Eastern Mediterranean Health Journal [2013; Vol.19, Issue 1]

Contents Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 19 / No. 1 January / Janvier 2013 1 ددع / شرع عساتلا دلجلما رياني / نياثلا نوناك V olum e 19 N um ber 1 January 2013 Letter from the Editor ............................................................................................................................................................3 Research articles Compliance with haemodialysis practice guidelines in Egypt ....................................................................................4 Effect of prenatal counselling on compliance and outcomes of teenage pregnancy ............................................. 10 Domestic violence against women in Kersa, Oromia region, eastern Ethiopia ....................................................... 18 Looking beyond legality: understanding the context of female sex workers in greater Cairo, Egypt .....................24 Dieting behaviours, obesity and predictors of dieting among female college students at Palestinian universities ............................................................................................................................................... 30 Pattern of psychiatric illnesses among long-stay patients at Mental Health Hospital, Taif, Saudi Arabia: a 10-year retrospective study ........................................................................................................37 Study of the effect of dietary counselling on the improvement of end-stage renal disease patients .....................45 Évaluation de la prise en charge des diabétiques par le médecin généraliste dans la province de Khouribga (Maroc) ......................................................................................................................................................52 Trends of skin cancer incidence in 6 geographical regions of the Islamic Republic of Iran, 2000–2005 ..............59 Acute respiratory infection and malnutrition among children below 5 years of age in Erbil governorate, Iraq ... 66 Epidemiological characterization of P. aeruginosa isolates of intensive care units in Egypt and Saudi Arabia ...... 71 Quality of clinical laboratory department in a specialized hospital in Alexandria, Egypt ....................................... 81 Salmonella spp. in patients suffering from enteric fever and food poisoning in Thamar city, Yemen .................... 88 Report Implementing the essential medicine concept in the country with the highest GDP per capita in the world...... 94 Eastern Mediterranean Health Journal reviewers’ panel, 2012 .......................................................................................97 Guidelines for authors ....................................................................................................................................................... 98 Chitral, Pakistan: WHO EMHJ extends good wishes for a healthy, peaceful and happy new year to all our readers, authors, reviewers, and our editorial board and advisory panel members. Cover 19-1.indd 1 1/10/2013 10:05:54 AM 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: khayat@emro.who.int/emhj@emro.who.int 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 is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed‑Full text on CD‑ROM, 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 2013 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 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 . نادوسلا بونج . 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 . South Sudan 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 . Soudan du Sud . Tunisie . Yémen Cover 19-1.indd 2 1/10/2013 10:05:54 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 19 No. 1 1 ددع شرع عساتلا دلجلما•  2013  • Letter from the Editor ......................................................................................................................................................................................................................................................................................................................................3 Research articles Compliance with haemodialysis practice guidelines in Egypt A.M.A. Ahmed, M.F. Allam, E.S. Habil, A.M. Metwally, N.A. Ibrahiem, M. Radwan, M.M. El-Gaafary and M.A. Gadallah ...............................................................................4 Effect of prenatal counselling on compliance and outcomes of teenage pregnancy F.A. Mersal, O.M. Esmat and G.M. Khalil............................................................................................................................................................................................................................................10 Domestic violence against women in Kersa, Oromia region, eastern Ethiopia W. Shanko, M. Wolday, N. Assefa and A.R . Aro ..................................................................................................................................................................................................................................18 Looking beyond legality: understanding the context of female sex workers in greater Cairo, Egypt I.A. Kabbash, I. Abdul-Rahman and Y.A. Shehata .............................................................................................................................................................................................................................24 Dieting behaviours, obesity and predictors of dieting among female college students at Palestinian universities W.D. Bayyari, L.J. Henry and C. Jones .....................................................................................................................................................................................................................................................30 Pattern of psychiatric illnesses among long-stay patients at Mental Health Hospital, Taif, Saudi Arabia: a 10-year retrospective study H. Al-Zahrani, A. Al-Qarni and M. Abdel-Fattah ..............................................................................................................................................................................................................................37 Study of the effect of dietary counselling on the improvement of end-stage renal disease patients I.S. Hegazy, H.A. El Raghy, S.B. Abdel-Aziz and E.M. Elhabashi .................................................................................................................................................................................................45 Évaluation de la prise en charge des diabétiques par le médecin généraliste dans la province de Khouribga (Maroc) S. Hassoune, S. Badri, S. Nani, L. Belhadi et A. Maarouf .................................................................................................................................................................................................................52 Trends of skin cancer incidence in 6 geographical regions of the Islamic Republic of Iran, 2000–2005 M. Heidari and F. Najafi ..............................................................................................................................................................................................................................................................................59 Acute respiratory infection and malnutrition among children below 5 years of age in Erbil governorate, Iraq D.A.K. Chalabi ...............................................................................................................................................................................................................................................................................................66 Epidemiological characterization of P. aeruginosa isolates of intensive care units in Egypt and Saudi Arabia S.A. Mansour, O. Eldaly, A. Jiman-Fatani, M.L. Mohamed and E.M. Ibrahim ........................................................................................................................................................................71 Quality of the clinical laboratory department in a specialized hospital in Alexandria, Egypt T.A. Elhoseeny and E.K. Mohammad .....................................................................................................................................................................................................................................................81 Salmonella spp. in patients suffering from enteric fever and food poisoning in Thamar city, Yemen R.R. Taha, S.M. Alghalibi and M.G. Saeed Saleh ...............................................................................................................................................................................................................................88 Report Implementing the essential medicine concept in the country with the highest GDP per capita in the world A.M. Cheraghali .............................................................................................................................................................................................................................................................................................94 Eastern Mediterranean Health Journal reviewers’ panel, 2012 ............................................................................................................................................................................97 Guidelines for authors .................................................................................................................................................................................................................................................................................................................................98 M. Haytham Khayat MD, PhD, FRSPH, Editor-in-chief Editorial Board Ahmad Ezzat Abdou BSc, DPH, PhD, (Secretary) Naeema Al Gasseer MSc, PhD Ahmad Bassel Al-Yousfi PhD, PE, DEE Mohamed M. Ali BSc, MSc, PhD, DTMH Abdulla S. Assaedi MBBS, MPH Mounir Farag MD, DGS, DEmS, DHP Zuheir Hallaj MD, DPH, DrPH Nahla Khamis Ibrahim MD, MPH, Dr.PH (Epidemiology), DHPE (Medical Education) Mamunur Rahman Malik MBBS, Dip(Health Economics), MSc, MPhil Ezzedine Mohsni PhD Abdulaziz Saleh Dip(Hosp Pharm), Dip(Indus Pharm), PHD Kassem Sara MD, MAM Joanna Vogel MScHS, MScPH Mohamed Helmy Wahdan MD, DPH, PhD International Advisory Panel Dr S. Aboulazm. Professor of Orthodontics. Egypt Dr Abdul Rahman Al-Awadi BSc, MD, MPH, Honorary FRCM, Ireland Dr M. Al-Nozha, MD, FRCP, FACC, FESC. Professor of Medicine and Consultant Cardiologist. Saudi Arabia Dr Ala’din Alwan MD, FRCP, FFPHM. Iraq Dr F. Azizi. Professor of Internal Medicine and Endocrinology. Islamic Republic of Iran Professor K. Dawson BA, MD, PhD, FRCP, FRACP, FRCPCH, DObst, RCOG. New Zealand Professor Kaussay Dellagi MD. Tunisia Dr R. Dybkaer MD. Denmark Dr M. Aziz El-Matri. Professor of Medicine. Tunisia Professor F. El-Sabban BSc, MS, PhD. United States of America Dr A.H. El-Shaarawi MSc (Stat), PhD (Stat). Canada Professor N. Fikri-Benbrahim PhD (Pub health) (SocSci). Morocco Professor A.T. Florence BSc (Pharm), PhD, DSc, FRSC, FRPharmS, FRSE. United Kingdom Professor Cheherezade M.K. Ghazi BS (Nursing), MS (Nursing), DPH, MPA. Egypt Professor M.A. Ghoneim MD, MD (Hons). Egypt Dr J.A. Hashmi DTM&H, FRCP. Pakistan Professor J. Jervell MD, PhD. Norway Professor G.J. Johnson MA, MD, BChir, FRCS (C), FRCOphth, DCEH. United Kingdom Dr M. Kassas. Emeritus Professor of Plant Ecology. Egypt Professor M.M. Legnain MBBS, MRCOG, FRCOG. Libyan Arab Jamahiriya Professor El-Sheikh Mahgoub DipBact, PhD, MD, FRCPath. Sudan Professor A.M.A. Mandil MSc (Paediatr), MPH, DrPH. Egypt Professor A.B. Miller MB, FRCP. Canada Professor S.S. Najjar MD. Lebanon Dr Abubaker A. Qirbi BSc, MD (Edin), FRCPC (Can), FRCP FRCPath (UK). Republic of Yemen Professor O.S.E. Rasslan MD, PhD. Egypt Professor W.A. Reinké MBA, PhD. United States of America Professor I.A. Sallam, MD, Dip High Surgery Cairo, Honorary FRCS, PhD (Glasgow), LRCP, MRCS, FRCS (London), ECFMG. Egypt Dr C.Th.S. Sibinga FRCP (Edin), FRCPath. The Netherlands Mr Taoufik Zeribi Eng BSc, MSc. Tunisia Editors Fiona Curlet, Eva Abdin, Alison Bichard, Guy Penet Graphics Suhaib Al Asbahi, Hany Mahrous, Diana Tawadros Administration Nadia Abu-Saleh, Yasmine El Sakhawy المجلة الصحية لشرق المتوسط المجلد التاسع عشر العدد الأول 3 رسالة من المحرر rotidE eht morf retteL تم في هذا العام 2102، كما هو الحال في كل عام، تقديم عدد 817 من الورقات البحثية للنظر في إمكانية نشرها في المجلة الصحية، بمعدَّ ل قبول للنشر وصل إلى نحو 02%. وفي هذا العام، َوَرَدت أوراق بحثية من 02 بلدًا من داخل الإقليم، إضافًة إلى 62 بلدًا من خارجه، مما يمثل زيادة كبيرة عما كان عليه الحال في العام الماضي 1102، الذي لم يزد فيه عدد البلدان التي َوَرَدت منها أوراق بحثية للنشر، من خارج الإقليم، على عشرة بلدان، الأمر الذي يشير إلى اتساع الآفاق الدولية التي تصل إليها المجلة. وجاءت جمهورية إيران الإسلامية، ومصر، والمملكة العربية السعودية، كأكثر ثلاثة بلدان ُقدِّ مت منها أوراق بحثية للنشر في المجلة، حيث بلغ عدد هذه الأوراق 781، 69 و 86 ، ورقة بحثية على التََّوالي. وتصل حاليًا المدة ما بين قبول الورقة ونشرها حوالي 11 شهرًا، غير أن جهودًا ُتْبَذل الآن لجعل هذه المدة أقصر من ذلك، مع العمل أيضًا على تحسين جودة المجلة وملاءمتها، بصورة عامة. وَيُضم آخر أعداد هذا العام، 2102، مجموعة متنوعة من الورقات البحثية التي تتصل غالبيتها بموضوعات متعلقة بالمجالات الخمس ذات الأولوية المحددة في وثيقة رسم ملامح المستقبل الصحي في إقليم شرق المتوسط: تعزيز دور منظمة الصحة العالمية. وتسلط هذه الوثيقة الضوء على التحديات الرئيسية التي تواجه هذا الإقليم، كما تحدد الثغرات في مجابهة هذه التحديات، وهي تقدم أيضًا توجهات استراتيجية عامة حول أعمال منظمة الصحة العالمية في هذا الإقليم، في الفترة من 2102 إلى 6102، مع الإشارة، بصفة خاصة، إلى المجالات ذات الأولوية، وهي: تقوية النُُظم الصحية، وصحة الأمهات والصحة الإنجابية وصحة الأطفال والتغذية، والأمراض غير السارية، والأمراض السارية، والاستعداد للطوارئ ومجابهتها. وتحدد الوثيقة كذلك ما سوف تقوم به المنظمة لتحسين أدائها، وما يمكن للدول الأعضاء القيام به في هذا المجال. وَنَودُّ أن نغتنم هذه المناسبة كي نعرب لمراجعينا الأجلاَّء، الذين قاموا بمراجعة أعداد هذا العام 2102، والواردة أسماؤهم في نهاية هذا العدد، عن امتناننا العميق، لتقييماتهم الدقيقة والصريحة، التي مكنتنا من اتخاذ قرارات مستنيرة بشأن الورقات البحثية التي ُقدِّ مت من أجل النشر. ولا ريب أن هذه التقييمات هي بالقطع حيوية وحاسمة للحفاظ على جودة المجلة. ولا يفوتنا في هذا المقام أن نتقدَّ م بصادق التمنيات الطيبة بعام جديد سعيد، لكل قّرائنا، ومقدِّ مي الأوراق البحثية، والمراجعين، وهيئة التحرير، وأعضاء الهيئة الاستشارية، مع دعواتنا القلبية لهم بمزيد من التقدُّ م والازدهار.  erew srepaP .%02 tuoba fo etar ecnatpecca na htiw JHME ni noitacilbup rof noitaredisnoc rof dettimbus erew srepap 817 ,2102 nI  nehw 1102 morf esaercni elbaredisnoc a ,noigeR eht edistuo seirtnuoc 62 morf sa llew sa noigeR eht fo seirtnuoc 02 morf deviecer  eht ,noigeR eht nihtiW .lanruoJ eht fo hcaer lanoitanretni gniworg eht setacidni siht ;detneserper erew seirtnuoc lanoiger-non 01 ylno -bus 86 dna 69 ,781 htiw ,lanruoJ eht ot srepap gnittimbus seirtnuoc 3 pot eht erew aibarA iduaS dna tpygE ,narI fo cilbupeR cimalsI ecuder ot edam gnieb era stroffe tub shtnom 11 tuoba ta sdnats won noitacilbup ot ecnatpecca morf emit eTh .ylevitcepser snoissim .ecnaveler dna ytilauq s’JHME ecnahne ot gnikrow eb lliw ew lareneg ni dna rehtruf emit dael noitacilbup latot eht  ni detangised saera ytiroirp evfi eht ot ecnaveler evah hcihw fo tsom scipot fo yteirav a no srepap sedulcni 2102 fo eussi lanfi siTh rojam eht sthgilhgih tnemucod siTh .OHW fo elor eht gnicrofnier :noigeR naenarretideM nretsaE OHW eht ni htlaeh fo erutuf eht gnipahS -eR eht ni krow s’OHW rof snoitcerid cigetarts daorb stneserp dna ,esnopser ni spag eht sefiitnedi ,noigeR eht rof segnellahc htlaeh  evitcudorper ,lanretam ;gninehtgnerts metsys htlaeh :era hcihw saera ytiroirp eht ot ecnerefer ralucitrap htiw 6102–2102 rof noig  osla tI .esnopser dna ssenderaperp ycnegreme ;sesaesid elbacinummoc ;sesaesid elbacinummocnon ;noitirtun dna htlaeh dlihc dna .pleh ot od nac setatS rebmeM tahw dna ecnamrofrep sti evorpmi ot od lliw OHW tahw seniltuo  nac seman esohw ,2102 rof sreweiver detcepser ruo ot edutitarg erecnis ruo sserpxe ot ereh ytinutroppo eht ekat ot ekil dluow eW lacitirc era dna srepap no snoisiced ruo mrofni depleh evah slasiarppa didnac dna hguoroht rieTh .eussi siht fo dne eht ta dnuof eb  ot dna ,sreweiver ,srohtua ,sredaer ruo lla ot 3102 rof sehsiw doog dnetxe ot ekil osla dluow eW .JHME fo ytilauq eht gniniatniam ot .srebmem lenap yrosivda dna draob lairotide EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 4 Compliance with haemodialysis practice guidelines in Egypt A.M.A. Ahmed,1 M.F. Allam,2 E.S. Habil,2 A.M. Metwally,1 N.A. Ibrahiem,1 M. Radwan,2 M.M. El-Gaafary 2 and M.A. Gadallah 2 ABSTRACT Evidence- and consensus-based clinical practice guidelines for haemodialysis have recently been developed in Egypt. This study aimed to measure compliance with the guidelines in a sample of 16 government hospitals in Cairo and Giza governorates. Each haemodialysis unit was visited to assess the haemodialysis unit and patient care practices for all patients under dialysis at the time of the visit. The mean percentage compliance with haemodialysis guidelines among all study hospitals was 59.3% (SD 11.2%) overall. Within the 5 separate domains, compliance was: 58.8% (SD 12.4%) for personnel, 68.5% (SD 16.0%) for patient care practices, 61.3% (SD 15.4%) for infection prevention and control, 51.5% (SD 18.2%) for the facility and 56.5% (SD 7.1%) for documentation/ records. There were no statistically significant differences between Cairo and Giza governorates except for facility measures which were slightly better in Giza. Overall, compliance with the developed practice guidelines for haemodialysis in Egypt was not satisfactory and was not uniform across facilities. 1National Research Centre, Cairo, Egypt. 2Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt (Correspondence to M.F. Allam: fm2faahm@uco.es). Received: 29/08/11; accepted: 11/01/12 صرم في لايدلا تاسرامم لوح ةيداشرلإا لئلادلل لاثتملاا للها داج نسمح ،يرفعلجا اهم ،ناوضر دممح ،ميهاربإ دانه ،ليوتم لامأ ،ليباه داحش بايهإ ،ملاع قوراف دممح ،دحمأ ةيرمأ سايق لىإ ةساردلا هذه فدتهو .عاجملإا لىإو تانّيبلا لىإ ًادانتسا صرم في لايدلا في ةيريسرلا تاسرمالما لوح ةيداشرإ لئلاد ًارخؤم تّدعأ :ةـصلالخا تادحو نم ةدحو لك ةرايزب نوثحابلا ماق دقو .ةزيلجاو ةرهاقلا يتظفامح في ىفشتسم 16 نم فلأتت ةنيع ىدل ةيداشرلإا لئلادلا هذله لاثتملاا ىدم ةيوئلما ةبسنلا يطسو نأ نوثحابلا دجوو ،ةرايزلا تقو لايدلل نوعضيخ اوناك نيذلا ضىرلما عيجم ةياعر تاسرامم مييقتو اهمييقت لجأ نم لايدلا تلااجلما بسحب لاثتملاا تلايصفت امأ )%11.2 ±( %59 يه ةساردلاب ةلومشلما تايفشتسلما عيجم في لايدلا لوح ةيداشرلإا لئلادلل لاثتملال ةياقولاو ىودعلا ةحفاكلم )±15.4%( %61.3 ،ضىرلما ةياعر تاسرمالم )%16 ±( %68.5 ،ينلماعلل )%12.4 ±( %58.8 :ليي ماك تناكف ةسملخا ةلصفنلما ءانثتساب ،ةزيلجاو ةرهاقلا يتظفامح ينب ًايئاصحإ ابه دَتْعُي قورف كانه نكت لمو .قيثوتلاو تلاجسلل )%7.1 ±( %56.5 ،قفرملل )%18.2 ±( %51.5 ،اهنم لوح صرم في اهدادعإ مت يتلا ةيداشرلإا لئلادلل لاثتملاا نكي لم ؛لاجملإا هجو لىعو .ةزيلجا في ليلقب لضفأ تناك يتلا قفارلما تاءارجإب قلعتي ام .قفارلما رئاس في ةدحوم نكت لمو ،َضىرلا لىع ةثعاب لايدلا في ةعبتلما تاسرمالما Respect des lignes directrices sur les pratiques d'hémodialyse en Égypte RÉSUMÉ Des lignes directrices consensuelles et fondées sur des bases factuelles traitant des pratiques d'hémodialyse ont récemment été mises au point en Égypte. L'étude visait à mesurer le respect de ces lignes directrices dans un échantillon de 16 hôpitaux publics des gouvernorats du Caire et de Giza. Chaque service d'hémodialyse a été visité pour être évalué et pour évaluer les pratiques de soins destinés à tous les patients sous dialyse au moment de la visite. Le pourcentage moyen global par le respect des lignes directrices sur les pratiques d'hémodialyse dans l'ensemble des hôpitaux participant à l'étude était de 59,3 % (ET 11,2 %). Plus précisément, dans les cinq domaines évalués, le respect des lignes directrices était de 58,8 % (ET 12,4 %) pour le personnel, 68,5 % (ET 16,0 %) pour les pratiques de soins aux patients, 61,3 % (ET 15,4 %) pour la prévention et la lutte contre les infections, 51,5 % (ET 18,2 %) pour l'établissement et 56,5 % (ET 7,1 %) pour la documentation/les dossiers. Aucune différence statistiquement significative n'a été observée entre les gouvernorats du Caire et de Giza, sauf pour les mesures concernant les établissements qui étaient légèrement meilleures à Giza. Globalement, le respect des lignes directrices élaborées sur les pratiques d'hémodialyse en Égypte n'était ni satisfaisant ni homogène entre les établissements. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 5 Introduction Health care facilities are seeking nowa- days to develop practice guidelines for improving health care services. In the health care sector in Egypt, trials for establishing guidelines have been led by the Ministry of Health and Population (MOHP) [1]. Recently, practice guide- lines for haemodialysis were developed in Egypt. These included 5 main do- mains: personnel, patient care practices, infection prevention and control, facility and documentation/records [2]. Prior to the distribution of the developed practice guidelines it was necessary to establish current levels of compliance in order to monitor the effectiveness of the guidelines. The aim of this study was to measure baseline compliance with the recently developed evidence- and consensus-based clinical practice guidelines for haemodialysis in Egypt. Methods Study design and setting The study was conducted in haemo- dialysis units of government-affiliated hospitals in Cairo and Giza governo- rates. It was carried out in 2 phases over 6 months: in phase 1 the practice guide- lines and the checklist for verification were preparation; in phase 2 field visits to haemodialysis units were conducted to assess the compliance of these units to the practice guidelines set. Sample Haemodialysis units Haemodialysis units in 16 hospitals were selected for the study. In Cairo governorate a total of 7 general hospitals affiliated to the MOHP Directorate of Health Affairs in Cairo were included. In Giza governorate, we included 9 hospitals, some affiliated to the MOHP Directorate of Health Affairs in Giza, plus other hospitals affiliated to the Ministry of Interior, Health Insurance Organization and Ministry of Higher Education and Scientific Research. Hospitals that were not affiliated to the MOHP were included to have a sample of all types of hospitals in Egypt. In ad- dition, consultants from these hospitals had participated in the development of the Egyptian haemodialysis guidelines [2]. Patients All patients attending morning haemo- dialysis sessions during the study period (6 months) were invited to participate in the study. All patients agreed to par- ticipate in the study with participation rate of 100%. We observed 160 patients during their haemodialysis sessions. This sample represented more than one-third (35.2%) of the total patients (n = 454). For medical records we assessed 160 patients’ records. The selection was done by a consecutive non-random technique. Data collection Each haemodialysis unit was visited twice: one visit for assessing the haemo- dialysis unit and another visit for assess- ing patient care practices for all patients under dialysis at the time of the visit. The tools of the compliance as- sessment study were an observational checklist, with documentation review and analysis, and a face-to-face inter- view. Scoring of haemodialysis guidelines In phase 1 of the study a description of each practice guideline was written, together with the criteria for its verifica- tion. The guidelines checklist comprised 5 domains with items and sub-items covering personnel (6 items); patient care practices (5 items); infection pre- vention and control (5 items); facility (4 items); and documentation/records (3 items) [2]. Most sub-items were scored yes/no while some sub-items were scored ranging between 0 and 1 (satisfactory = 1, partially met = 0.5, not satisfactory = 0). For quantitative measures as in the case of observing 10 patients or revising 10 records, if there were 7 patients or records satisfying the criteria the score was 0.7. Next the total score of the sub-items was divided by the total number of sub-items × 100 to get the mean percentage compliance for the item. Then the mean percentage of each domain was calculated by add- ing the mean percentages of each item under this domain and calculating the average. Finally the overall mean per- centage compliance of the hospital was calculated by adding the mean percent- ages of each domain, then calculating the average. Ethical considerations Approvals were obtained from the MOHP to conduct the field visits in the haemodialysis units. Informed consent was taken to interview staff units. In- formed consent was obtained from all patients participating in the study. We also provided the Department of Total Quality at the MOHP with the final haemodialysis practice guidelines that had been approved by the panel and experts, in addition to the final results of assessment of the 16 haemodialysis units and the final recommendations. Statistical analysis First, the following descriptive analy- sis was done: frequency, percentages, mean and standard deviation (SD). Thereafter, a comparison was done between Cairo and Giza haemodialysis units using Student t-test for quantita- tive variables and Fisher exact test for qualitative variables. Data entry and sta- tistical analysis were done using SPSS, version 11.0. The level of significance was set at P < 0.05. Results The mean percentage compliance with haemodialysis guidelines among all EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 6 respectively), but highly significantly different for the presence of 1 nurse for 3 patients/session (0% and 77.8% respectively). For the patient care domain the highest compliance with the guidelines was 86.7% (SD 16.1%) for post-dialysis and the lowest was 36.9% (SD 7.8%) for between-dialysis practices. Compliance with the guidelines on writing orders for haemodialysis (P = 0.018) and the dialysis process (P = 0.001) were signifi- cantly better in Giza than in Cairo, while predialysis preparation was significantly better in Cairo than in Giza (P = 0.049) (Table 3). For infection prevention and con- trol guidelines the mean compliance ranged from 78.8% (SD 16.3%) for housekeeping and waste management to only 13.7% (SD 29.7%) for vac- cination of patients (Table 4). There were statistical significant differences between Cairo and Giza governorates for occupational health (P = 0.027) and housekeeping and waste management (P = 0.004), with Giza governorate facilities demonstrating better compli- ance. For sub-items of the facility do- main the mean compliance with guidelines was 39.6% (SD 16.3%) for administration standards, 75.2% (SD 17.9%) for physical standards and 50.0% (SD 18.26%) for dialysis treat- ment area. Table 5 shows that compli- ance with facility guidelines was better in Giza facilities than in Cairo facilities although only the physical standards sub-item was statically significant (P = 0.039). The mean compliance for sub-items of documentation/records guidelines for employee records and medical records were 19.8% (SD 29.0%) and 63.6% (SD 16.2%) respectively, with no significant differences between Cairo and Giza governorates (Table 6). study hospitals was 59.3% (SD 11.2%) overall. The highest score for individual domains was for personnel [68.5% (SD 16.0%)] and the lowest for the facility guidelines [51.5% (SD 18.2%)] (Table 1). There were no statistical significant differences between overall compliance in Cairo and Giza governorates except for the facility and infection prevention and control domains, for which compli- ance was significantly better in Giza governorate (P = 0.007). No significant differences were found between Cairo and Giza gover- norates regarding the sub-items of the personnel guidelines domain (Table 2). The percentage of staff with a current Basic Life Support Certificate ranged from only 0% to 14.3%, with no sta- tistical significant difference between Cairo and Giza governorates. The mean percentage of families with 1 physician for 8 patients/session were similar in Cairo and Giza (57.1% and 55.6% Table 1 Comparison between Cairo and Giza governorates regarding percentage compliance with the 5 principal domains of the haemodialysis guidelines Principal domains All hospitals (n = 16) Cairo (n = 7) Giza (n = 9) t-test P-value Mean (SD) Mean (SD) Mean (SD) Personnel 58.8 (12.4) 56.6 (14.9) 60.5 (10.6) 0.61 0.55 Patient care practice 68.5 (16.0) 57.1 (15.4) 77.4 (10.1) 0.24 0.82 Infection prevention and control 61.3 (15.4) 52.3 (18.9) 68.4 (7.1) 2.36 0.03 Facility 51.5 (18.2) 47.5 (22.9) 54.6 (14.2) 3.17 0.01 Documentation/ records 56.5 (7.1) 56.0 (6.8) 56.9 (7.7) 0.76 0.46 Total (overall) 59.3 (11.2) 53.9 (14.3) 63.6 (6.1) 1.83 0.89 SD = standard deviation. Table 2 Comparison between Cairo and Giza governorates regarding percentage compliance with some sub-items of the personnel guidelines Personnel guidelines Cairo (n = 7) Giza (n = 9) P-valuea No. % No. % Consultants have current certificate in BLS 1 14.3 1 11.1 0.99 Medical directors have current certificate in BLS 1 14.3 1 11.1 0.99 Nursing supervisors have current certificate in BLS 1 14.3 0 0.0 0.44 Staffing: physician for 8 patients/session 4 57.1 5 55.6 0.99 Staffing: nurse for 3 patients/session 0 0.0 7 77.8 0.003 aFisher exact test. BLS = basic life support. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 7 Discussion Compliance with the developed guidelines was evaluated using an ob- jective tool, which was a pre-designed checklist. However, before reaching conclusions based on the present re- sults, it is necessary to remember that compliance was assessed prior to the distribution of the developed practice guidelines. Thus, these results were baseline assessment for haemodialy- sis facilities rather than evaluation of adherence to the Egyptian practice guidelines. Another possible limita- tion related to our results was that the MOHP gave approval to assess the compliance with developed Egyptian haemodialysis practice guidelines in hospitals which had haemodialysis units. It is expected that these hospitals offer better health care services and that independent haemodialysis facilities adhere less to the international guide- lines, especially private facilities. The overall mean percentage of compliance with haemodialysis guide- lines was 59.3%, with no statistically significant difference between facilities in Cairo and Giza governorates. This means that our haemodialysis facilities already applied less than two-thirds of the newly developed Egyptian haemo- dialysis practice guidelines. We expect an improvement in the mean percent- age of compliance after we have distrib- uted the developed guidelines. It is necessary to know the main defective items in each governorate. The overall mean percentage compliance with personnel guidelines was 58.8%, and Cairo and Giza governorates had similar figures. Among the sub-items of the personnel domain, the propor- tions of consultants, medical directors and nursing supervisors with a current Basic Life Support Certificate was very poor, ranging from 0% to 14.3%, with no statistical significant difference between Cairo and Giza governorates. Compli- ance with other sub-items for personnel were better but still defective, i.e. < 75% of units. For example, just over half of facilities had 1 physician for 8 patients/ session (57.1% and 55.6% in Cairo and Giza governorates respectively). How- ever, the standard of 3 patients for every 1 working nurse in the haemodialysis facilities was met by 0% of facilities in Cairo and 77.8% in Giza. Understaffing can lead to higher rates of nosocomial infections, higher rates of medical staff infections, lower patient satisfaction and poor performance [3]. The shortage in trained nurses within the haemodialysis units is a frequent problem in developed countries as well. In the United States of America, a shortage in practising dialysis nurses was observed in many surveys, and it is predicted that with the Table 3 Comparison between Cairo and Giza governorates regarding percentage compliance with sub-items of the patient care guidelines Patient care guidelines All hospitals (n = 16) Cairo (n = 7) Giza (n = 9) t-test P-value Mean (SD) Mean (SD) Mean (SD) Writing orders for haemodialysis 45.9 (12.8) 37.9 (8.1) 52.2 (12.3) 2.67 0.018 Pre-dialysis preparation 38.1 (11.1) 44.2 (11.0) 33.3 (9.0) 2.10 0.049 Dialysis process 75.0 (9.9) 66.3 (5.0) 81.7 (6.9) 4.94 0.001 Post-dialysis 86.7 (16.1) 92.9 (6.7) 81.9 (19.9) 1.38 0.154 Between dialysis 36.9 (7.8) 39.0 (8.6) 35.3 (7.1) 0.92 0.375 SD = standard deviation. Table 4 Comparison between Cairo and Giza governorates regarding percentage compliance with sub-items of the infection prevention and control guidelines Infection prevention guidelines All hospitals (n = 16) Cairo (n = 7) Giza (n = 9) t-test P-value Mean (SD) Mean (SD) Mean (SD) Vaccination of patients 13.7 (29.7) 0.0 (0.0) 24.4 (36.8) –1.99 0.081 Occupational health and immunization 63.7 (19.0) 50.6 (21.0) 73.8 (9.2) 2.73 0.027 General infection prevention measures 55.6 (17.2) 50.1 (18.8) 59.8 (15.9) 1.12 0.280 Reprocessing and sterilization 53.3 (19.9) 44.5 (25.8) 60.1 (10.9) 1.64 0.122 Housekeeping and waste management 78.8 (16.3) 66.7 (16.9) 88.1 (7.5) 3.43 0.004 SD = standard deviation. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 8 increasing rates of end-stage renal dis- ease the shortage of nephrology nurses will be an increasing problem [4]. The mean percentage compliance with haemodialysis guidelines among all study hospitals for patient care prac- tice were 57.1% and 77.4% in Cairo and Giza governorates respectively. The patient care practice was better in Giza than in Cairo for writing orders for haemodialysis, predialysis prepa- ration and dialysis process. The sub- items writing orders for haemodialysis, predialysis preparation and between dialysis were very defective in both Cairo and Giza governorates, ranging from 33.3% to 44.2%. In general, there was deficiency in writing orders for pre- dialysis, dialysis and between dialysis preparations. Written procedures are mandatory for accreditation systems [5] and are key items for standardizing, defining duties, overcoming gaps in knowledge and maintaining consistent patient care [6]. In the present study, the mean percentage compliance for infection prevention and control guidelines was 61.3%, with significantly better compli- ance in Giza than in Cairo haemodialysis facilities. General infection prevention measures were deficient in Cairo and Giza governorates (50.1% and 59.8% respectively). Hand-washing between patients, after removal of gloves and after contact with any contaminated objects were not habitually practised by the studied health care workers. Similarly, in a study carried out in a hae- modialysis unit in Spain, hand-washing was done in 32% of cases after patient intervention and in 3% before patient intervention [7]. Poor adherence to standard precautions for hand-washing has been shown in other studies [8]. Housekeeping and waste manage- ment were better in Giza than in Cairo haemodialysis facilities. However the mean rates of compliance with house- keeping and waste management in both governorates were more or less satisfac- tory (88.1% and 66.7% respectively). This difference between Cairo and Giza could be explained by haemodialysis facilities in Giza governorate being rela- tively new compared with haemodialy- sis facilities in Cairo governorate. The mean percentage of compliance with haemodialysis guidelines for the facility was only 51.5% among all study hospitals. Compliance at Giza haemo- dialysis facilities remained significantly better than at Cairo facilities. Physical standards in Giza haemodialysis facili- ties were far better than physical stand- ards in Cairo haemodialysis facilities. The mean percentage of compliance with facility guidelines in Giza was 83.3% compared with 65.2% in Cairo. This could be attributed, as previously mentioned, to the relatively new build- ings in Giza governorate. The documentation/records item in the haemodialysis units was deficient, with a mean percentage compliance less than 57%. Although a bad docu- mentation/records structure may be encountered in many health facilities, it is one of the privileged zones of a quality system [9]. All standards for the docu- mentation/records item were poor. The records were incomplete in most of the cases. This may be due to the multiple data to be filled in the record together with the shortage of the nurses or person in charge to complete these records. One solution could be imple- menting a computer system in a busy dialysis unit to be used as the primary recording instrument [10]. Another possible solution is developing a simple record format for only the important data [11]. Table 5 Comparison between Cairo and Giza governorates regarding percentage compliance with sub-items of the facility guidelines Facility guidelines All hospitals (n = 16) Cairo (n = 7) Giza (n = 9) t-test P-value Mean (SD) Mean (SD) Mean (SD) Administration standards 39.6 (16.3) 33.1 (35.6) 43.7 (14.7) 0.20 0.842 Physical standards 75.2 (17.9) 65.2 (15.2) 83.3 (16.2) 2.27 0.039 Dialysis treatment area 50.0 (18.3) 46.4 (22.5) 52.8 (15.0) 0.68 0.509 SD = standard deviation. Table 6 Comparison between Cairo and Giza governorates regarding percentage compliance with sub-items of the documentation/records guidelines Records guidelines All hospitals (n = 16) Cairo (n = 7) Giza (n = 9) t-test P-value Mean (SD) Mean (SD) Mean (SD) Employee records 19.8 (29.0) 19.0 (37.8) 20.4 (22.5) 0.09 0.932 Medical records 63.6 (16.2) 58.3 (19.5) 67.7 (12.7) 1.17 0.263 SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 9 References 1. Quality assurance manual for primary health care services, 2nd ed. Cairo, Ministry of Health and Population, 1999. 2. Ahmed AM et al. Development of practice guidelines for hemodialysis in Egypt. Indian Journal of Nephrology, 2010, 20:193–202. 3. Bolton WK. Nephrology nurse practitioners in a collabora- tive care model. American Journal of Kidney Diseases, 1998, 31:786–793. 4. Bednar B, Steinman TI, Street J. Changing the operating struc- ture. Nephrology News and Issues, 2002, 16:25–28. 5. Report on the Expert Group Meeting on Hospital Accreditation. Cairo, World Health Organization Regional Office for the East- ern Mediterranean, 2003. 6. Zimmerman JF. The importance of standard operating proce- dure for investigators. SoCRA Source, November 1999 (http:// www.impactcg.com/docs/SOCRA_11.99_SOPs.pdf, accessed 12 October 2012). 7. Jimenez DA et al. Audit on the degrees of application of uni- versal precautions in a haemodialysis unit. Nephrology, Dialy- sis, Transplantation, 1999, 14:1001–1003. 8. Doebbeling BN, Stanley GL, Sheetz ZT. Comparative efficacy of alternative hand washing agents in reducing nosocomial infections in intensive care units. New England Journal of Medi- cine, 1992, 327:88–93. 9. Hermelin A et al. Quality management in the hospital environ- ment: ISO 9002 certification: our experience. Nephrologie, 2002, 23:7–10. 10. Ash SR et al. Evolution of the medical record format during two years' use of an open-format microcomputer charting system. Journal of Clinical Engineering, 1991, 16:337–348. 11. Hendrickson G, Kovner CT. Effects of computers on nursing resource use. Do computers save nurses time? Computers in Nursing, 1990, 8:16–22. In conclusion, overall compliance with the developed practice guidelines for haemodialysis in Egypt was defective. Also of note, compliance was not uniform across the haemodialysis facilities and this was especially prominent comparing Giza and Cairo governorates for some sub-items. This denotes an unsystematic approach in the Egyptian haemodialy- sis units and variability in adoption of evidence-based guidelines between fa- cilities affiliated to the MOHP. The formulated practice guidelines for haemodialysis should be distributed to all haemodialysis facilities in Egypt. Organizing workshops for haemodialy- sis consultants and directors of haemo- dialysis facilities to orient them with all items of the developed practice guide- lines is necessary. Attendants should be from both public and private sectors. Acknowledgements This project was funded by a grant from EMRO/WHO (RPC TSA 05/8). The development of the Egyptian Haemodialysis Practice Guidelines is the product of a collaborative project between the National Training Insti- tute (Egyptian Ministry of Health and Population) and the Eastern Mediter- ranean Regional Office (World Health Organization). We give sincere thanks to all the members of the research team for their willing cooperation in this national pro- ject: Development of checklist: Dr Amira Mohsen Gadallah, National Training Institute, Dr Ehab Shehad, Ain Shams University, Dr Mohamed Farouk Allam, National Training Institute/Ain Shams University and Professor Dr Mohsen Gadallah, Na- tional Training Institute/Ain Shams University. Field visits: Dr Ahmed Wasfy, National Training Institute, Dr Amira Mohsen Gadallah, National Training Institute, Dr Ehab Shehad, Ain Shams University, Dr Milad Ismail AboBakr, Directorate of Cairo Health Affairs, Professor Dr Mohsen Gadallah, Na- tional Training Institute/Ain Shams University, Dr Salah Abd El-Ghaffar, Directorate of Giza Health Affairs. Data management: Dr Amira Mohsen Gadallah, National Training Institute, Dr Mohamed Farouk Allam, National Training Institute/Ain Shams University, Professor Dr Mohsen Gadallah, National Training Institute/ Ain Shams University EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 10 Effect of prenatal counselling on compliance and outcomes of teenage pregnancy F.A. Mersal,1 O.M. Esmat 1 and G.M. Khalil 2 ABSTRACT To evaluate the effect of prenatal counselling on compliance for health promotion and pregnancy outcomes we conducted an experimental randomized control study on a sample of 86 teenage pregnant women attending the maternal and child health centre in Elkhosos village, Egypt. Data were collected pre-counselling, post-counselling and after delivery. At the post test, women in the study (counselling) group showed statistically significantly greater knowledge and compliance of health promotion (P < 0.001) than women in the control group. In the study group, 90.7% were full term at labour compared with 41.9% in the control group; 88.4% of the women in the study group had normal vaginal delivery compared with 76.7% of those in the control group. The health condition in 90.7% of the study group neonates was classified as good compared with only 46.5% in the control group. Only 9.3% of the study group babies had low birth weight compared with 32.6% of the control group babies (P = 0.008). 1Department of Community Health Nursing, Faculty of Nursing, Ain-Shams University, Cairo, Egypt (Correspondence to F.A. Mersal: khomarkh@ yahoo.com). 2Department of Public Health, Faculty of Medicine, Zagazig University, Zagazig, Egypt. Received: 11/07/11; accepted: 16/10/11 تاقهارلما لملح لئاصلحاو لاثتملاا لىع ةدلاولا لبق ةيعوتلا رثأ ليلخ دوممح ةداغ ،تمصع دممح ةميمأ ،لاسرم دحمأ ةيحتف ،ةحصلا زيزعت ئدابلم لاثتملاا لىع ةدلاولا لبق ةيعوتلا راثآ مييقت لجأ نم دهاوشلاب ةطوبضم ةا َّشَعُم ةيبيرتج ةسارد تاثحابلا ترجأ :ةـصلالخا نوثحابلا عجم دقو ،صرم في صوصلخا ةيرق في ملأاو لفطلا ةحصل ًازكرم نعجاري نمم ًلاماح ةقهارم 86 ةساردلا تلمشو .لملحا لئاصح لىعو فراعم ةدلاولا لبق ةيعوتلا ينقلت تيلالا ةساردلا ةعوممج نم لماولحا رهظأ ،ةيعوتلل لياتلا رابتخلاا فيو .ةدلاولا دعبو اهدعبو ةيعوتلا لبق تايطعلما ندلو نهنم %90.7 نإف ؛ةساردلا ةعوممج في امأ .)P<0.001( دهاوشلا ةعوممج ىدل امم ّلقأ ةحصلا زيزعت ئدابلم لاثتما عم ًايئاصحإ هب ُّدَتْعُي ردقب بركأ نم %76.7 عم ةنراقلماب ةيعيبط ةيلبهم ةدلاو نيهدل ناك ةساردلا ةعوممج نم %88.4 نأ ماك دهاوشلا ةعوممج نم %41.9 عم ةنراقلماب لملحا ماتم في ةعوممج ىدل طقف %46.5 لباقم في ةديج انهأ لىع ةساردلا ةعوممج في نادلولا نم %90.7 ىدل ةيحصلا ةلالحا نوثحابلا فنص دقو .دهاوشلا ةعوممج .)P = 0.008( دهاوشلا ةعوممج نم %32.6 لباقم في ًاضفخنم ةدلاولا دنع منهزو ناك ةساردلا ةعوممج في لافطلأا نم %9.3 نإ مث .دهاوشلا Effet des conseils prénatals sur l'observance de recommandations et sur l'issue des grossesses d'adolescentes RÉSUMÉ Afin d'évaluer l'effet des conseils prénatals sur l'observance des recommendations favorisant une bonne santé et sur l'issue des grossesses, nous avons mené une étude contrôlée, randomisée et expérimentale sur un échantillon de 86 adolescentes enceintes consultant au centre de santé maternelle et infantile du village d'Elkhosos (Égypte). Des données ont été recueillies avant et après l'offre de conseils, puis après la naissance. Lors de l'évaluation suivant l'offre de conseils prénatals, les femmes du groupe à l'étude (conseils) montraient des connaissances favorisant une meilleure santé statistiquement plus importantes et étaient plus nombreuses à les appliquer (P < 0,001) que les femmes du groupe témoin. Dans le groupe à l'étude, 90,7 % ont mené leur grossesse à terme contre 41,9 % dans le groupe témoin ; 88,4 % des femmes du groupe à l'étude ont accouché par voie basse contre 76,7 % dans le groupe témoin. L'état de santé des nouveau-nés du groupe à l'étude a été jugé satisfaisant pour 90,7 % d'entre eux contre seulement 46,5 % dans le groupe témoin. Seuls 9,3 % des enfants du groupe à l'étude présentaient un faible poids de naissance contre 32,6 % des enfants du groupe témoin (P = 0,008). طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 11 Introduction Teenage pregnancy is a worldwide phenomenon affecting both developed and developing countries [1]. About 15 million women/girls aged under 20 years give birth each year, roughly 11% of all births worldwide. The vast majority of these births, almost 95%, occur in developing countries [2]. In Egypt, by the age of 19 years, one-fifth of married women have already begun childbearing [3]. Adolescent pregnancy is one of the main issues in every health care system since early pregnancy can have harmful implications on girls’ physical, psycho- logical, economic and social status [4]. A girl who becomes pregnant while still a teenager faces a multitude of problems: she faces motherhood prematurely, usually before her own maturation has been completed [5]. Potentially severe medical complications place both the mother and infant at risk for illness and death. Teenage mothers often have poor antenatal care as they do not always attend their antenatal appointments; they tend to deliver more low birth- weight babies, premature babies and babies who die during the first year of their life [4]; infant mortality and mor- bidity rates are higher for infants born to teenage mothers than infants born to older women [6]. Education is a key aspect of nursing care provided during the prenatal pe- riod. Appropriate education may result in positive outcomes for the mother and her infant. [7,8]. To achieve healthy outcomes, pregnant women must be offered relevant health education and health promotion information through- out their pregnancy [9]. Pregnant ado- lescents who receive little or no prenatal care have higher rates of complications than those who receive adequate care [10]. Prenatal health education is an im- portant strategy for reducing prenatal health disparities for women who are members of a vulnerable population [11]. Nurses and health care provid- ers are in a position of being able to provide counsel and communication to the clients with a multitude of prob- lems. They are in a unique position to develop interventions that will impact and enhance patients’ ability to adhere to their prescribed regimens [12]. Re- ceiving adequate counselling during pregnancy has an impact on delivering healthy infants and decreases the risk of low birth weight [13]. Patterson et al. reported that women who engage in self-care behaviours, change their diets, rest, exercise, and consume no alcohol or medications seek safe passage for their infants and themselves [14]. The aim of this study was to evaluate the effect of prenatal counselling on teenage pregnancy knowledge, compli- ance with health promotion in teenage pregnancy and pregnancy outcomes. Methods We conducted this randomized con- trolled study at Elkhosos, a village in El-Kalubia Governorate, Egypt, with a population of 167 055. This village has 1 maternal and child health centre, affiliated to the Ministry of Health and Population, and this is where our study was carried out. For the postnatal assessment, how- ever, we visited the homes of the moth- ers and neonates to collect information on the birth and the outcomes of preg- nancy (43 mothers and their babies in the experimental group and 43 in the control group). Sampling All the pregnant teenage women who participated in this study were attending the antenatal clinic in the maternal and child health centre. Inclusion criteria were: under 20 years of age; primigravida, in second trimester; had not participated in any previous educational programme re- garding health promotion; and free from noncommunicable disease (heart disease, diabetes, hypertension). We invited a total of 103 women to participate in the study; 10 of these women were unwilling to participate for various reasons, including illness and lack of time. We divided the partici- pants into two groups, 47 in the study group and 46 in the control group. However, 4 were excluded from the study group and 3 from the controls owing to incomplete data. The total number of participants was, therefore, 86 teenage pregnant women, 43 in each. The women in the study group were given the education intervention and the women in the control group and had no intervention. Ethical considerations Oral verbal consent to take part in the study was obtained from the teenage pregnant women in our sample. The purpose of the study was explained to the women prior to their consent. They were assured about anonymity, confi- dentiality of the data and their right to withdraw from the study at any time with no penalty. Pilot study A pilot study was carried out on 5 preg- nant teenage women who were not included in the later study. The aim of the pilot study was to test clarity, simplicity and applicability of the study tools. Data collection was carried out via interviews conducted by the research- ers. We used a structured question- naire covering personal characteristics, knowledge regarding health promotion needs and health promotion activities; a compliance tool (designed by the researchers); and a physical assess- ment, which covered present health condition, postnatal health condition and physical assessment of the neonate (through home visit 3–6 days after de- livery). EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 12 Data were revised, coded, and tabu- lated and analysed using SPSS, version 16. P < 0.05 was considered statistically significant. Results The age of the women in the 2 groups was similar, ranging from 15 to 18 years. Mean age was 16.33 [standard deviation (SD) 1.26] years for the study group and 16.92 (SD 1.23) years for the control group (P = 0.71) (Table 1). Age at marriage ranged from 14 to 18 years. Mean age at marriage was 15.33 (SD 1.19) years in the study group and 15.55 (SD 1.31) years in the control group (P = 0.42). There was a statistically significant difference between the 2 groups in regard to education level: 69.8% of the study group and 37.2% of the control group had less than secondary education (P = 0.002). The recruitment visit was the first antenatal clinic visit for 76.6% of the study group and 79.1% of the control group (P = 0.79). Table 2 illustrates the general health condition of our pregnant teenage par- ticipants. The mean body mass index was 28.62 (SD = 5.04) kg/m2 in the study group and 30.64 (SD = 5.17) kg/ m2 in the control group (P = 0.07). Also, 18.6% of the study group and 14.0% of the control group had had a previous abortion (P = 0.05). The most common complaint in the study group was muscle cramps and in the control group anaemia (Table 2). Only muscle cramps, nausea and con- stipation differed significantly between the 2 groups. Table 3 illustrates the knowledge about health promotion aspects among teenage pregnant women in the study and control groups before and after the counselling programme. Before the intervention, around half of the participants in each group had satisfactory knowledge with regard to nutrition but less than 50% had Implementation phase Data collection was carried out over 3 days per week during the period September 2008–March 2009. The pre-intervention test was done for 86 pregnant teenagers over a period of 2 months. The implementation phase lasted for 5 months to assess the out- come of the pregnancy. The prenatal counselling programme was designed by the researchers and based on the information obtained from the pre-test study tools and findings from similar research; it was revised and modified according the related literature. The post test was conducted in the MCH on all participants 3 months after the pre-test. Pregnancy outcome was assessed in the home 3–6 days after delivery. According to the assessment phase and agreement that was obtained in the first session, counselling was imple- mented in the maternal and child health room; 3–4 sessions were conducted for each teenage pregnant woman. Table 1 Distribution of teenage pregnant women according to personal characteristics Characteristic Study group (n = 43) Control group (n = 43) P-value % % Education level Less than secondary 69.8 37.2 0.002 Secondary 30.2 62.8 0.80 Occupation Housewife 76.7 74.4 0.80 Student 23.3 25.6 0.04 Type of family Nuclear 79.1 74.4 0.79 Extended 20.9 25.6 Monthly income/basic needs Sufficient 51.2 30.2 0.048 Insufficient 48.8 69.8 No. of antenatal visits 1 76.6 79.1 0.79 2 23.3 20.9 Mean (SD) Mean (SD) Age (years) 16.33 (1.26) 16.92 (1.23) 0.71 Age at marriage (years) 15.33 (1.19) 15.55 (1.31) 0.42 SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 13 satisfactory knowledge regarding the other items, with exercise be- ing the lowest (Table 3). Before the programme, there was no statisti- cally significant difference for knowl- edge between the 2 groups. After the programme there was a great improvement in health promotion knowledge in the study group but not in the control group, with a statistically after the counselling programme, the study group had statistically significant- ly better compliance compared to the women in the control group (P < 0.001) except for compliance to medication use. Only 4 of the babies born to moth- ers in the study group were pre-term (< 38 weeks) while 18 of the mothers in the control group had pre-term babies significant difference between the 2 groups for all items (P < 0.001). Table 4 describes the adequacy of compliance with certain aspects of health promotion in the study and con- trol groups. At the pre-test, no statisti- cally significant differences were present between the study and control groups as regards compliance to certain aspects of health promotion. At the post-test, Table 2 Distribution of teenage pregnant women according to their health condition Health parameter Study group (n = 43) Control group (n = 43) P-value No % No % Albumin in urine 4 9.3 6 14 0.5 Previous abortion 8 18.6 6 14 0.5 Most common complaint Muscle cramps 30 69.8 18 41.9 0.009 Anaemia (Hb < 11 g/dL) 26 60.5 29 67.5 0.5 Nausea 22 51.2 11 25.6 0.01 Haemorrhoids 21 48.8 16 37.2 0.27 Heartburn 20 46.5 14 32.6 0.18 Headache 15 34.9 22 51.2 0.12 Shortness of breath 7 16.3 12 27.9 0.19 Constipation 4 9.3 14 32.6 0.008 Mean (SD) Mean (SD) BMI (kg/m2) 28.62 (5.04) 30.64 (5.17) 0.07 Haemoglobin 10.86 (1.06) 10.28 (1.11) 0.7 BMI = body mass index; SD = standard deviation. Table 3 Distribution of teenage pregnant women according to satisfactory knowledge regarding aspects of health promotion pre- and post-counselling Item Satisfactory knowledge (%) Pre-counselling Post-counselling Study group (n = 43) Control group (n = 43) P-value Study group (n = 43) Control group (n = 43) P-value Nutrition 51.2 46.5 0.66 93.0 44.2 < 0.001 Smoking 46.5 37.2 0.38 95.3 55.8 < 0.001 Clothing 46.5 32.6 0.18 93.0 37.2 < 0.001 Ante-natal follow-up 44.2 23.3 0.04 93.0 23.3 < 0.001 Rest & activity 44.2 39.5 0.66 95.3 39.5 < 0.001 Travelling 44.2 37.2 0.51 97.7 37.2 < 0.001 Medication use 41.9 20.9 0.03 93.0 32.6 < 0.001 Danger signs 37.2 39.5 0.8 100.0 37.2 < 0.001 Minor discomfort 37.2 39.5 0.8 83.7 39.5 < 0.001 Immunization 37.2 41.9 0.6 100.0 48.8 < 0.001 Hygiene 32.6 37.2 0.65 83.7 53.5 0.003 Exercise 23.3 18.6 0.26 95.3 30.2 < 0.001 EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 14 (P = 0.001) (Table 5). There was a sta- tistically significant difference between the study and control groups regarding occurrence of complications during labour (P = 0.003). There were also statistically signifi- cant differences in regard to the general health of the babies in the 2 groups: 30 of the 43 mothers in the study group had babies with good general health compared with only 20 of the 43 moth- ers in the control group (P < 0.001) (Table 5); 4 of the babies in this group were stillborn. Birth weight (low/normal), breast feeding (exclusive/not exclusive/artifi- cial) and the condition of the umbilicus (clean/septic/bloody) also showed sta- tistically significant differences between the 2 groups (Table 5). Discussion Although the legal age for marriage in Egypt at the time of our study was 16 years for females and 18 years for males, the mean age at marriage of the pregnant women in our study was 15.33 years for the study group and 15.55 years for the control group, indicating that under-age marriage is still a concern. A recent study on teenage mothers in India showed similar results. Although the legal age for marriage is 18 years for females and 21 years for males in India, early marriage is common [15]; by age 15 years, 26% of females are married. As is usual in Egyptian culture, all the teenage pregnant women in our study were married and received sup- port from their families. Also, fertility is highly valued: reproduction is encour- aged by religious and social beliefs and the wife has higher self-esteem after having children. More than 70% of our participants had made only 1 visit to the antenatal care clinic. Similarly, antenatal care ser- vices in Indonesia are still under utilized. Approximately 95% of pregnant women in Indonesia attended at least 1 antena- tal care visit, but only 66% had made the recommended 4 visits [16]. The prevalence of anaemia in the study and control groups was quite high, over 60%. In developing countries over 50% of pregnant women suffer from iron deficiency anaemia [17]. It is also prevalent among adolescent girls because the growth spurt and onset of menstruation increase iron require- ments. Iron supplementation during adolescence is one of the strategies advocated to improve iron balance in pregnancy [18]. Our findings indicated a deficit in knowledge and compliance with health promotion actions in the 2 groups. Af- ter the programme, an improvement was noted in the study group but not the control group. Education about the importance of good nutrition before and during pregnancy should be given to adolescents, including information about the obstetric complications re- sulting from poor nutritional status in pregnancy. Nutritional deficiencies in pregnancy have been found to con- tribute to poor maternal outcomes [19,20]. This is supported by Reron et al., who suggest that pregnant women do not make significant changes in their nutrition habits because they are insuffi- ciently informed about the importance of a healthy diet during pregnancy [21]. In a study of lifestyle practices of Jor- danian pregnant women, it was found that the physical activity behaviour, which measures the women’s ability to follow a regular exercise pattern, was ranked last among the health-promot- ing lifestyle behaviours [13]. Our par- ticipants also showed little knowledge of the benefits of exercise pre-counselling. In the study group however, after coun- selling, over 95% of the women demon- strated satisfactory knowledge. Our findings were in accordance with those of Maimbola, Ahmed and Ransjo-Arvidson, who stated that health promotion is an essential component Table 4 Distribution of teenage pregnant women according to pre- and post-counseling compliance regarding aspects of health promotion Parameter Pre (adequate compliance) Post (adequate compliance) Study Control P-value Study Control P-value % % % % Antenatal follow-up 14.0 20.9 0.3 95.3 16.3 < 0.001 Nutrition 20.9 16.3 0.57 90.7 16.3 < 0.001 Exercise 0.0 0.0 – 60.5 9.3 < 0.001 Hygiene 39.5 46.5 0.51 100.0 41.9 < 0.001 Rest & activity 48.8 32.6 0.12 74.4 44.2 0.004 Immunization 53.5 44.2 0.38 100.0 60.5 < 0.001 Smoking 23.3 16.3 0.41 100.0 16.3 < 0.001 Medication use 55.8 51.2 0.66 76.7 72.1 0.24 Travelling 32.6 37.2 0.65 100.0 44.2 < 0.001 Clothing 44.2 55.8 0.28 100.0 51.2 < 0.001 طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 15 Table 5 Distribution of teenage pregnant women regarding pregnancy outcomes according to their attendance to counselling programme Parameter Study group (n = 43) Control group (n = 43) P-value No. % No % Gestational age at labour 0.001 At term (38–42 weeks) 39 90.7 25 58.1 Pre-term (< 38 weeks) 4 9.3 18 41.9 Type of delivery 0.15Normal vaginal 38 88.4 33 76.7 Caesarean section 5 11.6 10 23.3 Complications during labour 5 11.6 17 39.5 0.003 Obstructed labour 2 4.7 8 18.6 0.04 Vaginal bleeding 2 4.7 5 11.6 0.43a Tears of perineum 1 2.3 4 9.3 0.35 Pregnancy outcome 0.006 Full-term baby 39 88.4 25 58.1 Pre-term baby 4 9.3 12 27.9 General condition of baby Good 39 90.7 20 46.5 < 0.001 Bad 4 9.3 19 44.2 < 0.001 Dead 0 0 4 9.3 0.12a Birth weight Low (< 2.5 kg) 4 9.3 14 32.6 0.008 Normal (2.5–3.5 kg) 39 90.7 29 67.4 Breastfeeding Exclusive 35 81.4 16 37.2 < 0.001 Not exclusive 6 14 23 53.5 < 0.001 Artificial 2 4.7 4 9.3 0.67a Umbilicus Septic 4 9.3 18 41.9 < 0.001 Clean 36 83.7 16 37.2 < 0.001 Blood 3 7 9 20.9 0.06 aYates corrected χ2. of antenatal care: it provides the op- portunity for the individual pregnant adolescent mother to discuss her health, pregnancy, labour and plans for child- bearing and child care [22]. Counsel- ling on health promotion and disease prevention and cure is a fundamental part of any medical consultation. It has a direct impact on patient health and an overall impact on the burden of disease in the community [23]. Our data confirm the findings of other investigators who indicated that antenatal care provides an opportu- nity to educate the pregnant woman about pregnancy and childbirth [24]. Antenatal education programmes are a very important component of antenatal care worldwide since they encourage women themselves contribute for a bet- ter pregnancy outcome and care of the neonate [25,26]. We found that pregnancy out- comes were better in the study group compared with the control group. This agreed with the findings of other studies which found rates of stillbirths to aver- age about 50% higher for adolescent mothers compared with mothers in their 20s [27]. Too-early childbearing also has a negative impact on the sur- vival of babies. A large American study found a 55% greater risk of neonatal death in babies of mothers aged 10–15 years, a 19% higher risk in babies of 16–17-year-olds, and a 6% higher risk in babies of 18–19-year-olds [28]. A study in Latin America found a 50% greater risk of neonatal death in babies of mothers aged under 16 years [29]. Large national surveys show neonatal death risk levels are typically 50%–100% higher in babies of adolescents com- pared with those of older women [30]. Studies have shown an independent EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 16 adverse effect of early pregnancy on newborn health conditions such as pre- term birth, low birth weight, small for gestational age, asphyxia and malforma- tions [2]. Flynn, Budd and Modelski concluded that pregnant adolescents are a very vulnerable population, expe- riencing disproportionately high rates of adverse birth outcomes [31]. In a review of 14 studies, Coren, Barlow and Stewart-Brown concluded that educa- tional interventions can have a positive impact on outcomes for this vulnerable group [32]. In agreement with our findings, Grady and Bloom found that a posi- tive, supportive prenatal health expe- rience may encourage and empower adolescents to care for themselves and their children [33]. Some research on teenage pregnancy has indicated that with good psychosocial support and appropriate and adequate prena- tal care, teenagers could have similar pregnancy outcome to that of older women [34,35]. In this study we have demonstrated that prenatal health education is an important and successful strategy for re- ducing health disparities for women who are members of a vulnerable population. This is supported in other research [11]. Prenatal health education should be an integral part of prenatal care as a means of improving the perinatal outcomes for women and their infants. References 1. Nash ES. Teenage pregnancy-need a child bear a child? South African Medical Journal, 1990, 77:147. 2. Position paper on mainstreaming adolescent pregnancy in efforts to make pregnancy safer. Geneva, World Health Organization, Making Pregnancy Safer, 2010. 3. Ibrahim SE, Ibrahim BL. Egypt’s population policy: the long march of state and civil society. In: Jain A, ed. Do population policies matter? Fertility and politics in Egypt, India, Kenya and Mexico. New York, Population Council, 1998. 4. Tsai YF, Wong TK. Strategies for resolving aboriginal adoles- cent pregnancy in eastern Taiwan. Journal of Advanced Nursing, 2003, 41(4):351–357. 5. Allender JA, Spradley BW. Community health nursing: promot- ing and protecting the public’s health, 6th ed. Philadelphia, JB Lippincott Co, 2005:654–655. 6. Department of Health. Saving lives: our healthier nation. Lon- don, The Stationery Office, 1999. 7. Nichols M, Roux G, Harris N. Primigravid and multigravid women: prenatal perspectives. Journal of Perinatal Education, 2007, 16(2):21–32. 8. Enriquez M et al. Pregnancy, poverty, and HIV. Journal of Nurse Practitioners, 2007, 3(10):687–93. 9. Risica PM, Phipps MG. Educational preferences in a prenatal clinic population. International Journal of Childbirth Education, 2006, 21(4):4–7. 10. Stanhope M, Lancaster J. Foundations of Nursing in the Com- munity, Community Oriented Practice. 3rd ed. Philadelphia, Mosby, 2008. 11. Vonderheid SC, Norr K F, Handler AS. Prenatal health promo- tion content and health behaviors. Western Journal of Nursing Research, 2007, 29(3):258–276. 12. Aminoff U, Kjellgren K. The Nurse Source in Hypertension Care. Journal of Advanced Nursing, 2002, 35(4):582. 13. Gharaibeh M, AL-Ma’aitah R, AL Jada N. Lifestyle practices of Jordanian pregnant women. International Nursing Review, 2005, 52:92–100. 14. Patterson ET, Freese MP, Goldenberg RL. Seeking safe passage; utilizing health care during pregnancy. Nursing Image, 1990, 22:27–31. 15. Mukhopadhyay P, Chaudhuri RN, Paul B. Hospital-based perinatal outcomes and complications in teenage preg- nancy in India. Journal of Health, Population & Nutrition, 2010, 28(5):494–500. 16. Indonesia Demographic and Health Survey 2070. Calverton, Maryland, Badan Pusat Statistik, National Family Planning Coordinating Board, Ministry of Health and ORC Macro, 2008. 17. Lynch SR. The potential impact of iron supplementation during adolescence on iron status in pregnancy. Journal of Nutrition, 2000, 130(2 Suppl.):448s–451s. 18. Kalanda BF, Verhoeff FH, Brabin BJ. Chronic malnutrition in pregnant adolescents in rural Malawi: an anthropometric study. Acta Obstetricia et Gynecologica Scandinavica, 2006, 85(1):33–39. 19. Demir S, Balci E, Günay O. Comparison of life quality of preg- nant adolescents with that of pregnant adults in Turkey. Upsala Journal of Medical Sciences, 2010, 115:275–281. 20. Reynolds HW, Wong EL, Tucker H. Adolescents’ use of mater- nal and child health services in developing countries. Interna- tional Family Planning Perspectives, 2006, 32(1):6. 21. Reron A et al. Nawyki zywieniowe kobiet ciezarnych [Nutrition habits in pregnant women]. Przeglad lekarski, 2003, 60(Suppl. 6):8–11. 22. Maimbola M, Ahmed Y, Ransjo-Arvidson AB. Safe mother - hood perspectives and social support for primigravidae women in Lusaka, Zambia. Social Science & Medicine, 2003, 58(11):34. 23. Ahsen F et al. Developing counseling skills through pre- recorded videos and role play: a pre- and post-intervention study in a Pakistani medical school, BMC Medical Education, 2010, 10:7. 24. Haggaz AA, Radi EA, Adam I. High maternal mortality in Darfur, Sudan. International Journal of Gynaecology & Obstetrics, 2007, 98:252–253. 25. Renkert S, Nutbeam D. Opportunities to improve maternal health literacy through antenatal education: an exploratory study. Health Promotion International, 2001, 16:381–388. 26. Turan JM, Sale L. Community base antenatal education in Is- tanbul, Turkey: effects on health behaviours. Health Policy and Planning, 2003, 18(4):391–398. 27. Position paper on mainstreaming adolescent pregnancy in efforts to make pregnancy safer. Geneva, World Health Organization, De- partment of Making Pregnancy Safer, 2010 (WHO/MPS/10.03). 28. Salihu HM et al. Childhood pregnancy (10–14 years old) and risk of stillbirth in singletons and twins. Journal of Pediatrics, 2006, 148(4):522–526. 29. Conde-Agudelo A, Belizan JM, Lammers C. Maternal-per- inatal morbidity and mortality associated with adolescent pregnancy in Latin America: Cross-sectional study. American Journal of Obstetrics & Gynecology, 2005, 192(2):342–349. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 17 Saving the lives of mothers and children in the Region Addressing the health of mothers and children is at the heart of the Millennium Development Goals (MDGs) and health and development index. It is the subject and focus of several United Nations and WHO resolutions adopted by all Member States. To reduce mortality among mothers and children, the World Health Organization (WHO), United Nations Children's Fund (UNICEF) and the United Nations Population Fund have jointly organized a high-level meeting "Saving the lives of mothers and children: accelerating progress towards achieving MDGs 4 and 5 in the Region". The meeting will take place in Dubai, United Arab Emirates, from 29 to 30 January 2013, under the patronage of Her Royal Highness Princess Haya Bint Al Hussein, wife of His Highness Sheikh Mohammed Bin Rashid Al Maktoum, Vice-President and Prime Minister of the United Arab Emirates and Ruler of Dubai. The high-level meeting will be in the form of a global forum featuring unique partnerships to address the increase in mother and child mortality rates in the Eastern Mediterranean Region. Further information about the work of WHO in the Region to improve the health of mothers and children can be found at: www.emro.who.int/health-topics/child-health-and-development/ and www.emro.who.int/entity/rhrn/ 30. Chen XK et al. Teenage pregnancy and adverse birth out- comes: a large population based retrospective cohort study. International Journal of Epidemiology, 2007, 36(2):368–373. 31. Flynn L, Budd M, Modelski J. Enhancing resource utilization among pregnant adolescents. Public Health Nursing, 2008, 25(2):140–148. 32. Coren E, Barlow J, Stewart-Brown S. The effectiveness of indi- vidual and group-based parenting programmes in improving outcomes for teenage mothers and their children: a systematic review. Journal of Adolescence, 2003, 26:79–103. 33. Grady M, Bloom K. Pregnancy outcomes of adolescents en- rolled in a centering pregnancy program. Journal of Midwifery & Women’s Health, 2004, 49(5):412. 34. Mahfouz AR et al. Teenage pregnancy: are teenagers a high risk group? European Journal of Obstetrics, Gynecology & Reproduc- tive Biology, 1995, 59:17–20. 35. Lao TT, Ho LF. The obstetric implications of teenage pregnan- cy. Human Reproduction, 1997, 12(10):2303–2305. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 18 Domestic violence against women in Kersa, Oromia region, eastern Ethiopia W. Shanko,1,2 M. Wolday,2 N. Assefa 2 and A.R. Aro 3 ABSTRACT Intimate partner violence is common in rural areas of Ethiopia. The aim of this study was to assess the knowledge and prevalence of domestic violence among women in Kersa district of Oromia region and identify the types, perpetuators and triggers for violence. A community-based cross-sectional interview-based survey was conducted in 2008 on 858 women of reproductive age. Only 39.7% of women reported that they recognized that violence against women was a problem in their area. Ever experience of violence by an intimate partner was reported by 166 women (19.6%) and 70.3% of the perpetuators were husbands. Ever experience of domestic violence among women was significantly related to Amhara ethnicity and age group 30–49 years. Only 33 (19.9%) women who ever experienced violence had reported it to the legal authorities. Women’s reasons for failing to report to the legal system were not wanting to expose the issue and not knowing where to go. 1Faculty of Health Sciences; 3Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark (Correspondence to W. Shanko: wondimus@yahoo.com). 2College of Health Sciences, Haramaya University, Harar, Ethiopia. Received: 20/01/11; accepted: 26/07/11 ايبويثإ قشر ،ايموروأ ةقطنم ،اسيرك في ءاسنلا دض ليزنلما فنعلا ورآ .ر .اجرأ ،ةفصأ اقين ،يادلاو وتسغنم ،وكناش ومدنو ءاسنلا ىدل هراشتنا لدعمو ليزـنلما فنعلا لوح فراعلما مييقت لىإ ةساردلا هذه فدتهو .ايبويثإ فايرأ في ميملحا نيرقلا دض فنعلا عيشي :ةـصلالخا ،تلاباقلما لىإ ًادنتسمو ًاضرعتسمو زَكَتْرُمـلا َّيعمتمج ًاحسم نوثحابلا ىرجأ دقو .هييرثمو هيفترقمو هطمانأ لىإ فرعتلا لىإو ،ايموروأ ةقطنمب اسيرك في ؛ةقطنلما هذه في ةلكشم ءاسنلا دض فنعلا نوبرتعي ننهأ نع نغلبأ ءاسنلا نم طقف %39.7 نأ اودجوو ؛2008 ماع باجنلإا نس في ةأرما 858 لمش تناكو .جاوزلأا اوناك فنعلا فيترقم نم %70.3 نأو ،اتهايح في ةدحاو ةرلم ولو ميملحا نيرقلا نم فنعلل اهضرعت نع )%19.6( ةأرما 166 تغلبأ ماك 49-30 ةيرمعلا ةعومجلمابو ،ةَرَهملأا قرع نم رادحنلااب ًايئاصحإ هب دَتْعُي رادقمبو قلعتب نتهايح في ةدحاو ةرلم ولو ءاسنلا ىدل فنعلا نم ةاناعلما بابسأ امأ .ةينوناقلا ةيلحلما تاطلسلل فنعلل نهضرعت نع نغلبأ دق )%19.9( نتهايح في ةدحاو ةرلم ولو فنعلل نضرعت نمم ةأرما 33 ناكو .ًاماع .غلابلإل باهذلا نهيلع ينعتي نيأ لىإ نفرعي لا ننهأ وأ ،ةلكشلما حْضَف ندري لا ننهأ لىإ دوعتف ةينوناقلا تاطلسلل غلابلإا نع ءاسنلا فلتخ Violence domestique contre les femmes à Kersa dans la région d'Oromia (Éthiopie orientale) RÉSUMÉ La violence exercée par le partenaire intime est courante dans les zones rurales d'Éthiopie. La présente étude visait à évaluer la connaissance et la prévalence de la violence domestique chez les femmes dans le district de Kersa de la région d'Oromia et à identifier les différents types de violence, les auteurs et les facteurs déclencheurs de cette violence. Une enquête transversale reposant sur des entretiens dans la communauté a été menée en 2008 auprès de 858 femmes en âge de procréer. Seules 39,7 % des femmes interrogées reconnaissaient que la violence contre les femmes était un problème dans leur district. Au total, 166 femmes (19,6 %) ont rapporté avoir déjà été victimes de violence par un partenaire intime et 70,3 % des auteurs étaient leur époux. L'expérience de la violence domestique chez les femmes était fortement associée à l'ethnie Amhara et au groupe d'âge des 30–49 ans. Seules 33 femmes (19,9 %) ayant déjà subi des violences avaient informé les autorités légales. Les femmes qui n’avaient pas informé les autorités donnaient comme raison le fait qu'elles ne souhaitaient pas révéler le problème ou ne savaient pas à qui s’adresser. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 19 Introduction In recent years, the international com- munity has increasingly recognized violence against women as a significant human rights and global health issue. Studies have found that it occurs in all geographic regions, countries, cultures and socioeconomic classes, with some surveys showing that women in devel- oping countries experience higher rates of violence than those in developed countries [1]. According to a World Health Or- ganization (WHO) multi-country sur- vey in 2000–03, 30%–54% of women in Bangladesh and provinces of Ethiopia, Peru and Tanzania reported that they had experienced violence and 55%– 95% of physically abused women had never sought help from formal agencies. Instead, women reached out to family and friends. Women generally seek help only when violence is severe. According to WHO the highest current rate of vio- lence was in rural Ethiopia where 54% of women have experienced intimate part- ner violence [2]. Literate rural women who were married to an illiterate spouse had the highest odds of physical harm, and community-based studies in Ethio- pia indicated that 50%–60% of women experienced domestic violence in their lifetime [3,4]. The aim of the current study was to assess the prevalence of domestic violence against women in Kersa dis- trict of Oromia region, Ethiopia, and the types, perpetuators and triggers of violence. Few studies have been conducted so far in rural areas of the country and no previous studies were conducted in our study site. It was hoped that the study would help to identify the scope of the problem and act as a stimulus for further research in rural areas, where access to health information and dissemination are the basic challenges due to the scarcity of health care professionals and com- munity workers. Methods Study design and setting A community-based, cross-sectional study design was used. An interviewer- administered questionnaire was used in a house-to-house survey conducted in Kersa district, East Hrarge, Oromia region on 858 women of reproductive age from January to February 2008. This study site was selected because it is part of the field research site of the Kersa Demographic Surveillance and Health Research Centre and various projects are being undertaken on different health-related topics in Kersa district. Sample The study subjects were recruited from the source population in Kersa based on their age. The study was conducted in 12 rural and urban kebeles/localities using a sample proportion to the size of the households in each kebele. Study households were selected for home visits from each kebele by systematic random sampling from a random start- ing point. The subsequent households were selected based on the household interval in the kebele, which was deter- mined by dividing the total number of households by the required sample size. In each household one woman aged between 15–49 years was interviewed. If there were no eligible women in the selected household, the next household was visited. If more than one eligible female was found in the household, the woman with a husband was interviewed and if more than one married woman was found in the house, a lottery method was used to determine the woman to be interviewed. If the eligible member of the household was not present during the visit, a re-visit was arranged. If the re-visit was not possible the next house- hold was selected. Data collection A questionnaire was specially designed for the study by the research team. The validity and reliability was checked for appropriateness and consistency. The questionnaire addressed the women’s knowledge about domestic violence, their ever experience of violence, the common types of violence that they considered severe, the main perpetu- ators as well as trigger factors for vio- lence and reporting to the legal system when a violent incident occurs. The questionnaire was developed first in English and was then translated back into the local language (Amharic) for use in the survey. It was structured in a way that the respondents could respond easily. All the questions were closed-ended, and the woman selected 1 or more responses from the list of 4–5 choices. The questionnaire was then translated from English back into the local language (Amharic) and the translated Amharic version was ad- ministered. To complete the questionnaire data collectors made house-to-house visits and conducted interviews with the selected women in their homes. Care was taken that the women could respond freely. The women were given assurances about the confidentiality of their responses and that no informa- tion would be shared with third parties except the investigators and verbal informed consent was obtained be- fore administering the questionnaire. Data collectors were recruited who had completed high school education and were trained using demonstra- tions and role play and in a pilot test. The collected data were checked on a daily basis for completeness and ap- propriateness. Ethical clearance for the study was obtained through the ethical committee of Haramaya University. An approval was secured from the local authorities and verbal consent was obtained from participants before the interview. To preserve confidentiality the respond- ents were not identified on the ques- tionnaires. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 20 house had a higher risk of experiencing violence than those who had no radio for information (P < 0.001). While more women living in rural areas had ever experience of violence than those in urban areas the association was not statistically significant (Table 3). All the 166 women (100.0%) who ever experienced violence had encountered verbal insults, 85.5% had been physically harmed and 34.3% had suffered gestures and non-verbal insults. Given a list of triggers for violence in a closed ended question women who ever experienced violence indicated that the main triggers for violence from their husband or intimate partner were when they failed to finish assignments given to Data analysis The collected data were analysed using SPSS, version 16.0. Proportions, chi- squared test and odds ratios and 95% confidence intervals (CI) were used to describe the data and P < 0.05 was considered statistically significant. Results Demographic characteristics The study was conducted on 858 female participants. Table 1 shows their demographic characteristics. The majority of the study participants were Muslims, illiterate and married (95.2%, 84.3% and 89.4% respectively). A total of 849 women agreed to be interviewed concerning violence and related issues. Women’s awareness of intimate partner violence in their community Only 337 of the 849 women (39.7%) recognized that violence against women was an issue in the area. These women were asked about their perceptions of how violence against women was expressed, regardless of their personal experience. To 83.4% of these women it meant physical harm and to 65.3% it included verbal insults (Table 2). When asked about the most common forms of violence against women being practised in their community 55.2% reported that physical harm/beating was the most common form, followed by verbal in- sults (30.9%). Women’s experiences of intimate partner violence Of the respondents, 166/849 (19.6%) had experienced violence from an intimate partner/close relative; the majority (70.3%) of the perpetuators were husbands and 27.2% were other relatives. Violence was statistically as- sociated with being of Amhara ethnicity (P = 0.031) and Muslim religion (P = 0.019) and age group 30–49 years (P = 0.05). Women who had a radio in the Table 1 Sociodemographic characteristics of the study sample of women (n = 858) Variable No.a % Age (years) 15–19 39 4.8 20–24 113 14.0 25–29 153 19.0 30–34 154 19.1 35–39 131 16.3 40–44 100 12.4 45–49 35 4.3 50+ 80 9.9 Religion Muslim 811 95.2 Orthodox Christian 34 4.0 Protestant Christian 7 0.8 Educational level Cannot read/write 723 84.3 Read and write 52 6.1 Primary (grade 1–8) 49 5.7 Secondary (grade 9–12) 22 2.6 Tertiary (grade 12+) 12 1.4 Marital status Single 31 3.6 Married 761 88.7 Divorced 10 1.2 Widowed 49 5.7 Occupation Housewife 800 94.6 Government/NGO 7 0.8 Student 2 0.2 Street trader 15 1.8 Farmer 19 2.2 Other 3 0.4 Ethnicity Oromo 821 95.7 Amhara 36 4.2 Gurage 1 0.1 aData were missing in some categories. NGO = nongovernmental organization. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 21 them and when they went out to work without the husbands’ or partners’ knowledge (Table 4). Respondents were also asked about the reporting of incidents. Only 33 of these women (19.9%) had reported their case to the legal authorities. Women’s reasons for not reporting violence were not wanting to expose the issue (68.7%) and not knowing where to go with the problem (22.9%) (Table 4). Discussion Violence against women undermines women’s right to dignity and degrades their self-esteem. It also reduces the productivity of women. In this study in a rural area with a low literacy rate in eastern Ethiopia only two-fifths of participants (39.7%) reported that they recognized the existence of violence against women in the area. Those women willing to explain the forms of violence mentioned physical harm such as beating as the most common, fol- lowed by verbal violence and physical and verbal together. Only one-fifth of the women inter- viewed (19.6%) reported ever experi- encing intimate partner/close relative violence. Yet it is known that domestic violence is a common practice in Ethiopia, especially in rural settings. In rural Ethiopia a study conducted in the year 2005 revealed a higher preva- lence of domestic violence in the com- munity (54%) [2]. In another study in north-west Ethiopia the lifetime prevalence of all forms of domestic violence was 50.8% [4]. Our figure for the prevalence of ever experience of violence is also much lower than the recent study conducted in 2010 in another part of the country in which 32% of the women had experienced physical violence during the previ- ous 12 months [3]. These differences may be due to variations in cultural Table 2 Women’s perceptions of types of violence ever experienced and the most common forms of violence against women in Kersa district (n = 337) Type of violence Ever experienceda Most commonly experienced No. % No. % Physical harm 281 83.4 186 55.2 Verbal threats 220 65.3 104 30.9 Physical and verbal combined 152 45.1 23 7.0 Sexual harassment/violence 140 41.5 10 3.0 Gestures and non-verbal threats 124 36.8 7 2.1 Other 5 1.5 aSeveral forms of violence could be reported. Table 3 Women’s ever experience of violence by sociodemographic variables Variable Total Ever experience of violence P-valuea Yes No No. % No. % Ethnicity 0.031 Oromo 810 164 20.2 646 79.8 Amhara 38 2 5.3 36 94.7 Religion 0.019 Muslim 797 161 20.2 636 79.8 Christian 45 5 11.1 40 88.9 Age (years) < 20 82 8 9.8 74 90.2 0.05 20–29 219 49 22.4 170 77.6 30–39 284 71 25.0 213 75.0 40–49 130 23 17.7 107 82.3 50+ 80 15 18.8 65 81.3 Residence 0.69 Urban 103 16 15.5 87 84.5 Rural 754 150 19.9 595 78.9 Radio ownership 0.001 Yes 424 107 25.2 317 74.8 No 409 59 14.4 350 85.6 aChi-sqaured test EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 22 norms, illiteracy and fear of disclosing cases in different areas. Local policies, including the local women’s affairs office, might also vary in the extent to which they promote women’s rights and how they handle and treat victims, so that women may be prevented from reporting if they are not getting ad- equate information. The majority of the perpetuators of violence in our study (70.3%) were husbands, which is in line with other studies [3,5]. The low prevalence of violence in the study location might be associated with male dominance and sociocultural norms that seek to hide family matters or that view do- mestic violence as normal practice. This is supported by data from Egypt, in 2005 which show that 95% of women believed that it was acceptable to be beaten by a husband or intimate partner [6]. In this study, verbal threats (100.0%) and physical assault (85.5%) were the leading forms of violence against women. Findings in a study conducted in Brazilian towns and in rural Ethiopia have shown that physi- cal and psychological violence can cause psychiatric problems (such as depression) and trauma [2,7,8]. Psy- chological violence was not addressed in this study. In the previous study in north-west Ethiopia, in which the life- time prevalence of domestic violence was higher than ours, the prevalence of physical violence was only 32.2% [4]. This is very low compared with our study. This might be due to victims’ fear of exposing the issue and reporting incidents. According to the women the most common triggers for violence were when they were blamed by their hus- band/partner for failing to complete their duties (100.0%), of going out- side the home without his knowledge (100.0%) or neglecting to take care of their children (94.6%), although 28.9% of women reported that violence oc- curred when the perpetrator thought he was not being fed properly. These justifications for violence clearly reflect the views of husbands in this area as being the leaders of the household who do not allow their wives to do any- thing without their consent. In Peru the main reason for intimate partner violence was reported to be drinking alcohol. The prevalence of domestic violence was 76.8% for partners who were drinking alcohol and 25.0% for partners who were not drinking [9]. In similar studies, living in a rural area in a violent family as well as alcohol- ism have been found to be triggering factors for intimate partner violence in Ethiopia [4]. In Kersa, alcohol is rarely consumed, which might be related to religion, as 95.2% of respondents were Muslims. In Egypt a low educational level of the partner was associated with wife beating and the prevalence was reduced when both partners had sec- ondary or higher education [10]. In our study the skewed distribution of educational level, with most women being illiterate (84.3%), did not allow us to study the association between education and ever experience of vio- lence in our study area. Seeking help and support from the legal system after the occurrence of violence was not actively used as a solu- tion by women in this study, as barely 20% of women had reported violence to the legal authorities. Women who did not report violence said that they did not have knowledge about where to go or they did not want to expose the incident. In similar studies in Peru, Tan- zania and Ethiopia between 55% and 95% of physically abused women had Table 4 Women’s’ experiences of type of violence, their views of triggers to violence and the reasons for not reporting the incidents to the legal authorities (n = 166) Variable No. % Type of violence ever experienced Verbal threats 166 100.0 Physical harm 142 85.5 Both physical and verbal 59 35.5 Gestures and non-verbal threats 57 34.3 Sexual harassment 25 15.1 Other type 4 2.4 Triggers for violence Went out of home without his knowledge 166 100.0 Failed to finish duties he gave me 166 100.0 Accused of neglecting care of children 157 94.6 Accused of not feeding him properly 104 62.7 Raised the issue of divorce 78 47.0 Sexual incompatibility 67 40.4 Suspected of being unfaithful 51 30.7 Raised the issue of family panning 48 28.9 Other reason 18 10.8 Reasons for not reporting violence to legal authorities Fear of exposing the issue 114 68.7 Fear of additional violence 90 54.2 Didn’t know where to go 38 22.9 Fear of divorce 36 21.7 Cultural tradition to accept it 30 18.1 Other reason 96 57.8 طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 23 References 1. Blanchfield L et al. International violence against women: US response and policy issues. CRS report for Congress. Washington DC, United States Foreign Affairs, Defense, and Trade Divi- sions, 2008 (RL34438). 2. WHO Multi-country study on women’s health and domestic violence against women. Geneva, World Health Organization, 2005. 3. Deyess N et al. Violence against women in relation to literacy and area of residence in Ethiopia. Global Health Action, 2010, 3, doi: 10.3402. 4. Yigzaw T, Yibrie A, Kebede Y. Domestic violence around Gondar, Northwestern Ethiopia. Ethiopian Journal of Health Development, 2004, 18(3):133–139. 5. Diop-Sidibé N, Campbell JC, Becker S. Domestic violence against women in Egypt: wife beating and health outcomes. Social Science and Medicine, 2006, 62:1260–1277. 6. State of world population 2005. The Promise of Equality: gender equity, reproductive health and the millennium development goals. Geneva, United Nations Population Fund, 2005. 7. D’Oliveira AF et al. [Factors associated with intimate partner violence against Brazilian women.] Fatores associados a vio- lencia por parceiro intimo em mulheres brasileiras. Revista de Saude Publica, 2009, 43(2):299–311. 8. Deyessa N et al. Intimate partner violence and depression among women in rural Ethiopia; a cross-sectional study. Clini- cal Practice and Epidemiology in Mental Health, 2009, 5:8. 9. Morrison A, Orlando MB, Pizzolitto G. The impact of intimate partner violence against women in Peru: estimates using match- ing techniques. Washington DC, World Bank, 2007. 10. Akmatov MK et al. Factors associated with wife beating in Egypt: analysis of two surveys (1995 and 2005), BMC Women's Health, 2008, 8:15. 11. Berhane Y. Ending domestic violence against women in Ethiopia, Ethiopian Journal of Health Development, 2004, 18(3):131–132. never sought help from formal agencies [2,6]. According to the WHO 2000–03 report on violence against women, in- cidents were often not reported to the authorities, even in cases where women had suffered from major complications such as bleeding and abortion from physical violence or even attempted suicide [2]. Some legal provisions are in place in Ethiopia to protect women. However, women need to be encour- aged and facilitated to report violent incidents to the legal system [11]. Conclusions Only one-fifth of the women in this survey reported ever experience of do- mestic violence, most commonly verbal insults and physical violence from their husband when they were blamed for leaving the house without permission or neglecting their duties. Women who experienced violence kept it to them- selves, and the great majority did not appeal to the courts. All the concerned bodies should work together with the local and regional women’s affairs of- fices in Ethiopia to protect women against future harm. Acknowledgements To Haramaya University that made possible the establishment of Kersa De- mographic Surveillance and Health Re- search Centre. To the people of Kersa district, authorities in the region and data collectors for their cooperation. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 24 Looking beyond legality: understanding the context of female sex workers in greater Cairo, Egypt I.A. Kabbash,1 I. Abdul-Rahman 2 and Y.A. Shehata 3 ABSTRACT Data on demographic, social and behavioural characteristics of female sex workers in greater Cairo are very scarce. A cross-sectional study was conducted with 431 randomly selected sex workers after mapping of sites where they gather. Data collection was performed by direct interviewing using a questionnaire sheet covering sociodemographic data and sexual history with paying and non-paying partners. More than one half of participants (52.7%) were aged < 30 years. Only 39.3% were exclusively working as sex workers while the rest had other jobs beside sex work. Almost 70% were responsible for dependants. The age of first selling sex was < 15 years for 4.7% of the women and 15–25 years for 58.7%. Unwanted pregnancies were experienced by 36.2% and 34.8% had had an abortion. Many participants had ever been arrested by the police (71.2%). The study has provided some useful background data for further studies in this very sensitive area of research. 1Department of Public Health and Community Medicine, Faculty of Medicine, University of Tanta, Tanta, Egypt (Correspondence to I.A. Kabbash: iakabbash@yahoo.com, kabbash-ia@maktoob.com). 2National AIDS Control Programme, Ministry of Health and Population, Cairo, Egypt. 3Department of Public Health and Community Medicine, Faculty of Medicine, University of Menoufiya, Menoufiya, Egypt. Received: 03/03/11; accepted: 14/08/11 صرم ،ىبركلا ةرهاقلا في اياغبلاب طيحلما قايسلا مهف :ةينوناقلا دودلحا ءارو ثحبلا ةتاحش اطع سراي ،نحمرلا دبع دحمأ بايهإ ،شابك ليع ميهاربإ ةسارد نوثحابلا ىرجأ دقو .ًادج ةحيحش ىبركلا ةرهاقلا في اياغبلل ةيكولسلاو ةيعماتجلااو ةيفارغوميدلا تماسلا لوح تايطعلما برَتعُت :ةـصلالخا للاخ نم تايطعلما نوثحابلا عجمو .اهيف نعمجتي يتلا عقاولما لىع فرعتلا دعب ًايئاوشع ةساردلا في نلخدأ تيلالا اياغبلا نم 431 تلمش ةضرعتسم نوعفدي لا ءانرقو نوعفدي ءانرق عم سينلجا خيراتلاو ةيفارغوميدلاو ةيعماتجلاا تايطعلما يطغي يقرو نايبتسا مادختساب نهعم ةشرابلما تلاباقلما امأ ،ءاغبلا فاترحا لىع ًاصرتقم طقف نهنم %39.3 لمع ناكو .ًاماع 30 نع لقي رمعب )%52.7( ةساردلا في تاكراشلما فصن نم رثكأ ناكو .نله ءاغبلا في ءدبلا رمع ناكو .مهتشيعم في نهيلع نودمتعي صاخشأ نع تلاوؤسم نهنم %70 ناكو .ءاغبلا بناج لىإ ىرخلأا نلهماعأ نيهدلف نهتيقب ىناع ماك ،هب بوغرلما يرغ لملحا نم نهنم %36.2 ىناع دقو .%58.7 ىدل ًاماع 25و 15 ينب حواتري ناك ينح في ،نهنم %4.7 ىدل ًاماع 15 نم لقأ ةيلاتلا تاساردلل ةديفم ةيساسأ تايطعم ةساردلا مدقتو .)%71.2( ةطشرلا لبق نم نفقوأ نأ نهنم تايرثكلل قَبَس دق ناكو .ضاهجلإا نم %34.8 .ثوحبلا نم ةيساسلحا غلابلا لاجلما اذه في اله Par delà la légalité : comprendre le contexte des professionnelles du sexe dans le Grand Caire (Égypte) RÉSUMÉ Les données sur les caractéristiques démographiques, sociales et comportementales des professionnelles du sexe dans le Grand Caire sont très rares. Une étude transversale a été menée auprès de 431 professionnelles du sexe sélectionnées aléatoirement après avoir cartographié leurs lieux de rassemblement. Le recueil des données a été réalisé par entretien direct à l'aide d'un questionnaire couvrant les données sociodémographiques et les antécédents sexuels avec des partenaires payants ou non. Plus de la moitié des participantes (52,7 %) avait moins de 30 ans. Seules 39,3 % exerçaient exclusivement cette activité professionnelle alors que les autres avaient un autre emploi en plus de leur activité de professionnelle du sexe. Près de 70 % avaient des personnes à charge. L'âge de la première vente de services sexuelles était inférieur à 15 ans pour 4,7 % des femmes et se situait entre 15 à 25 ans pour 58,7 %. Au total, 36,2 % avaient eu une grossesse non désirée et 34,8 % avaient subi un avortement. Les participantes étaient nombreuses à avoir été arrêtées par la police (71,2 %). L'étude a fourni des données contextuelles utiles pour la réalisation d'autres études approfondies dans ce domaine de recherche très sensible. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 25 Introduction Female sex workers (FSW) represent an important public health issue [1–5]. They have long been considered as reservoirs for sexually transmitted in- fections (STIs) [2] and it has been documented that higher rates of HIV and other STIs exist among those involved with sex work than in most other populations [5]. Commercial sex is also associated with complex socio- economic problems such as social and moral deprivation, poverty, violence and drug misuse [6]. Although greater Cairo is home to nearly 20% of the Egyptian population [1], there are little data available on the demographic, social and behavioural characteristics of FSW. Studies car- ried outside Egypt have indicated that the rates of HIV infection are high- est among at-risk populations such as FSW, because of their high-risk behav- iours (having multiple partners with lit- tle or no protective measures) [7–10]. There are no reliable estimates of the number of sex workers in Egypt nor is there information on the types of sex work that women are mostly involved in. This study aimed to describe the characteristics of FSW in greater Cairo, Egypt, to provide important baseline information needed for programmes addressing harm reduction for HIV infection among this most at-risk population. Methods Study setting This cross-sectional study was conducted in greater Cairo which includes 3 governorates (Cairo, Giza and Qualyobia) and accommodates a population of nearly 14 million [1]. The target population was FSW. Dif- ferent categories of FSW were iden- tified by 3 focus group discussions which were conducted before starting fieldwork. Each focus group included 6–8 FSW recruited by the Al-Shehab project. Al-Shehab is a nongovern- mental organization (NGO) which had a long experience working with sex workers on different issues related to prevention of HIV infection and providing social and legal support in different regions of greater Cairo. From the focus groups and from the experience of fieldwork done by Al- Shehab we identified 6 categories of FSW and the main sites where they gather: street FSW; FSW in bars and nightclubs; dancers; FSW in brothels; FSW in coffeehouses; and FSW in hotels. Sample size and technique Based on a prevalence of HIV among sex workers of 0.3% and an expected error margin of 3%, the total sample size was estimated as less than 400. So we aimed to recruit between 400–500 women to ensure a high level of validity of the results. For each category of FSW a cat- egory of site was selected so as to locate FSW for interview (street, nightclub/ bar, hairdressing shop where dancers gather to prepare themselves before working, brothel and coffee shop). Sex workers at hotels were difficult to ac- cess as the researcher did not obtain approval from hotel management to conduct fieldwork there, so they were not included in the study. Data collec- tors were directed to randomly selected sites to collect data from all FSW avail- able at the interview time. The process was repeated and another group of sites were randomly chosen and visited until the desired sample size was obtained. For each category a suitable time for visiting the site was identified to ensure cooperation of the study subjects and avoid interfering with their work needs. A suitable place which offered comfort- able conditions and confidentiality was chosen by data collectors to conduct the interviews. A total of 431 women were interviewed. The rate of refusal to participate was 3%. Data collection methods and tools The study was conducted during the period from August 2009 to April 2010. Data collection was performed through interviews with study subjects by trained interviewers who were 6 ex-FSW who used to participate in Al-Shehab’s outreach programme for harm reduction for HIV infection among sex workers. A questionnaire sheet was used to collect data on the behaviours of FSW. This was adapted from a be- havioural surveillance survey ques- tionnaire published by Family Health International [11]. Modifications were made to adjust for the situation of sex work in Egypt, based on the experience of the research team and consultation with experts from Al- Shehab who had worked previously with this group. The questionnaire included questions covering the fol- lowing: background characteristics; marriage, family and work; sexual history (age of first time selling sex, duration of sex work and information about paid/unpaid sexual partners). A pilot study was conducted in order to test the questionnaire to ensure its suitability for data collection. Data collection was anonymous. Confidentiality was ensured during the whole study period where no data were linked to names or specific per- sons. No pressure of any kind was used for recruitment of the study subjects. Witnessed verbal consent was taken before the interview. The study objec- tives and content of the questionnaire were explained to the women recruited before starting data collection. The col- lected data were only used for research purposes according to the study objec- tives and for the benefit of the study subjects. Financial incentives were given to the recruited FSW for par- ticipating in the study to compensate for the time lost during the interview. This incentive helped to minimize the refusal rate. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 26 11.6% and 10.7% respectively (Table 2). Among the studied sex workers, 71.9% had been involved in sex work for a duration ranging from 1–10 years with a mean of 6.3 (SD 6.4) years, median 4 years (Table 2). Only 16.7% had previous experience of working outside greater Cairo. The mean age at which sex was first practised in exchange of money or some other benefits was 22.3 (SD 6.7) years. The Statistical analysis The collected data were organized, tabulated and statistically analysed using SPSS, version 17. For each variable the number and percentage distributions of different options were calculated. As the study was mainly descriptive no further sta- tistical analysis was needed. Results Demographic characteristics of FSW The total number of the FSW studied was 431. Over half of them (52.7%) were aged < 30 years, with a mean age of 29.4 (SD 9.5) years and a median age of 27 years. Nearly a half of the FSW (49.2%) had completed primary education and 19.1% had completed university education with a mean of 10.2 (SD 3.2) years of education; 59.2% could only read and write. Two-thirds (65.9%) of the women had been married or were currently married. The age at first mar- riage was 15–25 years for 80.3%. The greatest proportion lived with their family (41.3%) or a husband (36.7%). As many as 70.8% had dependants and 57.6% were responsible for 3 or more dependants. Characteristics of sex work Women who depended solely on sex work for their living were 39.3% of respondents and 54.4% reported hav- ing other jobs. The most frequently reported jobs were hostess at a hotel or bar (14.8%), housemaid (10.4%) or dancer (7.7%) (Table 1). The majority of studied FSW were found to a have a monthly income from sex work of US$ < 200 (65.8%). The women’s preferred methods of contacting clients were by waiting on the street (27.8%), through an intermediate per- son (21.8%) and from bars (20.0%). Pimps and coffee shops were other places to find clients as reported by Table 1 Sociodemographic characteristics of the studied female sex workers (n = 431) Characteristic No. % Age (years) < 20 44 10.2 20– 183 42.5 30– 98 22.7 40– 51 11.8 50– 18 4.2 Unrecorded 37 8.6 Education Attended school 262 60.8 Duration of education (n = 262) Primary (1–9 years) 129 49.2 Secondary (10–12 years) 83 31.7 University 50 19.1 Marital status Ever married 283 65.7 Age at first marriage (years) (n = 283) < 15 27 9.5 15– 148 52.5 20– 79 27.8 25– 23 8.1 30+ 3 1.1 Unrecorded 3 1.1 Living with: Husband 158 36.7 Male sexual partner 20 4.6 Female sexual partner 2 0.5 A friend 25 5.8 Family 178 41.3 Alone 42 9.7 Unrecorded 6 1.0 Having other job as a source of income No 172 39.9 Yes 232 53.8 Unrecorded 27 6.3 No. of dependants 0 126 29.2 1–2 100 23.2 3–4 129 29.9 5+ 76 17.6 طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 27 age of first selling sex was < 15 years for 4.7% of the women and 15–25 years for 58.7%. The majority had ex- perienced arrest by the police (70.1%) and 12.9% of those arrested reported sexual abuse during arrest at police stations. More than one-third of partici- pants had ever experienced unwanted pregnancy (36.2%) and 34.8% had ever had an abortion (Table 3). Sexual practices The number of paying sexual partners in the previous month ranged between 2–5 as reported by 70.8%, while the number of non-paying partners was reported as only 1 by 51.5% and 0 by 42.5%. The total number of sexual partners (paying and non-paying) in the previous month was 1–5 for 63.8% of FSW. The number of sexual partners on the last day of work was 1 for 70.5% of the women (Table 3). Vaginal sex was the most frequent type of sexual practice with paying partners (61.0%), followed by kiss- ing and cuddling (53.6%) and oral sex (46.4%). Superficial sex only was practised by 16.2% of paying sexual partners. The types of sexual practice by non-paying partners was vaginal sex (65.1%), kissing and cuddling (52.9%) and oral sex (48.2%) (Table 4). Lesbian sex was practised by 3.0% of participants, some of them during menstruation. Discussion More than half of FSW were aged < 30 years. Most of them had attended school and could read and write but some had completed university edu- cation. These findings are in accord- ance with findings of most studies on FSW in the Middle East and North Africa [12–15]. On the other hand, most of the FSW had been married at a relatively young age. This contrasts with studies showing that in some cul- tures high dowry payments delay mar- riage for men and increase the median age of women at marriage. It has been Table 2 Distribution of studied female sex workers in relation to preferred methods of getting clients (n = 431) Method of getting clients First choice Second choice Third choice No. % No. % No. % Waiting on street 120 27.8 33 7.7 10 2.3 Through intermediate person 94 21.8 42 9.7 10 2.3 From bars 86 20.0 7 1.6 1 0.2 Through pimps 50 11.6 13 3.0 11 2.6 From coffee shops 46 10.7 50 11.6 17 3.9 From hotels 2 0.5 4 0.9 7 1.6 From discotheques 10 2.3 7 1.6 4 0.9 From Internet 1 0.2 1 0.2 1 0.2 Respondents could give more than response. Table 3 Distribution of studied female sex workers in relation to information about their sexual history and clients (n = 431) Variable No. % Age in years of first time selling sex < 10 2 0.5 10– 18 4.2 15– 127 29.5 20– 126 29.2 25– 51 11.8 30+ 56 13.0 Unrecorded 51 11.8 Duration of sex work in years < 1 16 3.7 1– 216 50.1 5– 94 21.8 10– 49 11.4 15– 24 5.6 20+ 27 6.3 Unrecorded 5 1.2 Previous sex work outside greater Cairo 72 16.7 No. of paying sexual partners last month 0 42 9.7 1– 149 34.6 3– 156 36.2 5– 70 16.2 10+ 14 3.3 EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 28 argued that this trend encourages high rates of prostitution [16]. The same findings apply in other parts of the world where rapid increases in educa- tion have accounted for increases in the median age at marriage, with a subsequent increase in the demand for commercial sex [17,18]. This difference in age of marriage in this study com- pared to other studies elsewhere might be attributed to religious and cultural differences between communities. FSW in Egypt behave as those in other countries in the region [14] in having other jobs rather than working openly as sex workers. Having a job facilitates them leaving the home and getting in contact with clients. These covering jobs included dancer, waitress, receptionist or housekeeper. Those who depended solely on sex work for their living represented only 36.6% of the sample and a majority were responsible for dependants. These findings might be due to the low income of most of FSW in contrast to their male clients, as when men’s income rises, their ability to pay for commercial sex will rise [19]. The age at which sex was practised in exchange of money or some other benefits was concomitant with the age of marriage. It was observed in this study that majority of studied FSW were mar- ried below the legal age of marriage in Egypt which is 18 years. This early start renders them at greater risk for HIV infection [20]. Unwanted pregnancy was reported by 36.2% of participants, with subsequent experience of abortion for 34.8% of participants. Other studies in Nigeria and the Islamic Republic of Iran have reported similar findings [21,22]. This might be explained by the subservient position of FSW with little control over contraceptive methods, especially condom use, and the sub- sequent risks of unwanted pregnancy and abortion. This observed low use of condom and experience of unwanted pregnancy is a proxy for the exposure to unsafe sexual relations which may carry the risk for HIV infection. A study in the Nile delta among males aged 15–49 years showed a low use of condoms, with only 23.9% ever using condoms, mainly for contraception; only a quarter reported knowing how to use condoms properly [23]. Table 4 Distribution of female sex workers by sexual practices by paying and non- paying clients Sexual practice Sexual practice preference Paying partners (n = 431) Non-paying partners (n = 255) No. % No. % Vaginal 263 61.0 166 65.1 Anal 38 8.8 21 8.2 Oral 200 46.4 123 48.2 Superficial 70 16.2 30 11.8 Kissing & cuddling 231 53.6 135 52.9 Group sex 2 0.5 1 0.4 Respondents could give more than response. Table 3 Distribution of studied female sex workers in relation to information about their sexual history and clients (n = 431) (concluded) Variable No. % No. of non-paying sexual partners last month 0 183 42.5 1 222 51.5 2 20 4.6 3–5 6 1.4 No. of total sexual partners last month 0 21 4.9 1– 116 26.9 3– 172 39.9 5– 107 24.8 10+ 15 3.5 No. of sexual partners last day practising sex 1 304 70.5 2 81 18.8 3 28 6.5 4 4 0.9 Unrecorded 14 3.2 Monthly income from sex work (US$) < 100 126 29.2 100– 158 36.7 200– 90 20.9 500+ 45 10.5 Unrecorded 12 2.8 Practise lesbian sex 13 3.0 Practise lesbian sex during menstruation (n = 13) 5 1.2 Ever had unwanted pregnancy 156 36.2 Ever had an abortion 150 34.8 Ever been arrested by policea 302 70.1 a5 women did not answer. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 29 References 1. Rohaa SM, Hafez Y. Monitoring urbanization growth in Cairo city. Journal of Engineering and Applied Sciences, 2002, 49:667– 679. 2. Shahmanesh M, Wayal S. Targeting commercial sex-workers in Goa, India: time for a strategic rethink? Lancet, 2004, 364:1297–1299. 3. AIDS epidemic update. Geneva, Joint United Nations Pro- gramme on HIV/AIDS, 2009 (UNAIDS/09.36E/ JC1700E). 4. Report on the global AIDS epidemic. Geneva, Joint United Na- tions Programme on HIV/AIDS, 2004. 5. Chipfakacha V. Prevention of sexually transmitted diseases: the Shurugwi sex-workers project. South African Medical Jour- nal, 1993, 83:40–41. 6. Wolffers I, van Beelen N, Brussa L: Violence, repression and other health threats. Sex workers at risk. Research for Sex Work, 2001, 4:1–32. 7. Ward H et al. Prostitution and risk of HIV: female prostitutes in London. British Medical Journal, 1993, 307:356–358. 8. Plummer FA et al. The importance of core groups in the epi- demiology and control of HIV-1 infection. AIDS, 1991, 5(Suppl. 1):S169–S176. 9. Melbye M, Biggar RJ. Interactions between persons at risk for AIDS and the general population in Denmark. American Jour- nal of Epidemiology, 1992, 135:593–602. 10. Spina M et al. Human immunodeficiency virus seroprevalence and condom use among female sex workers in Italy. Sexually Transmitted Diseases, 1998, 25:451–454. 11. Amon J et al. Behavioral surveillance surveys. Guidelines for repeated behavioral surveys in populations at risk for HIV. Arling- ton, Virginia, Family Health International, 2000:210–230. 12. Abu-Raddad LJ et al. Epidemiology of HIV infection in the Middle East and North Africa. AIDS, 2010, 24(Suppl. 2):S5–S23. 13. Mahfoud Z et al. HIV/AIDS among female sex workers, inject- ing drug users and men who have sex with men in Lebanon: results of the first biobehavioral surveys. AIDS, 2010, 24(Suppl. 2):S45–S54. 14. Abdelrahim MS. HIV prevalence and risk behaviors of female sex workers in Khartoum, north Sudan. AIDS, 2010, 24(Suppl. 2):S55–S60. 15. Kriitmaa K et al. HIV prevalence and characteristics of sex work among female sex workers in Hargeisa, Somaliland, Somalia. AIDS, 2010, 24(Suppl. 2):S61–S67. 16. Caraël M, Glynn R. HIV, resurgent Infections and population change in Africa. Studies in Family Planning, 2010, 3:238–240. 17. Hirschman C. Premarital socioeconomic roles and the timing of family formation: a comparative study of five Asian societies. Demography, 1985, 22:35–59. 18. Brien MJ, Lillard LA. Education, marriage, and first conception in Malaysia. Journal of Human Resources, 1994, 29:1167–1204. 19. Rhodes T et al. Police violence and sexual risk among female and transvestite sex workers in Serbia: qualitative study. British Medical Journal, 2008, 337:a811. 20. Góngora-Biachi RA et al. Knowledge, behavior and seropreva- lence towards HIV infection among female sex workers in Yucatan, Mexico. Revista Biomédica, 2002, 13:257–263. 21. Onyenechere E. Female condom in HIV/AIDS prevention among female commercial sex workers in Nigeria: a geograph- ical perspective. Retrovirology, 2010, 7(Suppl. 1):118. 22. Ghahfarokhi et al. HIV/AIDS related knowledge and attitude among female sex workers in Tehran/Iran. Retrovirology, 2010, 7(Suppl. 1):130. 23. Kabbash IA et al. Condom use among males (15–49 years) in Lower Egypt: knowledge, attitudes and patterns of use: attitude and patterns of use. Eastern Mediterranean Heath Journal, 2007, 13:1405–1416. This was a descriptive study explor- ing a very sensitive area of research in Egypt and its main purpose was to generate background findings for further research. This study had some limitations concerning the population sampling frame and sample selection that may limit the generalizability of the findings. However, it is extremely diffi- culty to accurately determine the study population in research concerning sex workers and there is no consensus on the definition of sex work. The study also lacked a qualitative assessment of FSW and further qualitative research on this subject is needed in Egypt. Fur- ther research is also needed into the specific health-related aspects of FSW in Egypt and the risk factors for enter- ing sex work, which may include lower education, low income, early marriage and experience of sexual abuse. Acknowledgements This study received funding from the Global Fund for Prevention of AIDS, Tuberculosis and Malaria donated to the Ministry of Health and Population for conducting bio-behavioural stud- ies among most at-risk populations in Egypt. The authors express their thanks and appreciation to Dr Mervat El-Gueneidy, Professor of Neuropsy- chiatric Nursing, University of Alex- andria for her help. We thank all the women who participated in our study and those who helped by referring us to others, especially Al-Shehab, a non- governmental organization working in the same field. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 30 Dieting behaviours, obesity and predictors of dieting among female college students at Palestinian universities W.D. Bayyari,1 L.J. Henry 1 and C. Jones 1 ABSTRACT The purpose of this study was to explore dieting practices of female Palestinian college students. Participants (n = 410) were selected by cluster-sampling from 4 Palestinian universities. A regression model investigated dieting using: body mass index (BMI); body satisfaction; self-esteem; dress style; exercise; sociocultural factors; residence; strength of faith; perceived impact of weight on social interaction; and number of previous times dieting. Significant predictors of dieting were low body satisfaction, number of previous dieting times, perceived media pressure, regular exercising, BMI, and perceived impact of weight on social interaction. The model accounted for 45% of the variance in dieting. Body satisfaction was not significantly correlated with self-esteem or strength of faith, which indicates that “internalization of thinness” may be becoming evident among populations in certain developing countries, as in “Western” countries. 1Department of Health Science, Kinesiology, Recreation, and Dance, University of Arkansas, Fayetteville, Arkansas, United States of America (Correspondence to W.D. Bayyari: wafadiab22@hotmail.com). Received: 14/09/11; accepted: 16/10/11 ينطسلف في تايعمالجا تابلاطلا ىدل ةيئاذغلا مُظُنلا لوح تائبنلماو ةنادبلاو ةيئاذغلا مُظُنلا تايكولس زنوج سيش ،يرنه ينج ،يرايب بايد ءافو تابلاط 410 ةساردلا في كراش دقو .تاعمالجا في تاينيطسلفلا تابلاطلا ىدل ةيوذغتلا تاسرمالما لىع فرعتلا لىإ ةساردلا هذه تفده :ةـصلالخا ،مسلجا ةلتك بسنم مادختساب ةيذغتلل فيّوتح طمنل تاءاصقتسا اورجأ مث ،ةينيطسلف تاعماج عبرأ نم يدوقنعلا نايتعلااب نوثحابلا نهراتخا كَردلما رثلأاو ،ةديقعلا ةوقو ،نكسلاو ،ةيفاقثلاو ةيعماتجلاا لماوعلاو ،ةيضايرلا نيرماتلاو ،سبلالما ءايزأو ،تاذلا ريدقتو ،دسلجا نع ضىرلاو َضىرلا ضافخنا يه ،يئاذغ ماظن عابتلا ةمالها تائبنلما نأ نوثحابلا دجوو .يئاذغ ماظن عابتلا ةقباسلا تارلما ددعو ،يعماتجلاا لعافتلا لىع نزولل رثلأاو ،مسلجا ةلتك بسنمو ،ةضايرلل ةمظتنلما ةسرمالماو ،ملاعلإا لئاسو نم كَردلما طغضلاو يئاذغ ماظن عابتلا ةقباسلا تارلما ددعو ،دسلجا نع ٍوحن لىع ًاطبترم دسلجا نع َضىرلا نكي لمو .ةيئاذغلا مُُظنلا في توافتلا نم %45 نع ًلاوؤسم طمنلا اذه دَعُيو .يعماتجلاا لعافتلا لىع نزولل كَردلما ماك ،ةيمانلا نادلبلا ضعب في سانلا ينب ًاحوضو رثكأ نوكي دق "ةفاحنلا ناطبتسا" نأ لىإ يرشي امم ،تادقتعلما ةوقو تاذلل ريدقتلا عم ًايئاصحإ هب ُّدَتعُي ."ةيبرغلا" نادلبلا في لالحا هيلع وه Habitudes alimentaires, obésité et facteurs prédictifs de régimes chez des étudiantes à l'université en Palestine RÉSUMÉ La présente étude visait à connaître les habitudes alimentaires des étudiantes à l'université en Palestine. Les participantes (n = 410) ont été choisies par échantillonnage en grappes dans quatre universités palestiniennes. Un modèle de régression a été utilisé pour étudier leur alimentation en tenant compte des indicateurs suivants : l'indice de masse corporelle, la satisfaction vis-à-vis de son corps, l'estime de soi, le style vestimentaire, l'exercice physique, les facteurs socioculturels, le lieu de résidence, la force de la foi, la perception de l'impact du poids sur les interactions sociales, et le nombre de régimes adoptés auparavant. Les facteurs prédictifs importants pour l'adoption d'un régime étaient une faible satisfaction vis-à-vis de son corps, le nombre de régimes adoptés antérieurement, la perception de la pression des médias, la pratique régulière de l'exercice physique, l'indice de masse corporelle et la perception de l'impact du poids sur les interactions sociales. Le modèle représentait 45 % de la variance pour l'adoption d'un régime. Il n'y avait pas de corrélation significative entre la satisfaction vis-à-vis de son corps et l'estime de soi ou la force de la foi, ce qui indiquerait une possible assimilation de la notion « d'intériorisation de la minceur » dans la population de certains pays en développement, à l'instar des pays occidentaux. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 31 Introduction Most countries in the Middle East are becoming part of the global obesity pandemic, and the problem becomes significant when the trend towards a more “Western” lifestyle is considered in developing countries. This “West- ernization” can put the populations of those countries at a higher risk of obesity and metabolic syndrome than the populations of European and North American countries [1]. Sociocultural pressures to be thin via the media are strong [2], and perceptions of weight appropriateness have been found to be an important component of eating and weight loss behaviours [3]. Dieting is often linked to high body weight and low body satisfaction, thus those who consider themselves overweight and are dissatisfied with their bodies are more likely to diet than those with normal body weight [4,5]. While the issue of dieting and body satisfaction has been deeply investigat- ed in the Western countries, Arab and Muslim populations have rarely been investigated for their dieting behaviours, perceptions of body image, or body sat- isfaction. Haddad and Moore reported that Muslim women who chose to dress “Islamically” commonly felt free of Western views of women as sex objects [6]. Among Australian Muslim women, strength of religious faith was inversely related to body satisfaction, body self- objectification, and dietary restraint [7]. These relations were mediated by increased use of modest clothing and by reduced media consumption. Other studies showed evidence of internaliza- tion of the “thin ideal” and evidence of the presence of eating disorders among Muslim women indicating that this population was not immune against such medical conditions [8,9]. Some studies have noted that in- creased exposure to the Western picture of desired thinness through the Internet and the media, along with other socio- cultural changes, encourages women to adopt unhealthy dieting behaviours, the most serious of which are anorexia nervosa and bulimia nervosa [10,11]. The aim of this study was to explore dieting practices of female Palestinian college students, and to report rates of obesity and overweight among this population. Methods Procedure This study was carried out between May and October 2010. Institutional review board approval was obtained from the University of Arkansas. All par- ticipants gave their consent to complete the survey, which consisted of 2 parts: demographics and measures used as predictors for dieting behaviours. The dependent variable was frequency of different dieting practices. Independent variables were: body satisfaction, body mass index (BMI), perceived media pressure, perceived family pressure, perceived pressure from friends, per- ceptions of the impact of body weight on social interactions, self-esteem, dress style, residence (urban, rural, refugee camp), number of previous times diet- ing, and strength of faith. Dieting was assessed using 17 questions related to dieting behaviours practised by the participants within the previous 6 months. The questions were based on the Weight Control Behav- iour Scale [12]. Body satisfaction was assessed using pictorial BMI-based body-size guides (http://www.hsc.wvu.edu/ som/hrc/pdfs/IJO%20Final.pdf) [13]. Participants were asked to choose the picture they thought looked most like their body shape, and then to choose the picture that best represented their desired body shape. The difference be- tween the number of the desired picture and the number of the actual picture can range from –9 to 9, with negative scores indicating a desire to lose weight, positive scores indicating a desire to gain weight, and a zero score indicating body satisfaction. We used the standard weight status categories for adults: BMI < 18.5 = underweight, BMI 18.5–24.5 = normal, BMI 25.0–29.9 = overweight, and BMI ≥ 30 = obese. Perceived pressure from media was assessed using a subscale of the Socio- cultural Attitudes Towards Appearance Questionnaire 3 [14]. Perceived pres- sure from family and perceived pressure from friends were assessed using sub- scales from the Perceived Sociocultural Pressure Scale [15]. This is a 13-item scale related to social interactions of young adults with chronic health condi- tions [3]. The items assessed the re- spondents’ perceptions of the extent to which their weight negatively influences social interactions. Self-esteem was measured using the Rosenberg Self-Esteem Scale [16]. Strength of faith was measured us- ing the Santa Clara Strength of Reli- gious Faith Questionnaire [17]. A 2-way analysis of variance test was used to investigate the relationship be- tween body satisfaction and dress style. Body satisfaction was categorized into 3 groups: satisfied, wanted to gain weight, and wanted to lose weight. Dress style was categorized into 3 groups: jilbab (any long and loose-fitting coat or similar garment), modern (dress, skirt, pants) with headscarf, and modern without headscarf. Participants Multiple regression is a large-sample procedure. It is recommended to have 15–30 participants per predictor. We used 12 different variables (including age) as predictors so the estimated sample size would be 360 using the higher value. We used a sample size of 500 to ensure the representativeness of the sample. Using a cluster-sampling technique, 500 female college students, undergraduates from different majors and different college levels, were se- lected from 4 Palestinian universities EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 32 Results The average age of the 410 participants was 20.01 [standard deviation (SD) = 1.27] years. BMI ranged from 13 to 40 (mean = 21.91, SD = 2.92) km/m2, with the ma- jority being of normal or healthy weight (77.3%, n = 317), 8.5% (n = 35) under- weight, 12.4% (n = 51) overweight, and only 1.7% (n = 7) obese. Almost 53% (n = 217) reported their residence as ur- ban, 43.4% (n = 173) as rural, and only 3.7% (n = 15) as refugee camp. Dress style was described as jilbab by 39.5% (n = 162) of participants, as modern with headscarf by 42.9% (n = 176), and as modern with no headscarf by 17.6% (n = 72). The most practised unhealthy di- eting behaviour was skipping break- fast:16.1% (n = 66) reported either often or always practising this behaviour (Table 1). The second most practised unhealthy dieting behaviour was skip- ping other meals during the day: 10.0% (n = 41) reported often or always prac- tising this behaviour. The most practised healthy dieting behaviour was increasing the consump- tion of fruit and vegetables: 47.4% (n = 194) reported often or always practising this behaviour (Table 1). The second most practised healthy dieting behav- iour was increasing exercise: 26.1% (n = 107) reported often or always practising this behaviour. When participants were asked to choose the picture that best represented their perceived body shape, 38.3% (n = 157) chose the second picture, repre- senting normal body weight; 24.4% (n = 100) chose the third picture, represent- ing normal body weight; and 17.8% (n = 73) chose the first picture, representing underweight. However, when asked to choose the picture they most desired to look like, 49.0% (n = 201) chose the in the West-Bank only. Due to the political situation and restrictions on movement, we divided the West Bank into 3 geographical areas, north, middle, and south, and we randomly selected 1 university from the north, 2 from the middle, and 1 from the south. Participants were randomly selected from the summer classes offered at each university. The response rate was 85% (n = 425). Data from 15 participants were discarded due to missing data; thus, the study sample consisted of 410 female college students. Statistics Multiple regression analysis was used to investigate the relationship between dieting and other variables. All vari- ables used in the regression model were continuous except for “exercise” and “residence,” which were dummy-coded to fit this model. Data were analysed using SPSS, ver- sion 17. Table 1 Prevalence of healthy and unhealthy dieting behaviours among female Palestinian students (n = 410) Behaviour type Frequency Always Often Sometimes Never No. % No. % No. % No. % Healthy dieting Increase consumption of fruit & vegetables 106 25.9 88 21.5 104 25.4 112 27.3 Eat less meat 49 12.0 51 12.4 114 27.8 196 47.8 Increase exercise 43 10.5 64 15.6 125 30.5 178 43.4 Use artificial sweeteners 42 10.2 59 14.4 125 30.5 184 44.9 Eat low-calorie foods 34 8.3 67 16.3 114 27.8 195 47.6 Eliminate sweets and junk food 34 8.3 61 14.9 121 29.5 194 47.3 Reduce amount of food at each meal 33 8.0 44 10.7 168 41.0 165 40.2 Eliminate snacking between meals 29 7.1 59 14.4 133 32.4 189 46.1 Eat low-carbohydrate food 22 5.4 48 11.7 132 32.2 208 50.7 Eat or drink low fat food 20 4.9 40 9.8 60 14.6 290 70.7 Unhealthy dieting Skip breakfast 29 7.1 37 9.0 71 17.3 273 66.6 Skip other meals to lose weight 15 3.7 26 6.3 85 20.7 284 69.3 Increase smoking 7 1.7 3 0.7 9 2.2 391 95.4 Fast for more than 24 hours 7 1.7 12 2.9 19 4.6 372 90.7 Vomit after eating 5 1.2 8 2.0 27 6.6 370 90.2 Initiate smoking 4 1.0 4 1.0 19 4.6 383 93.4 Use medicationsa 3 0.7 7 1.7 25 6.1 375 91.5 aDiet pills, laxatives, enemas, diuretics, appetite suppressants. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 33 second picture, 27.3% (n = 112) chose the first picture, and 20.0% (n = 82) chose the third picture. The majority of the study population (52.8%, n = 217) wanted to lose weight no matter what their weight category was. Only 17.8% (n = 73) wanted to increase their weight. Of those participants who described themselves as satisfied with their body weight (n = 120), 6.7% (n = 8) described themselves as underweight, 89.2% (n = 107) as normal, and 4.2% (n = 5) as overweight. Of those who wanted to gain weight (n = 73), 45.2% (n = 33) categorized their body weight as under- weight, and 54.8% (n = 40) as normal. Of all those who wanted to lose weight (n =(217)), 4.1% (n = 9) categorized themselves as underweight, 62.2% (n = 135) as normal, 26.3% (n = 57) as overweight, and 7.4% (n = 16) as obese. Stepwise regression analysis was conducted to investigate significant pre- dictors of dieting. This analysis involved several multiple regression analyses in which a new predictor was added each time to the prediction model. Correla- tions among variables and the final pre- diction model are displayed in Tables 2 and 3. Age was not entered in the regres- sion model. Three predictors were re- moved from the final regression model: those who were satisfied with their weight [mean difference (MD) = 8.10, P < 0.05], and those who wanted to gain weight (MD = 9.75, P < 0.05) (Table 4). There was no statistically significant difference in the means of dieting be- tween those who were satisfied with their weight and those who wanted to gain weight. Discussion Despite an overall low prevalence of overweight and obesity, our findings indicate that participants practised vari- ous dieting behaviours, with a tendency towards healthy dieting behaviours. The proportion of women practising healthy dieting behaviours did not match the proportion who were overweight or obese, indicating that healthy dieting was also practised by those who do not actually need to lose weight. Although this could indicate the presence of some warning signs for disordered eating, it may also be an indication that some participants used healthy dieting be- haviours to maintain body weight. It may also be that dieting has become the norm among females in developing countries, just as in the more developed countries, where dieting has become a perceived family pressure, perceived pressure from friends, and residence. The results of the regression analysis were statistically significant: F (6.403) = 55.61, P < 0.001, R2 = 0.45, adjusted R2 = 44, standard error (SE) = 6.24. The value of R2 in this model indicated that the prediction model accounted for 45% of the variance in dieting behaviour frequency. The regression analysis showed that differences in the levels of perception about family pressure or pressure from friends to lose weight had no statisti- cally significant impact on dieting. More importantly, there was no statistically significant difference in the dieting be- haviours among participants in regard to residence (city, village, refugee camp). Neither self-esteem nor strength of faith had a statistically significant correlation with dieting, thus, both variables were excluded from the prediction model. There were no statistically significant interactions between dress style and the different levels of body satisfaction. However, there were statistically sig- nificant differences in means of dieting among the levels of body satisfaction. There was a statistically significant dif- ference between the means of dieting of those who wanted to lose weight, Table 2 Correlations between dieting behaviours and inter-correlations among predictors for female Palestinian students (n = 410) Predictor Predictor 1 2 3 4 5 6 7 8 9 10 1 1 –0.53** 0.49** 0.45** 0.40** 0.41** 0.38** 0.24** –0.07 –0.01 2 1 –0.67** .42** –.30** –.39** –.36** –.13** .04 –0.02 3 1 0.34** 0.3** 0.42** 0.39** 0.12* –0.06 –0.03 4 1 0.17** 0.27** 0.18** 0.07 –0.02 –0.1* 5 1 0.50** 0.45** 0.23** –0.12* –0.08 6 1 0.75** 0.28** –0.06 –0.07 7 1 0.36** –0.15** –0.09 8 1 –0.23** –0.01 9 1 0.09 10 1 1 = dieting behaviours, 2 = body satisfaction, 3 = body mass index, 4 = previous dieting attempts, 5 = pressure from media, 6 = family pressure, 7 = pressure from friends, 8 = perceived impact of weight on social interaction, 9 = self-esteem, 10 = strength of faith. *Correlation significant at 0.05 level (2-tailed). **Correlation significant at 0.01 level (2-tailed). EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 34 way of life, and that a large proportion of women have dieted at some point in their lives, as seen in other studies [18,19]. In this study, the most practised unhealthy dieting behaviour was skip- ping meals, particularly breakfast; the prevalence of other unhealthy dieting behaviours was very low. Despite the fact that identification of these behav- iours alone was not intended to identify disordered eating or eating disorders, it might raise concern about the probabil- ity of a clinical or subclinical diagnosis of such conditions. These findings are con- sistent with the results of other studies reporting such practices among female college students [20–22]. Our study population showed body dissatisfaction in 2 directions: those who wanted to gain weight, and those who wanted to lose weight. Other stud- ies have reported that even females who are not overweight or obese still desire to be thinner [23]. In our study, only 14% were overweight or obese, yet 53% wanted to lose weight, which might re- flect low body satisfaction. Almost 4% of those who wanted to lose weight identi- fied their body weight as underweight, and 62% as normal, which indicates that the internalization of thinness is evident among this population, and that the desire to lose weight is not necessarily correlated with high body weight. Our results indicate that body dis- satisfaction, rather than actual BMI, is a better predictor of dieting. The number of previous dieting attempts and the sig- nificant correlation with current dieting indicated that those who had previously engaged in dieting, mainly during ado- lescence, were more likely to continue practising some dieting behaviours as young adults. Sociocultural factors have been explored by researchers in regard to their influence on women's dieting behaviours. As might be expected, per- ceived media pressure was a significant predictor of dieting. In a previous study, perceived media pressure to be thin was correlated with increased weight and body dissatisfaction, and this experi- ence of pressure involved exposure to, and internalization of, the slender ideal, which in turn increased the probability of various eating and emotional prob- lems [24]. Perceived family pressure to lose weight did not emerge as a significant predictor of dieting. One explanation for this is that most previous studies have been conducted among adoles- cent females, so there is a probability that, because our study population was older, perceived family pressure was lower, or participants may not have provided an accurate evaluation of such pressure. Perceived family pressure might also be confused with pressure from the media or the community, so participants might not be aware of it. Another possible explanation is that participants might purposely deny any Table 3 Summary of regression analysis predicting total frequency of dieting behaviour in female Palestinian students (n = 410) Predictor B SE B β t sr2 R2 Model 0.45 Constant –9.60 3.06 –3.14** Body satisfaction –1.41 0.32 –0.23 –4.36*** 0.28 Previous dieting 0.73 0.13 0.24 5.69*** 0.06 Media pressure 0.25 0.05 0.20 5.80*** 0.06 Exercise 2.64 0.63 0.16 4.21*** 0.02 Body mass index 0.49 0.14 0.15 3.42** 0.02 Social pressure 0.11 0.04 0.11 2.98* 0.01 *P < 0.05, ** P < 0.01, ***P < 0.001. SE = standard error. Table 4 Two-way analysis of variance testing the interaction between body satisfaction and dress styles in female Palestinian students (n = 410) Source df SS MS F R2 Dress style (A) 2 119.43 59.71 1.15 0.00 Body satisfaction (B) 2 6729.20 3364.60 64.97*** 0.23 A*B interaction 4 123.43 30.87 0.60 0.00 Within groups 401 20766.92 51.79 Total 409 28663.65 ***P < 0.001. df = degrees of freedom, SS = sum of squares, MS = mean square. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 35 such family pressure in order to feel more independent in their college years. In this study, self-esteem had no significant correlation with dieting, nor was there any significant correlation with body satisfaction or strength of faith. To date, little research has been conducted exploring the relationship between strength of faith and body satisfaction and dieting behaviours. However, outward differences in ex- pression of the Muslim faith (only 9 of our participants were not Muslim), such as dress, would appear to warrant exploration of this factor. In contrast to the findings of Mussap, who found that among Muslim women, strength of faith was inversely related to body dissatisfaction and dietary restraint [7], we found no such relationship between faith and dieting, faith and self-esteem, or faith and body satisfaction. A pos- sible explanation for this contrast may be the difference in the mean age be- tween the 2 Muslim populations: the mean age in Mussap’s study was 27.34 years, while the mean age in our study was 20.1 years. Also, the population in Mussap’s study was living in Australia, a “Western” environment, while our participants lived in the West Bank, a Muslim environment. This might have affected perceptions of the impact of faith on different aspects of life. Wear- ing the jilbab (traditional Islamic dress) does not prevent Muslim females from having the desire to diet or to be thin- ner. With the effects of globalization, the impact of the media on body image is expected to increase, so eating dis- orders may start to appear among this population. According to 1 study, many media researchers have asserted that observation of Arab society reveals ob- vious “Western” influence on women and girls with regard to fashion, dress, and fast food consumption [25]. This study had a number of limita- tions. The sample was not randomly chosen and responses were self-report- ed, which may raise concerns about generalization of the results. Some of the factors used as predictors for di- eting (e.g. media) need to be further investigated for their impact on dieting. Neither the media content, nor the ex- posure time to media were investigated, therefore, our study does not explain the mechanism by which media impacts di- eting, and does not report the degree of “westernization” in the media to which the participants were exposed. Another limitation is that body dissatisfaction was assessed only through body weight or size, so the results related to this par- ticular variable may not be generalized to overall body satisfaction status. The results do not reflect a clinical diagnosis of any eating disorder or disordered eating, but they indicate that this pop- ulation may not be immune to such conditions. These would need further investigation based on clinical diagnosis to estimate the actual prevalence rates among this population. Despite these limitations, the study explores dieting in a new population living in a developing country that is undergoing rapid social and economic changes. 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Everyone knows that mass media are/are not [pick one] a cause of eating disorders: a critical review of evidence for a causal link between media, negative body image, and disordered eating in females. Journal of Social and Clinical Psychology, 2009, 28(1):9–42. 25. Obeidat R. Content and representation of women in the Arab media. Paper presented at the Expert Group Meeting on “Participation and access of women to the media, and the impact of media on, and its use as an instrument for the advancement and empowerment of women”, Beirut, Lebanon, 12–15 November 2002. New York, United Nations Division for the Advancement of Women, 2002 (EGM/ME- DIA/2002/EP.11) (http://www.un.org/womenwatch/daw/ egm/media2002/reports/EP11Obeidat.PDF, accessed 29 September 2012). طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 37 Pattern of psychiatric illnesses among long-stay patients at Mental Health Hospital, Taif, Saudi Arabia: a 10-year retrospective study H. Al-Zahrani,1 A. Al-Qarni 1 and M. Abdel-Fattah 2 ABSTRACT To identify the pattern and determinants of psychiatric illness and the predictors of long stay among long-stay patients at the Mental Health Hospital, Taif, Saudi Arabia, we examinede a total of 430 records of patients who had been admitted during the period January 1999–January 2009 and had stayed for > 9 months. More than half these patients had a history of drug addiction (60.7%). The majority were diagnosed with schizophrenia (88.8%) and mental retardation was reported in 17.7%. Personality disorders and epilepsy were diagnosed in 3.7% and 1.9% of the participants respectively. The mean duration of hospital stay was 6.16 (standard deviation 2.32; range 1–10) years. Multivariate logistic regression analysis showed that patients diagnosed with schizophrenia accompanied by mental retardation, those with lower education levels, and those with a history of co-morbid chronic diseases stayed for more than 2 years. 1Department of Family Medicine; 2Department of Preventive Medicine, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia (Correspondence to M. Abdel-Fattah: mezo106@yahoo.com). Received: 05/05/11; accepted: 05/10/11 ةسارد :ةيدوعسلا ةيبرعلا ةكلملماب فئاطلا في ةيسفنلا ةحصلا ىفشتسم في ةليوط تاترفل اوماقأ ضىرم ىدل سيفنلا ضرلما طمانأ تاونس شرعل ةيداعتسا حاتفلا دبع دممح زتعم .نيرقلا ناثيغ ليع ،نيارهزلا للها مرغ متاح ةيسفنلا ةحصلا ىفشتسم في ةليوط ةترفل ثكلماب تائبنلماو ةيسفنلا ضارملأل تاددحلما طمانأ لىع فرعتلل ةساردلا هذه نوثحابلا ىرجأ :ةـصلالخا /نياثلا نوناكو 1999 رياني/نياثلا نوناك ينب ام ةترفلا للاخ ىفشتسلما اولخدأ ضىرلم ًلاجس 430 اوسردف ،ةيدوعسلا ةيبرعلا ةكلملماب ،فئاطلا في .)%60.7( تاردخلما لىع نامدإ خيرات ميهدل ضىرلما ءلاؤه فصن نم رثكأ نأ ينثحابلل حضتاو .رهشأ ةعست نع ديزت ًةدم اوثكمو ،2009 رياني ةيصخشلا تابارطضا ْتَص ِّخُشو .مهنم %17.7 ىدل َل ِّجُس دقف ليقعلا فلختلا امأ ،)%88.8( ماصفلاب باصم هنأ لىع ص ِّخُش دق مهمظعم ناكو ددعتلما ليلحتلا رهظأو .)10 – 1 لاجمبو 2.32 ±( ًاماع 6.16 ىفشتسلما في ةماقلإل يطسولا نمزلا ناكو .مهنم %1.9 ىدل عصرلاو ،مهنم %3.7 ىدل ةيميلعتلا تايوتسلما يوذ نأ ماك ،ليقعلا فلختلا صيخشتب كلذ ميهدل َقَفاَرَت ماصفلا ميهدل َص ِّخُش نيذلا ضىرلما نأ يتسجوللا فوحتلل تايرغتلما .ينماع لىع ديزت ةدلم ىفشتسلما في اوثكم دق قفارم نمزم ضرم خيرات ميهدل نيذلا كئلوأو ،ةضفخنلما Profil des troubles psychiatriques chez des patients en séjour de longue durée à l'hôpital psychiatrique de Taïf (Arabie saoudite) : étude rétrospective sur dix ans RÉSUMÉ Afin d'identifier le profil et les déterminants des troubles psychiatriques et les facteurs prédictifs d'un séjour de longue durée chez des patients en séjour de longue durée à l'hôpital psychiatrique de Taïf (Arabie saoudite), nous avons examiné au total 430 dossiers de patients qui avaient été admis entre janvier 1999 et janvier 2009 et dont le séjour avait duré plus de neuf mois. Plus de la moitié de ces patients avait des antécédents de toxicomanie (60,7 %). La majorité a reçu le diagnostic de schizophrénie (88,8 %) et une arriération mentale a été observée dans 17,7 % des cas. Le diagnostic de troubles de la personnalité et d'épilepsie a été posé chez 3,7 % et 1,9 % des participants, respectivement. La durée moyenne du séjour en établissement hospitalier était de 6,16 ans (écart type 2,32 ; extrêmes 1-10 ans). L'analyse de régression logistique multivariée a démontré que les patients ayant reçu le diagnostic de schizophrénie associée à une arriération mentale, les patients ayant un niveau d'études plus faible, et ceux ayant des antécédents de comorbidités chroniques y séjournaient plus de deux ans. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 38 Introduction Serious and persistent mental illnesses can result in considerable functional impairment requiring long-term hos- pitalization. Most patients requiring institutional care of extended duration have limited functional capacity in rela- tion to a number of primary aspects of daily life, including personal hygiene and self-care, self direction, interper- sonal relationships, social transactions, learning and recreation [1]. The deleterious influence of tradi- tional custodial care on the long-stay population of mental hospitals has been well-documented [2]. The last 2 dec- ades have witnessed a major shift in the provision of psychiatric services to the acutely disturbed patients in general, and to the chronically disabled group of patients in particular. Increasingly, patients are living in the community, and the number of mental hospital beds has correspondingly decreased. In the United Kingdom for instance, 38 (29%) of 130 hospitals with more than 100 beds were closed between 1980 and 1993 [3] while in the United States of America 65 (20%) of 321 state hospitals were closed between 1972 and 1993 [4]. Whereas “too rapid” a shift from hospital-based to community-based care has proved counterproductive in some cases [5], most workers have found it to encompass greater potential for stabilization, and even improvement, of the condition of long term psychiatric patients. In addition, community-based care has been shown to be cost effec- tive. In a 3-year follow-up study of 321 discharged state hospital patients in the United States of America, the cost of community care was lower than the estimated cost of state hospitalization [6]. Similar findings have been reported by other researchers [7,8]. Estimates vary as to how many long- stay psychiatric patients could possibly be discharged into the community. Obviously, it depends on the nature of their illness and the degree of functional deficits of the patients as well as the availability of suitable accommodation and activity programmes in the com- munity. In a national sample survey of 15 mental hospitals in England and Wales, about one-third needed further hospital care, one-third were suitable for discharge into the community, and the remaining third, because they had multiple handicaps (including physical disability and mental retardation), were in hospital simply because no other agency would accept them [9]. Chronic psychiatric conditions are emerging challenges facing both developing and industrialized nations [10]. Despite the growing awareness of the public, and health and education professionals regarding the economic, psychological and medical impact of mental illnesses, limited research has been carried out to determine the pattern of mental disorders in Saudi Arabia [11,12]. Perhaps the most important obstacle in implementing intervention programmes is the lack of appropriate epidemiological research on the general population. Moreover, the appropriateness of the official men- tal statistics for determining the level of care needed by psychiatric patients is a controversial issue and therefore needs to be emphasized more [13]. In addition, many people with psychiatric conditions require continuous health care, home help and other supportive services, including substantial medical, educational, social and rehabilitative care, which makes care programmes very costly. Most of the studies designed to as- sess the population profile of psychiatric institutions and the deinstitutionaliza- tion process were carried out in indus- trialized countries. Little is known about these institutions and their residents in Saudi Arabia. There are number of difficulties associated with conducting research on psychiatric related issues in Saudi Arabia. Some of these difficulties are related to the characteristics of Saudi Arabian society, e.g. some families feel ashamed about having a family member with a psychiatric illness and as a result, tend to avoid participation in such re- search. Saudi society’s view of people with psychiatric disorders is based on a simple notion of disability; this includes helplessness, continuing dependence, being home-bound, low quality of life, lack of productivity [12] and for mental illnesses, being a danger to others. Hospital- and community-based research to determine the pattern of psychiatric disorders could contribute to information about prevalence, type and distribution of mental disorders in Saudi Arabia. It will also provide infor- mation for health planning and policies addressing the needs of such special group of people. The present study was conducted to identify the pattern and determinants of psychiatric disorders among long-stay patients in Taif Mental Health Hospital. Methods This study was conducted at the Minis- try of Health Mental Health Hospital, Taif, Western Region, Saudi Arabia. This hospital has 690 beds, making it the biggest mental health hospital in the country. It has forensic psychiatric wards and outpatient clinics. Patients are referred from all over the country, and all types of psychiatric disorder are accepted, including schizophrenia, epilepsy, mental subnormality, affective disorders, personality disorders, drug addiction. We carried out this retrospective cohort study during 2010, reviewing the records of patients with mental health disorders who stayed in the hospital for more than 9 months (long stay), according to the classification of Gath, Hassall and Cross [14]. Records for patients diagnosed during the 10-year period January 1999–January 2009 were included in the study. Length of stay was calculated from the date of admission to the date of discharge [14]. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 39 and co-morbid diseases were treated as independent categorical variables. Multiple associations were evalu- ated in the multiple logistic regression model, based on backward stepwise selection where significant variables from the univariate analysis were in- cluded. This allowed the estimation of the strength of the association between each independent variable while taking into account the potential confound- ing effects of the other independent variables. The covariates were removed from the model if the likelihood ratio, based on the maximum likelihood estimates, had a probability of > 0.10. Each category of predictor variables was contrasted with the reference category. The adjusted measure of association between risk factor and depression was expressed as odds ratio (OR) with 95% confidence interval (CI). Adjusted or crude OR with 95% CI that did not include 1.0 was considered significant. Results Sociodemographic characteristics A total of 430 records of patients who were admitted to Taif Mental Hospital during the period January 1999–Janu- ary 2009 were reviewed to identify the pattern of psychiatric illnesses and to determine predictors of long stay at the hospital. Age ranged between 23 and 77 years, with a mean of 44.08 (SD 7.80) years (Table 1). There were 386 males (89.8%) and only 44 females. All patients were Saudi Arabian, most of them from the Western Region (76%). Most of the patients in the study were single (66.5%). The majority were not working (88.4%). None were educated above secondary school level. Smoking and addiction history Only 19.5% of the studied patients were non-smokers and 38.2% were ex- smokers (Table 1). More than half had history of drug addiction (60.7%). The majority of patients were di- agnosed with schizophrenia (88.8%). Mental retardation was reported in 17.7% of the participants, personality disorders in 3.7% and epilepsy in 1.9%. History of co-morbidity was reported among 88 patients (20.5%): diabetes mellitus was reported in 39 (44.3%) cases and hypertension in 37 (42.0%), while heart disease was reported in only 12 cases (13.6%). Schizophrenia was significantly associated with smoking status (P < 0.001) (Table 2). The vast majority of the patients with schizophrenia were either smokers or ex-smokers (83.7%) compared to 54.2% among non- schizophrenic patients. Almost two- thirds of patients with schizophrenia had a positive history of drug addiction compared with just under one-third of non-schizophrenic patients. The differ- ence was statistically significant (P < 0.001) (Table 2). Duration and determinants of duration of hospital stay The mean duration of hospital stay was 6.16 (SD 2.32) years with a range of 1–10 years and a median of 6 years. Older patients were more likely to have a longer hospital stay (> 2 years): just over two-thirds of those in the age groups 41–50 years and 58.5% of those > 50 years stayed in hospital more than 2 years compared with only 47.7% of patients in the age group ≤ 40 years (Table 3). Males tended to stay in the hospital longer than female patients, but the difference was not statistically sig- nificant (P = 0.109). More than half the patients with lower levels of education stayed more than 2 years in the psychi- atric hospital compared with 34.3% of those who were educated to secondary school level (Table 3). The difference was statistically significant. Patients whose families refused to take them back were about 2 times as likely to have a longer stay than those who stayed on the orders of high- ranking officials (this was, however, Medical records were reviewed and comparisons made regarding medical status, sociodemographic data and du- ration of hospitalization. Patients were categorized according to their diagnosis. The total number of patients admit- ted during the study period was 11 310, and the estimated number of long stay (> 9 months) patients was 430. Data collection A checklist was designed to include demographic and personal predictors (age, sex, nationality, education, mari- tal status, occupation); and medical predictors (date of admission, date of discharge, reason for discharge, diag- nosis, any associated co-morbidities). Sampling of patients’ records was re- viewed to ensure the availability of all data included in the checklist. Diagnosis was made using DSM IV criteria [15]. The diagnosis was confirmed by a team comprising 1 psychiatric consultant and two family medicine consultants. Approval for this research was obtained from the research and eth- ics committee at Taif Armed Forces Hospital. We also obtained approval from the administration at Taif Mental Health Hospital to access patient re- cords. Statistical analysis We used SPSS, version 16.0, for data entry and analysis. Descriptive statistics [e.g. number, percentage, range, stand- ard deviation (SD), arithmetic mean] and analytic statistics using chi squared to test for the association between 2 categorical variables were applied. The duration of hospital stay was divided into 2 categories: those who had stayed ≤ 2 years and those who had stayed > 2 years. We excluded those patients admitted after 2008 (n = 31). Hospital stay was treated as a depend- ent variable in multivariate logistic re- gression analysis. Age, sex, marital status, education level, work status, housing, salary, smoking status, drug addiction, reason for long hospital stay, diagnosis EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 40 usually at the request of the patient’s close relatives) [odds ratio (OR) = 2.02; 95%confidence interval (CI): 1.13–3.60]. Patients with a history of co-morbid chronic disease had an increased risk of long-hospital stay compared with patients with no history (OR = 2.02; 95% CI: 1.19–3.46 (Table 3). Patients with a combined history of schizophre- nia and mental retardation had a 9-fold risk compared with those with history of personality disorder (OR = 9.0; 95% CI: 1.90–46.22)). Sex, marital status, work status, housing, salary, smoking status and history of drug addiction were not independently associated with long-stay at the hospital. Longer stay was significantly as- sociated with lower education level compared with secondary school education (Table 4). Patients diag- nosed with schizophrenia and mental retardation were more likely to have stayed more than 2 years in hospital than those with personality disorder (OR = 7.02; 95% CI: 1.95–33.12). Patients with history of chronic co- morbid disease had a 2-fold risk com- pared with those with no history of chronic disease (OR = 2.18; 95% CI: 1.47–4.13) (Table 4). Age and rea- son for long hospitalization were not independently associated with long hospital stay. Discussion This study focused on outlining the re- lationship between sociodemographic characteristics and clinical diagnosis of patients and length of stay in a psychi- atric hospital. In accordance our findings, in a study on long-stay patients in a psychi- atric hospital in Southern Brazil, the de- mographic data of the study population mostly showed long hospital stay, high level of illiteracy and low education, poor engagement in occupational/job activities, and situations where familial Table 1 Sociodemographic characteristics and addiction history of long stay (> 9 months) patients in a psychiatric hospital in Saudi Arabia (n = 430) Characteristic No. % Age (years) ≤ 40 132 30.7 41–50 232 54.0 > 50 66 15.3 Range 23–77 Mean (SD) 44.08 (7.80) Sex Male 386 89.8 Female 44 10.2 Residence Western Region 327 76.0 Central Region 62 14.5 South Region 25 5.8 North Region 10 2.3 Eastern Region 6 1.4 Marital status Single 286 66.5 Divorced 120 27.9 Married 20 4.7 Widowed 4 0.9 Education level Illiterate or R&W 145 33.7 Primary schools 143 33.3 Intermediate schools 104 24.2 Secondary school 38 8.8 Work status Not working 380 88.4 Working 10 2.3 Retired 40 9.3 Housing Owned 318 74.0 Rented 112 26.0 Private income No 408 94.9 Yes 22 5.1 Smoking status Current smoker 182 42.3 Ex-smoker 164 38.2 Non-smoker 84 19.5 History of drug addiction Yes 261 60.7 No 169 39.3 SD = standard deviation. R&W = just able to read and write. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 41 Table 2 Smoking status and addiction history among long stay (> 9 months) patients with and without schizophrenia Habit Schizophrenia χ2 P-value Yes (n = 382) No (n = 48) No. % No. % Smoking status Current smoker 164 42.9 18 37.5 25.96 < 0.001* Ex-smoker 156 40.8 8 16.7 Non-smoker 62 16.3 22 45.8 Addiction history Yes 247 64.7 14 29.2 22.52 < 0.001* No 135 35.3 34 70.8 *Statistically significant. Table 3 Sociodemographic, habitual and medical determinants of long-stay hospitalization among long stay (> 9 months) psychiatric patients (n = 399), univariate analysis Determinant Duration of hospital stay Crude OR 95% CI ≤ 2 years (n = 214) > 2 years (n = 216) No. % No. % Age (years) ≤ 40a 59 52.3 54 47.7 1.0 41–50 73 33.1 148 66.9 2.22 1.36–3.62* > 50 27 41.5 38 58.5 1.54 0.79–2099 Sex Malesa 137 38.5 219 61.5 1.0 Females 22 51.2 21 48.8 0.60 0.30–1.18 Marital status Singlea 97 36.5 169 63.5 1.0 Married 10 55.6 8 44.4 0.46 0.16–1.31 Divorced or widowed 52 45.2 63 54.8 0.70 0.44–1.11 Education level Secondary schoola 23 65.7 12 34.3 1.0 Intermediate school 39 39.4 60 60.6 2.95 1.23–7.16* Primary school 55 40.7 80 59.3 2.79 1.20–6.54* Illiterate or R&W 52 37.1 88 62.9 3.24 1.40–7.60* Work status Not workinga 136 39.0 213 61.0 1.0 Working 8 80.0 2 20.0 0.16 0.02–0.83* Retired 15 50.0 15 50.0 0.64 0.28–1.43 Housing Renteda 44 43.1 58 56.9 1.0 Owned 115 38.7 182 61.3 1.20 0.74–1.94 Private income Yesa 13 59.1 9 40.9 1.0 No 146 38.7 231 61.3 2.29 0.89–5.47 Smoking status Current smokera 67 39.6 102 60.4 1.0 Ex-smoker 63 42.3 86 57.7 0.90 0.56–1.44 Non-smoker 29 35.8 52 64.2 1.18 0.66–2.12 History of drug addiction Yesa 99 41.7 141 58.8 1.0 No 60 37.4 99 62.6 1.16 0.75–1.78 EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 42 bonds had been cut [16]. However, in our study, we found no association between lack of work and long hospital stay. In the current study, we found no association between sex and length of hospital stay and this was consistent with the findings of Taiwo et al. in Ni- geria [17]. A comparison between our findings and those described for some British psychiatric hospitals in the TAPS pro- ject is worth mentioning [18]. In both studies around 90% of the sample was diagnosed with schizophrenia. Van Os and Kapur noted that schizophrenia was the most commonly reported mental disorder worldwide [19]. In a Brazilian study, diagnosis of schizophrenia and mental retardation were almost equally distributed, and together accounted for Table 4 Predictors of long-stay hospitalization among psychiatric patients (n = 399) multivariate logistic regression analyses Variable Adjusted OR 95% CI Education level Secondary school (n = 38)a 1.0 Intermediate school (n = 104) 2.96 1.41–10.03* Primary school (n = 143) 1.55 1.16–8.13* Illiterate or R&W (n = 145) 4.25 1.61–8.11* Diagnosis Personality disorder (n = 14)a 1.0 Schizophrenia (n = 382) 1.78 0.74–7.56 Mental Retardation (n = 26) 2.09 0.60–10.14 Schizophrenia + mental retardation(n = 44) 7.02 1.95–33.12* Epilepsy + other diseases (n = 8) 2.40 0.40–17.55 Co-morbid disease No (n = 335)a 1.0 Yes (n = 95) 2.18 1.47–4.13* Patient’s age and reason for long hospitalization were removed from the final logistic regression model. aReference category. *Statistically significant. OR = odds ratio; CI = confidence interval; R&W = just able to read and write. Table 3 Sociodemographic, habitual and medical determinants of long-stay hospitalization among long stay (> 9 months) psychiatric patients (n = 399), univariate analysis (concluded) Determinant Duration of hospital stay Crude OR 95% CI ≤ 2 years (n = 214) > 2 years (n = 216) No. % No. % Reason for long hospitalization Orders from high-ranking officialsa,b 34 52.3 31 47.7 1.0 Family refused to take patient home 101 35.2 186 64.8 2.02 1.13–3.60* No family care 24 51.1 23 48.9 1.05 0.46–2.39 Diagnosis Personality disordera 9 69.2 4 30.8 1.0 Schizophrenia 126 40.9 182 59.1 3.25 0.89–12.84 Mental retardation 11 44.0 14 56.0 2.86 0.57–15.17 Schizophrenia + mental retardation 9 20.0 36 80.0 9.00 1.90–46.22* Epilepsy + other disease 4 50.0 4 50.0 2.25 0.26–20.99 Co-morbid disease No 133 43.6 172 46.4 1.0 Yes 26 27.7 68 72.3 2.02 1.19–3.46* aReference category. bGenerally, at the request of patient's close relatives. *Statistically significant. OR = odds ratio; CI = confidence interval. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 43 90% of all diagnoses [16]. Historical issues leading to the creation of health policies in these 2 countries along with the disparity in the availability of alterna- tive resources for these patients could explain some of these differences. Cattapan-Ludewig et al. reported that persons with serious mental ill- ness, especially schizophrenia, smoke at much higher rates than those without schizophrenia [20], and patients with schizophrenia have a harder time quit- ting smoking. Our observations agreed with this: 42.9% of schizophrenic pa- tients were current smokers and 40.8% were ex-smokers. This compares with 37.5% and 16.7% respectively for non- schizophrenic patients. Certain thinking patterns are affected in schizophrenia including sustained attention, focused attention, working memory, short-term memory, recogni- tion memory and even processes that are preattentive (e.g. reflexes) [20]. Some studies have suggested that there may be improvements in these areas after treatment with nicotine [21–23]. So, it may be that nicotine is used as a “self- medication” strategy by those with schiz- ophrenia to improve these difficulties as well as the side-effects of antipsychotic medications (e.g. extrapyramidal effects). There is greater co-morbidity, or co- occurrence, of substance dependence in individuals who have mental illness, especially schizophrenia, compared with individuals without any mental disorder. This indicates either a shared neurobiological basis for both, or an interaction of effects at some level [24]. We also noted a statistically significant association between schizophrenia and drug addiction. In the current study, presence of co-morbid illness was statistically significantly associated with longer hospital stay. Similar findings have been reported by other researchers [25]. For long-stay patients, it seems clear that the greatest influence on how long they stay in hospital is where they are discharged to. In a national sample survey of 15 mental hospitals in Eng- land and Wales, about one-third of the patients needed further medical care, one-third were suitable for discharge into the community, and the remaining one-third, because of multiple handi- caps including physical disability and mental retardation, were in hospital simply because no other agency would accept them [9]. In our study, long hos- pital stay was mainly due to the refusal of the family to take patients back into the home. One of the strengths of the current study was the relatively large number of patient records examined, which al- lowed for division into sub-groups. The study was, however, not without limitations. We did not have enough resources to look into clinical and social data in detail, e.g. previous treatment, family support, social functioning on ad- mission and discharge, etc. These could be important factors influencing the duration of hospital stay. Further studies into these areas would be valuable. In addition, the study included patients from only one institution (although it did accept patients from throughout Saudi Arabia). Thus, the results of this study should be generalized to other geographic regions with caution. 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Survey of English mental illness hospitals. Bir- mingham, England, Health Service Management Centre, 1993. 4. Manderschied RW, Sonnenschein MA, eds. Mental health, United States. Rockville, Maryland, Department of Health and Human Services, 1994. 5. Tantum D. Alternatives to psychiatric hospitalisation. British Journal of Psychiatry, 1985, 146:1–4. 6. Rothbard A et al. Service utilization and cost of community care for discharged state hospital patients: a 3-year follow-up study. American Journal of Psychiatry, 1999, 156:920–927. 7. Rothbard AB et al. Service use and cost in 2002 among clients in community settings who were discharged from a state hos- pital in 1989. Psychiatric Services, 2007, 58(12):1570–1576. 8. Hallam A et al. The costs of accommodation and care. Com- munity provision for former long-stay psychiatric hospital pa- tients. European Archives of Psychiatry & Clinical Neurosciences, 1994, 243:304–310. 9. 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EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 44 14. Gath DH, Hassall C, Cross KW. Whither psychiatric day care? A study of day patients in Birmingham. British Medical Journal, 1973, 1:94–98. 15. Diagnostic and statistical manual of mental disorders (DSM IV), 4th ed. Washington DC, American Psychiatric Association, 1994. 16. Fleck MPA et al. Long-stay patients in a psychiatric hospital in Southern Brazil. Revista Saúde Pública, 2007, 41(1):124–130. 17. Taiwo H et al. Long stay patients in a psychiatric hospital in Lagos, Nigeria. African Journal of Psychiatry, 2008, 11:128–132 18. O’Driscoll C et al. The TAPS project 10: the long-stay popula- tions of Friern and Claybury hospitals. The baseline survey. British Journal of Psychiatry, 1993, 162(19 Suppl.):30–35. 19. Van Os J, Kapur S. Schizophrenia. Lancet, 2009, 374(9690):635– 645. 20. Cattapan-Ludewig K et al. Warum rauchen Schizophreniepa- tienten? [Why do schizophrenics smoke?]. Nervenarzt, 2005, 76:287–294. 21. Harris JG et al. Effects of nicotine on cognitive deficits in schizo- phrenia. Neuropsychopharmacology, 2004, 29(7):1378–1385. 22. Lyon ER. A Review of the effects of nicotine on schizophrenia and antipsychotic medications. Psychiatric Services, 1999, 50(10):1346–1350, 23. C Smith RC et al. Effects of cigarette smoking and nicotine nasal spray on psychiatric symptoms and cognition in schizophrenia. Neuropsychopharmacology, 2002, 27(3):479–497. 24. Ridgely MS et al. Chronically mentally ill young adults with sub- stance abuse problems: a review of research, treatment, and train- ing issues. Baltimore, Maryland, University of Maryland, School of Medicine, Mental Health Services Research Center, 1987. 25. Wancataa J et al. Does psychiatric comorbidity increase the length of stay in general hospitals? Abstracts of the Academy for Health Services Research and Health Policy Meeting, 2002, 23(1):8–14. Improving quality and human rights in mental health All over the world, people with mental and intellectual disabilities and substance use disorders are subject to poor quality care and violations to their basic rights. These conditions are also highly stigmatised resulting in social exclusion and marginalization of affected people. Health settings are not free of stigma and discrimination towards people with mental and intellectual disabilities and substance use disorders. In fact, some of the worst violations of rights and most discriminative practices occur within the health care facilities. The United Nations Convention on the Rights of Persons with Disabilities is the basis for human rights standards that must be respected, protected and fulfilled in facilities. The Convention was endorsed on 3 May 2008, and 16 of the 22 Member States of the Eastern Mediterranean Region have ratified it. Translating the provisions of the Convention on the Rights of Persons with Disabilities into action, WHO has developed the QualityRights Toolkit to support countries in assessing their mental health and social care facilities in order to improve the quality of services with observance the rights of patients. The WHO Regional Office, as a joint initiative between the departments of health systems and noncommunicable diseases and mental health with support from WHO headquarters, conducted a training of trainer’s workshop in December 2012. The workshop was attended by mental health and human rights focal points from selected Member States and country offices of WHO. The objectives of the workshop were to familiarize the participants with the QualityRights project, the Toolkit and develop an action plan for implementing the project in respective countries. Further information about the work of WHO in the Region on mental health and the rights of people with disabilities can be found at: www.emro.who.int/entity/mental-health/ طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 45 Study of the effect of dietary counselling on the improvement of end-stage renal disease patients I.S. Hegazy,1 H.A. El Raghy,1 S.B. Abdel-Aziz 1 and E.M. Elhabashi1 ABSTRACT Proper nutrition may help to reverse the wasting syndrome in dialysis patients with kidney disease on dialysis. This intervention study aimed to identify malnutrition problems and assess the effect of dietary counselling on improvement of health status of end-stage renal disease patients subjected to haemodialysis. Pre-intervention data were collected from 41 patients attending El Haram dialysis centre, Giza, Egypt; 97.5% of the patients were considered mildly to moderately malnourished and multiple malnutrition problems were detected (protein–energy malnutrition, hypocalcaemia, and anaemia and hyperphosphataemia). Nutritional counselling sessions resulted in statistically significant post-intervention improvements in Karnofsky performance scale scores, malnutrition inflammation scores and nutritional knowledge of the patients. Providing one-to-one nutrition counselling could be linked to improvements in the patients’ nutritional knowledge and practices and to their health status and performance in activities of daily life. 1Department of Public Health and Community Medicine, Faculty of Medicine, University of Cairo, Cairo, Egypt (Correspondence to S.B. Abdel-Aziz: shaimaabaher@yahoo.com). Received: 11/03/11; accepted: 11/01/12 يولكلا ضرلما نم ةيئاهنلا ةلحرلما ضىرم ينستح في ةيوذغتلا ةيعوتلا رثأ ةسارد شيبلحا نمايإ ،زيزعلا دبع رهاب ءمايش ،يحجرلا نانح ،يزاجح ميهاربإ ءوس تلاكشم لىع فرعتلا لىإ ةيلخدتلا ةساردلا هذه فدتهو .يولكلا لايدلا ضىرم ىدل لازلها ةمزلاتم سرتح نأ ةمئلالما ةيذغتلل نكمي :ةـصلالخا نوثحابلا عجم دقو .لايدلل ينعضالخا يولكلا ضرلما نم ةيئاهنلا ةلحرلما ضىرم ىدل يحصلا عضولا ينستح في ةيوذغتلا ةيعوتلا راثآ مييقتو ةيذغتلا فيفط ةيذغت ءوسب ينباصم نوبرتعي مهنم %97.5 نأ اودجوو ،صرم في ةزيلجا في لايدلل مرلها زكرم نوعجاري ًاضيرم 41 نم لخدتلا لبق تايطعلما دقو .)مدلا تافسف طرف ،مدلا رقف ،مدلا مويسلاك صقن ،ةقاطلاو ينتوبرلا ةيذغت ءوس( ةد ِّدعتلما ةيوذغتلا تلاكشلما نم ًاددع اوفشكو ،طسوتم لىإ ةيوذغتلا فراعلما فيو يوذغتلا باهتللاا زارحأو ،يكسفونراكل ءادلأا سايقم زارحأ في ًايئاصحإ ابه ُّدَتعُي تانستح لىإ ةيوذغتلا ةيعوتلا صصح تدأ فيو ضىرلما ىدل ةيوذغتلا فراعلما في تانسحتلاب ةطبترم نوكت نأ نكمي رخلآ صخش نم مدقت يتلا ةيوذغتلا ةيعوتلا نوثحابلا ىريو .ضىرلما ىدل .ةيمويلا متهايح في ةطشنلأل مهئادأ فيو يحصلا مهعضو فيو متهاسرامم Étude de l'effet des conseils diététiques sur l'amélioration de l'état des patients atteints d'une maladie rénale en phase terminale RÉSUMÉ Une alimentation adaptée peut contribuer à lutter contre le syndrome cachectique chez les patients atteints d'une maladie rénale sous dialyse. La présente étude d'intervention visait à identifier les problèmes de malnutrition et à évaluer l'effet de conseils diététiques sur l'amélioration de l'état de santé des patients atteints d'une maladie rénale en phase terminale soumis à une hémodialyse. Les données avant l'intervention ont été recueillies auprès de 41 patients fréquentant le centre de dialyse El Haram à Giza (Égypte) ; 97,5 % des patients étaient légèrement à modérément malnutris, et des problèmes de malnutrition multiples ont été détectés (malnutrition protéïno-énergétique, hypocalcémie, anémie et hyperphosphatémie). Des sessions de conseils nutritionnels ont entraîné des améliorations statistiquement significatives dans les scores sur l'indice de performance de Karnofsky, les scores de l'inflammation et de malnutrition et les connaissances diététiques des patients après l'intervention. L'offre de conseils nutritionnels en entretien individuel a entraîné des améliorations dans les connaissances diététiques des patients et dans leurs pratiques en la matière. Elle a également permis d'améliorer leur état de santé et leur performance dans leurs activités quotidiennes. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 46 Introduction Chronic kidney disease is a major public health problem and its incidence and prevalence are increasing [1]. World- wide, the reported annual incidence of end-stage renal disease (ESRD) ranges between 34 and 200 per million popula- tion [2] and there is an even higher number of patients in the earlier stages of chronic kidney disease, facing ad- verse outcomes such as kidney failure, cardiovascular disease and premature death [3–5]. Malnutrition is common in pa- tients with ESRD. Various studies have shown signs of malnutrition in 23%–76% of patients on haemodialy- sis and 18%–50% on peritoneal dialy- sis. Such variations in the prevalence of malnutrition may be related to fac- tors such as age, comorbid conditions and quality of dialysis therapy. The aetiology of malnutrition in ESRD is complex and may include poor food intake because of anorexia, nausea and vomiting due to uraemia, hor- monal derangements, acidosis and increased energy expenditure [6,7]. Proper nutrition may help to reverse the wasting syndrome. Several in- ternational studies have suggested a strong association between nutrition and clinical outcome in haemodialysis patients [8,9]. Nutritional education and counsel- ling for patients with renal disease plays a major role in the preservation of renal function and the overall wellbeing of the renal patient. In preparation for renal replacement therapy, a consulta- tion with the renal nutritionist to estab- lish a diet consistent with the existing diagnosis may increase the likelihood of reducing cardiovascular risk factors, preventing malnutrition and anaemia, and slowing the progression of renal disease, all of which can contribute to positive patient outcomes [10]. In- novations in nutrition education to patients have included a variety of approaches to deliver the message: one-to-one counselling, group coun- selling, involvement in patient and family support groups, cookery classes, recipes with food samples, posters, vid- eos, quizzes, competitions, newsletters and report cards. Nutrition tips are another effective way of providing a practical nutrition education message in a simple format, where patients can make one small change at a time in their food choices [11]. In 2003 in Egypt the incidence of EDRD was reported as 74 per million [4]. The current study aimed to iden- tify malnutrition problems and assess the effect of dietary counselling on the improvement of health status of ESRD patients attending a dialysis centre in Egypt. Methods Study setting and sample This was an intervention study carried out at El Haram dialysis centre, Giza, Egypt from 1 October 2008 to 31 March 2009. This dialysis centre has 12 haemodialysis machines unit and is managed by the Egyptian health insur- ance organization. Eligible patients were all those undergoing regular haemodialysis at the centre, i.e. 3 times per week every alternate day with Friday off. At the time of the study there were 83 patients (56 males and 27 females). A sex-stratified random sample of about 50% of the total dialysis patients were selected and enrolled in phase 1 of the study: 41 patients (28 males and 13 females). The number of patients in the follow-up (phase 3) was reduced to 37 as 2 pa- tients died, 1 patent was in the intensive care unit and 1 was hospitalized for an eye operation. The study was conducted after explaining the steps of the study and its objectives to the participants. Only those who agreed were included. Verbal consent was obtained from all the par- ticipants in the study. Study design The study was conducted in several phases: • Phase 1 (pre-intervention): collec- tion of baseline data through inter- views and laboratory reports with patients attending the centre to assess their nutritional status. • Phase 2 (intervention): nutritional counselling that involved communi- cating evidence-based practices to all the patients in one-to-one sessions delivered by the researcher. Renal failure dietary guidelines tables [12] were used to show different types, quantities of food categories and the importance of each food group for health. Eating habits that needed to be emphasized or changed were dis- cussed, e.g. the importance of fluid restriction and restricted salt intake. Each session involved the use of a laptop computer showing slides with nutritional messages and animations showing the importance of fluid re- striction. Printed materials with all messages were distributed at the end of each session to the patients, the doctors and the nurses. Printouts of important general information about diabetes were also distributed to dia- betic ESRD patients to emphasize the importance of controlling diabetes. • Phase 3 (post-intervention): a reas- sessment of the impact of nutritional counselling through follow-up inter- views and the latest laboratory re- ports. This was conducted about 1 month later to allow sufficient time for assimilation and implementation of the taught messages. Data collection We met each patient 5 times over the course of the research, in order to con- duct the pre- and post-intervention in- terviews and the nutritional counselling sessions. These were scheduled around the various dialysis shifts/groups. Interview data Baseline data were collected from the study sample using an interview طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 47 (≤ 50%), needs improvement (50%– 75%), acceptable (75%–100%), normal (100%–120%) and unacceptable (≥ 120%). Biochemical data For the biochemical analysis blood samples were taken at the pre- and post- intervention interviews for estimation of serum urea, serum creatinine, serum calcium, serum phosphorus and red cell haemoglobin levels. Statistical analysis Data were computerized and ana- lysed using SPSS, version 16 software. Simple statistics such as frequencies, percentages, arithmetic means and standard deviation (SD) were used. Comparison between pre- and post- assessment values was done using the McNemar test for qualitative variables and paired Student t-test for quantita- tive variables. Results Background characteristics This study sample included 41 patients (13 female and 28 male), i.e. a male to female ratio of 2.1. The age of the study group ranged from 27–75 years, mean age was 51.7 (SD 12.6) years, 43.9% of the study sample were illiterate and 73.1% were not working, 92.7% were married. Just over half the sample were smokers (53.7%). A great majority of ESRD patients (90.2%) had hypertension, 17.1% were diagnosed with diabetes and 9.8% with cardiovascular disease. Nearly half of them had hepatitis C virus (43.9%) and 4.9% had bilharziasis. Almost all the patients were suffering from bleeding problems and impaired wound heal- ing and 30%–60% reported symptoms such as fatigue and malaise, headache, weight loss, muscle wasting, frequent infections and bone problems. The duration of dialysis was more than 2 years for 70% of them. There was a first-degree family history of ESRD in 9.8% of the patients. Pre- and post-intervention comparisons Nutritional assessment The nutritional background and di- etary profile showed that before the intervention only 29.3% of patients on dialysis received nutritional sessions that were conducted by doctors on an occasional basis. The majority of the sample (90.2%) knew nothing about nutritional assessment methods. The most common reasons for not follow- ing a dietary regime were appetite issues or ignorance, followed by social issues and, in a few cases, financial issues. According to the patients’ 24-hour recall of dietary habits (National Nutri- tion Institute classification) one-third of them (34.1%) needed improvement in their protein intake and were suffering from an unsafe sodium intake, 51.2% had an unacceptable intake of potas- sium and were suffering from an unsafe phosphorus intake, while 20.0% were suffering from unsafe calorie intake that needed improvement. It was noted that 90.2% of the patients had an unac- cepted level of fluid intake. According to the National Nutrition Institute clas- sification only 48.8% of patients were practising healthy eating habits before the intervention This increased from to 78.4% post-intervention (P < 0.002) (Table 1). Nutritional knowledge Table 1 shows a comparison of patients’ nutritional knowledge pre- and post- intervention. There were improvements in all items of knowledge post-interven- tion, although these were not statistically significant for the definitions of malnu- trition and how malnutrition can affect ESRD patients’ health status. “Don’t know” responses to the item on knowl- edge about the effect of malnutrition on health decreased dramatically from 82.9% to only 5.4% after the interven- tion and the item concerning knowing questionnaire containing the following sections: general information, soci- odemographic data, medical history, dietary pattern, nutritional status and health-related quality of life/functional impairment. Functional impairment and quality of life was assessed using the Karnofsky performance status scale index [13] which rates patients’ ability to carry on normal activity and work and their need for assistance with personal needs or for institutional or hospital care on a scale from 0 (dead) to 100 (normal no complaints; no evidence of disease). Patients’ functional impairment scores were classified as follows: normal (80– 100), mild (50–80), moderate (25–50) and severe (≤ 25). Patients’ nutritional status was as- sessed based on history taking using the malnutrition inflammation score (MIS) [14]. This has 10 items in 2 sec- tions: patient's related medical history [change in end dialysis dry weight (in past 3–6 months); dietary intake; gas- trointestinal symptoms; nutritionally related functional impairment; comor- bidity (including number of years on dialysis)] and physical examination [decreased fat stores or loss of subcuta- neous fat; signs of muscle wasting; body mass index (BMI); serum albumin, serum total iron binding capacity or serum transferring]. Only 6 out of the 10 MIS components were used and total scores were classified as follows: normal (≤ 1), mild (1–8) and moder- ate (8–18). Weight and height were measured and BMI was calculated and classified according to World Health Organization cut-offs: underweight (< 18.5 kg/m2), normal (18.5–24.9 kg/ m2), overweight (25.0–29.9 kg/m2), obese (30.0–39.9 kg/m2) and morbid obese (> 40 kg/m2). Dietary patterns of patients were estimated from patients’ 24-hour re- call using to the National Nutrition Institute methods [15]. Patients’ were classified according to their daily nutri- tion requirements into 5 classes: unsafe EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 48 Table 1 Comparison between the pre- and post-intervention responses of end-stage renal disease (ESRD) patients about their nutritional knowledge and practices Knowledge/practice item Pre-intervention (n = 41) Post-intervention (n = 37) P-valuea No. % No. % Knowledge items Definition of overnutrition Incorrect 18 43.9 21 56.8 Don’t know 21 51.2 13 35.1 > 0.05 Correct 2 4.9 3 8.1 Definition of undernutrition Incorrect 1 2.4 14 37.8 Don’t know 21 51.2 13 35.1 > 0.05 Correct 19 46.4 10 27.1 Definition of bad quality nutrition Incorrect 19 46.3 1 2.7 Don’t know 21 51.2 13 35.1 > 0.05 Correct 1 2.5 23 62.2 How malnutrition affects ESRD patients’ health Don’t know 34 82.9 2 5.4 No relation 3 7.3 2 5.4 Improves condition 3 7.3 2 5.4 > 0.05 Worsens condition 1 2.4 31 83.3 Which proteins are high biological value Incorrect 2 4.9 0 0.0 < 0.003 Don’t know 12 29.3 9 24.3 Correct 27 65.9 28 75.7 Allowed amount of fluids/day Incorrect 4 9.8 3 8.1 > 0.05 Don’t know 33 80.5 6 16.2 Correct 4 9.8 28 75.7 Which food items are rich in potassium Incorrect 2 4.9 1 2.7 0.099 Don’t know 33 80.5 19 51.4 Mentioned < 3 6 14.6 14 37.8 Mentioned > 3 0 0.0 3 8.1 Which food items are rich in sodium Incorrect 2 4.9 1 2.7 0.001 Don’t know 33 80.5 11 29.7 Mentioned < 3 6 14.6 20 54.1 Mentioned > 3 0 0.0 5 13.5 Which food items are rich in phosphorus Incorrect 1 2.4 0 0.0 0.093 Don’t know 17 41.5 10 27.0 Mentioned < 3 20 48.8 21 56.8 Mentioned > 3 3 7.3 6 16.2 Practice item Practising healthy eating habits No 21 51.2 8 21.6 < 0.002 Yes 20 48.8 29 78.4 aMcNemar test. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 49 how far this relationship can worsen the condition increased from 2.4% to 83.3% (not significant, McNemar test). There was a significant improvement between the pre- and post-intervention phases in the proportion of patients who knew which proteins were of high biological value (75.5% versus 65.9%) (P < 0.003) (Table 1). The percentage who knew the right allowed amount of fluids that should be taken every day also increased from 9.8% to 75.7% (not significant, McNemar test). Patients’ knowledge about food items rich in certain miner- als increased post-intervention. For ex- ample, the proportion who mentioned more than 3 foods rich in potassium increased from 0% to 8.1% and for foods rich in phosphorus from 7.3% to 16.2% (P > 0.05), while there was a significant increase in those who mentioned more than 3 foods rich in sodium from 0% to 13.5% ( P < 0.001). Biochemical parameters Comparison of patients’ biochemical parameters showed statistically sig- nificant decreases in the mean values of creatinine, urea and calcium before and after the intervention (paired Student t-test) (Table 2). Phosphorus levels decreased and haemoglobin levels in- creased but these differences were not significant. Karnofsky performance scale The proportion of patients within the normal band of the Karnofsky func- tional impairment scale was only 22.0% before the intervention but this rose significantly to 78.4% post-intervention, while those in the mild band decreased from 73.2% pre- to 18.9% post-interven- tion. The mean Karnofsky scale score (range 0–100) for 41 patients before the intervention was 70.5 (SD 8.5) and for the 37 patients after the counselling was 78.1 (SD 9.9). Malnutrition inflammation score Before the intervention the great major- ity of patients 97.5% were considered to be mild to moderate malnourished and only 2.5% were well nourished us- ing the MIS score (Table 3). After the intervention, the proportion of patients within the mild band remained almost the same (90.2% and 91.9%) while the percentage who were well nourished increased to 8.1% post-intervention (Table 3). The proportion in the mod- erate band decreased from 7.3% pre- intervention to 0% post-intervention. The mean MIS score (range 0–18) before the intervention was 4.6 (SD 1.9) and after the counselling was 3.1 (SD 1.7) (P < 0.001). Discussion Malnutrition is a major comorbid condition in ESRD, with a prevalence of 40%–50% in patients with ESRD [10,16,17]. Malnutrition compromises the prognosis in ESRD, and nutri- tional status is therefore an important predictor of outcomes for patients on maintenance haemodialysis. Assess- ment of nutritional status needs a sys- tematic nutritional evaluation based on anthropometric, laboratory and clinical parameters from which a malnutrition score can be calculated [18]. Medical nutrition therapy and nutrition educa- tion and counselling have been shown to be essential components of effective management of ESRD. Early nutritional intervention is thought to play a major role in the preservation of renal function and the overall well-being in the renal patient [10,19]. Based on this evidence, the current research was carried out with the aim of revealing the effects of dietary counselling on improving the health status of dialysis patients. Half of the patients at our dialysis centre were enrolled in this study and the mean age of patients was 51.7 (SD 12.6) years. Previous national studies in Egypt found a mean age of 43.0 (SD 17.7) years in 1987 by Mohammed [20] and a mean of 45.6 (SD 14.2) years in 1999 [21]. The higher mean age of ESRD patients in our study in Egypt reflects the universal trend towards dialysis patients living longer due to improving health care [21]. Our study showed that 90.2% of the sample were suffering from hyperten- sion and 17.1% from diabetes mellitus, diseases that are considered the 2 ma- jor risk factors of renal failure. Web- ster Gandy et al. and Moriyama also reported that the most common risk factors for kidney failure were diabetes and hypertension, together account- ing for almost 69% of new cases [5]. In Egypt hypertension was reported to be responsible for 28% of cases of ESRD in 1996 and for 22% in 2001 [21] and in Yemen for 30% of cases [17]. The Table 2 Comparison between the pre- and post-intervention biochemical parameters of end-stage renal disease patients Parameter Pre-intervention (n = 41) Post-intervention (n = 37) P-valuea Mean SD Mean SD Creatinine (mg/dL) 9.6 3.2 8.3 2.8 < 0.001 Urea (mg/dL) 141.6 39.8 128.0 38.3 < 0.031 Calcium (mg/dL) 7.5 1.1 6.8 0.9 < 0.002 Phosphorus (mg/dL) 4.8 1.6 4.4 1.5 > 0.05 Haemoglobin (g/dL) 10.7 2.3 11.4 2.1 > 0.05 aPaired Student t-test. SD = standard deviation. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 50 high incidence of hypertension in our study is consistent with reports from the United States, Japan and Germany and other European countries [22]. Poor nutritional status of haemo- dialysis patients is the result of sev- eral interrelated factors. Apart from the catabolic effect of dialysis, nutrient loss in dialysis and uraemic toxicity, several comorbid conditions may also contribute to malnutrition, including chronic infection and superimposed diseases that result in anorexia and inadequate food intake [23]. It was also observed from the present study and that of Afshar et al. [9] that many patients were suffering from symptoms related to malnutrition such as fatigue and malaise, headache, weight loss, muscle wasting, frequent infections, impaired wound healing and bone troubles. This finding can be compared with Basaleem et al.’s study, where all the 50 study patients were suffering of bone pains and arthralgia [17]. Moe et al. also reported that renal osteodys- trophy was common in ESRD patients and related to disturbance in bone and mineral metabolism [24]. In the present study, 97.5% of pa- tients were considered to be mild to moderate malnourished at baseline and only 2.5% were well-nourished according to the MIS score. A study in Yemen reported that out of 50 patients 70% of them had moderate malnutrition and 20% were severely malnourished [17]. Other interna- tional data showed that up to 76% of maintenance haemodialysis patients were malnourished [6]. The higher percentage of malnutrition in our study may be explained by the fact that patients showed a very low level of nu- tritional knowledge at baseline. After nutritional counselling, however, a sta- tistically significant improvement was observed as regard patients’ knowledge about nutrition and how malnutrition can affect their general health. Patients’ knowledge increased for the items about the allowed amount of fluids per day and their compliance with it, about proteins of high biological value, about foods rich in sodium, phosphorus and potassium and the risk of malnutrition. It is likely that this can be attributed to the intervention in our study. Our results are similar to the programme implemented in Canada by Berg et al., who found improvements in patients’ nutritional knowledge and their salt and fluid intakes after an educational programme [11]. They used an incen- tive method in the form of a lotto draw for patients who did not exceed their recommended interdialytic weight and, as in our study, they distributed nutritional tips aiming to improve pa- tients’ nutritional status. Analysis of the data about patients’ nutritional practices also showed an improvement in different aspects of their diet after the intervention. Before the intervention 51.2% of the sample were not practising healthy eating hab- its, a figure that is similar to Basaleem et al.’s study in which 58% of the sample were not following dietary instructions [17]. This may be explained by the finding that only 29.3% of our patients reported ever receiving nutritional edu- cation sessions before the intervention and these were not on a regular basis. The most common reasons for not following a dietary regimen were due to lack of appetite or to ignorance. So different tips and ideas were given in the counselling to help patients with the social, appetite and financial is- sues, each according to his personal problem, while for those with poor knowledge counselling acted to raise their knowledge level. Abnormal levels of biochemical parameters are usually encountered in patients with ESRD, some of which (e.g. high blood urea and creatinine) are predictors of mortality. In the present Table 3 Comparison between the pre- and post-intervention Karnofsky performance scale and malnutrition inflammation score of end-stage renal disease patients Scale/scores Pre-intervention (n = 41) Post-intervention (n = 37) P-valued No. % No. % Karnofsky scale scorea,b Normal (80–100) 9 22.0 29 78.4 < 0.001 Mild (50–80) 30 73.2 7 18.9 Moderate (25–50) 2 4.9 1 2.7 Mean (SD) 70.5 (8.5) 78.1 (9.9) Malnutrition inflammation scorea,c Normal (≤ 1) 1 2.5 3 8.1 Mild (1–8) 37 90.2 34 91.9 < 0.001 Moderate (8–18) 3 7.3 0 0.0 Mean (SD) 4.6 (1.9) 3.1 (1.7) aNo cases were found within severe band; bRange 0–100; cModified scale, range 0–18. dStudent t-test. SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 51 References 1. Levey AS et al. Definition and classification of chronic kidney disease: a position statement from kidney disease: improv- ing global outcomes (KDIGO). Kidney International, 2005, 67:2089–2100. 2. Eknoyan G et al. The burden of kidney disease, improving global outcomes. Kidney International, 2004, 66:1310–131. 3. Barsoum RS. End-stage renal disease In North Africa, Cairo, Egypt. Kidney International, 2003, 63:S111–S114. 4. Collins AJ et al. Excerpts from the United States Renal Data System 2006 annual data report. American Journal of Kidney Disease, 2007, 49(1 Suppl. 1):A6–7, S1–296. 5. Moriyama T. [Causes and characteristics of chronic kidney disease.] Japanese Journal of Clinical Medicine, 2008, 66:1664– 1670 [in Japanese]. 6. Stenvinkel P et al. Are there two types of malnutrition in chronic renal failure? Evidence for relationships between mal- nutrition, inflammation and atherosclerosis (MIA syndrome). Nephrology, Dialysis, Transplantation, 2000, 15:953–960. 7. Alpers DH et al., eds. Manual of nutritional therapeutics, 4th ed. Philadelphia, Lippincott, Williams and Wilkins, 2002. 8. Qureshi AR et al. Inflammation, malnutrition, and cardiac dis- ease as predictors of mortality in hemodialysis patients. Journal of the American Society of Nephrology, 2002, 13(Suppl. 1):S28–S36. 9. Afshar R, Sanavi S, Izadi-Khah A. Assessment of nutritional status in patients undergoing maintenance hemodialysis: a single-center study from Iran. Saudi Journal of Kidney Diseases and Transplantation, 2007, 18:397–404. 10. Moore H et al. National Kidney Foundation Council on Renal Nutrition survey: past-present clinical practices and future strategic planning. Journal of Renal Nutrition, 2003, 13:233–240. 11. Berg J et al. Incentive program to control interdialytic weight gains. Journal of Renal Nutrition, 2004, 14(1):52–59. 12. Webster-Gandy J, Madden A, Holdsworth M. Oxford hand- book of nutrition and dietetics, 2nd ed. Oxford, Oxford Univer- sity Press, 2008. 13. Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM, ed. Evaluation of chemotherapeutic agents. Columbia, Columbia University Press, 1949:196. 14. Kalantar-Zadeh K et al. A malnutrition inflammation score is correlated with morbidity and mortality in maintenance he- modialysis patients. American Journal of Kidney Disease, 2001, 38:1251–1263. 15. Dietary guidelines for Americans. Unite States Department of Health and Human Services [website] (http://health.gov/ dietaryguidelines/, accessed 5 November 2012). 16. Cano N. [Malnutrition and chronic renal failure]. Denutrition et insuffisance renale chronique. Annales de Medecine Interne, 2000, 151:563–574. 17. Basaleem HO et al. Assessment of the nutritional status of end- stage renal disease patients on maintenance hemodialysis. Saudi Journal of Kidney Diseases and Transplantation, 2004, 15:455–462. 18. Schulman G. Nutrition in daily hemodialysis. American Journal of Kidney Diseases, 2003, 41(Suppl. 1):S112–S115. 19. Burrowes JD. Incorporating ethnic and cultural food prefer- ences in the renal diet. Advances in Renal Replacement Therapy, 2004, 11:97–104. 20. Afifi A, Karim MA. Renal replacement therapy in Egypt: first annual report of the Egyptian Society of Nephrology, 1996. Eastern Mediterranean Health Journal, 1999, 5(5):1023–1029. 21. Mohammed N. Tuberculosis in chronic renal failure patients under dialysis treatment [thesis]. Cairo, Egypt, Ain Shams Uni- versity, 1987. 22. Mallick NP, Jones E, Selwood N. Annual report on manage- ment of renal failure in Europe XXVII, 1996. XXXIVth Con- gress of the European Renal Association–European Dialysis and Transplantation Association. Geneva, 21–24 September 1997. American Journal of Kidney Diseases, 1997, 30(Suppl. 1):S1– 213. 23. Stenvinkel P et al. A Comparative analysis of nutritional pa- rameters as predictor of outcome in male and female ESRD patients. Sweden, Nephrology, Dialysis, Transplantation, 2002, 17:1266–1274. 24. Moe S et al. Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney International, 2006, 69:1945–1953. study a statistically significant decline in creatinine, urea, calcium and phos- phorus levels were detected comparing before and after the intervention and this is similar to what was reported by Basaleem et al. [17]. To summarize, providing one-to- one nutrition counselling in our study was followed by an improvement in patients’ nutritional knowledge and practice and improvement of their compliance with dietary guidelines for the dialysis patient, which in turn could be linked to significantly improvement in their health status and performance in activities of daily life. Acknowledgements We thank all health care providers in El Harm Centre for Dialysis for their cooperation and all staff colleges in pub- lic health department of the medical college, University of Cairo, Egypt for their continuous support. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 52 Évaluation de la prise en charge des diabétiques par le médecin généraliste dans la province de Khouribga (Maroc) S. Hassoune,1 S. Badri,2 S. Nani, 1 L. Belhadi3 et A. Maaroufi1 RÉSUMÉ Le diabète est une pathologie préoccupante par sa fréquence croissante et le coût élevé de sa prise en charge. Cette étude transversale menée entre décembre 2010 et mars 2011 auprès de 54 médecins généralistes exerçant dans les centres de santé de la province de Khouribga a évalué les modalités de prise en charge des diabétiques dans les structures de première ligne à l’aide d’un questionnaire prétesté. Pour le diabète de type 2, 46 % des généralistes se limitaient à prescrire un régime hygiéno-diététique. Le milieu d’exercice influençait les modalités de la prise en charge du diabète de type 1 : 88,5 % des médecins en milieu rural prescrivaient l’insuline prémixée contre 58,3 % en milieu urbain (p = 0,02). Les analogues d’insuline étaient prescrits par 20,8 % des généralistes en milieu urbain contre 3,8 % en milieu rural (p = 0,09). Il existe plusieurs défaillances dans la qualité de la prise en charge des diabétiques. La formation des médecins généralistes pourrait être une solution, surtout devant la pénurie de spécialistes dans notre pays. 1Laboratoire d’Épidémiologie, Faculté de Médecine et de Pharmacie de Casablanca, Casablanca (Maroc) (Correspondance à adresser à S. Hassoune : s.hassoune@yahoo.fr). 2Médecin généraliste, Casablanca (Maroc). 3Service d’Endocrinologie, Centre hospitalier Baouafi, Casablanca (Maroc). Reçu : 21/02/12; accepté : 08/05/12 برغلما في ةجبروخ ةيلاو في ينماعلا ينسرمالما لَبِق نم ينّيركسلا ضىرلما ةياعر مييقت فيورعلما نحمرلا دبع ،يداهلب لىيل ،نيان ةيرمس ،يردب نايفس ،نوسح ةيرمس تاضيرلما لىإ مدقت يتلا ةياعرلا طمانأ ةضرعتسلما ةساردلا هذه مّيقتو .ةياعرلا في ةيلاعلا هتفلكتل ًارظن ضارملأا ينب ةماه ةناكم يركسلل :ةـصلالخا كراشو ،2011 سرام/راذآو 2010 برمسيد/لولأا نوناك ْيَرهش ينب ةساردلا تيرجأ دقو .نتهلااح يربدتل ةيلولأا ةياعرلا في يركسلاب تاباصلما ضىرملل مهتياعر لوح رابتخلاا لبق نايبتسا ءلم مهنم بلط ثيح ،ةجبروخ ةيلاو في ةيحصلا زكارلما في نولمعي ًاماع ًاسرامم ًابيبط 54 اهيف تاسرمالما عقاوم ددتحو .طقف ةايلحا طمنو يئاذغلا ماظنلا نوفصي ينماعلا ينسرمالما ءابطلأا نم %46 نإف يركسلا نم 2 طمنلل ةبسنلاب امأ .ينيركسلا نم %58.3 لباقم ًاقبسم جوزملما ينلوسنلأا نوفصي فايرلأا في ينماعلا ينسرمالما ءابطلأا نم %88.5 نأ ذإ ؛يركسلا نم 1 طمنلل ةلجاعلما يربدت ةيفيك %3.8 لباقم ندلما في ينماعلا ينسرمالما ءابطلأا نم %20.8 لبق نم ينلوسنلأا تايهاضُم فصوتو .) P = 0.02( ندلما في ينماعلا ينسرمالما ءابطلأا ،ينماعلا ينسرمالما ءابطلأا بيردت في ُّلَلحا لَّثمتيو .يركسلا ضىرم ةياعر ةدوج في روصقلا نطاوم نم ديدعلا كانهو .)P = 0.09( فايرلأا في مهنم .برغلما في ينصاصتخلاا ةلق لظ في ماَّيسلاو Evaluation of the care for diabetes patients by general practitioners in the province of Khouribga, Morocco ABSTRACT Diabetes is a disease of concern due to its increasing frequency and high cost of care. This cross- sectional study evaluated the types of care provided to diabetes patients in primary care for management of the condition. Between December 2010 and March 2011, 54 general practitioners (GPs) in health centres in Khouribga province were asked to complete a pretested questionnaire on their care of diabetes patients. For type 2 diabetes, 46% of the GPs would prescribe diet and lifestyle treatment alone. The practice setting influenced how treatment was managed for type1 diabetes patients: 88.5% of rural doctors prescribed premixed insulin versus 58.3% of urban GPs (P = 0.02). Insulin analogues were prescribed by 20.8% of urban GPs as against 3.8% of rural GPs (P = 0.09). There are several shortcomings in the quality of care for diabetes patients. Training GPs could be a solution, especially with the lack of specialists in our country. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 53 Introduction Le diabète est un problème de santé publique majeur par sa prévalence importante et croissante d’une part, et son impact socio-économique d’autre part [1]. Il touche une partie active de la population et constitue un problème sanitaire mondial en pleine expansion avec 285 millions de diabétiques de par le monde en 2010 [2]. Actuellement, au Maroc, pays en pleine phase de transition démographique, nutritionnelle et épidémiologique [3,4], les études ont montré des chiffres se situant autour de 6,6 %, soit plus d’un million et demi de Marocains en 2010 ; ce chiffre atteindra 2,5 millions à l’horizon 2030 [2]. Le diabète étant une maladie dont le traitement est à vie, la prévention de ses complications, à savoir, la cécité, l’insuffisance rénale, les cardiopathies et les amputations va non seulement améliorer la qualité de vie des patients mais réduira aussi les coûts de leur prise en charge pour le secteur de la santé et les services sociaux (USD 206 millions au Maroc et USD 367 milliards dans le monde en 2010, soit 12 % des dépenses de santé mondiales) [5]. Une prise en charge spécialisée exclusive par les structures de deuxième ligne est impossible vu leur rareté et le nombre réduit de médecins spécialistes dans notre pays. De plus, des études ont montré que la prise en charge du diabète par les structures de première ligne peut égaler celle de deuxième ligne, à condition que les médecins généralistes portent un intérêt spécial pour le diabète et que les soins soient bien organisés [6,7]. L’objectif de notre étude était d’évaluer les modalités de prise en charge des patients diabétiques dans les structures publiques de première ligne de la province de Khouribga. Méthodes Il s’agit d’une étude d’observation transversale à visée descriptive menée dans la province de Khouribga. La population totale de cette province a été estimée en 2009 à 500 000 habitants, dont 338 000 en milieu urbain et 162 000 en milieu rural [8]. Cette province est dotée de 38 établissements de soins de santé de base publics, dont 12 en milieu urbain et 26 en milieu rural, d’un hôpital provincial dans la ville de Khouribga et de deux hôpitaux locaux à Oued- Zem et Bejaad. Cinquante-quatre médecins généralistes exercent dans le réseau de soins de santé de base de la province et il n’y a qu’un seul médecin endocrinologue dans le secteur public de la province qui exerce à l’hôpital provincial de Khouribga. La population étudiée était c o n s t i t u é e d e s 5 4 m é d e c i n s général istes exerçant dans les structures de soins de santé de base de la province de Khouribga, dont 4 ont refusé de participer à l’étude, se justifiant de ne suivre aucun malade diabétique dans leurs consultations en raison de leur affectation récente. Les données ont été collectées de décembre 2010 à mars 2011 à l’aide d’un questionnaire prétesté et auto-administré. Les variables étudiées comprenaient l’utilisation de référentiels de prise en charge et les modalités adoptées par les généralistes concernant le traitement et le suivi des patients. Les données ont été saisies et analysées sur logiciel SPSS version 16. Des fréquences absolues et relatives ont été calculées pour les variables qualitatives et les moyennes et écarts types (ET) pour les variables quantitatives. Nous avons utilisé le test χ2 pour comparer les pourcentages et le test de Student pour comparer les moyennes. Le seuil de significativité a été fixé à 5 %. Avant leur inclusion dans l’étude, les médecins ont été informés des objectifs de l’enquête et leur consentement oral a été obtenu avant l’administration du questionnaire. Par ailleurs, l’anonymat et le respect de la confidentialité des données ont été assurés. Résultats Caractéristiques générales de l’échantillon Les médecins interrogés avaient un âge moyen de 39,5 (ET 7,3) ans avec une légère prédominance masculine. Cinquante-deux pour cent d'entre eux exerçaient en milieu rural (Tableau 1). Organisation de la consultation diabétique La moyenne de diabétiques reçus en consultation chaque semaine était de 11,3 (ET 8,0) avec un maximum de 40 diabétiques par semaine. Parmi les médecins interrogés, 96 % ont affirmé avoir un registre pour diabétiques au centre de santé qui était informatisé dans 8,3 % des cas. Dix-huit pour cent d’entre eux réservaient des consultations spéciales pour diabétiques ; la plupart (88 %) le faisaient l’après-midi et une fois par semaine (44 %). Concernant les moyens de suivi existant au centre de santé, les bandelettes urinaires n’étaient disponibles que dans 10 % des centres. La disponibilité des autres moyens est présentée dans la figure 1. Soixante pour cent des médecins interrogés ont jugé que la qualité et la quantité des moyens thérapeutiques existants au centre étaient insuffisantes pour couvrir les besoins de leurs patients diabétiques. Prise en charge des diabétiques au niveau du centre de santé Traitement Utilisation de référentiels de prise en charge de diabétiques : parmi les médecins interrogés, 46 % disposaient de référentiels de prise en charge du diabète et 95 % parmi eux les utilisaient dans la prise en charge de leurs patients diabétiques. Les référentiels étaient affichés au centre de santé dans 17,4 % des cas. Éducation des patients diabétiques : les médecins assuraient, dans 96 % des cas, l’éducation de leurs patients diabétiques. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 54 4 % des cas. Les analogues d’insuline n’étaient utilisés que dans 12 % des cas. Les médecins généralistes des centres de santé demandaient l’avis de l’endocrinologue avant de démarrer l ’insulinothérapie dans 64 % des cas. Selon les médecins interrogés, le manque d’observance des règles hygiéno-diététiques et du traitement était la cause principale d’échec de l’insulinothérapie. Les autres causes sont présentées dans la figure 2. Traitement du diabète de type 2 : à la découverte d’un diabète de type 2, 46 % des médecins démarraient par les règles hygiéno-diététiques seules, alors que 40 % leur associaient la metformine et 14 % les sulfamides. L’attitude habituelle des médecins en cas d’échec de la première thérapie consistait à associer un deuxième antidiabétique oral (60 %), alors que 10 % préféraient adresser le patient à un diabétologue et 8 % procédaient à un changement de l’antidiabétique oral (ADO). La grossesse (88 %) et l’échec de la thérapie per os (84 %) v e n a i e n t e n t ê t e d e s r a i s o n s amenant les médecins à initier le patient à l’insulinothérapie. Plus de la moitié (54 %) des médecins ont estimé que la valeur d’HbA1c à ne pas dépasser pour parler d’un bon équilibre glycémique était de 7 %. Suivi La majorité des médecins généralistes demandaient un dosage de l’HbA1c tous les trois mois à leurs patients quelle que soit la qualité du contrôle diabétique, mais seulement 31 % d e s p a t i e n t s l e r é a l i s a i e n t . L a pauvreté (80 %) et les problèmes d ’ a c c è s a u l a b o r a t o i r e ( 1 4 % ) venaient en tête des raisons citées par les médecins comme entravant la réalisation du dosage de l’HbA1c demandé aux patients au cours de leur Les infirmiers participaient dans 54 % des cas à cette éducation. Par ailleurs, les diététiciens étaient totalement absents dans les centres de la province. Traitement du diabète de type 1 : le schéma d’insuline le plus utilisé était celui à base de 2 injections d’insuline prémixée prescrit par 74 % des médecins, suivi par le schéma fait de 2 injections d’insuline mixée au moment de l’utilisation (18 %) et enfin le schéma basal-bolus prescrit dans Tableau 1 Caractéristiques des médecins interrogés (n = 50) Caractéristiques Nbre % Moyenne (ET) Âge (ans) - < 40 31 62 40-49 11 22 39,5 (7,3) ≥ 50 8 16 - Sexe Masculin 27 54 - Féminin 23 46 - Milieu d’exercice Urbain 24 48 - Rural 26 52 - Durée d’exercice (années) Milieu urbain Totale - - 14,4 (8,2) Centre actuel - - 6,7 (3,1) Milieu rural Totale - - 6,9 (3,5) Centre actuel - - 2,9 (1,7) ET : écart type. 98 86 72 66 64 10 0 0 20 40 60 80 100 Te ns iom ètr e Pè se pe rso nn e M ètr e r ub an To ise Le cte ur de gl yc ém ie ca pil lai reBa nd ele tte s ur ina ire s Le cte ur d’ Hb A1 c % Figure 1 Disponibilité des moyens de suivi des patients diabétiques طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 55 suivi. Le moyen remplaçant le dosage de l’HbA1c, si non effectué, était en général la réalisation de glycémies ponctuelles capillaires (90 %). Le bilan dégénératif demandé par les médecins comportait le plus souvent les trois volets du bilan, à savoir rénal (96 %), ophtalmologique (90 %) et cardiologique (80 %). L’examen des pieds n’était fait systématiquement que dans 6 % des cas. La majorité (89 %) des médecins demandait un bilan dégénératif une fois tous les ans, mais les trois quarts de leurs patients ne le réalisaient pas à leur demande. La pauvreté (72 %) venait en tête des problèmes empêchant la réalisation de ce bilan. Concernant le bilan lipidique, il était demandé par 94 % des médecins, à un rythme annuel dans 81 % des cas. Le dosage de l’acide urique n’était demandé que par 56 % des médecins qui le prescrivaient une fois par an dans 89 % des cas. Influence du milieu d’exercice sur les modalités de prise en charge diabétique Le nombre moyen de diabétiques reçus en consultation par semaine était significativement plus élevé en milieu urbain (16,38 ET 7,81) qu’en milieu rural (6,56 ET 4,73) avec p < 0,01. Par ailleurs, nous avons relevé quelques différences dans la prise en charge (PEC) des diabétiques entre les milieux rural et urbain qui sont présentées dans le tableau 2. Le problème de manque de moyens économiques venait en tête des problèmes de non-réalisation du dosage de l’HbA1c dans les deux milieux rural (69,2 %) et urbain (91,7 %), mais avec l’accès au laboratoire encore plus difficile pour les patients du milieu rural (23,1 %) que pour ceux du milieu urbain (4,2 %). 60% 11% 9% 6% 4% 4% 4% 2% Manque d’observance RHC traitement Manque d’éducation Manque de suivi régulier Problème économique Mauvaise conservation de l’insuline Infections Manque de moyens de surveillance Hypoglycémies à répétition Figure 2 Problèmes les plus incriminés dans l’échec de l’insulinothérapie RHD : règles hygiéno-diététiques Tableau 2 Influence du milieu d’exercice sur les modalités de prise en charge du diabétique Modalités de prise en charge Milieu p Urbain Rural Nbre (%) Nbre (%) Consultations spéciales pour diabétiques 3 (12,5) 6 (23,1) 0,47 Utilisation de référentiels de PEC 11 (100) 11 (91,7) 1 Éducation des diabétiques 24 (100) 24 (92,3) 0,49 RHD seules 13 (54,2) 10 (38,5) 0,39 Insuline prémixée 14 (58,3) 23 (88,5) 0,02 Insuline mixée au moment de l’utilisation 7 (29,9) 2 (7,7) 0,07 Prescription du schéma basal-bolus 1 (4,2) 1 (3,8) 1 Avis de l’endocrinologue avant l’insulinothérapie 17 (70,8) 15 (57,7) 0,39 Analogues d’insuline 5 (20,8) 1 (3,8) 0,09 Orientation du patient si besoin 24 (100) 24 (92,3) 0,49 PEC : prise en charge ; RHD : règles hygiéno-diététiques. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 56 Discussion Notre échantillon initial était représenté par les 54 médecins généralistes exerçant dans les structures de première ligne de la province de Khouribga, dont 4 ont refusé de participer à l’étude. La population étudiée était jeune, puisque 84 % étaient âgés de moins de 50 ans avec une moyenne d’âge de 39,5 ans(ET 7,3) et une légère prédominance masculine (54 % d’hommes). Cinquante-deux pour cent des généralistes exerçaient en milieu rural. Le nombre moyen de diabétiques reçus en consultation par semaine était significativement plus élevé en milieu urbain (16,38 ET 7,81) qu’en milieu rural (6,56 ET 4,73). Ceci pourrait être expliqué par le fait que deux tiers de la population de la province est urbaine [8] ainsi que par l’accès plus facile de la population urbaine aux centres de santé. Parmi les médecins interrogés, 96 % ont affirmé avoir un registre pour diabétiques au centre de santé, ce qui se rapproche des chiffres retrouvés en Irlande du Nord et en Angleterre qui sont respectivement de 92 % et 96 % [6,7]. Ce registre est un moyen nécessaire pour le suivi de toute maladie chronique [7]. Néanmoins, seulement 8,3 % des registres étaient informatisés. Un registre informatisé facilite la conservation des données, pour un suivi plus facile des patients, et leur exploitation à grande échelle pour des études statistiques ultérieures [9- 11]. Dix-huit pour cent des généralistes réservaient des consultations spéciales pour diabétiques, ce qui reste très faible par rapport aux études similaires (71 % et 75 %) [6,7]. La plupart (88 %) le faisait l’après-midi et une fois par semaine (44 %). Les centres de santé ne disposaient pas de tous les moyens de base pour un suivi clinique de l’évolution de la maladie diabétique, à savoir un lecteur de glycémie capillaire, un tensiomètre, une toise, un pèse personne, un mètre ruban et des bandelettes urinaires. Les bandelettes urinaires étaient le moyen de suivi de base qui manquait le plus au niveau des centres, avec seulement 10 % des centres qui en disposaient, limitant ainsi le diagnostic de cas de protéinurie et de cétonurie [12]. Concernant les moyens thérapeutiques existants au centre de santé, 60 % des médecins interrogés estimaient qu’ils étaient insuffisants en qualité et en quantité pour couvrir les besoins de leurs patients diabétiques. Les référentiels de prise en charge diabétique n’étaient disponibles que chez 46 % des médecins. La majorité d’entre eux les utilisaient dans la prise en charge de leurs patients diabétiques. Des référentiels sont nécessaires pour aider les praticiens à prendre les meilleures décisions thérapeutiques pour leurs patients [13], chaque centre pouvant adopter des référentiels développés au niveau national ou adaptés afin de refléter leur situation particulière, à savoir, leurs moyens, situation géographique et population [12,14]. Les diététiciens étaient absents dans les centres de la province, alors que les recommandations de l’American Diabetes Association (ADA) voudraient que tous les diabétiques nouvellement diagnostiqués soient évalués par un diététicien [15], objectif irréalisable vu leur absence totale dans les structures sanitaires locales. Pour le traitement du diabète de type 1, les médecins du milieu rural préféraient en grande majorité (88,5 %) l’utilisation d’insuline prémixée en première intention contre 58,3 % des médecins du milieu urbain en raison de sa disponibilité dans tous les centres de santé et la facilité d’utilisation au quotidien, malgré son efficacité médiocre dans l’obtention d’un bon contrôle glycémique [16,17]. L’avis du médecin endocrinologue avant de démarrer l’insulinothérapie chez le diabétique type 1 était plus souvent demandé en milieu urbain (70,8 %) qu’en milieu rural (57,7 %), différence qui s’expliquerait par l’éloignement des centres ruraux de l’hôpital provincial où exerce le seul endocrinologue de la province. Son avis devrait être demandé dans tous les cas nouvellement diagnostiqués [12,15,18,19]. L’utilisation d’analogues d’insuline était très rare en milieu rural (3,8 %) par rapport au milieu urbain (20,8 %) malgré le meilleur contrôle glycémique obtenu après leur utilisation, à savoir moins de risque d’hypoglycémies nocturnes et la possibilité de prendre les repas directement après l’injection [19,20]. Ceci pourrait s’expliquer par leur prix élevé et l’insuffisance de couverture médicale de base, mais aussi par l’inégalité d’accès aux pharmacies pour les régions éloignées [16,21]. Le manque d’observance des règles hygiéno-diététiques et du traitement était considéré comme la cause principale d’échec de l’insulinothérapie. Presque la moitié (46 %) des m é d e c i n s n e p r e s c r i v a i e n t q u e le régime hygiéno-diététique à la découverte du diabète de type 2. P l u s i e u r s o r g a n i s a t i o n s ( A D A , European Association for the Study of Diabetes [EASD]) recommandent que le patient nouvellement diagnostiqué, en plus des règles hygiéno-diététiques, soit mis sous agent hypoglycémiant unique par voie orale, la metformine étant le choix de première intention sauf contre-indications [15,22]. L’attitude habituelle des médecins en cas d’échec de la première thérapie consistait à associer un deuxième antidiabétique oral (60 %), ce qui est conforme aux recommandations consistant à une intensification du traitement avec ajout de nouvelles molécules afin d’atteindre et de maintenir les objectifs glycémiques [15,22,23]. L a m a j o r i t é d e s m é d e c i n s généralistes demandaient un dosage de l’HbA1c tous les trois mois à leurs patients, quelle que soit la qualité du contrôle diabétique. La notion de diabète bien équilibré semblait chez certains (26 %) modifier le rythme طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 57 de demande de dosage de l’HbA1c. L’ADA recommande en effet de réaliser un dosage de l’HbA1c tous les trois mois dans la limite des moyens disponibles, de limiter la réalisation de ce dosage à deux fois par an si le diabète est bien équilibré [15]. Plus de la moitié (54 %) des médecins ont estimé que la valeur de l’HbA1c à ne pas dépasser pour parler d’un bon équilibre glycémique était de 7 % et ceci est en concordance avec les recommandations de l’ADA et de l’EASD [1,15]. Un peu plus d’un patient sur quatre (31 %) réalisait le dosage d’HbA1c à la demande des médecins. La pauvreté, renvoyant au coût de la réalisation du dosage d’HbA1c en laboratoire privé car indisponible dans les laboratoires des structures publiques, et les problèmes d’accès au laboratoire, à savoir l’éloignement géographique surtout pour la population rurale, venaient en tête des raisons citées par les médecins comme entravant la réalisation du dosage de l’HbA1c demandée au patient au cours de son suivi. Le moyen remplaçant le dosage de l ’HbA1c, si non fait , était en général la réalisation de glycémies ponctuelles capillaires (90 %). Doser l’HbA1c reste la méthode de référence car elle reflète la moyenne de la glycémie pour plusieurs mois [15] ; son remplacement par la mesure de la glycémie paraît une assez bonne alternative. La mesure de la glycémie, soit la glycémie à jeun soit la glycémie postprandiale, est corrélée positivement à l’atteinte de l’équilibre glycémique chez les diabétiques [1]. Le bilan dégénératif demandé par les médecins comportait le plus souvent les volets rénal (96 %), ophtalmologique (90 %) et cardiologique (80 %). L’examen des pieds n’était fait systématiquement que dans 6 % des cas, bien que le diabète reste la cause d’amputation non traumatique la plus commune [23,24]. La majorité des médecins demandaient un bilan dégénératif une fois tous les ans comme le voudraient les recommandations de l’ADA et de la Haute Autorité de santé (HAS) française [15,18,19,23]. L a m a j o r i t é d e s m é d e c i n s d e m a n d a i e n t à l e u r s p a t i e n t s diabétiques un bilan lipidique une fois par an. Ce bilan est recommandé chez les patients diabétiques car les dyslipidémies avec le diabète font partie des facteurs de risque cardio- vasculaires à contrôler [22], d’autant plus que le diabète de type 2 s’inscrit habituellement dans le cadre d’un syndrome métabolique [25]. Cinquante-six pour cent des médecins demandaient un dosage d’acide urique à leurs pat ients diabétiques ; parmi eux, 89 % le faisaient une fois par an. Le taux d’acide urique est élevé dans le syndrome métabolique, dont le diabète type 2 peut être la manifestation la plus franche [25,26]. Au vu des résultats de notre étude, il nous a semblé important de formuler certaines recommandations. Il serait judicieux de standardiser la prise en charge des diabétiques à l’échelle nationale par l’élaboration des référentiels thérapeutiques, d’équiper les centres en moyens diagnostiques et thérapeutiques suffisants et de former les médecins à leur utilisation, de réorganiser la consultation des diabétiques au niveau des centres de santé en impliquant activement les infirmiers dans l’éducation des patients, d’améliorer l’accessibilité financière à travers l’extension de la couverture médicale de base à tous les diabétiques, d’organiser des séminaires de formation continue sur le diabète au profit des médecins généralistes en tenant compte de leurs besoins et de leur milieu d’exercice et de créer un centre de référence de diabétologie où une prise en charge multidisciplinaire serait possible. Conclusion Le domaine d’activité du MG est sans limite et il ne peut avoir une connaissance parfaite de toutes les nouvelles thérapeutiques de toutes les pathologies. La formation de généralistes particulièrement motivés et intéressés par le diabète pourrait être la solution pour améliorer la prise en charge de cette pathologie. Le service spécialisé pourra n’être contacté qu’en cas de nécessité. Références 1. Farouqi A, Harti M-A, Nejjari C. Prise en charge du diabète au Maroc : résultats de l’International Diabetes Management Practices Study (IDMPS) – Vague 2 [Management of diabetes in Morocco : Results of the International Diabetes Management Practices Study (IDMPS) – Wave 2]. Médecine des Maladies métaboliques, 2010, 6:704–711. 2. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the preva- lence of diabetes for 2010 and 2030. Diabetes Research and Clinical Practice, 2010, 87:4–14. 3. Amuna P, Zotor Francis B. Epidemiological and nutrition transi- tion in developing countries: impact on human health and de- velopment. Proceedings of the Nutrition Society, 2008, 67:82–90. 4. Benjelloun S. Nutritional transition in Morocco. Public Health Nutrition, 2002, 5:135–140. 5. Zhang P et al. Global healthcare expenditure on diabetes for 2010 and 2030. Diabetes Research and Clinical Practice, 2010, 87:293–301. 6. Kenny CJ, Pierce M, McGerty S. A survey of diabetes care in general practice in Northern Ireland. Ulster Medical Journal, 2002, 71:10–16. 7. Pierce M, Agarwal G, Ridout D. A survey of diabetes care in general practice in England and Wales. British Journal of Gen- eral Practice, 2000, 50:542–545. 8. Santé en chiffres 2009. Rabat, Ministère de la Santé, Direc- tion de la Planification et des Ressources financières, Divi- sion de la Planification et des Études, Service des Études et de l’Information sanitaire (http://srvweb.sante.gov.ma/ Publications/Etudes_enquete/Documents/SANTE_ENCHIF- EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 58 FRES_2009,%20EDITION%202010.pdf, consulté le 30 octo- bre 2012). 9. Elwyn GJ, Vaughan NJA, Stott NCH. District diabetes registers: More trouble than they are worth? Diabetic Medicine, 1998, 15:44–47. 10. Recommandations for the management of diabetes in primary care, 2nd ed. London, British Diabetic Association, 1997. 11. Coppell KJ et al. Evaluation of diabetes care in the Otago re- gion using a diabetes register, 1998–2003. Diabetes Research and Clinical Practice, 2006, 71:345–352. 12. Recommendations for the provision of services in primary care for people with diabetes 2005. London Diabetes UK, 2005 (http://www.diabetes.org.uk/Documents/Professionals/ primary_recs.pdf, consulté septembre 2012). 13. Manchikanti L. Evidence-based medicine, systematic reviews, and guidelines in interventional pain management, part I: in- troduction and general considerations. Pain Physician, 2008, 11:161–186. 14. Al Khaja KAJ, Sequeira RP, Damanhori AHH. Comparison of the quality of diabetes care in primary care diabetic clinics and general practice clinics. Diabetes Research and Clinical Practice, 2005, 70:174–182. 15. American Diabetes Association. Standards of Medical Care in Diabetes 2010. Diabetes Care, 2010, 33:S11–S61. 16. Indian National Consensus Group. Premix Insulin: Initiation and Continuation Guidelines for Management of Diabetes in Primary Care. Journal of the Association of Physicians of India, 2009, 57:S42–45 (http://www.japi.org/february_2009/7.pdf, consulté september 2012). 17. He T, Matthews DR. The use of fixed-mixture insulins in clini- cal practice. European Journal of Clinical Pharmacology, 2000, 56:19–25. 18. Haute Autorité de santé (HAS). Guide - Affection de longue durée. Diabète de type 1 de l’adulte [Chronic Disease Guide. Adult Type 1 Diabetes] 2007 (http://www.has-sante.fr/por- tail/upload/docs/application/pdf/ald8_guidemedecin_dia- betetype1_revunp_vucd.pdf, consulté le 30 octobre 2012). 19. Haute Autorité de santé (HAS). Guide - Affection de longue du- rée. Diabète de type 1 de l’enfant et de l’adolescent [Chronic Disease Guide. Child and Adolescent Type 1 Diabetes], 2007 (http://www.has-sante.fr/portail/upload/docs/application/ pdf/ald8_guidemedecin_diabetepediatrie_revunp_vucd.pdf, consulté le 30 octobre 2012). 20. Hanna A. Les analogues de l’insuline à longue durée d’action [Long-acting insulin analogs]. Endocrinologie – Conférences scientifiques, 2005, 5(4) (www.endocrinologieconferences. ca/crus/endocan_0405_fre.pdf, consulté le 30 octobre 2012). 21. Kherbach F. El Alami El Fellousse. Étude sur le financement des soins de santé au Maroc [Study on healthcare financing in Morocco]. Genève, Organisation mondiale de la Santé, 2007 (http://gis.emro.who.int/HealthSystemObservatory/ PDF/Health%20Care%20Financing/Mapping%20Health%20 care%20Financing%20Morocco.pdf, consulté le 30 octobre 2012). 22. Harkins V. A practical guide to integrated type 2 diabetes care. Dublin, Irish Endocrine Society, 2008 (http://www.hse. ie/eng/services/Publications/topics/Diabetes/A_Practical_ Guide_to_Integrated_Type_II_Diabetes_Care.pdf, consulté septembre 2012). 23. Haute Autorité de santé (HAS). Guide - Affection de longue durée. Diabète de type 2 de l’adulte [ Chronic Disease Guide. Adult Type 2 diabetes], 2007(http://www.has-sante.fr/por- tail/upload/docs/application/pdf/ald8_guidemedecin_dia- betetype2_revunp_vucd.pdf, consulté le 30 octobre 2012). 24. Turning the corner: improving diabetes care. London, Depart- ment of Health, 2006 (http://www.dh.gov.uk/prod_con- sum_dh/groups/dh_digitalassets/@dh/@en/documents/ digitalasset/dh_4136011.pdf, consulté septembre 2012). 25. Bonnet F, Laville M. Le syndrome métabolique : définition, épidémiologie, complications [Metabolic syndrome: defini- tion, physiopathology and complications]. Spectra Biologie, 2005, 145:27–29 (http://www.pcipresse.com/spectrabiol- ogie/wp-content/uploads/2012/05/SB145_27-29.pdf, con- sulté le 30 octobre 2012). 26. Association de Langue française pour l'Étude du Diabète et des Maladies métaboliques (ALFEDIAM) et Société Française de Cardiologie (SFC). Recommandations SFC / ALFEDIAM sur la prise en charge du patient diabétique vu par le cardiologue [SFC/ALFEDIAM (French Cardiology Society/French-speaking Association for the Study of Diabetes and Metabolic Diseases) recommendations on the management of the diabetic patient seen by a cardiologist] (http://www.alfediam.org/membres/ recommandations/recos_sfc_alfediam.pdf., consulté le 30 octobre 2012). طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 59 Trends of skin cancer incidence in 6 geographical regions of the Islamic Republic of Iran, 2000–2005 M. Heidari 1 and F. Najafi 1 ABSTRACT Data about the incidence of skin cancer in the Islamic Republic of Iran are lacking. This study investigated trends in the incidence of skin cancer (ICD-10 category C44, other malignant neoplasms of skin) in 6 regions using data from the Iranian cancer registry from 2000 to 2005. The standardized incidence rates in each year were calculated by the direct method using the standard World Health Organization population and a Poisson regression model was applied to analyse trends. Over the study period, 30 701 cases of cancer were identified, rising from 2353 in 2000 to 8484 in 2005. The male-to-female ratio was 1.6. The age-standardized incidence rose significantly from 3.8 cases per 100 000 in 2000 to 13.0 in 2005 (slope = 0.26), and the same trend was seen in all regions except the region to the east of the Caspian Sea. This increasing incidence of skin cancer in the Islamic Republic of Iran is similar to that reported in other countries. 1School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Islamic Republic of Iran (Correspondence to F. Najafi: farid_ n32@yahoo.com; fnajafi@kums.ac.ir). Received: 22/11/11; accepted: 26/01/12 2005 - 2000 ةيملاسلإا ناريإ ةيروهجم في ةيفارغج قطانم ةتس في دللجا ناطسر ثودح تلادعم تاهاتجا يفجن ديرف ،يرديح دممح ثودح تلادعم تاهاتجا ةساردلا هذه صيقتستو .ةيملاسلإا ناريإ ةيروهجم في دللجا ناطسر ثودح لدعم لوح تايطعملل بايغ كانه :ةـصلالخا مادختساب ،قطانم تس في ؛)ةيمونلايمـلا يرغ دللجا تاناطسرو ،)ضارملأل ليودلا فينصتلل ةشراعلا ةجارخلإا في C 44 زومارلا( دللجا ناطسر ،ةشرابم ةقيرطب ماع لكل ةيرايعلما ثودلحا تلادعم ناثحابلا َبَسَح دقو .2005 – 2000 ةترفلل ناطسرلل نياريلإا لجسلا نم ةدمتسلما تايطعلما مت ،ةساردلا ةترف للاخ هنأ ماله حضتاو .ليلحتلا تاهاتجا لىع ماهقيبطتو ،نوساوب ف ُّوتحو ،ناكسلل يرايعلما ةيلماعلا ةحصلا ةمظنم جذومن مادختساب لدعم عفتراو ،1.6 = ثانلإا لىإ روكذلا ةبسن تناكو .2005 ماع في 8484 لىإ تعفتراو 2000 ماع في 2353 تناك ،ناطسر ةلاح 30 701 صيخشت ؛)0.26 = لَماَمـلا( 2005 ماع فلأ ةئم لكل ةلاح 13.0 لىإ 2000 ماع فلأ ةئم لكل ةلاح 3.8 نم ًايئاصحإ هب دتعي ًاعافترا رمعلل ًاقفو َّريرعلما ثودلحا ناريإ ةيروهجم في دللجا ناطسر ثودح لدعم في دايدزلاا نأ ناثحابلا ىريو .نيوزق رحب قشر ةقطنم ءانثتساب قطانلما عيجم في هتاذ هاتجلاا ظحول ماك .ىرخلأا نادلبلا في ل ِّجُس الم هباشم ةيملاسلإا Évolution de l'incidence du cancer de la peau dans six régions géographiques de la République islamique d'Iran entre 2000 et 2005 RÉSUMÉ Les données sur l'incidence du cancer de la peau en République islamique d'Iran font défaut. L'étude a examiné l'évolution de l'incidence du cancer de la peau (CIM-10 catégorie C44, autres tumeurs malignes de la peau) dans six régions à partir des données du registre du cancer iranien entre 2000 à 2005. Les taux d'incidence normalisés chaque année ont été calculés par méthode directe à l'aide de la population type de l'Organisation mondiale de la Santé. Un modèle de régression de Poisson a été appliqué pour analyser les évolutions. Pendant la période de l'étude, 30 701 cas de cancer ont été identifiés, passant de 2353 en 2000 à 8484 en 2005. Le rapport hommes/femmes était de 1 pour 6. Le taux d'incidence normalisé selon l'âge a nettement augmenté, passant de 3,8 cas pour 100 000 en 2000 à 13,0 en 2005 (pente = 0,26), et la même évolution a été observée dans toutes les régions à l'exception de la région située à l'est de la mer Caspienne. L'incidence croissante du cancer de la peau en République islamique d'Iran est similaire aux incidences notifiées dans d'autres pays. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 60 Introduction Skin cancer is the most prevalent type of cancer in Caucasian populations (Indo-Europeans) [1]; 80% of the total incidence is observed in the United States (US), Europe, Australia and New Zealand [2]. In the US only, more than 1 million new cases of skin cancer were diagnosed in 2009 and approxi- mately 12 000 people lost their lives in the same year [3]. There are 2 types of skin cancer: melanoma and non- melanoma. While melanoma accounts for only 1% of cases of skin cancer [4], it is considered the main cause of mortal- ity from the disease [3]. As for the non- melanoma type, Caucasians have the highest incidence compared with Asian and Hispanic races. However, it rarely occurs in black populations [5–7]. Monitoring the incidence of skin cancer has shown that there is an increasing trend in most countries in the world. Some examples are the Netherlands, where the incidence increased by 80% between 2000 and 2005 [8], and Brazil, where the incidence increased from 50 cases per 100 000 in 2000 to 94 per 100 000 in 2006 [9]. The important risk factors for skin cancer are high exposure to solar ultravi- olet (for both melanoma and non-mel- anoma types) and racial susceptibility of Caucasians [3]. Decreasing latitude is associated with increased incidence of non-melanoma skin cancer [10]. For example in Queensland, Australia, the incidence is higher than in Europe and North America [2]. Although sunlight is an important risk factor, the develop- ment of skin cancer is mainly related to solar ultraviolet radiation [3,8,11], the dose of which are thought to be increas- ing as a result of thinning of the ozone layer of the atmosphere [12]. Among other risk factors are high alcohol con- sumption [13], diets high in fat and meat [14] and genetic predisposition [15]. In the Islamic Republic of Iran, skin cancer is also the most prevalent cancer [16,17] with a male-to-female ratio of 1.6 [18]. In 2004, a study in Golestan province showed that the incidence of skin cancer in men aged 80+ years was 161.9 per 100 000, the highest reported rate for skin cancer worldwide [19]. From the epidemiological viewpoint, the peak of skin cancer incidence in Islamic Republic of Iran is observed in the 7th and 8th decades of life [18] and is mostly reported in farmers [20]. The present study was designed to evaluate the age-standardized incidence trend for non-melanoma skin cancer from 2000–05, based on data from the Iranian cancer registry. The results of the study were expected to inform policy- makers about future trends in skin can- cer in the Islamic Republic of Iran in order to plan health interventions. Methods Data sources In this population-based study data were obtained from the national cancer registry at the Centre for Disease Con- trol of the Iranian Ministry of Health. Each year, cancer data are collected from all pathology centres across the country. The data received are then monitored for errors in coding, demo- graphic information, duplicates and missing identities. It should be noted that recording and reporting cases of cancer became mandatory in 1984 in the Islamic Republic of Iran, and the first report was published in 1986. With the development of the Pars software, the Iranian national cancer registry was improved in 2000. Cancers are classi- fied according to the International Clas- sification of Disease (ICD-10) second revision [21]. Coding and analysis For the purpose of this study, we used ICD-10 category C44 for skin cancer, non-melanoma type (other malignant neoplasms of skin). The country was di- vided into 6 geographical regions: south and west of the Caspian Sea (Gilan and Mazandaran provinces), east region of the Caspian Sea (Golestan province), flat region (Tehran, Qom, Qazvin, Zanjan, East Azerbaijan, West Azerbaijan and Ardebil provinces), mountainous region (Kermanshah, Kurdestan, Hamedan, Ilam, Chaharmahal va Bakhtiari and Kohkiluye va Buyerahmad provinces), desert region (Fars, Kerman, Sistan va Baluchistan, Yazd, Semnan, Khorasan, Birjand and Isfahan provinces) and re- gion around the Persian Gulf (Khuzestan, Bushehr and Hormozgan provinces). Cases with no information on residential province were considered in the calcula- tion of overall national incidence rate and not in calculations for different geo- graphical regions. For standardization of incidence, the results of the national population consensus of 2006 were used [22]. Con- sidering the annual population growth rate of 1.01%, the population of different geographical regions was determined for 2000, 2001, 2002, 2003, 2004 and 2005. The World Health Organization (WHO) standard population was used as the reference population [23]. Using direct methods and STATA software, version 11, age–sex incidence rates and 95% confidence interval (CI) for the country overall and for the 6 geo- graphical regions were calculated. The sig- nificance of incidence trends was tested by a Poisson regression model. All graphs were drawn with Microsoft Excel 2007. Results Over the 6-year period of the study, 30 701 cases of skin cancer were reg- istered in the Islamic Republic of Iran, with an increase from 2353 cases in 2000 to 8484 cases in 2005. The male- to-female ratio was 1.6. The mean age was 61.4 [standard deviation (SD 14.6)] years: 60.0 (SD 14.9) for women and 62.0 (SD 14.3) for men. There was a significant increase in age-standardized incidence from 3.8 cases per 100 000 in 2000 to 13.0 cases per 100 000 in 2005. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 61 for both sexes were very similar, with a rise observed in 2001. Apart from 2000, the incidence of skin cancer was higher for men. The Poisson regression test showed a significant trend in men only. Mountainous region The mountainous region had the high- est incidence of skin cancer compared with the other regions (Figure 2). Except for 2000, the age-standardized incidence was higher than other re- gions. There was an increasing trend in incidence, with 4.5 cases per 100 000 in 2000 rising to 16.1 cases in 2005. The age-standardized incidence for men rose dramatically from 5.4 cases per 100 000 in 2000 to 19.7 cases in 2005, the highest incidence among the regions. The figure for women increased from 3.5 cases per 100 000 in 2000 to 12.5 cases in 2005 (Table 1). The trend was similar for both sexes. Desert region This region was ranked 3rd considering the 6-year average incidence, after the mountainous and flat regions (Figure 2). Like other regions, the general trend of age-standardized incidence was in- creasing from 5.8 cases per 100 000 in 2000 reaching 12.4 cases in 2005. In 2001, the incidence was almost half that of the previous year before rising in 2002. The increase had a steeper gradient from 2003 onwards. Trends of incidence in men and women were similar (Table 1). Both sexes showed a decrease in incidence in 2001 and a gentle gradient up to 2003, followed by a large increase from 2003 onwards. Flat region This region came 2nd after the moun- tainous region in terms of the highest risk for skin cancer (Figure 2). The age standardized rate increased from 2.2 cases per 100 000 in 2000 to 15.1 cases in 2005, indicating a 7.5-fold increase in incidence over the period. After a slight decrease in 2002, the occurrence of skin cancer increased sharply. The trend for age-standardized incidence was similar for men and women with both drop- ping slightly in 2002. The incidence for men was higher and rose from 2.3 cases per 100 000 in 2000 to 18.7 cases in 2005. The figure for women rose from 2.0 to 11.5 cases per 100 000 in the same period (Table 1). Region around the Persian Gulf The region around the Persian Gulf had the lowest incidence of skin cancer (Figure 2). In fact, the average 6-year incidence was 10 times lower than in the mountainous region, where the greatest number of cases was found. Here the trend was also upwards, albeit with a gradient lower than other regions. The age-standardized incidence increased from 0.05 cases per 100 000 in 2000 to 3.0 cases in 2005. Unlike other regions and similar to the mountainous region, there was an increase in the incidence in all the years under study. The difference between the incidence of skin cancer in men and women was small and slightly higher for women (contrary to other regions). While the age-standardized incidence for men increased from 0.04 cases per 100 000 in 2000 to 3.0 in 2005, women showed an increase from 0.05 to 2.9 cases per 100 000 in the period. Although the incidence for men experi- enced a continuous increase, the rate for women decreased slightly in 2004. Discussion Overall, the results of the study showed an upwards trend in the incidence of skin cancer in the Islamic Republic of Iran, with a 3.4-fold increase over the 6-year period. Although a rising trend was observed in all regions the change gradient was different, with the low- est and highest increases in incidence for the mountainous and Persian Gulf regions respectively. In all regions, the incidence was higher for men and for both sexes the incidence rose slowly at This increasing trend was observed with various gradients in all the 6 geographi- cal regions of the country. The age-standardized incidence for men was higher, rising from 4.5 cases per 100 000 in 2000 to 16.0 cases in 2005, while the rate for women in- creased from 3.0 cases per 100 000 in 2000 to 9.8 cases in 2005 (Table 1). Despite different gradients of inci- dence trend for different years, the trend across age groups was similar each year: a very slow rise in the age groups < 20 years, with a 4-fold increase by the age group 50–59 years, rising sharply thereafter up to the age 80+ years, where it reached the highest incidence (Figure 1). Over the period of the study and on average, the highest incidence of skin cancer occurred in the mountainous region followed by the flat and desert regions (Figure 2). South and west of the Caspian Sea The region with the highest amount of rainfall ranked 4th for average incidence of skin cancer (Figure 1). The age- standardized incidence for skin cancer increased significantly from 2.6 cases per 100 000 in 2000 to 8.9 cases in 2005. In 2001, the incidence fell sharply to half the figure of 2000, only to bounce back 3-fold in 2002. The trend was steady for 2005, rising only 0.4 per 100 000 above the figure for 2004. The incidence trend for both sexes was similar, with the age- standardized incidence decreasing in 2001, and then increasing onwards with almost the same gradients (Table 1). However, as seen in other regions, the incidence for men was higher. East of the Caspian Sea Except for 2001, where the incidence of skin cancer rose dramatically to 5.4 cases per 100 000, the regional inci- dence was lower than that of the other regions of the Caspian Sea (Table 1). The region saw an increase from 1.0 cases per 100 000 in 2000 to 6.1 cases in 2005. The changes in incidence trend EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 62 Ta bl e 1 A nn ua l t re nd s in a ge s ta nd ar di ze d in ci de nc e ra te o f s ki n ca nc er in 6 g eo gr ap hi ca l r eg io ns o f t he Is la m ic R ep ub lic o f I ra n, 2 0 0 0 –0 5 Re gi on In ci de nc e pe r 1 0 0 0 0 0 p op ul at io n (9 5% C I) 20 0 0 20 0 1 20 0 2 20 0 3 20 0 4 20 0 5 Sl op e P- va lu e So ut h an d w es t o f t he C as pi an S ea M al e 3. 2 (2 .4 –3 .9 ) 1.4 (0 .9 –1 .9 ) 4. 0 (3 .2 –4 .8 ) 6. 5 (5 .5 –7 .6 ) 10 .0 (8 .7 –1 1.3 ) 10 .4 (9 .1– 11 .7 ) 0 .3 0 < 0 .0 0 1 Fe m al e 2. 0 (1 .4 –2 .6 ) 1.1 (0 .7 –1 .6 ) 2. 9 (2 .2 –3 .6 ) 5. 5 (4 .5 –6 .4 ) 7.1 (6 .0 –8 .2 ) 7.5 (6 .4 –8 .6 ) 0 .3 3 0 .0 0 5 To ta l 2. 6 (2 .1– 3. 1) 1.3 (0 .9 –1 .6 ) 3. 4 (2 .9 –4 .0 ) 6. 0 (5 .3 –6 .7 ) 8. 6 (7 .7 –9 .4 ) 8. 9 (8 .1– 9. 8) 0 .3 0 0 .0 0 2 Ea st o f t he C as pi an S ea M al e 0 .9 (0 .1– 1.7 ) 6. 1 ( 4. 0 –8 .2 ) 1.6 (0 .5 –2 .8 ) 4. 6 (2 .6 –6 .5 ) 6. 1 ( 3. 9– 8. 3) 6. 6 (4 .3 –8 .9 ) 0 .2 0 0 .0 7 Fe m al e 1.1 (0 .2 –1 .7 ) 4. 6 (2 .7 –6 .5 ) 0 .5 (0 .1– 1.0 ) 1.6 (0 .5 –2 .6 ) 2. 1 ( 0 .9 –3 .4 ) 5. 7 (3 .6 –7 .8 ) 0 .18 0 .2 To ta l 1.0 (0 .4 –1 .6 ) 5. 4 (4 .0 –6 .9 ) 1.0 (0 .4 –1 .7 ) 3. 1 ( 2. 0 –4 .2 ) 4. 1 ( 2. 8– 5. 4) 6. 1 ( 4. 6– 7.7 ) 0 .2 0 0 .1 D es er t r eg io n M al e 7.1 (6 .4 –7 .8 ) 3. 3 (2 .9 –3 .8 ) 4. 8 (4 .2 –5 .3 ) 4. 7 (4 .1– 5. 2) 7.5 (6 .8 –8 .2 ) 15 .0 (1 4. 0 –1 5. 9) 0 .10 0 .0 2 Fe m al e 4. 5 (3 .9 –5 .0 ) 2. 4 (2 .0 –2 .8 ) 3. 3 (2 .8 –3 .7 ) 3. 8 (3 .3 –4 .3 ) 5. 2 (4 .7 –5 .8 ) 9. 8 (9 .0 –1 0 .6 ) 0 .2 0 0 .0 4 To ta l 5. 8 (5 .3 –6 .2 ) 2. 9 (2 .6 –3 .2 ) 4. 0 (3 .7 –4 .4 ) 4. 2 (3 .8 –4 .6 ) 6. 4 (5 .9 –6 .8 ) 12 .4 (1 1.8 –1 3. 0 ) 0 .2 0 0 .0 3 Fl at re gi on M al e 2. 3 (1. 9– 2. 4) 4. 3 (3 .8 –4 .8 ) 3. 9 (3 .4 –4 .4 ) 10 .6 (9 .7 –1 1.4 ) 13 .3 (1 2. 3– 14 .2 ) 18 .7 (1 7.6 –1 9. 7) 0 .4 0 < 0 .0 0 1 Fe m al e 2. 0 (1 .6 –2 .4 ) 3. 4 (2 .9 –3 .9 ) 2. 7 (2 .2 –3 .1) 6. 1 ( 5. 4– 6. 7) 8. 5 (7 .8 –9 .3 ) 11 .5 (1 0 .6 –1 2. 3) 0 .3 0 0 .0 0 7 To ta l 2. 2 (1. 9– 2. 4) 3. 9 (3 .5 –4 .2 ) 3. 3 (2 .9 –3 .6 ) 8. 3 (7 .8 –8 .9 ) 10 .9 (1 0 .3 –1 1.5 ) 15 .1 (1 4. 4– 15 .8 ) 0 .3 0 < 0 .0 0 1 M ou nt ai no us re gi on M al e 5. 5 (4 .8 –6 .2 ) 8. 8 (7 .9 –9 .7 ) 10 .6 (9 .7 –1 1.7 ) 12 .7 (1 1.6 –1 3. 8) 17 .0 (1 5. 8– 18 .2 ) 19 .7 (1 8. 4– 21 .0 ) 0 .2 0 0 .0 0 1 Fe m al e 3. 5 (3 .0 –4 .1) 6. 1 ( 5. 4– 6. 9) 7.8 (6 .9 –8 .6 ) 8. 2 (7 .4 –9 .1) 11 .0 (1 0 .0 –1 2. 0 ) 12 .5 (1 1.4 –1 3. 5) 0 .2 0 0 .0 1 To ta l 4. 5 (4 .1– 5. 0 ) 7.5 (6 .9 –8 .1) 9. 2 (8 .6 –9 .9 ) 10 .5 (9 .9 –1 1.2 ) 14 .0 (1 3. 1– 14 .7 ) 16 .1 (1 4. 9– 16 .6 ) 0 .18 0 .0 2 R eg io n ar ou nd th e Pe rs ia n G ul f M al e 0 .0 4 (0 .0 1– 1.0 ) 0 .5 (0 .2 –0 .7 ) 1.0 (0 .5 –1 .4 ) 2. 0 (1 .3 –2 .6 ) 2. 4 (1. 7– 3. 1) 3. 0 (2 .2 –3 .8 ) 0 .4 7 0 .0 2 Fe m al e 0 .0 5 (0 .0 1– 1.0 ) 0 .4 (0 .1– 0 .7 ) 0 .9 (0 .4 –1 .4 ) 1.9 (1 .3 –2 .6 ) 1.7 (1 .1– 2. 3) 2. 9 (3 .9 –6 .9 ) 0 .5 3 0 .0 2 To ta l 0 .0 5 (0 .0 1– 1.0 ) 0 .4 (0 .2 –0 .6 ) 1.0 (0 .6 –1 .3 ) 1.9 (1 .5 –2 .4 ) 2. 1 ( 1.6 –2 .5 ) 3. 0 (2 .4 –3 .5 ) 0 .4 7 0 .0 3 A ll re gi on s M al e 4. 5 (4 .3 –4 .8 ) 4. 3 (4 .0 –4 .5 ) 7.6 (7 .3 –7 .9 ) 11 .9 (1 1.5 –1 2. 3) 13 .6 (1 3. 1– 14 .0 ) 16 .0 (1 5. 6– 16 .5 ) 0 .2 7 < 0 .0 0 1 Fe m al e 3. 0 (2 .8 –3 .2 ) 3. 2 (3 .0 –3 .5 ) 5. 0 (4 .8 –5 .3 ) 7.5 (7 .2 –7 .8 ) 8. 5 (8 .2 –8 .9 ) 9. 8 (9 .4 –1 0 .1) 0 .2 5 0 .0 1 To ta l 3. 8 (3 .6 –3 .9 ) 3. 8 (3 .6 –3 .9 ) 6. 3 (6 .1– 6. 5) 9. 8 (9 .5 –1 0 .0 ) 11 .1 (1 0 .8 –1 1.4 ) 13 .0 (1 2. 7– 13 .2 ) 0 .2 6 0 .0 0 2 C I = co nfi de nc e in te rv al . طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 63 younger ages and accelerated at older age groups up to 80+ years. This finding of an increased inci- dence of skin cancer in the Islamic Re- public of Iran is compatible with findings from studies other in other countries. For instance, Italy [24], the Netherlands [25], England [26], Brazil [9], Finland [27] and Pakistan [28] have all reported an increased incidence of skin cancer. However, despite the global increase in the incidence, the mortality rate from the condition has decreased, especially in the US and Europe [29]. Researchers consider higher rates of reported (due to higher awareness of the symptoms and early detection) [30], thinning of the ozone layer and thus higher exposure to ultraviolet light [12], changes in peo- ple’s exposure to sunlight and bad sun protection habits [31] and diet changes towards higher intake of fat and meat [32] as the major underlying causes of the increased incidence of skin cancer. In recent years, Iranians have gained greater awareness of skin cancer symp- toms and its complications. For instance, a study by Montazeri et al. showed that 95% of skin cancer patients were eager to know more about cancers [33]. At the same time, improvements in the health services in Islamic Republic of Iran has made diagnosis easier [34], perhaps ex- plaining the increased incidence of skin cancer. Furthermore, the country has followed similar changes in nutritional patterns as developed countries, from lower-calorie diets rich in vegetables and fruits to fatty and high-calorie foods [35]. There is also direct relationship between skin cancer and working outdoors and direct exposure to sunlight [10,36]. This is likely to be one of the underlying caus- es of increases in the incidence of skin cancer in rural regions of Islamic Repub- lic of Iran. Zamanian et al. showed that in Hamedan most skin cancer patients were farmers who had a high exposure to sunlight [37]. Another study in Alexan- dria, Egypt showed a positive association of sun exposure and skin colour, in which the relative risk of skin cancer incidence was 4.8-fold greater in those with high exposure to sunlight [38]. 0 50 100 150 200 250 0–9 Pe r 10 0 0 0 0 2000 2001 2002 2003 2004 2005 10–19 20–29 30–39 40–49 50–59 60–69 70–79 >80 0 50 100 150 200 250 Pe r 10 0 0 0 0 Males 0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 >80 Females 0 20 40 60 80 100 120 140 Pe r 10 0 0 0 0 Age group (years) 0–9 10–19 20–29 30–39 40–49 50–59 60–6970–79 >80 Age group (years) Age group (years) Figure 1 Annual trends in age-standardized incidence of skin cancer per 100 000 population in the Islamic Republic of Iran by age group and sex, 2000–2005 EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 64 1. Boyle P et al. Cancer of the skin: a forgotten problem in Eu- rope. Annals of Oncology, 2004, 15:5–6. 2. Boyle P, Levin B. World cancer report 2008. Lyon, France, Inter- national Agency for Research on Cancer, 2008. The most important risk factor for skin cancer is skin colour and more than 80% of ultraviolet light damage occurs in individuals with sun-sensitive skins [2]. As mentioned earlier, the mountainous region had the highest incidence of skin cancer. This region has mild to cold weather and the population are mainly Turks, Lore and Kurd with white complexions susceptible to skin cancer. On the other hand, the region around the Persian Gulf had the lowest incidence of skin cancer. Interestingly, the region has a hot and humid climate and its Fars and Arab inhabitants have darker skin, closer to black. This is in contrast to the theory that the incidence of skin cancer increases with decreasing latitude. An important finding regard- ing trends in different regions was that the steepest and lowest gradients were observed in the Persian Gulf and moun- tainous regions respectively. While interpreting the results of our study, it should be noted that in- creases in the average age of the Iranian population, reflecting increases in life expectancy [24], may partly explain the steadily increasing incidence of skin can- cer with age. Another important item to consider is the cancer registry system in the country. It has been shown that a large proportion of the increase in inci- dence is due to advances in diagnostic techniques and developments of the cancer registry system [39]. Despite the recent improvement in the cancer regis- try in the Islamic Republic of Iran, there are still some problems that need to be considered [40]. The Iranian national cancer registry was established under the supervision of the Tehran University of 12 10 8 6 4 2 0 Pe r 1 0 0 0 0 0 South and west of the Caspian Sea East of the Caspian Sea Desert region Flat region Mountainous region Persian Gulf region Figure 2 Average age-standardized incidence of skin cancer per 100 000 population in 6 geographical regions of the Islamic Republic of Iran over the 6-year period 2000–2005 Medical Sciences in 1984 and has been publishing data since 1999 [41]. The coverage of the registration system in Islamic Republic of Iran has been im- proving in recent years [41]. According to the Iranian Ministry of Health, cancer registration rates have risen from 18% in 1999 to 80% in 2005 [38]. This could ex- plain the upward trend in the incidence of all cancers including skin cancer in the country. Studies of cancer rates in the Islamic Republic of Iran should ad- dress the effect of such improvements in the cancer registry on observed trends. Although studies such as ours do not aim to investigate the reasons for such changes over time, there is a need to investigate the contribution of differ- ent factors on the observed increases in incidence of skin cancer in the Islamic Republic of Iran in future studies. References 3. Cancer facts and figures. Atlanta, Georgia, American Cancer Society, 2004. 4. Leboit PE et al., eds. IARC/World Health Organization clas- sification of tumours. Pathology and genetics of skin tumours. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 65 Lyon, France, International Agency for Research on Cancer, 2006. 5. Koh D et al. Basal cell carcinoma, squamous cell carcinoma and melanoma of the skin: analysis of the Singapore Cancer Registry data 1968–97. British Journal of Dermatology, 2003, 148:1161–1166. 6. Scotto J, Kopf AW, Urbach FJS. Non-melanoma skin cancer among Caucasians in four areas of the United States. Cancer, 1974, 34:1333–1338. 7. Koh D et al. Basal cell carcinoma, squamous cell carcinoma and melanoma of the skin: analysis of the Singapore Cancer Registry data 1968–97. British Journal of Dermatology, 2003, 148:1161–1166. 8. Almahroos M, Kurban A. Ultraviolet carcinogenesis in non- melanoma skin cancer. I: incidence rates in relation to geo- graphic locations and in migrant populations. Skinmed, 2004, 1:29–36. 9. Nunes DH, et al. Incidencia do carcinoma de celulas esca- mosas da pele na cidade de Tubarao (SC)–Brasil nos anos de 2000, 2003 e 2006. [Incidence of squamous cell carcinoma of the skin in the city of Tubarao (SC)–Brazil in the years 2000, 2003, and 2006]. Anais Brasileiros de Dermatologia, 2009, 84:482–488. 10. Suzuki T et al. Doses of solar ultraviolet radiation correlate with skin cancer rates in Japan. Kobe Journal of Medical Sciences, 1996, 42:375–388. 11. Tatalovich Z et al. The objective assessment of lifetime cumu- lative ultraviolet exposure for determining melanoma risk. Journal of Photochemistry and Photobiology. B, Biology, 2006, 85:198–204. 12. Abarca JF, Casiccia CC. Skin cancer and ultraviolet-B radiation under the Antarctic ozone hole: southern Chile, 1987–2000. Photodermatology, Photoimmunology and Photomedicine, 2002, 18:294–302. 13. Le Marchand L et al. Sun exposure, diet, and melanoma in Hawaii Caucasians. American Journal of Epidemiology, 2006, 164:232–245. 14. Ibiebele TI et al. Dietary pattern in association with squamous cell carcinoma of the skin: a prospective study. American Jour- nal of Clinical Nutrition, 2007, 85:1401–1408. 15. Schauberger G, Keck G, Cabaj A. Trend analysis of solar ultra- violet exposure of the Austrian population caused by holiday patterns since 1969. Photodermatology, Photoimmunology and Photomedicine, 1992, 9:72–77. 16. Habibi A. Epidemiological aspects of cancer in Iran. Interna- tional Surgery, 1985, 70:105–108. 17. Mousavi SM et al. Cancer incidence and mortality in Iran. An- nals of Oncology, 2009, 20:556–563. 18. Noorbala MT, Kafaie P. Analysis of 15 years of skin cancer in central Iran (Yazd). Dermatology Online Journal, 2007, 13(4):1. 19. Marjani A, Kabir MJ. Male skin cancer incidence in Golestan province, Iran. Journal of the Pakistan Medical Association, 2009, 59:287–289. 20. Zamanian A, Farshchian M, Meheralian A. A 10-year study of squamous cell carcinoma in Hamedan in the west of Iran (1993–2002). International Journal of Dermatology, 2006, 45:37–39. 21. Fritz A et al., eds. International Classification of Disease for Oncology, 3rd ed. Geneva, World Health Organization, 2000. 22. Statistical Center of Iran [online database] (http://www.amar. org.ir/Default.aspx, accessed 11 November 2012). 23. WHO Statistical Information System (WHOSIS). World Health Organization [online database] (http://www.who.int/who- sis/indicators/en/, accessed 11 November 2012). 24. Italian cancer figures, report 2009. Cancer trend (1998–2005). Epidemiologia e Prevenzione, 2009, 33(4 –5 Suppl. 1):1–168. 25. De Vries E et al. Predictions of skin cancer incidence in the Netherlands up to 2015. British Journal of Dermatology, 2005, 152:481–488. 26. Hughes JR et al. Increase in non-melanoma skin cancer—the King’s College Hospital experience (1970–92). Clinical and Experimental Dermatology, 1995, 20:304–307. 27. Stang A et al. Time trend analysis of the skin melanoma inci- dence of Finland from 1953 through 2003 including 16,414 cases. International Journal of Cancer, 2006, 119:380–384. 28. Zeb A, Rasool A, Nasreen S. Cancer incidence in the districts of Dir (North West Frontier Province), Pakistan: a prelimi- nary study. Journal of the Chinese Medical Association, 2008, 71:62–65. 29. Leiter U, Garbe C. Epidemiology of melanoma and nonmela- noma skin cancer—the role of sunlight. Advances in Experimen- tal Medicine and Biology, 2008, 624:89–103. 30. Bulliard JL, Panizzon RG, Levi F. Prevention du metanome en Suisse: ou en sommes-nous? [Melanoma prevention in SwitM- zerland: where do we stand?]. Revue Medicale Suisse, 2006, 2:1122–1125. 31. Ibiebele TI et al. Dietary pattern in association with squamous cell carcinoma of the skin: a prospective study. American Jour- nal of Clinical Nutrition, 2007, 85(5):1401–1408. 32. Moan J, Dahlback A. The relationship between skin cancers, solar radiation and ozone depletion. British Journal of Cancer, 1992, 65(6):916–921. 33. Montazeri A et al. Cancer patient education in Iran: a descrip- tive study. Support Care Cancer, 2002, 2010;169–173. 34. Khosravi A, Najafi F, Rahbar M. [The indicators of heath feature in Iran]. Tehran, Ministry of Health and Medical Education, 2010 [In Farsi]. 35. Delavari A, Alikhani S, Alaedini F. [A national profile of noncom- municable disease risk factors in the IR Iran]. Tehran, Ministry of Health and Medical Education, Deputy for Health Directory, CDC, 2005 [In Farsi]. 36. Gallagher RP et al. 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EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 66 Acute respiratory infection and malnutrition among children below 5 years of age in Erbil governorate, Iraq D.A.K. Chalabi 1 ABSTRACT Malnutrition is an important risk factor for acute respiratory infection (ARI), which is a leading cause of mortality and morbidity among children aged < 5 years. This case–control study aimed to determine the relationship between nutritional status and ARI among young children aged < 5 years attending a teaching hospital in Erbil, Iraq. Children admitted to hospital with a diagnosis of ARI over a 4-month period in 2006–2007 (n = 190) were compared with a control group without ARI (n = 192). Significantly more ARI cases were male (64.7% versus 53.1%) and the mean age was lower [15.6 (SD 15.4) versus 26.4 (SD 19.7) months]. Weight and height were lower in the ARI group but there was no significant difference in weight-for-age or in height-for-age. There was a significant association between ARI and indicators of malnutrition according to the Gomez and Welcome anthropometric criteria but not the Waterlow criteria. 1Department of Paediatrics, Medical College, Hawler Medical University, Erbil, Iraq (Correspondence to D.A.K. Chalabi: dulair_chalabi@yahoo.com). Received: 21/11/11; accepted: 26/01/12 قارعلا ،ليبرإ ةظفامح في ةسمالخا نس نود لافطلأا ينب ةيذغتلا ءوسو ةدالحا ةيسفنتلا ىودعلا يبلج نيدلا رون قلالخا دبع يرلد نس نود لافطلأا ينب ةَضارلماو تايفولل ًايساسأ ًاببس برتعت يتلا ةدالحا ةيسفنتلا ىودعلل ةمالها راطتخلاا لماوع نم ةيذغتلا ءوس برتعُي :ةـصلالخا نس نود لافطلأا ينب ةدالحا ةيسفنتلا ىودعلا ينبو ةيوذغتلا ةلالحا ينب ةقلاعلا لىع فرعتلا لىإ دهاوشللو تلااحلل ةساردلا هذه فدتهو .ةسمالخا ةيسفنت ىودع صيخشتب ىفشتسلما لىإ اولخدأ نيذلا لافطلأا ينب ثحابلا نراق دقو .قارعلا ،ليبرإ في يميلعتلا ىفشتسلما نوعجاري نمم ةسمالخا 192 مهددعو ،ةيولع ةيسفنت ىودعب ينباصلما يرغ دهاوشلا نم ةعوممج عم ،ًلافط 190 مهددعو ،2007 – 2006 ةترفلا في عبارلا رهشلا دعب ةيولع ناك يطسولا رمعلا نأ ينح في ،)ثانلإل %53.1 لباقم روكذلل %64.7( ًايئاصحإ هب دتعي رادقمب لىعأ روكذلا ينب تلاالحا نأ ثحابلا دجوو .ًلافط نود ،دهاوشلا ىدل هيلع وه امم ينباصلما ةعوممج ىدل ضفخأ ناك لوطلاو نزولا نأ ماك .)ًارهش 19.7 ± 26.4 لباقم ًارهش 15.4 ± 15.6( ضفخأ ةيولعلا ةيسفنتلا ىودعلا ينب ًايئاصحإ هب دتعي طبارت كانه ناكو .رمعلل ةبسنلاب لوطلل وأ رمعلل ةبسنلاب نزولل ًايئاصحإ هب دتعي قرف كانه نوكي نأ .ولرتاو يرياعلم ًاقفو طباترلا اذه لثم ظحلاُي لمو ،مكليو و زيموغل ةيجولويبورثنلأا يرياعملل ًاقفو ،ةيذغتلا ءوس تاشرؤمو Infection respiratoire aiguë et malnutrition chez des enfants de moins de cinq ans dans le gouvernorat d'Erbil (Iraq) RÉSUMÉ La malnutrition est un facteur de risque important d'infection respiratoire aiguë ainsi qu'une cause majeure de mortalité et de morbidité chez les enfants de moins de cinq ans. La présente étude cas-témoins visait à déterminer la relation entre l'état nutritionnel et l'infection respiratoire aiguë chez des enfants âgés de moins de cinq ans admis à l'hôpital universitaire d'Erbil (Iraq). Les enfants hospitalisés ayant reçu le diagnostic d'infection respiratoire aiguë au cours d'une période de quatre mois en 2006 et 2007 (n = 190) ont été comparés à un groupe témoin sans infection respiratoire aiguë (n = 192). Les enfants de sexe masculin étaient nettement plus nombreux à être atteints d'une infection respiratoire aiguë (64,7 % contre 53,1 %) et l'âge moyen était inférieur (15,6 mois [ET 15,4] contre 26,4 mois [ET 19,7]). Le poids et la taille étaient inférieurs dans le groupe des patients infectés mais aucune différence significative n'a été observée pour le poids selon l'âge ou la taille selon l'âge. Il existait une forte association entre une infection respiratoire aiguë et les indicateurs de malnutrition selon les classifications anthropométriques de Gomez et Welcome, mais pas selon les critères de Waterlow. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 67 Introduction Acute respiratory infections (ARI) are major causes of morbidity and mortality in the children of developing countries. While the incidences of ARI are similar in developed and developing countries the course of the disease and the out- comes of ARI may be more severe in developing nations [1]. The effect of poor nutrition, lack of immunization, overcrowding, air pollution and other factors have been reported by several investigators [1,2]. ARI is the cause of al- most one-third of all deaths in children < 5 years of age. Most of these deaths are from pneumonia [2]. Risk factors for deaths in children with ARI have been identified as age < 1 year, malnutrition and pneumo- nia as a complication of infection with measles, pertussis, malaria or HIV [3]. Significant associations have also been observed regarding type of feeding and ARI; breastfeeding appears to be highly protective against the occurrence of ARI in infants [4]. The epidemiological evidence is now overwhelming that, even in developed countries, breastfeed- ing protects against gastrointestinal and to a lesser extent respiratory infection [5]. Malnourished children with severe acute upper respiratory tract infection (URTI) were shown to have a 2–3 times higher mortality rate than healthy children [6]. Malnutrition generally im- plies undernutrition. In children, under- nutrition manifests as underweight and stunting (short stature) while severely undernourished children present with symptoms and signs characteristic of conditions known as kwashiorkor, mar- asmus or marasmic kwashiorkor [6]. In northern Iraq (including Erbil city) a significant improvement was found between 1994 and 2002 in chil- dren’s nutritional status; the percentage of underweight children aged < 5 years fell from 25.8% in 1994 to 10.7% in 2002. Nevertheless, among children aged < 5 years, 13.2% were underweight in 2000 with 4.3% acute (wasted) and 13.0% chronic (stunted) [7]. The ob- jective of the current study was to study the relationship between nutritional status and ARI among young children attending a teaching hospital in Erbil, Iraq. Methods A case–control study was undertaken in Raparin teaching hospital, which is the only specialized paediatric hospital in Erbil city. Study sample A total of 190 children < 5 years old who were admitted to Raparin hospital with a diagnosis of ARI over a period of 4 months from 1 November 2006 to 1 March 2007 were recruited. The inclusion criteria were all children with respiratory infection who had been admitted to the emergency department during the study period. Neonates and children with known chronic respirato- ry problems (e.g. asthma, cystic fibrosis, congenital respiratory malformations, tuberculosis), prolonged cough more than 3 weeks, congenital heart disease or foreign body inhalation were excluded from the study. A control sample of 192 children was collected from children at- tending the paediatric surgical or dental department over the same period for simple surgical procedures, excluding any child with acute or chronic medical illness. ARI was defined as the presence of cough with or without fever for less than 2 weeks. Acute URTI was diagnosed in those with rhinorrhoea, cough with or without fever, sore throat and tonsillar enlargement, pharyngeal congestion or audible stridor [2]. Acute LRTI was diagnosed in those who presented with prodromal symptoms of rhinorrhoea, cough, fever, with wheeze, dyspnoea, chest retractions, scattered rales and fea- tures of hyperinflation, consolidation, patchy or interstitial infiltrates on chest radiography [8]. Data collection Information was collected from par- ents via a face-to-face interview. This included the child’s age, sex, duration of illness, symptoms, type of feeding and whether exclusively breastfed in the first 4–6 months. Oral consent was taken from the parents of each child enrolled in the study. A respiratory system examination was done and anthropometric meas- ures were taken. Weight was measured by precision dial scale (Seca Optima). Participants were weighed in light clothing as far as possible and without shoes. The scales were calibrated before use. Height was measured by using the Centers for Diseases Control measur- ing board. Individuals were measured barefoot and standing erect, with feet together and head against the measur- ing rod, looking straight ahead, with arms hanging loosely at the sides and palms facing thighs. Length was meas- ured for children below age of 2 years, with the child lying supine with legs fully extended at the hips and knees and feet at right angles to legs [9]. Three classification systems that are commonly used for assessing growth retardation and nutritional status in the community were applied (Gomez, Welcome and Waterlow) [10] (Ta- ble 1). Wasting (decreased weight for length or height) is associated with acute malnutrition and is distinguished from stunting (decreased length-for- age or height-for-age) seen with chronic malnutrition. This system depends on a standardized normal distribution using Z-scores in which the 5th percentile is 2 standard units below the mean [10]. Data analysis SPSS, version 18.0 was used for analysis. We used the t-test to compare means and the chi-squared test for categori- cal variables to check the relationship between ARI and demographic, anthro- pometric and nutritional status vari- ables. P-values ≤ 0.05 were considered EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 68 Mean weight was significantly lower in the ARI group than the controls [8.9 (3.6) kg versus 11.7 (4.8) kg] (P < 0.001) and so were mean height [73.4 (14.5) cm versus 83.4 (17.7) cm] (P < 0.001). However, weight-for-age on growth chart (P = 0.104) and height- for-age on growth chart (P = 0.104) were not statistically significantly re- lated to ARI. There was no significant different between the groups using the Waterlow nutritional state assessment (P = 0.06), but ARI was more common among children with indicators of malnutri- tion according to the Welcome (P = 0.007) and Gomez criteria (P < 0.001) (Table 2). Two ARI cases had oedema but their weight-for-age was normal so they were not considered as marasmic kwashiorkor or kwashiorkor. When the Gomez malnourished classes (mild, moderate and severe) were combined the risk of ARI was more than 2-fold higher (OR = 2.30; 95% CI: 1.48 –3.58). Similarly, when the Welcome malnourished classes (60%–80% and < 60%) were combined the risk of ARI was also nearly twice as high as in the control group (OR = 1.95; 95% CI: 1.15 –3.30). Discussion We found that sex was a risk factor for ARI in this study, in agreement with other studies have shown that males were more vulnerable to ARI than were females [3,4,11,12]. Our finding of lower mean age in the ARI group also agrees with findings showing that younger children were more likely to have ARI [3,4], with infants being main group affected. Tupasi et al. in Manila found that age < 2 years significantly increased the risk of having ARI [13] and Kanchi and Kakeri reported that among children aged < 5 years with ARI in a Bombay hospital, 40.9% were < 1 year of age [12]. One study showed that among 800 children studied, 59% were boys and 56.3% were infants with mean age 6.5 (SD 5.6) [11]. Feeding pattern (exclusive breast- feeding, bottle feeding or mixed feed- ing) was not statistically significant in relation to ARI even when plotted in statistically significant. Odds ratios (OR) were used to estimate the relative risk of ARI for certain variables with 95% confidence interval (CI). Results Of the 190 patients with ARI 78 had lower respiratory tract infection (LRTI), 51 had URTI and 61 had mixed URTI and LRTI. There was a higher proportion of male children in the ARI group than in the control group (64.7% versus 53.1%) (P = 0.02) (Table 2). The mean age of the ARI group was significantly lower than the control group [15.6 (15.4) versus 26.4 (19.7) months] P < 0.001). Although fewer children in the ARI group were exclusively breastfed com- pared with the control group (34.7% versus 43.8%), type of feeding was not significantly different between the groups (P = 0.20) (Table 2). Breastfeeding was not a significant risk factor, even when ex- clusive breastfeeding was plotted against both mixed and bottle feeding (OR = 1.46; 95% CI: 0.96–2.21, P = 0.07). Table 1 Classifications of malnutrition used in the current study [6] Classification Criteria Class Gomez Weight below % median weight-for-age 75%–90% Mild malnutrition 60%–74% Moderate malnutrition < 60% Severe malnutrition Waterlow Z-scores (SD) below median weight-for-height 80%–90% Mild malnutrition 70%–80% Moderate malnutrition < 70% Severe malnutrition WHO, wasting Z-scores (SD) below median weight-for-height < 3rd percentile or Z-scores 2 SD below mean Moderate and severe wasting WHO, stunting Z-scores (SD) below median height-for-age < 3rd percentile or Z-scores 2 SD below mean Moderate and severe stunting Welcome Weight-for-age 60%–80% With oedema: kwashiorkor Without oedema: undernutrition < 60% With oedema: marasmus-kwashiorkor Without oedema: marasmus WHO = World Health Organization; SD = standard deviation. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 69 2 categories (exclusive breastfeeding versus other feeding patterns). This in agreement with previous studies in Iraq by Albargish and Hasony [14] and Yousef and Khaleq [4] in which in other developing countries showed that children under 5 years with ARI were mainly, partially or not breastfed up to 6 months [11,16]. Again, Arifeen et al. compared exclusive breastfeeding Table 2 Comparison of demographic, anthropometric, feeding and malnutrition variables in children aged < 5 years with and without acute respiratory infection (ARI) Variable ARI group (n = 190) Control group (n = 192) P-value Mean (SD) Mean (SD) Age (months) 15.6 (15.4) 26.4 (19.7) < 0.001 Weight (kg) 8.9 (3.4) 11.7 (4.8) < 0.001 Height(length) (cm) 73.4 (14.5) 83.4 (17.7) < 0.001 No. % No. % Sex 0.021 Male 123 64.7 102 53.1 Female 67 35.3 90 46.9 Feeding 0.196 Exclusive breastfeeding 66 34.7 84 43.8 Bottle feeding 49 25.8 42 21.9 Mixed feeding 75 39.5 66 34.4 Weight-for-age on growth chart 0.104 Normal 143 75.3 161 83.9 < 5th percentile 34 17.9 21 10.9 > 95th percentile 13 6.8 10 5.2 Height (length)-for-age on growth chart 0.104 Normal 150 78.9 156 81.3 < 5th percentile 25 13.2 14 7.3 > 95th percentile 15 7.9 22 11.5 Weight-for-height (length) (Z scores) 0.150 3SD below 21 11.1 11 5.7 Normal 165 86.8 175 91.1 3SD above 4 2.1 6 3.1 Welcome classification 0.007 Normal 144 75.8 165 85.9 60%–80% 40 21.1 27 14.1 < 60% 6 3.2 0 0.0 Waterlow classification 0.062 Normal 133 70.0 153 79.7 Mild 30 15.8 27 14.1 Moderate 22 11.6 10 5.2 Severe 5 2.6 2 1.0 Gomez classification 0.001 Normal 110 57.9 146 76.0 Mild 52 27.4 36 18.8 Moderate 24 12.6 10 5.2 Severe 4 2.1 0 0.0 SD = standard deviation. breastfeeding had no clear protective effect against infection, whereas Al- Jassar found in another study in Iraq that breastfeeding prevented severe forms of ARI [15], while other studies EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 70 in the first few months of life with partial or no breastfeeding and its effect on ARI as mortality rate increase by 2.23 fold in those with no exclusive breastfeeding [17]. Children with lower mean weight and height (or length) were more likely to have ARI than the control group and this agrees with studies in which mal- nutrition and underweight were risks for acute LRTI in children < 5 years old [7,18,19]. However, weight-for-age and height-for-age were not statistically significantly related to ARI. ARI was more likely in underweight children assessed according to the Gomez and Welcome criteria, with the risk around 2-fold higher compared with the control group (OR = 1.95; 95% CI: 1.15–3.30 and OR = 2.30; 95% CI: 1.49–3.58 re- spectively). Wahed and Islam showed that most children with pneumonia had mild protein–energy malnutrition ac- cording to Gomez criteria [11]; in our study, 57.9% were normal and 27.4% had mild protein–energy malnutrition according to Gomez classes. Malnutri- tion by Gomez criteria was shown to be more frequent among children with ARI than other diseases, and more frequent in children aged < 5 years with LRTI rather than URTI [20]. Tupasi et al. found that malnourishment was signifi- cantly associated with increased risk of ARI morbidity [13], while a study in a Bombay hospital reveal that the severity of undernutrition correlated with sever- ity of ARI, with 23.9%, 21.6% and 4.5% of ARI cases having grade I, II, III malnutri- tion respectively according to Gomez criteria [12]. We found no significant relation between ARI and underweight according to Waterlow criteria. Conclusion Most cases of ARI in this hospital in Er- bil occurred below the age of 1 year and boys were more prone to ARI than girls. Malnutrition according to Gomez and Welcome criteria significantly increase the risk of having ARI among children < 5 years of age. References 1. Osinusi K, Oyejide O. Child care practice with respect to acute respiratory tract infection in a poor urban commu- nity in Nigeria. Reviews of Infectious Diseases, 1990, 12(Suppl. 8):S1039–S1041. 2. Smyth A. Acute respiratory infection. In: Southall D, et al, eds. International Child health care (a practical manual for hospitals worldwide). London, BMJ Publications, 2002:155. 3. Hadi A. Management of acute respiratory infections by com- munity health volunteers : experience of Bangladesh Rural Advancement Committee (BRAC).. Bulletin of the World Health Organization, 2003, 81:183–189. 4. Yousif T, Khaleq B. Epidemiology of ARI among children under five years old attending Tikrit General teaching Hospital. Mid- dle East Journal of Family Medicine, 2006, 14(3). 5. Kramer M, Kakuma R. The optimal duration of exclusive breast- feeding: a systemic review. Geneva, World Health Organization, 2002. 6. Classification of malnutrition in children. Medical Criteria [on- line factsheet] (http://www.medicalcriteria.com/site/index. php?option=com_content&view=article&id=275%3Amalnutr ition&catid=66%3Anutrition&Itemid=80&lang=en, accessed 20 November 2012). 7. The situation of children in Northern Iraq. An assessment based on the United Nations Convention on the Rights of the Child. Baghdad, Iraq, United Nations Children’s Fund, 2002 (http:// old.krg.org/986/unicef-children-sep-2002.pdf, accessed 4 November 2012). 8. Hemalatha R et al. Respiratory syncytial virus in children with acute respiratory infections. Indian Journal of Pediatrics, 2010, 77 (7):755–758. 9. Gupte S. Growth and development. In: Gupte R, ed. In: Short textbook of Pediatrics, 5th ed. New Delhi, Jaypee Brothers, 1985:20–21. 10. Waterlow JC. Classification and definition of protein-calorie malnutrition. British Medical Journal, 1972, 3:566–569. 11. Wahed M et al. Effect of micronutrients on morbidity and du- ration of hospital stay in childhood pneumonia. Mymensingh Medical Journal, 2008, 29:519–523. 12. Kanchi P, Kakeri M. ARI and some associated epidemiological factors in children of 0–5 years of age group. Bombay Hospital Journal, 2005, 47. 13. Tupasi T et al. patterns of acute respiratory tract infection in children: a longitudinal study in a depressed community in Metro Manila. Reviews of Infectious Diseases, 1990, 12 (Suppl. 8):S940–S949. 14. Grant C et al. Child nutrition and lower respiratory tract bur- den in New Zealand: A global context for a national perspec- tive. Journal of Pediatrics and Child Health, 2011, 4 (8):497–504. 15. Cunha A. Relationship between acute respiratory tract infec- tion and malnutrition in children under 5 years of age. Acta Paediatrica, 2000, 89(5):608–609. 16. Albargish K, Hasony H. Respiratory syncytial virus infection among children with acute respiratory tract infection in Iraq. Eastern Mediterranean Health Journal, 1999, 5(5):941–948. 17. Al-Jassar NFJ. Clinico-epidemiological study of acute respira- tory infections (ARI) in children under 5 years of age. Iraqi Jour- nal of Medical Science, 1994, 10:200–207. 18. Diallo FB et al. The effects of exclusive versus non-exclusive breastfeeding on specific infant morbidities in Conakry. Pan African Medical Journal, 2009, 2:2. 19. Arifeen S et al. Exclusive breast feeding reduces acute res- piratory infection and diarrhea deaths among infants in Dahka slums. Pediatrics, 2001, 108(4):E67. 20. Arnaut I et al. Acute respiratory infections in rural morocco. Arab Journal of Medicine, 1985; 4(10):16–18. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 71 Epidemiological characterization of P. aeruginosa isolates of intensive care units in Egypt and Saudi Arabia S.A. Mansour,1 O. Eldaly,1 A. Jiman-Fatani,2 M.L. Mohamed 3 and E.M. Ibrahim 4 ABSTRACT This study aimed to characterize Pseudomonas aeruginosa isolates in 2 intensive care units in Egypt and Saudi Arabia. P. aeruginosa isolates from patients’ and staff hands and environmental samples were typed using antibiotyping and ERIC-PCR. In Egypt, isolates from suction apparatus tubing and drainage containers (A7) and AV tubing (A8) were linked to those from patients who had these antibiotypes. In Saudi Arabia, isolates from suction apparatus tubing (A6) and AV tubing (A7) were linked to patients with the same antibiotypes. In Egypt, patients’ isolates had ERIC VII, VIII and IX patterns linked to suction apparatus tubing, AV machine tubes and drainage containers. In Saudi Arabia, patients’ isolates had ERIC VIII and XI patterns linked to suction apparatus tubing and AV machines. In Egypt and Saudi Arabia, ERIC typing gave higher discriminatory indices (0.801 and 0.785 respectively) than the antibiotyping (0.7123 and 0.728 respectively). ERIC was superior to antibiotyping and should be used in tracing sources of infection. 1Department of Medical Microbiology and Immunology; 3Department of Obstetrics and Gynaecology; 4Department of General Surgery, Faculty of Medicine, University of Zagazig, Zagazig, Egypt (Correspondence to S.A. Mansour: shymaa_abdelazim@yahoo.com). 2Department of Medical Microbiology, King Abdulaziz University, Jeddah, Saudi Arabia. Received: 05/09/11; accepted: 18/01/12 ةيدوعسلا ةيبرعلا ةكلملما فيو صرم في ةزكرلما ةياعرلا تادحو في ةيراجنزلا ةفئازلا تلاوزعلم ةيئابولا تماسلا ديدتح ميهاربإ دممح ملاسإ ،دممح يفطل دممح ،نياتاف-نمايج فصاع ،ليادلا رمع ،روصنم ميظعلا دبع ءمايش تد ِّدح دقو .ةيدوعسلا ةيبرعلا ةكلملما فيو صرم في ةزكرلما ةياعرلل ينتدحو في ةيراجنزلا ةفئازلا نم تلاوزعلما تماس ديدتح لىإ ةساردلا هذه فدته :ةـصلالخا ةرملبلا ميزنإ لعافت و ،ةيويلحا تاداضلما ططمخ مادختساب كلذو ،ةئيبلا نم ةذوخأم تانيع نمو ينلماعلا يديأ و ضىرلما نم ةلوزعلما ةيراجنزلا ةفئازلا طمانأ بيبانأو )A7( فيصرتلا بيبانأو صلما زاهج بيبانأ نم تلاوزعلما نأ صرم في جئاتنلا نم ينبتو .ERIC-PCR ةيوعلما ميثارجلل يراركتلا دادعتلاو ليسلستلا تلاوزعلما تطبارت ،ةيدوعسلا ةيبرعلا ةكلملما فيو .ةيويلحا تاداضلما طمانأ سفن ميهدل نيذلا ضىرلما نم تلاوزعلما عم طباترت )A8( ةيعانطصلاا ةيوهتلا دادعتلا تاذ تلاوزعلما تطبارت صرم فيو .اتهاذ ةيويلحا تاداضلما طمانأ يوذ ضىرلما عم )A7( ةيعانطصلاا ةيوهتلا بيبانأو )A6( صلما زاهج بيبانأ نم تطبارت ةيدوعسلا ةيبرعلا ةكلملما فيو .فيصرتلا ضاوحأو ةيعانطصلاا ةيوهتلا بيبانأ و ،صلما زاهج بيبانأب IX و VIII و VII ةيوعلما ميثارجلل ىراركتلا ةيبرعلا ةكلملما فيو صرم فيو .ةيعانطصلاا ةيوهتلا بيبانأ و صلما زاهج بيبانأب IX و VIII ةيوعلما ميثارجلل ىراركتلا دادعتلا جذمان يوذ ضىرلما نم تلاوزعلما 0.7123) ةيويلحا تاداضلما تاططمخ تطعأ امم )0.785 لباقم 0.801( لىعأ ةيزييتم بسانم ةيوعلما ميثارجلل يراركتلا دادعتلا طمانأ ديدتح ىطعأ ،ةيدوعسلا .ىودعلا رداصم ءافتقا في همادختساب نوثحابلا صيويو ،ةيويلحا تاداضلما تاططمخ لىع ةيوعلما ميثارجلل يراركتلا دادعتلا ق َّوفت دقو .)0.728 لباقم Caractérisation épidémiologique d'isolats de Pseudomonas aeruginosa dans des unités de soins intensifs en Arabie saoudite et en Égypte RÉSUMÉ La présente étude visait à caractériser des isolats de P. aeruginosa dans deux unités de soins intensifs en Arabie saoudite et en Égypte. Des isolats de P. aeruginosa prélevés sur les mains du personnel et des patients et des échantillons environnementaux ont été typés par antibiogramme et ERIC-PCR. En Égypte, des isolats prélevés sur les tubulures d'appareils d'aspiration et de respiration artificielle (A8) et sur les cuvettes (A7) étaient liés à ceux prélevés chez les patients ayant ces antibiotypes. En Arabie saoudite, des isolats prélevés sur des tubulures des appareils d'aspiration (A6) et de respiration artificielle (A7) étaient liés à ceux prélevés chez les patients ayant les mêmes antibiotypes. En Égypte, les isolats des patients étaient de types ERIC VII, VIII et IX et correspondaient à ceux des tubulures des appareils d'aspiration et de respiration artificielle et des cuvettes. En Arabie saoudite, les isolats des patients étaient de types ERIC VIII et XI correspondaient à ceux des tubulures des appareils d'aspiration et de respiration artificielle. En Égypte et en Arabie saoudite, le typage ERIC a permis d'obtenir des index de discrimination supérieurs (0,801 et 0,785 respectivement) à ceux de l'antibiogramme (0,7123 et 0,728 respectivement). La méthode ERIC était supérieure à l'antibiotypage et devrait être utilisée pour déterminer les sources d'infection. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 72 Introduction The Gram-negative bacterium Pseu- domonas aeruginosa is frequently associ- ated with hospital-acquired infections in intensive care units (ICUs) [1]. It has been identified as the 2nd most frequent organism causing ventilator- associated pneumonia, the 4th most common causing catheter-associated urinary tract infections, the 5th cause of surgical site infections and the 7th cause of central-line-associated bloodstream infections [2]. P. aeruginosa has inherent resistance to many drug classes [3,4]. Moreover, it can acquire resistance via mutations and harbouring integrons with multiple resistance genes such as those coding for metallo-β-lactamases (MBL) that can cleave the most active antimicrobial agents against it (carbap- enems) [3]. The source of P. aeruginosa in in- tensive care units (ICUs) can be either endogenous or exogenous; isolates that have unique genotypes are considered as possibly endogenous while those of the same genotype with either patient or environmental samples are considered as possibly exogenous [5]. Optimal control of P. aeruginosa outbreaks may require rapid identification and strain differentiation. Traditionally, it has been typed on the basis of its phenotypic characteristics but this technique may lack discriminatory power and stabil- ity [6]. Molecular techniques offer a considerable improvement, and can complement phenotypic data to obtain a better understanding of bacterial di- versity [7]. Pulsed field gel electropho- resis is commonly employed and has achieved widespread recognition as the gold standard for P. aeruginosa deoxy- ribonucleic acid (DNA) typing [8,9]. However, this method is limited by its technical complexity, expense and prolonged turnaround times for re- sults [7]. As an alternative, repetitive- element-based polymerase chain reaction (rep-PCR) assays that utilize primers targeting highly-conserved repetitive sequence elements in the bacterial genome have shown con- siderable potential as DNA typing tools in the laboratory [10]. One of such groups of repetitive elements is the enterobacterial repetitive intergenic consensus (ERIC) sequences which are common to Gram-negative enteric bacteria [11,12]. The products of ERIC- PCR, with chromosomal DNA of dif- ferent bacterial strains, were found to generate very characteristic patterns when separated on agarose gels. Thus, it has been proposed that ERIC-PCR is a useful method to fingerprint bacterial genomes [13]. This work was designed to elucidate the epidemiology of P. aeruginosa iso- lates in ICUs in both Egypt and Saudi Arabia and to identify MBL-producing isolates. It also aimed to compare typing methods by antibiogram and ERIC- PCR for their discriminatory power and compatibility. Methods This study was conducted in the De- partment of Medical Microbiology and Immunology, Faculty of Medicine, University of Zagazig, Egypt and the Department of Medical Microbiology, King Abdulaziz University, Saudi Arabia in the period from January 2009 to De- cember 2010. This study was approved by the ethics committees of Zagazig University Hospital and King Abdulaziz University. Study sample A total of 270 samples were collected from patients, staff hands and the en- vironment from surgical adult ICUs of both hospitals: • 180 samples were collected from patient sources, including 30 spu- tum, endotracheal aspirate, blood, wound exudate, burn exudate and urine specimens. • 30 samples were collected from staff hands at midday, by which time staff members had been in contact with patients for several hours. For each staff member 30 mL of sterile nutri- ent broth was poured into a sterile plastic bag and the hands were mas- saged in the broth for 30 s [14]. • 60 environmental samples were tak- en throughout the ICU, including water taps, faucet handles, drainage containers, mops, manual resuscita- tion bags, AV tubing, suction ap- paratus tubing, air condition outlets and antiseptic solutions. Surfaces were swabbed with sterile cotton swab sticks and fluid samples were pipetted using sterile disposable plastic pipettes. Isolation and identification of P. aeruginosa Blood samples were used for inoculating blood culture bottles (Egyptian Diag- nostic Media) then incubated at 37 °C for 7–14 days. Subcultures were done every 48 h on blood agar plates. Sputum, endotracheal aspirate, wound exudate, burn exudate and urine specimens were cultured on Pseudomonas cetrimide agar (Oxoid). Pseudomonas spp. isolates were subcultured on nutrient agar plates at 37 °C for 24 h to identify the growth characters. For analysis of staff hand specimens, a loopful sample of the broth was cultivated. Environmental samples were cultured in nutrient broth to dilute any disinfectants present and to encour- age growth of low organism numbers. After 24 h incubation, subcultures were made onto Pseudomonas cetrimide agar plates and incubated at 37 °C. Any growth was identified as P. aeruginosa if it has the following criteria: characteristic colony morphology, grape-like odour, exopigments production [15], Gram- negative motile bacilli, positive oxidase test (Oxoid code BR0064A), growth at 42 °C [16], gelatin liquefaction test positive [17] and red butt and slant of triple sugar–iron medium [18]. Antibiogram Antibiotic resistance testing was done by the Kirby–Bauer disk diffusion طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 73 DNA detection by agarose gel electro- phoresis Amplification products and DNA molecular weight marker (Gene- Ruler™ 1 kb Plus®) were detected by using agarose gel electrophoresis [23]. These were visualized on a UV trans- illuminator (Biometra) and photo- graphed. Statistical analysis All data were tabulated and then processed using SPSS, version 12.0. Qualitative variables were expressed by percentages and compared using the chi-squared test or Fisher exact test when appropriate. A P-value < 0.05 was considered statistically sig- nificant. The numerical discrimina- tory index, which is a measure of the discriminatory ability of the typing methods was calculated according to Hunter [24]. Results Isolation rate of P. aeruginosa Table 1 shows that in Egypt and Saudi Arabia, P. aeruginosa was isolated from 32.8% and 30.0% of patient samples respectively. In Egypt, the highest isolation rate was from burn exudates (66.7%), while in Saudi Arabia, it was from endotracheal aspirates (36.7%). There was a statistically significant dif- ference between data from Egypt and Saudi Arabia only in the rate of isolation of P. aeruginosa from burn exudates (P = 0.02). The isolation rate of P. aeruginosa from environmental samples in Egypt was 25.0% overall and was highest (57.1%) from suction apparatus tubing (Table 1). In Saudi Arabia, it was 23.3% overall and was highest from suction ap- paratus tubing and artificial ventilation machine tubes (42.9%). Table 1 shows that 10.0% and 6.7% of staff hand samples from Egypt and Saudi Arabia respectively were culture positive Risk factors for acquiring P. aeruginosa Table 2 shows the univariate analysis of risk factors for acquiring P. aer- uginosa infection based on analysis of patient samples in Egypt and Saudi Arabia. There were statistically sig- nificant difference as regards age ≥ 60 years (P = 0.04 in Egypt; P < 0.001 in Saudi Arabia), length of hospital stay ≥ 7 days (P < 0.001 in both countries), cancer in Egypt only (P = 0.01), sur- gery (P < 0.001 in both countries) and use of antibiotics ≥ 2 days (P = 0.009 in Egypt; P < 0.001 in Saudi Arabia). Antibiotic resistance Table 3 reveals that antibiotic resist- ance rates of clinical isolates in Egypt and Saudi Arabia were highest to aztreonam (96.6% and 98.1%), fol- lowed by cefepime (76.3%) and tobramycin (67.8%) in Egypt, and followed by meropenem (72.2%) and ceftazidime (70.4%) in Saudi Arabia. On the other hand, the resistance rate of environmental isolates was 100% to aztreonam and ceftazidime in Egypt and ceftazidime and cefepime in Saudi Arabia (Table 3). Colistin was the only antibiotic to which nearly all strains were sensitive. Table 4 shows the frequency of MBL-producing imipenem-resistant strains was 16/29 (55.2%) in Egypt and 36/54 (66.7%) in Saudi Arabia from clinical isolates, was 2/3 (66.7%) from environmental strains and was not detected in staff hand strains in either Egypt or Saudi Arabia. These differ- ences were statistically significant (P < 0.001) in the same country. Antibiotyping Tables 5 and 6 shows the antibiotyping of isolates, showing 9 anti biotype pat- terns in Egypt and 8 in Saudi Arabia, ranging from pattern A1, which was sensitive to all tested antibiotics to pat- tern A9 and A8 which were resistant to all tested antibiotics except colistin. In method according to Clinical Labora- tory Standards Institute guidelines [19]. The following antibiotics (Oxoid) were used: piperacillin 100 µg, ceftazidime 30 µg, cefepime 30 µg, aztreonam 30 µg, imipenem 10 µg, meropenem 10 µg, colistin 25 µg, amikacin 30 µg, gentamycin 10 µg, tobramycin 10 µg and ciprofloxacin 5 µg. Screening for MBLs was performed by the imipenem- EDTA combined-disk test as described by Yong et al. [20]. PCR methods DNA extraction All strains were freshly cultured on nu- trient agar before DNA extraction using the QIAamp DNA mini kit (Qiagen GmbH) according to the manufac- turer’s instructions. The extracts were then kept at –20 °C until use. ERIC-PCR typing ERIC-PCR typing was performed as reported previously [21] using PCR- GOLD Master-Mix Beads (Bioron, The Enzyme Company). The fol- lowing materials were added to each PCR bead: 50 ng of DNA template, 10 pmole of each primer (Bioneer™ Corporation); ERIC1R (5′ ATG TAA GCT CCT GGG GAT TCA C 3′) and ERIC2 (5′ AAG TAA GTG ACT GGG GTG AGC G 3′) [22] and deionized distilled water to a final volume of 50 µL. These were mixed well by automatic pipette, followed by brief centrifugation to collect the contents at the bottom of the tube. For the negative control reaction, all com- ponents of PCR reaction were added to the bead except for DNA to exclude any source of contamination. The gene segments were amplified using a DNA thermal cycler (Biometra). The reaction conditions were as follows: initial denaturation at 94 °C for 1 min, followed by 35 cycles of denaturation at 94 °C for 45 s, annealing at 52 °C for 45 s and DNA chain extension at 72 °C for 2 min, and a final extension at 72 °C for 10 min. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 74 Egypt, there were epidemiological re- lationships between suction apparatus tubing and drainage containers (A7) and artificial ventilation (AV) machine tubes (A8) and patients who had A7 and A8 antibiotypes; however, there was no direct link between isolates from staff hands (A1 and A2) and patients. In Saudi Arabia, there were relationships between antibiotypes of suction ap- paratus tubing (A6) and AV machine tubes (A7) and patients where they had A6 and A7 antibiotypes but there was no direct link between isolates from staff hand (A3 and A4) or patients. ERIC-PCR typing P. aeruginosa isolates were typeable by ERIC-PCR and yielded 15 and 12 ERIC patterns from Egypt and Saudi Arabia respectively, with 4 to 11 bands in Egypt (Figure 1) and 3 to 9 bands in Saudi Arabia (Figure 2). The size of amplified DNA bands ranged from 110 bp to 1535 bp. From ERIC-PCR typing methods MBL-producing strains showed epide- miological relationships among 3 sites in Egypt: suction apparatus tubing, AV tubing and drainage container (ERIC VII, VIII and IX genetic patterns re- spectively). In Saudi Arabia, we found links to suction apparatus tubing and AV machine sites (ERIC VIII and XI genetic patterns respectively). On calculating the discriminatory index of both typing methods (antibio- typing and ERIC), we found that ERIC typing gave a higher discriminatory index in Egypt and Saudi Arabia (0.801 and 0.785 respectively) than the anti- biogram (0.712 and 0.728 respectively) (Table 7). Discussion In spite of significant changes in the spectrum of organisms causing noso- comial infections in ICUs, P. aeruginosa has held a nearly unchanged position as an important pathogen [2]. In Egypt and Saudi Arabia, the rate of isolation from patient samples was 32.8% and 30.0% respectively. This in agreement with rates reported in Egypt by Ash- our et al. (30.0%) [25] and Gad et al. (24.0%) [26] and in Saudi Arabia by Al Johani et al. (30.6%) [27]. In Egypt, the highest isolation rate from patient sam- ples was from burn exudates (66.7%). This in accordance with Gad et al. (72.0%) [24] and may be attributed to inappropriate infection control meas- ures to burn patients. On the other hand, in Saudi Arabia, isolation was highest from endotracheal aspirates Table 1 Isolation rate of Pseudomonas aeruginosa strains from samples obtained from patients, the environment and staff hands in surgical adult intensive care units in Egypt and Saudi Arabia Source No. of samples P. aeruginosa isolates P-value Egypt Saudi Arabia No. % No. % Patient samples Burn exudates 30 20 66.7 11 36.7 0.02 Wound exudates 30 11 36.7 10 33.3 0.78 Blood 30 9 30.0 5 16.7 0.22 Urine 30 8 26.7 9 30.0 0.77 Endotracheal aspirate from patients with ventilator associated pneumonia. 30 6 20.0 11 36.7 0.15 Sputum 30 5 16.7 8 26.7 0.34 Total 180 59 32.8 54 30.0 0.57 Environment samples Suction apparatus tubing 7 4 57.1 3 42.9 1.00 Drainage container 7 3 42.9 2 28.6 1.00 Artificial ventilation tubing 7 2 28.6 3 42.9 1.00 Mops 6 2 28.6 1 20.0 1.00 Air condition outlet 5 1 20.0 2 28.6 1.00 Manual resuscitation bags 7 1 20.0 2 28.6 1.00 Faucet handles 7 1 20.0 1 20.0 1.00 Water tap 7 1 20.0 0 0.0 1.00 Antiseptic solutions 7 0 0.0 0 0.0 1.00 Total 60 15 25.0 14 23.3 0.83 Staff hand samples Total 30 3 10.0 2 6.7 1.00 طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 75 and burn exudates (36.7%) and this is in agreement with Al Johani et al. (43.0%) [25]. The univariate logistic regression analysis showed that the risk factors for P. aeruginosa infection were age group ≥ 60 years, hospital stay ≥ 7 days, cancer, surgery and use of antibiotics ≥ 2 days. These findings are consistent with those of other studies [28–30]. In the current study the environ- mental sampling in Egypt and Saudi Arabia showed that 25.0% and 23.3% of the samples were positive, which is slightly higher than a previous study in Egypt (19.5%) [26]. This reflects the fact that P. aeruginosa is ubiquitous in the hospital environment. The isolation rate was the highest from suction apparatus tubing in Egypt (57.1%) and from both suction apparatus tubing and AV ma- chine tubes from Saudi Arabia (42.9%). This may be explained by the failure of sterilization of suction apparatus tubing and inadequate application of standard precautions for infection control. On the other hand, 10.0% and 6.7% of staff hands in this study were culture- positive in Egypt and Saudi Arabia re- spectively, which is higher than the rate reported by Crivaro et al. in Italy (3.5%) [31]. The higher rate of isolation from staff hands in this study could be due to lack of compliance of health care work- ers to hand-washing practices. In Egypt antibiotic resistance rates were highest to aztreonam (96.6%), followed by cefepime (76.3%) and to- bramycin (67.8%). Kamel et al., also in Egypt, reported that isolates were completely resistant to tobramycin and gentamicin and were sensitive to amika- cin (68%), imipenem and meropenem (52%) and ciprofloxacin (36%) [32]. This difference could be attributed to the different rate of use of these anti- biotics in different localities. In Saudi Arabia we found antibiotic resistance rates were also highest to aztreonam (96.6%), but followed by meropenem (72.2%) and ceftazidime (70.4%). This is in agreement with a study by Al Johani et al. in Saudi Arabia who found that the resistance significantly increased after 2007, especially for carbapenem (34% in 2004 to 74% in 2009), ceftazidime (31% in 2004 to 36% in 2009) and ciprofloxacin (33% to 51%) [27]. The difference between Egypt and Saudi Arabia in antibiotic resistance patterns was not statistically significant in our study, presumably due to the different rates of use of antibiotics in different countries. As regards screening for MBLs production in imipenem-resistant strains in Egypt and Saudi Arabia, the high resistance was consistent with an Egyptian study, which found that 10/31 (32.3%) of strains were MBL-positive [33]. In Saudi Arabia, Al-Agamy et al. found that the prevalence of resistance Table 2 Univariate logistic regression analysis of risk factors for infection by Pseudomonas aeruginosa isolated from samples obtained from patients in surgical adult intensive care units in Egypt and Saudi Arabia Variable Egypt (n = 180) P-value Saudi Arabia (n = 180) P-value Infected Non-infected Infected Non-infected (n = 59) (n = 121) (n = 54) (n = 126) No. % No. % No. % No. % Sex Female 24 40.7 51 42.1 0.85 20 37.0 41 32.5 0.55 Male 35 59.3 70 57.9 34 63.0 85 67.5 Age (years) 12–20 7 11.9 20 16.5 6 11.1 18 14.3 20–40 26 44.1 68 56.1 19 35.2 75 59.5 40–60 18 30.5 28 23.1 19 35.2 31 24.6 ≥ 60 8 13.5 4 3.3 0.04 10 18.5 2 1.6 < 0.001 Length of hospital stay (days) ≥ 7 55 93.2 39 32.2 < 0.001 50 92.6 63 50.0 < 0.001 Comorbid conditions Diabetes mellitus 16 27.1 26 21.5 0.4 10 18.5 20 15.9 0.66 Cardiac disease 10 16.9 36 29.8 0.06 16 29.6 42 33.3 0.11 Cancer 9 15.3 4 3.3 0.01 5 9.3 9 7.1 0.76 Trauma 16 27.1 27 22.3 0.47 18 33.3 26 20.6 0.06 Surgery 30 50.8 26 21.5 < 0.001 39 55.7 24 19.0 < 0.001 No. of antibiotics used ≥ 2 36 61.0 49 40.5 0.009 45 64.2 53 42.1 < 0.001 EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 76 to carbapenem was 34%, and 22% of them produced MBLs [34]. ICUs are epicentres of antibiotic resistance and the principal sources of outbreaks of multi-resistant bacteria. The non genetic causes of antibiotic resistance include excessive consumption of antibiotics by the population. More than 80% of ad- mitted patients in Egypt are prescribed antibiotics and in many cases without documented proof of infection and this exerts a selective pressure on bacteria [35] and/or horizontal dissemination [36]. Genetic causes of antibiotic resist- ance are mutation, over-expression of efflux pumps, loss or modification of porins, and acquired extended-spec- trum β-lactamases [37]. Table 3 Antibiotic resistance rates of Pseudomonas aeruginosa isolates from samples obtained from patients, the environment and staff hands in surgical adult intensive care units in Egypt and Saudi Arabia Source/Antibiotic Resistant isolates P-value Egypt Saudi Arabia No. % No. % Patient samples (n = 59) (n = 54) Colistin 0 0.0 0 0.0 1.00 Imipenem 29 49.2 36 66.7 0.06 Meropenem 30 50.8 39 72.2 0.02 Gentamycin 31 52.5 29 53.7 0.90 Amikacin 32 54.2 30 55.6 0.88 Piperacillin 34 57.6 33 61.1 0.70 Ceftazidime 37 62.7 38 70.4 0.38 Ciprofloxacin 38 64.4 28 51.9 0.17 Tobramycin 40 67.8 36 66.7 0.89 Cefepime 45 76.3 35 64.8 0.18 Aztreonam 57 96.6 53 98.1 0.93 Environment and staff hand samples (n = 18) (n = 16) Colistin 0 0.0 0 0.0 1.00 Gentamycin 10 55.6 10 62.5 0.68 Amikacin 11 61.1 11 68.8 0.64 Tobramycin 12 66.7 11 68.8 0.89 Imipenem 12 66.7 13 81.2 0.44 Piperacillin 13 72.2 12 75.5 0.83 Meropenem 13 72.2 12 75.5 0.83 Ciprofloxacin 14 77.8 10 62.5 0.45 Cefepime 16 88.9 16 100.0 0.48 Ceftazidime 18 100.0 16 100.0 1.00 Aztreonam 18 100.0 14 87.5 0.21 Table 4 Frequency of metallo-β-lactamases-(MBLs)-producing imipenem-resistant Pseudomonas aeruginosa isolates from samples obtained from patients, the environment and staff hands in surgical adult intensive care units in Egypt and Saudi Arabia Source MBL-producing imipenem-resistant P. aeruginosa strains P-value Egypt Saudi Arabia No. % No. % Patient samples 16/29 55.2 36/54 66.7 0.30 Environment samples 2/3 66.7 2/3 66.7 1.00 Staff hand samples 0/3 0.0 0/2 0.0 1.00 Total 18/35 51.4 38/59 64.4 0.21 P-value < 0.001 < 0.001 طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 77 Evidence-based prevention strate- gies targeting specific pathogens should be based on a thorough knowledge of their epidemiology, reservoirs in the ICU and modes of transmission [38]. However, isolation of P. aeruginosa per se is not sufficient to determine the epidemiological importance of the site of isolation, and typing techniques are needed. The numerical discriminatory index for antibiotyping in Egypt and Saudi Arabia gave a low D index (0.712 and 0.728 respectively). This can be explained by the small number of types defined by it (9 antibiotypes in Egypt and 8 Saudi Arabia) and the hetero- geneous distribution of the isolates in the groups (22 out of 77 isolates were present in one group in Egypt). This is in agreement with Freitas and Barth who declared that the low discrimina- tory power of susceptibility tests was not surprising since the power of a method was determined by the number of types defined by it and the relative frequencies of these types [39]. The D index for the ERIC method demonstrated that in Figure 1 Different 15 enterobacterial repetitive intergenic consensus (ERIC)-PCR patterns of Pseudomonas aeruginosa strains isolated from samples obtained from patients, the environment and staff hands in Egypt. ERIC genotypes of staff hands were ERIC I to III, environmental isolates were IV to IX and XII to XV and patient isolates belong to ERIC VII to XI Figure 2 Different 12 enterobacterial repetitive intergenic consensus (ERIC)-PCR patterns of Pseudomonas aeruginosa strains isolated from samples obtained from patients, the environment and staff hands in Saudi Arabia. ERIC genotypes of staff hands were ERIC IV to V, environmental isolates were I to III and VI to XI and patient isolates belong to ERIC VII to XII bp 3000 2000 1500 1200 1000 900 800 700 600 500 400 300 200 100 bp 3000 2000 1500 1200 1000 900 800 700 600 500 400 300 200 100 M 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1535 950 750 720 580 510 420 380 350 300 260 150 110 M 1 2 3 4 5 6 7 8 9 10 11 12 1535 950 750 720 580 510 420 380 350 300 260 150 110 EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 78 Ta bl e 5 Th e 9 di ffe re nt a nt ib io ty pe s of P se ud om on as a er ug in os a st ra in s is ol at ed fr om s am pl es o bt ai ne d fr om p at ie nt s, th e en vi ro nm en t a nd s ta ff h an ds in a s ur gi ca l a du lt in te ns iv e ca re u ni t i n Eg yp t A nt ib io ty pe A m ik ac in A zt re on am C ef ep im e C ef ta zi di m e C ip ro flo xa ci n C ol is ti n G en ta m yc in Im ip en em M er op en em Pi pe ra ci lli n To br am yc in A 1 S S S S S S S S S S S A 2 R R S S S S S S S S R A 3 S R R R S S S S S S R A 4 S R R S R S S R S S S A 5 R R R R S S R S S S S A 6 S R R R R S R S S R S A 7 R R S R R S R S R R R A 8 R R R R R S S R R R R A 9 R R R R R S R R R R R S = se ns iti ve ; R = re si st an t. Ta bl e 6 Th e 8 di ffe re nt a nt ib io ty pe s tt an ti bi ot yp es o f P se ud om on as a er ug in os a st ra in s is ol at ed fr om s am pl es o bt ai ne d fr om p at ie nt s, th e en vi ro nm en t a nd s ta ff h an ds in a s ur gi ca l ad ul t i nt en si ve c ar e un it in S au di A ra bi a A nt ib io ty pe A m ik ac in A zt re on am C ef ep im e C ef ta zi di m e C ip ro flo xa ci n C ol is ti n G en ta m yc in Im ip en em M er op en em Pi pe ra ci lli n To br am yc in A 1 S S S S S S S S S S S A 2 S R S S R S S S S R R A 3 S R S S R S R R S S R A 4 S R R R R S S S S R S A 5 R R R R R S S S R S S A 6 R R R R R S R S S S R A 7 R R R R R S R S S R R A 8 R R R R R S R R R R R S = se ns iti ve ; R = re si st an t. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 79 References 1. Driscoll JA, Brody SL, Kollef MH. The epidemiology, patho- genesis and treatment of Pseudomonas aeruginosa infections. Drugs, 2007, 67:351–368. 2. Hidron AI et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Preven- tion, 2006–2007. Infection Control and Hospital Epidemiology, 2008, 29:996–1011. 3. Livermore DM. Multiple mechanisms of antimicrobial resist- ance in Pseudomonas aeruginosa: our worst nightmare? Clini- cal Infectious Diseases, 2002, 34:634–640. 4. Cornaglia G, Giamarellou H, Rossolini GM. Metallo-β- lactamases: a last frontier for beta-lactams? Lancet Infectious Diseases, 2011, 11:381–393. 5. Cuttelod M et al. Molecular epidemiology of Pseudomonas aeruginosa in intensive care units over a 10-year period (1998– 2007). Clinical Microbiology and Infection, 2011, 17:57–62. 6. Pitt TL. Epidemiological typing of Pseudomonas aeruginosa. European Journal of Clinical Microbiology and Infectious Dis- eases, 1988, 7:238–247. 7. Olive DM, Bean P. Principles and applications of methods for DNA-based typing of microbial organisms. Journal of Clinical Microbiology, 1999, 37:1661–1669. 8. Douglas MW et al. Multi-drug resistant Pseudomonas aer- uginosa outbreak in a burns unit--an infection control study. Burns, 2001, 27:131–135. 9. Talon D et al. Discriminatory power and usefulness of pulsed field gel electrophoresis in epidemiological studies of Pseu- domonas aeruginosa. Journal of Hospital Infection, 1996, 32:135–145. 10. Kersulyte D et al. Comparison of arbitrarily primed PCR and macrorestriction (pulsed-field gel electrophoresis) typing of Pseudomonas aeruginosa strains from cystic fibrosis patients. Journal of Clinical Microbiology, 1995, 33:2216–2219. 11. Syrmis MW et al. Rapid genotyping of Pseudomonas aerugi- nosa isolates harboured by adult and paediatric patients with cystic fibrosis using repetitive-element-based PCR assays. Jour- nal of Medical Microbiology, 2004, 53:1089–1096. 12. Sharples GJ, Lloyd RG. A novel repeated DNA sequence located in the intergenic regions of bacterial chromosomes. Nucleic Acids Research, 1990, 18:6503–6508. Table 7 Numerical discriminatory index of enterobacterial repetitive intergenic consensus (ERIC) and antibiogram in Egypt and Saudi Arabia Variable Egypt Saudi Arabia No. of different types No. of strains belonging to most numerous type Numerical discriminatory index No. of different types No. of strains belonging to most numerous type Numerical discriminatory index ERIC 15 26 0.801 12 22 0.785 Antibiogram 9 22 0.723 8 18 0.728 Egypt and Saudi Arabia, ERIC typing gave a higher D index (0.801 and 0.785 respectively). Sharing of certain ERIC types be- tween patient strains may be explained by horizontal transmission from patient to patient, probably from the hands of health care workers or environmental sources. Although P. aeruginosa was iso- lated from the hands of nursing staff, both typing methods failed to show a direct link with strains isolated from patients. Other studies revealed that staff hands play an important role in its spread in the adult ICU [40] and neonatal ICU [31]. As regards P. aeruginosa isolated from environmental sites in our study, 3 sites in Egypt—suction apparatus tubing, AV machine tubes and drainage container—had direct epidemiological relationships with patients. Evacuation of suction apparatus fluid into drain- age containers is a possible link that could explain this relationship. In agreement with our study, Yorioka et al. in Japan found that P. aeruginosa was one of the main contaminant bacteria isolated from suction tubes [41]. In Saudi Arabia, 2 sites (suction apparatus tubing and AV machine tubes) had a direct epidemiological relationships with patients. On the other hand, in our study in Egypt and Saudi Arabia, MBL-producing strains were epide- miologically linked to suction apparatus tubing, AV machine tubes and drainage containers, while in Saudi Arabia they linked epidemiologically to suction apparatus tubing and AV machines. This finding can be explained by the fact the MBL genes are harboured in mobile genetic elements and integrons [42]. The same argument can be used to explain why some non-MBL-producing strains shared the same genotype as MBL-producing strains. Also, MBL- producing strains may have originated from the non-MBL strains that acquired the genes through some mobile genetic elements [43]. In summary, this study adds to the evidence that strain typing using the ERIC method is superior to antibio- typing and can increase the efficiency of infection control procedures by de- termining the patient sources of infec- tions that need to be eliminated and the environmental sources of P. aeruginosa that may receive less stringent action. Evidence was also provided that stricter antibiotic prescribing policies and re- sistance surveillance programmes are needed in Egypt and Saudi Arabia to assist in implementing infection control measures. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 80 13. de Bruijn FJ. Use of repetitive (Repetitive Extragenic Palindro- mic and Enterobacterial Repetitive Intergeneric Consensus) se- quences and the polymerase chain reaction to fingerprint the genomes of Rhizobium meliloti isolates and other soil bacteria. Applied and Environmental Microbiology, 1992, 58:2180–2187. 14. 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Imipenem resistance and BLAIMP gene among hospital strains of Pseudomonas aeruginosa at university hos- pital in Egypt. Journal of Infection in Developing Countries, 2007, 1:42–47. 34. Al-Agamy MH et al. High prevalence of metallo-beta-lacta- mase-producing Pseudomonas aeruginosa from Saudi Arabia. Journal of Chemotherapy (Florence, Italy), 2009, 21:461–462. 35. El-Teheawy MM et al. The pattern of antimicrobial use in gen- eral hospitals in Egypt. Chemiotherapia, 1998, 7:387–392. 36. Hocquet D et al. Genetic and phenotypic variations of a resist- ant Pseudomonas aeruginosa epidemic clone. Antimicrobial Agents and Chemotherapy, 2003, 47:1887–1894. 37. Pellegrino FLPC et al. Occurrence of amultidrug-resistant Pseudomonas aeruginosa clone in different hospitals in Rio de Janeiro, Brasil. Journal of Clinical Microbiology, 2002, 40:2420– 2424. 38. Trautmann M, Lepper PM, Haller M. Ecology of Pseudomonas aeruginosa in the intensive care unit and the evolving role of water outlets as a reservoir of the organism. American Journal of Infection Control, 2005, 33(5 Suppl.):S41–S49. 39. Freitas AL, Barth AL. Typing of Pseudomonas aeruginosa from hospitalised patients. Comparison of susceptibility and bio- chemical profiles with genotypes. Brazilian Journal of Medical and Biological Research, 2004, 37:77–82. 40. Foca M et al. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. New England Journal of Medicine, 2000, 343:695–700. 41. Yorioka K, Oie S, Kamiya A. Microbial contamination of suction tubes attached to suction instruments and preventive meth- ods. Japanese Journal of Infectious Diseases, 2010, 63:124–127. 42. Poirel L et al. Characterization of class 1 integrons from Pseu- domonas aeruginosa that contain the blaVIM-2 carbap- enem-hydrolyzing beta-lactamase gene and of two novel aminoglycoside resistance gene cassettes. Antimicrobial Agents and Chemotherapy, 2001, 45:546–552. 43. Rossolini GM. Acquired metallo-beta-lactamases: an increasing clinical threat. Clinical Infectious Diseases, 2005, 41:1557–1558. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 81 Quality of the clinical laboratory department in a specialized hospital in Alexandria, Egypt T.A. Elhoseeny 1 and E.K. Mohammad 2 ABSTRACT Assessment and improvement of turnaround times (TAT) as well as customer satisfaction is essential for laboratory quality management. This study in a specialized hospital in Alexandria, Egypt measured the current TAT for outpatient department bilirubin samples and evaluated the satisfaction of physicians with aspects of clinical laboratory services. While the mean TAT for 110 bilirubin tests [58.1 (SD 31.8) min] was within the College of American Pathologists' benchmark, the 90th percentile was long (96.7 min); 62.7% of tests were reported within 60 min. The mean overall satisfaction score of physicians (range 1–5) was 3.46 (SD 0.49). The highest satisfaction rating was for staff courtesy while the lowest ratings were for laboratory management responsiveness, outpatient stat TAT and critical value notification. Quality or reliability of results was judged by physicians as the most important factor (32.3%), followed by routine test TAT (18.5%). Further analysis of the different steps of the TAT would be helpful and follow-up through examining outliers is recommended. 1Department of Hospital Administration, High Institute of Public Health, Alexandria, Egypt (Correspondence to T.A. Elhoseny: taghareed@hotmail.com). 2Department of Clinical Pathology, Fever Hospital, Alexandria, Egypt. Received: 01/10/11; accepted: 01/11/12 صرم ،ةيردنكسلإا في ةيصصختلا تايفشتسلما دحأ في ةيريسرلا تابرتخلما مسق في ةدولجا دممح سيخم نمايإ ،ينيسلحا سابع ديراغت هذه تيرجأ دقو .ةيساسلأا روملأا نم تابرتخلما في ةدولجا ةرادإ نع ،ينلماَعَتُمـلا ضىرو لمعلا لماكتسا نمز ينستحو مييقت برتعُي :ةـصلالخا ضىرلما مسق في ينبورليبلا تانيع سايقل ليالحا لمعلا لماكتسا نمز سايقل ،صرم ،ةيردنكسلإا في ةيصصختلا تايفشتسلما ىدحإ في ةساردلا 110 في لمعلا لماكتسلا يطسولا نمزلا نأ نم مغرلا لىع هنأ ناتثحابلا تدجوو .ةيبرتخلما تامدلخا بناوجب ءابطلأا ضىر مييقت عم ينيجرالخا ةليوط تناك ةينيعستلا ةيوئلما ةيحشرلا نإف ،ينيجولوثابلل ةيكيرملأا ةيلكلل لوبقلما دودلحا نمض ناك )31.8 ± ةقيقد 58.1( ينبويرلبلا تارابتخا نم حواتري وهو( ءابطلأا ضىرل لياجملإا يطسولا زَرَحـلا امأ .ةقيقد 60 للاخ اهنع ريراقتلا تدعأ دق تارابتخلاا نم %62.7 نأ ينح في ؛)ةقيقد 96.7( نمز لىإو ،تابرتخلما ةرادإ ايهدبت يتلا ةباجتسلاا لىإ اهاندأو ،ينلماعلا ةقابَل لىإ تاجردلا لىعأ ْتَيطعُأ دقو .)0.49 ± 3.46( ناك دقف )5و 1 ينب رثكأ يه اهتيقوثوم وأ جئاتنلا ةدوج نأ اوأر ءابطلأا نأ ماك .ةروطلخا ةغلابلا ةيدلحا ميقلا نع غلابلإا لىإو ،ينيجرالخا ضىرلما ةلالح لمعلا لماكتسا ةفلتخلما تاوطخلل ليلحتلا نم ديزلما ءارجإ دعاسي فوسو .)%18.5( ةينيتورلا تارابتخلال لمعلا لماكتسا نمز اهولتي ،)%32.3( ًةيهمأ لماوعلا .هئارجإب ناتثحابلا صيوتو ،ةيئانلا تايرغتلما ةسارد للاخ نم ثحبلا ةعباتم في ،لمعلا لماكتسا نمزل Qualité du service de laboratoire clinique dans un hôpital spécialisé d'Alexandrie (Égypte) RÉSUMÉ L'évaluation et l'amélioration des délais de traitement et de la satisfaction du client sont essentielles pour la gestion de la qualité en laboratoire. La présente étude réalisée dans un hôpital spécialisé d'Alexandrie (Égypte) a mesuré le délai de traitement courant des échantillons prélevés en consultation externe et destinés à un dosage de la bilirubine. L'étude a aussi évalué la satisfaction des médecins en termes de services fournis par un laboratoire clinique. Si le délai de traitement moyen de 110 dosages de la bilirubine (58,1 minutes [ET 31,8]) se situait dans la fourchette de référence du College of American Pathologists, le 90e percentile était long (96,7 minutes) ; 62,7 % des analyses étaient transmises dans les 60 minutes. Le score de satisfaction moyen des médecins (extrêmes 1–5) était de 3,46 (ET 0,49). Le pourcentage de satisfaction le plus élevé a été décerné à la courtoisie du personnel alors que les résultats les plus faibles ont été attribués à la réactivité de la direction du laboratoire, au délai de traitement des analyses express dans les services de consultations externes et aux notifications ayant une valeur critique. La qualité ou la fiabilité des résultats a été jugée par les médecins comme étant le facteur le plus important (32,3 %), suivi par le délai de traitement des analyses courantes (18,5 %). Des analyses approfondies des différentes étapes du délai de traitement seraient utiles et un suivi des valeurs extrêmes ou aberrantes est recommandé. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 82 Introduction Clinical laboratory testing is an essential element in the delivery of health care services [1,2]. The dependence of pa- tient management on laboratory data highlights the need for ensuring the quality of these services [1,2]. Delays in reporting laboratory results can cause a concomitant delay in the diagnosis and management of patients [3]. The Joint Commission has underlined this fact by stating that the laboratory is required to systematically assess and improve im- portant functions and work processes and their outcomes [4]. Turnaround time (TAT) is one of the most obvious measures of a labora- tory service. Direct assessment of TAT helps managers to understand whether local performance is improving and how it compares with published norms. De- spite advances in analytical technology, transport systems and computerization, however, many laboratories have had difficulties improving their TATs [5]. In the USA, TAT has remained at or greater than 1 hour since at least 1965 [6]. Non-analytical delays may be re- sponsible for up to 96% of total TAT [7]. Investigating causes of outlier TATs that exceeded 70 min showed that only 28% were caused by the analytic phase of the total testing process; most delays occurred in the pre-analytic steps associ- ated with specimen collection and trans- port or the post-analytic steps involved with reporting the results [5]. While laboratories have tradition- ally restricted discussion of quality to technical or analytical quality, focusing on imprecision and inaccuracy goals, clinicians are interested in other dimen- sions of service quality too. In addition to total test error (imprecision and inac- curacy), this encompasses, availabil- ity, cost, relevance and timeliness [8]. Measurement of customer satisfaction brings customer preferences into the quality assessment process and cor- rects for mistaken assumptions about which particular aspects of services customers value most [9]. Assessing customer satisfaction with laboratory services is required for accreditation by the College of American Patholo- gists (CAP) and The Joint Commission [10,11]. Physicians are one of the pri- mary customers of laboratory services and obtaining their feedback provides laboratory managers with opportuni- ties to identify areas for improvement. The CAP’s Q-Probes laboratory quality improvement programme, which has produced numerous publications defin- ing performance benchmarks in pathol- ogy and laboratory medicine [12], has provided a standardized survey tool for assessing customer satisfaction with laboratory services [12–14]. Assessment and improvement of TAT as well as assessment of physician satisfaction as a base for improvement efforts is essential for laboratory qual- ity management. The present study in a hospital in Alexandria, Egypt was un- dertaken to measure the current TAT for outpatient department samples of bilirubin which is a key and common test in the study hospital. The study also attempted to evaluate physician satis- faction overall and with specific aspects of clinical laboratory services. Methods Study setting The study was conducted in the labora- tory of a 280-bed specialized fever hos- pital affiliated to the Ministry of Health in Alexandria, Egypt. The hospital has an occupancy rate of 71.5% [hospital statistics department data]. The hospital laboratory provides clinical chemistry, haematology, coagulation, microbiol- ogy, immunology and toxicology ser- vices. It provides 200 000 tests per year, with approximately 70% of the results pertaining to inpatients and 30% to out- patients. The laboratory system consists of a core laboratory that performs the majority of testing for inpatients, with 7 satellites in different buildings of the hospital. The laboratory information system is a paper-only manual system. Blood drawing and sample collection are performed by a phlebotomist in the laboratory department. After analysis of specimens, results are transcribed into a laboratory register and the laboratory reports are transported manually to the requesting physicians. Sample Turnaround times The study population for measurement of TAT were outpatient department bilirubin tests requests. The sample size was calculated using Medcalc, version 13.0, based on previous studies on TAT for chemistry specimens [15]. Using a TAT of 68.7 min and SD 11.3, accepted error of 3 min, an alpha of 0.05 and power 80%, the minimum sample size required was calculated as 112. Bilirubin test requests from the outpatient de- partment from 09.00–14.00 hours were included until completion of the sample size (14 working days were needed to complete the sample). Physician satisfaction The study population for the assess- ment of physician satisfaction was all working physicians in the hospital. For measurement of physician satisfaction, all physicians in the hospital (n = 107) were included. The response rate was 60.8% (n = 65). Data collection Turnaround times For measurement of TAT, it was clas- sified into 3 phases: pre-analytical; analytical; and post-analytical. The pre- analytical phase included T1 (waiting time of patient for sampling): starting from patient arrival to the laboratory to the start of processing of test request, T2 (processing of test request), T3 (col- lection of blood), T4 (placing of blood in tubes and labelling) and T5 (centri- fuge). The analytical phase included T6 (sample analysis) and T7 (verification of results). The post-analytical phase طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 83 report format and test menu adequacy. Stat laboratory tests and services are those that are needed immediately in order to manage medical emergencies. Evaluations were provided by physi- cians using a scale of 1–5 (1 = poor, 2 = below average, 3 = average, 4 = good and 5 = excellent). Physicians were asked to indicate which one of the 11 aspects of service was the most important to them. Data analysis Three composite satisfaction measures were used. Overall mean satisfaction score = [(no of excellent ratings ×5) + (no. of good ratings × 4) + (no. of average rat- ings ×3) + (no. of below average ratings × 2) + (no. of poor ratings ×1)]/total no. of ratings (1–5) Percentage of excellent or good rat- ings = [(no. of excellent or good ratings for specific laboratory service category ×100)]/total no. of ratings (1–5) for that specific laboratory service category. Percentage of below average or poor ratings = [no. of below average or poor ratings for specific laboratory service category × 100)]/total no. of ratings (1–5) for that specific laboratory ser- vice category. Results Turnaround times Of 110 laboratory tests 62.7% tests were reported within 60 min, 24.5% were reported between 60–90 min and the TAT of 12.7% (14 tests) was longer than 90 min. Table 1 shows the mean, median and percentile TAT of the different phases (pre-analytical, analytical and post-analytical) and the total TAT in this outpatient department. The mean TAT was 58.1 (SD 31.8) min. The mean pre-analytical, analytical and post-analytical TATs were 33.6 (SD 25.4), 19.6 (SD 12.3) min and 4.9 (SD 4.2) min respectively. It was found that the 50th percentile (median) of pre- analytical, analytical, post-analytical and total TAT were 23 min, 16 min, 3 min and 49.5 min respectively while the 90th percentile of pre-analytical, analytical, post-analytical and total TAT were 67.9 min, 33.9 min, 10.9 min and 96.7 min. Physician satisfaction Table 2 shows the distribution of labo- ratory service categories according to physicians’ ratings. The highest excellent rating of all laboratory service categories was for staff courtesy (43.1%), which had the highest mean satisfaction score (4.20), followed by quality or reliability of results (21.5%). The highest poor rat- ings of the laboratory service categories was for laboratory management re- sponsiveness, outpatient stat TAT and critical value notification (10.8%, 7.7%, 7.7%) respectively. The lowest mean satisfaction score was for outpatient stat TAT and clinical report format (3.26) followed by routine test TAT (3.31). Table 3 shows that the overall scores of physician satisfaction with included T8 (transcription of results by physicians) and T9 (reporting of results to physicians). An observational form including these steps was used by one of the researchers to track bilirubin tests and record their TAT. The laboratory methods used were as follows (Diamond Diagnostics). For total bilirubin: mix the 3 reagents with the specimen and incubate for 10 min at 20–25 °C then add the 4th reagent. Mix and incubate for 5 min at 20–25 °C; read absorbance of specimen against specimen blank. For direct bilirubin: mix the 2 reagents with NaCl (0.9%) and the specimen and incubate for 5 min at 20–25 °C; read absorbance of specimen against specimen blank. The equipment used for analysis were the BioSystem 310 BTS and the Hetch centrifuge at 4000 rpm for 5 min. Physician satisfaction For measurement of physician satis- faction with the laboratory service a self-administered closed-ended ques- tionnaire designed by CAP [9] was used. The questionnaire was designed to collect data about satisfaction with 15 aspects of clinical laboratory services. Eleven aspects of laboratory services were included. The quality/reliability of test results (which means accuracy and precision of results), accessibility of pathologist, accessibility of laboratory manager, staff courtesy, phlebotomy services, accessibility of laboratory staff, routine test TAT, laboratory manage- ment responsiveness, inpatient stat TAT, critical value notification, clinical Table 1 Mean, median and percentiles of the pre-analytical, analytical, post-analytical and total laboratory turnaround times (TAT) for bilirubin analysis from an outpatient department (n = 110 tests) Phase Mean (SD) Percentilesa 10th 25th 50th (median) 75th 90th Pre-analytical TAT (min) 33.6 (25.4) 10 15 23 49 67.9 Analytical TAT (min) 19.6 (12.3) 7 11 16 26.3 33.9 Post-analytical TAT (min) 4.9 (4.2) 2 2 3 7 10.9 Total TAT (min) 58.1 (31.8) 24.1 35 49.5 76.3 96.7 aHigher percentile ranks indicate worse relative performance. SD = standard deviation. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 84 clinical laboratory services ranged from 1.91–4.55 with a mean and median score of 3.5. Table 4 shows the rankings of physicians’ ratings for each laboratory service category. Staff courtesy had the highest percentage of excellent/good ratings (76.9%). Five service categories received the lowest percentage of excellent/good rating (46.2%): stat TAT and routine test TAT, laboratory management responsiveness, clinical report format and accessibil- ity of laboratory staff. The laboratory management responsiveness had the highest percentage ratings (23.1%) for poor/below average. Table 4 also shows the distribution of laboratory service categories ac- cording to their importance to the physicians. Quality or reliability of results was considered to be the most important by the physicians (32.3%) followed by routine test TAT and outpatient stat TAT (18.5% each) while the least chosen categories were staff courtesy, accessibility of phlebotomist, accessibility of laboratory staff and test menu adequacy (1 response, 1.5% for each). Discussion In the current study we used the mean, the median, the 90th percentile and the outlier rate (percent- age of TAT exceeding 60 min) to express the TAT. Measuring the mean and the median was important as the TAT was not measured before in the study hospital and we needed to determine our actual time and whether it was within the acceptable measures before starting comparison with external benchmarks and detection of the outliers. The mean TAT for this fever hospital outpatient department bilirubin testing was 58.1 (SD 31.8) min and the median was 49.5 min. This result seems to be within the acceptable benchmark using TAT goals of < 60 min for chemical laboratory tests as an initial goal for acceptable TAT according to CAP Q-Probes standards [16]. On the other hand, the 90th percentile of TAT (96.7 min) was much longer than in the 2004 CAP Q-Probes study on biochemical markers of myocardial injury where the 90th percentile of order-to-report TAT for creatine kinase (CK-MB) was 66.5 min and 61.0 min for troponin in the emer- gency department [17]. Also in the current study TAT was longer than that reported by the Asian Medical Center analysis study to measure the TAT of chem- istry analytes including bilirubin from the outpatient department, where the 90th percentile of overall TAT (barcode printing to report) was 51.8 min [15]. Ta bl e 2 D is tr ib ut io n of p hy si ci an s’ ra ti ng s of la bo ra to ry s er vi ce c at eg or y an d m ea n sc or e fo r e ac h se rv ic e (n = 6 5 ph ys ic ia ns ) Se rv ic e ca te go ry Ph ys ic ia ns ’ r at in gs M ea n sa ti sf ac ti on s co re a Ex ce lle nt G oo d A ve ra ge Be lo w a ve ra ge Po or N o. % N o. % N o. % N o. % N o. % St af f c ou rt es y 28 43 .1 22 33 .8 15 23 .1 0 0 .0 0 0 .0 4. 20 Q ua lit y/ re lia bi lit y of re su lts 14 21 .5 20 30 .8 20 32 .3 11 15 .4 0 0 .0 3. 57 A cc es si bi lit y of p hl eb ot om is t 11 16 .9 20 30 .8 20 30 .8 12 18 .5 2 3. 1 3. 40 A cc es si bi lit y of la bo ra to ry st af f 10 15 .4 20 30 .8 23 35 .4 12 18 .5 0 0 .0 3. 43 A cc es si bi lit y of la bo ra to ry m an ag er 10 15 .4 25 38 .5 18 27 .7 8 12 .3 4 6. 2 3. 45 La bo ra to ry m an ag em en t r es po ns iv en es s 10 15 .4 20 30 .8 22 30 .8 8 12 .3 5 10 .8 3. 34 C rit ic al v al ue n ot ifi ca tio n 10 15 .4 25 38 .5 20 30 .8 5 7.7 5 7.7 3. 46 Te st m en u ad eq ua cy 7 10 .8 25 38 .5 23 35 .4 9 13 .8 1 1.5 3. 43 Ro ut in e te st T AT 5 7.7 25 38 .5 22 33 .8 11 16 .9 2 3. 1 3. 31 O ut pa tie nt st at T AT 5 7.7 25 38 .5 22 33 .8 8 12 .3 5 7.7 3. 26 C lin ic al re po rt fo rm at 5 7.7 25 38 .5 21 32 .3 10 15 .4 4 6. 2 3. 26 To ta l ( av er ag e) 16 .0 35 .2 31 .6 13 .2 3. 1 3. 46 a R an ge 1– 5, w he re 1 = po or a nd 5 = e xc el le nt . TA T = tu rn ar ou nd ti m e. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 85 This difference may be attributed to the manual approach of the laboratory in the current study. The present study defined labora- tory TAT as the time taken from patient attendance to laboratory department until the test report became available. The TAT begins with patient arrival at the laboratory then manual registration of his/her data in the laboratory regis- ter, preparation for venesection, phle- botomy and labelling of the test-tube. In previous studies these steps were saved through automation so that the patient data were captured through the labo- ratory information system and using automated barcode printing [15,17]. In the Asian Medical Center, laboratory TAT started from barcode printing. The prolonged 90th percentile is an indicator of high variability among the results. These findings agree with the result that only 62.7% of specimens (69 test results) were reported within 60 min. This proportion is much less than that reported by the study of the Asian medical centre of South Korea where 98% of the tests were reported within 60 min [15]. In this study the median pre-analyt- ical phase time was 23 min, the median analytical time was 16 min and the me- dian post-analytical time was 3 min. It is very useful to analyse the component steps of TAT in it to identify the sources of delay. The pre-analytical phase steps included patient waiting times for sam- pling, processing of test requests, collec- tion of blood, placing of blood in tubes and labelling and centrifuge. Root cause analysis studies may be needed to identify the sources of delay to enable planning for improvement and reduction of variability, which is a target for quality programmes. An important point to mention is that the TAT measured here did not include the time taken from the physi- cian order until the patient entered the laboratory. Also reporting of results was considered when the results were docu- mented and the report became ready and not when the result reached the physician. Taking these time periods into consideration could elongate the TAT further. The mean satisfaction score of phy- sician in this study was 3.46 (SD 0.49) (on a scale of 1–5) and the median was 3.45. This result is not far from 3 studies in the USA, which used the same tool to measure the physician satisfaction and reported a mean satisfaction score between 4.0 and 4.1 [13,18,19]. The highest excellent rating of laboratory service category was for staff courtesy (43.1%) followed by quality or Table 3 Physicians’ overall satisfaction with clinical laboratory services (n = 65 physicians) Variable Mean (SD) Range Percentiles 10th 25th 50th (median) 75th 90th Mean satisfaction scorea 3.46 (0.49) 1.91–4.55 2.84 3.18 3.45 3.86 4.04 aRange 1–5, where 1 = poor and 5 = excellent. SD = standard deviation. Table 4 Physicians’ ratings of satisfaction with each laboratory service and opinions of which service was the most important Service category Physicians’ satisfaction ratings Most important service (n = 65 physicians)Excellent/ good service (n = 715 ratings) Poor/ below average service (n = 715 ratings) % % % Staff courtesy 76.9 0.0 1.5 Accessibility of laboratory manager 53.9 18.5 6.2 Critical value notification 53.9 15.4 10.8 Quality/reliability of results 52.3 15.4 32.3 Test menu adequacy 49.2 15.4 1.5 Accessibility of phlebotomist 47.7 21.5 1.5 Routine test TAT 46.2 20.0 18.5 Laboratory management responsiveness 46.2 23.1 3.1 Outpatient stat TAT 46.2 20.0 18.5 Clinical report format 46.2 21.5 4.6 Accessibility of laboratory staff 46.2 18.5 1.5 TAT = turnaround time. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 86 reliability of results (21.5%), while the highest poor rating was for laboratory management responsiveness, critical value notification and outpatient stat TAT (10.8%, 7.7% and 7.7% respec- tively). Staff courtesy had the highest percentage of excellent/good ratings (76.9%). Laboratory management re- sponsiveness scored the highest poor/ below average rating (23.1%). The per- centage of poor/below average ratings for routine test TAT and outpatient stat TAT was 20.0% for each. These findings are comparable with the find- ings of the Q-Probes programme of the CAP. Staff courtesy had the highest median value (45.2%) for percentage of excellent ratings among all service categories, followed by quality of results (38.9%) and critical value notification (38.7%). Outpatient stat TAT had the highest poor/below average rat- ing (8.8%), after excluding dimensions that were not included in the current study [13]. The Q-Probes programme in 2002 showed that quality of results had the highest excellent or good rat- ing (86.7%), followed by staff courtesy (85.8%), while outpatient stat TAT also had the highest poor/below av- erage rating (9.5%) after exclusion of the non-included dimensions in the current study [18]. The surveyed data in 2007 showed that quality/reliabil- ity of test results and staff courtesy had the highest median excellent or good rating percentages (89.9% for each), followed by accessibility of laboratory staff (87.6%) and accessibility of pa- thologist (87.5%). The outpatient stat TAT also had the highest poor/below average rating (5.9%), after exclusion of the non-included dimensions in the current study [19]. The most important laboratory services for physicians were quality and reliability of results (32.3%) and routine and outpatient stat TAT (18.5%). The Q-Probes studies also showed that physicians found quality and reliability of results and TAT the most important aspects of the service [18,19]. This high importance of TAT for the physicians can explain our re- sults of low satisfaction with the TAT. The lowest satisfaction scores were given for the routine and stat TATs. We can add the high variability and lack of predictability of the results timing which were demonstrated by the prolonged 90th percentile and the high outlier rate. Conclusion The average TAT of the bilirubin test in our laboratory was within the recom- mended benchmark of the CAP but the lengthy 90th percentile indicated variability and lack of a standard or expected target for this test. Physicians were satisfied with the courtesy of the laboratory staff but less satisfied with the TAT in general, which is considered to be the second most important aspect of laboratory service. Further analysis of the different steps of the TAT is needed to identify sources of delay so that planning for improve- ment can be done. Follow-up measure- ment of the TAT is recommended by detecting the rate of outliers. Physician satisfaction should be measured fre- quently to identify opportunities for im- provement and as an outcome measure of improvement plans. References 1. Shahangian S, Snyder SR. Laboratory medicine quality indi- cators: a review of the literature. American Journal of Clinical Pathology, 2009, 13:418–431. 2. Chawla R et al. Evaluating laboratory performance with quality indicators. Labmedicine., 2010, 41:297–300. 3. Holland LL, Smith LL, Blick KE. Total laboratory automation can help eliminate the laboratory as a factor in emergency depart- ment length of stay. American Journal of Clinical Pathology, 2006, 125:765–770. 4. Comprehensive accreditation manual for pathology and labora- tory services. Oakbrook Terrace, Illinois, Joint Commission, 2009. 5. Steindel SJ, Novis DA. Using outlier events to monitor test turnaround time. Archives of Pathology and Laboratory Medi- cine, 1999, 123:607–614. 6. Howanitz JH, Howanitz PJ. Timeliness as a quality attribute and strategy. American Journal of Clinical Pathology, 2001, 116:311–315. 7. Manor PG. Turnaround times in the laboratory: a review of the literature. Clinical Laboratory Science, 1999, 12:85–89. 8. Watts NB. Reproducibility (precision) in alternate site testing. A clinician’s perspective. Archives of Pathology and Laboratory Medicine, 1995, 119:914–917. 9. Jones BA et al. Physician satisfaction with clinical laboratory services: College of American Pathologists Q-probes study of 138 institutions. Archives of Pathology and Laboratory Medicine, 2009, 133:38–43. 10. Laboratory general checklist. Laboratory accreditation program. Northfield, Illinois, College of American Pathologists, 2006 (GEN. 20368). 11. Comprehensive accreditation manual for laboratory and point-of- care testing. Oakbrook Terrace, Illinois, Joint Commission on Accreditation for Healthcare Organizations, 2005–06:PI.1.10. 12. Howanitz PJ. Quality assurance measurements in departments of pathology and laboratory medicine. Archives of Pathology and Laboratory Medicine, 1990, 114:1131–1135. 13. Miller KA, Dale JC. Physician satisfaction with clinical laboratory service, 99-03: Q-probes. Northfield, Illinois, College of Ameri- can Pathologists, 1999. 14. Jones BA, Walsh MK, Ruby SG. Hospital nursing satisfaction with clinical laboratory services: a College of American Pathol- ogists Q-Probes study of 162 institutions. Archives of Pathology and Laboratory Medicine, 2006, 130:1756–1761. 15. Chung HJ et al. Analysis of turnaround time by subdividing three phases for outpatient chemistry specimens. Annals of Clinical and Laboratory Science, 2009, 39:144–149. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 87 Quality assurance in laboratories The maintenance of a quality management system is crucial to a laboratory for providing the correct test results every time. Important elements of a quality management system include: • Documentation • Standard Operating Procedures (SOPs) • Quality control samples • External Quality Assessment Scheme Quality control procedures are used in each assay to assure a test run is valid and the resultsobtained are reliable; these procedures include the use of kit controls and quality control samples. External quality assessment schemes aim to analyse the accuracy of the entire testing process from receipt of sample and testing of sample to reporting of results. Source: www.who.int/diagnostics_laboratory/quality/en/ 16. Lee-Lewandrowski E et al. Utilization and cost analysis of bed- side capillary glucose testing in a large teaching hospital: impli- cations for managing point of care testing. American Journal of Medicine, 1994, 97:222–230. 17. Novis DA et al. Biochemical markers of myocardial injury test turnaround time: a College of American Pathologists Q-Probes study of 7020 troponin and 4368 creatine kinase-MB determi- nations in 159 institutions. Archives of Pathology & Laboratory Medicine, 2004, 128:158–164. 18. Howanitz PJ. Physician satisfaction with clinical laboratory ser- vices: Q-probes data analysis and critique. Northfield, Illinois, College of American Pathologists, 2002. 19. Jones BA, Bekeris LG. Physician satisfaction with clinical labo- ratory services: College of American Pathologists, Q-probes study of 138 institutions. Archives of Pathology and Laboratory Medicine, 2009, 133:38–43. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 88 Salmonella spp. in patients suffering from enteric fever and food poisoning in Thamar city, Yemen R.R. Taha,1 S.M. Alghalibi 1 and M.G. Saeed Saleh 1 ABSTRACT Salmonella remains a public health concern around the world, including Yemen although data on its incidence are few. This study determined the incidence of Salmonella infection in 250 enteric fever and 210 food poisoning cases attending Thamar general hospital and Dar Alshafaa medical clinic in 2008. In total, 773 clinical specimens were taken: 250 blood, 187 urine and 336 stool samples. Of the patients with enteric fever and food poisoning, 16.4% and 15.2% respectively were infected with Salmonella. The serovars isolated were: Salmonella Typhi (45.6%), Salmonella Enteritidis (24.4%), Salmonella Paratyphi B (14.4%), Salmonella Typhimurium (13.3%) and Salmonella Paratyphi A (2.2%). The distribution of somatic groups was: D (70%), B (27.7%) and A (2.2%). None of the isolates was resistant to ciprofloxacin, sparfloxacin, ceftriaxone or moxifloxacin, while 71.1% were resistant to co-trimoxazole, 62.2% to gentamicin, 56.6% to ampicillin and 35.5% to nalidixic acid. 1Department of Biology, Faculty of Science, University of Sana’a, Sana’a, Yemen (Correspondence to R.R. Taha: rihab_azawii@yahoo.com). Received: 22/11/11; accepted: 26/01/12 نَمَيلاب ،رامذ ةنيدم في يئاذغلا ممستلاو ةيوعلما ىملحا ضىرم ىدل لاينولماسلا عاونأ حلاص ديعس ليجم دارم ،يبلاغلا صرنم ديعس ،هط ديشر باحر تايطعلما ةردن مغر كلذو ،نميلا اهنمو ،لماعلا لود في ةيمومعلا ةحصلا في قلقلا يرثت يتلا اياضقلا ىدحإ لِّثتم لاينولماسلا لازتلا :ةـصلالخا اوعجار نمم ،يئاذغلا ممستلاب ينباصلما نم 210و ،ةيوعلما ىملحاب ينباصلما نم 250 ىدل لاينولماسلاب ىودعلا لدعم ةساردلا هذه ددتحو .الهوح ةنيع 187و ،مد ةنيع 250 اهنم ،ةنيع 773 ةساردلا في ةيريسرلا تانيعلا عوممج غلبو .2008 ماع في ةيبطلا ءافشلا راد ةدايعو رامذ في ماعلا ىفشتسلما عاونلأا امأ .تلاينولماسلاب ىودع ميهدل يئاذغلا ممستلا ضىرم نم %15.2و ةيوعلما ىملحا ضىرم نم %16.4 نأ حضتاو .زارب ةنيع 336و ،لوب ةيفيتلا لاينولماسلاو ،)%14.4( بي ةيفيتلا هيرظن لاينولماسلاو ،)%24.4( ةيوعلما لاينولماسلاو ،)%45.6( ةيفيتلا لاينولماسلا :تناكف ةدَرفتسلما ةيلصلما ُّيأ نكت لمو ،D )%70(، B )%27.7(، )%2.2( A تناكف ةيدسلجا تاعومجلما عيزوت امأ .)%2.2( فلأ ةيفيتلا ةيرظن لاينولماسلاو ،%13.3 ةيذرلجا ةمواقم تناك اهنم %71.1 نأ ينح في ،ينساسكوفليسكولما وأ ،نوسكايترفيسلا وأ ،ينساسكولفرابسلا وأ ينساسكولفوبرسلل ةمواقم تادرفتسلما نم .كيسكيديلانلا ضملح ةمواقم اهنم %35.5و ،ينلسيبملأل ةمواقم اهنم %56.6و ،ينسيماتنجلل ةمواقم %62.2و ،لوزاسكوميرتوكلل Infection à Salmonella spp. chez des patients atteints d'une fièvre entérique et d'une intoxication alimentaire dans la ville de Thamar (Yémen) RÉSUMÉ Les salmonelles restent une préoccupation de santé publique dans le monde, y compris au Yémen, même si les données sur leur incidence sont rares. La présente étude a déterminé l'incidence de l'infection à Salmonella chez 250 cas de fièvre entérique et 210 cas d'intoxication alimentaire s'étant présentés à l'hôpital général de Thamar et dans l'établissement de soins de santé Dar Alshafaa en 2008. Au total, 773 échantillons cliniques ont été recueillis : 250 échantillons de sang, 187 échantillons d'urine et 336 échantillons de selles. Parmi les patients souffrant de fièvre entérique et d'intoxication alimentaire, 16,4 % et 15,2 % respectivement étaient infectés par une salmonelle. Les sérotypes isolés étaient les suivants : Salmonella Typhi (45,6 %), Salmonella Enteritidis (24,4 %), Salmonella Paratyphi B (14,4 %), Salmonella Typhimurium (13,3 %) et Salmonella Paratyphi A (2,2 %). La répartition des groupes somatiques était la suivante : D (70 %), B (27,7 %) et A (2,2 %). Aucun de ces isolats n'était résistant à la ciprofloxacine, à la sparfloxacine, à la ceftriaxone ou à la moxifloxacine, alors que 71,1 % étaient résistants au co-trimoxazole, 62,2 % à la gentamicine, 56,6 % à l'ampicilline et 35,5 % à l'acide nalidixique. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 89 Introduction Salmonella Typhi and Salmonella Paratyphi are prevalent in develop- ing countries causing frequent illness. However, they also a potential threat to the more developed nations due to increasing air travel and global opera- tions. For example, enteric fever, which is caused by strains of Salmonella Typhi or Salmonella Paratyphi A, B or C, is estimated to occur in 16 million people a year causing 600 000 deaths world- wide [1]. Non-typhoidal Salmonella (NTS) infections (salmonellosis) are one of the most important causative agents of acute diarrhoeal disease in children and adults. The World Health Organization has determined that NTSs are emerging as one of the most important etiological agents of infec- tious diseases in the world [2]. Over the last 2 decades the incidence NTS infections has increased considerably and reached epidemic levels in several countries [3]. Recently, specific serovars have been linked with certain foods or exposure. NTSs are primary pathogens of animals (e.g. poultry, cows, pigs, birds, sheep) and approximately 95% of hu- man salmonellosis cases are associated with consumption of contaminated food such as meat, poultry, eggs, milk, seafood and fresh produce [4]. Antibiotics therapy is not recom- mended for uncomplicated Salmonella gastroenteritis. However, determination of antimicrobial resistance patterns is often valuable for surveillance purposes and may be performed periodically to monitor the development and spread of antibiotics resistance among these strains [5]. Resistance has emerged even to newer, more potent antimi- crobial agents and the development of resistance to multiple drugs is a major problem in the treatment of salmonel- losis [6]. Resistance to commonly used antibiotics, such as chloramphenicol, ampicillin and co-trimoxazole, has been reported from different parts of world in the last 2 decades [7]. In Yemen, Salmonella cases tend not to be recorded and so the incidence of Salmonella infection is not clearly known. In addition, the diagnosis proce- dure does not follow up-to-date meth- ods used by international laboratories. Furthermore, local laboratory equip- ment and resources are limited and the number of trained personnel dealing with this issue is inadequate. The aim of this study therefore was to determine the incidence of Salmonel- la cases in Thamar general hospital and Dar Alshafaa medical clinic, Thamar, Yemen. This research will add to the knowledge about the specific serotypes of Salmonella in Yemen that cause food poisoning and fever; this information has not been reported before and pro- vides important in epidemiological data. Methods The study included patients with sus- pected enteric fever or food poisoning who were attending General Thamar hospital and Dar Alshafaa hospital in 2008 when the research team was pre- sent and from whom clinical specimens were taken. Blood samples were inoculated in tryptic soy broth while stool and urine samples were inoculated in selenite and tetrathionate broth. They were then streaked on the differential media xylose lysine deoxycholate (XLD) and salmonella–shigella agar (SSA). All samples were incubated at 37 °C for 24 h. After incubation all colonies that gave typical characteristics of Salmo- nella were submitted for biochemical testing according to Holt et al. [8]. Finally, all presumptive Salmonella isolates were sent for serotyping at the Micro Analytical Centre in Cairo University, Egypt, according to the Kauffmann white scheme [9]. The difference between the 2 selective enrichment media in isolation of Sal- monella serovars was examined using one-way ANOVA. All confirmed Salmonella isolates were examined for antibiotic sensitiv- ity using the Kirby–Bauer disk diffu- sion method (National Committee for Clinical Laboratory Standards). Results A total 460 patients who visited were included in this study: 250 with suspected enteric fever and 210 with suspected food poisoning. There were 249 females and 211 males, and their ages ranged between 5 and 60 years. From these patients, 773 clinical specimens were collected: 250 blood samples, 187 urine samples and 126 stool samples from patients with suspected enteric fever and 210 stool samples from patients with suspected food poisoning. Of the 250 patients with suspected enteric fever, only 41 (16.4%) were con- firmed with Salmonella infection, while only 32 (15.2%) of the 210 suspected food poisoning patients were infected with Salmonella. The total number of confirmed Salmonella isolates obtained from the different clinical samples examined was 90: 58 isolates from patients with enteric fever and 32 from patients with food poisoning. These isolates com- prised 5 serovars: Salmonella Typhi (41 isolates), Salmonella Enteritidis (22), Salmonella Paratyphi B (13), Salmo- nella Typhimurium (12) and Salmonella Paratyphi A (2) (Table 1). Salmonella Typhi, Salmonella Paratyphi A and Sal- monella Paratyphi B were only found in people with enteric fever. Salmonella Typhimurium was only isolated from patients with food poisoning. Only Sal- monella Enteritidis was isolated from both groups. The most prevalent sero- var in enteric fever patients was Salmo- nella Typhi, which represented 70.7% of the total serovars isolated, followed by Salmonella Paratyphi B 22.4% (Table 1). The most prevalent serovar in food poi- soning was Salmonella Enteritidis which EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 90 represented 62.5% of the total serovars, followed by Salmonella Typhimurium 37.5% (Table 1). The antigenic formula of the Salmonella serovars is also shown in Table 1. The serovars belonged to 3 somatic groups: group D, which represented 70%, group B 27.7% and group A 2.2%.The most prevalent serovar was Salmonella Typhi which represented 45.6%, then Salmonella Enteritidis 24.4%, Salmonella Paratyphi B 14.4%, Salmonella Typhimurium 13.3% and Salmo- nella Paratyphi A 2.2% (Table 1). Comparison of the selective enrichment media for isolation of Salmonella serovars showed tetrathionate broth to be more effective than selenite broth. With enrichment tetrathionate broth, Salmonella was isolated from 73 (14.0%) stool and urine samples, compared to 45 (8.6%) positive samples using selenite broth. Direct streaking or plating on differential agar media (XLD and SSA) only produced 22 (4.2%) positive Salmonella samples (Table 2). There was a statistically significant difference between the 2 selective enrichment media (P < 0.01). We evaluated the frequency infection with Salmonella ac- cording to age and sex (Table 3). Infection was more frequent in people aged 11–20 years (35.7%) followed by those aged 21–30 years (20.5%). As regards sex, infection was more common in women (54.8%) than men. Thirteen antibiotics were tested for sensitivity. The resistance pattern of the isolates is shown in Table 4. None of the isolates was resistant to ciprofloxacin, sparfloxacin, ceftriaxone and moxifloxacin. However, 71.1% were resistant to co-trimoxazole, 62.2% to gentamicin, 56.6% to ampicillin and 35.5% to nalidixic acid (Table 4). Discussion We found that of patients with suspected enteric fever or food poisoning, 16.4% and 15.2% respectively were confirmed with Salmonella infection. For enteric fever, 4 serotypes were isolated, the most com- mon being Salmonella Typhi (70.7%) followed by Salmonella Paratyphi (25.8%). The high prevalence of Salmonella Typhi may be due to the fact that Salmonella Typhi is spread predomi- nantly within the household, whereas Salmonella Paratyphi is mainly transmitted outside the home [10]. Sources and sites of contamination of Salmonella include house members with clini- cal disease, pets with sub-clinical infection, contaminated items brought into the home, toilet bowls, carpet, floors, refrigerators and kitchen sinks and counter tops [10]. Consistent with this, independent risk factors for the intra-household spread of Salmonella Typhi are poor hand-washing hygiene and sharing of food from the same plate [11]. In Yemen, there are many popular dishes that are eaten by hand (without a spoon) and shared between family members, which can help the spread of Ta bl e 1 Sa lm on el la s er ov ar s is ol at ed fr om p at ie nt s w it h en te ri c fe ve r a nd fo od p oi so ni ng Sa lm on el la s er ov ar Is ol at es fr om p at ie nt s w it h: Sa lm on el la gr ou ps A nt ig en ic fo rm ul a En te ri c fe ve r + ve fo r S al m on el la Fo od p oi so ni ng +v e fo r S al m on el la Bo th N o. (% ) N o. (% ) N o. (% ) So m at ic an ti ge n Fl ag el la r ( H ) a nt ig en p ha se 1 /2 C ap su la r ( V i) an ti ge n Sa lm on el la T yp hi 41 (7 0 .7 ) 0 (0 ) 41 (4 5. 6) D 9, 12 d – +a Sa lm on el la P ar at yp hi A 2 (3 .4 ) 0 (0 ) 2 (2 .2 ) A 1,2 ,12 a – – Sa lm on el la P ar at yp hi B 13 (2 2. 4) 0 (0 ) 13 (1 4. 4) B 1,4 ,5 ,12 b 1,2 – Sa lm on el la E nt er iti di s 2 (3 .4 ) 20 (6 2. 5) 22 (2 4. 4) D 1,9 ,12 m ,g - – Sa lm on el la T yp hi m ur iu m 0 (0 ) 12 (3 7.5 ) 12 (1 3. 3) B 1,4 ,12 i 1,2 – To ta l n o. o f i so la te s 58 (1 0 0 ) 32 (1 0 0 ) 90 (1 0 0 ) A = 2 , B = 2 5, D = 6 3 Su sp ec te d pa tie nt s/ in fe ct ed p at ie nt s 25 0 /4 1 ( 16 .4 ) 21 0 /3 2 (1 5. 2) 46 0 /7 3 (1 5. 8) a 6 is ol at es o f S al m on el la T yp hi h ad v iru le nc e ca ps ul ar V i. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 91 Salmonella Typhi among members of one family or several families. On the other hand, risk factors for transmis- sion of Salmonella Paratyphi tend to be outside the household (e.g. consump- tion of foods from street vendors). The low hygiene standards of street vendors contribute not only to the transmission of paratyphoid fever but also other food- borne diseases such as typhoid [11]. In our study both Salmonella Ente- ritidis (62.5%) and Salmonella Typh- imurium (37.5%) were isolated from patients with food poisoning. This is to be expected because Salmonella Enter- itidis accounts for approximately one- fifth of all human Salmonella isolates reported to the Centers for Disease Control and Prevention (CDC), At- lanta, each year. Out of 371 outbreaks reported to CDC between 1985 and 1999, in which a vehicle of transmission was identified, 80% were egg-associated [12]. In a previous study in Thamar, Salmonella Typhimurium, Salmonella Enteritidis, Salmonella Anatum, Sal- monella Newport, Salmonella Arizona, and Salmonella Muenchen were iso- lated from poultry accessories, workers’ hands and tools of the slaughter [13], indicating the potential risk to spread infection. Another study in India found that Salmonella Typhi (55.5%) followed by Salmonella Paratyphi A (44.5%) were the most common isolates in enteric fever [14], while in Egypt, only Salmo- nella Typhi was isolated from patients with enteric fever [15]. In the Islamic Republic of Iran the most common iso- late from patients with enteric fever was Salmonella Typhi (69.6%), while in food poisoning Salmonella Typhimurium (69.0%), was the most common serovar [16]. In non-typhoidal Salmonella food poisoning in Korea, Salmonella Enter- itidis (68%) and Salmonella Typhimu- rium (32%) were the most common serovars, which is similar to the results of our study [17]. This difference between our study and these studies may be due to the difference in geographical region which is known to affect the prevalence of the different Salmonella serovars. In addition, difference in serotypes of Sal- monella isolated between our results and those of other studies may be due to differences in trade, customs and food preparation methods. In our study, the Salmonella isolates belonged to 3 groups, the most preva- lent being group D (70%). A previous study done in Yemen in 2001 reported that the majority of isolates in child- hood diarrhoea cases were Salmonella group C followed by Salmonella group B [18]. This study was concerned with fever and diarrhoea caused by typhoid and paratyphoid strains while we, in addition to this, evaluated food poison- ing and enteric fever strains caused by other strains of Salmonella, and this may account for the difference between their findings and ours. Also it is possible that new strains may enter to the country with feed, animals, food or foreigner people. Although Thamar and Sana’a cities are in a similar geographical area, they differ in the nature of their popula- tions. Most of the inhabitants of Thamar city are from rural areas; they tend to be uneducated and their knowledge of public health is low. On the other hand, in Sana’a, being a capital city, the people are more urban and educated. A study in Saudi Arabia found that the major- ity of isolates were Salmonella group D 33%, followed by group B 30%, group C 24%, Salmonella spp. 8% and group E 5% [19]. Tetrathionate broth was more suc- cessful in isolation of isolates than sel- enite broth. These results are consistent with those obtained in Mexico, where out of 88 stool samples, 29.5% were positive with sodium tetrathionate, compared with only 7.9% with sodium selenite [20]. When clinical samples were streaked on XLD and SSA directly, isolation of Salmonella was very low. Table 2 Effect of selective medium on the isolation of Salmonella serovar Medium Positive samples No. % (n = 523a) Tetrathionate broth then streaked on XLD and SSA 73 14 Selenite broth then streaked on XLD and SSA 45 8.6 Plating directly on XLD and SSA 22 4.2 a336 stool 336 and 187 urine samples. XLD = xylose lysine deoxycholate; SSA = salmonella–shigella agar. Table 3 Salmonella infection by of age and sex Variable Patients positive for Salmonella No. % Age group (years) 5–10 (n = 76) 11 14.5 11–20 (n = 98) 35 35.7 21–30 (n = 78) 16 20.5 31–40 (n = 47) 3 6.3 41–50 (n = 96) 3 3.1 51–60 (n = 65) 5 7.7 Total (n = 460) 73 15.8 Sex Female (n = 249) 40 54.8 Male (n = 211) 33 45.2 Total (n = 460) 73 100 EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 92 References 1. Xinguang C et al. Adults’ perceived prevalence of enteric fever predicts laboratory-validated incidence of typhoid fever in children. Journal of Health, Population and Nutrition, 2007, 25:469–478. 2. Panhotra BR et al. Emerging nalidixic acid and ciprofloxacin resistance in non-typhoidal Salmonella isolated from patients having acute diarrhoeal disease. Annals of Saudi Medicine, 2004, 24:332–333. 3. Patrick ME et al. Salmonella enteritidis infection, United States, 1985–1999. Emerging Infectious Diseases, 2004, 10(1):1–7. 4. Callaway TR et al. Gastrointestinal microbial ecology and the safety of our food supply as related to Salmonella. Journal of Animal Science, 2000, 85:457–490. 5. Rustici MC et al. Antibiotic resistance among Salmonella enter- ica isolates. European Journal of Pediatrics, 2006, 165:577–578. Therefore the use of at least one selec- tive enrichment broth is always highly recommended [21]. The age group 11–20 years were the most infected age group with Salmonella (35%). These results are in agreement with Itah and Uweh in Nigeria who found that age group 11–20 years was the most infected age group (33%) by Salmonella infection [22]. However, our results do not concur with those of Saha et al. in India who found that the age group 2–3 years was the most susceptible to Salmonella infection (35%) [23]. Members of the age group 11–20 years are generally schoolchil- dren and university students who start to leave the house and eat outside the home, especially from vendors in the streets. They are more exposed to the consumption of all kinds of food and therefore more at risk as vendors may be carriers of Salmonella or their level of hygiene in the preparation of food may be very low. In general, the standard of hygiene, quality control and monitoring procedures for food preparation and storage in Thamar city is low [personal observation]. Furthermore, the people who are involved in food preparation are not very well educated or aware of the role of foods transferring pathogenic infection to the consumers. We found that Salmonella serovars isolates were highly resistant to co-tri- moxazole (71.1%), gentamicin (62.2%) and ampicillin (56.6%). This finding is consistent with results of Guatam et al. who reported the high resistance of Salmonella isolates to: resistant to co- trimoxazole (74%), gentamicin (68%) and to ampicillin (50%) [24]. This resistance may be due to the fact that antibiotics, particularly ampicillin and co-trimoxazole, are frequently used for treating children for almost all respiratory tract infections (viral or bacterial) and diarrhoea in almost all the private clinics and hospitals in Yemen. Indiscriminate use of these antibiotics, as it is currently practised in most of our polyclinics and private hospitals, may have led to this resistance problem. Use of antimicrobial drugs in animals feed may also lead to Table 4 Resistance of Salmonella serovar isolates to antibiotics Salmonella serovar Antibiotica C NA NX AS S G CO CFX AK No (%) No (%) No (%) No (%) No (%) No (%) No (%) No (%) No (%) Salmonella Typhi (n = 41) 6 (14.6) 15 (41.6) 1 (2.4) 17 (41.5) 1 (2.4) 22 (53.7) 23 (56.1) 0 (0) 6 (14.6) Salmonella Enteritidis (n = 22) 4 (18.2) 8 (36.4) 0 (0) 18 (81) 0 (0) 14 (63.6) 19 (86.4) 0 (0) 3 (13.6) Salmonella Paratyphi B (n = 13) 1 (7.7) 3 (23) 0 (0) 8 (61.5) 0 (0) 9 (69.2) 11 (84.6) 0 (0) 0 (0) Salmonella Typhimurium (n = 12) 1 (8.3) 5 (41.7) 0 (0) 7 (58.3) 0 (0) 10 (83.3) 9 (75) 2 (16.6) 1 (8.3) Salmonella Paratyphi A (n = 2) 0 (0) 1 (50) 0 (0) 1 (50) 0 (0) 1 (50.0) 2 (100) 0 (0) 0 (0) Total (n = 90) 12 (13.3) 32 (35.6) 1 (1.1) 51 (56.7) 1 (1.1) 56 (62.2) 64 (71.1) 2 (2.2) 10 (11.1) aNo Salmonella serovars were resistant to: ceftriaxone, sparfloxacin, ciprofloxacin and moxifloxacin. C = chloramphenicol, NA = nalidixic acid, NX = norfloxacin, AS = ampicillin, S = streptomycin, G = gentamicin, CO = co-trimoxazole, CFX = cefixime, AK = amikacin. n = number of isolates. resistant strains of pathogens, which may be transmitted to humans through food [25]. All Salmonella isolates in our study were susceptible to ciprofloxacin, ceftri- axone, sparfloxacin and moxifloxacin. Ciprofloxacin is a currently recommend- ed drug for the treatment of Salmonella Typhi and invasive non-typhoidal Salmo- nella spp. and for prophylaxis in recurrent or relapsing cases of salmonellosis [26]. Although Salmonella has been known to cause illness for over 100 years, yet it remains a public health con- cern in developed and developing coun- tries, despite controls and therapeutic procedures that are already in place. The customs, traditions and sanitary level of people play an important role in controlling the spread of Salmonella, and improvement in hygiene standards will reduce the number of Salmonella infec- tions. However, two major problems exist with regard to Salmonella infection that add to the complexity of this sub- ject; the emergence of new serotypes and new strains resistant to the antibiot- ics currently available. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 93 6. Khanal B et al. Antimicrobial susceptibility patterns of Salmo- nella enterica serotype Typhi in Eastern Nepal. Journal of Health, Population, and Nutrition, 2007, 25:82–87. 7. Kalu IG et al. Pattern of multi-drug resistant Salmonella enterica serovar Typhi isolates in Nigeria. African Journal of Pediatrics, 2008, 7:3817–3820. 8. Holt JG et al. Bergey’s manual of determinative bacteriology. Philadelphia, Lippincott, Williams & Wilkins, 1994:215–216. 9. Grimont PAD, Weill F-X. Antigenic formulae of the Salmonella serovars, 9th ed. Paris, Institut Pasteur and World Health Or- ganization Collaborating Centre for Reference and Research on Salmonella, 2007. 10. Rice DH et al. Household contamination with Salmonella en- terica. Emerging. Infectious Diseases, 2003, 9:120–122. 11. Vollaard MA et al. Risk factors for typhoid and paratyphoid fever in Jakarta, Indonesia. Journal of the American Medical As- sociation, 2004, 291:2607–2615. 12. Marcus R et al. Re-assessment of risk factors for sporadic Sal- monella serotype Enteritidis infections: a case-control study in five FoodNet Sites, 2002–2003. Epidemiology and Infection, 2006, 135:84–92. 13. Odhah MNA. [Isolation of Salmonella species from poultry slaugh- ter house in Thamar province] [MSc thesis]. Thamar,Yemen, Faculty of Agriculture and Veterinary Medicine, Thamar Uni- versity,2009 [In Arabic]. 14. Capoor MR et al. In vitro activity of azithromycin, newer qui- nolones and cephalosporins in ciprofloxacin-resistant Salmo- nella causing enteric fever. Journal of Medical Microbiology, 2007, 56:1490–1494. 15. Srikantiah P et al. Population based surveillance of typhoid fe- ver in Egypt. American Journal of Tropical Medicine and Hygiene, 2006, 74:114–119. 16. Yousefi MR, Moshtaghi AA. Frequency of typhoidal and non- typhoidalSalmonella species and detection of their drugs resistance patterns. Journal of Research in Health Sciences, 2007, 7:49–56. 17. Cheong HJ et al. Characteristics of non-typhoidal Salmonella isolates from human and broiler- chickens in South western Seoul, Korea. Journal of Korean Medical Science, 2007, 22:773– 778. 18. Banajeh S. M et al. Bacterial aetiology and anti-microbial ren- sistance of childhood diarrhoea in Yemen. Journal of Tropical Pediatrics, 2001, 47:301–303. 19. Alzamil FA, Alanazi AR. Serogroups and antimicrobial suscep- tibility of non-typhoidal salmonellas in children. Saudi Medical Journal, 2001, 22:129–132. 20. Abuxapqui JJ et al. Comparación entre medios de cultivo de selenito de sodio y tetrationato de sodio, ambos incubados a 37 ºC y 42 ºC para el aislamiento de Salmonella spp de las heces fecales de portadores [Comparison between sodium selenite and sodium tetrathionate broths, incubated at 37 °C and 42 °C for the isolation of Salmonella spp. from faeces of carriers]. Revista Biomédica, 2003, 14:215–220. 21. Nye KJ et al. An evaluation of the performance of XLD, DCA, MLCB, and ABC agars as direct plating media for the isolation of Salmonella enterica from faeces. Journal of Clinical Pathology, 2002, 55:286–288. 22. Itah AY, Uweh EE. Bacteria isolated from blood, stool and urine of typhoid patients in a developing country. Southeast Asian Journal Tropical Medicine and Public Health, 2005, 36:673–676. 23. Saha MR et al. A note on incidence of typhoid Fever in diverse age group in Kolkata, India. Japanese Journal of Infectious Dis- eases, 2003, 56:121–122. 24. Gautam V et al. Sensitivity pattern of Salmonella serotypes in Northern India. Brazilian Journal of Infectious Diseases, 2002, 6:281–287. 25. Davis MA et al. Changes in antimicrobial resistance among Salmonella enterica serovar Typhimurium isolates from hu- mans and cattle in the north-western United States, 1982–1997. Emerging Infectious Diseases, 1999, 5:802–804. 26. Li W et al. Ceftriaxone resistance of nontyphoidal Salmonella enterica isolates in Northern Taiwan attributable to production of CTX-M-14 and CMY-2-Lactamases. Journal of Clinical Micro- biology, 2005, 43:3237–3243. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 94 Report Implementing the essential medicine concept in the country with the highest GDP per capita in the world A.M. Cheraghali 1 ABSTRACT Qatar, an oil-exporting country with a population of about 1.7 million, achieved the highest gross domestic product (GDP) per capita in the world in 2010. Total health expenditure as a percentage of GDP in 2010 in Qatar was 2.0%, with the government’s share at 75% of the total health care budget. Hamad Medical Corporation hospitals and the independent public Qatar Primary Health Care (PHC) centres are the main public health care service providers. PHC consists of 24 centres providing a wide range of health services. The PHC medicines list is a subset of the Hamad Medical Corporation medicine list. However, the PHC list of medicines could be improved both in its selection procedures and medicines included to correlate more directly to type of medical services provided by the Qatar PHC system in its different types of centres. 1Department of Pharmacology, University of Baqiyatallah Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to A.M. Cheraghali: majidcheraghali@gmail.com). Received: 01/11/11; accepted: 11/01/12 لماعلا في ًاعافترا رثكلأا يه لياجملإا ليحلما جتانلا نم درفلا ةصح برتعت يذلا دلبلا في ةيساسلأا ةيودلأا موهفم قيبطت لياغايرش ديجلما دبع .2010 ماع لماعلا في لياجملإا ليحلما جتانلا نم درفلل ةصح لىعأ هيفو ،ةمسن نويلم 1.7 هيف ناكسلا دادعتو ،طفنلا ردصي دلب رطق نإ :ةـصلالخا .ةيحصلا ةياعرلل ةيلاجملإا ةينازيلما نم %75 ـب هيف ةموكلحا مهاست ،2010 ماعل لياجملإا ليحلما جتانلا نم %2 ةحصلا لىع قافنلإا لياجمإ ةبسن لصتو عاطقلا في ةيلولأا ةيحصلا ةياعرلل ةلقتسلما زكارلماو ةيبطلا دََح ةسسؤم تايفشتسم يهف ةيحصلا ةياعرلا في تامدلخا ميدقتل ةيسيئرلا فارطلأا امأ ةيساسلأا ةيودلأا ةمئاق فلأتتو .ةيحصلا تامدلخا نم ًاعساو ًافيط م ِّدقُت ًازكرم نيشرعو ةعبرأ ةيلولأا ةيحصلا ةياعرلا زكارم ُّمضتو .ماعلا يرَطَقلا نم ةيلولأا ةيحصلا ةياعرلا في ةيودلأا ةمئاق ينستح نكميو .ةيبطلا دََح ةسسؤلم ةيودلأا ةمئاق نم ةيعرف ةعوممج نم ةيلولأا ةيحصلا ةياعرلا زكارم في ةيحصلا ةياعرلا ماظن اهمدقي يتلا ةيبطلا تامدلخا طمن عم بركأ ًاشرابم ًاقفاوت قفاوتت ىتح اهيف ةجردلما ةيودلأا ثيح نمو ءاقتنلاا تاءارجإ ثيح .هيف زكارلما فلتمخ في يرَطَقلا ةيلولأا Mise en œuvre du concept des médicaments essentiels dans le pays ayant le PIB par habitant le plus élevé au monde RÉSUMÉ Le Qatar, pays exportateur de pétrole dont la population s'élève à environ 1,7 million d'habitants, a atteint le produit intérieur brut par habitant le plus élevé au monde en 2010. Dans ce pays, les dépenses de santé totales en pourcentage du produit intérieur brut (PIB) en 2010 étaient de 2,0 % et le gouvernement assumait 75 % du budget des soins de santé total. Les hôpitaux de la Hamad Medical Corporation ainsi que les centres de soins de santé primaires publics et indépendants du Qatar sont les principaux prestataires de services de soins de santé publics. Ces centres, qui sont au nombre de 24, fournissent un large éventail de services de soins de santé. La liste des médicaments de ces centres de soins de santé primaires représente un sous-ensemble de la liste de médicaments de la Hamad Medical Corporation. Toutefois, la liste des médicaments essentiels des centres de soins de santé primaires pourrait être améliorée à la fois dans les procédures de sélection et le choix des médicaments pour correspondre plus directement au type de services médicaux offerts par le système des centres de soins de santé primaires dans ses différents types de centres. طسوتلما قشرل ةيحصلا ةلجلماشرع عساتلا دلجلما لولأا ددعلا 95 Introduction Qatar is a member state of World Health Organization (WHO) Eastern Mediterranean Region (EMR). The economy of the country is mainly de- pendent on oil and gas, which makes up about 56% of its total gross domestic product (GDP) in 2010 [1,2]. Qatar has experienced a significant increase in its population over the last 10 years. The population of Qatar has increased by 176% between 2000 and 2010 (from 616 000 to 1 700 000) [3]. The high de- mand of oil and gas over the past decades and the corresponding cash revenues generated have resulted in a demand for labour, especially young expatriate males. Therefore the majority of people residing in Qatar are non-Qatari expatri- ates. The expatriate labourers constitute about 54% of the population [3]. Due to constant increases in the price of oil and gas, the GDP per capita in Qatar in 2010 was about US$ 88 559, the highest in the world. Total health expenditure as a percentage of GDP in 2010 in Qatar was 2.0%. The Qatar government’s share of the health care budget in 2010 was 75%. However, private health services have also grown at a fast growth pace in recent years in Qatar. Currently Hamad Medical Corporation (HMC) hospi- tals and the independent public Qatar Primary Health Care (PHC) centres are the main public health care service providers. According to report published by the policy affairs directorate of the Su- preme Council of Health of Qatar on June 2011 health care and public health services in Qatar are comparable with those of developed countries and have steadily improved over the past 30 years [4]. The crude death rate has declined from 2.5 per 1000 inhabitants in 1981 to 1.9 in 2005. Infant mortality has halved from 17.0 per 1000 live births in 1981 to 8.2 in 2006. The Supreme Council of Health as the steward of the health of Qatar’s peo- ple was established in 2009 and given the responsibility to guide reform in Qatar in order to establish “one of the world’s most admired and renowned health systems” [4]. The Council’s role is to create a clear vision for the nation’s health direction, set goals and objec- tives for the country, design policies to achieve the vision, regulate the medical landscape, protect the public’s health, set the health research agenda and monitor and evaluate progress towards achieving those objectives. The Council does not provide clini- cal services. Instead its goal is to vest responsibility for care in the hands of public institutions such as HMC, Qatar PHC and the private sector while regulat- ing, monitoring and evaluating this care against agreed-upon outcomes to ensure that acceptable quality of care is provided. HMC, which was established in 1979, provides secondary and tertiary health care services through its hospitals [5]. Qatar Primary Health Care The establishment of Qatar PHC in Qatar goes back to as early as 1954 in an effort to cope with the increasing population after oil production acceler- ated. In 1978 the Ministry of Health developed a comprehensive scheme for a PHC system. The aim was to raise the health standard of the community as a first line of health defence and also to provide support to the hospitals. Qatar PHC consists of 24 centres (11 of which are in Doha) and provides general and clinical services plus emer- gency services. The range and type of PHC services provided in Qatar are more extensive than the services usu- ally provided by PHC centres in other countries [6]. PHC centres provide health services including diagnosis and treatment of disease, basic dentistry services, pregnancy care, vaccination, health education, pharmacy and drug prescription services, laboratory analy- ses, vital statistics, social work, home visits and referral of patients for second- ary care. Patients who need inpatient services and/or hospitalization or spe- cialty treatment are referred to HMC hospitals. Although Qatar PHC centres provide different level of medical servic- es in different centres (mainly could be categorized in 2 different levels), there is obviously some degree of overlap in medical services provided in Qatar PHC and HMC centres. Current list of medicines Registration of medicines in Qatar is based on safety, quality and efficacy. Marketing authorization is handled by the department of registration in the Su- preme Council of Health. Both HMC and PHC have their own medicine lists which have been selected by their own pharmacy and therapeutic committees. The HMC medicine list contains more than 4000 medicines [5]. The HMC pharmacy and therapeutic committee has more members (12 members) than the Qatar PHC committee (6 mem- bers). The PHC medicines list (about 700) is a subset of the HMC medicine list. The HMC pharmacy and therapeu- tic committee carries out the following functions: • Develops and maintains a basic drug list or formulary of accepted drugs for use in the hospital. • Serves as an advisory body to the medical staff and hospital administra- tion in all matters pertaining to the use of drugs. • Establishes formulary policies and regulations and ensures strict adher- ence to them. • Carries out regular review and updat- ing of these policies. • Reviews requests for addition/dele- tion of drugs to the list. • Establishes subcommittees for prob- lem related to the different groups of drugs. EMHJ  •  Vol. 19  No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 96 prepared by HMC was selected by the PHC therapeutic committee. However, the PHC list of medicines could be im- proved both in its selection procedures and medicines included. The list could be rearranged in a more scientific pres- entation and correlate more directly to the range and type of medical services provided by PHC in its different types of centres. A small reorganization of current procedures in Qatar PHC could result in implementation of the essential medicines concept in Qatar PHC system. These are some of the proposed modifications to upgrade Qatar national medicine list. • Establishment of an expert commit- tee for developing/revising the Qatar PHC medicine list. Such a commit- tee should follow the structure and working procedures recommended by WHO guidelines [7]. The phar- macy and therapeutic committee of the PHC service, with some minor modification in its organization and membership, could act as the PHC committee for developing/revising the medicines list. After establishing the committee, the content of the current PHC medicines list could be revised based on scientific evidence and the range of services provided by PHC centres in an agreed time frame. At this stage the committee should pay special attention to the needs of children for appropriate medicines and/or dosage forms [7]. • The new list should be categorized based on types and range of the medi- cal services which each level of PHC centre offers to patients. The com- mittee should decide which medi- cines on the list could be prescribed in which PHC centres. The new Qatar PHC list of medicine should then be implemented in PHC centres. • Based on the author’s observations in some PHC centres it was clear that Qatar national health officials should pay more attention to promoting appropriate use of medicines. Due to inappropriate use of medicines in some occasions especially high number of items per prescription it is recommended that an orchestrated programme in promoting rational prescription of medicines should also be a priority for the Qatar national health system. Such a programme should include all 3 components of training, supervision and monitoring of prescription patterns in Qatar PHC centres. Currently there are high num- bers of non-Qatari physicians practis- ing in Qatar health care centres and in fact most of physicians in these cen- tres are non-Qatari. Therefore, based on possible different educational background it would be worthwhile to compare the prescribing pattern of medicine in these 2 groups of physi- cians (Qatari and non-Qatari). • In addition to revising the current medi- cines list the establishment of a national pharmacovigilance programme could greatly improve safety of the medicines use. Therefore, the establishment of a nationwide pharmacovigilance pro- gramme should be as one of the priority of Qatar national health system. • Initiates a system to monitor medica- tion errors. A PHC list of medicines has been de- veloped by the Qatar PHC therapeutic committee. The committee consists of 2 pharmacists and 4 physicians from dif- ferent disciplines. The committee meets regularly and deals with different aspects of medicines and pharmacy practices in PHC centres including the medicines list, policy-making, medicine errors and follow ups of prescribers. In addition to the medicines on the list, physicians practising in PHC centres can request out-of-list medicines for specific patients. There are also some therapeutic guide- lines developed by the pharmacy and therapeutic committee, e.g. for manage- ment of type 2 diabetes. The department of pharmacy service of PHC provide monthly reports of the total medicines used in different departments and PHC centres. As an example in July 2011 this department filled 175 951 prescriptions in 24 PHC centres. Based on an internal report the PHC service pays on average about US$ 3.5 million for medicines in its centres . However, the total expendi- ture on drugs and pharmaceuticals of the public sector in Qatar in 2010 was US$ 143 million [4]. Future activities in Qatar PHC Qatar PHC already uses a fairly com- prehensive medicine list which includes more than 700 medications. This list which in fact is part of a larger list References 1. World economic book database. International Monetary Fund [online database] (http://www.imf.org/external/pubs/ft/ weo/2011/update/02/index.htm, accessed 12 November 2012). 2. Census 2010. Qatar Statistics Authority Fund [online database] (http://www.qsa.gov.qa/QatarCensus/Default.aspx, ac- cessed 23 September 2012). 3. Country profiles: Qatar. World Health Organization [online database] (http://www.who.int/countries/qat/en/, accessed 23 September 2012). 4. Qatar national health accounts: 1st report years 2009 and 2010. A baseline analysis of health expenditure and utiliza- tion, June 2011. Qatar, Supreme Council of Health State of Qatar, Policy Affairs Directorate, 2011 (www.sch.gov.qa/ sch/UserFiles/File/QHA_2011_eng(1).pdf, accessed 23 Sep- tember 2012). 5. Hamad Medial Corporation [website] (http://www.Hmc.org. qa, accessed 23 September 2012). 6. The world health report 2008: primary health care (now more than ever). Geneva, World Health Organization, 2008. 7. Summary of the report of the 18th meeting of the WHO Expert Committee on the Selection and Use of Essential Medicines. Ge- neva, World Health Organization, 2011. طسوتلما قشرل ةيحصلا ةلجلما شرع عساتلا دلجلما لولأا ددعلا 97 Eastern Mediterranean Health Journal reviewers’ panel, 20121 The Eastern Mediterranean Health Journal extends sincere thanks the following experts for their generous and invaluable assistance in the review of papers considered for publication during the year 2012. Professor Hilmy Abaza Professor Mohammed Abdel Sabour Dr Faten Ibrahim Abdellatif Professor Ekram Abdel-Salam Dr Alaa A.R. Abd-Elsayed Professor Ahmed Ezzat Abdou Dr Asmaa Ahmed Abdulsalam Professor Mostafa Abdelfattah Abolfotouh Dr Basil H. Abou Enein Professor Kamilia Ragab Abou Shabana Dr Ahmed A.A. Adeel Dr Salim Adib Dr Bushra Afroze Dr Muhammad Afzal Dr Mary Agocs Professor Suhail Ahmed Professor Kamel Ajlouni Dr Tasleem Akhtar Professor Mansour M. Al Nozha Dr Asya Ali Al Riyami Dr Khaldoun Al Roomi Dr Najeeb Al Shorbaji Dr A. Basel Al Yousfi Ms Deena Alasfoor Professor Ahmed M.B. Alkafajei Professor Ezzat Khamis Amine Dr Abdel Moneim Ashour Dr Mohamed Assai Dr Hoda Atta Dr Abla Ibraheem Ayoub Dr Hanan Al-Sayed Badr Dr Samiha Baghdadi Dr Jennifer Wendi Bailey Dr Mohamed Hassan Baldo Dr Faraj Barah Dr Hyam Bashour Dr Anwar Batieha Professor Myron Belfer Professor Abdulbari Bener Dr Jill Benson Professor Sanaa Sabet Botros Dr Laila Maurice Boulos Dr John Brooks Dr Monique Maurice Chaaya Dr Irtaza Chaudhuri Dr Abdul Hanan Choudhury Professor Kian Fan Chung Dr Antoinette M. Cilliers Dr Leonard A. Cohen Professor Fazal Karim Dar Professor Laila Shehata A. Dorgham Dr Bassel H. Doughan Professor Gholam Hossein Edrissian Professor Ezzeldin Saeed El-Denshary Dr Wafaa Essam Eldin Professor Abdel-Hady El-Gilany Dr Zenab El-Gothamy Dr Eman Ellabany Professor Ihab Hafez El-Sawy Professor Nawal Abdel Rehim El-Sayed Dr Ghanem El-Sheikh Professor Sarah Beatrice England Professor Alaa Mohamed Fadel Dr Mounir Farag Dr Shadley Fataar Professor Mahmoud Fahmy Fathalla Dr Julia Fitzner Dr Heba Fouad Professor Mohsen Abdel Hameed Gadallah Dr Ahmed Heshmat Gado Dr Maisoon A. Ghaleb Professor Gamal Gordon Dr Bulent Gorenek Dr Allan Gottschalk Dr Motasim Habiballah Dr Farrokh Habibzadeh Dr Rana A. Hajjeh Dr Samia Halileh Professor Randah R. Hamadeh Professor Mohammad Ismail Hamed Dr Sarah Ahmed Hamza Professor Abdulla Saeed Hattab Professor Samia A.R. Hemeda Professor Claus Christian Heuck Dr Syed Jaffar Hussain Dr Afaf Gaber Ibrahim Dr Osama Ibrahim Dr Jamshaid Iqbal Dr Mostafa Kamel Ismail Dr Ibrahim Ali Kabbash Professor Samir Mohamed Kabil Dr Imad Labib Kaddoura Dr Zeina Kassaify Dr Ali Khader Dr Nawal Moahmed Khalafallah Dr Fawzy Megahed Khalil Mr Wasiq Mehmood Khan Ms Zahra Khatami Professor Mohamed Taky El Din Khayyal Dr Ali Khogali Dr Tawfik A.M. Khoja Professor Nabil Kronfol Dr Wesam I. Kurdi Mr Anthony John Laurance Dr Nicolas Lechopier Dr Vernon Lee Dr Joel Lexchin Dr Matthew Lim Dr Anna Leena Lohiniva Dr Hans Oulf Lyon Mr Osama Maher Professor Moghazy Ali Mahgoub Dr Mamunur Malik Dr Adel M.M. Mansour Dr Boutros Mansourian Dr Seyed Alireza Marandi Professor Mohamed Naguib Massoud Dr Ghassan Matar Dr Awad Mataria Dr Jacquline Wilson Matta Dr Jeanne Maugein Professor Afaf I. Meleis Professor Mohamed Mokhtar Messahel Dr Nabila Metwalli Dr Atarod Modjtabai Dr Azza Hassan Mohamed Professor Soltani Mohamed Dr Amira Mohsen Professor Kamel Monastiri Dr Nivan Morgan Dr Robert Emmet Morris Dr Tosson Aly Morsy Professor Nahed Daoud Saleh Mortada Dr Samar Muwakkit Professor Kamal K. Naguib Dr Mona Nasrallah Dr Nuha Nuwayri-Salti Dr Omar Obeid Mrs Stephen Abimbola Odusanya Dr Hiroshi Ogawa Professor Tarek Ahmed Okasha Professor Taissir Ali Ibrahim Omar Dr Ikushi Onozaki Dr Langoya Marin Opoka Dr Salah-Eddine Ottmani Dr Ann Powers Dr Maqbool Qadir Mr Abid Quddus Qazi Dr Farouk Qureshi Dr Naseem Akhtar Qureshi Dr Azza Saleh Radwan Dr Ahmed R.A. Ragab Professor Ashraf Mohamed Nasr Refaie Dr Tonia Rifaey Dr M. B. Rokni Professor Bassem Saab Dr Ali A.A. Sadek Dr Bijan Sadrizadeh Dr Abdel Aziz Saleh Dr El Sayed Salem Professor Abdel Rahman Salim Dr Saqer S. Al-Salem Saqer Professor Mohamed Attia Seida Dr Aristarhos Seimenis Dr Ermin Sergery Dr Fatima Serhan Dr Amira Shaheen Dr Javad Shahidi Dr Sherine Shawky Dr Asem A. Shehabi Dr Olla Shideed Dr Younis A.A. Skaik Dr Ali Mohammed Somily Dr Soliman Azmy Tahoon Dr Sabira Tahseen Professor Wagdy Talaat Dr Maha Tantawy Dr Afaf Abdel Fattah Tawfik Professor Kholoud Yehia Tayel Dr Mohammed Adnane Tazi Dr Anne M. Teitelman Dr Jean-Francois Tessier Dr Mukund Uplekar Dr Jinan Usta Dr Mojtaba Vaismoradi Dr Martin Van Den Boom Ms Joanna Vogel Dr Fritz Wagner Dr Momtaz Omar Wasfy Dr Kris Weerasuriya Dr Samiha Samuel Wissa Doss Professor Randa M. Youssef Dr Ghazi Zaatari Dr Hany Ziady Dr Fabio Zicker 1Arranged in alphabetical order according to the family name. EMHJ  •  Vol 19     No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 98 1. Papers submitted for publication to the Eastern Mediterranean Health Journal (EMHJ) must not have been published, accepted for publication or currently be under consideration for publication elsewhere. The World Health Organization (WHO) Regional Office for the Eastern Mediterranean reserves all rights of reproduction and republication of material that appears in the EMHJ. 2. Papers submitted for publication to the EMHJ should conform with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (URM) of the International Committee of Medical Journal Editors (ICMJE) 3. Submission: Original papers written in Arabic, English or French may be submitted for consideration by e-mail to EMHJ@emro.who.int. Papers can also be sent to the Editor-in-chief, Eastern Mediterranean Health Journal, WHO Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City (11371), Cairo, Egypt. Abstracts of papers accepted for publication will be translated into all three languages. To ensure the correct spelling of authors’ names to accompany the Arabic abstract, authors writing in English or French but whose mother tongue is written using Arabic characters should provide their full names in Arabic script along with transliterations in English or French 4. All papers considered for publication will be peer reviewed. The Editorial Board reserves the right to accept or reject any paper based on the reviewers’ comments, scientific rigor and suitability for the journal. Papers are accepted on the understanding that they are subject to statistical and editorial revision as deemed necessary, including abridgement of the text and omission of tabular or graphic material. 5. Topics: The subject of the paper should pertain to public health or a related biomedical or technical subject within the field of interest of the WHO, and should have particular relevance to the Eastern Mediterranean Region. 6. The title of the paper should be as concise as possible, preferably not more than 15 words. The full name(s) of the author(s), institutional affiliations(s) and highest scientific degrees obtained should be provided. Please include the e-mail address and any other contact information (mailing address, fax, telephone) of the corresponding author. The number of authors should not exceed seven. All authors should have made material contribution to the design, analysis or writing of the study and have approved the final version submitted. No change in authorship will be permitted after the paper has been accepted for publication and any change before this must be agreed by all authors listed. Authors may be asked to verify their contribution. Names of other contributors may be included in the acknowledgements. Please see the ICMJE guidelines for authorship and contributorship. 7. Research articles and Reports: Papers reporting original research findingsshould follow the IMRAD format: Introduction; Methods; Results; Analysis; and Discussion. The text of Research articles and Reports should not exceed 3000 words (excluding the accompanying abstract, references, tables and figures). An abstract of not more than 150 words should be supplied, clearly and briefly stating the objectives, context, results and conclusions. The maximum number of references permitted is 25. The number of tables and figures should not exceed one per 1000 words. 8. Review articles, i.e. critical assessments of research on topics of relevance to public health in the Region. These should contain sections dealing with objectives, sources, methods of selection, compilation and interpretation of data and conclusions. The text should not exceed 3000 words (excluding the accompanying abstract, references, tables and figures), and should be accompanied by an abstract of not more than 150 words. The number of tables and figures should not exceed one per 1000 words. 9. Case reports: Only reports of cases of an unusual nature are considered for publication. Text should include an Introduction, the Report of the case(s) and a Discussion. The text should not exceed 1500 words and the number of references kept to a minimum. No abstract is required. 10. Letters to the Editor: Letters commenting on published articles are welcome. Letters will be sent to the authors of the original article for their comments, and these will be published along with the letter. The text of letters should be kept as short as possible. 11. Short communications: Articles which do not constitute a complete research study but are of particular relevance or importance to public health issues in the Region are occasionally considered for publication. The text should not exceed 1500 words (excluding the accompanying abstract, references, tables and figures), and should be accompanied by an abstract of not more than 150 words. The number of tables and figures should not exceed one per 1000 words. 12. Ethical considerations: Where applicable, a statement must be included indicating approval for the study was granted by the ethics committee/institutional review board of the relevant institution. Authors should verify where appropriate that all persons on whom research has been carried out have given their voluntary, informed, written consent, and where participants (living or dead) were unable to give such consent, that surrogate consent was obtained. Authors may be asked to supply such consent forms. In cases where participants cannot read and write, oral consent is acceptable. 13. Conflicts of interest: Authors must provide a statement detailing any competing interests. Please see the ICMJE guidelines. 14. Manuscripts should be provided in word processed format (preferably Microsoft Word) double-spaced, A4-size. Manuscripts submitted as hard copy should be double- spaced, A4 pages typewritten or printed on one side only. 15. References: In-text citations of published works should be limited to essential up-to-date references. These should be numbered separately as they occur in the text with sequential Arabic numerals in parentheses, e.g. [1,5-8]. These references should appear in a numbered list on a separate page after the Discussion. They should contain the following elements as appropriate: name(s) and initial(s) of author(s); title of paper or book in its original language plus translation; for research articles, complete name of journal plus volume number and page range; for books and other texts, place of publication (city and country) and name of publisher (commercial or institutional); and date of publication; for texts published exclusively on the Internet, exact URL of the page cited and date when last accessed. For texts with up to 3 authors, all authors must be named. For texts with more than 3 authors, only the first author is named followed by “et al”. The following are examples of the Journal’s preferred style: Book: Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990. Journal article: Jones A et al. One day in Tibet. Journal of tautology, 1993, 13(5):23–7. Document: Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization, 1985 (WHO/DOC/537). Web text: Child growth standards. Geneva, World Health Organization, 2006 (http://www.who. int/childgrowth/en/, accessed 8 October 2008). 16. Figures and tables with appropriate captions should each be on a separate page, numbered sequentially with Arabic numerals and attached at the end of the paper. Each figure and table must be referred to in the text. Where appropriate, sources should be given. If any figures, tables or other materials have been copied from other sources, authors have the sole responsibility for securing the necessary permission. In order to avoid layout problems in final production, tables and figures should be limited as far as possible. Figures must be supplied in a format which can be edited, preferably Microsoft Excel format, and figures derived from data must be accompanied by those data, e.g. Excel data sheet, to enable redrawing if necessary. Photographs and illustrations should also be sent as separate files. The preferred format is JPG or TIFF; resolution should be minimum 300 dpi. For manuscripts submitted as hard copy, it is necessary to provide two sets of original photographs and figures along with the background data. 17. Submissions that do not comply with these Guidelines will be returned to the author for correction before being considered for publication. Guidelines for authors المجلة الصحية لشرق المتوسط المجلد التاسع عشر العدد الأول 99 دلائل إرشادية للمؤلفين 1. إن الأوراق البحثية المقدَّ مة للمجلة الصحية لشرق المتوسط للنشر يجب ألا يكون قد تم نشرها من قبل، أو تم قبول نشرها، أو أنها قيد الدراسة بغرض النشر في أي مكان آخر (نرجو الرجوع إلى السياسة الخاصة بأخلاقيات النشر الخاصة بنا).ويحتفظ المكتب الإقليمي لمنظمة الصحة العالمية لشرق المتوسط بالحق في إعادة نشر وطباعة أي مادة علمية تظهر في المجلة الصحية لشرق المتوسط. 2. إن الأوراق البحثية المقدَّ مة للنشر في المجلة الصحية لشرق المتوسط يجب أن تـتوافق مع المتطلَّ بات الموحدة للمخطوطات المقدَّ مة للمجلات الطبية البيولوجية التابعة للجنة الدولية لمحرري المجلات الطبية. 3. التقديم: تقدَّ م الأوراق البحثية الأصلية المكتوبة باللغة العربية أو الإنكليزية أو الفرنسية للدراسة عن طريق البريد الإلكتروني tni.ohw.orme@JHME كما يمكن إرسال الأوراق البحثية لرئيس تحرير المجلة الصحية لإقليم شرق المتوسط، بالمكتب الإقليمي لشرق المتوسط، صندوق بريد 8067، مدينة نصر: (17311)، القاهرة، مصر. ويتم ترجمة ملخصات الأوراق البحثية التي يتم قبول نشرها إلى اللغات الثلاث. ولضمان كتابة أسماء المؤلفي المرفق أسمائهم بالملخصات العربية كتابة صحيحة، فإنه يتعيَّ على المؤلفي الذين تكون العربية هي لغتهم الأم، ويكتبون بالإنكليزية أو الفرنسية، أن يرفقوا أسماءهم بالكامل بالعربية، بالإضافة إلى كتابة الحروف العربية باللغة الإنكليزية أو الفرنسية. 4. تخضع كل الأوراق البحثية المقترح نشرها لمراجعة الزملاء. ويحتفظ مجلس التحرير بالحق في قبول أو رفض أي ورقة بحثية استنادًا إلى تعليمات المراجعي، والدقة العلمية ومدى الملاءمة للمجلة. ويتم قبول الورقة البحثية على أساس أنها تخضع للمراجعة الإحصائية والتحريرية إذا لزم الأمر، بما في ذلك تلخيص النص وحذف الجداول أو مادة الرسم البياني. 5. الموضوعات: يتعيَّ أن يرتبط موضوع الورقة البحثية بالصحة العمومية، أو موضوع طبي بيولوجي متعلق بها، أو موضوع تقني يرتبط بمجالات المنظمة، وذي أهمية خاصة لإقليم شرق المتوسط. 6. يتعيَّ أن يكون عنوان الورقة مختصرًا قدر الإمكان، ويحّبذ ألا يزيد على 51 كلمة، على أن يرسل الاسم الكامل للمؤلف، والمؤسسات التي يكون عضوًا فيها، وأعلى درجة علمية حصل عليها. لذا نرجو إرسال عنوان البريد الإلكتروني، والمعلومات الأخرى اللازمة للاتصال بالكاتب (العنوان البريدي، الفاكس، الهاتف). ويتعيَّ ألا يزيد عدد المؤلفي على سبعة، على أن يسهم جميع المؤلفي بشكل مادي في تصميم أو تحليل أو كتابة الدراسة، والموافقة على النسخة الأخيرة. ولن يسمح بإجراء أي تغيـير يتعلَّ ق بالتأليف بعد قبول الورقة للنشر، وأي تغيـير قبل ذلك يجب أن يقّره جميع المؤلفي المدرجي. وقد يطلب من المؤلفي تأكيد مساهمتهم. كما يمكن تضمي أسماء أي مساهمي آخرين في الشكر والتقدير. نرجو الرجوع إلى الدلائل الإرشادية للجنة الدولية لمحرري المجلات الطبية فيما يتعلق بالتأليف والمساهمة. 7. التقارير والمقالات البحثية: وينبغي في الأوراق التي تدون النتائج البحثية الأصلية اتباع الشكل الخاص: المقدمة والطرق والنتائج والمناقشة، على ألا يزيد نص التقارير والمقالات البحثية عن 0003 كلمة (ولا يتضمن ذلك الملخص المرفق، والمراجع، والجداول، والأشكال). ويتعيَّ تقديم ملخص لا يتعدى 051 كلمة ليوضح الأغراض والسياق والنتائج والخلاصة بشكل مختصر وواضح، بالإضافة إلى أن أقصى عدد للمراجع يجب ألا يتجاوز 52 مرجعًا، وكذلك عدد الجداول والأشكال يجب ألا يتجاوز واحدًا لكل 0001 كلمة. 8. مقالات حول المراجعات بمعنى التقيـيم النقدي للبحوث حول الموضوعات ذات الصلة بالصحة العمومية في الإقليم. ويتعيَّ أن تـتضمَّ ن قسًما يتناول الأغراض، والمصادر، وطرق الاختيار، والتجميع وتفسير المعطيات والاستنتاجات. ويتعيَّ ألا يتعدَّ ى النص 0003 كلمة (ولا يتضمن ذلك الملخص المرفق، والمراجع، والجداول، والأشكال). وعلى أن يصحبها ملخص لا يزيد عن 051 كلمة؛ وألا يتجاوز عدد الجداول والأشكال واحدًا لكل 0001 كلمة. 9. تقارير الحالات: يتم دراسة نشر التقارير الخاصة بالحالات ذات الطبيعة غير المعتادة فقط. ويتعيَّ أن يشمل النص مقدمة، وتقرير الحالة، والمناقشة، وألا يتجاوز النص 0053 كلمة مع إيراد أقل عدد من المراجع. ولا يلزم في هذه الحالة تقديم ملخص. 01. رسالة إلى المحرر: ُيَرحَّ ب بتلقي الرسائل والملاحظات حول المقالات المنشورة في المجلة، وسترسل هذه الرسائل إلى مؤلفي المقالات الأصلية، للتعليق عليها. وينشر التعليق مصاحبًا للرسالة، على أن يكون نص الرسائل موجزًا قدر الإمكان. 11. الاتصالات الموجزة: إن المقالات التي لا تشكل دراسة بحثية مكتملة، ولكنها ذات أهمية خاصة لموضوعات الصحة العمومية في الإقليم يتم من حي لآخر دراسة إمكانية نشرها. ويتعيَّ ألا يزيد النص عن 0051 كلمة (ولا يتضمن ذلك الملخص المرفق، والمراجع، والجداول، والأشكال) وأن يصحبها ملخص لا يزيد عن 051 كلمة. ويجب ألا يزيد عدد الجداول والأشكال عن واحد لكل 0001 كلمة. 21. الاعتبارات الأخلاقية: متى وجب ذلك، يرفق بيان بموافقة لجنة الأخلاقيات ومجلس المراجعة في المؤسسة المعنّية. ويتعّي على المؤلفي إثبات أن جميع الأشخاص الذين شملهم البحث، قد وافقوا موافقة واعية كتابية وطوعية، وإذا لم يتمكن المشاركون (أحياءًا كانوا أم أمواتًا) من إعطاء هذه الموافقة، يتم الحصول على موافقة أوليائهم. وقد يطلب من المؤلفي تقديم نماذج الموافقة هذه، وحتى في حالة عدم إلمام المشاركي بالقراءة والكتابة، فقد تقبل الموافقة الشفهية. 31. تضارب المصالح: ينبغي أن يقّدم المؤلفون بيانًا يوضح أي تضارب في المصالح بالتفصيل. يرجى الرجوع إلى الدلائل الإرشادية للجنة الدولية لمحرري المجلات الطبية. 41. تقديم المخطوطات في شكل إلكتروني (يحّبذ استخدام برنامج مايكروسوفت وورد) مع ترك مسافتي بي السطور. وأن يكون مقاس الورقة 4A. أما بالنسبة للمخطوطات التي تقدَّ م في شكل ورقي فيجب أيضًا ترك مسافتي بي السطور، وأن يكون حجم الورقة 4A على أن تـتم الطباعة على وجه واحد من الصفحات. 51. المراجع: ينبغي أن يقتصر الاستشهاد من نصوص أي أعمال منشورة على المراجع الحديثة الأساسية. ويلزم ترقيم المراجع، كلما ظهرت في النص، وأن يليها إعداد عربية بي أقواس مربعة مثل: [1، 8-5]. كما ينبغي تدوين هذه المراجع في قائمة مرقمة، في صفحة منفصلة، في نهاية الورقة، وأن تـتضّمن المعلومات التالية إن أمكن: اسم المؤلف، أو أسماء المؤلفي، والأحرف الأولى من أسمائهم، وعنوان الورقة البحثية أو الكتاب في اللغة الأصلية، إضافة إلى ترجمتها؛ وبالنسبة للمقالات البحثية، يتم ذكر الاسم الكامل للمجلة بالإضافة إلى رقم المجلد، وعدد الصفحات؛ وبالنسبة للكتب وسائر النصوص، يتم ذكر مكان النشر (البلد والمدينة) واسم الناشر (التجاري أو المؤسسة) وتاريخ النشر؛ وبالنسبة للنصوص التي تنشر حصرًا على الإنترنت، يتم ذكر العنوان الإلكتروني للرابط (LRU) الخاص بالصفحة المستشهد بها وتاريخ آخر وصول لها. بالنسبة للنصوص التي يشترك فيها أكثر من ثلاثة مؤلفي، يذكر اسم المؤلف الأول فقط يتبعه كلمة "وزملائه". وفي ما يلي أمثلة للأسلوب الذي تفضل المجلة الصحية لشرق المتوسط أن يتبع: .ytitnedi fo ngis htffi ehT .A htimS ,B azmaH lA :kooB .la te A senoJ :elcitra lanruoJ .0991 ,sserP ytisrevinU naciremA ,oriaC 7-32 :(5)31 ,3991 ,ygolotuat fo lanruoJ .tebiT ni yad enO ,aveneG .ytniatrecnu fo selpicnirp ehT .de ,M neentI-lA :tnemucoD (735/COD/OHW) 5891 ,noitazinagrO htlaeH dlroW htlaeH dlroW ,aveneG .sdradnats htworg dlihC :txet beW ,/ne/htworgdlihc/tni.ohw.www//:ptth) 6002 ,noitazinagrO (8002 rebotcO 8 dessecca 61. وفي ما يتعّلق بالرسومات والجداول، المشفوعة بالشروح الملائمة، فإنه ينبغي أن ترد كل منها في صفحة منفصلة، ومرقمة على التوالي بالأعداد العربية، وملحقة في نهاية الورقة. كما ينبغي الإشارة إلى كل رسم وكل جدول يشار إليه في النص، وحّبذا لو أمكن تحديد مصدر كل رسم وكل جدول. وفي حالة نقل أي رسومات أو جداول من مواد أخرى، فإنه تقع على عاتق المؤلف أو المؤلفي المسؤولية الكاملة عن الحصول على الأذون اللازمة. وُبْغَية تجنب أي مشكلات في طريقة تنسيق المنتج النهائي، فإنه يتعيَّ الاقتصار قدر الإمكان في إدراج الجداول والرسومات. وينبغي تقديم الأشكال بالشكل الذي يسمح بتنقيحها، ويحّبذ برنامج ميكروسوفت إكسيل. وبالنسبة للأشكال المستندة إلى بيانات، فيجب أن ترفق بها هذه البيانات، مثل قوائم بيانات إكسيل على سبيل المثال لتيسير عملية إعادة الرسم إذا لزم الأمر. أما بالنسبة للصور والإيضاحات فينبغي إرسالها كملفات منفصلة، ويحّبذ في صورة GPJ أو FFIT وألا يقل وضوح الصورة عن003 ipd. بالنسبة للمخطوطات المقدَّ مة بشكل ورقي، فينبغي إرفاق مجموعتي من الصور والأشكال الأصلية مع المعطيات الأساسية. 71. سيتم إعادة الأوراق المقّدمة والتي لا تلتزم بهذه الدلائل الإرشادية إلى المؤلف للتصويب قبل دراسة نشرها. EMHJ  •  Vol 19     No. 1  •  2013 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 100 Directives à l’intention des auteurs 1. Les articles soumis pour publication à La Revue de Santé de la Méditerranée orientale ne doivent pas avoir été publiés, être en cours d’examen par d’autres revues, ou avoir été acceptés pour publication dans d’autres revues (veuillez vous reporter à notre Politique en matière d’éthique). Le Bureau régional de l’Organisation mondiale de la Santé (OMS) pour la Méditerranée orientale se réserve tous les droits de reproduction et de republication des matériels qui paraissent dans La Revue de Santé de la Méditerranée orientale. 2. Les articles soumis pour publication à La Revue de Santé de la Méditerranée orientale doivent être conformes aux Uniform Requirements for Manuscripts Submitted to Biomedical Journals [Exigences uniformes appliquées aux manuscrits soumis aux revues médicales, URM] de l’International Committee of Medical Journal Editors (Comité international des éditeurs de revues médicales, ICMJE). 3. Soumission : Les articles originaux rédigés en anglais, arabe ou en français peuvent être soumis pour examen par courrier électronique à l’adresse suivante : EMHJ@emro.who.int. Les articles peuvent aussi être envoyés au Rédacteur en chef, La Revue de Santé de la Méditerranée orientale, Bureau régional de l’OMS pour la Méditerranée orientale, BP 7608, Cité Nasr (11371), Le Caire (Égypte). Les résumés des articles acceptés pour publication seront traduits dans les trois langues. Pour assurer que les noms des auteurs soient correctement écrits dans les résumés en arabe, les auteurs rédigeant en anglais ou en français mais dont la langue maternelle s'écrit en caractères arabes doivent fournir leur nom complet en écriture arabe et une translittération de leur nom en anglais ou en français. 4. Tous les articles dont la publication est envisagée seront revus par des pairs. Le Comité de rédaction se réserve le droit d’accepter ou de refuser tout article, sur la base des commentaires des réviseurs, de la rigueur scientifique et de la pertinence de l’article pour la Revue. Les articles sont acceptés sous réserve de la révision statistique et rédactionnelle dont ils feront l’objet, comme jugé nécessaire, ce qui peut amener à abréger le texte et à supprimer certaines données présentées sous forme de tableaux ou de graphiques. 5. Sujets : Le sujet de l’article doit concerner la santé publique ou un autre sujet biomédical ou technique connexe faisant partie du champ d’intérêt de l’OMS, et se rapporter plus particulièrement à la Région de la Méditerranée orientale. 6. Le titre de l’article doit être aussi concis que possible, et de préférence ne pas dépasser 15 mots. Le(s) nom(s) complet(s) du ou des auteur(s), leur(s) affiliation(s) institutionnelle(s) et l’intitulé de leur plus haut diplôme scientifique doivent être indiqués. Une adresse électronique et toute autre information permettant de contacter le ou les auteurs(s) (adresse postale, numéro de télécopie, numéro de téléphone) devront aussi être mentionnées. Le nombre des auteurs ne devrait pas être supérieur à sept. Tous les auteurs devraient avoir apporté une contribution importante à la conception, à l'analyse ou à la rédaction de l'étude et avoir approuvé la version finale soumise. Aucun changement dans les noms des auteurs ne sera autorisé après l’acceptation de l’article pour publication ; avant cette acceptation, tout changement doit être accepté par l’ensemble des auteurs figurant dans la liste. Une vérification de leur contribution peut être demandée aux auteurs. Les noms d’autres contributeurs peuvent être inclus dans les remerciements. À ce sujet, veuillez vous reporter aux ICMJE guidelines for authorship and contributorship [Directives de l’ICMJE relatives à la qualité d’auteur et de contributeur]. 7. Articles et rapports de recherche : Les articles présentant des résultats de recherche originale devront suivre le format IMRAD : introduction, méthodes, résultats, analyse et discussion. Le texte des articles et des rapports de recherche ne doit pas excéder 3000 mots (résumé, références, tableaux et figures exclus) Un résumé de 150 mots maximum sera fourni et mentionnera clairement et brièvement les objectifs, le contexte, les résultats et les conclusions. Le nombre maximal de références autorisées est de 25. Il ne faut pas inclure plus d’un tableau ou d’une figure tous les 1000 mots. 8. Articles d’analyse (évaluations critiques d'études de recherche sur des sujets pertinents concernant la santé publique dans la Région). Ils doivent être composés de paragraphes traitant des objectifs, des sources, des méthodes de sélection, de la compilation et de l’interprétation des données et des conclusions. Le texte ne doit pas excéder 3000 mots (résumé, références, tableaux et figures exclus) et doit être accompagné d’un résumé de 150 mots au maximum. Il ne faut pas inclure plus d’un tableau ou figure tous les 1000 mots. 9. Études de cas : Seules les études de cas inhabituels seront examinées pour publication. Le texte doit comprendre une introduction, un exposé du/des cas et une discussion. Il ne doit pas excéder 3500 mots et le nombre de références doit être minimal. Il n’est pas nécessaire de fournir un résumé. 10. Lettres à la rédaction : Les lettres commentant des articles publiés sont les bienvenues. Elles seront envoyées aux auteurs de l’article afin qu'ils fournissent leurs commentaires, qui seront publiés aux côtés de la lettre. Le texte des lettres doit être aussi court que possible. 11. Communications brèves : Les articles ne constituant pas une étude de recherche complète, mais présentant un intérêt ou revêtant une importance particulière pour les questions de santé publique dans la Région sont occasionnellement examinés pour publication. Le texte ne doit pas excéder 1500 mots (résumé, références, tableaux et figures exclus) et doit être accompagné d’un résumé de 150 mots au maximum. Il ne faut pas inclure plus d’un tableau ou d’une figure tous les 1000 mots. 12. Considérations éthiques : Le cas échéant, une déclaration devra être incluse, indiquant que le Comité d’éthique ou le Comité d’examen institutionnel de l’organisme concerné a donné son accord à l’étude. Les auteurs doivent vérifier, le cas échéant, que toutes les personnes sur lesquelles la recherche porte ont donné leur consentement volontaire et informé par écrit et que si certains participants (en vie ou décédés) n’ont pas pu le donner, un consentement de substitution a été obtenu. Il peut être demandé aux auteurs de fournir ce type de formulaire de consentement. Lorsque les participants ne savent ni lire ni écrire, un consentement oral est acceptable. 13. Conflits d’intérêts : Les auteurs doivent fournir une déclaration détaillant tout conflit d'intérêts. Veuillez vous reporter aux directives de l'ICMJE (ICMJE guidelines). 14. Les manuscrits doivent être fournis en format traitement de texte (Microsoft Word, de préférence), A4 avec double interlignage. Les manuscrits soumis en version papier doivent être dactylographiés ou imprimés sur le recto seulement, sur des feuilles A4 avec double interlignage. 15. Références : Les citations dans le texte de travaux publiés doivent être limitées aux références essentielles récentes. Elles doivent être numérotées séparément à l’aide de chiffres arabes indiqués entre crochets, par exemple [1,5-8], selon l’ordre dans lequel elles apparaissent dans le texte. Les références doivent figurer sous forme de liste numérotée sur une page séparée après la partie « Discussion ». Elles doivent contenir les éléments suivants, selon le cas : nom(s) et initiales du ou des auteurs ; titre de l’article ou de l’ouvrage dans sa langue originale ainsi que sa traduction ; pour les articles de recherche, le nom complet de la revue ainsi que le numéro du volume et les pages concernées ; pour les ouvrages et autres textes, le lieu de publication (ville et pays) et le nom de la maison d’édition (commerciale ou institutionnelle) ; la date de publication ; pour les textes publiées exclusivement sur Internet, l'URL exact de la page citée et la date du dernier accès. Lorsque les textes comptent moins de trois auteurs, tous les auteurs doivent être nommés. Lorsque les textes comptent plus de trois auteurs, seul le nom du premier auteur est mentionné, suivi de « et al. ». Exemples du style préféré de La Revue : Livre : Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990. Article de Revue : Jones A et al. One day in Tibet. Journal of tautology, 1993, 13(5): 23–7. Document : Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization, 1985 (WHO/DOC/537). Texte Web : Child growth standards. Geneva, World Health Organization, 2006 (http: //www. who. int/childgrowth/en/, accessed 8 October 2008). 16. Les figures et les tableaux accompagnés des légendes appropriées doivent être placés chacun sur une feuille séparée, numérotés en chiffres arabes selon leur ordre et joints à la fin de l’article. Chaque figure et chaque tableau doit être référencé(e) s dans le texte, et le cas échéant, les sources doivent être indiquées. Si des figures, tableaux ou d’autres matériels ont été copiés d’autres sources, les auteurs portent l’entière responsabilité d’obtenir les autorisations nécessaires. Afin d’éviter les problèmes de mise en page lors de la production finale, le nombre de tableaux et de figures doit être aussi limité que possible. Les figures doivent être fournies dans un format permettant les modifications, de préférence Microsoft Excel, et celles qui sont établies à partir de données doivent être accompagnées de ces données, sur une fiche technique Excel par exemple, pour permettre une recomposition, le cas échéant. Les photographies et illustrations doivent être envoyées dans des fichiers séparés. Les formats préférés sont JPG et TIFF, et la résolution des images doit être de 300 dpi au minimum. Si les manuscrits sont soumis en version papier, deux jeux de photographies et de figures originales accompagnées des données de base doivent être fournis. 17. Les manuscrits ne respectant pas ces directives seront renvoyés à leur auteur pour correction avant d’être examinés en vue de la publication. 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: khayat@emro.who.int/emhj@emro.who.int 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 is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed‑Full text on CD‑ROM, 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 2013 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 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 . نادوسلا بونج . 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 . South Sudan 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 . Soudan du Sud . Tunisie . Yémen Cover 19-1.indd 2 1/10/2013 10:05:54 AM Contents Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 19 / No. 1 January / Janvier 2013 1 ددع / شرع عساتلا دلجلما رياني / نياثلا نوناك V olum e 19 N um ber 1 January 2013 Letter from the Editor ............................................................................................................................................................3 Research articles Compliance with haemodialysis practice guidelines in Egypt ....................................................................................4 Effect of prenatal counselling on compliance and outcomes of teenage pregnancy ............................................. 10 Domestic violence against women in Kersa, Oromia region, eastern Ethiopia ....................................................... 18 Looking beyond legality: understanding the context of female sex workers in greater Cairo, Egypt .....................24 Dieting behaviours, obesity and predictors of dieting among female college students at Palestinian universities ............................................................................................................................................... 30 Pattern of psychiatric illnesses among long-stay patients at Mental Health Hospital, Taif, Saudi Arabia: a 10-year retrospective study ........................................................................................................37 Study of the effect of dietary counselling on the improvement of end-stage renal disease patients .....................45 Évaluation de la prise en charge des diabétiques par le médecin généraliste dans la province de Khouribga (Maroc) ......................................................................................................................................................52 Trends of skin cancer incidence in 6 geographical regions of the Islamic Republic of Iran, 2000–2005 ..............59 Acute respiratory infection and malnutrition among children below 5 years of age in Erbil governorate, Iraq ... 66 Epidemiological characterization of P. aeruginosa isolates of intensive care units in Egypt and Saudi Arabia ...... 71 Quality of clinical laboratory department in a specialized hospital in Alexandria, Egypt ....................................... 81 Salmonella spp. in patients suffering from enteric fever and food poisoning in Thamar city, Yemen .................... 88 Report Implementing the essential medicine concept in the country with the highest GDP per capita in the world...... 94 Eastern Mediterranean Health Journal reviewers’ panel, 2012 .......................................................................................97 Guidelines for authors ....................................................................................................................................................... 98 Chitral, Pakistan: WHO EMHJ extends good wishes for a healthy, peaceful and happy new year to all our readers, authors, reviewers, and our editorial board and advisory panel members. Cover 19-1.indd 1 1/10/2013 10:05:54 AM