results obtained from each pathologist (A, B and C) were independently documented as being either negative for malignancy (normal), positive for malignancy (ab- normal) or inconclusive, i.e. in need of further immunohistochemical stains or repeat biopsies. Analysis The results were tabulated and analysed using the multiple-reader Cohen kappa statistical analysis method (7,11) using SPSS, version 18. The aim was to assess the precision pertaining to agreement between observers (interobserver agreement). The Gleason score (grade of malignant cases) was not, however, recorded as this parameter was outside the scope of this retrospective study. Results The results obtained by the 3 partici- pating pathologists are summarized in Table 1. The kappa score for interob- server agreement between pathologists A and B was 0.71 (P < 0.001), between pathologists A and C was 0.69 (P < 0.001) and between pathologist B and C was 0.85 (P < 0.001). Our results also showed that almost all cases of diagnostic uncertainty and interobserver differences in interpreta- tion were due to the presence of small atypical or atrophic acini areas consist- ing of 5 or fewer acini. The percentages of such cases varied between 2% and 6% and were mainly due to the presence of small atypical acinar proliferation. Discussion It may sometimes be challenging for the pathologist to deliver a definite di- agnosis of adenocarcinoma in prostate biopsies, particularly if the size of the lesion is too small to judge the pres- ence of an infiltrative pattern. This issue has become more pertinent in recent years due to clinical stage reduction of Table 1 Frequency distribution of prostatic specimen observations among the 3 pathologists (n = 810) Observation Pathologist A Pathologist B Pathologist C No. % No. % No. % Normal 558 68.9 575 71.0 562 69.4 Abnormal 200 24.7 214 26.4 231 28.5 Inconclusive 52 6.4 21 2.6 17 2.1 EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 580 prostate cancer, which occurred as a consequence of widespread prostate- specific antigen testing and increased numbers of biopsies leading to “early” diagnosis of smaller cancerous foci (6). Also repeat biopsies in the context of ac- tive surveillance treatment might lead to an increased frequency of small foci of adenocarcinoma, high-grade prostatic intraepithelial neoplasia and lesions reported as suspicious for malignancy or atypical small acinar proliferation. In this study of prostate core biopsy specimens the degree of concordance among the 3 histopathologists was es- timated using the kappa coefficient. This is the most commonly reported measure in the medical literature, and can provide more information than a simple calculation of the raw propor- tion of agreement. The method is excel- lent for comparing results obtained by individuals but is slightly affected by prevalence (11). The study showed a good degree of concordance in the in- terpretation of prostatic needle biopsies among the 3 participating histopathol- ogists, with interobserver agreements which varied between kappa 0.69 and 0.85. There was substantial interob- server agreement between pathologists A and B (0.71) and A and C (0.69) (kappa values 0.61–0.80 are generally interpreted as substantial agreement) (11), while the interobserver agree- ment between pathologist B and C (0.85) fell within the kappa range of 0.81–1, which is generally interpreted as almost perfect agreement (11). In- conclusive interpretations were mostly due to the presence of small atypical or atrophic acini. These findings are keep- ing with those reported in the literature (7,12–15). Despite the interpretative difficul- ties and the burden of an increasing workload, experienced surgical pathol- ogists have a high level of accuracy in prostatic needle biopsy interpretation and Gleason grading. Interobserver reproducibility of Gleason grading among urologic pathologists has been shown to acceptable (5,16–19). The greater differences of interpretation result from low-grade cancers (6), cancers with small cribriform pattern (20) and cancers whose histology is on the border between Gleason patterns (16,17). The false-negative rate (missed prostate cancer) was 0.6–1% and the false-positive rate (overdiagnosis of prostate cancer) was 0.3 (6,18). These numbers indicate a small but significant error level that could be avoided by sec- ondary pathology review (18,19). The findings obtained from the biopsies in the current study were not compared with those seen in the excision speci- mens (prostatectomies) as we aimed to assess the reproducibility of the results and not measure the accuracy of the initial diagnoses. Conclusions This study show good interobserver agreement in the interpretation of prostatic and needle biopsies among the participating histopathologists (kappa ranges 0.69–0.85). Incon- clusive interpretations were mostly due to the presence of small atypical or atrophic acini. The establishment of an intradepartmental system of consultation with joint reporting and signing out of prostatic carcinoma by at least 2 experienced histopatholo- gists will help maintain a high degree of diagnostic concordance. Based on the results presented, we would en- courage other hospital pathologists, in collaboration with their urologists, to review periodically the uniformity of their diagnoses in an attempt to im- prove their prostate gland pathology practices. Acknowledgements The authors would like to express their gratitude to Dr Abdulmalik Al-Sheikh who kindly agreed to participate in this study. The secretarial help of Ms Roxanne Alamares during the typing of this manuscript is also greatly ap- preciated. Funding: None. Competing interests: None declared. References 1. Nelson WG, De Marzo AM, Isaacs WB. Prostate cancer. N Engl J Med. 2003 Jul 24;349(4):366–81. PMID:12878745 2. Zaridze DG, Boyle P, Smans M. International trends in prostatic cancer. 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Grading of invasive cribriform carcinoma on prostate needle biopsy: an interobserver study among experts in geni- tourinary pathology. Am J Surg Pathol. 2008 Oct;32(10):1532–9. PMID:18724248 EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con- cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. 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 collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2014 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. ISSN 1020-3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emhj@emro.who.int طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen Cover 20-10 (69 Cyan - 37 Yellow).indd 4-6 14/10/2014 10:20 All people should have access to needed health services without having to risk financial hardship. Social health insurance (SHI) is an effective instrument for countries to achieve this. SHI is a principal method of health financing to raise and pool money through a mix of obligatory insurance contributions and government revenues so everyone can have health care cover. Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 20 / No. 9 September/Septembre 9 ددع / نوشرعلا دلجلما برمتبس / لوليأ2014 Contents V o lu m e 2 0 N u m b er 9 S ep tem b er 2 0 1 4 Editorial Benefits and pitfalls of social health insurance in pursuit of universal health coverage: lessons for the Eastern Mediterranean ..................................................................................................................... 527 Research articles Pattern of cigarette and waterpipe smoking in the adult population of Jordan ..................................................... 529 Quitting smoking and utilization of smoking cessation services in Jordan: a population-based survey .............. 538 Household storage of medicines and self-medication practices in south-east Islamic Republic of Iran ............. 547 Use of complementary and alternative medicine among midlife Arab women living in Qatar ........................... 554 Knowledge of periconceptional folic acid use among pregnant women at Ain Shams University Hospital, Cairo, Egypt .............................................................................................................................. 561 Factors affecting the process of obtaining informed consent to surgery among patients and relatives in a developing country: results from Pakistan .......................................................................................... 569 Interobserver variations in reporting of prostatic adeno carcinoma using core biopsy specimens: a retrospective study from a tertiary referral hospital in Saudi Arabia .................................................................... 578 Cover 20-09 (69 Cyan - 37 Yellow).indd 1-3 9/29/2014 1:46:13 PM